Every finding on record at Arcadia Retirement Residence

Based on record review and interviews, the facility failed to ensure a resident's privacy and dignity were maintained for one of two residents. The deficient practice compromised Resident (R) 36's privacy and dignity.Findings Include:Review of the facility reported incident (Intake #2636069) received on 10/04/25, documented that a Certified Nurse Aide (CNA) reported a video was taken on 09/30/25 during evening shift using the facility's cell phone. The video depicted R36 during peri-care with a heavily soiled incontinence brief.R36 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, dysphagia, obstructive sleep apnea, hemiplegia/hemiparesis due to cerebral infarction, Diabetes type 2, mild cognitive impairment, and epilepsy.Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/07/25, documented in Section H (Bladder and Bowel) that R36 is always incontinent of urine. In Section GG (Functional Abilities and Goals) documented R36 was dependent on staff for toileting hygiene, including perineal hygiene and adjusting clothes before and after voiding.Review of the facility's INVESTIGATIVE REPORT FOLLOWING ADVERSE EVENT for the incident on 09/30/25 regarding R36, documented the event as Possible Neglect & Privacy Breach. The report documented A recorded video was taken of resident's buttock with saturated urine by License Staff. Video was then shared to other staff members during shift-to-shift report for the purposes of reminding staff to change resident to prevent skin breakdown.On 11/19/25 at 08:35 AM, an interview was conducted with R36. R36 reported she was unaware that a video was taken while she was receiving personal care, stating, why would they do it? She stated she would not be okay with any picture or video being taken of her and reported that if asked for consent, she would object to it because there is no reason to do it.On 11/20/25 at 11:15 AM, an interview was conducted with the Administrator. During the facility's investigation, Administrator reported they learned there was tension between day and evening shift staff, and the evening staff were frustrated with the resident's condition. The Administrator confirmed the video contained an image of R36's uncovered buttocks, a urine saturated incontinence brief, and pad, and was shown during shift-to-shift report. On 11/20/25 at 11:15 AM, an interview was conducted with CNA 31. CNA31 stated a video was shown during shift report depicting a resident with urine leaking from the incontinence brief. CNA31 confirmed the video included the resident's buttocks and stated the video was disturbing because staff should not be recording residents, and it may be a violation.On 11/20/25 at 12:13 PM, a telephone interview was conducted with Registered Nurse (RN) 33. RN33 stated on 09/30/25 at approximately 07:00 PM, a CNA reported that R36's clothes, incontinence brief, and pad were soiled. RN33 stated the resident verbalized she had only been changed once during the day shift. RN33 admitted she recorded a video of the urine saturation using the facility's cell phone to remind everybody to change the resident more frequently because the wound on her butt was not healing and to prevent future skin breakdown. RN33 stated she knew she was not supposed to take a video, acknowledged the facility had a policy prohibiting recording without consent, and confirmed she did not request consent from R36 or determine whether R36 was aware that a video was taken. RN33 stated the facility counseled her for violating the video-recording protocol and protections related to resident dignity.Review of RN33's Counseling Memo, dated 10/17/25, documented that the facility concluded RN33 made a video recording of a resident without consent and inappropriately instructed another RN to share the unauthorized video with others, violating protocols regarding privacy, documentation, and the protection of resident dignity.Review of the facility's policy and procedure HIPAA (Health Insurance Portability and Accounting Act) Audio, Photography and Video Recording Policy, last approved on 08/2022, documented unless authorized by specific facility staff members, Audio Recordings and/or Photography of Persons Served by Workforce Members and Guests are not permitted under the following circumstances:.During treatment or any type of care being provided to Persons Served.To document behavior, or conditions or any environmental condition of Persons Served.For research purposes or other purposes that violated the HIPAA Privacy Rules and/or State and Federal regulations.

Based on observations and staff interview, the facility did not follow proper sanitation practices in the kitchen. As a result of this deficiency, there was an increase risk for foodborne illness and an increase risk for hazards such as a fire. Findings include: 1)During observation of the kitchen on 10/01/24 at 08:00 AM, the area between the stoves appeared dirty and not cleaned. The area had crumpled paper, dirty plastic bags, dirty napkins, and dirty paper bowls. Staff interview, on 10/01/24 at 08:05 AM, Kitchen Supervisor (KSupvr) acknowledged that the area previously mentioned was dirty and not cleaned. KSupvr said they will have the area cleaned and addressed for future cleaning services. 48351 2)Observation was conducted on 10/03/24 at 07:52 AM in one of the unit kitchens. A metal pan was observed filled with condiments and sauces. The metal pan contained a large container of creamy peanut butter labeled, Best if Used by August 31, 2024. The pan also contained yellow mustard labeled, Best by date of July 16, 2024. Interview was conducted with the night shift Licensed Practical Nurse (LPN)10 on 10/03/24 at 07:54 AM in the kitchen. LPN10 was shown the creamy peanut butter and yellow mustard. LPN10 confirmed that the two food items should have been discarded. 3)Observation was conducted on 10/03/24 at 08:23 AM in one of the unit kitchen's refrigerators. The refrigerator contained a bottle of cranberry juice with an expiration date of 08/22/24. Interview was conducted with the night shift LPN11. LPN11 was shown the cranberry juice bottle, and LPN11 confirmed that it should have been discarded. A review of the facility policy titled, Food Brought by Family/Visitors, dated 09/19/2024, was conducted on 10/04/24. The policy noted, The nursing staff is responsible for discarding perishable food on or before the use by date .

Based on interview and record review, the facility failed to provide information of the risks and benefits of using psychotropic medications to three out of five sampled residents (Resident (R) 29, R63, and R46). This deficient practice has the potential to negatively affect the residents wellbeing and has the potential to affect all the residents in the facility on psychotropic medications. Findings Include: 1) R29 is an [AGE] year-old male admitted to the facility on [DATE]. R29 has a medical history that includes, but not limited to, dementia with psychotic disturbance, Parkinson's disease, and generalized anxiety disorder. On 10/03/24, a review of R29's Electronic Health Record (EHR) noted that R29 had a medication order for antidepressant since 05/30/24. There was no documentation found in R29's EHR that noted a facility consent form was provided to R29 or R29's representative that went over the risks and benefits of using the antidepressant medication. Interview was conducted with the Administrator on 10/04/24 at 11:23 AM. The Administrator stated that the facility usually has the resident or the representative sign a consent form prior to treatment with psychotropic medications. The Administrator confirmed that R29 and or his representative did not sign a consent prior to the use of antidepressant. 2) R63 is a [AGE] year-old female admitted to the facility on [DATE]. R63 has a medical history that includes, but not limited to, Alzheimer's disease, dementia with behavioral disturbances, and generalized anxiety. On 10/03/24, a review of R63's EHR noted that R63 had medication orders for an antipsychotic since 01/04/24 and an antidepressant since 12/23/23. There was no documentation found in R63's EHR that noted a facility consent form was provided to R63 or R63's representative that went over the risks and benefits of using antipsychotic and antidepressant medications. Interview was conducted with the Administrator on 10/04/24 at 11:23 AM. The Administrator stated that the facility usually has the resident or the representative sign a consent form prior to treatment with psychotropic medications. The Administrator confirmed that R63 or her representative did not sign a consent prior to the use of antidepressant and antipsychotic medications. 37954 3) R46 is a [AGE] year old male admitted to the facility on [DATE]. R46 has a medical history that includes, but not limited to, unspecified dementia, unspecified severity, with mood disturbance, and depression, unspecified. On 10/04/24 a review of R46's EHR revealed R46 had a medication order for an antidepressant since 09/06/24 and an antipsychotic since 07/03/24. There was no documentation found for R46's facility consent form for an antipsychotic and an incomplete facility consent form was found for R46's antidepressant. On 10/04/24 at 09:02 AM requested copies of R46's informed consents for his antidepressant and antipsychotic medications from the Administrator. On 10/04/24 at 11:05 AM interviewed Administrator who provided a copy of R46's antidepressant consent form which she confirmed was not fully filled out, it did not include a check mark for the type of medication with the list of side effects and indication for use. Administrator confirmed the resident or their representative should have been given a consent form fully filled out prior to signing and prior to taking the medications.

Based on observations, staff interview and review of policy, the facility failed to secure an electrical panel on the third-floor nursing unit. As a result of this deficiency, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings include: During an observation of the third-floor nursing unit on 10/02/24 at 09:20 AM, one electrical panel was not secured. The padlock was not latched on and there was no staff in the immediate vicinity to prevent any residents and/or visitors from accessing the panel. Staff interview on 10/02/24 at 09:30 AM, Maint Staff 2 acknowledged that the electrical panel is supposed to be secured and the door should have been locked. Review of policy on Control of Hazardous Energy (Lockout/Tagout) read the following: Policy, company adheres to a strict Control of Hazardous Energy Policy (Lock-Out/Tag-Out). Purpose, to ensure the health and safety of staff and residents in compliance with State and Federal Laws and regulations . Definitions, lockout is the physical placement of a lock on an energy isolating device. The device must physically prevent the release or transmission of energy. The lock must be facility issued, must be uniform for the facility, and must indicate the identity of the person who applied the lock . Procedure, company will ensure that new or overhauled equipment can accommodate locks, lockout/tagout will be placed only by an authorized person of the Environmental Services Department. The Lockout/Tagout can be released only by the same authorized person who locks/tags out the equipment and/or power. Locks or tags must be uniform and standardized, must be durable, must not be used for any other purpose . An annual inspection of the Lockout/Tagout program will be conducted to ensure the procedures are being followed and are effective. The authorized supervisory and management staff will document and confirm that the inspections have been performed . Machinery and equipment covered by the Lockout/Tagout program include but not limited to the following: Any electrical circuit breaker .

Based on observations, record review and interview the facility failed to correctly identify on Resident (R)13's Care Plan (CP) that she would be residing with her husband in a shared room. The deficient practice could affect all residents in the facility who are residing in a shared room with their husband or wife if they are not correctly identified as so. Findings Include: On 10/01/24 at 11:14 AM observed R46 sleeping in his bed and observed R13 resting in her bed in the shared room, each on their own side of the room. On 10/02/24 at 11:25 AM while observing lunch delivery to resident rooms observed R46 in his bed resting and R13 in her bed resting in their shared room. During record review on 10/04/24 found R13 had a CP with a Psychosocial Management/ Well-being problem with the following Resident is pleasant and easy to engage into conversation. Resident may not initiate conversations and seems to be more on the quiet side. Resident husband has also moved into HCC but per resident and family request, they will not be moved in to a shared room together. On 10/04/24 at 02:33 PM interviewed Administrator who stated resident's husband has documented on his CP that he and his wife would be in shared room and provided an email from the Power of Attorney (POA) stating the two residents would be in a shared room. Administrator confirmed R13's CP was not updated to reflect this.

