Kuakini Geriatric Care, Inc

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident (R) 9 received treatment and care in accordance with professional standards. This was evidenced by the failure to timely assess, treat, and notify the Medical Doctor (MD) 2 regarding R9's complaint of pain during repositioning in bed reported by facility staff on 04/27/26 night shift (11:00 PM - 07:30 AM) and 04/28/26 day shift (07:00 AM - 03:30 PM). This deficient practice had the potential of contributing to worsening injury to R9 as the resident was admitted to the hospital several days later for left hip fracture identified as injury of unknown source.

Inspectors wroteBased on interview and record review the facility failed to provide documentation that written notice of transfer or discharge was provided to the resident or resident's representative (RRP), a copy of the notice was sent to the Office of the State Long-Term Care Ombudsman, and documentation that written notice of bed-hold was provided to the resident or RRP for 5 of 6 residents (Resident (R) 2, R3, R4, R9, and R10) sampled for discharge process. This deficient practice has the potential to affect all residents needing to be transferred from the facility to the emergency room/hospital.

Inspectors wroteBased on interviews and record reviews, the facility failed to document pertinent findings and interventions for 1 of 3 residents (Resident (R) 5) sampled for transfers to the emergency department (ED) due to abdominal pain. This deficient practice puts residents at risk for their needs not properly being identified and addressed. Findings Include:On 03/20/26 at 09:22 AM, the Department of Health, Office of Health Care Assurance (OHCA) received a complaint (intake #296005) from a family member (FM) 2 on behalf of R5. FM2 noted that R5 is a [AGE] year-old male who suffered a brain bleed and was admitted to the hospital on [DATE]. R5 was then transferred to the facility on [DATE] for rehabilitation. On 01/31/26, FM2 noted that R5 was complaining of severe stomachache, but the nurses thought it was just a bowel movement problem and just gave him medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to do a thorough investigation post-fall for 2 of 5 Residents (Resident (R) 4, R10) sampled. This deficient practice placed the residents at risk for further falls and injury.

Inspectors wroteBased on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for the water temperature to raise to 180 degrees Fahrenheit (F) or more during the final rinse cycle before processing the dishes from the conveyor belt, placing them on the storage racks of clean dishes, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents and staff, who eat their meals at the facility, at risk for foodborne illness. The State Agency (SA) identified an Immediate Jeopardy (IJ) at §483.60 (F812) on 01/05/25 at 08:44 AM. Findings Include: On 01/05/25 at 08:43 AM an initial tour was conducted with Food Services Supervisor (FSS)1. During initial tour of the kitchen found the kitchen uses a dishwasher with high temperatures to sanitize their dishware and silverware. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's right to inform the resident's representative in advance, of the risk and benefits of proposed treatment one of five residents (Resident (R)72) sampled for unnecessary medication(s). As a result of this deficient practice, residents receiving psychotropic medications are at risk for more than minimal harm.

Inspectors wroteBased on observations, record review and interviews the facility failed to develop and implement a care plan (CP) for two of 23 residents sampled. Resident (R) 89 for the use of oxygen and R38 for a urinary tract infection with extended spectrum beta lactamase (ESBL), a bacteria that is resistant to many antibiotics. Findings Include: 1) On 01/05/25 at 11:56 AM interviewed R89 in her room. R89 was observed sitting up in her wheelchair and had a nasal cannula on that was attached to the wall oxygen. Confirmed with R89 that her oxygen (02) was at 2 liters (L) which she reported is on at all times. Resident stated she was diagnosed with chronic obstructive pulmonary disease (COPD) 20 years ago and only the last 2 years she has had symptoms of shortness of breath and needing to use oxygen. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement interventions to treat one of one Resident (R)79 in the sample for constipation. The deficient practice may affect the resident's quality of life due to increased pain and discomfort.

Inspectors wroteBased on observations and interviews, the facility failed to provide appropriate care and services to prevent complications of enteral feeding (a way of delivering nutrition directly into the stomach or small intestine) for three of the 23 sampled residents (Resident (R)74, R50 and R59). The facility did not ensure the equipment used were properly cleaned and maintained. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications.

