Hale Nani Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews, record reviews and review of policy, the facility failed to ensure the resident's right to a dignified existence for three Residents (R) 7, 14, 42 of five residents sampled for dignity and as reported by Resident Council Members. As a result of this deficiency, the residents were not promoted the right to the maintenance or enhancement of their quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure call system equipment was within reach for three Residents (R) 87, 132, 167 of eight sampled residents sampled. The deficient practice placed residents at risk of not having emergent needs met in a timely manner and had the potential to affect all residents that rely on staff for assistance with activities of daily living.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a homelike environment in six Resident rooms (Rm (110, 114, 115, 116, 118 and 119) on the unit Pensacola 1. An unhomelike environment could significantly affect their physical, mental and social well-being and affect any resident in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of their right to formulate an Advanced Health Care Directive (AHCD) for three of seven residents (Resident (R) 17, R170, and R153) reviewed for AHCD. This failure placed R17, R170, and R153 at risk of not having their health care preferences known or honored, potentially resulting in care that is not consistent with their wishes. Findings Include: 1) Review of R17's Electronic Health Record (EHR) revealed that on 04/14/25, the facility discussed AHCD information with the resident. Documentation indicated that R17 did not have an AHCD at that time and requested a blank AHCD form. Further review of the EHR revealed no evidence that an AHCD was completed or that follow-up assistance was provided thereafter.,On 04/30/26 at 10:06 AM, an interview was conducted with the Social Services Assistant (SSA). [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain a clean environment as evidenced by a dirty lab specimen refrigerator. As a result of this deficiency, there was an increased risk for the spread of disease-causing organisms.

Inspectors wroteBased on record review and interviews, the facility failed to develop comprehensive care plans for one of five residents (Resident (R) 5) reviewed for unnecessary medications and one of three residents (R153) reviewed for pressure ulcers. Specifically, R5's care plan did not address the resident's use of an anticoagulant medication and include interventions related to dementia care. In addition, R153's care plan did not address pressure ulcer prevention measures or identify the resident's risk for pressure ulcer development. This placed residents at risk for adverse outcomes, including medication-related complications, unmanaged dementia-related behaviors, impaired skin integrity, and the development or worsening of pressure ulcers due to the lack of individualized care planning and interventions. Findings Include: [...]

Inspectors wroteBased on resident interview, staff interview and record review, the facility did not update/revise the care plan for two Residents (R) 11 and 221 of thirty-five residents reviewed. As a result of the deficiency, there was an increased risk of uncoordinated delivery of care.

Inspectors wroteBased on observation, interviews, document and record review, the facility failed to ensure three Residents ((R)16, R176 and R221 of a sample size of three received the treatment and care in accordance with professional standards of practice and their person-centered comprehensive care plan (CP). This deficient practice put these residents at increased risk of not meeting their highest practicable physical, mental and psychosocial wellbeing, and could affect any resident in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide supervision for one Resident (R)176 of sample of one, that was consistent with her needs, goals, care plan and current professional standards of practice to eliminate the risk of a fall. As a result of lack of assistance, there was increased risk of a fall that could result in a negative outcome. This deficient practice could affect any resident in the facility.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide appropriate services to prevent urinary tract infections for one resident (Resident (R)8). The deficient practice exposed the residents to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.

Inspectors wroteBased on Interviews, document and record review, the facility failed to report to the physician that one Resident (R)16, of a sample of one, had a trend of significantly lower intake than baseline. In addition, R16's last documented weight indicated a significant weight loss, which was not confirmed with a reweigh according to standards of care and their own policy. As a result of this deficient practice, timely medical review to determine of these signs were a part of a broader decline in health status was not done and increased the risk of a negative outcome. This deficient practice could affect any Resident in the facility and prevent them from maintaining the highest practicable level of well-being. 1) R16 was a [AGE] year-old female long-term resident at the facility. [...]

