Islands Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1205 Alexander Street, Honolulu, Hawaii 96826
- CMS Provider Number
- 125067
- Inspections on file
- 19
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Islands Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility did not submit required direct care staffing information, including payroll data for agency and contract staff, to CMS for a fiscal quarter. Review of the PBJ Staffing Data Report showed no data was submitted, and the Administrator confirmed missed deadlines for submission.
The facility did not keep records of dryer lint removal and cleaning as required by policy. Observation revealed lint present in the dryer lint traps, and the Environmental Services Director confirmed that record-keeping for this task had recently stopped.
Staff were observed standing over multiple residents while assisting with meals, rather than sitting or being at eye level, and a resident's urinary catheter bag was left uncovered and visible from the hallway despite an order for a privacy cover. Facility policies did not address these dignity concerns, and the DON confirmed that staff typically stand during meal assistance.
Two residents did not have comprehensive care plans addressing their specific needs. One resident lacked a care plan for bed rail use despite documented consent and observed use, while another resident's care plan did not address declining ROM, even though assessments showed impairments. These omissions were confirmed by the IDON and staff during interviews and record reviews.
A resident with a facility-acquired stage 3 pressure ulcer, which later progressed to stage 4, was not consistently repositioned according to the care plan and facility protocols. Review of turning logs showed the resident was documented as being on the same side for consecutive intervals, and the Interim DON confirmed staff should have turned the resident as required.
A resident with significant mobility impairments and a history of brain cancer was found resting in bed without an upper right bed rail, which staff were unaware had been removed. The missing bed rail, later found in the resident's bathroom, was not identified or addressed by staff until prompted by a surveyor, indicating a lack of adequate supervision and failure to maintain an environment free from accident hazards.
A resident with multiple diagnoses and on several medications did not have a pharmacist's recommended lab work communicated to the physician, as required by facility policy. The Interim DON confirmed the omission was due to a vacant DON position, resulting in the facility's failure to act on the Medication Regimen Review recommendation.
Surveyors found that medication cart keys, including those for controlled drugs, were left unattended on the cart rather than kept with nursing staff as required by policy. Required signatures for narcotic count reconciliation were missing on two shifts. Additionally, expired insulin was not disposed of and was administered to a resident, and blood glucose testing supplies lacked required labeling for open and discard dates, making it impossible for staff to determine their usability.
A grayish-green residue was found under the ice dispenser during a kitchen inspection, and the Kitchen Manager acknowledged the buildup had not been previously noticed despite recent servicing and monthly inspection logs.
A resident with multiple medical conditions did not have an Advanced Health Care Directive or a designated healthcare POA, yet the POLST form incorrectly listed the spouse as the agent. The facility lacked documentation and a process for naming a surrogate decision-maker, resulting in an inaccurately completed POLST.
A buildup of dust was observed on the backs of ceiling-mounted televisions and their wires in several rooms, including those occupied by residents with tracheostomies. Housekeeping staff had not performed high dusting recently due to a lack of proper equipment, and facility leadership acknowledged the issue after being shown photographic evidence.
A resident was not accurately assessed for range of motion limitations, as discrepancies were found in MDS documentation compared to the resident's actual abilities. Staff interviews and record reviews revealed that the resident could assist with movement, but the MDS was incorrectly coded as having impairments on both sides, leading to an inaccurate assessment.
A resident was admitted with orders for insulin to manage hyperglycemia, but did not have a documented diagnosis of diabetes or hyperglycemia in the medical record. Despite ongoing insulin administration and physician documentation of hyperglycemia, no baseline care plan was developed to address the resident's condition or insulin use. The absence of both a diagnosis and a care plan was confirmed by the IDON.
Staff did not follow infection prevention protocols, including failing to keep a urinary catheter bag off the floor for a dependent resident, not performing hand hygiene between glove changes, and not wearing required PPE such as gowns during care of residents with gastrostomy tubes. These actions were inconsistent with facility policies and staff training.
A resident with complex medical needs suffered harm due to the nursing staff's failure to demonstrate appropriate competencies and skills. The staff did not follow protocol to obtain emergency physician services when needed and applied a scopolamine patch without a physician's order, leading to adverse symptoms. The facility's records lacked documentation of the patch application, and the staff failed to follow the chain of command when the on-call provider was unreachable.
A resident with complex medical needs was inappropriately discharged from an LTC facility without proper documentation or notification. Despite the facility's capability to provide necessary care, the resident was not allowed to return post-hospitalization due to issues with the parents' behavior. The facility failed to follow its transfer/discharge policy and did not provide the required notice to the resident's representative or Ombudsman.
A resident was transferred to a hospital for higher care, and the facility decided not to readmit him. The facility failed to notify the resident's representative and the ombudsman of this decision, preventing the representative from appealing. The social worker misunderstood the process, assuming a transfer was a discharge, and did not send a formal notice of the decision not to readmit.
A facility failed to follow its discharge policy and did not provide the required notice to a resident's representative or Ombudsman. After a resident was hospitalized, the facility refused to readmit him despite having an open bed and the capability to care for him, citing concerns about the mother's behavior. The decision was made without involving the family or addressing the concerns, and the refusal was not based on the resident's behavior or medical condition.
A resident's care plan was not updated to include specific care preferences requested by the POA, despite being documented in the medical records. The resident, with a history of cerebral hemorrhage and quadriplegia, had special instructions such as the use of pressure boots and temperature control measures that were not reflected in the care plan. The DON acknowledged the oversight, noting that these instructions were visible to staff but should have been included in the care plan.
A resident with a complex medical history experienced an increased heart rate and behavioral changes, requiring emergency physician services. Despite multiple attempts, the nursing staff was unable to reach the on-call APRN, resulting in a delay before the resident was transferred to the Emergency Department. The facility's policy mandates prompt physician consultation, but there was no documentation of the attempts to contact the provider.
The facility failed to maintain an accurate and up-to-date facility-wide assessment, inaccurately reporting zero residents requiring respiratory treatments or mechanical ventilation. However, the facility matrix showed 24 residents with tracheostomies and 15 on mechanical ventilators. This discrepancy indicates reliance on a template rather than a comprehensive assessment, increasing the risk of harm to residents.
