Every finding on record at Ann Pearl Nursing Facility

Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions resulting in 2 elopement incidents (01/19/26 and 01/28/26) for Resident (R) 36. This deficient practice created the likelihood for a serious adverse outcome (e.g. serious bodily injury and /or death from being hit by a car) due to open access to a busy road from the facility entrance and adjacent parking lot. Findings include:The Office of Health Care Assurance (OHCA) received a facility-reported incident (FRI) Intake #2721134, documenting an incident of elopement that occurred on 01/19/26 at 06:28 PM by R36. A second FRI, Intake # 2731191, was received by OHCA on 01/28/26 at 05:54 PM, regarding another elopement by R36 that occurred on 01/28/26 at 04:10 PM, 9 days after the first incident (01/19/26). The State Agency (SA) entered the facility on 03/11/26 for annual recertification survey where both FRIs were investigated.R36 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including DMII (diabetes), adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, obstructive sleep apnea. R36 was discharged from the facility on 02/28/26.On 03/10/26 at 2:00 PM a review of R36's progress notes in the electronic health record (EHR) were reviewed. There were 5 entries documented ranging from 10/27/25 to 12/16/25 that R36 verbalized wanting to go home and/or verbalizing wanting to go home with frequent phone calls made to family. There was 1 episode documented on 11/6/25 where R36 was asking other staff and residents to take her home. There were 6 entries documented ranging from 10/22/25 to 12/05/25 that R36 was wandering in the facility and stating wanting to go home. There were 27 entries documented ranging from 10/28/25 to 01/18/26 that R36 was ambulating near facility entrance/exit door or displaying exit seeking behavior. On 01/19/26 at 06:10 pm R36 eloped through the main exit doors. There was no plan preventing elopement for R36 prior to the 01/19/26 elopement incident as evidenced by: 1) R36's care plan did not address the wandering and exit seeking behaviors that occurred prior to the 01/19/26 elopement incident; 2) Activity Aide took R36 for a stroll outside the facility on 01/19/26 at approximately 4:00 PM and left resident alone sitting at a table outside. A documented note by Resident Care Manager (RCM) 1, dated 01/202/26 stated, I was walking out of the office door near the Pikake lanai with [DON] when we noticed that resident [R36] was sitting at the resident smoking tent alone. I asked [DON] is she allowed to be there and she said no and that she was going to get her back inside. On 03/11/26 at 06:45 AM, upon entry through the main entrance, SA observed the doors were unlocked and lacked an alarm or automatic locking mechanism. There was no indication that the door could secure automatically to prevent an elopement. The main entrance opened up to a large open area with no reception or receiving area observed.On 03/11/26 at 07:00 AM, the facility investigation packets received for the 01/19/26 and 01/28/26 elopement incidents were reviewed. On 01/19/26 and 01/28/26, R36 was found in the parking lot near the first handicap stall. For both incidents, staff were not aware of R36's elopement until notified/made aware by another facility resident.On 03/11/26 at 10:11 AM, the Administrator and Director of Nursing (DON) were interviewed:-The Administrator stated there was currently no electronic wander management system in place. There was a doorbell at the front entrance doors and when it rings, staff supposed to look up but confirmed that the R36 did walk out on her own through the front door on 01/19/26 and 01/28/26. -The DON confirmed resident was having exit seeking behaviors prior to the 01/19/26 elopement incident and that on 01/19/26 she was functionally at the supervision level and could ambulate with a front wheeled walker.-The facility Elopement Risk Evaluation was completed on 10/16/25 and DON stated score was a 0. On 10/28/25 another evaluation was completed with a score of 2. The bottom of the evaluation stated, A score of 1 or greater = At risk for elopement. The Administrator was asked how the evaluation is utilized and she stated that we review change in score and determine what other interventions need to be done. No interventions regarding resident risk of elopement were identified prior to the 01/19/26 incident.-A concurrent review of a root cause analysis (RCA) done by the DON after the 01/19/26 incident listed more frequent rounding as an intervention. The Administrator stated, increased monitoring is everyone's responsibility and not one on one. SA requested documentation for increased monitoring. On 03/12/26 at 05:45 PM, reviewed facility Behavior Monitoring and Interventions Reports received for 01/01/26 to 02/28/26 which included a section that could be marked for Elopement/Exit Seeking. Upon review, times were documented once for each shift (day, evening, night) and did not reflect increased times being documented after the 01/19/26 and 01/28/26 elopement incidences. Most of the documentation was marked as, No Behaviors Observed which was inconsistent with the exit seeking episodes noted in R36's progress notes. No other documentation reflecting increased monitoring was presented by the facility.-The Administrator and DON were asked during the interview about education provided after the 01/19/26 and 01/28/26 incidents. The Administrator stated that an elopement drill was conducted and an in-service that included the topic of elopement was provided. A review of the facility education documents provided by the facility showed an Elopement Drill dated 02/12/26. An in-service titled, Survey 2026 Prep & Updates that included 2 questions, 6. Who runs a Code Pink? 7. Is Elopement Risk only Nursing's responsibility . was conducted on 02/18/26 and 02/19/26. The dates for the elopement drill and in-services did not reflect that elopement education was provided after the first elopement incident (01/19/26) and that timely education was provided after both elopement incidents to assist in keeping R36 safe. The signature records also did not reflect that majority of staff participated.-During the interview, the Administrator also stated that online education regarding elopement was assigned to staff in January 2026. SA received the online education on Managing Elopement from the facility labeled, Learner Status at the top of the first page, a date of 03/09/26 following, and Due Date Range of 03/01/26 - 03/09/26. This did not reflect that it was done in January 2026 after the initial elopement (01/19/26).On 03/11/26 at 11:53 AM, the Administrator stated there was still one resident, R6, listed as an elopement risk.

Based on interviews and record review, the facility failed to prevent potential abuse for one of three residents sampled for abuse (Resident (R) 12) and other residents at risk due to delayed initiation of the investigation for R12's allegation of abuse. As a result of this deficient practice, the residents were placed at a potential risk for physical and psychosocial harm. Findings include: Cross Reference to F609 Reporting of Alleged Violations. The facility failed to report an allegation of abuse within 2 hours which resulted in the facility not implementing its policy and procedure to ensure the immediate safety of the alleged victim, timely reporting of an alleged crime, and a timely abuse investigation. R12 is a [AGE] year-old female admitted to the facility on [DATE] with hospice services. Review of Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/25, revealed in Section C that R12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated R12 had severe cognitive impairment. Section GG (Functional Abilities) noted that R12 required dependent assistance (requires full assistance from another person(s)) for self-care and bed mobility. On 03/19/25 at 09:30 AM, a review of R12's Resident Progress Notes was done. A progress note dated 02/01/25 at 11:24 AM, with a notation, Recorded as Late Entry on 02/04/25 at 11:40 AM, was inputted by Registered Nurse (RN) 10 and stated, resident screaming she raped last night, in front of husband. However, there was no documentation that the facility's Administrator or Director of Nursing (DON) was notified. On 03/19/25 at approximately 11:45 AM, a form titled, [Provider] Alleged AMN (Abuse, Misappropriation, Neglect), with a submission date listed as 02/03/25, was reviewed. The form listed 02/01/25 at 05:00 PM as the date and time of the alleged abuse event. The date and time the Administrator and DON was notified of the alleged abuse event was listed as 02/03/25 at 09:00 AM. On 03/19/25 at approximately 10:30 AM, a review of the facility policy titled, Abuse and Neglect, dated 03/03/21, documented in the section titled, Overview of the Seven Components included 5) Investigation: Abuse Policy Requirement: The facility's immediate response is to protect the alleged victim. To protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, ensure the safety of all other residents and the integrity of the investigation. On 03/19/25 at 03:45 PM, interviewed the DON in her office. The DON confirmed that she was made aware of the allegation of abuse two days later (02/03/25) but should have been sooner so the investigation could start immediately. This would have provided immediate protection for the residents. On 03/19/25 at 03:20 PM, interviewed the Social Services Director (SSD) in her office. The SSD stated she does a Safe Survey form with the residents as part of any abuse investigation. The SSD stated she completes the form as soon as possible once she is made aware of an abuse incident. The SSD confirmed that the Safe Survey forms were started on 02/03/25 when she was made aware of the allegation. On 03/20/25 at 07:55 AM, interviewed the Administrator and SSD together. The SSD stated the purpose of the Safe Survey form is to ensure the residents feel safe and to check if they have any concerns. The Administrator stated the safe surveys should be initiated right away. On 03/20/25 at 09:20 AM, an interview was conducted with the Regional Nurse Consultant (RNC). RNC stated staff interviews regarding the allegation are done as part of the abuse investigation. A concurrent review of the Interview Statement forms conducted with staff reflected dates of 02/03/25 - 02/04/25. The RNC stated that if she was made aware of the allegation sooner, the staff interviews would have started sooner after the allegation. She also stated that is the normal process and that becomes priority.

Based on interviews and record review, the facility failed to consult with the physician for worsening injury sustained after a fall, which required a physician's intervention for one of three residents (Resident (R)19) sampled for falls. As a result of this deficient practice, the resident was at risk for more than minimal physical harm. Findings Include: On 03/19/25 at 02:27 PM, conducted a review of R19's Electronic Health Record (EHR). Review of the progress notes documented: -01/25/25 at 02:45 PM, At 1120, the writer heard resident calling out. Upon arrival to room, resident found on floor next to bed lying on back . c/o (complained of) pain to right forearm only. Right forearm with full ROM (range of motion) though resident is moving it weakly related to pain. Notified .on-call provider (OCP1) . with no new orders received . -01/26/25 at 06:48 AM, Resident fell on day shift 1/25/25. Resident has pain and swelling to right wrist. Resident has decreased strength in right hand compared to left hand. Endorsed to oncoming nurse about getting order for an x-ray. -01/27/25 at 06:23 AM, .Resident has swelling to right wrist . -01/27/25 at 08:43 AM, New order for xray to right wrist due to swelling. Phoned (imaging company) stated would be here today. -01/207/25 at 01:22 PM-, .Xray ordered and completed with impression of acute displaced fractures of the distal radial metaphysis and ulnar styloid. On 03/20/25 at 10:56 AM, conducted a concurrent telephone interview and review of R19's EHR with OCP1. OCP1 reviewed R19's EHR and provider notes of the resident on 01/25/25 and confirmed staff was instructed to call back if there were any changes in the resident's condition. OCP1 reviewed R19's progress notes and confirmed when staff identified swelling to the resident's right wrist, on 01/26/25 at 06:48 PM, staff should have called the on-call provider to report the swelling to a physician/provider and an x-ray would have been ordered given the obvious change. On 03/20/25 at 11:28 AM, conducted a concurrent interview and review of R19's EHR with the Director of Nursing (DON). After reviewing R19's progress notes, DON confirmed the on-call physician/provider should have been called when staff identified the resident's wrist was swollen and the noted discrepancy of strength between the resident's right and left hand and requested an x-ray but did not.

Based on interviews and record review, the facility failed to ensure for one of three residents (Resident (R) 12) sampled for abuse, that alleged violations are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This deficient practice resulted in the facility not implementing its policy and procedure to ensure the immediate safety of the alleged victim, timely reporting of an alleged crime, and a timely abuse investigation. Findings include: Cross reference to F610 Investigate/Prevent/Correct Alleged Violation. The facility failed to prevent potential abuse for one of three residents sampled for abuse (Resident (R) 12) and other residents at risk due to delayed initiation of the investigation for R12's allegation of abuse. 1) On 03/19/25 at 09:00 AM, a review of the [State Agency] Event Report regarding an allegation of abuse was noted to be submitted to the State Agency (SA) on 02/03/25 at 11:08 AM via email. The Initial Report section of the report was noted with a date and time of 02/03/25 at 11:06 AM. The date and time of the incident (abuse allegation) noted on the report was 02/01/25 at 05:00 PM. On 03/19/25 at 09:30 AM, a review of R12's Resident Progress Notes was done. A progress note dated 02/01/25 at 11:24 AM, with a notation, Recorded as Late Entry on 02/04/25 at 11:40 AM, was inputted by Registered Nurse (RN) 10 and stated, resident screaming she raped last night, in front of husband. However, there was no documentation that the facility's Administrator or Director of Nursing (DON) was notified. On 03/19/25 at approximately 11:45 AM, a form titled, [Provider] Alleged AMN (Abuse, Misappropriation, Neglect), with a submission date listed as 02/03/25, was reviewed. The form listed 02/01/25 at 05:00 PM as the date and time the allegation was made. The date and time the Administrator and DON was notified of the event was listed as 02/03/25 at 09:00 AM. On 03/19/25 at 02:45 PM, interviewed the Administrator in her office. The Administrator stated for any allegations of abuse, floor staff will notify the clinical on call person, who will then notify the Administrator. This is usually done by phone. She confirmed the incident occurred on 02/01/25, but was notified on 02/03/25, and she should have been notified right away. On 03/19/25 at 03:45 PM, interviewed the DON in her office. The DON stated that anytime there is an allegation of abuse, staff should immediately call the Administrator and DON. She confirmed that she was notified on 02/03/25 and that was not immediate. On 03/20/25 at 11:25 AM, an interview with RN10 was conducted via telephone call. RN10 stated that she was the Nurse on duty when the resident voiced the allegation of sexual abuse (rape). RN10 stated that at approximately 4:00 PM, R12's husband visited and R12 started yelling that she wanted to go home and to call the ambulance to take her home. She then stated that she was raped the previous night. RN10 stated that she knew it was a serious allegation and was previously educated that it should reported, but did not report it because she was busy and forgot. 2) On 03/19/25 at approximately 10:30 AM, a review of the facility policy titled,Abuse and Neglect, dated 03/03/21, revealed the section titled, Overview of the Seven Components included 7) Reporting/Responding: .The Administrator/designee will ensure that that all alleged violations involving abuse, neglect, exploitation, or mistreatment .are reported no later than 2 hours after the allegation is made, if events that cause the allegation abuse or result in serious bodily injury; or not later than 24 hours if the events that caused the allegations do not involve abuse and do not result in serious bodily injury, to the state survey agency and others (police, APS, OIG, AG, etc.) . On 03/19/25 at approximately 10:45 AM, a review of a document titled, Honolulu Police Department noted the date initiated as 02/03/25 for the allegation of abuse by R12 which occurred on 02/01/25. On 03/19/25 at 02:45 PM, interviewed the Administrator in her office. A concurrent review of the [State Agency] Event Report was done. The Administrator confirmed 02/01/25 at 05:00 PM was listed as the date and time of the incident and 02/03/25 at 11:06 AM as the date and time the initial report was completed. The Administrator confirmed the report was not initiated within the time frame as stated in the facility policy.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by five medication errors observed out of 31 opportunities for errors, for an error rate of 16%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, three residents (Residents (R) 37, R7, and R52) were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff. Findings include: 1) On 02/27/25 at 07:46 AM, observations were done of Registered Nurse (RN) 1 preparing medications for R37 at a medication cart outside of room [ROOM NUMBER]. Review of R37's Medication Administration Record (MAR) and medication orders noted there was an Amlodipine 2.5 mg (milligrams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR as Not Administered: Drug/Item Unavailable. Further review of the MAR revealed the medication had been documented as Not Administered: Drug/Item Unavailable since 02/22/25, with the last time it was administered documented as 02/21/25. On 02/27/25 at 01:49 PM, an interview was done with RN1 outside of room [ROOM NUMBER]. RN1 confirmed that she did not administer R37's Amlodipine as it was out of stock in the medication cart. When asked what is usually done when a medication is out of stock, RN1 stated that the nurse should call the pharmacy and find out when it was being delivered. RN1 acknowledged that she had not done this. On 02/27/25 at 02:01 PM, an interview was done with Director of Nursing (DON) in her office. When asked about the process that should be followed when a medication is found to be out of stock, DON stated first, the nurse should check the RX NOW system (electronic medication storage) to see if the medication is in the machine. If it is, and the medication is overdue, the nurse calls the provider to get a one-time order to administer the medication late. Whether the medication is in the machine or not, the pharmacy is called to find out when the medication will be delivered. This information is documented in a progress note and passed off in shift report to the oncoming nurse. DON checked the RX NOW system and confirmed that the medication is available and should have been given. 2) On 02/27/25 at 08:05 AM, observations were done of RN1 preparing medications for R7 at a medication cart outside of room [ROOM NUMBER]. Observed RN1 crush all the prepared tablets together then mix them into one (1) teaspoonful of applesauce. RN1 then opened an Omeprazole DR (delayed release) 20 mg capsule, emptied its contents on top of the same spoonful of applesauce, and mixed it in. Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following: Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. On 02/27/25 at 01:54 PM, an interview was done with DON in her office. DON confirmed that the Omeprazole DR capsule should not be opened and mixed in with applesauce. During a concurrent review of the medication orders, DON stated that the Omeprazole DR had a 'Do Not Crush' special instruction. 3) On 02/27/25 at 08:05 AM, observations were done of RN1 preparing medications for R7 at a medication cart outside of room [ROOM NUMBER]. Review of R7's MAR and medication orders noted there was Polyethylene Glycol (a laxative) 17 gm (grams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR at 10:22 AM as Charted late . given on time. On 02/27/25 at 12:18 PM, an interview was done with RN1 outside of room [ROOM NUMBER]. RN1 stated that she gave R7 the Polyethylene Glycol with her other medications that morning. State Agency Surveyor (SA) reminded her that she did not take any medication that was not in the spoonful of applesauce into the room that morning. At 12:24 PM, RN1 prepared and administered the Polyethylene Glycol, mixed in approximately 60 ml (milliliters) of fluid to R7. R7 drank a little more than half the fluid, then handed the cup back to RN1. RN1 placed the remaining fluid (with medication) on R7's bedside table and left the room. Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following: The resident is always observed after administration to ensure that the dose was completely ingested. The individual who administered the medication dose, records the administration on the resident's MAR immediately following the medication being given. On 02/27/25 at 01:54 PM, an interview was done with DON in her office. DON confirmed that no medication should be left at the bedside to finish unless the resident has orders to self-administer. DON also confirmed that a medication should not be documented as given until after it is administered. Review of R7's provider/physician orders noted that she did not have an order to self-administer. 4) On 02/27/25 at 08:19 AM, observations were done of RN1 preparing medications for R52 at a medication cart outside of room [ROOM NUMBER]. Amongst other medications, observed preparation of the following: Sennosides-Docusate Sodium 8.6-50 mg (a stimulant laxative with stool softener combination) At 08:23 AM, observed RN1 administering a total of six (6) tablets/medication to R52. At this time, observed RN1 ask R52 if he wanted his stool softener, which he refused. RN1 did not inform R52 at any time that one of the medications she had given him contained a stool softener. Review of R52's MAR and medication orders noted there was Polyethylene Glycol (a laxative) 17 gm (grams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR at 08:28 AM as Not Administered: Refused. On 02/27/25 at 12:27 PM, interviewed RN1 outside room [ROOM NUMBER]. RN1 confirmed that R52 refused the stool softener and after prompting by the SA, acknowledged that she did give a stool softener to him at that time. RN1 explained that R52 doesn't like the powder [Polyethylene Glycol] because he thinks it makes him go more. RN1 also stated that (the Polyethylene Glycol) is what she meant when she asked R52 if he wanted the stool softener. RN1 did not seem aware that Polyethylene Glycol is a laxative and not a stool softener. Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following: Explain to resident the type of medication being administered . On 02/27/25 at 02:01 PM, an interview was done with DON in her office. DON agreed that if R52 refused a stool softener, he either should not have been given the Sennosides-Docusate Sodium, or he should have been informed that there was a stool softener component in the medication he was given and been allowed the opportunity to refuse it. 5) On 02/27/25 at 08:19 AM, observations were done of RN1 preparing medications for R52 at a medication cart outside of room [ROOM NUMBER]. At 08:23 AM, observed RN1 administering a total of six (6) tablets/medication to R52. At this time, observed RN1 telling R52, I didn't bring your . [Acetaminophen], is that OK? Review of R52's MAR and medication orders noted there was Acetaminophen 1000 mg due at 07:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR at 08:20 AM as Not Administered: Refused. Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following: Medications are administered within 60 minutes of scheduled time . On 02/27/25 at 02:01 PM, an interview was done with DON in her office. DON agreed that medication cannot be marked as refused before it is offered and should be offered and/or administered within one hour of its scheduled time.

