Every finding on record at Hale Anuenue Restorative Care

Based on observation, record review and interview the facility failed to assure staff were cleaning the kitchen ice machine to prevent any growth of infectious organisms on a regular basis. The facility failed to assure staff were documenting the kitchen dishwasher was reaching the 120 degrees Fahrenheit (F) for the wash cycle observed and documented each meal, breakfast, lunch and dinner. The deficient practice puts all residents and staff at risk for exposure to infectious organisms who are provided with ice or meals from the kitchen. Findings include: On 02/25/25 at 10:55 am during initial tour with Food Service Director (FSD) observed the ice machine in the kitchen. Opened the top of the ice machine and observed it had dark gray to black debris on the upper inside of the ice machine. Interviewed FSD at this time and asked who cleans the ice maker and he stated it is cleaned by maintenance. On 02/27/25 at 11:35 AM a re-visit was conducted of the kitchen to observe the trayline. After trayline was observed reviewed dishwasher log and found the facility staff are recording temperatures in the 80's - 120's for the wash cycle. Inquired about the temperature log of FSD and requested to observe a wash cycle with the dishwasher. FSD ran the dishwasher and the highest temperature observed was 108 degrees F. Review of the Low Temperature Dish Machine Log for [DATE] states During the COVID-19 outbreak, along with name of vendor, we are requesting PPM's to be at 100 PPM [parts per million] and your rinse temperature to remain at a minimum of 120 degrees. Reviewed this with FSD. Inquired with FSD what the temperature has to be to clean the dishes. FSD was able to scan the QR code on the dishwasher with his cellular phone and get the specifications from the vendor regarding this dishmachine. FSD shared the dishwasher has to operate at wash (minimum) of 120 degrees F and sanitizing rinse (minimum) of 120 degrees F. Surveyor requested FSD contact the vendor to discuss temperatures required for their low temperature sanitizing dish washer. On 02/27/25 at 01:30 PM Administrator shared an email from their dish washing machine vendor. FSD and Administrator were able to contact the vendor who clarified by email dated 02/27/25 at 01:07 PM the following With the name of vendor dish machine located at Name of Facility, it is totally acceptable for the dish machine to start a cycle under a 120 degrees at times and ending with 120 plus degrees with a chemical sanitizer at the end with a test between 50-100 ppms. Inquired with Administrator if the facility has had a foodborne illness and she denied this. On 02/28/25 at 09:35 AM interviewed Maintenance Manager who was able to explain the deep cleaning process his department does when they clean the ice machine. Maintenance Manager stated they use a sanitizing and descaling solution to clean the emptied ice machine which is done every six months with the last cleaning done in October 2024. Maintenance Manager stated the day to day cleaning is done by the kitchen staff, this is not something that maintenance does currently. On 02/28/25 at 09:45 AM interviewed Administrator and asked if the kitchen staff are responsible for cleaning the ice machine and she stated she would find out if this task is on the cleaning check list and provide a copy to me. On 02/28/25 at 10:01 AM Administrator was able to provider a copy of the kitchen cleaning checklist. The kitchen cleaning checklist was reviewed and ice machine cleaning was not listed and Administrator confirmed it does not include ice machine cleaning. Administrator stated this was somehow dropped or communicated and she said the ice machine cleaning was going to be added to the checklist.

Based on observations, interviews, and policy reviews, the facility failed to provide a clean and homelike environment in a random number of rooms on two units. The floors in the resident's rooms had buildup of dirt and scuff marks. In one resident rooms bathroom, there was a strong urine odor and yellow stains on the floor. The deficient practice increases the risk of infection and decreases the resident's psychosocial well-being. Findings include: 1) The following random observations were made between 02/25/25 to 02/28/25. In room [ROOM NUMBER] on 02/25/25 at 11:00 AM. The skid strip next to bed was peeled up into a curled strip that may be a trip hazard. The bathroom has black scuff marks all over the floor with dirt and dust. The entrance to the room at the door has a large amount of dust, and dirt stains on the tiles. In room [ROOM NUMBER] on 02/25/25 at 11: 03 AM, the floor tiles next to the bed near the bathroom had black dirt and dust on the tiles. In the bathroom the floor tiles were soiled with black dirt and scuff. A strong urine odor was present in the bathroom. A plastic urine collection container was sitting on the back of the toilet. In room [ROOM NUMBER] on 02/26/25 at 11:43 AM observed dust, dirt, and black marks on the bathroom floor. Interview with Resident (R) 196s Family member (FM) 1 in room [ROOM NUMBER] while visiting with R196 in his room. The surveyor asked FM1 if she felt that the room is quiet and clean enough. FM1 pointed to the floor and said, they need to clean this, pointing to a large, soiled area on the floor near the foot of the bed. It used to be nicer in here, but maybe they are short staffed. Observation of the Housekeeper (HK) 11 on the 300 wing on 02/27/25 at 09:27 AM Observed the cleaning cart with microfiber rags in the bucket and no water. HK11 picked up several yellow plastic caution signs and took them to a storage room. Interview with HK11 on 02/27/25 at 09:36 AM on the Keola' [NAME] unit near the nurse's station. The surveyor asked her what her work assignment in the facility was for the day. HK11 said that she works in the laundry room and also on both Units. HK11 explained that she starts her day putting up the yellow signs, then she wipes down the common areas on the unit. Next, she cleans the bathrooms, wiping down everything, inside and outside. She uses the orange cloth to wipe the furniture; the blue towels are only used in the bathrooms. In the bathrooms the sinks are cleaned then the rubbish cans are emptied, then the toilet. HK11 stated that she mops the floors every day. The surveyor asked her if the Supervisor goes behind her to check on her work. HK11 stated, yes, she does and will tell us if there is anything else that we need to do. HK11 showed the surveyor a cleaning checklist with each location where she signs off the time it was cleaned. Listed were the Resident rooms, nurses station, etc. listed on the sheet. She expressed that if the residents are in the room eating, they are not allowed to mop or use any chemicals. Observation and interview with the Director of Nursing (DON) on 02/28/25 at 09:22 AM the surveyor showed the DON the soiled and scuffed floors in rooms 203, 205 and 211. The DON agreed there was a strong odor of urine in room [ROOM NUMBER]s bathroom. The DON said they have been asking the housekeeping staff to clean the floors and that the house keeping department is working on a strip/ wax plan. Observation and interview with the Housekeeping Supervisor (HS) on 02/28/25 at 09:45 AM on the Keola' [NAME] unit, 200 room wing. The surveyor showed the HS the rooms with the dirty and scuffed tile floors. The surveyor showed the HS the bathroom in 205 with the strong urine odor. The HS agreed there was a very strong odor of urine and noted a yellow stain visible on the floor next to the toilet. The HS said the staff need to do a better job cleaning the bathroom. The HS stated that she is working on a plan to have the floors in each of the rooms cleaned and will address the bathrooms with the housekeeping staff. 2) On 02/26/25 at 10:36 AM, observed the floors of rooms 501, 504, 508 and 510 with a dark residue. Brought observations to the attention of Registered Nurse (RN)5 who inspected the floors of all four rooms mentioned. RN5 acknowledged that the floors had a dark residue and said, They look dirty and it does not look good. RN5 said she will let the housekeeper know so they can strip and wax the floors. On 02/28/25 at 09:30 AM, inspected the floors of rooms 501, 504, 508 and 510 with the Director of Nursing (DON). DON confirmed that the dark residue on the floors is built-up dirt, and they will need to strip the floors of the old wax and build-up of dirt before applying another layer of wax to keep them clean. Housekeeping services policy revised 08/09/22 reviewed on 02/28/25. The resident has a right to a safe, clean, comfortable, and homelike environment .Routine Cleaning. 1. Keep housekeeping surfaces visibly clean on a regular basis .Resident rooms. A. Clean high-touch surfaces at least daily to include handwashing sinks and floors .

Based on record review and interviews, the facility failed to maintain complete and accurate medical records in accordance with acceptable standards and practice for three of 21 residents (Resident (R)37, R295 and R56) in the sample. Specifically, the Advance Health Care Directives (AHCD) did not include end-of-life decision choice and resident-specific information in the orders for pain assessment and management were left blank. This deficient practice has the potential to prevent the residents from achieving their individual goals and objectives. Findings include: 1) On 02/26/25 at 11:22 AM review of R37's Electronic Health Record (EHR) was conducted. R37 is a [AGE] year-old resident admitted on [DATE] for long-term care. R37 had an AHCD scanned into the EHR that was signed by R37's brother, and surrogate decision maker on 11/04/22. On page four of the document under End-Of-Life Decisions, where the choices are (a) Choice Not To Prolong Life . (b) Choice To Prolong Life ., both checkboxes were left blank. Further review of the EHR revealed that in the admission Record, stated under Advance Directive was, Full Code with Full Treatment. On 02/27/25 at 10:21 AM, a concurrent interview and record review conducted with Registered Nurse (RN)6 at the nurse's station. Asked RN6 what was R37's code status. RN6 checked the EHR and said R37 was full code. Asked RN6 if that information was documented in the AHCD. RN6 checked in the EHR and acknowledged that the section of the ACHD where the resident's end-of-life decision should be documented was left blank. RN6 checked the documents in the physical chart and found a copy of R37's POLST (Provider Orders for Life-Sustaining Treatment) dated 07/13/22 that documented R37 was a full code. RN6 added that he will find out why this was not documented in the AHDC. On 02/27/25 at 10:52 AM, concurrent interview and record review was conducted with the Social Services Director (SSD) at the nurse's station. SSD reviewed the AHCD and confirmed that the document was not completed to include guardian's choice for end-of-life decision. SSD said they will have the guardian come in to complete the document. 2) On 02/27/25 at 10:10 AM, while reviewing the physician's orders in R37's EHR with RN6, noted that an active order dated 07/11/22 had information that was left blank as stated: Acceptable level of pain: Numeric Scale ______/10 Location of pain: 1. ______________ 2.____________ 3._____________ Numeric pain scale three times a day Attempt non-med interventions prior to administering PRN pain medications: 1.______________ 2.______________ 3.______________ 4.______________ Do not arouse from sleep. Do not exceed 3,000 mg Acetaminophen in a 24 hour period from all sources. Numeric scale for acceptable pain level, location of pain, and non-medical interventions to attempt prior to giving pain medications were left blank. Asked RN6 why there were missing information in the physician's order. RN6 said the order is for the nurses to assess the resident's acceptable pain level and based on that, pain medication will be administered as ordered. On 02/27/25 10:51 AM, concurrent interview with Director of Nursing (DON) and RN6 conducted at the nurse's station. Reviewed above order with DON and she confirmed that the order was missing resident-specific information so it was not comlpeted as intended. RN6 added, We'll get it corrected. The same order was found in the EHR for R295 and R56. During a concurrent interview and record review with the DON in the conference room on 02/28/25 at 11:20AM, she confirmed that the order is not complete since it does not include the acceptable pain level as identified in the pain assessment, location of pain as identified by the resident and non-pharmalogical interventions to be carried out prior to administering medications.

Based on observation, interview and record review, the facility failed to ensure one resident was treated with dignity and respect while he waited for an hour to eat his lunch during a random dining observation on the [NAME]' [NAME] unit. The deficient practice caused discomfort for the resident while he watched other residents on the unit eating their lunch and he had to wait. Findings include: Observations on the [NAME] '[NAME] unit dining room on 02/25/25 at 12:00 PM. The lunch trays were brought to the unit. Staff began pulling trays from the cart and setting them up for the residents in the dining room. Some of the residents were being taken to the other dining room to each their lunch. Observation at 12:15 PM, Resident (R) 28 was sitting in his wheelchair in the dining room in front of the nurse's station. R28 had his eyes open and was looking around the room. No tray present in front of him. Other residents in the room were receiving their trays and having them set up. Observation at 12:41 PM. R28 continued to be without his meal tray. The surveyor observed R28s lunch tray on the meal cart sitting in the hall. Observed the tray pushed to the back on the cart. Observation at 12:48 PM. R28 is awake in his chair looking around, all of the other residents are eating, or finished eating. One Certified Nurse Aide (CNA) 47 is feeding the resident behind R28, two other CNAs are seen walking around the unit. staff are observed walking around the unit, R28 was sitting in his chair. Observed two Activity Aides (AA) 1 and 2 were standing in the middle of the dining room. The surveyor asked them if they assist the residents to eat during the mealtimes. AA 1 said sometimes. The surveyor asked the AA2 if the activity staff need permission from the nursing staff to assist the residents to eat. AA2 said, if the nursing staff ask us to assist the resident to eat, we will. Observed CNA47 bring R28 his tray from the cart and set on an overbed table at 12:53 PM. CNA set up the lunch plate and utensils for R28 and started assisting him to eat. Interview with Registered Nurse (RN) 25 on 02/25/25 at 12:55 PM. The surveyor asked her what the activity staffs' responsibilities during mealtimes are and if they assist the residents for eating. What are the expectations of the nursing staff. RN25 said they can feed the residents if they are trained, and the activity staff can set up the resident with their tray. Once the nursing staff see they are set up, they know that the resident is ready to eat lunch and will assist them. The surveyor shared with R28 the observation on the unit and that R28 waited for an hour to receive his lunch after most of the other residents on the unit finished their lunch. Reviewed the minimum data set (MDS) admission assessment dated [DATE]. R28 is dependent on staff to eat. The helper does all of the effort. Reviewed the Care plan on 02/28/25. Resident is at risk for malnutrition or nutrition-related problems related to (r/t) Parkinson's disease, dementia, increased nutritional needs due to large stature, dysphagia requiring altered texture diet, dependent on staff for nutrition/hydration. The resident needs a calm, quiet setting at mealtimes with adequate eating time, total assist at meals. Interview with Licensed Practice Nurse (LPN) 55 on 02/28/25 at 09:40 AM. The surveyor shared an observation on the unit on 02/25/25 of R28 waiting an hour for his lunch. LPN55 said she was aware that R28 waited a very long time on Tuesday for his meal and that everyone on the unit is responsible to assist the residents who need assistance with the setup of their trays. If the staff are trained, they can assist the resident to eat if the resident doesn't have difficulty swallowing. Interview with the Director of Nursing (DON) on 02/28/25 at 11:28 AM. The DON said when the trays are brought to the unit, the activity and hospitality staff pass trays to the residents who can feed themselves. The residents who are independent will get their trays first and the residents who need assistance are set up and assisted by the staff. The activity staff are able to assist the residents with eating as long as they have been trained. Facility Dignity Policy revised dated 09/26/24 reviewed on 02/28/25. Each resident has the right to be treated with dignity and respect .enhancing the resident's self-esteem, self-worth .Promoting resident independence and dignity while dining . Feeding, long-term care policy revised 09/12/2024 reviewed on 02/28/25 .Feeding a resident in a respectable and patient manner, enhance the resident's nutritional status and psychosocial well-being.

Based on record review and interview, the facility failed to ensure that the Discharge Assessment for one of three Residents (R)94 sampled for closed records review, accurately reflected the resident's discharge status. Findings include: On 02/26/25 at 02:24 PM, review of R94's Electronic Health Record (EHR) was conducted. R94 was admitted to the facility for short-term rehabilitation services on 01/09/25 and discharged on 01/25/25. R94 was sampled as a closed records review for discharge to the hospital. Review of the last Progress Notes entry on 01/25/25 at 09:37 AM stated, Resident was discharged home, left unit at 0935 [09:35 AM], escorted by CNA [Certified Nursing Assistant] to parking lot and left in stable condition. Review of Minimum Data Set (MDS) Nursing Home Discharge with an Assessment Reference Date (ARD) of 01/25/25 noted R94 was documented as discharged to Short-Term General Hospital (acute hospitals, IPPS [inpatient prospective payment system]) under Section A, question A2105 Discharge Status. On 02/26/25 at 10:36 AM, a concurrent interview and record review was conducted with Registered Nurse (RN)6 and Director of Nursing (DON) at the nurse's station. Asked RN6 if R94 was discharged home or to the hospital. RN6 said she remembered R94 since she was the one that discharged her and that she was discharge home. Reviewed MDS Nursing Home Discharge document with RN6 and DON, both said question A2105 Discharge Status was answered incorrectly since R94 was discharged home and not to the hospital.