The facility did not post complete daily Nursing Staffing Information, omitting the hours worked by RNs and CNAs and the resident census. The Daily Assignment sheet only listed staff names, assigned areas, and shifts. The DON confirmed the missing information during an interview.
The facility failed to ensure that physicians documented the review of pharmacist recommendations for three residents. One resident's trazodone PRN continuation lacked a rationale, another's acetaminophen limit was not adjusted, and a third resident's behavioral monitoring and tests were not implemented. Documentation of physician review was missing in all cases.
The facility failed to monitor behaviors related to psychotropic medication use for three residents, including those with major depressive disorder, anxiety, and PTSD. Records lacked documentation of monitored behaviors and physician rationale for extended PRN use, as confirmed by an RN.
A facility experienced a high medication error rate of 38.36% due to improper administration practices. Errors included administering medications via the wrong route and not adhering to physician orders regarding hold parameters. One resident received medications through a G-tube that were ordered to be given by mouth, and another resident's medication was not held despite low blood pressure. Additionally, a nurse administered multiple medications together via a G-tube, contrary to policy.
The facility failed to implement comprehensive care plans for three residents prescribed psychotropic medications, omitting non-pharmacological interventions and behavior monitoring. A resident with major depressive disorder and insomnia, another with dementia and anxiety, and a third with PTSD and adjustment disorder were affected, as identified during record reviews and RN interviews.
A facility failed to update the care plan for a resident with a tracheostomy, omitting the representative's decision against a tracheostomy cap trial. The care plan lacked documentation on the use of a Passy Muir valve for communication and the representative's wishes, despite these being discussed in an interdisciplinary team meeting. This oversight potentially disregards the resident's rights.
A resident with multiple health issues did not receive care according to physician orders, as the facility failed to withhold a stool softener despite documented loose stools. This oversight, confirmed by an RN, increased the risk of skin breakdown and discomfort, contrary to the facility's bowel elimination policy.
The facility failed to maintain an effective infection control program, with unclean resident rooms, reused disposable equipment, and incomplete policies. Observations included soiled floors, reused G-Tube tips, and peeling paint in the kitchen. Staff interviews revealed confusion over cleaning responsibilities and a lack of comprehensive oversight in the infection control program.
The facility failed to accurately document medication administration for two residents. A nurse administered medications via G-tube to a resident that were ordered to be given by mouth, and another resident had medications left unattended at the bedside, yet marked as administered. The discrepancies were confirmed by the unit manager and director of nursing.
A facility failed to change a suction cannister for a resident receiving tracheostomy care, which was half full with dark red-brown fluid and clots. The facility's policy requires disposable equipment to be replaced as needed, but the cannister was not changed until observed by surveyors. The resident had a bacterial infection and was on IV antibiotics.
A facility failed to provide necessary supplies for optimal nutrition and hygiene for residents, with six residents receiving enteral nutrition by gravity due to pump tubing shortages. One resident experienced significant weight loss and a stage four pressure ulcer. Another resident frequently ran out of suction toothbrushes, and a resident was given briefs that were too small. Staff and family members reported frequent shortages of essential supplies, with budget constraints and supply chain issues contributing to the problem.
The facility failed to properly label and store medications, left controlled substances unattended, and inaccurately documented medication administration. An insulin pen was mislabeled, and a resident's pain medication was left unattended without ensuring it was taken. Another resident's medications were left at the bedside without proper documentation of self-administration. These practices risked medication errors and resident safety.
The facility failed to maintain privacy and dignity for three residents. A resident on a ventilator was exposed during personal care due to an inadequate privacy curtain. Two residents with urinary catheters had their bags uncovered and visible in the hallway. The facility's policy on dignity was not effectively implemented.
A resident's rights were violated when a tracheostomy cap was placed without the legal guardian's consent, causing distress to the resident. Despite the guardian's disagreement, a Speech Therapist obtained a doctor's order, and a Respiratory Therapist placed the cap, leading to the resident's upset reaction. The incident was reported to the Director of Rehabilitation, who acknowledged the need for guardian consent.
The facility failed to ensure that three residents or their representatives received and acknowledged the Notice of Medicare Non-Coverage (NOMNC) forms as required. The forms were left at the bedside for two residents and not emailed to the representative of a third resident with severe cognitive impairment. The facility lacked a policy for NOMNC form delivery, and staff misunderstood the requirement for obtaining signatures.
The facility failed to report allegations of abuse and an injury of unknown origin involving two residents to the State Survey Agency within the required time frame. In one case, a resident was reportedly mistreated by a CNA, and the incident was not reported within the mandated two-hour window. In another case, a resident had a bruise on his forearm from a dialysis session, with no documentation or timely reporting of the injury. These failures constitute a deficiency in regulatory compliance.
A facility failed to remove a CNA accused of abuse from the premises during an investigation, allowing her continued access to a resident who reported feeling harassed. Despite the facility's policy requiring immediate suspension of accused employees, the CNA continued working, and the investigation was not completed until two days later. The allegations were ultimately unsubstantiated, but the failure to follow protocol led to a deficiency.
A facility failed to provide written transfer/discharge notifications to a resident, their representative, and the LTCO for three hospitalizations due to medical conditions. The Social Services Director cited the resident's VA insurance status as the reason for not issuing the notifications, despite facility policy requiring such notices.
A facility failed to conduct a quarterly fall assessment for a resident, as required by their Fall Prevention Program. The last assessment was done in December, and the next one due in March was missed. A new RN was unaware of the assessment schedule, and the DON confirmed the oversight.
A facility failed to include a resident's daily preferences in her baseline care plan within 48 hours of admission. The resident, who has a tracheostomy and uses a ventilator, was admitted without her preferences documented, despite her daughters being involved in her care decisions. The DON confirmed that all areas of the baseline care plan should be completed within 48 hours, which was not done in this case.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, to the Centers for Medicare and Medicaid Services (CMS) for fiscal quarter 3 of 2024. Review of the CMS Payroll-Based Journal (PBJ) Staffing Data Report indicated that no staffing data was submitted for the specified quarter. During an interview, the Administrator confirmed that there were two instances when the facility did not submit the required PBJ information on time and stated that once the deadline is missed, submission is no longer allowed. This deficiency was identified through record review and staff interview.
