Every finding on record at Hale Makua - Wailuku

Based on observation, interviews, and record reviews, the facility failed to remove R6's pressure dressing after four hours from the completion of his hemodialysis (HD) treatment for one of two residents sampled for dialysis services. The deficient practice was not consistent with professional standards of practice and put the resident at risk for complications to his access site.Findings Include:On 01/28/2026 08:45 AM, observed Resident (R) 6's left upper arm (LUA) fistula pressure dressing still on from the previous day which was more than 15 hours after he completed the dialysis treatment. R6 said that he came back from dialysis yesterday around 5:00 PM and that staff sometimes do not check his fistula access every shift and will leave the dressing on because of bleeding. At 09:00 AM, conducted an interview with Registered Nurse (RN) 1. When asked what the facility's policy was on removing a pressure dressing after a resident return from their hemodialysis treatment, RN1 stated she was not sure but would find out. At 10:30 AM, RN1 informed the surveyor that they can remove dressing after 24 hours after dialysis and that it is in the care plan.On 01/29/2026 at 09:00 AM, record review of R6's electronic health record (EHR) noted that there were no physician's orders to leave the dressing on for 24 hours. Review of the care plan noted an entry to remove dressing within 24 hours of return, was created on 01/28/26 by the Unit Manager (UM). On 01/29/2026 at 10:00 AM, interview with the UM confirmed that there were no physician's orders to leave the dressing on for 24 hours and acknowledged that he included it in the care plan yesterday. The UM noted that he included it since he could not find any intervention to address R6's access bleeding. Reviewed the progress notes with the UM and confirmed that there was no documentation of R6's access site bleeding and he was not made aware of any issues. The UM acknowledged that any problems with access site, bleeding, or any interventions outside of the standard of practice to address the access site problems requires physician notification.On 01/30/26 at 09:00 AM, review of the facility's Hemodialysis policy, dated 10/01/24, in the Care of the Vascular Access section, it notes, 7. Assess patient after hemodialysis treatment by checking for at least the following: b. Pressure dressing post dialysis will not be removed from the AVF/AVG site for a minimum of 4 hours. C. Monitor of access site-after dialysis check for bleeding.i. if bleeding occurs, apply direct pressure until it is controlled. Notify provider if bleeding lasts longer than 30 minutes or is severe.

Based on observations, staff interviews, and record review, the facility failed to implement the fall risk plan of care for fall mats to be placed at the sides of the bed for one out of 19 residents sampled for comprehensive care plan review. The deficient practice increased the resident's risk for falls.Findings Include:On 01/27/2026 at 1;00 PM, observed Resident (R) 47 sitting in a wheelchair outside his room. R47 had on a right arm sling. When asked what happened to his right arm, R47 stated he fell yesterday around 3:00 PM when he tried to pick up something he had dropped on the floor. R47 said that he had to be taken to the emergency room (ER) for evaluation and is awaiting the results of his x-ray. R47 stated he is weak on his right side due to a previous stroke and has blurred vision. On 1/28/26 at 08:32 AM, observed R47 asleep in bed and no floor mats in place. At 11:00 AM, observed R47 outside in wheelchair. No floor mats in place in room or at bedside.On 1/29/26 at 08:30 AM, observed R47 asleep in bed and no fall mats in place.On 01/29/26 at 10:05 AM, interview with the Unit Manager (UM) and confirmed that resident fell outside while sitting on his wheelchair in the hallway when he tried to reach for something he dropped. Reviewed Fall Risk care plan dated 09/03/25 with the UM and confirmed that floor mats should be in place at all times. The UM noted that the care plan should be revised to remove the floor mats as R47 has not fallen while he has been in bed. The UM confirmed that R47's Falls care plan was revised on 01/29/26 after the fall but it still included continue interventions on the at-risk plan, which notes, to have fall mats on both sides of the bed, and fall mats in place at all times. The UM further acknowledged that floor mats were not in place for a while and not in place after R47's fall and as noted in the revised care plan. On 01/30/26 at 08:40 AM, observed resident in bed and still no fall mats in place. On 01/30/26 at 11:00 AM, review of the facility's Fall Prevention and Management Program Guidelines, it notes in the E. Dynamic Treatment Plan section, 2. As information is updated, it needs to be communicated to the staff.a. Staff 3. Individual care plan developed, communicated with staff and implemented. Review of the facility's Comprehensive Care Plans policy, in the Policy Statement it notes, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident/guest.that includes measurable objectives and timeframes to meet a resident/guest's medical, nursing.needs that are identified in the resident's/guest's comprehensive assessment.

Based on interviews and record review, the facility failed to ensure the State Long Term Care Ombudsmen (LTCO) was provided written notification of resident's transfer/discharge from the facility for two of three residents sampled for hospitalizations. Findings include: On 01/28/26 at 3:40 PM, requested a copy of the written notification of transfer/discharge to the LTCO, for Resident (R) 76's transfer to the hospital on [DATE]. On 01/29/26 at 11:32 AM, reviewed a notification of transfer/discharge. The notification provided, documented it was faxed to the LTCO on 01/28/26 at 4:32 PM, after the documentation was requested by the surveyor. On 01/30/26 at 8:27 AM, conducted an interview with the Social Worker (SW) regarding R76's notice of transfer to the LTCO. The SW confirmed the notification to the LTCO was not sent and that the notification is normally faxed within a day or two of the resident's transfer, but in this case, the family did not sign the document, and it was not sent to the LTCO. 2) On 01/28/2026 at 08:45 AM, interview with R6 noted that he went to the hospital on [DATE] for left leg above the knee amputation. On 01/29/2026 at 1:00 PM, record review or R6's Electronic Health Record (EHR) noted the notice of resident discharge/transfer and bed hold policy was sent to R6's representative, however, no notification to the LTCO was done for the transfer. Requested confirmation of notification, but what was provided by the Administrator was a fax confirmation sent to the LTCO dated 01/29/26 at 3:50 PM, which was after the documentation was requested. On 01/29/2026 at 3:50 pm, interview with the SW confirmed that she only faxed the notification to the LTCO today and was missed being sent out with November's batch of notifications.

Based on observations and interviews the facility failed to prevent flies and a bird from entering the dining room while residents were eating their lunch and lunch trays were being made. This deficient practice puts the residents at risk for foodborne illnesses. Findings Include: On 11/14/24 at 11:45 AM while observing kitchen staff put containers of uncovered hot food onto the trayline observed there were flies near the trayline flying above the open food. Food Service Director (FSD) shooed away the flies and covered the food with aluminum foil. FSD spoke with kitchen staff to remind her to cover the food with lids or foil as she is placing the containers on the trayline to prevent flies from going into the food. During this time a small bird was observed flying in the dining room and landed on the counter next to the microwave. On 11/14/24 at 01:00 PM interviewed FSD and inquired about the flies that were observed during the trayline. FSD stated she spoke with kitchen staff about covering the food with lids when it is on the trayline. FSD also stated she asked the facility to purchase the ECO Lab blue lights for the flies. On 11/14/24 at 01:58 PM interviewed Director of Nursing (DON) and inquired about bird that flew in the dining room/kitchen and landed on the counter, he confirmed he saw this. DON stated the dining room has screen doors that were left open. Inquired about problem with flies near the trayline flying above the food and DON stated FSD requested ECO blue lights for the kitchen which has been approved for order.

Based on observation and interview the facility failed to store food kept in the freezer at 0 degrees Fahrenheit or less. This deficient practice puts all the residents at risk for foodborne illness, Findings Include: On 11/12/24 at 09: 48 AM during initial tour of the kitchen interviewed kitchen staff (KS)1. Inquired about temperature log for the freezer that showed temperatures logged from 0 to 6 degrees Fahrenheit. Review of the Freeze Temp Record form has standard Freeze temperature less than or equal to 0. Review of this form found a row for re check temp and maintenance notified boxes which were left blank. The temperatures above 0 degrees (8) did not have re check temp and maintenance notified filled out. Inquired of KS1 if she is supposed to re-check the temperature of the freezer or notify maintenance and KS1 stated she rechecked the temperatures but did not document it. Continued review of this form found the following # temps in acceptable range:, # times temps to be taken, and % compliance. On 11/15/24 at 10:13 AM a phone interview was conducted with the Acting Director of Nutrition Services (ADNS). Inquired if she audits the freezer temperature logs from the facility and she confirmed she or another staff do the audits of the temperature logs for the refrigerators and freezers after they are sent to her. Inquired if anyone had spoken to her about the logs at the facility and she stated the Dietician and Food Service Director (FSD) had discussed the log with her. Inquired if she had seen temperatures above zero on the logs and what she would do. ADNS stated she has to look back at the logs she has and will let me know if she sees this on the logs. She stated she would ask the staff about the temperatures, if it was done later or after the door was open which might cause the temperature to rise. She stated the staff have not asked her for a work order in awhile for the freezer. ADNS stated she would call surveyor back with more information regarding this matter. On 11/25/24 at 12:35 PM surveyor called ADNS to follow up with freezer temperature log. Inquired with ADNS if she was able to follow up with the freezer temperature logs and she stated she did have KS1 look back at any work orders that were done for September. ADNS stated KS1 did fill out one work order for September. Inquired if she saw any above zero temperatures and she confirmed there were a couple of 5's and 2's. ADNS stated she is working with the facility maintenance to follow up with the freezer temperature to assure it is working properly. ADNS provided a copy of the work order

Based on observations and staff interview, the facility failed to establish an infection prevention and control program relating to birds. As a result of this deficiency, there was increase risk of disease outbreak in the facility. Findings include: During observation of the Lanai Nursing Neighborhood on 11/14/24 at 09:05 AM, three birds were seen in the resident's room. One bird was on the foot of the resident's bed and the other two birds were moving around on the floor. Other resident rooms had screen door barriers but this room did not. Staff interview on 11/15/24 at 10:15 AM, Director of Nursing (DON) said they were aware of the birds entering the resident rooms, but they did not have written standards, policies, procedures or a system of surveillance.

Based on observations and staff interview, the facility failed to store one oxygen cylinders (O2 tank) in a safe manner. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards. Findings include: During an observation of a resident's room in Lanai Nursing Neighborhood on 11/12/24 at 11:45 AM, one O2 tank was leaning upright and propped between the bedside drawer and wall. The O2 tank was not in a Oxygen Cylinder Cart and there was increase risk for the O2 tank falling over. Staff interview on 11/12/24 at 11:50 AM, Staff Nurse (Nurse) 2 acknowledged that the O2 tank was not stored properly and there was risk for it falling over. Nurse 2 then took the O2 tank to be properly stored in the Oxygen Cylinder Cart.

Based on observations, interviews and policy review the facility failed to protect Resident (R)47's privacy while receiving peri-care (washing the genitals and anal area) exposing R47's naked body from the waist down to her roommate, R52. This deficient practice puts all residents who require assistance from staff, such as peri-care, at risk for being exposed to others causing psychological harm. Findings Include: On 11/12/24 at 11:40 AM surveyor walked into R47's room. The privacy curtain was pulled to block anyone from the outside walkway seeing R47 who at this time was having peri-care done by Certified Nurse Assistant (CNA)1. Surveyor walked further into the room and observed R47's roommate, R52, sitting in a recliner facing R47's bed. The privacy curtain was too short to go around R47's bed and R47's genitalia was exposed to R52. Inquired with CNA1 about the privacy curtain and she stated it was not big enough to go around the resident's bed and she showed surveyor how R52's privacy curtain goes around the bed. Surveyor pulled on R47's privacy curtain and found it was not big enough to cover all the areas around her bed to provide full privacy. On 11/13/24 at 08:40 AM interviewed Director of Nursing (DON) who confirmed the privacy curtain had been taken off and washed but had not been put up again. DON agreed this was a dignity issue for R47 and never should have happened. DON stated he had maintenance hang up the privacy curtain that was missing. On 11/13/24 at 03:15 PM went into R47's room to observe privacy curtain and found the privacy curtain was hung but still did not fully provide privacy for the resident. The resident could still be seen in her bed and would be exposed to anyone who was at or near the foot of her bed such as the roommate sitting in the reclining chair. On 11/13/24 at 03:30 PM met with DON to share findings. He confirmed staff had done as requested (hung up the privacy curtain) but it was not enough to provide privacy for the resident. Requested and received the facility policy pertaining to privacy curtain use. Review of facility policy Dignity and respect with an original and effective date 10/01/2021 states Policy It is the policy of this facility that all residents/guests be treated with kindness, dignity, and respect. Procedure . 3. Residents/guests shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or a drawn curtain shields the resident/guest from those who pass by.

Based on observations, interviews and record review, the facility failed to ensure food and drink items were stored in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents who have their meals served by the facility placing them at risk for food-borne illnesses. Findings include: On 04/30/24 at 10:03 AM, initial tour of the off-site kitchen conducted with the Nutrition Service Director (NSD). During the inspection of the walk-in refrigerator, an opened one-gallon jug of milk was found without an open and discard date. NSD confirmed that the opened jug of milk was not labeled properly. Another refrigerator was inspected just outside the walk-in refrigerator. Two opened bottles of juice and two opened jars of mayonnaise were found with no open and discard dates. NSD confirmed that the items were not labeled properly and said that the staff are usually good at making sure all food items are labeled as soon as they are opened. Inspected freezer near the food preparation area, found a partially covered box of cheesecake with no open and discard date. NSD confirmed that all opened food and drink items should be labeled with the open and discard dates, and all items stored in the refrigerator and freezer should be covered. On 05/02/24 at 09:59 AM, inspected nourishment refrigerator in the front wing of the facility with Certified Nurse Aide (CNA) 19. Found an open container of sports drink and a bowl of food covered with foil. Both items were labeled with the residents' names but there were no open and discard dates noted. Asked CNA19 how long are the food items good for if kept in the refrigerator. CNA19 said three days. When asked how he would know if three days have passed since there was no open date noted on the food items, CNA19 said he will ask the residents since both were verbally responsive. Review of the facility policy titled, Labeling and Dating Policy conducted. The policy stated, . If food is held for more than 24 hours, it shall be clearly marked to indicate the date or day by which the food item shall be consumed on the premises, sold or discarded. The policy included a table with a list of food and drink items and stated, Items with use by date, defer to that date UNLESS opened, then use the policy below. Under the 3 Days column, it included Hot or cold food leftover. Under the 7 Days column, it included Milk, Juices/Iced Tea. Under the 30 Days column, it included Mayonnaise.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services included an effective process to provide routine drugs to meet the needs of the residents, and failed to dispose of medications past their expiration date. As a result of this deficient practice, 2 residents (Residents 33 and 14) had routine medications that were out of stock, and residents who needed intravenous fluid were placed at risk of receiving expired fluids. This deficient practice has the potential to affect any patient taking medication. Findings include: 1) On [DATE] at 08:43 AM, while observing medication pass with Registered Nurse (RN)8, it was noted that the Losartan (a medication for high blood pressure) 100 milligrams due at 09:00 AM for Resident (R)14 was out of stock. RN8 stated he would check the emergency kit (E-kit) for it. On [DATE] at 09:08 AM, RN8 confirmed that there was no Losartan in the E-kit. RN8 called the pharmacy to check on when it would be delivered and stated he would also call the doctor to inform him the medication was out of stock. RN8 explained that he ordered the medication refill on [DATE], but he also gave the last dose in the blister pack then. RN8 confirmed that it should have been ordered before it got down to the last dose. On [DATE] at 09:37 AM, an interview was done with Unit Manager/Charge Nurse (CN)1 at the nurses' station. CN1 stated that the expectation is when starting the last row of medications in the blister pack (meaning 7 days left of medications), nurses should start re-ordering the medication either through the electronic health record (EHR)/pharmacy interface or by faxing the refill sticker from the blister pack to the pharmacy. CN1 confirmed that since there is only one refill sticker per blister pack, the refill sticker method can only be done once. On [DATE] at 10:14 AM, CN1 provided documentation that the refill sticker for the Losartan was faxed to the pharmacy on [DATE]. CN1 confirmed that it appeared that the re-ordering process was not followed which led to the medication now being out of stock. Review of R14's EHR revealed that on [DATE] at 09:46 AM, RN8 documented the Losartan due at 09:00 AM as Not Administered: Drug/Item Unavailable. At 09:50 AM, RN8 entered a one-time order from the provider to administer the Losartan at 01:00 PM. A second order was entered changing the scheduled time due to 02:00 PM, and the medication was administered successfully between 02:00 PM and 03:00 PM. 47783 2) On [DATE] at 11:48 AM, observed R33 lying in bed with head elevated. When asked how she was doing, R33 complained of back pain. Asked R33 if she takes medication for the pain. R33 said she did not get any pain medications yet and asked for the nurse. Notified Charge Nurse (CN) 1 of R33's complaint of back pain. CN1 said R33 has a routine pain medication scheduled and will administer it. Review of R33's Electronic Health Record (EHR) conducted. R33 is a [AGE] year-old resident admitted to the facility on [DATE]. Orders for pain medication were Gabapentin 300 mg (milligrams) at bedtime for low back pain, Morphine 2 mg every 4 hours PRN (as needed) for pain 8-,d+[DATE], and Tramadol 50 mg twice a day and every 4 hours PRN for pain. Documented under Progress Notes on [DATE] at 01:48 PM, Called pharmacy re: (regarding) gabapentin refill. Per pharmacy tech, this is being process [sic] for evening delivery. Another note was entered on [DATE] at 09:46 AM stated. Gabapentin was not delivered. LN (licensed nurse) again called pharmacy . On [DATE] at 09:48 AM, concurrent interview and record review conducted with CN1 at the nurses' station. Asked CN1 if the Gabapentin for R33 was delivered in time for her evening dose. CN1 checked the Medication Administration Record (MAR) to see if it was administered. A note on the MAR entered for [DATE] at 06:00 PM stated, Not Administered: Drug/Item Unavailable. Asked CN1 how early does the staff reorder routine medications. CN1 said they reorder seven days prior to the last available dose. Asked CN1 why R33's Gabapentin was not available if it was reordered 7 days prior to the last dose. CN1 said she will check the delivery records to see if it was delivered. After looking at the list of medications delivered on [DATE], CN1 said that Gabapentin for R33 was not included on the list for that day. CN1 also showed another document titled pending Orders Report from the contracted pharmacy stating Gabapentin was last filled on [DATE] with a handwritten note stating, need signed receipt by nurse that it was received on [DATE]. CN1 said that the nurse that received the medications delivered checked what was physically delivered against what is listed on the delivery record to make sure it matches. Delivered medications are not checked against a list of what was ordered so they are not able to tell if an ordered medication was missing. CN1 added that the Gabapentin for R33 was delivered on [DATE] so the resident only missed one dose and the attending physician was notified. 3) On [DATE] at 08:57 AM, inspection of the medication storage room was conducted with CN1. Five one-liter bags of 0.9% Sodium Chloride solution were found in one of the storage cabinets with an expiration date of [DATE]. One of the five bags did not have a protective plastic cover. CN1 confirmed that the five bags were past their expiration date and should have been discarded.

