Every finding on record at Hale Kupuna Heritage Home, LLC

Based on Observation, interviews and record reviews. The facility failed to provide supervision based on the individual resident's assessed needs and the risks identified in the environment to prevent accidents for three of three Residents (R) 7, R5 and R54. The deficient practices resulted in falls with major injuries for two (R5 and R54) of three residents sampled for free of accident hazards/supervision/devices, and an injury for one resident, R7. Findings Include: Cross reference to F725 sufficient nursing staff. Observation and interview with R7 sitting in a chair at the dining room table on [DATE] at 11:14 AM in the dining area on C wing. Observed an adhesive bandage on top of his head. Asked R7 what happened to his head. R7 said he fell in the bathroom last Saturday and went to the emergency room (ER). R7 added that they did all the tests and he passed but he is still having some pain. Asked if he is taking any pain medicine for his head and R7 replied that he is currently having some pain and the nurse is preparing his medications. Asked if he had any falls before that and he said yes, he had a couple of falls. Observed with a walker next to him. He said he can only walk with a walker. Observation on [DATE] at 12:50 PM in the C wing dining table, observed R7 without the bandage on top of his head. Observed a large circular purple area of his skin that looked like a bruise. Also observed an excoriation to his right upper cheek.R7's Electronic Health Record (EHR) reviewed on [DATE]. Care plan reviewed. Focus: The resident has had an actual fall: [DATE] unwitnessed fall-head pain, right lateral pain, right ear bruise. [DATE] unwitnessed fall - bruising to back and toe abrasion. [DATE] unwitnessed fall slid out of bed (OOB) reaching for urinal no injury. [DATE]: unwitnessed fall in bathroom abrasion and hematoma to top of head.Health Status Note [DATE] 12:08 At 1045, R7 had an unwitnessed fall in the bathroom. R7 stated he was attempting to adjust his bottoms and walking with front wheel walker (FWW). Resident was found on the right side of his body, stating that he hit his head. Noted two abrasions to top of head. Left lateral abrasion measures 1.5 centimeters (cm x 0.5 cm with small amount of serosanguineous (bloody) drainage and medial abrasion measured 1 cm x 0.1 cm without any drainage. First abrasion with surrounding bruise and lump, measuring 2 cm x 1.5 cm. Lump noted to right lateral side of head, measuring 3 cm x 5 cm. This writer & two other nursing staff assisted resident up from the floor. Resident complained of (c/o) pain at 8/10 (on 0-10 pain scale) aching pain to head & nausea. As needed (PRN) ondansetron (medication for nausea) given. Notified physician.Received order to send resident to ER status post (S/P) unwitnessed fall & altered mental status (AMS). Emergency services contracted at 1120 & arrived to facility at 1150. Left facility at 1155 with paramedics.Registered Nurse (RN) 33 interviewed on [DATE] at 10:23 AM. Asked RN33 if she was aware of R7's fall that occurred on [DATE]. RN33 said she was working in the morning. The fall happened at 10:45 AM in the bathroom. It was one of the housekeepers that let her know that R7 had fallen. He was found on his right side in the bathroom on the floor, his pants and underwear were on his thighs and his door was closed, he usually will pull the call light string, but he didn't do that. We saw him on the floor, did his neuro checks, his walker was lying on the ground, and his belongings were on the ground. Me and the Certified Nurse Aide (CNA) helped get him off the ground. He sustained injuries on top of his head. He complained of pain to his head and had nausea. He had rubber slippers on. We assisted him up. He wanted to lie down. I notified the staff managers and the doctor; he said to send him out. He had nausea, he sustained two bruises on top of his head and left lateral side, applied first aid, and a lump by his left lateral abrasion and another bump on his right lateral side. Prior to that he had a fall the month prior. Since this fall, he has been having more weaknesses. We encourage him to use his walker. If he gets weaker, he uses his wheelchair. It was the housekeeping staff that heard him saying help me, help me. He was on the ground. The call light is mounted on the wall by the toilet, and he was by the door. I do think he needs more supervision. He is good with his walker but since the fall I noticed he is on the weaker side. 2) R5 was interviewed on [DATE] at 11:43 AM on the D wing in the activity area. Asked R5 if she had a fall in the facility. R5 stated that she fell in October of 2025. R5 explained that she tried to stand up in her new wheelchair and fell on her face. R5 said that her niece is a retired physical therapist, (PT) and she said it shouldn't have happened. It happened at night; the CNA was in the room helping the other resident.I had 8 staples in my head when I had the fall. Fall should not have happened. My sister was so angry. I think it was because of short staffing. EHR reviewed on [DATE]. R5 is a [AGE] year-old female with diagnosis that includes Dysphagia, History of falling, generalized muscle weakness. admitted to the facility on [DATE].Minimum Data Set (MDS) sig change assessment with an assessment reference date (ARD) of [DATE] reviewed. R5 was coded with 1 fall with major injury. The previous assessment with an ARD of [DATE] (before R5's fall) was reviewed and compared with the assessment on [DATE]. R5 showed a decline in eight of the ten areas measured in GG0170, Mobility. Progress notes reviewed on [DATE]. Resident fell from wheelchair on [DATE]. Was sent out to ER for evaluation and treatment. Health Status Note dated [DATE] 01:30. R5 was found on the floor by the CNA and Charge Nurse (CN 5) at 2355. She was face down in a push up position. She stated that she had stood up from her wheelchair and was not expecting it to be so high, because she had received a new wheelchair. She was helped up by two staff members to her wheelchair and neuro checks were initiated . Assessed for injuries and found approximately a two-inch laceration that was actively bleeding. R5 was assisted into her wheelchair by the Charge Nurse (CN) and CNA, and pressure was applied to her laceration with contusion forming on the left side of the face, left eye, and left cheek. Note text: ER notes dated [DATE] .Diagnosis. Closed fracture of left maxillary sinus. Closed fracture of left orbital floor, scalp laceration, and closed head injury.Note text: [DATE] 11:55. Back to facility around 0930 AM resident vomited x 3 on the way back. Left (Lt.) eye surrounding area with bruise 4.5 x 3 cm, and swelling noted. Lt. scalp area with laceration (7 cm long), with 8 staples with dry blood. Bruise to Lt. outer base of Lt. ear 3 x 5 cm.CNA45 was interviewed on [DATE] at 10:37 AM. Asked CNA45 how long she has worked at the facility and if she was working when R5 had a fall. CNA45 said that she has worked at the facility for 1 year as a CNA. I was working on the night shift. I was doing my rounds, and I was in the room with her neighbor and the curtain was closed. I heard the fall and opened the curtain and then I got the nurse. R5 was face down on the floor. 3) Facility reported incident reviewed. R54 was Found on [DATE] on the floor on the B wing of building 1 at 1:40 PM. No shoes or socks and no walker present. Found lying on her right side, she said she was trying to go to the bathroom. X-ray results indicating resident had a fracture to the right hip. She had surgery on [DATE] and was admitted to the intensive care unit (ICU) due to low blood pressure. Received and reviewed the hospital reports on [DATE]. Resident went to the ED, underwent surgery for repair of a hip fracture. admitted to the ICU post-surgery for hypotension. Resident died on [DATE].Death Summary from the acute care hospital dated [DATE] at 3:07 PM reviewed. Expiration Date: [DATE]. The patient was pronounced dead on: [DATE] at 2:45 PM. Principal cause of death; acute respiratory failure due to aspiration pneumonia. Reviewed R54's EHR on [DATE]. Orders reviewed: R54 was started on Quetiapine Fumarate (an antipsychotic medication) on [DATE]; and Mirtazapine (an anti-depressant medication) on [DATE]. Side effects of both medications include drowsiness, dizziness, and low blood pressure upon standing.Care plan reviewed: Cross reference to F656. Fall history: two falls in the facility on [DATE] and [DATE].Alert Note Focus: Date: [DATE] 22:21:11 Note Text: At 1340, R54 found on the floor. Stated was trying to go to the bathroom when she fell. Fall was unwitnessed. Complained of 10/10 right hip pain with movement. Unable to bend right leg. Taken to the ER at 2:30 PM. Resident diagnosed with right hip fracture and will be admitted .Final Investigation Summary and Determination received reviewed on [DATE].The fall occurred while the resident attempted unsupervised ambulation without her walker.the care plan had not been updated to fully reflect the resident's current needs related to consistent walker use. Additionally, staff did not fully adhere to the existing care plan interventions regarding availability and use of the walker at the time of the incident.Final Determination.The unwitnessed fall with right hip fracture is considered a contributing event that exacerbated overall medical decline but was not the primary cause of death.Interview with RN 25 on [DATE] at 11:05 AM. RN25 said R54 was in the dining room during lunch, I believe R54 stood up and started walking. She was in the B wing dining room. I believe it was an unwitnessed fall. The kitchen staff was in the portable kitchen. One staff member was providing care in the bathroom, and the CN was called to assist another resident. Asked if R54 needed close supervision, RN25 said yes, line of sight, having the resident always in your vision because she would suddenly stand up without warning and she was unsteady and she needed someone there when she was walking. Asked her if there were enough staff to provide close enough supervision for the residents who need it. Usually there is another CNA but at that time she was helping with lunch. The dining staff were in the kitchen, and the Charge nurse had to leave briefly for something else. I think she needs standby assistance when she is walking with her walker because sometimes, she gets tired and might get weak. Interview with RN50 on [DATE] at 11:19 AM. Staff put R54 in the dining area in front of the nurse's station on the B wing watching the television (TV). I was sitting at the nurse's station documenting and got called away on the A side. RN50 said she was in another resident's room. When she was walking back to the nurses station and the kitchen staff notified her that R54 fell, and she was laying on her side I had asked the kitchen staff if she saw what happened, she said no, she saw her on the ground and she called for help and I checked her vitals, she had pain, her left leg or right leg. R54 couldn't bend her right leg without severe pain. I called the management and said I needed help, said R54 fell and she couldn't get up, they told me to call the ambulance. I got her paperwork and notified the on-call position. Shortly after Emergency medical services (EMS) came, they used a special transfer lift to get her up and she was in a lot of pain. She was alert and verbal and talking, she said she was cold and she said she was on the floor for 15 minutes before she could get up. I didn't even know the outcome and had to ask about her and found out she had expired.Asked RN50 what level of supervision did R54 needed since she was a fall risk. She needed eyes on her in case she tried to get up. It just so happened that I had to walk away at that time, it was unfortunate. It gets busy, and it gets stressful in that building. We always need more staff on that side because the staff are always on the A wing helping those Residents who need it. We keep asking for more help and continue to be short staffed. We need more staff for that B wing.Fall prevention and management program guidelines policy undated. Reviewed on [DATE].Fall Prevention and Management Guidelines Objectives: Reduce falls, minimize injuries, and ultimately improve the quality of life of resident through appropriate fall management.Minimize the severity of injuries sustained by the resident resulting from a fall.

Based on observations, interview, and policy review, the facility stored items in the walk-in refrigerator that were past the expired date; an open container was not labeled with an open or expiration date. The deficient practice placed residents at risk for foodborne illness. Findings include: Brief tour of the kitchen on 03/09/26 at approximately 09:15 AM. In the walk-in refrigerator, observed a clear plastic container of hot dogs with a prep date of 03/02/26 and an expiration date of 03/08/26 and an open container of yogurt about 1/3 full without a label. Interviewed the cook (5) at 09:25 AM. Asked the cook5 to verify the items found in the walk-in refrigerator to determine if they were expired. The cook5 pulled the hot dogs and the yogurt from the walk-in and discarded them saying they should have been thrown away. Observation in the walk-in refrigerator on 03/11/26 at 11:15 PM revealed a clear container of mayonnaise labeled with an expiration date of 03/09/26. Asked the Dietary Aide (DA) 2 to check the expiration date. Verified with DA2 the mayonnaise had expired on 03/09/26. The DA2 removed it from the walk-in refrigerator and discarded it.The Dietary Manager (DM) was interviewed on 03/11/26 at 11:35 AM in the kitchen. Discussed the findings in the walk-in refrigerator on 03/09/26 during the brief initial tour with Cook5. The hot dogs that were expired in the walk-in and the open container of yogurt didn't have a date and opened. Confirmed the findings in the kitchen with the Food Service Director (FSD) on 03/11/26 at 11:40 AM. Food and Nutrition Policy dated 10/01/24 was reviewed. Food Storage and Labeling Policy stated it is the policy of the facility that all food and non-food items shall be stored separately and appropriately to provide product integrity and safety. Food items shall be properly labeled and dated. Procedures: The Director/Manager of food & nutrition is responsible to 4. d. Refrigerators, reach-in coolers, and walk in coolers iv. Review inventory weekly and as needed and discard old foods .Foods opened have a use by date and must be identified. If not in packaging that identifies a use by date.

