Every finding on record at Hale Malamalama

Based on interview, record and document review, the facility failed to protect one resident (R)1 of two investigated for staff abuse/neglect. Specifically, Certified Nurse Assistant (CNA)2 was witnessed to make inappropriate, unsympathetic comments to R1, and willfully neglected to provide her the necessary services of toileting on more than one occasion. As a result of these willful acts, R1 suffered mental anguish and emotional harm. Findings include: 1) On 01/10/2025, the Office of Healthcare Assurance (OHCA) received an anonymous report of potential abuse of R1 (alleged victim/AV) by facility staff. The narrative account included but not limited to: - R1 was admitted to the facility on [DATE] for skilled nursing level of care after being hospitalized . - Presenting Problem: Allegations of physical abuse and psychological abuse of a [AGE] year old female short-term rehab (rehabilitation) resident by a male Certified Nursing Assistant (CNA) .and a female Certified Nursing Assistant. - On 01/07/2025, AV reported to .Social Worker (SW)1 that a male (alleged perpetrator/AP) and female AP threw her on the bed after she was done using the bedside commode and sustained a lump to the back of her head 5 days ago during the night.AV did not report this earlier because she was afraid of retaliation, so felt it better to remain quiet. - AV did not have any known pain/injury, but was afraid. - AV needs care, but does not want to remain at facility because she is afraid due to the incident. - AV stated she knows staff get frustrated because she frequently asks to go to the bathroom. Reviewed the APS Incident Report completed by the SW1 submitted on 01/07/2025. The report included the following: - Abuse types: Caregiver Neglect, Physical Abuse, Psychological Abuse - Abuse indicators: Change in behavior or appearance, Failure to provide necessary care/health care in a timely manner, Injury-suspicious, Nervous, anxious, Threatened or intimidated. - Narrative-This afternoon, SW (SW1) had a conversation with the resident regarding her discharge planning and resident stated that she would prefer to go home as she has been mistreated by staff during the evening and night shifts. This is the first time the resident brought this up, so SW requested to elaborate more. Resident stated that 5 days ago, when she requested to be toileted, a man and a woman (CNAs) came into her room and were rough with her. She stated that she understands that it is hard because she keeps wanting to go to the bathroom and she knows that staff gets frustrated with her because of that, but that gives staff no right to treat her the way they do. Resident stated that on that night 5 days ago, .a male and female came into her room and were rough with her while pulling her off the bedside commode. The 2 CNA's threw her on the bed with no care and she sustained a lump on the back of her head. SW checked resident's head and found a lump on the back of her head and immediately reported to the DON (Director of Nursing) and [sic] who came to take a look and also saw the lump on the back of resident's head. SW asked the resident why she waited so long before saying anything, and the resident stated that staying quiet is better as she does not want any staff to retaliate against her and she appeared anxious when she said that. SW told the resident she needs to make a report immediately when something happens like that, and if she does, she is not putting anyone in trouble as these CNAs are here to care for the residents and not to hurt them. 2) Review of Medical records revealed R1 is a [AGE] year old Korean female admitted to the facility on [DATE]. She had medical diagnosis that included cancer of the stomach, Type 2 Diabetes, hypertension, heart disease, atrial fibrillation, repeated falls, weakness, ascitis (accumulation of fluid in the cavity of the abdomen), Stage 2 coccyx pressure ulcer and is vision impaired. She has occasional bladder incontinence and is on diuretic therapy for her edema, hypertension and congestive heart failure. R1 is a fall risk due to her impaired mobility and weakness. She was able to bear weight, but required assistance for transfers, and to use the toilet. R1's baseline was that she was alert, oriented, and although primary language was Korean, she spoke and understood English well and a translator was not needed Her records included a Physician Certificate of Capacity dated 12/17/2024 that certified R1 had the ability to understand significant benefits, burdens, risks, and alternatives to proposed health care and does have the ability to make and communicate health care and financial decisions. Her BIMS (Brief Interview for Mental Status/snapshot of cognitive functioning) score was 14, which indicates intact cognitive response on the MDS (Medical Data Sheet) dated 12/24/2024. Reviewed R1's progress notes that included: 01/07/2025 at 02:45 PM, Social Services note by Social Worker (SW)1: . This afternoon, SW had a conversation with the resident regarding her discharge planning and resident stated that she would prefer to go home as she has been mistreated by staff during the evening and night shifts. This is the first time the resident brought this up, so SW requested to elaborate more. Resident stated that 5 days ago, when she requested to be toileted, a man and a woman (CNA) came into her room and were rough with her. She stated that she understands that it is hard because she keeps wanting to go to the bathroom and she knows that staff gets frustrated with her because of that, but that gives staff no right to treat her the way they do. Resident stated that on that night 5 days ago, .a male and female came into her room and were rough with her while pulling her off the bedside commode. The 2 CNA's threw her on the bed with no care and she sustained a lump on the back of her head. SW checked resident's head and found a lump on the back of her head and immediately reported to the DON and who came to take a look and also saw the lump on the back of resident's head. SW asked the resident why she waited so long before saying anything, and the resident stated that staying quiet is [NAME] as she does not want any staff to retaliate against her and she appeared anxious. 01/07/2025 at 03:52 AM, Nursing Behavior note entered by RN3: . Res (Resident/R1) continues to be awake most of the time throughout the night, requesting to be on recliner, bed, commode, sitting in bed, falling asleep, calling out help me, expressed being afraid but don't know what, requesting staff to stay with her all the time, explained why we cant [sic] stay beside her for a long time. 3) Reviewed staff statements the facility collected during their investigation, which included: RN2's email statement provided on 01/15/2025 regarding events week of 12/30/2024: On my noc shift, R1 was under the care of CNA2. Throughout the shift, R1 would request for assistance to transfer to the toilet . This is a common request of R1 given her health status.I observed CNA2 telling R1 that she was not going to transfer her to commode because she had just moved her back into bed. Despite her pleas, CNA2 ignored R1. CNA2 would be seen not wearing a mask in R1's room. When R1 would cough, CNA2 would say, Cover your mouth, and if I get sick I'm blaming you. RN1's typed statement dated 01/15/2025 regarding the shift on 01/06/2025: CNA reporting resident (R)1 requiring more assistance with toileting, unable to bear weight and a major fall risk with only one CNA. Around 1930, noted yelling coming from the dining room. Resident requesting to go to the toilet; however CNAs not taking resident as they claimed, she just went and didn't do anything. Resident getting upset at staff and raising voice, to which one CNA (CNA2) responded by also raising voice to resident. Shouting between resident and CNA2 increased to a point where writer asked what was happening.Writer told resident that CNA will take her to the toilet in a few minutes. 4) On 01/29/2025 at 09:00 AM interviewed SW1 in the conference room. She said when she met with R1 about discharge planning, she said she wanted to go home because of how she was mistreated. She told SW1 that a certain night CNAs were rough with her and she sustained a hematoma on her head. She said R1 initially could not identify the CNAs and did not want to file a complaint for fear of retaliation, but later identified the male (CNA1). SW1 said after interviewing other staff, about three days later, she found out about an argument CNA2 had with R1 that was witnessed and overheard. SW1 said she reported this incident to the DON. She said she checked in with R1 to see how she was doing several times and that the incident really upset R1 and that she became teary eyed and they cried together. On 01/30/2025 at 01:30 PM, conducted an interview with CNA2 on the telephone. She said she often cared for R1, and that she had been deteriorating. She went on to say R1 is hard to get up to stand, get back to bed and that she asks to go to the bathroom every five minutes. When inquired if she knew why R1 feels she had to go to the bathroom so often, she said No, they said she has cancer, that's all I know. She has medicine for her to pee a lot. CNA2 described the routine care she provided to R1, which was to assist her with getting to the commode at bedside at noc. She said she would give her the walker and guide her to the commode a few steps away, and that one person could provide this assistance safely. CNA2 went on to say during the day R1 usually was in the recliner in the dining area and would often need assist to the bathroom. She said she worked the 02:00 PM to 10:00 PM shift and the night shift 01/06/2025, and recalled R1 being in the dining area and that she took her to the bathroom. CNA1 said she told her to stay awhile and she would return. After she returned and put her in the dining area, about five minutes later, she wants to go [NAME] (urinate) again. I told her I would take her at 09:00 PM before putting her to bed. I told her Mama if you feel like going, then you can use the diaper because that day she had a hard time to stand up. I told her I'd just finish my work. I told her that she needs to sleep and she can use diaper so she can sleep. This is the only time I told her to use her diaper. On 01/31/2025 at 11:32 AM, during another interview with SW1, she confirmed that R1 was cognizant until the last couple of days and that her mental status had declined and she was no longer responding to questions and only speaking Korean. Inquired if the facility had completed their investigation of the allegation of mistreatment related to the bump on R1's head, and she referred to the Investigion Report Form. She went on to say the investigation was completed and it was not substantiated as they could not identify any witnesses or specific event that might have caused the injury. SW1 said there were eye witness accounts of the argument, so they did substantiate verbal abuse. Review of the Investigation Report Form revealed it contained no details related to the verbal comments CNA2, made to R1, or that she neglected to provide the needed services of toileting. On 01/30/2025 at 10:20 AM, interviewed RN3 by telephone. Inquired about the behavior note she wrote on R1 01/07/2025. She confirmed she wrote the note, and that R1 was afraid to be alone that night, and wanted someone there with her all the time. RN3 said they left the lights, and she thought maybe it was a new environment for R1. She said she did not pursue the issue further or ask why she was afraid. 5) Observed R1 in bed. She was awake, appeared comfortable, but unable to answer questions.