Inspectors wroteBased on observations and interview the facility failed to assure one of one resident (R) 40, sampled for respiratory care, was provided oxygen assuring the O2 tubing was connected to the O2 concentrator. This deficient practice puts all residents who are using oxygen at risk for respiratory distress and complications related to not receiving lifesustaining O2. Findings Include:On 04/28/2026 at 11:08 AM went into R40's room and observed her resting in her bed with her oxygen concentrator running at 3L with the nasal cannula placed on resident's face with tongs placed in resident's nostrils. Went to check date on oxygen (O2) tubing and noticed O2 tubing was not attached to the O2 concentrator and tubing was on the ground. Went out and got resident's nurse, Registered Nurse (RN)105, asked her to bring her pulse oximeter which she placed on the resident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide access site care as ordered by the physician for one of one resident (R) 138, sampled for Dialysis. The deficient practice puts all residents who receive dialysis at risk for complications related to improper care of resident's hemodialysis access site potentially putting the resident's at risk for reduced blood flow, clotting, and narrowing or stenosis of the Arteriovenous Fistula (AVF). Findings Include:On 04/29/2026 at 11:53 AM interviewed R138 in his room. Surveyor inquired about his access site which is used for hemodialysis. R138 explained it is on his right arm. Inquired of R138 when do the nurses at the facility take off the dressing on his access site after he returns to the facility from dialysis and R138 stated nurses take the dressing off the day he comes back or the next morning. [...]

Inspectors wroteBased on record review and interviews, the attending Physician's (MD1) post hospitalization visit examination notes for one Resident (R)16 of a sample size of one, did not reflect a thorough examination of R16's current health status on return to the facility Each visit must document review of resident's current, progress and problems in maintaining or their health status. Specifically, the progress note did not include R16 had been hospitalized for sepsis, hypernatremia (high sodium and low water in blood), or that she had a Peg tube inserted (feeding tube inserted directly into the stomach to provide nutrition). This deficient practice could affect any resident in the facility and increase the risk that Residents would not meet their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services necessary to meet residents' needs in a safe manner and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being for five Residents (R) 170, 187, 222, Anonymous 1, Anonymous 2 of thirty five residents sampled. These failures placed residents at risk for unmet care needs, delays in assistance, decline in hygiene and psychosocial well-being, and diminished quality of life. Findings Include: 1) On 04/28/26 at 08:51 AM, an interview was conducted with R170. R170 stated the facility was short staffed and when there were not enough staff, Certified Nurse Aides (CNAs) did not have time to provide showers and instead provided bed baths. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe administration of medications in accordance with standards of nursing practice when four residents (Residents (R) 44, R170, R169, and R203) of a sample size of 38 were not directly observed taking their medications and licensed staff left them at the bedside. As a result of this deficient practice, there is a risk of hoarding, diversion, inaccurate timing of administration, and omission, which increases risk of an adverse outcome. This deficient practice could affect any resident in the facility.1) On 04/28/26 at 12:04 PM, during an interview with R44 observed Registered Nurse (RN) 42 enter R44's room, hand a cup of medication to R44 and tell her one of the medications was tums, then left the room without observing R44 take the medication. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the attending physician documented review of the consultant pharmacist's monthly medication regimen review (MRR) recommendations, including actions taken in response to the pharmacist's recommendations, for one of five residents (Resident (R) 5) reviewed for unnecessary medications. This deficient practice placed R5 at risk for unresolved medication-related concerns, including adverse drug reactions, medication interactions, continued use of unnecessary medications, ineffective treatment, and potential decline in health status. Findings Include: Review of R5's MRR notes from April 2025 to April 2026, revealed the pharmacist documented the MRR was complete and included Sending rec [recommendation] regarding fluid restrictions on 07/09/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that antipsychotic and antidepressant medications received adequate documented behavior monitoring for one of five residents (Resident (R) 5) reviewed for unnecessary medications. This failure placed R5 at risk for ineffective treatment monitoring and continued unnecessary medication use. Findings Include:Review of R5's physician orders revealed R5 is taking Abilify 5 milligrams (mg) one tablet in the evening for depression, trazadone 50mg one tablet at bedtime for depression/anxiety, and vilazodone 10mg two tablets at bedtime for depression. On 04/30/26 at 12:38 PM, an interview was conducted with the Director of Nursing (DON) in training. The DON stated behavior monitoring is usually documented on the treatment administration record for nursing staff to monitor. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one Resident (R)52 of sixteen residents selected for review, is free of medication errors. List of wrong medications given to R52 included psychiatric medications, antihypertensive (medications to control high-blood pressure), furosemide, and blood thinner. As a result of this deficiency, R52 was at risk of experiencing potential side effects, adverse health issues and harm.