Based on interview and record review, the facility failed to develop a resident-centered trauma-informed care (TIC) care plan for one of one resident (Resident (R) 41) reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD). As a result of this deficient practice, the facility staff did not have sufficient information to meet the R41's needs. Findings include: Cross-reference to F699 TIC for R41. The facility failed to develop a TIC plan of care to address the trauma triggers and specific needs of R41 with a diagnosis of PTSD.

Based on record review and interview, the facility failed to revise the care plan for one of one sampled resident (Resident (R) 42) for elopement. This deficient practice has the potential to place R42 at risk for future elopements. Findings include: R42 is a [AGE] year-old male, admitted to the facility on [DATE]. R42 has medical diagnoses that include, but not limited to schizophrenia and dementia. A review of R42's Electronic Health Record (EHR) was conducted on 02/26/25. R42's EHR noted a progress note that on 10/11/24, R42 had walked out of the front door of the facility because he was needing money for cigarettes. A review of R42's current care plan noted that on 07/10/24, the facility had created a plan of care for R42's wandering and exit seeking behaviors. Since 07/10/24, there was no revision done for this plan of care. Interview was conducted with Director of Nursing (DON) on 02/27/25 at 10:22 AM in her office. DON confirmed that the facility would normally address the root cause of his elopement, which was seeking money for cigarettes, and update the resident's care plan. She added that a revision of R42's care plan should have been done after he walked out of the facility door on 10/11/24.

Based on observations, interviews, and record reviews, the facility failed to ensure one of two residents (Resident (R)12) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM in her left hand and elbow, as evidenced by inconsistent application of orthotic devices and ROM exercises. As a result of this deficient practice, R12 was placed at risk of a decline in ROM and a loss of function. Findings include: R12 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of R12's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 12/01/24 noted that her diagnoses include, but are not limited to, left-sided weakness and paralysis following a stroke, chronic pain, and heart failure. The Annual Assessment also documents R12 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that she is cognitively intact. On 02/25/25 at 09:16 AM, observations and interview were done with R12 at her bedside. Observed that R12 was not moving her left arm. When asked, R12 stated that she had a stroke in 2015 and has not been able to move her left arm too much since. No braces or splints were visible at the bedside at this time. On 02/25/25 at 01:07 PM, observations and interview were done with R12 at her bedside. Observed an elbow splint and wrist splint sitting on the nightstand behind her bed. R12 stated that they were for her left arm because of her stroke and resulting paralysis and weakness, and that facility staff helped her put them on every day. R12 confirmed that they had not been applied yet that day. Review of physician/provider orders revealed the following orders related to R12's splints: 01/10/25 Splint: Apply left elbow splint for 1-2.5 hours during day shift (06:00 AM - 02:00 PM), once a day. 01/10/25 Splint: Apply left palm protector splint with finger separators for 1-2.5 hours during day shift, once a day. 01/10/25 Splint: Apply left wrist, hand, finger, orthosis for 1 - 2.5 hours during evening shift (02:00 PM - 10:00 PM), once a day. On 02/26/25 at 08:00 AM, a review of R12's electronic health record (EHR) revealed that Point-of-Care (POC) responses for splints and passive range of motion (PROM), which is ROM that is achieved when an outside force (such as a therapist) exclusively causes movement of a joint, did not reflect the application or offer of application of her splints or PROM, on any shift, since 02/23/25. On 02/26/25 at 09:05 AM, an interview was done with Certified Nurse Aide (CNA) 52, who was also the Restorative Nurse Aide (RNA), out in the activities area. When asked, CNA52 stated that she documents individual therapies as soon as possible but definitely gets all charting in by the end of day. For R12, CNA52 stated that she does PROM first, then applies her splints, daily after her morning medications (per resident preference). Further review of POC responses for RNA services in the last thirty (30) days revealed PROM was done, and splints were documented as applied, for half that number of days. On 02/28/25 at 11:13 AM, an interview was done with Director of Nursing (DON) in her office. During a concurrent review of MDS Quarterly Assessment with ARD of 12/19/24 revealed PROM and Splint application was documented as being performed 2 days out of the 7-day observation period. DON explained that the data is compiled through observation and review of POC responses. DON agreed that if splints are ordered for daily application, the expectation is that the assessment result should be 7 of 7 days.

Based on observations, record reviews, and interviews, the facility failed to ensure residents remain as free of accident hazards as possible for two of six residents (Resident (R) 35 and R42) sampled for accidents. The facility failed to identify and eliminate a known and foreseeable accident hazard in the resident environment (wet floor); failed to lock up R35's cigarettes and lighter; and failed to ensure R42's seizure pads were in place. The deficient practices have the potential for ambulatory residents on the unit to sustain a preventable injury; the potential of a fire accident in the facility that has residents who are on oxygen; and the potential for R42 sustaining injuries in bed when having a seizure. Findings include: 1) On 02/26/25 at 07:38 AM, clear colored wetness was noted on the hallway floor outside of rooms 111-118 and extended to the floor inside resident room [ROOM NUMBER]. From the initial observation at 07:38 AM until 08:02 AM, multiple staff were observed walking on and around the wetness observed on the floor in the hallway and resident room [ROOM NUMBER], taking no action to wipe it up. There were no wet floor caution signs observed on the areas of wetness. On 02/26/25 at 08:28 AM, Director of Nursing (DON) was interviewed and stated that a cone with a wet floor sign should typically be placed. Housekeeping should be notified if staff cannot get to it in time to clean it up. DON confirmed the wetness in the hallway and in resident room [ROOM NUMBER] remained, and agreed that it should have been wiped up. 43414 2) On 02/25/25 at 09:36 AM, observed R35 smoking in the designated smoking area. Review of the list of residents who smoke in the facility, R35 was not included on the list. On 02/25/25 at 10:12 AM, an interview and observation of R35 was done in his room. Observed in his left breast pocket on his shirt a green box. R35 confirmed that the green box was his cigarettes, and he also had his lighter. R35 reported a staff member is usually with him when he smokes and helps him light his cigarettes except when he gets back from dialysis in the evening. Before coming in the building, he will smoke, they give him his cigarettes and lighter when he leaves for dialysis. R35 further reported he is blind and only smokes half of his cigarette, so he does not burn himself. R35 admitted he was supposed to forfeit his cigarette and lighter to the nurse, but he forgot to. On 02/26/25 at 08:09 AM, observed R35 in the common dining room tapping his green cigarette box on the dining room table. His lighter was observed to be on his left side visibly on top of the table. Other residents and staff members were around and the tapping sound he was making was audibly loud. When asking for the nurse, two staff members approached him, cigarettes and lighter visibly on the table. On 02/26/25 at 09:09 AM, a staff member was observed to take R35 outside, cigarette pack and lighter was visibly outlined in left breast pocket on his shirt. At 09:12 AM, R35 was observed smoking. On 02/27/25 at 08:59 AM, observed R35's cigarettes and lighter on the table in the dining room while he was eating breakfast. On 02/27/25 at 01:44 PM, a concurrent observation and interview was done with Resident Care Manager (RCM) 21 and Infection Preventionist (IP). Inquired about the facility's smoking policy on locking residents' cigarettes and lighter, RCM21 reported the facility locks up residents' cigarettes and lighter, and when a resident wants to smoke, they can request it from the nurse. There are no situations where a resident is allowed to hold on to their cigarettes or lighter in the facility. Concurrent observation of R35 in the dining room with his cigarettes and lighter on the table with RCM21 and IP. Inquired with R35 if the cigarettes and lighter was his on the table, R35 stated it was. IP confirmed the resident should not have had his cigarettes and lighter with him in the facility and reported it was for safety because the facility would not know if a resident smoked inside their room or somewhere in the facility, and there are residents that use flammable oxygen. Review of the facility's policy and procedure Smoking effective 04/02/22, documented Residents regardless of smoking privileges are not permitted to keep cigarettes, e-cigarettes/vaping devices, pipes, tobacco, and other smoking articles in their possession. Those grandfathered in prior to the date of this policy and assessed as safe to smoke on their own may keep their supplies in a locked box in their room when not in use, which will be audited regularly for safety. If resident is non-compliant, supplies will be removed from room .Smoking materials must be checked out and in with the nurse and stored by the nurse . 48351 3) R42 is a [AGE] year-old male, admitted to the facility on [DATE]. R42 has medical diagnosis include, but not limited to epilepsy. Multiple observations were conducted from 02/25/25 to 02/27/28 of R42's bed rails. The right side of R42's bed rail was covered with a blue padding. The left side bed rail did not have a blue padding. Record review of R42's Electronic Health Record (EHR) was conducted on 02/27/25. R42's EHR noted a progress note that on 02/26/25, R42 was witnessed having a tonic seizure during the evening. Interview was conducted with RCM54 in R42's room on 02/27/25 at 09:33 AM. RCM54 was shown R42's bed, which had the blue padding only on the right-side rail. RCM54 confirmed that seizure pads should have been placed on the left-side rail as well for R42's safety since he is on seizure precaution. A review of the facility document titled, Seizure management, with an effective date of 06/19/23 was conducted. The document noted, EQUIPMENT .Padding for side rails and bed headboard.

Based on observation, interview, and record review the facility failed to provide the physician ordered oxygen therapy during assistance with a meal for one of two residents (Resident (R) 2) sampled for oxygen use. This deficient practice has the potential for R2 to encounter difficulty breathing and discomfort. Findings include: On 02/27/25 at 07:58 AM, Certified Nurse Aide (CNA) 7 was observed removing R2's oxygen mask and replacing it with a nasal cannula. The flow rate of oxygen was observed to be set at five liters per minute via oxygen concentrator. CNA7 stated that she was informed by the nurse that the resident must always have oxygen on, and it was okay to replace the face mask with the nasal cannula. A review of the physician orders for R2 noted the following 06/05/21 oxygen order: Difficulty breathing: Oxygen 5-10 (five to ten) LPM (liters per minute) via face mask for SOB (shortness of breath) or SpO2 (oxygen saturation) < 90%. Special Instructions: Notify MD (physician) if O2 (oxygen) is applied or increased as needed. On 02/27/25 at 08:07 AM, Registered Nurse (RN) 4 was interviewed. She stated that when the resident eats, the face mask is switched to the nasal cannula and the certified nurse aides are aware to do that. She also confirmed that there was no order for that.

Based on interviews and record reviews, the facility failed to adequately assess for and identify past trauma experienced by one of one residents (Resident (R) 41) sampled for trauma-informed care (TIC). As a result of this deficient practice, R41 did not have her trauma triggers identified, placing her at increased risk of re-traumatization, and was hindered from attaining her highest practicable mental and psychosocial well-being. Findings include: R41 is a [AGE] year-old female admitted to the facility on [DATE]. A review of R41's electronic health record (EHR) noted that she was admitted with diagnoses that include cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). The initial physician (MD) 2 note for R41, dated 10/26/24, noted a psychiatric history of post-traumatic stress disorder with avoidant behavior. On 02/25/25 at 02:00 PM, R41 was interviewed in an unoccupied resident room (resident requested privacy) and stated that she is unable to sleep because of hearing other residents and past roommates having personal emergencies like falling out of bed and coughing all night. R41 also stated that loud disruptive noises and staff talking loud in the hallway keep her awake at night. On 02/27/25 at 09:33 AM, an interview with Director of Nursing (DON) was conducted. DON stated that Social Services Director (SSD) 46 meets with the resident on admission. If the resident has a history of trauma or PTSD then a TIC care plan should be initiated. On 02/27/25 at 09:42 PM, an interview and concurrent review of R41's care plan was conducted with SSD46. During the interview, SSD46 confirmed that there was no TIC care plan addressing R41's specific trauma triggers and needs. During concurrent review of the facility's TIC policy with SSD46, the following was noted: A resident will be screened for trauma upon admission, quarterly, annually, and as needed using the tool in the electronic medical record. SSD46 stated the quarterly screen was not done. On 02/28/25 at 07:19 AM, a review of R41's Comprehensive Care Plan and facility TIC policy was conducted. The TIC policy noted that trauma events and triggers identified through screening will be used to develop a care plan. Review of R41's Mood State care plan noted some resident triggers in the Problem area of that care plan. However, there were no interventions listed to address them.