Based on interviews and record review, the facility failed to report two of a sample size of two allegations of Resident (R)1 and R2 abuse/neglect as mandated to the Office of Healthcare Assurance (OHCA). The Administrator (ADM)was not notified immediately of R1's allegation of mistreatment, and the facility failed to notify OHCA of results and actions taken. Findings include: 1) On 01/10/2025, the Office of Healthcare Assurance (OHCA) received an anonymous report of potential abuse of R1 (alleged victim/AV) by a staff member of the facility. The narrative account included: - R1 was admitted to the facility on [DATE] for skilled nursing level of care after being hospitalized . - Presenting Problem: Allegations of physical abuse and psychological abuse of a [AGE] year old female short-term rehab (rehabilitation) resident by a male Certified Nursing Assistant (CNA) .and a female Certified Nursing Assistant. - On 01/07/2025, AV reported to .Social Worker (SW)1. that a male (alleged perpetrator/AP) and female AP threw her on the bed after she was done using the bedside commode and sustained a lump to the back of her head 5 days ago during the night.AV did not report this earlier because she was afraid of retaliation, so felt it better to remain quiet. - AV did not have any known pain/injury, but was afraid. - AV needs care, but does not want to remain at facility because she is afraid due to the incident. -AV stated she knows staff get frustrated because she frequently asks to go to the bathroom. - Facility is in the process of doing an investigation. Record review revealed the following: 01/07/2025 at 02:45 PM Social Service (SS) note by SW1: . This afternoon, SW had a conversation with the resident regarding her discharge planning and resident stated that she would prefer to go home as she has been mistreated by staff during the evening and night shifts.Resident stated on that [sic] night 5 days ago, .a male and female came into her room and were rough with her while pulling her off the bedside commode. The 2 CNA's threw her on the bed with no care and she sustained a lump on the back of her head. SW checked resident's head and found a lump on the back of her head and immediately reported to the DON (Director of Nursing) and who came to take a look and also saw the lump on the back of resident's head.told the resident that a report would be put into APS, . On 01/29/2025 at 02:00 PM. interviewed the DON in the conference room. She said she was informed of the incident by SW1 on 01/07/2025. The DON said the Administrator (ADM) was notified two days later. When asked what the delay was notifying the ADM, she replied I thought SW1 had already informed her. On 01/30/2025 at 12:30 PM interviewed the ADM in the conference room with the DON. She said she was aware a CNA was accused of verbal abuse and was going to determine actions based on the APS and OHCA investigations. The ADM said she had learned of the second case around the time OHCA came in, and thought that one had been resolved. On 01/31/2025 at 11:30 AM, interviewed SW1 in the conference room. At that time, SW1 confirmed this case was actively being investigated by APS, and confirmed the allegation and findings (within 5 days) had not been reported to OHCA. She said when she was made aware of the event, she notified the DON, but did not notify the Administrator (ADM). 2) On 01/14/2025, OHCA received an anonymous report of caregiver neglect of R3. The report alleged on 12/18/2024, caregivers did not provide the necessary services and care to R3 when she was soiled with feces and needed a diaper change. Despite the fact that APS notified the facility they opened a case related to R3 for investigation, and the facility knew of concerns related to R3 being soiled and CNA assignments, the facility failed to investigate for neglect and notify OHCA. 3) Reviewed the facility policy titled Reporting Abuse to Facility Management, with date at bottom of policy 04/00. The policy included: 4. When an alleged or suspected case of mistreatment, neglect, injury of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State Licensing/Certification agency (OHCA) responsible for surveying/licensing the facility; . Reviewed the facility policy titled Protection of Residents During Abuse Investigations with date at bottom of policy 09/07. The policy included: 2. Upon completion of the investigation, the resident, the resident's representative, the ombudsman, state survey and certification agencies (OHCA) .will be provided a written report of the findings of the investigation and summary of corrective action taken to prevent such incident from recurring. Reviewed the facility policy titled Reporting Abuse to State Agencies and Other Entities/Individuals with date at bottom of policy 04/00. The policy statement was All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. The policy included 1. Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse . be reported, the facility administrator, or his/her designee, will promptly notify the following persons to agencies (verbally and written) of such incident: a. Department of Health Office of Healthcare Assurance; .