Based on record review and interview, the facility failed to revise one of 18 sampled residents (Resident (R) 63) care plan after she sustained two falls. This deficient practice places R63 at risk for future falls and may affect all the residents in the facility who have fallen. Findings Include: A review of R63's Electronic Health Record (EHR) was conducted on 10/02/24. R63's EHR noted that she had a fall on 07/26/24 and 09/03/24. A review of R63's care plan did not contain new interventions that were implemented after her fall on 07/26/24 and 09/03/24. Interview was conducted with the Director of Nursing (DON) on 10/04/24 at 08:23 AM in his office. DON reviewed R63's care plan and confirmed that new interventions should have been placed in the care plan after R63's two falls. A review of the facility policy titled, Falls, dated 02/08/24 was conducted on 10/03/24. The policy noted, The IDT [Interdisciplinary Team] will meet the next business day to review falls, do a root cause analysis, follow-up actions with further recommendations when indicated and update care plan. A review of the facility policy titled, Fall Charting Protocol, dated 12/04/23 was conducted on 10/03/24. The policy noted, The resident's care plan will be updated with appropriate interventions following each fall including assessment of adequate supervision and measures for prevention of subsequent falls.

Based on record review, staff interview and review of policy on Advance Health Care Directives (AHCD), the facility failed to ensure that the code status was consistent with the AHCD for one Resident (R)51 of two residents sampled. As a result of this deficient practice, there was the potential for R51 to receive unnecessary Cardiopulmonary Resuscitation (CPR). Findings include: Review of the Electronic Health Record (EHR), on [DATE], showed R51 was admitted on [DATE] with diagnosis including Supranuclear Opthalmoplegia (unable to move eyes at will in all directions), Chronic Kidney Disease, Alzheimer's, Dementia, and High Cholesterol. A doctor's order, dated [DATE] read Full Code, Active which was not what R51 wanted according to the AHCD. Review of R51's AHCD instructions for health care, on [DATE] at 10:10 AM, showed the following choice; to not prolong life if the following is present: an incurable and irreversible condition that will result in my death within a relatively short time, I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, the likely risks and burdens of treatment would outweigh the expected benefits. Review of R51's AHCD, Provider Orders for Life-Sustaining Treatment (POLST), on [DATE] at 10:20 AM, also showed the choice; Do Not Attempt Resuscitation (DNAR). On [DATE] at 10:05 AM, Social Worker (SW)1 was queried about R51's current code status and acknowledged that it was not consistent with the AHCD. SW1 stated that they will follow up and make the necessary correction. On [DATE] review of facility policy on Advance Directives and POLST read: Purpose, to encourage all residents to complete an Advance Directive and POLST form. Procedure, upon entry to Arcadia, residents are encouraged to submit an Advance Directive and POLST. Social Services verifies whether the resident would like to change or update the Advance Directive and/or POLST during admission and annually. Assistance will be offered if needed. The POLST form is placed in the resident chart. The Medical Records Department will scan the documents into the resident's electronic medical record. In the event of an emergency, or in case of transfer to the hospital, a copy of the POLST, Advance Directive and other necessary information from the resident's record will be sent with the resident to the acute care facility.

Based on interviews, document and record review, the facility grievance policy did not include the necessary requirements of 1) how to file a grievance anonymously, 2) identify and communicate who the grievance official was or how to contact, 3) did not determine a reasonable timeframe that complainant could expect a completed review of the grievance, 4) that they have the right to obtain the review in writing, or 5) ensure written grievance decisions meet documentation requirements. In addition, the facility failed to identify a concern verbalized by one Resident's (R)1 Family Member (FM)1, as a grievance, did not investigate the concern timely or keep FM1 apprised of the resolution. As a result of this deficiency, FM1 did not get the results of the investigation regarding all concerns. Without an efficient process to address grievances, anyone that has a concerns, may not have their issue addressed in a timely manner. Findings include: 1) R1 was an [AGE] year old female, who had two admissions to the facility. The initial admission was on 10/25/2023, when she was admitted to the facility for rehabilitation for a left femur fracture following a car accident. She made good functional progress during her rehabilitation and was discharged home from that admission. R1 was admitted to the facility again on 07/29/2024 for rehabilitation after a surgical procedure. R1's other pertinent medical history included coronary artery disease, hypertension, acute hypoxic respiratory failure, and dementia. On 07/31/2024, R1 reported that a male nurse made an inappropriate comment and sexual suggestions to her. On 08/05/2024, facility leadership met with R1's family to discuss the investigation of this report. At that time, family member (FM)1, informed the facility she was upset about two other unrelated issues, 1) R1 received melatonin (for sleep) after FM1 told staff she and R1 did not want or need the medication, and 2) R1 had a fall during the initial admission (10/25/2023), which FM1 felt was not acknowledged or investigated by the facility. 2) Cross reference F553 Right to Participate in Planning Care. R1 and FM1 verbalized to nursing staff they did not want melatonin administered, but the staff failed to communicate this request to the provider and did not honor their choice not to receive the medication. As a result, R1 continued to receive the melatonin, until FM1 brought the issue up at a meeting with administration. 3) Reviewed the Unwitnessed Fall Report dated 11/16/2023 at 02:35 PM (incident occurred on 11/06/2023). The report included per resident's daughter's report Mom said she slid a step in the restroom but she grabbed something and stood by herself then backed to bed but has some lt (left) hip pain/sore. Wet floor was checked as being a Predisposing Environmental Factor. Reviewed the Post Fall Evaluation form V7 related to this event, completed on 11/17/2023 at 09:25 PM. The report documented there was an unwitnessed fall when R1 attempted to self toilet in her room. The Provider was notified of the fall on 11/20/2023. At that time a hip x-ray was ordered. The fall details note were 11/06/23 reported by resident's daughter, initial assessment: no pain on lt (left) hip. later reported lt hip pain, then checked x-ray, no fx (fracture), no malalignment noted. The vital signs recorded on the report were noted to have a 12/06/2023 date with time of 09:33 PM. There was no documentation in section A9 Care Planning. Reviewed the Orthopedic Surgeon progress note for 12/08/2023. The note included Tripped and fell at Arcadia, no displacement of fixation. 4) On 09/06/2024 at 12:00 PM during an interview with the Administrator in Training (ADM), inquired who the facility grievance official was, and she said it would probably be the Corporate Compliance person. Asked who kept the grievance log for the long term care facility, and she said anyone can add to it, but it is maintained on site. She went on to say she is the one who kind of oversees the grievances at the facility. Requested any documents related to the investigation of R1's fall in 2023. The ADM said the person who followed up on that was no longer at the facility, so details other than what was in the incident report were not available. Review of the grievance log revealed FM1's complaint about the melatonin was logged as a grievance, but the fall was not. When asked ADM if the verbal concern expressed by FM1 about the fall had been processed and handled as a grievance, she replied No. The ADM said both of FM1's concerns, the fall and issue of melatonin administration had been found to have been validated, but they had not communicated the findings to FM1, because the concerns had been part of the alleged sexual assault investigation, and APS (adult protective services) had not completed the investigation yet. On 09/06/2024 at 01:10 PM, interviewed the Occupational Therapist (OT) who provided care giver training to R1's family prior to discharge from her initial admission when the fall occurred. The OT, said when she was doing discharge training with the family, they verbalized R1 had a recent fall while in the facility. OT said she had not been made aware of it prior to the family mentioning it. She said she spoke with the Interim Director of Nursing about the fall at that time and that it has not been reports. On 09/06/2024 at 02:15 PM, interviewed the Director of Nursing (DON). He explained when there is a grievance/complaint, it is discussed at the daily stand up meeting and determined who the point person will be for the investigation. Inquired who maintains the grievance log, and he said The IDT (interdisciplinary team) has access, but typically it is the Social Worker. The DON said FM1's concern about the melatonin had been investigated, and they found the request to discontinue the medication was made by R1 and FM1, but that the information did not get passed on to the provider to discontinue the order. 4) Reviewed the facility policy titled Complaints Policy (ACS (Arcadia Community Services)) last reviewed 12/08/2021. The policy included: - The purpose of this policy is to protect the rights of residents, clients, members, or their legal representatives and/or interested individuals, file grievances or complaints in accordance with State and Federal laws and regulations. -Grievance: Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether or not any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care. - A complaint may be submitted orally or in writing. A written complaint must be signed by the Complainant. The COO, Program Director, Administrator, or the Member Services manager may assign the responsibility of investigating the complaint to an appropriate investigator who will complete the investigation in a timely manner.The COO, Program Director, Administrator, or the Member Services Manager or his/her designee will keep the Complainant appropriately apprised of the determination. The response may include the finding of the investigation and any corrective actions taken. If Complainant is dissatisfied with the findings, he or she may: 1. Request a meeting ., or 2. File a complaint with a governmental or advocacy agency. -If a staff member overhears or receives a complaint voiced by a resident, a resident's representative, family member, an appointed advocate, or any individual regarding: 1. Alleged abuse, neglect .or other violations of a resident's rights, the staff member must immediately report the complaint to his or her supervisor 2. Treatment, medical care, or behavior of another resident or staff member; when it involves a verbal complaint that cannot be resolved by the staff present when the complaint is made, the staff member must: a. Report the complaint by the end of his/her shift to the supervisor, . , and b. Inform the resident, a resident's representative, family member, or an appointed advocate, that their concern has been reported to management for further action and that he or she may file a written complaint without fear of reprisal in any form. -An investigation report should be filed with the COO, the Program Director, Administrator, or Member Services Manager within five (5) working days of the complaint. If the investigation cannot be completed within five (5) working days, the investigator shall provide the COO, the Program Director, Administrator, or Member Services Manager with an update on the status of the investigation and an estimate for completion of the investigation. - The COO, Program Director, Administrator, . or designee will keep the Complainant appropriately appraised of the findings or status of the investigation, as well as any corrective actions. - The COO, Program Director, . will : 1. Submit the original complaint concerning allegations of abuse, neglect, .including staff behavior;and submit the investigation, determination, actions taken, response and all other related documents to the Corporate Compliance office, or 2. File the original complaint concerning treatment, medical care, or behavior of other residents; and all related documents and actions taken into the appropriate resident's medical file, with a copy to the Corporate Compliance Officer. -The disposition of all verbal and written complaints concerning allegations of abuse, neglect harassment or other violations of resident rights should be recorded on the Complaint Log. The Corporate Compliance Officer will be responsible for recording and maintaining this log. 5) Reviewed the document titled Resident Complaint Rights & Instructions. This document included: -Verbal: Please share any complaints or concerns with any staff member. If the staff member cannot resolve your concern, you are encouraged to bring your concern to the immediate attention of the following management staff: Department Supervisor, Manager, Director; Health Care Center Charge Nurse; Social Services; Resident services Manger; Office of the COO; Corporate Compliance Officer; and President/CEO. -Written: You may file a written complaint: . On the form, please answer all applicable questions accurately, and be sure to sign and date the form; . 6) Reviewed the Arcadia Health Care Center Handbook 2024 (37 pages), which is provided to all Residents. Page 36 of the handbook included: E. Complaints. If you believe your rights have been violated, you may file a complaint with our organization, by using our confidential hotline service, the Friends Services Alliance Compliance Line at [PHONE NUMBER] or with the secretary of the Department of Health and Human Services. To file a complaint with our organization or if you have questions regarding this notice, please contact: .Corporate Compliance & Privacy Officer Arcadia Family of Companies. All complaints must be submitted in writing. There was no contact information for the secretary of the Department of Health and Human Services referenced in this handbook. There was no reference to the right to file an anonymous complaint.

