Nuuanu Hale

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to ensure a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to ensure the following: Keep Urinary catheter tubing off the floor and tubing with visible sediment was cleaned or changed as required for of two of two residents (Resident (R) 8 and R53) sampled for urinary catheter care. Use Personal Protective Equipment (PPE) while providing catheter care to Resident (R) 53 who is on Enhanced Barrier Precautions (EBP). To implement the water management plan for legionella prevention and control. To dispose of trash promptly, instead piled trash outside of the trash bin. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a written notification to the resident representative of resident's transfer for three out of three residents (Resident (R) 66, R1, and R6) sampled for hospitalizations and failed to send a notification of the discharge to the long term care ombudsman's office for one of one resident (R68) sampled for discharges. The facility also failed to have the Ombudsman address and appeals right information noted on their notification form. As a result of this deficient practice, residents who are discharged /transferred from the facility are affected. Findings Include: 1) On 02/25/2026 at 01:00 PM, record review of R66's Electronic Health Record (EHR) noted that R66 was sent to the emergency room (ER) for critically low platelets on 11/28/25. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure that food items stored in the walk-in freezer and refrigerators were labeled properly and old food discarded. This deficient practice places residents in the facility at risk of foodborne illness. On 02/24/26 at 08:20 AM, during the initial walkthrough of the kitchen with Dietary Lead (DL), observed frozen vegetables and meats without any labels in the walk-in freezer. The refrigerator also had vegetables and soup base items not labeled with receive and discard date. Observed a minced onion container in with a Best used by date of 01/26/26 still in the refrigerator. Concurrent interview with DL confirmed that in the freezer they have not been labeling the food items with received/discard date and for the refrigerator they only label food with the discard date. [...]

Inspectors wroteBased on observation, staff interviews and review of the dishwasher temperature logs, the facility failed to maintain the dishwasher temperature gauge was in safe operating condition. This deficient practice puts residents at risk for foodborne illnesses. Findings Include:On 02/24/25 at 08:30 AM, initial walkthrough of the kitchen with Dietary Lead (DL), observed dishwasher machine temperature daily log at 125 for the entire month of January until 02/24/26. Facility has a low temperature dishwasher where the recommended wash temperature should be at a minimum of 120 . Requested for Dietary Aide (DA) to complete a wash cycle. Observed throughout the wash and rinse cycle, the dishwasher temperature gauge did not move and stayed at 100 throughout the entire process. [...]

Inspectors wroteBased on interview and record review the facility failed to assure staff treated one of one resident, Anonymous Resident (AR)1, with respect and dignity when caring for them while providing care with Activities of Daily Living (ADLs). This deficient practice has the potential to affect all residents in the facility who require assistance with ADLs. Findings Include:On 02/24/26 at 02:20 PM a family interview was conducted with AR1's representative. Inquired if AR1 was treated with respect and dignity and AR1's representative stated sometimes the staff talk rough to AR1. AR1's representative stated they tell staff that they are talking rough to AR1 when they witness this. Inquired if they told the unit manager or Director of Nursing and the resident representative said they did not, they chose to say something directly to the staff who was talking rough with AR1 at the time it occurred. [...]