Based on interview and record review, the facility failed to ensure that medication regimen irregularities/recommendations were addressed by the physician for one of five residents (Resident (R) 7) sampled for unnecessary medications. As a result of this deficient practice, R7 was placed at risk of avoidable complications related to continuing an as needed psychotropic (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) past 14 days without a clinical rationale. Findings include: R7 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of R7's Minimum Data Set (MDS) Quarterly Review Assessment with an Assessment Reference Date (ARD) of 12/03/24 noted that her diagnoses include, but are not limited to, dementia with behavioral disturbance-aggression, and left-sided weakness and paralysis following a stroke. A review of R7's electronic health record (EHR) noted the following open-ended physician order on 08/26/24: Lorazepam 0.5 mg [milligrams] PO [by mouth] or dissolve in water and place under tongue every 4 hours as needed for Anxiety. Review of R7's Medication Regimen Reviews (MRRs) revealed the following recommendation made by the pharmacist on 08/31/24: This resident is currently receiving the PRN [as needed] psychotropic medication lorazepam . Please provide a specific stop date or time period (e.g [sic] six months) AND a clinical rationale to continue PRN psychotropic medication past 14 days: The physician made the following response and signed the MRR form on 09/10/24: Nonpharmacological interventions are either ineffective or not practical for this resident's situation . Further review of the MRRs noted the pharmacist made the same recommendation the following month, on 09/30/24, however, this recommendation had no documented physician response. On 02/27/25 at 09:13 AM, an interview was done with Director of Nursing (DON) in her office. When asked about the MRR process, DON explained that the facility gives themselves thirty (30) days to receive and print the recommendations from the pharmacy, place it in the appropriate provider/physician binder, receive a response from the provider/physician, and make the appropriate changes to close it out. During a concurrent review of the 08/31/24 MRR recommendation, DON agreed that the physician response did not align with or address the pharmacist's recommendations, specifically, provide a specific stop date or time period . AND a clinical rationale to continue PRN psychotropic medication past 14 days. DON stated that either the Resident Care Manager (RCM) or DON should catch it when the provider/physician response does not match the pharmacist's request/recommendation. DON agreed that the inappropriate response should have been noticed and addressed with the physician prior to the receipt of the same recommendation being made the following month. Review of the facility policy and procedure Medication Regimen Review and Reporting, last revised 01/24, revealed the following: A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format . within 48 hours of completion. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days .

Based on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control measures for one of two residents (Resident (R) 35) sampled for Transmission Based Precautions (TBP). The facility did not ensure nursing staff hand hygiene between glove use while providing wound care for R35. This deficient practice has the potential to put residents at risk of spreading infections and communicable diseases. Findings include: R35 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis on right ankle and foot, stage 4 pressure ulcer of right heel, non-pressure chronic ulcer of right lower left with fat layer exposure and left lower left limited to breakdown of skin, local infection of the skin and subcutaneous tissue, and pseudomonas. Review of R35's Electronic Health Record (EHR) found R35 started contact precautions on 02/22/25 due to lab results of methicillin-resistant Staphylococcus aureus (MRSA) infection (a bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infection) to leg wound. On 02/25/25 at 11:47 AM, observation of Resident Care Manager (RCM) 21 and Director of Nursing (DON) cleaning and changing the wound dressing to R35's leg wounds was done. DON was observed to hold R35's right leg up, take off the old wound dressing and helped direct RCM21 with cleaning and redressing the wounds. DON and RCM21 ran out of the dressing and the DON directed RCM21 to ask for more silver alginate wound dressing. RCM21 took off her gloves, radioed for someone to bring more silver alginate, threw her gloves in the trash, walk to the entrance door to R35's room, grabbed a pair of gloves and donned them without hand hygiene between glove use. RCM21 proceeded to dress the wounds after receiving the silver alginate wound dressing. At 12:09 PM, after NM21 completed R35's wound dressing with DON, an interview with RCM21 was done. Inquired if she hand-sanitized before donning the new pair of gloves while providing wound dressing care for R35, NM21 confirmed she did not and stated she was supposed to hand-sanitize between gloves.

Based on interviews, document and record review (RR), the facility failed to provide one Resident (R)1 the right to equal access of quality care. Specifically, R1's primary language was Korean and the facility did not have an effective process in place to access interpreters. Due to this deficiency, staff were unable to communicate and understand R1's needs to provide her the quality of care she had the right to. This deficiency has the potential to affect any resident whose primary language is not English. Without appropriate communication, the resident's may not meet their highest level of physical and psychosocial well-being. Findings include: 1) R1 was an [AGE] year female admitted to the facility on [DATE], for short term physical and occupational therapy after a brief hospitalization for generalized weakness. Her primary language was Korean, she used hearing aides, and had mild cognitive impairment. R1's medical history included but not limited to anemia, chronic kidney disease, and Type 2 Diabetes on insulin. She required assist of one to transfer from wheelchair to bed. On 05/16/2024, R1 was transferred to the Emergency Department for psychiatric evaluation after she attempted self harm. She was readmitted to the facility the next day, and then discharged home on 06/16/2024. 2) Record review revealed the following nursing notes: 05/15/2024, 01:55 PM: Resident admitted at 11:30 AM from hospital.Mild cognitive impairment. Resident is alert and oriented 2-3 (alert and oriented to person, place and time, but not situation) ., Korean speaking primarily. Resident had hearing aids .Resident denies any pain at this time. 05/15/2024, 10:58 PM: .Resident is hard of hearing and Korean speaking. Resident is noted with difficulty understanding English and communicating with staff. At 1700 (05:00 PM) is noted with multiple attempts to stand from bed and self transfer. Resident noted with lower extremity weakness and trouble bearing weight. Resident transferred with wheelchair and with periods of agitation about wanting to go home. 1:1 supervision provided. Daughter updated and willing to drive to facility to attempt to calm Resident. Daughter on site for a few minutes then states she is leaving because she can not help Resident. She (R1) does not recognize her voice and unwilling to listen.Resident with ongoing agitation.Resident noted to purposely sit on ground from recliner and scoot to the door.Resident stated, I don't want to be here. I am going home.NP (Nurse practitioner) updated .with orders for PRN (as needed) Melatonin (for sleep).Resident continues with restlessness with constant 1:1 provided. 05/16/2024, 01:06 AM: NP notified for residents continued attempts to slide down/off wheelchair, lay on floor. Resident refused assistance to get back into wheelchair, or allow staff to assist into sitting position. Order to use GERI CHAIR (padded recliner, reduces fall and other injury risks) this shift.MD updated. Resident at this time is with CN (Charge Nurse) 1:1 Supervision, no behaviors, no attempts to get out of chair, resting with eyes closed. PRN melatonin given . 05/16/2024, 06:02 AM: Tolerated sitting in Geri chair during night, multiple attempts to continue to get out of chair. Resident given continuous 1:1 entire shift, .Resident cooperative with getting into wheelchair this morning. 05/16/2024 at 09:11 AM, entry by Resident Care Manager (RCM): Resident needing 1:1 assistance this morning. Per CN-resident with attempts to self harm with call light cord, bed remote and personal nail clippers. Items removed and safety ensured of resident.Resident primarily Korean speaking, but able to speak/understand some English words. Resident requesting to speak with Korean person via telephone. Provided assistance for resident. Resident wanting door and curtain closed for privacy.Resident prefers Korean foods. 05/16/2024, 01:50 PM: Spoke with NP and Physician (MD1) .MD1 requesting to have resident sent out 911 to hospital for further eval (evaluation). 05/17/2024, 01:30 PM: .Spoke with RN (Registered Nurse (at Hospital emergency room )) .No admission will be done, resident treated for UTI (urinary tract infection).No ETA (estimated time of arrival) on return back to facility . 05/17/2024, 06:12 PM: Late entry for 5/16/24 14:28 (02:28 PM). Noted with attempts to harm self. Using nail file on nail clippers repeatedly jabbing and poking at right wrist causing bleeding. Opening to skin is superficial.Resident assisted to bed and monitored with one to one.On call MD updated with self harm and refusal behaviors . 05/17/2024, 06:15 PM: Returned to facility in stable condition. Resident in no distress, calm and cooperative with care . 3) On 07/10/24 at 09:00 AM conducted a telephone interview with Licensed Practical Nurse (LPN), who admitted R1 on 05/15/2024. She said she received a telephone report from the hospital nurse and there was nothing out of the ordinary. She said when R1 arrived, she was kind of sleepy but was cooperative during the initial assessment and interactions that day. LPN said the report provided by the hospital appeared to be accurate and reflected how R1 presented. She went on to say she had been in orientation that day as a new LPN, so had a preceptor. She said she was still working as a CNA some shifts at the facility, and she came back the next day as a CNA. That morning, RN4 told her R1 had been 1:1 the previous shift. Asked her the process to obtain a translator, and she said she had not really encountered the situation and recalled having a pad to contact someone a few years ago. On 07/09/2024 at 05:00 PM, during an interview with RN2, the evening CN, he said R1 was restless and wanting to go home. RN2 said her daughter came in for a short period of time, but was unable to calm her. He said when he left that evening, R1 was still restless. RN2 said he called the DON (Director of Nursing) to update her on the situation, and confirmed there was a language barrier. He said they didn't have a translator that shift, but often use staff if on duty and translation apps (applications on the phone). RN2 said they really didn't know R1's baseline cognitive status because it was her first shift at the facility. On 07/10/2024 at 10:30 AM, conducted a telephone interview with RN3, the night nurse. She said at shift change, the evening charge nurse, said R1 kept forcefully sliding herself out of the wheelchair onto floor. They didn't want her to injure herself or fall, so let her lie on the floor. RN3 said she didn't want to leave her on the floor, so called the provider and got an order for the geri chair and kept her within eye sight. RN3 said she sat next to R1 to calm her when she was weeping, crying, a heartfelt cry. She (R1) kept repeating the same sentence and speaking Korean. I didn't know what she was saying. I didn't know what her story was, couldn't translate anything, and couldn't access anyone to translate. RN3 said R1 had her purse with her and wouldn't give it up, so couldn't inventory belongings in the bag. She said R1 was adamant she was not supposed to be there. Google translate was not working. I sat, she was talking, but no idea what she was trying to say. I wanted her to know we cared, so showed her I was actively listening. It seemed to calm her. She was needing to get what ever she had to say out. RN3 said she tried calling R1's daughter, but unable to reach her. Inquired what resources the facility had for interpreters, and she said they really didn't have anything place. RN3 went on to say she had worked in facilities that had access to a 1-800 interpreter service. I don't have a resource if someone comes in and there is a language barrier. There is no one to call. Common sense is to use Google translate when nothing else is available. RN3 said she had an orientee with her that night, who asked her about interpreters. On 07/09/2024 at 03:30 PM, interviewed the day Charge Nurse (RN4) on duty 05/16/2024. Her recall was the incident of self harm took place early AM, shortly after she arrived. She said R1 was lying in the hallway with her head on her purse. The off going RN (RN3) reported R1 had been agitated, didn't want to give up her purse or sleep in bed and had been monitored 1:1 all night. RN4 said R1 was at peace lying on the floor. She went on to say, later the CNA came to me and said R1 had a nail clippers and had self inflicted scratches on her arm. RN4 reviewed her progress note for that shift and confirmed it was a late entry and documented the day after the event occurred. RN4 said she had not cared for R1 before, so thought R1 may have had some behavioral problems and may even sleep on the floor at home. RN4 said she thought when R1 was admitted , someone was able to reach the daughter who provided all the information. She said if they couldn't find someone to speak the resident's language, they would go to management, or can do Google translate. On 07/10/2024 at 08:30 AM, interviewed the Unit Clerk (UC) assigned to monitor R1 after the incident of self harm. She said when putting R1 in bed, R1 kept grabbing at other objects or striking the rail to harm herself. UC said I kept telling R1, please don't do that, and R1 replied If not today, tomorrow. The UC interpreted this as R1 wanted to hurt herself. When asked the UC what resources the facility had for interpreters, she replied I know we do have something, but would have to ask. I would continue to ask until someone could assist me. On 07/09/2024 at 03:00 PM, during an interview with the RCM, she said if someone had a communication barrier, they would try to locate a translator and there is a bilingual access line. Inquired if any nurse could access the bilingual services, and she said I believe so, but was not sure of the specific guidelines. The RCM said she sat with R1 awhile after the incident, and during that time, R1 asked to talk to someone in Korean. She said at that time, she didn't know about the bilingual access line, couldn't reach the daughter, and ended up contacting one of her own family members, who speaks fluent Korean. The RCM went on to say she couldn't understand all that was said, but from what she understood, R1 didn't know why she was at the facility, seemed very confused and thought her daughter was coming back with food. She wanted the door closed and had Asian food preferences. Inquired how many Residents the facility had that did not have English as primary language, and she said a good handful. The RCM said when R1 was admitted , the daughter was not there, but believed the staff talked to her on the phone. On 07/10/2024 at 09:30 AM, conducted an interview with Social Services (SS). She explained she meets with all new admissions, and if the Resident is unable to communicate due to condition or language barrier, she will contact family to assist. SS said she was made aware of R1's intent to self harm on 05/16/2024, but had been off. The weekend was the 17th and 18th and her first day back, 05/19/2024 she saw R1. The intent of that first visit was to do the SS admission assessment as well as to follow up after the incident. SS said R1 could understand hand gestures and she said would repeatedly respond to questions by saying her daughter's name. Inquired if SS talked with R1 about the incident to assess her mental and emotional status, and she said she was calm and cooperative, and thought R1 understood what she was saying. SS said R1 kept saying I'm OK now, and Little pieces of English. Inquired what her practice was to complete assessments if residents primary language is not English, and she said in this case, the daughter was contacted and assisted in completion of the assessment. When asked if she used interpreter services for admissions, she said most times it is the family. SS said if she needed an interpreter, she would try to find someone in the facility. She said she had not used other (external) interpreter services while employed at the facility. On 07/10/2024 at 11:35 AM, conducted a second interview with SS and reviewed the 5 day MDS assessment. She confirmed the documentation on 05/19/2024, which indicated Section C (cognitive) and D (mood) were not completed, because R1 wouldn't answer questions. SS confirmed the PHQ9 (instrument for screening of depression and presence of suicide ideation), also was not completed. She said the only interpreter she used to communicate with R1 was her daughter. On 07/10/2024 01:11 PM, during an interview with the Administrator (ADM), she said Human Resources maintains a list of staff that speak other languages, and they try to utilize staff first for interpreting. If unable to find staff, the process would be to use the Bilingual access line. The ADM was unsure if the access line was available 24/7. 4) Reviewed the facility policy titled Resident Rights, original effective date 05/01/2022, last revised 10/01/2022. The purpose of the policy included To ensure that resident rights are respected, protected and promoted. The policy also included 1. The resident has the right to exercise his /her rights as a resident of the facility and as a citizen or resident of the United States.23. The resident has the right to be fully informed in language that he/she can understand of his/her total health status, including but not limited to his/her medical condition. Reviewed the facility policy titled Limited English Proficiency (LEP), effective date 11/17/2015. The policy included the following: Policy: [NAME] Pearl Rehab and Nursing will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy .to ensure meaningful communication with LEP patients/clients and their authorized representatives involving their medical conditions and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment .etc.Language assistance will be provided through the use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services. All staff will be provided notice of this policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective us of an interpreter. [NAME] Pearl Rehab and Nursing will conduct regular review of the language access needs of our patient population, as well as update and monitor the implementation of this policy and those procedures, as necessary. Procedures: 1.will promptly identify the language and communication needs of the LEP person. 2. Administrator and/or designee at [PHONE NUMBER] is/are responsible for: (a) maintaining an accurate and current list showing the name, language, phone number and hours of availability of bilingual staff; (b) Contacting the appropriate bilingual staff member to interpret, in the event that an interpreter is needed, if an employee who speaks the . (c) Obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak the needed language. Helping Hands Hawaii Bilingual Access Line has agreed to provide qualified interpreter services.Some LEP persons may prefer or request to use a family member or friend as an interpreter. However family members or friends of the LEP person will not be used as interpreters unless specifically requested by that individual and after the LEP person had understood that an offer of an interpreter at no charge to the person had been made by the facility. Such an offer of an interpreter and response will be documented in the person's file. If the LEP person chooses to use a family member or friend as an interpreter, issues of competency of interpreting, confidentiality, privacy, and conflict of interest will be considered.