Based on interviews and document review, the facility failed to provide evidence they conducted thorough investigations of two Resident (R)1 and R3 abuse/neglect allegations of a sample of two. In addition, the facility failed to remove the alleged perpetrators immediately when identified for R1's case. The facility also failed to internally investigate an Adult Protective Services (APS) case on R3 for neglect to provide needed services because they felt it was a resolved issue with staff assignments. Due to this deficiency, the underlying issue of providing timely services was not investigated to identify any quality issues or neglect. Findings included: 1) R1 is a [AGE] year old female admitted to the facility from the hospital on [DATE] for skilled nursing services. She had a history that included, but not limited to hypertension, cardiomyopathy, heart failure, atrial fibrillation, malignant neoplasm of stomach, malignant ascites, Type 2 Diabetes, difficulty in walking and muscle weakness. On [DATE], R1 informed the Social Worker (SW)1 she had been mistreated. Request made for all facility investigation documents related to R1's allegation. Documents provided included the Investigation Report Form dated [DATE] and copies of staff statements. The Investigation Details included: - Investigator Names: Director of Nursing and Social Worker - Date of investigation: [DATE] to present - Resident interviews conducted [DATE] and [DATE]. - Investigation Findings included choices to be marked Yes or No. The choices were: Substantiated, Unsubstantiated or Unable to Determine. The form was marked Yes for unsubstantiated, with the comment for lump on back of resident's head. - DON and SW1 conducted extensive interviews with all staff members, including over the phone interview with alleged perpetrators. Investigators could not substantiate or find reasonable reasons for how resident got bump on back of her head. - All CNA and nursing staff members in-serviced regarding resident abuse and neglect and a safety plan was developed for the resident by updating residents care plan and making sure that resident receives adequate supervision to prevent issues of abuse/neglect in the future. - Some risk factors identified during the investigation are as follows: 1. Urge Incontinence/Fluid accumulation which are all due to her health status. 2. Lack of staff training about individualized care in order to support residents needs, capabilities, and rights. DON implemented consistent staffing assignments and took steps to ensure adequate staffing at all times. Statements of staff scheduled the PM and Night shift of [DATE] were collected by SW1. The statements revealed information that CNA2 displayed inappropriate behaviors and neglected to assist R1 to the bathroom in timely manner on more than one occasion. Other performance issues were identified, but not related to R1. On [DATE] at 09:00 AM interviewed SW1 in the conference room. She confirmed R1 informed her of mistreatment on [DATE]. SW1 said she immediately reported it to the DON, APS and initiated the investigation as directed by the DON. She said she did not notify the Administrator or OHCA. SW1 said when CNA1 was identified, she recommended the DON or Administration interview CNA1 due to a previous encounter she had with him. SW1 went on to say, about three days into the investigation she found out about an argument CNA2 had with R1 and that she refused to take her to the bathroom and provide services. On [DATE] at 10:20 AM, a second interview was conducted with SW1 after review of the investigation packet provided. At that time inquired if she interviewed CNA2 and CNA3. She said she talked to them on the phone, but they could not remember anything. SW1 said there was no documentation of time or date of the calls, or specifics of the interview. SW1 said interviews were not conducted with other residents these staff cared for. On [DATE] at 11:00M, a third interview was conducted with SW1. Inquired if the facility had completed their investigation, and she said yes, and referred to the investigation summary referenced above, dated [DATE]. She went on to say they did not substantiate physical abuse as there were no witnesses to any event that might have caused the bump on R1's head, but that they did substantiate the verbal abuse because there were eye witness accounts of the incident. When inquired what action had been taken to prevent any further occurrence, she said it would be up to administration, and to her knowledge, there was discussion about progressive disciplinary action. She confirmed all three CNAs were still suspended. On [DATE] at 01:30 PM, conducted an interview with CNA2 on the telephone. She confirmed she was on suspension related to the care of R1. CNA2 said the Administrator called her and told her there was a problem and she would be off the schedule, and to wait for a call from APS. She said she tried to contact the DON, but unable to reach her. CNA2 said she did not know specifics of the concern and was not asked to provide a written statement. She said she had not yet talked to APS. On [DATE] at 02:45 PM, conducted an interview with CNA1 on the telephone. He said he had been contacted by the DON first, and then SW1 about one week after the suspension. They told me that my name came up related to R1, and to wait for the APS investigation. CNA1 confirmed he worked scheduled shifts after the date the allegation was made, and prior to the suspension. On [DATE] at 01:00 PM, interviewed the DON in the conference room. She said she was informed of the incident by SW1 on [DATE]. When inquired what happened after she was informed, she said I told her to do an inservice for abuse, an incident report and chart if R1 had any decline in condition. Inquired who was in charge of the investigation, she said SW1 should initiate the investigation and I will collaborate with her. The DON said the ADM was notified two days later because she thought the SW1 had already informed her. On [DATE] at 12:30 PM interviewed the Administrator (ADM) in the conference room with the DON. The ADM said she had heard that a CNA was accused of verbal abuse, and that they were going to wait until the OHCA and APS investigation was complete to determine what actions to take. She said SW1 is doing the investigation. When asked if any abuse had been substantiated, she replied, I relied on SW1. Discussed the requirement of the facility to timely conduct their own internal investigation with findings and take action on those findings to prevent any future occurrence. Timeline events and investigation: [DATE] at 02:45 PM: R1 informed SW1 she has been mistreated by staff during the evening and night shifts. Said the CNA's threw her on the bed with no care and she sustained a lump on the back of her head. Reported to the DON and who came to take a look and also saw the lump on the back of resident's head.told the resident that a report would be put into APS (adult protective services), . SW will conduct an investigation as mandated. [DATE] at 05:10 PM, SS progress note by SW1: MD notified of resident's injury. [DATE] at 07:36 PM, Health Status Note by Nursing: Exam by physician. [DATE] and [DATE], CNA1 and CNA worked and provided care to residents. [DATE] at 03:37 PM, SS progress note by SW1: : Investigations was [sic] carried out by the DON (Director of Nursing) and SW and staff were interviewed. [DATE] at 05:19 PM, SS progress note: .All staff members (CNA1, CNA2 and CNA3) that were named/described by resident will have no contact with any resident until the investigation is done by APS.Ongoing investigation continues . Staff suspended (CNA1, CNA2 and CNA3) pending investigation after facility had discussion with APS. [DATE]: The DON signed the Investigation Report Form, documented Investigators could not substantiate or find reasonable reasons for how resident got the bump on back of her head. [DATE]: Staff statements collected and included accounts of inappropriate comments CNA2 made to R1, as well as refusal to provide services needed to take her to the bathroom. There were no statements from CNA1, CNA2 or CNA3. [DATE]-[DATE]: OHCA investigation. At the time of survey, all three CNA's were still suspended and waiting to hear from the facility regarding findings. Cross Reference F600 Free from Abuse/neglect The facility failed to protect R1 from verbal abuse and neglect to provide needed services of toileting. CNA2 refused to assist R1 to the toilet, witnessed shouting at R1 and reported to have made other inappropriate comments. CNA2 stated during interview that she told R1 to urinate in her diaper. As a result of these willful acts, R1 suffered mental anguish and emotional harm. 2) R3 was a [AGE] year old female admitted to the facility on [DATE]. Her medical diagnosis included but not limited to chronic kidney disease, Type 2 Diabetes, hypertension, dysphasia, Hemiplegia and hemiparesis affecting right dominant side following stroke, full incontinence of bowel and bladder. R3 is dependent on staff for meeting emotional, physical and social needs due to her physical limitations. She was on hospice and expired on [DATE]. The facility was notified by APS that they opened a case for R3 and requested documents. Reviewed a typed unsigned statement that included On [DATE]. I was the evening Charge Nurse .when 1 CNA came to me and told me that the agency CNA and a regular staff of the facility are arguing loudly inside room [ROOM NUMBER]. I went to intervene and saw them close to eachother still arguing. Prior to the incident, I learned that they were arguing about resident assignment .When asked if she (agency CNA) can change the said resident (R3), the agency CNA agreed to change her.After separating them, I was not really sure what happened why they came to a point where they are shouting to each other. I just wanted to separate them. On [DATE] at 10:00 AM, interviewed the DON in the conference room. At that time, she said she was aware of a situation with R3 on [DATE], and that she was in charge at that time. The DON confirmed the unsigned statement referenced above was hers. She went on to say there was an issue with CNA assignments at change of shift but that the issue had been resolved and assignments had been worked out. The DON said apparently R3 was found to be soiled by the assigned CNA, and there was a question of why she had been assigned to that particular resident. The DON said she had recently been made aware that there was a APS case opened on R3. When inquired if she reviewed R3's medical records to identify any potential care issues and specifically if she had reviewed the CNA task documentation for timely brief changes on [DATE], since this had been brought to her attention, she replied no. The DON reviewed the documentation and agreed there was lack of evidence R3 had been checked every two hours for incontinence that day. There was no investigation to identify any care issues or neglect to provide services conducted by the facility after the CNA expressed concern of staff not changing residents in a timely manner and the incident that occurred on [DATE]. It was viewed as an interpersonal conflict between staff related to assignments which was considered resolved. Cross Reference F684 Quality of care The facility failed to provide the needed incontinence care and standards of practice for R3, which was to check her every two hour checks to ensure she was clean and dry. RR revealed staff did not provide these checks on multiple occasions, which put her at increased risk of skin breakdown. On review of CNA task documentation revealed on [DATE], R3 was checked at 12:00 PM, and not again until 07:25 PM. 3) Reviewed the facility policy titled Protection of Residents During Abuse Investigations with date at bottom of page ,d+[DATE]. The policy included: -The policy statement Our facility will protect residents from harm during investigations of abuse allegations. - 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of the alleged abuse will be immediately reassigned to duties that do not involve contact with any resident or will be suspended with or without pay until the findings of the investigation have been reviewed by the administrator or representative clearing the employee of any wrong doing. b. Duties that do not involve contact with any resident include work in the dietary department or the administrative office. Reviewed the facility policy titled Abuse Investigations with date ,d+[DATE] at bottom of page. The policy included: - Policy statement: All reports of resident abuse, neglect, and injuries of an unknown source shall be promptly and thoroughly investigated by .management. - 3. The individual conducting the investigation will , at [sic] a minimum: . i. Interview other residents to whom the accused employee provides care or services; .