Inspectors wroteBased on observations and staff interview, the facility did not properly secure two Medication and Treatment Carts, of six reviewed, which contained various medications and medical supplies. As a result of this deficiency, there was an increased chance of missing equipment/medications and/or accident hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents food preferences were honored for one of four residents (Resident (R) 187) reviewed for food services. This failure placed R187 at risk of dissatisfaction with meals and overall quality of life. Findings Include: On 04/28/26 at 12:54 PM, during a dining observation and interview, R187 stated that she was not supposed to have gravy or chicken skin but the facility continued to serve foods with gravy on her plate. Observation of R187 lunch tray revealed chicken with the skin on and gravy covering the chicken. Review of R187's meal card on the meal tray revealed R187 was ordered a No Added Salt (NAS) diet with instructions for no sauce, gravy, or chicken skin. On 04/29/26 at 07:56 AM, Resident 187 reported that her dinner plate the previous evening had a lot of gravy. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assure their sanitation solution kept in their sanitation buckets in the kitchen were maintained at the correct sanitation level. The deficient practice places the residents at risk for spread of foodborne illness. On 04/28/26 at 9:02 AM requested staff, Dietary Aide (DA) 5, check the sanitation level of the red sanitation bucket. DA5 used the Hydrion QT-40 test strip, which she dipped in the bucket. Inquired of DA5 how long the strip must be kept in the sanitation bucket and she said, 15 seconds. Showed DA5 the Hydrion QT-40 test strip container which states Dip paper in quat solution, not foam surface, for 10 seconds. Don't shake. Compare colors at once. [...]

Inspectors wroteBased on observations, interviews, record reviews and review of policy, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary environment and to prevent the transmission of communicable diseases and/or infections. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings Include:1) R58 was a [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services to include physical and occupational therapy. Diagnoses included but not limited to generalized muscle weakness, bacterial pneumonia and positive for Clostridioides difficile (C. diff - bacterium that causes an infection of the colon). On 04/28/26 at 11:54 AM, observed signage outside R58's room with a heading that stated, Stop, Contact Precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely for 6 of 9 residents (Residents 1, 2, 3, 4, 7, and 8), and 4 of 7 floors sampled. Specifically, residents were not receiving their showers or restorative nursing services as scheduled, residents were not being transferred by mechanical lift per the facility policy and protocol for safety, and a resident requiring an around-the-clock one-to-one (1:1) sitter did not consistently have one. As a result of this deficient practice, residents were placed at risk of a preventable accident/injury or decline in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its nurse staffing information was posted in a prominent place readily accessible to all residents. In addition, the facility failed to ensure the staff information that was posted met the data requirements, specifically, facility name, resident census, and the total number and actual hours worked by licensed and unlicensed staff.

Inspectors wroteBased on interview and review of the current Facility Assessment, the facility failed to review and update the assessment when there was a change to a six-hour Certified Nurse Aide (CNA) shift schedule on 11/02/25. As a result of this deficient practice, the assessment did not reflect that the facility assessed how many CNAs were needed on each shift to safely care for the needs of the residents.