Failure to Maintain Records of Dryer Lint Removal and Cleaning
Penalty
Summary
The facility failed to maintain records of dryer lint removal and cleaning as required by its own policy. During an observation of the dryer lint traps, a thin layer of lint was noted mid-cycle, indicating that lint removal may not have been performed as needed. In an interview, the Environmental Services Director stated that the facility had recently stopped keeping records of dryer lint removal and cleaning, but later indicated that record-keeping would resume. Review of the facility's laundry policy confirmed that daily lint removal and monthly washing of dryer vents are required, but there was no documentation to show these tasks had been completed.
Failure to Maintain Resident Dignity During Meal Assistance and Catheter Care
Penalty
Summary
Staff failed to ensure the right to a dignified existence for four residents. Certified Nurse's Aides (CNAs) were observed standing over three residents while assisting them with meals, rather than sitting or being at eye level. These residents were in bed with their heads elevated during meal assistance. Facility policies on meal supervision and promoting dignity did not specify that staff should be seated or at eye level when assisting residents with meals. The Interim Director of Nursing confirmed that staff typically stand while assisting, regardless of resident preference, and acknowledged the lack of policy guidance on this matter. Additionally, a resident with a urinary catheter was observed lying in bed with the catheter collection bag visible from the hallway and not covered with a privacy bag, despite a physician's order requiring a privacy cover. The Interim Director of Nursing confirmed that all urinary catheter collection bags are to be covered at all times, indicating a failure to follow established orders and maintain resident dignity.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. For one resident, there was no care plan in place to address the use of bed rails, despite the presence of a signed consent form for bed rail use and multiple observations of the resident with and without bed rails in place. The absence of a care plan for bed rail use was confirmed by the Interim Director of Nursing (IDON) during a phone interview. For another resident, the care plan did not address the resident's declining range of motion (ROM), even though assessments indicated impairments in both upper and lower extremities. The IDON confirmed that ROM exercises were not included in the care plan, and that ROM interventions were only added after the issue was identified. The lack of documentation and planning for ROM needs was acknowledged by facility staff during interviews and record reviews.
Failure to Follow Turning Schedule and Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow the care plan and facility policies for the prevention and treatment of skin breakdown for one resident with a pressure ulcer. Record review showed that the resident had a facility-acquired stage 3 pressure ulcer, which progressed to a stage 4 ulcer and remained at that stage over several months. The resident's care plan included following facility protocols for skin breakdown prevention and treatment. However, review of the turning logs revealed that on multiple occasions, the resident was documented as being positioned on the same side for consecutive turning intervals, rather than being repositioned as required. The Interim Director of Nursing confirmed that staff should have turned the resident and acknowledged the documentation discrepancies, noting that the resident's fiancé may have also moved the resident, which could have contributed to the inconsistent records.
Failure to Ensure Bed Rail Availability and Staff Awareness
Penalty
Summary
A deficiency was identified when a resident was observed resting in bed with the upper right bed rail missing. Staff, including the Environmental Services Supervisor, were unaware of the missing bed rail until it was brought to their attention. The Environmental Services Supervisor confirmed the bed rail was missing and speculated that the resident's wife may have removed it. The resident's medical record indicated significant health concerns, including a history of malignant brain tumor, dependence on supplemental oxygen, reduced mobility, muscle contractures, and tracheostomy status. The resident was documented as being totally dependent on staff for personal hygiene and movement, and had a signed bed rail consent form indicating the use of bed rails for fall prevention. The absence of the bed rail was not noticed or addressed by staff until questioned by the surveyor, and the bed rail was later found in the resident's bathroom and reattached. This incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents, particularly for residents who are dependent on staff and require bed rails for safety.
Failure to Act on Pharmacist Medication Regimen Review Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to act on a pharmacist's Medication Regimen Review (MRR) recommendation for one resident. The resident, who had diagnoses including paraplegia, depression, anxiety, hypertension, and pulmonary embolism, was receiving multiple medications such as Apixaban, Mirtazapine, Morphine Sulfate, Oxycodone, and Sertraline. The pharmacist's MRR recommended specific lab work (Primidone level, Phenobarbital level, Magnesium level), but there was no documentation that this recommendation was communicated to the physician. During staff interviews, the Interim Director of Nursing (IDON) acknowledged that the recommendation was not communicated due to a vacancy in the Director of Nursing position at the time. Review of facility policy confirmed that MRR recommendations are to be documented and acted upon, with follow-up to verify appropriate action. The failure to communicate and act on the pharmacist's recommendation resulted in the deficiency.
Medication Security, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors observed that medication cart keys, including those for controlled substances, were left unattended in a disposable cup on top of the medication cart near the nurse's station. When questioned, a registered nurse stated that staff had been instructed by management to leave the keys in this location, rather than keeping them on their person as required by facility policy. The nurse confirmed that the narcotic key was included in this set. Additionally, review of the narcotic endorsement log revealed missing signatures for the change of shift count on two occasions, indicating that the required reconciliation and documentation of narcotic counts were not consistently performed. Further inspection of the medication cart revealed a vial of Humulin R insulin that was past its discard date but had not been disposed of, and the medication administration record showed that a resident had received doses from this vial after the discard date. The cart also contained blood glucose testing supplies, including test strips and control solutions, that were not labeled with open or discard dates, contrary to manufacturer instructions and professional standards. Staff were unable to determine when these supplies had been opened or when they should be discarded.
Ice Machine Not Maintained in Sanitary Condition
Penalty
Summary
During an initial kitchen tour, a grayish-green buildup was observed under the area where ice is dispensed from the facility's ice machine. The Kitchen Manager confirmed the presence of this residue and was able to partially remove it with a dry paper towel. The Kitchen Manager stated that the ice machine had been serviced by an outside vendor recently, but the buildup under the dispenser had not been noticed prior to this observation. Documentation showed that monthly inspections of the ice machine were being logged, with the next service scheduled, but the unsanitary condition under the dispenser had not been addressed at the time of the survey.
