Pu'uwai 'o Makaha

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure call system equipment was within reach for one of one resident (Resident (R)2) sampled. The deficient practice placed R2 at risk of not having emergent needs met in a timely manner and has the potential to affect all residents that rely on staff for assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the activities of daily living (ADLs), specifically personal and oral hygiene, for 1 of 1 resident sampled for ADLs. As a result of this deficient practice, Resident (R)41 was hindered from attaining his highest practicable well-being and placed at risk for a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 6 residents (Resident (R)52) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in his mobility. As a result of this deficient practice, R52 was placed at risk of worsening contractures and hindered from reaching his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and manage pain adequately for 1 of 2 residents (Resident (R)8) sampled for pain. Specifically, the facility failed to ensure that R8's narcotic pain medication remained available and in stock for her as needed use and failed to offer her any non-pharmacological interventions in its absence. As a result of this deficient practice, R8 was prevented from attaining or maintaining her highest practicable level of well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medications in two of two medication carts were stored and locked in accordance with professional standards. Proper storage of medications and locking of the medication cabinet is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one refrigerator was kept in a clean and sanitary condition in accordance with professional standards for food safety and resident food items were expired and not discarded. Both storing food items in an unsanitary refrigerator and not discarding expired food items has the potential to result in development of foodborne pathogens which may cause discomfort to the residents upon consumption and development of foodborne illnesses for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate protective and preventative measures were performed to prevent infections and communicable diseases as evidenced by two staff members not removing gloves and not performing hand hygiene after completing incontinence care and before touching clean items for Resident (R) 1. This deficient practice has the potential to affect other residents who require assistance with care of bowel and bladder incontinence.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the residents a safe and clean environment. The sink in one of the shower rooms had water leaking into a plastic bucket and spilling onto the floor. This deficient practice could affect all residents and staff in the facility if the environment is not kept in good repair, putting them at risk for falls and injury.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a comfortable temperature of hot water to residents that received showers in two shower rooms in Unit Two. In addition, there was no hot water available in the bathroom sink between room [ROOM NUMBER] and 29.

Inspectors wroteBased on observations, temperature log review and interview, the facility failed to: 1. Store clean dishes, pots, and pans on a rack free of rust colored debris: 2. Failed to document temperatures of all refrigerators and freezer on their logs for one day (07/14/24) and: 3. Failed to take off and dispose of dirty gloves before going from one kitchen to another. The deficient practice could affect all residents and visitors who eat meals provided by the kitchen. Findings Include: On 07/22/24 at 8:30 AM during initial tour observed clean dishes and clean pots and pans stored on a dirty rack which had rust colored debris. Inquired with Kitchen Manager who acknowledged rust colored debris on the rack. During this initial tour of the kitchen requested to review the temperature logs for the refrigerators and freezers and Kitchen Manager brought out five paper sheets of logs. [...]

Inspectors wrote4) R60 was a [AGE] year old female with a medical history that included acute respiratory failure due to acute on chronic heart failure. RR revealed the following: Physician written order start date [DATE]: Code Status: Do Not Attempt Resuscitation/No artificial nutrition by tube. Provider Orders for Life-Sustaining Treatment (POLST) Document dated [DATE]: Do Not Attempt Resuscitation/DNAR (allow natural death) signed by R60. Social Service (SS) Progress note dated [DATE] at 10:44 AM.She does not wish to fill out an advance directive nor did she want educational pamphlet explaining it. Full code status . The SS progress note was inaccurate. 3) R32 is a [AGE] year-old male resident with a diagnosis that included Dementia with other behavioral disturbances. [...]

Inspectors wroteBased on record review (RR) and interview, the facility failed to: 1. Include an accurate assessment of resident's psychological state in the quarterly Minimum Data Set (MDS) for one Resident (R32) and; 2. Failed to identify that a bed alarm was in place. The deficient practice failed to accurately assess the resident's psychosocial wellbeing. The residents in the facility with psychological needs are affected.

Inspectors wroteBased on observation, interview, and record review (RR) the facility failed to revise one Resident's (R35) care plan (CP) timely to reflect the status/treatment of her fractured leg after a fall. As a result of this deficiency, staff may not have been aware of the treatment plan required monitoring and interventions needed. This deficient practice could affect any resident.