Based on interviews and record review, the facility failed to implement interventions to treat one of one Resident (R)37 in the sample for constipation. As a result, R37 was placed at risk of increased pain and discomfort. This deficient practice has the potential to affect all the residents in the facility at risk for constipation. Findings include: R37 was a [AGE] year-old resident admitted on [DATE] for long-term care. Diagnoses included but not limited to Osteoarthritis, depression, and constipation. On 02/26/25 at 11:32 AM, an interview was conducted with R37 in her room. R37 said she had constipation last week where she did not have a bowel movement (BM) for four days. Asked R37 if she takes any stool softeners. R37 said the nurses give her one every morning but does not remember the name. When asked if the constipation causes her any pain or discomfort, R37 said, My stomach not sore. Review of R37's Electronic Health Record (EHR) was conducted on 02/26/25. R37 had the following laxatives (medications that treat constipation) ordered: Sennosides-Docusate Sodium 8.6-50 milligram (mg) tablet daily; Sennosides 8.6 mg as needed for no BM after 2nd (second) day; and Bisacodyl Suppository 10 mg rectally as needed for no BM after 3rd (third) day. Review of R37's Bowel and Bladder Elimination log in the EHR revealed that from 02/17/24 to 02/20/24, she did not have a BM for four days. Review of the Medication Administration Record (MAR) for February 2025 revealed that Sennosides and Bisacodyl Suppository were not administered as ordered when R37 did not have BM for four days. On 02/27/25 at 10:39 AM, concurrent interview and record review was conducted with Registered Nurse (RN)6 at the nurse's station. Reviewed the Bowel and Bladder Elimination log in the EHR for the past 30 days with RN6 and asked if R37 had any episodes of constipation. RN6 said there was a period of four days where R37 did not have BM, form 02/17/25 to 01/20/25. Asked RN6 if any PRN (as needed) laxatives were given to R37 on those days. RN6 reviewed the current MAR and said R37 should have been given Sennosides on 02/19/25 after the second day without BM and Bisacodyl Suppository after the third day without BM on 02/20/25.

Based on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents experienced a decreased quality of life and were unable to attain their highest practicable well-being. Findings include: 1) On 01/30/24 at 01:43 PM interviewed AR4 in his/her room. Inquired if there are enough staff to provide care for him/her. AR4 reported there are not enough staff, they are so short staffed, and he/she made a note to the social worker regarding this. AR4 stated, it's a shame to have such a nice place and not have it fully staffed. AR4 asked, what can we do as a community? What can our representative do? (Legislator). Such a shame. One time I rang the buzzer and they didn't come, sometimes it takes 15-20 minutes, it's not right away, one time I felt like I was going to die and I could have. 2) On 01/30/24 at 02:40 PM, interviewed R76 who stated facility is short staffed when asked if there are enough staff to help her. R76 would not elaborate when questioned about this, stated she was being discharged soon. 3) On 01/31/24 at 10:42 AM interviewed R132 in her room. R132, who is a high risk for falls, had fallen at home and had hip surgery before coming to the facility. R132 reported, in the early morning it takes them about 15 minutes to respond, to her call light and that she will, go on my own because I have to go. 43414 4) On 01/30/24 at 02:19 PM an interview with Resident (R) 52 was done. R52 reported the facility seemed to be short staffed and described an incident when she waited for an hour for staff to help her. She used her call light and needed to use the bathroom and because she waited an hour, she had an accident in her bed. 43245 5) On 01/30/24 at 11:00 AM, a resident who asked to remain anonymous was interviewed in his/her room. When asked about staffing, Anonymous Resident (AR)1 stated, they're short of help. AR1 explained that the facility is frequently lacking both Aides and Nurses, resulting in several times in the last year that he/she has lost control of his/her bladder or bowels while waiting for assistance to the bathroom after hitting his/her call light. AR1 stated that he/she also fell and hit his/her head after waiting for assistance so long that he/she tried to walk to the bathroom unassisted. 6) On 01/30/24 at 12:02 PM, when asked about staffing, AR2 also responded that there is not enough staff to meet the needs of the residents. AR2 reported that he/she too has had multiple accidents in his/her briefs while waiting for staff to respond to his/her call for assistance to the bathroom. 7) On 01/31/24 at 09:06 AM, when asked about staffing, AR3 reported that the facility often runs so short that he/she does not get his/her scheduled two showers per week. AR3 stated that the showers depend on having enough staff, so when the facility is short-staffed, it means that showers get missed. AR3 stated that if he/she could, he/she would shower every day, so to not be able to shower even twice a week really bothers him/her. In a review of the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) Staffing Data Report, it was revealed that the facility had triggered for Excessively Low Weekend Staffing every quarter of fiscal year 2023. On 02/01/24 at 02:56 PM, an interview was done with the Health Information Management Director (HIM), who was also the Nurse Staffing Coordinator, in her office. When asked about the PBJ Report, and if the results sounded accurate, HIM responded yes. HIM confirmed that the staff schedule has been very challenging to do as the facility is short of nursing staff. HIM reported that the Certified Nurse Aide (CNA) positions seemed to be shorter than the Registered Nurse/Licensed Practical Nurse (RN/LPN) positions. CNAs are already short [on the schedule] then they call out sick and we're even shorter. When asked about weekend staffing, HIM reported that sick calls do seem to increase on the weekends. On 02/01/24 at 03:34 PM, a second interview was done with HIM in the facility breezeway. When asked about staffing ratio goals, HIM reported that they ideally shoot for a 10:1 ratio for CNAs to residents (on the day shift). When asked how often they hit that goal, HIM answered not too often, because of sick calls. For the RN/LPN staffing goal, HIM reported that they would like to have 2 nurses on each side of the facility, plus a Unit Manager (UM) on the larger side, for a total of 5 licensed nurses on day shift, however there are not enough licensed nurses for that, so the UM is usually used as a floor nurse. On 02/01/24 at 03:46 PM, an interview was done with the Administrator and Director of Nursing (DON) in the Administrator's office. When asked about the PBJ Report, and if the results of excessively low weekend staffing for every quarter of fiscal year 2023 sounded accurate, both the Administrator and DON stated yes.

Based on observation, interview, and record review the facility failed to ensure residents dietary needs and preference were met. 1) Resident (R) 52 food preferences were not followed. 2) Staff members providing feeding assistance and/or passing meal trays to residents were not aware of residents' special dietary texture needs to ensure residents are receiving the proper diet texture on their meal trays. 3) R62's food preferences were not followed. 4.) R50's fluid preferences were not given. Findings include: 1) On 01/31/24 at 08:41 AM an observation and interview with R52 was done. Observed Certified Nurse Aide (CNA) 10 approach R52 while R52 was eating breakfast. After CNA10 left R52's room, R52 reported she is supposed to get milk with her breakfast and when she got her meal tray 30 minutes ago, she asked a staff member for milk but had not received it yet. She asked CNA10 about her milk. At 08:45 AM, CNA10 returned with R52's milk. Observed R52 dietary form to include milk with her meal. R52 was then observed to pour her milk in her cereal. R52 further reported when she gets the weekly menu, she reviews it in advance and marks an X to indicate she plans to order from the alternative menu. Reviewed R52's marked menu with an X for dinner on Tuesday (01/30/24) and Thursday (02/01/24). R52 explained that she fills out the form to request an alternative menu in advance and gives the form the day before or the day of to the CNA. R52 ordered Salesbury steak as her alternative menu on 01/30/24 instead of the baked honey glaze ham for dinner but did not receive her menu preference. Instead R52 received the ham but did not want to turn the food away because from experience it would take another 20 minutes to get the correct menu ordered. On 02/01/24 at 08:59 AM, R52 reported she received the Salesbury steak she ordered on 01/30/24, last night instead. Dinner on 01/31/24 was supposed to be teriyaki beef and she wanted to eat the teriyaki beef but instead got the Salesbury steak. R52 did not understand why dietary staff got the days mixed up. R52 ate the Salesbury steak because she did not want to wait any further for dinner. R52 did not receive her menu preference. The facility's policy and procedure Food Preferences revised 04/25/23 documented Individual .food preferences are honored, when possible, to enhance resident's satisfaction with food and dining. 2) On 01/30/24 at 12:47 PM an interview with Family Member (FM) 16 was done. FM16 reported Resident (R) 69's ordered diet texture is currently moist minced after choking on her food. FM16 reportedly found dietary staff have been inconsistent in R69's ordered diet and would sometimes give R69 regular diet, chopped diet, minced diet, and pureed diet which may have resulted in the incident when R69 choked on her food. R69 reportedly expressed to FM16 and another FM that she thought she was going to die. On 01/31/24 at 08:21 AM interview with Activities Aide (AA) 1 was done. While AA1 was providing feeding assistance to a resident, inquired what does PU4 on the resident's dietary form stand for, AA1 stated she did not know. On another resident's dietary form, inquired what MM5 stands for, AA1 stated she did not know. On 01/31/24 at 08:24 AM an interview with Certified Nurse Aide (CNA) 42 was done. While CNA42 was providing feeding assistance to resident, inquired what does PU4 on the resident's dietary form stand for, CNA42 stated she was not sure, but it might stand for pureed. Inquired why CNA42 may think it stand for pureed diet, CNA42 stated because the resident's food is all pureed. Inquired about MM5, CNA42 stated she cannot memorize all the abbreviations to the diet textures but there is a chart with all the abbreviation and referred to Registered Dietician. Review of the list of abbreviations for texture diets provided by RD included but not limited to: Regular - RG7 Easy To Chew - EC7 Soft & Bite-Sized -SB6 Minced & Moist - MM5 Pureed- PU4 On 01/31/24 at 08:29 AM an interview with CNA10 was done. Observed CNA10 passing trays to residents in their rooms, inquired with CNA10 what MM5 stood for in the residents' dietary form. CNA10 stated she did not know. Review of the facility's policy and procedure Meal Service reviewed on 08/24/23 documented Verify the meal being served matches the correct diet that is prescribed for the resident. 48351 3) Interview was conducted with R62 on 01/31/24 at 07:54 AM. R62 stated that the kitchen sends over meals containing chocolate multiple times in a month, when her diet preference card documented chocolate as one of her allergies/dislikes. Observation was conducted on 01/31/24 at 12:26 PM in R62's room. CNA10 was observed delivering R62's lunch tray. When CNA10 uncovered R62's plate, it was observed that R62's chicken entree was grinded/grounded. On R62's diet preference card, it documented, no grounded meat. R62 stated that the kitchen makes an error on her meals at least twice a week. Interview was conducted with Dietary Manager (DM) on 02/01/24. DM was shown a picture of R62s lunch tray on 01/31/24. DM was also shown R62's diet preference card. DM stated that R62 is on an easy to chew diet, which means that the chicken entree for that day needed to be grounded. Since R62 preferred no ground meat, DM stated that a substitution entree should have been provided to meet R62's diet preference. 37954 4) An interview was conducted with R50 on 01/30/24 at 2:13 PM. Observed R50 was sitting in front of his bathroom. He reported that he is lactose intolerant, stated he has been given milk five times in the past two weeks. R50 reported today he tried the milk in his cup that came on his lunch tray and said it was regular milk, not the almond milk that he requested. At this time R50 complained of having loose stool, stated he believes it is from the milk he was given.

Based on observations, interviews and record review, the facility failed to apply standard infection control precautions to ensure the health and safety of its residents, staff and visitors. Findings include: 1) On 01/31/24 at 08:28 AM observed Activities Aide (AA)2 set up resident(R)77's breakfast. Interviewed AA2 at this time and asked if she gave R77 hand sanitizer or wipes to wipe her hands before breakfast and she said no. Inquired if facility staff usually provide hand wipes or hand sanitizer before meals and AA2 said no and said the hand sanitizer is kept around as she looked around the room. Asked if R77, who is in a wheelchair, would roll herself to the hand sanitizer and she said no. On 01/31/24 at 08:33 AM interviewed Registered Nurse (RN)8 about patient's cleaning their hands before breakfast. RN8 said if the resident uses the bathroom staff have them wash their hands. RN8 also stated when residents are sitting out of their room or are up in their room to eat their meal staff provide hand sanitizer before meals. On 01/31/24 at 08:44 AM met with and interviewed Administrator regarding hand hygiene for residents before meals. Administrator explained residents who are provided care would also do hand hygiene at that time. Administrator did state they (facility) need to correct this because they do not know if they (residents) touched anything afterwards. On 01/31/24 at 08:48 AM interviewed R77 and inquired if staff had been provided hand sanitizer or hand wipes to use on her hands before she ate her breakfast. She stated she washes her face and hands in the morning before she comes out of her room to eat her meals. An interview was performed with the Infection Preventionist (IP) on 02/01/24 at 1:57 PM in his office. Inquired if the facility offers residents hand sanitizer or hand wipes before meals. IP stated when residents used to eat in the big dining room the staff would give the residents hand sanitizer as they entered the room. Currently, because of COVID, residents are now eating on their units either in the main room or in their rooms. IP confirmed staff should be giving residents hand sanitizer before meals. 2) On 01/31/24 at 10:26 AM observed R132's room did not have signs posted outside of her room notifying staff and visitors of transmission based precautions (TBP) and need for all to use personal protective equipment (PPE) (use of gloves, gowns, mask and goggles) prior to entering R132's room. R132 was admitted to the facility on [DATE] with an active case of COVID-19. Concurrent interview was done with RN8 who was not aware signage was not placed outside of R132's room for everyone to use PPEs for TBP. RN8 taped the sign up to the wall outside of R132's room at that time. 43414 3) On 01/30/24 at 11:48 AM, observed dietary staff bring a cart full of lunch trays to the area used for activities and dining. Observed AA1 prepare residents in the dining area for lunch by clearing their tables and putting tablecloths on the tables and/or tray tables. No observation of staff members offering residents hand sanitizer or to wash their hands. At 12:05 PM, observed staff members begin passing out trays to residents. A total of 19 residents were dining outside of their room and there was no observation of staff members offering residents hand sanitizer or to wash their hands from any of the staff members passing the trays. At 12:15 PM, inquired with AA1 how residents wash their hands before meals, AA1 pointed to a portable hand sanitizer bottle that is used. Inquired if she offered the hand sanitizer to the residents before lunch, AA1 stated she did not.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1) On [DATE] at 10:25 AM, during the initial kitchen tour with Dietary Manager (DM) observed in the walk refrigerator 19 uncovered cakes. Inquired with DM if the cakes should be covered, DM stated they should have been. On [DATE] at 11:41 AM, observed in a nourishment room with DM a total of three cranberry cocktail juice containers past the used by date of [DATE] on the shelf and one opened cranberry cocktail juice container past the used by date of [DATE] in the refrigerator. DM stated they should be discarded and observed DM throw the containers in the trash. On [DATE] at 11:09 AM, observed DM check the temperatures of the food to be served to residents for lunch. Observed DM take the temperature of the whole regular chicken with temperature 127 degrees Fahrenheit (F) from the steam table, then immediately take the chicken out of the tray and put it in the steamer to get warmed up. Inquired if the chicken was at safe holding temperatures, DM reported it was not and that is why he took it out of the tray line to warm it up. Review of the facility's policy and procedure (P&P) Food Safety revised on [DATE] documented steam tables must be able to maintain hot foods at temperature of 135 degrees F or above. Danger Zone described in the P&P .temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that all the rapid growth of pathogenic microorganisms that can cause foodborne illness. 48351 2) Observation of the nourishment room between room [ROOM NUMBER] and the nurse's station was conducted on [DATE] at 02:13 PM. The nourishment room contained 25 grape jellies, 14 honey, eight breakfast syrups, and three peanut butters. All listed condiments did not have use by dates or expiration dates. Interview was conducted with the Director of Nursing (DON) on [DATE] at 02:15 PM in the nourishment room. DON was shown the undated condiments. DON stated that there is no way to tell if the condiments are expired or not. She stated that she will ask the DM. On [DATE] at 02:35 PM, after asking the DM, DON stated that the staff members should have put a date on all the condiments.