Based on observations, staff interview and review of policy, the facility failed to label the humidified sterile water bottle for one Resident (R)177 of five residents sampled. As a result of this deficiency, the facility put R177 at increase risk for sterile water contamination. Findings include: During observation of R177's oxygen delivery set up on 05/01/24 at 08:30 AM, the humidified Sterile Water Bottle was not labeled with the date and time opened. Staff interview on 05/01/24 at 08:40 AM, Charge Nurse (CN)2 acknowledged that the Sterile Water Bottle should have been labeled with the date and time opened and initials. CN2 subsequently replaced the oxygen delivery/sterile water bottle with new equipment. Review of facility policy on Oxygen Administration read Purpose; To deliver oxygen to the guest/resident when insufficient oxygen is being carried by the blood to the tissues. Procedure . c. Attach humidifier to flowmeter by screwing nut onto the flow meter if needed. If the humidifier has an audible alarm, check this by adjusting the flow rate and pinching the tubing until the alarm sounds . g. Label humidifier with date and time opened and your initials .

Based on observation, interview, and record review, the facility failed to ensure 2 of 7 residents (Residents 62 and 29) sampled were free from accident hazards. The facility failed to develop effective interventions to prevent avoidable falls for Resident (R)62, and R29 was transferred from his bed to a shower chair using a mechanical lift device he had not been evaluated as safe to use. Placing residents at risk of avoidable accidents and injuries by not providing the appropriate assessments, planning, monitoring, and recommendations, and/or implementing the appropriate interventions is a deficient practice that has the potential to affect all the residents at the facility. Findings include: 1) R62 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include but are not limited to traumatic brain injury following a motor vehicular accident; fractures to base of skull, maxilla (upper jawbone), orbit (eye socket), nasal bones, right clavicle (collar bone), and left carpal bone (wrist); and acute respiratory failure. On 04/30/24 at 12:50 PM, observed R62 lying supine in bed with his eyes closed. Height of bed was at the lowest setting and there was a fall mat on the right side of the bed. Review of R62's Electronic Health Record (EHR) conducted. Fall risk assessment was completed on 02/29/24 and R62 had a score of 10 indicating he is at a moderate fall risk. After his first fall on 03/08/24, another fall risk assessment was done and score increased to 17 indicating a high fall risk. The most recent fall risk assessment was done on 04/26/24 with a score of 25 indicating a high fall risk. Care plan interventions included offering snacks and activities, use of pommel cushion while on wheelchair to prevent sliding, frequent reminders to not attempt to stand up from wheelchair alone, use of a tab alarm, provide assistance with toileting, provide physical therapy as ordered, use padded fall mats around bed, increased staff supervision, setting bed at lowest position with wheels locked, and medication review to assess for medications that increase the risk of falls. Care plan also documented that the resident prefers not to use side rails while in bed and refused to use a helmet as recommended by the physician. Progress notes revealed that R62 had falls on the following dates: 03/08/24 at 10:30 AM, found on the floor in his room. 03/14/24 at 08:00 AM, found kneeling on the floor in his room after hearing tab alarm. 03/20/24 at 04:05 PM, staff witnessed R62 fall to the floor in front of the nurses' station while trying to stand up from wheelchair. 03/21/24 at 08:50 AM, found sitting on the floor in his room while responding to tab alarm. 03/23/24 at 09:55 AM, staff witnessed R62 fall to the floor in front of the Activities Department walkway while trying to stand up from wheelchair. 03/29/24 at 07:55 AM, staff witnessed R62 fall to the floor in front of the nurses' station while trying to stand up from wheelchair. 03/30/24 at 05:25 AM, found sitting on the floor in his room while responding to tab alarm. 04/02/24 at 07:15 AM, staff witnessed R62 trying to get up from the wheelchair and fell hitting his face on the frame of the door. Wheelchair was parked in front of the nurses' station. 04/20/24 at 11:00 AM, staff witnessed R62 fall to the floor in the common area near the nurses' station trying to stand up from wheelchair. 04/24/24 at 03:50 PM, staff witnessed R62 fall on the floor at the TV area in front of the nurses' station while trying to stand up from the wheelchair by pulling himself up using the railings. 04/26/24 at 11:15 AM, found sitting on the floor next to his wheelchair at the table area near the nurses' station. On 05/03/24 at 09:27 AM, an interview was conducted with Charge Nurse (CN) 1 at the nurses' station. Asked CN1 how often do the staff check on R62. CN1 said staff check on R62 every hour and document it on the log that is kept in the nurses' station. Reviewed log with CN1, hourly checks were initiated on 03/08/24 after the first fall. When asked if the hourly checks were effective given that R62 has had 10 more falls since it was implemented, CN1 said I think it is working, the falls happen on various times. CN1 also stated that the facility provides a sitter when R62 becomes restless, was prescribed an antianxiety medication on 03/28/24 to help him calm down and started on physical therapy on 03/13/24 to strengthen his legs. On 05/03/24 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) by the Lanai wing nurses' station. Asked DON if the hourly checks are enough to prevent more falls for R62. DON said the facility is not able to provide one-on-one supervision for any residents 24 hours a day. DON also stated that they hired extra clerical staff that help monitor R62 in the afternoon and therapy was started to strengthen his legs to prevent him from falling when he attempts to stand up from the wheelchair. DON added that the facility does not want to implement the use of restraints on R62. 43245 2) Resident (R)29 is an [AGE] year-old male admitted to the facility on [DATE] for long-term care following a stroke. A review of R29's Minimum Data Set (MDS) quarterly assessment with an assessment reference date (ARD) of 04/03/24, Section GG-Functional Abilities and Goals, noted that R29 is completely dependent on staff for all Activities of Daily Living (ADLs) such as eating, toileting, dressing, and bathing, as well as all mobility activities such as rolling from side to side in bed, sitting up in bed, and transferring in and out of bed. Of note is that on the last three MDS assessments documented, no weight-bearing activities were evaluated, and instead were documented as Not attempted due to medical condition or safety concerns. On 05/02/24 at 02:29 PM, observed Certified Nurse Aide (CNA)24 and CNA3 preparing to use a mechanical lift to transfer R29 from his bed to a shower chair. The mechanical lift used for the transfer was one that lifts the resident from the seated position at the edge of the bed to a standing position on the lift itself. Observed that R29 was unable to sit up or remain in the seated position at the edge of the bed on his own. CNA24 and CNA3 had difficulty manually lifting R29 to the seated position and holding him there as the lift harness was applied. R29 fell back onto the bed in a semi-reclined position at one point and had to be manually lifted to a seated position a second time. Observed CNA24 lift both R29's feet up and place them on the lift platform without his assistance. Then observed CNA24 lift R29's right hand and place it on the right handle of the lift. CNA24 was able to grip the handle once his hand was placed there. CNA3 then lifted R29's left hand to do the same on the left handle, however she had to open R29's left hand, place it on the handle, and manually close his fingers around the handle. R29 was unable to tighten his grip onto the left handle as he had done on the right. At no point during the transfer were the wheels on the mechanical lift placed in a locked position. When asked if the lift wheels should be locked for safety, CNA3 responded that they should have locked the wheels before lifting R29 from the seated position to standing. A review of the User Instruction Manual for the mechanical lift used revealed the following: The . [mechanical lift] is suitable for patients in the SITTING position only who have a degree of weight-bearing ability but require assistance to stand. A review of R29's comprehensive care plan for ADLs revealed no determination of weight-bearing ability, but does note the following: I [R29] am dependent on staff for all my ADLs. I [R29] am non-ambulatory. A review of the last Physical Therapy PT Evaluation & Plan of Treatment, dated 09/06/22, revealed that R29 had been referred for transfer and strength training. The therapist documented that he was unable to complete an assessment of R29's level of function due to his refusal to participate. Further review of the document notes that no plan of treatment had been developed, and no recommendations were made. On 05/03/24 at 08:55 AM, an interview was done with the Director of Rehab [rehabilitation] (DOR) in the Therapy Gym. DOR confirmed that she could not find a Physical Therapy Evaluation since 2022. Upon concurrent review of the 2022 Physical Therapy Evaluation, DOR agreed that she would expect to see recommendations made, especially if unable to complete an assessment, probably the highest safety recommendations. DOR stated that although she is not a Physical Therapist (PT) so she cannot speak for the PT that performed the 2022 evaluation, when she does an evaluation of her own as an Occupational Therapist (OT) or as the DOR, she would first ask the nursing staff what they are doing, then she would watch a transfer, and make recommendations based on that. If she were unable to do that (speak to nursing staff and watch a transfer), she would most likely recommend using the maximum level of safety for all transfers, meaning a mechanical lift used for fully dependent residents who are unable to participate or help in the transfer. Since the PT who conducted the 2022 evaluation was unavailable for interview, on 05/03/24 at 09:05 AM, a phone interview was done with PT5, who stated he was not familiar with R29. When asked what he would look for when assessing a resident for functional ability/mobility specifically to make a recommendation regarding the mechanical lift used with R29, PT5 responded that he would want to ensure the resident was able to place their feet on the floor/lift device, able to extend their knees, able to hold themselves up in a seated position, and able to tighten their grasp on the lift handles on both sides. On 05/03/24 at 09:08 AM, further questioning was done of DOR, who stated she was familiar with R29's occupational therapy function. DOR confirmed that R29 would not be able to tighten his grasp on the lift handle on the left side due to contractures in his left hand.

Based on interview and record review, the facility failed to appropriately perform diabetes management for 1 of 18 residents (Resident 22) in the sample by failing to ensure his blood sugars were measured, and his sliding scale insulin was administered at the appropriate times. As a result of this deficient practice, Resident (R)22 was placed at risk for an avoidable decline and/or injury related to his diabetes. This deficient practice has the potential to affect all the residents at the facility with insulin-dependent diabetes. Findings include: 1) Resident (R)22 is a [AGE] year-old male admitted on [DATE] with diagnoses that include spondylosis, lumbosacral region (age-related change of the bones (vertebrae) and discs of the lower spine, causing pain), fusion of spine, thoracic region (a surgical procedure in which two or more bones (vertebrae) of the upper and middle part of the back are joined together), osteoarthritis, right shoulder (the wearing down of the protective tissue at the ends of bones), chronic pain, and diabetes with long-term use of insulin. On 05/01/24 at 08:51 AM, an interview was done with R22 at his bedside. When asked about his blood sugar checks and his sliding scale insulin, R22 reported that sometimes the nurses check his blood sugar and give him his sliding scale insulin after he has already begun eating his meal, or even after he has completed it. When R22 has commented on it, the nurses have told him, We have a one-hour grace period. A review of R22's provider orders noted an order for Insulin Lispro sliding scale (dosage is titrated based on blood sugar result) before meals, scheduled for 06:00 AM, 11:00 AM, and 04:00 PM, and started on 03/15/24. From 02/22/24 to 03/15/24, there was an order for Insulin Aspart sliding scale before meals, also scheduled for 06:00 AM, 11:00 AM, and 04:00 PM. A review of R22's Medication Administration Record (MAR) for March 2024 noted that the sliding scale insulin was documented as Late Administration: Charted Late [reflecting it was given more than one hour after it was due] 20 times. A review of R22's MAR for April 2024 noted late administration of his sliding scale insulin documented 11 times. On 05/03/24 at 09:36 AM, an interview was done with the Director of Nursing (DON) and the Administrative Nurse/Charge Nurse (CN)3 in the DON office. Both the DON and CN3 confirmed that sliding scale insulin should be administered immediately after the blood sugar is taken, and documented on the MAR immediately after it is given. They also agreed that since the insulin dose is dependent on the blood sugar result, which would be altered with food consumption, it is crucial that it is done before the resident begins eating to decrease the risk of a hypoglycemic (low blood sugar) episode. As a result, the DON and CN3 confirmed that there is no grace period for sliding scale insulin and late administration(s) should not be happening. Upon concurrent review of the late administrations documented on the MARs with CN3, she expressed surprise that there were so many and explained that the Unit Managers should be monitoring that daily. Review of Treatment of Type 2 Diabetes Mellitus in the Older Patient, last updated on 01/04/24, and found at https://sso.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient?search=slding%20scal%20insulin%20in%20an%20older%20adult§ionRank=1&usage_type=default&anchor=H33&source=machineLearning&selectedTitle=1%7E150&display_rank=1#H4 noted the following: Hypoglycemia should be avoided in older adults . Even a mild episode of hypoglycemia may lead to acute, adverse outcomes in frail older patients, including falls and fractures.

Based on an interview with one Resident (R)42 of seven residents sampled, the facility failed to provide reasonable accommodations related to R42's showering and meals. As a result of this deficiency, there was risk for decline of R42's maintenance of independent functioning, dignity and well-being. Findings include: During resident interview on 05/02/24 at 09:30AM, R42 stated when facility staffing was short, it would take around thirty minutes to an hour for staff to respond to his call light. R42 said he needed assistance reaching for the soap when taking a shower. Also, it would take longer (around forty-five minutes) for staff to deliver meals to resident's rooms when short staffed. Review of Electronic Health Record showed that R42 was admitted on [DATE] with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, Pulmonary Edema, Congestive Heart Failure, Atrial Fibrillation, Pulmonary Arterial Hypertension, Atherosclerotic Heart Disease, Cardiomegaly, Abdominal Aortic Aneurysm, High Cholesterol.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by 2 medication errors observed out of 28 opportunities for errors, for an error rate of 7%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, two residents were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff. Findings include: 1) On 05/02/24 at 08:43 AM, observed medication pass with Registered Nurse (RN)8 as he prepared and gave medications to Resident (R)14. Observed RN8 prepare R14's Polyethylene Glycol (a laxative) 17 grams (gm) using 8 ounces of water, split into two 4-ounce cups. One cup of prepared liquid was administered with R14's other oral medications. The second cup of prepared liquid (with half of the Polyethylene Glycol dose) was left at the bedside with R14 while RN8 left the room to prepare and administer medications to R31. On 05/02/24 at 09:51 AM, an interview was done with Unit Manager/Charge Nurse (CN)1 at the nurses' station. CN1 confirmed that medications should not be left at the bedside. When CN1 was asked specifically about Polyethylene Glycol, she responded, that is a medication so it should not be left at the bedside. Review of Section 7.5, Medication Administration Orals policy, dated 01/23, noted the following: Administer medication and remain with resident while medication is swallowed. Review of R14's provider orders revealed no orders for self-administration of any medications. 2) On 05/02/24 at 08:55 AM, observed RN8 prepare and administer medications to R31, among them was his Metformin 1000 milligrams, due at 09:00 AM. When RN8 entered R31's room with his medications, it was observed that there was no breakfast tray at his bedside. At 09:10 AM, confirmed with R31 that he had long since completed breakfast. During a review of R31's provider orders, the following was noted regarding his Metformin 1000mg: Special Instructions: give with meal.

Based on observation, interview, and record review, the facility failed to manage pain adequately for 1 of 4 residents (Resident 22) sampled for pain. Specifically, the facility failed to ensure that Resident (R)22's pain regimen was implemented on a timely basis. As a result of this deficient practice, R22 was prevented from attaining or maintaining his highest practicable level of well-being. Findings include: Resident (R)22 is a [AGE] year-old male admitted on [DATE] with diagnoses that include but are not limited to, spondylosis, lumbosacral region (age-related change of the bones (vertebrae) and discs of the lower spine, causing pain), fusion of spine, thoracic region (a surgical procedure in which two or more bones (vertebrae) of the upper and middle part of the back are joined together), osteoarthritis, right shoulder (the wearing down of the protective tissue at the ends of bones), and chronic pain. On 05/01/24 at 08:55 AM, an interview was done with R22 at his bedside. R22 was sitting up in bed with a stiff posture, leaning awkwardly to the right, and appeared as if he did not want to move his head. When asked about pain, R22 stated I'm always in pain, it's so hard to get my pain managed. When they [nursing staff] constantly late [with his routine/scheduled pain medication] that's when I get upset. R22 complained that between 03:00 PM and 11:00 PM especially, his routine/scheduled pain medications are always late. When he complains to the nurses about his medication being late, he is told we have a 1-hour grace period. R22 rated his current pain level as a 7 out of 10, located to his neck and lower back. R22 repeated, I cannot handle when the meds [medications] come late. A review of R22's provider orders noted the following orders for routine/scheduled pain medications: Acetaminophen 1000 milligrams (mg) three times a day, scheduled for 08:00 AM, 02:00 PM, and 08:00 PM. Baclofen 10mg three times a day, scheduled for 08:00 AM, 02:00 PM, and 08:00 PM. Gabapentin 400mg (increased to 600mg on 04/25/24) three times a day, scheduled for 08:00 AM, 02:00 PM, and 08:00 PM. Marinol 10mg twice a day, scheduled for 08:00 AM and 04:00 PM. Oxycodone 20mg routine every six hours, scheduled for 08:00 AM, 02:00 PM, 08:00 PM, and 02:00 AM. A review of R22's Medication Administration Record (MAR) for March 2024 revealed the following: Acetaminophen documented as Late Administration: Charted Late [reflecting it was given more than one hour after it was due] 6 times. Baclofen and Gabapentin documented as given late 7 times. Marinol documented as given late 9 times. Oxycodone documented as given late 10 times. A review of R22's MAR for April 2024 revealed the following: Acetaminophen, Baclofen, and Gabapentin documented as given late 13 times. Marinol documented as given late 6 times. Oxycodone documented as given late 20 times. 4 of those times, the reason was documented as R22 was sleeping at the scheduled time, and the medication was documented as given between 1 hour, 21 minutes to 3 hours, 16 minutes late. On 05/01/24 at 10:17 AM, a follow-up interview was done with R22 at his bedside. When told that it was noted that his scheduled pain medications were sometimes documented as given late due to the resident sleeping, R22 became visibly upset and stated that he has told staff numerous times that he wants to be woken up to take his routine pain medication around-the-clock so that he can keep his pain at a tolerable level. That shouldn't matter if I am sleeping, they should still wake me up and give it to me! On 05/03/24 at 09:36 AM, an interview was done with the Director of Nursing (DON) and the Administrative Nurse/Charge Nurse (CN)3 in the DON office. Both the DON and CN3 agreed that every effort should be made to give scheduled pain medication on time and confirmed that all nurses should be documenting the administration of any medication on the MAR immediately after giving it. If the medication is a controlled substance (e.g., Marinol and Oxycodone), all nurses should be signing it out on the narcotic log, giving it immediately, then documenting it on the MAR as administered immediately after that. Surveyor confirmed with both that if a medication is documented as Late Administration, it means it was given an hour or more after it was scheduled.

Based on resident interviews, staff interviews, record reviews and review of policy, the facility failed to ensure that two Residents (R)23, R25 of seven residents sampled understood the Binding Arbitration Agreement. As a result of this deficiency, R23, R25 did not fully understand the details of the Agreement. Findings include: R23 interviewed on 05/01/24 at 02:45 PM, stated that she did not remember signing the Binding Arbitration Agreement. Also, did not know what the Agreement was about. Review of Electronic Health Record (EHR) showed that R23 was admitted to the facility 05/22/23 and signed the Binding Arbitration Agreement 05/28/23. R25 interviewed on 05/01/24 at 03:10 PM, stated that she signed all admission papers but did not remember the discussion of the Binding Arbitration Agreement. Also, R25 was not familiar with any details of the Agreement when presented to her. Review of EHR showed that R25 was admitted to the facility on [DATE] and signed her own Binding Arbitration Agreement 05/28/23. Staff interview on 05/03/24 at 10:30 AM, Administrative (Admin) Assistant said the facility follows the Binding Arbitration Agreement policy during the admission process for all residents. Review of facility policy on Binding Arbitration Agreements read; Policy, This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at this facility . Policy explanation and compliance guidelines; When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement .

Based on observation and interview, the facility failed to ensure one Resident's room (Rm), 134 was clean and in good repair. room [ROOM NUMBER] had cleaning needs, required several repairs, and furniture replacement. As a result of this deficiency, the rooms did not provide a homelike comfortable environment for the Residents residing in the room. Findings include: On 11/06/23 at 1:25 PM, conducted facility tour of the Resident physical living environment and identified the following issues: room [ROOM NUMBER]: - Entrance door to the room had large pieces of material broken off at the bottom. - Entrance door had several large white marks on the external side that appeared to be dry liquid. At that time, requested housekeeping staff (HK) to try to remove the marks. On 11/07/2023 at 3:21 PM, the marks were gone, and the door was clean. - Several pieces of resident furniture were in disrepair with obvious damage. - Large gouges in wall. - Commode chair in the bathroom shower noted to be dirty with brown/dark material in several areas of the seat. At that time, brought to the attention of HK, who confirmed it needed to be cleaned. - Pipe above the shower noted to have constant drip, 11/06/2023, 11/07/2023 and 11/08/2023. - Entrance to shower had missing pieces of baseboard and floor. - Wire with frayed ends hanging from ceiling outside by bathroom. On 11/08/2023 at approximately 08:15 AM, met with the Administrator and toured Rm. 134 to identify and confirm the items that needed attention.

Based on observation, interview and record review, the facility failed to maintain resident's (R)41's dignity when R41 was seen in the hallway with food drooling down the side of mouth onto neck. A fly was seen also flying around R41's face. This deficient practice hinders the right of residents for a dignified existence. Findings include: Observation on 11/06/2023 at 11:26 AM were done and R41 was noticed in wheelchair outside with food running down the side of his mouth onto his neck. A fly was seen flying around face. Interview and concurrent observation were done at 11/06/23 at 11:30 AM with Registered Nurse (RN)1 and RN2. RN1 stated that they would clean R41 up. Staff took resident to room. Observation at 11/06/23 at 2:00 PM showed R41 sleeping outside in wheelchair, relaxed and clean. Record Review (RR) of the Minimal Data Set (MDS) dated [DATE] under section GG reveals that the resident is dependent for personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying in makeup, washing/drying face, and hands.

Based on observations, interviews, and record review (RR), the facility failed to revise two Residents (R)40, and R225) of 17 residents care plans. 1) R40's Care Plan (CP) revision was not revised to control, distribute, and monitor his alcohol intake as ordered by the physician. R40 had access to alcohol located at his bedside. As a result of this deficient practice, there was the potential R40 would consume more alcohol than allowed, which could cause an accident or interaction with his medications, resulting in an adverse outcome. 2) R225's care plan was not revised after an actual elopement to include interventions to prevent elopement. Findings include: 1) R40 was a [AGE] year-old male with a history of hemiplegia and hemiparesis following a stroke affecting his right dominant side. In addition, his medical history included, but not limited to localized edema of lower legs, major depressive disorder, hypertension, atherosclerotic heart disease, pulmonary embolism, generalized muscle weakness, difficulty in walking, right hip pain, lack of coordination, and urinary tract infection. R40 requires some assistance for activities of daily living. He was admitted to the facility on [DATE]. R40 has a BIMS (Brief Interview for Mental Status) of 15, which indicated he was cognitively intact. His medications included, but not limited to, Oxycodone and tramadol for pain, Gabapentin for nerve pain, and bupropion for depression. R40 requested to drink alcohol, so the facility obtained a physician order that allowed him to drink with restrictions. On 11/06/2023, attempted to interview R40, but he refused to participate. Observed him lying in bed with curtains drawn and lights out. Noted R40 had a cluttered environment with several large cardboard boxes stacked on a lounge chair next to his bed, outside the curtain. In addition, there were several other personal items stacked on a bedside table. On 11/07/2023 at approximately 11:30 AM, attempted to interview R40 again, but he refused to participate. At that time noted three cans of [NAME] Blue Ribbon beer on the bedside table. On 11/07/2023 at 11:45 AM, during an interview with Licensed Nurse (LN)13, she said R40 could have alcohol if he wanted, but thought he was no longer getting it. She went on to say, if he had any alcohol, it would be locked in the medication room, and given to him according to the physician order. On 11/07/2023 at 12:00 PM, during an interview with LN10, she said R40 was allowed alcohol and that it is kept in the medication room. Proceeded to go to R40's room with LN10, where she observed and removed the beer cans. When asked how R40 obtains the beer, she said she was not sure. RR of R40's Care Plan (CP) revealed the following entries: Problem (12/09/2022): Alcohol Use: I have an order for alcohol 1-2 standard drinks per night. Approach: Allow me to drink alcohol in accordance with my orders daily. Standard Drink refers to NIH (National Institute of Health) definition, equal to 12 oz (ounces) regular beer (5% ABV (alcohol by volume)) or 1.5 oz liquor (40% ABV). I have been educated about the risks of alcohol with my edema, heart disease, and narcotic use. Monitor for balance issues if I get OOB (out of bed). Goal: I will not experience adverse effects of alcohol while at I will be allowed to have the amount of alcohol that I desire (or as ordered). Reviewed R40's Geriatric Psychiatry Follow-up Note, dated 03/10/2023 by Psychiatrist (MD)10, which included: .Since Oct-Nov, pt has 2 beers or 2 oz liquor at night prn (as needed) to help anxiety and sleep and has requested it at 1-2 am. Pt refuses interview. Discussed management of mood. MD10's plan included . would decrease alcohol use and not give during late night which disrupts sleep. RR revealed the following Physician order dated 03/14/2023 for R40: Alcohol: pt (R40) may have 2 standard drinks (based on NIH standard drink). This equals to 2 beers, 3 oz liquor, or 1 beer + 1.5 oz liquor. This was a once-a-day order and special instructions included do not offer this to pt after 8 pm, and he must drink it prior to 9 pm nightly. On 11/08/2023, the Administrator said the facility does not have a written policy for alcohol use, but the practice is to follow the physician's order. He went on to say if a resident has an order, the alcohol is kept in a locked area, and distributed according to the specific order. 22063 2) Cross Reference to F689 - Accidents. R225 was assessed as high risk for elopement on admission. On 10/24/23, R225 attempted to exit the facility and on had an actual elopement, he was found outside of the facility. Based on an assessment to identify possible contributing factors, the facility did not revise R225's care plan following the attempt to exit the facility on 10/24/23. Subsequently, the facility did not revise R225's care plan after he actually eloped.

Based on record reviews and interviews, the facility failed to prevent Resident, (R)34's alleged sexual abuse by R52, and did not monitor R52's sexual behavior, and failure to report R52's behavior to R52's physician. The facility failed to protect R34, who was a vulnerable resident from sexual abuse. This deficient practice has the potential to affect all vulnerable residents residing in the facility. Findings include: On 05/18/22 at 11:59 AM, reviewed the completed Event Report dated 05/13/22 retrieved from the Aspen Complaints/Incidents Tracking System (ACTS), intake number 9520. The Event Report was completed by the facility's Administrator and described an alleged sexual abuse incident between R34 and R52 that occurred on 05/12/22 at 12:06 AM. The physician was notified on 05/12/22. R52 exposed his genitalia to R34 and R34 grabbing it. The certified nursing assistant (CNA) observed this incident, separated the residents, and reported it to the supervising nurse. On 03/29/22, R34 was assessed to have a Brief Interview for Mental Status (BIMS) score of 7, which means that that R34's mental status is severely impaired. On 04/12/22, R52 was assessed to have a BIMS score of 11, which means he is moderately impaired. On 05/20/22 at 06:27 AM, R52's electronic medical record (EMR) was reviewed. R52 is a [AGE] year old resident admitted to the facility on [DATE] for unspecified dementia with behavioral disturbance. The progress notes for 04/20/22 to 05/20/22 were read. Nursing staff documented on 05/10/22 at 10:10 PM that R52 was observed to be looking into a female resident's room with a female resident lying in bed. Another nursing staff documented on 05/11/22 at 1:30 PM that R52 was staring at the same female resident while she sat in her wheelchair. R52 then started to shows (sic) his private to the res. R52 was then advised by the nurse to go back to his room. The nurse further documented that R52 came back again to park his wheelchair next to [the same resident] .but without showing his private. On 05/11/22 at 9:29 PM, nursing documented that R52 angled his wheelchair so that he was very close to resident, nearly touching her. R52 was redirected by the nursing staff to which he moved his wheelchair away from the resident and went to his room. There was no documentation by the nursing staff that R52's physician was notified of R52's sexual behavior. On 05/20/22 at 06:53 AM, R34's EMR was reviewed. R34 is a [AGE] year old resident readmitted to the facility on [DATE] after suffering a stroke. A Lack of Capacity Determination for Surrogate Making was signed by R34's physician on 05/16/19. On 05/20/22 at 07:01 AM, the facility's policy and procedure, Comprehensive Abuse Policy and Prevention Program, was reviewed. 3) Prevention: . The facility will assume for the safety of a resident deemed incapable of decision making that the resident is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act and therefore, the act would constitute sexual abuse. On 05/20/22 at 08:45 AM, the Social Worker (SW) and the Director of Nursing (DON) were interviewed in the conference room. SW stated that R52 was moved to a different room approximately one week prior to the alleged sexual abuse incident. R52 was moved closer to the nursing station for increased monitoring by staff. SW stated that the facility was unsure if R52 was fixated on a certain female resident. SW confirmed that R34's husband was her surrogate decision maker. The DON stated that the physician was not notified of R52's escalating sexual behavior. On 05/20/22 at 11:00 AM, the facility's policy on Behavior Assessment and Monitoring, revised April 2007, was reviewed. Under Assessment, . 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition including: a. Onset, duration and frequency of problematic behavior or changes in behavior, cognition, or mood .; Monitoring 1. If the resident is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review, and interviews, the facility failed to protect Resident (R)27 from any more potential falls by not ensuring that: 1) the Care Sense fall prevention alarm placed on R27's bed was engaged to alert staff if R27 got out of bed unassisted, 2) other staff were aware that R27 was able to disengage from her clothing a personal tab alarm used for fall prevention, 3) R27's care plan was updated and individualized to recognize R27's capability of unclipping her personal tab alarm from her clothing and her refusals to wear the alarm, and 4) staff were following facility policy and procedures. These deficient practices places R27 in at a high of injury due to her medical diagnosis and history of falls. This has the potential to affect residents in the facility who are prone to falls, have a medical diagnosis that makes them prone to fractures, and use fall prevention alarms. Finding includes: On 05/18/22 at 12:41 PM, reviewed the completed Event Report dated 02/07/22 retrieved from ACTS, intake number 9330. R27 suffered a right upper arm fracture with decreased movement of her shoulder after having an unwitnessed fall in the bathroom. R27 was identified as being at high risk for falls and injury due to her history of falls and diagnosis of [CONDITION(S)] (weakened bones that are susceptible to fracture). On 05/19/22 at 09:19 AM, R27 was observed to be sitting up at the edge of the bed in her room, facing the doorway looking out of her room, both feet on the floor, her personal alarm was not clipped to her clothing. A minute later, CNA3 passed by R27's room, looking at R27, but not entering her room. At 10:58 AM, R27 was observed to be lying in bed, sitting up. Activities assistant (AA)8 went into R27's room and provided her with water and left. At 11:00 AM, State Agency (SA) observed that R27's personal alarm was still not clipped to her clothing. On 05/19/22 at 11:01 AM, concurrent observation and interview were done with Licensed Practical Nurse (LPN)11 in R27's room. LPN11 confirmed that R27's personal alarm was not clipped to her shirt during the morning and attempted to clip it to R27's shirt, but R27 refused. LPN11 stated that R27 had been in and out of bed all morning, going to the bathroom using her walker. LPN11 instructed R27 that she needed to clip the personal alarm to her shirt for her safety, but R27 continued to refuse. On 05/19/22 at 11:10 AM, an interview was done with RN5. RN5 stated that R27 was a high fall risk, and she gets out of bed without calling. R27 has a personal alarm that needs to be attached to her and that staff try to check on R27 at least once every hour or more within the hour. RN5 did not receive any notification from other staff that R27 had unclipped her personal alarm. On 05/19/22 at 11:18 AM, an interview was done with CNA6. CNA6 stated that R27 takes off the clip from the personal alarm and clips it to the bed sheet or chux pad and probably had been off since R27 returned from the dining room after eating breakfast. R27's assigned CNA, CNA2, is aware of R27 being able to remove the clip of the personal alarm off her person and that CNA2 frequently checks on her. On 05/19/22 at 11:30 AM, a concurrent observation and interview was done with CNA2 at R27's bedside. CNA2 confirmed that R27 removes the clip from her personal alarm because that it is her personal choice, but stated that R27 had another fall prevention alarm, Care Sense, on her mattress to alert staff if R27 got out of the bed. CNA2 uncovered the Care Sense alarm control at the foot of R27's bed and noted that it was unplugged. CNA2 stated that the Care Sense alarm needed to be plugged in for it to work and prevent R27 from getting out of bed unassisted and proceeded to place the plug into the Care Sense alarm. CNA2 stated that she checked the alarm at the beginning of her shift at 06:30 AM and the electrical connection was plugged and doesn't know when it became disconnected. On 05/19/22 at 1:00 PM, R27's EMR was reviewed. R27 is a [AGE] year old resident admitted to the facility on [DATE] for unspecified dementia without behavioral disturbance and age-related [CONDITION(S)]. A progress note written by nursing on 05/23/21 at 10:45 PM, revealed that R27 had an initial unwitnessed fall in the facility on 05/23/21 at 10:15 PM. The progress note also stated that the Care Sense and personal tab alarm were used, but that R27 was able to remove the clip from the personal tab alarm. A progress note written by nursing on 05/24/21 at 8:34 PM, revealed that R27 sustained a left rib fracture after the fall. A root cause analysis of R27's fall was done and documented on 05/26/21 at 11:07 AM by nursing. The capability of R27 to remove her personal tab alarm was not addressed. Progress notes documented by nursing on 01/19/22 at 09:03 PM to 01/26/22 at 09:17 PM revealed that a trial run of not utilizing the Care Sense alarm was done. R27 sustained another fall on 02/04/22 at 4:28 PM where she suffered a right upper arm fracture. R27's fall prevention alarms were re-instituted after this second fall. On 05/19/22 at 04:02 PM, a concurrent record review and interview were done with the DON in the conference room. DON stated that was not aware of R27 being able to unclip her personal alarm from her person and that it would the responsibility of the staff to inform the nurse in charge if it was unclipped or if R27 refused to use it. While reviewing R27's care plan, it was confirmed that R27's capability to unclip her personal alarm and R27's refusals to wear the alarm, were not identified on the care plan. The DON further verbalized that R27's care plan should be personalized and updated to recognize R27's individual and specific behaviors with her personal tab alarm. On 05/20/22 at 10:30 AM, reviewed the facility's Fall Prevention and Management policy with effective date of 05/01/21. B. Dynamic Treatment Plan 1. Specific interventions based on results of fall assessments and individual resident's preferences. The interdisciplinary team members must address: . c. Resident's daily routines d. Mental status/behaviors. On 05/20/22 at 12:45 PM, the facility's policy on Resident Alarms Copyright 2020 was reviewed. Under Policy Explanation and Compliance Guidelines: 1. The use of alarms do not eliminate the need for adequate supervision of the resident ., . 4. Evaluation and analysis of risk a. The interdisciplinary team shall analyze each resident's unique risks and medical symptoms to determine the root cause(s) of each risk , and . 5. Implementation of interventions a. Resident-directed approaches shall be implemented in accordance with the resident's needs, goals, and preferences .