Based on interviews and document and medical record review (RR), the facility failed to honor the rights of one Resident (R)1 of a sample size of three. Although R1 and a Family Member (FM)1 verbalized to nursing staff they did not want melatonin (sleep aid) administered, the staff did not honor that request, or follow up with the provider to discontinue the medication in a timely manner. As a result of this deficient practice, R1 continued to receive the melatonin, and R1 and FM1 were not included in the treatment plan after expressing concern. This could affect any resident and has the potential to be a barrier for them to obtain their highest level of psychological well being. Findings include: 1) R1 was an [AGE] year old female admitted to the facility on [DATE] for rehabilitation after small bowel resection. She had an abdominal post-op wound with secondary diagnosis that included coronary artery disease, hypertension, acute hypoxic respiratory failure, and dementia. Her records indicated she had late onset Alzheimer's disease. R1 required assistance with activities of daily living, bed mobility and transfer. On 07/31/2024, while a resident in the facility, R1 reported that a male nurse made an inappropriate comment and suggestions to her. On 08/05/2024, facility leadership met with R1's family to discuss the investigation. At that time, the Family Member (FM)1, informed the facility she was upset about two other unrelated issues, 1) R1 received melatonin, after she told the staff she not want R1 to receive the medication, and 2) R1 had a fall on a previous admission, which the FM1 felt was not acknowledged or investigated in a timely manner. 2) The Office of Healthcare Assurance received a report from Adult Protective Services regarding the alleged abuse R1 reported to the facility on [DATE]. The report included the additional concerns: - On 07/30/24, RN1 informed FM1 that she attempted to give AV (alleged victim/R1) melatonin, but AV refused; FM1 questioned if AV needs melatonin because she does not have trouble sleeping. RN1 informed FM1 that it is PROTOCOL. - FM1 informed RN1 that AV does not want melatonin and does not have trouble sleeping so she does not want melatonin given to AV. RN documented to Discontinue Melatonin on 7/30/23. - On 8/5/24, FM1 went to visit AV and observed AV appeared Drugged because she was very groggy and unable to communicate as usual; at baseline AV appears alert/oriented and able to communicate well. - FM1 asked if AV was given melatonin and AP (alleged perpetrator) confirmed that she just gave AV melatonin, FM1 informed AP that RN1 documented that it is discontinued. .- On 8/6/24, FM1 visited AP and she appeared Drugged Out and could not communicate well; AV was very drowsy and not herself. FM1 approached RN1, who checked and stated AV was given melatonin; stated she thought it was strange AV was given melatonin after it was documented on 7/30/2024 to discontinue. melatonin. - On 8/7/24, FM met with Administrator, Nursing Director, Certified Nursing Assistant Director, and Social Worker. FM1 expressed concern that Arcadia continued to administer melatonin to AV after it was documented on 7/30/24 to discontinue melatonin. 3) Review of R1's Medical Record revealed the following entries: 07/29/2024, 04:49 PM Nursing Progress Note: . Alert and Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. 07/30/2024, 08:50 AM Nursing Progress Note: Received sleeping soundly. 07/30/2024, 09:02 PM Order Administration Note by Registered Nurse (RN)1: Melatonin Oral Tablet by mouth at bedtime for Insomnia Take 1.5 mg (milligram) at bedtime. Resident refused, verbalized not needed, she can sleep without sleeping aid. 07/30/2024, 01:31 AM Nursing Progress Note: .Refused melatonin, resident verbalized she can sleep without taking any sleeping aid. Husband and daughter came to visit this shift. 07/31/2024 08:44 AM Nursing Progress Note: . Per evening shift LN (licensed nurse), resident refused Melatonin t [sic] HS (hour of sleep). Order Recap Report included the order Melatonin (for sleep) Oral Tablet 3 mg. Give 0.5 tablet by mouth at bedtime for Insomnia Take 1.5 mg at bedtime. The order was started on 07/29/2024 and discontinued in the electronic medical record on 08/07/2024. Review of the Medication Administration Record revealed the nursing staff documented melatonin was administered on 07/29/2024, 07/31/2024, and 08/01/2024 through 08/06/2024. The medication was refused by R1 on 07/30/2024. The order was discontinued on 08/07/2024, after the meeting and request made again by FM1. 4) On 09/05/2024 at 02:30 PM, interviewed RN1 in the conference room. She said she took care of R1 on maybe the second or third day of her admission. RN1 said she informed R1's family she had refused the melatonin because she said she didn't need it. RN1 went on to say FM1 questioned why R1 was getting melatonin because she didnt have trouble sleeping, and that she told FM1 it was routine medication. RN1 said FM1 verbalized she did not want R1 to get any more melatonin. She said she did not call the attending physician because it was off hours and not urgent, but endorsed it to the night shift, and noted it on the 24 hour report. RN1 said she expected the day shift would notify the physician and get the order to discontinue the melatonin. She said she waa back on that unit a few days later and talked to the family again. RN1 said FM1 asked if R1 had received melatonin, and she told her she had just given it to R1. She said FM1 was upset. RN1 said the melatonin was still an an active order, so assumed something had changed because she saw in the record R1 had been getting it routinely. She said at that time, FM1 asked please to just get an order to discontinue.

Based on interviews, document review and medical record review (RR), the facility failed to promptly notify the ordering physician of significant radiology findings. One Resident's (R)2 repeat chest xray findings showed significant changes from the previous xray taken three days earlier, and were not communicated to the physician for approximately one hour after the radiologist recorded the interpretation. In addition, the facility does not have a policy/procedure or effective process in place to identify which imaging results should be called to provider. This deficient practice has the potential to affect all residents and may result in adverse outcomes. Findings include: 1) R2 was a [AGE] year old male with past pertinent medical history of hypertension, Parkinson's disease, Alzheimer's, Arteriosclerotic heart disease, diabetes, urinary retention, unsteady on feet and muscle weakness. He had advanced functional and activity of daily living dependence with on an off confusion. R2 had a fall on [DATE] while at the facility that resulted in a fractured right femur requiring surgical intervention. He was readmitted on [DATE]. Upon return R2 was diagnosed COVID positive, placed on isolation and started on antibiotic therapy. 2 ) RR revealed the following: Nursing Progress Notes: [DATE] at 14:43 (02:43 PM): Received resident (R2) in bed, alert, able to follow command and make need know [sic]. VS BP (blood pressure) ,d+[DATE], P (pulse) 90, R (respirations) 20, O2 sat (oxygen saturation) 91% @ 2.5 LPN (liters per minute) per NC (nasal cannula). Occasional cough noted.Continue on Ceftriazone (antibiotic) 1 gram IV (intravenous) q (every) 12 hrs (hours) x7 days ([DATE]-[DATE]) and levofloxacin (antibiotic) 500 mg (milligrams) IV QS (every day) x6 Days ([DATE]-,d+[DATE]) for sepsis, . PCP (Primary care Provider) came to visit and order Chest x-ray today for generalized infiltration heard on auscultation (when listened to lungs). [DATE] at 23:24 (11:24 PM): Resident received still on isolation. @ 1745 per CNA (Certified Nurse Assistant) on duty resident refused dinner she then gave him PM care. This writer went to check on him @ 1850 and found him pale, O2@3LPM/NC VS (vital signs) checked BP (blood pressure)-,d+[DATE], P (pulse) 63 RR (respirations) 0. Fingers still moving. No chest/abdomen rise and fall, unable to read O2 sat (oxygen saturation). Sternum rub (painful stimulus to test consciousness level) was done but unable to arouse. BP slowly dropped to Error. Charge Nurse on duty came down to check on him. Death was pronounced at 1855. Resident passed away peacefully.Called PCP @ 1903 pcp verbalized patient was okay when he did his round this morning. Read him (PCP) the result of Xray with the impression of fluid overload/pulmonary edema. Radiology Result Reports: On [DATE], a single view chest x-ray was ordered. The Radiology Results Report documented the radiologist's impression (interpretation) of significant findings was No acute cardiopulmonary disease. recommend follow-up as clinically indicated. On [DATE], a repeat chest x-ray was ordered. The radiologist's interpretation included: Comparison: [DATE].Impression: Findings suggesting pulmonary edema/fluid overload (an urgent medical condition caused by too much fluid in the lungs, making it difficult to breath). Infection cannot be excluded. 3) On [DATE] at approximately 02:00 PM interviewed RN2 in the conference room. RN2 explained the vendor that does the x-rays for the facility sends the interpretations to the Medical Record Manager (MRM), who then will forward to the nursing staff, who would follow up as needed. She went on to say there had been a recent change, and that they are now receiving the reports to a new fax machine on the third floor. RN2 said although the MRM works until around 04:00 PM, reports are sent to her after hours. RN2 was Charge [DATE], the evening R2 expired, and she responded to the unit. She said when the RN contacted the MD about the expiration, she read the xray results to him, but R2 had already expired. RN2 said there is no phone call from the vendor if there is an interpretation that may require medical intervention, but that the nurse has to go into emails and continually look for the report. She acknowledged the process was not efficient and could cause delays in timely notification of MD of significant findings. On [DATE] at 03:15 PM, interviewed the MRM in the conference room. She said the radiology vendor fax the report to me and I shoot it out to the nurses via email. MRM explained all the nursing staff have their own email and she sends the results to all staff. She said receiving the reports and sending them on to nursing is her duty ,d+[DATE]. MRM said she gets an alert when a fax is coming in. When asked if she would be able to track what time a report was emailed to nursing, she said they are automatically deleted at a certain time. She explained she does not upload the reports in the medical record, and that is done by the day Unit Secretary, after nursing reads the reports and notifies the MD. On [DATE] at approximately 03:35 PM, during an interview with the Administrator in training, she said the facility did not have a policy for when the RN should contact a provider of Radiology findings.

