Every finding on record at Hi'olani Care Center at Kahala Nui

Based on observations and interviews the facility failed to dispose of food items that have passed the use by date, failed to assure food items were stored in accordance with professional standards, failed to test temperatures of all food on the trayline and stored clean pots and pans on a rack that had rusty colored debris. This deficient practice puts all the residents and staff at risk for foodborne illnessess. Findings Include: 1) On [DATE] at 08:30 AM an initial tour of kitchen was done with dietician and Head Chef (HC). The following food items were found in the kitchen: expired chicken base found with a use by date of [DATE], pork with a prep date of ,d+[DATE] but no use by date, three containers of cooked pork in metal containers with use by date of [DATE]. The following items were found in the dry storage area opened with no open on and discard by date label: Almond Flour manufactures best by date of [DATE] with ,d+[DATE] written on front of package. Gelatine leaf gelatine open in box with the lid open, not sealed closed. Soup stock powder packet which was left open. Bottle of marsalla White truffle oil Curry block box was open and half of curry block was left in the open box and with an open wrapper. During the initial tour of the kitchen, interviewed HC and inquired if kitchen staff took temperatures of cooked food and HC stated the staff check the temperatures but do not log them. Facility was unable to provide any temperature logs of food cooked in their kitchen. One item (Dijon mustard) in the walk in refrigerator was found with a smudged unreadable opened label, unable to determine what the discard by date was. 2) On [DATE] at 11:20 AM, followed Dietary Aide (DA) 1 and Dietary Supervisor (DS) to deliver food to the trayline on the 5th floor. Food temperature checks were done for the following food items: broccoli, lasagna, soup and white rice. There were multiple containers of hot food on the trayline that were not tested at this time before the food was dispensed to the residents. Inquired how temperatures are taken and DS stated for 3 seconds. When surveyor did not say anything DS stated 10 seconds or when the temperature stops changing. 3) On [DATE] at 09:50 AM, revisited the kitchen and walked through with the Director of Dining Services (DDS) and facility dietician. During the walk through found a metal rack that had rusty colored debris which the clean pots and pans were stored on. Inquired of the DDS about the metal rack and he acknowledged the rack had rusty colored debris and stated he had this on order through his vendor. At this time requested copies of facility policies regarding labeling and food storage, temperatures of food cooked in the kitchen and trayline temperatures. On [DATE] dietician provided copies of facility policies requested. Review of facility policy titled Labeling Food Items, with an effective date [DATE], stated Procedure (Guidelines) 1. At the time foods are removed from hot or cold holding and placed in a container, Date with preparation date and the date is to be used or discarded. 2. At the time foods are removed from their original container and placed in another container, Date with preparation date and the date that it is to be used or discarded. 4. Items not included in the .labeling machine must be labeled by hand using appropriate labeling stickers as followed: i. Prepared foods must be labeled with the name of the item, date it was prepared and include a use by date set for 3 days. ii. Shelf stable items must be labeled with the name of the item, date it was opened and include a use by date set for 30 days. v. Raw meats must be labeled with the name of the item, date it was received, and include a use by date set for 5 days. Review of facility policy titled Kitchen Cooking and holding of hot food with an effective date of [DATE] stated IV. Procedure (Guidelines) B. The .[State] .defines properly cooked foods to reach and maintain the designated internal temperatures (beef minimum of ,d+[DATE] degrees Fahrenheit for rare, pork 155 degrees Fahrenheit, poultry 165 degrees Fahrenheit and fish 145 degrees Fahrenheit) for a minimum of 15 seconds measured with an instant read probe thermometer. C. Final cooking temperatures should be notated on log sheet notating the type of product, time the temperature was taken and the final cooking temperature. E. When the food is taken out of the holding cabinet and placed in the hot well. [sic] The temperature and time should then be noted on the designated log sheet. Review of facility policy titled Hot and Cold Foods (Trayline) with an effective date of [DATE] stated IV. Procedure (Guidelines) 1. The kitchen shall take the temperature of ALL foods using assigned thermometers. 2. The satellite kitchen staff are required to check the internal temperature of ALL hot foods to ensure they are greater than 135 degrees Fahrenheit for 15 seconds in the thickest part of the food. a. Foods between 41 degrees Fahrenheit - 135 degrees Fahrenheit for less than 2 hours must be reheated to 165 degrees Fahrenheit before being served. b. Foods between 41 degrees Fahrenheit - 135 degrees Fahrenheit for greater than 2 hours must be discarded immediately.