Based on interviews, document review and medical record review (RR), the facility failed to ensure a person-centered comprehensive care plan (CP) was developed to address one resident's (R)1 needs of a sample size of three. R1 had significant hearing impairment, but the CP did not include this barrier to communication. As a result of this deficiency, the care team may not have been aware of her hearing impairment when interacting with her. There is a potential any resident may not reach their highest practical physical and psychosocial potential if their needs are not identified and addressed in the CP. Findings include: 1) R1 was an [AGE] year female admitted to the facility on [DATE], for short term physical and occupational therapy after a brief hospitalization for generalized weakness. Her primary language was Korean, she used hearing aides, and had mild cognitive impairment. On 05/16/2024, R1 was transferred to the Emergency Department for psychiatric evaluation after she attempted self harm. She was readmitted to the facility the next day, and then discharged home on 06/16/2024. 2) RR revealed the following progress note entries: 05/15/2024 at 01:55 PM, Nursing Progress New Admit note: .Resident is alert and oriented 2-3 (oriented to person, place and time), can response [sic], Korean speaking primarily. Resident has hearing aids . 05/15/2024 at 10:58 PM, Nursing Progress note: . Resident is hard of hearing and Korean speaking. Resident is noted with difficulty understanding English and communicating with staff. 05/24/2024 at 03:43 PM Social Services Progress note: . R1 is primarily Korean speaking, hard of hearing but uses hearing aids, . Reviewed R1's baseline care plan and comprehensive care plans, which included the following: Baseline CP dated 05/16/2024: .I communicate verbal. My preferred language is Korean. My hearing is adequate I need nothing to improve my hearing. Comprehensive CP included: - Resident does not speak in the dominant language of the facility. Primary language of resident-Korean. - Long term Goal .Resident will establish a reliable means of communication with staff. - Approach .Encourage resident to use gestures, communication board when expressing self. There were no updates or revisions throughout R1's stay regarding her hearing impairment. Reviewed the Minimum Data Set assessment dated [DATE], which documented in Section B-Hearing, Speech and Vision, R1 had minimal difficulty, for ability to hear, and that she used hearing aid or other hearing appliance. Review of the Emergency Department Provider notes from R1's visit on 05/16/24 revealed the following entries: .History is mostly from EMS (Emergency Medical Services) as the patient is Korean speaking only and is very hard of hearing.We did get the Korean translator system but she states that she cannot hear the Korean translator.Patient sent from rehab due to thoughts of harming self and potential aggression toward staff. She is calm here but there is a significant barrier due to her not having her hearing aids. We will try translator services and try to contact the care facility for hearing aid batteries. 3) Reviewed the facility policy titled Comprehensive Care plans, last revision date 05/23/2023. The policy included the following: Policy statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their lives. Policy: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided ., as outlined by the comprehensive care plan, shall be culturally-competent and trauma informed. 3. The comprehensive care plan will describe at a minimum the following: . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identify, as indicated.

Based on interview and record review, the facility failed to ensure the resident's (R)12's physician was notified after an incident that occurred resulted in an injury for one resident sampled. On 02/08/24, R12 reported that during physical therapy he experienced a loud crack and sharp pain to his hip when physical therapist (PT)1 pushed R12's left knee to the resident's chest. R12's physician and his treatment team were not notified of the incident which resulted in a left hip fracture that was delayed in diagnosis and treatment. On 02/26/24, R12 was transferred to a hospital for a surgical repair of the fracture. As a result of this deficient practice, R12 suffered pain, continued to decline and sustained harm. Findings include: Cross reference to F610 Investigation. During an interview with R12 on 03/20/24 at 2:40 PM in his room, he stated he recently had hip surgery. R12 reported during physical therapy during an assisted exercise of his legs, the physical therapist (PT)1 was pushing his legs to his chest. When PT1 extended his left leg on the third push to his chest, he heard a crack and felt a sharp pain. The PT1 then stopped and stated, All [NAME] (finished) for the day. Conducted a review of R12's electronic health record (EHR) of the incident. Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/22/23, documented in Section C. Cognitive Patterns, R12 scored a 15 out of 15, indicating the resident's cognition is intact. Reviewed progress notes of R12's reported incident: -02/02/24 at 8:50 PM, Nurse Practitioner (NP) in facility with new order to obtain x-ray of the left knee and left hip. Order carried out. -02/06/24 at 8:54 PM, NP in facility with new orders. Referral to orthopedic surgeon for further eval for osteo arthritis (OA) to left (L) hip and L knee (Send copies of recent x-rays). Start Tramadol (pain medication) 50 milligrams (mg) every night (QHS) for right (R) knee pain. Orders carried out. -02/07/24 at 08:10 AM, Received and reviewed progress note from NP facility visit on 02/2/24, seen for knee pain. See scanned note for details. -02/08/24 02:02 AM, Nurses notes. Resident complained of (c/o) 10/10 sharp pain to left knee whenever he moves it. Resident states he hurt it while he was in PT. Resident mention that the guy was pushing it down and lifting his knee against his chest and resident heard a loud crack noise. No sign of swelling or redness to area. Resident unable to fully make his left knee straight. Administered as needed (PRN) tramadol and hot pack. P: continue plan of care. Review of R12's progress notes after reporting the incident to registered nurse (RN)99. -02/12/24 02:43 AM, resident awake when entering room to care for another resident, resident voiced he was in pain to the right lower extremity (RLE). The resident was asked to rate it and voiced 5/10. Resident was given the option of PRN Tylenol or PRN tramadol; residents request was PRN tramadol. Given 0244. -02/13/2024 at 4:12 PM, NP in facility with new orders. Apply a small amount of Voltaren to L hip and L knee and reposition. Offer heat packs PRN. Orders carried out. -02/14/24 at 1:45 PM, Received and reviewed progress note from NP facility visit on 2/6/24, seen for follow up on pain. See scanned note for details. -02/15/24 at 13:59, medical doctor (MD) in facility. Reviewed x-ray on 2/3/24, see scanned note for details. -02/19/24 at 2:32 PM, .Resident states that he is unable to move left knee since two nights ago. Residents had complaints of pain to L knee . -02/20/24 at 5:11 PM, NP in facility with new orders to repeat X-ray of L hip and L knee for Diagnosis (Dx). Pain. Orders carried out. Imaging to be here late this evening. -02/20/24 at 8:20 PM, Received X-ray results: L knee unchanged. L hip: New acute avulsion fracture involving the lesser trochanter, along the attachment of the iliopsoas tendon. Called physician, awaiting call back. Notified director of nursing (DON). - 02/23/24 at 9:48 PM, Resident continue to have left hip pain 10/10, noted left leg unable to move .New order to send resident to . (acute hospital) .for evaluation. Acute lack of sensation to left lower extremities (LLE); diminished sensation to RLE .Resident left facility at 9:40 PM -02/24/24 02:27AM, Called Emergency department for an update on resident. Resident was admitted for Hip fracture. DON and resident clinic manager (RCM) notified. Review of provider notes documented: - 02/13/24, NP1 documented, He presented in stable condition but noted to still have pain to his left knee and hip at rest and with movement. He notes pain cream was effective to left knee but had not tried to hip. Reported tramadol was effective during night to both led hip and knee pain. Was still able to reposition left leg but limited ROM (range of motion). Noted PT was held due to (d/t) pain. Requested for trial of pain cream to hip and encouraged him to request for PRN tramadol during day if needed since only scheduled QHS. Discussed if pain did not improve will repeat imaging. - 02/20/24, NP1 documented, -Since x-ray on 2/3, he initially reported pain improved with tramadol, pain cream, and repositioning of left side. Prior ortho referral was still pending. - Today registered nurse (RN) reported he was not able to move his left leg. During the visit, he noted he was also unable to tolerate turning side to side with certified nurse aide (CNA). During the exam, he was not able to move or straighten his leg and noted to have more tenderness to his left hip and surrounding area. No warmth, edema, erythema noted. Still had lack of sensation below the knee, which he stated having in the past but intact sensations proximal from knee. Skin remained warm to touch along with extremity, given pain progressed, he agreed to repeat x-ray. -02/23/24, NP1 documented, Today during his visit, he noted since he was last seen, he lost sensation to his left upper leg and knee as well as right upper leg. Of note, had loss of sensation below knee which was his baseline. The pain to L-leg described as sharp but still unable to move but noted Tramadol; was slightly effective. During exam, he was noted to also loss sensation to his left hip and surrounding area upon palpation, which he had pain to on Tuesday . Review of x-ray results taken on 02/03/24 documented .No obvious displaced or impacted fracture noted at this time No evidence of osteomyelitis . A second x-ray taken on 02/20/24 documented There is an avulsion fracture of the lesser trochanter, new from prior . An avulsion fracture occurs when an injury causes a ligament or tendon to break off (avulse) a piece of a bone that's attached to it and usually happens as the result of a traumatic injury or explosive movement. Indicating an incident with force needed to have happened for this type of injury to occur. On 03/20/24 at 2:55 PM, conducted a confidential interview with direct care staff (DCS). Inquired regarding R12's level of function prior to sustaining a left hip fracture. DCS1 and DCS2 confirmed prior to physical therapy, R12 was able to move his lower extremities, but was unable to bear weight. Both DCS confirmed R12 informed them that during a physical therapy session, there was a loud pop, then sharp pain, then over the next couple of days the resident's pain increased and his movement decreased to the point R12 decided he shouldn't do physical therapy, related to the pain. Inquired with both staff about R12's cognition and if the resident is a reliable source of information. DCS1 and DCS2 confirmed R12 is a reliable source of information, and the resident is alert and oriented to person, place, time, and situation. On 03/21/24 at 3:45 PM, conducted an interview with the DON, resident care manager (RCM)1 and RCM2 regarding the facility's investigation of R12's hip fracture. Reviewed the facility's investigation which was submitted to the state agency (SA). Informed the DON, RCM1, and RCM2 about the progress note written on 02/08/24 by RN99 during which R12 informed the staff of an incident during physical therapy regarding the resident hearing a loud crack and felt a sharp pain. Inquired if the facility was aware of the situation. DON, RCM1, and RCM2 reviewed R12's EHR, the facility's morning meeting huddle information and all other additional documents then confirmed the facility was not aware of R12's report of the incident to RN99 and it was not investigated as a potential source of R12's left hip fracture. RCM1 and RCM2 both confirmed R12 is a reliable source of information. On 03/22/24 at 08:54 AM, conducted an interview and concurrent record review with NP1. Inquired if NP had been informed that R12's verbalized incident during a physical therapy session, where PT1 assisted the resident with range of motion and the resident heard a loud crack and experienced a sharp pain. NP1 confirmed she was not notified of the incident. Reviewed R12's progress notes and inquired if she had been informed of the incident would the course of treatment have been different. NP1 confirmed, the course of treatment would have been different, an x-ray would have been done on 02/08/24 to ensure there was no injury to the resident. The identification of an injury would have ended all future physical therapy sessions, and the resident would have been sent out to an acute setting for further treatment. NP1 confirmed R12's treatment was delayed 12 days. NP1 stated she was in close communication with R12's physician and confirmed they both were not informed of R12's report of the incident. Review of the facility's policy and procedure, change in a Resident Condition of Status, revision date 05/19/23, documented .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): 1. accident or incident involving the resident; b. discovery of injuries of an unknown source .

Based on observation, interview and record review, the facility failed to maintain the dignity of one of the 14 residents (R) in the sample. The urinary catheter bag for R101 was not covered and visible from the hallway, revealing his medical condition to other residents and visitors to the facility. This deficient practice has the potential to affect all residents in the facility with an indwelling urinary catheter. Findings include: R101 is an [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation and wound care. R101 had an indwelling urinary catheter (flexible tube placed in the body to drain and collect urine from the bladder) to prevent getting the wounds to groin area wet. On 03/19/24 at 08:47 AM, observed R101 lying in bed in his room watching videos on his tablet. R101's bed was positioned closest to the door and is visible from the hallway. The collection bag for his indwelling urinary catheter was hung on the right side of his bed facing the door. There was no cover for the bag. On 03/21/24 at 3:01 PM, an interview was conducted with Licensed Practical Nurse (LPN) 50 just outside of R101's room. Asked LPN50 what was the reason they cover the collection bag for the indwelling urinary catheter. LPN50 responded The cover for the bag is used to maintain the resident's dignity. LPN50 added. It's supposed to be on the collection bag all the time, even when they get up on their wheelchairs. Review of R101's baseline care plan done. Under the problem Indwelling Catheter, intervention included but not limited to, Keep drainage bag below level of bladder. Place in dignity bag.

Based on interview and record review, the facility failed to ensure an injury of unknown origin was thoroughly investigated for one resident sampled. On 02/25/24, the facility submitted a completed event report for resident (R)12 who sustained a left hip fracture, origin of the injury was not known. The investigation report did not include documentation of R12's incident during physical therapy that was reported to nursing staff. Interview of staff responsible for completing the investigation confirmed the facility was unaware of the resident's report and the incident during PT could have potentially been the source of R12's injury. The investigation was initiated by the facility after becoming aware of R12's left hip fracture. As a result of this deficient practice, the Resident experienced a delay in the diagnosis and treatment of a left hip fracture. Findings include: Cross reference F580- notification of physician. Conducted a review of R12's electronic health record (EHR). Initial x-ray results take on 02/03/24 documented No obvious displaced or impacted fracture noted at this time No evidence of osteomyelitis . A second x-ray taken on 02/20/24 documented There is an avulsion fracture of the lesser trochanter, new from prior .An avulsion fracture occurs when an injury causes a ligament or tendon to break off (avulse) a piece of a bone that's attached to it and usually happens as the result of a traumatic injury or explosive movement. Indicating an incident with force needed to have happened for this type of injury to occur. On 03/21/24 at 3:45 PM, conducted an interview with the director of nursing (DON), resident care manager (RCM)1 and RCM2 regarding the facility's investigation of R12's hip fracture. Reviewed the facility's investigation which was submitted to the state agency (SA). Informed the DON, RCM1, and RCM2 about the progress note written on 02/08/24 by RN99 during which R12 informed the staff of an incident during physical therapy regarding the resident hearing a loud crack and felt a sharp pain. Inquired if the facility was aware of the situation. DON, RCM1, and RCM2 reviewed R12's EHR, the facility's morning meeting huddle information and all other additional documents then confirmed the facility was not aware of R12's report of the incident to RN99 and it was not investigated as a potential source of R12's left hip fracture. RCM1 and RCM2 both confirmed R12 is a reliable source of information.