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 two of six residents (Resident (R) 64 and R4) reviewed for AHCD. This failure placed R64 and R4 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: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff reported an injury of unknown source that resulted in serious bodily injury no later than two hours after discovery to the facility Administrator for one of one resident (Resident (R) 70) reviewed for abuse. Specifically, staff were aware that R70 had a large bruise on left hip and thigh, first observed on [DATE], but the injury was not reported to the Administrator and State Agency until [DATE]. Findings Include:Cross reference to F726, Competent Nursing Staff. The facility failed to ensure licensed nursing staff demonstrated the appropriate competencies and skill set to provide a thorough and accurate skin assessment of R70 after observing a large bruise on the resident's left hip and thigh. R70 was admitted to the facility on [DATE] and deceased with hospice services on [DATE]. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to develop a care plan for bed rail use for one of six residents sampled for accidents, Resident (R) 38. The deficient practice puts all residents in the facility who have bed rails and do not have a care plan for bed rail use at risk for injury. Findings Include:On 02/25/26 at 09:05 AM observed R38 lying in her bed with bilateral upper quarter bed rails up on her bed. Inquired of R38 about the bed rails and she said she uses if she needs to hold onto it and the staff use it. Record review of R38's Electronic Health Record on 02/25/26 found R38's care plan did not include use of bilateral upper quarter bed rail use. Interview with Acting Director of Nursing (DON) on 02/27/26 at 10:42 AM was conducted in the conference room. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure one of three residents (Resident (R) 63) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts R63 at risk of a decline in ROM and further contractures. Findings Include:R63 is a [AGE] year-old male, admitted to the facility on [DATE] with a primary diagnosis of dysphagia following cerebral infarction. On 02/24/26 at 08:28 AM observed R63 with right (R) hand and R foot contracture. No splint applied to R hand/R foot. At 10:32 AM, no splint applied to R hand/R foot. AT 01:07 AM, no splint applied to R hand/R foot. On 02/25/26 at 07:33 AM, no splint applied to R hand/R foot. [...]

Inspectors wroteBased on record review and interview the facility failed to monitor one resident's fluid intake for one of one resident sampled for dialysis, Resident (R) 6. This deficient practice put R6 at risk for fluid overload and complications with his dialysis. Findings Include:On 02/25/26 record review of R6's Electronic Health Record revealed R6 was readmitted to the facility on [DATE] and receives dialysis three times a week on Tuesday, Thursday, and Saturday. R6 was ordered a Renal diet; puree texture consistency; Thin liquid (Fluid restriction 1200 mL/day). Review of meals and fluid intake found the Certified Nursing Assistants (CNAs) documented this at each meal for R6. Review of R6's Medication Administration Record (MAR) found there was no monitoring of R6's fluid intake with medication administration. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to assess the risk of entrapment from bed rails prior to installation for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. This deficient practice could place R56 and R38 at risk for harm from bed rail use. The deficient practice could affect all residents in the facility who are using bed rails if a risk assessment is not completed prior to use of their bed rails. Findings Include:Cross-reference to F909 Resident Bed. The facility failed to implement a regular maintenance program to identify areas of possible entrapment with bed rail use for residents observed using bed rails, Resident (R) 56 and R38. 1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nursing staff demonstrated the appropriate competencies and skill set to perform a timely, thorough, and accurate skin assessment for one of one resident (Resident (R) 70) reviewed for abuse. Specifically, staff were aware that R70 had a large bruise on left hip and thigh, first observed on 07/30/25, but an initial assessment was not conducted, and subsequent skin assessments did not document the presence, location, size, characteristics and/or progression of the bruise. This deficient practice places R70 at risk for unrecognized injury progression and delays in appropriate monitoring, intervention, investigation, and implementation of protective measures to safeguard the resident's health and safety. Findings Include: Cross Reference to F609, Reporting of Alleged Violation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were locked and under direct observation of authorized staff in an area where residents could access it for one of four medication carts observed. This practice does not ensure the protection and control of medications. Findings Include: On 02/26/26 at 10:12 AM, after exiting a resident's room, an unlocked medication cart was observed in the Ewa Unit hallway and left unattended. Facility staff were observed walking by the cart, and residents in wheelchairs were present in the hallway at the time. At 10:13 AM, Registered Nurse (RN)5 was observed walking from the Diamond Unit while carrying a pitcher of water. RN5 briefly spoke with another staff member while walking past the nurse's station to the Ewa Unit, not at direct observation of the medication cart. [...]