Based on interview and document review, the facility failed to report an alleged abuse to proper authorities within prescribed timeframe's. Specifically, the facility staff became aware of an alleged abuse on 07/31/2024 and did not report it to Adult Protective Services (APS) until 08/05/2024. In addition, the facility did not report the incident to the Office of Healthcare Assurance (OHCA) until 08/12/2024. Findings include: 1) The Office of Healthcare Assurance (OHCA) received a report from an outside agency (APS (Adult Protective Services)) regarding an alleged sexual abuse complaint on 08/09/2024. The report included, but not limited to: On 7/31/24 AV (alleged victim/R1) reported to a Certified Nursing Assistant (name unknown) that during the night (either on 7/30/24 or 7/31/24, AP (alleged perpetrator) came to AV's room and grabbed AV's hand then forced her to touch his penis. OCHA received a Facility Reported Incident (ACTs #11142) completed by the facility on 08/12/2024. The report was a combined initial and completed report initiated by the Administrator-in-training. 2) Reviewed the APS report titled Adult Protective Services (APS) Report Form For Vulnerable Adult Abuse dated 08/05/2024 initiated by the facility Social Worker and sent to APS. The report form included: - Directions: To report abuse, neglect, and/or exploitation of vulnerable adults: 1. As soon as possible, call the Statewide APS Reporting line: [PHONE NUMBER]. 2. Submit this form to Statewide APS Intake Unit as soon as possible, including after business hours. - Alleged Victim (AV) was [AGE] year old female resident at the facility. - Presenting concerns included: Falls, Frail/weak and Alzheimer's Disease. - Capacity: Questionable decisional capacity, alert and orients, coherent and disoriented. - Alleged Perpetrator (AP): Staff of Care Facility. - The narrative information included: Incident was reported to day CNA (certified nurse assistant) on 7/31/24. SW (Social Worker) and DCNA (Director of CNA's) went to speak with resident (R1) about incident. Resident stated that last night, she isn't sure what time, a male nurse came into her room. He was short, haole (white) and wore eyeglasses. He grabbed her hand and tried to have her touch his penis. Discussion with DON (Director of Nursing) and DCNA concluded that there was no staff (employed by facility or agency) that matched that description. Administrator reviewed camera footage of 7/31/24 to see if there was anyone matching that description who entered resident's room. [NAME] was found. SW and DCNA went to speak with resident again on 8/1/24 Resident stated that she hasn't seen the male again. 3) Reviewed the facility Investigative Report Following Adverse Event Final/Completed Report of the alleged abuse which included timeline of investigation. The report included the following: 07/31/2024 approximately 10:00 AM: Resident shared with CNA inappropriate comment made to her. 08/01/2024 approximately 08:15 AM: Social Worker notified resident's family/POA of incident. 08/05/2024 approximately 12:30 PM: Family member called SW to see if SW had any updates .Family member inquiring about filing a report. SW to file report with APS today. 4) Reviewed the facility policy titled Residents' Rights - Freedom from Abuse, Neglect and Exploitation Policy (15C HCC, ARR HCC, HOKA) last reviewed 05/15/2024. The policy statement read The Arcadia Family of Companies (AFC) has written procedures in compliance with Federal and State regulation, regarding the rights and responsibilities of residents, including freedom from abuse. The policy included the following: - Investigation: Complaints/Grievances: If the resident's complaint is of a serious nature, involving improper care, abuse or neglect, the Director of Nursing, Health Care Administrator or Social Worker will respond to the resident immediately. An investigation will be initiated , and a report shall be submitted to the State Agency immediately. - Reporting/Response: The IDT (interdisciplinary team) conducts an immediate investigation of the circumstances of the incident and submits a written report of the investigation to the Administrator and CCPO. The Administrator notifies the appropriate agency of all substantial abuse, mistreatment or neglect immediately. A written report of the investigation is also done by the Administrator and submitted within 24 hours, with a final report sent within five days of completion, to required agencies, including the State Survey Agency (OCHA), the Long Term Care Ombudsman, the Office of Aging, Adult Protective Services and CCPO. Incident Reporting for Alleged Abuse inaccurately directs staff. - The policy included an attachment titled Algorithm (flowchart) for Healthcare Reporting Process Incident Reporting for Alleged Abuse. The algorithm does not direct staff to notify APS or OHCA on an alleged sexual abuse, and directs them to notify authorities only if the abuse had been substantiated by the facility. 5) On 09/06/2024 at 10:00 AM, conducted a telephone interview the Social Worker (SW) who completed the APS report and was actively involved in the alleged sexual abuse investigation. She said it is not just the Social Worker's role to report to APS, and that anyone can do it, as they are mandatory reporters. The SW went on to say in this investigation, she was assigned to complete the APS report, and she thought the Administrator was the individual responsible to report to OHCA. The SW confirmed the timeline and that the alleged abuse was reported to facility staff on 07/31/2024 (Thursday) and R1's family was not notified until the next day. The SW said on Monday (08/05/2024) R2's family member called her for any updates, and asked about an APS report. The SW informed FM that a report had not yet been filed, but that she would do so that day. When asked why the APS report was not made sooner, she said we didn't find anything on the investigation, so didn't report it. She went on to say, That's one of the things we learned, that we have to report right away.

Based on observation, interviews, and record review, the facility failed to ensure pain management was provided to the resident according to the resident's goals and preferences. R7 reported lumbar pain which impeded the resident from using the Hoyer lift to get out of bed for showers and/or socializing with staff and/or other residents. R7 reported receiving Lidocaine patches and Tylenol as the current plan for pain management, however, the medications are ineffective. R7 reported increased feeling of depression and being worn down by constant, unrelieved pain, and the inability to get out of bed. R7 goal and preferences for pain management is to be able to use the Hoyer lift, increased sleep, and minimal severe pain. The resident confirmed a strong medication option was not discussed or offered and she does want the option of receiving a stronger medication despite the potential for sedative side effects. As a result of this deficient practice, R7 has experienced physical and psychosocial harm related to ineffective pain management. Finding includes: During an interview with R7 on 10/31/23 at 10:15 AM the resident reported having back pain. Inquired about the origin of the pain, pain management offered to the resident, what was the resident's goals were for pain management, and how the pain has affected the resident. R7 stated the back pain started with no source of injury and started having pain a couple of days ago. The facility took an x-ray but it did not show anything and is currently receiving Tylenol and lidocaine patches for pain management. R7 stated the lidocaine patches and Tylenol are not working to relieve her pain. R7 reported since the back pain started, she has not been able to get out of bed to shower due to pain. The resident stated she does not get out of bed because her back hurts too much to be in the Hoyer lift, the lift requires her back to be in a certain angle and the pain she experienced was unbearable. R7 further reported that her sleep has been affected and is not getting quality rest. R7 reported that as a result of the unmanaged pain and being stuck in the bed, she is feeling more down and depressed. Throughout the interview, R7 was visibly in pain as evidenced by grimacing and would wince when she attempted to move. Inquired if the resident was willing to take stronger medication, even if the medication could potentially be sedating. R7 immediately confirmed, with no hesitation, willingness to take a stronger pain medication if it would help with her pain, and stated, then I could get in the Hoyer lift and be able to get out of the room. R7 also confirmed the physician did not offer the resident a strong medication to alleviate the resident's pain. On 11/02/23 at 01:26 PM, conducted a concurrent interview and record review of R7's Electronic Health Record (EHR) with Nursing Staff (NS)42. Review of R7's November Medication Administration Record (MAR) and physician orders documented R7 was scheduled to receive: -Gabapentin 300 mg by mouth at bedtime for pain (started on 07/24/23, prior to the back pain) -Lidocaine patch 4% to lower back topically in the morning for lumbar spinal pain (started on 10/29/23) -Acetaminophen 650 mg two times a day for lumbar spinal pain for 2 weeks (started 10/28/23) NS42 reported that prior to reporting the lumbar pain, R7 would come out of bed, but since reporting lumbar pain, the resident has been refusing due experiencing too much pain when attempting to use the Hoyer lift. Review of the MAR documented on 11/01/23 at 05:26 PM, the resident reported pain level 8/10 after getting out of be to shower and having to be in the Hoyer lift. Certified Nurse Aide (CNA)63, 58, and 12 was in the area and this surveyor inquired with staff regarding R7's pain. NS42, CNA63, CNA58, and CNA12 confirmed R7 did not recieve pain medication prior to the Hoyer lift and showering and upon returning to bed and receiving the Tylenol, R7's pain remained unrelieved and the resident was in visible pain as a result of being in the Hoyer lift. NS42 stated that R7 does refuse treatments and that is probably why the physician had only ordered Acetaminophen. Inquired and requested documentation of R7 refusing stronger pain medication or the offer for stronger pain medication. NS42 confirmed there was no documentation in R7's EHR to include but not limited to progress notes, physician notes, or care plan meeting notes of R7 refusing stronger pain medication. Inquired as to how NS42 would treat R7's break through pain or severe pain. NS42 confirmed the lidocaine patches and acetaminophen are the only pain relief medications as needed (PRN) medications that are ordered for R7 and have not been effective with break through pain or severe pain. On 11/03/23 at 10:27 AM, conducted a concurrent interview and record review of R7's EHR with the Director of Nursing (DON) and an Advising DON (AADON). The DON and AADON was informed of this surveyor's observations and interview with R7 regarding the reported lumbar pain. After reviewing R7's EHR, the DON and AADON confirmed R7's current pain management plan was not effectively treating the resident's pain and agreed that although the resident may potentially refuse stronger medication, R7 should be offered or have the option to receive stronger medication break through pain or severe pain. DON and AADON also confirmed they were unaware that R7's pain was affecting the resident's activities of daily living and sleep.

