Every finding on record at Hale Makua - Kahului

Based on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one of three residents (Resident (R) 5) sampled for hydration, despite identifying the resident as at risk for compromised nutrition and hydration. This deficient practice puts R5 at risk of complications due to dehydration. Findings Include:On 01/06/26 at 10:14 AM, concurrent observation and interview with R5 at bedside. Resident was seen sitting in his wheelchair at bedside. No water container observed on the bedside table. When R5 was asked if he feels thirsty or mouth feels dry, he replied Yes.On 01/07/26 and 01/08/26 observation was done with R5 at bedside. No water container observed at bedside.On 01/08/26 at 02:51 PM, an interview was conducted with Nurse Supervisor NS (266). When asked if R5 was on any fluid restriction, she replied No he is not. And when NS266 was asked if resident should have water pitcher at bedside, she stated yes, let me ask one of my staff to give him a water pitcher. NS266 also explained that R5 is at risk for dehydration. Observed staff grabbing water container, filled with ice and water and give it to R5.On 01/09/2026 at 10:30 AM, an interview was conducted with NS266 at the nurse's station. When asked to clarify if R5 should have been offered fluids and maintained at more than 2000 milliliters (ml) fluid daily, she confirmed that R5 should have been adequately hydrated and monitored to have at least 2000 ml of fluid daily. RN266 also explained that she educated the staff to ensure they included it in their daily tasks to monitor resident's fluid intake and to ensure they fill his water container with water and leave it at resident's bedside.On 01/09/26, review of R5's Electronic Health Record (EHR) found his diagnoses included, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; Hypertensive heart disease with heart failure; dysphagia following cerebral infarction; and dehydration. Review of R5's physician orders included fluid daily goal of 2000 ml with an ordered date of 01/06/26 and for staff to check skin weekly. R5's Treatment Administration Record (TAR) for January 2026 indicated less than 2000 ml of fluids were not met daily as prescribed. Review of skin assessment done by staff using NSG: Skin Check indicated, .1. Skin Condition b. Dry.2. Skin turgor: b. Poor Elasticity (less than 3 second recoil). R5's care plan detail with a review start date of 05/13/25, noted . resident is at risk for dehydration related to fluid intake less than desired . enjoys coffee, ice water, apple juice. Review of R5's most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/25, Section GG. Functional Abilities, .Self-Care. A. Eating: The ability to use suitable utensils.liquid to the mouth and swallow food and/or liquid. Setup or clean-up assistance. The facility's policy and procedure titled, Hydration, with an effective date of 10/30/24, reviewed on 01/09/26, stated that, . The facility will have available at all times a variety of beverages to accommodate residents' preferences and dietary needs.

Based on record review and interviews, the facility failed to ensure pain management was provided to one of three residents in the sample. The facility failed to monitor and assess pain level with (Resident (R) 56) every shift. This deficient practice may put R56 at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. Findings Include:R56 was re-admitted to the facility on [DATE], with an initial admission date on 05/25/21. R56 diagnoses included, but not limited to, Parkinson's disease with dyskinesia, with fluctuations; Vitamin D deficiency; hyperlipidemia, unspecified, hypocalcemia; unspecified right bundle branch block; essential tremor; gout, unspecified; bilateral primary osteoarthritis of hip; bilateral osteoarthritis of knee; abnormal posture; and pain, unspecified. Review of the physician's order includes Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg) to be given by mouth three times a day related to pain, hold to respiratory rate less than 14, order date of 11/16/25. Another order for Acetaminophen 650 mg, oral tablet to be given by mouth every four hours as needed for mild to moderate pain, do not exceed three grams for 24 hours. An order to monitor pain every shift was also ordered on 11/17/25. The staff assessment for pain was conducted, indicators of pain include non-verbal sounds, vocal complaints, and facial expressions.Furthermore, a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), R56 received Acetaminophen Oral 650 mg on 12/16/25, with pain level at 0 per staff assessment. Further review of TAR for December 2025, there were missing pain level assessments done for December 17, 20, 22, 23, 24, 28, and 29, 2025, night shift. Also missing pain level assessments for January 2, 3, 6, 7, and 8, 2026, night shift. On 01/09/26, at 09:55 AM, concurrent interview and record review of the resident's record was done with Nursing Supervisor (NS) 266 confirmed the facility did not do pain assessments on R56's pain. Inquired with NS266 regarding the administration of the pain medication on MAR and pain level assessments every shift, NS266 reviewed the MAR and TAR, and she confirmed that facility did not have documentation of the pain level assessment every shift and Acetaminophen was given even with zero pain level on 12/16/25. NS266 also reported nursing staff should document in the progress notes if the pain subsided and if not, they are to call the physician. Inquired whether the facility's system for monitoring R56's pain was effective. NS266 did not confirm effective management of the resident's pain. Review of the facility's policy and procedure on 01/09/26, titled Pain Management Program stated, . The patient/resident is evaluated for pain.during periodic scheduled assessment.and whenever a change occurs in their condition .

Based on interviews and record review, the facility failed to develop a comprehensive care plan addressing the presence of a pacemaker for one of one resident (Resident (R) 10) reviewed with a pacemaker. This puts R10 at risk of cardiac complications due to lack of individualize care planning related to the pacemaker.Findings Include:On 01/07/26 at 09:10 AM, an interview with Family Member (FM) 2 and FM3 was conducted. FM2 reported R10 underwent surgery in December for pacemaker generator replacement.Review of R10's Electronic Health Record (EHR) revealed that R10 was admitted to the facility on [DATE] with a cardiac pacemaker in place. Documented diagnoses included, but not limited to, Parkinson's disease without dyskinesia and atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart's arteries without chest pain).Review of R10's cardiologist consultation form dated 11/12/25 indicated that R10 carried a diagnosis of Sick Sinus Syndrome (a heart rhythm disorder). The consultation documented that R10 was scheduled for a dual chamber pacemaker generator replacement on 12/10/25. Pre- and post-operative instructions included refraining from eating or drinking eight hours prior to the procedure, medication administration instructions, maintaining the surgical bandage and keeping it dry until the one-week follow-up visit, and use of the pacemaker home communicator/monitor.Further review of a cardiology follow-up consultation dated on 12/17/25 documented an estimated pacemaker battery life of eight years and noted that R10 was cleared to get the incision site wet and resume normal arm movement. Review of R10's comprehensive care plan revealed that the presence of the pacemaker and related care considerations were not included in the care plan. On 01/08/26 at 12:58 PM, an interview was conducted with Nursing Supervisor (NS) 287 and Registered Nurse (RN) 173. RN173 stated R10 has a pacemaker and recently underwent a surgical procedure to replace the generator. RN173 further stated that nursing staff are to monitor the incision and confirmed R10 has a machine that came with him post-operative to monitor his pacemaker, and they are to ensure it is on (the light is green). NS287 confirmed that R10's care plan did not include documentation regarding the presence of the pacemaker or the related care and monitoring and should be in there. NS287 later stated she would like to add a care plan regarding R10's pacemaker.

Based on interviews and record review, the facility failed to revise the comprehensive care plan for one of four residents (Resident (R) 10) reviewed for range of motion (ROM). R10's restorative nursing program (RNP) care plan was not revised following a pacemaker surgery that resulted in suspension of restorative services. This failure placed R10 at risk for not achieving preventative goals including maintaining strength, balance, and transfer ability, and for experiencing complication related to immobility. Findings Include:Cross Reference to F684, Quality of Care. The facility failed to communicate R10's post-operation status within departments to ensure R10 received continuous treatment and care, as soon as practicable. R10's RNP was not followed up on after the facility received documentation from the cardiologist indicating that R10 could resume normal arm movement. On 01/07/26 at 09:10 AM, an interview with Family Member (FM) 2 and FM3 was conducted. FM2 reported R10 underwent surgery in December for pacemaker generator replacement and that the facility had suspended R10's RNP services. FM2 stated that during R10's post-procedure cardiology follow-up on 12/17/25, the cardiologist cleared R10 to resume exercises. FM2 stated he followed up with a staff member yesterday and was awaiting a response.Review of R10's cardiology follow-up consultation dated 12/17/25 documented that R10 was cleared to get the incision site wet and to resume normal arm movement. The consultation form was signed by the facility receiving nurse on 12/17/25 and by the attending physician on 12/18/25. On 01/08/26 at 12:53 PM, an interview was conducted with Restorative Nursing Aide (RNA) 67, RNA154, and RNA274. The RNAs confirmed R10 previously received RNP services, which were discontinued following his pacemaker generator replacement on 12/10/25. The RNAs stated they are waiting for physician clearance and a rehabilitation therapist assessment for R10 to resume services. The RNAs reported that once a resident is cleared to resume exercises, the nursing supervisor is responsible for submitting a referral to therapy for reassessment. The RNAs stated they had not received any information regarding whether R10 would be returning to RNP services. Review of R10's comprehensive care plan documented that R10 was at risk of decreased strength balance and ability to transfer. The care plan goals included improving strength and balance to stand and transfer by participating in RNP services six times per week and remaining free from complication related to immobility, including contractures, thrombus formation, skin-breakdown, fall related to injury. On 01/08/26 at 12:58 PM, an interview was conducted with Nursing Supervisor (NS) 287. RS287 stated she was not familiar with R10's RNP status. RS287 confirmed R10 was cleared by the cardiologist for normal arm movement on 12/17/25. RS287 was not able to find documentation that therapy had been notified by nursing of R10's clearance to discuss resuming RNP services. NS287 confirmed that R10's care plan was not updated to reflect the suspension of RNP services or to include steps required to resume those services.

Based on interviews and record review, the facility failed to communicate a resident's post-operation status within departments to ensure resident received continuous treatment and care, as soon as practicable, for one of four residents (Resident (R) 10) reviewed for range of motion (ROM). Specifically, R10's restorative nursing program (RNP) was not followed up on after the facility received documentation from the cardiologist indicating that R10 could resume normal arm movement. This failure placed R10 at risk for not achieving preventative goals including maintaining strength, balance, and transfer ability, and for experiencing complication related to immobility. Findings Include:On 01/07/26 at 09:10 AM, an interview with Family Member (FM) 2 and FM3 was conducted. FM2 reported R10 underwent surgery in December for pacemaker generator replacement and that the facility had suspended R10's RNP services. FM2 stated that during R10's post-procedure cardiology follow-up on 12/17/25, the cardiologist cleared R10 to resume exercises. FM2 stated he followed up with a staff member yesterday and was awaiting a response.Review of R10's cardiology consultation dated 11/12/25 documented a diagnosis of Sick Sinus Syndrome (a heart rhythm disorder). The consultation documented that R10 was scheduled for a dual chamber pacemaker generator replacement on 12/10/25.Review of R10's cardiology follow-up consultation dated 12/17/25 documented that R10 was cleared to get the incision site wet and to resume normal arm movement. The consultation form was signed by the facility receiving nurse on 12/17/25 and by the attending physician on 12/18/25. On 01/08/26 at 12:53 PM, an interview was conducted with Restorative Nursing Aide (RNA) 67, RNA154, and RNA274. The RNAs confirmed R10 previously received RNP services, which were discontinued following his pacemaker generator replacement on 12/10/25. The RNAs stated they are waiting for physician clearance and a rehabilitation therapist assessment for R10 to resume services. The RNAs reported that once a resident is cleared to resume exercises, the nursing supervisor is responsible for submitting a referral to therapy for reassessment. The RNAs stated they had not received any information regarding whether R10 would be returning to RNP services. Review of R10's comprehensive care plan documented that R10 was at risk of decreased strength balance and ability to transfer. The care plan goals included improving strength and balance to stand and transfer by participating in RNP services six times per week and remaining free from complication related to immobility, including contractures, thrombus formation, skin-breakdown, fall related to injury.On 01/08/26 at 12:58 PM, an interview was conducted with Nursing Supervisor (NS) 287. RS287 stated she was not familiar with R10's RNP status. RS287 confirmed R10 was cleared by the cardiologist for normal arm movement on 12/17/25. RS287 was not able to find documentation that therapy had been notified by nursing of R10's clearance to discuss resuming RNP services and confirmed he has not had services since his surgery. NS287 reviewed R10's EHR and found no other documented reason for R10 not to resume RNP services. NS287 confirmed that follow-up should have occurred.On 01/08/26 at 02:47 PM, an interview was conducted with Director of Rehab (DOR). DOR stated if the physician cleared the resident to resume normal arm movement, then he should be able to restart RNP services. DOR further stated the rehabilitation department received a referral from nursing for R10's wheelchair only and completed an assessment of the wheelchair on 01/07/26, but not regarding RNP status. On 01/09/26 at 08:32 AM, an interview was conducted with Director of Nursing (DON). After review of the cardiology follow-up consultation dated 12/17/25, DON stated he would expect nursing staff to follow-up with the physician to confirm whether RNA services could resume. DON further stated he would have expected communication between nursing, therapy, and the RNP regarding recommendations for the resident's care. DON confirmed that this did not occur.

Based on observations, interviews, and record review, the facility failed to provide treatment/services to maintain and/or prevent a decline in range of motion (ROM) for one of three residents (Resident (R) 160) sampled for limited ROM. This deficient practice puts the resident at risk for decline in ROM and further contractures. Findings Include:On 01/06/26 at 11:13 AM, observed R160 lying in bed, supine with head slightly elevated and both arms against his chest area. Both hands were also bent on the wrists and angled down towards his feet. No splints or braces were observed to both upper extremities. On 01/07/26 at 11:00 AM and 02:30 PM, R160 was observed lying in bed without any splints, braces or pads to his upper extremities. R160 was a [AGE] year-old resident admitted for long-term placement on 09/02/25. Diagnoses included, but not limited to, cerebral palsy (group of conditions that affect movement and posture) and cognitive communication deficit. R160 was admitted with contractures to both upper extremities. On 01/08/26 at 01/36 PM, a concurrent interview and record review was conducted with Nursing Supervisor (NS)95 in the nurses' station. Reviewed care plan in Electronic Health Record (EHR) dated 11/24/25. Interventions stated for . at risk for decreased of ROM . included, . apply both padded elbow extenders. Place pads between forearm and bicep, wear for 2-3 hours as tolerated . Asked NS95 if the staff documented the use of the pads and where to find it in the EHR. NS95 said the Certified Nursing Assistants (CNA) documented it in the EHR but was not able to find it. On 01/08/26 at 01:41 PM, concurrent observation and interview conducted with CNA35 in R160's room. R160 was in bed with eyes closed and was observed without any splints, braces or pads to his upper extremities. Asked CNA35 if they applied padded elbow extenders to both arms and placed pads between R160's forearm and bicep. CNA35 said they used to apply them prior to R160's hospitalization in December 2025. Asked CNA35 why R160 was not observed using the pads for the past three days. CNA35 stated that when R160 returned from the hospital on [DATE], he did not have the pads with him and may have been left at the hospital. On 01/08/26 at 01:43 PM, NS95 stated in an interview that the staff should have notified her that R160 returned from the hospital without the pads used on his upper extremities since he was very contracted. On 01/09/26 at 09:55 PM, an interview was conducted with the Director of Nursing (DON) in his office. The DON confirmed that the staff were to apply the padded elbow extenders as stated in the care plan to prevent further decrease in ROM for R160

Based on observation, interviews, and record review, the facility failed to ensure adequate supervision and/or measures were in place to prevent accidents for one of one resident (Resident (R) 172) reviewed for elopement risk. As a result of this failure, R172 was able to elope from the facility without staff knowledge and arrived at a family member's home with assistance from another resident's visitor. Findings Include:R172 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, osteoarthritis of the right and left shoulders, spinal stenosis in lumbar region without neurogenic claudication, pain in the right and left feet, unsteadiness on feet, and a history of falls. Review of R172's quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 09/12/25, revealed in Section GG (Functional Abilities and Goals) that the resident used a wheelchair for mobility and had impairment of one lower extremity. In Section E (Behavior), the resident was documented to wander, with the behavior occurring 1 to 3 days during the assessment period. No other behavioral symptoms were noted. Additionally, the MDS documented the wandering behavior as worse compared to prior assessments.Review of the initial facility reported incident (Intake #2687314), received on 12/06/25, documented on 12/06/25 at approximately 03:46 PM, R172 left the facility and went to a family member's house located in front of the facility with assistance. The incident report documented someone opened the door for her and took her to the house. Facility staff became aware of the incident when R172's son notified staff that the resident was at the family member's home.Review of a nursing note documented on 12/06/25, at approximately 03:56 PM staff were notified by resident's son that R172 was in their driveway. The notes further documented that the door alarm sounded when the licensed nurse wheeled the resident back into the facility (indicating R172's wander management bracelet was working properly). When asked what happened, R172 verbalized in her native language, someone held the door open for me and assisted me back home. On 01/08/26 at 09:03 AM, an interview, concurrent observation, and record review were conducted with Director of Maintenance (DOM) and Maintenance Supervisor (MS) regarding the facility's wander management system and the door alarms. DOM reported that only a limited number of residents (fewer than ten) wear wander management bracelets that activate the system near facility exits.Concurrent observation of exit doors equipped with the wander management system revealed a green indicator light on top of the doors that changed red as the bracelet approached the doors. DOM demonstrated that when a resident wearing a bracelet approaches an exit, the door automatically locks, but no alarm will sound. An alarm sounds only if the resident attempts to open the door, and the door will open after approximately 15 seconds of continued pressure. During, observation, DOM pushed the door for approximately 15 seconds and exited the facility, at which time the alarm increased in frequency and volume. DOM further explained that if doors were ajar and unable to lock, an alarm will sound upon exit. The alarms would only shut off when a staff member enters a code.Concurrent review of the facility's monitoring log for operation of door monitors and wander management system showed routine weekly checks with no identified issues prior to the incident including checks completed prior to the incident on 12/02/25 and post-incident on 12/09/25.Review of R172's nursing tasks documented R172 had her bracelet with her and was functioning on 12/06/25.On 01/09/26 at 09:01 AM, an interview was conducted with Director of Nursing (DON) and Administrator. DON and Administrator reported that during their investigation they learned that a visitor of another resident had been talking with R172, who requested assistance getting to her home. The visitor was unaware of facility protocols for residents leaving the building and did not notify staff. The visitor assisted R172 and walked her to her family member's home located next to the facility's entrance driveway. Administrator confirmed that staff were unaware R172 was missing until her son called the facility. When asked how R172 was able to leave the facility without staff intervention, the Administrator reported that a staff member heard the door alarm, did not observe any residents in the immediate vicinity, and shut the alarm off. When further asked whether staff were required to immediately check all residents wearing wander management bracelets after hearing an alarm without identify a resident nearby, DON stated that such check were not part of the facility's protocol. DON further stated that the facility only initiates a search once a resident is identified as missing and acknowledged this may need to be addressed moving forward. Review of the facility's Elopement policy and procedure, effective 10/01/24, revealed that the outlined procedures are implemented only after it has been established that a resident is missing. The policy does not include procedures for staff response when the wandering management system alarm is activated, and staff are initially unable to identify a missing resident nor does it include a process to ensure residents wearing wander management bracelets are immediately accounted for.

Based on observations, interviews and record review, the facility failed to discard expired medications and intravenous solution stored in three of five medication rooms observed. Proper storage of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications and receive intravenous solutions.Findings Include:1) On 01/08/26 at 07:15 AM, the Ilima unit medication room was inspected. In the medication refrigerator, a clear plastic storage bag containing medication vials for Resident (R) 89 was checked. The medication label on the storage bag documented four vials of Lorazepam 2 milligram/milliliter (mg/ml) received on 06/10/25. The storage bag contained three vials (which matched the narcotic log sheet in place for this ordered and current medication), two of the three vials had an expired date of 10/2025 printed on the label. The two vials were shown to Registered Nurse (RN) 266, who confirmed that they were expired and should have been discarded. 2) On 01/08/26 at 08:02 AM, the Gardenia unit medication room was inspected with the Assistant Director of Nursing (ADON). During observation of the medication refrigerator in the room, four expired Humulin N 100u (100 units of insulin per ml) insulin pens. ADON stated the observed insulin pens were a stock supply for emergency use. Three of the pens had an expired date of 05/28/25, and one pen had an expired date of 10/10/25. The expiration dates were confirmed with ADON who stated that the expired insulin pens should have been discarded and replaced. 3) On 01/08/26 at 07:56 AM, inspection of [NAME] unit medication storage room was conducted with Nursing Supervisor (NS) 95. Observed two 1000 ml and one 500 ml bags of intravenous (IV) fluid solutions in the medication storage room. The expiration dates for all three bags were November 2025. NS95 acknowledged that the three IV bags were past their stated expiration dates and stated they should have been discarded. Asked NS95 if there were any residents in the unit currently on IV medications of IV fluids. NS95 said they had one resident that was recently receiving IV medications. Asked NS95 how often the staff check the medication room for expired medications. NS95 said the night shift nurse checks the room once a week. Review of facility policy titled Disposal of Medications, Syringes and Needles dated January 2024 stated, . Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed .

Based on observations, interview, and record review, the facility failed to ensure appropriate protective and preventive measure for infections as evidenced by the failure to label and store nebulizer equipment for one of two residents (Resident (R) 78) reviewed for infection prevention related to respiratory. As a result of this deficient practice, the facility put the resident at increased risk for infections.Findings Include:On 01/06/26 at 11:04 AM, observed R78's undated and uncovered nebulizer mask with medication chamber and tubing connected to the nebulizer machine placed on R78's nightstand.On 01/07/26 at 07:52 AM, observed R78's uncovered mask with medication chamber and tubing connected to the nebulizer machine and wedged between the nebulizer machine and box of personal belongings on R78's nightstand.On 01/08/26 at 08:29 AM, observed R78's uncovered nebulizer mask with medication chamber and tubing connected to the nebulizer machine with the tubing and mask placed over the nebulizer machine.On 01/09/26 at 08:30 AM, a review of the physician orders for R78 noted a current order that stated, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally three times a day for cough until 01/13/2026.On 01/09/26 at 08:40 AM interviewed the Assistant Director of Nursing (ADON) in her office who stated that after a nebulizer treatment is given, the mask should be washed with soap and water, air dried, and then stored in a clean, labeled storage bag. A facility policy titled, Medication Administration Nebulizers (Updraft) dated 01/23 stated, 19. When treatment is complete.disconnect.21. Rinse and disinfect the nebulizer equipment.23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.

Based on resident interview and review of policy, the facility failed to treat residents with dignity and respect for one of three residents (Resident (R) 150) reviewed for dignity. As a result of this deficiency, R150 was not promoted the right to the maintenance or enhancement of her quality of life.Findings Include: During resident interview on 01/07/26 at 10:11 AM, R150 relayed the following concerns: Staff took a long time to answer the call light (up to 30 minutes), would say they would be back and never return or would say just go in your pad; referring to urinating in incontinence underwear. R150 felt ignored and not treated with dignity because of this.Review of facility policy on call light use read: Purpose, to respond promptly to resident's call for assistance. Procedure, all facility personnel must be aware of call lights at all times, answer all call lights promptly whether or not you are assigned to the resident. Answer call lights in a prompt, calm, courteous manner, turn off the call light as soon as you enter the room, if you cannot provide the service, go get someone who can, do not leave the light on and walk away. Never make the guest/resident feel you are too busy to give assistance, offer further assistance before you leave the room.