Inspectors wroteBased on observations, record review and interviews the facility failed to properly label oxygen tubing when it was initiated for three of four Residents (R) 89, R19 and R216 sampled for respiratory care. The deficient practice placed the residents at risk of facility acquired respiratory infections. Findings Include: Cross Reference to F656 Develop/Implement Comprehensive Care Plan 1) On 01/05/25 at 11:56 AM an interview was conducted with R89 in her room. R89 was observed sitting in her wheelchair with a nasal cannula which was hooked up to the oxygen (O2) in the wall. Inquired of R89 if the oxygen was on and she confirmed it was on and at 2 Liters per minute (LPM) at all times for her shortness of breath due to her diagnosis of chronic obstructive pulmonary disease (COPD). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control measures for three out of twenty-three resident sampled. a. Resident (R)23 and (R)38 who were on isolation precautions did not have signage outside of their rooms at the door. b. The facility failed to assure staff to use proper personal protective equipment (PPE) when delivering a meal to a Resident (R)72 who was on droplet precautions. This deficient practice placed everyone at risk for developing preventable infections and other adverse health complications.

Inspectors wroteBased on interview and record review the facility failed to consult with the physician for three residents reviewed when Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents at the facility and impede care the physician would order. Findings Include: Cross reference F600 - Free From Abuse and Neglect 1) On 07/17/24 at 11:54 AM interviewed ADON who confirmed he was present at R12's bedside with DON when they interviewed her. ADON reported resident stated CNA was rough handling her during her shower. ADON was not sure if it occurred more than once, not sure of the details. ADON reported R12 was afraid but not physically hurt, looked a little upset and concerned. ADON stated R12 was worried that CNA in question would retaliate against her. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. Three residents reviewed, Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents in the facility, placing the residents at risk of harm, if the facility fails to protect resident's right to be free from abuse by staff. Findings Include: Cross Reference F580 - Notify of Changes (injury/decline/room, Etc.) 1) On 07/17/24 at 10:47 AM interviewed Registered Nurse (RN) 1. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to report allegations of abuse to the state agency within two hours of being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). During the review of two Residents (R) 26 and 33 allegations of abuse were reported to a NS, or ADON and DON. Initial reports submitted by the facility were sent to the state agency two days after the incidents were reported to the CN, NS, or ADON and DON. This deficient practice could affect all residents in the facility who have a reported or witnessed incident of abuse and the facility fails to notify the state agency within two hours. Findings Include: Cross Reference F600 Free From Abuse and Neglect 1) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient nursing staff on 02/07/24 and 07/05/24 during their second shift (03:00 PM - 11:30 PM) on the skilled nursing unit. The deficient practice puts the residents at risk for harm such as abuse by staff and staff working outside of their scope of practice. Findings Include: Cross Reference F600 - Free From Abuse and Neglect and F726 Competent Nursing Staff On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. [...]

Inspectors wroteBased on interviews and record review the facility failed to assure a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice. This deficient practice could affect all residents and put them at risk for harm if licensed staff delegate tasks to unlicensed staff such as medication administration, which is outside their scope of practice. Findings Include: On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. [...]

Inspectors wroteBased on interview and record review the facility failed to assure staff accurately documented medication offered to and refused by resident (R)40. This deficient practice could affect all residents who receive medication in the facility if their medication administration is not documented accurately. Findings Include: On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Shift Coordinator for help and RN3 denied this. [...]

Inspectors wroteBased on interviews, record review (RR) and observation, the nursing staff failed to demonstrate the competence and skill sets to provide safe nursing care in a manner to meet one resident's (R)2 physical needs. Specifically, the Certified Nurse Assistants (CNA) had been administering oxygen (O2), which is outside their scope of practice. In addition, the nursing staff administered oxygen to R2, who had Chronic Obstructive Pulmonary Disease (COPD) when her oxygen saturation level (sat) was outside the parameters ordered by the physician. Due to this deficient nursing practice, there was high likelihood that a Resident with COPD and oxygen administration parameters would be administered oxygen by licensed or unlicensed staff outside the order parameters and suffer harm. [...]