Based on interviews and record review, the facility failed to provide written notification to resident or resident's representative and the Long-Term Care Ombudsman (LTCO) forone of one sampled residents for hospitalization s, (Resident (R) 13). This deficient practice has the potential to affect all residents that are transferred to an acute care hospital. Findings Include: R13 is a [AGE] year-old female who was transferred and admitted to the hospital on 3/16/24. A review of R13's Electronic Health Record (EHR) was conducted, and it did not contain any documentation that R13's family representative and the LTCO was provided with a written notification of R13's transfer to an acute care hospital. Interview was conducted on 06/26/24 at 01:44 PM with Social Worker (SW) 1. SW1 stated that during a transfer to the hospital, the nursing staff calls the resident's family and informs the representative that the resident is being transferred to the hospital. SW1 added that a written notification of the resident's transfer to the hospital is not provided to the resident's representative and the LTCO. Interview was conducted on 06/26/24 at 02:09 PM with the Director of Nursing (DON). DON stated that during a resident's transfer to the hospital, a phone call is made to the resident's family by the nursing staff. DON confirmed that a written notification is not provided to the resident's representative and the LTCO during a resident's transfer to the hospital. A review of the facility records titled, Discharge/Transfer of the Resident, dated April 22, 2024, was conducted. The record documented, Explain transfer and reason to the Resident and/or representative and give copy of signed transfer or discharge notice to the Resident and/or representative or person(s) responsible for care. (NOTE: If an emergency transfer occurs, the Transfer or Discharge Notice form may be completed later, but as soon as possible).

Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for one of 16 sampled residents (Resident (R) 168). This deficient practice has the potential to negatively affect the resident's physical and overall well-being. Findings Include: R168 is a [AGE] year-old female admitted to the facility on [DATE]. R168 has a medical history including, but not limited to dementia, kidney disease, and poor food intake by mouth. A review of R168's Electronic Health Record (EHR) was conducted on 6/24/24. R168's EHR contained information on her measured weights. On 05/22/24, R168's weight was 89.8 pounds (lbs). On 05/28/24, R168's weight was 89.8 lbs. On 06/04/24, R168's weight was measured 0 lbs. On 06/11/24, R168's weight was 80.0 lbs. No other weights were documented since 06/10/24. A review of R168's care plan was conducted. R168's care plan noted, Monitor weekly weights x 4 weeks (from admission) then monthly thereafter if weight is stable. Start: 05/29/24. Interview was conducted with the Director of Nursing (DON) on 06/27/24 at 10:39 AM. DON was shown R168's documented weights on the EHR. DON confirmed that the facility did not weight R168 weekly for 4 weeks, which should have been done, based on R168's care plan.