Inaccurate Completion of POLST Due to Lack of Advance Directive and Surrogate Process
Penalty
Summary
The facility failed to accurately complete a Physician Orders for Life Sustaining Treatment (POLST) form for a resident with multiple complex medical conditions, including dysphagia, type 2 diabetes mellitus with skin complications, unspecified dementia, psychotic and mood disturbances, anxiety, and tracheostomy status. The resident's electronic health record did not contain an Advanced Health Care Directive (AHCD) appointing a Power of Attorney (POA) for healthcare decisions. Despite this, the POLST form prepared for the resident indicated that his wife was his agent designated in a Power of Attorney for Healthcare, which was not accurate, as confirmed by the social worker and facility records. Further review revealed that the correct designation on the POLST should have been 'Surrogate selected by consensus of interested persons,' as the resident's wife was not his healthcare POA. Additionally, the facility did not have documentation such as a surrogate form or a physician's letter identifying the resident as lacking capacity to make his own healthcare decisions. The social worker confirmed that the facility did not have a process in place for initiating a surrogate decision-maker for residents without capacity, contributing to the inaccurate completion of the POLST form.
Failure to Maintain Clean and Homelike Environment Due to Dust Buildup
Penalty
Summary
Surveyors observed a buildup of dust on the back of ceiling-mounted televisions and their wires in multiple resident rooms. In one room, all four televisions had visible dust accumulation, and a resident reported not having seen staff clean the backs of the televisions. Additional observations in other rooms revealed similar dust buildup, including in rooms occupied by residents with tracheostomies. Photographic evidence was taken to document the condition. Interviews with facility leadership, including the Administrator, Interim Director of Nursing (IDON), and Environmental Services Supervisor (EVS), confirmed that housekeeping staff are expected to perform high dusting as part of their daily service, with high dusting specifically scheduled once a month. However, the EVS acknowledged that high dusting had not been performed recently due to the lack of appropriate equipment, specifically a long-handled duster needed to reach the backs of the televisions. Both the Administrator and IDON agreed that the dust buildup was present and should have been addressed.
Inaccurate Assessment of Range of Motion in Resident
Penalty
Summary
The facility failed to accurately assess a resident for limitations in range of motion. Review of the resident's electronic health record showed discrepancies in the Minimum Data Set (MDS) assessments over several periods. Initially, the MDS indicated no impairment in upper and lower extremities, but subsequent assessments coded impairments on both sides. Interviews with staff revealed that the resident was able to assist with turning on his right side, suggesting that the coding of impairments on both sides may not have been accurate. The MDS coordinator confirmed that, upon review, there was a coding error in the most recent assessment, where impairment should have been recorded on only one side rather than both. This deficiency was identified through record review and staff interviews, which highlighted inconsistencies between the resident's documented functional abilities and the MDS coding. The inaccurate assessment placed the resident at risk of not receiving proper treatment to maintain range of motion, as the documentation did not reflect the resident's actual physical capabilities at the time of the assessment.
Failure to Develop Baseline Care Plan for Insulin Use in Non-Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was receiving insulin for hyperglycemia following admission. Upon review, it was found that the resident did not have a documented diagnosis of diabetes mellitus or hyperglycemia in the electronic health record, despite having an active order for insulin glargine administered twice daily. The resident's Minimum Data Set indicated insulin administration, but did not reflect a diagnosis of diabetes or hyperglycemia. Family interview confirmed the resident was receiving insulin, which began during a prior hospital stay, and the resident's blood sugars were reportedly stable. Further investigation revealed that the attending physician's admission note documented hyperglycemia as the reason for insulin therapy, with no history of diabetes. However, this diagnosis was not added to the resident's official list of diagnoses, nor was a baseline care plan created to address hyperglycemia or the use of insulin. The Interim Director of Nursing confirmed the absence of both the diagnosis and the baseline care plan for managing the resident's blood sugar levels.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to implement infection prevention and control measures in several instances involving residents with indwelling medical devices. One resident, who was totally dependent on staff and had an indwelling urinary catheter, was observed with the catheter tubing and urinary bag resting on the floor next to the bed, despite the bag being covered with a privacy bag. The Interim DON confirmed that no part of the Foley catheter system should be on the floor. Additionally, staff did not consistently perform hand hygiene between glove changes during resident care, as observed during medication administration and dressing changes. Facility policy requires hand hygiene before donning gloves and after removing them, but this was not followed by staff in multiple instances. Further observations revealed that staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents with gastrostomy tubes. In two separate cases, staff administered medications or flushed feeding tubes without wearing the required gown, and in one case, only gloves and a mask were used. The facility's policy mandates the use of gown and gloves during high-contact care activities for residents with indwelling medical devices, including gastrostomy tubes. The Infection Preventionist confirmed that staff are trained to follow these protocols, but the observed practices did not align with facility policy.
Inadequate Nursing Competency and Unauthorized Medication Application
Penalty
Summary
The facility nursing staff failed to demonstrate the necessary competencies and skills to provide adequate care for a resident, leading to significant harm. The resident, a male with a complex medical history including cerebral hemorrhage with quadriplegia, chronic respiratory failure, and other conditions, experienced a rapid heart rate, fever, and behavioral changes. Despite these symptoms, the nursing staff did not follow the proper protocol to obtain emergency physician services when they were unable to reach the on-call provider. This inaction persisted until the resident's mother intervened, expressing concern over the lack of transfer to an emergency department. Additionally, the nursing staff applied a scopolamine patch to the resident without a physician's order, which may have contributed to the resident's adverse symptoms, including hallucinations and an increased heart rate. The facility's medication administration records did not document the application of the patch, and there was no active order for its use. This oversight should have prompted an investigation by the responsible nurse, but it did not occur, leading to further complications for the resident. Interviews with facility staff, including the Director of Nursing and the resident's physician, confirmed the absence of an order for the scopolamine patch and the failure to follow the chain of command when the on-call provider was unreachable. The Director of Nursing acknowledged the lack of documentation and the inability to determine who applied the patch. The physician was unaware of the unauthorized use of the patch and had left instructions for the APRN to cover in his absence, but the staff failed to reach the APRN in a timely manner.