Inspectors wroteBased on observation and interview the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. The deficient practice puts all residents at risk for possible entrapment if they have bed rails and they are not inspected and maintained according to manufacturer's recommendations and requirements. Findings Include:1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed. 2) On 02/25/2026 at 9:05 AM R38 was observed lying in her bed with bilateral upper quarter bed rails which were up in use. Inquired of R38 about the bed rails and she said she uses it if she needs to hold onto it and the staff use it. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a safe discharge for one Resident (R)2 of a sample size of three. Specifically, prior to an inpatient hospitalization, R2 was moderately independent with some assistance, but his functional level changed. At discharge, he required maximum assistance for most activities of daily living. There was lack of evidence that R2's discharge home met his identified needs of 24/7 supervision. Caregiver availability, capacity and capability were not determined. As a result of this deficiency, R2 was at high risk of readmission and harm. This deficient practice has the potential to affect any resident discharged home.

Inspectors wroteBased on observation and staff interviews, the facility failed to have maintain a sanitary and clean shower room for two of the four shower rooms observed. This deficient practice could affect all residents at the facility if appropriate cleaning of the showers are not done.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation that written notice of transfer or discharge was provided to the resident and resident's representative(s), and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of five resident samples. This deficient practice has the potential to affect resident or resident's representative(s) right to appeal the discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident-centered Comprehensive Care Plan (CP) for 8 of 18 residents (R) sampled (R20, R21, R55, R37, R32, R24, R27, and R56). 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 well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) Cross-reference to F641 Accuracy of Assessments for R20. The facility failed to include R20's active diagnosis Contracture of muscle, left upper arm, in his Minimum Data Set (MDS) Quarterly Assessment. The facility failed to develop and implement a care plan to address R20's limited ROM needs of his left arm. 2) Cross-reference to F641 Accuracy of Assessments for R21. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the comprehensive person-centered care plan (CP) was reviewed and/or revised by the interdisciplinary team for four of 18 residents (Resident (R) 29, R55, R38, and R54) sampled for care plans. As a result of this deficit practice, R29's need for assistance with meals was not care planned for which was something new with the resident, R55's range of motion (ROM) was not addressed as recommended by physical therapy to prevent further contractures, R38's respiratory care was not person-centered and/or revised to appropriately reflect her status, and R54's pressure ulcer status was not updated to a Stage 4 with person-centered interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to ensure a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1) ensure a pill cutter, used for multiple residents, was cleaned between patient use, observed from one of three medication carts; 2) ensure staff perform hand hygiene after discarding dirty gloves before assisting resident (R) 123 with her meal, one unsampled resident; 3) ensure clean medical supplies to be used are kept on clean surfaces and follow standard precautions by performing hand hygiene between glove change for one of five residents (Resident (R) 54) sampled for wound care; [...]

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to identify and support the bathing schedule preference of 1 of 2 residents (R) sampled for Self-Determination. As a result of this deficient practice, R32 did not have his needs met and was hindered from attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide documentation that written notice of bed-hold policy was provided to the resident or resident's representative within 24 hours of emergency transfer for one of one resident (Resident (R) 69) reviewed for closed record. This deficient practice does not ensure the resident's right to have a place to return and does not provide continuity of care.