Based on observation, interview, and review of the facility's policy and procedure, the facility failed to ensure the controlled drug records were reconciled between shifts. The deficient practice potentially places the facility at risk for the diversion of controlled medications. Findings include: On 03/21/24 at 09:08 AM, while conducting medication administration observations with registered nurse (RN)19, staff proceeded to initial the controlled medication reconciliation count sheet, for the off-going (11 PM- 7 AM) shift and the on-coming (3 PM-11 PM) shift. Inquired with RN19 what the facility's procedure is for verifying the count of the controlled medications between shifts is. RN19 stated the off-going shift and the on-coming shift nurses do the count together and sign the sheet once the count is completed and correct. RN19 stated, I probably shouldn't have done this in front of you, then confirmed he/she did not sign the controlled medication reconciliation sheet in the presence of the off-going nurse and pre-signed the form for the on-coming shift and by doing so there is an opportunity for an error in the reconciliation of the controlled medication(s). While conducting an interview with the director of nursing (DON) on 03/21/23 at 3:45 PM, informed the DON of observation of RN19 not signing the controlled medication reconciliation in the presence of the off-going or on-coming shift. DON confirmed for the facility to ensure all controlled drug counts are in order and accurate, staff is required to reconcile the controlled medication between shifts, and the nurses should be signing (initialing) the reconciliation sheet in the presence of each other right after the count is confirmed. Review of the facility's policy and procedure, 7.4 Controlled Substances (01/23), 7. At each shift change, a physical inventory of controlled medications, as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record.

Based on observation, interview and record review, the facility failed to label medications in accordance with acceptable professional standards. Proper labeling of medications is necessary for safe administration practices and to decrease the risk of medication errors. This deficient practice has the potential to affect all the residents in the facility. Findings include: On 03/20/24 at 08:03 AM, observed Licensed Practical Nurse (LPN)23 during the morning medication pass. While LPN23 was preparing the medications for Resident (R)252, observed the box for the inhaler (device used to deliver medicine into the lungs) with no open and discard dates. On 03/20/24 at 09:41 AM during a concurrent interview with LPN23 and inspection of the medication cart for the Ilima wing, LPN23 confirmed that the inhaler for R252 was supposed to be labeled with the open and discard dates. Review of the facility policy titled Medication Storage stated, . 10. Medications, . need to be labeled when opened. It [sic] using a label tag that requires open and discard dates, these should be filled in appropriately.

Based on observations, record reviews and staff interviews, the facility failed to ensure one of 22 residents (Resident (R) 20) sampled was free from accident hazards from the use of an electric heating pad. As a result of this deficient practice, R20 sustained second-degree burns to both left and right calf areas. Findings include: Cross Reference to F600 (Free from Abuse and Neglect). The facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Cross Reference to F609 (Reporting of Alleged Violations). The facility failed to report suspected neglect to the Stage Agency. Cross Reference to F610 (Investigate/Prevent/Correct Alleged Violation). The facility failed to investigate and prevent further potential neglect after R20 sustained second-degree burns from the use of a heating pad. R20 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include paraplegia (paralysis affecting lower half of the trunk and legs), type 2 diabetes mellitus (high blood sugar) and peripheral vascular disease (narrowing of blood vessels reducing blood flow to the limbs). On 02/28/23 at 10:37 AM, observed R20 lying in bed sleeping. Both legs were elevated off the bed with a pillow to both heels and noted ace wrap to left and right calf area. On 02/28/23 at 11:53 AM, observed R20 still in bed sleeping, but ace wrap to both left and right calf area were removed and revealed open wounds. On 02/28/23 at 12:23 PM, observed Licensed Practical Nurse (LPN) 2 by R20's bedside and both legs were now wrapped with light brown colored bandage. LPN2 said the wound nurse just finished changing the dressing. Interview with R20 done on 03/01/23 at 09:26AM. When asked about wound to calf area on both legs, R20 replied they are burns from a heating pad that happened in May 2022. R20 said, I asked a nurse to place an electric heating pad under my legs before I went to sleep, and it was left on overnight. R20 also said, I did not feel it burning since I can't feel anything down there. On 03/01/23 at 12:30 PM, asked Administrator if an investigation was done for the above incident and if they could supply us a copy along with the facility's policy on electrical heating pads. At 02:00 PM, Administrator provided investigation report and said there is no policy for heating pads since they are not allowed in the facility. Review of investigative reports revealed that the blister was noted on the evening of 05/18/22, and that the resident asked a girl form eve (evening shift) to apply the heating pad. The heating pad was seen on R20's wheelchair on the morning of 05/19/22. R20 did not want to disclose who gave her the heating pad. Review of witness statements revealed that on 05/15/22 (no time noted), a certified nurses' aide (CNA) 1 noticed the electric heating pad on R20's right leg and was asked by R20 to remove it. CNA1 also stated that she did not inform the charge nurse because she thought it was okay to use the heating pad. CNA13 stated that on 05/17/22 after R20 was transferred into her bed after dinner, R20 asked her to get the heating pad from her bag, put it in a pillowcase and place it on top of the wedge used to elevate her calves. R20 also asked CNA13 to put it on the highest setting. CNA13 stated that the heating pad was in use from 08:00 PM to 10:30 PM. She also stated that she did not inform the nurse or oncoming CNAs that the pad was being used and the reason R20 wanted to use it was to relax her muscles. CNA1 stated that on 05/18/22, she noticed a big blister on R20's left leg and reported it to her charge nurse around 05:00 AM. Nurse Manager (NM) 3 stated that on 05/18/22, she was called to assess fluid area on legs. Noted bubbled blister on right and left leg, intact with fluid. R20 also with pitting edema (swelling from too much fluid buildup in the body, when pressure is applied to the swollen area, a pit, or indentation, will remain) to both legs. NM3 stated that there is nothing on the bed that could be the cause of the blisters. CNA17 stated that on 05/19/22 while getting R20 ready to come out of her bed, she noticed a heating pad on R20's wheelchair. CNA17 told R20 that heating pads were not allowed in the facility. When asked if that is what caused the blisters on her legs, R20 said Yes. When asked who placed the heating pad under her legs, R20 said A girl from eve (evening shift). NM3 stated that on 5/19/22, she spoke to attending physician and was told that the blisters were second degree burns from a heating pad. R20 verbalized getting the heating pad from another resident on another unit. On 05/19/22, when a resident was shown the heating pad, she stated I gave it to the Hawaiian lady, she said she was cold on her legs. Review of electronic health records (EHR) done. In Progress Notes dated 05/18/22, at 06:50 AM the nurse documented, This writer was informed that the resident had a blister on her right outer aspect of heel. Blister is intact, measuring 2cm (centimeters) x 1cm. Findings reported to day (day shift) nurse. Will continue to monitor. On 05/18/22 at 14:30 PM, the nurse documented, While providing ADL's (activities of daily living - basic tasks like personal hygiene, grooming, dressing and eating), staff noted skin problem to BLE (both legs). Pt noted to have two fluid-filled blisters to lateral (side of) RLE (right leg) measuring 1x1.5 cm and 2x1 cm. Pt also has a fluid filled blister to posterior (back of) LLE (left leg) measuring 20x9 cm. Daiya Healthcare notified w/ (with) no new orders. Pt's (patient's) emergency contact, . also notified. Pt voices no c/o (complaints of) pain or discomfort to BLE. On 05/19/23 at 07:28 AM the nurse documented, .This writer was informed that the resident's blisters had popped. Will endorse day nurse to further assess when lighting is better and resident is awake. Will continue to monitor. On 05/19/22 at 13:28 PM the nurse documented, Charge nurse starting treatment for resident's burst blister to RLE. Stated resident had burns and MD (attending physician) was in to assess resident's blisters. RLE burst blistered area 7.0 x 10.0cm, . LLE with larger intact serous-filled blister 25.0 x 13.5cm. Asked resident what happened and stated I don't want to say who gave me the pad. I don't want them to get in trouble. No sore. I'm paralyzed down there. Explained needed to do teaching with whoever gave her pad and with staff; however, she didn't want to speak about it. Stated, You can throw it away. Heating pad taken from room and discarded. MD stated that burns were 2nd degree. Administrator notified. In Admission Agreement, it was documented that, . items that are not permitted at Ann Pearl which include but are not limited to: coffee pots, electric blankets, heating pads, heaters and weapons.

Based on observations, record reviews and interviews, the facility failed to provide resident centered needed care and services for three residents, R159, R20, and R47, out of a total of 17 sampled residents. The facility did not follow the physician ordered bowel regimen for R159 and R20, which resulted in a family member performing digital stimulation on R159. R159 and R20 potentially suffered discomfort and fecal impaction. R47 did not receive the appropriate care for her swollen legs and monitoring of her left kneecap for possible displacement. These deficient practices could potentially affect all residents in the facility. Findings include: 1) R159 was admitted to the facility on [DATE] and discharged to home with hospice on 08/13/21. Residents' primary language is Korean. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Event Report completed by the facility on 07/30/21, the facility reported during routine rounds on 07/28/21 at 08:00 AM, R159 was assessed to have multiple purple bruises on her buttocks and anal area. Medical Director assessed bruises and felt that they were likely trauma related as they were not over bony prominences and due to the fact that the daughter had stated yesterday that resident has difficulty pooping sometimes so she massages resident and pokes her. Daughter clarified poking to mean performing digital stimulation [involves moving the finger around in a circular motion inside the rectum to stimulate the bowel reflex]. On 03/10/22 at 11:16 AM interviewed Infection Preventionist (IP), IP clarified on 07/27/21, prior to the discovered bruising, in the care plan meeting R159's daughter .shared her mom has poor output and she massages and pokes her mom . Which raised a red flag . IP did not know when and how often R159's daughter performed digital stimulation at the facility. IP shared R159 did have a history of constipation and was on bowel medication. Inquired what the protocol is for a resident who is constipated, .the nurses look at the bowel regimen. Prune juice day two, then milk mag. (milk of magnesium) day three . Concurrent review of R159's daily bowel movement output log and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . IP confirmed R159 was not administered the PRN (as needed) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inquired if the bowel protocol should have been implemented from 07/15/21 to 07/21/21, IP stated the protocol should have been implemented, .the physician should have been called and it should have been documented. Review of R159's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Infection Preventionist (IP) and Director of Nursing (DON) on 03/11/22 at 08:39 AM, IP stated the facility was aware R159 was constipated. On 03/11/22 at 10:15 AM, reviewed R159's nursing progress notes, on 06/24/21 resident with no BM (bowel movement) since 6/21/21, suppository administered. On 06/27/21, Observed resident with her gesture that she wanted to move her bowel. Resident on 3 days no BM. On 06/29/21 .resident needing frequent PRN medications to help with constipation, resident shows signs of grimacing and would occasionally yelp. Talked to resident's daughter and she said resident is constipated. on 07/01/21 in the care conference summary it was noted Daughter mentioned that resident has been complaining of pain upon having a bowel movement. Dietary to add papaya and prune juice to assist. In another note dated 07/01/21, Dtr. (Doctor) concerned about BM pattern. Resident has small BM on 06/30/21 . On 07/25/21, Saline enema administered for 3 days no BM resident in distress, produced medium formed stool and resident expressed relief. On 07/29/21, Resident daughter shared in care plan meeting that she performed an attempted rectal digital dis-impaction [a large, hard mass of stool that gets stuck so badly in your colon or rectum that you can't push it] outwithout nursing staff being aware. Daughter educated that any and all needs of the residents need to be performed by nursing staff only. During a follow-up interview with IP on 03/11/22 at 12:51 PM and concurrent review of R159's daily bowel movement output log and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross reference to F610. The facility failed to complete a thorough investigation of abuse. The facility concluded the bruises around R159's buttocks and anus area were because of R159's daughter massaging and performing digital stimulation due to constipation, with no documentation of interviews with R159, the daughter, and other staff members after the bruises were discovered. Cross reference to F657. The facility failed to revise R159's plan of care (POC) to include treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2) R20 was admitted to the facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/08/22 at 09:30 AM a resident interview done, the resident reported having constipation, sometimes going three to four days without bowel movement. Further queried whether he is offered medication, resident responded he doesn't worry about that and then it just comes out. On 03/09/22 at 2:45 PM a record review was done which found a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's output for January 2022, notes R20 did not have bowel movement from 01/05/22 to 01/07/22 and 01/28/22 to 01/31/22. In February 2022, R20 did not have bowel movement for the following periods, 02/01/22 to 02/07/22, 02/12/22 to 02/17/22, and 02/19/22 to 02/27/22. A review of the MAR for January and February could not find documentation that the physician ordered bowel regimen prescribed was implemented. A review of the nursing progress notes found refusal of interventions that were offered on 02/19/22, 02/25/22, 02/26/22, and 02/27/22. There is no documentation R20 was offered interventions during a five day period, from 02/20/22 to 02/24/22. R20 did not have bowel movement from 03/04/22 to 03/07/22. There is no documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview and concurrent record review was done with Infection Preventionist (IP) on 03/11/22 at 08:54 AM. IP confirmed R20 did not have bowel movement for two days (01/05/22 to 01/07/22), however, reported prune juice would have been offered on the 01/08/22. IP confirmed R20 did not have bowel movement from 01/28/22 to 01/31/22 and there was no documentation of R20 refusing any interventions. Reviewed the output and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . IP confirmed R20's bowel regimen was not implemented during the following time periods, 02/03/22 to 02/06/22 (four days), 02/12/22 through 02/17/22 (six days), and 02/19/22 through 02/27/22 (nine days) and 02/20/22 to 02/24/22 (five days). The IP confirmed there was no documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . IP confirmed R20 had no bowel movement from 03/04/22 to 03/07/22 and there is no documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) On 03/08/22 at 09:18 AM, an initial observation of R47 was done. R47 was sitting up in her wheelchair watching television in the activity room. Her left foot was visible underneath her blanket. It was swollen. Both of her legs were close to the ground. On 03/08/22 at 12:05 PM, R47 was sitting up in her wheelchair in the activity room watching television and eating her lunch. Both of her legs were close to the ground. On 03/08/22 at 12:30 PM, R47 was sitting up in her wheelchair, her legs close to the ground. She was observed to be asking Registered Nurse (RN)6 to go back to her room. RN6 stated that she would need assistance back to her room and there was no staff available to help her. On 03/08/22 at 1:00 PM, observed R47 assisted back to bed by CNA4. R47 stated that she was tired and that her legs were swollen. CNA4 stated that she will notify the nurse regarding her swollen legs. On 03/08/22 at 1:07 PM, R47 was interviewed in her room. She stated that she formerly worked as a nurse. She also stated that her legs were swollen, but denied any pain. Her legs were not elevated on pillows. On 03/09/22 at 08:39 AM, R47 was observed to be sitting up in her wheelchair, her legs low to the ground, eating her breakfast. At 09:34 AM, Physician's Assistant (PA)2 visited R47. The PA assessed R47's feet and stated that they were swollen. The PA2 instructed her to keep her legs elevated. On 03/10/22 at 08:11 AM, R47 was eating her breakfast in the activity room and a black splint was noted on her left lower leg. Her legs were noted to be swollen. Her legs were low to the ground. At 08:26 AM, R47 wheeled herself from the activity room to the dining room. Both of her legs were close to the ground. CNA4 assisted R47 to the restroom. At 08:40 AM, R47 was back in the activity room watching television. Both of her legs remained close to the ground. On 03/10/22 at 12:00 PM, a record review was done of R47's electronic health record (EHR). Discharge Summary from a hospital dated 12/13/21 stated that she had a left kneecap fracture that was nondisplaced, or the bone was cracked in only one place that did not change the alignment of the knee, which did not require surgery. But if her knee did become displaced, then surgical intervention would be needed. R47 is an [AGE] year-old female admitted to the facility on [DATE] for dementia, fracture of left humerus (left upper arm), fracture of left patella (kneecap), difficulty in walking, muscle weakness, and fall. R47's POC, last reviewed/revised on 02/14/22, was read. The only entry regarding her left kneecap fracture was: Resident has complaints of acute pain R/T [related to] fracture of left humerus and left patella fracture. Intervention included: Left knee immobilizer to be used as ordered. There were no interventions to monitor and treat for leg swelling and possible displacement of her left kneecap. Further review of R47's EHR revealed that there was no note by the PA2 regarding the education given to R47 to keep her legs elevated for the swelling and no order to keep R47's lower extremities elevated. On 03/10/22 at 12:09 PM, the facility's policy Care Plans, Comprehensive Person Centered was reviewed. It stated, .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. On 03/11/22 at 10:20 AM, RN6 was interviewed at the unit's nursing station. She stated that R47's legs should be elevated because they were swollen and that the RCM will revise the care plan after she reviews the resident's health record. Cross reference to F725. R47's request to go back to bed was not accomodated due to the insufficient number of nursing staff.