Inappropriate Discharge and Failure to Document
Penalty
Summary
The facility violated federal regulations by initiating a discharge for a resident without an adequate reason and failing to provide the necessary documentation and notification. The resident, a male with a history of hypertension, quadriplegia, and respiratory issues, was transferred to an acute care hospital due to a medical condition requiring a higher level of care. Despite the facility's capability to provide the necessary respiratory specialty services, they decided not to allow the resident to return post-hospitalization, citing issues with the behavior of the resident's parents. This decision was made without the resident's representative's request and was not aligned with the resident's care goals and preferences. The facility failed to document the required elements of the discharge in the resident's medical record. There was no documentation by a provider regarding the transfer on the specified date, nor was there a discharge summary after the decision not to allow the resident to return. The facility's policy on transfer and discharge was not followed, as it states that residents should be permitted to return to the facility unless their clinical or behavioral status cannot be met. The facility did not provide the resident's representative or the Ombudsman with the required written notice of the facility-initiated discharge, which should have included the date and specific reasons for the discharge. Interviews with facility staff revealed that the decision not to allow the resident to return was made by upper management, despite the facility having the capacity to care for the resident's respiratory issues. The Admissions Director confirmed that there were available beds at the time and that the decision was communicated to the hospital's Social Service staff. The facility's failure to follow its established transfer/discharge policy and comply with regulations resulted in the resident being denied the right to return to the facility and the representative being unable to appeal the discharge.
Failure to Notify Resident's Representative of Discharge Decision
Penalty
Summary
The facility failed to provide the required notification of transfer or discharge to a resident's representative and the ombudsman, resulting in a deficiency. The resident, a nonverbal male with a history of hypertension, quadriplegia, and other medical conditions, was transferred to a hospital for a higher level of care. The facility decided not to readmit the resident after his hospitalization but did not formally notify the resident's representative or the ombudsman of this decision, as required by regulations. The facility's social worker completed a notice of transfer/discharge, indicating that the resident's welfare could not be met at the facility. However, the notice was intended to address the initial transfer to the hospital, not the decision not to readmit the resident. The social worker assumed the resident would return and did not provide a formal notice of the facility-initiated discharge. The notice was sent via text to the resident's representative and left at the bedside, but it did not include the necessary information about the decision not to readmit. Interviews with facility staff revealed a misunderstanding of the transfer and discharge process. The social worker believed that a transfer equated to a discharge and did not send a separate notice for the decision not to readmit. The admissions director confirmed that the decision not to allow the resident to return was made by the facility team, but no formal notice was sent to the representative or ombudsman. This lack of communication prevented the resident's representative from exercising their right to appeal the discharge decision.
Failure to Follow Discharge Policy and Provide Notice
Penalty
Summary
The facility failed to adhere to its established transfer/discharge policy and did not comply with regulations regarding discharges. A resident, who had been at the facility since March 7, 2024, was transferred to the Emergency Department on May 31, 2024, for a higher level of care. Once stabilized, the hospital's Social Service department attempted to arrange for the resident's return to the facility. Despite having an open bed and the capability to care for the resident, the facility refused to readmit him, citing concerns about the mother's behavior. This decision was made after discussions among the Admissions Director, Administrator, and Director of Nursing, without involving the resident's representative or addressing the concerns with the family. The facility did not provide the required written notice of the facility-initiated discharge to the resident's representative or the Ombudsman. The Administrator confirmed that the refusal to readmit the resident was not based on the resident's behavior or medical condition. The facility's actions were based on previous interactions with the resident's mother, and no efforts were made to resolve these concerns through a conference or communication with the family. This lack of communication and failure to follow proper discharge procedures led to the deficiency.
Failure to Update Resident's Care Plan with Specific Preferences
Penalty
Summary
The facility failed to update a resident's care plan to include specific requests and preferences made by the resident's power of attorney (POA). The resident, a male with a history of cerebral hemorrhage, quadriplegia, chronic respiratory failure, and other medical conditions, was admitted for skilled nursing and respiratory care. Despite the POA's active involvement and the documentation of special instructions in the resident's medical records, the care plan did not reflect these agreed-upon interventions. The care plan included only the routine Facetime calls with family, omitting other critical instructions such as the use of pressure boots, call light placement, wearing gloves to prevent scratches, preference for gauze to wipe eyes, and temperature control measures. During an interview, the Director of Nursing acknowledged that the special instructions were documented in a specific chart location to ensure visibility to staff. However, she agreed that these instructions should have been incorporated into the care plan to ensure comprehensive and individualized care. The failure to update the care plan with these important details resulted in a deficiency, as the care plan was not comprehensive or individualized to meet the resident's needs and preferences.
Failure to Provide 24-Hour Physician Services
Penalty
Summary
The facility failed to provide 24-hour availability of physician services, which resulted in a delay in care for a resident. On 05/31/2024, the nursing staff was unable to reach a physician or provider to discuss the condition of a male resident with a history of cerebral hemorrhage, chronic respiratory failure with a tracheostomy, and other medical issues. The resident exhibited an increased heart rate, behavioral changes, and developed a temperature, necessitating the notification of a provider. Despite multiple attempts to contact the on-call APRN throughout the day, the nursing staff could not obtain a response before transferring the resident to the Emergency Department. The facility's policy on Notification of Changes requires prompt consultation with the resident's physician when there is a change in condition. However, the Director of Nursing confirmed that there was no documentation of the phone calls made to the covering APRN. The Respiratory Therapist on duty confirmed the resident's hallucinations and anxiety were suspected to be caused by a scopolamine patch, which was removed earlier that day. The lack of response from the on-call provider and the absence of documented attempts to reach them contributed to the deficiency in providing timely physician services.