Inspectors wroteBased on observation, interview and record review errors on Minimum Data Set (MDS) Quarterly Assessments were found for two of 18 residents sampled, Resident (R)20 and R21. Error for R20 was made under section I. Active Diagnoses and error for R21 was made under section M. Skin Conditions. Findings Include: 1) Cross Reference to F656 (Comprehensive Care Plan). On 02/03/25 at 10:50 AM R20 was observed lying in his bed and surveyor noticed he had a contracture to his left hand. Asked R20 if he can open or close his hand and he reported it is not so well, resident was not able to do this. During record review of R20's Electronic Health Record (EHR) found he has an active diagnosis of Contracture of muscle, left upper arm dated 02/15/24. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the proper care and treatment, including assistive devices/tools, to improve and promote the communication abilities of 3 of 3 residents (R) sampled for Language/Communication. 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, or an interpreter for Residents (R)37, R24 and R55. As a result of this deficient practice, the residents are at an increased risk of not having their needs met and experiencing a decline in their physical well-being, psychosocial well-being, and quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that addressed the needs of 1 of 2 residents sampled for Activities. Despite identifying that he had a visual deficit, the facility failed to implement activities Resident (R)37 could perform. As a result of this deficient practice, R37 was placed at risk of a decline in his psychosocial 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 implement a hydration program that recognizes, evaluates, and addresses the hydration needs of 1 of 2 residents (Resident 37) sampled for hydration. Individuals who do not receive adequate fluids are more susceptible to urinary tract infections, pneumonia, pressure injuries, skin infections, confusion, and disorientation. In addition, despite identifying and documenting an ongoing pruritic (itchy) skin condition for 1 of 5 residents (Resident 32) sampled for non-pressure related skin conditions, the facility failed to adequately address and provide relief for his itching, impacting his comfort and psychosocial well-being. These deficient practices have the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment, consistent with professional standards of practice, to promote healing of a stage 4 pressure injury for one of five residents (Resident (R) 54) sampled for pressure injuries. R54 did not get the support she needed to turn and reposition every two hours causing discomfort. This deficient practice put R54 at risk for failed progress toward healing.

Inspectors wrote2) On 02/03/25 at 10:50 AM observed R20 in his room in bed. Observed resident with contracture to his left hand and inquired if he could open and close his hand and R20 reported it is not so well. Asked resident if staff put a splint on his hand or a rolled up wash cloth and he denied this. At this time neither were observed in/on R20's left hand. Record review of R20's Electronic Health Record found he has a diagnosis that include and is not limited to quadriplegia, unspecified (Primary, Admission), central cord syndrome at unspecified level of cervical spinal cord, subsequent encounter and contracture of muscle, left upper arm. Review of R20's CP found Resident's name is quadriplegic and has left arm and hand contractures related to this. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's oxygen (O2) tubing was connected to the O2 concentrator consistent with professional standards of practice for one of one resident sampled (Resident (R) 38) for respiratory care. As a result, R38 was not receiving continuous O2 as physician ordered. This failure placed R38 at risk for respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to manage and monitor the medication regimen for one of five residents sampled for unnecessary medications, by not implementing a physician ordered gradual dose reduction (GDR) for an antidepressant. This deficient practice does not protect residents from the possible side effects of overmedication and has the potential to affect other residents prescribed with psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications administered were stored, labeled, and administered according to professional standards. Proper labeling and administration practices of medications are necessary to decrease the risk of medication errors. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident's (Resident (R)2) environment was free from accident hazards related to elopement from the facility. R2 was able to exit the facility without authorization and was found at a driveway across the street. This deficient practice has the potential to affect ambulatory residents in the facility and result in injury related to falls or car striking resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (R)8 sampled. The facility implemented interventions to allow the resident to self-transfer from the bed to the floor mattress, but did not evaluate, analyze, identify, or address any environmental hazards which existed once R8 self-transferred to the floor mattress prior to implementing this intervention. Also, after implementing the did not monitor the effectiveness or safety for the floor mattress. As a result of this deficient practice, R8 sustained multiple skin tears, bruising, and wounds on both lower legs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident's right to a dignified existence for one of three residents (R)8 sampled. R8 is dependent on staff for toileting needs. R8 removed a soiled incontinent brief which staff removed from the room and did not apply another incontinent brief for the resident. R8 was found on the ground, naked, tangled in cords, calling out for help, in full view of the resident's roommate. As a result of this deficient practice, all residents dependent on care from staff are at risk of potential for physical and psychosocial harm.

Inspectors wroteBased on observation and interview the facility failed to post the results of the most recent survey of the facility.