Inspectors wrote2) On 05/12/25 at 12:54 PM observed Certified Nurse Aide (CNA) 11 assist Resident (R) 56 with her lunch. CNA11 uncovered R56's food, mixed some of the food together and took a spoonful and offered it to R56. Right afterwards CNA11 left R56 and went into room [ROOM NUMBER] and retrieved a used meal tray and placed it in the cart. CNA11 returned to R56, stirred her food some more, took another spoonful and offered it to the resident which she took. CNA11 left R56 and walked down the hall to another resident and pushed the resident down the hall past R56 to help move him out of the way while a delivery was coming down the same hallway. CNA11 returned to R56, did not perform hand hygiene and proceeded to assist R56 with her lunch again by offering her more spoonful of food. On 05/12/25 at 02:00 PM interviewed Director of Nursing (DON) in her office. [...]

Inspectors wroteBased on interviews and record review, for the facility failed to ensure the disharge/transfer form used by the facility included all of the Ombudsman's address or the resident's appeal rights and provide written notification of transfer/discharge to the resident and the resident representative for two of three Residents (R)187 and R166 sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide two Residents (R) 166, 216, out of two sampled, the amount of treatment/services to maintain and/or prevent a decline in range of motion (ROM) as evidenced by inconsistent application of splint and ROM exercises. This puts the residents who have limited mobility at risk for decline in ROM and further contractures.

Inspectors wroteBased on observation, interview, record review and review of policy, the facility failed to ensure two Residents (R)201 and R49, of six residents sampled for accident hazards, had their risk of preventable accidents occurring minimized. R201 who wanders didn't receive adequate supervision from the staff and R49 did not have a safe designated smoking area for him to smoke. As a result of this deficient practice, there was increased risk of avoidable accidents and injuries by not providing the appropriate planning, monitoring and/or implementing the interventions to meet their identified needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage pain adequately for 2 Residents (R)9 and R44 of 4 residents sampled for pain. Specifically, the facility failed 1) accurately assess and monitor R9's pain in a manner that she understood, resulting in inadequate pain control and 2) failed to manage R44's pain while being provided passive range of motion (PROM) exercises by the Restorative Nursing Assistant (RNA) and had not been pre-medicated prior. As a result of this deficient practice, these residents were prevented from attaining or maintaining their highest practicable level of well-being.

Inspectors wroteBased on resident/representative interviews, staff interview, record review and review of policy, the facility failed to ensure that three Residents (R)9, 54, 140 of three residents sampled understood the Binding Arbitration Agreement. As a result of this deficiency, R9, 54 and 140 did not fully understand the details of the Agreement.

Inspectors wrote3) On 05/12/25 at 12:54 PM observed CNA11 assist R56 with her lunch. CNA11 was observed standing up while assisting R56. CNA11 uncovered R56's food, mixed some of the food together and took a spoonful and offered it to R56 as she stood near R56. Right afterwards CNA11 left R56 and went into room [ROOM NUMBER] and retrieved a meal tray and placed it in the cart. CNA11 returned to R56, stirred her food some more, took another spoonful and offered it to the resident which she took. CNA11 continued to stand near resident during this time. CNA11 left R56 and walked down the hall to another resident and pushed the resident down the hall past R56 to help move him out of the way while a delivery was coming down the same hallway. CNA11 returned to R56, and proceeded to assist R56 with her lunch again by offering her more spoonful of food. [...]

Inspectors wroteBased on interview and record review, the facility failed to facilitate the inclusion of the resident's representative in the resident's care planning for 2 of 5 residents Resident (R) 203 and 532. As a result of this deficient practice, the resident's representative was not able to support and provide input on the resident's goals, choices and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 36 residents Resident (R)9 in the sample had been determined clinically appropriate to self-administer her medications before leaving them at the bedside for her to take independently. This deficient practice placed R9 at risk of adverse effects related to unsafe medication administration practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the shower preferences of 1 of 2 residents Resident (R)9 sampled for accommodation of needs by having a shower gurney available. In addition, the facility failed to ensure the continuous availability of a mechanical lift for the transfer of the 9 of 40 residents on the floor who require it. As a result of these deficient practices, R9 did not have her needs met and was placed at risk of not attaining her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to identify and support the shower preference of 1 of 2 residents Resident (R)9 sampled for Self-Determination/Choices. As a result of this deficient practice, R9 did not have her needs met and was hindered from attaining her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the individual financial records of 2 of 3 residents Residents (R)104 and R49 sampled for personal funds were made available to them through quarterly statements. As a result of this deficient practice, the residents were not aware of their current account balances and were not afforded the opportunity to periodically reconcile their accounts.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that the personal information and clinical records of Resident (R)134 were protected. As a result of this deficient practice, residents are at risk of their health information not remaining private.