Based on observation, interview, and record review, the facility failed to protect and promote quality of life for 3 of 4 residents sampled for dignity (Residents 74, 41, and 12). Specifically, the facility failed to ensure that Resident (R)74's hair was combed prior to placing her in the common area used for dining, and failed to ensure staff did not stand over R41 and R12 while providing feeding assistance. This deficient practice has the potential to affect all residents in the facility requiring assistance with hygiene, grooming, and feeding. Findings include: 1) On 01/30/24 at 12:16 PM, observed R74 sleeping in her high-backed wheelchair out in the common room used for dining, as at least 15 other residents waited in the common room for lunch service to begin. Noted that R74's hair was sticking up in disarray, appearing uncombed/unbrushed. On 02/01/24 at 08:25 AM, a second observation was made of R74 seated in her high-backed wheelchair in the common area used for dining with at least 15 other residents in various stages of breakfast service. Noted that R74's hair was sticking up in disarray, appearing uncombed/unbrushed. On 02/01/24 at 08:30 AM, an interview was done with Certified Nurse Aide (CNA)14 out in the common area. After looking at R74's hair, CNA14 confirmed that it had not been combed or brushed, and that R74 could not perform that task herself. CNA14 agreed that residents' hair should absolutely be groomed prior to being brought out of their rooms. A review of R74's comprehensive care plan (CP) revealed the following regarding her activities of daily living (ADLs) such as grooming/personal hygiene: ADL Assistance . needed to maintain or attain highest level of function. Assist with mobility and ADLs as needed. PERSONAL HYGIENE: Extensive to total assist . 43414 2) On 01/31/24 at 08:31 AM, observed in R41's room, Registered Dietician (RD) providing feeding assistance to R41 standing up. A chair was observed to be in R41's room but was not positioned to be used while RD was providing feeding assistance. 3) On 02/01/24 at 09:12 AM, observed in the activities room, also used for dining, Activities Aide (AA) 4 providing feeding assistance to R12 standing up. AA4 reported he should not be standing up while providing feeding assistance and usually uses a chair. AA4 further reported R12 can feed herself, but needs encouragement, and sometimes total assist. On 02/01/24 at 03:36 PM an interview with the Director of Nursing (DON) was done. DON stated staff should be sitting while providing feeding assistance for resident dignity. Review of the facility's policy and procedure Dignity reviewed on 09/25/23 documented Each resident has the right to be treated with dignity and respect .Promoting resident independence and dignity while dining, such as avoiding .c. Staff standing over residents while assisting them to eat .

Based on interview and record review, the facility failed to provide proper notification of transfer/discharge for 4 of 4 residents sampled for hospitalization (Residents 15, 24, 12, and 9). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives for 2 of the 4 residents, and failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO) for 2 of the 4 residents. This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: 1) On 01/31/24 at 12:20 PM, a review of Resident (R)15's electronic health record (EHR) noted that she was hospitalized from 12/08/23 to 12/14/23 for gastrointestinal bleeding (she had blood in her stool). No written notice of the transfer/discharge was found in her EHR. On 02/01/24 at 09:28 AM, the Director of Nursing (DON) provided a Notice of Resident Transfer or Discharge that was dated 12/08/23 but was not signed by R15's family representative verifying receipt of the written notice. DON confirmed that without the signature verifying receipt, there was no documentation to verify that the written notification of transfer/discharge was issued. 43414 2) Review of R24's EHR documented R24 was transferred to the emergency room (ER) on 10/26/23 after X-ray results from an orthopedic clinic indicated R24 had a fracture to left hip and required surgery. R24's EHR did not include documentation that written notification was given or sent to R24's or his representative. Review of the NOTICE OF RESIDENT TRANSFER OR DISCHARGE form does not include a signature under VERIFICATION/NOTICE OF RECEIPT that R24 or his representative received a copy of the form. 48351 3) Review of R12's EHR documented R12 was transferred to an acute care hospital on 09/02/23 for a change in her level of care. R12's EHR lacked documentation that the facility had sent written notification to the State Long Term Care Ombudsman (SLTCO). Interview with the facility's Social Service (SS) 1 was conducted on 02/02/24 at 09:11 AM. SS1 confirmed that written notification to the SLTCO, regarding R12's transfer to the hospital, was not sent. 4) Review of R9's EHR documented that R9 was transferred to an acute care hospital on 08/03/23 for a change in her level of care. R9's EHR lacked documentation that the facility had sent written notification to the State Long Term Care Ombudsman (SLTCO). Interview with SS1 was conducted on 02/02/24 at 09:11 AM. SS1 confirmed that written notification to the SLTCO, regarding R12's transfer to the hospital, was not sent.

Based on interview and record review the facility failed to provide written notification of the facility's bed hold policy to the resident or resident representative for two of four sampled for hospitalization (Residents (R) 24 and R12). Findings include: 1) Review of R24's Electronic Health Record (EHR) documented R24 was transferred to the emergency room (ER) on 10/26/23 after X-ray results from an orthopedic clinic indicated R24 had a fracture to left hip and required surgery. R24's EHR did not include documentation that written the facility's bed hold policy was given or sent to R24's or his representative. On 02/01/24 at 02:38 PM an interview with Social Services (SS) 1 was done. SS1 reported R24's EHR documents that a phone call was made out to his representative regarding the facility's bed hold policy but there was no documentation a written copy was sent out to R24 of his representative. 48351 2) Review of R12's EHR documented that R12 was transferred to an acute care hospital on 09/02/23 for a change in her level of care. R12's EHR lacked documentation that a written notification of the facility's bed hold policy was provided to R12's representative. Interview was conducted with the facility's Health Information Management Director (HIMD) on 02/02/24 at 08:59 AM. HIMD stated that the facility's process includes, the nurses calling the resident's representative and verbally providing them with the bed hold policy. HIMD confirmed that the facility does not send the resident's representative a written notification of the bed hold policy.

Based on interview and record review, the facility failed to electronically transmit minimum data set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System within 14 days of its completion following the discharge of Resident 70. Transmitting health data in a timely manner facilitates computer-aided data analysis which impacts payment and quality. Findings include: On 01/31/24 at 02:24 PM, during a review of Resident (R)70's electronic health record (EHR), it was noted that he was discharged from the facility on 09/29/23, with his discharge assessment documented as completed on 10/04/23. While searching for confirmation of the data transmittal, noted that the Assessment History displayed as Assessment was never added to a batch. Requested transmittal documentation from Minimum Data Set Coordinator (MDSC)1. On 01/31/24 at 02:49 PM, an interview was done with MDSC1 and MDSC2 in the administration conference room. MDSC1 confirmed that R70's discharge assessment had not been transmitted, and stated that they had just submitted it. Transmittal Report provided by MDSC1 verified the assessment was transmitted and accepted on 01/31/24.

Based on observation, interview, and record review, the facility did not ensure that comprehensive person-centered care plans were developed and/or implemented for 2 of 21 residents (Residents 17 and 132) in the active patient sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F688 Increase/Prevent Decrease in ROM/Mobility. Based on observation, interview, and record review, the facility failed to implement interventions from the comprehensive care plan of Resident (R)17 to help increase and/or prevent further decrease in range of motion (ROM) of her left knee and hand. 37954 2) On 01/31/24 at 11:02 AM observed and interviewed R132 in her room while she was sitting in her wheelchair. Edema (swelling) was noted in R132's left leg and foot. Inquired when she noticed the swelling and she stated she had fallen at home and had broke her hip and had to have hip replacement surgery, they put a new ball in there referring to the artificial hip joint. R132 was unable to state exactly when she acquired the swelling in her left leg and foot. On 01/31/24 Record Review (RR) of R132's Electronic Health Record (EHR) found she was admitted on [DATE] and her diagnoses include, but are not limited to, displaced midcervical fracture of left femur (misaligned broken left upper leg bone), presence of left artificial hip joint and pain in left hip. During RR of R132's care plan (CP) there was no mention of monitoring for edema (swelling) and interventions staff would do to prevent and alleviate it. On 02/01/24 at 03:48 PM interviewed Registered Nurse (RN)8 who stated since R132 came to facility she has had some noted swelling in her left leg and foot and this is usually due to the resident spending more time in bed while she was in the hospital and then spending more time sitting up in her wheelchair at the facility. RN8 stated she checked for deep vein thrombosis (blood clot) and it was not present.

Based on observation, interview, and record review, the facility did not ensure that 1 of 1 resident (Resident 74) sampled for a urinary tract infection (UTI) received the appropriate treatment and services to manage her acute urinary retention, as evidenced by repeated and routine intermittent catheterizations over a period of 5 days, causing unnecessary trauma to her urethra and placing her at increased risk of bladder spasms and UTIs. Findings include: Resident (R)74 is an [AGE] year-old female admitted to the facility on [DATE] following a fracture to her right hip. Multiple observations made of R74 on 01/30/24 and 01/31/24, both in her room and out in the common area used for dining, noted R74 as extremely somnolent, very poor appetite, consuming a maximum of 10% of lunch on 01/30/24, and 10% of breakfast on 01/31/24, and non-responsive to staff, family, and State Agency (SA) questions. On 01/31/24 at 10:46 AM, a review of R74's electronic health record (EHR) noted that on 01/26/24, after assessing R74 with an abdomen hard to touch and distended, and documentation of her last bowel movement at 05:35 AM, the facility obtained an order to perform an intermittent catheterization. When the catheter was inserted, 800 milliliters (less than a cupful under a liter) of dark tea color urine was drained. R74's physician was informed and gave an order for intermittent catheterization every 8 hours for urinary retention until 01/29/2024. On 01/29/24, another order was obtained for intermittent catheterization for urine retention three times a day . A review of R74's Treatment Administration Record (TAR) noted that from 01/26/24 to 01/31/24, R74 was catheterized 15 times with outputs ranging from 80 - 950 milliliters (mLs). Many of the urine outputs were documented as dark urine, with sediment, and foul smell, however a urinalysis (UA) to test for a UTI was not done until 01/29/24. On 01/30/24, R74 was diagnosed with a UTI and started on oral antibiotics. A review of the facility policy for Indwelling Urinary Catheter (Foley) Management, last revised 06/27/23, and last reviewed on 08/24/23, revealed the following: Examples of Appropriate Indications for Indwelling [as opposed to intermittent] Urethral Catheters 1. Patient has acute urinary retention . The National Institute of Health at https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/definition-facts, defines acute urinary retention as a condition in which you are unable to empty all the urine from your bladder . happens suddenly and lasts only a short time, and states, Acute urinary retention can cause severe pain and be life threatening. On 02/01/24 at 03:46 PM, an interview was done with the Director of Nursing (DON) in the Administrator's office. DON confirmed that the facility began routinely and intermittently (three times a day) catheterizing R74 on 01/26/24 for urinary retention of unknown causes. DON reported that normally they would catheterize a resident only after assessing them with retained urine of a volume above a predetermined parameter, however the facility's bladder scanner was inoperable until 01/31/24, so they had no idea how much urine R74 might be retaining and had to drain her bladder routinely. When asked why an indwelling catheter had not been placed, DON stated the facility did not feel that an indwelling catheter was indicated when they didn't know what was causing the retention. DON confirmed that R74 had no history of a neurogenic bladder (a condition where a person lacks bladder control due to brain, spinal cord, or nerve problems) or urinary retention. On 02/02/24 at 08:31 AM, an interview was done with R74's physician (DO)1 in her facility office. DO1 stated that had the bladder scanner been operational earlier, she would have modified the orders for routine intermittent catheterization to as needed for urine retention above a specific volume. DO1 reported that on 01/26/24, there was only the urinary retention, there was no indication of an infection of any kind, so a UA was not ordered. She did however, order blood tests for Monday 01/29/24, which showed mildly elevated white blood cells, and that was when a UA was ordered. DO1 agreed that since there was no UA done on 01/26/24, there was no way to tell if R74 had the UTI already, or it was caused by the repeated catheterizations. In the American Family Physician Journal 2000:61(2):369 - 376, a review of the article Urinary Catheter Management, found at https://www.aafp.org/pubs/afp/issues/2000/0115/p369.html#:~:text=An%20initial%20episode%20of%20acute,after%2010%20to%2014%20days, revealed the following: An initial episode of acute urinary retention should be treated with an indwelling catheter to allow the bladder to regain its tone, with catheter removal and a voiding trial after 10 to 14 days . a single in-and-out catheterization may cause bacteriuria [the presence of bacteria in the urine] in as many as 20 percent of older people .

Based on observation, record review, and interview, the facility failed to ensure Resident (R)17 received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in range of motion (ROM) of her left knee and hand. As a result of this deficient practice, R17 was hindered from reaching her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits. Findings include: Resident (R)17 is a [AGE] year-old female admitted to the facility for long-term care on 05/10/19. Her current diagnoses include, but are not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) of the left side following a stroke, contracture (a tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part) of the left hand and left knee, and generalized muscle weakness. R17 is non-verbal and minimally responsive to stimuli. A review of R17's electronic health record (EHR) revealed the following interventions in her comprehensive care plan for Alteration in Musculoskeletal Status Related to Contractures of the Left Hand and Left Knee: Left resting splint: AM [morning/day shift] STAFF: L) resting hand splint on beginning of shift off 4 hours later. Check skin pre/post wear time for redness/swelling. PM [evening shift] STAFF: L) resting hand splint on beginning of shift, off 4 hours later. Check skin pre/post wear times for redness/swelling. Left knee contracture splint on 2 hrs [hours] day shift and 2 hrs evening shift; remove for night shift and for skin checks and hygiene. The same interventions were also noted in the physician orders and on R17's Treatment Administration Record (TAR). On 01/30/24 at 11:15 AM, 01/31/24 at 03:30 PM, and 02/01/24 at 08:46 AM, observations were done of R17 as she slept in bed. No observations were made of a supportive device/splint on her left knee, left hand, or at the bedside. On 02/01/24 at 10:40 AM, observed Certified Nurse Aide (CNA)14 performing peri care (washing the genitals and anal area) on R17. While she was uncovered, observed no supportive device/splint on her left knee, left hand, on the bed, or at the bedside. Noted R17's left wrist was severely contracted. At 10:52 AM, once peri care was completed, asked CNA14 if she had ever seen R17 wearing any splints. CNA14 stated yes, but I don't know where it went. After looking around R17's bed, CNA14 looked in the closet and pulled out a blue splint and a black splint. CNA14 explained that she usually sees a splint on R17's hand but did not know which of the splints she found in the closet was the correct one as the nurses are the ones who apply it. There was no mention of ever seeing a splint on R17's left knee. CNA14 left the room to get Registered Nurse (RN)16 to apply the splint(s). On 02/01/24 at 11:35 AM, observed R17 with the blue splint on her right wrist/hand. Her left hand and left knee both remained bare. On 02/01/24 at 11:42 AM, an interview was done with Licensed Practical Nurse (LPN)5 at the Nurses' Station. LPN5 stated that R17 should have a splint for her left hand. If placed, it should be documented on her TAR; if not placed, the reason should be documented in a progress note. At 11:45 AM, a review of R17's TAR noted RN16 had signed off that R17's left knee splint had been applied for 2 hours that morning, and that her left hand splint had been on at 06:30 AM and off at 10:30 AM. This documentation does not align with any of the multiple observations made that morning. At 12:17 PM, observation of R17 sleeping in her bed revealed the blue splint remained on R17's right hand, with her left hand and left knee still bare. A review of the progress notes noted no documentation of why there was no splint applied to R17's left hand or left knee, nor why there was a splint applied to her right hand where there was no contracture.