Based on observations, interviews, and record reviews, the facility failed to provide quality care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for three (3) residents (Resident (R)11, R38, and R68) sampled. R11 treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R11 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11 annual minimum data set (MDS) with an assessment review date (ARD) of 02/22/22 documented in Section G. R11 requires extensive assistance (resident involved in activity, staff provides weightbearing support) for bed mobility. R11's pain was not managed according to professional standards of care. During an interview with R11 on 05/17/22 at 1:39 PM, the resident stated that he has chronic pain and ask staff for medication, but the medication doesn't always help. Review of R11's electronic medical record (EMR) on 05/19/22 at 3:05 PM documented R11's care plan did not include the implementation of non-pharmacological interventions to treat, minimize, or reduce the resident's pain prior to administering pharmacological interventions. Review of R11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen 650 milligram (mg) suppository rectally for mild to moderate pain; Ibuprofen 600 mg as needed three times a day; and [MEDICATION(S)]-Acetaminophen 7.5-325 mg every 6 hours (Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of this, the resident's pain rating of 9 could be undertreated with Ibuprofen or a pain rating of 2 (minimal pain) could be over treated with [MEDICATION(S)]-Acetaminophen 325 mg. Review of the facility's policy and procedure on pain management documented the facility will identify non-pharmaceutical interventions effective in the past (massage, acupuncture, etc.) and other nursing measures such as low light, soft music, repositioning, and conversation can be used, and the resident will be reassessed for response to treatment and response documented. In four random observations between 05/17/22 at 1:37 PM and 05/20/22 at 09:30 AM, R11 was laying supine in bed. No wedges or pillows were implemented to off-load the resident from being in one position during observations. During one observation on 5/19/22 at 11:45 AM, a pillow was placed under R11's knees to float the resident's heels, however, R11's heels were in direct contact with the bed. A follow up observation at 2:11 PM, noted R11 remained in the same position with his heels still in touch with the bed. Review of the resident's care plan documented R11 is dependent on staff for all needs due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/20/22 at 9:20 AM, conducted concurrent observations, record review, and interview with Nursing Supervisor (NS)1. Observed R11 laying in bed and inquired about R11's footdrop due to no documentation of it in the resident's record. NS1 stated that previously R11 did not have footdrop. NS1 informed the Nurse Practitioner (NP)1, who did an assessment on R11 and verbally confirmed to NS1 and this surveyor, R11 did not previously have footdrop and currently has footdrop. Inquired if R11 is receiving services for the prevention of contractures, footdrop, and range of motion as R11 was not seen with devices applied for the prevention of contractures or footdrop. R11's electronic medical record (EMR) revealed that R11 received physical therapy from 02/20/22 to 03/18/22 and was ordered restorative nursing program (RNP) on 04/24/22. On 04/24/22 at 09:05 AM, NS1 documented in a progress note that nursing received the physical therapy discharge summary with recommendations for RNP 6x/week for passive range of motion (PROM) and bed mobility. The NP agreed. Surveyor inquired why it took a month for R11 to receive the orders for RNP. The NS1 provided progress notes and explained that on 04/11/22 at 12:16 PM, NS1 documented a conversation with occupational therapy requesting clarification on RNP for R11 because no program was specified. Review of the RNP logs that document R11 name was handwritten onto the Restorative Nurse Aide (RNA)1's log the week of April 18 to 24. R11's name did not appear on the RNA1's log for the following three weeks (April 25-May 1; May 2-8; May 9-15) and the resident's name was handwritten for the week of May 16-22. Review of the log documented R11 did not receive any services or PROM from the RNA1. Surveyor conducted an interview with the RNA1 on 05/20/22 at 12:10 PM. RNA1 confirmed R11 did not receive RNP services since the resident was admitted to the program. RNA1 could not indicate whether the resident refused services or was offered services. RNA1 stated that there are just too many residents and not enough staff to assist all the residents on the RNP. RNA1 stated he/she has not provided PROM for R11. Cross reference to F688 Increase/prevent a decrease in ROM and mobility. 1) Resident (R)38 is a [AGE] year-old female with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She has dementia with behavioral disturbance, and contracture of the right hand. R38 does not speak English and was heard yelling out very loud on a few occasions during the survey. Surveyor made six random observations between 05/17/22 at at 08:48 AM and 05/19/22 at 11:26 AM, R38 did not get out of bed. Surveyor did not observe any passive or active range of motion being provided to R38. On 05/19/22 at 02:52 PM surveyor spoke with the restorative nurse aide (RNA) and asked if she has a daily RNA schedule? She stated that they just bring the residents to her who are in the restorative nursing program. She also stated that she is the only one covering for now. Surveyor reviewed the list of residents on the schedule for the last three weeks. R38 had not received any restorative care. When the surveyor asked the RNA if she is receiving services she said, no, that one always refuses. On 05/20/22 at 09:43 AM surveyor reviewed R38 electronic medical record (EMR). Care plan reviewed. Risk for skin breakdown. I am at risk for skin breakdown due to . the need for extensive assistance with bed mobility. Approach includes . Staff to assist me with turning at each round and as needed. Category: ADL functional/ rehabilitation potential. Approach includes . Turn me with the assist of one to two staff. Transfer me with the assist of one to two staff. Get me out of bed daily. Turn and reposition R38 in bed and chair every round. Encourage R38 to have physical activity, mobility, and ROM. On 05/20/22 at 12:56 PM surveyor interviewed the charge nurse (CN) 5. Surveyor asked CN5 what is the expectation for the staff and how is he ensuring that R38 and the other residents are being turned and repositioned. He responded that if the individual can't turn and requires assistance, then nursing staff should be turning them every two to three hours. Nursing progress note reviewed: Root cause analysis by Intra disciplinary team (IDT) for found on floor (FOF) on 5/8/22 at 1755. Recommend physical therapy (PT) referral for bilateral lower extremity (BLE) strength and transfers. On 05/20/22 at 12:56 PM surveyor interviewed the charge nurse (CN) 5. Surveyor asked the CN5 what is the expectation for the staff and how is he ensuring that she and the other residents are being turned and repositioned. He responded that if the individual can't turn and requires assistance, then nursing staff should be turning them every 2-3 hours. 2) Resident (R)68 is a [AGE] year-old female admitted to the facility on [DATE] for rehabilitation services for strengthening and mobility following a fracture of the right femur and hospital discharge. Eight random observations were made between 05/17/22 at 9:30 AM to 05/20/22 at 11:30 AM. Surveyor only observed R68 out of her bed one time in her wheelchair on 05/17/22. On 05/17/22 at 12:26 PM, surveyor asked certified nurse aide (CNA)6 how many residents he takes care of. He shared that he takes care of 10 residents and works with another CNA, there is one licensed nurse. When asked how if there are enough staff to ensure the residents are adequately cared for, he replied that staffing has been difficult at times due to staff calling out sick but today is good. On 05/17/22 at 12:55 PM, surveyor noted resident R68 sitting in a wheelchair at the bedside in her room eating lunch. There were signs posted outside the door that stated to see the nurse before going in. Registered nurse (RN)6 explained that the resident is on droplet precautions because she was exposed to a staff member who tested positive for COVID-19. On 05/18/22 at 9:45 AM, Surveyor reviewed the care plan for R68. I am at risk for skin breakdown related to (R/T) impaired mobility, incontinence of bowel and bladder. Approach: Elevate heels when I am in bed. Assist me with turning. Encourage me to be in chair or walking as tolerated. Activities of daily living (ADL) assistance: I require extensive to total assistance with ADLs, due to recent surgery, bilateral upper and lower weakness. Approach: Assist with transfers as needed. encourage participation in therapy/ ADLs to my maximum potential. On 05/19/22 at 10:43 AM during a discussion with the director of nursing (DON) who stated that the residents who are extensive assist should be turned every two to three hours, but two hours is preferable. On 05/20/22 at 12:52 PM during a discussion with Registered Nurse (RN)5 if R68 is receiving restorative therapy. RN responded that therapy works with R68 throughout the day. They round with her. When surveyor asked how the nursing staff are ensuring the residents are being turned and repositioned, he responded that if the individual can't turn and requires assistance, then nursing staff should be turning them every two to three hours. Surveyor explained that several observations were made during the survey process and R68 was observed to be in bed in the same position most of the day.

Based on observation, record review and interview, the facility failed to ensure that residents who require [MEDICAL TREATMENT], receive such services consistent with the professional nursing standards of practice, including accurate assessments of the resident's condition to monitor for complications of the arteriovenous fistula (AVF) (an access site in the arm for [MEDICAL TREATMENT]), specifically after HD treatments for one of one resident Resident (R)1 selected for review. R1 is at high risk for increased [MEDICAL CONDITION] (occlusions) and has a history of occlusions to his access site. Good post [MEDICAL TREATMENT] care of the AVF site is crucial to prevent negative outcomes that may result in the following: Occlusions; hemmoraging (bleeding out from the site) and/ or death. R1 did not receive professional nursing care of the site as evidenced by a licensed nurse who took blood pressures readings on R1's left (L) arm which has the AVF access site. Since R1 is at a high risk and has a history of occlusions, he should not have had blood pressure readings done on his left arm. In addition, the licensed nurse did not consistently document R1's post [MEDICAL TREATMENT] nursing assessment. This deficient practice, had the potential to cause serious harm and/ or death to R1, and any other resident residing in the facility who receives [MEDICAL TREATMENT] treatments. Findings Include: R1 is an alert and oriented resident who has a [DIAGNOSES REDACTED]. During an interview with R1 on 08/27/19 at 12:22 PM, he said he goes out to receive HD treatments at an outside certified [MEDICAL TREATMENT] center on Mondays, Wednesdays and Fridays during the evening shift. R1 pointed to his left upper arm (LUA) and said his access site was there. He said it was an AV fistula. R1 also said he twice underwent surgery when it got clogged. They had ballooned it to open up the blockages in the AVF. R1 said he has no blockages to his access site at present. When asked whether the licensed staff checked the site when he returned to the facility he said sometimes, and that staff did not always check him thoroughly, i.e., heart and lung sound assessments, AVF site assessment, vital signs check, etc. R1 said one thing he did know was that he would give the [MEDICAL TREATMENT] communication form to the nurses upon his return to the facility. He said that form had his HD treatment information which the [MEDICAL TREATMENT] staff completed each time he left the center. A sample review of R1's HD treatment record was done. It was found that R1's most recent HD treatments were on the following days: 08/28/19; 08/26/19; 08/23/19; 08/21/19; 08/19/19; 08/16/19 and 08/14/19. However, review of licensed practice nurse (LPN) 34's vital sign entries for R1 upon his return from HD on 8/7/2019, 8/16/2019 and 8/21/2019, found her entries had L Arm Sitting. LPN34 had documented that she was taking R1's blood pressure (BP) on the arm where R1's AV fistula access site was. There were two additional entries by LPN34 on the Vital Signs form for 8/9/2019 and 8/14/2019 which noted Right (R) Arm Sitting. LPN34 was the only licensed staff on this form performing BP checks on R1's left arm from 07/15/19 to 08/28/19. The other licensed staff were documenting the BP checks were being done on R1's right arm. Vascular access fact sheet American Nephrology Nurses Association (ANNA) (YEAR) states the AVF can provide good blood flow for many years of [MEDICAL TREATMENT]. Recent studies show that patients with AVFs have the least amount of complications such as infections or clotting .Caring for a Fistula. Good AVF care will help maintain the patency of the vascular access. Measures can be taken to prevent clotting or infection to the access .The access should be kept clean and free of injury or restriction to prevent clotting of the access . Not allow blood pressure to be taken in the access arm. The Fresenius Medical Care 2013, NephroCare Patient Training Focus On: Fistula Care Protecting Your Lifeline, states to, minimize the danger of infection or [MEDICAL CONDITION], which are the most common dangers for your fistula . Avoid pressure of any kind on your fistula arm, as it can lead to [MEDICAL CONDITION], . Measuring your blood pressure in the fistula arm with a blood pressure meter, as inflating the cuff induces a compression of the blood vessels .The mechanism of [MEDICAL CONDITION] can be activated by so-called 'hemodynamic mechanisms' such as low blood speed, change in temperature or changes in blood pressure. The fistula arm of a [MEDICAL TREATMENT] patient is particularly vulnerable to these phenomena for a number of reasons. After repeated cannulations the fistula becomes sensitive and delicate. In addition, within the Resident Notes Report, there was no entry by LPN34 of the resident returning to the facility on [DATE] 22:02 (10:02 PM), except for a L Arm Sitting blood pressure reading of 114/62 found on the Vital Signs form. There also was no nursing entry in the Clinical Notes Report by LPN34. On 08/29/19 at 02:09 PM, an interview with the Director of Nursing (DON) was done. The DON was queried what their standard of care was for her nursing staff to provide to residents returning from [MEDICAL TREATMENT] treatments. The DON stated she would expect her staff, would be monitoring the site for vital signs, adverse bleeding, infection, and stated it would include the assessment of the bruit and thrill for a fistula. The DON was informed that R1's HD days and the nursing entries did not coincide with the nursing assessments which she stated should be be done. An example included a 08/17/19 weekly skin assessment by a registered nurse which stated, LUA AV shunt + bruit and thrill; no infection and bleeding noted. Lotion to dry skin. Cont to monitor weekly as ordered. However, R1 did not go for his HD treatment on 08/17/19 and went on 08/16/19, of which there was no nursing entry except for the sole blood pressure reading which LPN34 took on the resident's left arm. There was a failure to identify, and consistently monitor the clinical condition and patency of the left AVF for R1. The licensed staff failed to follow a 07/30/18 physician order [REDACTED]. This was not found to be done every shift in R1's clinical entries. As a result, the facility did not ensure R1 was provided with safe, consistent clinical assessments and monitoring post-HD treatments for the patency of the left AVF.

Based on observation, interview, record review (RR), and Policy review, the facility failed to prevent two of six Residents (R)49 and R30 investigated for accidents from multiple falls with one fall (R49) resulting in major injuries. The deficient practice caused R49, who is a [AGE] year old female resident with a severe cognitive impairment at high risk for falls to suffer harm by sustaining multiple facial fractures that resulted from being left to sit in a wheelchair unsupervised and R30 has had eight documented falls and is at a potential risk for major injuries. In addition, the facility failed to accurately assess the safety of a third Resident (R)40 while smoking. This deficient practice has the potential to cause [MEDICAL CONDITION] injury to the resident with contractured fingers who was smoking unsupervised and without safety devices to prevent smoking accidents like a an apron. Findings include: 1) During an observation on 08/27/19 at 12:09 PM at the dining table in the common area in between room's 143 and 148, R49 was sitting in her wheelchair alone at the table. R49 appeared to have multiple purple marks (bruising) on both lower arms and forehead. A fall alarm was attached to her wheelchair. R49 was moving around in her chair and appeared agitated when she suddenly stood up from the wheelchair and when the chair alarm started to beep very loud she sat back down. During a tour of the Lanai unit on 08/27/19 at 12:26 PM, did not note any signage to indicate potential fall risk outside of any of the individual resident rooms. The facility provided matrix revealed that R49 was listed with a fall with a major injury. RR revealed that R49 is a [AGE] year old female diagnosed with [REDACTED]. During an interview with the Charge Nurse (CN) on 09/29/19 at 03:32 PM stated that R49 had a fall and was sent to the hospital and diagnosed with [REDACTED]. When asked how to identify a resident at risk for falls since there are no signs outside the rooms to identify those resident's, she responded that there isn't a protocol in place. Clinical notes report reviewed. Fall history: a. 03/07/19; 04:40 AM staff found resident in supine position on the floor next to her bed; no injuries sustained. At 0535 AM, staff responded to the care sense alarm and found resident on supine position near the foot of her bed. R49 sustained a hematoma to left frontal area. b. 03/09/19: R49 was out of bed ambulating without assistance and started to fall. The certified nurse aide (CNA) assisted her to the floor at 03:10 PM, no injuries. c. 03/14/19 R49 standing up a ambulating on her own with unsteady gait. d. 03/15/19: Restless this evening, standing up from wheelchair, chair, bed; triggering alarm. e. 03//16/19: Witnessed fall at 09:00 AM. CNA noted resident standing from wheelchair. Pushed her bed side table to her left side and started to ambulate two - three steps forward. CNA attending to other resident and unable to assist R49 who fell . No injuries. f. 03/18/19: R49 observed getting up from her wheelchair multiple times during the shift. g. 03/21/19 R49 got up from bed and started calling out loudly. h. 07/09/19 12:25 PM CNA found resident on floor; laying left side. Noted left forearm (LFA) skin tear approx. 2.5 centimeters (cm) skin tear; dressed with steristrip noted with guarding and complaint of pain to LF[NAME] Noted bruising to upper lip; nose bleed to right nare only. Hematoma 7 cm diameter approx. to left cheek with skin tear 2.5 cm in length. Noted small 1 cm cut to left upper eye lid. Approx 3 cm hematoma to mid forehead. R49 was transported by ambulance to the Emergency Department (E). At 05:44 PM received report from ER nurse that R49 will be returning to the facility and that she sustained multiple facial fractures. During an observation of R49 on 08/28/19 at 08:31 AM. R49 laying in bed with eyes closed. Skin tear on her left lower leg. The hospital bed was in the medium position and the mattress was scooped. The call light was under R49 bed out of her reach. Per the clinical notes dated 03/16/19 Power of Attorney (POA) requested use of a lap buddy while R49 is in her wheelchair and foam noodles underneath her bed mattress. Something, that will keep her safe from falling. Further review revealed the Lap buddy was not implemented. 07/10/19 POA requested for padded floor mats. In spite of the resident having several falls prior to the fall on 07/09/19, floor mats were ordered. Each of the falls staff reported responding to the chair alarm, although when they were able to attend to the resident, she had already fallen. Care plan dated 12/04/15 to present reviewed. Noted the following interventions for risk for fall/ injury. 1. Monitor R49 frequently in case she forgets to call for help. 2. Ensure that R49 is supervised while sitting in her wheelchair or other device. 3. Keep call light secured and within easy reach. R49 was not supervised while in her wheelchair or in her bed when each of the falls occurred. R49's call light was found under her bed on 08/28/19 at 08:38 AM while lying in bed. Facility Falls and Fall Risk, Managing Policy reviewed. Resident-Centered Approaches to Managing Falls and Fall Risk 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall Risk. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interveions. During an interview with Licensed Practical Nurse (LPN)90 on 08/30/19 at 08:59 AM to discuss the account of R49 fall on 07/09/19 described that it was a witnessed fall. R49 fell right in front of the nurses station. I went to another residents room to help because the sensor alarm in that room was beeping. I remember hearing a sensor alarm go off near the nurses station but I was unable to go help since I was already assisting the other resident. I learned that R49 fell from a standing position after getting up from her wheelchair. I called the medical doctor (MD) to report the fall and the PO[NAME] R49 was taken to an acute care facility by ambulance. Prior to the fall R49 was restless, calling out to her family members a lot. We try very hard to keep the residents restraint free. When asked what the protocol after a fall is, LPN90 replied that we assess them if its appropriate to keep them here. If there is significant injuries we call the Nurse Practitioner (NP). We assess what happened prior to the fall. Although the alarms help, if you cant get to the resident in time they can still fall. I know the staff here work very hard to get to those residents when their alarms are going off. When asked after the fall what kinds of interventions were in place, LPN90 replied that our main goal was to keep her comfortable. The mat was ordered, she already had her care sense alarm in place. Staff monitored her closely, to make sure she wasn't doing the same thing again. During an interview with the Administrator and DON, when asked how this fall could have been prevented, the DON stated that we don't have the ability to provide 1:1 supervision. The administrator added we could implement more frequent checks on the resident. From my experience, the lap belts don't necessarily stop falls. Especially if we don't want to restrain them. After the fall we had an IDT and resident care council (RCC). Physical Therapy (PT) will do an evaluation. I would like our facility to eventually stop using the chair alarms. 2) R30 is an [AGE] year old female resident diagnosed with [REDACTED]. R30 has had eight documented falls since being admitted to the facility on [DATE]. During an observation on 08/28/19 at 1:00 PM R30 stated, I got to get out of here, its too hot . she was restless and agitated, moving around in her bed. The bed was noted to be in the medium height position. EMR reviewed. Clinical notes reviewed. Fall history: [NAME] 12/08/18: 07:35 staff found R30 on the floor with her head partially under the bed near the footboard. Noted a lump on the left aspect of lower occipital lobe and a lump & abrasion to right shin. B. 12/10/18: Resident was hollering out and was found face down beside the bed, alarm tab still intact. C. 01/16/19 R30 found on floor, no injuries. D. 03/21/19 found on floor at 0925 AM. No injuries. E. 03/22/19 found on floor at 0715 AM, no injuries. F. 05/22/19 R30 found sitting on floor mat, no injury. G. 05/26/19 R30 found kneeling on the floor mat, no injury. H. 08/06/19 R30 found sitting on the floor mat, no injury. During an observation on 08/28/19 at 4:30 PM, noted R30 sitting in a semi fowler position in her bed. Bed at medium level height. Eyes open and alert. Care plan dated 12/05/18 to present reviewed. R30 is at risk for falls and injuries due to poor safety awareness and/ or impulsiveness related to dementia and unsteady balance. Interventions include: 1. Keep bed in the lowest position with wheels locked. 2. Monitor resident frequently in case she forgets to call for help. During the four days of the survey R30 was observed to have her bed in the mid level position. During an interview with LPN66 on 08/29/19, when asked how the residents are identified as having a high fall risk, she replied that it is in their Kardex and care plans. LPN66 did not know how residents are being identified to new staff or temporary staff without looking in the EMR. LPN66 stated that we check on the residents at least every two hours during rounds. 3) R40 is a paraplegic who does not have use of his lower extremities and limited use of upper extremities due to contractures to both hands. He requires the full assistance to transfer him into a wheelchair which is his primary mode of transfer. On 08/27/19 at 03:00PM during an interview with R40, he stated he likes to go to the lanai (patio) to smoke about three times a day and that he can smoke without supervision. He said, this is my private time. Asked R40 where he kept his lighter and cigarettes, and he said, I use to keep them in the pouch on the side of my wheelchair, but one of the resident's took them, so now I keep them with me, or in my room. RR revealed R40's care plan documented he was at Risk of injury due to smoking. The goal stated Risks for self-injury related to smoking will be minimized. R40 will abide by the smoking policies of the facility. Interventions identified included the following: a.Per resident's preference, R40 keeps his cigarettes and lighters on his person in his room. He is fully alert and fully cognitive and able to make his own decisions. b. Per medical physician (MD) orders, will continue to discourage R40 from smoking, but he continues to smoke against medical advice. c. R40 knows to smoke in only the designated smoking areas. If discovered smoking outside designated smoking boundaries, remind and encourage him in practice of appropriate policy guidelines of facility. Notify charge Licensed Nurse (LN), Director of Nursing (DON), or Social Service Worker (SSW) if inappropriate behavior. d. Smoking aprons are encouraged R40 is non-compliant. He prefers not to use a smoking apron. e. Monitor R40 for signs [MEDICAL CONDITION] clothes, skin. Report to charge nurse and interdisciplinary team (IDT) if any evidence found. f. Monitor R40's ability to understand and practice good safety precautions during smoking. g. .At this time, R40 is safe to smoke independently. IDT to perform smoking assessment annually and if experience change of condition. Review of the facility policy dated (MONTH) (YEAR), titled, Smoking Policy states Smoking by residents shall be permitted if, after initial assessment by the IDT, it is determined the resident can safely handle a cigarette. The policy also states, The assessment shall also include whether the resident is capable to storing and handling smoking materials independently. Residents deemed capable of storage and handling will be provided a locked bedside drawer. Residents deemed not capable will have smoking materials kept at the nursing station. RR of R40's, Resident Smoking assessment dated [DATE] stated, The resident must be evaluated with the following physical abilities to be permitted to smoke per facility policies and procedures. The facility identified 11 physical tasks the resident must be able to perform .to be permitted to smoke with supervision. R40 could not perform the following two of those physical tasks required. a. Ability to touch thumb to each finger on each hand. This task was marked N/A (not applicable with the hand-written entry, Joint contractures to both hands. b. Ability to open and close index finger and middle finger is scissor motion with each hand. This physical task was marked N/A with the hand-written entry, Joint contractures to both hands. The box minimal assistance was checked on the assessment form which was defined as Resident exhibits physical ability to smoke with minimal assistance as evidenced by the evaluation of motor skills. On 08/28/19 at 12:05 PM R40 was observed smoking in the lanai area. He was in a motorized wheelchair and had a small cylinder ashtray resting on the right side of his abdomen propped in place with a rolled-up washcloth. His lighter, cigarettes and two vaping products were also organized for access on his lap. While holding the cigarette in his mouth, observed R40 use both hands to light the cigarette. Because he wasn't able to hold the cigarrette with his contractured fingers, R40 used a hair comb with missing teeth to place the cigarette. He could hold the comb while he smoked. When R40 was done smoking he put the smoking product in the ashtray, which extinguished right away. R40 had no supervision while out in the lanai smoking. On 08/29/19 at 09:34 AM during an interview with Social Worker (SW) asked if he was familiar with R40's smoking assessment. SW said he is very familiar with the situation and that he works with resident's rights. The IDT monitors and reassesses every year. Reviewed the facility policy titled, Smoking Policy-Wailuku revised date of (MONTH) (YEAR). The policy states that, Smoking by residents shall be permitted if, after initial assessment by the IDT it is determined the resident can safely handle a cigarette. The policy also states, The assessment shall also include whether the resident is capable of storing and handling smoking materials independently. Resident's deemed capable of safe storage and handling will be provided a locked bedside drawer. Residents who are not deemed capable will have smoking material kept at the Nursing Station and distributed . On 08/29/19 at 11:27 AM during an interview with RN57, asked if R40 had a locked drawer in his room to store his cigarettes and lighter, and she replied, I'm not sure. RN57 later reported that there was no locked drawer in R40's room and agreed that he would not be able to open a locked drawer due to the contractures in his hands. R40's smoking products were not secure and were accessible to any resident that wandered in to the room. On 08/30/19 at 02:30 PM during an interview with the DON, she stated R40 is due for his annual smoking assessment. We are going to be using a different assessment form . The DON agreed that R40 was not able to perform all the physical tasks the facility had identified necessary to allow a resident to smoke safely without supervision.