Inspectors wroteBased on staff interview and record review (RR) the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis, ensure that the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Findings Include: On 01/26/24 at 08:44 AM met with DON to interview her about Sufficient and Competent Nurse Staffing. DON explained facility uses ABC, Prime Time, Express and a 4th agency to help supplement their staff. DON also stated they use a local agency. Facility staff sign up for overtime to cover the open shifts. DON stated when she first started working at the facility (date of hire 06/01/2023) she was helping to cover shifts to provide care to the residents as a floor nurse. RR found the DON was working 07:00 AM to 03:00 PM and 03:00 PM to 11:00 PM shifts. [...]

Inspectors wroteBased on record review and interviews, facility failed to implement and document a water management program minimizing the risk of Legionella and other opportunistic pathogens in their water system using nationally accepted standards. They failed to provide a facility assessment identifying where Legionella and other opportunistic water pathogens could grow and spread, and what measures they have in place to prevent the growth of opportunistic waterborne pathogens and how they would monitor them. This deficient practice could affect the residents, staff and visitors to the facility if exposed to Legionella and other opportunistic waterborne pathogens. Findings Include: On 01/26/24, reviewed facility policies titled Infection Prevention and Control Program and Legionella Surveillance which were both reviewed and revised on 08/05/23. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the attending physician reviewed and responded to the recommendations of the pharmacist on the monthly Medication Regimen Reviews (MRR) for four of the five residents (Resident (R) 5, R9, R29 and R30) sampled for medication review. As a result of this deficient practice, there was a potential to cause adverse consequences to residents where the consultant pharmacist had recommended actions to be taken for medication management. This deficient practice has the potential to affect all the residents in the facility taking psychotropic medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure all medications and blood glucose testing supplies were labeled in accordance with professional standards and stored in a locked compartment. Proper labeling and storage of medications are necessary to promote safe administration practices and decrease the risk for medication errors. Proper labeling of blood glucose testing supplies is necessary to ensure the efficacy of the supplies used to test the blood glucose meter for accuracy. This deficient practice has the potential to affect all residents in the facility.

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

Inspectors wroteBased on interview, observation and record review (RR) the facility failed to provide care in a timely manner for a resident (R)52 who is dependant upon staff with activities of daily living (ADLs) who required assistance with changing his adult brief after he was incontinent of urine. The facility failed to treat the resident with respect and dignity and care for him in a manner and in an environment that promotes maintenance or enhancement of his quality of life. This deficient practice can affect all residents in the facility who are incontinent of bowel or bladder and are dependant upon staff and require staff assistance. Findings Include: On 01/23/25 while making observations on the second floor, met with and interviewed R52 who complained of having to wait for staff to assist him after he presses his call light. He reported it can take up to an hour for staff to respond to him. [...]

Inspectors wroteBased on resident (R) 11's interview, observation and staff interview the facility failed to have maintenance maintain a sanitary, orderly, and comfortable room for the resident. This deficient practice could affect all residents at the facility if staff do not notify the maintenance department once the problem is found and maintenance does not address deteriorating walls in a timely manner. Findings Include: On 01/22/24 during observations of the second floor, met with and inquired with R11 if she had any concerns about the facility and she said yes and pointed at the wall in her room. The wall behind the surveyor was deteriorating, appeared damaged with some areas missing paint and there were some areas that been patched up. 01/23/24 at 10:19 AM, met with Mainteancne Manager and requested and reviewed work order to repair wall in R11's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident (R) 32 was free from abuse from another resident.

Inspectors wroteBased on review of the facility's policy and procedures and staff interview, the facility failed to immediately report allegation of abuse to the Adult Protective Services (APS) in accordance with State Law for two of three facility reported incidents related to allegations of abuse or injury of an unknown origin.

Inspectors wroteBased on review of the facility's policy and procedures and staff interview, the facility failed to thoroughly investigate two of three facility reported incidents related to allegations of abuse or injury of an unknown origin.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered comprehensive care plan for two of the 18 residents (Resident (R)46 and R67) sampled. A comprehensive care plan was not developed to address R46's contractures and oxygen therapy was not included in R67's care plan. As a result of this deficient practice, the residents were placed at risk for not reaching their highest practicable physical, mental, and psychosocial well-being and has the potential to affect all residents.