Based on observations, interviews and review of policy, the facility failed to treat one Anonymous Resident (ARes1) and Resident (R)499 of six residents sampled, with respect and dignity. As a result of this deficiency ARes1 was not promoted the right to the maintenance of enhancement of their quality of life. The facility also left R499 in her soiled diaper for more than 40 minutes, putting R499 at risk for urinary tract infection (UTI) and perineum skin breakdown. Findings include: 1) During Resident interview on 04/10/25 at 03:00 PM, ARes1 relayed the following concerns: 1. Staff took a long time (sometimes up to forty minutes) to answer the call light. Staff would consistently say that they're not assigned to that room and pass the room without helping. ARes1 felt ignored because of this. 2. Staff did not maintain resident privacy after receiving a bath. ARes1 said the privacy curtains would be left wide open and felt exposed without wearing any clothing. 3. Staff did not wash hands before feeding. ARes1 said staff would have to be reminded to wash their hands before feeding and/or grabbing the finger foods and 4. Staff would speak in their native language (not English) when doing care. ARes1 said staff would speak to one another and felt they were talking about him/her. Review of facility policy on Call Light Use read the following; Purpose, to respond promptly to resident's call for assistance . Procedure, all facility personnel must be aware of call lights at all times, answer all call lights promptly whether or not you are assigned to the resident . Answer call lights in a prompt, calm, courteous manner, turn off the call light as soon as you enter the room, if you cannot provide the service, go get someone who can, do not leave the light on and walk away. Never make the guest/resident feel you are too busy to give assistance, offer further assistance before you leave the room . 51870 2) On 04/09/25 at 11:30 AM, observed R499 (seated in a wheelchair) and Family member (FM) (seating next to R499) outside the resident's room. As this surveyor approached R499 and F, a strong, fecal odor was smelt. FM confirmed R499 had had a bowel movement in the resident's incontinent brief a while ago. FM looked for and could not find R499's assigned Certified Nurse Assistant (CNA). Observed FM going to nurse's station to let staff know that R499 had a bowel movement and if R499 could be changed. When FM returned from speaking with a nurse (who was seated in nurse's station at the computer), FM reported the nurse instructed her to activate the call light because she was not assigned to that area. On 04/09/25 at 12:15 PM, 45 minutes after FM approached the nurse for assistance, observed CNA1 approach the resident and assisted R499 to her room to clean her soiled incontinent brief. On 04/10/25 at 12:15 PM, interview with Licensed Practical Nurse (LPN)1 completed. Asked what is the facility's policy for responding to call light or resident's family request for help to change resident's incontinent brief, she replied, If the staff is not busy with another resident, then they should help change the resident. On 04/10/25 at 12:20 PM, interview with Neighborhood Supervisor (NS)1 completed. NS1 confirmed that if the family is requesting to change the resident's incontinent brief, that NS1 would first try to find a CNA to delegate the task, and if no CNA is available, then she would help change resident's incontinent brief, if it could be safely done. On 04/11/25 at 09:05 AM, discussed the situation with the Director of Nursing (DON). DON confirmed that nurse in the nursing station should have assisted R499. DON also reported staff should be able to help residents even if they are not assigned to them. Record review of the facility's Call Light, Use of policy dated 06/12/2023, in the Purpose section, it states, To respond promptly to resident's call for assistance. In the Procedure section, it states, 2. Answer ALL call lights promptly whether or not you are assigned to the resident. 7. Never make the guest/resident feel you are too busy to give assistance

Based on observations, record review, and interview with staff members, the facility failed to implemented residents' care plans to eliminate risk of an accident related to wandering and elopement and monitor the effectiveness of interventions as necessary for 3 of 4 (Residents 1, 2, and 3) residents sampled. 1) Resident (R)1 had an actual elopement, the facility failed to revise the resident's care plan to develop person centered interventions, direct care staff were unaware of approaches/interventions to employ for R1's wandering behavior and the wandering and exit seeking behaviors were not accurately monitored resulting in no baseline data to determine the efficacy of the interventions. 2) The facility failed to develop a care plan to prevent elopement for R2 with wandering behaviors prior to the start of the survey. The facility also did not implement or accurately document care plan approaches for monitoring the function of WanderGuard once a day and the targeted behaviors (wandering and refusal of medications). 3) The facility did not implement R3's care plan to assure an elopement assessment was done quarterly. The facility also did not recognize an elopement incident, resulting in no assessment of the incident and need for care plan revision. Findings include: 1) Cross Reference to F657. The facility failed to revise Resident (R)1's care plan following an incident of actual elopement and unsafe wandering (wandering into other residents' rooms). The facility submitted an Event Report on 12/06/24 at 08:30 PM regarding R1's elopement. On 12/06/24, R1 was found outside near fence in back of unit. R1's WanderGuard (a system that provides wander management for those at risk of elopement) bracelet reportedly was in place and functioning at the start of the shift. No alarms were heard. The final report was submitted on 12/10/24 at 02:35 PM. The facility clarified, R1 was found outside of the building behind the activities center. The House Supervisor saw the WanderGuard alert on another unit (North) and notified R1's unit (Pikake). Another staff member saw R1 from the window of another unit (Ilima) and notified the Pikake unit. The facility's investigation found the door to enter the activities department from the Pikake unit was not locked and R1 was able to enter the room and access the emergency exit door at the rear of the building. The emergency exit door is equipped with a locking mechanism that will allow the exit door to open after being held for 15 seconds. On 01/13/25 at 10:50 AM record review was done. R1 was readmitted to the facility on [DATE]. Diagnoses include but not limited to unspecified dementia, unspecified severity with anxiety; unspecified dementia, unspecified severity with agitation; nondisplaced intertrochanteric fracture of left femur (routine healing); cognitive communication deficit; aphasia (a language disorder that makes it difficult to understand or express language); and anxiety disorder. Review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/21/24 notes R1 has severe cognitive impairment and was coded for wandering behavior. R1 requires supervision or touching assistance for walking. A review of the Elopement Risk Evaluation dated 10/24/24 documents R1's risk score was 5 (high risk - further assessment is needed). Interventions recommended included elopement deterrent device implemented and elopement prevention care plan initiated or updated. Subsequent assessment dated [DATE] (following actual elopement), R1's risk score was 3 (moderate risk - improvement) with intervention recommended for elopement prevention care plan initiated or updated. Review of R1's care plan for behavioral symptoms with a start date of 11/09/22 identifies R1 has depression and agitation and may demonstrate the following challenging behaviors: agitation, restlessness, anxiety, wandering exit seeking behaviors, entering other resident's room, and refusal of care. An approach with start date of 08/23/23 was developed for wandering. Approaches include, ask me if I need anything or offer me drink/food/toilet/lie down/activity; monitor my whereabouts; provide redirection and reorientation as needed, state what I should do, not what I should not do; follow me for safety until I can be redirected; and I was issued a WanderGuard device that locks exit door when I approach. Other approaches include: being at risk for wandering/elopement due to cognitive impairment, refer to wandering care plan (start date 03/14/23); resident may express confusion and insist on going home, at these times, do frequent visual checks, as I may wander off unit, flow sheet for every hour (start date of 08/01/24); I use a Wander Guard, please check the placement every shift (start date of 06/23/23); and a falls care plan to monitor resident frequently for safety, encourage to take rest periods in between walking activity, when walking, I may become agitated when staff tells me that I require assistance, encourage me to use my walker and take breaks; and if I appear restless, increase rounding until I am calm. A review of the progress notes from 11/29/24 to 01/12/25 found documentation of R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, R1 wandered into another resident's room at night; 12/08/24 at 03:30 PM, R1 sometimes walks into other residents' rooms looking for the toilet; 12/15/24 at 08:55 PM, R1 was wandering a lot on the unit and it was reported R1 was found in another resident's room. The documentation in the progress notes were not detailed to identify which rooms R1 entered, what she was doing in the room, if other residents were present at that time, what interventions were tried to deter the behavior. There were other entries documenting R1 wandering on the unit, going from room to room and standing at the door, and exit seeking behavior. On 01/13/25 at 01:16 PM, observed R5 seated by the door of her room, R5 reported R1 was once found in her room, sitting on the toilet. R5 resides in room [ROOM NUMBER]. R5 reported being surprised to find R1 using her toilet. Upon discovery, R5 stated R1 shook her finger at her to indicate R5 was in the wrong. R5 also reported seeing R1 stand in front of other residents' doors, blocking their way into their room and walking about the unit. On 01/13/25 at 02:11 PM, observed R1 in a wheelchair, self-propelling on the unit. Did not observe staff members employing approaches for wandering. At 02:17 PM, observed R1 enter room [ROOM NUMBER]. R1 transferred herself from the wheelchair onto Bed A and laid down. At 02:30 PM observed two staff members enter the room, they stood by the foot of Bed A, then exited the room. At 02:35 PM, observed Certified Nurse Aide (CNA)1 enter room [ROOM NUMBER], the curtain was drawn closed while CNA1 assisted R1 back to the wheelchair. CNA1 wheeled R1 back to her room and assisted R1 back to bed. On 01/13/25 at 02:40 PM, interviewed CNA1. CNA1 confirmed R1 was in the wrong room. Inquired what are the approaches used to for R1's wandering. CNA1 reported the nurses know what to do. Further queried as an aide, what is she supposed to do, CNA1 responded she doesn't know what to do but the nurses know. CNA1 was asked how often is R1's whereabouts monitored, CNA1 responded one to two hours. On 01/14/25 at 07:50 AM interviewed the Unit Nurse (UN) at the Pikake unit in the nurses' station. Reviewed the progress notes with the UN. Inquired about incident of 11/29/24 when staff discovered R1 in a resident's room and the team decided to place a Stop banner in the doorway. UN initially could not recall the incident and later stated this entry documents R1 was found in room [ROOM NUMBER] and the team agreed to place a Stop banner on the door. Concurrent review of the progress notes documenting incidents of R1 wandering into other residents' rooms was done with UN. Requested UN review the care plan for revisions after the incidents. UN was unable to confirm R1's care plan approaches were revised to address wandering into other residents' rooms. Based on the progress notes, UN was unable to identify which rooms R1 wandered into and stated it isn't feasible to place Stop banners in all residents' doorways to prevent R1 from entering. Concurrent observation of room [ROOM NUMBER] was done with the UN. There was a banner affixed to the doorway which was not placed across the doorway. Inquired when does the facility use the banner, UN responded it is up to the resident. Further review of the Treatments Administration History (TAH) for December 2024 found a flow sheet for the approach to check WanderGuard placement every shift with instruction to use (+) present and (-) not. The flow sheet for December 2024 had entries documenting the WanderGuard was not present (-) for the following dates and shifts: 12/05/24 - NOC; 12/07/24 - PM; 12/09/24 - day; 12/12/24 - PM shift; 12/15/24 - PM; 12/16/24 - PM; 12/17/24 - day; 12/17/24 - PM; 12/23/24 - PM; 12/23/24 - NOC; 12/26/24 - day; 12/26/24 - PM; and 12/27/24 - NOC. There was also a flow sheet to monitor the following target behaviors: 1) agitation, 2) restlessness, 3) anxiety, 4) depression, 5) ambulate without assistance, 6) refuse care/treatment, and 7) poor appetite. Of the 63 opportunities to document for ambulating without assistance, there were only five entries to document R1 ambulated without assistance. This documentation was inconsistent with the progress note entries which noted 17 entries of wandering on unit (ambulating without assistance) and exit seeking behavior. Requested additional information on the morning of 01/14/25 to demonstrate the multidisciplinary team met to do root cause analysis and update R1's care plan. The facility provided a grievance report from R6 complaining that R1 has been wandering into her room every night and was awakened to find R1 staring at her. The team agreed to place a Stop banner across the R6's room and nursing staff was reeducated regarding wandering residents. On 01/14/25 at 11:07 AM interviewed the Administrator. The Administrator explained the staff reenacted the event and found that the WanderGuard triggered at the North unit, however, the alarm to the emergency exit could not be heard on the unit as the door was closed. The Administrator reported the team consulted the physician and assessed a possible causal factor was the drug interaction of Remeron (antidepressant) and Sertraline (antidepressant) may have contributed to increase in wandering behavior. R1's Sertraline dosage was decreased to 75 mg for seven days, then 50 mg after the first seven days. On 01/14/25 at 01:05 PM, discussed inconsistent documentation of wandering and elopement occurrences with the Administrator. Administrator reported the charting may be done according to who observes the behavior, the nurses or the aides. The Administrator provided documentation, Point of Care History for 11/14/24 to 12/14/24. There were six entries to indicate interventions were taken to alter wandering. Administrator reported the electronic record needs to be programmed for the aides to document wandering behavior. Inquired when was this behavior loaded to enable the aides to document this behavior. The Administrator was not sure. 2) Cross Reference to F686, Comprehensive Care Plan. The facility did not ensure R2's care plan was implemented consistently to monitor resident's targeted behavior of wandering every shift and ensuring the functioning of WanderGuard functioning once a day. Observation on 01/13/25 at noon saw R2 seated in a wheelchair in the hall next to the door of her room. Observation at 01:00 PM, R2 was standing at a table with two other female residents and talking. Subsequently, R2 was observed to follow staff around the unit. R2 was independently ambulatory. Later R2 was observed sitting at a table by the nurses' station, watching television. Later observed R2 seated in activities for volleyball, R2 was smiling. On 01/13/25 at 01:39 PM a record review was done for R2. R2 was admitted to the facility on [DATE]. Diagnoses include but not limited to, Alzheimer's with early onset; dementia in other diseases classified elsewhere, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety; chronic kidney disease, stage 2 (mild); wandering in diseases classified elsewhere; and other abnormalities of gait and mobility. A review of the quarterly MDS with an ARD of 11/26/24 noted R2 was assessed with moderate cognitive impairment for decision making skills. R2 was also coded for wandering behavior, occurred one to three days during the assessment period. The facility developed a care plan during the survey for R2 being at risk for elopement due to history of wandering and severe cognitive impairment. Approaches included: if I am going toward unit exit, please help me back to my room where staff can supervise me; I use a WanderGuard for safety, please check the placement every shift; if I become agitated and difficult to redirect, I may require 1:1 supervision to manage my wandering; and please refer to my activity care plan for my preferences and things that interest me. Prior approaches for wandering with a start date of 02/09/21 included but not limited to: 12/17/22 - WanderGuard to my dominant risk (right side) as I tend to wander around at night and attempt to leave the facility out of curiosity. Monitor my WanderGuard is in place every shift; and 12/27/22 - Wandering/exit seeking, when observed redirect me to my unit/room, offer me something to eat/drink or offer me to use the bathroom, encourage me to engage in group activities every shift Further review found no Wandering/Elopement Risk assessment was done since R2's admission. On 01/13/25 at 03:13 PM, requested to review R2's wandering/elopement risk assessment. At 03:30 PM, the Administrator and Administrator in Training (AIT) reported they could not find an assessment but would continue to locate an assessment. The facility did not provide documentation of wandering/elopement risk assessment prior to exit. The Treatments Administration History (TAH) for December 2024 and 01/01/25 through 01/14/25 found an order to monitor target behaviors, wandering and refusal of medication. There were missing entries for the following dates-shifts: 11/07/24 - day, 11/11/24 - PM, 11/18/24 - PM, 12/08/24 - day shift, 12/16/24 - day shift, 01/02/25 - day shift, and 01/02/25 - PM shift. The entry spot for Exhibited Behavior # was populated with 0s and 1s. There was also an area to document, Intensity Before, and Frequency Before. It was unclear what the numbers represented. Further review noted missing entries to ensure functioning of WanderGuard (start date of 12/27/24) on the following dates, 12/29/24, 12/30/24, 01/03/25, 01/04/25, and 01/08/25. On 01/14/25 at 10:20 AM, an interview with the UN was done. The UN reported the coding for exhibited behavior # is: 1 for documenting wandering behavior and 2 for refusal of medication and a 0 would indicate there were no behaviors observed. On 01/14/25 at 11:07 AM, interviewed the Administrator and Administrator In Training (AIT). Administrator reported, she was surprised R2 did not have an elopement risk and a care plan as the facility audited the chart. Administrator acknowledged the TAH for monitoring of target behaviors (wandering and refusal of medication) could be confusing and they will considering separating the two behaviors. Review of the facility's policy and procedures entitled Wandering/Elopement Risk Assessment with original effective date of 05/0/21 notes the facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. The policy includes but not limited to the following: 3) Patients/residents are re-assessed for elopement potential by the MDS Nurse/Social Service/Nurse or designee quarterly throughout a patient's/resident's stay and with a significant change. 4) Interventions will be added to the patient's/resident's care plan after analyzing the information obtained. 5) The licensed nurse or social service designee completes the Elopement Risk Evaluation and presents the information to the Interdisciplinary Team for further interventions. 3) R3 was admitted to the facility on [DATE]. Diagnoses include but not limited to unspecified dementia, unspecified severity without behavior disturbance, psychotic disturbance, mood disturbance and anxiety; Type 2 diabetes mellitus, and primary osteoarthritis. On 01/13/25 at 10:10 AM an entrance interview was conducted with the Administrator. Requested a list of residents that eloped from the last recertification survey done on 10/18/24 to present. At 11:18 AM, the Administrator reported there were no other incidents of elopement and provided a listing of residents who wear WanderGuard devices. R3 was selected from this listing. On 01/13/25 at 02:56 PM a record review was done. The quarterly MDS with an ARD of 12/30/24 noted R3 was assessed with moderate cognitive impairment. R3 was not coded to exhibit wandering behavior in the assessment period. A review of the Elopement Risk Evaluation dated 09/14/24 indicated R3 was assessed at high risk (further assessment is needed) for elopement risk. There was no documentation of a subsequent quarterly risk evaluation completed for December 2024. Review of the care plan with start date of 06/26/24 for risk of elopement had the following approaches with a start date of 01/13/25, ensure an elopement assessment is done on me quarterly and/or PRN as necessary. A review of the progress notes found an entry dated 11/12/24 at 08:59 AM by social services documenting social services heard exit alarm and found resident outside of East exit door in front of SS office. A review of the facility's campus map notes the East Entrance is across the social services' office. Further review found no follow up elopement risk assessment or care plan revision. On 01/14/25 at 10:10 AM, Administrator confirmed the East Entrance is equipped with WanderGuard system. On 01/14/25 at 10:15 AM interview with UN was done at the nurses' station. Concurrent review of the progress notes of 11/12/24 was done. UN reported that this was not an elopement, R3 was found outside of the social services' office within the facility.

Based on observation and interview with staff members, the facility did not execute a resident's right to reside in a clean home environment. Findings include: On 01/13/25 at 02:11 PM, observed Resident (R)1 in a wheelchair, self-propelling on her unit. At 02:17 PM, observed R1 enter room [ROOM NUMBER]. R1 transferred herself from the wheelchair onto Bed A and laid down. At 02:30 PM observed staff members enter room [ROOM NUMBER], stood by the foot of Bed A, then exit the room. At 02:35 AM, observed Certified Nurse Aide (CNA)1 enter room [ROOM NUMBER], close the privacy curtain and assisted R1 back to the wheelchair. CNA1 wheeled R1 back to her room. Observed room [ROOM NUMBER] with signage for Enhanced Barrier Precautions (EBP - set of infection control practices that involve wearing gowns and gloves during high-contact care for residents at risk of infection, i.e. indwelling medical devices, wounds). CNA2 reported the reason for EBP is R6 receives dialysis treatment. Observation from 02:40 PM to 02:50 PM, the linen for R6 was not changed. CNA1 was observed leaving the unit with personal belongings (bags). Interviewed Licensed Nurse (LN)1 at 02:50 PM. LN1 confirmed the linen needed to be changed and she would have someone change it. On 01/14/25 at 10:10 AM interviewed Infection Preventionist (IP) in the hall. Observation of R1 lying in R6's bed was shared with the IP. IP reported R1's lying in R6's bed may affect R6, however, it is basically a hygiene concern. IP further stated transmission of an infection is low.

Based on observations, record review, and interview with staff members, the facility failed to develop a person-centered comprehensive care plan for 1 (Resident 2) of 4 residents reviewed for wandering/elopement behavior. This deficient practice has the potential to place resident at risk for accidents (i.e., falls, resident to resident altercations) and affect the resident's ability to achieve and maintain her highest medical, mental, and psychosocial needs and to cause adverse effects related to falls and resident to resident altercations. Findings include: Cross Reference to F689. Resident (R)2 has been identified for being at risk for elopement with a history of wandering behavior. The facility failed to conduct annual and quarterly elopement risk assessments, and implement care plan for wandering behavior. On 01/13/25 from 12:00 PM to 01:00 PM intermittent observations found R2 wandering on her unit, sometimes stopping to talk to other residents and at times would follow staff around the unit. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/26/24 noted R2 was assessed with moderate cognitive impairment for decision making. R2 was also coded for wandering behavior which occurred one to three days in the observation period. On 01/14/25 at 11:07 AM, the Administrator reported they missed R2 in their audits. The Administrator also reported the facility does not have any documentation of an Elopement Risk Evaluation and confirmed a care plan for elopement risk was just developed on 01/13/25 upon discovery elopement risk evaluations for this resident was not done

Based on observations, record review, and interviews with staff members, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised following an actual incident of elopement for 1 (Resident 1) of 4 residents in the sample. Findings include: Cross Reference to F689. Resident (R)1 had an actual elopement on 12/06/24 and wandering behavior that places R1 at risk for falls, resident to resident altercations, and elopement. Review of R1's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 10/21/24 notes R1 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. R1 was also coded for wandering, occurring one to three days during the observation period. R1 requires supervision or touching assistance for walking 10 feet, walking 50 feet with two turns, and walking 150 feet. A review of R1's progress notes from 11/29/24 to 01/12/25 found entries of R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, R1 wandered into another resident's room at night; 12/08/24, R1 sometimes walked into other residents' room looking for the toilet; and 12/15/24 at 08:55 PM, R1 was wandering a lot on the unit and was found in another resident's room. Review of R1's care plan found approaches for wandering with a start date of 08/23/23. Approaches/Interventions included: ask me if I need anything or offer me drink/food/toilet/lie down/activity; monitor my whereabouts; provide redirection and reorientation as needed, state what I should do not what I should not do; follow me for safety until I can be redirected, I was issued a WanderGuard device that locks exit door when I approach. There were no care plan revisions to assess the efficacy of current approaches and/or to develop new approaches following actual event of elopement and incidents of resident entering other residents' rooms. On 01/14/25 at 07:50 AM an interview and concurrent record review was done with the Unit Nurse (UN). Inquired whether the facility revised R1's care plans after the wandering incident on 11/29/24. UN stated the team decided to place a Stop banner across the door of the room R1 entered. UN also stated it wouldn't be feasible to place these banners across all residents' doorways to prevent R1 from entering. UN was unable to confirm R1's care plan was revised.