Inspectors wroteBased on observations and interviews the facility failed to provide a clean area inside and outside of two of four Residents (R) 75, 159 sampled for Environment. R75's bed side mats were dirty with black marks and R159 sat underneath a dirty ceiling tile with a large black spot. 1) On 05/12/25 at 08:57 AM observed R75 resident in her room in her bed. R75 has fall mats on both sides of her bed. Closer inspection of fall mats found them to be dirty with black marks. On 05/14/25 at 05:38 PM observed R75 in her bed. Observation of fall mats on either side of her bed do not appear to have any changes, appears dirty with black marks. On 05/15/25 at 06:12 AM observed R75 in her bed as a CNA provided care for her. At this time noted fall mats on either side of R75's bed continues to be dirty with black marks. On 05/15/25 at 07:27 AM interviewed Housekeeper 25. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct an assessment that accurately reflects the status of two Residents (R) 9 and R201 of 36 residents in the sample. As a result of this deficient practice, these residents did not have their needs properly identified or met and were hindered from attaining their highest practicable well-being.

Inspectors wrote2) On 05/12/25 at 04:41 PM record review of R75's Electronic Health Record (EHR) revealed she is a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses that include, but are not limited to, vascular dementia, unspecified severity, with other behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain, unspecified and constipation, unspecified. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to revise one Resident (R) 119 of four residents sampled for dialysis, Care Plan (CP). The facility also failed to provide an intervention to care for R119's dialysis access site after he returned from dialysis with a pressure dressing covering his access site. The deficient practice puts the resident at risk of decreased blood flow and/or occlusion of the access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the proper care and treatment including assistive devices/tools to improve, promote the communication abilities and to communicate needs and express choices for 2 Residents (R)9 and 203 of 3 residents sampled. Despite identifying upon admission that their primary language was not English, the facility failed to implement the use of alternative communication methods, such as a communication board, non-verbal pain assessment tools or commonly used phrases in their primary language. As a result of this deficient practice, the residents were placed at an increased risk of not having their needs met, hindered from attaining their highest practicable well-being and placed at risk for decrease in quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who require dialysis services are consistent with professional standards of practice. The facility failed to remove the pressure dressing for one of one resident Resident (R) 73 sampled, who was on dialysis. This deficient practice puts residents on dialysis at high risk for access clotting and complications.

Inspectors wroteBased on interview and record review, the facility failed to adequately assess for and identify past trauma experienced by one of one Resident (R) 211 sampled for Trauma-Informed care (TIC). As a result of this deficient practice, R211 did not have his trauma triggers identified placing him at increased risk of re-traumatization and was hindered from attaining her highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the necessary behavioral health care services that were person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety were provided for one Resident (R) 201 of four residents in the sample. This deficient practice has the potential to affect all of the residents residing on the unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure the accurate administering of all drugs to meet the needs of 1 Resident (R) 9 of 36 residents sampled. R9 was given medications more than 2 hours early without consideration of safety/efficacy and 2) Assure licensed staff signed the narcotic log each time it was reconciled. The deficient practices placed R9 at risk of adverse effects related to unsafe medication administration practices and put other residents at risk for drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure that the consultant licensed pharmacist's (CLP) 1 medication regimen review (MRR) recommendations were acted upon for one of one Resident (R) 203 sampled for drug regimen review. As a result of this deficient practice the facility did not maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize potential adverse consequences related to medication therapy.