Based on observation, record review and interviews, the facility did not: A. Evaluate and analyze hot water temperatures that exceeded 120 degrees Fahrenheit in the resident's bathrooms; and implement interventions to reduce hazards and risks.; B. Ensure staff followed standards of practice of care to prevent accidents and falls for 2 of 20 residents, (R#69 and R#79), in the Stage 2 survey sample, and a random sample resident. Findings include: A. Environmental Hazards 1. During the Stage 2 investigation, a review of the residents' room water temperature was triggered. On 7/25/14 at approximately 8:37 A.M., the Director of Maintenance (DM) produced a log, "Resident Room Water Temperatures" which showed water temperatures taken for preselected resident rooms. According to the DM, these rooms were identified as the rooms which showed variance in the water temperatures due to the location of the rooms from the boiler room. However, rooms 142 and 149 on the Lanai unit were noted to have several hot water temperatures at or above the 120 degree Fahrenheit (F) range. The DM was asked what was done after the water temperature for room 142 was taken on 1/15/14 and found to reach a hot water temperature of 128.7 degrees F, as the next recorded temperature reading was documented 2 months later on 3/13/14. It was brought to the DM's attention that this subsequent 3/13/14 water temperature was equally high and recorded at 128.5 degrees F. Of note, room 149 also had similar high hot water temperatures for January and March 2014 (129.2 and 128.9 degrees F). The water temperature log had "Temp should NOT be BELOW 100 degrees or ABOVE 120 degrees" written on it. The DM looked at the log and stated, "We have no follow-up," and said they should be doing it. The DM stated maintenance made the adjustments, but reiterated there was no follow-up documentation to show any monitoring of the water temperatures which exceeded 120 degrees F. A concurrent review of the log with the DM revealed that room 142's water temperature recordings were as follows: On 1/15/14 - hot water temperature of 128.7 degrees F; 3/13/14 - hot water temperature of 128.5 degrees F; 4/6/14 - hot water temperature of 120.5 degrees F; 5/19/14 - hot water temperature at 120 degrees F; 6/10/14 - hot water temperature of 120 degrees F, and 7/18/14 - hot water temperature of 125 degrees F. The DM said he obtained the water temperature by running the hot water for 2-3 minutes and used his thermometer to demonstrate. He said if the temperature did not change much at the end, he recorded that temperature reading. Surveyors asked him to follow the same protocol to check room 142's water temperature. At 9:13 A.M., the DM was observed using the facility's thermometer to check room 142's bathroom sink's hot water temperature. At 9:14 A.M., the hot water temperature was 126.4 degrees F after one full minute. Surveyors requested he re-test the water temperature again for a full 3 minutes since this was the protocol he used. At 9:22 A.M., the DM was observed to retest the hot water and at 9:24 A.M. (two minute run), it reached a temperature of 127.3 degrees F. At the end of the full 3 minute run at 9:25 A.M., the hot water temperature remained at 127.3 degrees F. The DM was asked if there was any notification to the staff, the resident or anyone else about the water temperature results when it exceeded 120 degrees F. The DM replied, "No, we don't notify anyone." He stated the maintenance staff would "make the adjustment" if the hot water temperature was high. He said they only recorded the monthly checks as shown on the log. Upon inquiry at 9:27 A.M., LN #1 confirmed one resident in room 142 was able to do her own self-care and used the bathroom in her room. The resident however had left for an appointment and was unavailable to interview. The time required for a 3rd degree burn to occur for a water temperature at 127 degrees F is 1 minute. The DM and maintenance staff knew of the high hot water temperatures and thus aware of the existing hazard. Yet, there was no documented measures or other reasonable efforts found to ensure the residents' risk for injury would be avoided when a known hazard was found to exist. The facility failed to demonstrate any on-going monitoring, failed to document follow-up results if any, and failed to communicate this information to quality assurance, patient safety, and/or across all necessary disciplines about this hazard. The documented hot water temperatures, albeit in preselected resident rooms, reached critical levels in which burn injuries could occur. In addition, the majority of the residents have medical conditions such as reduced reaction time, decreased cognition, decreased mobility, etc., which place them at greater risk for scalding or skin burns. 2. On 7/25/14 during a walk through of the Lanai unit with the DM, he stated the missing paint and/or noticeable chipped areas evident along various spots on the handrails "is an on-going thing." He said there should not be any missing paint or chipped areas which were found on the handrails. The handrails felt rough in the spots where the paint was peeling, missing and/or chipped off on both the Lanai and Molokai neighborhoods. B. Accident and Fall Hazards and Risks 1. During the lunch observation in the Lanai neighborhood on 7/21/14, CNA #1 was observed pulling Res #69's wheelchair backward while the resident sat in it. CNA #1 pulled the wheelchair back with one hand, while balancing the resident's meal tray with her other hand. CNA #1 pulled the resident's wheelchair into the corridor and up to the bedroom wall where she situated the resident in order to feed her lunch. 2. On 7/25/14 at 8:25 A.M., a random observation on the Molokai neighborhood found CNA #4 pushing a random sample resident in a wheelchair with one hand, while holding a meal tray in the other. As CNA #4 turned the resident into the dining area, she told the resident to watch her right arm up so as not to hit the wall while making the right turn. This was also observed by LN #2 who confirmed she saw CNA #4 push the resident with one hand while holding the meal tray in the other. LN #2 said the CNA, "should have two hands on wheelchair" and pushing a resident with both hands was the correct way to transport residents. LN #2 said it was for the safety of residents. On 7/25/14 at 9:45 A.M., per the DON, she acknowledged the one handed method observed to transport residents while holding a meal tray in the other was a safety concern. The DON stated, "I'm not going to make any excuses for my staff" and nodded. 3) During a staff interview on 7/22/14 at 11:18 A.M. it was reported that the R#79 sustained a fall on 7/9/14. Record review was conducted on 7/24/14 at 10:50 A.M. It was documented that R#79 was under a 1:1 supervision when he/she sustained a fall on 7/9/14 at 3:40 A.M. The R#79 was taken to the emergency department (ED) for laceration above right eyebrow, and the CT scan was negative for bleeding and fracture. The CP was reviewed on 7/24/14 at 11:00 A.M. There was documented under the CP approach/frequency column, "R#79 will attempt to throw herself out of the wheelchair even when it is being pushed which poses a serious threat to her safety." Documented on the Hale Makua Resident Care Sheet, under additional comments was written, "Fall Risk: frequently check on resident at all times." Per record review it was indicated that the resident was seated in a wheelchair inside the resident's room requesting to use the restroom. When staff went to turn on the bathroom light, upon return, staff saw resident falling down from the wheelchair within 5-10 seconds. Interviewed the LN#1, DON, and Nurse Supervisor, and they all concurred that the staff should not have left the resident alone when the staff member went to turn the bathroom light on.