Based on observation, interview, and record review the facility failed to ensure Resident (R) 52 was offered sufficient fluid when requested to maintain proper hydration and health. Findings include: R52 was admitted to the facility on [DATE] with a diagnosis not limited to Urinary Tract Infection (UTI). On 01/31/24 at 08:41 AM an observation and interview with R52 was done. Observed Certified Nurse Aide (CNA) 10 approach R52 while R52 was eating breakfast. After CNA10 left R52's room, R52 reported she asked for water at approximately 07:15 AM and a staff member took her water pitcher but has not returned and she just asked CNA10 for her water again. At 08:45 AM, CNA10 returned with R52's water pitcher. Review of R52's care plan documented DEHYDRATION RISK: The resident has dehydration or potential fluid deficit r/t [related to] recent UTI.

Based on record review and interviews, the facility failed to follow the standards of care when two residents (R)1 and R2 left against medical advice (AMA). Specifically, the facility failed to: 1. Document physician (MD) assessment of residents competency, 2. Staff failed to document the specific risks and potential adverse outcomes of leaving AMA. 3. Discharge instructions an education were not documented when discharged . 4. The AMA form for R1 was not signed by R1, but by a family member (FM), who was not Power of Attorney (POA). 5. R1 did not have a nursing assessment of medical condition prior to leaving the facility. All residents that leave AMA have the right to be informed of the risks and potential adverse outcomes to be able to make an informed decision before leaving. Findings include: 1) R1 is a [AGE] year old female who was admitted to the facility on [DATE] for short term rehabilitation. Her past pertinent medical history included chronic congestive heart failure, pneumonia, Type 2 diabetes, and chronic kidney disease. She was incontinent of bowel and bladder, had a stage 3 pressure ulcer (PU) on her sacrum and unstagable PU of the right heel. R1 was diagnosed COVID + after admission. She was alert and oriented x3 and able to make her needs known. R1 required extensive assist with activities of daily living and the assist of two staff with transfers. Physical therapy recommended using a lift for transfers. R1 was competent and did not have a Power of Attorney for healthcare decisions. On 06/02/2023, sometime after 09:00 AM, R1's FM came to visit and was not able to open the door to R1's room because the bathroom door handle and entrance door handles interlocked preventing access. At 02:20 PM, R1's family member (FM) signed R1 out of the facility AMA because she felt it was an unsafe environment. Review of the R1's Against Medical Advice Discharge Form, signed by 06/02/2023 at 02:20 PM by FM revealed the following: - The form template date was 2006. - The form was signed by FM, and witnessed by Social Services Assistant (SSA) and Licensed Nurse (LN)1. - There were no specific risks or potential adverse outcomes listed on the form or in the progress notes. Content included: This is to certify I, ., a resident in . am being discharged against the advice of the attending physician and the facility administration. I acknowledge that I have been informed of the risks involved and hereby release the attending physician and the facility from all responsibility for and from anything that may result from such discharge. I am also aware that I will be responsible for any costs incurred that my insurance company refuses to cover. - Statement regarding authorization; Authorization must be signed by the resident, by the nearest relative in the case of a minor, or by the Durable Power of Attorney when the resident is physically or mentally incompetent. Reviewed Nursing Progress notes, which included the following entries: 06/01/2023 at 05:17 PM: .BP (blood pressure) 100/60 . Saturating 97% on 2 liters via NC (nasal cannula) .Resident c/o (complain of ) SOB (shortness of breath) when lying flat during care 06/02/2023 (Effective date) at 03:45 PM: Resident left AMA .with family. SS (Social Service) in the unit at the time. The Created date was 06/03/2023 at 01:57 AM by LN2. The Executive Director (ED) confirmed this was a late entry and entered into the medical record after the incident occurred. The last nursing assessment documented prior to R1 leaving AMA was 06/01/2023 at 05:17 PM. On 08/07/2023 at 03:00 PM, interviewed LN2, who documented R1's AMA progress note. When inquired if the physician (MD) or LN1 had talked to R1 or FM about the risks and potential adverse outcomes of leaving AMA, said she was not sure. At that time, LN2 said when she came on duty, she was told R1 was leaving AMA, and the SSA was facilitating the AMA. She did not know why R1 was leaving. LN2 said when SSA asked if the facility could call for an ambulance transport for R1, she informed him R1 was AMA, and the facility could no longer call or assist. LN2 confirmed she did not provide any discharge education or instructions to R1 or FM. On 08/08/2023 at 08:00 AM, interviewed SSA, who signed as a witness on R1's AMA form. He said his role in an AMA was to inform the resident and family what it entails, and advocate for their wishes. He said he was asked by his supervisor (Director of Social Service (DSS)) to assist with the AMA. SSA said he had a conversation with FM to confirm she wanted to take R1 home. He said he spoke with nursing staff, who placed a call to the physician. RN (LN1) and I met with the family and got signature. FM was informed AMA meant the facility wouldn't provide any further services. Inquired what that might involve, and he said medication due, would not be given. SSA said he heard RN inform FM about risk of COVID + and possible transmission, but did not hear any other risks discussed. He said Social Services do not have privy to detailed information about the medical condition, so it was a general risk explanation. Reviewed SSA's post event statement regarding the AMA, which included This writer (SSA) proceeded to speak with nursing staff to have an RN accompany this writer to have FM sign AMA paperwork. RN, came to the front foyer with SSA to speak with FM to inform her of what AMA meant and what it entailed for discharge. FM was agreeable and signed AMA paperwork with both RN and SSA present. On 08/08/2023 at 08:20 AM, during an interview with the DSS, she said on the way to a meeting she saw R1's FM, who said she was waiting for a phone call and wanted to take R1 home. DSS informed SSA, and asked him to follow up. She said it wasn't until later she found out R1 left AMA. DSS said SSA mentioned FM was feeling frustrated about R1's care at the facility. The DSS said the Social Services (SS) usually facilitates the request for AMA. She went on to say we talk to the resident/representative and find out why they want to leave, notify the Doctor (MD) and Executive Director (ED). They should be working with nursing, especially if the resident is not ready to be discharged because of medical condition, as they need to know the risks of leaving. The DSS said the facility does not have very many AMA's, but she felt the SS staff should do everything possible to assist them to make sure they have what they need when they leave. At that time. reviewed R1's AMA form and medical record. DSS said she was aware there were issues with the documention of the AMA with no SS notes and minimal nursing notes. Later the DSS confirmed FM was not the Power of Attorney (legal document that is effective upon disability which appoints person to make healthcare decisions during any period of incapacity), and agreed R1 should have been present during any discussions and the one to sign the form. On 08/08/2023 at 09:15 AM, during an interview with R1's MD, she confirmed she last saw R1 on 06/02/2022 in the AM, and at that time had a phone discussion with the FM about meds and clinical status. She said FM had mentioned a couple of concerns and referred FM to nursing to discuss. MD said there was no discussion of leaving at that time. She said sometime after that, nursing called to inform her R1 leaving AMA. MD said she did not see or talk to FM or R1 after the notification. When asked MD what the specific risks were for R1 to leave AMA, she said it would have included CHF (congestive heart failure) and fall risk, safety of where she is going. She was medically a lot more stable, . but then couldn't take care of herself. MD said the practice at the facility is nursing will give the MD a heads up if a resident wants to leave, but they do not discuss and document competency or specific risks with the Resident/representative. The medical record did not contain any documentation that R1 received discharge instructions or any education at the time of discharge. R1's FM made arrangements for transport, home oxygen and hospice services because she was told all facility services ended when the AMA was signed. 2) Reviewed R2's medical records, which revealed there was no documentation by the physician of R2's competency and ability to understand the adverse outcomes of leaving against medical advice. The AMA form dated 03/21/2023 at 02:52 PM signed by R2 and nursing progress notes did not document specific risks or potential adverse outcomes of leaving AMA. 3) Reviewed the facility policy titled Against Medical Advice Discharges revised 06/20/2023. The policy included the following: - Policy: If a resident wishes to be discharged prior to the completion of medical treatment or against the advice of the attending physician to a setting that does not appear to meet his or her needs or appears unsafe, the facility will treat this situation similarly to refusal of care. The facility will complete the required documentation and provide written discharge instructions as with any discharge. - Procedure: This facility will utilize the [NAME] Procedure (link to procedure): Discharge against medical advice, long-term care. The [NAME] policy revised May 22, 2023, included the following: - .Discharge AMA is a right of a mentally competent resident. If discharge AMA can't be prevented, a practitioner must evaluate the resident's mental capacity to be sure that the resident can understand the condition, the nature and effect of the proposed treatment, and the attendant risks in pursuing the treatment and not pursuing the treatment. An AMA consent should be properly documented in the resident's medical record. .Before discharge, the nurse should explain all risks and consequences of premature discharge to the resident. The facility must take reasonable steps to secure the resident's signature on the designated form.As with any discharge, the facility is required to provide written discharge instructions, including follow-up with Practioner's, medication management, the need for continued therapy, and any durable equipment necessary. - Explain previously discussed goals for treatment, risks, and potential adverse consequences of not completing the treatment plan in the facility setting. - If the resident still wants to sign the discharge AMA form, request that the resident sign a discharge AMA form or release from responsibility form .that indicated the resident understands the discussed goals, risks, and potential adverse consequences. - Resident Teaching: Provide the resident with written information about medication management, follow-up care, medical equipment, and further discharge arrangements with home health care or other agencies. - Documention associated with discharge AMA included but not limited to: residents decision-making capacity, discussion of the treatment goals, risks of not completing the goals in the facility setting and the resident's understanding of those risks, .discharge arrangements made with community agencies, written discharge instructions, physical assessment findings, teaching provided and understanding of that teaching.

Based on interviews and record review, the facility failed to ensure the licensed staff had the knowledge to respond to a resident's request to leave the facility against medical advice (AMA). Specifically, the staff did not know the requirements of documentation and did not know the resident needed discharge instructions and education in a resident initiated discharge. The nursing staff also failed to assess and document one of two residents (R)1 patient's condition prior to leaving AMA. As a result of the deficient practices, there was increased potential of adverse outcome after discharge. In addition, the nursing staff did not complete event reports when resident doors interlocked preventing access to the rooms, presenting an unsafe environment. Due to this deficient practice, leadership was not aware of the issue, so an investigation, analysis and actions measures were not taken to prevent reoccurrence of same issue. Findings include: 1) The Licensed Nurse (LN) did not understand the role and components involved when a resident left AMA. The Social Service department takes a lead role in facilitating the discharge, and the RN is to provide information regarding the risks and potential adverse outcomes. Interviews revealed the licensed staff did not know the physician was required to determine competency and must be documented the resident is able to understand the potential adverse outcomes if treatment is not continued. On 06/02/2023, the LN who discharged R1 did not provide discharge instructions or education prior to R1 leaving. When FM wanted assistance to call for transport, she was told after the AMA is signed, the facility is no longer responsible and could not provide assistance. There was no assistance provided to make the transition as safe as possible. Cross reference F552: Right to Be Informed/make Treatment Decisions R1 signed out AMA on 06/02/2023. The facility failed to inform and document the specific risks and potential adverse outcomes of signing out AMA. The discussion regarding leaving AMA was held with a Family Member (FM), who signed the release form, rather than R1, who was competent to make her own decisions regarding her care. Interviews revealed the staff was not aware the physician needs to determine competency of the resident to sign AMA and that the resident understands the risks. In addition, there was no documentation of the residents condition or assessment prior to resident initiated discharge. The nursing staff did not provide discharge instructions or patient education at the time of discharge. 2) The Office of Health Care Assurance received a facility reported event dated 06/09/2023. the report included the following information: - On 06/09/2023 the facility received a report from an outside agency regarding an incident that alleged caregiver neglect. -The incident occurred on 06/02/2023 at approximately 10 AM, when R1's door was unable to be opened from the outside. Maintenance responded and accessed the room through the outside window, and was able to open the door. The resident hallway door was closed and the inside handle and the bathroom door handle unexpectedly interlocked preventing access to the room. On 08/08/2023 at 10:30 AM, interviewed Certified Nurse Assistant (CNA), assigned to R1 on 06/02/2023. She said the door got jammed. She said she was unable to open the door and asked to have maintenance called. CNA went on to say maintenance entered the room through the outside window and was able to open the door. When asked if CNA had this issue happen before, she said she was fairly new to the facility, but the Housekeeper on that day said it had happened before. She said both residents in the room were total assist, unable to get out of bed on their own and the doors were shut due to COVID. CNA said the room was hot because the air conditioner was broken so the window was open. CNA thought maybe the wind blew the bathroom door. Review of event reports revealed no incident/event report was made by nursing on the 06/02/2023 or any other incident related to interlocking doors preventing access to residents. During an interview with the Executive Director (ED), she said the first she became aware of the incident was when the facility was contacted by an external agency, who was investigating the case. She said to her knowledge, this had not happened before any where in the facility The nursing staff did not demonstrate knowledge of the importance to identify, and report incidents that present a safety risk to residents so they could be investigated, analyzed and actions implemented to prevent future incidents of similar nature.

Based on staff interviews, and record review, the facility did not ensure a resident received care to maintain her highest practicable dental well-being. There was no documentation routine dental care was provided by a Dentist between March 2017 to January 2021 and from January 2021 to July 2022. Also, R1's recent oral assessment was inaccurate. Due to poor oral care, Resident (R)1 requires oral surgery under sedation to extract remaining lower six teeth which is not being recommended due to the risk (advanced age). Findings include: Cross Reference to F641 and F791. On 08/02/22 at 02:49 PM an interview was conducted with R1's son. R1 reported his mother requires a referral to an oral surgeon for sedation to complete teeth extractions. R1's son reported the extraction under sedation is not recommended as it may cause too much trauma. He further clarified that his mother will be [AGE] years old. R1's son reported observing mother wincing while eating and he was not sure whether she had a weight loss but noted her appetite decreased. He also noted his mother being more animated and would engage in card game (Hanafuda). Record review was done for Resident (R)1. R1 was admitted to the facility on [DATE]. Diagnoses include unspecified dementia without behavioral disturbance, age-related osteoporosis without pathological fracture, muscle weakness, and personal history of COVID-19. A review of the quarterly Minimum Data Set (MDS) with assessment reference date of 06/28/22 notes R1 yielded a score of 6 (six) on the Brief Interview for Mental Status, indicating severe cognitive impairment. Record review found no documentation of routine dental services for R1. On 08/03/22, the facility provided a dental consultation report dated 09/10/20. R1 was seen by the dentist for upper impression for an upper partial denture. Also noted in the consultation report was R1 has not been seen for full exam in a while, moderate to general periodontitis with heavy plaque and calc .lower anteriors with carious [decayed] lesions (deep). On 08/04/22 at 11:00 AM an interview was conducted with the Director of Nursing (DON) and Social Worker Director (SWD). The DON reported during COVID, the dentists were not seeing their residents and nursing staff were assessing residents' oral cavity. DON reported the facility has two contracted dentists, however, were closed due to COVID. Inquired when did the dentists open again to do exams. The DON and SWD were not aware of when the dentists began seeing patients and agreed to follow up. Requested documentation of routine dental services for R1. The facility provided consultation notes dated from 01/06/21 to 07/13/22 from the dentist which documents progression of preparing and obtaining upper partial dentures. The consultation report of 04/29/21 notes R1 has poor oral hygiene with recommendation to work on oral hygiene. The consultation report of 07/13/22 notes root tips 23/24 causing pain upon percussion with recommendation to refer to an oral surgeon for extraction. On 08/04/22, the facility provided a dental consultation dated 03/21/17 for dental check. R1 was seen by dentist due to pain to her upper right-side gums. R1's dentures were adjusted. Requested documentation of routine dental services from 2017 to present. The DON reported the resident's medical records were in storage. On 08/04/22 at 11:41 AM a telephone interview was conducted with the dental office. The staff member reported R1's teeth have decayed as the teeth were not cared for, she added teeth need to be flossed. The staff member further shared R1's teeth needs to be extracted and would require a referral to an oral surgeon for sedation. The staff member stated R1 became combative during an appointment with the dentist. On 08/04/22 at 12:01 PM a telephone interview was conducted with the R1's dentist. Inquired what does pain on percussion mean. The dentist reported when R1's tooth was tapped, she flinched. The dentist reported R1's front lower teeth are decayed which is caused by poor oral hygiene (no toothbrushing of the front teeth). The dentist also reported R1 must be experiencing pain when she eats as the decay is down to her nerves. The dentist stated upon examination, R1 was observed with food impacted between her teeth. R1's dentist recommends extraction by an oral surgeon, requiring sedation as R1 became combative during an appointment. R1's dentist also reported she is at risk for infection. The facility provided copy of an email from R1's dentist. The email is dated 08/04/22. The dentist documents R1 was seen on 07/12/22 for emergency exam due to complaints about teeth (#23 and #24). A review of her x-rays notes the teeth were fractured and decayed to the pulp and were extracted. Furthermore, R1 requires a referral to an oral surgeon to extract six lower front teeth (#22 to #27). The dentist notes the treatment is quite extensive and recommended R1 be sedated. Review of progress note dated 07/06/22 documents care plan meeting with R1's son and daughter. R1's children expressed concern regarding R1's appetite and dentition, expressing they observed mother wincing when chewing food. Also noted discussion regarding extraction. Also documented, the facility's physician (MD1) determined it would be contraindicated. Subsequent progress note dated 07/07/21 by facility physician (MD2) notes R1 needs new denture and questions whether R1 would tolerate dental extractions. MD2 notes based on the resident's age he would not recommend dental extraction unless there is an observable reason, for example, weight loss, nutritional deprivation or evidence of dental infection.