Based on observation, interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standard of practice for one of 16 residents sampled (Resident (R) 15). The facility did not follow the physician ordered bowel instruction. This failure could place the resident at risk of adverse consequences from diarrhea. Findings include: R15 was admitted to the facility on [DATE] with diagnoses, not limited to, weakness, presence of foley catheter for urinary retention, severe protein-calorie malnutrition, pressure ulcer of sacral region, history of sepsis, history of urinary tract infection, impaired mobility, self-care disability, and constipation. On 06/24/24 at 10:06 AM, an observation and interview with R15 was done. R15 reported he has constipation all the time and receives a suppository twice a day. R15 further reported he needs assistance when he has loose stools and makes a mess. After the interview, R15 was observed going to the restroom to have a bowel movement, inquired if he needs assistance going to the bathroom, R15 stated no and can go on his own. Review of R15's routine physician ordered bowel regimen included MiraLAX twice a day for constipation, hold for loose stool, Senna Plus twice a day for constipation, hold for loose stool, and bisacodyl rectal suppository at bedtime for constipation, hold for loose stool. R15's physician ordered bowel regimen included as needed (PRN) medications with instructions if continued constipation or by resident's request. Review of R15's daily documented bowel movement for June found R15 with bowel movements more than once, daily. R15 had documented loose stools on 06/15/24 at 05:56 AM and 10:13 AM and on 06/16/24 at 09:45 AM. Review of R15's June Medication Administration Record (MAR) documented on 06/15/24 and 06/16/24, R15 was administered MiraLAX at 08:00 AM and 05:00 PM, Senna Plus at 08:00 AM and 08:00 PM, and the Bisacodyl rectal suppository at 08:00 PM. R15's medications for constipation were not held as ordered after having loose stools on 06/15/24 and 06/16/24. On 06/16/24 at 11:55 AM, R15 was administered a PRN by resident request Bisacodyl rectal suppository although R15 had a loose stool two hours prior to request. On 06/26/24 at 11:28 AM, interview with License Practical Nurse (LPN) 4 was done. Inquired how nursing staff review residents' bowel movement status prior to administering bowel regimen related medication such as stool softeners, LPN4 was able to pull up a report from the Electronic Health Record (EHR) that showed numbers indicating what type of bowel movement was made. LPN further reported, nursing staff would look at the report by the end of every shift and inform the next shift nurse if a resident had a loose stool to ensure they do not give a resident a suppository. Inquired what 5 indicated and LPN4 reported extra-large bowel movement. Requested for LPN4 to check again what 5 indicated and reported loose stool. On 06/26/24 at 11:32 AM, interview with Certified Nurse's Aide (CNA) 19, CNA 22, and Registered Nurse (RN) 5 was done. CAN 19 and CNA22 reported they do not put numbers on the record when documenting bowel movements, as shown on the EHR but describe the kind of bowel movement, by size or type, such as small, medium, large, extra-large, or loose stool. RN5 confirmed 5 indicated loose stool in the EHR. ON 06/26/24 at 02:23 PM, interview with RN5 was done. RN5 confirmed R15 had loose stools on 06/15/24 and 06/16/24 and confirmed bowel regimen medication was administered. Inquired if the medication administrating nurse should have held the medication as indicated in the physician order those days, RN5 reported she would hold the medications if the resident had loose stools the shift before. RN5 further reported R15 is very particular and adamant about having a bowel movement, however, there could be complications if he had continuous loose stools and we (the nurses) must follow the physician's order. Inquired if the resident was adamant in taking medication used for constipation although he had a loose stool, should the nurse call the physician regarding his insistence in taking the medication and document in the resident's chart, RN5 stated she will check. At 02:59 PM, RN5 was not able to provide documentation that the physician approved the administration of the medications despite the order. On 06/27/24 at 12:42 PM, interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) was done. DON reported the nurses should not go against the physician's order and to call the physician to get clarification. ADON reported if a resident had loose stools, he would hold medications as ordered by the physician and if the resident was insistent in taking the medication would get clarification from the physician.

Based on interviews and records review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled for two of two medication carts sampled. This deficient practice increases the risk of diversion of residents' medications. Findings Include: A review of the facility's records titled, Controlled Drug Count Record 4th Floor Cart A, dated June 2024 was conducted on 06/25/24. The record lacked documentation of licensed nurse signatures for two shifts on 06/24/24 and one shift on 06/25/24. A review of the facility records titled, Controlled Drug Count Record 4th Floor Cart B, dated June 2024 was conducted on 06/25/24. The record lacked documentation of licensed nurse signatures for one shift on 06/15/24, and one shift on 06/16/24. Interview was conducted with the Director of Nursing (DON) on 06/25/24 at 10:20 AM. DON explained the process for controlled medications count, an outgoing nurse and an incoming nurse for the shift will count the controlled medications together. After verifying the accuracy of the count, both nurses sign their names on the facility's controlled drug count record. DON was shown the count records for the fourth-floor carts A and B. DON confirmed that there were missing signatures on the record, which she agreed should have all been filled out. A review of the facility's record titled, Narcotic Count and key, dated May 1, 2006, was conducted. The record documented, The signature of the Licensed Nurses on the Shift Count of Narcotic Sheet confirms the accuracy and legal accountability for the drugs at the time of the count .A signature on a Narcotic Count Sheet means that you accept responsibility for the presence/absence of that dose/drug and are accepting, legal responsibility for the missing dose/drug.