Based on observation and interview, the facility failed to serve food at a preferable temperature for one lunch tray sampled. The foods that were to be kept cold were not served at the preferred temperature of 40 degrees Fahrenheit. The deficient practice may affect good nutrition and hydration status to help prevent, or aid in the recovery from, illness or injury. Findings include:Observation and interview with Resident (R) 7 on 03/09/26 at 10:30 AM. Asked how the food at the facility was. R7 replied, that some dishes are better than others. It, depends. Alot of the time the food tastes bland. Observation and interview with R5 on 03/09/26 at 12:05 PM. When asked how the food was, R5 said, the food is bland and sometimes the food is late. Observation and interview with R25 on 03/09/26 at 12:32 PM. R25 said the food sucks. It doesn't have any taste. The meatloaf is good but the fish and the chicken sucks.A test tray from the tray line was requested on 03/11/26 at 12:15 PM to taste the food and check the temperatures. Temperatures of the foods on the tray were checked with Dietary Aide (DA)12. The beets and mayonnaise salad temperature was checked at 69 degrees. DA12 said that it should be served at a temperature of 40 degrees Fahrenheit. A second container of the beets and Mayonnaise were checked at 69 degrees Fahrenheit. Discussed the temperature of the beets and mayonnaise salad with [NAME] (7) on 03/11/26 at 1:45 PM. She explained that she prepared the beets and mayonnaise and kept them in the cooler and thought maybe they became too warm while inside the warmer with the other trays when transported to the unit for the lunch distribution.

Based on observations, interviews and record reviews, the facility failed to assure that there were sufficient numbers of qualified nursing staff available in areas of the facility where vulnerable residents with high fall risk reside, to provide the supervision needed to promote safety and prevent unwitnessed falls for two of three residents (Resident (R) 7 and R54) sampled for Accident Hazards/Supervision/Devices and sufficient nurse staffing. The deficient practice resulted in pain, hospitalization and decline in function due to injuries that resulted from the falls. Cross reference to F689 Free of Accident Hazards/Supervision/Devices. Findings include: Observation on 03/09/26 at 08:45 AM. The facility has two buildings (1 and 2) each with two wings where the Residents reside. (A & B and C & D).R54 had an unwitnessed fall on the B wing on 02/06/26, that resulted in a hip fracture, transfer to the emergency room (ER) for evaluation and surgery to repair the right hip fracture. The daily schedule assignments for Friday 02/06/26, were reviewed. One licensed nurse worked from 06:30 AM to 7:00 PM in building 1 (covering both the A & B wings); and one Certified Nurse Aide (CNA) worked from 06:00 AM to 2:30 PM on the B wing at the time of R54's fall. One charge nurse and one CNA was assigned to float between buildings 1 and 2. It was reported by staff during a confidential interview that there was no nursing staff present on the B wing at the time of R54s fall. The kitchen dining staff found R54 lying on the floor and informed the nursing staff about the fall. Cross reference to F689.R7 had an unwitnessed fall in the bathroom on 03/07/26, that resulted in a head injury and transfer to the ER for evaluation and treatment. Cross reference to F689. The daily schedule assignments for Saturday 03/07/26, were reviewed. One licensed nurse worked from 06:30 AM to 7:00 PM in building 2 (covering both the C & D wings); and one CNA worked from 06:00 AM to 2:30 PM on the C wing at the time of R7's fall. One CNA was assigned to float between buildings 1 and 2. Total CNAs per wing was 1.5. Random observations in the two buildings on 03/09/26; 03/10/26; 03/11/26 in the morning and afternoons. Observed one or fewer staff and residents present on A & D wings. Observed increased resident activity on the B & C wings.R29 was interviewed on 03/09/26 at 10:37 AM and stated sometimes it takes a long time for staff to come answer the call light, especially when I have to use the bathroom. If I use call light it might take 20 minutes or more. When I'm out in the activity area staff aren't around so I need to use the bell or wait for them to come around. During a Resident Council meeting on 03/11/26 at 11:06 AM, R7 said he fell down on Saturday and had to yell for help. He said at the time it took 10 to 15 minutes for someone to come to help. Another resident added that she heard R7 yelling from the bathroom and had to go find someone to help him. There was no nursing staff immediately available to help him. Payroll Based Journal (PBJ) Data Report CASPER Report 1705D FY quarter 1 2026 October 1 - December 31 reviewed on 03/09/26. Metric: Excessively Low Weekend Staffing result: Triggered. Definition: Triggered = submitted weekend staffing data is excessively low.Facility Assessment approved dated 03/02/26 reviewed on 03/11/26. Services and care we offer based on our residents' needs .Mobility and Fall Prevention. Specific Care or Practices: Monitoring and Supervision .Enhanced supervision protocols are implemented for residents identified as high risk, particularly during shift changes, toileting, or nighttime hours.

Based on observations, interviews, and record review, the facility failed to ensure that its response to a Resident Council grievance was implemented and sustained in practice for one of four identified concerns. The Resident Council requested that the daily menu boards in the units be updated regularly to reflect current meal offerings. Although the facility developed action plans in response to the grievances, the facility failed to implement and sustain the interventions, resulting in menu boards that were not updated timely, or accessible to residents on a consistent basis. The deficient practice affected the resident's ability to make informed choices about their meals. Findings Include: On 03/09/26 at 10:49 AM, observed the posted daily menu in the building 1, B Wing. The breakfast and dinner menus posted were not updated. The lunch menu was not posted in the designated area but was found on a side table in front of the menu board and reflected a turkey sandwich for the previous day (03/08/26). Additionally, the A Wing did not have a menu board to post the daily menus.On 03/09/26 between 11:33 AM and 12:14 PM, multiple resident interviews (R42, R6, R21, and R4) revealed residents were unaware of the lunch meal for that day. R42 stated she was hungry and waiting for lunch but did not know what would be served, stating probably turkey something. Other residents similarly reported they did not know the meal being served.Record review of the facility's planned menu indicated lunch for 03/09/26 was meatloaf with gravy, steamed rice, mixed vegetables, and chocolate pudding.The resident council agenda and minutes for the months of November 2025, January 2026, and February 2026 were received and reviewed. Review of the minutes in November 2025 and January 2026, the resident's stated concern regarding the menu boards were not being updated regularly. In November 2025, the residents requested timely menu updates, with follow-up consultation with the Dietary Manager (DM). In January 2026, the residents reported that the menu boards continued to not be updated regularly. The facility documented a plan, from the Administrator and the DM, for nursing staff to update menu boards the night prior and indicated that nursing staff had been educated.On 03/11/26 at 11:06 AM, during a group interview with Resident Council members (R46, R5, R1, R4, R21, and R7), the residents reported the menu boards continued to not be updated. R5 stated, sometimes it's changed and sometimes it's not. R46 reported needing to hound staff to update the menu boards. R46 stated she had suggested the facility do it the night before. The residents said when the menus were not posted, they had to ask the staff what was going to be served, and not all of the residents were able to ask.On 03/11/26 at 12:16 PM, an interview was conducted with R4 who reported that staff do not inform her of the daily menu. She stated she is aware of a daily menu board located in B Wing; however, she rarely goes to that area (R4's room is in A Wing) and therefore does not check it.On 03/11/26 at 12:29 PM, an interview was conducted with R40. R40 stated he was unaware of what was being served for lunch and typically finds out when the meal is provided. He reported that if he does not like the meal, he may choose not to eat it and instead request an alternative. R40 stated that the facility sometimes provides a weekly menu but assumes residents can read it. During the interview, R40 looked around his room to see if he had received a weekly menu but was unable to locate one. He also reported that a menu is posted in B Wing, however, he does not go to that area to review it (R40's room is in A Wing).On 03/12/26 at 08:37 AM, observation revealed the menu boards in Building 1, B wing, were not updated, displaying menus from the day before on 03/11/26.On 03/12/26 at 09:03 AM, an observation was conducted in Building 2. A menu board was observed in C Wing for posting daily menus, however, no menu board was observed in D Wing for posting daily menus. On 03/12/26 at 09:08 AM, an interview was conducted with Registered Nurse (RN) 11. RN11 reported she updated the menu board in Building 2 early that morning after noticing it had not been done. RN11 stated that dietary staff are responsible for posting the daily menus.On 03/12/26 at 09:56 AM, an interview was conducted with the Social Worker (SW). TheSW stated that when residents express concerns during Resident Council, she documents them in the meeting minutes and initiates a grievance. SW reported she has created grievances regarding menu boards not being updated regularly in the buildings. SW emphasized the importance of residents knowing the daily menu, stating it is a resident right and that she would also want to know what meals are being served in advance.On 03/12/26 at 10:24 AM, an interview was conducted with the Administrator. The Administrator stated he had issued a directive for nursing staff to update menu boards the night before. When asked whether there was documentation confirming that nursing staff received this directive, the Administrator stated that directives are typically not documented.Review of a grievance form dated 11/18/25 documented that R46 reported during a Resident Council meeting that menu boards were not being updated. R46 requested that menus be posted the day before so residents would know the meals in advance. The facility's action plan indicated dietary staff would update menus and that menu boards would be posted on both wings of each building.Review of a grievance form dated 01/20/26 revealed that during a Resident Council meeting, R46 again reported that menu boards in the buildings were not being updated regularly. The facility's action plan stated the Administrator would work with nursing staff to ensure menu boards are updated the night before for the following day. The Dietary Manager was also noted to be aware to ensure accurate menus are available for posting.Staff were unable to identify whose responsibility it is to update the daily menu boards or demonstrate awareness of the Administrator's directive during the following interviews conducted on 03/12/26:At 10:36 AM, Certified Nurse Aide (CNA) 15 stated that housekeeping staff or dietary aides were responsible.At 10:38 AM, Dietary Aide (DA) 12 stated that housekeeping staff were responsible.At 10:39 AM, Housekeeper (HK) 9 did not respond when asked; DA12 interjected and stated the Housekeeping Manager (HKM) was responsible.At 10:41 AM, HKM stated dietary staff are responsible for updating menu boards, but she occasionally assists if it is not completed.At 10:50 AM, the Dietary Manager (DM) stated she prints the daily menus and is responsible for posting them in the buildings. DM acknowledged that the menu board in Building 1 was not updated timely on 03/12/26.At 10:54 AM, during a follow-up interview, RN11 confirmed that dietary staff, not nursing staff, are responsible for posting daily menus in the buildings.

Based on observation, interview and record review, the facility failed to ensure the staff followed infection control and prevention measures while providing care for residents. Staff observed not performing hand hygiene as meals were being served to seven residents. This deficient practice placed the residents at risk for the potential spread of preventable infections and other adverse health complications. Findings Include:On 03/09/26 at 12:03 PM, observed Dietary Staff (DS) 3 bring the meal cart to the unit. Seven residents were in the common area and were waiting for their lunch. DS3 opened the cart and pulled out a tray with the residents' meals. After placing all the food items and drinks on the table in front of the residents, DS3 went back to the cart and immediately pulled another tray for the next resident. DS3 was not observed performing hand hygiene as he served lunch for all seven residents in the common area.Review of facility policy titled Meal Service with an effective date of 01/05/26 reviewed. The policy stated, . Prepare the room or serving area for mealtime . and provide hand hygiene as appropriate . On 03/11/26 at 01:53 PM, an interview was conducted with the Infection Preventionist (IP) in her office. Shared with IP the observations made of DS3 not performing hand hygiene as he passed the meals for seven residents on 03/09/26. IP confirmed that staff are to perform hand hygiene when moving from one resident to another to prevent possible spread of infections.

Based on record review and interview, the facility failed to provide proper notification of transfer/discharge for one of three residents sampled for closed records review. The facility did not send written notification to the office of the State Long Term Care Ombudsman (LTCO) when Resident (R) 53 was discharged . This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings Include:R53 was a [AGE] year-old resident admitted to the facility for short-term rehabilitation services following the removal of internal fixation device (metal implant used to stabilize broken bones). Diagnoses included but not limited to acute osteomyelitis and infection and inflammatory reaction due to internal right hip prosthesis. Review of Electronic Health Records (EHR) under Progress Notes revealed that R53 was discharged and placed under the custody of the police department on 11/05/25 for an out-of-state warrant of arrest. No documentation was found in the EHR of the facility notification to the LTCO. On 03/12/26 at 10:27 AM, an interview was conducted with the Regional Director of Operations (RDO) who was serving as the Administrator for the facility at the time R53 was discharged . RDO confirmed that the office of the State LTCO was not notified of R53's discharge from the facility.