Based on interviews and record review, failed to ensure one resident's right to be free from abuse. R106 hit R141 in her legs with his wheelchair, then left laughing. R141 sustained a 10 cm x 10 cm blue/purple discoloration on the left medial knee and 0.5cm x 0.5 cm light red mark on the left leg just below knee and reported to staff that she was going to her room because she was feeling unsafe because R106 hit her. As a result of this deficient practice, residents in the presence of R106 have the potential for abuse and more than minimal harm. Findings include: Review of the Facility Reported Incident (FRI) #11157, documented on 08/21/24 at 01:15 PM, R141 reported R106 hit her with his wheelchair, reversed the wheelchair then propelled away from the resident laughing. R141 reported that both resident's knees contacted each other when R106 banged her. Staff assessed R141 and documented a 10 cm x 10 cm blue/purple discoloration on the left medical knee and 0.5 cm x 0.5 cm light red mark on the left leg just below R141's knee. R141 reported that she does not feel safe and R106 intentionally hit her and R141 did not report it to staff at the time of the incident but reported the incident due to bruising and fear of her safety. The facility reviewed and revised both resident's care plans and R106 was immediately moved to another unit for R141's safety. At the time of this surveyor's investigation, the facility had corrected the deficient practice and ensured residents with contact with R106 remained safe and free from abuse and found this deficient practice to be past non-compliance and no Plan of Correction is required for this citation.

Based on observations, interview, Electronic Health Record (EHR) review and policy review the facility failed to assess pain prior to and manage one Resident (R) of the sampled, R252's pain during a dressing change for his stage 4 pressure ulcer (PU) on his right buttock. The deficient practice prevented R252 from attaining and maintaining his highest level of wellbeing. Findings Include: On 10/17/24 at 01:40 PM spoke with Registered Nurse (RN) 26 and inquired if she had done the dressing change for R99. She confirmed she had already done the dressing change to R99's feet/legs. Inquired if she was going to do a dressing change soon and RN26 stated she was going to do a dressing change for R252. On 10/17/24 at 01:50 PM observed dressing change for R252's stage 4 PU to his right buttock. RN26, RN30 and Advance Practice Registered Nurse RX (APRN RX) 1 were present in R252's room for the dressing change. R252 was assisted with turning onto his left side by RN26 and RN30 and his clothing and adult brief was pulled down to expose his right buttock. Dressing to R252's right buttock was intact and RN30 told R252 she was going to remove the dressing. RN30 removed the top of the dressing to expose R252's skin and wound packing that was in place. RN 30 and RN26 switched places. RN30 was now facing resident and RN26 was behind R252. RN26 started to remove the packing from R252's wound and resident could be heard crying and saying repeatedly It hurts! It hurts! It hurts! R252 was also observed extending his right arm and balling up his fist a couple of times (not to hit anyone) as he cried. RN30 told resident You're ok. APRN RX1 inquired when resident was last medicated for pain and RN26 responded around 9 am. RN26 continued with dressing change by cleansing the wound bed with Dakin's Solution (sodium hypochlorite) 0.125% and packed the wound bed with 1/4 strength Dakins moistened gauze. R252 continued to cry. RN26 covered the wound with an abdominal pad and applied tape. R252 was turned to his back by RN26 and RN30 and repositioned in his bed. APRNRX1, RN26, and RN30 left R252's room. R252 was interviewed at this time. R252 had his eyes closed and was crying. R252 was encouraged by surveyor to take deep breaths which he did. R252 was able to calm down and talk with surveyor. Inquired with R252 if he was medicated or offered pain medication prior to the dressing change and he said, no I forgot to ask the staff for the medication and he stated it was my fault. Resident was reassured this was not his fault. Surveyor asked R252 what his pain was at on a scale of 1-10 and resident stated, 8 or 9. On 10/17/24 at 02:05 PM interviewed RN30, who is the unit manager. Inquired what stage R252's PU is and RN30 stated it is a stage 4 PU, that it was on his admission paperwork yesterday when he was admitted . Inquired if she would medicate a resident prior to a dressing change and RN30 stated not necessarily. Inquired if she would premedicate a resident who has a stage 4 PU before a dressing change and she said yes. On 10/17/24 Record Review (RR) of R252's EHR revealed R252 is a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis that includes, but are not limited to, pressure ulcer of right buttock, stage 4; insomnia, unspecified; and pain, unspecified. R252 weighs 95.2 pounds. Review of R252's Care Plan (CP) revealed Problem Start Date 10/17/2024 Category: Pain I am at risk for acute/chronic pain that may affect my wellbeing. Goal Target Date: 01/17/2025 will have relief from pain within one hour of PRN pain medication administration. Approach Start Date: 10/17/2024 Administer pain medications as ordered, see MAR (Medication Administration Record). Assess and provide pre-medication as indicated prior to activities, therapies, procedures, treatments to optimize my function and comfort. Assess me for breakthrough pain and provide PRN analgesics as ordered. Document the effectiveness on MAR. Assess the effectiveness of the medication, current treatment regime, and the impact of the pain management program on me. Assess the impact of acute/chronic pain on my function and wellbeing. Notify MD for concerns Assess the location, severity, duration, time of onset, and pattern of my pain. Observe me for signs of non-verbal expression of pain, such as grimacing, crying, guarding, rocking, etc. Last reviewed/revised on 10/17/24 at 09:55 AM by RN35. Review of R252's Brief Interview for Mental Status (BIMS) dated 10/17/24 with a score of 13 out of 15 identified him as cognitively intact. Continuation of RR revealed medications ordered to control R252's pain include the following: Oxycodone 5 mg tablet 1 tablet by mouth every 4 hours PRN (as needed) for moderate - severe pain. R252 received this medication on 10/16/24 at 20:24 (08:24 PM) for pain he rated a 6 out of 10 and the medication was documented as NE (Not Effective). Morphine concentrate solution 100 mg/5 ml (20 mg/ml) amount to administer 5 mg oral every 4 hours PRN (as needed) Dx: Pain, Unspecified. This was given on 10/17/24 at 01:59 AM, at 09:14 AM and at 14:03 (2:03 PM) for pain and documented as E (Effective). R252 also has an order for Pain monitor Q (every) shift. R252's pain was documented with no pain on 10/16/24 evening shift, had 10 out of 10 pain to his peri area/buttocks on 10/16/24 night shift and 9 out of 10 pain to his coccyx on 10/17/24 day shift. Continued RR on 10/17/24 found RN26 documented in R252's EHR a progress note with a date and time of 10/17/2024 at 14:29 (02:29 PM) Res (Resident) A&Ox4 (Alert and oriented X4). Calm and cooperative with care. Compliant with medications. Denied therapy d/t experiencing pain. No facial droop noted. Bilat hand grip equal in strength. Speech clear, medications taken W/T w/ no concerns or difficulty swallowing. Res (Resident) up in WC throughout shift. Res (Resident) c/o pain 5/10 while laying in bed, requested morphine. Morphine concentrate 5mg given at 0914 (09:14 AM) w/ positive effect. Frequent rounding completed, no signs of distress noted. Sacral wound dressing change completed as ordered. Cleansed with 1/4 strength Dakins, gently pack wound bed w/ moistened gauze and cover with ABD pad. Res (Resident) grimacing during change but no request to stop. Upon assessment post dressing change, res (resident) reported 9-10/10 pain. Morphine concentrate 5mg given at 1403 with positive effect. Safety precautions maintained. Call light within reach while in bed. please refer to CNA charting for ADLs. Continuation of RR on 10/17/24 of R252's EHR found RN30 had written a progress note that was dated and timed 10/17/2024 at 15:43 (03:43 PM) which stated This RN observed wound care for res (resident) to R (right) buttock stage IV. LN (Licensed Nurse) (staff's initials) conducted wound care tx (treatment) with this RN and APRN (staff's initials) present. Noted to be passed out initially, res (resident) verbalized, I was passed out. Noted to be in pain during middle of wound care visit while this RN and LN (staff's initials) repositioned him. Wound noted to be clean. No odor noted. Res (Resident) able to tolerate wound care tx (treatment) with therapeutic communication, reminded that tx (treatment) is being provided and that he is OK and was crying by verbalizing ow, ow, ow. Res (Resident) stopped crying out after repositioning completed and staff able to complete wound care tx (treatment). Resident appeared to have fallen back asleep. APRN (staff's initials) notified regarding pain - will offer prn pain meds prior to wound care. Continue with Q2 hour repositioning with cushion under [NAME]. Verbalize understanding. Continue to monitor. On 10/18/24 at 08:25 AM interviewed unit manager, RN30. Inquired about R252's pressure ulcer and RN stated it was her first time seeing the resident's wound. RN30 stated R252 has a stage 4 pressure ulcer to his right buttock. Inquired if RN30 could explain what it meant when a resident has a stage 4 pressure ulcer and RN30 stated there is a wound bed and things can be seen. Asked RN30 to explain the difference between a stage 2 and a stage 4 pressure ulcer and she was able to share the stage 2 pressure ulcer has some skin breakdown and the stage 4 has a wound bed and things can be seen such as bone. RN30 shared that sometimes people don't feel sensation or pain with this type of sore. RN30 stated R252 is new to her. Inquired of RN30 what the routine procedure would be for doing a dressing change with someone who has a stage 4 pressure ulcer. RN stated, assess for pain. Inquired if this was done with R252 and RN30 stated no that he had received medication earlier at around 9 am. RN30 stated she had to tap the resident and say his name to arouse him before the dressing change. Inquired if she would assess for pain prior to dressing change and she said yes. RN30 stated if you have medications you can give it and then get everything ready for the dressing change. RN30 stated they could have given R252 the fast-acting morphine prior to the dressing change. Inquired of RN30 if this was a liquid form and she confirmed it is. RN30 confirmed this was not done for the resident prior to the dressing change on 10/17/24. On 10/18/24 at 09:10 AM requested from Administrator copies of all Medical Doctor (MD) and/or APRN progress notes written for R252. Also requested facility policies and training on wound care and pain management. Requested dates nursing staff completed these trainings. Administrator provided these soon afterwards. On 10/30/24 review of SNF Visit Note written by APRN RX1 which was signed electronically on 10/23/24 at 03:47 PM for Date of Encounter: 10/17/2024 included . 2. Subjective: 74 yo male patient presents for SNF tuck in visit. He is observed resting quietly in bed without signs or symptoms of pain or discomfort. Multiple attempts to wake him made with RN at bedside. He does wake up with physical stimuli and states i was passed out. Patient is agreeable to dressing change at this visit. Myself, RN (Staff's first name) and RN (Staff's first name) at bedside for wound evaluation and dressing change. Patient able to independently reposition BLE (bilateral lower extremities) and BUE (bilateral upper extremities) for wound care. Wound packing removed with mild discomfort. Wound cavity assessed and re-packed. Patient with mild discomfort but tolerable. Dressing change completed. Review of facility policy titled Skin Management System with revision date 11/2/23 states Licensed nurses will: a. Assess all residents for pain and treat the resident accordingly before, during and after treatments as needed. Review of facility staff Skin and Wound Care training revealed RN30 did this training on 12/26/23. RN26's name was not listed as completing this training. The training discusses Stage 4 PU identifying it as: Full thickness skin loss with exposed or directly palpable fascia, bone, tendon, ligament, cartilage or muscle Slough or eschar may be present on some parts of the wound bed Often include undermining and tunneling Treatment for PU in the Skin and Wound Care training included: Considerations Etiology of the wound Characteristics of the wound Location of the wound Goals and preferences of resident/representative (healing vs palliation/comfort) Manage tissue load Wound care Pain management Review of facility policy titled Pain Management Policy with a revision date of 07/12/2023 states Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. 7. Patient/Resident should be evaluated for any needed pain medication prior to, during and after treatments (i.e. wounds),care and/or therapies. Review of facility Pain Management Program with a revision date of 07/12/2013 states The first step in the management of pain is the recognition of pain. Is pain present? The patient/resident is evaluated for pain upon admission, during periodic scheduled assessments, before, during and after therapies and treatments and whenever a change occurs in their condition (e.g., after a fall or other trauma or when a change occurs in the patient/resident's behavior, daily routines or mental status). Nonspecific and often nonverbal signs that may suggest the presence of pain include: . Fidgeting, increasing or recurring restlessness . Sighing, groaning, crying, breathing heavily .

Based on observations, interview, record review, narcotic count sheet review and policy review the facility failed to: 1) Label open on dates for five of six blood glucose test strips stored in two medication carts, have a nurse sign the narcotic count sheet when the count was done, store unopened insulin in a refrigerator per manufacture instructions and discard expired medication by the discard by date, 2) Ensure all medications used in the facility were stored in accordance with manufacturer recommendations in 3 of 16 medication carts and 3) Discard an expired medication stored on the storage cart. The deficient practice could affect residents having their blood glucose tested if the strip is expired, affect a resident receiving narcotic pain medication if the count has to be reconciled, affect a resident who is ordered insulin but cannot receive what is on hand due to it being stored incorrectly, affect a resident receiving an expired medication. Proper storage of medications is necessary to promote safe administration practices and decrease the risk of medication errors and/or adverse effects. Findings include: 1) On [DATE] at 09:43 AM observed a medication cart with Registered Nurse (RN) 10. Observed three bottles of blood glucose test strips in a drawer with no opened on date written on the containers. The three bottles were taken out of the medication cart and lined up. All three bottles did not have a seal covering the opening. RN10 confirmed there were no opened on dates on the three bottles and then proceeded to write [DATE] on one of the bottles. Inquired how she knew which bottle she opened and stated because of the placement in the drawer. Below the date opened box, on the blood glucose test strip bottles, the manufacture instructed Use within 90 days (3) months of first opening. On [DATE] at 10:13 AM observed a second medication cart with RN11 who also had three bottles of glucose test strips in the medication cart with two without the opened on date written on the bottles. RN11 confirmed he could not tell if the other containers were opened as there is no seal on the other two undated blood glucose strip containers. 43245 2) On [DATE] at 09:08 AM, an inspection of the North Team 2 medication cart was done with RN3. Observed what appeared to be an unopened box of Humulin R insulin for Resident (R)8 in the top drawer of the medication cart. Concurrent interview with RN3 was done. RN3 agreed all insulin should be refrigerated until opened. RN3 removed the plastic tape on the insulin box, opened the box, and confirmed that the seal on the insulin vial was intact. RN3 reported that she did not know who or when the insulin was placed in the cart. Confirmed that there was also an open vial of Humulin R insulin for R8 in the cart already. On [DATE] at 09:40 AM, during an interview with RN3 in the Nurses' Station, RN3 stated she had put the unopened insulin back in the refrigerator. Review of facility policy and procedure for Medication Storage, last revised [DATE], revealed the following: Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurse's station. 39754 3) Observation of a Medication Storage Cart on [DATE] at 09:00 AM, a bag containing Hydrocortisone 25mg was expired with a label which read discard by ,d+[DATE]. During staff interview on [DATE] at 09:05 AM, RN4 acknowledged that the medication previously mentioned was expired and should have been discarded.

Based on interviews and record review, the facility failed to ensure the resident's right to be informed in advance, of the risk and benefits of the use of a psychotropic medication, and consent to treatment for two of five (Resident (R)134 and R141) sampled. R134's Resident Representative (RR)4 was not aware that the resident was receiving duplicate antidepressant therapy. RR4 confirmed the risk/benefits, education was not provided to RR4 regarding duplicate antidepressant therapy and did not sign a consent form. Requested a consent form from the facility and the facility confirmed a consent form was not obtained from RR4. As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: 1) On 10/16/24 at 10:13 AM, conducted an interview with R134's Resident Representative (RR)4. During the interview, inquired about the three large bandages on R134's head. RR4 reported R134 frequently scratching and picking at his skin, on his head. Asked RR4 what interventions are the facility implementing for R134's scratching/picking behavior. RR4 confirmed being R134's healthcare decision maker and stated they are covering the area with bandages. Asked RR4 if R134 was on a medication to help with the resident's scratching/picking behavior. RR4 reported R134 is taking melatonin for his sleep and something else to help the resident with eating but could not remember the name of it. This surveyor informed RR4 that this surveyor was going to list several antidepressants and if RR4 recognizes any of these medications, to let this surveyor know, RR4 agreed, then listed the following medications: Celexa also known as citalopram (generic name); Lexapro also known as escitalopram (generic name); Remeron also known as mirtazapine (generic name); ; and Zoloft also known as sertraline (generic name). RR4 reported mirtazapine sounded familiar and it's to help with R134's appetite, but the other medications did not sound familiar. This surveyor informed RR4 that R134 has been receiving Lexapro also known as escitalopram since 08/17/24 and the medication is another group of antidepressant medication. Inquired if RR4 recalls signing a consent form and/or education on the risk and benefits of Lexapro. RR4 confirmed he recalls a consent form for melatonin and Mirtazapine for R134's appetite (which RR4 confirmed was recently increased) but did not complete a consent form for Lexapro. RR4 did not recall the facility informing him about the Lexapro prior to R134 receiving the medication and was not informed of R134 being on two different types of antidepressants. Review of R134's Electronic Health Record (EHR) on 10/16/24 at 09:54 PM, documented a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD)) on 09/15/24, documented Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 4, indicating the resident has significant cognitive impairment. R134 had a physician's order for an antidepressant, Lexapro tablet, 5 milligrams (mg) by mouth (PO) once a day, started on 08/17/24 at 08:00 AM and is open ended (no stop date), with a diagnosis of skin picking disorder. Review of the EHR did not include an Informed Consent for Psychotropic Medication-Antidepressant form for the use of Lexapro. R134's progress notes documented two progress notes, in which the first progress notes documents, on 08/16/24, prior to administration of the medication, evening staff endorsing to day shift to update the family. Then on 08/17/24 during day shift, the facility attempted to call POA (RR4) regarding new orders. There is no documentation after the 08/17/24 progress note documenting the facility got a consent, was updated, or was explained the risk/benefits of Lexapro, until 10/17/24 at 01:08 PM, which is after this surveyor completed an interview and concurrent record review of R134's EHR with the Unit Manager (UM)4 regarding a consent form for the use of Lexapro. - On 08/16/24 at 22:02 (10:02 PM) .Start Lexapro 5 mg q AM (every morning). Endorsing day shift to update the family. - On 08/17/24 at 01:09 PM, was edited, on 08/17/24 at 06:23 PM, to include At 1310 (01:10 PM) Attempted to call POA but LM regarding new orders. On 10/17/24 at 09:46 AM, conducted a concurrent interview and record review of R134's EHR with UM4. Requested to review R134's Informed Consent for Psychotropic Medication- Antidepressants form for the use of Lexapro. UM4 reviewed R134's EHR and could not locate an informed consent for the use of Lexapro for R134. Requested and provided UM4 an opportunity to provide any other form of documentation that RR4 was informed of the risk/benefits for Lexapro and consented to the treatment. UM4 confirmed the facility did not have any documentation, verbal or written, that RR4 consented to or was informed of the risk/benefit of R134 taking Lexapro prior to staff administering the medication to the resident. In the afternoon on 10/17/24, this surveyor returned to the conference room and reviewed documentation of R134's use of Lexapro. These documents were completed by the facility after this surveyor's concurrent interview and record review of R134's EHR with UM4, during which the facility became aware of the deficient practice and was unable to provide documentation of an informed consent and education on the risk/benefits prior to administering the medication to R134. These documents were: - A progress note written on 10/17/24 at 01:08 PM documented, This LN (licensed nurse) called POA (Power of Attorney, (RR4)) about Lexapro 5 mg for skin picking disorder, POA stated, Yeah, I'm aware that he's taking that medication. I gave consent. CN TR aware. - An Informed Consent for Psychotropic Medication- Antidepressants, dated 10/17/24 at 01:20 PM, and did not contain RR4's signature or staff attestation that RR4 provided a verbal consent. 2) Conducted a review of R141's EHR on 10/16/24 at 10:15 AM. Review of R141's physician's orders documented an order for Mirtazapine tablet; 7.5 mg; amt: 7.5 mg; oral Special Instructions: poor po intake Once a Day 20:00 (08:00 PM) was started on Review of R141's EHR did not contain documentation of an Informed Consent for Psychotropic Medication- Antidepressant for the use of Mirtazapine. On 10/16/24 at 02:55 PM, requested a copy of R141's Informed Consent for the use of Mirtazapine and documentation of education for the risk/benefits of the medication completed by the resident or RR3. The Director of Nursing (DON) confirmed there was no informed consent of Mirtazapine for R141. During an interview and concurrent record review of R141's EHR with UM4 on 10/17/24 at 08:28 AM, reviewed the Physician's Orders which documented an open order started on 09/24/24 for Mirtazapine 7.5 mg once a day. UM4 reviewed the progress notes and other parts of the EHR and confirmed it did not contain documentation of a consent form or education on risk versus benefits was completed by R141 or RR3 for the use of Mirtazapine. UM4 confirmed R141 received Mirtazapine without a completed informed consent. Review of the progress notes documented the first dose of Mirtazapine administered to R141 was on the evening shift and the informed consent was endorsed to the morning shift the next day, and the consent form was not completed. After it was confirmed by UM4, there was no consent form for the use of Mirtazapine for R141, a Late Entry on 10/17/24 at 01:39 PM for consent for the use of Mirtazapine was entered into R141's progress notes.