Based on record review and interviews, the facility failed to prevent the development of multiple pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) in one resident, R48, out of a total of 17 sampled residents. The facility did not obtain the orthopedist consult which provided instruction for the removal of a boot used for R48's left ankle fracture to assess the skin on regular intervals. This deficient practice resulted in the development of avoidable multiple pressure ulcers and could potentially affect all residents. Findings include: R48 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review was done on 03/10/22 at 07:15 AM. A progress note documented on 09/27/21 at 07:26 AM, R48 complained of pain to her left foot and ankle. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R48 was seen by the orthopedist and returned to the facility with a left leg cast on 10/05/21. The nurse that accompanied R48 to the orthopedist reported R48 needs to wear the leg cast 24/7 (24 hours, seven days a week). R48's physician was notified on 10/05/21 at 12:02 PM and ordered aircast to left leg be worn 24/7 until further notice. Progress note dated 10/24/21 documents weekly skin check was performed. The assessor noted three pressure ulcers under R48's air cast to the left lower extremity. R48 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A second unstageable pressure ulcer was identified to the ball of the left foot, measuring 2 cm (L) by 6 cm (W) and covered with yellow tissue, unable to determine the depth of injury. The third pressure ulcer was assessed as a Stage Two (superficial tissue injury) to the bottom of the second toe on the left foot, measuring 1.4 cm (L) x 1.5 cm (W) with beefy red wound bed. Assessor also noted purulent exudate on the foot and air cast. R48 reported pain to her foot. Review of skin assessments found no documentation of assessments were performed from 10/05/21 (application of boot) through 10/16/21. The skin assessment for 10/17/21 documents no new skin issues noted. Skin was warm, dry, normal color, no petechiae, normal skin turgor, and no alterations to the skin. Interview and concurrent record review were done with the Infection Preventionist (IP) and Director of Nursing (DON) on 03/11/22 at 09:19 AM. Staff members confirmed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff members confirmed skin assessments were not done from 10/05/21 through 10/16/21. Inquired how would nurses assess R48's skin while wearing a boot? IP responded, the order was not to remove the boot so the nurse would assess the skin that is not covered by the boot, pain, temperature changes, and areas that could contribute to a pressure ulcer. Requested to review the orthopedist consult note, the type of boot the resident was wearing, and what lead to the nurse opening the resident's boot on 10/24/21. Interview, review of requested documentation, and record review were done with the Administrator, DON, and Regional Clinical Operations Specialist (RCOS) on 03/11/22 at 10:13 AM. RCOS confirmed that there was miscommunication regarding the orthopedist's instruction for R48 to wear the boot 24/7. A copy of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RCOS reported the facility was following the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The team confirmed the facility did not obtain the orthopedist report and the reports were requested on 03/10/22. The orthopedist report was provided for review on 03/11/22 at 11:28 AM. Review of the orthopedist report, dated 10/05/21 documents the following, This CAM [Controlled Ankle Movement boot is an adjustable device that limits ankle and foot movement which is comprised of a flexible liner which the foot fits into and a rigid shell supports and protects the leg] boot can be removed or repositioned as necessary to keep the patient in a position of comfort and to assess the skin on regular intervals for reassessment. The facility provided documentation of weekly skin assessment for 10/17/21 and 10/24/21. RCOS reviewed the progress notes for possible documentation of skin assessments from 10/05/21 through 10/17/21. It was confirmed weekly skin assessments were not done during this period. RCOS was unable to recall what type of boot R48 was prescribed. The DON reported due to the use of a boot, R48's skin should be checked for sensation, color, temperature and swelling. Staff members reported, R48's boot was removed on 10/24/21 due to foul-smelling odor as documented in the progress note. Cross Reference to F689. As a result of improper transferring, R48 sustained an avoidable injury, left tibia/fibula fracture to her left foot.

Based on observations, interviews, and record reviews, the facility failed to establish a prevention control program to provide safety and protection for the residents of the facility. Immediate Jeopardy (IJ) was identified on 02/09/21 at 01:06 PM, the facility failed to isolate and place a resident on droplet precautions when the resident presented with signs and symptoms (fever, nausea, vomiting, and chills) of COVID-19 and screened positively for a person under investigation. The facility's noncompliance could result in serious adverse outcomes (spread of COVID-19 to facility staff and other residents and possibility of COVID-19 related deaths). The need for immediate action was required to prevent a COVID-19 outbreak. The facility also failed to assure: residents were prevented from entering the yellow zone (unit reserved for newly admitted residents or residents under investigation for COVID-19; staff members did not don and doff appropriate personal protective equipment while on the yellow zone; staff member did not demonstrate proper technique for cleaning of bodily fluids; staff member utilized proper hand hygiene practices; proper set up of room for resident on contact isolation (the biohazard bin for doffing personal protective equipment was placed outside of the room); storing activity item in an unsanitary location; and storing scoopers in powder. Findings include: 1) R15 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/05/21 at 07:55 AM, observed Certified Nurse Aide (CNA)23 exiting R15's room with an emesis basin. CNA23 later confirmed R15 had vomited and was not feeling well. During the observation, this surveyor noted there were no isolation precaution or droplet precaution signs posted outside of R15's room. In addition, staff did not don the personal protective equipment (PPE) while assisting R15 and roommates and no PPEs located outside of R15's room for staff use. On 02/08/21 at 09:00 AM, reviewed R15's medical record. It was documented in the progress notes on 02/05/21 at 07:36 AM, R15 first presented with two (2) episodes of emesis, a temperature of 99.6° Fahrenheit (F), nausea, and chills. At 7:30 PM, R15 had emesis, temperature of 100.9°F, staff administered Acetaminophen 650 mg, and rechecked R15's temperature (99.5°F). At 11:45 PM, R15 had a fourth episode of emesis and a temperature of 101°F. Nursing staff administered a COVID-19 test on 02/06/21 at 00:29 AM which was negative. On 02/09/21, conducted a review of R15's COVID-19 Screening Tool, completed by the Infection Preventionist (IP) on 02/05/21, due to R15's elevated temperature, vomiting, nausea, and chills. The screening tool evaluates four (4) clinical features and epidemiological risk, which includes other symptoms associated with COVID-19 and at risk for severe disease. The IP circled chills and nausea/vomiting as other symptoms. According to the evaluation instructions R15 should have been considered a positive screen for a person under investigation (PUI). If the screen is positive, staff is prompted to first report findings the primary care physician (PCP), IP, Medical Director (MD), and the Director of Nursing (DON) to determine if criteria is met for PUI, then isolate the resident. On 02/09/21 at 09:15 AM, conducted an interview with the DON and the IP. It was initially explained to this surveyor the screening tool includes a dialogue with the MD and PCP then they use the tool to decide if the resident is a PUI. However, later in the interview, the IP stated the screening tool is used to assist nursing staff with reporting to the physician in an SBAR (Situation, Background, Assessment, Recommendation) format. Inquired if there is a process for completing the COVID-19 Screening Tool in the facility's COVID-19 Mitigation Plan. IP stated the COVID-19 Screening Tool is just a tool used to identify if the criteria for a PUI is met. If they are identified as a PUI then they are isolated for suspected COVID-19. Inquired if staff should immediately isolate a resident who presents with signs and symptoms associated with the COVID-19 virus, prior to calling the MD, PCP, IP, and DON to immediately contain the potential spread of the COVID-19 virus to staff and other residents. The IP and DON confirmed R15 was not immediately isolated and had R15 tested positive for the virus, there was the potential for an outbreak of the COIVD-19 virus throughout the facility. On 02/09/21 at 10:39 AM, conducted an interview with the Medical Director (MD)2. Inquired with MD2 the process used to identify a potential PUI. MD2 stated staff report a resident's symptoms to the resident's PCP and the MD, then it is determined if the resident is a potential PUI. Inquired how the MD uses the facility's COVID-19 Screening Tool in determining a potential PUI. MD2 stated that prior to the surveyor mentioning the COVID-19 Screening Tool, MD2 was unaware the facility had implemented a COVID-19 screening tool or that staff was using it to evaluate residents. Inquired about identifying R15 as a potential PUI, MD2 stated R15 was not initially identified as a potential PUI because R15 did not have any respiratory symptoms and was not immediately concerned that R15's fever, vomiting, nausea, and chills are associated with the COVID-19 virus. MD2 stated the presence of respiratory symptoms is an important symptom when evaluating a resident for COVID-19. Inquired regarding the decision to test for the COVID-19 virus almost seventeen (17) hours after the onset of R15's symptoms. MD2 stated R15 had two (2) recorded temperatures over 100°F which prompted the testing to rule out COVID-19. MD2 also stated although COVID-19 was considered at first, maybe it should be considered initially for all residents, due to the wide range of different signs and symptoms a resident could experience. Additionally, MD2 stated, maybe a COVID-19 test should be implemented as a routine response to immediately rule out COVID sooner than later. If R15 had tested positive for the COVID-19 virus, it could have meant a facility wide outbreak. MD2 confirmed a resident should be isolated and droplet precautions implemented prior to contacting the doctors to evaluate if a resident is a PUI. Review of the facility's COVID-19 Risk Mitigation Plan (revised 12/30/2020) documented a resident is only isolated and droplet precautions implemented once a resident is identified as a PUI. Additionally, the COVID-19 Screening Tool was not in the mitigation plan. The facility was notified of the Immediate Jeopardy (IJ) on 02/09/21 at 1:06 PM. The facility provided an acceptable plan for removal of the IJ on 02/09/21 at 4:46 PM to the survey team. The corrective measure included: 1) Inservice for nursing staff regarding COIVD-symptoms, testing, isolation and reporting on 02/09/21. Inservice will be ongoing as needed. Nurses will not be allowed to work until training is completed; 2) Residents will be assessed every shift for signs/symptoms (s/sx) of COVID. If temperature is greater than 100°F or two or more other symptoms are present, residents will be given a point of care (POC) test and isolated as indicated by testing. Other symptoms include: Temperature greater than 100, chills, muscle/body aches, headaches, sore throat, nausea/vomiting, new loss of taste, fatigue, congestion/runny nose, and diarrhea. If positive resident has roommates, other roommates will be isolated for 14 days and will be tested every 4-5 days while quarantined. If asymptomatic and negative on the 14th day, then isolation will be terminated; 3) DON/IP/RCM will monitor for compliance through auditing vital sign sheets, medical record documentation and COVID-19 screening tools daily for a minimum of 12 weeks or until compliance is achieved; and 4) Audits will be a part of the Quality Assurance Performance Improvement Committee for a minimum of 3 months or until substantial compliance is achieved. 2) The facility developed a COVID-19 plan that would immediately isolate a positive COVID resident from the other residents. The plan was to utilize room [ROOM NUMBER] in the designated COVID unit area, Pikake (rooms 125-127). The plan included, If needed to expand the COVID unit, we would relocate the residents from rooms (122-124) . One of the strategies to prevent transmission was to place new/readmissions and PUI's under observation (quarantine) in these rooms to be monitored for signs and symptoms of COVID-19. When the unit does not have any positive COVID-19 residents, it is designated as a Yellow zone which required additional transmission-based precautions and was considered a restricted area to authorized staff only. No resident or visitor were to enter the area without face shield/eye protection and mask. The facility had a Courtyard accessible to residents to go outside. Some residents were assisted to the Courtyard area by staff and others had the ability to self-propel in the wheelchair or ambulate. The Courtyard had two walkways that had a door at each end. Two of the doors opened into the recreational lanai area and the other two open directly into the hallway of the Pikake unit. On 02/09/21 at 01:14 PM, observed R32 entering the Pikake unit through one of the Courtyard doors. R32 was in a wheelchair unaccompanied and self-propelled himself to the door, opened it and was preparing to enter the unit. There were no unit staff visible in the area. A dietary staff member saw R32 trying to get in and assisted him. On entry, R32 did not appear familiar with his surroundings and the dietary staff realized he was in the wrong unit, assisted him back through the courtyard door and to the other side of the facility. 3) The IP said the facility requirement for transmission-based precautions for personal protective equipment, (protective items or garment) to prevent cross contamination in the yellow zone included gown, mask, face shield and gloves when entering the resident room. PPE equipment was available outside each room on the Unit and the staff had been provided with face shields. On 02/10/21 at observed RN6 pass the morning medications to the residents on Pikake. RN6 did not put on a gown when she entered the rooms to administer medications. When RN6 administered meds to room [ROOM NUMBER], she was within approximately 2 feet and did not have her face shield down. This practice did not follow the facility policy or CDC guidelines. On 02/10/21 at 01:05 PM during an interview with the IP, she said it was the expectation the RN's wear face shields and put on gowns when entering the room. 4) On 02/04/21 at 12:30 PM, observed R25 sitting in a wheelchair with an overhead table positioned over him in the hallway by the nursing station. RN3 was standing in front of the medication cart within sight. R25 had expelled (spit) an inordinate amount of bubbly saliva on the floor which covered an area of approximately two foot by two foot which included under the overbed table, on the table legs, the table extension arm and extended into two different hallways. RN3 did not immediately respond. When she did, she pulled some wipes from the purple container on the med cart, put on gloves, bent over, and proceeded to clean up some of the saliva and throw the wipe into the trash next to the nursing station door. She then pulled a rolling chair through some of visibly remaining saliva on the floor and positioned it so she could assist feeding R25. Prior to sitting, RN25 threw a wipe on the floor and with her foot moved the wipe back and forth to clean up the remainder of the fluid on the floor. The housekeeper (HK)1 walked toward the area, and said, Oh, there's a spill, and immediately pulled a yellow safety cone from the holder on the wall next to the nursing station and placed it to warn others of a wet floor. When surveyor left the area, there was still visible saliva under the table and on the table leg and extension while RN3 was assisting to feed R25. On 02/05/21 at approximately 01:45 PM during an interview with the HK1, inquired if she had cleaned up the spill the previous day, and she said, Yes, its not a problem, I'm used to it, it happens a lot with him (R25). HK1 went on to say she moved R25 in his wheelchair to another location so she could clean the area and the overbed table. Review of the facility Isolation Policy's dated 01/11/20 included the statements: page 3: spills of blood or other body fluids should be removed, and the area decontaminated using the facility-approved spill kit. Page 6: resident/guest care equipment and environmental surfaces can become contaminated. Proper cleaning/disinfecting is important in the prevention of spreading infections. Environmental surfaces (to include floors and tabletops) will be cleaned on a regular basis, if spill occurs, and if visibly soiled. 5) On 02/08/21 at 11:30 AM the resident council interview was held. The surveyors were escorted through double doors on the Pikake Unit to room [ROOM NUMBER]. On arrival, the residents were already seated in the room. room [ROOM NUMBER] is located across the social services office. The residents were escorted out of the room, through the double doors. On the facility map, the Pikake unit has been designated as a COVID-19, yellow unit for newly admitted residents and for residents under investigation. This unit is also designed to transform into a red COVID unit with the use of zip walls to cohort positive COVID residents. At the time of entrance (02/04/21) the facility had a census of six residents on the Pikake unit. On 02/08/21 at 03:00 PM,interview with the Infection Preventionist (IP) confirmed residents should not have been taken on the Pikake unit. The IP stated the interview would have been better if it was held outside. 6) During lunch meal on 02/05/21, observed R25 being assisted with his meal by Registered Nurse (RN)3. RN3 was wearing gloves and was handed a face shield. RN3 did not remove the gloves and put on the face shield which had a drawstring at both ends of the band that needed to be pulled to tightly affix the face shield. RN3 did not change her gloves/hand sanitize and continued to assist R25 with his meal. 7) On 02/08/21 at 01:51 PM observed a red trash bin, lined with a clear bag outside of R30's room (next to the door). Concurrent observation and interview with RN1 confirmed R30 is on contact precaution. RN1 also confirmed the red trash bin should be placed in the resident's room to doff personal protective equipment (gloves, gown) before exiting the resident's room. Interviewed the IP on 02/08/21 at 03:00 PM. The IP reported R30 is on contact precaution for MRSA in a wound. The IP confirmed the red trash bin should be placed in the resident's room. Further queried whether the facility utilizes red trash liners to indicate the contents are biohazard materials. The IP replied the facility does not utilize red bags to indicate contents are biohazard materials. Biohazard materials/waste are double bagged then these bags are disposed in the designated bin for biohazard materials. 8) On 02/10/21 at 08:20 AM observed a colorful round disk stored in the excess catcher of the alcohol-based hand sanitizer dispenser. RN40 stated the disk, with a manufacturer's label Simon Says is for R25. Inquired whether the disk should be stored on the waste catcher of the ABHS gel dispenser. RN40 responded, no and agreed to return it to activities. 9) Medication storage observation was done on 02/10/21 at 10:10 AM. Concurrent observation with RN1 found a container of thickener with the scoop stored in the powder. Second observation at 10:40 AM with RN40 found no scooper in the container of thickener, RN40 reported the scooper has been missing so disposable spoons are used as a scoop. The scooper was stored in the fiber powder.