Based on observations, staff interviews, and record review, the facility failed to ensure a resident's right to be free from neglect. The facility did not assure Resident (R)10 was provided the care to address positioning needs and as a result of this deficiency, R10 experienced psychosocial harm and an increased potential for physical harm. Findings Include: Cross Reference to F656 Development/Implement Comprehensive Person-Centered Care Plan and F725 Sufficient Nursing Staff R10 had a stroke and was admitted to the facility on [DATE]. R10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/07/21 documented R10 is totally dependent on 2+ staff physical assistance for bed mobility, transfer (between surfaces) dressing, eating (1 staff assist), toileting, bathing, hygiene (1 staff assist), and incontinence care. R10 is unable to operate a call light system or clearly verbalize needs. Multiple observations (07/13/21 at 1:55 PM; 07/15/21 at 9:54 PM and 1:39 PM; 07/16/21 at 08:57 AM) were made of R10 heard making loud moaning sounds which could only be hear from immediately outside the resident's room. There were no staff in the area to hear R10's moans and no staff went to check on or address the resident. On 07/15/21 at 1:39 PM, this surveyor heard a loud crying/wailing type of noise coming from R10's room. The crying/wailing could be heard from 3 doors down the hallway from room [ROOM NUMBER]. Two (2) staff members were observed to be in room [ROOM NUMBER], were R10 was loudly crying/wailing and did not check on R10 or address the resident's needs. This surveyor entered the room and saw Certified Nurse Aide (CNA)11 assisting R10's roommate with a meal and Facility Staff (FS)99 finished cleaning the floor and exited the room. The privacy curtain was drawn between R10 and the roommate which blocked CNA11 from any visual contact of R10. Observed R10 crying, the resident's entire face was red in color and teary-eyed. R10 was dressed in a shirt and incontinent brief only, with a small blanket placed between the resident's knee and wall (knee leaning on the wall) and right side of R10's forehead was resting directly on the wall. No pillows or cushions were observed on R10's bed and observed a call light clipped to the lower left part of R10's bed. CNA11 did not come over to assess R10 despite the resident's continued crying. This surveyor finally verbally requested for CNA11 to assess and attend to R10. CNA11 came over and immediately started to raise the head of R10's bed (HOB) prior to repositioning the resident which caused R10's right forehead to drag along the surface of the wall. Immediately instructed CNA11 to stop raising the head of the bed and reposition R10. Inquired with CNA11 as to why R10 was not checked on or addressed when staff heard the resident crying loudly. CNA11 reportedly was busy assisting R10's roommate with a meal and confirmed other staff was not alert that R10 required assistance. Queried CNA11 regarding R10's positioning needs and ability. CNA11 stated R10 is unable to reposition without 1-2 staff assistance and is known to lean towards the wall (the resident's right side). CNA11 further stated R10 usually makes noises when he needs to be repositioned. Inquired with CNA11 if R10 is able to reach and/or appropriately use the call light that was clipped to R10's bed (on the lower left corner). CNA11 confirmed R10 is unable to reach or appropriately utilize the call light button and reiterated R10 will make noises when the resident needs help. On 07/15/21 at 3:10 PM, conducted a record review of R10's Electronic Medical Record (EMR). Review of R10's care plan documented R10 has Activity of Daily living (ADL) self-care deficit as evidenced by R10 requires total assistance with ADLs related to the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of not implementing frequent checks R10 was in direct contact with the wall more than once, placing the resident at an increased risk of injury and potential for pressure ulcers. The care plan documented also documented for communication, staff should anticipate and meet needs per non-verbal indicators or discomfort/distress and follow-up as indicated. CNA11 failed to meet R10's communication needs despite R10 crying out in distress. On 07/16/21 at 08:45 AM, queried Nursing Staff (NS)60 regarding the use of a call light for R10. NS60 confirmed R10 is not capable of appropriately and physically using the call light button. NS60 stated R10 will make noises when the resident needs help or is uncomfortable, however, if staff is not in the area and does not hear R10's noises, then R10 does not receive assistance. Inquired if the location of R10's room, which is one of two rooms at the end of a hall away from the nurse's station on the Keolamau Unit. NS60 confirmed due to the distance of R10's room for the nursing station and the noise of the activities, residents and other staff make it difficult to hear when R10 is making noise and needs assistance. NS60 stated staff attempt to do frequent rounds to check R10, however, staff is not always able to complete rounds frequently. On 07/16/21 at 09:18 AM, conducted a concurrent interview with the Director of Nursing and the Assistant Director of Nursing regarding observations made of R10. The DON and ADON confirmed staff should have assisted R10 with positioning needs or alerted other staff to assist R10. After reviewing R10's comprehensive care plan, the DON and ADON confirmed a cushion or cushion device should be used to ensure R10 is not leaning directly on the wall according to R10's individual care plan interventions but was not implemented. Further queried the DON and ADON regarding the observation of the call light clipped to R10's bed. The DON and ADON confirmed R10 is unable to appropriately use and operate a call light due to the resident's medical condition. Queried the DON and ADON regarding staff's ability to hear R10's verbal noises used to alert staff for assistance given that the resident is in the last room down the hall and in the bed furthest from the door if the staff is not in the area. The DON and ADON confirmed it would be difficult for staff to hear R10 from the nursing station.

Based on observation, interviews and record reviews, the facility failed to protect three residents, R103, R302 and R39, from falls while residing at the facility. R103 and R302 had sustained major injuries after their falls and R39 continues to suffer from falls. The deficient practice resulted in the decline and expiration of R103; R302 was transferred to acute care and R36 could potentially suffer from a major injury if he continues to have falls in the facility. Findings Include: 1) Surveyor reviewed the electronic medical record (EMR) on [DATE] at 03:14 PM. The event completed report dated [DATE] stated that R103 was found on the floor lying next to her bed. The nursing assessment noted that she had swelling to her right shoulder. R103 was sent to an acute care Emergency Department (ED) at 07:25 AM. At 07:25 the ED informed the facility staff that R103 sustained a proximal right humeral fracture (right upper arm) verified by x-ray. Detailed description of the report: R103 is an [AGE] year-old female admitted to facility on [DATE] for long term care. At 04:35 resident was observed lying on the floor beside her bed lying on her right shoulder and right hip. R103 had a small amount of hard stool noted on the floor and in her brief .The resident indicated that she had right shoulder pain and demonstrated unequal strength in her right hand. Physician (MD) ordered resident to be sent to the ED for evaluation. Night shift nurse was interviewed and stated that resident appeared to be asleep twenty minutes prior to the fall when the certified nurse aide (CNA) checked on her. Resident was toileted approximately two hours before fall .After a thorough investigation, staff felt that it is likely that resident was incontinent of BM and moved around in bed, and consequentially rolled out of bed landing on the floor . Surveyor reviewed discharge summary from the acute care hospital on [DATE] at 1:00 PM. [DATE] 07:05 Impression: 1. Acute fracture of the surgical neck of the proximal humerus (shoulder X-ray) Surveyor noted the following: Findings .A large amount of stool is noted throughout the entire colon, consistent with constipation or colonic impaction (Pelvis and right hip radiographs) . Surveyor reviewed the Electronic medical record (EMR) for R103 on [DATE] at 4:12 PM. Progress notes reviewed revealed: [DATE] 15:57. Admission assessment. admitted from care home on [DATE] with diagnosis of dementia, Mild Protein Malnutrition, Hearing loss, Constipation On [DATE] found on floor and got sent to HMC for further evaluation and returned on same day with diagnosis of right proximal humeral fracture. Requires extensive to total one to two-person assist for activities of daily living (ADL's). Resident complained of right upper extremity (RUE) pain with movement, rated pain medium. Sling is in place. [DATE] 14:47 R103 continue to complain of pain and discomfort to right shoulder. Continue to have poor oral intake even tried to encourage and feed resident. Continue to have cough during mealtime and resident refused to eat when staff helped her with her meals. MD ordered and started on intravenous (IV) fluids. [DATE] 13:59 Resident stayed in bed .continues with poor oral intake, refused meals, noted grimacing with movements, applied [MEDICATION(S)] patch to right shoulder for pain management. On [DATE] R103 had a second unattended fall while sitting up in her wheelchair, it was presumed that she fell face first to the floor after being left unsupervised in her wheelchair after a physical therapy session. R103 was taken the ED for evaluation and treatment and diagnosed with a fracture of the right greater trochanter and questionable incomplete nondisplaced fracture of the base of the neck of the right femur. Surveyor reviewed the discharge summary from the acute care hospital dated [DATE]. MD documentation at 20:13 (8:13 PM) .Had a discussion with son which I explained that R103 will not be able to use a walker anymore because of her shoulder fracture and that if she is non-ambulatory and bed-bound there may be no indication to fix her hip. [DATE] at 15:20 (3:20 PM) .Impression: Right hip greater trochanteric fracture with unlikely extension into femoral neck. Given both upper and lower extremity injuries I do not recommend surgery based on frailty and comorbidities. [DATE] 09:16 Physical therapy (PT) screen. Patient is unable to follow commands. Moans in pain with bed mobility and passive range of motion to bilateral extremities, dependent for mobility. Not presenting with need for skilled PT at this time. Surveyor reviewed the EMR on [DATE] at 2:00 PM. The progress notes revealed that R103 was readmitted to the facility on [DATE]. Further review showed: Care plan dated [DATE]: R103 is at risk for falls. Goal: R103 will not sustain serious injury requiring hospitalization through the review date. Initiated: [DATE] (initial admission). The resident will be free from fall over the next review. initiated: [DATE]. Surveyor noted interventions for constipation were implemented on [DATE]. R103 was noted to have constipation at the time of her first fall on [DATE] when hard stool was found on the floor. R103 was noted to have colon impaction when she was evaluated at the ED. Progress note written on [DATE] 15:03 (3:03 PM). IDT meeting to discuss R103's fall on [DATE]. It was noted that she was lying face down and was overheard making a slight moaning noise. Her right upper extremity (RUE) was in a splint due to a previous fall with a fracture. The certified nurse aide (CNA) reported that the resident had just returned from working with rehabilitation. It appears likely that the resident may have fallen asleep and fell forward landing on the floor in front of her wheelchair. Resident was assisted back in bed and a full head-to-toe assessment was completed by RN. Resident was noted to be guarding her right hip/leg and moaned when asked if she had pain there. She denied pain to any other areas. Scattered small bruises were noted to her knees. She had a purplish bruise that appeared on her left cheek bone. When asked what happened, resident stated, Ow, ow, ow. Continued moaning and grimacing was noted during assessment. Notifications were made appropriately. Surveyor reviewed the minimum data set (MDS) on [DATE] at 10:15 AM. Assessment review date (ARD) [DATE]. R103 was noted to have a significant change; Her functional abilities changed from extensive assist (admission assessment) to total dependence. Progress note on [DATE] at 15:18 (03:18 PM), telephone call from Unit registered nurse (RN) who reported resident expired at 1320 (1:20 PM) today and daughter was in the room. Surveyor interviewed the director of nursing (DON) and assistant director of nursing (ADON) on [DATE] at 09:26 AM. Surveyor asked if the resident was considered a high risk for falls and if so what type of interventions were in place prior to the first fall? Details of the interview are as follows: The DON summarized the first fall that occurred on [DATE]. It was believed that R103 was lying in bed, repositioned herself in bed and slid onto the floor. She was toileted before that. She couldn't recall how she fell ; she had a small amount of hard stool (BM). She did say bathroom. She was a heavy sleeper and sleeps a lot during the day. Historically was sleepy, she would fall asleep easily while sitting up in her chair. The root cause was related to waking up in the middle of the night needing to have a BM and trying to get up and slid out of bed. We gave her a pressure sensitive call light so if she repositioned in bed, the call light would go on. We cannot stop all falls, but we can keep it safe as possible. The second fall happened on [DATE] when R103 was left in her room in her wheelchair after her physical therapy session. The therapist left her sitting up in her chair with the call light. Surveyor asked if R103 was safe to be left in her chair unsupervised, especially since it was documented that she frequently would fall sleep in her chair? The DON replied that the Therapist stated that R013 was safe to stay in her chair. It was believed that she fell forward after falling asleep. Surveyor asked when R103 came back from the acute care hospital after the second fall, did she have a change in her health status? Did she have decline in her activities of daily living (ADL's)? The DON responded yes; a Hospice referral was started while she was at the acute care hospital. When she came back to the facility she declined. Hospice was started on [DATE] and she expired on [DATE]. 2) On [DATE] at 1:45 PM, surveyor reviewed the facility's Office of Health Care Assurance (OHCA) completed Event Report for a facility reported incident (FRI) about R302's fall on [DATE] at 2:45 PM. Details included that the certified nursing assistant (CNA) checked R302's blood pressure (BP) at 1420 or 2:20 PM that day. She had low BP. R302 was lying in bed when the CNA left the room to report to the nurse about R302's low BP. At 1445 or 2:45 PM, R302 was found lying on the floor in front of the bathroom. R302 was not responding to painful stimuli. Staff then elevated R302's legs and checked her BP, it was low at ,d+[DATE], HR (heart rate) 100. R302 opened her eyes and became verbally responsive. The physician and daughter were notified. R302 sustained skin tears to both arms and a bruise to the back of her scalp. A Health Status Note written on [DATE] at 07:21 (AM) by the RN revealed that R302 was sent to the emergency room (ER) at 0415 (04:15 AM). R302 was not responding verbally to the staff, and she was not following their commands to test for motor function. A Health Status Note documented on [DATE] at 10:38 (AM) showed that R302 was admitted to the hospital for bleeding in the brain and bladder rapture (sic). Continued review of R302's EMR revealed that R302 is a [AGE] year-old female with diagnoses of: Alzheimer's disease (gradual and progressive brain disorder affecting memory, thinking and behavior), dementia (a group of symptoms affecting memory, thinking and social abilities severe enough to interfere daily life), heart failure, chronic kidney disease (CKD, failure of the kidneys to filter waste in the blood and fluid in the body), uterovaginal prolapse (pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus causing urinary leakage and the sensation of pelvic heaviness) and frequent falls. R302's care plan revealed for Focus - Resident is at risk for falls due to poor safety awareness related to Dementia, comorbidities. Date Initiated: [DATE] Goal - The resident will not sustain serious injury requiring hospitalization through the review date. Date Initiated: [DATE], Interventions/Tasks .FREQUENT SAFETY CHECKS RESIDENT WILL NOT CALL FOR HELP AND HAS URINARY FREQUENCY ISSUES. Date Initiated: [DATE] In the afternoon of [DATE], surveyor reviewed R302's facility incident reports for falls. R302 had a fall on [DATE] at 02:30 AM and sustained a bruise on her left hand. A fall occurred on [DATE] at 11:30 PM (23:30) and R302 did not have any visible injury. R302 fell in the bathroom on [DATE] at 2:20 PM (14:20) with no visible injury but she complained of pain to her right leg and hip. On [DATE] at 11:25 PM (23:35), R302 stated to staff that she fell in the bathroom, and she was found to have a skin tear on her left wrist and cut to her left knee. R302 experienced a fall on [DATE] at 11:45 PM (23:45) with complaints of left knee pain and no visible injury. R302 had a fall on [DATE] at 09:45 AM which she sustained a small lump to the left side of her head and redness to her left knee. On [DATE] at 2:45 PM (14:45), R302 had her final fall in the facility where she sustained a bruise on her scalp and ruptured bladder. She was transferred to an acute care facility on [DATE]. The ADON and DON were interviewed on [DATE] at 09:20 AM. Surveyor asked them if R302 was considered for one-to-one care with staff. The DON stated that they didn't think she needed one to one care because when she slept, she slept very soundly. The DON further stated that R302 was difficult to care for because she was up 20 times at night, had muscle spasms, medications for hemorrhoids, co-morbidities (other medical diagnoses) that made her feel uncomfortable and she was not a surgical candidate. Surveyor then queried the DON that if R302 was difficult to care for, then wouldn't she have one to one care? The DON stated, She would get tired if she had one to one care. (Refer F725) 3) An observation of R36 was made on [DATE] at 09:32 AM. R36 was sitting up in bed with his eyes closed and was slow to respond when his name was called several times in a loud tone. His breakfast tray was hardly touched and sat on the rolling bedside table in front of him. A vital signs (VS) monitor (equipment to check BP and heart rate) on a rolling apparatus was placed next to his bed. He had difficulty opening his eyes and groggily stated that he needed help with his eggs. Surveyor noted that R36's call light was up high on the right side of his pillow. Surveyor asked RN12 if R36 can reach up and activate his call light. RN12 looked for R36's call light and found it on the right side of his pillow and stated, No. CNA10 entered the room and stated, I left him (R36) because I had to go help someone else. (Refer F919) A review of R36's EMR was done in the morning of [DATE]. A review of Event Notes in R36's progress notes revealed that R36 has had multiple falls. R36 had sustained a fall on [DATE] at 08:03 AM. He had two open areas to his 4th and 5th toes on his right foot. Further review of R36's EMR revealed that R36 had previous falls on [DATE], [DATE] and [DATE]. R36 is receiving Hospice care and has diagnoses of history of falls, generalized muscle weakness, cognitive communication deficit and retention of urine. A subsequent review of R36's care plan was done. Under Focus - FALLS: Resident is at risk for falls due to impaired balance, hx (history) of falls, RLE (right lower extremity) [CONDITION(S)] (serious bacterial infection of the skin), LE (lower extremity) venous stasis ulceration. Date initiated: [DATE], Goal - The resident will not sustain serious injury requiring hospitalization through the review date. Date Initiated [DATE], Interventions/Tasks .Call light within reach. Remind frequently to call and wait for assistance as needed. Date Initiated: [DATE]. (Refer F656)