Based on observation, interview, and record review (RR), the facility failed to provide a resident-centered environment for 2 of 2 Residents' (Residents 28 and 67) sampled for accommodation of needs, by not utilizing a shower chair for Resident (R)28 that fit her comfortably and allowed her to shower thoroughly, and failing to ensure that R67's call light was always placed within her reach and line-of-sight. As a result of this deficient practice, these residents were hindered from attaining their highest practicable well-being. Findings include: 1) Resident (R)28 is a [AGE] year-old female admitted to the facility on [DATE]. R28 has an active diagnosis of morbid obesity. On 10/16/24 at 08:51 AM, an interview was done with R28 at her bedside. When asked about her showers, R28 stated that she showers 2-3 times a week in a small shower chair in the bathroom of her room. R28 stated that the shower chair in her bathroom feels kind of small, and she would like to have a bigger one, describing the shower chair as uncomfortable, pressing into her on each side. R28 explained that the standard-sized shower chair does not allow her to open her legs to wash while seated so she usually does not feel completely clean after a shower. R28 further stated that there is a larger shower chair that she has used before, but it requires staff to take her to the nearby shower room as opposed to showering in her own bathroom. R28 also stated that she was unsure if the shower room was even used by staff anymore because there is a lot of stuff in there. Observation done of R28's bathroom confirmed the standard-sized shower chair just fit in the shower stall and the tiled walls enclosing the shower stall did not allow any room to maneuver for a resident who filled up the shower chair. On 10/16/24 at 09:14 AM, an interview was done with Licensed Practical Nurse (LPN)1 outside the unit's shower room, which was less than 200 feet from R28's room. Concurrent observation of the shower room with LPN1 confirmed that it was filled with storage items. LPN1 stated that the room was no longer used for showers and was just used for storage. Asked if there was a larger shower chair stored in the room as one could not be seen from the doorway. LPN1 stated she did not know. On 10/17/24 at 01:23 PM, interviewed Senior Certified Nurse Aide (CNA)2 near R28's room. CNA2 confirmed that there is one larger shower chair that is kept in the shower room. Stated that R28 is showered on the evening shift and that the CNAs on the evening shift should be taking the larger shower chair into R28's bathroom whenever they shower her. Agreed that the standard shower chair would not be comfortable for a resident of R28's size. Asked CNA2 if the larger shower chair would fit in R28's bathroom. CNA2 stated it should. CNA2 retrieved the larger shower chair from the shower room, which she confirmed had been cleaned since the state agency observation the previous morning and tried to wheel it into R28's bathroom shower stall. CNA2 verified and confirmed that the larger shower chair did not fit all the way into the shower stall so that it could be positioned under the shower head. CNA2 agreed that meant the larger chair was probably not being used to accommodate R28 for her showers. When specifically asked, CNA2 stated that she was surprised the evening shift CNAs would ask R28 to squeeze onto the smaller (standard-sized) chair. CNA2 agreed that the smaller chair in the small shower stall would make it difficult for R28 to get thoroughly clean as it did not allow for R28 to open her legs, bend forward, or maneuver. Review of R28's Comprehensive Care Plan revealed the following under Baseline Needs: Help me maintain dignity by assisting with . maintaining good hygiene. 48351 2) R67 is an [AGE] year-old female admitted to the facility on [DATE]. R67 has a medical history that includes, but not limited to, chronic obstructive pulmonary disease, dependence on supplemental oxygen, acquired absence of eye, and anxiety disorder. R67 had an annual assessment on 08/14/2024. During the assessment R67 had a Brief Interview for Mental Status (BIMS) score of 15, which means R67 is cognitively intact. Concurrent observation and interview were conducted on 10/15/24 at 10:27 AM in R67's room. R67 was laying in bed. R67's call light was laying on a chair that was against a wall. R67 was not able to reach her call button. R67 asked State Agency (SA) if he/she can hand her the call light. R67 stated that she can call for help, but frequently the call light is not nearby for her to use. Observation was conducted on 10/17/24 at 09:08 AM in R67's room. R67 was laying in bed and asked SA if he/she has seen her call light. SA observed R67's call light laying on the floor. Interview was conducted with the Director of Nursing (DON) on 10/18/24 at 10:53 AM. DON confirmed that call lights should always be accessible for residents to use. Facility policy titled, Call Light, Use of, dated 06/12/23, was reviewed. Policy noted, 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand or clipped to the guest/resident or placed in reach when sitting up.

Based on interviews, document and record review, the facility failed to provide the appropriate supervision and put interventions in place to prevent one Resident (R)1 with moderate cognitive impairment from elopement, resulting in harm. Although R1 exhibited exit seeking behavior on [DATE], he was able to leave the premises in his truck on [DATE]. R1 got lost and was returned to the facility approximately five and a half hours later by the local police department. As a result of the elopement, R1 suffered psychological and physical harm. R1 was afraid when police found him. When returned to the facility, he was cold, and both feet were swollen. In addition, the facility did not follow their own elopement risk program which endangered R1's health and/or safety as well as putting the public at serious risk when R1 drove a vehicle. Findings include: 1) On 07 ,d+[DATE], the Office of Healthcare Assurance (OHCA) received a Facility Reported Incident (FRI), #11099 that included the following: R1 is a [AGE] year old male patient admitted on [DATE] with primary diagnosis of alcohol induced acute pancreatitis, alcoholic cirrhosis of the liver, alcohol dependence with withdrawal delirium and anemia. The patient is his own responsible party and has no family contact available. His emergency contact is a friend. The patient has mild to moderate cognitive impairment as evidenced by a BIMS (brief interview for mental status) of ,d+[DATE]. (BIMS score ,d+[DATE] indicate severe cognitive impairment, scores between 8 and 12, moderate impairment while scores above 13 show little to no impairment). On [DATE], at 1248, the LN (licensed nurse) made rounds and noted the resident was gone. At 1349 (01:49), R1's emergency contact/friend called the facility and reported R1 had contacted her to let her know where he was. The emergency contact called the police who were in active search for him. R1 was found to have gotten in his vehicle and drove to Wailuku where his car battery allegedly died . The police left the car in place and brought him back to the facility at 1820 (06:20 PM). 2) Review of Progress Notes revealed the following: [DATE] 03:15 PM, Nursing note .Alert x,d+[DATE], . no acute pain reported.Bipedal edema noted. [DATE] 02:16 PM, Nursing progress note: At 1315 (01:15 PM) resident was observed by East staff propelling his wheelchair exiting East exit door. East staff notified the unit. Went to check resident, observed resident left wheelchair on East gate, observed walking out the building with unsteady gait. Per resident he wants to go home. He doesn't want to [sic] his medications because it makes him loopy. Resident re-oriented .he is here for therapy to get stronger for him to go home safe. Made aware that resident have rights to refuse his medications; that if he wants to leave the facility, he will be AMA (against medical advice), Resident brought back to unit via wheelchair. Wanderguard (wander alert system) initiated. Notified Administrator, .Therapeutic communication done. Encouraged to wait until tomorrow to get his wallet, talked [sic] to social worker and the doctor before he decides to leave AMA. Resident calmed down.Will continue to monitor. [DATE] 03:27 PM. Nursing note: .Resident with restlessness.Triggered alarm several times. Very impulsive. Resident observed walking on own with unsteady gait. Difficult to redirect. He is able to propel self around the unit. Close supervision required. [DATE] 04:17 PM, Nursing note: BLE (bilateral lower leg) pitting edema (type of swelling that leaves an indentation when pressed on the skin) . [DATE] 00:27 AM, Nursing note: Self reported fall/pain .observed ambulating inside his room, and unit hall with no assistive device. Remind res (R1) that he is not cleared yet to ambulate by himself. Res continues to ambulate by himself. S/P (after) fall (self reported) res complaints of pain to R (right) knee due to fall per res, also his usual pain to shoulders, feet, and abdomen going up to his upper body.edema to bilateral feet. [DATE] 06:28 AM, Physician order: ACE wrap to bilateral feet and calves while up daily. [DATE] 09:11 AM, Dietary Progress note: . Previously noted with pitting edema to BLE, currently noted with no edema to BLE per MD. [DATE] 02:40 PM, Social Services note: Social Service Assistant (SSA)1 observed to be in East Unit talking to LN (licensed nurse). He (R1) was holding a map. SSA intervened and approached resident in a gentle manner and asked if he needed assistance. Resident stated that he was looking for the parking lot as he was worried that his truck will be towed. SSA assured him that Admin (Administrator) is aware of his parked truck on premises and that Admin approved. He was relieved and grateful. No concerns noted. Resident returned to [NAME] unit with no issues. [DATE] 03:47 PM, Nursing note: . Res (R1) redirected often as he is ambulating with no device around his room and unit, encouraged to use wheelchair for safety. Res continues working with therapies and needs supervision as he is weak and unsteady at times. some mild confusion at times but able to be re-directed. [DATE] 04:49 PM, Nursing Note: .At 1220 this RN noticed that the resident was not in his room and began to search . [DATE] 09:41 PM, Nursing Note: resident returned from elopement 1820 (06:20 PM), resident c/o (complained of) being cold and shaking slightly.Resident c/o pain in feet, both feet swollen d/t (due to) walking around.Car keys, phone and wallet obtained by supervisor. 1830 (06:30 PM) c/o ,d+[DATE] pain to entire body, given prn (as needed) narco (for pain) with some effect. 2000 (08:00 PM) Prn (as needed) melatonin (for sleep) given with no effect, resident remains restless and wandering around unit, . [DATE] 05:06 PM, Nursing note: .Continues with pitting edema + 1 to BLE, on ace wrap order, encouraged BLE elevation when in bed. [DATE] 10:58 PM, Nursing note: 1820 (06:20 PM) - Resident stated he just wanted to go to the Ka'ahummanu mall to look for an iPad for his son but got lost coming back. He stated he did not let the staff know because he thought he will only take ,d+[DATE] mins (minutes). Stated that his battery went off. He tried to come back but and went all the way to Walgreens Wailuku. He went to Walgreen to charge his phone and was able to contact friend and she updated MPD (Maui Police Department). Per MPD, they found him near the Trampoline Park (approximately two miles from facility) in Wailuku and left his car. Friend came in for visit, spoke with resident and car key given. Per friend, she will keep his car for now. Elopement risk completed. Resident educated on Elopement and OOP (off of premise) procedures. Stated understanding and will let staff know when he wants to go .No other concerns at this time. Placed on hourly monitoring s/p elopement. Wander guard in place. [DATE] 04:47 PM, Nursing note: Continues with pitting edema + 1 to BLE, on ace wrap order, encouraged BLE elevation when in bed. 3) Reviewed the facility policy titled Elopement Risk Program effective date [DATE]. The policy included the following: 1. Utilizing the Elopement Risk Evaluation-evaluate the resident for exit seeking risk on admission/quarterly/with significant change of condition. a. If resident is a risk for elopement: l. Facilities with wanderguard (or similar system): If the resident is evaluated at risk for elopement/wandering, obtain a physician's order for a wanderguard and to check function each day.ll. When a resident is determined to be an elopement/wandering risk, staff need to account for the resident's location every two hours. lll. For the resident identified as a risk for elopement/wandering complete the Missing Resident Profile with the resident's picture, and place it in a binder kept at the nursing stations and receptionist desk. lV. Initiate the Behavior Monitoring form with the behavior wandering or exit seeking to monitor the resident's wandering behavior. V. Care plan behaviors, specific prevention interventions and obtain physician orders as necessary. (a) Communicate the elopement/wandering prevention interventions to staff. (b) Make sure the risk for wandering/elopement is on the resident's care plan. The facility did not conduct another elopement risk evaluation after his exit seeking behavior on [DATE]. Although the RN put a WanderGuard on at that time, the RN did not obtain the MD order, or revise the Care Plan or implement frequent monitoring for the exit seeking behavior. RR revealed the first Elopement Risk Assessment was completed on admission [DATE], at which time R1 showed no evidence of risk for elopement. The next Elopement Risk Assessment was completed [DATE] at 07:10 PM, after R1 eloped and was returned to the facility by the police. 4) On [DATE] at 10:15 AM, conducted an interview with Social Service Assistant (SSA)1 in the conference room. She said she saw R1 looking at a facility map on [DATE], and inquired what he was doing. R1 told her that he was trying to look for a parking space, as administration had made an exception to policy, and was going to allow him to keep his car on the premises. SSA1 acknowledged she was aware of his exit seeking behavior at that time. On [DATE] 10:30 AM, conducted an interview with Registered Nurse (RN)1, who cared for R1 on [DATE], when he first displayed exit seeking behavior. RN1 said after he located R1 and brought him back to the unit, he explained leaving the facility was a safety issue and he could get injured. At that time R1 placed a WanderGuard on R1, but did not do an incident report, did not revise the CP, and did not obtain an order for the WanderGuard, which would generate the task for the staff to monitor and document R1's whereabouts to ensure he was safe. RN1 also did not complete the Elopement Risk Evaluation per the facility Elopement Risk Program. On [DATE] at 11:06 AM interviewed the Director of Nursing (DON) on the telephone, who said when a resident displays new exit seeking behavior, a new Elopement Risk Evaluation should be done, and the RN should obtain an order for the WanderGuard. Staff would then monitor the residents whereabouts every two hours and document. In addition, the CNA (Certified Nurse Assistant) would check and document every shift the WanderGuard was on and functioning correctly. The DON said he was not aware that R1 had attempted to leave the facility on [DATE], and did not have details of the [DATE] elopement, such as how far R1 walked or drove, and that the Unit Manager (UM)2 had been assigned to investigate. He confirmed he did not do a root cause analysis or have documentation of an investigation. On [DATE] at 11:15 AM, interviewed UM2 in the conference room. She said when she was reviewing the [DATE] elopement, it was discovered there was no order for the WanderGuard, so a nursing order was entered at [DATE] at 11:45 AM, two days after the elopement. This order generates a notification to check the WanderGuard is on and operational every shift. When inquired if staff were educated on the process and knew if the WanderGuard order should be a nursing order or MD order, and what the specific monitoring expectations are, UM2 said they were putting a plan in place. She went on to say We are going to have a binder on the unit with Residents that have a WanderGuard. The facility policy stated there are binders on the units. Inquired what the missing Resident profile was that is suppose to be put in the binder, and she was not able to answer. Asked UM2 if she knew how far R1 had walked, she said He was coming down from Wailuku Walgreens, got lost coming down. Walked a couple miles. UM2 did not know specifics, or if he drove the car. She said His feet were sore and painful. UM2 later returned to the conference room to explain that the missing Resident profile would be a copy of the Resident's demographics in the medical record. On [DATE] at approximately 12:00 PM, interviewed the Administrator (ADM) in the conference room. Asked the ADM about follow up after the elopement and if a root cause analysis had been done. She asked if the DON had shared that information during his telephone interview, but informed her the DON said UM2 was doing the investigation. The ADM said she had not been aware R1 had previous exit seeking behaviors on [DATE], and acknowledged there had not been an incident report made for that event. She said when R1 eloped on [DATE] he took his truck and drove. She went on to say she had made an exception to policy, and allowed R1 to keep his truck on the premises, because he was so worried about it. Informed the DON the staff verbalized some discrepancies in policy regarding the WanderGuard order, and if it was a Nursing Order or Physician order. The ADM returned to the conference room shortly after the interview and provided a Google map of distance from Walgreens in Wailuku to where R1 was found by the police. The distance R1 is believed to have driven to Walgreens from the facility is approximately 2.6 miles. He got lost on the way back and found approximately .4 miles from the Walgreens. 5) Due to the high risk of this incident, there should have been a thorough investigation/root cause analysis conducted post elopement. The investigation was inadequate, undocumented and did not identify many of the issues that led up to the elopement on [DATE]. 6) Review of the Police Department Case Summary Report last modified [DATE] revealed the police were notified by the facility R1 was missing about 01:25 PM, approximately one hour after they noticed he was missing. The report included: - he (R1) suffers from dementia and multiple other medical conditions and should not be out alone. - R1 notified his friend via telephone, and relayed he was lost and unable to get back to Hale Makua. On [DATE] at about 1730 (05:30 PM), contact was made with V,d+[DATE] (R1) near the intersection of [NAME] and Paa Street in Wailuku. V,d+[DATE] relayed he was lost, scared, and needed help getting back to Hale Makua, . 7) Cross Reference F657 Care Plan The facility failed to revise R1's care plan after his exit seeking behavior on [DATE]. The CP was not updated to include this high risk behaviors until [DATE].

Based on observations, interview, and record review (RR), the facility failed to follow the proper washing and sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as evidenced by wash and final rinse temperatures of the water in the High Temperature Dishwasher (using heat sanitization) that were well below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda.gov/media/110822/download), in addition to not monitoring that the proper temperatures were being maintained as evidenced by no retrievable documentation of temperatures since [DATE]. As a result of this deficient practice, patient safety was compromised, and an Immediate Jeopardy (IJ) was identified. The State Agency (SA) identified an IJ on [DATE] at 10:03 AM (with the start of the IJ later determined as [DATE]). On [DATE] at 11:37 AM, the Administrator was notified of the IJ at 483.60 (F812) and provided with the IJ template. The Administrator signed the template to attest receipt of the notice. In addition, the facility failed to store, monitor, and discard food/drink items in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. On [DATE] at 12:50 PM, the facility provided a removal plan approved by the SA. The removal plan consisted of repair of the dishwashing machine and calibration to the proper washing and sanitizing temperatures, handwashing and chemical sanitization of all dishes and utensils until the dishwasher machine was repaired, development and implementation of a new temperature monitoring/documentation process for staff, and staff training regarding all of the above. On [DATE] at 10:55 AM, the SA finalized onsite verification that the IJ Removal Plan had been implemented and confirmed IJ Removal, however a pattern of deficient practices at F812 remained. Findings include: On [DATE] at 09:59 AM, entered the dishwashing area where three staff members were processing dirty and clean dishes. One staff member pointed out the temperature panel to the SA when asked what the temperatures were for the dishwasher. The SA recorded the following temperatures from the dishwasher panel: Prewash 128, Wash 136, Rinse 140, Final Rinse 113. Per the staff member(s) present, the facility uses heat sanitization, and an enzymatic prewash on all dishes and utensils, and the utensils get an additional pre-soak in a shine solution. While conducting a record review on [DATE], the SA noted that the dishwasher temperatures recorded on [DATE] were well below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (Food Code). On [DATE] at 10:01 AM, as soon as the SA arrived back on-site to the facility, the SA recorded the following temperatures from the dishwasher panel: Prewash 126, Wash 138, Rinse 143, Final Rinse 118. These temperatures were validated with the Director of Nutrition Services (DNS) at 10:03 AM. The DNS reported that the Wash temperature should be at least 150 degrees Fahrenheit, and the Final Rinse (which was the heat sanitization step) should be 180 degrees. (The 'safe' temperatures were confirmed in a review of the Food Code by the SA). Upon concurrent observation, the DNS validated that the dishwasher temperatures were below what they should be for proper washing and sanitization. The SA asked for the temperature logs. The DNS reported that the clipboard with her 'Master Log' was not on the dishwasher as it should be. She did find a piece of paper with handwritten logs on top of the machine with B/L/D [breakfast, lunch, and dinner] temperatures for [DATE] and B [breakfast] temperatures for [DATE] that recorded temperatures below the acceptable ranges for safety, yet did not document that any action had been taken. The DNS confirmed that no one had notified her that the temperatures were low for a while. The DNS explained that the Master Log that she could not locate included specific instructions on what to do if the Wash or the Final Rinse temperatures were lower than listed, and one of the steps was to notify the DNS. The DNS further explained that staff were responsible to check and document Wash and Final Rinse temperatures three times a day (following each meal) on the Master Log. The DNS confirmed a second time that she had not been notified that temperatures were low. When asked what they normally do when temperatures are low, the DNS reported that if Wash temperatures were low, staff would report it to her, a work order would be put in, and the dishes would be hand washed until the dishwasher had been repaired. If the Final Rinse temperatures were low, staff would report it to her, put a work order in, and add a chemical sanitization tablet to the dishwasher for every cycle until the dishwasher had been repaired. On [DATE] at 10:50 AM, the DNS reported it was possible that the dishwasher temperature gauge was what was faulty, and asked the SA to return to the kitchen for manual testing. At 10:51 AM, the DNS sent a test strip through for the Final Rinse temperature, explaining that if the temperature were at least 180, the black stripe (in the center of two bright orange stripes) at the end of the test strip should turn orange. At 10:53 AM, the test strip came out with the black stripe appearing to be dark red in color, but still very visible in between two bright orange stripes. The DNS looked at the test strip and reported to the SA that she thought the center (black) stripe had turned orange and was the color that it should be, indicating the Final Rinse temperature was good. At 10:56 AM, the DNS sent a thermometer through the dishwasher and stopped it on the wash cycle. The thermometer reading was 140 degrees, validated by the DNS. The DNS stated they would handwash and chemically sanitize the dishes and utensils. At 10:57 AM, a second Final Rinse test strip was sent through the dishwasher with the results being the same as the first run. A dark red stripe in between two bright orange stripes. The SA requested the test strip packaging and/or the manufacturer's instructions/recommendations on the test strips being used. All that could be observed on the packaging available was ECOLAB. The DNS was unable to produce the manufacturer's instructions/recommendations for the test strips used. On [DATE] at 11:11 AM while researching the test strips, the SA watched a video on thermal disinfection indicator tests strips and learned that the test strip should go into the dishwasher with a black stripe down the middle of a bright orange test bar, and come out with the test bar being completely orange so that a middle stripe is no longer visible. At 11:14 AM, showed the video to the DNS who reported that she had been taught that the dark red stripe was an acceptable result, and never knew that the center stripe should disappear. With this information, the DNS agreed that the Final Rinse temperature was not in the acceptable range for safety. On [DATE] at 01:19 PM, during an interview with the DNS, she confirmed that she had searched the kitchen and could not locate the Master Log for October. The DNS was able to produce the Master Logs for September, August, and July. With this information, the SA determined that the start of the IJ was [DATE]. A review of the Master Log for September revealed 7 times where the Final Rinse temperature had either not been recorded, or was recorded as below 180, with no indication that a work order had been put in or chemical sanitization utilized despite there being spaces on the Master Log specifically to document those actions taken. 2) On [DATE] at 10:15 AM, a tour of the food preparation and storage parts of the kitchen, with the DNS, found two sealed boxes (each with twelve 12-count bags) of boiled eggs plus one open box of boiled eggs with four 12-count bags in it, with all boxes labeled: Use by 6 [DATE]. Per an interview with the DNS at this time, the boiled eggs were used for egg salad sandwiches (made daily) for unit/neighborhood fridges as snacks, and also used in the kitchen as an alternate menu option. The DNS immediately pulled the expired eggs and assured the State Agency (SA) that she would have all the prepared sandwiches pulled off the units/neighborhoods and disposed of immediately. When asked what the process for checking expiration dates was, the DNS reported that between herself and the Nutrition Services Supervisor (NSS), expiration dates were checked daily. The DNS stated that she did not know how the expired boiled eggs were missed. Further observations on the tour of the kitchen revealed two gallons of whole milk with an expiration date of [DATE] and one gallon with an expiration date of [DATE].