Inspectors wrote4) On 05/12/25 at 09:54 AM observed R116 sitting in his wheelchair in front of his room. Noticed R116 had a medication cup with pills and one loose pill on his table. At this time R116's assigned nurse, RN 50 was at the medication cart, to R116's left side. RN50 was focused on who he was talking to, with his back to R116. Surveyor stood in front of R116 to observe what he was going to do with the medication. RN50 noticed surveyor in front of R116 and stated, I have my eye on him. Once RN50 was done talking with the male person he was addressing he walked over to R116. RN50 looked down at R116 and did not say anything. Inquired of RN50 what he would do in such a situation and he said put the medication in the med cart. RN50 picked up the medication cup and started to walk away. Surveyor stopped RN50 and let him know there was a loose pill on R116's table. RN50 picked up the loose pill. [...]

Inspectors wroteBased on observations, interviews, record review and review of policy, the facility failed to accommodate one Resident (R)250, of four residents sampled, preference of food and drink. As a result of this deficiency, R250 did not like the food and/or drink provided by the facility and would not eat it or would have other food, from outside the facility, brought in.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice placed the residents residing on the unit at a potential risk for illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on one Resident (R) 9, of 36 residents sampled that were accurately documented, in accordance with accepted professional standards and practices.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain the following equipment in safe operating condition: 1) medication refrigerator, and 2) medication refrigerator thermometer. This deficient practice puts residents who are prescribed medications that needs refrigeration at risk for receiving ineffective medications and unexpected reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from abuse, specifically resident-to-resident physical abuse, for 9 of 9 residents (Residents (R)10, R7, R8, R3, R1, R2, R4, R5, and R6) sampled for this type of abuse. The facility failed to provide sufficient protection to prevent resident-to- resident abuse from occurring or recurring once aware of aggressive behaviors. As a result of this deficient practice, at least one resident (R10) sustained physical injuries and experienced pain related to those injuries. In addition, given that R10 has both communication and cognitive barriers, the psychosocial harm and potential for negative effects as a result of this deficient practice cannot be fully determined.

Inspectors wroteBased on interviews and record review, facility did not employ a qualified social worker on a full-time basis as required for a facility with more than 120 beds and this facility was licensed for 288 beds. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document and provide evidence that 2 of 5 resident-to-resident abuse investigations (ASPEN Complaints/Incidents Tracking System (ACTS) #11610 and #11159) conducted by the State Agency (SA) had been thoroughly investigated. This deficient practice potentially compromised the safety of Residents (R)10, R7, R5, and R6, and affects all residents at the facility with abuse allegations.

Inspectors wroteBased on interviews and record review the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of services covered by Medicare for 1 of 3 residents (Resident (R) 11) sampled for discharge notification. This deficient practice did not allow R11 and responsible party the right to file an immediate, independent medical review (appeal) of the decision to end Medicare services and did not allow R11 and responsible party time to make decisions regarding future care.

Inspectors wroteBased on interview and record review, the facility failed to report to law enforcement, allegations of resident-to-resident abuse that included physical assault for 3 of 5 resident-to-resident abuse investigations (ASPEN Complaints/Incidents Tracking System (ACTS) #11519, 11204, and 11090) conducted by the State Agency (SA). This deficient practice potentially compromised the thoroughness of the facility's investigations into these events and placed Residents (R)10, R8, R7, R1, and R2's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services to 1 of 3 residents (Resident (R)10) in the sample. Specifically, the facility failed to ensure psychosocial follow-up for R10 following an allegation of physical abuse. As a result of this deficient practice, R10 was hindered in his ability to attain or maintain his highest practicable psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain a medical record for 1 of 3 residents (Resident (R) 11) sampled for accurate documentation in accordance with accepted professional standards and practices. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on interview, and record review, although informed of an allegation of neglect, the facility failed to document the verbalized complaint as a grievance for 1 of 3 residents sampled (Resident 1). As a result of this deficient practice, Resident (R)1's right to have her grievance investigated, resolved, and be informed about the resolution were violated, and she was placed at risk for psychosocial harm and unmet medical and/or physical needs. This deficient practice has the potential to affect all residents with the functional capacity to file a grievance.