Inaccurate Facility Assessment Puts Residents at Risk
Penalty
Summary
The facility failed to conduct, document, and annually review a comprehensive facility-wide assessment, which is required to include both the resident population and the resources needed to care for them. The assessment was found to be outdated and inaccurate, particularly in the areas of special treatments and conditions. Specifically, the facility's assessment inaccurately reported zero residents requiring respiratory treatments, oxygen therapy, suctioning, tracheostomy care, or mechanical ventilation. However, a review of the facility matrix revealed that there were 24 residents with tracheostomies and 15 residents on mechanical ventilators who required special respiratory treatments. This discrepancy indicates that the facility used a template rather than an accurate and up-to-date assessment, placing all residents at an increased risk of harm.
Failure to Post Complete Daily Nursing Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to provide daily Nursing Staffing Information, which includes the hours worked by Registered Nurses (RNs) and Certified Nurse Aides (CNAs), as well as the resident census. On May 15, 2024, at 08:40 AM, an observation was made of the facility's Daily Assignment sheet posted near the nurse's station on the treatment cart. The sheet listed the names of RNs and CNAs, their assigned work areas, and shifts, but did not include the hours worked or the resident census for the day. On May 16, 2024, at 02:06 PM, the Director of Nursing (DON) was interviewed and confirmed that the posting was missing the required information regarding resident census and total hours worked by RNs and CNAs, as per the requirements of F732.
Failure to Document Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of medication regimen review (MMR) recommendations from the pharmacist for three residents. For Resident 4, the physician did not provide a rationale for continuing trazodone PRN medications past 14 days, despite recommendations from the pharmacist in August, October, and November 2023. The physician also failed to document the review of these recommendations. Similarly, for Resident 12, the physician did not document a review of the pharmacist's recommendation to limit acetaminophen intake to 3 grams per day, as the existing order allowed up to 4 grams. For Resident 29, the physician did not document a review of the pharmacist's recommendation to implement a behavioral monitor sheet and conduct specific tests such as a Lipid Panel, LFTs, and A1c. The Treatment Administered Record (TAR) and Medication Administered Record (MAR) for this resident lacked documentation of specific behaviors, and the recommended tests were not ordered. In all cases, the Registered Nurse (RN) was unable to find documentation that the physician had reviewed and responded to the pharmacist's recommendations.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to specify and monitor behaviors related to the use of psychotropic and sedative medications for three residents, leading to deficiencies in medication management. Resident 4 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia. The resident's physician orders included psychotropic medications such as trazodone and sertraline. However, the Treatment Administered Record (TAR) and Medication Administered Record (MAR) lacked documentation of monitored behaviors for these medications. Additionally, there was no documentation of the physician's rationale for extending the use of trazodone PRN medications beyond 14 days. Similarly, Resident 12, diagnosed with dementia, major depressive disorder, and anxiety disorder, had physician orders for lorazepam and escitalopram. The records for this resident also lacked documentation of monitored behaviors for these medications. Resident 29, with diagnoses of adjustment disorder with anxiety and PTSD, was prescribed venlafaxine, aripiprazole, and lorazepam. Again, the TAR and MAR did not specify monitored behaviors for these medications. In all cases, Registered Nurse 23 confirmed the absence of documentation in the Electronic Health Record (EHR), indicating a failure to adhere to the facility's policy on psychotropic medication use.
High Medication Error Rate Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a significant error rate of 38.36 percent. This was observed during medication administration to two residents and a review of a closed record for another resident. The errors included administering medications via the wrong route and not adhering to physician orders regarding when to hold medications based on vital signs. One resident, who had a history of cognitive communication deficit and hemiplegia, was administered medications via a gastrostomy tube that were ordered to be given by mouth. The nurse, RN80, crushed medications that were not supposed to be crushed and administered them through the G-tube without an order permitting this method. Additionally, medications that should have been held due to the resident's blood pressure were administered, contrary to the physician's orders. Another resident's closed record review revealed that a medication with specific hold parameters was administered despite the resident's blood pressure being below the threshold. Furthermore, during an observation, a nurse administered multiple medications together in one cup via a G-tube, contrary to the facility's policy of administering them one at a time. This practice was not corrected by the nurse manager, who was unaware of the nurse's method.
Failure to Implement Comprehensive Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents who were prescribed psychotropic and sedative medications. These care plans did not include non-pharmacological interventions or monitored behaviors related to the medications administered. Specifically, Resident 4, who was diagnosed with major depressive disorder, generalized anxiety disorder, and insomnia, was prescribed trazodone and sertraline. However, their care plan lacked non-pharmacological interventions and behavior monitoring for these medications. Similarly, Resident 12, with diagnoses including dementia, major depressive disorder, and anxiety disorder, was prescribed lorazepam and escitalopram, but their care plan also omitted non-pharmacological interventions and behavior monitoring. Resident 29, diagnosed with adjustment disorder with anxiety and PTSD, was prescribed venlafaxine, aripiprazole, and lorazepam, yet their care plan did not include necessary non-pharmacological interventions or behavior monitoring. These omissions were identified during record reviews and interviews with a registered nurse.
Failure to Update Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R27, who has a tracheostomy and uses a Passy Muir valve (PMV) to improve communication. The resident's representative decided against a tracheostomy cap (T-cap) trial, a decision discussed during an interdisciplinary team (IDT) meeting but not documented in the care plan. This omission has the potential to disregard the rights of R27 and her representative. The report indicates that the IDT meeting minutes and care plan did not include any mention of capping the trachea or weaning off the tracheostomy. The care plan only included interventions such as monitoring respiratory rate and suctioning as necessary, without addressing the use of the PMV or the representative's wishes regarding T-cap trials. An interview with the respiratory therapy supervisor revealed that there was no prior discussion with the family about the T-cap trial, which is typically part of the IDT meeting discussions.
Failure to Withhold Stool Softener as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident, identified as R29, who was admitted with multiple diagnoses including chronic kidney disease, gastrotomy status, tracheostomy status, and long-term use of antibiotics. The deficiency arose from the facility's failure to adhere to the physician's orders regarding the administration of a stool softener, Senna-Docusate, which was to be held in the event of loose stools. Despite documentation of numerous instances of loose stools in March, April, and May, the medication was not consistently withheld as ordered, except on two occasions. This oversight was confirmed during a concurrent record review and interview with RN23, who acknowledged that the stool softener should have been held on days when the resident experienced loose stools. The failure to do so placed the resident at increased risk of avoidable skin breakdown, infection, and discomfort, as evidenced by documented skin issues such as a rash and redness in the groin and buttocks areas. The facility's policy on bowel elimination, which mandates regular monitoring and adjustment of bowel regimens to prevent complications, was not followed, contributing to the deficiency.