Based on observations, record reviews and interview with family and staff members, the facility failed to ensure 1 of 4 residents (R) 77 sampled received the treatment and services to promote healing of an existing pressure injury resulting in harm. Sampled R77 based on the facility matrix provided by the facility indicating, worsening of pressure injury. R77 was admitted status [REDACTED]. R77 was admitted with a Stage 1 pressure injury to the coccyx, which worsened and currently assessed as an unstageable pressure injury with deep tissue injury. R77 also has a facility acquired Stage 2 pressure injury to the left medial heel as a result of positioning. Although the treatment for [REDACTED]. The facility did not have documentation to support the repositioning of the resident every two hours and there is no documentation by the nursing staff to endorse R77 was positioned correctly to ensure offloading of the coccyx. Also, the interventions for healing the pressure injury were not revised to address the worsening progression of the injury to the coccyx and to prevent further skin breakdown. As a result of the facility's deficient practices, R77's pressure injury to the coccyx worsened, the resident also developed a facility acquired Stage 2 pressure injury to the left medial heel, and has pain related to the pressure injury to the coccyx. Findings include: Cross Reference to F690 and F726. On 01/24/20, Resident (R) 77 was admitted to the facility with the following Diagnoses: [REDACTED]. coli); and type 2 diabetes mellitus with [MEDICAL CONDITION]. On 03/03/20 during the initial tour, R77 was observed in bed, placed on his/her back. R77 appeared to be in pain, asked whether he/she had pain and the resident waved his/her arm in response. Notified the nursing staff of R77's pain. Observed R77 up in the wheelchair for lunch. On 03/04/20, R77 was up in the wheelchair for breakfast. At 09:15 AM, observed R77 being wheeled to therapy. At 10:10 AM, R77 was engaged in physical therapy. R77 was at the parallel bars attempting to stand. On the afternoon of 03/04/20, observed R77 in bed with a grimace. Inquired whether she was in pain, she said yes. Informed staff member that R77 was in pain, subsequent observation found R77 asleep, snoring. On 03/05/20 at 09:47 AM, observed R77 asleep in bed. There was a bolster placed under the resident's left shoulder. Subsequent observation at 02:50 PM found R77 with the physical therapist (PT), transferring out of bed to the wheelchair. R77 sat at the edge of the bed and slid forward while attempting to stand. Noticed the resident to grimace. The PT asked the resident if he/she had pain, the resident nodded yes. When the resident slipped against the side of the mattress, noticed he/she to grimace again. The PT asked R77 whether the pain was to the buttock or back. R77 replied, The back. The PT was unable to transfer R77 to the wheelchair and elicited the assistance of another staff member. The PT reported that R77 could tolerate position for 45 minutes then needs to be repositioned. The PT reported that R77 needed repositioning and rotating to alleviate pain and prevent the pressure injury from progressing. Asked the PT who documents the repositioning of R77, the PT replied the certified nurse aides (CNA) will document. On 03/05/20 at 03:45 PM, observed R77 asleep, placed on his/her back, covered with blanket and bed quilt; and, unable to ascertain whether offloading of coccyx. On 03/06/20 observed R77 up in the wheelchair for breakfast. Sitting alone, R77 had consumed some of his/her breakfast. Observed there was no Ensure Clear Plus on the breakfast tray. Inquired with staff member, the staff member responded, she/he would have to get it. Record review done on the morning of 03/05/20 found an admission minimum data set (MDS) with an assessment reference date of 01/31/20. The brief interview for mental status was administered, R77 yielded a score of eight (moderately impaired cognition). R77 was coded to require extensive assistance with two+ person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). R77 also required extensive assistance with one-person physical assist for eating (how resident eats and drinks), per MDS coding. The MDS coding under section M. Skin Conditions, noted R77 had a Stage 2 pressure ulcer, which was present on admission, and a surgical wound. Also, R77 was admitted with a Foley catheter (discontinued on 01/27/20), due to frequently incontinent of bladder and bowel per MDS coding. The MDS coding under Section J. Health Conditions, noted R77 to have a pain medication regimen and received pain medication as needed (PRN). The pain assessment interview found R77 experienced pain frequently, at level four (on scale of 0-10) that did not affect sleep or day-to-day activities. Also noted, R77 received opioid medication during the last seven days. R77 presently has a physician order [REDACTED]. A review of the Braden Scale (risk assessment for predicting pressure ulcer risk) dated 02/14/20 noted R77 yielded a score of 11 (high risk). The risk factors included: slightly limited sensory perception; very moist; chairfast; very limited mobility; very poor nutrition; friction and shear problem; decreased or impaired bed/chair mobility; recent surgery; existing pressure injury; urinary or bowel incontinence; pain that affects movement or mood; chronic renal, liver, or [MEDICAL CONDITION]; failure to thrive or anorexia; [MEDICAL CONDITION]; diabetes; cognitive communication deficit; and urinary tract infection. On the afternoon and evening of 03/05/20 a review of the Nursing: Wound Observation Tool - V1 found R77 also had a Stage 2 facility-acquired pressure injury to the left medial heel (onset of 02/18/20). Further review found the Stage 2 pressure injury to the coccyx worsened. The assessment of 01/24/20 documented, R77 had a Stage 1 pressure injury to the coccyx (1.5 cm x 1.5 cm x 0) on admission. The interventions included foam dressing (change every three days) and pressure relieving mattress. R77's assessment on 01/31/20 noted a superficial open area and treatment changed to A&D ointment every shift. Subsequent assessment on 02/08/20 noted improvement of the pressure injury (1.0 cm x 0.5 cm x 0), and treatment changed to clean with NS and use [MEDICATION NAME] dressing. The 02/17/20 assessment noted the pressure injury was improving (0.3 cm x 0.3 cm x 0). On 02/18/20, Intervention to float the resident's heel (splint boot) was added after R77 had a Stage 2 pressure injury to the heel. On 02/26/20 documentation noted the pressure injury to the coccyx worsened (5.5 cm x 5.0 cm x 0.1 cm), and, then assessed as unstageable with deep tissue injury (DTI). Also noted, the wound had serosanguinous drainage with 30% purple tissue with suspected DTI and the wound edges were irregular with several open areas and areas of broken skin throughout. The treatment for [REDACTED]. Also started on IV fluids starting on 02/27/20, R77 had signs and symptoms of dehydration. The last 03/05/20 assessment noted the pressure injury is unchanged and presented with three open areas, and slough and necrotic tissue. The treatment changed to foam dressing with [MEDICATION NAME]. The wound assessment dated [DATE] noted a facility acquired Stage 2 (blister) pressure injury to the left medial heel (4.5 cm x 4.0 cm x 0.0). At that time the treatment was to use a splint boot. Subsequent assessments dated 02/28/20 and 03/05/20 notes improvement. A review of the progress note dated 02/18/20 documents R77 refused to get up for dinner and was complaining of pain. A family member checked R77's foot, noticed the blister and notified the staff member. On 03/05/20 at 02:15 PM interviewed the Nursing Staff Development Coordinator (SDC), also identified as the wound nurse. Inquired what caused the pressure injury to worsen from Stage 1 (on admission) to Stage 2 to unstageable. SDC responded R77's pressure injury to the coccyx went from a Stage 1 to Stage 2 in one week and usually [MEDICATION NAME] dressing would facilitate the healing. SDC also reported R77 currently had pain and a urinary tract infection that makes it difficult to get the resident to move. SDC reported the worsening of the pressure injury was unavoidable, R77 was provided with a pressure-relieving mattress on admission, clarifying all the mattresses in the facility are pressure-relieving mattress; however, on 03/02/20, R77 was placed on an air mattress. SDC reported the pressure injury (blister) to the resident's left medial heel happened quickly and was a surprise. Queried how the pressure injury to the left medial heel developed. According to the SDC, R77 was positioned with the hip up to the side due to the pressure injury on the coccyx, and the pressure injury developed from leaning the heel on the bed, possibly over one day of bad positioning. The SDC was asked whether he/she checked R77's to ensure proper positioning for offloading of the coccyx and proper placement of the splint boot. SDC reported that staff observed R77's positioning; however, did not document. Further queried SDC how often checked for proper positioning and correct application of the splint boot, SDC responded during the weekly wound assessment. Inquired whether considered repositioning/turning from every two hours to more frequently, and whether the care plan should include ensure no friction and shear. The SDC responded that a draw sheet is utilized for every resident. SDC provided a copy of R77's care plan. A review of the care plan found a focus area for skin integrity, noting R77 was admitted with a Stage 2 pressure injury to the coccyx and has a Stage 2 (onset 02/18/20) pressure injury to the left medial heel. The interventions related to the coccyx pressure injury included: educate resident and/or family regarding skin problem and treatment (date initiated: 1/24/20); pressure reducing mattress (date initiated: 01/24/20); treatment as ordered and monitor effectiveness of treatment (date initiated: 01/24/20); weekly skin checks (date initiated: 01/24/20); reposition resident q2 hours in side lying with pillow between thigh/knees, use pillow to support lower back and pelvis to reduce pressure to coccyx (date initiated and revised: 02/27/20); provide incontinence care after incontinence episodes, apply moisture barrier as needed (date initiated: 02/06/20); report changes in skin status to physician (date initiated: 02/06/20); and notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care (date initiated: 02/06/20). The interventions related to the Stage 2 pressure injury to the left medial heel included: elevate heels so they do not touch bed (date initiated 02/19/20); floating heel splint to left foot while resident is laying in bed while on back or lying on the side (date initiated 02/19/20); while resident is lying in bed, apply left floating heel splint with option to use heels off positioning cushion when lying on his/her back (date initiated and revised: 02/27/20); and reposition resident q2 hours in side lying with pillow between thigh/knees, use pillow to support lower back and pelvis to reduce pressure to coccyx (date initiated and revised: 02/27/20) The care plan also included nutritional interventions to address the healing of R77's pressure injuries. The interventions included: provide fortified foods as tolerated, fortified ice cream (date initiated 01/30/20 and revised: 02/03/20); Ensure Clear with meals, liquacel 30 ml daily for additional protein (date initiated: 01/31/20 and 02/20/20 and revised 03/02/20); and provide with additional tofu, Ensure Clear with meals and liquacel 30 ml daily for additional protein (date initiated: 02/20/20 and revised: 03/02/20). On 03/05/20 at 03:45 PM, Registered Nurse (RN) 2 was asked whether the facility documents repositioning of R77. RN2 responded there is no documentation of repositioning for R77, the records do not support a place to document the repositioning. Further review found a progress note entry dated 03/05/20 (03:11 PM) documenting R77's surgical incisions healed well, and resident complains of coccyx pain and lower back pain. R77 was repositioned for comfort and continues [MEDICATION NAME] 100 mg BID and at night and receives routine [MEDICATION NAME] 650 mg three times a day. R77 also has [MEDICATION NAME] gel applied to the lower back and coccyx. On 03/05/20 at 07:00 PM, observed R77 in activities, engaged in karaoke with three family members present. At 07:20 PM interviewed a family member (FM) 1 that reported R77's course at the facility has been up and down. FM1 reported R77 continued with a bladder infection and bed sore on the coccyx. FM1 reported that R77 complained to family of pain to the foot and the pressure injury on the left medial heel was discovered. R77 requested for the family member to massage his/her foot and winced when the left heel was touched. FM1 removed the sock and found the injury, approximately a 1/2-dollar size and the facility did not provide an explanation regarding how the pressure injury developed. Inquired whether family members observe R77 in different positioning (back/side) while in bed, FM1 responded only recently has R77 been observed to be in different positions. FM1 also reported R77 has coccyx pain. On 03/06/20 at 09:12 AM interviewed the medical director, director of nursing (DON) and administrator. The team was aware of R77's pressure injuries, and were providing daily treatment options, therapy to address change in positioning, utilization of the splint boot, and topical treatments. The DON reported that R77 was included in discussion during the facility's resident at risk (RAR) meetings. The DON further reported the therapy department has documentation regarding repositioning; however, the facility does not document when the resident is repositioned. The DON was agreeable to provide copies of the RAR meetings for R77. A review of the RAR minutes found an entry dated 02/02/20 of R77 having a decrease in appetite. R77's family reported the decrease in appetite as affected by pain or the use of antibiotics. Ensure Clear was added, in addition to the fortified ice cream. On 02/07/20, the RAR minutes noted R77 with continued poor appetite, needed encouragement with intake, and ordered additional Ensure Clear with breakfast. Subsequently noted on 02/14/20, staff to provide Ensure Clear three times a day with consumption of 600 to 720 ml a day. Also, R77 received multi-vitamin supplement and fortified ice cream to aid in wound healing. In addition, [MEDICATION NAME] added for adjustment disorder. The recent 03/02/20 RAR minutes noted, continued poor appetite and limited participation with rehab services. R77 did not self-initiate feeding, and facility initiated use of an air mattress. Also noted, IV fluids provided for re-hydration. On 01/24/20, R77 was admitted from an acute hospital with a Stage 1 pressure injury (PI) to the coccyx and a Foley catheter that was discontinued on 01/27/20. On 02/26/20, the coccyx Stag1 PI was then a Stage 2 PI, and worsened to unstageable with possible deep tissue injury (DTI). On 02/18/20, R77 developed a facility acquired Stage 2 PI on the left heel (requiring floating of heel and splint). On 02/27/20, R77 was provided intravenous fluids for approximately three days, and started antibiotics for an asymptomatic urinary tract infection.