Based on interviews and record review, the facility failed to timely update one Resident's(R)1 care plan. R1 initially required one assist for toileting/transfers. When her condition declined, she required two person assist and then the Hoyer lift to safely transfer her, but the facility did not revise her CP in a timely manner. As a result of this deficiency, there was the potential not all staff were aware of what assistance R1 required to provide safe transfers, increasing the potential for falls with injury or harm. Findings include: R1 is a [AGE] year old female admitted to the facility from the hospital on 12/11/2023 for skilled nursing services. She had a history that included, but not limited to hypertension, cardiomyopathy, heart failure, atrial fibrillation, malignant neoplasm of stomach, malignant ascites, Type 2 Diabetes, difficulty in walking and muscle weakness. Reviewed the electronic medical record which included the following entries: 01/03/2025 at 02:44 PM, Nursing note: .Toileted by staff with extensive assist as per request. 01/05/2025 at 03:37 AM, Nursing note: While trying to put her in recliner, knee buckled and staff slide [sic] and guided down the Res (resident) to the floor. No c/o of pain. Able to get up with 2 assist with good weight bearing.: 01/06/2025 09:35 PM, Nursing note: .CNA reports resident requiring more assistance with toileting. 01/07/2025 12:52 PM, Nursing note: Resident had her last PT (physical therapy) session this shift and able to participate with some activities given by the therapist, but weakness noted per PT. 01/22/2025 02:10 PM, Social Services note: Late entry significant change for 01/16/2025: Resident was readmitted to .Hospice on 01/08/2025 as she was previously on hospice before she had a fall and sent to the hospital. She has hospice diagnosis of Gastric Cancer .she requires extensive to total assistance with her ADL's (activities of daily living) and care due to increased weakness. She is unable to ambulate but can bear weight partially and requires 2-3 staff assistance during transfers. Reviewed R1's active care plan (CP), which included the focus The resident has an ADL self-care performance deficit r/t (related to) impaired mobility, muscle weakness. The interventions included the following: - Toilet Use: The resident requires substantial/maximal assistance by (1) staff for toileted. Date initiated 12/26/2024. Revision on 01/15/2025. - Transfer: The resident requires substantial/maximal assistance by (1) staff to move between surfaces as necessary. Revision on 01/15/2025. R1 was documented to require more assistance with toileting on 01/06/2025 and on 01/22/2025, indicated she required 2-3 staff assistance for transfers. On 01/28/2025, it was documented she required the Hoyer lift for transfers. The CP was not revised to include these changes in a timely manner.

Based on observation, record review (RR) and interviews, the facility failed to provide the needed incontinence care and standards of practice for two residents, (R)2 and R3, of a sample size of three that needed incontinence care. This deficient practice has the potential to affect any resident requiring incontinence care. Findings include: 1) R2 is a [AGE] year old female admitted to the facility on [DATE]. She has a medical history that includes but not limited to dementia, retention of urine, muscle weakness, difficulty walking and syncope. She is chairfast and has very limited ability to change position without moderate to maximum assistance, and is considered high risk for developing pressure sores. Reviewed R2's Care plan (CP) which included the following: - Date initiated: [DATE]: The resident has bladder incontinence r/t (related to) Dementia, Impaired Mobility. - Interventions initiated [DATE] included Brief use: The resident uses disposable briefs. Check every 2 hours and prn (as needed) and change prn., and Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Reviewed the documentation of Certified Nurse Assistant (CNA) tasks for the period of [DATE] through [DATE], which revealed bladder elimination was not checked and documented every two hours per R2's CP, facility policy, or current standard of care. The entries below are not all inclusive of missed checks for incontinence care by the nursing staff: - [DATE] checked at 11:27 PM. (incontinent). Next check [DATE] at 09:48 AM (did not void). - [DATE] checked at 11:21 PM. Next check [DATE] at 06:00 AM (incontinent both times). - [DATE] checked at 11:10 PM. Next check [DATE] at 06:00 AM (incontinent both times). - [DATE] checked at 12:00 PM. Next check [DATE] at 05:11 PM (incontinent both times). - [DATE] checked at 11:36 PM. (incontinent). Next check [DATE] at 09:42 AM (did not void). - [DATE] checked at 01:10 PM. Next check [DATE] at 07:33 PM (incontinent both times). - [DATE] checked at 11:03 PM. Next check [DATE] at 09:22 AM (incontinent both times). - [DATE] checked at 11:18 PM. Next check [DATE] at 09:45 AM (incontinent both times). - [DATE] checked at 01:30 PM. Next check [DATE] at 07:44 PM (incontinent both times). - [DATE] checked at 11:07 AM. Next check [DATE] at 07:23 PM (incontinent both times). - [DATE] checked at 12:57 PM. Next check [DATE] at 08:43 PM (incontinent both times). - [DATE] checked at 03:44 PM. Next check [DATE] at 08:45 PM (incontinent both times). - [DATE] checked at 11:07 PM. Next check [DATE] at 10:01 AM (incontinent both times). - [DATE] checked at 12:00 PM. Next check [DATE] at 08:16 PM (incontinent both times). - [DATE] checked at 10:56 PM. Next check [DATE] at 11:10 AM (incontinent both times). - [DATE] checked at 12:54 PM. Next check [DATE] at 08:22 PM (incontinent both times). 2) R3 was a [AGE] year old female admitted to the facility on [DATE]. Her medical diagnosis included but not limited to chronic kidney disease, Type 2 Diabetes, hypertension, dysphasia, Hemiplegia and hemiparesis affecting right dominant side following stroke, full incontinence of bowel and bladder. R3 is dependent on staff for meeting emotional, physical and social needs due to her physical limitations. She was on hospice and expired on [DATE]. Reviewed R3's Care plan (CP) which included the following: - Date initiated: [DATE]: The resident has bladder incontinence r/t Impaired Mobility. - Interventions initiated [DATE] included Brief use: The resident uses disposable briefs. Check every 2 hours and prn and change prn. Clean peri-area with each incontinence episode, and Incontinent: Check every 2 hours and as required for incontinence episodes. Reviewed the documentation of Certified Nurse Assistant tasks for the period of [DATE] through [DATE], which revealed bladder elimination was not checked and documented every two hours per R3's CP, facility policy, or current standard of care. The entries below are not all inclusive of missed checks for incontinence by the nursing staff: - [DATE] checked at 12:58 PM. Next check [DATE] at 07:06 PM (incontinent both times). - [DATE] checked at 11:00 PM. Next check [DATE] at 05:51 AM (incontinent both times). - [DATE] checked at 01:13 PM. Next check [DATE] at 07:45 PM (incontinent both times). - [DATE] checked at 10:56 PM. (incontinent) Next check [DATE] at 06:00 AM (Did not void). - [DATE] checked at 12:00 PM. Next check [DATE] at 07:25 PM (incontinent both times). - [DATE] checked at 11:23 PM. Next check [DATE] at 11:45 AM (incontinent both times). On [DATE], the DON was made aware that R2 had been found by oncoming CNA incontinent of bowel and bladder. 3) Reviewed the facility policy (not dated) titled Perineal Care For The Incontinent Patient. The policy purpose included 2. Perineal care is completed every morning and/or after each incontinence episode. At the bottom of the policy was REMINDERS: *Check the patient every two hour for incontinence. 4) On [DATE] at 01:50 PM, interviewed CNA1 in the conference room. CNA1 said she was familiar R3, and she needed to have her briefs checked every one to two hours due to incontinence. At that time, she said the policy and expectation was that the staff were suppose to document every two hours whether the resident voided or not. On [DATE] at 10:40 AM, interviewed the Director of Nursing (DON) in the conference room. She said the facility policy for incontinence care was to check the resident every two hours to see if they needed to be changed, and to document in the computer if the resident was incontinent or did not void. At that time, reviewed the documentation of CNA tasks for incontinence checks on R3 and the DON confirmed the gaps in documentation. She said staff may have been busy and unable to document, but agreed it was the expectation to do so.