Inadequate Infection Control Program and Environmental Cleaning
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Environmental cleaning of resident rooms was not routinely conducted, with resident care equipment left uncleaned and disposable equipment being reused. For instance, a feeding pump with brown stains was found in a resident's room, and the floors in another room were soiled with various debris. Nursing staff were observed reusing purple tips for G-Tube feedings due to a shortage, contrary to the facility's policy that disposable equipment should never be reused. The Infection Preventionist was unaware of these practices, and the facility lacked a comprehensive infection control policy. The facility's infection control and prevention policy was incomplete and did not align with recognized guidelines. The policy did not cover essential areas such as environmental cleaning and disinfection, isolation precautions, and reporting protocols for reportable diseases. The Director of Nursing provided outdated and incomplete policy documents, and the infection preventionist was not actively involved in the infection control program. The facility's infection control committee lacked signatures from key members, indicating a lack of comprehensive oversight. Additional observations included peeling paint in the kitchen above the food prep area, which could lead to contamination, and a feather found near the trayline. A discarded glove was found on a resident's windowsill, and a fall mat in another resident's room was dirty. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for cleaning and maintaining hygiene standards, with staff citing short staffing as a reason for inadequate cleaning.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents, leading to potential risks of incorrect medication administration. For Resident 17, a registered nurse administered medications via a gastrostomy tube (G-tube) that were ordered to be given by mouth, including losartan potassium, hydralazine HCL, meclizine HCL, multivitamin, stimulant laxative, and vitamin D. The nurse documented these medications as administered as ordered in the electronic health record, despite the absence of an order to crush and administer them via G-tube. This discrepancy was confirmed by the unit manager, who acknowledged that there was no order permitting the alteration of the medication administration route. For Resident 14, medications were left unattended on the bedside table, yet marked as administered in the Medication Administration Record (MAR). The resident confirmed that nurses sometimes leave medications at the bedside because she takes a long time to swallow them, and she admitted to not taking certain medications immediately due to stomach discomfort. The resident's electronic health record did not indicate any assessment or care plan for self-administration of medication, and the director of nursing confirmed that medications should not be marked as administered unless the nurse observes the resident taking them.
Failure to Change Suction Cannister for Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R1, who required tracheostomy care. During observations conducted on two consecutive days, the suction cannister in R1's room was found to be half full with dark red-brown fluid and clots, and the date on the cannister was smeared and unreadable. The facility's policy states that disposable equipment should never be reused and should be replaced according to a specific frequency or as needed when not clean in appearance. However, the respiratory therapist indicated that cannisters are changed once per week on Tuesday or when full, which was not adhered to in this case. R1, a dependent female resident, was admitted on an unspecified date and had a bacterial infection confirmed by a sputum culture on 05/06/24, for which she was started on intravenous antibiotics. The failure to change the suction cannister as needed placed residents receiving tracheostomy care at an increased risk of illness.
Supply Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide necessary supplies for optimal nutrition, grooming, and personal hygiene for seven residents. Six residents receiving enteral nutrition were fed by gravity instead of using a pump due to a shortage of pump tubing. This issue was observed during random checks, and it was noted that pumps were not in use despite being attached to poles. One resident experienced significant weight loss and developed a stage four pressure ulcer, highlighting the impact of inadequate feeding methods. Additionally, a resident frequently ran out of suction toothbrushes needed for managing increased secretions, and another resident was provided with briefs that were too small. Interviews with family members and staff revealed that the facility often ran out of essential supplies like absorbent pads and briefs, leading to discomfort and inadequate care for residents. The supply supervisor mentioned that the facility's budget constraints and supply chain issues contributed to these shortages. The facility's Resident Council Minutes documented ongoing concerns about supply shortages, with residents expressing discomfort due to inadequate supplies. Staff interviews confirmed frequent shortages of larger-sized briefs, and the supply supervisor acknowledged the challenges in maintaining adequate stock levels. Despite attempts to source supplies from local vendors and other facilities, the facility struggled to meet the residents' needs, impacting their overall well-being.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for medication labeling and storage, as observed during a survey. An insulin pen with an unreadable label was found in a medication cart, and a bottle of Polyethylene glycol suspension lacked an expiration date. The insulin pen was improperly labeled with a post-it note, and the medication was taken from emergency stock without proper documentation. Additionally, the facility did not ensure that narcotic medication counts were endorsed by nurses at each shift change, as evidenced by unsigned entries in the Narcotic Endorsement Log. In another instance, a nurse left a resident's pain medication, including oxycodone, unattended on the bedside table without ensuring the resident took it. The resident's health records did not indicate participation in a self-administration program, and the resident had diagnoses of major depressive disorder and anxiety disorder. The Director of Nursing confirmed that it was against policy to leave controlled medications unattended, especially for residents with such diagnoses. Furthermore, a resident was found with a cup of medications left unattended on her bedside table, which was documented as administered in her medical record. The resident confirmed that nurses sometimes leave her medications at her bedside because she takes a long time to swallow them. However, there was no documentation in her care plan indicating she was on a self-administration program. These deficiencies in medication management practices placed residents at risk for medication errors and potential harm.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignity for three residents during care, as observed by surveyors. One resident, who was dependent and on a mechanical ventilator, was found exposed in his bed while receiving personal care, with the privacy curtain only partially closed and inadequate to cover the area around the ventilator and respiratory equipment. This left the resident visible to staff and visitors, compromising his dignity and privacy. Additionally, two other residents with urinary catheters had their catheter bags uncovered and visible to people in the hallway. One resident's catheter bag was observed uncovered on two separate occasions, while another resident's bag was later covered after initial observation. The facility's policy on dignity and privacy was not effectively implemented, as staff did not consistently cover urinary catheter bags, and the privacy curtain was insufficient to ensure bodily privacy during personal care.