Inspectors wroteBased on record review and interview, the facility failed to implement their policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property for 1 of 2 employees sampled.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide written transfer notification to the resident or the resident's representative for five out of five sampled residents (Resident (R)29, 49,128,182, and 266). This deficient practice has the potential to affect all the residents that are transferred to an acute care hospital.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for five out of five sampled residents (Resident (R) 29, 49,128,182, and 266). This deficient practice has the potential to affect all the residents that are transferred to an acute care hospital.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the nurse staffing data was posted daily at the beginning of each shift, in a prominent place readily accessible to residents and visitors, and ensure staffing information was complete with specific units reflected on the posting.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's care plan meetings were completed quarterly, and resident's care plans was revised and prepared by an Interdisciplinary (IDT) team, that includes but is not limited to the attending physician, registered nurse, nurse aide, and the resident's representative(s) for four residents (Resident (R) 58, R168, R253, and R38) sampled.

Inspectors wroteBased on observation, interview, and record review, 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 wroteBased on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed standard precautions by performing hand hygiene, implemented enhanced barrier precautions when appropriate, and sanitized shared medical equipment after each use. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on interviews and facility policy review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes maintenance or enhances his or her quality of life, recognizing the resident's individuality for four out of 37 sampled residents (Resident (R)50, R113, R29, and R126). Findings Include: Review of the facility's policy and procedure RESIDENT RIGHTS Respect and Dignity revised on 03/2023, document The resident has a right to be treated with respect and dignity. 1) Review of R50's most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/24, documented R50 had a score of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition is intact (a reliable source of information). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Resident Representative's (RR) 21 right to exercise the resident's rights to the extent provided by state law for one Resident (Resident (R) 5) sampled. RR21 is the Durable Power of Attorney (DPOA) for R5 and identified by the facility as the R5's healthcare decision-maker. R5 has a diagnosis of Alzheimer's Disease and does not have the capacity to make medication related decisions. Review of R5's Electronic Health Record (EHR) documented an informed consent for the use of an antidepressant medication signed by R5 and not RR21. Also, an Interdisciplinary (IDT) care plan meeting form documented RR21 attended the meeting on 04/23/24 and participated via phone and declined dental, vision, podiatry, and hearing services for R5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the shower preferences of 2 of 3 residents (Residents 171 and 199) sampled for accommodation of needs. As a result of this deficient practice, Resident (R)171 and R199 did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the individual financial record of 1 of 1 resident sampled for personal funds was made available to Resident (R)20 through quarterly statements. As a result of this deficient practice, R20 was not aware of her current balance and was not afforded the opportunity to periodically reconcile her account unless she made a request.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident's right to a clean and homelike environment. The facility's wallpaper/paint was peeling off the wall, ceilings had water damage, and toilets were not properly working. As a result of this deficient practice, there is the potential to affect the resident's overall mood and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents (Resident 92) sampled was free from physical restraints that were not required to treat her medical symptoms. As a result of this deficient practice, Resident (R)92's patient rights were violated, and she was placed at risk of avoidable injury and/or a decline in her psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, after receiving report of an injury of unknown origin from Resident (R)25's wife, the facility failed to report the allegation to the State Survey Agency (SA) and adult protective services (APS). In addition, the facility failed to report an allegation of abuse for one other Resident (R209), out of three residents sampled for abuse, to other officials, including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow the resident further review of the abuse by APS.

Inspectors wroteBased on interview and record review, after being informed by adult protective services (APS) of an allegation of abuse of 1 of 3 residents (Resident 569) sampled, the facility failed to document and provide evidence that the allegation had been thoroughly investigated.