Based on interviews and record review, the facility failed to create an annual Performance Improvement Project (PIP) that focuses on high risk or problem prone areas identified through the data collection and analysis. This deficient practice has the potential to negatively affect all the residents' overall wellbeing. Findings Include: Interview and facility document review were concurrently conducted on 09/27/24 at 10:33 AM with the facility Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) binders did not contain documents on an annual Performance Improvement Project (PIP). Administrator confirmed that the committee met quarterly to discuss current facility issues and improvements but did not have an official PIP. A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan for HALE MALAMALAMA, was conducted. The policy documented, In addition, the QAPI Committee will implement any PIP topics indicated by data analysis .PIPs are implemented in accordance with CMS' protocol for conducting PIPs .

Based on observation, interview, and record review. The facility failed to provide an orderly and comfortable home for the residents residing in the facility, due to the following: Resident care equipment that was not maintained was stored in one resident's room which gave it a disorderly and cluttered appearance. Staff working at night were noisy and disrupted the residents sleep. The temperature in the dining room/ activity room was too cold at night. The efforts of the resident council to address the concerns failed to resolve the problems that were ongoing. The deficient practice affects the rights of the residents to live in a homelike and comfortable environment. Findings include: 1)During an observation in Resident (R) 186 room on 09/25/24 at 08:13, an Oxygen (O2) concentrator was observed under the counter next to the right side of the bed and two (O2) tanks next to the bed. Verified with staff that R186 is not currently being treated with O2. One wheelchair, two footrests, and a cane were found on the floor at the head of the bed (behind the bed against the wall). During a second observation on 09/26/24 at 07:32 AM in R186 room, the regulator on top of one of the O2 tanks showed the needle was in the red zone indicating it was empty and needed to be refilled. The 02 concentrator under the counter on the right side of the bed had a smeared service date. An unlabeled O2 tubing with a nasal canula was laying on the counter. Requested and reviewed the policy Facility Preventive Maintenance (05/08). Purpose: In order to provide a safe environment for residents and staff, it is important that all care devices and equipment used in .be checked and maintained on a regular basis. Procedures. The following items will be inspected, checked, tested and/ or cleaned: Nursing Equipment: Oxygen Concentrators Check weekly. Service when necessary. Oxygen tanks. Check weekly and ensure that they are operational and full. Interview with the Director of Nursing (DON) on 09/27/24 at 09:30 AM in the central area next to the nurse's station. The surveyor asked the DON, if it is the facilities responsibility to provide the maintenance checks on the O2 equipment? The DON explained that R186 is on Hospice and the Hospice Nurse will report any problems with the equipment to the DON and the facility will either contact the provider to replace it or contact the maintenance supervisor to repair it. Routine maintenance is done by the facility maintenance staff. The surveyor shared observations of the equipment (02 Concentrator with no maintenance date and the 02 tank that is empty in the room). The DON confirmed that the maintenance staff should be checking it. The facility Maintenance Supervisor was unavailable for interview. 2) Surveyor received and reviewed the following concerns from the long-term care ombudsman who recently visited the facility: Housekeeping staff were spraying disinfectant and cleaning the dining room while the residents were eating; housekeeping staff mopped the floors without placing a caution wet floor sign; ongoing concerns about the dining room being too cold for the residents. Resident Council minutes dated 06/17/24 reviewed. Old business concerns and resolutions: R150 had a concern about the dining room temperature, but matter was resolved. Agenda new business .R150 stated that the temperature in the dining room has been set to cold again and even when the residents complain that they are cold, nothing is being done .He also suggests that staff should consider the feelings of the residents and be considerate because the nursing facility is considered their home and they should be able to feel comfortable. He also stated that staff are still noisy at night which keeps him up and asked if the staff can be disciplined so that the behavior is not repeated The Social Worker (SW) stated this ongoing problem has been reported to the DON and the Administrator and awaiting their response . Resident Council minutes dated 08/19/24 reviewed. Old business/ concerns .R150 had a concern about the dining room temperature and claimed that the Air Conditioner (A/C) is always cold again. SW notified the resident that a sign was placed on the (A/C) to show what temperature to leave it on but resident said no staff follows that or even takes the time to read it .New business R150 states that the staff continues to be noisy at night which prevents him from sleeping. Interview with the SW on 09/27/24 at 08:55 AM in the central area next to the nurses station. The surveyor asked the SW how the residents' concerns were addressed and if they were resolved? The complaints that I haven't been able to resolve has been about the staff being too loud at night, and the residents are complaining that they can't get any sleep. We have talked to the staff and the ombudsman who has made suggestions. We have asked the staff to close the windows while they are on their break. The break room is right outside of the dining room. We have talked to the two charge nurses to remind the staff to be quiet. The other complaint that hasn't been resolved has been about the A/C being too cold. We have talked to the staff and put up a sign on the A/C but there is one staff who doesn't adhere to it. Interview with the DON on 09/27/24 at 09:30 AM. The surveyor asked the DON how the residents' complaints about noise at night is being addressed. The DON stated, once a week there is a huddle with the nursing staff. They are reminded to keep it quiet at night. The issue with the air conditioner is not a problem on the dayshift, but there is a staff person in the evening that is not following the rules about the A/C. We keep reminding the staff person, who is not following what the sign says is on the eve shift to turn the A/C off in the evening.