Based on observation, interview, and record review, the facility failed to ensure 3 of 8 residents (R) in the sample were free from accident hazards. R149 was not kept safe from being grabbed by another resident with a known history of this behavior. As a result of this deficient practice, R149 suffered a potentially avoidable accident with injury. Despite having been identified as a high falls risk upon admission in 2021, R133 did not have a Falls Care Plan added to his Comprehensive Care Plan until after he suffered an unwitnessed fall with multiple major injuries in June 2023. R110 was found to have a cigarette lighter on his bedside table. Placing residents at risk of avoidable accidents and injuries by not providing the appropriate planning and monitoring, and/or implementing the interventions to meet their identified needs is a deficient practice that has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)149 is a [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnoses include, but are not limited to, unspecified trochanteric fracture of left femur (fracture of upper left thigh bone/hip), Alzheimer's disease, dementia, and anxiety disorder. On 09/26/23, the State Agency (SA) received a facility-reported incident (FRI) through e-mail. The FRI (ACTS #10564) detailed an incident where R186 reached out and grabbed R149's right forearm, leaving a reddish-colored discoloration to RFA [right forearm] measuring approximately 3 cm x 3.5 cm. The FRI also documented that Resident .[R186] has a history of grabbing things/staff. Review of the incident report/FRI from the facility noted that there were two witnesses to the incident, R37 and Certified Nurse Aide (CNA)66. Review of R37's minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/21/23 noted that with a Brief Interview for Mental Status (BIMS) score of 15, she had been determined to be cognitively intact. On 10/12/23 at 12:34 PM, an interview was done with R37 regarding the incident. During the interview, R37 shared that she has been grabbed by R186 before as well, and reported that he has a long reach and a strong grip. R37 continued on to report that I tell everybody don't get too close to him [R186] because he will grab you. R37 described that the day of the incident, R149 had been wheeling herself (in her wheelchair) past the table R186 was seated at when R186 reached out and grabbed R149's right forearm and wouldn't let go. CNA66 came over and moved the two residents away from each other. R37 stated R149 was crying little bit after it happened. R37 also stated that everybody knows about R186's behavior. On 10/12/23 at 03:48 PM, an interview was done with CNA66 near the unit courtyard. When asked about the incident on 09/26/23, CNA66 stated she was assisting another resident when she heard a commotion at the common area in front of the Nurses' Station (NS). When she looked over, she saw R186 had a hold of R149 on her right forearm. CNA66 immediately responded, got R186 to let go, and moved the two residents away from each other. CNA66 stated she noted the red mark/bruise on R149's forearm and reported the incident to Registered Nurse (RN)8. Regarding R186, CNA66 stated everybody knows he will grab if you get close, ask anybody, they know. CNA66 reported that she has seen R186 grab numerous residents and staff, including herself. Review of R149's MDS assessment with an ARD of 08/17/23 revealed a BIMS score of 3, indicating severe cognitive impairment. Review of R186's MDS assessment with an ARD of 08/02/23 revealed severely impaired cognitive skills. As a result, neither resident was interviewable. Observations made on 10/12/23 and 10/13/23 noted R186 seated in his wheelchair in the common area in front of the NS. R186 always observed alone at his table, however other tables occupied with multiple residents (including R149) were within 10 feet of his. On 10/12/23 at 11:45 AM, an interview was done with Licensed Practical Nurse (LPN)7 near the unit courtyard. When asked about R186, LPN7 reported that he grabs people a lot, I think he wants attention. On 10/12/23 at 03:34 PM, an interview was done with Registered Nurse (RN)27 at the NS. When asked about R186, RN27 reported that she reminds residents to stay away from him because he has a known history of grabbing people. Described this as kind of like normal behavior for R186. When asked if she had witnessed R186 grabbing any residents, RN27 reported that she saw R186 grab another resident (R176) that went too close to him the day after he grabbed R149, but there was no injury left on R176. Review of R149's nursing progress notes in her electronic health records (EHR) revealed that despite the incident occurring on 09/26/23, the reddish skin discoloration on her right forearm was still present and being monitored on 10/10/23. Cross-reference to F657 Care Plan Timing and Revision. The facility failed to revise R149's care plan following the incident to keep her safe from future injury from R186. Cross-reference to F842 Resident Records. The facility failed to accurately document revisions made to R186's care plan regarding his behavior of grabbing others. 2) R133 is an [AGE] year-old male admitted to the facility on [DATE]. R133's current diagnoses include, but are not limited to, dementia with anxiety, history of falling, generalized muscle weakness, cognitive communication deficit (difficulty with thinking and how someone uses language), and difficulty in walking. On 06/18/23, the SA received a facility-reported incident (FRI) through e-mail. The FRI (ACTS #10374) detailed an incident where R133 had an unwitnessed fall with multiple injuries and was sent to the emergency room where he was admitted to the acute hospital for four days. A review of R133's discharge summary from the acute hospital noted the following active problems listed as a result of the 06/18/23 fall: L4 (one of the two lowest vertebrae of the lumbar spine) fracture, facial bone fracture, epidural hematoma (an accumulation of blood between the skull and the thick membrane covering the brain), right distal humerus fracture (lower end of the upper arm bone), right orbital (eye) fracture, right maxilla (upper jaw) fracture, and closed head injury. A review of R133's Fall Risk Assessment completed at admission on 06/01/21 revealed that R133 had been determined to have a Total Fall Risk Score of 14 . [greater than] 13 Total Points = High Fall Risk. A review of R133's electronic health record (EHR) noted that he had an unwitnessed fall (found on the floor beside his bed) with minor injuries on 10/03/22. The resulting Fall Risk Assessment scored him with a Total Fall Risk Score of 23. Following his fall with major injury on 06/18/23, R133 had been determined to have a Total Fall Risk Score of 25. A review of a Comprehensive Care Plan History Report with a date range of 06/01/21 to 10/19/23 noted no Falls Care Plan until 06/23/23, the day after R133 returned from the acute hospital following multiple fall-related injuries. A review of the interventions planned for his high risk of falls revealed that Keep bed in lowest position with brakes locked was not added until 07/12/23. 47783 3) On 10/10/23 at 11:24 AM, interview conducted with R110 in his room. R110 was lying in bed watching television. The table on his right side had a tray with a pitcher filled with water, 2 cups of cranberry juice and a cigarette lighter. Asked R110 if he was a smoker, he replied, Yes. R110 said a staff member is always with him when he goes outside to smoke. Asked if he is allowed to keep his cigarettes and lighter in the room with him. R110 said, No, the nurse keeps it in her cart. When this surveyor pointed out that there was a cigarette lighter next to the tray on his table, R110 said, They must have forgotten to take it after I smoked this morning. Review of R110's care plan on smoking dated 08/04/23 documented that staff are to provide moderate assistance and supervision when smoking. Additionally, intervention also included that the nurse would keep his cigarette, lighter and apron in the medication cart, and the accompanying staff will give back the lighter and apron to the nurse when R110 was done smoking. On 10/17/23 at 02:06 PM, an interview was conducted with Registered Nurse (RN) 4 at the nurses' station. RN4 confirmed that all smoking materials including cigarette lighters or matches are kept and locked in the medication cart. The residents are not supposed to have them in their possession for safety. Review of the facility's policy titled Smoking with an effective date of 04/02/22 stated, . 12. Residents regardless of smoking privileges are not permitted to keep cigarettes . and other smoking articles in their possession.

Based on observation, interview, and record review, the facility failed to provide care and services (reassessing the residents' dietary/nutritional needs, consistently implementing related care-planned interventions, monitoring for effectiveness, and ensuring coordination of care among the interdisciplinary team) to prevent significant weight loss for 2 of 6 residents (Residents 153 and 147) in the sample, despite having identified them as at risk for compromised nutrition. As a result of this deficient practice, the facility placed these residents at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) Resident (R)153 is an [AGE] year-old female admitted to the facility on [DATE]. R153's admitting diagnoses include, but are not limited to, dementia, high blood pressure, complete AV [atrioventricular] heart block (when the electrical signal that controls your heartbeat is completely blocked requiring a pacemaker), chronic obstructive pulmonary disease, and protein-calorie malnutrition (PCM [a nutritional status in which reduced availability of nutrients leads to changes in body composition and function]). On 10/10/23 at 11:29 AM, an interview was attempted with R153 at her bedside. Although R153 was lying awake in bed, she would not look at or respond to surveyor greetings or questions. R153 appeared extremely thin, with her collarbone, sternum, and a few upper ribs strikingly prominent above the neckline of her normal adult-sized institutional gown. On 10/11/23, a review of R153's electronic health record (EHR) noted documentation in her Nursing Progress Notes that she frequently refuses her prescribed medications, food, and nutritional supplements. A review of R153's weights since admission revealed the following: 08/13/2023 Weight: 81.4 pounds (lbs.). 08/19/2023 Weight: 80.2 lbs. (reflecting a 1.2 lb. or 1.47% weight loss in 1 week). 08/27/2023 Weight: 77 lbs. (reflecting a 3.2 lb. or 3.99% weight loss in 1 week, with a 2% or greater loss per week indicating clinically significant weight loss). 09/03/203 Weight: 75 lbs. (reflecting a 2 lb. or 2.59% weight loss in 1 week, and indicating clinically significant weight loss for the second week in a row). 09/10/2023 Weight: 74.2 lbs. (reflecting a 0.8 lb. or 1% weight loss in 1 week, but a 7.2 lb. or 8.84% weight loss in 1 month, with 5% or greater loss per month indicating clinically significant weight loss). 09/16/2023 Weight: 73.6 lbs. (reflecting a 0.6 lb. or less than 1% weight loss in 1 week). 09/25/2023 Weight: 71.8 lbs. (reflecting a 1.8 lb. or 2.44% weight loss in 1 week indicating clinically significant weight loss). 09/30/2023 Weight: 71.2 lbs. (reflecting a 0.6 lb. or less than 1% weight loss in 1 week). 10/08/2023 Weight: 70.2 lbs. (reflecting a 1 lb. or 1.40% weight loss in 1 week, but a 4 lb. or 5.39% weight loss in 1 month, indicating clinically significant weight loss for the second month in a row). The review of weights and progress notes display a pattern of consistent and continued unintended weight loss since admission, with R153 becoming increasingly non-responsive and non-compliant with any interventions. A review of the Dietary Progress Notes and Assessments noted that despite being triggered for 2 weekly significant weight losses and 1 monthly significant weight loss in the 1 month since admission, there were no nutritional assessments or interventions done by the Registered Dietician (RD) between the period of 09/14/23 to 10/11/23. During that time, R153 continued to consistently lose weight and triggered for another weekly significant weight loss of 2.44% on 09/25/23 and another monthly significant weight loss of 5.39% on 10/08/23. On 10/12/23 at 02:23 PM, an interview was done with RD2 in her office. RD2 confirmed that she had completed a nutritional assessment on R153 the day before (10/11/23), and prior to that, her last assessment was done on 9/12/23. When asked about the normal process of monitoring for residents admitted with nutritional concerns like PCM, RD2 reported that residents are put on weekly weight monitoring, every Monday RD2 checks residents' weights, and completes a nutritional assessment only if they trigger [for significant weight loss]. When RD2 was specifically asked if R153 triggered for significant weight loss and that is why RD2 completed a nutritional assessment on 10/11/23, RD2 stated no twice. When asked why the nutritional assessment had been completed if the normal process is to complete one only when they [residents] trigger, RD2 responded that it was just to follow up because it's been a month [since the last assessment]. On 10/12/23 at 03:00 PM, during an interview with the Dietician Coordinator (DC)1 in the conference room, DC1 confirmed that significant weight loss triggers are 2% or more in a week, and 5% or more in a month. On 10/12/23 at 03:25 PM , during an interview with DC1 in her office, DC1 validated that she had been covering for RD2 while she was out the last week of September when R153 had triggered for a 2.44% significant weight loss in 1 week. DC1 stated I missed it [checking and following up on R153's significant weight loss]. DC1 confirmed that a nutritional assessment should have definitely been done at that time. On 10/19/23 at 11:29 AM, a phone interview was done with R153's son (FR2). FR2 confirmed that he had noticed R153 losing weight since she was admitted two months earlier, he also confirmed that R153 was less responsive and cooperative with her care at the facility than when she was admitted . Stated that she has always been quiet, but she speaks even less now and sometimes won't even look at him when he visits. FR2 reported that the facility has not asked him to bring in some of her favorite foods nor has he had a discussion with the RD about her weight loss. Stated that the nurses mentioned to him a couple weeks ago about R153's weight loss but it was not brought up again since. 22063 2 ) Cross Reference to F657 Care Plan Timing and Revision. The facility did not assure care plan revisions were done to develop interventions to prevent further weight loss and/or ensure resident maintained acceptable parameters of nutritional status to prevent skin breakdown. R147 was admitted to the facility on [DATE]. Diagnoses include but are not limited to Alzheimer's disease; Type 2 diabetes mellitus with hyperglycemia; depression; acute kidney failure, unspecified; and dysphagia, oropharyngeal phase. On 10/10/23 at 12:44 PM observed R147 lying in bed. At 12:55 PM, Certified Nurse Aide (CNA)87 was observed to present R147 with her lunch. CNA87 informed resident of the food that was provided on her lunch tray. R147's food was pureed. R147 refused the rice and Boost (liquid nutritional supplement). R147 was agreeable to eat some applesauce. CNA87 was asked what she does if R147 refuses, CNA87 responded they can't force the resident to eat. On 10/11/23 at 08:12 AM R147 was lying in bed asleep. Regional Nurse Manager (RNM) brought in the resident's breakfast tray. The staff member introduced herself to the resident and informed R147 that she would be helping her with breakfast. The tray consisted of Boost, tofu, fruit, juice, eggs, coffee, and whole milk. RNM removed plates from the tray and placed it on her over bed tray. R147 was repositioned and began to feed herself (eggs) and drank coffee. RNM was observed to sit at bedside, encourage R147 to eat and talk story with her. On 10/11/23 at 10:15 AM an interview was conducted with Resident (R)147's representative. The resident's representative reported R147 had a noticeable weight loss. Inquired whether the representative was aware of the interventions that were implemented to address the weight loss. The representative responded that she was not aware of the interventions that were tried. Record review confirmed R147 with significant weight loss. On 04/01/2023, the resident weighed 97 lbs. and on 10/01/2023, the resident weighed 85.4 pounds which was an 11.96 % weight loss in six months. On 07/06/2023, the resident weighed 94.8 lbs. and on 10/01/2023, the resident weighed 85.4 pounds which was a 9.92 % weight loss in three months. On 10/18/23 at 07:46 AM interview was conducted with CNA82. CNA82 reported sometimes R147 will feed herself and sometimes she will be dependent on staff. CNA82 also reported at times R147 will refuse to eat and will not open her mouth. CNA82 noted R147 eats the most at breakfast and if she feeds herself, staff will stay with her until she is done. A review of the quarterly Minimum Data Set (MDS) with assessment reference date of 04/28/23 documented R147 with a weight loss of 5% or more in the last month or loss of 10% or more in the last six months while not on a physician-prescribed weight loss regimen. Subsequent annual MDS with an ARD of 07/01/23 noted R147 coded for weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Review of the care plan included the following goals: I will maintain weight between 81-89 pounds in the next 3 months. Weight maintenance is goal; I will tolerate my diet with no signs and symptoms of aspiration in the next 3 months; and I will consume at least 50-75% of all meals in the next 3 months. A review of the quarterly Nutrition assessment dated [DATE] noted R147 had a diet order of no concentrated sweets, puree texture, nectar thick liquids, and Boost Glucose Control 240 ml three times a day with meals. Review of the history noted, one month (09/02/23) with a weight loss of 1.4%, three months (07/06/23) with a weight loss of 9.9% and six months (04/01/23) with a weight loss of 12.0%. Review of Nutritional Weight and Skin Reviews was done. The assessment dated [DATE] noted R147 with meal intake at 25% with two refusals of dinner, and Boost with a documented intake ranging from 35 to 41% with five refusals. Noted resident with significant weight loss past 90 to 180 days due to poor food intake with refusal of meals and supplements. Also noted gradual dose reduction for use of Remeron due to no beneficial effects on appetite. The recommendation was to monitor weekly weights, continue Boost with meals, encourage daily fluid goal of 1250 ml, and provide feeding assistance (encouraging food intake). Subsequent Nutritional Weight and Skin Review dated 09/12/23 noted a review was done due to significant weight changes and R147 noted with deep tissue injury to right heel and redness to the coccyx. The recommendations included, encourage fluid goal of 1250 ml/daily, provide feeding assistance as needed, continue Boost Glucose Control three times a day with meals, and encourage at least 50% or more intake. R147 continued monthly weight monitoring. Review of the 10/04/23 Nutritional Weight and Skin Review noted weight of 86.6 pounds on 09/02/23 and 85.4 pounds on 10/01/23. Resident was noted with stable weight in 30 days and continues with long-term weight loss. R147 also with chronic poor food intake (1-50%) and continues Remeron with minimal effect on appetite. R147 also continues Boost Glucose Control three times a day and drinks 50 to 100% of supplement. The recommendations included, continue monthly weights, continue nutritional supplement for support and help with meals as needed. An interview and concurrent record review of the assessments (Nutritional Weight and Skin Review) was conducted with Registered Dietitian (RD)2 on 10/18/23 at 08:44 AM. RD2 reported R147 was assessed on 08/09/23 as the resident triggered for significant weight loss. The use of Remeron was assessed as not effective in stimulating the resident's appetite. The recommendation was to continue supplement (Boost glucose control) with meals and switch her to weekly weights. RD2 recalled R147's weight stabilized so she was switched back to monthly weights. Inquired what is R147's ideal body weight, RD2 responded 100 pounds. R147 was reevaluated in September 2023 as she had deep tissue injury to the right heel in August. Inquired whether the resident was assessed for increase of supplements. RD2 responded at that time no changes were made to the interventions. The plan was to monitor the resident's skin to see if she would do okay. RD2 confirmed no labs were ordered. RD2 reviewed R147's weight variance report and noted resident had a weight loss from 07/06/23 (94.8 lbs.) to 08/02/23 (86 lbs.) a 9.3% weight loss in a month. Queried when the Boost Glucose Control was added. RD2 replied it started in January 2023 at 240 ml three times a day. RD2 recalled R147's daughter requested to discontinue super pudding with meals. RD2 also reported in May 2023 enhanced mashed potatoes (dinner) and cereal (breakfast) was added to the diet. Queried RD2 whether R147's interventions were revised to prevent further weight loss or whether the use of other supplements was explored (i.e., increase of Boost or use of another supplement with medication administration). RD2 responded Resource is a supplement that is sometimes given during medication administration. Resource is high in calories and protein. However, RD2 stated that this hadn't been suggested and was not considered.