Inspectors wroteBased on observations, interviews and record reviews (RR) the facility failed to provide appropriate treatment and services to two of the 18 residents (Resident (R) 32 and R46) in the sample with limited range of motion. The facility did not apply prescribed splint for R32's right hand and did not provide services for R46's contractures to right arm and right leg. As a result of this deficient practice, the two residents were put at risk for further decrease in range of motion. This deficient practice has the potential to affect all residents in the facility with contractures and limited range of motion. Findings Include: 1) On 01/23/24 at 10:09 AM observed R32 was wearing a splint on her right hand. Inquired if she wears this every day and she stated sometimes I wear it for 3 hours, the staff always forget to put it on. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement interventions to ensure one resident (Resident (R) 222) was free from accident hazards related to possible elopement from the facility. As a result of this deficient practice, R222 was able to exit the facility without authorization and was found outside of the building. This deficient practice has the potential to affect residents that are able to ambulate independently.

Inspectors wroteBased on observations, interviews and record review (RR) the facility failed to provide fluids routinely and when requested by Resident (R) 32 to maintain proper hydration and health. This deficient practice could affect all residents who rely on staff to provide fluids to them throughout the day to maintain proper hydration and health. Findings Include: On 01/23/24 at 09:56 AM while interviewing R32, observed her pitcher, that was left on her bedside table, was empty. Inquired if staff fill this up for her and she stated her pitcher is always empty unless I ask them to fill it up. R32 stated sometimes the staff tell her they will fill it up later because there's no ice cubes and then they forget to fill it up. On the morning of 01/24/24, after observing R32's pitcher empty for a second day, on her bedside table, met with and interviewed Unit Manager (UM). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide treatment and services to prevent complications of enteral feeding for two residents (Resident (R) 7 and R39) in the sample. The facility did not ensure the formula bags were properly labeled to indicate they are changed every 24 hours. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R) 67, receiving oxygen services, had a physician's order to receive oxygen therapy.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident (R) 30, who require dialysis services, had a physician's order to receive dialysis services.

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate monitoring for the use of insulin (medication to lower blood sugar level) for one of the five residents (Resident (R) 47) sampled for unnecessary medications. The facility was not documenting if R47 was being monitored for signs and symptoms of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). As a result of this deficient practice, R47 was put at risk for avoidable adverse health complications related to her condition and the use of insulin. This has the potential to affect all diabetic residents in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure three of the five residents (Resident (R) 5, R9 and R29) sampled for medication review were free from unnecessary medications. The PRN (as needed) order for a psychotropic medication (drugs affecting behavior, mood, thoughts or perception) for R9 and R29 was not limited to 14 days and there was no documented rationale for continuance. Also, the facility failed to ensure Gradual Dose Reductions (GDR) for the psychotropic medications for R5, R9 and R29 were done as recommended by the pharmacist. As a result of this deficient practice, the facility failed to promote or maintain the highest practicable mental, physical and psychosocial well-being of these three residents. This has the potential to affect all residents in the facility that are prescribed psychotropic medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the medical records were accurately documented for one of the three residents (Resident (R) 222) sampled for closed records review. Statements from staff interviews did not match what was documented in the Electronic Health Record (EHR). This deficient practice has the potential to affect the care provided to all the residents in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain resident (R)34's bed cord control, that raises and lowers the bed, in safe operating condition. The bed cord was frayed in multiple places putting the resident and staff at risk for electrocution. Findings Include: Upon entry to facility on 01/22/24, went to second floor to observe residents. Residents had already eaten their breakfast and some were still in their beds. During this time observed R34 in her bed with a bed cord which is used to raise and lower her bed that had multiple areas that were frayed exposing the colored cords underneath the protective covering. On 01/23/024 at 08:10 AM, went to R34's room to observe if her bed cord was fixed. The same frayed bed cord remained on her bed and was attached near the resident on her bedrail giving her access to the control. [...]