Based on observation, interview and review of policy, the facility failed to ensure housekeeping services were being provided to the residents in a manner that was safe. Housekeeping staff were cleaning the dining tables with chemicals that were toxic to the skin and eyes while residents were seated at the table. The deficient practices places the residents at risk for illness. Findings include: Observations made in the dining room on 09/25/24 at 11:52 AM. Two House Keeping (HK) workers observed to spray the residents dining tables with a chemical cleaner then wipe with a cloth, while the Residents were sitting at the table. Observed residents at two tables with glasses of liquid and straws. The surveyor pointed to a caution label on the spray bottle that said Danger, keep out of reach of children and asked the HK Supervisor (HKS) if it's a safe chemical to be spraying on the table when the residents are sitting there. HKS said its safe, we spray it like this, and demonstrated holding the cloth over the table and squirt the spray under the cloth. The chemical was labeled quat sanitizing spray. The surveyor requested the Material Safety Data Sheet (MSDS) information on the sanitizing quat, with uses and restrictions during use and the housekeeping policy from the Infection Preventionist (IP) at 12:15 PM. Received and reviewed the Cleaning and Disinfection/ Non-Critical Care and Share Equipment 04/24.Environmental services staff should use their discretion when cleaning to prevent potential chemical harm to the residents. Received and reviewed the MSDS for OASIS 146 Multi-quat Sanitizer. .First Aid Measures. in case of eye contact Rinse with plenty of water. In case of skin contact Rinse with plenty of water. If swallowed Rinse mouth. Get medical attention if symptoms occur. if inhaled Get medical attention if symptoms occur. Section 11. Toxicological information. Causes eye and skin irritation. Observation and interview with the HKS on 09/27/24 at 07:40 AM. The surveyor asked the HKS to explain the use of the 146 quat. If it is diluted and what surface areas are they using it for. Stated that it is used in the dining room on the tables and chairs. Surveyor asked if it is safe, and how does he ensure the staff are using it properly, without exposing the residents to chemicals? The HKS said it can burn the skin, so we spray a small amount under the cloth then wipe the area. The surveyor asked HKS how is he monitoring his staff and ensuring they are safely applying the chemical? The surveyor explained that HK4 was observed to be openly spraying the table then wiping it with the towel where the residents were sitting with their drink glasses. HKS said, I tell them they need to do it this way, spray under the towel then wipe. The HKS said the long-term care ombudsman was here at the facility and told us not to be spraying the chemical while the residents are eating.

Based on observations, interviews, and record review, the facility failed to treat one of 13 sampled residents (Resident (R) 4) with respect and dignity while assisting with R4's meal. This deficient practice has the potential to negatively affect R4's environment in promoting and maintaining her quality of life. This deficient practice has the potential to affect the residents that need assistance with their meals. Findings Include: Observation was conducted on 09/24/24 at 11:42 AM in R4's room. Certified Nurse Aid (CNA) 7 was observed assisting R4 with her lunch. CNA7 was sitting on R4's bed while assisting her with feeding. CNA7 stated that sometimes the CNAs would sit on R4's bed when assisting her with her meals due to a shortage of stools. At the same time and in the same room, CNA15 was observed assisting an unsampled resident with feeding. CNA15 was standing up. CNA15 stated that she usually stands up when assisting residents with their meals because it is easier. Interview was conducted with the Director of Nursing (DON) on 09/26/24 at 09:26 AM at the nurse's station. DON confirmed that CNAs who are assisting a resident with feeding should sitting down at eye level with the resident. DON stated that standing up and sitting down on a resident's bed while assisting with feeding is not okay. A review of the facility policy titled, Resident Rights-Respect, Dignity/Right to Have Personal Property, dated 04/24, was conducted. The policy documented, The resident has a right to be treated with respect and dignity .

Based on record review and interview, the facility failed to revise one of the 13 sampled residents (Resident (R) 18) care plan after R18 had a fall with injury. This deficient practice has the potential to place R18 at risk for future falls and has the potential to affect all 34 residents in the facility. Findings Include: A review of R18's Electronic Health Record (EHR) was conducted. R18's EHR documented that R18 had a fall on 07/19/24. A Registered Nurse (RN) note documented, Resident was conscious and responsive. Skin tears on right arm measuring 3x2cm, left arm 4x1 cm, right leg 2x1cm and abrasion on left elbow 1.5x0.2 cm. Bump and redness on the side of his right face. R18 was then sent out to the emergency room via ambulance. A review of R18's care plan was conducted. R18's care plan did not contain any update or revision for R18's plan of care after the fall on 07/19/24. Interview was conducted with the Director of Nursing (DON) on 09/26/24 at 09:26 AM at the nurse's station. After reviewing R18's care plan, DON confirmed that R18's care plan should have been revised after his fall on 07/19/24.

Based on observations, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident's medications. This deficient practice has the potential to affect all 34 of the residents in the facility. Findings Include: Concurrent observation and interview were conducted on 09/26/24 at 07:10 AM in the dining room. The medication cart was seen left unattended and unlocked. Two staff members were seen walking pass the medication cart while accompanying a resident. Registered Nurse (RN) 4 was observed administering medications to R27, who was seated at the dining table. RN5 was facing the resident. When RN5 was queried about the unlocked medication cart, RN4 stated that she was nearby, but confirmed that the medication cart should have been locked since it was left unattended. Interview was conducted with the Director of Nursing (DON) on 09/26/24 at 09:30 AM at the nurse's station. DON confirmed that nurses should lock the medication cart when left unattended. A review of the facility policy titled, Medication Storage in the Facility, was conducted. The policy documented, Medications and biologicals are stored safely, securely, and properly .medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observations, interviews, and record review, the facility failed to provide care to residents in accordance with professional standards of practice. Resident (R)89 is allergic to iodine (disinfectant) and the facility did not identify and provide a substitute for iodine. The staff member used alcohol pads to cleanse the area before inserting a catheter. This deficient practice had the potential to cause burning of the skin or pain. Finding includes: R89 was admitted to the facility on [DATE] with admitting diagnoses of rectal pain/anal fissure (tear in the thin, moist tissue that lines the anus) and unspecified dementia, unspecified severity, with other behavioral disturbance. Record review found a progress note dated, 09/15/23 at 01:37 AM. R89 was documented as unable to sleep, claimed she is unable to sit a long time because of rectal pain but complained of pain 'inside' not the vagina but hypogastric area and agreed to be assessed. The vaginal and rectal area no redness, rash, or hemorrhoid. Bladder area noted to be slightly distended and resident complained of pain. R89 was agreeable to straight cath. Also noted, R89 is allergic to iodine, the nurse cleansed the peri area with alcohol pads. A review of the physician order noted may straight cath (small hollow, flexible tubes that are placed in the urethra to empty urine from the bladder) every 8 hours as needed for urinary retention. R89 was also identified with an allergy to iodine. There was no order of an alternative cleansing solution without iodine to cleanse the area. On 09/15/23 at 09:12 AM interviewed the DON. DON reviewed the progress note and confirmed R89 is allergic to iodine. Inquired what effect does cleansing the peri area with alcohol pads have for the resident. DON responded the alcohol might sting the skin. Further inquired what should be used to cleanse the area, DON responded she is not sure what to use, they may have to ask the pharmacy.