Based on record review and interviews, the facility failed to implement the person-centered intervention to provide stand by assist in the care plan to prevent falls for one resident (R) 54 sampled for Free of accident hazards/Supervision/Devices Develop/Implement Comprehensive Care Plan. The deficient practice resulted in an unsupervised fall that resulted in a major injury which caused pain and suffering for the resident. Findings include:Cross reference to F689.Electronic Health Record (EHR) reviewed. R54 had an unwitnessed fall in building 1 on the B unit on 02/06/26, that resulted in a hip fracture, transfer to the emergency room (ER) for evaluation and surgery to repair the right hip fracture. Cross reference to F689.Care plan reviewed: Revision on 01/23/2026. Focus: The resident is at risk for falls related to debility, legally blind, congestive heart failure, Diabetes Mellitus, medication side effects and fall history. Prior to the fall on 02/06/26, R54 had two falls in the facility on 12/29/25; witnessed fall-fell onto buttocks while fixing clothing by mirror; and on 01/19/2026, guided fall off balance while walking. Goal: Resident will be free of falls through the review date. Target date 03/25/26.Intervention: Standby assist with ambulation. Updated 01/22/2026. Interview with RN 25 on 03/12/26 at 11:05 AM. RN25 verified that R54 had a fall that was unwitnessed and said R54 needs assistance because she would suddenly stand up without warning and she was unsteady and she needed someone there when she was walking. Interview with RN50 on 03/12/26 at 11:19 AM. Asked RN50 what level of supervision did R54 need since she was a fall risk. RN50 said that R54 needed eyes on her in case she tried to get up. It just so happened that I had to walk away at that time, it was unfortunate and the CNA was busy with another resident so there was no one there to assist her to get up. Final Investigation Summary and Determination received reviewed on 03/12/26.The fall occurred while the resident attempted unsupervised ambulation without her walker.the care plan had not been updated to fully reflect the resident's current needs related to consistent walker use. Additionally, staff did not fully adhere to the existing care plan interventions regarding availability and use of the walker at the time of the incident.

Based on observations and staff interviews, the facility failed to: 1 and 2) ensure food were stored and frozen food thawed in a manner that avoids foodborne illness to the residents and 3) perform hand hygiene when distributing food trays to residents. As a result of these deficiencies, the facility put the residents at risk for foodborne illness. Findings include: 1) On 09/03/24 at 09:42 AM, initial observation of kitchen, thawing individually wrapped salmon fillets in water in a sink. Inquired with Kitchen Staff (KS)2 about the thawing salmon. KS2 stated they are having miso salmon for dinner and confirmed the salmon has been in the water for about one hour. Requested for KS2 to take the temperature of the salmon and the internal temperature of a larger fillet was 62.8 degrees Fahrenheit (F). 09/04/24 12:00 PM Conducted and interview with [NAME] (Food service Director and Dietician) shared observation with her of staff defrosting salmon and salmon was 62.8 degrees F. [NAME] confirmed temperature is out of range and salmon will defrost quicker than 40 lbs of chicken. Stated she would in-service staff on proper thawing of frozen foods. 2) On 09/03/24 at 09:38 AM, observed a scooper in the thickener container. Kitchen Manager (KM) confirmed the scooper should not be stored in the container. During an interview with the FSD ([NAME]) confirmed the scooper should not be stored in the same container as the product. 39754 3) On 09/03/24 at 12:15 PM, during observation of lunch on the Makalapua Unit, Manager 5 did not perform hand hygiene after removing gloves. Manager 5 proceeded to distribute lunch trays to three residents and did not perform any hand hygiene between or after the distribution of the trays. Staff interview on 09/04/24 at 12:00 PM, Administrator acknowledged that hand hygiene should have been done during distribution of lunch trays.

Based on observation, interview and policy review, the facility failed to ensure staff followed the Infection Prevention and Control policies and procedures for proper use of personal protective equipment (PPE) to follow proper infection control practices. Staff working with residents on isolation precautions did not correctly doff (remove) their PPE after providing care to Covid-19 positive residents in both resident care units in the facility. The same staff were also caring for residents who were not Covid-19 positive. The deficient practice places all residents in the facility at risk for healthcare associated infections that can result in significant adverse consequences. Findings include: Facility matrix and Electronic Health Record (EHR) reviewed. Resident (R)13 is a resident in room D3 documented with Covid-19 and on isolation precautions. A second Resident in room D2 was on transmission-based precautions due to an exposure to Covid-19. A third Resident, R33 in room B1 was documented Covid-19 positive and is also on isolation precautions. Observation on Makalapua unit on 09/03/24 at 10:43 AM. Observed Certified Nurse Aide (CNA)15 walk into room D2 wearing personal protective equipment (PPE), face shield, mask, gown, and gloves. A few minutes later CNA15 walked out of D2 still wearing the PPE and walked into room D3. A minute later CNA15 walked back out of room D3 and walked back into room D2 wearing the PPE. A few minutes later CNA15 walked out of D2 and doffed (removed) her PPE in the hall and walked into D3 and put it in the trash. Observation and interview with Registered Nurse (RN)25 on 09/03/24 at 11:00 AM. RN25 came out of D3 and approached the surveyor. The surveyor asked RN25 what is the process for donning (put on) and doffing PPE for the residents are on transmission-based precautions. RN25 said the staff don the PPE outside the room, then after they go into the room and provide care, they doff the PPE inside the room, and throw it in the trash bins in the room before going outside. When asked why the staff doffed the PPE outside of the room, RN25 said, we didn't have a bin in the room to throw away the PPE. During an observation and interview in R33's room on 09/05/24 at 11:15 AM with CNA20, this surveyor was preparing to exit the room and asked how to doff the PPE. CNA20 said take-off gloves, gown, and face shield but you don't need to remove the N95, you don't need to change that one. Surveyor asked CNA20, I don't need to change my mask? CNA20 stated, only the gown, gloves, and face shield. Interview with the Infection Preventionist (IP) in an office in the Ilima building on 09/06/24 at 10:35 AM. The surveyor discussed the observation on 09/03/24 when the CNA15 came out of room D2 wearing full PPE, then was observed to go into room D3 and come out with the PPE still on and then go back into room D2 then leave the room and doff PPE outside the room. The surveyor asked the IP if staff are required to change the N95 when doffing the PPE? The IP confirmed yes that the staff are required to Doff all the PPE (including the N95 mask) prior to coming out of the room. Infection Prevention and Control Program 2001 MED-PASS, Inc. (Revised August 2016) reviewed. 7. Prevention of Infection. a. Important facets of infection prevention include: (3) educating staff and ensuring that they adhere to proper techniques and procedures; .

Based on interviews and record review, the facility failed to ensure the resident's right to be informed of the risk and benefits of proposed care for one Resident (R42) sampled. R42 had a decline in cognition due to the resident's health status. R42's cognition was not re-assessed for the resident's capacity to consent to medication(s)/treatment. The resident signed a consent for the use of antidepressant and antipsychotic medications. As a result of this deficient practice, residents with changes in condition which affect the resident's ability to understand the information required to make an informed decision are at risk for the potential of harm. Findings include: Review of the facility's policy and procedure, Psychotropic Medication (Original Effective Date 05/01/2021), use of documented, 5. Residents and/or representatives shall be educated on the risk and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. R42 was admitted to the facility on [DATE] with diagnosis which include hemiplegia and hemiparesis of the left dominant side after an intracranial hemorrhage, epilepsy, hypertension, and cognitive communication deficits. Conducted a review of R42's Electronic Health Record (EHR). Review of the R42's physician orders documented orders for an antidepressant, Lexapro (escitalopram oxalate) tablet; 10 mg PO (by mouth) daily at 08:00 AM, ordered on 04/12/24, for depression, and an antipsychotic, Quetiapine (Seroquel) tablet; 25 mg PO at Bedtime 09:00 PM, ordered on 04/12/24, for restlessness and agitation. Review of the facility's Informed Consent for Psychotropic Medications for Lexapro and Seroquel documented R42 was unable to sign: verbal consent on 04/12/24 at 01:30 PM. The form was filled in by Registered Nurse (RN)109. Review of the resident's submitted Minimum Data Set (MDS) documented: - Admission MDS with an Assessment Reference Date (ARD) of 11/21/23 documented Section C. Cognitive Patterns, the Brief Interview for Mental Status (BIMS) score which is a test of the resident's cognition documented a score of 12, indicating the resident has moderate cognitive impairment. - Quarterly MDS with an ARD of 05/21/24, BIMS score was not completed - Quarterly MDS with an ARD of 08/08/24, BIMS score was 99, indicating the test could not be completed Review of R42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 08/08/24, Section B. B060. Speech Clarity, R42 has unclear speech- slurred or mumbled words; B.0700 Rarely/Never understtod or has the ability to express ideas and want both verbal and non-verbal expression. Review of a Nursing Home to Hospital Transfer Form on 08/3/24 at 06:52 AM documented, Patient cognitive status has changed with less ability to swallow secretions . Review of R42's progress notes documented the resident was sent out to the emergency room (ER) and/or admitted to the hospital a total of five (5) times since admitted to the facility: -02/06/24 at 11:12 PM, R42 was unresponsive. Emergency Medical Services (EMS) was activated, and the resident was sent to the emergency room (ER) via ambulance. (R42 was admitted to the Intensive Care Unit (ICU)) -02/07/24 at 03:16 AM, R42 will be admitted (to an acute hospital) for a Urinary Tract Infection (UTI) with sepsis (a life-threatening infection) and hypoxia (low levels of oxygen which could be life-threatening). -02/15/24 at 05:12 PM, R42 was admitted back to the facility. -03/02/24 at 10:35 AM, R42 went back to the ER and was admitted to the ICU at 10:58 PM due to unresponsiveness and rule out a cerebral vascular accident (CVA, stroke) -03/20/24 at 09:50 PM, R42 was admitted back to the facility -04/09/24 at 05:50 PM, R42 admitted to the hospital for seizures -04/12/24 at 03:34 PM, R42 returned to the facility -04/16/24 at 03:05 PM, R42 was drooling and unresponsive to sternal rub and verbal commands, sent to ER -04/16/24 at 08:21 PM, R42 returned to the facility -08/03/24 at 08:20 PM, R42 returned to the facility. -08/03/24 at 07:38 AM, R42 has a change in cognitive status with less ability to swallow secretions, sent to the ER On 09/05/24 at 01:41 PM, conducted an interview with the Administrator regarding R42's cognitive ability to consent and requested a copy of a physician's assessment of the resident's ability to consent. Administrator stated R42 usually makes his own decisions. Asked if R42 has a designated representative in the event the resident is not able to make any decisions for himself. The Administrator did not know if the resident had a designated healthcare decision maker/representative and would get back to this surveyor with that information. On 09/05/24 at 02:44 PM, the Administrator confirmed, on admission, R42 could make his own decisions, but the resident has been sent out to the acute hospital several times since his original admission and the resident's cognition has declined since then. The Administrator also confirmed R42's capacity to consent has not been reassessed by the physician. On 09/06/24 at 11:25 AM, conducted a concurrent record review of R42's EHR and interview with the [NAME] President of Clinical Operations (VPCO), the Director of Nursing (DON) (new to the facility), the Infection Preventionist (IP) (assisted previous DON), Regional Nurse (RRN)1 and RRN2. Reviewed R42's progress notes (in the EHR) and R42's decline in health status, decline in cognition, and the facility's Informed Consent for Psychotropic Medications form which was verbally consented to by R42 on 04/12/24. VPCO, RRN1 and RRN2 confirmed R42's health and cognitive status has declined and the resident's capacity to consent should have reassessed but was not.

Based on interviews and record review, the facility failed to ensure one resident (Resident (R)39) was free from resident-to-resident abuse. R20 willful and intentionally punched R39 while smoking with staff present. As a result of this deficient practice, R39 sustained harm due to physical contact. The facility investigated, implemented updated interventions for resident safety, educated staff, and counseled the residents. Past non-compliance was determined as a result of the facility's corrective actions. Findings include: Review conducted for the Facility Reported Incident (FRI) document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) #11078. Initial report was submitted to the Office of Healthcare Assurance on 07/10/24 and the completed report on 07/15/24. An altercation occurred when R39 requested to use R20's lighter and proceeded to take the lighter from R20's personal bag. R20 became upset that R39 was going into his personal bag and punched R39. Certified Nurse Aide (CNA)107 was present in the area, but not close enough to the residents to prevent R39 from being punched by R20. The residents were separated and R39 did not sustain a major injury. The facility corrective actions included but not limited to, immediately separated, and assessed the residents and conducted an investigation. Every 15-minute checks were implemented for both residents for 72-hours. Interventions implemented as a result of the altercation included both residents will not utilize the designated smoking area simultaneously throughout the day and each resident will have their own designated lighters which staff will provide to them during smoke breaks. CNA107 was permanently removed from the schedule due to failure to intervene in the resident-to-resident altercation. Facility staff were educated on the significance of separating residents during an altercation to prevent further escalation and to mitigate to potential of harm.