Based on record review and interview with staff member, the facility failed to ensure the attending physician reviewed an identified irregularity from the pharmacist's monthly medication review (MRR) for one of five residents sampled (Resident (R) 8). This failure had the potential for medication error and adverse consequences; the potential for R8 administered an as needed (PRN) medication without a frequency indicated in the physician's order. Findings include: Review of R8's MRR for the month of March, dated 03/16/24 documented Please add a frequency of administration to the prn Tylenol 325m [milligrams] tablet order. Follow-Through in the MRR was left blank. Review of R8's physician's order for Tylenol 325 mg tablet, GIVE 650 mg (2 TABS) by Mouth As Needed (NTE [not too exceed] 3 GMS [grams] APAP [acetaminophen]/DAY) For .BACK PAIN starting 09/22/23. The frequency was not included in the order. On 06/26/24 at 02:31 PM, an interview with Registered Nurse (RN) 5 was done. Concurrent record review of the MRR for March and physician's order, RN5 confirmed the MRR was not addressed, and the Tylenol order should include every four hours. Review of the facility's policy and procedure Monthly Drug Regimen Review with no effective date documented The Medical Director or the Associate Medical Director will review the report, make comments, and discuss any recommendations with the attending physicians, Director or Assistant Director of Nursing or the QAPI/CQI Committee on an as needed basis.

Based on interviews and record review, the facility failed to maintain complete medical records for two of 16 sampled residents (Resident (R) 168 and R4). This deficient practice has the potential to affect all the residents in the facility. Findings Include: A review of R168's Electronic Health Record (EHR) was conducted on 06/24/24. During the review, R168's EHR only had weights documented on 05/22/24 at 89.8 pounds (lbs.), 05/28/24 at 89.8 lbs., 06/04/24 at 0 lbs., and 06/11/24 at 80.0 lbs. A telephone interview was conducted on 06/26/24 at 11:10 AM with Director of Nursing (DON), regarding R168's documented significant weight loss. DON stated that with a significant weight loss, the assigned nurse would let the facility dietician know as soon as possible. DON agreed that based on the weight documented, R168's weight loss was significant, and the nurse should have notified the dietician. An second interview was conducted with DON on 06/26/24 at 01:00 PM. DON showed State Agency (SA) a piece of paper dated 06/12/24. The paper contained a handwritten note with R168's name and a reweigh of 86.9 lbs. DON was not able to tell SA which staff had written the note. DON stated that the staff had forgotten to document the weight in R168's EHR. DON also provided a printed EHR documentation dated 06/12/24. On the documentation it noted that it was edited on 06/26/24 at 12:27 PM by Registered Nurse (RN) 10. RN10 was not scheduled to work on 06/26/24. DON explained that RN10 came in to work to edit her 06/12/24 charting in the EHR. A follow up review of R168's EHR was conducted on 06/26/24 at 01:10 PM. The EHR now contained a documented weight of 86.9 lbs., dated 06/12/24. It also contained an edited note written by RN10, dated 06/12/24. The edited note contained additional documentation, Reweighed resident today=86.9 lbs. A follow up interview with DON was conducted on 06/27/24 at 10:39 AM. DON stated that resident weights and notes should be documented in the EHR prior to the end of shift. DON also confirmed that it should have been documented as a late entry. 