Based on interviews with staff members, resident and resident's representative, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents when Resident (R)1 was left alone while the Transport Aide (TA) went to get the vehicle which resulted in a fall with injury (fractured left hip). The facility also failed to perform fall risk assessments. Findings include: On [DATE] at 02:21 PM, the facility submitted an Event Report to the Office of Health Care Assurance (OHCA) reporting an elopement which occurred on [DATE] at 09:40 AM. The facility submitted an addendum report on [DATE] at 03:14 PM which identified the type of incident as a fall with injury. The facility reported on [DATE] at 09:50 AM, Transport Aide (TA) notified facility that there was an incident involving Resident (R)1, during transport. R1 was transported for a medical appointment. R1 was brought out of the office and placed on the sidewalk, wheelchair brakes were applied while TA went to get the transport vehicle. TA reported as he was driving the vehicle around, he saw R1 rolling her wheelchair to the curb where she fell from her chair. R1 had a laceration to the left eyebrow and left hand. She was transported back to the facility, Pikake neighborhood where her lacerations were treated. R1 reportedly stated The driver went to get the bus to pick me up. He locked my wheelchair so I unlocked it to get closer to the curb. At 04:15 PM, R1 returned to the facility from the emergency department via wheelchair. Resident was transferred to bed and asked if she remembered what happened. The resident reportedly stated it's like I catapulted out of my chair. No active bleeding, laceration above left eyebrow, steri-strips reportedly intact and strips applied to left hand laceration. On [DATE] at 10:12 AM a record review was done. R1's initial admitted was [DATE]. Review of the Face Sheet lists unspecified dementia, unspecified severity without behavior disturbances as the primary diagnosis. A review of R1's care plan includes other diagnoses: functional quadriplegia; rheumatoid arthritis, unspecified; and altered mental status. A review of a quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] notes R1 yielded a score of 14 (cognitively intact) when the Brief Interview for Mental Status (BIMS) was administered. R1 required extensive assist with one-person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Transferring (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) occurred one to two times during the reference period with one-person physical assist. Walking in the room or corridor did not occur. R1 also noted with functional range of motion (how far and in what direction you can move a joint or muscle) on both sides of the upper extremities and to one side of the lower extremities. Subsequent quarterly MDS with an ARD of [DATE] (post fall evaluation) notes R1 yielded a score of 9 (moderate cognitive impairment) on the BIMS. R1 was noted to require extensive assist with two plus physical assist for transferring. R1 was also coded to now require two plus person physical assist for bed mobility. A review of R1's care plan for falls notes the resident is at risk for fall/injury related to cognitive impairments, adult failure to thrive, weakness, severe protein calorie malnutrition, functional quadriplegia, rheumatoid arthritis, and other health conditions. Approaches developed on [DATE] include but not limited to: encourage resident to participate in range of motion exercise for strengthening and mobility; assess risk factors for experiencing falls and/or injury on admission, quarterly, and if there is a change in condition; eliminate as many risk factors as possible; if restless or attempting to self-transfer, ask what I need help with; and if R1 experiences a fall or other injury, investigate the causal factors and adjust my care plan as needed. Review of the progress note found an entry dated [DATE] at 10:04 AM by the Director of Nursing (DON) documents at 09:50 AM, DON was contacted by Nursing Secretary to notify R1 sustained an injury while out for her appointment with TA. TA reported he brought resident out from her appointment and locked her wheelchair brakes in place in order to go and get the transport vehicle. TA stated that when he was driving the vehicle around he saw resident rolling her wheel chair to the curb where she fell from the chair. The resident sustained a laceration to the left eyebrow and left hand. R1 was transported back to the facility where her lacerations were treated. DON visited with the resident and asked her what happened. R1 reportedly stated the driver went to get the bus to pick me up. He locked my wheelchair so I unlocked it to get closer to the curb. Staff explained to R1 that the driver locked her wheel chair for her safety to prevent any accidents. R1 reportedly stated well I unlocked it and that's what happened. The Nurse Practitioner (NP) visited with resident and will be sending her out for evaluation of the lacerations and complaint of right sided hip pain. Progress note entry dated [DATE] at 10:48 AM documents R1 returned to the facility at 09:40 AM. Vitals were taken and recorded within normal limits. R1 reported pain to the left hip as a 7 out of 10. Lacerations were cleaned with saline, and dressed with gauze and steri-strips. R1 was sent to the emergency department and returned on the same day at 04:15 PM. R1 was asked what happened, she reportedly stated it's like I catapulted out of my chair. On [DATE] at 10:30 AM an interview was conducted with R1. R1 was seated in a high back wheelchair at a table in the courtyard. R1 was wearing glasses, missing front top and bottom teeth, and wheelchair brakes were applied. Asked R1 about her fall. R1 acknowledged that she fell and was unable to express what happened. Inquired whether she can unlock the brakes of her wheelchair. She responded, she thought she can and showed surveyor her hands. R1's palms and fingers appeared contracted (fingers are bent toward the palm of the hand and can't straighten completely). R1 demonstrated that she is able to wiggle some of her fingers. R1 shared her wife would be coming today. On [DATE] at 11:36 AM interviewed R1 and Resident Representative (R1's spouse) in the conference room. Resident Representative (RR) reported she was unable to accompany R1 and TA for this medical appointment. RR reported when accompanying R1, she will meet her and TA at the facility, walk with them to the transport vehicle, and once R1 is on the van, she will follow them in her car. Upon arrival to the destination, she will meet the van and accompany her spouse to the appointment. RR was notified of the fall by the NP at approximately 09:45 AM. RR was informed R1 would be taken to the hospital. The facility notified RR of hip fracture and need for butterfly stitches and steri-strips were applied to R1's hand and knee. RR expressed concern that TA did not know what to do, he picked R1 up and put her back into the wheelchair then called the nurse. RR reported R1 does not wheel herself in the wheelchair and can't say R1 can release the wheelchair brakes. RR provided written correspondences that were sent to the Administrator. On [DATE] at 12:20 PM an interview was conducted with the TA in the conference room. TA reported R1 was transported for an x-ray appointment. The parking lot was crowded, he was able to park the van and transport R1 to the office. When R1's appointment was done, TA saw that he would not be able to transfer R1 to the van as there was a car parked in the stall next to him. The vehicle he was driving had a left entry and the parked car did not allow him to assist R1 onto the van. The handicapped stall was now open. TA placed R1 on the sidewalk, horizontal to the curb, locked the brakes then went to get the van. TA further reported while driving back, he saw R1 wheeling her chair on the sidewalk and sped up to get to her, and found that she had fallen, the wheelchair was on top of her. TA described R1 at the curb with her left knee on the ground and right leg straight in front of her. The footrest went up high, which TA thinks cause the cut to R1's forehead. TA reported he contacted the nurse (he was unable to identify the nurse he spoke with) by phone and asked whether to call 911. The nurse instructed to bring R1 back to the facility. TA further stated he was fortunate that there was a gentleman to help him place R1 back into the wheelchair. TA shared R1 was in pain, and he felt very bad for her, he wanted to save her from falling. TA was asked if he thought the resident was safe to be left alone, he responded 100% safe, R1 was alert and before leaving her, he locked the brakes and placed the wheelchair sideways so she would not roll down toward the curb. Inquired what kind of training he received as a transporter. TA responded, they teach transporters about safety and how to transfer residents. He further reported, [NAME] also receive training in first aide and how to use the fire extinguisher. Also asked if they are required to have Cardiopulmonary Resuscitation (CPR) training. TA was not sure. TA reported sometimes they need two people, and a Certified Nurse Aide (CNA) will go with the resident and transporter. TA also stated that sometimes family members will attend the appointments and assist. Further queried who determines whether a CNA will be assigned to assist. TA replied if the resident is alert and oriented they transport by themselves or they request to the Nursing Services Secretary and she will see if the unit has an extra aide to accompany the transporter. On [DATE] at 08:51 AM an interview was conducted with the DON in the conference room. DON reported the secretary notified him of the incident. DON unable to recall who the neighborhood nurse was on that day. Inquired when does the facility assign a second person to accompany the transporters. DON responded a second person is assigned if the resident has to be transferred and requires extensive assist. DON reported R1 had a chest x-ray and probably didn't require a transfer, the x-ray was probably done with her sitting in the wheelchair. DON saw R1 when she returned to the facility. DON recalled R1 informing him that she unlocked the brakes to get closer to the curb and this is how she fell . DON stated moving forward, R1 should have been left inside the office while the TA was getting the van instead of alone. DON also reported, he would have advised the TA to not pick up the resident and call 911. DON clarified, it is very difficult for folks not medically inclined to transfer the resident back to the wheelchair after a fall and R1 was hit hard enough that she had lacerations. The facility provided a copy of the Counseling Statement (dated [DATE]) with the Assistant DON (ADON) and TA. A review of the document notes the employee was informed of the following standards that will be expected in the future: if resident appears confused, request for aide; residents are not be to be left outside of office unattended if he/she is not alert/oriented; if resident falls out of facility, call 911 for assessment; inform DON and Administrator immediately; and if in facility notify licensed nurse before moving resident. A written statement by the Registered Nurse (RN)3 who was on duty was reviewed. RN3 documents she was notified on [DATE] at 09:00 AM by the TA that R1 fell in the parking lot. RN3 asked TA what happened. TA reportedly stated R1 had unlocked the wheelchair, rolled herself to the curb, and fell . TA also reportedly said that he placed R1 back in the wheelchair with assistance and placed her in the van. RN3 instructed TA to ask R1 if she wanted to go to the hospital, R1 reportedly said no. RN3 documents she consulted the Charge Nurse and was told to bring R1 back to the facility. Upon return to the facility, the Charge Nurse notified the DON and Nurse Practitioner (NP). R1's lacerations to the left side of her head, left knee, and left hand were cleaned and dressed. Emergency services were called, arrived at 10:40 AM, and R1 was transported to the emergency department. On [DATE] at 10:07 AM an interview was conducted with the ADON in the conference room. ADON confirmed she provided education to TA. Education was provided only to the TA involved in the incident and not the other transporter. ADON was asked about the education that was provided to TA. She explained, he was provided with education on what to do if a resident falls, who to notify, and not leave the resident alone if not oriented. Inquired whether the TA has the skills to assess a resident for orientation. ADON responded the TA is not assessing if the resident is alert, however, the TA is a Certified Nurse Aide (CNA). Further queried whether the TA has first aide and CPR training/certified. ADON was not sure. ADON was asked who makes the determination if a second staff member is needed, ADON responded usually the nursing clerk manages the scheduling of the ride. ADON also stated the transporters will ask for an aide or have family meet them if the resident has behaviors. ADON further stated, the TA felt R1 was alert and oriented and didn't think it would end up this way. Requested ADON follow-up on first aide and CPR training for TA. On [DATE] at 10:39 AM, the facility provided the Job Description (JD) for Transportation Aide (CNA). The [NAME] are primarily responsible for transporting or accompanying residents to and from physicians' offices or other sites of health care appointments. The qualifications include: high school graduate preferred with CNA training (one year experience) and good attendance record. The TA must also have knowledge of safe and appropriate transfer techniques and demonstrate use of proper body mechanics and adherence to all safety rules. On [DATE] at 11:20 AM, requested copies of R1's fall assessments from the Administrator. Follow-up with the Administrator at 11:29 AM, Administrator confirmed there was no documentation of fall assessments for R1. On [DATE] at 12:30 PM an interview was conducted with the Administrator in the conference room. Inquired why the type of event was initially identified as an elopement. The Administrator responded this was a typographical error. Further queried what did she think went wrong. Administrator replied, R1 is usually very alert and it may have been safe to leave the resident but leaving R1 with the x-ray facility's staff members would have been better. Administrator further stated that she trusted TA locked the resident's wheelchair brakes and he did not intend to hurt her. Moving forward, TA has been instructed not to leave resident unattended at curbside and to leave her inside the facility. Administrator noted if the resident is alert, another staff is not needed and recalled R1's BIMS was pretty solid. Administrator shared there were some discrepancies between the statements made by the TA and the nurse. The nurse reported that when the TA called, the resident was already in the van, the TA reported he sat the resident up for safety. Administrator stated the transporters have been instructed to call 911 if the residents fall and the facility will provide a staff member to accompany transporter and if R1's spouse is unable to make the appointment. Prior to exit on [DATE], although the TA is a CNA, the facility did not provide documentation/confirmation TA is CPR certified or had first aide training. On [DATE] at 10:10 AM, the facility provided a copy of the policy and procedures titled, Fall Prevention and Management (original effective date of [DATE]). The policy addresses the facility will prevent and/or manage the resident's risk for falls and implement a fall program for residents determined to be at risk for falls in order to better manage these factors and prevent and/or manage as much as is possible the resident from falling and/or sustaining injuries related to falling. Key element of the fall prevention and management program includes assessments and re-assessments, implementation and evaluation of treatment plan. Clinical nursing assessments are to be done at admission, change of condition, quarterly and as needed related to falls and mental status (judgment - safety awareness). The ongoing education/awareness also includes guidance for review of fall/safety information as, admission, care plan meetings, quarterly resident population education on falls management, after a fall, and prior to discharge. The contents of the review include: instructions and information concerning safety awareness; proper use of call bells, walking devices, wheelchairs, and other assistive devices, and individual interventions as defined on care plan.

Based on interviews and record reviews, the facility failed to provide discharge instructions for Resident (R)1 that include special instructions for ongoing care to family member related to wound care dressing changes, toileting, medications, and failed to notify a physician before discharging R1 against medical advice (AMA). Findings include: On 09/21/22 at 3:00 PM a record review (RR) of the Minimum Data Set (MDS) stated that R1 was admitted to the facility on [DATE]. R1 has a history of delusional disorder, paranoid schizophrenia, right hemiplegia/hemiparesis following a cerebral infarction, history of amputation to multiple right toes, generalized muscle weakness. R1 required extensive assistance for toileting and required use of an indwelling Foley catheter. During his stay, staff assisted R1 with toileting for incontinence of urine and bowel function. Ongoing RR of care plan revealed problem start date 08/08/22 that resident was on psychotropic drugs for paranoid schizophrenia with target behaviors of paranoia, suspiciousness and difficulty thinking daily. Interview done on 09/21/22 at 3:30 PM with Social Services Director (SSD) was done. SSD stated that R1's family member caregiver (FMC) wanted support if R1 came home but also was stating that she/he did not want to, nor could she/he take care of R1 at home. SSD stated that he/she encouraged FMC that he/she could do it and went through Steps on how to care for R1. SSD told FMC that he/she was able to set up transport for R1. SSD stated that he/she was not able to secure home health or a care coordinator because R1 had refused this in the hospital and the insurance carrier cancelled these services. SSD stated that she/he would have to re-initiate it again. SSD stated he/she did not know this at the time of discharge and it would take a few days to re-initiate. SSD stated that she could not reach R1's family member on the day of discharge. Interview was done on 09/21/22 at 04:00 PM with Advanced Practice Registered Nurse (APRN) stated that she did not call a physician before discharging R1 AMA. RR of Discharge Policy states on Page 2, #6. Should the resident/guest be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident/guests clinical record by the resident/guests Attending physician: 8. Should a resident/guest be transferred or discharged for any reason, the following information will be communicated to the receiving community or provider. (g) All other necessary information, including a copy of the resident/guests discharge summary, and any other documentation as applicable, to ensure a safe and effective transition of care. Telephone interview with R1's family member caregiver (FMC) was done on 09/22/22 at 08:40 AM. FMC was hard of hearing and kept asking this surveyor to identify and repeat questions. FMC stated they just dropped R1 off in front of the house and one of my nephews happened to be here. Nobody told me. When I was there at the facility, they stated oh you're here and then they wanted me to sign a paper. I told them I cannot take care of R1. I take care of my grandson and he is mentally disabled. I am [AGE] years old. I felt pressured. R1 did not come home with medications and no dressing change on his foot and did not get anyone to come and change the dressing. FMC stated that R1 could not lift himself and I could not lift him. Two days after he was discharged , he was on the floor, and I couldn't change his diaper. I noticed blood in his dodo. I called the facility, and a nurse advocate came and saw R1 on the floor and dodo in his pants with the blood. I called the ambulance. FMC further stated that R1 has been in the hospital for quite a while since that day and is still there. I hurt myself trying to lift him and I am a diabetic. R1's FMC stated that R1 was told about costs per day to R1 and the resident did not want to incur further charges.

Based on observation, interview and record review, the facility failed to obtain a signature on the Notice of Medicare Non-Coverage(NOMNC) notice to Resident 2 (R2). As a result of this deficient practice, an unsafe discharge resulted with R2. An incomplete NOMNC with resident and/or responsible party may indicate disagreement, and/or lack of understanding of the requirements of the NOMNC notice. Findings include: R2 had an above the knee amputation in July of 2022. R2 lives alone and has a bed on the floor at home. R2 was receiving physical therapy for a short time in the facility. Record Review (RR) was done on 09/21/22 of an Occupational Therapy note dated and certified for care from 07/22/22 through 08/13/22 which stated the discharge plan equals patient to live at home w/support from others. Assistance/support to be provided = Housekeeper. An interview and concurrent Record Review (RR) was done on 09/22/22 at 09:53 AM with patient service representative (PSR). The NOMNC dated and signed by the PSR on 07/29/22, at 3:50 PM, Friday to Resident 1 (R2). NOMNC was not signed by R2 because of a language barrier and R1 cannot understand English. R2 only speaks Spanish. Further queries into the NOMNC reveals that R2's friend did not agree with the discharge and did not want to sign the NOMNC. RR of progress notes dated 08/01/22 states that R2's friend stated to the facility I called the insurance company to file an appeal twice on 08/01/22, Monday and left a voicemail. R2's friend further stated that she/he was not notified about the facility-initiated discharge until Friday, 07/29/22 approximately at 4:20 PM and the insurance office was closed. On 08/01/22 at 4:13 PM,it was recorded in record that R2's friend did talk to the insurance coordinator and requested 24/7 assistance and the need for a hospital bed. The insurance coordinator was going to call R2's friend back after speaking to his/her supervisor regarding 24/7 assistance. No further documentation regarding an appeal was evident. R2's friend was not reachable by telephone for interview. R2 was discharged on [DATE] to home where he lives alone . The next day R2 was found alone in his bed and had defecated on himself. His neighbors reported R2 screaming for help and crying. R2 was readmitted to an acute care hospital on 08/06/22. This deficient practice resulted in an unsafe discharge with readmission to an acute facility the next day.

Based on observation, interview, and record review, after receiving report of an alleged abuse of Resident (R)1 by a certified nurse aide on 01/07/22 at approximately 05:30 AM, the facility failed to immediately and fully implement their Comprehensive Abuse Policy and Prevention Program in response. Specifically, the facility failed to ensure appropriate protective measures for R1, failed to conduct a thorough investigation, and failed to report the abuse allegation to the state agency (SA) and adult protective services (APS) in a timely manner. As a result of this deficient practice, resident safety was compromised, and an immediate jeopardy (IJ) was identified. Barring a two-day suspension on 01/13/22-01/14/22, pending investigation results, the alleged perpetrator (AP) was allowed continued access to R1, working on the same unit R1 resides on from the date of the allegation until the IJ was called, causing the resident further psychosocial harm. This deficient practice has the potential to affect all residents in the facility who report abuse or neglect. The State Agency (SA) identified immediate jeopardy (IJ) on 01/26/22 at 08:30 AM. On 01/26/22 at 08:55 AM, the Administrator was notified of the IJ at 483.12 (F607) and provided with the IJ template. The Administrator signed the template to attest receipt of the notice. Despite R1's report to multiple staff of her feelings of fear and shame towards the AP, the facility failed to protect R1 by immediately removing the AP from the unit, allowing him continued access to her. The facility also failed to implement continued assessment and monitoring of R1 for psychosocial, emotional, or physical needs. In addition, the facility failed to conduct a full investigation of the allegation before making a final determination, failed to identify other residents at risk for similar abuse, failed to report the abuse allegation to the SA until 01/13/22, or report it to APS at all. On 01/26/22 at 11:13 AM, the facility provided a removal plan. The removal plan consisted of immediate removal and reassignment of the AP from R1's unit, immediate reporting of the abuse allegation to APS, implementation of a thorough investigation into the allegation, in addition to continuous monitoring and assessment of R1 to ensure her needs are met, and re-education of all staff regarding the Comprehensive Abuse Policy and Prevention Program. The SA approved the removal plan. On 01/26/22 at 12:50 PM, the SA verified the IJ was removed. Findings include: 1) The facility submitted an initial Event Report to the SA on 01/13/22 at 01:45 PM of an alleged staff to resident abuse. The date of the incident was documented as 01/10/22 at 06:10 AM. The report read SSA [Social Services Assistant 1] social visit to follow up with resident regarding an incident reported. At first I [SSA] tried to explain what was noted [to occur], but she [R1] was unable to hear me clearly with my mask/face shield on, resident insisted on reading the paper of what was said [e-mail sent by the Shift Supervisor (SS)1 to Administration reporting the incident]. The content of SSA1's progress note entered on 01/13/22 at 12:03 PM was included in the event report which read: While resident [R1] was reading [the e-mail] she noted yes this is true, yes this is true, yes this is true (I [SSA1] could hear how uncomfortable it made her feel) I didn't ask her too [sic], but while she explained in her words/she showed what he did (over her blanket she pointed to private area and moved hand in a circular motion, she repeated it like 3-4x [times]). She noted he was persistent and kept saying I'm wet, and touching me, but I told him I'm not wet please don't do that, but he didn't stop, he wanted to see my private. I'm scared if he find out I reported him what will he do, I don't want no man changing me only ladies please don't let any man touch or change me, I want to go home, i [sic] want to talk to my son SSA[1] assured resident . Event final investigation included: Per email (SSA1 referenced above) from Shift Supervisor (SS)1: At approximately 06:10 LN [Licensed Nurse] . reported that the . resident [R1] . reported to .[Certified Nurse Aide (CNA)2] that she was scared of .[the AP]. LN . went in to ask what the problem was and resident [R1] stated that . [the AP] stated that she was pretty during peri care [perineal care involving cleaning of the private areas], and this make [sic] her feel uncomfortable . [CNA2] stated that when he was passing by her room, he heard the toilet flush, and . [R1] was leaving the bathroom . [CNA2] asked why she did not use the call light she stated that she was afraid . [the AP] will come, and she is scared of him. [CNA2] . said that the resident stated that during peri care he touched her brief to see if it was wet. The resident said she was not and . [the AP] said she was and ripped the brief off to change her and this make [sic] her feel uncomfortable and scared. I [SS1] assured the resident that she was safe and that if she did not want . [the AP] to care for her that would be fine, and that we would follow up. She did state that . [CNA2] is OK [to provide care to her]. Per e-mail (dated 01/13/22 at 06:48 PM) from the AP: On early morning of Wednesday 1/5/22 around 6:00 AM, I checked . [R1]. When I get into her bed [sic] I asked her how was she doing and she replied I'm OK. I told her that I'm there to change her diaper. She said I don't need to do it because she's ashamed of me . So I asked her if I can check her pull up [disposable adult brief] if wet and it was. I told her pull up was wet but she insisted not to be changed . That was the last time I saw her. The next day 1/6/22, she was in my team again, I asked . [CNA3] to take care of her instead. I voluntarily switched her as I know she will refuse my care. When I came back to work on Friday night . our nurse told me that I'm no longer allowed to provide care for her [R1] . The event report also included: Per interviews with staff resident [R1] did have a preference of only certain male staff but prefers female staff. This was not in the care plan at the time the incident occurred . The facility documented Investigation closed as unsubstantiated. 2) R1 is a [AGE] year-old female that has resided at the facility since 01/17/19. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 needs assist with activities of daily living due to her advanced age. Her BIMS (brief interview for mental status to identify cognitive status) score is 12, moderately impaired cognition. R1 is oriented to person and place, but forgetful at times. She wears a disposable adult brief for occasional incontinence and is able to use her call light to request assistance with transfers and toileting. R1 is aware of her limitations and usually does not attempt to self-transfer. R1's care plan (CP) indicated she was at risk for falls and had an unsteady gait and balance. 3) On 01/25/22, reviewed the facility policy titled Comprehensive Policy and Prevention Program last updated 03/03/21. The objective of the Abuse policy is to comply with the seven-step approach to abuse, neglect and exploitation detection and prevention . The seven components identified in the policy included Screening, Training, Prevention, Identification, Investigation, Protection and Reporting/Responding. The following specifics revealed the facility failed to immediately and fully implement their Comprehensive Abuse Policy and Prevention Program in response to the allegation of abuse. Prevention: The policy included It is the policy of this facility to prevent and prohibit all types of abuse and neglect by the following measures including, but not limited to . Identifying, care planning, implementing appropriate interventions and monitoring residents with behaviors and care needs that may increase their risk. On 01/26/22 at 06:30 AM during an interview with licensed practical nurse (LPN)2, she said R1 only likes a couple of the male CNAs. She went on to say she thought this had been in R1's CP at one time, but it was not there at the time of the incident. R1's CP was not updated in a timely manner after the incident was reported. SSA1 updated the CP on 01/13/22, six days after it was reported. The CP was revised to include: Problem Start Date: 01/13/2022 . I (R1) prefer to have female CNA/Staff assigned to provide my daily care needed here at the facility, For I feel unsafe/uncomfortable having a male cna/staff care for me. R1's feelings were more than a preference. The CP did not clearly state R1 would have no male CNA's assigned with the exception of the ones she told staff she was comfortable with. Identification: Policy included It is the policy of this facility that staff assess and monitor residents and be able to identify potential signs and symptoms of abuse . Procedures: Staff will be able to identify unobserved possible indicators of abuse such as injuries of unknown origin and sudden changes in behavior (such as fear of person or place or feelings of guilt or shame). There was lack of documentation the staff assessed and monitored R1 after the incident was reported to identify her needs for additional support, monitoring and interventions. Although the AP no longer provided direct care to R1, he remained on her unit. R1 verbalized to CNA2 she didn't use her call light for fear the AP would respond. Staff reported and surveyor noted that the AP had a very distinct, loud voice in such a low register that it would be easy for even those who were hard of hearing to hear. Staff reported they had no doubt R1 would be able to hear his presence on the unit. The interview and observation of R1 on 01/26/22 revealed she continued to have feelings of shame, and became tearful when recalling the incident. Investigation: Policy Protocols included: Upon receiving an allegation of abuse, committed against a resident, the staff member receiving the allegation must ensure the safety of the resident and immediately notify the supervisor on duty. The supervisor on duty will immediately notify the Administrator or designee. The alleged perpetrator will be asked to leave the facility immediately and be escorted out of the facility . If an employee, the alleged perpetrator will be suspended pending a full investigation. The alleged perpetrator will be interviewed by phone. The alleged perpetrator may not return to the facility until notified by the Administrator.The Administrator or designee will report to the state survey agency alleged abuse with physical injury no later than 2 hrs. of the allegation . Residents who are identified at risk for similar abuse will be interviewed and/or assessed. Residents who came into contact with the alleged perpetrator will be interviewed and/or assessed. Interventions will be put into place as needed.The resident will be assessed for any needs every shift for 72 hours or until comfortable regarding incident. Nurses will chart each shift for 72 hours regarding resident's condition. Social service will conduct safe surveys. The Administrator with the assistance of the DON (Director of Nursing), Social Services, and regional support will determine the findings of the investigation based on a thorough review of the incident information. On 01/26/22 at approximately 02:30 PM during a phone interview with SS1, he explained his immediate response when notified of the incident. The SS1 said he spoke with CNA2 and LPN2 to find out what they knew because they had both spoken to R1 about her concerns. He said he did not interview any of the other staff or residents. The SS1 said he may have some personal notes, but the only documented report he prepared was the e-mail he sent to Administration that morning, 01/07/22. The SS1 said the AP was not working at the time the incident was reported, so there was no documented interview with him. The SS1 said he was not aware of any other concerns or complaints from residents about the AP. The Administrator confirmed there were no other interviews with staff or residents, and no additional information other than what had been included in the report to the SA. Protection: Policy included It is the policy of this facility that the alleged victim and all residents are protected from [sic] physical and psychosocial harm during and after the investigation. Procedures: Staff will respond immediately to protect the alleged victim, the other residents and the integrity of the investigation. the alleged perpetrator will immediately be removed from the facility and denied access to the alleged victim and all other residents. The resident will be assessed, examined (if necessary) and interviewed to determine any injury and clinical interventions needed, and MD and family notified.Follow-up counseling will be made available as needed .The alleged victim's care plan will be updated. The alleged victim will receive increased supervision and assessment throughout the investigation and as long as deemed necessary. On 01/26/22 at 07:30 AM, during an interview with the AP, he confirmed the incident of question occurred on 01/05/22 at approximately 06:00 AM on his last round. He said he worked his next scheduled shift 01/06/22 and asked CNA3, a coworker to care for R1 that night because he knew she would refuse his care. AP said he was first made aware R1 had an issue with him when he arrived to work on Friday 01/07/22 when LPN2 told him he should not take care of R1. AP worked that shift on R1's unit. AP said the Administrator called him on 01/13/22 when she asked him to send her details of his account of the incident. At that time AP was informed he was suspended until further investigation. He returned to the same unit on 01/15/22. On 01/26/22 reviewed the Point of Care History for R1, where the CNAs document How did the resident use the toilet? and Staff support provided for toileting? For the question how R1 used the toilet, AP documented Total Dependenceon 01/05/22 and Limited Assistance on 01/06/22. For staff support, AP documented 1 person physical assist for 01/05/22 and 01/06/22. The documentation would indicate the AP provided care to R1 on 01/06/22. There was no documentation on 01/06/22 to show CNA3 provided care to R1 that shift. On 01/26/22 reviewed the AP's Employee Timesheet to validate the dates the AP worked as there were discrepancies noted on the staff schedule provided to surveyor. The timesheet confirmed the AP worked four shifts (01/07/22, 01/10/22, 01/11/22, and 01/12/22) on R1's unit after the incident was reported. Cross Reference to F610: Investigate/Prevent/Correct Alleged Violation. The facility failed to prevent further potential for abuse during the investigation process. Administration was initially notified via email on 01/07/22 of the incident. The alleged perpetrator was scheduled to work on the alleged victim's unit until his suspension on 01/13/22. The facility also failed to have evidence that the alleged violation was thoroughly investigated Reporting/Responding: Cross Reference to F609: Reporting of Alleged Violations. The resident's allegation was reported to administration by SS1 on 01/07/22 via e-mail and phone. The facility did not notify the SA until six days later, on 01/13/22. In addition, the facility did not make a report to Adult Protective Services (APS). The facility did not respond in a timely manner to assess R1's needs. SSA1 did not see R1 until six days after the event was reported. Review of e-mails revealed the following: 01/07/22 (Friday) at 07:12 AM, SS1 emailed the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) about the incident. 01/10/22 (Monday) at 10:18 AM, the Administrator e-mailed SSA1 Can you please follow up for me. 01/13/22 at 06:48 PM, the AP sent an email to the Administrator of his account of the incident. On 01/25/22 at 04:00 PM during an interview with SSA1, she said the first she became aware of the incident was on 01/12/22. She said she had been home sick, did not have her computer, and did not receive the e-mail sent to her by the Administrator on 01/10/22. She went on to say she came in to pick up her computer on 01/12/22, read the email and immediately called the Administrator who was also interim Social Services Director and informed her she would be in the next day to follow up with R1. SSA1 said the Administrator was aware she had been out sick. R1's son was notified by SSA1 on 01/13/22 of the incident. SSA1 said there were four SSAs and each is assigned a unit. Her unit was the one R1 resided on. Record review revealed the nursing staff did not document every shift that R1 was assessed for behavior changes, needs and/or emotional support for 72 hours after identification of the incident as directed in the policy. 4) On 01/26/22 at 09:50 AM an interview was conducted with Resident (R)1 in her room with SSA1 and a state surveyor. R1 was seated in her wheelchair next to the bed. She was dressed neatly and observed to be wearing a necklace with a cross. R1 was hard of hearing and questions were asked by the Surveyor and SSA1. R1 was asked if she was afraid of the AP. She responded, men is men and further stated that she was ashamed to have the AP provide care to her. Due to R1's hearing limitations, SSA1 reported R1 can read and SSA1 offered to print an e-mail for R1 to read. SSA1 stated when she interviewed R1 on 01/13/22 she showed R1 the e-mail regarding the allegation and R1 told SSA1 it was true. SSA1 reported during that interview R1 would cover her mouth with her hand. SSA1 further reported R1's reaction indicated that she was afraid. At that time R1 told SSA1 she wanted to go home and wanted her son called. At 10:15 AM, the Surveyor and SSA1 returned to continue the interview with R1. SSA1 provided a copy of an e-mail to R1 containing the allegations that were made. R1 read the email (SS1's email to administration) aloud and intermittently said yes .yes, confirming the documentation was accurate. R1 was asked if the AP said she was pretty, she confirmed he did. R1 stated the AP asked her if she was wet, and she responded no as she had just come from the bathroom. R1 gestured rubbing her groin area up and down, stating it is not right to do that. R1 further stated the AP said he would change her, ripped open her personal brief, and proceeded to change her. R1 commented, why show the 'bilot' (Filipino slang for female genitalia)? R1 reported she had forgotten about this one and became tearful. Surveyor wrote the question asking R1 if she was afraid of the AP, she responded she is not afraid but shame. R1 said she does not want him to come to provide care to her again and does not want somebody do that to me. R1 was tearful and repeatedly stated promise not to come here please. 5) Cross Reference to F835: Administration. The Administrator who was also serving in the role of Social Services Director, failed to ensure the Comprehensive Abuse Policy and Prevention Program was fully implemented and failed to use resources effectively and efficiently in response to an abuse allegation.