Inspectors wroteBased on interviews and document review, the facility failed to ensure the grievance policy included all the required elements. In addition, the facility was unable to provide documentation that Residents were informed they have the right to file a grievance anonymously and the right to obtain a written decision regarding the grievance. There was lack of documentation of the pertinent findings or conclusions regarding the care concerns of two Residents (R), R1 and R2. As a result of these deficiencies, there was the potential residents do not know how to file an anonymous complaint and grievance findings may not be adequately communicated to the complainant, resulting in dissatisfaction.

Inspectors wroteBased on interviews and record review (RR), the facility failed to revise Care Plans (CP) of two Residents (R)1 and R2, of a sample size of three in a timely manner. The facility did not 1) update R1's CP to include use of the abduction pillow or the skin condition on right forearm, and 2) did not update R2's CP in a timely manner to include parameters for oxygen administration when ordered. As a result of this deficiency, there was the potential the residents may not meet their highest potential of physical and mental well-being. This deficiency had been corrected prior to the survey, and met the criteria for past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to provide proper notification of transfer/discharge for five of 11 residents sampled for Hospitalization (Residents (R) 9, R37, R71, R89, and R74). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives and/or failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred.

Inspectors wroteBased on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to 10 of 11 residents sampled for Hospitalization (Residents (R) 9, R69, R37, R71, R89, R74, R66, R86, R58, and R55). This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital.

Inspectors wroteBased on facility policy review and staff interview the facility failed to review it's infection and control program (IPCP) annually which included annually reviewing their facility policies including Infection Control and Prevention and Antibiotic Stewardship, Influenza Quarantine Protocol DON/Medical Director Guide, Influenza Prevention and Control Program, and Pneumococcal Vaccine Administration. [...]

Inspectors wroteBased on record review (RR) and staff interview the facility failed to inform Resident (R) 55 or their public guardian in advance, by the physician or other practitioner or professional, of the risks and benefits of taking an antipsychotic and antidepressant medication, of treatment alternatives or treatment options and to choose the alternative or option she prefers. Findings Include: On 01/11/24 at 05:47 PM, RR of R55's Electronic Health Record (EHR) found her diagnoses include, but are not limited to, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance; depression, unspecified psychosis not due to a substance or known physiological condition. R55 has doctors orders for the following medications: Seroquel oral tablet 50 milligrams (mg) (Quetiapine Fumarate) (antipsychotic) give 1 tablet by mouth two times a day for behavioral disturbances. [...]

Inspectors wroteBased on record review (RR) and staff interview the facility failed to update Resident (R) 58's comprehensive care plan to include antidepressant as an intervention for the medication he is receiving to treat his depression, correctly identify R58 is taking a blood thinner (Eliquis) to treat his pulmonary emboli (blood clot in the lung) and discontinue Mirtazapine as an intervention on his care plan for his poor intake when it was discontinued on 10/30/2023. Findings Include: During RR on 01/11/24 at 04:44 PM found R58 had doctor's orders for the following medications: Duloxetine HCL DR (antidepressant) 60 milligrams (mg) give one capsule by mouth one time a day related to depression, unspecified, Eliquis (blood thinner) 5 mg tablet give one tablet by mouth two times a day for PE (pulmonary emboli which is a blood clot in the lung). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one of the residents (Resident (R) 13) in the sample. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to ensure nurse competency in medication administration and assessing for risk of falls. This deficient practice places the residents at increased risk for medication errors and avoidable falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled, administered, and stored in accordance with professional standards. Proper labeling, safe administration practices, and timely reconciliation of stored medications is necessary to decrease the risk for medication errors. The facility failed to dispose medications after the expiration stated by the manufacturer, an insulin pen stored in the medication cart was not labeled to include the resident's name, medication dosage and route of administration and properly store a resident's medication after declining to take the medication during administration time. This deficient practice has the potential to affect all residents in the facility who receive medications.

Inspectors wroteBased on observation and interview the facility failed to store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility.