Inspectors wroteBased on observation, interviews, and record review (RR), the facility failed to make arrangements for one Resident (R35) to be transported to an appointment with a consultant. As a result of this deficiency, there was a delay taking her cast off. This deficient practice could affect any resident with outside appointments and may prevent them from meeting their highest potential of psychosocial and medical well-being.

Inspectors wroteBased on observation, interviews, and record review RR), the facility failed to provide supervision of one Resident (R) 3 to ensure the safety of female residents. Specifically, the facility investigated an allegation that R3 inappropriately touched a female resident (R6). As a result of that investigation R3 was to be supervised when in the presence of vulnerable females to ensure their safety. R3 was observed to be alone in the dining area with a female resident (R39) on 07/24/24, which put her safety at risk. If R3 is not supervised, it puts all female residents at risk of a similar occurrence, which could result in psychological or physical harm.

Inspectors wroteBased on observation, interview, and record review (RR) the facility failed to: 1. Ensure it provided an environment to promote the mental and psychosocial wellbeing for one resident in the sample Resident (R) 32 was agitated and distressed evidenced by loud yelling and acting out while isolated in his room. 2. The nursing staff did not monitor R32's behaviors or; 3. Report changes to the physician for four days and; 4. Implement non-pharmacological interventions in his plan of care. The deficient practice resulted in the resident having poor psychological and emotional health and self-inflicted injuries that occurred as a result of his behavioral outbursts. Residents in the facility with psychological and emotional health needs are at risk.

Inspectors wroteBased on record review and interview the facility failed to assist Resident (R) 13 in scheduling a dental appointment that he missed on 11/28/23 (per Dental clinic) and 12/05/23 (per resident's Care Plan) for a cleaning. The deficient practice could affect all residents in the facility who require assistance in scheduling dental appointments. Findings Include: On 07/23/24 at 10:48 AM during Record Review (RR) of R13's Electronic Health Record (EHR) found resident has a Care Plan (CP) in place for at risk for mouth or facial pain related to decaying (cavity) and/ or broken natural teeth 10/19/23 oral thrush. Dental appointment made for 12/05/23 for cleaning. During this record review of R13's progress notes found a nurse had documented on 12/5/23 R13 left the facility to go to an appointment but the facility nurse did not state what the appointment was for. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident sampled (Resident (R)2) sampled received professional standard quality of care. R2 was readmitted to the facility on [DATE] from an acute hospital with an ostomy bag. The facility did not develop care plans, which drives the care of residents for malnutrition, pain, and prevention of pressure injury/pressure ulcer. On admission, the physician identified R2 to be at risk for malnutrition, R2 was not assessed by the Dietician until 9 days after admission when contacted by the facility due to R2's poor oral intake, refusing meals, and having a significant weight loss of 12.09%. R2 was not ordered pain medication for severe pain (7-10 on the Numeric Pain Rating Scale) despite R2 reporting a pain score of 8 on two separate documented occasions, and a care plan was not developed for pain. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the QAPI program made a good faith attempt to analyze the data collected to identify performance indicators of the corrective actions implemented to determine if the facility is sustaining corrections. The facility conducted audits related to deficient practices identified by the survey team during a recertification survey. The data from the audits was not analyzed to determine if the corrective actions were sustained, or if revisions are necessary.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident's right to a dignified existence for four residents (Resident(R)65, Anonymous Resident (AR)1, AR2, and AR3). R65 reported staff did not respond to the resident's activated call light or assess/acknowledge the resident if staff could not immediately assist the resident for 30-45 minutes while on isolation precautions. Observations and/or interviews with AR1, AR2, and AR3 confirmed call lights were not being addressed in a timely manner despite the presence of staff. As a result of this deficient practice, the residents are at risk for potential physical and psychosocial harm.