Based on observations, medical record review and staff interview, the facility failed to maintain necessary nutritional support for one of seven residents (R) 39 which resulted in a significant weight loss of 16% over a three month period. Findings include: Cross reference to F657 Cross reference to F740 R39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission, R39 did not refuse meals and was not experiencing mood or behavior problems. An observation of R39 on the morning of 01/29/19 at 10:41 AM found her in bed with the curtains drawn as she was banging on the wall and yelling for help. She yelled, Help me. Help me. Don't leave me here. I need help. Surveyor went into her room to ask how she was doing. She said she wasn't feeling well. R39 appeared distressed and worried. She stated, My stomach hurts. I need Tylenol. Surveyor informed her she would notify the Licensed Nurse (LN) to assist her. She stated, Don't say that. You always say that. Don't say you're coming back. They always say that. Make sure you bring the nurse back or she won't come. Surveyor assured her she would make sure the nurse came in to assist her. Surveyor found LN43 to endorse R39's wishes. LN43 attended to R39 within five minutes. Observation of R39 on 01/29/19 at 11.20 AM found her asleep in bed. On 01/29/19 at 12:00 PM R39 was heard banging on the wall in her room and yelling for Staff 107 and Staff 37. R39 was yelling, (Staff 107, Staff 37) .You leave me here and don't come back .(Staff 107) don't leave me here .(Staff 37) come and get me. Don't leave me. At 12:04 PM the Registered Dietician (RD) walked into R39's room to assist her. R39 was upset and telling the RD she needs help. At 12:06 PM Staff 107 walked in and assisted R39 out of bed and into her wheelchair. Staff 107 wheeled R39 to the bathroom where he stopped to get her hairbrush and brushed her hair. R39 saw the surveyor standing in the hallway observing her. R39 appeared agitated and anxious with her brow furrowed. R39 stated, Don't you let that young (pause) woman wheel me. Staff 107 brought R39 to the dining room and placed her at a table. The lunch trays were passed out and she saw her meal of chopped pork and rice and yelled, I don't want to eat that. Take me back to my room. Staff 107 returned approximately two minutes later and wheeled her back to her room and placed her back to bed. An interview of Staff 107 on 01/29/19 at 12:30 PM revealed he placed R39 back to bed because she didn't like the way the pork was chopped. Staff 107 was asked whether she was offered a substitute for her meal which he didn't answer as he moved on to his next task. R39 did not have lunch on 01/29/19. An observation of R39 on 01/30/19 at 09:00 AM found her in bed asleep; At 12:00 PM she was in bed asleep. On 01/31/19 at 10:00 AM R39 was found in bed asleep. On 01/31/19 at 12:00 PM she was observed up in her wheelchair in the hallway waiting for lunch. She appeared worried and anxious with her brow furrowed and appearing restless as though she needed to go somewhere. At 12:02 PM, R39 began yelling for staff to return her to her room. A staff member returned her to her room. Again, R39 missed lunch. On the morning of 02/01/19 at 9:30 AM R39 was found in bed asleep. LN100 stated she was out earlier for breakfast then returned to bed. On 02/01/19 at 11:00 AM R39 was heard banging on her wall and yelling for staff to help her. A review of R39's intake log on the afternoon of 01/31/19 at 01:55 PM found she often refused her meals, particularly lunch and dinner. R39 almost never accepted the afternoon and bedtime snacks. In the month of (MONTH) (YEAR), R39 refused breakfast on 2 days; Refused lunch 9 days; and Refused dinner 7 days. For the month of (MONTH) (YEAR), R39 refused more than one meal per day: 10/1/18 refused lunch and dinner; 10/22/18 refused lunch and dinner; 10/24/18 refused lunch and dinner; 10/27/18 refused breakfast and dinner; 10/31/18 refused lunch and dinner. In the month of (MONTH) (YEAR), R39 refused breakfast 10 days; Refused lunch 10 days; and Refused dinner 10 days. For the month of (MONTH) (YEAR), R39 refused at least two meals on the following days: 11/02/18 refused breakfast and lunch; 11/03/18 refused breakfast and lunch; 11/09/18 refused lunch and dinner; 11/13/18 refused breakfast, lunch and dinner; 11/15/18 refused breakfast and dinner; 11/17/18 refused breakfast, lunch and dinner; 11/18/18 refused breakfast and dinner; 11/19/18 refused breakfast and lunch; 11/20/18 refused breakfast and dinner; and 11/22/18 refused breakfast, lunch and dinner. In the month of (MONTH) (YEAR), R39 refused breakfast 2 days; Refused lunch 2 days; and Refused dinner 6 days. In the month of (MONTH) 2019, R39 refused lunch 2 days and refused dinner 8 days. For the month of (MONTH) 2019, R39 refused lunch and dinner on 1/29/19. On the morning of 01/30/19, a review of R39's weights found she weighed 122 pounds on 9/17/18. On 10/15/18 R39 weighed 117 pounds, or 5% loss from 9/17/18 (one month). On 11/12/18 R39 weighed 106 pounds or 13% loss from 9/17/18 (two months). On 12/03/18 R39 weighed 102 pounds or 16% loss from 9/17/18 (three months). Her latest weight was 102 pounds on 01/14/19. On the afternoon of 01/3/19 at 3:00 PM, a review of R39's Resident At Risk (RAR) notes found an entry dated 10/25/18 which noted, appetite getting worse; continues to yell. Another entry dated 10/26/18 noted, Weight change likely related to fluctuation in appetite with mood swings/shingles pain. The 10/26/18 plan was to recommend 2Cal HN 60 ml three times daily with medpass. An entry dated 1/10/19 noted, Behavior interferes with meals. A review of R39's care plan titled Nutrition with onset date 04/03/18 did not discuss the fact that the resident frequently refused meals with the recommended approaches. On the morning of 02/01/19 at 08:30 AM, the physician's progress notes dated 06/19/18 to 12/31/18 were reviewed. On 10/18/18 the physician noted R39's appetite was satisfactory and had a 3 pound weight loss (117 pounds). However, from her baseline weight of 122 pounds, that was a 5% loss within one month (or significant). On 10/30/18, the physician noted R39's appetite was satisfactory with no significant weight change and that she was experiencing epigastric pain (10/29/18 weight 115 pounds or 6% loss in 1.5 months). The physician's plan for R39's epigastric pain noted it was [REDACATED] vs PUD ([MEDICAL CONDITION] Ulcer Disease) - Trial (PPI) Proton Pump Inhibitors daily to assess if this helps. On 10/31/18 the physician noted R39 had epigastric pain and she was constipated. An interview of LN100 on the afternoon of 01/31/19 at 03:09 PM revealed R39 had uncontrolled behaviors which the LN attributed to the resident's poor intake. LN100 stated R39 has outbursts, screams a lot, and refuses care on a daily basis. The LN noted R39's behaviors have interfered with her nutritional intake causing her to have a significant weight loss. LN100 stated R39 often refuses meals as a result of her labile behaviors. LN100 stated R39 receives 2Cal (nutritional supplement) three times daily with medication pass, which she takes. An interview of the Registered Dietician (RD) on the morning of 02/01/19 at 08:51 AM revealed R39's behaviors have progressively gotten worse. The RD noted, Sometimes her behavior affects her appetite. The RD stated she referred R39 for a swallow evaluation by a Speech Language Pathologist (SLP) on 04/09/18. She reported the SLP had difficulty completing her swallow evaluation because R39 did not like the SLP and she therefore had to stand at a distance during observations. The SLP recommended a regular, mechanical soft diet. The RD noted around (MONTH) or (MONTH) (YEAR) the facility did a significant change Minimum Data Set (MDS) because it seemed like her behavior started to affect her appetite. At that time, she was started on 2Cal (nutritional supplement) three times daily. The RD said it was her understanding that the physician was adjusting her medications and the RD wanted to see if it had any impact on her intake/weight. The RD was flipping through R39's medical record and mentioned, Oh it says here she had shingles. That may have gotten the ball rolling. The RD concluded that it's very likely her behaviors have affected her nutritional intake causing an avoidable significant weight loss.