Based on observations and staff interview, the facility failed to maintain a safe, homelike environment as evidenced by two different areas of the building being in disrepair and staff not maintaining comfortable sound levels. Findings include: 1) Observation on 11/02/23 at 01:00 PM of the third floor Diamond Head Nursing Unit revealed two different areas of the building where there was broken corner protectors, cracked drywall and unfinished wall repair. This also created a risk for accident hazards. During staff interview on 11/03/23 at 07:40 AM, Housekeeping Supervisor (HSupvr) acknowledged the areas of disrepair but stated that they were not aware of it. HSupvr further stated that they would have the areas repaired immediately. 42160 2) While conducting an interview with Resident (R)29 on 10/31/23 at 11:05 PM, the resident reported staff being very loud and waking up the resident, daily, when they come into the room at 04:30 AM to assist the resident's roommate to the bathroom. R29 confirmed she wants to sleep in and does not want to be awaken by staff at that hour. During an interview with the Director of Nursing (DON) and an Advising DON (AADON) on 11/03/23 at 10:19 AM, the DON confirmed staff should minimize the sound level to avoid disturbing resident's sleep.

Based on record review (RR) and staff interview the facility failed to include R12's choices for her advanced healthcare directives in her baseline care plan. The deficient practice could affect any newly admitted resident at the facility. Findings Include: On 11/02/2023 at 01:21 PM RR did not find a signed Baseline Care Plan form for R12. On 11/02/2023 at 04:33 PM medical records was able to provide a copy of the baseline care plan for R12. Baseline care plan was signed by staff completing the baseline care plan on 09/29/2023 for R12 who was admitted that day. Noted the Advanced Directives/Code Status section was left blank. On 11/03/2023 at 11:41 AM reviewed R12's baseline care plan with Interim DON who stated the Advanced Directives/Code Status section is to be filled out, this area was left blank. Requested and received a copy of the Baseline Care Plan policy, from the Interim DON, which is dated from 05/2022. Policy states: Purpose: The facility must develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission to include the minimum healthcare information necessary to properly care for a resident including, but not limited to: 1) Initial goals based on admission orders, 2) Physician orders, 3) Dietary orders, 4) Therapy services, and 5) Social services. Day 3 (within 48 hours) 1. The MDS (Minimum Data Set) nurse will, review nursing admission assessment and care plan,-and incorporate pertinent information to baseline care plan. 2. MDS nurse will complete baseline care plan and summary within 48 hours.

Based on observations and interviews, the facility failed to ensure the resident's right to a dignified existence for two residents sampled. As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: On 11/02/23 at 09:57 AM, observed Activity Staff (AS)4 standing next to Resident (R)25 looking out the window, in the activity room/dining room looking out the window. Observed R25 tap AS4's arm with the back of her right hand. AS4 responded to the incident by quickly hitting away the resident's hand and immediately moving away from the resident. AS4 initially appeared annoyed by R25 touching him/her and rubbed the area if his/her arm that R25 touched. At 10:12 AM, while conducting activities, another resident stood up from the chair, observed AS4 walk behind the resident, put both hands on her shoulders and applied some force to the resident's shoulders, prompting the resident to sit back into the chair, twice. The third time the resident stood from the chair, AS4 placed his/her right hands on the resident's left shoulder while standing at the resident's side and applied force to ensure the resident would sit. While conducting an interview with the Director of Nursing (DON) and an Advising DON (AADON) on 11/03/23 at 10:19 AM, informed them of the observations of AS4's interactions with two residents. The DON was able to identify both residents involved in the observations and confirmed staff should never use force to make the resident sit and staff should not assist residents into a seated position from behind, staff should be within the resident's view to avoid a potential accident. On 11/03/23 at 12:18 PM, conducted an interview with AS4 regarding his/her interaction with both residents. AS4 confirmed hitting R25's hand away to avoid the resident grabbing him/her. It was explained that the resident had made contact with AS4 using the back of her hand and was not grabbing the staff. AS4 stated he/she could have inquired with the resident to see if the resident needed assistance instead of immediately moving away from R25. AS4 also confirmed, applying force on the resident's shoulders to get the resident to sit was not a dignified manner of interacting with the resident.

Based on observation, record review (RR) and resident interview the facility failed to include use of a walker in Resident (R)35's comprehensive care plan and use of antidepressant in R12's comprehensive care plan. The deficient practice could affect any resident at the facility. Findings Include: 1. On 10/31/2023 at 09:29 AM met and spoke with R35 in her room. R35 asked surveyor if I saw her walker on the other side and she pointed towards the partition in her room. Looked on other side of partition but saw a walker that was in the living space of R35's roommate. R35 stated a facility staff, nurse, had told her she could not use her walker. Inquired if R35 had fallen and she denied falling in the facility. R35 stated she walked in the hallway yesterday with the therapist and she took the walker away. On 10/31/2023 at 10:00 AM spoke with R35's nurse and asked if she told resident she could not have her walker and nurse denied this. On 11/02/2023 at 09:14 AM went to interview R35 and found her sitting in her room with her walker next to her. R35 said she saw it on the other side near the bathroom when staff assisted her to the bathroom. R35 stated she will make big noise next time they take my walker. On 11/02/2023 01:09 PM RR of R35's electronic health record (EHR) found resident's walker use was not included in her care plan that was initiated on 10/24/2023. Noticed facility staff added [NAME] is to be kept within reach Date Initiated: 11/01/2023. 2. On 11/01/2023 at 03:43 PM During RR of R12's EHR noted she had escitalopram (antidepressant) 10 mg tablet one tablet by mouth daily ordered for anxiety and depression which was ordered on 10/17/2023. Reviewed R12's care plan and found she had a care plan for psychosocial management but it did not include her antidepressant use as an intervention.

Based on interviews and record review, the facility failed to ensure the resident representative's right to make decisions on behalf of the resident for one resident (Resident (R)70) sampled. As a result of this deficient practice, there is a potential risk of more than minimal harm. Findings include: R70 is an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis which include but are not limited to peripheral vascular disease, Dementia, diabetes mellitus type 2. Review R70's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/23, documented in Section C. Cognitive Patterns a score of 9 on the Brief Interview for Mental Status (BIMS), indicating the resident has moderate cognitive impairment. Review of the resident's documents and consent forms documented R70 has a Power of Attorney (POA) for health care decision and the POA is actively involved in exercising his/her right to make decisions on behalf of R70. Review of six consent forms in R70 Electronic Health Record (EHR) documented two consent forms: informed consent for use of psychoactive medications dated 08/07/23 and informed consent for use of a potentially restrictive device (dated 09/18/23). Both documents were signed by the resident and not the health care POA. The remaining consent forms were all signed by R70's health care POA. Review of a psychiatrist (P)2 note documented P2 assessed the resident for capacity and documented sue to R70's progressive Dementia, R70 is no longer able to participate in medical and financial decisions. On 11/03/23 at 10:09 AM, conducted a concurrent interview and record review of R70's EHR with the Director of Nursing (DON) and an Advising DON (AADON). DON and AADON reviewed both consent forms which were signed by R70 and confirmed from admission, R70's cognition has been impaired and both consent forms should have been reviewed and signed by the resident's health care POA, not the resident.

Based on observations and interviews, the facility failed to provide reasonable accommodation of resident's needs to one out of 21 sampled residents (Resident (R) 21). This failed practice has the potential to affect all the residents in the facility. Findings Include: R21 is a [AGE] year-old male admitted to the facility on [DATE]. R21 is currently receiving hospice care in the facility. Concurrent observation and Interview were conducted on 11/01/23 at 10:17 AM in R21's room. R21 stated that he is constantly requesting for more water, and it takes telling two or three staff until someone finally provides him with more. The resident has two small cups on his bedside table. One cup was filled halfway with water and the other cup was filled with clear light brown liquid. Resident's water pitcher was located on top of the bedside dresser, which is located behind the resident. Due to the location, the resident is unable to reach the water pitcher. Observation was conducted on 11/01/23 at 12:10 PM in R21's room. R21's water pitcher remained on the bedside dresser, not within reach of R21. Observation and interview were concurrently conducted on 11/02/23 at 07:37 AM in R21's room. R21 did not have water on his bedside table in front of him. Water pitcher and cups remained on the bedside dresser. R21 stated that he does not get enough water and it was, humbug because I can't reach it, I don't know why they don't put it closer.