Based on observation, review of clinical records and facility records, interviews with residents, visitors and staff, the facility did not provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident for 7 of 24 residents (#1, 2, 3, 11, 12, 15, 18) in the case sample and 3 Random Sample residents (RS2, RS3, RS 4). Findings include: I. Observations of residents on units during the survey revealed there were no individualized diversionary activities/interventions such as direct staff interaction (excluding redirection of behaviors) to encourage the resident to participate in the unit's scheduled activities. The staff were not seen to engage and involve the resident in activities that interested the resident. Residents were observed to wander about the unit with no directed or focused activity provided to him/her. A. On the Maui unit, observations of Resident #15, Random Sample Resident #2 (RS-2), and other random observations of residents and during the focus group activity revealed there were no meaningful, individualized activities provided for the residents. 1. On 2/10/09, random morning observations of Resident #15 found him/her walking up and down the unit's corridor and sitting in the outdoor chairs. The resident was noted to repetitively pull at facial stubble and pick at his/her nose when he/she sat looking into the courtyard. a. On 2/11/09 at 10:45 A.M., the resident walked into the unit's garden area and pulled several dead leaves off some plants. A Certified Nurse Aide (CNA) saw the resident, went to the resident and escorted him/her out. b. At 11:47 A.M., Resident #15 was found in another resident's room using the toilet. The resident had his/her shirt off and the surveyor informed a staff that Resident #15 was in Resident #7's room. The staff went into the room and brought Resident #15 out of the room and stated, "How come you hemo (take off) your shirt? Let's go get your shirt." The resident had no response and followed the staff back to his/her room. 2. Record review of the resident's clinical record on 2/12/09 found the resident had [DIAGNOSES REDACTED]. a. The annual Minimum Data Set (MDS) with Assessment Reference date of 5/20/08, noted the resident preferred activities such as cards/other games, exercise/sports, music, reading/writing, trips/shopping, walking/wheeling outdoors, watching TV, gardening or plants and talking or conversing. b. There was no triggered RAP for Activities but the Psychosocial Well-Being RAP was triggered and noted the resident had "episodes of persistent anger...withdrawal from activities (ie: doesn't care to sweep anymore like... used to)...reduced social interaction, repetitive physical movements...wandering (into other rooms), resisting care..." 3. Review of the resident's current plan of care called for monitoring and recording of behaviors, including entering other residents' rooms. a. The resident's sleep pattern disturbance care plan noted an intervention to encourage the resident "to be involved in acts/exerc to keep me busy during the day." b. The activity care plan noted the resident preferred to be by him/herself and would sit in the hallway looking at the courtyard. However, diversion activities/interventions such as direct staff interaction (excluding redirection of behaviors) to encourage the resident to participate in the unit's scheduled activities and involvement to take the resident for select activities he/she identified with, such as gardening activities, were not seen. B. Observation of RS-2 on 2/10/09 during the initial tour noted the resident walked around the unit and sat at different locations in the corridor on the outdoor chairs. 1. On 2/11/09 at 10:00 A.M., RS-2 wandered into another resident's room by the nurse's station. A licensed staff directed the resident out of the room and brought him/her to the day room. 2. The staff said, "sometimes (resident) goes to activities or watches TV." The staff had the resident sit to watch TV, which was on CNBC news channel. a. There was minimal volume from the TV and the staff left the room. b. At 10:07 A.M., the resident stood up and walked out to the corridor again and was observed to walk around, sit, look around, stand up and walk around some more. c. There were no activities offered by the unit staff who saw or walked by the resident. At 11:40 A.M., RS-2 was sitting in front of room [ROOM NUMBER] and was holding a box of drinking straws, labeled with another resident's name on it. A CNA saw this and asked the resident, "Where did you get this?" The resident said he/she did not know but nodded "yes" when the staff asked if he/she wanted to eat lunch. 3. After lunch on 2/10/09, RS-2 was observed to open the refrigerator in the day room and grabbed a nourishment drink. a. One of the CNAs on the unit saw that RS-2 was drinking a Carnation Instant Breakfast drink and stated, "(resident) doesn't eat sometimes," and that it was okay for the resident to drink fluids. b. By the mid-afternoon of 2/10/09, RS-2 was found sitting in front of room [ROOM NUMBER], having partially eaten half a sandwich and held the other half in his/her right hand. Staff were observed to pass by the resident but did not notice what he/she was eating or doing. c. At 3:50 P.M., interview with the Registered Dietitian (RD) revealed that RS-2 "likes to eat on the run." The RD said the resident liked to take people's food and would go into the refrigerator for it. The RD explained RS-2 had an organic [MEDICAL CONDITION] and his/her behaviors were such that it could not be helped. The RD stated RS-2 was on a pureed diet with thin liquids and acknowledged eating a sandwich was not safe (risk for choking and aspiration). 4. Review of RS-2's records revealed he/she had [DIAGNOSES REDACTED]. a. The quarterly MDS with ARD of 12/10/08 noted the resident was involved in activities from "1/3 to 2/3 time." b. RS-2's current care plan for the lack of participation in most activities due to his/her forgetfulness and tendency to wander off related to the frontal dementia, included interventions to offer such as: "Please keep me invl in some of past acts like watching sports on tv, religious services, gardening...Most times I just wander around the facility and can't seem to sit and participate in any acts offered to me. But there are times when I will sit long enough to watch tv or enjoy an entertainment...my activity goal is at least 1-3x week. If I am unable to meet my goal please visit me in my room for soc cont/ interact and offer me acts like music, exerc, snacks, precrafts, tv, or update me as to what's going on outside of my room." 5. The observations of resident on the unit during the survey revealed there were no diversion activities/interventions such as direct staff interaction (excluding redirection of behaviors) to encourage the resident to participate in the unit's scheduled activities. The staff were not seen to engage and involve the resident in "past activities" of the resident's preference and instead left the resident to wander about the unit with no direct or focused activity provided to him/her. C. On 2/11/09 at approximately 6:50 A.M., a female resident in a wheelchair was placed in front of the large screen television prior to being served breakfast. The television program was "Math 115" and the volume was minimally audible. The resident shortly thereafter began to sing "Happy Birthday" out loud and he/she leaned on the overbed table placed in front of him/her. A CNA was asked what television program the resident liked and he/she did not know and went to change it to the mainland headline news channel. The volume was not turned up and the resident continued to sing, and repeatedly asked "What's your name, what's your name; oh I like water, I like water." D. On 2/11/09 at 10:20 A.M., a female resident in a wheelchair was eating oriole cookies for the morning snack. A National Geographic magazine was placed in front of the resident. The resident was asked if he/she enjoyed the magazine. The resident laughed, spoke in Filipino, opened the magazine up, closed it, picked it up and threw it forward and laughed again and proceeded to eat the cookies. At 11:40 A.M., the same day, the resident was seen with his/her head down and eyes closed with pieces of laundry items placed in front of him/her on the overbed table. The resident was observed to be engaged in folding laundry items from the initial tour of the unit and during the random observations. Staff stated the resident liked the activity and kept the resident busy. In addition, another female resident was also noted to be engaged in folding laundry when he/she was placed in the day room or when she sat in the outdoor area with pillow cases and sheets placed in front of her. This resident had no response but shrugged her shoulders and smiled when asked whether he/she enjoyed what he/she was doing. E. Observation of the focus group on the Maui unit found the focus group had no meaningful activity provided to the residents in the group. On 2/11/09 at 4:35 P.M., a focus group session was being conducted in the unit's day room. Two aides were noted to be sitting with 13 residents and a movie, "The Wedding Planner" was on the large screen TV. One aide was talking to a resident and they were sitting at the front of the room. Another aide was sitting across the room by other residents. Of the 13 residents, four were asleep or had their eyes closed, and one resident who sat on the sofa did not turn his/her head to the left to look at the movie, but looked straight ahead. The aides were not observed walking around to ensure the residents were engaged in watching the movie. F. Interview with the unit's clinical manager on 2/12/09 at 8:40 A.M. revealed the Maui unit's residents were "mainly behaviors" and the staff were working with the activities department to prevent behaviors. He/she stated the purpose of the focus group was to provide an activity to divert the attention and potential for behaviors to erupt. The manager stated a focus group "should be any time" and especially for those residents identified with restless behaviors. The manager acknowledged the staff needed more training on dealing with residents with behavioral issues and acknowledged there was no one on the unit to start the focus groups when needed. G. Resident #11 had [DIAGNOSES REDACTED]. Observation and interview with the resident revealed the resident could respond to yes/no questions when he/she focused on the speaker, and could communicate some needs. During interviews, some staff stated the resident could not communicate his/her needs. He/she was on medications for dementia, for behavioral disturbance, and pain. The facility did not provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. 1. On 2/9/09 after 7:15 PM, the resident was heard verbalizing loudly. The Shift Supervisor (SS) and Charge Nurse (CN) confirmed the person calling was Resident #11. The SS stated as tour of the unit neared the activity room, that the resident was kept away for the pathway fronting resident rooms as he/she became agitated when placed in that area. The resident was initially alone in the room, until a CNA came into the room and asked the resident if he wanted to eat something. The SS stated that the resident liked to watch television, however "no signal" was noted on the TV, and there was no program on the Television. The resident continued to call out for over and hour. Staff stated the resident was quiet when the family was present. 2. Observation of the resident on 2/20/09 and 2/11/09 revealed the resident did not call out loudly, and responded to family who visited during the day. When asked how he/she was feeling, the resident focused his/her eyes on the speaker, then indicated by nodding, that he/she was okay. The resident also indicated that he/she understood when spoken to, and seemed to communicate by nodding and shaking his/her head. He/she indicated preferences for fishing, golfing, animal planet, and country music. 3. Review of the Resident Assessment Instrument Protocols (RAPs) revealed: a. Under "Cognition": "...is able to answer yes/no questions. (He/she) has long and short term memory impairment and moderately impaired decision-making related to (his/her) Dementia with Behavior Disturbance and Depression and [MEDICAL CONDITION]. Is not able to consistently make (his/her) needs known... is combative and aggressive during care and does not always follow the directions of the staff..." b. Under "Communication": "... is triggered related to the resident inability to speak clearly and make (his/her) needs known ...staff anticipates needs..." b. Under "Mood State": "...Resident has episodes of repetitive verbalizations (i.e. calling out). ...Staff also noted episodes of socially inappropriate behaviors (I.e. throwing meds on the floor, making excessive noises/screaming), verbally abusive.... The team did not document assessment/evaluation of whether the inability to make needs known affected this resident's mood and behavior, or consider what activities would interest this individual, or how communication could be facilitated,individual to his/her interests and needs. 4. Review of the Activities RAP noted that the resident was "able to make (his/her( own choice with activities he/she wants to participate in, attended activities of his/her choice, but did not address activities that could be implemented after 7:00 PM, when the activity person left. a. The activity care plan "Potential for Lack of Activity :Participation r/t dementia w/ Bhvr Disturbances and R hemi". b. The goals were: "I will stay involved in the social life of Hale Makua." "I want to cont to be (involved) in some of my past acts, as well as other acts as well as other acts adaptable to my current abilities/choices..." The goal did not include identification of activities to decrease the calling out and did not reassess programs/activities which could e presented to the resident after 7 PM to decrease the calling out other behaviors. c. The interventions and approaches did not identify activity/programs to engage the resident's attention in the evening hours. H. Resident #2 was admitted with [DIAGNOSES REDACTED]. According to facility records, he/she was found to have behavioral problems including combative behaviors towards others, resistance to care, pacing, wandering and exit seeking. The facility record included the following goal: "Care planning is ...to monitor and manage the resident's medications and behaviors to allow him to be able to achieve the highest quality of life he is able to achieve." (RAP Review Report, page 7, 6/28/08). 1. An Activity Assessment was completed for Resident #2 on 6/30/08. The care plan for Resident #2 documented that he/she "constantly pace around the unit in a lean forward gait". 2. The facility record included documented instances of exit seeking 4 times during 12/08, several incidents of interpersonal conflict with facility residents and staff (8/22/08, 11/10/08, 11/29/08, and 12/7/08), [MEDICAL CONDITION], instances of crying and verbalizing wishes to return to his/her family home. 3. The monthly Behavior Risk Assessment Tool showed safety awareness risk increased from medium to high risk since the admitted . 4. Review of the care plan in effect for the date of the survey included the following: a. "Provide diversional activities, i.e. walks outside of locked area, pet therapy, music, entertainment, etc....Provide SWS counseling as needed." b. These care planned activities were not observed during the survey dates, and the record review showed Resident #2 had participated in one facility planned outing in 10/08. c. One documented social services meeting took place on 12/8/08 when Resident #2 was informed that "...hitting others is inappropriate behavior". I. For Resident #3, activities were not observed to be provided by the staff when he/she began pacing and/or exhibited aggressive behaviors. Activities were also not provided for escalating aggressiveness to divert Resident #3's attention. 1. Resident #3 was admitted with [DIAGNOSES REDACTED]. An Activity Assessment was conducted on 3/4/08 for Resident #3. 2. Care planned activities included checking the activity poster for daily activities, attending the facility resident counsel and having activities staff visit with him/her to share conversation and/or crafts in his/her room. Record review found no documentation of these activities. 3. On 2/12/09, the resident was observed for one hour in the activity room. The resident slept in the wheelchair during the entire session. Staff reported that he/she often did arm exercises and walked with assistance in the activities room, but sometimes the CNA's brought him/her to the activity room to "chill" for "restless" behavior. 4. Planned activities which staff could implement, were not developed for implementation when he/she seemed anxious, to prevent and decrease episodes of restlessness, and to prevent escalation of behaviors. II. Activities to engage Residents on units were not on-going. A. Resident #1 was observed in the activity room on 2/11/09 asleep on the gerichair while the karaoke program was in progress. Ten minutes after the program ended, the resident was returned to the unit and placed outside of the resident's room, in the outdoor area. The resident was awake, with opened eyes. 1. Resident #1's care plan addressing activities was incomplete. Listed approaches for care plan problem #14 stated: "My activity is/not at the level I enjoy. I want to stay active in doing the things I love such as:" and the area below the statement was left blank. Item #2 addressed the resident's enjoyment of getting out of the room social events and parties. It also stated : I love entertainment especially:' and the area below that statement was left blank. Approach #4 stated, "When I was at home I loved doing:" and again the area below was blank. 2. The care plan approaches were not individualized to reflect specific activities that staff could assist Resident #1 with on a daily basis. Diversional activity for problem #16 related to alteration in mood and behavior stated, "Offer resident diversional activity of choice, wheelchair rides, books on martial arts, TV, activities department." The list did not have specific activities that Resident #1 would be interested in. B. Resident #12 was observed sitting outside of the nursing station in a wheelchair. The resident was calling out to people passing by. Periodically, staff would stop and listen to the resident. The resident spoke to the surveyor about how many friends commented to the resident that the resident was a good cook and especially made the best hamburgers. The resident verbally shared recipes he/she enjoyed cooking. Later, family members visiting during the meal service for lunch, stated that the resident loved to go fishing and liked to cook when she was in better health. Resident #12 was again engaged in a conversion with the family and surveyor, related to fishing and cooking. 1. Record review noted the resident's care plan included Problem #9 which were related to activities. The listed "Approache(s)/Frequency" were not individualized to address Resident #1's current interests. C. On 2/12/09 at approximately 10:00 A.M., Resident #18 was observed rummaging through his/her dresser drawers looking for his/her "purse", pointed toward his/her roommate's bed and stated "that lady (roommate) must have taken the purse." The roommate was not in the room. 1..The certified nurse aide (CNA) was observed making attempts to redirect the resident to leave the room and do activities. When queried, the CNA stated that he/she always blames the roommate, so we redirect her to other activities and let him/her sit here (pointing to the arm chair in the corridor outside of the resident's bedroom across from the nurses station. The resident proceeded to leave the bedroom and sat in his/her designated arm chair. 2. Interview conducted on 2/12/09 at 10:15 A.M. with Resident #18 revealed that he/she did not crochet anymore although he/she was taught by his/her grandmother. When queried, he/she stated that the "girls come and get me (pointing toward the activity room) when they are ready to take me and he/she likes to watch some TV, maybe try some crochet again." Resident #18 stated he/she was only here (Hale Makua) temporarily and hopes that his/her daughter will let him/her go home, but didn't think so since his/her daughter lives on the mainland." 3. Interview conducted with the Registered Nurse Unit Supervisor revealed that Resident #18 also wandered and visited in other resident's bedrooms as observed by the nursing staff that he/she yelled at the resident's in their bedrooms, occasionally provoking the other residents' to hit her/him. a. Random observation during the 2/12/09 day shift after lunch prior to the dinner time; resident #18 was observed to be sitting in the arm chair outside of his/her bedroom across from the nurses station with no specific activities for periods of time throughout the day. On occasion the resident would go to the 1/2 door of the nurses station and have a short conversation with any staff person in the nurses station, or begin to rummage through her belongings in his/her room and near his/her roommate's dresser. He/she was also observed to make numerous attempts to start a conversation with anyone who happened to pass by him/her. b, Review of the "Resident Care Plan, Run date: 6/17/2008, reviewed on 12/6/08, Problem 3, Goal 1...I will demonstrate the ability to follow through with simple tasks. I will cooperate with tx, activities...1. Approach Frequency 1...Staff will assign me appropriate task for me to follow through on...3. Staff will perform reality check with me prn..." "Problem 4 Alteration in Behavior r/t to Exit Seeking, ...Approach Frequency 8. Offer diversional activities, foods, games, TV, books, etc." c. The facility did not ensure that the resident was provided with activities designed to meet the resident's needs based on his/her interests and to reduce the resident's behaviors and wandering into other resident's bedrooms/areas in order to maintain the physical, mental, and psychosocial well-being of each resident.

Based on observation, review of clinical records and facility policies and procedures and records, and interviews with residents, visitors and staff, the facility did not ensure that care plans were periodically reviewed and revised by a team of qualified persons after each assessment and as needed for 8 of 21 residents (2. 3. 5. 6. 11. 17. 18. 19) in the active sample. Findings include: Care plans were not periodically reviewed and revised to meet the needs of residents. Review of the facility's policy "Resident Care Plans" (revised 7/06) noted: "Policy: The care plan shall be reviewed...and revised as necessary. It shall include measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs based ongoing, comprehensive assessments...Procedure: 2. Each member of the Interdisciplinary Team will: a: Identify any new, actual and/or potential problems/needs of the resident, and develop short-term goals with measurable objectives and time frames with specific interventions, actions, or approaches." A. Resident #6 had [DIAGNOSES REDACTED]. The resident had two incidents where he/she slapped or punched other residents, and three incidents where residents of the opposite touched him/her inappropriately. The facility revised the plan of care related to the resident's behavior, but did not develop a plan to protect the resident from inappropriate touching by other residents. 1. The facility developed and revised the plan of care to address his/her behavior of : "Alteration in mood/behavior ml/b tends to intervene to other res' behavior inappropriately, delusion, hx of audio-visual hallucinations, threatening behavior r/t [MEDICAL CONDITION] . - The problem statement included "interpersonal conflict with other residents 12/16/07 and 3/29/08. The resident was moved to another unit. - Care planned interventions addressed measures to decrease this resident's behavior: "Tends to intervene to other res' inappropriate behavior or help other res. Remind to call for help when other res need help. If resident becomes agitated and show signs of threatening behavior to other resident's remove (him/her) and redirect." 2. Review of care plans revealed the facility did not develop a care plan or interventions to protect the resident from being inappropriately touched by residents of the opposite sex. Staff stated during interviews, that there have been no known incidents of the resident being inappropriately touched after being moved to another unit. The resident was observed walking throughout the facility independently and without escort, with access to the dining room, activity room, and all units including the unit that he/she was previously moved from, throughout the day. B. Resident #11 had [DIAGNOSES REDACTED]. Observation and interview with the resident revealed the resident could respond to yes/no questions when he/she focused on the speaker, and could communicate some needs. During interviews, some staff stated the resident could not communicate his/her needs. The interdisciplinary team did not 1) develop care plans to facilitate communication between the resident and others and enable the resident to express him/herself; and 2) did not revise careplans to include individualized, resident-specific program of activities to decrease calling out at night, and which would enhance the resident's quality of life. 1. On 2/9/09 after 7:15 PM, the resident was heard verbalizing loudly. The Shift Supervisor (SS) and Charge Nurse (CN) stated the resident usually called out at night, and was put in the dining room away from the pathway fronting resident rooms because he/she became agitated when placed in that areas where there was a lot of activity. Staff stated the television left on for the resident to watch, however, upon entering the dining room, the resident was alone in the room, no program on the TV screen, and "No signal" was noted on the TV screen. A CNA entered and offered the resident a snack. After the snack, the resident continued to call out for over an hour. When asked what diversion was offered to the resident, staff stated they turned the TV on and offered snack. 2. Observation of the resident on 2/20/09 and 2/11/09 revealed the resident did not call out loudly, and responded to family who visited during the day. When asked how he/she was feeling, the resident focused his/her eyes on the speaker, then indicated by nodding, that he/she was okay. The resident also indicated by nodding and shaking his/her head, that he/she understood when spoken to. Review of the activity assessment and interview with the resident revealed he/she indicated preferences for fishing, golfing, animal planet, and country music. 3. Review of the Resident Assessment Instrument Protocols (RAPs) revealed: a. Under "Cognition": "...is able to answer yes/no questions. (He/she) has long and short term memory impairment and moderately impaired decision-making related to (his/her) Dementia with Behavior Disturbance and Depression and [MEDICAL CONDITION]. Is not able to consistently make (his/her) needs known... is combative and aggressive during care and does not always follow the directions of the staff..." b. Under "Communication": "... is triggered related to the resident's inability to speak clearly and make (his/her) needs known. Has [DIAGNOSES REDACTED]. - Interventions to facilitate communication were not specific in the plan of care. One intervention noted under the "Cognitively impaired ..." care plan was: "2. Staff will maintain a pleasant, quiet environment, approaching me in a calm and slow manner, giving me simple directions one at a time. Allow me time for responding and encourage me to cooperate with tx and activities. - The care plan was not revised to include specific actions/measures to facilitate the resident's ability to communicate his/her needs and staff's ability to understand the resident. b. Under "Mood State": "...Resident has episodes of repetitive verbalizations (i.e. calling out). ...Staff also noted episodes of socially inappropriate behaviors (I.e. throwing meds on the floor, making excessive noises/screaming), verbally abusive.... The team did not document assessment/evaluation of whether the inability to make needs known affected this resident's mood and behavior, or consider what activities would interest this individual, or how communication could be facilitated,individual to his/her interests and needs. 4. Review of the Activities RAP noted that the resident was "able to make (his/her( own choice with activities he/she wants to participate in, attended activities of his/her choice, but did not address activities that could be implemented after 7:00 PM, when the activity person left. a. The activity care plan "Potential for Lack of Activity :Participation r/t dementia w/ Bhvr Disturbances and R hemi". b. The goals were: "I will stay involved in the social life of Hale Makua." "I want to cont to be (involved) in some of my past acts, as well as other acts as well as other acts adaptable to my current abilities/choices..." The goal did not include identification of activities to decrease the calling out and did not reassess programs/activities which could e presented to the resident after 7 PM to decrease the calling out other behaviors. c. The interventions and approaches did not identify activity/programs to engage the resident's attention in the evening hours. C. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview with the resident on 2/11/09, the resident was alert and oriented to person, place and time, and able to make his/her needs known. 1. Review of the resident's Minimum Data Set with Assessment Reference Date of 1/4/09 found the resident was coded as independent in cognitive skills for daily decision making and able to understand and understood others; and required extensive assist in his/her Activities of Daily Living self-performance except for supervision and set up help to eat. 2. A facility self-reported incident of 12/7/08 at 7:30 P.M., noted the resident called out from his/her room when another resident entered the room. The resident who entered Resident #5's room and hit him/her had prior altercations with other residents on the unit. a. Resident #5 yelled out, "(He/she) hit me. Go away" and a housekeeping staff who was present intervened and redirected the other resident back to his/her room. b. Review of Resident #5's comprehensive care plan found: 1) the care plan was not revised to address the resident to resident altercation on 12/08; and 2) did not include interventions/measures to protect the resident from further occurrences/injury. D. Resident #2 was admitted with [DIAGNOSES REDACTED]. His/her initial care plan identified exit seeking behavior (Problem #5 initiated 6/19/08), and alteration in mood/behavior including wandering and attempting to hit other resident(s) (Problem #7 initiated 6/19/08). 1. "Nurses Monthly Summary" notes included frequent entries regarding the resident's frequent pacing, and conflict with other residents. 2. The "Interdisciplinary Care Plan Conference Notes" of 12/23/08 stated: "(Resident #2) Continues with usual behavior m/b pacing back & forth non-stop, tearful, sadness, agitation, etc." 3. Record review noted that the conflict with other residents took the form of slapping Resident #3 (8/22/08), verbally threatening staff (11/10/08), making a threatening gesture at another resident (11/29/08), and entering another residents room and hitting them (12/9/08). 4. The existing care plan included approaches such as "ascertain what causes the resident to become aggressive"(pg. 6), and "Psych. eval as needed." (pg.5). 5. Record review and interviews with licensed and other staff, including the social services coordinator and Director of Nursing, revealed measures were not taken to determine and treat the cause of Resident #2's aggressiveness to residents and staff, and consideration of a psychological evaluation, . E. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. 1. The care plan for Resident #3 included the following: "Please do the safety risk assessment every quarter and prn and make sure all the appropriate safety measures are taken and monitored for effectiveness." (Resident Care Plan, pg. 4) a.. Resident #3 had a care plan which included options for dealing with behavior related to lack of awareness of safety and potential for fall/injury (Problem #6 initiated on 3/12/08), need for waist restraint when in the wheelchair (Problem #14 initiated on 3/25/08), and [MEDICAL CONDITION] (Problem #15 initiated on 6/20/08). b. There were 11 reported falls during a four month period from 3/08 to 7/08. Restraints were in place when Resident #3 was found after three of these falls. c. While the dates of falls were recorded on the care plan, care plan review found no revisions in approaches to behavior, activities or restraint use until 11/08 which may have prevented the falls. d. Staff interviews including the Director of Nursing and the Social Services Coordinator revealed steps were not taken to prevent escalation of behavior beyond administering medications as ordered. 2. Record review noted that on 6/08/08 Resident #3 believed he/she was threatened, obtained a butcher knife and threatened staff with harm. a. On 6/9/08, the primary physician prescribed medication "...for extreme agitation m/b kicking staff, paranoid [MEDICAL CONDITION], inability to redirect, disrobing and unawareness of safety". b. A care plan for alterations in mood/behavior was added on 6/20/08 providing interventions such as diversional activities, reporting of behavioral changes, and monitoring of medications for effectiveness. The medication to be given when redirection was ineffective, [MEDICATION NAME], was administered 14 times in 6/08 and 16 times during 7/08. The "Nurses' Monthly Summary" completed 8/3/08 stated: "Medication, redirection, waist restraint, calm assurance NOT effective" and noted that mood/behavior status had deteriorated for Resident #3. However, the care plan for Resident #3 did not include individualized activities, nor behavioral diversions to provide staff with coping for acting out behaviors. F. Resident #17 was admitted with a history including dementia, [MEDICAL CONDITION] leading to cognitive disorder, [MEDICAL CONDITION] and wandering away from home. The existing care plan was not revised to include approaches to provide individualized diversions to effectively prevent further elopements. 1. Resident #17 was observed to pace briskly on 2/10, 2/11, 2/12, and 2/13/09 within the confines of a secured unit in the facility, and to especially frequent the magnetically locked gate areas. 2. Exit seeking behavior was observed on 2/11/09 when Resident #17 walked through an open gate with a brisk gait toward the main facility exit/entrance before he/she was returned by staff to the unit. 3. The care plan included potential for behavior including wandering, exit seeking, and elopement (Problem #7 page 4, and Problem #9). Review of the records found an elopement took place on 12/9/08 at approximately 5:30 P.M. when he/she wandered from a locked unit and was observed to exit through the facility main entrance/exit onto an adjacent arterial highway. He/she was later discovered approximately 0.4 miles from the facility and returned. 4. The "Nurses' Monthly Summary" forms for October and November, 2008 and January, 2009 document staff observations of exit seeking behaviors both before and after the 12/08 elopement. The records reviewed confirm frequent staff observations of exit seeking. a. Exit seeking behavior was noted as follows: November, 2008 the chart indicated he/she had "...37 episodes of wandering with few episodes of hard to redirect...Total of 82 episodes of mood/behavior. b. On 2/10, 11,12 and 13, 2009 during the survey period observations were made of Resident #17's continued frequent exit seeking. G. The facility did not ensure that Resident 19's care plan was reviewed, revised and individualized to address specific areas within the facility the resident can wear his/her hospital gown where other residents' may congregate in common areas. Additionally, the care plan did not address the specific behavior's to include approaches/interventions as to how his/her behaviors may be controlled in order to enhance his/her dignity as well as maintaining the dignity of other residents in the dining room for pleasant dining. 1. During breakfast on 2/11/09 at 6:40 A.M., Resident #19 was observed seated in a wheelchair in the dining room wearing a blue and white open-back hospital gown, with his/her back exposed and facing an open sliding glass door. Both legs were exposed from mid-thigh down to his/her feet while eating his/her breakfast to other facility staff and residents passing the dining room in the open common walkway, behind the resident. 2. Confidential resident interviews revealed "they should wear street clothes when eating in the dining room and did not feel that wearing "pajamas or hospital gowns" was appropriate." 3. Interview conducted on 2/12/09 at 8:40 A.M. with the registered nurse unit supervisor revealed that Resident #19 was encouraged to wear street clothes when eating meals in the dining room but once he/she is assisted/transferred to the wheelchair, he/she is able to go to the dining room on his/her own. When queried if other residents' complained about this resident's behavior, he/she could not recall receiving any complaints. 4. Resident #19's record review of the "Resident Care Plan, Run Date: 1/28/2009, on page 3 of 10, Problem 6, Goal 2, B Dressing...Approach Frequency 4...6. I prefer to wear gown in a.m. Pls help me into street clothes after my showers and on non shower days, after I finish my grooming/hygiene...7. I prefer to go out on the curb to do my worship in my gown at times." H. The facility did not ensure that Resident 18's care plan was reviewed, revised, and individualized to provide/include specific approaches/interventions of activities designed to meet the resident's needs based on his/her interests and to reduce his/her behaviors of yelling at fell ow residents and wandering into their bedrooms. 1. On 2/12/09 approximately 10:00 A.M. Resident #18 was observed to be rummaging through her dresser drawers looking for his/her "purse", pointed toward roommate's bed and stated "that lady (roommate) must have taken the purse." The roommate was not in the room. - The certified nurse aide (CNA) attempted to redirect the resident to leave the room and do activities. The CNA said the resident always blames the roommate, so we redirect him/her to other activities and let him/her sit here (pointing to the arm chair in the corridor outside of the resident's bedroom across from the nurses station. The resident proceeded to leave the bedroom and sat in his/her designated arm chair. 2. Interview with the Registered Nurse Unit Supervisor revealed that Resident #18 also wanders/visits in other resident's bedrooms and has been hit by other residents on occasion. Nursing staff said that he/she has yelled at the resident's in their bedrooms. 3. On the afternoon of 2/12/09, Resident #18 was observed sitting in an arm chair outside his/her bedroom across from the nurses station. Planned activities to engage the resident were not observed: - The resident went to the 1/2 door of the nurses station and talk with any staff person in the nurses station, - Rummaged through his/her belongings in his/her room and near his/her roommate's dresser. - Attempted to start conversations with persons who passed by him/her. 4. 12/6/08 review of the "Resident Care Plan, Run date: 6/17/2008 included: "Problem 3, Goal 1...I will demonstrate the ability to follow through with simple tasks. I will cooperate with tx, activities...1. Approach Frequency 1...Staff will assign me appropriate task for me to follow through on...3. Staff will perform reality check with me prn..." "Problem 4 Alteration in Behavior r/t to Exit Seeking, ...Approach Frequency 8. Offer diversional activities, foods, games, TV, books, etc."