Inspectors wroteBased on observation, interviews and record review, the facility failed to complete a comprehensive assessment for one resident sampled for being a smoker. As a result of this deficient practice, the facility failed to identify resident (R) 38 as a smoker and no plan of care was developed to address the health and safety risks associated with smoking. Findings Include: On 07/15/24 at 12:24 PM, observed R38 up in his wheelchair in the hallway at Unit 4, propelling himself to one of the doors that open to the parking lot. R38 stopped to talk to Registered Nurse (RN) 6 as she was preparing medications. R38 then proceeded to exit Unit 4 and went to the parking lot unsupervised. Asked RN6 where R38 was going, she said he was going to the parking lot to smoke. At 01:13 PM, observed R38 come back into Unit 4. R38 had a pack of cigarettes and a lighter in his shirt pocket. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for one of 37 residents sampled (Resident (R) 29). R29's was not care planned for diabetic foot nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to carry out daily living activities (ADLs) to maintain good grooming for one of two residents sampled (Resident (R) 29) dependent on ADL care. R29 did not receive proper foot nail care. This puts the resident at risk for cuts and wounds on her feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that fully identified and met the resident's needs, for 2 of 3 residents sampled for activity (Residents 171 and 198). As a result of this deficient practice, both residents were placed at risk of experiencing a decline in their psychosocial well-being and quality of life. 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 ensure the nursing treatment and care provided met the needs of 2 of 37 residents (Residents 188 and 171) in the sample and was in alignment with standards of good clinical practice. As a result of this deficient practice, the residents were placed at risk of avoidable injury and/or complications and were hindered from attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 199 and 20) sampled for limited range of motion (ROM) received the appropriate treatment and services to prevent, or delay, further decrease in their ROM, mobility, and independence. As a result of this deficient practice, Resident (R)199 can no longer be transferred into his motorized wheelchair, and R20 now has contractures to her left hand that were not present at admission. These outcomes hinder both their abilities to reach their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that one of the licensed nurses had the specific competencies and skill sets necessary to care for residents' needs. This failed practice has the potential to affect all the residents on one of the five nursing units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents.

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. Proper labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to date and label a food item to prevent the potential for foodborne illness. This deficient practice has the potential to affect all the residents on one of the five nursing units.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to safeguard medical record information against unauthorized use by not logging off of the Electronic Health Record (EHR) on a computer laptop left unattended in a nursing unit hallway. As a result of this deficiency, there was risk for violations of the Health Insurance Portability and Accountability Act (HIPAA) privacy or security rules.

Inspectors wroteBased on record review, staff interview and review of policy, the facility did not document the refusal of an influenza vaccine for one Resident (R)63 out of five residents sampled. As a result of this deficiency, there was a risk for miscommunication and misadministration of the influenza vaccine.

Inspectors wroteBased on interviews, observation and record review (RR), the facility failed to have an effective process to support each resident/representative's grievance. The facility did not have a process in place to capture all complaints/grievances, did not promptly address and thoroughly investigate two of five sampled Residents grievances (R3 and R4), and the three complainants (R1, R3 and R4) were not appropriately apprised of progress toward resolution.

Inspectors wroteBased on record review, and interviews the facility failed to develop and implement a comprehensive person-centered care plan for one resident (R)1 of a sample size of three. R1's primary language was Ilocano and spoke only a few English words. His care plan (CP) did not identify the need for an interpreter. As a result of this deficiency there was the potential R1 did not understand the staff and physician who cared for him. If communication barriers are not identified and included in the CP, there is the potential residents may not attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed for one resident (R)1 out of a sample size of three. As a result of this deficient practice, there was no concise summary of R1's stay and course of treatment at the facility available to continuing care providers.

Inspectors wroteBased on interviews and record review, the nursing staff failed to demonstrate competency when caring for one resident (R)1. The nursing staff did not: 1. Report a critical blood sugar (BS) to the physician (MD1), 2. Notify MD1 when R1's mental status changed, 3. Did not notify MD1 to obtain an order for pain medication, and 4. three progress notes did not accurately reflect R1's condition. As a result of these deficiencies, R1's physician (MD)1 did not have critical information to make treatment decisions, which resulted in harm. R1's pain was not treated in a timely manner and his transfer to acute care was delayed. These deficiencies have the potential to affect all residents if staff do not have identify and report critical values, trends and changes in condition, so interventions can be made to prevent further decline.