Based on interviews and record review, the facility failed to assure that two sampled residents (Resident (R)72 and R70 ) received an accurate assessment, reflective of the residents' status at the time of the assessment. This deficient practice places all the facility residents at risk for assessment inaccuracy. Findings Include: 1) A review was conducted of R72's Electronic Health Record (EHR). R72's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/28/23 indicated that R72 had three stage two pressure ulcers that were not present upon admission. Interview was conducted on 11/02/23 at 08:09 AM with R72 in the dining room. R72 stated that he had the pressure ulcer before admission to the facility. Interview was conducted with Director of Nursing (DON) on 11/03/23 at 10:26 AM. DON stated that R72's pressure ulcers were present during admission and was miscoded on the MDS. 42160 2) Review of R70's quarterly MDS with an ARD of 10/18/23, Section C. Cognitive Patterns documented the resident's Brief Interview for Mental Status (BIMS) scored was documented as 15, indicating the resident does not have impaired cognition. However, review of physician notes documented the resident was unable to make health care or financial decisions due to advancing Dementia. On 11/03/23 at 10:15 AM, during a concurrent interview and record review with the DON and Advising DON (AADON), DON confirmed the resident has cognitive impairment, does not have a BIMS score of 15, and the resident's quarterly MDS was inaccurate.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician after a resident fell and had the potential for requiring physician interventions for one resident (Resident (R)70) sampled. R70 fell and sustained multiple bruises and reported hitting her head, was on medications which inhibit the resident's blood clotting abilities (Aspirin and Xarelto) placing the resident at higher risk for internal bleeding, and the physician was not notified until 1 hour and 40-minutes after the resident fell . Facility staff reported R70's physician is regularly difficult to contact. As a result of this deficient practice, all residents under the same care of R70's primary physician is at risk for potential of harm. Findings include: On 10/31/23 at 01:05 PM, conducted a review of R70's Electronic Health Record (EHR). Review of the resident's progress notes documented on 10/08/23 at 08:20 AM, R70 had a witnessed, unassisted fall in the dining room and sustained bruising to the right forearm, abdomen, left breast, and a lump of the forehead. R70 was attempting to leave the dining room and return to her room. R70 stood up from a chair, pushed the chair back, took 2-3 steps forward, then turned. and lost her balance. R70 reported hitting the front of her head and right elbow on floor. Staff found R70 on the floor, lying on left side. The resident's cane, newspaper and cup of water found on floor next to her. Review of notification documentation showed R70's physician was notified at 10:00 AM, which was 1 hour and 40 minutes after the resident sustained multiple bruises from an unassisted fall. Review of the R70's physician orders and Medication Administration Record (MAR) documented R70 was on scheduled Aspirin EC 81 milligrams (mg) once a day for cardiovascular health and Xarelto 2.5 mg two times a day status post angiogram until 11/05/23. Both Aspirin and Xarelto is used to prevent the blood from clotting and increase the resident's potential for bruising, bleeding, and serious injury from falling. On 11/2/23 at 01:15 PM, conducted a concurrent interview and record review of R70's Electronic Health Record (EHR) with Nursing Staff (NS)42. Inquired about why there was a 1 hour and 40-minute delay in notifying R70's physician of the resident's fall, especially since the resident is on two medications which inhibit the resident's blood clotting abilities and places R70 at a higher risk of sustaining internal injuries/bleeding. NS42 stated it is difficult to get in touch with Physician (P)3. NS42 explained when staff call P3, the physician does not answer, and they are unable to leave a voicemail and the nurses must keep calling. NS42 stated if it is serious staff will call Medical Director (MD)8 but did not call in this instance. On 11/03/23 at 10:22 AM, conducted a concurrent interview and record review of R70's EHR with the Director of Nursing (DON) and an Advising DON (AADON). After reviewing the timeline, DON confirmed MD8 should have been called, but was not. On 11/03/23 at 11:44 AM, conducted a telephone interview with MD8 regarding staff's continued difficulty with contacting P3 for the medical treatment of residents at the facility. MD8 was aware that staff was unable to contact P3 when physician oversight was necessary for several months. Inquired with the Medical Director if a corrective plan or action implemented or provided oversight for P3 to ensure the physician is available to staff when called. MD8 reported speaking to P3, the physician reported having issues with his/her mobile provider service and did not implement a corrective action plan for P3. Inquired what steps have P3 taken to resolve the issue with his/her mobile provider. MD8 was did not know what steps, is any, P3 took and has not followed up with P3 or staff to ensure this issue was resolved.

Based on observations, record review, and interviews with staff members, the facility failed to 1) Ensure appropriate alert mechanisms on exit doors were functional on the nursing units after one resident (R)52, was able to elope from the facility. This deficient practice could have potentially placed any residents who wander in immediate danger and 2) Failed to implement interventions, including adequate supervision to prevent an avoidable fall for 1 out of 2 residents Resident (R)47 sampled for falls. As a result, R47 sustained a fracture to left ribs. Findings Include: 1) On 12/19/22 at 10:33 AM, observed R52 walking out of his room. R52 was observed to be walking up and down the hallway with a steady gait before lunchtime. On 12/20/22 at 09:57 AM, R52 ' s family member (FM) was interviewed via phone. FM stated that R52 has had elopement issues since residing in the independent living area. On 12/20/22 at 10:15 AM, reviewed R52 ' s electronic health record (EHR). R52 ' s Minimum Data Set (MDS) annual assessment with assessment reference date (ARD) of 10/20/22 revealed that his Brief Interview for Mental Status (BIMS) score was 03 or cognitive status with severe impairment. R52 ' s care plan revealed that he is a [AGE] year-old resident admitted on [DATE] and has diagnoses of age-related physical debility, Alzheimer ' s Disease, Dementia, generalized muscle weakness, abnormalities of gait and mobility, and peripheral vascular disease (narrowing of blood vessels in the legs). The clinical notes for nursing were reviewed and documentation entered on 10/10/22 at 12:03 AM revealed that R52 wandered down to the first floor from his room on the second floor. Another nursing clinical note entered on 12/19/22 at 12:49 AM, documented that R52 was found by security in front of the building on 12/18/22 at 11:15 PM with dirty socks and a wet jacket. On 12/21/22 at 1:12 PM, reviewed the facility ' s incident report about R52 ' s elopement on 12/18/22. The root cause of R52 ' s elopement was that an exit door alarm on his nursing unit was not triggered upon R52 ' s exit through that door. On 12/21/22 at 1:18 PM, interviewed the Environmental Services Manager (ESM). ESM stated that the four exit door alarms are checked quarterly for an audio alert, and they were last checked on 11/02/22. A follow-up test for the exit door alarm (A)1 that R52 exited through was done on 12/19/22 and it was functional. ESM stated that for R52 ' s elopement occurred because A1 was switched off, and provided no audio alert. ESM stated that he was going to replace the four exit door alarms for a product that could not be easily disengaged and had those in his possession, but had not replaced the alarms yet. On 12/21/22 at 1:45 PM, state agency (SA) observed ESM test the four exit door alarms and found that three of the four alarms did not have an audible alert when the exit doors were opened. The two exit door alarms on the floor where R52 resided did not provide an audio alert when they were opened. At 1:48 PM, an immediate jeopardy (IJ) situation was determined to exist due to R52 ' s history of elopement and malfunctioning of the exit door alarms on the floor R52 resided on. On 12/21/22 at 2:20 PM, the facility was notified of the IJ situation, and the facility provided an acceptable plan of correction at 3:45 PM. On 12/22/22 at 07:11 AM, nurse (N)80 was queried about the use of the new exit door alarm installed and N80 stated that the alarm was verified to be engaged when the key position is vertical. The manual key to engage and disengage the exit door alarm is kept in the medication carts on each unit. 43414 2) R47 was admitted to the facility on [DATE] with diagnoses not limited to age-related osteoporosis, anemia, cognitive communication deficit, depression, history of falling, abnormalities of gait and mobility, and dementia. Review of R47's Electronic Health Record (EHR), documents a fall prior to admission on 05/02/22, and subsequent falls at the facility on 06/25/22, 07/10/22, 08/04/22 and 11/01/22. Review of R47's quarterly Minimum Data Set (MDS) with an assessment reference date of 11/22/22, R47's Brief Interview Mental Status (BIMS) scored her at a 3 (severe cognitive impact). In Section G. Functional Status, under Balance During Transitions and Walking, R47 scored a 2 (not steady, only able to stabilize with human assistance) for moving from seated to standing position. Review of R47's clinical notes was done. On 08/04/22, R47 had an unwitnessed fall at 1500 [03:00 PM]: Licensed staff was in the hallway, when a loud voice was heard from the dining room. Licensed staff went to check on the residents in the dining room right away. When licensed staff responded, saw resident [R47] sitting on the floor right on the side of her wheelchair, with legs extended, and back leaning on the side of a dining chair .Res [resident] was having activity and watching television together with other residents in the dining room. Resident was restless and with multiple attempts to stand up in her wheelchair prior to the incident, redirection was provided. Lap pad was in placed but resident keep on taking it off. She verbalized that she is looking for her husband and she needs to go to school so she tried to stand up and probably she fell . The note does not document supervision in the dining room for residents and/or close supervision to R47 was provided after multiple episodes of attempting to stand up prior to the incident. On 08/05/22 R47 complained of left rib pain. On 08/06/22, R47's X-ray impression included an acute mildly displaced fracture of left 8th and 9th ribs. Review of R47's Care Plan Update Sheet and care plan documents interventions in place as a result of falls R47 had prior to 08/04/22. Interventions included for resident to use a wheelchair seatbelt when in wheelchair for safety reasons. On 07/28/22, the wheelchair seatbelt was put on hold and the facility attempted to try a weighted lap pad/blanket while R47 is seated in her wheelchair. Prior to 08/04/22, further review of R47's clinical notes document R47 removing the weighted lap pad and attempting to stand up on 07/28/22, 07/29/22, 07/30/22, 07/31/22, 08/01/22, 08/02/22, and 08/03/22. The clinical notes document on those dates close supervision was provided. Review of Fall Risk Assessment R47 scored 10 on 05/25/22, 13 on 07/09/22 , and 11 on 07/13/22, according to the assessment this puts R47 at High Risk and requires appropriate fall interventions from Protocol II. However, from the 10 listed fall preventions in Protocol II only one was instituted, 1 .Fall Prevention Protocol 1. The following were included in R47's Fall Prevention Protocol 1 dated 07/11/22: Frequently reorient and repetitively reinforce use of call bell and ensure it is within reach, Reassess for a clutter-free, well-lit environment, Reinforce use of assistive devices, if used, Physical Therapy for rehabilitation, if appropriate, and Conduct a medication review. On 12/21/22 at 09:44 AM interview and concurrent record review with Quality Assurance Nurse (QAN) 1 was done. QAN1 confirmed R47 has had four falls at the facility. Concurrent review of R47's clinical note on 08/04/22 documenting the unwitnessed fall, inquired if staff should have provided close supervision when resident removed the weighted lap pad and had multiple attempts to stand up, QAN1 stated a staff member should have been at the nurse's station facing the dining room to ensure close monitoring. Inquired how resident was discovered after the unwitnessed fall, QAN1 confirmed the progress note documents a staff member heard R47 yell from the hallway, was not at the nurse's station, and does not document staff members providing supervision in the dining room. On 12/22/22 at 09:55 AM interview and concurrent record review with Director of Nursing (DON) was done. DON stated after R47's first fall at the facility, the use of seat belt was ordered while resident was on the wheelchair and on 07/28/22 the facility trialed the weighted lap pad. DON further stated the weighted lap pad was not working as an intervention to remind R47 to stay seated because R47 would take it off, put it on the table and attempt to stand up. Concurrent review of R47's clinical note on 08/04/22 documenting the unwitnessed fall, DON stated it would have been ideal for someone to monitor R47 more closely due to R47 frequently trying to stand up prior to the incident.