Based on interviews and record review, the facility failed to ensure an injury of unknown source was reported no later than 24 hours to the State Agency (SA) and Adult Protective Service (APS) for one resident (Resident (R)42) sampled. R42 sustained bruising to the left eyebrow and left eyelid. The source of the injury is unknown due to the resident's inability to verbalize what happened and it was not witnessed by staff. The facility confirmed the injury of unknow source was not reported to the SA or APS. Review of the SA's database, Aspen Complaints/Incident Tracking System (ACTS), confirmed the facility did not submit a report of R42's injury of unknown source. As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: (Cross Reference to F610 Investigate/prevent/correct Alleged Violations) Review of R42's Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with diagnosis which include hemiplegia and hemiparesis of the left dominant side after an intracranial hemorrhage, epilepsy, hypertension, and cognitive communication deficits. Review of R42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 08/08/24, Section B. B060. Speech Clarity, R42 has unclear speech- slurred or mumbled words; B.0700 Rarely/Never understood or has the ability to express ideas and want both verbal and non-verbal expression. A progress note written on 08/03/24 at 07:38 AM documented R42 was sent out to the emergency room (ER). A 08/03/24 at 08:24 PM confirmed upon returning from the ER, R42 had .no bruise . A nursing progress note written on 08/05/24 at 12:41 AM documented, Staff reported bruises to resident's left eyebrow and left eyelid measuring 2.5x2cm and 1x1.5cm respectively. Both are red. Unable to verbalize how he got the bruises. No verbal/non-verbal signs of pain/discomfort. MD response initiated. Review of an observation report (Skin Assessment) completed on 08/05/24 documented R42 sustained an eyebrow bruise 2.5 cm x 2 cm bruise and left eye 1 cm x 1.5 cm bruise to left eye. During a concurrent record review of R42's EHR and interview with the [NAME] President of Clinical Operations (VPCO), the Director of Nursing (DON) (new to the facility), the Infection Preventionist (IP) (assisted previous DON), Regional Nurse (RRN)1 and RRN2, on 09/06/24 at 11:25 AM, the IP confirmed the facility did not recognize R42's bruises on his left eyebrow and eyelid as an injury of unknown source and did not report it to the SA or to APS.

Based on interviews and record review, the facility failed to thoroughly investigate an injury of unknown origin to prevent further potential abuse for one resident (Resident (R)42). Staff reported bruises to R42's left eyebrow and eyelid and the source of the injury was unknown due to the resident's inability to verbalize what happened and the injury was not witnessed by staff. The facility did not identify the injury of unknown source as a potential for abuse of a vulnerable resident and did not investigate the potential source of the injury. As a result of this deficient practice, non-verbal and/or cognitive impaired residents are at risk for more than minimal harm. Findings include: (Cross Reference to F609 Reporting of Alleged Violations) Review of R42's Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with diagnosis which include hemiplegia and hemiparesis of the left dominant side after an intracranial hemorrhage, epilepsy, hypertension, and cognitive communication deficits. Review of R42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 08/08/24, Section B. B060. Speech Clarity, R42 has unclear speech- slurred or mumbled words; B.0700 Rarely/Never understood or can express ideas and want both verbal and non-verbal expression. A progress note written on 08/03/24 at 07:38 AM documented R42 was sent out to the emergency room (ER). A 08/03/24 at 08:24 PM confirmed upon returning from the ER, R42 had .no bruise . A nursing progress note written on 08/05/24 at 12:41 AM documented, Staff reported bruises to resident's left eyebrow and left eyelid measuring 2.5x2cm and 1x1.5cm respectively. Both are red. Unable to verbalize how he got the bruises. No verbal/non-verbal signs of pain/discomfort. MD response initiated. Review of an observation report (Skin Assessment) completed on 08/05/24 documented R42 sustained an eyebrow bruise 2.5 cm x 2 cm bruise and left eye 1 cm x 1.5 cm bruise to left eye. During an interview with the Administrator on 09/05/24 at 01:41 PM, requested the facility's investigation into the origin of the bruises staff reported on R42's left eyebrow and eyelid. During a follow-up interview with the Administrator at 02:44 PM, the Administrator confirmed the facility did not investigate how R42 sustained the bruises. During a concurrent record review of R42's EHR and interview with the [NAME] President of Clinical Operations (VPCO), the Director of Nursing (DON) (new to the facility), the Infection Preventionist (IP) (assisted previous DON), Regional Nurse (RRN)1 and RRN2, on 09/06/24 at 11:25 AM, the IP confirmed the facility did not recognize R42's bruises on his left eyebrow and eyelid as an injury of unknown source and did not conduct a thorough investigation.

Based on record review, staff interview and review of policy, the facility failed to provide written notice of bed-hold policy for one Resident (R)8 of two residents sampled. As a result of this deficiency, there was potential for miscommunication. Findings include: Review of the Electronic Health Record indicated that R8 was transferred to the hospital on 10/25/23 for low blood pressure, Urinary Tract Infection. Further review did not show any written notice of bed-hold policy to the resident and/or representative. During staff interview on 09/05/24 at 12:30 PM, Administrator acknowledged that the facility did not provide written notification of bed-hold policy to R8 and/or representative. Administrator also said that the facility had used other forms for discharge/written notification at that time when R8 was discharged . Review of facility policy on Discharge, Transfer of the Guest/Resident read; Purpose, to ensure safe departure from the facility, to provide sufficient information for continued care of the resident. Discharge, to leave the facility without plans or intention to return (e.g. discharge to home, a lower level of care or another care facility). Transfer, to leave the facility with plans or intention to return (e.g. transfer to an acute care facility for appropriate care). Procedure, explain discharge procedure and reason to resident and give copy of Transfer & Discharge notice / Bed hold policy as required. Include guest/resident representatives . Transfer . explain transfer and reason to the guest/resident and/or representative. Give copy of signed transfer or discharge notice to the resident and/or representative or person(s) responsible for care . Explain and give copy of Bed Hold form to the resident and/or representative . Documentation Guidelines, documentation may include . Complete Bed Hold notification form per facility policy .

Based on record review (RR) and interview, the facility failed to have written, in their policies and procedures, data collections systems, monitoring, adverse event monitoring, feedback from direct care staff and other residents and representatives, opportunities for improvement, established with the minimum qualifications that should be established. This deficient practice has the opportunity for minimum Quality Assurance and Performance (QAPI) measures to be missed. Findings include: Observation of the policy on 09/21/23 at 10:00 AM revealed an incomplete policy and procedure demonstrating information needed to guide quality assurance and performance improvement. A concurrent record review and interview was done on 09/22/23 at 10:43 AM with the administrator and the Director of Nursing (DON). The facility was able to show their Quality Assurance and Performance Improvement (QAPI) projects and improvement but could not speak to their policy which lacked the information to describe and guide the details of a QAPI program. Administrator stated that she did not have the information needed in the policy and that the facility would be working on it.

Based on observations and interviews the facility failed to provide sufficient nursing staff to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well being for four out of 15 sampled residents (Resident (R) 37, 22, 34, 36). The deficient practice has the potential to negatively effect all of the facility residents' physical, mental, and psychosocial wellbeing. Findings Include: 1) Concurrent interview and observation were conducted on 09/22/23 at 08:14 AM in the dining room. R37 verbalized that she had requested for her assigned Certified Nurse's Aide (CNA) 1 to take her back to her room a while ago, but CNA1 was nowhere to be found. R37 stated that it is very frustrating. CNA1 was then observed returning to the dining area to take one of the residents, R26, to the bathroom. R37 verbally requested to be taken back to her room after R26. CNA1 replied, okay. On 09/22/23 at 08:28 AM, R37 was observed still waiting in the dining room. On 09/22/23 at 08:34 AM, CNA1 was observed assisting R26 in the bathroom and ambulating him to his room. On 09/22/23 at 08:36 AM CNA1 was observed assisting CNA2. CNA1 and CNA2 were both ambulating R31 because R31 needed two staff assistance during ambulation. During that time both CNAs were in unit A. Therefore, unit B did not have a CNA available for the residents. On 09/22/23 at 08:43 AM CNA1 transported R37 to her room. 2 ) Interview was conducted with R22 in unit A on 09/22/23 at 11:57 AM. R22 was observed waiting for his lunch tray near a dining table. R22 verbalized that since he has been admitted into the facility three years ago, he always received his meals late. Breakfast is scheduled for 07:00 AM but receives his tray at 08:00 AM. Lunch is scheduled at 12:00 PM but he receives his tray at 01:00 PM. R22 added that it wouldn't be too bad if the delay was ten or fifteen minutes, but one hour is just too long because he gets very hungry. R22 believed that the lack of staff is the cause for the delay in the meal tray passing. 37229 3) On 09/19/23 at 12:00 PM, dining service was observed in Makalapua unit. It was noted on 09/19/23 at 12:08 PM, in Room C3 all residents in their beds sleeping. At 12:11 PM, still waiting for lunch and residents in C3 still in room sleeping. It was noted that certified nurse's aide (CNA) 4 and CNA 5 were the only staff prepping the trays to receive the main meal. At 12:13 PM a visitor for C4 arrives to see resident. At 09/19/23 at 12:15 PM, spoons being placed on trays for prepping. At 09/19/23 at 12:24 PM the two CNAs and kitchen worker prepare and complete food trays. At 09/19/23 at 12:29 PM, no trays served yet. At 09/19/23 at 12:30 PM first tray served. At 09/19/23 at 12:31 PM two more trays are served. At 12:45 PM, R145 received her food in isolation room and housekeeper passed tray to CNA after CNA gowned up. At 12:55 PM tray arrived. At 12:56 on 09/19/23, R34 was still in the room sleeping and surveyor did not see a tray offered or for the resident to get up to eat. 09/19/23 at 01:19 PM, an interview with Registered Nurse (RN)1 who was in C4 room - Asked if resident (R)34 eats and she stated that the CNAs are instructed to see if he wants to eat and if not put into the fridge. Explained that surveyor did not see any interaction with R34 and that the CNAs seemed very busy and passed him by and he did not get offered a tray. RN1 stated that she would check on it and did not get back to surveyor. Interview was done on 09/22/23 with CNA3 who stated that they were busy and got a late start. We were trying to get the residents nice and clean for you all and before you know it, it was time to do lunch. We did the best we could with, and we put R34's tray up but did not get back in time to get him up. Interview with Administrator who confirmed that R34 did not get up and his tray was on the table. R34 was the last resident to get a tray after an hour's time and did not get up out of bed to eat. (Refer F802). 4)The facility did not assure there was sufficient staff on a unit to prevent Resident (R)39 from wandering into R36's room. This deficient practice has the potential to result in unsafe wandering/resident-to-resident altercations. (Refer F689)

Based on record review and interview with staff, the facility failed to collaborate with the hospice provider for the development and implementation of the coordinated plan of care for one of one resident selected for hospice review. This is evidenced by the failure to include the hospice provider in the development of a plan of care and no consistent documentation of the hospice providers communication with the facility. Findings include: Resident (R)9 was admitted to the facility on [DATE]. Diagnoses include but not limited to unspecified dementia, unspecified severity, without behavioral disturbance; psychotic disturbance, mood disturbance, and anxiety; generalized anxiety disorder; and adult failure to thrive. R9 is a hospice recipient (start date of 04/14/23). Record review found no copy of the election of benefit for hospice with the resident's diagnosis to qualify for hospice and the services to be supplied by hospice provider. On 09/22/23 at 11:44 AM interviewed the facility's Director of Nursing (DON). Requested to review R9's election of hospice benefit. Inquired what services is hospice providing. DON reported their staff continue to round on the resident. DON recalled the resident does not receive hospice aide services and recalls R9 receives spiritual care. Further queried how often does the nurse and spiritual counselor come to visit R9. There were monthly notes by hospice, dated 05/02/23, 05/30/23, 06/27/23, 08/11/23, and 09/11/23. Also found progress notes in the electronic medical record (07/11/23, 07/18/23, 8/8/23, 08/11/23, 08/15/23, 08/22/23, and 09/05/23). DON stated hospice is making weekly visits. DON reported nurses are making entries in the progress notes to document their communication with the hospice provider. Reviewed the care plan with the DON. There was no documentation the hospice provider participated in the development of the care plan for 04/11/23 and 07/12/23. The care plan documents discipline responsible for R9's care as hospice; however, there is no documentation of the hospice providers participation in the care planning process. Review of the election of hospice benefits found physician orders for lorazepam 2 mg/mL; morphine PRN; morphine concentrate solution 100 mg/5mL twice a day for pain; call hospice for discomfort, symptom management, changes, questions, concerns, fall; call hospice at time of death; call hospice if no urine output x12 hours; and call hospice prior to accessing hospice e-kit. There was no documentation of the services/durable medical equipment the hospice would provide. On 09/22/23 at 12:05 PM interview was done with the Social Services Designee (SSD). SSD reported she is aware a nurse and volunteer come to visit R9. Also, she thinks the Chaplain provides services. SSD shared that previously the hospice social worker would coordinate with their facility to participate in care plan meetings, however, this person left and presently there is no hospice person to participate in care plan meetings.