Based on interviews with resident and staff members and record review, the facility did not ensure a resident's right to a dignified existence was respected. A resident was not treated in a manner that recognized her individuality and promoted her quality of life. A staff member was not respectful of Resident (R)1's request to refuse peri care (peri care also known as perineal care involves cleaning the private areas of a resident). The staff member proceeded to provide care despite the resident's refusal which resulted in R1 expressing feelings of being scared and ashamed. The facility did not honor the resident's preference of not having male staff members provide direct personal care. The staff member continues to be assigned to R1's unit. Following the incident R1 reportedly doesn't use her call light to request assistance for fear the staff member will respond. R1 has been transferring herself from the bed to the wheelchair and wheelchair to the toilet, putting her at high risk for falls. These deficient practices resulted in harm and has affected the resident's psychosocial well-being, resulting in R1 feeling scared and shamed in her home. Findings include: The facility submitted an Event Report to the State Survey Agency on 01/13/22 with an allegation of abuse. The event report documents the incident occurred during the night shift on 01/10/22. A review of the report notes the Social Services Assistant (SSA) interviewed R1 using documentation of the resident's allegation. SSA noted R1 read the document and stated, yes this is true, yes this true. R1 gestured to SSA to demonstrate what the Alleged Perpetrator (AP) did. R1 was noted to point to her private area and move her hand in a circular motion approximately three to four times. SSA documents R1 stated he was persistent and kept saying I'm wet, and touching me, but I told him I'm not wet please don't do that, but he didn't stop, he wanted to see my private. R1 informed the SSA that she was scared and wanted to go home. R1 also stated that she did not want men to touch or change her. Resident (R)1 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was not coded for behavior or moods. R1 requires extensive assist with one personal physical assist for toileting (how resident uses the toilet room, transfers on/off toilet, cleanses self after elimination, and changes pad). R1 is noted to be occasionally incontinent of bowel and frequently incontinent of bladder. On 01/26/22 at 09:50 AM, R1 was interviewed by the State surveyor and the SSA. R1 was asked if she was afraid of the AP, she stated that she was shame and men is men. It was difficult for R1 to hear the surveyor and SSA, the SSA suggested to print R1's allegation statement for the resident to read. SSA and State surveyor returned at 10:15 AM. R1 read the statement aloud and would comment, yes .yes. R1 confirmed AP told her she was pretty while providing peri care. R1 reported she told AP that she was not wet and demonstrated AP rubbing up and down of her groin area, stating it was not right to do that. R1 further reported AP ripped open her personal brief and changed her. She commented why show the bilot (Filipino slang for the female genitalia). R1 became tearful during the interview and her breaths became short and rapid. R1 repeatedly stated, promise not to come here please and she asked interviewers, why he would do that. A review of the documentation provided to the resident during the interview is an email from the Shift Supervisor (SS)1 to the administrative team (Administrator, Director of Nursing, and Assistant Director of Nursing). The email is dated 01/07/22 and documents the information that was provided to SS1 by the Licensed Practical Nurse (LPN)2. SS1 wrote to the administrative team to inform them of an incident involving R1. The email documents R1 reported to Certified Nurse Aide (CNA)2 that she was afraid of the AP. CNA2 informed LPN2 heard the toilet flush and saw R1 leaving the bathroom. CNA2 inquired why R1 didn't use the call light. R1 stated that she was afraid of AP. CNA2 asked why? R1 reportedly responded that AP touched her brief to see if it was wet, R1 stated she was not wet and AP ripped off her brief to perform peri care. The email also documents LPN2 spoke with R1. LPN2 reports R1 stated the AP told her that she was pretty while providing peri care. R1 informed LPN2 that this made her uncomfortable. On 01/26/22 at 07:07 AM an interview was conducted with CNA2. CNA2 reported he observed R1 going to the toilet alone, he asked her why she didn't call, she reportedly responded because she is scared. CNA2 asked what she was afraid of, R1 responded she's afraid of the AP. R1 reported to CNA2 that AP like change her but she is afraid of what he would do to her. CNA2 stated R1 says she is afraid of yot. CNA2 reported this is the Filipino word for when someone puts something inside. CNA2 reported he assisted with the interview with R1 as an interpreter. CNA2 further reported prior to the incident, R1 would call for assistance; however, following the incident she does not call for help. CNA2 reported R1 has difficulty transferring and has been transferring herself from the bed to wheelchair, wheels herself to the bathroom, and then transfers herself to the toilet. R1's room is close to the nurse's station so when CNA2 hears the toilet flushing, he will go to assist her. Interview was conducted with Licensed Practical Nurse (LPN)2 on 01/26/22 at 06:34 AM. LPN2 reported the incident to the Shift Supervisor (SS). LPN2 was asked whether the AP reported R1 refused care, LPN2 replied there was no report for refusal of care. LPN2 stated in the past R1 requested no male caregiver and recalled that previously this was in the resident's care plan. She commented that she wonders what happened to that intervention. LPN2 reported she spoke with R1 regarding the incident. LPN2 stated R1 was descriptive regarding the care AP provided and reported to LPN2 that the AP commented to resident that she was pretty, how good she looks, and how she looks good for her age. R1 told LPN2 it didn't feel right. AP was interviewed on 01/26/22 at 07:30 AM. The AP is employed as a CNA, he completed his training and this is his first employment as a CNA. AP reported his hire date was 12/06/21. AP recalled incident took place on 01/05/22. AP reported he went to check R1 and as she is easy to clean, she was the last resident (at approximately 06:00 AM). He reported she told him there was no need to do that. AP stated that R1 told him he should not have to change her as he is a pastor for a church. Prior to the incident, R1 reportedly was receptive to receiving care so he was not expecting resistance on that morning. AP reported he checked her personal brief, if the brief is wet, there is a broken line, it smears. He recalled R1 telling him that she was not wet. Inquired whether he has encountered other residents refusing care. AP reported there was a time when he went to change R3 and she told him that she did not want him to change her diaper today, she wanted a female. Following the refusal, AP reported he approached her a second time and she was agreeable.

Based on interviews and record review (RR), the facility failed to ensure the recommendations made by Hospital (H)1 providers for changes in medication for one Resident (R)1 were fully assessed for risk and benefit with documented rational to implement or not in a timely manner. R1 suffered the harm of ongoing anxiety and suicidal ideation which resulted in four emergency room (ER) visits by not implementing interventions to stabilize his mood in a timely manner so he could reach highest physical, mental and psychosocial well-being. 1) R1 was admitted to the facility on [DATE] and has [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] type and [CONDITION(S)]. He was on multiple medications for his [CONDITION(S)] disorder and had increased anxiety and suicidal ideation that resulted in four ER visits in March. 2) R1's primary physician was listed as MD1, who is a part of a contracted group to provide physician services to the facility. Nurse Practioner (NP)1 was assigned to R1 and was in the facility three times a week, and telehealth two days. R1 saw two Psychiatrists (PMD)1 and PMD2, and a therapist. Documentation revealed R1 had stopped his therapy visits due to some concerns and considering a different therapist. 3) RR of R1's Provider notes, nursing notes, and H1 records revealed the following: 01/07/21 Facility PMD1 notes: Current [MEDICATION(S)] dose 225 mg (milligrams) in am and 900 mg hs (at bedtime). Prescribed reduce [MEDICATION(S)] to 225 mg in am and 300 mg in pm. 01/21/21 10:55 PM nursing note: Res (R1) . ask this LN (licensed nurse) re: current [MEDICATION(S)] doses. Brought up today he was having delusions and threatening to call the ombudsman, inquiring about why the medications were changed to a higher dose than was on prior to initial toxicity sx (symptoms) approx 2 weeks ago. Res on phone with mom (POA) at this time while this LN explaining medication changes however unable to provide explanation re: Increased morning dose. The LN spoke with POA and provided detailed report on days medications were changed and doses. , however POA remains upset of current doses. This LN called NP1 to update, POA would like NP1 to discuss medication changes. new orders received to hold AM dose of [MEDICATION(S)] and NP will re-eval tomorrow. 02/02/21 PMD2 notes: He (R1) states they lowered his dose of [MEDICATION(S)] from 900 to 300 mg. He wanted his old dose because he feels horrible so she (unknown who this references) moved it back to 900 mg. Patient says he is on [MEDICATION(S)] ([MEDICATION(S)]) 500 mg . I asked him who's managing that, and he said I was, which I am not. I need records from everyone that is involved with psychiatric care. PMD2's notes did not include a list of R1's current medications. Documention of Interdisciplinary Team (IDT) meeting held on 02/18/21 had no reference to PMD2's note needing records of R1's psychiatric care records or issue of medication reconciliation and there was no documentation of any action or follow up regarding the issue. 03/02/21-03/03/21 ER visit for suicidal ideation. Recommendation medication changes from Hospital (H)1 providers included: [MEDICATION(S)] ([MEDICATION(S)]) 300 mg tid (three times a day) prn (as needed) for anxiety, [MEDICATION(S)] 5 mg QHS (at night), and discontinue (dc) [MEDICATION(S)] due to prolonged QT interval. Documentation revealed the H1 psychiatric consult (NP2) called to discuss recommendations with NP1. There were no prescriptions sent to the facility and the After Visit Summary had handwritten notes unsigned, not dated or timed of the medication recommendations except the dc of [MEDICATION(S)]. Prolonged QT may cause potentially life-threatening heart arrhythmias. On 03/04/21 at 01:30 PM a Provider Communication Sheet was initiated by nursing which had the handwritten note: I am deferring to the prescribing doctor of patients new meds, [MEDICATION(S)] and [MEDICATION(S)], to write and sign orders and to approve whether or not there's a drug interaction. The note was signed by PMD2 03/04/21 at 01:30 PM and noted by RN on 03/05/21 at 01:30 PM. A hand written note was on the form that read No Rx, only ER recommendation (not signed) There were no additional notes with rational for not ordering the medications recommended, consultation with the pharmacist, or contact with the H1 provider to discuss. On 03/04/21 at 03:51 PM nursing notes: . Clarified order to PMD2's clinic and talked to Nurse-saying PMD2 is not ordering or approving the new meds because he did not prescribe it. NP MD stating she will follow PMD2's orders and will only agree to the order for PRN [MEDICATION(S)] 50 mg x 14 days that PMD2 sent thru fax. It had been recommended the [MEDICATION(S)] was discontinued. The [MEDICATION(S)] was discontinued 03/18/21. 03/07/21-03/08/21 (approx 12:00 AM) To ER for increased anxiety. The emergency room MD (ERMD)2 noted: He (R1) was evaluated here on March 3rd for similar symptoms. Recommendation was to start [MEDICATION(S)] 5 mg at bedtime. The patient is requesting to be put on [MEDICATION(S)] . I will follow ERMD1's recommendation from his (R1's) prior ER visit. On discharge a prescription (Rx) was written for [MEDICATION(S)] 5 mg oral tab daily at bedtime and sent to the facility. Review of the [MEDICATION(S)] Rx revealed the handwritten note; 3/8/21 Defer to PMD2 (psychiatrist) may give x1 prn today pending appt with PMD2. 03/08/21 (approx 10:30 PM) -03/09/21 To ER for increasing agitation. H1 Psychiatry consult 03/09/21 by PMD3; Notably, patient has been having episodes nightly. Previous recommendations for [MEDICATION(S)] and [MEDICATION(S)] have not resulted in follow up. This writer gathered collateral from the patients mother, the resident care manager as well as nursing supervisor at HM (Hale Makua) to discuss recommendations and dispo (disposition) planning. Discussed presentation and recommendations including added meds. Aware that follow up has been a challenge and appointments should be arranged to ensure continuity of care. Psychopharmacology: Will plan to increase Cozaril ([MEDICATION(S)]) with AM to 50 mg Qam, begin [MEDICATION(S)] ([MEDICATION(S)]) 1 mg PO QHS prn anxiety. Discontinue [MEDICATION(S)] and [MEDICATION(S)]. Psychiatric follow up is unclear at this time-HM to arrange. Prescriptions for 10 days were provided for [MEDICATION(S)] and [MEDICATION(S)]. The facility dc [MEDICATION(S)] 03/09/21. 03/09/21 R1 had a telehealth appointment at the request of R1 and FM with PMD1, which did not occur because R1 was in the ER. Nursing note at 02:52 PM documented: Per PMD1 she will approve of all the recc (recommendations) from the ER and she will see res (R1) tomorrow via telehealth appt. 03/17/21-03/18/21 To ER for suicidal ideation. H1 Psychiatric consult by NP2. Recommend: [MEDICATION(S)] 1 mgpo [sic] BID (twice a day) for extreme agitation and anxiety or [MEDICATION(S)] 1 mg po TID as needed. Psychotherapy daily for 2 weeks then reevaluate and readjust frequently accordingly. Psychotherapy is a term for a variety of treatment techniques that aim to help a person identify and change troubling emotions, thoughts, and behavior. The facility wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The appointment was scheduled for 03/25/21. There was no documentation of a plan for psychotherapy or frequent sessions with a therapist during this vulnerable time. 03/18/21 at 11:09 AM nursing note: Resident returned from ER pysch observation. Activity CNA (certified nurse assistant) reported to this LN that the resident (R1) keeps a sharp scissors at his bedside to cut open his coffee, resident is okay with this LN removing the scissors for safety. R1 had been on 1:1 sitter since 03/08/21 in the evening and had frequent suicidal ideations. 4) On 03/24/21 at 01:29 PM during an interview with NP1, she stated she was part of a contracted medical group to provide services at the facility, and is considered to be one of R1's primary care providers. NP1 said on R1's first visit to the ER, she spoke with NP2, the H1 psychiatric consult, who recommended medication changes. She said when he came back to the facility, they did not send prescriptions and there was only handwritten notes on a piece of paper (After Visit Summary/instructions) with no signature, time or date. NP1 said R1's psychiatrist (PMD)2 needed to approve the medications, and it was her policy as well for antipsychotics. NP1 went on to say the nursing staff contacted PMD2, who did not approve the medications and that there was a SBAR (situation, background, assessment, recommendation-communication tool nursing used) that looked like PMD2 signed saying whoever wrote the recommendations was responsible for the drug interactions and he wasn't approving them. NP1 said she did not personally talk to PMD2 about the note or recommendations. NP1 said He (PMD2) is difficult to get a hold of, we are frustrated with that too. NP1 said she never saw the note to discontinue [MEDICATION(S)] but would not have written the order and would have referred it to PMD2. NP1 said when they had a family meeting about R1's current medications and plan, R1 and Family Member (FM) expressed a lot of frustration with PMD2's lack of response and not happy with the decreased [MEDICATION(S)]. They didn't want to see PMD2 anymore and felt the quickest thing to do was to see PMD1 again. 5) On 03/24/21 at approximately 09:00 AM during an interview the Administrator (ADM) said she had been involved in family meetings and was aware R1 and FM were upset about difficulty contacting PMD2 and response to the H1 providers medication recommendations. She went on to say NP1 does minor medication changes but only makes recommendations for others. The ADM said, There were so many hands in the pot with R1. Inquired if the facility Medical Director (FMD) had been involved due to the complexity of the case, to which she said she had not made the FMD aware of the situation. 6 ) Review of the Medical Director Agreement established July 1, 2016 included the following statements: 3.4 Physician shall be responsible for the coordination of medical care in the Facility. Physician shall help the Facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice. 3.4.6 Review individual resident cases as warranted to evaluate quality of care or quality of life concerns or other problematic situations and take appropriate steps to resolve as necessary and as requested. 7) On 03/25/21 at 02:00 PM during a phone interview with the FMD, she said the facility will involve her if there are issues or questions and sometimes to clarify goals of treatment. The FMD said she and the Director of Nursing (DON) spoke about R1 about six months ago, but not recently and that she was not aware of any issues with R1's medication management, or PMD2's response and rational for not implementing suggested medication changes. The FMD went on to say NP1 is part of the medical group and is supervised by a physician, who should be involved in situations like this as well. Due to R1's multiple ER visits, ongoing symptoms, multiple providers, delays in appointments and R1's verbalized concerns, it would have been appropriate to involve the FMD to evaluate the case and assist to obtain timely and appropriate medical care. 8) The 2021 Facility Assessment listed Psychiatric /Mood Disorders as a common diagnosis/condition they care for at the facility. 9) Cross reference 657- Care Plan Timing and Revision R1's CP was not revised to include: current medications, increased anxiety/suicidal ideation with four ER visits, increased bladder/ bowel incontinence, or that R1 required a 1:1 sitter. 10) Cross reference 867-QAPI There was no consistent process to obtain all the medical information needed when R1 returned from ER visits. This may have contributed to the lack of timely interventions to stabilize his mood and behavior.