37954 2) On 06/25/24 at 10:37 AM, record review of R4's hospice chart found there were missing documentation of recent progress notes, recertification and the last Medical Doctor (MD) visit summary. During this record review found the last progress note for R4 was dated 4/12/24. Also found the hospice nurse last signed the sign in sheet to visit the resident on 06/13/24. At this time inquired of the Nurse Educator/Infection Preventionist (NE/IP) if she knew where the documents were and she stated she did not know but would find out. On 06/26/24 at 11:04 AM, another record review was done of R4's hospice chart and found the updated progress notes faxed to facility on 6/25/24 in the afternoon. During this record review, found resident had a 60 day re-certification of terminal illness dated for 6/12/24 -8/10/24 for R4 who is a [AGE] year old female with hypertensive chronic kidney disease with multiple comorbidities. This recertification form was faxed to the facility on [DATE] at 14:27 (02:27 PM). MD recert visit summary was dated 5/13/24 at 12:14 PM and faxed to facility on 6/25/24 at 15:14 (03:14 PM). One hospice nursing progress note was faxed on 6/25/24 at 15:14 (03:14 PM) and was dated for 05/30/24 at 10:27 AM by the hospice nurse. Two more hospice nursing progress notes were faxed on 6/25/24 at 15:43 (03:43 PM). The notes were dated on 6/6/24 at 6:09 PM and 6/13/24 at 05:34 PM and both signed by the hospice nurse. On 06/27/24 at 09:49 AM, interviewed Assistant Director of Nursing (ADON) and Director of Nursing (DON) regarding R4's missing hospice documents. Inquired how facility communicates with hospice and what is the expectation of hospice to provide progress notes. DON stated hospice nurses communicate with the assigned nurse after they meet with the residents and hospice staff fax or bring the progress notes in person. Restated progress notes, hospice recertification form and MD summary were added to R4's hospice chart on 06/26/24 after surveyor had requested items. At this time, requested and received facility policy titled Coordination of Care - Hospice Services. Review of facility policy titled Coordination of Care - Hospice Services with effective date of 03/30/16. Review of the policy found the following: The designated .[facility] .interdisciplinary team member are responsible for: 7. Ensuring that the documentation in the Resident's medical records is complete, up to date and filed in the appropriate place in the Resident's binder.

Based on observation, interview and record review the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for one of four residents sampled for infection control (Resident (R) 118). R118's humidifier bottle was not properly secured to the oxygen concentrator. This failure could place the resident at risk for infection. Findings include: R118 was admitted to the facility on [DATE] with Hospice and diagnoses, not limited to, bronchiectasis (a chronic lunch condition where the wall of your airways widen and are thickened from inflammation and infection) and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lunch disease that causes obstructed airflow from the lungs.) Review of R118's Electronic Health Record (EHR) found R118 uses an oxygen contractor at 1.5 - 2 liters per minute for COPD and bronchiectasis. On 06/24/24 at 09:33 AM, during an observation of R118's room, observed R118 on oxygen, oxygen contractor running, and the humidifier bottle hanging from the concentrator touching the ground. The metal clamps that secure the humidifier bottle to the contractor was not found. R118 reported she did not notice it on the ground and received a new humidifier bottle about a week ago and stated it must not fit on the concentrator. R118 was not able to recall how long the humidifier has been on the ground. On 06/25/24 at 08:50 AM observed R118's humidifier bottle taped to the oxygen concentrator. On 06/27/24 at 11:38 AM interview with Nurse Educator/Infection Preventionist (NE/IP) was done. Showed NE/IP a picture of the oxygen concentrator in R118's room as observed on 06/24/24 at 09:33 AM and inquired if there was something wrong with what was pictured, NE/IP reported the water humidifier should not be on the ground. NE/IP reported this could be a source of contamination for infection control.