Based on record review (RR), interview with family and staff, the facility failed to ensure one of two residents sampled were free from accidents. Resident (R) 7 had two avoidable falls. The facility failed to perform a root cause analysis and based on identification of probably contributing factors, develop interventions to prevent falls. The facility also implemented interventions that were not included in the resident's care plan. Findings include: Cross Reference to F657. Care Plan Timing and Revision. On 09/12/23 at 10:47 AM while introducing self to R7, who was resting sitting upright in his bed, observed he had multiple bruises and swelling to his face. When asked how he got the bruises on his face he reported I fell . Resident raised his hands to touch his face and stated he had pain. When asked if he took pain medication he reported he does when they bring it to him, referring to the nurse. On 09/13/23 at 02:06 PM a telephone interview was conducted with R7's son-in-law and daughter who have Power of Attorney (POA)1 and 2, to inquire about R7's care at the facility. R7's POA2 reported resident had fallen two times this year and they had been notified by the facility each time. R7's POA2 stated they had requested the facility use bed alarms and bedrails to prevent R7 from falling from or out of bed. POA1 stated the facility explained to them it is more dangerous to have bedrails as it might harm the resident if the resident is confused. POA2 did not know if the facility is using a bed alarm as requested. R7 is an [AGE] year-old male, initially admitted to the facility on [DATE] with admitting diagnoses that include atherosclerotic heart disease, chronic gout, hypertension, obstructive sleep apnea and restlessness and agitation. R7 had vascular dementia added to his diagnosis list on 10/01/22. R7 had an admission re-entry to the facility on [DATE] after his 05/09/23 fall and hospitalization for surgery to repair the fracture to his right hip. Admission re-entry diagnoses included the following: stress fracture, hip ., chronic kidney disease, stage 3 ., difficulty in walking ., fracture of unspecified part of neck of unspecified femur ., unspecified atrial fibrillation, unspecified fall ., and muscle weakness (generalized). On 09/13/23 during RR found two unwitnessed falls documented in R7's electronic health record (EHR). First fall was on 05/09/23 at 05:30 PM, R7 was found sitting on the floor beside his bed by CNA. R7 complained of pain and was transferred to the hospital, via ambulance, at 09:26 PM where he was found to have fractured his right hip requiring surgery to repair the injury with a four day stay in the hospital. Second fall occurred on 08/25/23 around 01:15 AM when resident was found in his room lying on the floor (face down with his urnial under him). Resident complained of headache and neck pain at the time. R7 had a 7.0 cm x 7.0 cm hematoma (lump with bruising) to his forehead, nose bleed, and multiple skin tears to his left forearm, both knees and left foot. R7 was transferred to the the hospital via ambulance, no fracture or head injury was found. Resident returned to facility the same day at 03:05 PM. During RR it was noted R7 was on a blood thinner, Rivaroxaban tablet 15 mg one tablet by mouth one time a day for A-Fib which was started on 05/13/23 and had a hold ordered from 09/01/2023 - 09/06/2023. This puts R7 at greater risk of unwanted bleeding. On 09/13/23 during RR found R7 had been assessed for falls by the facility, using the Morse Fall Scale, dated from 03/09/21 to 08/25/23 all of which rated the resident as a high risk for falls. The Morse Fall Scale rates a person high risk for falls at 45 and higher. On initial admission, 03/09/21, R7 scored 65, on 05/15/23 he was rated at 55, on 08/18/23 he was rated at 90 and on 08/25/23 he was rated 80. Review of R7's care plan did not have any changes or new interventions documented to prevent falls after R7 returned to the facility on [DATE]. R7's care plan does not have use of bed alarm being used as resident's POA2 requested. R7's care plan also does not have documented use of a pin alarm, which the facility staff were observed using today. On 09/14/23 at 03:52 PM interviewed Director of Nursing (DON) regarding R7's care plan. When asked what has been done for resident to prevent falls after resident had his first fall on 05/09/23, DON stated she told staff to provide close monitoring for this resident. This intervention was not involved in the resident's care plan. Queried what does close monitoring mean, how often are staff to monitor resident. DON stated close monitoring is checking in more frequently with the resident. DON confirmed parameter for monitoring was not included in R7's care plan and there was no documentation of close monitoring. Inquired about POAs with R7's care plan and DON stated R7's POA1 requested side rails and she discouraged use of full bed rails because resident is mobile, able to get in and out of bed. DON stated R7 might get more injuries from a fall related to bed rail use. DON shared POA1 was able to provide non-skid slippers. DON shared they tried to use the pin alarm with R7, when he first returned from the hospital in May, but resident became agitated by the pin alarm when he moved and got out of bed, its too loud. Shared with DON that earlier today CNA5 showed surveyor that R7 is using the pin alarm, DON was not aware and confirmed R7's Care Plan does not include use of a pin alarm as an intervention to prevent falls. Also shared observed mat on the floor in R7's room on the right hand side of his bed where resident gets in and out of bed. After this interview DON and surveyor went to R7's room to observe resident. DON confirmed pin alarm was being used and floor mat was not as staff determined it to be a trip hazard for the resident. On 09/14/23 review of facility policy, Fall Prevention, dated 02/12, provided by SW, stated multiple contributing factors including General weakness which R7's 05/13/23 admission re-entry diagnosis documented, muscle weakness (generalized) but was not included on his revised care plan for Falls. This same policy lists Use pin alarm and or bed alarm as an intervention for fall prevention and these interventions were not documented in R7's care plan.

Based on complaint report and interview, the facility failed to ensure residents of the facility had the right to receive visitors. Findings include: On 11/28/22, the Office of Health Care Assurance (OHCA) received a complaint alleging the facility was not allowing visitors due to identification of COVID-19 cases. The complainant provided photos of signage in the window which read, Please No Visitors At this time. Thank you. There was also a stand with a posted sign, COVID-19 cases have been identified in the facility. No visitors are allowed at this time until further notice. On 09/14/23 at 01:00 PM an interview was conducted with the Infection Control Coordinator (ICC). ICC reported the facility had a COVID-19 outbreak at the end of last year. ICC was agreeable to check on when the facility had the outbreak. Inquired whether the facility did not allow visitors at this time. ICC reported during an outbreak, the facility would notify families and strongly discourage visitation. Further queried were signs posted during this time to restrict visitors. ICC responded she could not recall whether visitors were restricted from entering the facility. On 09/14/23 at 02:21 PM, the ICC reported the outbreak started on 11/10/22 and ended on 12/01/22. ICC was asked when did Centers for Medicare and Medicaid Services (CMS) discontinue the COVID-19 waiver to prohibit visitations. ICC responded it was in 2021. The waiver restricting visitors was not in effect during the identified time period (November 2022).

Based on record review (RR), interviews with family and staff, the facility failed to involve and notify resident's representative(s) of scheduled care plan meetings for Resident (R)6, R7 and R29. The facility also failed to revise care plans. Findings include: 1) On 09/13/23 at 09:38 AM an interview was conducted with R7's Power of Attorney (POA)1 and POA2, who requested that the facility use bed alarms and bedrails to help prevent R7 from falling from or out of bed. POA1 was asked if they ever attend R's care plan meetings and POA1 said no they do not participate in resident's care planning and have not been notified of scheduled care plan meetings. POA1 was asked if he was given a copy of R7's care plan and he stated the facility might have given them a packet when his father-in-law was first admitted . On 0913/23 at 10:30 AM, R29 was interviewed in her room and was found to be alert and oriented to person, place, time, and situation. R29 stated that she was never invited to and has not attended her care plan meeting. On 09/15/23 during RR of R6, R7 and R29 found Care Plan Meetings were being held at the facility and this was documented on the Care Plan Meeting attendance sheet. It was noted there was an interdisciplinary team who signed the Care Plan Meeting attendance sheets such as the social worker, administration office manager, dietary manager services, DON, registered dietician and staff from hospice services for those residents with hospice services ordered. During this review did not find the resisdent or any resident representatives signature(s) on the attendance sheets. During RR did not find any documentation in residents medical record explaining why R6, R7 and R29's POAs or resident representative was not attending and participating in the Care Plan meetings to make decisions about the resident's care. On 09/15/23 at 12:35 PM interview with Director of Nursing (DON) and Social Worker (SW) found the facility is not involving resident representative in care planning, they do not notify the resident representatives of the scheduled care planning meetings, but are involving alert residents. SW confirmed facility did not utilize the phone or ZOOM/TEAMs meetings to include input from the resident representatives for resident's care planning. SW stated families are called after the fact to notify them of changes to care plans. 2) Cross Reference to F689, Accidents. Based on record review (RR), interview with family and staff, the facility failed to implement and revise the comprehensive care plan for falls for Resident (R)7, who had two falls on 05/09/23 and 08/25/23 with injury including fracture to his right hip, bruising and swelling to forehead, bloody nose, and multiple skin tears to his extremities. As a result of this deficient practice R7 was placed at risk of an avoidable accident (falls) with injuries.