Resident's Rights Violated in Tracheostomy Cap Placement
Penalty
Summary
The facility failed to ensure the rights of a resident's representative in a medical treatment decision involving the insertion of a tracheostomy cap (T-cap) for a resident. The resident, an elderly female with a diagnosis of respiratory failure and a tracheostomy, was under the care of a legal guardian who was responsible for making healthcare decisions. Despite the guardian's explicit disagreement with the treatment, a Speech Therapist (SLP) requested an order from the doctor, and a Respiratory Therapist (RT) placed the T-cap on the resident's trachea. This action was against the guardian's wishes and caused distress to the resident, who was visibly upset and began crying after the cap was placed. The incident was reported by the guardian to the Director of Rehabilitation (DOR), who acknowledged that the guardian should have given consent for the T-cap placement. The RT involved in the procedure noted that the resident was initially okay but became upset shortly after the cap was placed, indicating a misunderstanding as the resident thought it was a different device. The guardian was informed of the incident the following day and expressed significant distress over the unauthorized procedure, which was described as traumatic for the resident.
Failure to Provide and Acknowledge NOMNC Forms
Penalty
Summary
The facility failed to provide a written copy of the Notice of Medicare Non-Coverage (NOMNC) form to three residents or their representatives, as required by the NOMNC instructions. The residents involved were cognitively intact, except for one who had severe cognitive impairment. The facility documented that the NOMNC forms were left at the bedside for two residents and sent via secure email for the third resident. However, there was no evidence that the forms were acknowledged by the residents or their representatives, as required. Interviews with the facility's Administrator and Social Services Director (SSD) revealed that the facility did not have a policy regarding the NOMNC form and did not follow the NOMNC instructions. The SSD admitted to leaving the forms at the bedside without obtaining signatures, believing that verbal notification was sufficient. Additionally, the SSD confirmed that the NOMNC form was not emailed to the representative of the resident with severe cognitive impairment. The NOMNC instructions require that the beneficiary or representative sign and date the form to confirm receipt and understanding of the notice, and that providers develop procedures for delivering the notice to representatives when direct contact is not possible.
Failure to Timely Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Survey Agency (SA) within the required time frame. For the first resident, the Long-Term Care Ombudsman (LTCO) reported an incident where a family member accused a Certified Nurse's Aide (CNA) of mistreating the resident by using intimidation tactics and being rough during care. The LTCO informed the Director of Nursing (DON) and Administrator of the incident, but the facility did not report the allegation to the SA within the mandated two-hour window. The initial and completed investigation report was submitted two days later, which was confirmed by the DON as not being timely. In the second case, a resident had a large bruise on his right forearm, which was discovered to have occurred during a dialysis session. The facility did not have documentation of this injury, and there was no communication from the dialysis center regarding the incident. The Unit Manager (UM) and the resident's assigned nurse were unaware of how the bruise was acquired, and the DON was reminded to report this injury of unknown origin to the SA. The facility's failure to report these incidents in a timely manner constitutes a deficiency in adhering to regulatory requirements for reporting suspected abuse and injuries of unknown origin.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse or mistreatment during an investigation involving a resident and a CNA. The incident was reported by the Long-Term Care Ombudsman, who informed the Director of Nursing and Administrator of possible abuse between the resident and the CNA. Despite this, the facility did not remove the CNA from the premises, allowing her continued access to the resident and other vulnerable individuals. The resident reported feeling harassed by the CNA, who allegedly provided rough care and disregarded the resident's preferences during showering, which could exacerbate her ear infections. Interviews revealed that the CNA continued to work in the facility during the investigation, and the facility did not inform her of the ongoing investigation. The facility's policy required immediate suspension of any employee accused of abuse pending investigation, but this was not followed. The Director of Nursing acknowledged the oversight, confirming that the investigation was not completed until two days after the incident was reported. Ultimately, the facility found the allegations unsubstantiated, but the failure to remove the CNA during the investigation constituted a deficiency.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman (LTCO) as required. This deficiency was identified for one resident who was transferred to the hospital on three separate occasions due to medical conditions including tachycardia, recurrent aspiration pneumonia, acute aspiration pneumonia, and acute respiratory failure with hypoxia. A review of the resident's Electronic Health Record (EHR) revealed no documentation of the required written notifications for these hospitalizations. During an interview, the Social Services Director admitted that the facility did not issue the notifications due to the resident's Veteran Affairs (VA) insurance status. The facility's policy mandates that transfer/discharge notices be provided in a language and manner understandable to the resident and their representative, with copies sent to the Ombudsman for emergency transfers.
Failure to Conduct Quarterly Fall Assessment
Penalty
Summary
The facility failed to re-assess a resident, identified as R15, for falls on a quarterly basis as required. During a record review on May 14, 2024, it was found that R15's last fall assessment was conducted on December 12, 2023, and the subsequent quarterly assessment due on March 12, 2024, was not completed. Interviews with RN79, who was new to the facility, revealed a lack of awareness regarding the schedule for fall assessments, relying on the computer system to prompt when assessments are due. The Director of Nursing confirmed the oversight, acknowledging that the fall assessment for R15 was indeed missed, as per the facility's Fall Prevention Program policy, which mandates a fall risk assessment every 90 days and when the resident's condition changes.
Failure to Include Resident's Preferences in Baseline Care Plan
Penalty
Summary
The facility failed to include a resident's daily preferences in her baseline care plan within 48 hours of admission, as required. The resident, a [AGE] year old with adjustment disorder, unspecified, functional quadriplegia, a tracheostomy, and ventilator dependency, was admitted on [DATE]. Her baseline care plan, completed on 04/23/24, omitted the section for daily preferences, which should have included options such as choosing clothes, caring for personal belongings, and family involvement in care decisions. An interview with the resident and her daughter revealed that the resident's daughters are involved in her care decisions and are present at the facility daily. The Director of Nursing confirmed that nurses are required to fill out all areas of the baseline care plan, including daily preferences, within 48 hours of admission. However, this was not done for the resident in question, leading to the deficiency noted in the report.
Latest citations in Hawaii
A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
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