Based on observations, interviews, and record reviews, the facility failed to ensure food items were stored under sanitary conditions and the sanitizing solution was at the appropriate concentration for the three compartments sink. Findings include: On 08/08/23 at 08:05 AM an initial tour of the kitchen was done with Registered Dietitian (RD). In the walk-in refrigerator observed food items were stored without a cover: tray of cooked salmon, one pie atop clear wrap of a metal container, and metal container of cooked pearl onions (labeled as prepared on 08/07/23). Observation in another walk-in refrigerator found a rack storing several metal pans with a total of 12 blueberry pies and a rack with four trays of cooked beef with a label documented preparation date of 08/07/23 (there were three refrigeration fans above the rack) that were not covered. RD reported the items that were not covered was placed in the refrigerator to cool down after cooking. Noted cooked onion and beef were labeled with a preparation date of 08/07/23 and there were no labels of when the other food items were prepared/cooked. In the dry storage, observed a plastic container of champagne vinegar labeled with an open date of 06/14/23 and discard date of 06/30/23. The RD reported the staff that labeled the vinegar was probably following rule to discard food after 14 days. However, RD stated vinegar has a longer shelf life than 14 days. Observed a large plastic container of powder for thickening liquids. Although the handle of the scooper was not in the powder, the RD confirmed the scooper should not be in the container. A request was made to check the sanitizing solution at the three-compartment sink located at the back of the kitchen. Observed there were no test strips available at the sink or a log to document the findings of testing. Inquired what kind of solution is (i.e., chlorine, quaternary based) was used to sanitize the dishes. The RD checked the plastic container under the sink. A Kitchen Staff (KS)5 member provided a container of test strips. KS5 reported the strips are stored in the office. KS5 dipped the test strip in the sanitizing solution. Then compared the color of the strip with the manufacturer's color guide to determine whether the solution was at the correct parts per million (ppm). KS5 held the strip to the container and stated it was between colors. Further queried what are the acceptable ppm for this solution. The staff member looked at the manufacturer's container and stated 272 to 700 ppm. Further queried based on the color of the strip that was dipped into the sanitizing solution, is the solution within acceptable parameters. Staff member was unable to confirm. Requested a copy of logs with test results for the three-compartment sink. On 08/09/23 at 11:01 AM a follow-up visit to the kitchen was done. Interview with Sous Chef confirmed there is no log to document the test results of the sanitizing solution of the three-compartment sink. The Sous Chef checked the level of the sanitizing solution and stated the concentration was too strong. A review of the facility's policy and procedures, titled Labeling Food Items noted guideline, At the time foods are removed from hot or cold holding and placed in a container, DATE WITH PREPARATION DATE AND THE DATE THAT IS TO BE USED OR DISCARDED. A review of the facility's policy and procedures, titled Sanitation Workstation (three- compartment sink) to maintain proper levels and ratios of sanitation solution to ensure all non-porous food contact surfaces and utensils are properly disinfected and safe from chemical contamination was done. The procedures included: designated test strips are to be used to check the sanitation solution's concentration i.e. ppm color guide on test strip bottle matches what is shown on test strip (sanitation solutions must be corrected by adding more water or sanitation solution if concentration is above or below the acceptable ppm range; sanitation solution in 3 compartment sink must be discarded and replaced every 4 hours; and three-compartment sink log must be completed and signed daily to document the sanitary solution is at the correct concentration and used for duration of less than/greater than 4 hours. Attachment included a form for documentation of testing the 3 compartments sink with the parameters indicated at 272 to 700 ppm.

Based on observation and interview with staff members the facility failed to ensure R263's personal medical information was secured for confidentiality. Findings include: On 08/08/23 at 09:01 AM observed Registered Nurse (RN)5 enter R263's room and stated she was going to give R263 his insulin. Outside of R5's room, in the hallway shared by staff, residents, and visitors, the insulin cap that included R263's name and medication he was taking was left on the Personal Protective Equipment (PPE) cart unattended and easily assessable for anyone to pick up and read the information. On 08/10/23 at 09:16 AM interview with Director of Nursing (DON) was done. Inquired if it was standard of practice and acceptable to leave an empty medication bottle with resident's information on it out in the open unattended, DON stated no. Review of the facility's policy and procedure number DR-140 effective 06/15/12 Protected Health Information & HIPA documented This policy and procedure outlines the responsibility of Associates and other .[facility] .stakeholders to protect and safeguard individuals protected health information (PHI) that is maintained or transmitted in any form or medium. The policy and procedure defined PHI .as identifiable health information, whether oral or record in any form or medium, including electronic, that related to the individual's past, present, or future physical or mental health or condition . Under the facility's responsibility the policy and procedure documented We are required by law to maintain the privacy and security of your protected health information.