Based on interview with staff, the facility did not assure a system was in place to review the performance/competency of certified nurse aides (CNA) at least once every 12 months. This systemic deficient practice has the potential to affect the care residents receive to maintain and attain their highest practicable physical, mental, and psycho-social level. Findings include: On 09/14/23 at 02:15 PM interviewed the Administrator, Assistant Administrator, and Director of Nursing (DON) in their office. Inquired whether the facility does competency checks for certified nurse aides (CNA). For example, use of Hoyer lift or peri care. DON responded the Charge Nurse may perform observations of the CNAs. And if needed, on the spot correction is done. The Administrator reported the facility does not have documentation of CNA performance/competency evaluations.

Based on observations, interviews, and record reviews, the facility failed to provide safe storage for foods in the kitchen refrigerators and freezer and failed to develop a process to ensure that their low water temperature and chemical dishwasher was operated and monitored correctly. This deficient practice has the potential to cause harm to their residents, staff, and visitors who receive meals from the kitchen due to the possibility of contracting a food borne illness. Findings include: 1) On 09/12/23 at 08:10 AM, conducted an initial observation of the kitchen and concurrent interview with the Kitchen Manager (KM). Refrigerator #1 contained a tray with cut carrots located on the bottom shelf that was not labeled with the name of the food item and preparation date. KM confirmed that the items were carrots that were cut in the morning and will be cooked today. Refrigerator #2 contained a tray filled with meat located on the left side of the bottom shelf and a blue plastic bag containing meat on the bottom right of the shelf. KM confirmed that the meat was defrosting chicken and that both were supposed to be labeled with the name of the contents and the preparation date. On the lanai outside of the kitchen, Freezer #1 contained three gallon bags of a diced orange substance, that were not labeled with the item contents and prepared date. KM confirmed the three gallon bags were diced carrots. KM stated that they were received originally in a single large bag last week and then partitioned into smaller gallon bags for the ease of use. Record review of procedure, . Food Storage. It stated for both refrigerated and frozen foods, . All foods should be covered, labeled, and dated. 2) On 09/12/23 at 08:10 AM, conducted an initial observation of the kitchen and concurrent interview with the KM. A Daily Temperature Log for the month of September 2023 was posted on Refrigerator #1. The dishwasher Rinse box documentation for breakfast, lunch, and dinner was blank. KM stated that their dishwasher system was changed from hot water sanitation to low water temperature and chemical sanitation last year. KM further stated that no assistance or training by the company that installed their new dishwasher system was provided to her and the kitchen staff. On 09/15/23 at 09:34 AM, interviewed the Registered Dietitian (RD) at the nursing station. RD stated that she started at the facility a few months ago and is the Certified Dietary Manager (CDM). RD confirmed that the process for utilizing the dishwashing system was broken and that she will work with the KM to develop a process where the dishwashing system will be used and monitored correctly. Record review of the procedure, . Dish Machine Temperature Log. The procedure did not state what chemical and testing strips to be used, and the acceptable parameters for the chemical rinse. It also did not state the documentation process for the chemical rinse. It did state, .5. The dietary manager will spot check this log to assure compliance.

Based on observations, record review, and interviews the facility's nursing administration did not assure the facility was administered in a manner that enabled it to develop and maintain systems for residents of the facility to attain or maintain their highest practicable, physical, mental, and psychosocial well-being. The facility failed to: support residents' right to organize and participate in a resident group; support a residents' right to voice grievances; support residents' right to have visitors; create a system for checking the sanitizing of dishes and cookware; and ensure nurse aide competencies/evaluations are being done. Findings include: 1) On 09/12/23 at 07:58 AM an entrance interview was conducted with the Assistant Administrator. Inquired who is the resident council president? The Assistant Administrator replied the facility does not have a resident council president. On 09/14/23 at 02:15 PM interviewed the Administrator and Director of Nursing (DON). The Administrator reported resident council meetings are not done formally as nobody wants to be the president. Administrator further reported in the past the staff would get together and ask residents if they have concerns. Requested documentation of these informal meetings. The Administrator reported, they do not document meetings. The Administrator stated they assumed that there needed to be a president. 2) On 09/14/23 at 02:15 PM interviewed the Administrator and DON. Requested a copy of the facility's grievance policy and procedure. The Office Manager provided a copy of the policy and procedure. Requested to review the facility's grievance log. The Administrator responded the facility does not have a grievance log. Further queried how does a resident file a grievance. The Administrator responded, if a resident has a grievance, they will let the certified aide know. The Administrator deferred to the Social Worker (SW). Review of the policy and procedure notes, the administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. Also noted, grievances and/or complaints may be submitted orally or in writing. Interview with the Social Worker (SW) on 09/14/23 at 02:18 PM, she reported there has been no grievance for the last 1-1/2 years (since her employement). SW also reported to file a grievance, the resident needs to fill out a form. This is not congruent with the facility's policy and procedures. Although the Administrator deferred to the SW, the SW reported the facility does not have a grievance officer. 3) The State Agency (SA) received a complaint that the facility restricted visitors during a COVID-19 outbreak. The Infection Control Coordinator (ICC) was unable to recall whether the facility restricted visitor during a COVID-19 outbreak in November 2022. 4) The facility received a new dishwasher. Observations and interview with staff found, the kitchen staff were not aware of how to test the sanitizing solution and document the results of the solution. On 09/15/23 at 01:13 PM, discussed with the Administrator the observation of the kitchen. The Administrator reported the kitchen staff received education when the dishwasher was purchased. Queried whether she ensures a system is in place for checking the sanitizing solution. Administrator responded she doesn't double check and it is the supervisor's responsibility. Further queried, who sets up a system? The Administrator responded the supervisors and the Assistant Administrator ensures everything is in working order. 5) Interview with Administrator, Assistant Administrator, and DON was done on 09/14/23 at 02:15 PM. Inquired how does the facility do competency checks for their certified nurse aides (CNA). The DON responded the Charge Nurse performs observations of CNA performance and if needed, will provide correction. The Administrator reported the facility does not have documentation of the Charge Nurse's observations/corrections of CNA performance/competency evaluations.

Based on interview with the Administrator, the facility did not assure the governing body oversees the Administrator's management and operations of the facility. Findings include: On 09/15/23 at 01:13 PM an interview was conducted with the Administrator. Inquired who are the members of the governing body, the Administrator replied, it is mainly comprised of family members. The President is her son, the [NAME] President is her mother, the Treasurer is her husband and she is the Secretary. Also, her two daughters are the stake holders. Inquired how does the governing body oversee the Administrator's management of the facility. Further inquired how does she report to the governing body and the governing body hold her accountable for the operations of the facility. The Administrator responded this is a family owned facility and very small, what are they supposed to do.

Based on record review and interview, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility does not have a system to collect and use data to identify areas of improvement. Therefore, there is no evidence of performance improvement projects with monitoring of the efficacy of the project. This deficient practice has the potential to affect the quality of life and quality of care of all residents to maintain or attain their highest practicable physical, mental, and psycho-social well-being. Findings include: On 09/15/23 at 12:50 PM an interview was conducted with the Administrator. Inquired how does the facility identify issues which require quality improvement. The Administrator responded each department completes a questionnaire for their specific area and will bring the completed questionnaire to the QAPI meeting. Based on the issues brought forth, the committee will come up with a resolution. The Administrator provided an example, the facility was concerned with the use of psychotropic medication and the Director of Nursing (DON) did a chart review and determined if the use and dosage was appropriate. Further queried whether the facility tracks adverse events. The Administrator responded the nurse responds to adverse events to ensure it will not occur again. The Administrator reported the facility does not have a formal program for tracking and addressing adverse events. Further queried when issues come up, does the QAPI team perform root cause analysis. Administrator replied, it is not done formally and she relies on the DON to do the analysis. The Administrator was asked whether their electronic health record software will provide data/reports to aide in identifying quality issues/trends. Administrator stated they are still learning how to pull up reports and as the Administrator she focuses primarily on the business part, financial.