Based on record review (RR) and interviews, the facility failed to identify ensure Resident (R)51 received treatment and care in accordance with professional standards of practice and developed a comprehensive person-center care plan for 1 of 20 residents sampled. The facility did not assure R51 was provided with care to address to post fall needs and as a result of this deficiency, R51 experienced actual harm, hospitalization with surgical intervention, severe pain, decline in ROM (range of motion), loss of mobility, increased weight loss, fatigue and use of urinary catheter. Findings include: Cross reference F637 Comprehensive Assessment After Significant Change, F657 Care Plan Timing and Revision, and F842 Resident Records. R51 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/20, R51 had an unwitnessed fall and was found on the ground next to the bedside commode. R51 did not have any visible injuries but did complain of new left leg pain (10/10, severe pain). An initial x-ray (09/07/20) documented mild hip joint effusion, soft tissue swelling, and no hip dislocation. On subsequent days, R51 continued to complain of left leg pain, appeared fatigued, frequently incontinent of bladder and bowel, refused incontinent care despite education and encouragement, required the use of a Foley and straight catheter, increased as needed (PRN) pain medication, loss of range of motion (ROM), significant weight loss due to unmanaged pain, and decreased mobility. On 09/09/20, a Foley catheter is ordered for R51 due to concerns of urinary hesitancy as R51 was refusing to void as a result of left leg pain. R51 had an increased use of as needed (PRN) pain medication and a decline in ability to stand and movement of the left leg. Despite severe left leg pain, R51 participated in occupational therapy (OT) sessions which included weight bearing exercises as tolerated. Review of R51's most recent annual MDS with an Assessment Reference Date (ARD) of 07/23/20, Section V. Care Area Assessment (CAA) Summary, Section V . CAA and Care Plan (CP) decision, documented cognition loss/dementia, urinary incontinence, mood state, falls, nutritional status, dental care, pressure ulcer, [CONDITION(S)] drug use, and pain were triggered and identified to develop a care plan. Record Review (RR) of R51's quarterly MDS with an ARD of 09/16/2020, documented no care areas were triggered or developed in the care plan. Conducted a RR of R51's care plan (CP), last reviewed/revised on 02/04/21. Despite the interdisciplinary team's (IDT) decision to care plan for falls and pain during the annual MDS (ARD of 07/30/20), review found no documentation of care plan interventions for falls and pain. Falls were added to the care plan on 09/07/20 after R51 experienced a fall. R51's chronic back pain was addressed in the care plan on 08/04/20. Review of R51's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2020 and quarterly MDS with an ARD of 09/16/2020 documented significant decline in the extent of R51's ability for activities of daily living (ADLS). The annual MDS documented R51 needed only limited assistance with one-person assist for bed mobility, transfers between surfaces, and walking and for toileting required extensive assistance with one-personal physical assist (resident involved in activity; staff provide weight bearing assistance). R51's Quarterly MDS, dated 9 (nine) days after the fall, documented R51 required extensive assistance with two or more-person physical assistance for bed mobility and transferring between surfaces. R51 did not walk in room or on the unit and was totally dependent on staff with one person assist for locomotion on the unit. Toileting assistance increased requiring two person assist with extensive assistance. Review of Section H: Bowel and Bladder. Review of the Annual MDS with an ARD of 07/23/2020 noted R51 was always continent of bladder and bowels and did not have any appliances (indwelling catheter, external catheter, ostomy, or intermittent catheterization. Review of the Quarterly MDS with an ARD of 09/16/2020, documented R51 was intermittently catheterized and had two or more episodes of bowel incontinence and seven or more episodes of urinary incontinence. Review of weights documented R51 was 111.2 pounds (lbs) on 09/03/20 and lost 14.4 lbs over the next 8 days. From 09/11/20 to 09/18/20, R51 went from 96.8 lbs to 93.5 lbs, which is a 3.3 lb weight loss in one week (09/11-18/20) and a 15.92% weight loss in 15 days (09/03-18/20). MD2 related the use of two diuretics ([MEDICATION(S)] and Bumetanide), however, [MEDICATION(S)] 40 mg was discontinued on 09/11/20 and R51 continued to lose weight. During an interview with MD2 on 02/10/21 at approximately 1:55 PM, MD2 stated the continued rapid weight loss, despite discontinuing the [MEDICATION(S)], should have been reevaluated. Furthermore, MD2 was unaware of a progress note, written on 09/19/20 at 09:45 PM, which documented the resident expressed a loss of appetite due to pain. Review of R51's medical record progress notes documented severe left leg pain and continued back pain. Review of the September MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No comprehensive care plan was developed for pain and thus no interventions which were consistent with R51's needs and goals were identified. A second x-ray was done on 09/25/30 in preparation for an orthopedic appointment on 09/30/20 showed an acute left intertrochanteric hip fracture. The decision was made to not transport R51 to the hospital for immediate treatment and wait for the scheduled orthopedic appointment on 09/30/20. On 09/29/20, the orthopedic appointment was rescheduled to 10/05/20. MD2 made the decision to wait for the orthopedic appointment on 10/05/20 and not transport R51 to the hospital. That evening staff documented R51's left leg noted to be contracted, with guarded behavior and refusing to extend the left leg. The progress note of 09/30/20 at 10:35 AM, documents the Charge Nurse, MD and DON were at R51's bedside and noted she was unable to extend her left leg and the left hip was warm to touch and swollen. On 02/10/21 at 10:33 AM, conducted a telephone interview with Nursing Administration (NA)3, who is the primary MDS coordinator. NA3 simultaneously reviewed R51's chart during the telephone interview. NA 3 confirmed R51 did have changes in bowel/bladder continence, performance/assistance with ADLS, and significant weight loss. NA3 stated according to the Resident Assessment Instrument (RAI) Manual, R51 did experience changes in two or more areas of decline and a MDS for significant change should have been completed, however, the significant changes were not identified. Review of all Fall Risk Assessments provided by the facility for R51, a fall risk assessment dated [DATE] documented R51 was at moderate risk for falls. R51 continues to appear fatigued and now has incidents of incontinence and refuses care despite staff implementing non-pharmacological interventions, education, and encouraging R51 on the importance of incontinent care. Requested documentation of R51's care plan conferences for July 2020 to October 2020 from the Director of Nursing (DON). The facility provided the August 2020 Care Conference. Review of the August 2020 care conference, conducted on 08/05/20 did not include documentation of the IDT's rationale for not developing a care plan for the care areas identified in the annual MDS (ARD 07/23/20). Disciplines which participated in the August Care Conference included social services, activities, dietary, and nursing. The DON stated the facility has weekly At Risk meetings which discuss residents that are at risk or need additional monitoring. The DON stated it included residents who are monitored for changes, residents with history of risk, and residents who experience significant changes. The DON said the discussions were not documented in the resident's medical record, but the discipline responsible for implementing any new interventions will update the CP. Review of the At Risk meeting documented the IDT team was not aware of R51's significant weight loss, but attributed the loss to the administration of two diuretics. However, R51 continued to lose weight despite the discontinuation of one diuretic medication, the addition of nutritional supplements and R51 stating a loss of appetite due to pain. Furthermore, the At Risk meeting did not include documentation which addressed R51's pain, extensive decline in left leg ROM (range of motion) and mobility, bowel and bladder incontinence, and urinary retention. On 02/10/21 at approximately 1:55 PM, conducted a telephone interview with Medical Doctor (MD)2 regarding R51's fall and subsequent physical decline, post fall. MD2 stated R51's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MD2 stated after R51's fall an x-ray was done and there was no evidence of a fractured hip. MD2 contributed R51's pain to chronic back pain, stating R51 always has pain. Asked MD2 what steps were taken to manage R51's new left leg pain. MD2 stated [MEDICATION(S)] was added to the pain medication management regime, with minimal effectiveness. Inquired about R51's UTI, implementation of a Foley catheter, and R51 experiencing bowel and bladder incontinence. MD2 stated R51's UTI and incontinence issues were related to a [CONDITION(S)] bladder issue due to the L4 vertebra compression fracture and not related to R51's decline in ROM and mobility related to the fall. Inquired if R51 still experienced incontinence and urinary hesitancy post-surgery. MD2 stated after the surgery R51's [CONDITION(S)] bladder issues spontaneously resolved. Asked MD2, given R51's decline and continuous reports of left leg pain, were any other diagnostic test considered? MD2 replied, there was swelling present, but to get an MRI approved by insurance is a whole other story. Inquired if R51's severe left leg pain was an indicator that something more was going on than the x-ray showed. MD2 stated the increase in pain was not identified as anything more than chronic back pain, due to R51 continuous pain. Inquired if MD2 was aware a nursing progress note documented R51 reporting a loss of appetite due to the severe left leg pain. MD2 was not aware of the progress note. R51 had an unwitnessed fall on 09/07/20. Following the fall, R51 experienced pain which affected her activities of daily living (bed mobility, transferring, walking and toileting). R51 also experienced pain resulting in significant weight loss due to loss of appetite. The pain also prevented R51 from toileting and refusing incontinence care requiring intermittent catheterization. After 18 days, R51 received a second x-ray that revealed acute left intertrochanteric hip fracture. On the 23rd day (09/30/20) after the fall, R51 was sent to an acute facility and received an ORIF (open reduction interval fixation).

Based on interview and record review, the facility failed to provide treatment for 1 resident out of 7, resident (R)1 in accordance with professional standards of practice. The facility failed to notify the medical doctor of a declining status and respiratory changes. As a result, R1 developed pneumonia, respiratory compromise which resulted in a cardiac and respiratory arrest. R1 also had a [DIAGNOSES REDACTED]. Findings include: On 11/07/19, review of R1's electronic medical record (EMR) dated 07/16/19 at 03:57 PM, stated Resident with shortness of breath (SOB) this AM and O2 87%. Whenever needed (PRN) updraft administered and 2L(liters) Nasal Cannula (NC) via concentrator applied. O2 achieved 96% and residents breathing became even and unlabored. Denies chest pain and reports she is feeling like she is getting sick with a cold. T 98.5. Tylenol PRN administered which was effective for generalized pain 4/10. On 11/07/19, review of R1's EMR dated 07/16/19 at 09:13 PM stated R1's BP was 105/65, oxygen at 94% on 2 liters. RN2 readjusted the nasal cannula and R1's oxygen saturation came up to 97%. Although R1 replied to the nurse that she felt better, no call was made to the MD of a declining status. Further review on 11/07/19 of a late entry to EMR documents a nursing note dated 07/18/19 states Charge nurse was called by staff to assess resident. Resident found to be tachypneic . Blood pressure 105/69, pulse 120, O2 saturation 88-90% on 4 liters of O2. Breathing at 44 beats per minute (bpm). R1 was unresponsive to voice and touch. A call to the MD was made and facility received an order to send out via Emergency Medical Services (EMS) to emergency room (ER). EMS arrived at the facility at 01:00 PM. Vital signs upon leaving facility were BP 136/80, temperature was 100.0, O2 88% on 8 liters O2 and heart rate 116. There were no documented evidence that showed RN1, RN2 or RN3 had contacted the Medical Doctor (MD) for significant vital sign changes and declining status prior to the event on 07/17/18 at approximately 01:00 PM. The record shows a whenever needed (prn) oxygen order dated 06/04/18 which states: for difficulty breathing, give oxygen at 1-4L via nasal cannula prn for shortness of breath or SPO2 of less than 90%. There were no orders when to notify the MD or parameters when to call the MD. During an interview on 11/07/19 at 09:00 AM with certified nurses aide (CNA)1 who said, I was taking care of R1 on the day she was transferred. R1 was sick for a couple of days before that. That morning, R1 drank water but she never ate anything. I changed her in the morning and I was worried. I discussed R1 with RN1 and asked her if R1 was ok because R1 was not eating. RN1 said she should be ok. I checked on R1 when I was getting her roommate up and she kind of responded that she was ok. When we came back in, she was not responsive at all, but her eyes were open, and she couldn't talk. It was me and two other CNAs who discovered her. I called RN1 to 129-1 right now. During an interview on 11/07/19 at 12:30 PM with RN1. I remember R1. I was the one that sent her off to the hospital. I discovered her. I got report from the nurse the night before. R1 appeared more lethargic and the previous evening, she remained in her room. She usually comes out in her wheelchair. When I did my med pass in the am, R1 was still able to converse with me around 7:30 or 8:00 AM. In the morning, the CNAs were in R1's room and they called me in by walkie talkie to the room. She didn't look good. She wasn't responding. I called for help. She was not verbal. The case manager told me to call her doctor and get the order to send her out. During an interview on 11/07/19 at 02:00 PM with RN2 who said R1 had a call for fever the day before. RN2 stated R1 had shortness of breath (SOB). I want to say that it had started the day before. R1 really perseverated. R1 went low but she came back up. Surveyor asked, how low? RN2 stated to 87-88's saturation. Surveyor asked, Was that a concern for you to call the doctor? RN2 stated R1 gets a little anxious I didn't call the doctor. During an interview on 11/07/19 at 02:30 PM with R2 who said I saw she needed help and was struggling to breathe. R1's above light was on and I could see her. I pressed my light when I saw her head bob and her shoulders slump. I pressed my light and they took about 25 minutes and that is the normal. She was propped up and had a lot of pillows on her back. She started to turn color. I started to ring my manual bell and yell that it was an emergency. I was hoping that R1 would react to the bell and she didn't. When the nurse came in, she was shaking, and she couldn't assess her quick enough. I told her to call 911 right now. The ambulance came quickly. They put her on the monitor. They said glad you guys called right away. During an interview with with RN3 on 11/08/19 at 09:00 AM who said, I don't remember that RN2 said she notified the doctor in the morning, but I felt that she said the resident was getting a cold. RN2 said RN1 hooked R1 up to nasal cannula that AM. I did not listen to her lungs on my shift. I checked her SP02 and it was 94%. I repositioned her nasal cannula and I also asked her how she is feeling, and she said she felt better. She was also propped on pillows. I don't know that I thought about why she had changes, but I just treated her. I set her up for dinner and I don't know how much she ate that night. The protocol is we check the patient and use the PRN orders and if she feels better then we don't call the doctor. I'm not sure if it is written but that is what I was told when I was oriented. During an interview with the Director of Nursing (DON) on 11/08/19 at 02:45 PM, queried DON if there were any records that showed the MD was notified about the change in respiratory status from RA to 02 nasal cannula, blood pressure drop on 07/16/19 to 105/65. DON confirmed that the MD was not notified and that there were no MD notes since June. During a concurrent interview on 11/08/19 at 10:00 am and review of educational materials for competency of staff with DON who said we use Interact organization tool to meet requirements and this has been approved by our doctors. Interact is a tool that tells our staff when to report to the MD or nurse practitioner or physicians assistant when there is a change in condition. Review of facility's Interact SOB carepath titled Vital sign Criteria (any met?) shows that if an oxygen saturation is less than 90%, inability to eat or sleep due to SOB, respiratory changes, staff should notify the MD. The facility also states that the Quality Assurance Performance Improvement (QAPI) committee is tracking changes in condition on a log. DON stated that this change of condition was missed and that the information did not get to the daily huddle via the nurse, charge nurse or DON. Record review (RR) on 11/08/19 reveals that R1 was transferred via ambulance to the nearest emergency roiagnom on [DATE] at 01:00 PM. Family member (F)1 stated that the facility called her and told her that her mother had flatlined and was unresponsive and was taken to the nearest emergency room . RR of the emergency department physician's notes said R1 was diagnosed with [REDACTED].