Based on interviews and record review, the facility failed to provide the necessary care and services to ensure that one out of one sampled residents (Resident (R) 37) abilities in activities of daily living do not diminish. This failed practice has the potential to cause a decline in R37's mobility. Findings Include: R37 is a [AGE] year-old female admitted to the facility on [DATE]. R37 has a medical history that includes but not limited to Parkinson's disease. Interview was conducted with R37 on 09/20/23 at 11:51 AM in her room. R37 verbalized wanting to ambulate more often with a walker. R37 also added that she hasn't walked all week. Interview was conducted on 09/22/23 at 08:57 AM in the nursing administration office. State surveyor requested from the Director of Nursing (DON) R37's ambulation records. DON stated that R37 would not have any ambulation records because she was not cleared to ambulate with nursing staff. Interview was conducted with Physical Therapist (PT) in the rehabilitation room on 09/22/23 at 09:09 AM. PT confirmed that R37 was cleared to ambulate with nursing staff on 06/07/23 and staff should be attempting to help her ambulate. Interview was conducted with DON on 09/22/23 at 10:24 AM in the classroom. DON stated that the usual practice after PT discharges a resident from their services is to create a care plan. The care plan then triggers treatment. Certified Nurse's Assistant (CNA) will be triggered to perform the activity with the resident and CNAs will be able to chart into the records. Unfortunately, R37 did not have a care plan created for ambulation activity after she was discharged from rehabilitation services. A review of the Electronic Health Record (EHR) indicated that PT had discharged R37 on 06/06/23. In the discharge summary it stated, Patient will safely ambulate on level surfaces 100 feet using two-wheeled walker with Supervision or Touching Assistance with continuous steps to prepare for walk to dine for meals. EHR also indicated, Patient has met goals set and nursing has been educated on walking program .Discharge Instructions: see care plan. A review of the EHR indicated that R37 only ambulated eight times in the last month. EHR also indicated the lack of a care plan for R37's ambulation activity.

Based on observation, record review, and interview, the facility did not assure adequate supervision was provided to mitigate the risk of an accident for 1 (Resident 39) of 4 residents in the sample. The facility failed to ensure staff were present to implement the care plan to prevent Resident (R)39 from unsafe wandering. R39 wandered into R36's room which resulted in finding R39 on the floor. This deficient practice has the potential to result in resident-to-resident altercations. Findings include: On 09/19/23 at 12:37 PM observed the call light for Room D2 was on. There were no staff members on the unit. Staff members were on the C unit distributing residents' lunch meal at the kitchenette. Observed Registered Nurse (RN)4 pushing a cart with lunch trays on it When she approached Room D2, RN4 was heard speaking to someone, she then left the food cart and rushed off. Upon entering the room, observed Resident (R)39 on the floor in R36's room. D2 is not R39's room. R39 was observed in a sitting position with his forward wheel walker upright in front of him. R39 was on the floor next to the partially drawn curtain close at the foot of the bed across of R36. R36 was observed standing at his bedside. RN4 returned to the room with her vitals cart. R39 was stating he needed help. RN4 informed R39 that she would come back as she needed help. RN4 left the room. Observed R39 telling R36 that if he could get over to his bed he can pull himself up. During this time, R39 kept making attempts to grab his walker. RN4 returned and called for assistance, Mr. Strong. R39 kept telling the nurse he needed help. RN4 asked R39 how he landed on the floor, he replied he fell . She then asked if he hit his head. R39 started to become agitated, repetitively telling her he wanted to get up. RN4 kept responding they are coming. The R39 yelled I just need to get the fuck up. Staff members responded and was able to get R39 to stand. On 09/20/23 at 08:38 AM observed R39 lying in bed. Asked him about his fall and he did not remember he fell yesterday. He conversed about where he worked and how he earned a living. R39 was asked if he knows R36. R39 responded he doesn't know who that is. On 09/20/23 at 08:59 AM interviewed R36. R36 reported he is not sure what R39 was doing in his room. R36 stated he does not know how R39 fell , he couldn't see him behind the curtain. R36 reported he activated the call light when R39 entered his room and fell . R36 stated he told R39 to get out of his room. Further queried whether R39 was a welcome visitor, R36 responded, he didn't care, if R39 did not bother him. On 09/21/23 at 02:45 PM record review noted R39 was admitted to the facility on [DATE]. Diagnoses include but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance; orthostatic hypotension; syncope and collapse; and insomnia. A review of the John Hopkins Fall Risk Assessment Tool dated 09/19/23 documents, R39 did not have a fall in the previous six months and was assessed at moderate fall risk. Review of the quarterly Minimum Data Set with assessment reference date of 09/12/23 noted R39 had severe cognitive impairment. R39 was not coded as having behavioral symptoms (physical or verbal, rejection of care, or wandering. R39 was assessed as requiring supervision with set up for walking in room and corridor. He requires limited assistance with one-person physical assist for transfers (how resident moves between surfaces including to and from bed, chair, wheelchair, standing position). A review of R39's care plan documents R39 has cognitive communication deficits related to dementia and is hard to redirect and becomes aggressive. Start date of care plan was 06/19/23. Approaches include remove resident from other resident's rooms and unsafe situations; when resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.); and when resident wanders, approach resident from the front, walk in step with resident first before redirecting. On 09/21/23 at 09:00 interview was conducted with Certified Nurse Aide (CNA)3. CNA3 reported R39 wanders into other residents' room but this is the first time he went into R36's room. CNA3 also reported she had heard that R39 was sitting in the activities area and started swearing. R36 shouted to R39 to shut up and this is when R39 entered R36's room. CNA3 reported R39 will ambulate with the use of his forward wheel walker on the unit. CNA3 stated when she observes R39 wandering on the unit, she will attempt to redirect him. Review of the nursing schedule for 06/19/23 for Units C and D was one Charge Nurse and two CNAs. There was a total of 21 residents on the unit. The ratio of direct care staff (CNAs) to residents was 1:10.5. During the time of the incident, the two CNAs and Charge Nurse were assisting with passing meal trays to the residents. (Refer F725)

Based on observation, record review, interview and policy review, the facility failed to use a two-person assist to transfer a resident while using the hoyer lift (a mechanical floor lift and assistive device) for one resident (Resident (R) 31) selected for review. As a result, R31 sustained a significant head injury to the back of her head, which was a large hematoma (collection of blood from damage to a larger blood vessel) measuring 8 centimeters (cm) in length x 7 cm in width x 1 cm in depth and a laceration. The facility's investigation also did not determine why R31 was showered so early on the morning of 04/20/19 by the only certified nurse aide (CNA) 25 working the night shift. There was no documentation of CNA25's task performed as well. This deficient practice, including the lack of adequate supervision of CNA25 by the charge nurse that night, was a contributing factor for R31 sustaining serious injury and harm. This deficient practice also has the potential to cause serious harm to other residents residing in the facility, as the facility failed to complete their in-service education/training for hoyer lifts after the accident, and failed to monitor ADL activity/care provided to the residents during the night shift. Findings Include: Resident (R) 31 is an [AGE] year old resident who has a [DIAGNOSES REDACTED]. She was non-verbal, observed primarily in bed, and required staff assistance with her activities of daily living (ADLs). A family interview was done on 09/11/19 at 04:45 PM, and during the interview with R31's Family Member (FM), it was revealed that R31 had fallen out of a transfer lift sustaining a head injury. The FM said R31 was taken to the hospital emergency department for evaluation and treatment. The FM also found out for R31's showers, it was 3:30-4:00 in the morning and that was the night shift and they had been doing that for I don't know how long up until the incident anyway. Then they stopped after what happened. The FM said after R31's accident, the facility said they wanted to switch R31's showers to bed baths, but the family declined and told them to continue with the showers, but not that early in the morning. The FM further said her understanding of R31's fall from the hoyer lift was because, the attachments weren't attached properly. The FM said according to the nurses, she was told, their protocol is that it should be two people. They told me this. The FM said it was the older hoyer lift which was used on the morning of 04/20/19. Review of R31's Minimum Data Set (MDS) (MONTH) quarterly review with a 04/25/19 observation end date showed she requires a two person physical assist for bed mobility, transfer and toilet use. R31's comprehensive care plan at risk for falls and self-care deficit related to her Alzheimer's dementia and non-ambulatory status noted, . fall from Hoyer lift; CTs negative for injury; Staff re-educated for proper technique for Hoyer lift. Review of a 04/24/19 change in condition clinical entry revealed the resident was seen for, . the following acute problem of: f/up (follow-up s/p (status [REDACTED]. The resident sustained [REDACTED]. She was sent to the ER for further evaluation due to a large occipital hematoma . Further review found the following: 1) The mechanical lifts, including the hoyer lift, was a two person assist to ensure safe transfer of a resident. CNA25 had received in-service education on the use of a mechanical lift prior to the 04/20/19 accident. This was verified by the Director of Nursing (DON) on 09/13/19 at approximately 12:10 PM, when she produced CNA25's 12 hour inservice education sheet. The DON confirmed CNA25 received this training on 04/08/19, which was included in their topic, Safety & Body Mechanics. Yet, it was found that CNA25 did not follow this basic safety protocol, and by performing a single person assist/transfer of R31 from a shower chair to her bed, caused serious injury to the resident. The facility's protocol for the use of the hoyer (Tempo) lift for transferring R31 on the early morning of 04/20/19 was to have been a two person assist. This was further verified by Registered Nurse (RN) 11, during her telephone interview on 09/12/19 at 01:58 PM. RN11 stated, For the hoyer lifts, should be two people. However, this protocol was breached and not followed by CNA25. In addition, a lack of adequate supervision by RN11, who was the charge nurse on the night shift of 04/19/19 to 04/20/19, enabled CNA25 to perform an unsafe procedure using a mechanical lift, which in the end, caused a serious head injury to R31 from a drop/fall from the hoyer lift. 2) The FM interview revealed R31 was given an early morning shower on 04/20/19 and that, it was 3:30-4:00 in the morning and that was the night shift . Review of CNA25's witness statement found two versions, both dated 04/20/19 at 04:15 AM. One version revealed CNA25 completed R31's shower, brought the resident back to her room, . while transferring the 2 upper attachment came off, the resident fell down with shower chair on the floor with hard impact to the head, noticed moderate bright red on the floor. I called charge nurse to come and assist. CNA25's second version stated, .The resident was still in the shower chair and was able to do transfer using the hoyer lift. I set everything up, while transferring in the middle of lifting her up both upper attachment of the sling slipped off, I wasn't able to catch her, things happen so fast. the resident end up falling in the shower chair and hit her head by the shower chair. Immediately call the charge nurse. During the DON's interview on 09/13/19 at 08:21 AM, she said as part of their fall prevention review, including a fall with injury, it involved looking at the root cause of the fall and communicating it back to her staff to prevent future falls. The DON was then queried if she asked CNA25 about one of the primary antecedent factors as a probable root cause, which was why the aide showered R31 by herself early that morning. The DON replied, We felt this particular staff needed further training. We felt the use of the hoyer lift needed to be trained on. We could see this as a factor. We would report it as a near miss. However, review of CNA25's employee performance appraisal of 04/05/19 showed she exceeded expectations, including assisting residents with transfers and met expectations for the use of assistive devices, including a mechanical lift. The DON said the CNA's second version was probably written, to clear some things up. However, the DON did not have a clear response regarding which version accurately depicted the events and cause of injury to R31. The DON stated, a thorough investigation had been done and multiple people helped her investigate this accident. The DON did say CNA25 explained it to her and that the shower chair was on the floor. After this statement, the DON was unable to provide any further response about the discrepancies in the two written statements submitted by CNA25. At the end of her interview, the DON said she would look at providing more information from others who conducted the investigation with her. On 09/13/19 at 10:35 AM, the DON stated she did not have any additional documentation regarding this investigation. The facility leadership failed to thoroughly investigate CNA25's unsafe use of an assistive device, her decision to shower the resident by herself, and failed to review the lack of documentation by the CN[NAME] (Of note, the State Survey Agency (SA) attempted to contact CNA25 and left two telephone messages, but to no avail. The facility was also asked to assist in contacting this CNA as well, but to no avail. Thus, the SA was unable to obtain a direct interview with her to further clarify the events leading up to R31's drop or fall from the hoyer lift with the resulting head injury.) 3) There was a lack of adequate supervision by the charge nurse, RN11, during the night shift of 04/19/19 into the morning of 04/20/19. During a telephone interview of RN11 on 09/12/19 at 01:58 PM, she said she was not aware of CNA25's whereabouts when the accident occurred. RN11 confirmed CNA25 was her only CNA staffed on the Mokihana unit that night and did not know CNA25 had taken R31 for an early morning shower. RN11 had been orienting a new nurse and CNA25 did not communicate that she was going to shower and transfer R31 by herself using the hoyer lift. RN11 said as the charge nurse, she was responsible to know what was happening on the unit, including oversight of CNA25's actions. RN11 was not sure if the resident had, made a mess or had to shower her right away, as the reason for the early morning shower. RN11 said again, I know it's supposed to be two staff assist for the hoyer lift. She said, I told (CNA25) it has to be two staff assist next time with me or whoever is the charge nurse. RN11 was queried if the hoyer lift was done with a two person assist, would this accident have been preventable, and she replied, Yeah. R31 was showered early in the morning with no documented reason or knowledge as to why CNA25 was doing the shower and sole transfer. RN11 was asked if other residents were being showered in the early morning. RN11 said some of the other residents were receiving early morning showers, and was aware the CNAs would do these early morning showers. RN11 said she thought they should be documenting these early showers, but was unsure and stated, I know they do the showers, but it could be to help out the day, but I don't know. RN11 said she worked with CNA25 after the accident but was uncertain whether CNA25 continued to shower residents early in the morning since she worked in the other buildings. 4) The facility's fall protocol stated the root cause analysis or drill down method was used to determine how/why a fall occurred. However, for R31's accident, one primary antecedent factor which preceded the accident was her early morning shower. Although the resident's daily shower schedule for 04/19/19 was requested, the Chief Nursing Officer (CNO) on 09/12/19 at 11:32 AM said per their DON, they did not have the daily shower schedule when R31 fell , because it changes so often. The CNO was asked why her daily shower schedule would not have been kept as part of the facility's falls review/drill down method, to determine: 1) why such an early morning shower that resulted in a fall with injury occurred, and 2) why the CNA did it unsupervised and without the required two person assist. The CNO replied, sometimes if they're soiled they might. The CNO was asked again whether this was even reviewed, and the CNO stated she would check for a shower schedule during the time of the accident. This was not produced to the S[NAME] 5) The facility's investigation failed to determine if the correct standard sling and type was used by CNA25 during R31's transfer. The DON verified it was the Tempo lift used on 04/20/19. Although she produced the facility's policy, Mechanical Lift, Policy No. , it had no effective date on it. The policy did state there were different types of slings with a color to match a size and if it was a transfer or bathing sling. The product description in Fig. 2 also showed the different sling profiles used with the Tempo lift. Yet, although CNA25 stated in both written versions that both upper attachments slipped/came off during the resident's transfer, the type of sling used and/or why the attachments came undone, was not investigated by the facility in determining how the accident occurred. 6) The facility failed to look at CNA25's documentation for 04/20/19, the morning of the accident. CNA25 failed to document the 04/20/19 early morning shower for R31. The shower entries showed a shower entry on 04/20/19 at 01:01 PM, which was after R31 returned from the hospital at 10:18 AM. The other shower entry was on the night of 04/19/19 and documented at 10:45 PM. There was no other shower entry for the early morning shower done before the accident happened or why it was given. This discrepancy and lack of clinical documentation by CNA25 was not investigated by the facility. During an interview with CNA8 on 09/12/19 at 03:24 PM, she reviewed the ADL Verification Worksheet and said for 04/20/19, the 4/2 meant total assist with one person. CNA8 noticed the two shower entries and said if the resident was showered, although it may not be the real time of the shower, you have to put it in before the end of your shift. The shower entry of 04/19/19 at 10:45 PM may have been CNA25's entry, but then it meant it was documented before the shower was even given on the early morning of 04/20/19. Per CNA8, for the other shower entry, she said it was already, the day shift entry of the on-coming morning shift. 7) Record review also found CNA25 was counseled on 06/28/19 for using the hoyer lift by herself. CNA25's Employee Performance Improvement Plan (EPIP) stated the employee will use the hoyer lift with two staff assistance. Yet, her EPIP, dated more than two months after the accident, was found to be incomplete and invalid as it lacked the signatures and dates of CNA25, the supervisor, the human resources director and a witness. Although the DON said she counseled CNA25, she did not follow-up to check if CNA25 followed the hoyer lift protocol after she completed the initial one to one in-service with her on 04/26/19. The EPIP's Follow-Up Dates & Results, was also blank and incomplete. 8) The facility failed to ensure after this accident, that all staff, including the Registered Nurse (RN) 11, who was the charge nurse on the 04/20/19 night shift, received the in-service education/training on the use of the hoyer lift. Of the approximate 21 licensed staff and 35 CNAs, only 12 other staff were in-serviced. Thus, approximately 1/5 or 21% of the nursing staff completed the 04/23/19 in-service education on Transfers. In addition, the DON verified during her interview that she did not look at CNA25's lack of documentation and thus, did not provide any in-service education about inaccurate/incomplete documentation. The cumulative review found R31's head injury was avoidable based on the aforementioned findings. The facility leadership failed to thoroughly investigate how the accident occurred, and failed to implement measures to ensure residents who required transfers with mechanical lifts would be properly cared for. There also was a failure to ensure that adequate supervision and staffing needs were satisfactorily met, as no follow-up monitoring or documentation was provided to demonstrate what was done to prevent similar accidents from occurring by facility leadership. Cross-reference to findings at F725 and F726.