Inspectors wroteBased on observations and interview, the facility failed to ensure the most recent survey results and plan of correction post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide a homelike environment for a resident (Resident(R)49) in hospice care, staff interrupting resident meals to administer medication, and residents receiving meals in the shared dining areas. R49's is a hospice resident and the resident's room walls were bare, no pictures, calendars, or any personal items, to ensure a homelike environment and equipment (not in-use) was being stored in the room. Resident's meals were left on trays while dining in the main dining room on both units (Unit 1 and Unit 2) throughout the survey. As a result of this deficient practice the residents are potentially at risk of psychosocial harm.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to appropriately address out of range temperature for one of its two medication refrigerators and discard expired glucose testing supplies. This deficient practice has the potential to negatively affect the efficacy and integrity of medications that require to be stored at proper temperatures and placed all residents that need glucose testing at risk for potential harm as their medical care is dependent on precise glucose test results. Findings Include: On [DATE] at 09:07 AM, observation of the medication refrigerator was done with Resident Care Manager (RCM) 1 in the medication storage room. The refrigerator contained insulin, suppositories, and vaccines. A document titled Medication Refrigerator Temperature Record was placed in a plastic protective sleeve on the door of the refrigerator. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to follow food safety requirements. The temperature for the refrigerator used for food storage was out of range and a container of juice was found in a refreshment refrigerator that was over one month from the date it was opened. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess one Resident (R)16 for functional limitations of the bilateral upper extremities (BUE). The deficient practice affected R16's range of motion (ROM) due to not receiving the care and treatment needed to maintain or improve his functional status. As a result, the care plan was not implemented, and the restorative care not provided.

Inspectors wroteBased on observation, interview and record review the facility failed to update the care plan with new interventions to address two Resident's (R)14 and R16 of two residents in the sample had been refusing restorative care. The deficient practice negatively impacts the resident's functional capacity to prevent decline and maintain range of motion and mobility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the resident (R)14 and R16 with the care and services to maintain and prevent the further decline in the Range Of Motion (ROM) in both residents hands and legs. The deficient practice affects the resident's psychosocial well-being and mobility.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure professional standards of practice were implemented for a resident (Resident (R) 47) using a suction machine. As a result of this deficient practice, resident was placed at risk for potential of harm related to respiratory infection. This deficient practice has the potential to affect all residents that require suctioning. Findings Include: On 07/25/23 at 10:03 AM, observed R47 lying in his bed with his eyes closed. R47 had a suction machine on his bedside table and the suction tip wrapped in a paper towel on his bed. The cannister was filled with a frothy, clear to whitish fluid and was halfway full. Date written on the cannister was 07/09/23. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff demonstrated competency relating to medication administration. As a result of this deficient practice, all residents are at risk for more than minimal harm.

Inspectors wroteBased on observations and interview, the facility failed to ensure the daily nurse staffing information was in a prominent area.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the drug regime of each resident is reviewed at least once a month by a licensed pharmacist for 1 of 6 residents (Resident (R)8) sampled. Review of R8's Electronic Health Record (EHR) documented the pharmacist did not conduct a monthly drug regime review for May 2023 and June 2023 until 07/27/23, after surveyor requested documentation of May 2023 and June 2023 Drug Regime Review (DRR). As a result of this deficient practice, the residents are at potential physical harm.

Inspectors wroteBased on interviews and record review, the facility failed to designate an individual as the Infection Preventionist (IP) which works at least part-time in the facility and/or completed specialized training in infection prevention and control. The individual designated as the IP is also working full-time as the Director of Nursing (DON). The facility recently hired Nursing Staff (NS)33 as the IP, however, NS33 did not complete specialized training in infection prevention and control. As a result of this deficient practice all residents are potentially at risk for harm.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one of five residents (Resident (R) 47) sampled for immunization was provided the influenza vaccine. This deficient practice placed the resident at risk of acquiring, transmitting or experiencing complications from seasonal influenza. Findings Include: Review of Electronic Health Records (EHR) revealed that R47 is a [AGE] year-old resident admitted on [DATE] as a lateral transfer from another long term care facility. Diagnoses include diabetes (high blood sugar levels) and lung cancer. Immunization records from previous facility showed his last influenza vaccine was administered on 12/16/20. Review of scanned documents under Consent Forms revealed that R47 signed a consent to receive the influenza vaccine on 02/02/23, however, there was no record in the EHR showing the vaccine was administered. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide an adequate call system so the resident could communicate with the nursing staff. The deficient practice places the resident at an increased risk of harm. One Resident (R)36 had a touch pad call light that was placed out of reach. Resident was not able to demonstrate how to use it to call the nurse.