Based on observations, record review, and interviews with staff member, the facility failed to implement interventions, including adequate supervision consistent with the resident's needs, goals, and care plan to prevent an avoidable fall for 1 out of 4 residents (Resident (R) 17) that resulted in sustaining a fracture to right arm and significant weight loss. Findings Include: Review of R17's Investigate Report Following Adverse Event regarding an incident on 12/18/20, R17 had a witnessed fall and sustained fracture to right acute great tuberosity (prominent area of bone at the top of the humerus and is the attachment for the two large, powerful rotator cuff muscles, injured by landing directly onto the side of the shoulder or landing with arm outstretched) and humeral neck (bone in upper arm, located between the elbow and shoulder), causing right shoulder pain. The report further documented that on 12/18/20, R17 saw a candy container shaped like Santa's pants and it was filled with candy canes. The resident stood up from her chair and walked to the nurse's station using her front wheeled walker. She grabbed a candy cane then turned around and took a few steps to give the candy to her husband without utilizing her front wheeled walker then walked back to the nurse's station. The resident remained standing in front of the nurse's station, but she was not holding on to her walker. The resident started to walk backwards, lost her balance, and fell down on the carpeted floor. R17 is a [AGE] year-old with diagnoses of Alzheimer's Disease, muscle weakness (generalized), and unsteadiness on feet and with history of falls. Review of R17's Care Plan, documents a fall in her independent living apartment on 07/01/19, and subsequent falls at the facility on 02/05/20, 03/23/20, 04/12/20, 07/29/20, 11/19/20, and 12/18/20. Review of R17's quarterly Minimum Data Set (MDS) with an assessment reference date of 11/12/20, R17's Brief Interview Mental Status (BIMS) scored her at a 3 (severe cognitive impact). In Section G. Functional Status, under Transfers (how resident moves between surface including to and from bed, chair, wheelchair, standing position), R17 requires limited assistance with one-person physical assist. Walk in Room and Corridor, R17 requires limited assistance with one-person physical assist. Under Balance During Transitions and Walking, R17 scored a 2 (not steady, only able to stabilize with human assistance) for walking (with assistive device if used) and turning around and facing the opposite direction while walking. Review of R17's physician's encounter note dated on 11/23/20, R17 .requires very close monitoring and prognosis remains guarded with high risk for adverse events due to advanced age and comorbidities- Due to Muscle weakness, unsteady gait needs close observation due to high risk for falls, traumatic injuries .Safety monitoring for falls prevention with consideration for poor memory and safety awareness Review of Fall Risk assessment dated on 11/20/20 scored R17 at 11 and on 12/21/20 scored 12, according to the assessment this puts R17 at High Risk and requires appropriate fall interventions from Protocol II. However, from the 10 listed fall preventions in Protocol II only one was instituted, 1 .Fall Prevention Protocol 1. The following were included in R17's Fall Prevention Protocol 1: Frequently reorient and repetitively reinforce use of call bell and ensure it is within reach, Reassess for a clutter-free, well-lit environment, Reinforce use of assistive devices, if used, Assess for safe footwear, Monitor use of eyeglasses and hearing aid if applicable, Consider Wellness Center for strengthening, if appropriate, and Evaluate the need for adjustment in resident's daily activity schedule. Interview with the Director of Nursing (DON) and Administrator on 02/02/21 at 10:17 AM noted that there were two Registered Nurses (RN), 14 and RN9, behind the Ewa Nurse's Station when the incident happened on 12/18/20. RN14 initially was right by R17 when she grabbed candy for her husband, but RN14 went behind the station before the incident took place. According to DON, R17 is unpredictable sometimes and does not use her walker all the time. She further stated that R17 needs general supervision when walking but not stand by assist, many times when she does ambulate, we see her ambulating, so we can watch her. Concurrent review of the resident's care plan, effective from 11/18/20 to present, was done with the DON. Review of care plan under Impaired Mobility/Falls states that R17 .has balance problems and required 1-man limited to extensive assistance with ambulation and transfers. Interventions for ambulation notes that R17 uses a front wheeled walker (FWW) .with SBA [stand-by assistance] to contact guard assistance. According to DON stand-by assist means close by and contact guard assistance means .you are pretty much next to her. Inquired whether the resident's fall could have been prevented if the two nurses had intervened, to ensure R17 safely returned to her chair next to her spouse. The DON did not respond. Further inquired whether the interdisciplinary team (IDT) met to discuss the fall, DON responded they met; however, there is no documentation. The DON reported the root cause was weakness, poor balance, and poor safety awareness. DON explained that if R17 ambulated without the walker staff is expected to redirect her to use her walker. DON confirmed that R17 has a FWW and is supposed to use but also has a purple cane that she will use. Observed R17 on 01/27/21 at 09:27 AM, 11:53 AM, 12:56 PM, and 01:41 PM, R17 sitting in the hallway in front of Ewa Nurse's station on a chair without FFW. On 01/28/21 at 07:52 AM, sleeping in her room with no FFW in sight and at 11:42 AM in the hallway in front of the Ewa Nurse's station eating lunch seated on a chair with a purple cane on her left side. On 02/01/21 at 08:49 AM, resident in her room by the bathroom ambulating holding on to a wheelchair, yelling for help. On 02/02/21 at 10:43 AM, concurrent observation with the DON found no FWW in R17's room. Interviewed the Physical Therapist (PT). The PT stated he was looking for the FWW as well, it has been missing for two days in a row, noticed it was missing since Friday (01/29/21). Review of R17's documented weight on 12/08/20, her weight was 118 pounds (lbs.) and after the fall on 12/18/20 documented R17 weight on 12/21/20 was 111 lbs. R17 had a 6% weight loss within 13 days from 12/08/20 and 12/21/20. Interview with Registered Dietician (RD) on 02/01/21 at 12:59 PM, RD stated that she noticed resident also had a weight loss in July after a fall. RD further stated she thinks R17's refusal to eat is related to pain.