Based on observations and interiew with staff members,the facility failed to provide a homelike environment for two residents in the sample. Findings include: 1) On 08/08/23 at 09:10 AM, observation in Resident (R)4's room found areas of scraped off paint on the wall behind the resident's headboard. On 08/09/23 interview and concurrent observation was done with housekeeping staff. The staff confirmed the scraped paint on the wall and reported a work order was submitted approximately a week ago; however, staff was not sure if a work order was sent to maintenance. 2) On 08/08/23 at 08:45 AM observation in R263's room found two areas of scraped off paint behind the wall of R263's headboard. On 08/09/23 11:45 AM interview and concurrent observation was done with Registered Nurse (RN)5 in R263's room. RN5 confirmed the scraped paint on the wall and stated she does not know if it was reported, or a work order was submitted to maintenance. RN5 reported maintenance usually handles things within two to three hours for immediate work orders and within 24 hours for something non-immediate, such as scraped paint on the wall. On 08/09/23 at 04:15 PM a telephone interview was conducted with the Maintenance Supervisor (MS). Inquired whether he received work orders for room [ROOM NUMBER]B and 492A. MS responded he received a work order for room [ROOM NUMBER] for a clogged toilet and room [ROOM NUMBER] for the wall behind the bed board. MS clarified he received the work order for room [ROOM NUMBER] today (08/09/23) at 12:30 PM, when the housekeeping staff reported the scraped wall to him. MS confirmed he did not have a work order for the wall behind R4's headboard. MS reported anyone can generate a work order.

Based on record review and interview with staff member, the facility did not assure a resident's bowel protocol was implemented, which placed the resident at risk for constipation or bowel impaction related to use of an opioid (pain reliever with common side effect of constipation) for one of one resident in the sample. Findings include: Resident (R)1 was admitted to the facility on [DATE]. Diagnoses include but not limited to hypertensive heart disease with heart failure; encounter for palliative care; chronic diastolic (congestive) heart failure; and major depressive disorder. Record review noted physician orders for fentanyl patch (opioid) 24 mcg one patch transdermal every three days. Physician also ordered the following bowel protocol docusate sodium tab, 86 mg/50mg by mouth once daily for constipation (hold for loose stools); MiraLAX, give 17 gram/dose once daily for constipation; milk of magnesia (MOM), 30 ml by mouth daily as needed, x2 days no BM; and Dulcolax, 10 mg. rectally x3 days, no result from MOM (hold for loose stools). On 08/10/23 at 10:52 AM concurrent record review and interview was done with Charge Nurse (CN)5 at the nurses' station. CN5 confirmed resident receives fentanyl. Reviewed R1's bowel movement record and medication administration record (MAR). Review for the month of August 2023 found R1 did not have bowel movement for three days (08/01 to 08/03/23). CN5 reviewed the MAR and confirmed MOM and/or Dulcolax suppository was not offered or administered as ordered by the physician. CN5 confirmed if the medications were offered and refused, this information would be documented in the MAR. There was no documentation R1 refused medications. A review for the month of July 2023 noted R1 did not have bowel movement for three days (07/25 to 07/27/23) followed by large bowel movement on 07/28/23. Review of the MAR found MOM and/or suppository was not administered on day two or day three as prescribed. Also noted there was no documentation to note whether R1 had a bowel movement on the following shifts: day shift (07/09, 07/16, 07/17, 07/23, 07/29, and 07/30/23), evening shift (07/29/23), and NOC shift (07/01, 07/02, 07/15, an 07/19). CN5 confirmed the importance of documenting whether R1 had a bowel movement to ensure accuracy and the need to implement the physician prescribed bowel protocol.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with limited range of mobility received treatment to prevent decrease in range of motion/mobility for one of one Resident (R)4 in the sample for limited range of motion. Findings include: Resident (R)4 was admitted to the facility on [DATE] from an acute hospital. Admission diagnoses included acute stroke with left sided weakness, slurred speech, expressive aphasia, mild dysphagia, and multiple fracture to left rib. On 08/08/23 at 12:27 PM observed R4 lying in bed, her left arm was bent at the elbow and the left hand was fisted and turned toward the wrist. There was a rolled-up towel in her left hand and a large towel roll in the left crook of her arm (by the elbow). R4 reported that the Certified Nurse Aides (CNA) are afraid to do range of motion because they don't want to cause her pain. The therapist will perform the range of motion. