Nikkei Manor

Facility failed to have a back-up plan in the Assessment and Service Plan (ASP) for a resident receiving hospice bathing services.

Facility failed to ensure two staff members completed the required one-step TB skin test.

Facility failed to ensure staff met long-term care worker training requirements, including specialty training for dementia/mental health and annual continuing education.

Facility failed to ensure proper and safe installation of side bed rails for a resident, creating a risk of entrapment.

Facility failed to have a diet manual approved by a dietitian and updated at least every five years.

Facility failed to implement systems to promote safe medication services; staff failed to hold blood pressure medications as ordered based on resident vital signs.

Facility failed to implement safe nursing services when non-licensed staff administered medications without a nurse delegation program.

Facility failed to notify Construction Review Services prior to installing air conditioning systems.

Facility failed to provide signage on the exhaust hood or system cabinet indicating the type and arrangement of cooking appliances protected by the automatic fire-extinguishing system.

Fire sprinkler trim ring missing in kitchen near fire sprinkler room.

Strain protection shall be maintained for kitchen cooking appliances.

Rice steamer cord shall be repaired or replaced.

Missing signage stating: In case of appliance fire, use this extinguisher after fixed suppression system has been actuated.

Non-licensed staff administered medications to two residents without required nurse delegation, placing residents at risk.

Non-licensed staff administered medications without nurse delegation training to one resident, placing them at risk for compromised health status. This is a recurring and uncorrected citation.

The facility failed to develop a Negotiated Service Agreement (NSA) that clearly defined roles and responsibilities of private caregivers for two residents and failed to include an alternate plan for bath aide services from a hospice agency for another resident.

Failed to provide documentation for annual fire-resistance-rated construction inspection; broken ceiling tile in room 140A.

Failed to provide annual fire door inspection report.

Failed to provide smoke detector sensitivity report.

Failed to provide documentation for annual forward flow test for the backflow; sprinkler head in 1st floor nurses station was loaded with debris.

Facility failed to implement respiratory protection program, specifically regarding respirator fit-testing for staff.

Facility failed to complete full assessments regarding the safe use of bed mobility devices (side rails) for Residents 3 and 6.

Facility failed to ensure staff documented signatures or initials for medication administration for Residents 5 and 8.

Facility failed to ensure staff with positive TB test had a chest x-ray within seven days.

Facility failed to notify primary care provider for Resident 2 regarding low blood pressure readings as ordered.

Facility failed to perform TB screening for staff within three days of employment.

Facility failed to ensure orientation for 3 of 3 sampled staff members.

Facility failed to ensure pain assessments were conducted by licensed staff, resulting in uncontrolled pain for Resident 4 and administration of narcotics by non-licensed staff without proper nursing oversight.

Failed to implement a Respiratory Protection Program (RPP), resulting in staff not having fit tests for respirator masks during a COVID-19 outbreak.

Failed to ensure the Negotiated Service Agreement (NSA) included all required contents for four residents.