Inspectors wroteBased on interviews and record reviews, 1) the facility failed to ensure the attending physician reviewed and responded to the identified irregularities on the pharmacist Medication Regimen Review (MRR) for one of five residents R91) sampled for medication review. The pharmacist identified an irregularity for a resident prescribed a psychotropic medication without a diagnosis and recommended a gradual dose reduction (GDR). This placed the resident at risk for harm including negative side effects of the psychotropic medication, experiencing a fall, mental status changes, or sustained negative psychosocial outcomes. The medical record did not show evidence that the attending physician had reviewed and responded to the pharmacist MRR recommendation. [...]

Inspectors wroteBased on interviews the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis. Findings Include: During the entrance conference on 01/09/23 at 08:12 AM, Patient Care Coordinator (PCC)1 stated the facility currently does not have a DON effective 01/01/23 but the previous DON, Consultant Director of Nursing (CDON), was hired as a consultant. On 01/11/23 at 3:26 PM interview with CDON was done. CDON stated she was supposed to work two days per week, a total of 16 hours a week, as a consultant DON.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store food that was identifiable and/or had an expiration date and failed to provide a clean area to prepare food. This deficient practice has the potential to infect residents, visitors, and staff, who have meals served to them by the facility's kitchen, with a food-borne illness.

Inspectors wroteBased upon record review and interview with staff member, the facility failed to assure the facility assessment accurately reflected the resident and staffing ratios needed in the facility to ensure that the staffing resources met the needs of the resident population. The deficient practice affects all residents in the facility to maintain and attain the highest practicable physical, mental, and/or psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure protective and preventive measures for COVID-19 and other communicable infections. Facility staff did not follow protocols for standard and transmission-based precautions (TBP); did not wear the proper personal protective equipment (PPE); did not thoroughly clean and sanitize shower equipment after use; did not ensure an indwelling catheter tubing was correctly stored, and did not clean hands between glove use. These deficient practices have the potential to affect all residents, healthcare personnel, and visitors at the facility.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly conduct COVID-19 testing following the identification of a direct-care staff member and a resident diagnosed with COVID-19 in the facility. As a result of this deficient practice, the facility placed the residents at an increased risk of COVID-19 transmission. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on observation, and interview, the facility failed to provide the services necessary to maintain a clean, sanitary, and homelike environment for multiple residents (R) in the sample, as evidenced by a dirty room for R16, multiple rooms on the third floor with part or all of the room numbers missing, and dirty shower equipment in use on the fifth and third floor. As a result of this deficient practice, the residents were placed at risk for a decreased quality of life. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for three of 27 residents (Residents (R) 86, R55, R83) in the sample. Specifically, a resident identified with significant weight loss for two consecutive months had no care plan to address it. A resident with liver cancer who was admitted to Hospice for end-of-life care had no care plan to manage her pain. Activity care plans were not developed to include person-centered interventions that would engage the resident in meaningful activities. 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the staff was competent in performing quality control (QC) testing for the blood glucose meter. The QC solutions that were used for QC testing expired (as indicated by the manufacturer's expiration date) before the date the vials were opened. QC testing of the glucose meter verifies that precision of residents' glucose test results. As a result of this deficient practice, the facility placed all residents that need glucose testing at risk for potential harm as their medical care is dependent on precise glucose test results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient practice has the potential to affect all residents currently residing in the facility.

Inspectors wroteBased on record review and interview with staff members, the administration failed to provide support effectively and efficiently to the facility and staff members to ensure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure all areas of the facility's Plan of Correction (POC) were corrected and/or worked toward compliance by the corrective action date the facility chose, 02/28/23.

Inspectors wroteBased on observations and interviews, the facility failed to provide a functioning call system for one Resident (R)260, in a sample of 32 residents. The facility failed to ensure that the visual alerts outside of R260's room and at the nursing station lit when she initiated her call device. This deficient practice has the potential to affect all residents who can utilize their call devices for help due to the lack of processes to identify a broken call system, other than the direct patient care employees, and a lack of follow up on repairs done by their Biomedical department

Inspectors wroteBased on record review and interview with staff member, the facility failed to assure one of two residents (R)44 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes.

Inspectors wroteBased on record review and interviews the facility failed to follow the facility's grievance policy to ensure prompt resolution of all grievances for two sampled residents (R)58 and R85.