Based on observations, medical record review and staff interviews, the facility failed to maintain the highest practicable physical, mental and emotional well being for five of six residents (R) (R39, R33, R20, R41, R70) reviewed for behavior, with one resident (R39) who experienced actual harm from not receiving the necessary behavioral health care and services. Findings include: 1) Cross reference to F692 Cross reference to F676 Resident (R) 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R39 on the morning of 01/29/19 at 10:41 AM found she activated her call light and was banging on the wall in her room and screaming: Help me. Help me. I need help. Surveyor went into R39's room and asked how she was doing. She said her stomach hurt and she asked for Tylenol. Surveyor informed her she would return after she notified the nurse of the resident's needs. R39 yelled, Don't say that. Don't leave. You won't come back. Make sure you bring the nurse back or she won't come. She continued to scream that as the Surveyor went out to notify a Licensed Nurse (LN) of her request. LN43 said she would go in to help the resident and was observed going into the resident's room a few minutes later. At 11:30 AM the surveyor returned to follow up with R39 but she was asleep. On 01/29/19 at 12:00 PM R39 had again activated her call light and was banging on the wall, screaming the names of the Certified Nurses Aides (CNAs) who routinely care for her. She screamed, (CNA107) .(CNA37) .You leave me here and don't come back. Help! Various staff were present and continued with their tasks without checking on R39. At 12:04 PM the Registered Dietician (RD) walked into R39's room to assist her. The RD was seen talking with R39 while she lay in bed. R39 stated she was hungry and ready for lunch. CNA107 walked into R39's room at 12:06 PM and assisted her from the bed into her wheelchair. CNA107 wheeled R39 towards the door and stopped at the bathroom to brush the resident's hair. R39 could see the Surveyor standing in the hall observing. R39 was looking at the Surveyor and in an irritated voice she told CNA107, Don't let her wheel me. I don't want that young .(pause) .woman taking me anywhere. CNA107 assured R39 he would be the person wheeling her out of her room. R39 was brought to the dining room and placed at a table. The lunch trays were passed out and she saw the meal which consisted of chopped pork and rice. She yelled, I don't want to eat that. Take me back to my room. CNA107 brought R39 back to her room and placed her back in bed. An interview of CNA107 on 01/29/19 at 12:30 PM revealed he placed R39 back to bed because she didn't like the pork, particularly the (mechanical soft) texture. CNA107 was asked whether she was offered a substitute for her meal, which he didn't answer as he moved on to his next task. R39 did not have lunch on 01/29/19. On 01/30/19 at 10:30 AM R39 was heard yelling and banging on her wall from her room. While banging on the wall, she was screaming for a CNA, (CNA107) you come here now. I need help. She continued to scream until a staff member attended to her at 10:34 AM. When the staff member arrived, R39 told the staff to help her in an irritated tone of voice. On 01/31/19 at 12:00 PM R39 was up in her wheelchair, seated in the hallway with several other residents in preparation for the lunch meal. R39 began gettting restless and began raising her voice. She began yelling at the staff saying negative comments. She then yelled that she'd like to return to her room. A CNA returned R39 to her room and put back to bed. She did not have lunch that day. On 02/01/19 at 9:30 AM R39 was in bed asleep. An interview of LN75 on 02/01/19 at 9:30 AM revealed R39 came out of her room earlier for breakfast then returned to bed. A medical record review on the morning of 01/31/19 at 10:00 AM revealed multiple entries in the nurse's progress notes indicating R39 experiences distressed behaviors which included screaming, insulting staff/family members, physical aggression, banging on the wall and refusing to eat. A review of the nurses notes from 11/01/19 through 01/31/19 found R39 experiences distressful behaviors on a daily basis. According to the nurses notes, R39 would, on a daily basis, scream, bang on the wall, get restless, get agitated and insult staff and family members. In addition to these behaviors, R39 frequently refuses to eat. According to the nurses notes, the CNA staff would bring R39 out for meals where she would be among other residents. She would get agitated and ask to return to her room where she returns to bed. Occasionally R39's behaviors were inconsolable and the nurses would administer [MEDICATION NAME]. R39 was seen by a psychiatrist on 09/10/18. On the afternoon of 01/31/19 at 02:50 PM, a review of R39's visit with the psychiatrist noted the resident was fixated on one particular staff member whom she felt violent towards and had difficulty controlling her temper around. The psychiatrist diagnosed R39 with senile dementia with delusional features and [MEDICAL CONDITION] with delusions. He recommended a trial of [MEDICATION NAME] with slow increase. The psychiatrist suggested an alternative treatment using [MEDICATION NAME] (antidepressant) in combination with Aripiprazole (antipsychotic) instead of [MEDICATION NAME]. On the morning of 01/31/19 at 11:00 AM, a review of R39's intake from (MONTH) (YEAR) to (MONTH) 2019 found she ate breakfast on most mornings. However, she often refused meals particularly lunch and dinner. As noted above, observations during survey as well as nurses notes found she got agitated when placed among other residents in common areas. Observations and nurses notes found that R39 demands to return to bed within minutes of being placed among other residents. During the survey period, 1/29/19 to 2/4/19, R39 was often observed in bed asleep: 1/29/19, 11:30 AM; 1/29/19, 1:30 PM; 1/30/19 at 9:00 AM; 1/30/19 at 12:00 PM; 1/30/19, 2:30 PM; 1/31/19 at 10:00 AM; 1/31/19, 2:15 PM; 1/31/19, 4:00 PM; 2/1/19, 9:00 AM; 2/1/19 10:30 AM; and 2/4/19, 11:15 AM. On the afternoon of 01/31/19 at 1:30 PM a comparison of R39's last two Minimum Data Set (MDS), a resident assessment instrument, dated 11/23/18 (significant change) and 9/15/18 (quarterly assessment) found R39 experienced a significant change. The 11/23/18 MDS noted R39 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognitive patterns. The 09/15/18 MDS noted a BIMS score of 15 out of 15 indicating intact cognition. The 11/23/18 MDS noted an acute change in mental status from the resident's baseline. R39's mood score on the 11/23/18 MDS was 13 out of 27 as compared to 5 out of 27 on the 09/15/18 MDS, indicating increased symptoms of mood problems (feeling down, trouble sleeping or sleeping too much, poor appetite, restlessness). The 11/23/18 MDS noted R39 had verbal behavioral symptoms toward others 4 to 6 days as compared to 1 to 3 days on 09/15/18 MDS; and other behavioral symptoms (verbal/vocal symptoms like screaming) 1 to 3 days as compared to none on the 09/15/18 MDS. The 11/23/18 MDS noted the above named behaviors: Significantly interfered with the resident's care; Significantly interfered with the resident's participation in activities or social interaction; Significantly intruded on the privacy of others; and Significantly disrupted care or living environment. The 11/23/18 MDS noted R39 rejected care 4 to 6 days, but less than daily compared to 1 to 3 days on 9/18/18 MDS. The 11/23/18 MDS noted a worsening of R39's current behavior status, care rejection, or wandering compared to prior assessment. The 11/23/18 MDS noted R39 was frequently incontinent of bowel compared to always continent on 09/18/18 MDS. The 11/23/18 MDS noted R39 experienced a loss of 5% or more in the last month or 10% or more in the last six months but was not on a physician prescribed weight loss regimen. The 11/23/18 MDS noted R39 also experienced a decline in her functional status compared to the 9/18/18 MDS: Two person assist for bed mobility compared to one person assist; and One person assist compared with setup only for eating. On the afternoon of 01/30/19 at 02:30 PM a review of R39's physician's orders [REDACTED]. On the afternoon of 01/31/19 at 02:00 PM, a review of R39's behavior logs found one for use of [MEDICATION NAME]. Despite the many survey observations and review of nurse's note of R39's behaviors, the behavior log for the use of [MEDICATION NAME] only contained six entries between 11/01/18 to 01/31/19 (11/01/18, 11/09/18, 11/12/18, 12/01/18, 12/09/18, 01/31/19). Behaviors documented included verbal aggression, disruptive behaviors, calling names, yelling, wall pounding, and physical aggression. On the afternoon of 01/31/19 at 02:10 PM a review of the Medication Administration Records (MARs) for R39 found she received: 14 doses of [MEDICATION NAME] from 11/01/18 to 11/30/18; 3 doses from 12/01/18 to 12/31/18; and 8 doses from 01/01/19 to 01/30/19. The documentation on the behavior log for [MEDICATION NAME] did not match the MAR for use of [MEDICATION NAME] prn. On the afternoon of 01/03/19 at 02:30 PM, a review of the physician's notes dated 06/01/18 through 12/31/18 found the physician did not document R39's shingles outbreak in (MONTH) (YEAR). Additionally, the physician did not discuss R39's significant weight loss. The physician discussed R39's behaviors based on nurses' verbal reports. On the afternoon of 02/01/19 at 12:30 PM a review of the Interdisciplinary (IDT) notes for Residents At Risk (RAR) found a note dated 01/10/19 which noted, Behavior interferes with meals, with a corresponding plan stating, Increase breakfast/calories; Get order renewed for [MEDICATION NAME]. Another note dated 10/26/18 stated, Weight change likely related to fluctuation in appetite with mood swings/shingles pain. An interview of LN100 on the afternoon of 01/31/19 at 03:09 PM revealed the facility's approach to working with R39 is to use non-medication interventions. The LN stated R39's behaviors have gotten worse since her admission. LN100 stated R39 frequently says mean/hurtful things to her family and the staff. The LN noted R39 has clear preferences for staff and will vocalize her displeasure with persons. LN100 noted R39's behaviors are out of control and occur on a daily basis. She reports she bangs on the wall, is verbally aggressive, is very disruptive, and sometimes gets physically aggressive. The LN reported the nursing staff should be documenting R39's behaviors on the behavior log but acknowledges they haven't been. She validated the behavior log for [MEDICATION NAME] does not match the use of the medication (as it is documented on the MAR). LN100 noted the night shift nurses were responsible to review residents for an overall picture. She noted the information is inaccurate since the behavior logs were not being accurately done. LN100 stated R39's behaviors have interfered with her nutritional intake, resulting in a significant weight loss (16% in three months from (MONTH) to (MONTH) (YEAR)). The LN stated R39's significant weight loss could have been avoided if her behaviors were better managed. On the morning of 02/01/19 at 08:51 AM an interview of the Registered Dietician (RD) revealed her understanding that R39 experienced a significant weight loss which was not physician prescribed. The RD said, Sometimes (R39's) behavior affects her appetite. The RD noted a decline in R39's behavior. She reports R39 was initially pleasantly rude and has since gotten worse, noting her behavior is coming out more and has increasingly become more demanding. The RD referred R39 for a swallow evaluation which found she required a mechanical soft texture. The RD noted the staff discussed R39 at their weekly Resident At Risk (RAR) meetings where the Interdisciplinary Team (IDT) discussed residents with problems which include weight, behaviors, pain, falls, etc. The RD noted the IDT completed a significant change on the MDS as it seemed like R39's behaviors were affecting her dietary intake resulting in significant weight loss. The RD noted the physician was making revisions to her medications and the IDT was hopeful it would impact her intake/weight. The RD noted R39 had shingles in (MONTH) (YEAR) which may have started the ball rolling with her weight loss. The RD noted that R39's behaviors very likely contributed to her significant weight loss, which could have been avoided. An interview of R39's family member (FM) on the morning of 02/04/19 at 10:30 AM revealed that R39's behaviors have worsened. The FM noted R39 is always so angry. She understands she has dementia and noted it's turned her personality completely around. The FM stated R39 was hurtful to her husband as she told him she divorced him and married Staff 107. The FM stated R39's behaviors made her husband feel bad and for a while he didn't want to visit. An interview of R39's physician (facility's medical director) on the morning of 02/04/19 at 11:45 AM found R39 became more verbally aggressive with staff around (MONTH) (YEAR). The physician thought R39 was possibly depressed and she tried [MEDICATION NAME] (antidepressant) but she continued to exhibit behaviors. The physician referred R39 to a psychiatrist who found her to be paranoid and recommended an antipsychotic which was trialed. The resident's behaviors got worse so the physician tapered her off the antipsychotic. The physician noted R39 is very sensitive to medications. She stated she attempted [MEDICATION NAME] (dementia medication) as well as another antidepressant both of which worsened her behaviors. The physician tried her on prn [MEDICATION NAME] which she stated the family likes because it's not given daily. The physician stated the nursing staff are monitoring her sleep as R39 always wants to sleep. The physician noted the IDT could do better with managing her behaviors and will figure out a plan. The facility's failure to ensure the highest practicable physical, mental and psychosocial well being for R39's affected her nutritional intake, relationship with family, and her functional status. 2) Resident (R)41 is a [AGE] year old admitted to the facility on [DATE]. R41 has a history of asking for things and then refusing them per Staff (S)1. R41 has ongoing medical issues that have not been resolved because of her asking for treatment and then refusing. Record Review (RR) on 01/29/18, R41 has a care plan for Mood dated 09/13/17. Under goals, R41 mood and behaviors will be minimized with medication and interventions thru next review date with an onset date of 09/13/2017 and a target date of 03/08/2019. One of the approaches is to use alternate staff if acting out or refusing care. Come back later 10-15 minutes later. Interview on 01/29/19 at 10:50 AM with R41 who states, It's a lot of repetition. I don't go outside. I like watching TV and the news. I don't get out of bed. Interview on 01/29/19 at 11:00 AM with Staff (S)28 states, she gets up to shower. We have been encouraging her to get up but she refuses. Interview on 01/30/19 at 09:13 AM with R41 who states, I have a tooth that is supposed to be taken care of. However, R41 refused to do the teeth extraction on (MONTH) 16, (YEAR). (Reference F656). Interview on 01/30/19 at 09:45 AM with resident R41 My right breast has fallen to the side and it's hard. Resident shows this surveyor right breast. Right side of breast with different skin texture and some redness to area. R41 goes on to say that they told me that it is [MEDICAL CONDITION] and to go to my own physician. I don't have a physician. I went two different times, three different doctors. I would like it removed and it hurts. R41 offers me a copy of a report from a radiology service. Report states Our interpretation of your breast examination identified a finding that needs further evaluation. A full report has been forwarded to your physician. Interview on 01/30/19 at 10:18 AM with MD who stated that I didn't see that exact letter but we sent her to a surgeon and it was biopsied. The results came back as benign. We offered her to go to some surgeons here but she didn't want to. We offered her to go to Oahu but she didn't want to. We treated her with antibiotic. She shouldn't pick on it. (Reference F657). Record review (RR) on 02/01/2019 at 08:00 AM reveals the resident had a psychological examination on (MONTH) 17, (YEAR). At the time, R41 was diagnosed as having a Persistent [MEDICAL CONDITION]. Recommendations were 1) individual and family supportive counseling. 2) Follow-up regarding her concerns about her feet and walking. Confirmed by S41 that there were no other psych consults in record. On 02//01/19 at 09:05 AM, S66 stated there was a period that she was sitting in the wheel chair and sitting at the end of the bed and then she refused. (Reference F676). R41 refuses to get out of bed except to shower. Interview with S11 on 02/01/19 at 09:35 AM who stated she declined sitting at the edge of the bed. Behavior monitor form (BMF) was reviewed and showed that R41 is on [MEDICATION NAME] 25 mg for depression. Targeted behaviors for [MEDICATION NAME] was 1) calling out for help and 2) stating no one comes in to check on me. The targeted behavior for refusing care and treatment was identified on the care plan but not recorded on the behavior monitor form. 3) During an initial tour of the Wailani unit on 01/29/19 at 11:43 AM a loud banging/ pounding sound could be heard in the 400's section. The loud sound was coming from R70's room. Upon entering the room, R70 was observed to by laying supine in the bed across the middle with her feet dangling off the mattress. Her hair was disheveled and she appeared to be hitting a pad that was attached to the wall with her right hand. She looked up and shouted, get out of here! During an interview with Certified Nurse Aide (CNA) 32 on 01/29/19 at 11:55 AM she stated that R70 is not very happy this morning. She won't let the janitor into her room to clean. I think it is the progression of the disease that's causing her to be this way, she didn't used to be like this. Shortly after the interview a loud crash was heard coming from R70's room and loud garbled yelling was heard coming out of the room. Breakfast food (eggs) and a plastic dish with silverware were on the floor near the bed. CNA32 stated, she threw her tray this morning. During an interview with Licensed Nurse (LN) 43 on 01/29/19 at 01:45 PM, surveyor asked about R70 and how her behavior was being managed. LN43 reported that we use [MEDICAL CONDITION] as a last resort and try to use other methods like comfort care, food or positioning first to address the agitated behaviors. Nursing note dated 01/28/19 at 04:36 PM was reviewed. Staff reported R70 having increased angry outbursts, increase in anxiety, increased episodes of throwing things on the floor, easily gets upset and very needy. She threw the melanine plate this AM in sun room. R70 has increased confusion, demands things. Review of the behavior monitoring forms dated 01/26/19 to 01/29/19 that revealed non-pharmacological interventions were implemented. Provided 1:1, active listening, positive distraction, help resident become more comfortable and validation, reassurance/safety, nursing assessment for physical needs. Documented outcomes were improved and no change. 4) During an observation on 01/30/19 at 09:30 AM, R20 was sitting in her wheelchair (W/C) in the activity room restless, fidgeting, moving around in her chair, yelling out mommy! mommy!, crying, wheeling around in her W/C looking up at the nurse with wide eyes, tears streaming down her cheeks, and facial color bright red. On 01/31/19 at 09:15 AM R20 yelling out, crying with tears streaming down her cheeks, her face bright red and her sweater tightly bunched up in her left hand and pulled up on her chest exposing her left bare breast. During an interview with RN100 on 01/31/19 at 09:20 AM she stated to the surveyor, we don't use [MEDICAL CONDITION] until its the last resort. Nursing notes dated 01/26/19 at 07:45 AM R20 woke up around 04:00 this AM. Continues on [MEDICATION NAME] 150 mg every night for [MEDICAL CONDITION]. R20 was yelling and screaming out loud towards end of this shift. As of this note, resident sitting up in W/C, intermittently talking out loud. 5) Record Review (RR) on 01/31/19 reveals R33 was an [AGE] year-old female, who has moderately impaired cognition r/t Dx of [MEDICAL CONDITION] and late effect of [MEDICAL CONDITION]. (stroke). There was a Minimum Data Set (MDS) for significant change for R33 dated 08/23/18 that included the following: Verbal behavioral symptoms directed toward others, occurred 4 to 6 days Significant interference with the resident's care Put others at significant risk for physical injury Significantly disrupt care or living environment Residents behavior of rejection of care necessary to achieve goals for health and wellbeing occurred 4 to 6 days. The current behavior status, care rejection was marked Worse compared to prior MDS assessment dated [DATE]. The MDS significant change assessment dated [DATE] and quarterly assessment dated [DATE] Section I, Active [DIAGNOSES REDACTED]. RR of R33's comprehensive care plan initiated on 04/18/12 revealed the following Behavior Problem: a hx of being accusatory to staff and other residents. (e.g. saying hurtful things to caregivers and other residents), being verbally abusive and striking out at staff when she is angry or upset. Established goal was, R33 will be cooperative with care and not strike out at caregivers during caregiving tasks, and not be verbally abusive . Individualized nonpharmaceutical interventions/approaches were implemented at that time to address R33's behavior The facility failed to evaluate the effectiveness and revise R33's care plan after a significant change in her behavior and failed to investigate the underlying cause of R33's depression and aggressive behavior which led to three incidents of physical aggression toward CNAs, and ongoing rejection of medications and necessary care. (refer to tag 657) RR of IDT Social Service (SS) notes dated 08/29/18, which stated, . resident did express that she is depressed due to her health status. Resident was agreeable to consultation with Psychologist (P). During an interview with SS83 on 02/01/19 at 11:12 AM, discussed the IDT SS notes dated 08/29/18, and she stated, I attended the IDT meeting after the significant change and those are my notes. Asked SS83 if R33 attended, and she replied, Yes .her daughter was there also. Her daughter suggested her mother may benefit from a psychiatric consult. On 08/31/18 the care plan Psychosocial Well-Being problem was revised to include: Resident has a dx of Depression, her psychosocial well-being is at risk due to her declining health. When resident is not feeling well, resident often refuses to get out of bed. Approach was documented as follows, Observe need for psychological/psychiatric services. Provide for these services if agreed upon by resident/responsible party and ordered by physician. On 09/04/18 Registered Nurse (RN)41 documented in nurses notes she informed daughter R33 refused to see P. Entry was, POA (Power of attorney) updated regarding visit with Psychologist yesterday. On 09/10/18 Progress note by Dietitian 21 documented refused to talk to P. There was no additional documentation available regarding status of referral to P. On 11/21/18 Associate incident report form completed by Certified Nursing Assistant (CNA)36, documented R33 combative during shower, scratching and holding aid by the wrist-made verbal threats. On 11/23/18 R33's behavior care plan updated entry, R33 can be physically and verbally aggressive during shower time. Care Plan goal added was: R33 will not harm caregivers daily when taking a shower through the next review. This was the only revision to the behavioral care plan since it was initiated on 04/18/12. On 11/27/18 Associate incident report form completed by CNA26, documented, .she (R33) punched me. Resident hit my right chest with her right hand. Supervisor's (RN114) report dated 01/28/19 described incident as follows: CNA was providing care on R33 .when resident turned to L side, resident punched CNA to R chest area, without any reasons. Resident has hx of being physically aggressive to staff. During interview on 02/01/19 at 09:43 AM with SS49, asked what follow up occurred after CNA incidents 11/23/18 and 11/27/18. I talked to R33 but did not document it. Asked if a significant change would be reflected in the care plan, and she stated, Yes, it should be. At the time I reviewed it and felt the care plan was still applicable. Reviewed R33's care plan with SS49, who validated the behavior problem was initiated 04/10/12 with one revision dated 11/23/18. On 02/01/19 at 10:17 AM during interview with MD1, discussed R33's aggressive behavior and incidents with CNA's. Inquired if she had been notified, and MD1 stated, No, I was not aware. Hitting behavior new to me. Usually they notify me, so not sure why that didn't happen. Asked if MD1 was open to psychiatrist referral and she replied, Yes, I am always open to referrals. There were no additional psychiatrist referrals documented or attempts for R33 to see a referral for accurate [DIAGNOSES REDACTED].