Based on observation, record review and interview, the facility failed to ensure there was sufficient nursing staff to provide adequate supervision and care to prevent a potentially avoidable accident for one resident (Resident (R) 31). This deficient practice, including the lack of adequate supervision of CNA25 by the charge nurse that night, was a contributing factor for R31 sustaining serious injury and harm. This deficient practice also has the potential to cause serious harm to other residents residing in the facility, as the facility failed to complete their in-service education/training for hoyer lifts after the accident, and failed to monitor ADL activity/care provided to the residents during the night shift. In addition, another resident (R57) stated the facility lacked the staff to meet her toileting needs, and the resident council voiced there was not enough staff for the number of residents in the facility because of long wait times for assistance. This deficient practice had the potential to affect all residents residing in the facility. As such, the facility failed to ensure their staffing satisfactorily met the needs, care and services for their residents in order to have them maintain their highest practicable physical and psychosocial well-being. Findings Include: 1) There was a lack of nursing oversight and staffing for the Mokihana unit on 04/20/19. This lack of adequate supervision by the charge nurse, RN11, was revealed based on her telephone interview on 09/12/19 at 01:58 PM. RN11 stated that she was not aware of CNA25's whereabouts when R31's head injury occurred from a drop/fall from the hoyer lift. RN11 was the assigned charge nurse on the Mokihana unit on the night shift of 04/19/19 into 04/20/19. RN11 confirmed CNA25 was her only CNA staffed on the Mokihana unit that night and did not know CNA25 had taken R31 for an early morning shower. RN11 said as the charge nurse, she was responsible to know what was happening on the unit, including oversight of CNA25's actions. Because she did not know where or what CNA25 was doing, this was a contributing factor for R31 sustaining her head injury. By this lack of oversight of CNA25, it allowed CNA25 to perform a task (the early morning shower of R31) using the hoyer lift by herself and unsafely transfer R31. Further, RN11 was not sure if the resident had, made a mess or had to shower her right away, as the reason for the early morning shower. There was no documentation found as to why CNA25 showered R31 that early in the morning. As to the appropriate use of the hoyer lift, RN11 stated, I know it's supposed to be two staff assist for the hoyer lift. She said, I told (CNA25) it has to be two staff assist next time with me or whoever is the charge nurse. RN11 was queried if the hoyer lift was done with a two person assist, would this accident have been preventable, and she replied, Yeah. 2) RN11 also said some of the other residents were receiving early morning showers, and was aware the CNAs would do these early morning showers. RN11 said she thought they should be documenting these early showers, but was unsure and stated, I know they do the showers, but it could be to help out the day, but I don't know. Yet, the facility's investigation of R31's accident did not include any inquiries or documentation of why an early morning shower was given to R31, or whether this was a practice by the night shift staff that was on-going, but unreported and undocumented. 3) RN11 stated for their night shift staffing in the Mokihana unit where R31 resides, they were staffed with one nurse and one CN[NAME] She said the Mokihana charge nurse was also responsible for the care of the residents in the next building (Makalapua or Maka). RN11 said she went to the Maka unit whenever she got called to assess a resident. She said sometimes it would be an hour or so, depending on a resident's condition. RN11 said if she left Mokihana to go to Maka, it would leave the Mokihana residents with only one CN[NAME] The Maka unit too, would be without a licensed staff once she would return to Mokihana. RN11 affirmed the staffing currently remains the same, and did not change after the 04/20/19 accident involving R31. RN11 stated the Ilima building/unit had their own nurse, and that nurse did not need to travel between the buildings. RN11 said she could not remember how many times she had to go to the Maka unit since the (MONTH) incident. RN11 was asked if this was a safe practice to leave the Mokihana residents (or Maka residents) unattended and with one CNA, and she replied she did not think so. Of note, the daily staffing schedule showed the Maka unit was staffed with two night shift CNAs; however, on 04/25/19, the work schedule shows CNA25 worked the night shift on both the Mokihana and Maka units, which would have left one CNA in both buildings/units. 4) The potential for harm for the residents in Mokihana and Maka still exists since the facility failed to investigate and determine after R31's accident, if the night shift had been or still may be performing early morning resident showers, as well as one person assist transfers using the hoyer lift, instead of the required two. Given the current staffing in the Mokihana and Maka buildings/units, if there was a need to use the hoyer lift, the Mokihana unit may not always have this capability, based on RN11's account of covering both buildings at any given time. On 09/13/19 at 10:32 AM, the DON produced the CNA in-service training log for CNA25 on the topic of transfers. The DON said, it was verbal, and said she went over the hoyer lift in-service. DON verified she did not do any post incident monitoring or follow-up of CNA25 to show that staff were providing safe care using the hoyer lift. The DON verified she did not complete the staff in-service education/training on the hoyer lift and two person assist. The facility failed to show what was done to ensure the safety of all residents was being monitored for those who required the use of a mechanical lift for transfers. There was no documentation or evidence provided by the facility to show they performed any monitoring, such as on-site audits of staff involved in the accident and/or of other nursing staff. The facility also failed to determine whether their staffing sufficiently met the needs of the residents. During the DON's interview on 09/13/19 at 08:21 AM, she verified their staffing pattern did not change. She said only one nurse covers Mokihana and Maka for the night shift. The nurses worked a 12 hour shift, but the CNAs did not. She said the CNAs would switch out from the different buildings to help cover, but again, there was no documentation to show the allocation of staff, time and resources to verify their staffing was adequate to ensure the residents' needs were being met. Cross-reference to findings at F689 and F726. 5) On 09/11/19 at 08:52 AM, a follow-up interview was done with R57. She initially stated on the initial tour that the facility's staff took a while to answer her call light or toilet her when she needed to go. She said it happened on every shift. This interview revealed that R57 felt the facility has a lot of staff around, but they all busy. The longest I waited was 20 minutes. When I want to use the bathroom, I just call, call, call and nobody comes you know. R57 said it happens frequently, and sometimes, more than half an hour. I can't wait so I stand up, but I'm afraid you know. She reiterated that the wait time was usually was 20 minutes before staff could toilet her and it was, anytime. She said even though they toilet her every two hours, she, can't wait inbetween. I ring the bell at the bed and takes 20 minutes, sometimes longer. They have to hurry up, and sometimes the urine comes out, not much, just drops when I cannot hold. 6) During the Resident Council interview with the President and Vice President on 09/12/19 at 10:29 AM, the President stated that sometimes there were not enough staff for all of the residents in the facility. The President stated, During these times several of the call lights are going on and the staff try to get to those residents but it takes a long time. As the president I alert the nurse if there is a resident who fell , or if someone needs help immediately. It isn't during any specific period of time during the day or night it happens at different times.