Based on observations, staff interviews, medical record review and facility policy review, the facility failed to ensure five residents (R62, R68, R77, R36, and R45) were free from avoidable falls. Actual harm was identified after review of R62's fall which resulted in a fracture of her fourth finger on her left hand. Findings include: 1. Cross reference to F690 and F725 Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R62 was reviewed for a Facility Reported Incident (FRI) submitted to the State Agency. The FRI noted R62 experienced a fall which resulted in a fractured finger. Observation of R62 on the morning of 5/30/18 at 10:30 AM found her seated in a wheelchair across the nurses station, outside of her room. Upon approaching R62, there was an odor of feces. Moving away from R62 the odor faded away. Upon return to R62, the feces odor returned. R62 appeared restless as she attempted to get out of her wheelchair and appeared to want to say something. Two Certified Nurses Aides (CNAs) wheeled R62 into her room, assisted her out of her wheelchair and walked with her to the toilet. There was a cushion wrapped in a white pillow case on the seat of R62's wheelchair. The entire pillow case and cushion were soaking wet. CNA 99 stated R62 had a bowel movement (BM) and she therefore needed to shower the resident. R62 wore a personal incontinence brief. Observation of R62 on the morning of 5/31/18 at 9:00 AM found the resident seated across the nurses station outside her room. She appeared to be getting restless: Attempting to stand while seated in the hallway in her wheelchair; Waving her hands around; and Appearing as though she wants to say something or do something. CNA 99 recognized R62 was getting restless so she offered to take her to the bathroom. CNA 99 wheeled R62 into her room and assisted her out of her wheelchair and into the bathroom. The seat cushion on R62's wheelchair was wrapped in a white pillow case and was wet in the center - an area of approximately 16 inches x 8 inches. R62 wore a personal incontinence brief. Observation of R62 on the afternoon of 5/31/18 at 2:00 PM found her seated in a wheelchair across the nurses station outside her room. R62 appeared sleepy as she was falling asleep in her wheelchair. The Licensed Nurse (LN 86) recognized R62 was falling asleep and offered to take her back to bed which the resident agreed to. The LN asked CNA 99 to assist her with placing R62 back to bed. R62 was returned to bed where she immediately fell asleep. R62's wheelchair cushion was dry. The LN 86 stacked two Geomatts next to R62's bed. On the morning of 5/31/18, a medical record review found the most current quarterly Resident Assessment Instrument (RAI) dated 4/12/18 which noted R62 had a short term memory problem and moderately impaired cognitive skills for daily decision making. The 4/12/18 RAI further noted R62 required extensive assistance with toileting with one person physical assist. The 4/12/18 RAI noted R62 was frequently incontinent of bladder and always incontinent of bowel. The 4/12/18 RAI noted (since previous assessment) R62 had two falls without injury, two falls with injuries (except major) and one fall with major injury. Under Section N (Medications), R62 was noted to be on antipsychotics and antidepressants for the seven days prior to the assessment. Previous assessment noted she was only receiving antipsychotics. On the morning of 5/31/18, a review of the latest comprehensive RAI (significant change) dated 10/16/17 found R62's cognitive ability was the same (as 4/12/18 RAI) - short term memory and moderately impaired cognitive skills for daily decision making. R 62's bowel/bladder status was the same (as 4/12/18 RAI). The comprehensive assessment (10/16/17) noted R62 previously required limited assistance with one person assist, where most current (4/12/18) RAI noted she requires extensive assistance with one person assist. The 10/16/17 RAI noted R62 had one fall without injury and one fall with injury (except major). Under Section N (Medications), R62 was noted to be on antipsychotics for the seven days prior to the assessment. The facility did a fall risk assessment for R62 on 1/19/18 and 4/16/18, which noted a score of 10 (8-16=High risk) on each assessment. Despite R62's high risk for falls, she continued to experience multiple falls since her re-admission to the facility on [DATE] (Previous admission 3/6/17). The R62 experienced falls on: 10/12/17; 10/14/17; 10/22/17; 10/28/17; 11/4/17; 12/15/17; 2/2/18; 2/4/18; 2/10/18; 2/23/18; 2/27/18 (two falls); 3/9/18; 3/14/18; and 3/24/18. On 5/27/18 R62 fell while seated at the nurses station. On the morning of 5/31/18 a review of R62's care plan found a plan for Impaired mobility/falls. Interventions included maintaining close supervision and frequent checks to ensure resident safety. Following a fall on 2/2/18, the facility revised R62's care plan to include, Educate staff not to leave residents until another staff is present to supervise. On the morning of 5/31/18 a review of the FRI for R62 found she was seated at the nurses station on the afternoon of 2/27/18 at approximately 2:50 PM. R62 was seated in her wheelchair next to the charge nurse (CN) at the nurses station. The CN turned to one side to make a phone call when R62 attempted to get up and the CN was unable to stop her. R62 fell and landed on her left side. At the time of the fall, R62's wheelchair brakes were not engaged. The CN assessed the resident and found swelling, bruise and pain to her her left thumb, left 4th and 5th fingers. A physician was on site and assessed R62 with orders for an X-ray. The X-ray revealed an acute fracture to the left fourth digit. The facility's root cause analysis (RCA) of R62's fall on 2/27/18 revealed that environmental factors may have contributed to the incident. The FRI noted, Brakes of her wheelchair were not locked and when she stood up the wheelchair possibly moved which contributed to her fall due to increased unsteadiness and poor balance. On the same day R62 sustained the finger fracture on 2/27/18 at 5:15 PM, she was seated in her wheelchair in the dining room. A CNA was seated next to her, feeding her soup. The CNA left R62 at the dining table when the CNA was asked to assist with pushing meal carts into the dumbwaiter. The CNA turned back to the resident and found R62 standing. The CNA was unable to get to R62 in time and the resident fell . The licensed nurse on duty responded to find R62 sitting on the floor with her back resting against the wheelchair, both knees flexed with arms resting on her sides, and facing the table approximately 2 feet away from her. The licensed nurse assisted R62 to the bathroom and she voided and 3 drops of fresh bright red blood was noted. The licensed nurse instructed the CNA to supervise the R62 at all times. The physician was notified and he notified the resident's daughter. The physician recommended a surgical procedure related to R62's finger fracture but the family refused further treatment. An interview of CNA 99 on the afternoon of 5/31/18 at 2:00 PM found her description of R62 is she sometimes get restless and occasionally has behaviors. She reported R62 often tries to get up from her wheelchair without assistance. CNA noted R62 is sometimes continent of bladder and will attempt to get up to go to the bathroom. CNA 99 noted, We don't always have enough staff to help us and therefore we have to leave residents at the nurses station. An interview of CNA 84 revealed R62 is sometimes continent of both bowel and bladder. The CNA reported the resident's brief sometimes has something on it and will still go when placed on the toilet. The CNA 84 noted R62 is often restless. The CNA reported they leave her at the nurses station for the nurse to watch while we're providing care to residents. CNA 84 works day shift and noted that each CNA will have seven residents. An interview of Licensed Nurse (LN 87) on the morning of 6/1/18 at 11:18 AM revealed the nursing staff assist with watching R62 since she's restless. LN 87 noted the nurses help the CNAs when they're busy. To keep R62 safe, all of the staff checks on her frequently, every two hours. An interview of the Director of Nursing (DON) on the afternoon of 5/31/18 at 3:41 PM found the facility was aware that R62 was at high risk for falls prior to the 2/27/18 fall. The DON described the 2/27/18 incident as noted above. The DON stated that the facility determined the root cause analysis was that R62's wheelchair brakes were not engaged. The DON explained that R62 is capable of unlocking her wheelchair brakes. On 2/27/18 the DON was unable to determine whether staff failed to lock R62's brakes or whether the resident unlocked the brakes after a staff member locked them. The DON explained that no one observed R62 unlocking the wheelchair brakes. The DON further noted that a fracture was identified after X-ray. The DON noted R62's family refused further treatment, only agreeing to taping of her fingers to immobilize them. When asked her expectation of staff when managing R62's restlessness, the DON stated she expected staff to provide close supervision. When asked what close supervision meant, the DON stated, Have her sitting next to the nurse and she can self propel to the hallway. When asked if R62's fall was avoidable or unavoidable, the DON reported, If you ask me, every fall is avoidable. The DON was informed that the survey team was looking at harm based on avoidable falls with subsequent major injury. The DON responded that the facility coordinated a family meeting with the physician present to discuss R62's multiple falls. The DON noted the physician identified R62's advanced dementia and instability of her gait. The DON noted the facility, along with the physician, ruled out medications as the cause for gait instability and resultant falls. The DON reported that R62's family is aware of the risks/benefits and the potential outcome of major injury. The DON was asked to provide all the supporting documentation to demonstrate the family's understanding of the risks versus benefits. Additionally, the DON was asked to provide documentation that the family participated in the discussion and signed documents with the risks/benefits outlined for them. On the morning of 6/1/18 at 9:12 AM, a meeting with the DON, Administrator, and Administrator in Training revealed the facility's stance on the family's awareness of R62's fall risks versus benefits. The DON provided a copy of a meeting conducted on 2/9/18 which noted the facility's discussion with the family. The discussion included the use of antipsychotics and the possible negative outcomes which included sedation, weight gain, irreversible abnormal involuntary movements, confusion, death and gait instability/falls. Despite the facility's discussion with R62's family, the facility failed to provide adequate supervision and implement all safeguards (locking of wheelchair) to maintain R62's safety which thereby caused actual harm. 2. Cross Reference to F690, F725 and F919. Resident 68 (R68) was admitted to the facility on [DATE]. R68's [DIAGNOSES REDACTED]. On 5/30/2018 at 9:00 AM while walking through R68's unit, a voice was heard calling out for help. Upon arrival to R68's room, the resident was observed sitting on the floor with legs bent to her chest and scooting on her buttock toward the door. The resident's face was contorted and she kept repeating please help me and stating that she had to use the toilet. The resident's undergarment could be seen which was not soiled. There was no staff member in the hall, assistance was requested at the nurses' station. Staff Member 131 (SM131) accompanied the surveyor to R68's room where she was found at the threshold of the door. SM131 requested assistance from a Certified Nurse Aid (CNA). They were able to assist the resident to stand and ambulate to the bathroom with a forward wheel walker. R68 was placed on the toilet. Further observation found the resident's bed was in a low position with a thick blue pad next to the resident's bed. The floor was not wet or soiled. The call light was placed on the resident's bed and was found to be inoperable. On 5/31/2018 at 3:29 PM a record review found a quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 3/18/2018 noting R68's cognitive ability is moderately impaired. In Section J. Health Condition, R68 is noted to have had falls since admission or prior assessment (ARD of 12/18/2017). R68 is documented as having one fall without injury and one fall with injury (i.e. skin tears, abrasion, superficial bruises, etc.). A review of the resident's care plan (provided by the facility on 5/31/2018) notes R68 had falls on the following dates: 9/15/2017; 9/18/2017; 9/21/2017; 9/21/2017; 9/22/2017; 9/23/2017; 1/24/2018; and 2/20/2018. There is notation that the resident tends to scoot herself down from bed to floor but usually does not sustain any injury and is at risk for repeat falls and serious injury related to falls. The interventions include frequent checks on resident at least hourly and as frequently as every 15 minutes due to her tendency to sit at the edge of the bed, roll off on to geomatt to move about on the unit scooting in sitting position. And when staff is available, station a staff member by resident's doorway to anticipate her needs. Also included is to place the geomatt on the floor as the resident frequently rolls herself off the bed wanting to go out or wanting to go the the toilet by herself without waiting for assistance. 3. Cross Reference to F690 and F725. Resident 77 (R77) was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R77 was discharged from the facility on 3/11/2018. On 5/31/2018 at 10:04 AM a record review was done for R77. R77 was admitted to the facility following a hospitalized from [DATE] to 1/19/2018. The resident resided in an assisted living facility where he fell , sustaining an [MEDICAL CONDITION] following a fall with multifocal intracranial contusions. A review of the admission MDS with ARD of 1/26/2018 notes R77's cognition is moderately impaired. In Section G. Functional Status, R77 requires extensive assistance with one personal physical assist for toilet use. R77 was also coded to be occasionally incontinent of bladder and continent of bowel. In Section J., the resident was noted to have a fall in the last month prior to admission. The resident did not have any falls since admission. A review of the progress notes found an entry for 3/1/2018 at 10:34 AM noting R77 was found out of bed/chair calling for assistance. The staff member found the resident crawling on the floor with right foot still on the geomatt, the resident reported he was trying to go to the bathroom. The resident sustained [REDACTED]. Another entry for 3/1/2018 notes R77 was calling for help every five minutes, wanting to get up to the bathroom, when offered, the resident refused. The resident was noted to inform the staff that he will get up by himself and crawl on the floor if staff members don't come right away. A subsequent progress note of 3/3/2018 documents R77 was heard yelling for help at approximately 10:00 AM. The resident was found lying on the floor at the entry to the bathroom and front door. The resident was founding lying face up. At this time the resident reported he was going to the bathroom. The resident was asked why he did not call for assistance, he responded he did. 4. Cross reference F700 On 05/30/18 at 11:36 AM during RR it was noted that R36 was admitted on [DATE], [DIAGNOSES REDACTED]. It was noted that R36 fell on [DATE] and 12/31/2017, both near her bed. On 06/01/18 at 09:55 AM during RR and staff interview with S103 it was noted on the Care Plan Update Sheet that R36 fell on [DATE], Found resident sitting on the floor between the bed and the chair facing foot part of the bed . Also on 12/31/2017, per Care Plan Update Sheet, Resident activated the bedside call light and LN found her on the floor facing her bed, right hand holding the siderail and left hand holding the call light. No visible injury sustained and offers no complaint of pain. Per resident, she hit her head on the bedside mattress . Complete review of R36 CP with S103 found that R36 had fallen 9 times over the past year (June (YEAR)- (MONTH) (YEAR)). S103 stated that after each fall there was a review of R36's CP and updates made to the intervention(s) in the CP as needed and a root cause analysis was done for each fall by the IDT.