Based on observation, review of facility records, clinical records and policy and procedure, the facility did note ensure that a resident who displayed mental or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem for 5 of 21 residents (#2, 3, 11, 15, 17) in the active sample and one random sample resident (RS2). Findings include: A. Random observations of Resident #15 from 2/10/09 - 2/12/09, revealed the resident walked up and down the corridor of the unit, and sat in the chairs along the path. The resident had repetitive behaviors such as pulling at facial stubble and pick at his/her nose. Review of the resident's clinical record on 2/12/09 found the resident had [DIAGNOSES REDACTED]. 1. Review of the comprehensive assessment with an "Assessment Reference Date" (ARD) of 5/20/08, noted in the "Resident Assessment Protocol"(RAP) for Psychosocial Well-Being that the resident had "episodes of persistent anger...withdrawal from activities (ie: doesn't care to sweep anymore like... used to)...reduced social interaction, repetitive physical movements...wandering (into other rooms), resisting care..." 2. The resident's comprehensive plan of care included as an intervention, "monitoring and recording of behaviors, including entering other residents' rooms". a. On 2/11/09, Resident #15 was observed in another resident's room toileting him/herself. Review determined the incident was not documented in the facility's "Compressed Mood and Behavior Report". b. Further record review revealed the resident had repeated behaviors of wandering into other residents' rooms, laying on their beds, and with behaviors including spitting, yelling and kicking at staff. c. Documented incidents revealed on: "2/2/09 - Res had been wandering into other res rooms and lay on their beds. (Resident) is difficult to redirect most of the time...; 2/4/09 - ...wandering around unit and into other res rooms...; 1/3/09 - Observed in other residents' rooms in room [ROOM NUMBER]A...attempted to redirect...but yells and tries to kick...will monitor.; 1/11/09 - ...refused to get out of other resident's bed, attempted to kick staff, spit at staff multiple times, finally out of the room after about 20 minutes...; 12/30/08 - Res found laying in an unoccupied bed of another res. Staff attempted to redirect on several occasions but refused to come out - res becomes agitated and tried kicking this writer then picking...nose and trying to flick at LN. Res left safely and came out of room about 20 minutes later. Res agitated and moving chairs around unit. Redirected and close monitoring initiated; 12/4/08 - Resident laid down in room [ROOM NUMBER]-bed A, would not come out despite redirection by multiple staff, stayed in bed for about an hour, when...finally got out...was very loud, attempting to charge at staff, noted spitting and trying to kick this LN while in bed..." 3. Review of the 1/16/09, 11/28/08 and 11/17/08 monthly behavior assessments noted documentation that the resident continued to exhibit the target behaviors of wandering into other resident's rooms, combative, threatening, aggressive behaviors and refusing personal care/medications. a. Staff noted in the comment section that they would continue to encourage Resident #15 to comply with care/medications and provide encouragement and redirection. 4. A "Group Behavior Chart" showed that from 12/14/08 to 2/12/09, the resident had 48 total incidents. On 2/12/09 at 2:15 P.M., the Administrator and Director of Nursing stated the "Total Incidents" meant the number of behaviors demonstrated by the resident, but were not able to clarify how the data was used to reassess how Resident #15's recurrent behaviors were being effectively monitored or not. 5. The comprehensive care plan included interventions for monitoring and reminding the resident not to enter other resident's rooms. The resident continued to display his/her target behaviors. a. The resident's sleep pattern disturbance care plan noted an intervention to encourage the resident "to be involved in acts/exerc to keep me busy during the day." However, there was no indication the staff ensured, evident by the documentation and observation of the resident, that Resident #15 received on-going treatment and services, such as a systematic orientation program to include usual and customary routines and/or activities to maintain his/her mental and psychosocial functioning. b. There was no program implemented to assure the resident's target behaviors were continuously addressed with the goal of preventing injury to him/herself and/or to other residents and staff. c. Further, a 1/10/09 physician note stated, "No resident concerns or occasionally refuses food and meds...No Behavioral Issues." 6. The clinical record showed there were documented events related to the resident's mental, psychosocial and behavioral adjustment, but no assessment or query by the physician was found. B. RS-2 had [DIAGNOSES REDACTED]. 1. Observation of RS-2 on 2/10/09 during the initial tour noted the resident walked around the unit and sat at different locations in the corridor on the outdoor chairs. On 2/11/09 at 10:00 A.M., RS-2 was seen in another resident's room by the nurse's station. A licensed staff directed the resident out of the room and brought him/her to the day room to watch television. The resident left the room at 10:07 A.M. and did not stay to watch the CNBC news channel. a. After lunch on 2/10/09, RS-2 was observed to open the refrigerator in the day room and grabbed a nourishment drink. b. By the mid-afternoon of 2/10/09, RS-2 was found sitting in front of room [ROOM NUMBER], having partially eaten half a sandwich and held the other half in his/her right hand. Staff were observed to pass by the resident but did not notice what he/she was eating or doing. c. At 3:50 P.M., interview with the Registered Dietitian (RD) revealed that RS-2 "likes to eat on the run." The RD said the resident liked to take people's food and would go into the refrigerator for it. The RD explained RS-2 had an organic [MEDICAL CONDITION] and his/her behaviors were such that it could not be helped. The RD stated RS-2 was on a pureed diet with thin liquids and acknowledged eating a sandwich was not safe (risk for choking and aspiration). 2. RS-2's comprehensive care plan noted he/she had a tendency to "wander off" related to the frontal dementia. Several interventions included approaches such as: "Please keep me invl in some of past acts like watching sports on tv, religious services, gardening...Most times I just wander around the facility and can't seem to sit and participate in any acts offered to me. But there are times when I will sit long enough to watch tv or enjoy an entertainment...my activity goal is at least 1-3x week. If I am unable to meet my goal please visit me in my room for soc cont/ interact and offer me acts like music, exerc, snacks, precrafts, tv, or update me as to what's going on outside of my room." 3. Additional record review noted the resident had repeat behaviors of wandering into other residents' rooms, history of disrobing in public and taking "whatever food/beverages...can get a hold of." An 11/14/08 entry noted, "Wanders constantly to other residents' rooms, behavior easily altered but continues shortly thereafter." On 1/26/09, the IDT updated the care plan for the resident's behavioral management related to his/her diagnoses; however, it was not evident in the documentation nor during observation of the resident that the interventions such as "Provide daily orientation by nursing and Activities; Encourage resident to attend activities and socialize with others; Be observant of resident's whereabouts at all times; Give resident supervision and cueing to encourage and allow...to participate in...care and activities; Offer diversional activities, foods, games, TV, books, etc." were provided. 4. Except to redirect the resident, the staff were not observed to provide a structured program or routine to ensure the resident was provided with activities for behavior management. a. A routine physician visit note of 1/29/09 noted the resident's Plan of Treatment was "Overall doing well...continue environmental management for dementia." The physician did not specify what environmental management included or if treatment and services were indicated. b. The resident was observed to constantly walk around the unit, with redirection being the means of supervision by the staff when the resident was found in another resident's room or had items in his/her possession that did not belong to him/her. C. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. The initial assessment identified that this resident "...can't seem to stay at one place for too long because he wanders. And adjusting to his new home and will give him time to adjust at his own pace." (RAP Review Report, 6/30/08, page 4). 2. Documented facility monitoring in the Behavior Risk Assessment Tool noted an increase in risk scores from 13 to 19 over a 6 month period in the "High Risk" category. Aggressive behavior toward staff took place on 11/10/08, and toward other facility residents on 8/22/08, 11/29/08 and 12/7/08. 3. Facility records noted frequent pacing, exit seeking (10/29/08, 12/7, 12, 24, 30/08), [MEDICAL CONDITION] and crying. 4. The Interdisciplinary Care Plan Conference Notes of 12/23/08 noted: (Resident #2) "Continues with usual behavior ...pacing back & forth non-stop, tearful, sadness, agitation, etc.." 5. Record review and staff interview found interventions outlined in the care plan were updated to include "...monitor Res. whereabouts" (8/08), and "Frequent checks of his whereabouts" (12/08). 6. Steps were not taken to implement a psychiatric evaluation, an option included within the existing care plan, nor determine possible cause(s) of the escalating behaviors. D. Resident #3 was admitted with [DIAGNOSES REDACTED]. Resident #3 fell in the facility on 3/4/08 sustaining a head injury, and was readmitted after surgery and a brief hospitalization . 1. Behavior was noted as a "problem" on the Nurses' Monthly Summary form for 3/08, he/she was noted as being agitated and refusing care on the 4/08 Summary, and noted as having "...increased agitation and numerous behaviors" on the 5/08 Summary. 2. On 6/8/08 Resident #3 was involved in an incident in which he/she believed he/she was being held "hostage" and used a knife to threaten staff. When staff were unable to reassure Resident #3 verbally, the police were called to the scene and the incident ended without physical injury. 3. A psychiatric consultation was done on 6/24/08 after the facility care plan of 6/21/08 initiated mood/behavior monitoring and interventions. Medication was prescribed, however, no care measures were put in place to provide options to prevent further escalation of behaviors for Resident #3. E. Resident #17 was admitted to the facility with a history including dementia, [MEDICAL CONDITION] leading to cognitive disorder, [MEDICAL CONDITION] and wandering away from home. 1. Exit seeking behavior was noted in the reviewed records as follows: for November, 2008 the chart indicated he/she had "...37 episodes of wandering with few episodes of hard to redirect...Total of 82 episodes of mood/behavior. Increase in mood and behavior from last month." a. The facility requested a reevaluation of medications from the nurse practitioner. b. An elopement occurred on 12/9/08 at approximately 5:30 P.M. when he/she wandered from a locked unit and was witnessed to exit through the facility main entrance/exit onto an adjacent arterial highway. He/she was discovered approximately 0.4 miles from the facility and returned. 2. No revised options were care planned for staff to provide alternate activities for Resident #17 at the onset of exit seeking behaviors. 3. On 2/11 and 2/12/08 a magnetically secured gate to the Maui unit and to the main facility entrance/exit was observed to be open. 4. During the survey dates, Resident #17 was observed to pace briskly on 2/10, 2/11, 2/12, and 2/13 within the confines of a secured unit in the facility, and to frequent the magnetically locked gate areas on the secured unit. On 2/11/08, Resident #17 was seen to exit the open magnetic gates, and move toward the main entrance/exit before he was re-directed by staff. F. Resident #11 had [DIAGNOSES REDACTED]. 1. On 2/9/09 after 7:15 PM, the resident was heard verbalizing loudly. The Shift Supervisor (SS) and Charge Nurse (CN) confirmed the person calling was Resident #11. The SS stated as tour of the unit neared the activity room, that the resident was kept away for the pathway fronting resident rooms as he/she became agitated when placed in that area. The resident was initially alone in the room, until a CNA came into the room and asked the resident if he wanted to eat something. The SS stated that the resident liked to watch television, however "no signal" was noted on the TV, and there was no program on the Television. The resident continued to call out for over and hour. Staff stated the resident was quiet when the family was present. 2. Observation and interview with the resident on 2/10/09 and 2/11/09 revealed the resident could respond to yes/no questions when he/she focused on the speaker, and could communicate some needs. The resident did not call out loudly, and responded to family who visited during the day. When asked how he/she was feeling, the resident focused his/her eyes on the speaker, then indicated by nodding, that he/she was okay. The resident also indicated that he/she understood when spoken to, and seemed to communicate by nodding and shaking his/her head. He/she indicated preferences for fishing, golfing, animal planet, and country music. 3. Review of the Resident Assessment Instrument Protocols (RAPs) revealed: a. under "Cognitive loss" that the resident "is able to answer yes/no questions" but "is not able to consistently make (his/her) needs known." The resident was noted to be "Combative and aggressive during care and does not always follow directions of staff." b. The "Mood State" RAP noted "resident had episodes of repetitive verbalizations (i.e.: calling out). ... Staff also noted "episodes of socially inappropriate behavior (i.e.: throwing meds on the floor, making excessive noises/screaming., verbally abusive (i.e. cursing). The RAP did not address why the resident called out, and why behaviors were occurring, and interventions/approaches to decrease behaviors. 4. Review of the care plan: "Alteration in mood and behavior m/b bitting, scratching, calling out, spitting, kicking, and hitting staff and others, resistance to care, and sliding off bed and wheelchair r/[MEDICAL CONDITION] Dementia w/ behavioral disturbances>" a. The goals were: 1) Freedom from kicking and hitting staff and others; 2) Will comply with care; 3) Res will decrease calling out less than 4x a shift." b. Approaches included use of medication, [MEDICAL CONDITION] drug review, monitor behaviors, identified how to approach the resident, but did not include assessment for what triggered the behaviors 5. Under "Communication": "... is triggered related to the resident's inability to speak clearly and make (his/her) needs known. Has [DIAGNOSES REDACTED]. - Interventions to facilitate communication were not specific in the plan of care. One intervention noted under the "Cognitively impaired ..." care plan was: "2. Staff will maintain a pleasant, quiet environment, approaching me in a calm and slow manner, giving me simple directions one at a time. Allow me time for responding and encourage me to cooperate with tx and activities. - The care plan was not revised to include specific actions/measures to facilitate the resident's ability to communicate his/her needs and staff's ability to understand the resident. 6. Review of the Activities RAP noted that the resident was "able to make (his/her( own choice with activities he/she wants to participate in, attended activities of his/her choice, but did not address activities that could be implemented after 7:00 PM, when the activity person left. a. The activity care plan "Potential for Lack of Activity :Participation r/t dementia w/ Bhvr Disturbances and R hemi". b. The goals were: "I will stay involved in the social life of Hale Makua." "I want to cont to be (involved) in some of my past acts, as well as other acts as well as other acts adaptable to my current abilities/choices..." The goal did not include identification of activities to decrease the calling out and did not reassess programs/activities which could e presented to the resident after 7 Pm to decrease the calling out other behaviors. c. The interventions and approaches did not identify activity/programs to engage the resident's attention in the evening hours.