Based observation, interview, and record review, the facility did not ensure that based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. (Resident #77). Findings include: Resident #77, a [AGE] year old woman, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident developed a pressure ulcer after being admitted into the facility. Observation on 8/13/15 at 7:20 A.M. found resident sitting in her wheelchair in the dining room with a cushion behind her back. The charge nurse states it is the resident's pillow from home and it is not a pressure relieving pillow. Two staff then transferred the resident to a chair and a low table brought in from home. Staff observed to place the pillow behind the resident's back in her chair. The resident's back was hunched over and curvature of her spine was noticeable during the transfer. On 8/13/15 at 10:00 A.M. an observation was done of a dressing change by the charge nurse and the MDS Coordinator was also present. The resident was lying in bed with a special alternating pressure pad (APP) mattress on the bed. The wound along her mid-spine was almost closed and no drainage was observed on the old dressing. The nurse states the wound has improved and measured 1 cm x 1 cm. After cleansing the wound with normal saline, she applied nickel size santyl and then covered with a bordered dressing. The nurse states the resident developed this Stage III pressure ulcer in the facility. She attributed the development of the pressure ulcer to the wheelchair. The bony prominences along the curvature of her spine was clearly visible. Record review found an Admission Minimum Data Set with assessment reference date of 7/17/15. The resident was coded as modified independence in cognitive skills for daily decision making. Her speech is clear, able to understand others, and able to make self understood. She requires extensive assistance with activities of daily living skills with one person assisting. She is able to feed herself with set-up help. The resident requires extensive assistance of 2 persons for transfers and toilet use. Balance during transitions and walking noted the resident is not steady and is only able to stabilize with staff assistance. She did not have any impairment or functional limitation in range of motion in extremities. She utilizes a walker and wheelchair for mobility. Under Section M. Skin Conditions, the resident was coded as at risk of developing pressure ulcer. She did not have any pressure ulcers on admission to the facility. It was also noted that she had open [MEDICAL CONDITION] other than ulcers, rashes, cuts. The Care Area Assessment Summary noted pressure ulcer was triggered due to the resident's need for extensive assist with bed mobility, frequent bladder incontinence, and overall risk for skin breakdown. Her skin appeared very thin and moist from the summer weather. Most of her clothing are long sleeved. Over her mid spine area, she had a 1.2 cm x 1.2 cm superficial opening from shearing and sweating. Concurrent record review was done with Director of Nursing (DON) on the morning of 8/13/15. Clinical notes: 1) 7/20/15 Noted 2 x 2 cm superficial skin opening to R mid back, next to spine. 2) A review of the form titled Wound Care * Skin Integrity * Evaluation that was completed by the consultant wound nurse was done. Wound spine -- onset 7/20/15; assessment date 7/27/15; min exudate; full thickness; pressure ulcer Stage III; size 1.50 (L) x 1.50 (W cm); depth UTD (unable to determine); serous drainage; facility acquired. Wound bed: 90% yellow thin slough. 10% pink granular tissue. Periwound: [DIAGNOSES REDACTED], fragile. Clinical Rationale/Wound Comments: Bordered foam: minimize injury to area that is high risk for friction/shear/pressure. QD (documentation) is needed due to dressing becoming dislodged within 24 hours. Treatment intervention: cleanse per facility protocol. Pat dry, apply santyl (nickel thick) to wound bed. Cover with bordered foam QD & PRN. 3) Clinical note 7/27/15 - 1.5 x 1.5 cm wound to mid spine/back with yellow slough on wound bed. Redness noted to surrounding area. Cleansed and supplied skin prep on periwound. Covered with bordered foam. Power of attorney (POA) came and notified about the wound. POA with concerns and requested for mattress to be changed. APP mattress request made and maintenance aware. POA stated that she will bring foam to help alleviate pressure from the spine. 4) Clinical note 7/28/15 Maintenance install APP mattress to bed. Interview was done with the DON on 8/13/15 at 9:30 A.M. Also in attendance were two other surveyors. The DON stated that the resident was admitted to the facility on [DATE] without any pressure ulcers. The resident did have superficial opening on mid spine area. She was identified as moderate risk on the Norton Plus Pressure Ulcer Scale with a score of 12. Moderate risk is a score of 11-15. A review of the care plan risk for pressure related skin breakdown r/t need for assist with bed mobility, episodes of double incontinence, dependent on staff for assist with ADL's, back curvature, below IBW and dx dementia. Interventions include apply dressing change as ordered 7/22/15; cleanse wound to back with NS, pat dry, apply [MEDICATION NAME] gauze fanfolded, cover with bordered foam, change daily and PRN. 7/29/15 - d/c above. 7/28/15 Cleanse wound to back per facility protocol, pat dry, apply santyl (nickel thick), to wound bed, cover with bordered foam QD and PRN. The care plan was not updated to reflect the development of the Stage III pressure ulcer. There were no aggressive preventive measures included on the care plan to prevent the pressure ulcer. The facility reacted to concerns expressed by the POA who requested a special mattress on 7/27/15. The POA wanted to bring in foam to help alleviate pressure from the resident's spine. On 7/28/15, maintenance installed the APP mattress to the bed. The DON agreed that the care plan should have been updated to reflect the development of the Stage III pressure ulcer with the treatment changes. The facility identified upon admission that the resident had a superficial opening on the mid-spine area and she had bony spine curvature. They also identified the resident as moderate risk on the Norton Plus Pressure Ulcer Scale. The DON acknowledged that the pressure ulcer was avoidable and the facility could have done more and could have been more proactive in preventing the development of the Stage III pressure ulcer.

Based on observations, medical record review, and staff interviews, the facility failed to maintain or improve a resident's highest practicable outcome. (Resident #84) Findings include: CROSS REFERENCE TO F 323 CROSS REFERENCE TO F 280 Resident #84 was triggered for review during Stage 2 of the QIS survey based on his Minimum Data Set (MDS) which indicated a decline in urinary continence since his admission. Resident #84 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Observation of Resident #84 during the initial tour of the Ilima unit on the morning of 8/11/15 found him walking along the hallways in a Merry Walker. He used his right hand to hold the front of the Merry Walker and slowly walked along the hallway occasionally stopping to sit. The resident was observed walking along the hallways during the survey period from 8/11/15 to 8/14/15. On the afternoon of 8/12/15 at approximately 2:00 P.M., Resident #84 was observed slowly walking with the Merry Walker along the hallway without any staff present. On the morning of 8/13/15 at approximately 10:00 A.M., the resident was observed slowly walking in his Merry Walker without any staff present. Along the way the resident would stop and sit on the Merry Walker and eventually get up again and continue slowly walking. On the afternoon of 8/13/15 at approximately 3:30 P.M., the resident was observed slowly walking through the hallways. He stopped here and there to sit down and was able to locate his own room. On the morning of 8/14/15 at approximately 8:30 A.M., Resident #84 was observed in his Merry Walker slowly walking along the hallways without staff present. A review of the resident's medical record indicated he experienced a fall on the early morning of 6/20/15. He was transferred to the emergency room (ER) and admitted to the hospital for a skull fracture and subdural hematoma. Resident #84 was re-admitted to the facility on [DATE] and a significant change MDS was generated with an Assessment Reference Date (ARD) of 6/29/15. The MDS indicated significant declines in his Activities of Daily Living (ADLs) after the fall on 6/20/15. The resident declined in bed mobility, transfers, walking in room and corridor, locomotion on unit, dressing, eating, toileting, personal hygiene, and bathing. In addition, his balance during transitions also declined in the following areas: Moving from seated to standing position; walking; turning around; moving on and off toilet; and surface to surface transfer. The 6/29/15 MDS further indicated a decline in urinary continence from occasionally incontinent to always incontinent. Finally, the MDS indicated Resident #84 experienced weight loss of 5% or more in the last month. According to the nutritional assessments, the resident's diet texture and fluid consistency was downgraded. The initial nutritional assessment dated [DATE] indicated Resident #84 was on a regular diet with thin liquids. On 6/25/15 the resident was evaluated by the Speech Therapist, who downgraded his diet to moist minced and nectar thick liquids. On 7/25/15 the RD noted the resident was re-evaluated by the Speech Therapist, who again downgraded the resident's diet to pureed and upgraded the liquids to thin. During the survey period, 8/11/15 to 8/14/15, Resident #84 was on pureed textured food and thin liquids. Based on the significant declines in Resident #84's functional status, weight loss, and urinary continence, the facility did not make revisions to his care plan to ensure an improvement/maintenance in these areas. The facility generated a care plan for Self care deficit related to bowel/bladder incontinence (frequent) and need for supervision to extensive assistance with all ADLs secondary to dementia, weakness, and difficulties with ambulation, resistiveness with care, and difficulties following directions which was dated 5/20/15. Interventions were initiated on 5/20/15 and were not revised to reflect his current needs based on the significant declines he experienced following his hospitalization for skull fracture and subdural hematoma. There was one revision for ADL interventions dated 6/1/15, Provide limited to extensive assistance with all ADLs. May increase number of staff assistance if he is having behaviors. As of the survey date, 8/14/15, the resident was incontinent and wore a brief. He was on a pureed diet and thin liquids. He required a staff member to feed him food and fluids. He was using a Merry Walker to ambulate around the facility. He walked very slowly and appeared unsteady on his feet. He was responsive to his name and smiled back. He was not interviewable and had a flat affect. An interview with a Licensed Nurse on the afternoon of 8/13/15 at approximately 2:00 P.M. revealed that the resident was admitted being both continent and incontinent. She reported the resident remained the same as he was on admission being both continent and incontinent. When asked if the resident was on a scheduled toileting program she replied yes. An interview with a Certified Nurses Aide (CNA) on the afternoon of 8/13/15 at approximately 1:45 P.M. revealed the resident was continent and incontinent upon admission. The CNA reported that since the resident fell on [DATE] he had changed to always incontinent. During the time of the survey, the CNA stated they did not toilet him but rather changed his briefs. The CNA reported the resident was unable to verbalize his need to toilet. An interview with the Administrator and Director of Nursing (DON), on the morning of 8/14/15 at approximately 9:00 A.M., revealed their acknowledgement that Resident #84 experienced significant declines after his fall on 6/20/15. The Administrator and DON confirmed that Resident #84 declined with ADLs, urinary continence, had a significant weight loss, and his diet was downgraded since the fall. They also indicated the resident's sleeping pattern had changed from being normal prior to the fall and now experiencing disrupted sleep patterns. The Administrator and DON stated that their expectation was for staff to supervise him on the unit. They also stated that his cognitive status has declined. The staff notified the physician and they tapered the resident off [MEDICAL CONDITION] medications after the 6/20/15 fall. In summary, the facility failed to make revisions to Resident #84's care plan to improve/promote his optimal functional status. A lack of supervision and no revisions to his ADL care plan caused the resident's overall well being to decline rather than improve.