Based on observations, reviews of event reports, review of medical records, staff interviews, and facility policy review, the facility failed to ensure the safety of 11 residents (Resident #s 18, 21, 107, 130, 151, 163, 218, 255, 268, 298, 372) reviewed for accidents and elopements during stage 2 of the QIS survey warranting an Immediate Jeopardy (IJ). Findings include: 1) An observation of Resident #107 on the afternoon of [DATE] found her seated in a wheelchair in the common area. She was seated at a table with a staff member who was playing cards with her. The resident was unable to be interviewed due to cognitive impairment. Observation of Resident #107 on the morning of [DATE] found her seated in a wheelchair near the nurses station doing activties with a staff member. A review of an event report dated [DATE] revealed Resident #107 experienced a fall on [DATE] at 3:54 P.M. The event noted the resident was seated in the common area with facility staff nearby. From a sitting position, Resident #107 got up, lost her balance and fell to the floor onto the right side of her face. The staff reported Resident #107's right of her face was on the floor with bilateral upper extremities flexed and bilateral lower extremities extended. She sustained a lump to her right forehead and discoloration under the left side of her nose. Resident #107 did not lose consciousness and neurological test and vital signs were within normal limits. Ice packs were applied and the resident did not verbalize she had pain. The Licensed Nurse attempted to administer Tylenol but the resident spit it out. Later that same evening the resident experienced pain when right forehead was palpated. At that time, the Licensed Nurse noted bruising to the right orbital area and later noted swollen. Again Resident #107 refused the Tylenol. The resident was assessed by the physician on [DATE] at 2:30 P.M. when an xray was ordered of the right orbital to rule out a fracture. A care plan for risk for falls was already in place noting she was ambulatory requiring supervision and physical assistance at times as needed. The facility noted their goal of care was to manage Resident #107's pain. Additionally, they would refer Resident #107 for restorative program for ambulation and strengthening. A review of the xray report dated [DATE] at 4:19 P.M. noted, No definite fracture is noted, however, given the slight obiquity it would be difficult to determine if there is a hairline fracture. No displaced orbital fracture is noted. There is suggestion of mild chronic disease. Impressions were, No definite evidence of acute osseous abnormality, no depressed fracture. If pain persists or if otherwise indicated, CT scan of the face may be useful for further evaluation in the correct clinical setting. A medical record review found Resident #107 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set, MDS 3.0, with Assessment Reference Date, ARD, of [DATE], Resident #107 had a Brief Interview of Mental Status (BIMS) score of ,[DATE] indicating severe cognitive impairment. Under Section G Functional Status, the MDS noted Resident #107 required: Supervision with one person assistance for walking in room; Supervision with two person assistance for walking in corridor; Supervision with one person assistance for locomotion on unit; Steady at all times moving from seated to standing position; Steady walking; Steady turning around; Steady moving on and off toilet; Steady for surface to surface transfer; and did not use any mobility devices (cane/crutch, walker, wheelchair, limb prosthesis). A significant change MDS was not completed for Resident #107 as of the survey date, [DATE]. A review of Resident #107's care plan found a care plan titled, Risk for falls r/t osteoporosis. She has poor safety awareness. Resident has a history of falling out of bed and out of chair unattended and unable to verbalize what happened due to poor cognition r/t Alzheimer's disease. Interventions included: Monitor for safety, especially during large group settings. Keep at visual area where she can be easily gotten to, proper footwear. Monitor for signs of attempting to leave, looking around, fidgeting, or attempting to walk out, etc. At the time of her fall on [DATE], she was not supervised for a short period of time when she fell . After her fall on [DATE], Resident #107's care plan was not revised to indicate the facility had identified the cause of the fall and did not indicate new interventions to prevent additional falls. An interview with LN #5 on the afternoon of [DATE] revealed Resident #107 experienced 3 to 4 falls over the past month. The LN #5 stated the resident's latest fall was a few weeks ago. The LN #5 reported the resident experienced frequent falls. He reported the facility staff was aware that she was at high risk for falls before the latest fall a few weeks prior. He stated she fell frequently and after each fall, their primary intervention was to manage her pain and provide ice packs for swelling. The LN #5 stated that Resident #107 has experienced a decline in her Activities of Daily Living (ADLs). Prior to the [DATE] fall, the resident could ambulate with supervision. Since the [DATE] fall, she can no longer ambulate and is wheelchair bound. Additionally, he noted she is more confused and disoriented. An interview of a Certified Nurses Aide, CNA #4 on the afternoon of [DATE] at approximately 3:30 P.M. revealed Resident #107 was able to walk independently and go to the toilet on her own with 1 person assistance before her last fall on [DATE]. Since then, Resident #107 has experienced a decline in ADL function and requires assistance with all ADLs. According to CNA #4, Resident #107 was more independent before her fall on [DATE]. The CNA reported, Now when we put her on the toilet, she doesn't know what to do. She just stares at us. So we turn on the water and tell her to 'shishi' (urinate). Additionally, CNA #4 reported the resident now uses a wheelchair but didn't prior to the fall on [DATE]. Despite Resident #107's history of falls, she continued to experience falls the latest which marked a decline in her ADL function. The marked decline in Resident #107's functional ability was an avoidable adverse outcome. 2) A review of an event report dated [DATE] revealed Resident #130 experienced a fall at 3:45 A.M. on [DATE]. She was found on her bathroom floor laying on her right side. She was transferred to a hospital for an xray which found a right intertrochanteric fracture. Resident #130 was admitted to the hospital for surgical correction of her right hip fracture. The resident was readmitted to the facility from the hospital on [DATE]. A review of Resident #130's record found she had a history of [REDACTED]. A falls care plan was in place. Resident #130 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #130's admission nursing assessment revealed she was at high risk for falls. She had a care plan in place for fall risk prior to [DATE] fall. According to the event report, the resident had a RN+ bed alarm. The report indicated the staff immediately responded to the bed alarm. However, when the staff arrived in the resident's room, the resident was already in the bathroom, on the floor. She was incontinent of bowel and bladder and her brief was soiled. A review of Resident #130's MDS with ARD of [DATE] found a BIMS score of ,[DATE] indicating severe cognitive impairment. Care plans were generated for Resident #130 for At risk for falls and Anticipated decline secondary to dementia. An interview of the MDS Coordinator on the afternoon of [DATE] revealed the care plans remained as they were written and no changes were made following the fall on [DATE]. The Falls care plan included the following interventions: Place in a supervised area when she is out of bed; IDT RARE [DATE]: staff to provide close monitoring in common area after family leaves; and RN+ alarm in wheelchair and RN+ in bed. Do the safety risk assessment and adhere to protocol. Upon readmission ([DATE]) to the facility, Resident #130 experienced a lot of pain at times rated ,[DATE] from her right hip. According to the nursing note dated [DATE], Resident #130 experienced a 7.8 pound weight loss since her readmission. A follow up nursing note dated [DATE] noted a 2.8 pound weight loss since her readmission. The Licensed Nurse further indicated Resident #130 does less walking since her readmission. Resident #130 had a known history of falls. She experienced a fall resulting in a fracture of her right hip on [DATE]. Since that fall, she experienced a decline in walking ability and experienced unplanned weight loss. 3) While on survey, the facility notified the Hawaii State Survey Agency that Resident #130 eloped from the facility on [DATE]. The Administrator and Director of Nursing reported that Resident #130 left the facility unsupervised and was later found in the facility's parking lot. In the parking lot, she had fallen out of her wheelchair and was lying on the ground when a visitor found her. When she fell out of her wheelchair, she hit the left side of her head. The facility further noted the CNA caring for Resident #130 failed to secure her wheelchair alarm appropriately. The resident's departure from the facility would not have activated the wheelchair alarm. The alarm would only be activated if she attempted to get out of her wheelchair. The facility did not state whether the wheelchair alarm was activated when she fell out of the wheelchair in the parking lot. The facility staff was unaware she was missing until the visitor notified them. A record review on the morning of [DATE] found Resident #130 was admitted to the facility on [DATE]. A review of Resident #130's care plan on the morning of [DATE] revealed the family notified the facility she was a wanderer while living at her home. A care plan titled, Anticipated decline secondary to dementia was in place. At the time of survey ([DATE]), the care plan had not been updated since the elopement on [DATE]. The facility failed to provide adequate supervision for Resident #130. On [DATE], Resident #130 eloped from the facility, followed by her falling out of her wheelchair and hitting the left side of her head without significant injury. 4) A review of an event report for Resident #151 found she experienced a fall on [DATE]. The event report noted Resident #151 was being supervised by the Unit Clerk while the CNA answered a phone call. The Unit Clerk went to her desk to place a document onto her desk and also shredded a paper before returning to the common area where Resident #151 was last. The Unit Clerk noted she was in the nurses station for less than a minute when she heard a commotion in Room #4. At approximately 3:40 P.M. on [DATE], Resident #151 went into another resident's room, Room #4 (Resident's room was #10). The Unit Clerk went into Room #4, followed by a Licensed Nurse. The Unit Clerk found Resident #151 lying on her back on the floor outside of the open bathroom door in Room #4. She was found on the floor between the right side of the bed and the wall with her knees bent up and feet on the floor. She complained of right hip pain and was crying and moaning. Resident #151 informed the staff she was attempting to use the bathroom to void. The physician ordered for Resident #151 to be sent out for an xray. She was unable to tolerate a sitting position and required a gurney for transport. Resident #151 left the facility for the hospital via ambulance at 4:45 P.M. At approximately 9:50 P.M. the nurse from the hospital emergency room called the facility to notify them they will admit Resident #151 for right hip fracture. Resident #151's returned to the facility after her right hip fracture was surgically corrected. The Interdisciplinary Team (IDT) met on [DATE] to discuss the resident's current needs. A comparison of MDS' from last quarterly (ARD: [DATE]) and most current quarterly (ARD: [DATE]) noted Resident #151: Previously moved on and off the unit with extensive assistance and was now totally dependent; Previously required physical help for bathing with one person assistance and now required two person assistance; and Previously used a walker and wheelchair for mobility and now only used a wheelchair. A review Resident #151's record on the morning of [DATE] found an MDS with ARD of [DATE] which noted a BIMS score of ,[DATE] indicating moderately impaired cognition. The MDS noted resident #151 required assistance with all her ADLs and was experiencing delusions and verbal behavioral symptoms towards others. The MDS further noted Resident #151 experienced a 5% or more weight loss in the last month or loss of 10/% or more in last 6 months. Resident #151 had another fall on [DATE] without significant injury. She again fell on [DATE] without significant injury. A care plan for high risk for falls was generated for Resident #151 and in place prior to her falls on [DATE], [DATE] and [DATE]. The interventions included, (Resident #151) stays in the neighborhood common area for supervision .Monitor for signs of wanting to leave, looking around, wanting to stand, fidgeting, etc. Interventions remained as written and no other updates made after each fall. Observation of Resident #151 on the evening of [DATE] at approximately 7:45 P.M. found her lying in bed while her family was visiting with her in her room. She appeared content and without complaints. Resident #151's family member reported she experiences pain from her right hip fracture. The family member further noted she doesn't like when the family leaves, which is when the resident attempts to get out of bed on her own. An interview of CNA #5, who was caring for Resident #151 on the evening of [DATE] revealed her understanding of the resident was that she gets confused and will attempt to get up on her own. The CNA noted the care plan requires the nursing staff to check on her frequently and assist her to bathroom every 2 hours or more frequently as needed. The facility failed to provide adequate supervision for Resident #151 resulting in her fall on [DATE], resulting in a right hip fracture. In addition to the above events, more residents experienced falls or eloped from the facility. 5) A review of an event report dated [DATE] for Resident #255 found she eloped from the facility and subsequently fell on [DATE]. The resident was found unsupervised in the parking lot of the facility on [DATE]. A CNA reported seeing the resident walk past the smoking hut and asked the resident where she was going. Resident #255 did not respond and continued walking. The CNA followed the resident, and the resident turned a corner and was out of the CNA's sight. As the CNA got closer, she found Resident #255 on the ground. The resident got up on her own and refused to speak about the fall. A review of Resident #255's MDS with ARD of [DATE] found she had a BIMS score of ,[DATE] meaning she was cognitively intact. The MDS further noted she didn't have wandering behaviors. In response to the elopement, the facility initiated 15 minute checks. A review of physician's orders [REDACTED]. 6) According to the [DATE] event report for Resident #255, she again eloped on [DATE]. Resident #255 was found in the same location as she was found on [DATE], unsupervised. She was on the ground in the parking lot of the facility. The staff reported that She was not acting like her usual self and told the staff, Go away, I don't like you. Resident #255 then headed back toward the building and into the entrance. 7) A review of an event report dated [DATE] revealed Resident #255 eloped from the facility on [DATE], when she was found outside the business office of the facility unsupervised. The staff found the resident and encouraged her to return to the nursing unit. The staff was unable to redirect the resident and followed her as she walked off the campus. The resident walked several blocks followed by the staff member. She finally stopped a grocery store when she finally agreed to return to the facility. After this incident, the facility implemented 1 to 1 supervision. The facility failed to provide adequate monitoring and supervision, which compromised Resident #255's safety. 8) A review of an event report dated [DATE] found Resident #205 was found outside of the nursing unit on [DATE]. She was found by another nursing unit sitting on a bench outside a smoking hut behind the East neighborhood. The resident resided in the West neighborhood. Resident #205 is ambulatory with a front wheel walker and ambulates around the nursing unit. At approximately 11:38 A.M. on [DATE], a staff member observed Resident #205 picking flowers outside of the facility in a grassy area. The West staff members reported last seeing the resident on the unit at 11:28 A.M. The report noted that she didn't have wandering behaviors prior to this incident. They initiated one to one supervision. The facility failed to provide adequate supervision for Resident #205. She successfully eloped from the unit without staff knowledge. 9) A record review for R#21 on [DATE] found that the resident had fallen on [DATE] and [DATE] while attempting to go to the bathroom. On [DATE] at 12:39 PM in a staff interview, LN #3 stated, Res #21 is one of our frequent fallers; numerous education to use the call light is given. Res #21 had an unwitnessed fall at the edge of the bed when (Res #21) tried to go the Bathroom on his/her own. On [DATE] at 12:32 PM a concurrent review of the care plan was held with LN #3. The resident's Care Plan for falls states: Risk for Fall/Injury due to back pain and tendency for knees to give out due to pain. One of the interventions listed for falls included: If (Res #21) experience a fall or other injury, investigate the causal factors and adjust (Res #21's) plan of care as needed. The IDT notes dated [DATE] after Res #21 the fall on [DATE] states: No changes to the POC. There was no documentation found that an investigation of the causal factors of the fall had occurred after the [DATE] fall. A review of the Res #21's Resident Summary found the following intervention under Comments: [DATE] Resident was issued a cow bell as another devise to use to call for assistance when needed; respond to his calls promptly to prevent him from transferring self secondary to multiple falls. A review of the Res #21's care plan found no intervention on use of the cow bell to use to call for assistance. There was no consistent practice of interventions in resident summary and care plan. The intervention to determine causal factors for falls was not documented as occurring. 10) On [DATE] a record review was done concurrently with LN #1 for Resident #268. Res #268 was admitted to the facility on [DATE] and discharged on [DATE]. Res #268 had a care plan that documented risk for falls and injury and for risk for elopement. On [DATE] an email was sent out by the Gardenia Neighborhood Clerk that stated, risk for elopement, found safe wheeling self in Weinberg area, post this in neighborhoods. A review of the Resident Summary found no documentation on fall risk or elopement. LN #1 stated, there is a care plan for elopement and falls but I would have put that (the resident) had an event and to watch as a risk in the CNA summary, it is not sufficient, it should be in the summary. That (Res #268) did elope, I would have put that in the summary to watch. There was no update to the Resident Summary to communicate to staff providing daily care for fall risk and elopement. 11) On [DATE] at 10:00 AM a concurrent record review with LN #1 was done for Resident #372. Res #372 had an elopement incident on [DATE] where the resident was found in the parking lot. Res #372's care plan states: has episode of elopement [DATE] r/t his poor safety awareness. Interventions included: 3M monitoring for safety. The resident expired on [DATE]. The concurrent review of the Resident Summary with LN #1 found no update on the elopement incident for Res #372. A review of the Interdisciplinary Team notes dated [DATE] found no documentation that the elopement on [DATE] was addressed. When asked if there should be an update to the CNA Resident Summary on elopement LN #1 stated Yes, there should be a note, that is what I would have done, complete communication to the CNA staff on elopement precaution in written form. There was no update to the Resident Summary to communicate to staff providing daily care for elopement. On [DATE] at 11:18 AM interviewed CNA #4, when asked to describe how information on residents who fall or elope is known to the CNA if the incident does not occur on the same shift or day they are working. CNA #4 stated, if not my shift they (LN) tell us if fall down at this time, they tell us the necessary precaution. When asked about the Resident Summary, CNA #4 stated, yeah we read in the care plan that fall already, that risk for fall. The facility failed to update and revise resident care plans and each resident receives adequate supervision to prevent accidents. The CNAs rely on the Resident Summary for prevention and delivery of care. 12) During a review of an Event Report on [DATE] it was noted that Resident (R) #298 had suffered an injury on [DATE] from an unwitnessed fall. In the investigation report the resident was found on her bedroom floor in a sitting position facing the bed on her left side. She was alert and responsive stating that she wanted to go pee. Resident was noted to have a small skin laceration to right posterior upper arm but no other apparent injuries. A tab alarm was initiated to alert staff if she attempted to get up. At 10:20 P.M. the resident was found lying on her back ont he floor to the right side of the bed. The bed alarm had not activated. Resident had a laceration to her upper mid forehead. Resident stated she wanted to have a bowel movement. At 1:00 A.M. on [DATE], resident was transported to the emergency room (ER). Resident returned from the ER at 3:25 A.M. with dermapon paste and steri strips to the forehead, CT unremarkable. Prime snap alarm was reinitiated upon return. A review of nursing notes on dates following R#298's fall revealed a note on [DATE]: stating that resident was noted sitting on the edge of her bed when bed alarm trigger. Resident was , reminded to call for help. Her call light was within reach, however, the note states that the resident is forgetful. Monitored frequently for safety. A note on [DATE] revealed that R#298 was attempting to ambulate, self transferring. No new orders at this time. In a review of previous nursing notes it was noted that R#298 had previous fall resulting in injury while a resident on the Roselani unit. She was found on the ground on [DATE], complaining of right hip pain on and was sent to ER where a right hip hemiarthroplasty was performed. On [DATE] she was admitted to Gardenia unit for skilled physical and occupational therapy. Care plan initiated for falls included a goal of minimizing injury with the interventions in Risk of fall and injury will be minimized with the interventions in place. Interventions included: if resident is restless or attempting to self-transfer ask what she needs help with; anticipate needs if she is unable to ask; keep environment clean and clutter free; bed in lowest position; call light secured and within reach; monitor frequently in case she forgets to call for help; frequent toileting; observe daily for changes in condition; assist with ambulation; monitor for balance and gait; investigate the causal factors and adjust her plan for any fall or injury; assist with toilet needs in the morning, before, and after meals, and at bedtime and PRN. Pertinent [DIAGNOSES REDACTED]. MDS most recent quarterly report on [DATE]: Section G showed that R#298 was occasionally incontinent of bladder and bowel and always continent of bowel For transfers and toileting resident required a 2 person assist. Cognitive patterns: Skills for daily decision making : Moderately impaired Behavioral Symptoms: Intrusive of the privacy or activity of others and significantly disruptive to care or living environment No toileting program used to manage resident BIMS score -none as resident unable to complete the interview CAA triggers included: Alzheimer's, delirium, decline in continence, and fall risk. CAA summary under falls on [DATE] stated that resident is not demonstrating any impulsive or restless behaviors that may increase her risks for falls. Her needs are anticipated by staff. It appears her preference would be to stay in the bed r/t pain upon movement. Does not require any alarms or devices. Oriented to the call light A clinical note from [DATE] stated noted with episode of trying to stand up going to BR per self without calling for help, call light within reach at all times, assisted to the bathroom (BR) per self without calling for help. The call light was within reach at all times. Assisted to the BR then placed in wheel chair outside nursing station for safety. Resident #298 was admitted after a fall at home, continued to have falls in the facility resulting in a fractured hip. A care plan was in place for the resident but appropriate measures were not addressed after resident relayed information to staff about needing to use the restroom. Updates were not implemented after each fall to decrease likelihood of resident having a reoccurrence. 13) A record review on [DATE] showed R#163 was admitted on [DATE] following acute hospitalization for a Cerebral Vascular Accident (CVA). She speaks Cantonese and her daughter assists with translation, she also has options to use a picture board and pointing to communicate. She also has moderate hearing loss, diabetes, and cognitive loss. She requires extensive assistance for transferring, bed mobility, dressing, grooming, and hygiene activities and requires assistance to maintain balance. She requires extensive assistance with toileting due to impaired balance and was occasionally incontinent. In review of clinical notes from [DATE] IDT discussed plan of care. The note stated that staff have been encouraged to ambulate resident from bed to bathroom Resident wakes up around 2 am to go to the bathroom and feels sleep is a problem for her. Care plan reviewed and updated to help resident with toileting at night. On [DATE] a clinical note reads At 17:00 this LN heard Res yelling from her room and this LN rushed to the room to find Res sitting ont he floor with her back leaning against left side of her bed with W/C to her right. She transferred to her W/C because she was getting ready for this LN to come back to apply her Lidocaine ointment to bilat knees and did not want her linen to get greasy, so she self-transferred from bed to W/C, lost her balance and slid down to the floor slowly. LN reminded resident to use call light prior to transfers. A clinical note on [DATE] stated that Residents POA asked that resident be woken up every hour and a half and toileted. On [DATE] resident was found sitting on the floor with the back against left side of bed. She stated she was transferring herself from bed to wheelchair to have Lidocaine. On [DATE] resident was found sitting on floor in her room, resident was calling out for help. No injuries noted, denied hitting her head, had just been toileted 10 minutes prior and having loose stools. Resident is toileted on a schedule. Resident is alert and able to use call light, but did not try to call for help at that time. CAA Falls Summary from [DATE]: Annual Assessment stated resident had one fall in January, she was attempting to transfer herself from her wheelchair to her bed, and in March she was having loose stools and was trying to get into the bathroom. She is generally able to call for help and is alert enough to have reasonably good safety awareness. IDT discussed adding an alarm to her bed or wheelchair, she is alert enough to call for help, but will recommend if she continues to have falls. Both circumstances seemed to be isolated incidents. PT referral if falls increase in frequency. On [DATE] a clinical note reads Resident states that she sometimes gets up on her own at night if staff do not arrive fast enough, discussed RN alarm, daughter and resident agreeable to bedtime alarm, but she still may fall. Daughter understands In a record review of an event report for Resident (R)#163 on [DATE], it was noted that resident had a fall on [DATE] around 6:45 A.M She was heard calling for help from her room and was found sitting on the floor. She complained of pain to her lower back and right flank. X-rays completed on [DATE] confirmed subacute fractures to ribs 5,6, and 7 on the right side, and questionable fractures to ribs 8 and 9. Per report after assisting resident to get ready for the day, the Certified Nursing Assistant (CNA), left the resident inside her room sitting in her wheelchair. Per report because resident has a language barrier her daughter was called and interpreted for her what happened. Per resident's daughter she was sitting in her wheelchair facing her closet, twisted her body around to reach for her sweater behind her when she slid off. Her care plan included risk for falls/injuries with interventions including an RN+ alarm system in bed at night to monitor her attempts to get out of bed. After this incident an alarm system was also installed to her wheelchair to help monitor resident's activity. A record review of R#163's care plan for ADL assistance contained goals of: will have toileting needs met, maintain bowel continence, and maintain bladder continence during waking hours. Interventions included: assist with toilet needs in the morning, before and after meals, and at bed time and PRN. Has a communication board and can indicate if she wants bedpan or toilet. Offer toileting every rounds. Offer toileting at night per schedule requested by resident and daughter. If sitting outside her room and wants to use toilet, encourage and assist to ambulate to the bathroom to increase strength and mobility. The Care plan for Fall/Injury listed the following: risk of fall and injury will be minimized with the interventions in place. Interventions included RN+ system while in bed and when up in wheelchair to alert staff of residents attempts to get out of bed or wheelchair without asking for assistance. Offering toileting every 2 hours until further notice. 14) In a staff interview on [DATE] at 9:43 A.M., for Resident (R)#218 when asked how many falls the resident has had in the last 30 days, the LN answered more than two. She stated that one of the falls had resulted in an injury and two falls had resulted in superficial abrasions. The falls occurred on [DATE] when resident was ambulating in the hallway and lost her balance, on [DATE] when resident was f