Based on observation, record review, staff interviews and review of the facility's policy and procedure, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents for 8 of 21 residents (#2, 3, 6, 15, 16, 17, 18 in the active case sample and Random Sample Resident #2 (RS-2)) Findings include: The facility did not consistently implement its policy, "Safety Risk Assessment Procedure," the Purpose stated, "To assure that all residents are provided with a safe living environment, routinely assessed for individual safety issues...to allow the resident to reach or maintain their highest practicable physical, mental, and/or psychosocial well-being." I The facility did not ensure residents were prevented from injury to self and others thru fall prevention, protection from inappropriate contact between residents, behavior management and ensure a secured environment. A. Observation of Resident #15 from 2/10-2/12/09 found the resident to have repetitive behaviors such as pulling at facial stubble, picking at his/her nose and walking around the unit with no planned activity. Review of the resident's clinical record on 2/12/09 found the resident had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with Assessment Reference date of 5/20/08 RAP for Psychosocial Well-Being noted the resident had "episodes of persistent anger...withdrawal from activities (ie: doesn't care to sweep anymore like... used to)...reduced social interaction, repetitive physical movements...wandering (into other rooms), resisting care..." Refer to F 319 for details of findings. There was however, no on-going program implemented to assure the resident's target behaviors were assessed with [REDACTED]. The clinical record showed there were many documented events related to the resident's mental, psychosocial and behavioral adjustment, but no assessment or query by the attending physician was found. Review of the 1/16/09, 11/28/08 and 11/17/08 monthly behavior assessments documented the resident continued to exhibit the target behaviors of wandering into other resident's rooms, combative, threatening, aggressive behaviors and refusing personal care/medications. Staff noted in the comment section they would encourage Resident #15 to comply with care/medications and provide encouragement and redirection. A "Group Behavior Chart" showed that from 12/14/08 to 2/12/09, the resident had 48 total incidents. On 2/12/09 at 2:15 P.M., the Administrator and Director of Nursing stated the "Total Incidents" meant the number of behaviors demonstrated by the resident, but were not able to clarify how the data was used to reassess how Resident #15's recurrent behaviors were being effectively monitored/supervised or not. B. RS-2 had [DIAGNOSES REDACTED]. Observation of RS-2 on 2/10/09 during the initial tour noted the resident walked around the unit and sat at different locations in the corridor on the outdoor chairs. 1. On 2/11/09 at 10:00 A.M., RS-2 was seen in another resident's room by the nurse's station. After lunch on 2/10/09, RS-2 opened the refrigerator in the day room and grabbed a nourishment drink. By the mid-afternoon of 2/10/09, RS-2 was found sitting in front of room 110, having partially eaten half a sandwich and held the other half in his/her right hand. Staff passed by the resident, but did not notice what he/she was eating or doing. At 3:50 P.M., interview with the Registered Dietitian (RD) revealed that RS-2 "likes to eat on the run." The RD said the resident liked to take people's food and would go into the refrigerator for it. The RD explained RS-2 had an organic brain injury and his/her behaviors were such that it could not be helped. The RD stated RS-2 was on a pureed diet with thin liquids and acknowledged eating a sandwich was not safe (risk for choking and aspiration). 2. RS-2's comprehensive care plan noted he/she had a tendency to "wander off" related to the frontal dementia. Additional record review noted the resident had repeat behaviors of wandering into other residents' rooms, history of disrobing in public and taking "whatever food/beverages...can get a hold of." An 11/14/08 entry noted, "Wanders constantly to other residents' rooms, behavior easily altered but continues shortly thereafter." On 1/26/09, the IDT updated the care plan for the resident's behavioral management related to his/her diagnoses; however, it was not evident in the documentation nor during observation of the resident that the interventions such as "Provide daily orientation by nursing and Activities; Encourage resident to attend activities and socialize with others; Be observant of resident's whereabouts at all times; Give resident supervision and cueing to encourage and allow...to participate in...care and activities; Offer diversional activities, foods, games, TV, books, etc" were provided except to watch television and have snacks. 3. Review of the facility's policy, "Safety Risk Assessment Procedure," the Purpose stated, "To assure that all residents are provided with a safe living environment, routinely assessed for individual safety issues...to allow the resident to reach or maintain their highest practicable physical, mental, and/or psychosocial well-being." Except to redirect the resident, the staff were not observed to provide adequate supervision as there was no structured program or routine for the resident's behavior management and accident prevention. The resident was at risk for aspiration from eating other residents' foods on the unit and a 7/28/08 fall documented, "will remind staff to know resident's whereabouts and make sure that end bathrooms are closed/locked." The resident was observed to constantly walk around the unit, with redirection as the means of supervision by the staff when the resident was found in another resident's room or had items in his/her possession that did not belong to him/her. C. Resident #6 had [DIAGNOSES REDACTED]. The facility did not develop a care plan to prevent this resident from being inappropriately touched by residents of the opposite sex. 1. The resident had two incidents where he/she slapped or punched other residents, and three incidents where residents of the opposite touched s/him inappropriately. a. The residents involved resided in a secured unit of the facility, however, Resident #6 was able to enter the secured unit. b. Interviews with certified and licensed staff of the secured unit confirmed the resident was able to enter the secured unit. Staff stated when the resident was found in the unit, they redirected Resident #6 out of the secured unit. Staff stated the resident "likes to help others". c. Random observations during survey revealed the resident walked freely around the facility, to the dining room, and activities area. 2. Review of the resident's care plan revealed that the facility had developed a care plan to address her behavior: "Alteration in mood/behavior ml/b tends to intervene to other res' behavior inappropriately, delusion, hx of audio-visual hallucinations, threatening behavior r/t Alzheimer's Disease... . The problem statement included "interpersonal conflict with other residents 12/16/07 and 3/29/08. The resident was moved to another unit. a. Care planned interventions addressed measures to decrease this resident's behavior: "Tends to intervene to other res' inappropriate behavior or help other res. Remind to call for help when other res need help. If resident becomes agitated and show signs of threatening behavior to other resident's remove (him/her) and redirect." b. The facility did not develop a care plan or interventions to protect the resident from inappropriate touching by residents of the opposite sex. Staff stated during interviews, that there have been no known incidents of the resident being inappropriately touched as the resident had been moved from the units where the other individuals resided, and those resident were monitored to prevent recurrence. 3. Although staff monitored other resident behavior and redirected Resident #6 from the secured unit, the facility did not develop a plan of care to minimize and prevent others from inappropriately touching the resident. D. The facility did not ensure that the resident received adequate supervision and interventions on an ongoing basis to prevent confrontations between Resident #18 and other residents. Interview conducted on 2/10/09 with the Registered Nurse Unit Supervisor (RNUS) revealed that Resident #18 wandered/visited in other resident's bedrooms and had been hit by other resident's on occasion. The RNUS also stated that Resident #18 had yelled at resident's in their bedrooms, and could provoke these residents. 1. On 2/12/09 approximately 10:00 A.M. Resident #18 was observed to rummage through his/her dresser drawers looking for his/her "purse", pointed toward roommate's bed and stated "that lady (roommate) must have taken the purse." The roommate was not in the room. The certified nurse aide (CNA) made attempts to redirect the resident to leave the room and sit down outside. The CNA stated that the resident always blamed the roommate for taking his/her belongings, so we redirect him/her to other activities and let him/her sit here (pointing to the arm chair in the corridor outside of the resident's bedroom across from the nurses station. The resident left the bedroom and sat in his/her designated arm chair. 2. During the afternoon of 2/12/09, the resident was observed sitting in the arm chair outside of his/her bedroom across from the nurses station with no specific activities for periods of time throughout the day. The resident went to the 1/2 door of the nurses station and have a short conversation with any staff person in the nurses station, or rummaged through his/her and the roommates belongings in his/her room and near his/her roommate's dresser. Resident also made numerous attempts to start a conversation with anyone who happened to pass by him/her. 3. On 2/12/09, as Resident #18's roommate wheeled his/her wheelchair into the bedroom, the right wheel accidently bumped the overbed table in front of Resident #18, who then yelled at the roommate and tried to push the wheelchair away from the table. E. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. 1. The resident was identified with risk for falls. Measures to prevent falls, behavior, and prevent dislodging IV catheter during medical treatment, was not consistent. a. On 3/4/08 at 3:30 A.M. he/she was found on the floor and reported that his/her head above the right ear was hurting. The reviewed record noted: "Tab alarm was disconnected by resident before fall." On 3/6/08, the Resident #3 was admitted to (hospital), diagnosed with [REDACTED]. b. On 3/11/08 Resident #3 was readmitted to the facility from the hospital. c. Over the following four months, Resident #3 had 11 recorded falls. - He/she was "found on floor" on 3/19 and 3/22/08 with no injuries reported. The 9 staples in his/her head were removed on 3/23/08. - On 3/24/08 the resident #3 fell at 1:45 P.M. and again at 6:30 P.M. The evening fall involved his/her "climbing over side of (geri) chair" and falling onto the front of his/her head with a "small lump (to) front of head" noted in the record. - Records noted that resident #3 was found on the floor on 4/3/08, and 4/9/08. - On 6/21/08, he/she sustained a "lump to occipital area" when found on a bedside mat. - Falls were documented on 7/2, 7/3, 7/4, and 7/28/08. Except for elevated blood pressure readings, no major injuries were reported from these 11 reported falls. d. While the dates of falls were recorded on the care plan, care plan review found no revisions in approaches to behavior, activities or restraint use until 11/08 which may have prevented the falls. 2. The resident was identified with multiple behavioral issues. a. On 6/8/08 Resident #3 was "...wielding (a) butcher knife with 19 cm blade cursing and threatening" and threatened staff with harm. The police were called to intervene. - On 6/9/08, the primary physician prescribed medication "...for extreme agitation m/b kicking staff, paranoid delusions, inability to redirect, disrobing and unawareness of safety". b. A psychiatric consultation was done on 6/24/08 after the facility care plan of 6/21/08 initiated mood/behavior monitoring and interventions. Medication was prescribed, however, no care measures were put in place to provide options to prevent further escalation of behaviors for Resident #3 c. A care plan for alterations in mood/behavior was added on 6/20/08 providing interventions such as diversional activities, reporting of behavioral changes, and monitoring of medications for effectiveness. The medication to be given when redirection was ineffective, Ativan, was administered 14 times in 6/08 and 16 times during 7/08. The "Nurses' Monthly Summary" completed 8/3/08 stated: "Medication, redirection, waist restraint, calm assurance NOT effective" and noted that mood/behavior status had deteriorated for Resident #3. d. The care plan for Resident #3 did not include individualized activities, nor behavioral diversions to provide staff with coping for acting out behaviors. e. Staff interviews including the Director of Nursing and the Social Services Coordinator revealed steps were not taken to prevent escalation of behavior beyond administering medications as ordered. 3. The resident was not monitored adequately to ensure resident safety during medical treatment. On 2/12/09 Resident #3 was observed to have intravenous (IV) fluids infusing into his/her left forearm while seated in a wheelchair in the courtyard of the Maui unit. a. Staff were not in attendance as he/she was observed at 11:05 A.M. to pull at the tape securing an IV infusion device and ask, "What is this for?" Staff were called, and were observed to speak with him/her for approximately 2 minutes before leaving Resident #3 alone in the courtyard. b. At 11:16 A. M. Resident #3 removed the IV, and hold it above left his/her arm. Staff were notified, and a licensed staff attended to the bleeding arm. c. The care plan for Resident #3 during a previous IV infusion in 2008 noted: "Make sure that resident does not pull out IV" (Resident Care Plan, pg. 9). d. Measures to prevent recurrence during IV infusion was not implemented. II. The facility's system to ensure the safety of residents with potential for wandering were not maintained as: 1) doors were not always secured in the secured unit, and 2) there was no measure to account for residents on a regular basis. 1. On 2/9/09 at 2:10 P.M. the locking door to the secured Maui unit was observed to be open. Staff were informed, and immediately went to close and secure the door. No 'head count' was performed to determine the whereabouts of unit residents, several of whom are known 'wanderers', and some of whom have gone missing in the past year. 2. There were no consistently implemented measures to safeguard residents with behaviors of wandering and with potential/history of leaving the facility unattended. Refer to findings for Resident #2, #16, and #17. A. Resident #2 was admitted with [DIAGNOSES REDACTED]. 1. The initial care plan identified exit seeking behavior in Problem #5 which was dated on 6/19/08, and alteration in mood/behavior including wandering and attempting to hit other resident(s) in Problem #7 dated 6/19/08. 2. "Nurses Monthly Summary" notes included frequent entries regarding the resident's frequent pacing, and conflict with other residents. 3. The "Interdisciplinary Care Plan Conference Notes" of 12/23/08 stated: "(Resident #2) Continues with usual behavior m/b pacing back & forth non-stop, tearful, sadness, agitation, etc." 4. Record review noted that the conflict with other residents took the form of slapping Resident #3 (8/22/08), verbally threatening staff (11/10/08), making a threatening gesture at another resident (11/29/08), and entering another residents room and hitting them (12/9/08). 5. The existing care plan included approaches such as "ascertain what causes the resident to become aggressive"(pg. 6), and "Psych. eval as needed." (pg.5). 6. On 1/25/09 Resident #2 tripped on another residents wheelchair and fell striking his/her head on the wheelchair. The resulting laceration above his/her left eyebrow required 3 stitches. 7. Record review and interviews with licensed and other staff, including the social services coordinator and Director of Nursing, revealed measures were not taken to determine and treat the cause of Resident #2's aggressiveness to residents and staff, and consideration of a psychological evaluation, and pacing/wandering behavior. B. Resident #17 was admitted to the facility with a history including dementia, [DIAGNOSES REDACTED] leading to cognitive disorder, insomnia and wandering away from home. 1. Exit seeking behavior was noted in the reviewed records as follows: for November, 2008 the chart indicated he/she had "...37 episodes of wandering with few episodes of hard to redirect...Total of 82 episodes of mood/behavior. Increase in mood and behavior from last month." a. The facility requested a reevaluation of medications from the nurse practitioner. b. An elopement occurred on 12/9/08 at approximately 5:30 P.M. when he/she wandered from a locked unit and was witnessed to exit through the facility main entrance/exit onto an adjacent arterial highway. He/she was discovered approximately 0.4 miles from the facility and returned. 2. No revised options were care planned for staff to provide alternate activities for Resident #17 at the onset of exit seeking behaviors. 3. On 2/11 and 2/12/08 a magnetically secured gate to the Maui unit and to the main facility entrance/exit was observed to be open. 4. During the survey dates, Resident #17 was observed to pace briskly on 2/10, 2/11, 2/12, and 2/13 within the confines of a secured unit in the facility, and to frequent the magnetically locked gate areas on the secured unit. On 2/11/08, Resident #17 was seen to exit the open magnetic gates, and move toward the main entrance/exit before he was re-directed by staff. C. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED].M., that s/he could not find Resident #16. S/he brought it to the attention of facility staff who initiated a search for the resident. 1. Review of facility reports indicated that Resident #16 was last seen at 6:45 P.M. seated in a chair fronting room #143. The visitor stated s/he found several magnetically secured gates located within the facility were open when s/he arrived that evening, and asked facility staff where they believed Resident #16 might be. Staff informed the visitor that the resident was attending a party in the facility, but inquiry with the Activities staff found that the resident had not attended the party. 2. The search for Resident #16 ended at 7:50 P.M. when staff "Heard someone breathing loud @ the end of hallway on Maui Unit". He/she was located on the floor of an unlocked storage room near room #101. Resident #16 confirmed that s/he had fallen, but no injury was visible except a right cheek "indentation".

Based on observations, record reviews, staff interviews and review of the administrative records, the facility failed to assess the need for sufficient nursing staff to ensure the provision of nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident was met based on the assessments and individual plans of care for 13 of 24 residents (#1, 2, 3, 5, 6, 7, 11, 12, 15, 16, 17, 18, 19) and Random Sample Residents (RS-2, RS 3, RS 4) in the case sample. Findings include: A.. Cross reference to findings at F 225, F 241, F 246, F 253, F 280, F 319, F 323 for details related to services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. B. The facility did not ensure that the needs of residents requiring assistance during meal times (breakfast, lunch, and dinner) were met, to ensure food served was at a temperature which was safe and palatable. 1. The facility staff provided feeding and set up services for 89 out of the 118 residents for each meal. The time required ranged from from 5-30 minutes, with some residents requiring more time. 2. Review of information from each unit revealed staff of the 3 nursing units, a. set up 37 residents who are able to eat by themselves; b. set up and assist 20 residents who require partial assistance with eating; c. set up and feed 32 residents; d. set up and assist as needed, 29 residents who are able to independently set up and able to feed themselves. 3. During the observation of the Maui unit on 2/10/09- 2/13/09, interviews with staff revealed the unit had a lot of "feeders" or residents who required total feeding assistance from the staff or partial assistance. a. Observation of the continental breakfast on 2/11/09 revealed the staff were rushing to plate the residents' food, were not heating up the residents' foods as the hot food temperatures were below 140 degrees Fahrenheit during the start of meal service, served residents portion sizes that varied with no menu to follow (i.e., 3 oz of pureed ham), etc. b. Staff stated it was hard to perform and complete their tasks as they had to take the time to feed the residents. c. As of 2/12/09, the total number of residents who required total feeding assistance was 11; partial feeding assistance was 5 residents; total and partial feeding assistance was 3 residents. Sixteen residents were independent in eating with set-up help by the staff. Several of the total feeding assist residents required from 20 to 38 minutes to be fed by the staff. 4. Resident #15 was identified by staff as requiring only set up help, still the resident needed cueing or supervision to eat. An example was on 2/11/09 at 12:00 P.M., when the surveyor saw the resident stand up and throw away his/her roll into the rubbish can. Although a nursing supervisor was feeding another resident not more than ten feet from Resident #15, he/she stated it was not witnessed by him/her. Resident #15 then pushed the overbed table away with the tray and was not encouraged to eat any more of his/her meal as there were no other staff present to monitor his/her intake. C. Resident #7 was admitted with [DIAGNOSES REDACTED]. 1. On 2/11/09 at 10:50 A.M., during personal care provided by the Certified Nurse Aide (CNA), the resident was noted to have open excoriated areas on both knees. The CNA stated it was because the resident was itchy and the nurses knew about it. The CNA stated the resident also had a cream to apply for the itch. The resident confirmed he/she felt itchy a lot and would scratch but was not aware of the open excoriated areas to his/her bilateral knee and shin regions. 2. On 2/12/09, review of the resident's Treatment Administration Record (TAR) noted there was no order for a cream and no treatment prescribed for the resident's open excoriated areas to both knees and shins. a. The licensed staff who reviewed the TAR stated there was a cream before for the resident's pruritus (itch) but was not aware of the excoriated areas to the resident's knee and shins. b. Review of the physician's orders did not find any new orders for treatment of [REDACTED]. c. However, the 2/09 physician orders did have Steri strips to be applied to both upper eyelids to keep eyes open during the day. Observation of the resident for the 4 days from 2/10-2/13/09 found only the right upper eyelid was taped up to help keep his/her eye open.