Based on observations, interviews, and record reviews, the facility did not ensure that the resident environment remained as free of accident hazards as is possible, and that the resident received adequate supervision to prevent accidents for 2 of 2 residents in the Stage 2 sample. (Resident #93, #84) Findings include: 1) Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility provided documentation that the resident had 11 falls during 5 months, the last fall was on 8/10/15. Injuries from the falls included bruises, cut lips, and hematomas. There has been no causal analysis of the resident's falls and she remained at high risk for falls. Resident #93 was triggered in the Stage I sample as the staff interview reported 4 falls in a 30 day period. The licensed nurse on the unit reviewed data in the electronic record and reported the following falls: On 8/10/15 ---Resident in a wheelchair and slide out to floor with no injury. On 8/9/15 ---Resident was in her room, crawled out of bed. (mattress placed on the floor). no injury. On 8/2/15---Resident came out of her gerichair to the floor, there was no injury. On 7/23/15---Resident in shower, fell , hematoma to left upper forehead. One person in shower with her. big bump on head, put ice. (Date on Incident Report noted as 7/22/15) Observation during the initial tour noted the resident was sleeping on her mattress which was placed on the floor. Observation on 8/12/15 during breakfast and lunch had the resident sitting in a wheelchair with a lap buddy. On 8/13/15 resident was again observed in a wheelchair with a lap buddy when she was out of bed. On 8/12/15 at 8:20 A.M., the surveyor requested fall investigation reports from date of resident's admission. Eleven Incident Reports were provided to the surveyor on 8/13/15. There was no event report for the 8/2/15 and 8/9/15 falls as reported in the Stage I staff interview. According to the Nursing Operations Specialist (NOS) the facility would not do an event report for resident crawling off the mattress placed on the floor and no injury (8/9/15). She stated she would look for the 8/2/15 report (fall from gerichair to floor). The Interdisciplinary Team (IDT) Reports were also requested, and the administrator noted that the IDT report was attached to the Event Report. Three of the eleven Event reports, 6/22, 7/22, and 8/11/15 did not have the IDT report attached. The 11 Incident Reports are as follows: 1) Date: 4/15/15 at 10:35 P.M. Resident was found in a semi prone position on the floor next to resident's bed. Findings included bruise to right forearm 1.7 cm x 0.5 cm. Redness to right wrist -blanchable, redness to right knee-blanchable. Left medial forearm- 3 cm x 2.6 bruise. The IDT Focused Clinical Event Review-Falls noted that the fall was unwitnessed, and contributing factor was resident restless. Recommend alarm audit. 2) 5/1/15 at 1635. Fall. No injury noted. The IDT Focused Clinical Event Review-Falls reported the contributing factors as restless, clip alarm not on, resident left unattended. The section titled Summary and Plan of action noted: CN inserviced CNA re: chair alarm use. Resident on visual supervision when up in gerichair. 3) 5/3/15 at 10:45 P.M. Resident was found on the floor, attempting to crawl.gerichair was behind resident and clip alarm wasn't on. Noted a 22 cm bump and 0.3 cm depth hematoma to right cheek. Also, noted 0.50. (not legible_?)right knee scrape, no bleeding. 4) 5/25/15 at 7:00 A.M. Resident found on floor between two mattress. No injuries noted. 5) 5/29/15 Resident found lying at the foot of her mattress. Resident was again reported to be restless. No injury noted. 6) 6/13/15 at 6:40 A.M. Resident on her belly in her room, crawling, almost to the door. Obtained small cut to upper and lower lip (right side). IDT Focused Clinical Event Review-Falls noted that the pad alarms placed on each edge of bed. Ineffective as resident removes at times. Laser alarms at edge of bed (foot and side) recommended. 7) 6/19/15 at 2000. Found resident on her right side on the floor. She had been in the gerichair. Clip alarm stuck entangled in the chair. Noted alarm changed to chair alarm related to clip alarm clip to gerichair not alarming. On the IDT Focused Clinical Event Review-Falls documented poor safety awareness as a contributing factor. In the Summary section, staff noted increased restlessness and noted to be combative towards staff recently. CNA inserviced by CN for 1 on 1 visual supervision when up in Gerichair. Alarm changed from clip to chair alarm. Psych eval and treat for restlessness and combativeness. 8) 6/22/15 at 3:30 A.M. Resident on belly almost onto the floor of the 2nd mattress. Had minimal bleeding from right lower lip from pinpoint 2 openings which was previously noted. (Clinical note dated 6/22/15 at 04:16 A.M. had that She did have minimal bleeding from right lower corner of lip from previous pinpoint openings.) 9) 6/26/15 at 1610. Resident found in dining room hallway on ground by CNA, climbed out of gerichair. Resident expressed I wanted to go bathroom. No injury noted. 10) 7/22/15 at 2030. Resident found naked and lying on left side with head on floor in shower. Shower on and floor wet. Hematoma to left forehead 33 cm with 1.5 x 1.5 reddened scraped area, ice pack applied. Added note dated 7/27/15-bruise to left eyebrow 4 cm x 3 cm. Resident self transferred to standing while in shower. Staff at time was changing gloves but resident quickly fell . 11) 8/11/15 at 2040. Resident sitting on the floor facing wheelchair. I want to go to bed. Report noted she fell out of her wheelchair. Hematoma from previous fall still intact to left forehead. Review of the resident's electronic record contained the CAA Falls Summary dated 3/30/15. It noted the resident was at high risk for falls. The Falls CAA was triggered due to resident's loss of balance, including contributing factors of seizure history, left extremity weakness, and occasional restlessness. The Admission Fall Risk Assessment was completed with a score of 12 (high risk). It was noted that per staff, she had occasional episodes of restlessness, has attempted to get out of bed. According to her family, prior to her hospitalization , she was ambulatory and independent. The decision was made to proceed to care planning. The care plan(s) for falls since admission was requested of the administrator. The care plan dated effective 5/4/15 listed in the problem area that she had a fall history of falling out of bed, pulling self up while in gerichair, scooting self, occasional restlessness, seizure history, lack of balance and LE weakness. She seems to be fixated on scooting self or climbing out of gerichair, wheelchair, or bed despite staff supervision and redirection. Low bed had been provided in the past, however, she continued to crawl out of bed or be found off the mattress, including additional mattress near bed. The resident's care plan was not promptly revised after a fall on 7/22/15. On 7/22/15 the resident fell in the shower and sustained a hematoma. Review of the resident's care plan on the afternoon of 8/13/15 found that the care plan revision for the intervention for the supervision in the shower was dated effective 8/10/2015. The intervention was Keep (resident) within arms length reach while in bathroom/shower. The last change/revision in the care plan prior to 8/10/15 was dated 7/12/15. Interview with the administrator on the morning of 8/14/15 confirmed that the written care plan should have been revised earlier, a business day, and not delayed until 8/10/15. Interview with the DON, Administrator and the RCM at 5:10 P.M. on 8/13/15 confirmed that the resident had numerous falls since her admission on 3/20/15. They reported that due to resident's restless behavior and quickness of movement the facility used a lap buddy. They were asked as to the facility process in handling falls, whether there was a fall committee (answer was no), or a trigger of a high number of falls to alert the IDT to discuss the series of falls, (answer was no trigger of falls). Instead they reported that each fall is individually reported the morning after a fall occurs. The process is that the Interdisciplinary Team meets during the morning meeting. The average time for discussion regarding the fall was approximated at 10 minutes by the administrator. The Interdisciplinary Team notes are written by the RCM and then circulated for review and comments to the other team members. When asked by a surveyor if the team sits down and meets as a group for the purpose of discussion of the falls, the administrator and DON noted that the usual procedure is to circulate the IDT Focused Clinical Event Review-Falls form. Secondly, it was noted by a surveyor that there did not appear to be much added comments by other IDT members on the IDT Focused Clinic Event Review-Falls. The majority of the forms did not have comments by other members. Thee was no comment by the facility staff present. Thirdly, when asked whether there was a causal analysis done to look at the eleven falls that the resident had since April 2015, a 5 month period, the answer was no. When asked whether the facility reviewed the resident's drugs for possible side effects, the answer was that the pharmacist does that. When asked whether there was any lab work or drug levels done to look at possible contributing factors the answer was no. Lab work is done annually. The administrator noted that we could do a better job on investigating and analyzing falls. 2) CROSS REFERENCE TO F 311 CROSS REFERENCE TO F 280 Resident #84 was being investigated for a decline in urinary continence according to the Minimum Data Set (MDS). An interview with a Certified Nurses Aide (CNA), on the afternoon of 8/13/15 at approximately 1:45 P.M. revealed the resident experienced a fall about a month and a half to two months ago in the facility. The CNA reported a decline in his continence since the fall. The resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident experienced a fall on 6/20/15. According to the facility's event report, the resident had appeared restless prior to the fall. On 6/20/15 at approximately 12:15 A.M, a CNA reported seeing Resident #84 pacing through the hallways, switching light switches on/off, which wasn't unusual behavior for him. At approximately 12:40 A.M. on 6/20/15, a CNA went in to assist Resident #84's roommate, when the CNA found Resident #84 on the floor. He was lying in the fetal position on his left side next to his bed. The nurse was notified and assessed the resident. There was vomit on the floor next to the resident. He was alert, confused, pale, with cold sweats, and pain to his chest and arm. The staff assisted the resident back to bed and he vomited 3 times a medium amount of brown vomit. No visible injuries noted. Vital signs indicated an elevated blood pressure of 195/99 (his baseline: SBP 115-120; DBP 71-79) and Glasgow Coma Scale (GCS) = 15. They continued to monitor the resident and his blood pressure remained elevated and he continued to vomit. The physician was notified at 1:30 A.M. and ordered the resident to be sent to the emergency room (ER) for further evaluation. The facility's Licensed Nurse contacted the ER Nurse on 6/20/15 at approximately 7:20 A.M. to determine the resident's status. The ER Nurse stated the resident was diagnosed with [REDACTED]. The ER Nurse stated he was ready to be discharged . The resident was transported back to the facility at 9:05 A.M. on 6/20/15. He appeared tired and in no apparent distress. He ate <25% breakfast, refused his morning medications and returned to bed after breakfast. At 12:20 P.M., the resident was up in his wheelchair and vomited 2 times a moderate amount of food. The facility attempted to contact the physician without success. The nurse reassessed the resident and he complained of dizziness and chest pain. The physician called back and ordered Resident #84 to return to the ER. The resident left the facility at approximately 1:10 P.M. on 6/20/15. He was admitted to the hospital on [DATE] at approximately 6:25 P.M. with the [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] at approximately 4:40 P.M. He was alert and pleasantly confused - nodding and speaking short words. He was up in the wheelchair and attempted to stand multiple times. He had a 10 cm x 9 cm lump to the left side of the parietal area of his head. He was placed back to bed for low blood pressure - 70/51. On 6/24/15 at approximately 7:00 A.M., the resident's blood pressure was 91/54, appeared weak and tired, denied pain, and refused food and drinks. The physician was notified and the resident was again transferred to the ER. He was diagnosed with [REDACTED]. He returned to the ER two additional times with vomiting and hydration issues. He was only seen in the ER and discharged back to the facility following the last three ER visits. Observations of the resident during the survey period found him wandering up and down the hallways using a Merry Walker. On the morning of 8/11/15 at approximately 9:50 A.M., Resident #84 was observed walking through the hallway in a Merry Walker. He moved slowly and placed his right hand on the front rail of the Merry Walker. He wore socks, pants, and a T-shirt. He occasionally stopped and sat on the Merry Walker seat. On the afternoon of 8/11/15 at approximately 2:00 P.M., Resident #84 was observed walking through the hallway. There weren't any staff around while he slowly walked with the Merry Walker. He occasionally stopped to sit on the seat. On the morning of 8/12/15 at approximately 8:00 A.M. found Resident #84 walking along the hallways in the Merry Walker wearing long pants, a T-shirt, and socks. All staff were occupied assisting other residents and the resident independently walked around. On the afternoon of 8/12/15 at approximately 1:45 P.M., Resident #84 was observed walking in his Merry Walker without any staff present. On the morning of 8/13/15 at approximately 10:15 A.M., Resident #84 was again observed walking with his Merry Walker along the hallways without staff present. On the afternoon of 8/13/15 at approximately 2:00 P.M., the resident was again observed walking the hallways without staff present. On the afternoon of 8/12/15 at approximately 2:00 P.M., a review of the physician's orders [REDACTED]. An interview with the Licensed Nurse on the afternoon of 8/12/15 revealed they should have an order for [REDACTED]. She was unable to locate a physician order [REDACTED]. The Licensed Nurse stated that the expectation of the staff was for the resident to be supervised while in the Merry Walker. Review of the physician's orders [REDACTED]. 5 mg/ml, 3 mg intramuscular as needed every 6 hours - Given 6/16/15 at 3:06 A.M., discontinued 6/23/15; (6/16/15 & 6/18/15) Invega Sustenna 156 mg/ml, 156 mg intramuscular daily for 1 day - Given 6/16/15 at 10:00 A.M. and 6/18/15 at 10:00 A.M. A review of Resident #84's medical record indicated he was admitted to the facility on [DATE]. He was combative, agitated, and aggressive. He was ambulatory, spoke some English but primarily Micronesian, and alert. He would get agitated, hit the staff and chase the CNAs out of the unit while making a grunting sound. The admission MDS with Assessment Reference Date (ARD) of 5/11/15 indicated the resident was unable to complete the Brief Interview for Mental Status (BIMS) and he had moderately impaired cognitive skills for daily decision making; Mood - 2-6 days of feeling or appearing down, depressed, or hopeless. After his fall on 6/20/15 with subsequent skull fracture and subdural hematoma, the resident experienced a decline in his Mental Status and Activities of Daily Living (ADLs). The facility generated a significant change MDS to indicate his current status. A comparison of his admission MDS with ARD of 5/11/15 to his significant change MDS with ARD 6/29/15 revealed the resident experienced an acute change in mental status from the resident's baseline and a significant decline in his Activities of Daily Living (ADLs) in the following areas: Bed mobility - previously independent requiring no assistance to extensive assistance with 2 person assistance; Transfer - previously limited assistance with one person assistance to extensive assistance with 2 person assistance; Walk in room and corridor - previously limited assistance with 1 person assistance to activity not occurring; Locomotion on unit - previously limited assistance with 1 person assistance to total dependence with 1 person assistance; Dressing - previously limited assistance with 1 person assistance to extensive assistance with 2 person assistance; Eating - previously independent with setup assistance to extensive assistance with 1 person assistance; Toilet use - previously limited assistance with 1 person assistance to total dependence with 2 person assistance; Personal hygiene - previously limited assistance with 1 person assistance to extensive assistance with 2 person assistance; Bathing - previously physical help in part of bathing with 1 person assistance to total dependence with 2 person assistance. His balance during transitions and walking also declined with the following changes: Moving from seated to standing position - previously steady at all times to activity did not occur; Walking - previously not steady but able to stabilize without staff assistance to activity did not occur; Turning around - previously steady at all times to activity did not occur; Moving on and off toilet - previously steady at all times to activity did not occur; and Surface to surface transfer - previously not steady, only able to stabilize with staff assistance to activity did not occur. The resident's bladder and bowel status also changed: Urinary continence - previously occasionally incontinent to always incontinent. The facility conducted a Fall Risk Evaluation upon Resident #84's admission on 5/8/15 which was scored at 10. A score of 10 or greater indicated the resident was at HIGH RISK for potential falls. Another Fall Risk Evaluation was conducted on 6/23/15 when the resident returned from the hospital and his score was 11. The facility generated a care plan titled, (Resident) is at risk for falls related to dementia, seizure risk, and potential side effects of psychotropic use. He does not know how to use slippers/socks without staff cueing. The start date for the Falls care plan was 5/20/15. After the resident's fall on 6/20/15, the care plan interventions were updated to include a laser alarm (7/2/15), fall mattress near bed (7/2/15), and increased visual checks and supervision when restless (7/2/15). Upon readmission to the facility, Resident #84 experienced additional falls: 6/29/15 7:10 P.M. Resident found sitting next to bed on floor mattress, slight redness on right knee; 6/29/15 7:30 P.M. Resident sitting next to his bed on the mattress, no apparent injury; 7/8/15 Resident fell in hallways while trying to get out of Gerichair, 1 to 1 staff assistance; and 7/9/15 Witnessed fall while self-transferring from Gerichair, no injuries. Redness to right knee measuring 5.6 cm x 3 cm. An interview with the Administrator and the DON on the morning of 8/14/15 confirmed that the resident had a significant decline in his functional status after the fall on 6/20/15. The Administrator reported the resident had declined in appetite and his ability to feed himself, ambulation, urinary continence, general hygiene, ADLs and changes in his sleeping pattern (previously stable sleeping pattern). She further indicated the resident's cognitive status had also declined. The facility notified the physician and the resident was tapered off the psychotropic medications. An interview with the psychiatrist on the morning of 8/14/15 at approximately 9:15 A.M. revealed the resident had experienced multiple falls. The psychiatrist stated the resident's subdural hematoma may be pressing against his brain, causing changes in his cognitive status. The resident will return to the neurosurgeon for a repeat Magnetic Resonance Image (MRI) to determine the status of the subdural hematoma. The psychiatrist reported they may have to evacuate the hematoma. He stated that he was unaware that the resident's ADLs had declined since the fall on 6/20/15. The facility failed to perform an analysis to determine the root cause of the resident's falls; therefore, interventions were not revised to prevent further falls resulting in injury and hospitalization . Resident #84 had a decline in ADLs, cognitive decline and required a therapeutic diet. In summary, the facility failed to provide adequate supervision and interventions to ensure Resident #84's safety.