Based on observations, medical record review, staff interview and facility policy review, the facility failed to provide the necessary services and interventions to treat pressure ulcers for 2 of 3 (Resident #s 80 & 19) residents reviewed. Findings include: 1) Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the survey period (2/21/17 - 2/24/17) it was noted that Resident #80's stage 4 pressure ulcer made very little progress and had not yet healed. Observation of Resident #80 on the morning of 2/21/17 at approximately 10:30 A.M. found her in the hallway in a reclined Geri chair in front of a TV. Her eyes were closed and she was dressed in personal clothing and had blankets on her lap and chest. Resident #80 was sitting on a blue cushion which was placed on the seat of her Geri chair. At approximately 10:45 A.M. a Certified Nurses Aide (CNA) moved Resident #80 from the hallway to the Activity Room. Observation of Resident #80 during the lunch hour on 2/22/17 at approximately 12:45 P.M. found her sitting on the blue cushion in her Geri chair in the dining room. The resident's daughter was feeding her lunch. The resident's daughter stated that Resident #80 does not eat very well and therefore she comes during lunch to assist her. Observation of Resident #80 on the morning of 2/23/17 at approximately 11:30 A.M. found her in the Activity Room seated on the blue cushion in her Geri chair. Her eyes were closed. Observation of Resident #80 during the lunch hour of 2/23/17 found the resident's daughter with her in the dining room, feeding her. The resident was again sitting on the blue cushion on the Geri chair. Observation of Resident #80 on the afternoon of 2/23/17 at approximately 1:30 P.M. found her in the Activity Room seated on the blue cushion in her Geri chair. She had a lap blanket which she picked at, causing the blanket to bunch up in the center of her lap. During the observation period, the resident remained up in the Geri chair and did not get frequent, hourly repositioning. An interview of Staff #144 on the afternoon of 2/23/17 at approximately 2:00 P.M. revealed the blue cushion was brought in by the family for positioning of her upper body. Staff #144 stated that Resident #80 was supposed to sit on a pressure reducing cushion, which was under the blue cushion during the above observations. A medical record review for Resident #80 on the afternoon of 2/22/17 found she was admitted to the facility on hospice for a stage 4 pressure ulcer and adult failure to thrive on 1/5/15. In September 2015, Resident #80 was taken off hospice for improvement of the pressure ulcer and she also gained weight. On 9/11/15, laboratory blood tests were conducted indicating: low [MEDICATION NAME]; low red blood cells; low hemoglobin and hematocrit; and high glucose. Since September 2015 no further laboratory blood tests were conducted. An interview of Staff #145 on the afternoon of 2/23/17 at approximately 2:00 P.M. revealed no further blood tests were done because Resident #80 was on Comfort Care. Resident #80 was seen by her physician in December 2015 when the physician noted, left a message for the wound nurse to discuss possible use of [MEDICATION NAME] for wound odor. The Nurse Practitioner, NP, was the provider who visited next on 4/10/16 when she noted that Resident #80's pressure ulcer was, Chronic with very poor healing and foul smell at times. The plan was to continue with local care and prevention [MEDICAL CONDITION]. The physician then followed up on 4/13/16 when she stated the pressure ulcer was, Stable and to continue wound care. A physician did not see the resident again until 10/24/16, when medical care was transferred to another physician due to change of insurance. On 10/24/16, the physician noted, Stage four to coccyx with red base. Wound care. Expect prolonged recovery. The next physician's visit was on 12/22/16 when he noted, Wound over coccyx area with beefy red base. Plan was topical wound care. The physician again visited on 1/9/17 when he noted, Sacral wound red. The plan was for pain management. A review of Resident #80's weekly wound assessments found minimal progress from the 2/7/16 to the 2/21/17 assessments. On 2/7/16, the assessment noted Resident #80's pressure ulcer treatment was: Clean with wound cleanser, lightly pack with calcium alginate, pack with wet to dry gauze, cover with foam dressing or abd pad & secure with tape every other day and as needed. The 2/7/16 assessment noted the wound measured 1.4 cm L x 3.8 cm W x 0.7 cm Depth. The 2/7/16 assessment noted undermining measuring: 2.3 cm @ 3 o'clock; 1.6 cm @ 7 o'clock; 2.4 cm @ 9 o'clock; and 3.2 cm @ 12 o'clock. The wound edges were macerated and fragile; Odorous; Painful; Heavy serosanguineous drainage; and the status did not change. The most current assessment dated [DATE] found the pressure ulcer treatment was: Clean with normal saline, pack with triple helix collagen, pack opening with normal saline gauze to maintain wound opening, cover with foam dressing, change every day and as needed. The 2/21/17 assessment noted the wound measured 2.0 cm (1.4 on 2/16) L x 0.5 cm (3.8 on 2/16) W x 0.8 cm (0.7 on 2/16) Depth. The 2/21/17 assessment noted undermining measuring: 0.5 cm @ 6 o'clock; 1.0 cm (3.2 on 2/16) @ 12 o'clock; 0.2 cm (2.3 on 2/16) @ 3 o'clock; 2.3 cm (2.4 on 2/16) @ 9 o'clock; 1.8 cm (1.6 on 2/16) @ 7 o'clock; and 2.6 cm @ 11 o'clock. The wound edges were white, rubbery, thick, macerated tissue with surrounding skin intact; Foul odor; No pain; <25% dressing saturated with serous drainage; and the status was no change. Over one year, Resident #80's pressure ulcer made very little, if any, improvements. A review of Resident #80's care plans found one for Stage IV pressure ulcer. The goal stated, Pressure ulcers will begin to show signs of healing through next review (3/17). Interventions included, 11/23/16 Wound specialist consultation. An interview of Staff #50 on the afternoon of 2/22/17 at approximately 2:00 P.M. revealed she worked with a Wound Consultant for oversight of wound care in the facility. Staff #50 noted that Resident #80 has made very little progress in the healing of the pressure ulcer. Staff #50 further noted the resident stayed up in her Geri chair most of the day per the family's request. Staff #50 stated that the Wound Consultant thinks that the tunneling and undermining of Resident #80's pressure ulcer is scarred. She stated that the scarring therefore inhibits the healing of the wound. Staff #50 stated that Resident #80 may benefit from debridement. She further noted the resident has not been referred for consultation/debridement of the wound. Staff #50 noted that Resident #80 does not feel pain when the pressure ulcer dressing is changed, possibly due to [MEDICAL CONDITION]. Currently, Staff #50 noted the opening of Resident #80's wound has decreased in size but the tunneling and undermining was still present. Staff #50 stated the treatment changed on 2/21/17 to include packing of the wound with wicking at the opening to avoid closure because of the continued presence of tunneling and undermining. Staff #50 was asked to provide notes from the Wound Consultant. Staff #50 stated the notes were not available in the electronic medical record and instead were kept in the emails of Staff #145. On the morning of 2/23/17 at approximately 8:30 A.M., Staff #145 was asked to provide notes from the Wound Consultant. At approximately 10:30 A.M., Staff #145 provided the consultant's Patient Order Sheets for 11/23/16, 12/19/16, 1/17/17, and 2/13/17. The Patient Order Sheet noted the wound characteristics (location, measurements) and the products used for dressing changes. It appeared like an invoice. One Wound Care Skin Integrity Evaluation form was included for 11/23/16 but was printed on the facility's stationary. On 2/23/17 at approximately 1:30 P.M. Staff #s 144 and 145 provided copies of the rest of the Wound Consultant's notes. The Wound Consultant's notes indicated the wound size, drainage, and recommended treatment. There was no mention of referral for debridement. On the afternoon of 2/23/17 at approximately 1:13 P.M. and 2:05 P.M., the Surveyor attempted to contact the facility's Wound Consultant and left a message for her. On the afternoon of 2/23/17 at approximately 2:30 P.M. Staff #144 informed the Surveyor that the Wound Consultant was fearful of speaking with the Surveyor. The Wound Consultant called the Surveyor back on 2/24/17 at approximately 8:23 A.M. when she informed her that she was not a consultant for the facility. The Wound Consultant stated that she provided education and inservices to the facility. The Wound Consultant further noted that her company provided dressing supplies to the facility. The Wound Consultant noted that she didn't actually see Resident #80's wound and instead took the information documented by the facility staff and plugged that information in to order the necessary supplies. The role of the Wound Consultant stirred confusion. An interview of Staff #s 144 and 145 on the morning of 2/24/17 at approximately 8:00 A.M. explained the goal for utilizing a Wound Consultant included having outside consultation for the wound care; determine resident's progress; and consider change in treatments. Staff #145 noted Resident #80's wound was slow healing and stated that the goal was not to totally heal the wound. Staff #145 then stated that Resident #80 was on Comfort Care and that the goals were pain management and keeping the wound clean. Staff #s 144 and 145 both stated that the family of Resident #80 wanted to keep her comfortable. On 2/24/17 at approximately 12:00 P.M., Staff #144 provided a copy of the facility's agreement with the Wound Consultant which confirmed her role to provide, wound care education, to include, but not limited to, wound care prevention, assessment, treatment plans, dressing change protocols and documentation pertaining to the wound care products (Consultant Agency) provides. During the survey period, 2/21/17-2/23/17, Resident #80 was observed on multiple occasions up in the Geri chair in the Activity room. An interview of Staff #116 on the afternoon of 2/23/17 at approximately 12:45 P.M. revealed Resident #80 was up in the Geri chair all day every day. She reported that the resident returned to her bed only when she felt tired. An interview of Staff #48 on the morning of 2/21/17 at approximately 10:45 A.M. revealed Resident #80 was out in the Activity room all day per the family's preference. A review of the Interdisciplinary Team (IDT) meeting notes for Resident #80 on the morning of 2/24/17 revealed the resident's family did not attend any of the meetings over the past year. The IDT meeting on 12/15/16 noted, Per nursing, resident continues with Stage IV coccyx with new treatment added. Family did not attend the meeting. The IDT meeting on 9/28/16 noted, (Resident #80) continues with wound to sacrum, treatment applied daily as ordered. The family did not attend the meeting. The IDT meeting on 7/28/16 did not mention Resident #80's pressure ulcer. The family did not attend the meeting. The IDT meeting on 5/4/16 noted, Continues with stage IV pressure ulcer to sacrum. Treatment applies as ordered. (Resident) continues to utilize a Geri chair for comfort and to maintain her safety. The family did not attend the meeting. An IDT meeting for February 2016 was not available at the time of survey. The facility was unable to provide documentation of discussions/meetings with Resident #80's family members which would demonstrate their desire to maintain the pressure ulcer by keeping it clean, free of infection and pain. Additionally, the facility was unable to provide documentation from the family indicating their preference for the resident to be out of bed all day in the Activity room. On the morning of 2/24/17, a review of the facility's policy titled, Pressure Ulcer Problem Identification and Treatment dated 7/22/05 noted, B. Clinicians can reasonably expect a clean pressure ulcer with adequate innervation and blood supply to show evidence of healing within 2 to 4 weeks. Failure to do so should prompt a re-evaluation of the plan of care, and evaluation of adherence to the plan, and a possible modification of the plan. For example, draw labs, check [MEDICATION NAME] level, suspect colonization of bacteria. The policy further noted, Sitting individuals should be repositioned at least every hour and should shift their weight every 15 minutes if possible. If hourly repositioning is not feasible, the individual should be returned to bed. An interview of Staff #149 on the afternoon of 2/23/17 revealed the care for Resident #80's pressure ulcer would depend on her overall condition. She stated that since the resident was older, it may not be feasible to do wound debridement. However, Staff #146 stated that her expectation was for staff to do routine, frequent repositioning. In summary, the facility failed to maintain the highest practicable well being for Resident #80's pressure ulcer based on her current condition with consideration and documentation of the facility's, resident's and/or family's goals and/or expectations. 2) Resident #19 was admitted to the facility on [DATE] from an acute hospital. A review of the resident's record on 2/21/17 at 2:00 P.M. found an admission note dated 11/9/16 with documentation of the following: right heel deep tissue injury 4 x 3 cm; left foot 2.5 x 3 cm; left foot base great toe 1 x 1 cm; Stage II healing ulcer; left center abdominal fold with 1 (one) cm skin tear; and coccyx area excoriation on left buttock 4 x 3 cm, center area with 1 (one) x 0.5 cm, right buttock 2 x 2 cm. A record review on the morning of 2/22/17 found a comprehensive Resident Assessment Instrument with an assessment reference date of 11/15/16 which documents in Section M. Skin Conditions, Resident #19 is noted to have two Stage 2 pressure ulcers which were present on admission. Further review found documentation of the facility's Weekly Skin Rounds. An assessment was done on 11/16/16 which notes a Stage II pressure ulcer to coccyx and a Stage II pressure ulcer to the left buttock. The ulcer to the coccyx measured 0.5 x 0.5 with no odor, pain or drainage. The ulcer to the left buttock measured 0.8 x 0.4 cm. with no odor, pain or drainage. On 2/22/17 at 1:30 P.M. an interview and concurrent record review was done with Staff Member #50. The staff member confirmed Resident #59 was admitted on [DATE] with two Stage II pressure ulcers, one to the coccyx and one to the left buttock. At the time of admission, the resident was a hospice recipient. A review of the physician's orders [REDACTED]. A review of the resident's care plan found an episodic care plan, created 11/10/16 with the goal to resolve the Stage II pressure ulcers over 21 days. The interventions included the following: apply sensi-care as ordered; turn resident Q1 hour to prevent further injury; update physician if unresolved; weekly skin assessment; and weekly wound rounds. Further review found a care plan to address no further pressure related skin breakdown through the next review. The interventions include: extensive assistance with bed mobility; hospice to provide air mattress; provide incontinent care, PRN; and weekly skin assessment by the CN. Further review with Staff Member #50 found no documentation of a skin assessment on admission (11/9/16), the first documentation was dated 11/16/16, a week after the resident's admission. There was no further documentation of subsequent weekly skin assessments to determine the status of the resident's pressure ulcers prior to discharge on 12/5/16. The staff member assisted in the review of Resident #59's treatment/medication administration of applying sensi-care three times a day; there is documentation the resident received sensi-care as ordered with a start date of 11/17/16. Interview with Staff Member #50 confirmed Resident #59 was admitted with two Stage II pressure ulcers without admission orders [REDACTED]. The staff member was queried whether the facility would provide treatment for [REDACTED]. The staff member replied for residents on hospice with pressure ulcers, treatment will be provided. A review of the facility's policy and procedure related to pressure ulcers was provided on 2/24/17 at 9:30 A.M. The procedure for Pressure Reduction & Prevention Program includes the Pressure Ulcer Risk Assessment tool will be used upon admission . Although Resident #59's admission notes documented the presence of Stage II pressure ulcers, the facility failed to assess the resident's skin integrity upon admission; therefore, delaying treatment of [REDACTED].