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive assessment of functional capacity within fourteen (14) days of admission, for two of 27 residents (R)103 and R83 in the sample. As a result of this deficient practice, the facility failed to identify R103's cognitive status which is important in defining care and staff did not have the information necessary to adequately care for R83 so that she could meet her highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all newly admitted residents to the facility.

Inspectors wroteBased on record review and interview with staff members, the facility did not assure resident assessments were electronically transmitted within 14 days after completion. There was no record of successful transmittals to reflect the discharge for 3 (Residents 96, 88, and 64) of 3 residents identified.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately complete a comprehensive assessment of functional capacity for two residents (R) in the sample. As a result of this deficient practice, resident-specific care areas were not triggered for further evaluation and staff did not have the information necessary to adequately care for the residents (R55 and R83) so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to identify residents' medical needs and failed to provide caregivers important interventions on the initial care plan to give personalized and effective care to treat these medical needs for two residents (R), R259 and R260, in a sample of two. This deficient practice has the potential for ineffective and unindividualized care to be given to all newly admitted residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the comprehensive person-centered care plan was reviewed and/or revised by the interdisciplinary team after each assessment and as needed for two of 27 residents (Resident (R)91 and R85) sampled.

Inspectors wroteBased on observation, and interview, the facility failed to provide the necessary care and services to maintain the activities of daily living, including grooming and personal hygiene for one resident (Resident 45) in the sample. As a result of this deficient practice, Resident (R)45 was hindered from attaining his highest practicable well-being and was placed at risk for a decreased quality of life. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, record reviews and interviews, the facility did not ensure bowel regimen was provided in accordance with the physician's order for Resident (R)40 and the facility failed to appropriately provide the needed medical care for R259, who has kidney failure. R259 has kidney failure and was not yet receiving hemodialysis (a life-saving treatment involving a machine to clean the individual's blood of toxins). This deficient practice has the potential to affect all residents and residents who have kidney failure but are not yet receiving their life-saving treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide treatment to prevent or improve pressure ulcers/injury for one Resident (R)259, in a sample of six residents. R259 was at risk to develop pressure ulcers, and due to the lack of timely repositioning, she developing a worsened skin wound. This deficient practice has the potential to affect the health of residents in the facility who are dependent on the staff for positioning.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (Resident (R)91) sampled.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure a resident (Resident (R) 85) with an indwelling catheter was removed as soon as possible after a successful void trial. The facility failed to ensure R85 received appropriate interventions to restore as much urinary function as possible without use of a catheter and education on implications and risks associated with the use of a catheter without an indication for continued use. As a result, all residents are at risk of unnecessary use of indwelling catheters.

Inspectors wroteBased on observation, record review and interview with staff members, the facility failed to assure two Residents (R)72 and R83 of two residents sampled, maintained acceptable parameters of nutritional status as evidenced by significant weight loss. As a result of these deficient practices, the facility placed this resident at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observation, record review and interview with staff member, the facility did not ensure enteral formula for two Residents (R)5 and R81, of two residents sampled, receiving enteral nutrition (also known as tube feeding, a way of delivering nutrition directly to the stomach or small intestine) did not exceed the expiration date.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and manage pain adequately for one resident Resident (R)55, in the sample. Specifically, the facility failed to recognize and act upon indicators of unmanaged pain, failed to evaluate, or assess what (R)55's pain management goals were, and failed to develop a resident-centered care plan for pain management. As a result of this deficient practice, R55 was prevented from attaining or maintaining her highest practicable level of well-being.

Inspectors wroteBased on interviews with residents, a family member, and a staff member the facility did not ensure enough nursing staff is provided to respond to each resident's basic needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, receives gradual dose reductions (GDR) unless clinically contraindicated and documented in the clinical record for one of five (Resident (R)91) residents sampled.

Inspectors wroteBased on interview and record review (RR), the facility failed to ensure documentation that all residents who were eligible for the pneumococcal vaccine were offered or received it. Coupled with advanced age and chronic conditions, this deficient practice made one out of the five residents sampled potentially vulnerable to the bacteria that causes pneumonia. This deficient practice has the potential to affect all residents at the facility.