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 05/24/23, R4 was coded with functional limitation in range of motion for the upper and lower extremities on one side. A review found a care plan for activities of daily living to follow therapy recommendations when available. Review of rehab note dated, 07/25/23 documented, alternative elbow splint when posey elbow splint not available/working, apply as tolerated at all times except for meals, bed bath, and removed as requested. Further noted intervention to provide range of motion prior to applying and after removing splints, check skin integrity (redness, swelling, skin breakdown, or pain) before application and after removal of splints. On 08/09/23 at 09:11 AM, interviewed CNA8. CNA8 reported she will perform range of motion when the splint is removed and prior to applying the splint. CNA8 reported the splint is removed during mealtimes. Inquired where do they document that range of motion was performed. CNA replied they do not document when they do range of motion. CNA further explained that physical therapy does range of motion two to three times a week. Further questioned what she does upon removal and application of splint. CNA8 stated she will massage the arm and try to stretch the arm out straight. CNA8 also stated R4 will sometimes request to remove the splint. On 08/09/23 at 11:15 AM, observed a posting next to the resident's bed for splint treatment plan, effective 07/25/23. Instructions include: Keep both splints on at all times except meals, shower, and as requested for temporary removal by resident: provide range of motion prior to applying and after removing splints; check skin integrity before application and after removal of splints (please notify licensed nurse of redness, swelling, skin breakdown, or pain); apply elbow splint first followed by resting hand splint; and straps, hand washing in warm water and mild soap, dry at room temperature, be sure the splint is completely dry before reapplying, if splint has a cover you can remove and wash cover separately. Date updated was 07/25/23. On 08/09/23 at 04:05 PM, interview and concurrent record review was conducted with the Assistant Director of Nursing (ADON) at the nurses' station. ADON confirmed there is no physician order for performing range of motion and there is no documentation in the electronic health record that range of motion is being performed after removal and before applying the splint.

Based on observation, interview and record review, the facility failed to provide one resident (R)5 of one resident in the sample, adequate supervision and assistance to prevent falls. R5 was not receiving adequate hydration (cross reference (cr) to F692 Nutrition and hydration) and timely assistance to use the bathroom (cr to F690 bladder and bowel incontinence). The deficient practice places the resident at risk for injury. Findings include: Observed R5 on 08/08/23 at 09:57 AM lying in bed with her eyes closed. Noted bed in low position, fall mat on the floor on her right side. When asked if R5 is alert and oriented or whether she gets out of bed, the Housekeeper (H)1 said she usually doesn't say anything or talk much. Sometimes she gets up to go to activities. During a telephone conversation with R5's family member (FM)1 on 08/08/23 at 2:05 PM. FM1 stated, I don't think she (R5) uses the bedside commode, and I don't think the staff are getting her up to go to the bathroom as often as they should be. She fell last week because she got up in the middle of the night to go to the bathroom. She's okay, the staff called me to tell me that she fell and has no injuries. They do take a long time to respond to my mom's call light when she needs help. Surveyor asked how many falls has she had in the last year? FM replied that R5 has fallen around four times. She didn't have any noticeable injuries, but she did have a lot of pain and soreness. Most of the time it's because she frequently needs to go to the bathroom. I've hired a private certified nurse aide (CNA) to come in during the evening because she is not drinking enough fluids, or getting out of bed. They come in before dinner and stay until she goes to sleep. The CNA comes in and assists her at dinner, and does her evening bath. Electronic medical record (EMR) reviewed on 08/08/23 at 3:35 PM. Care plan reviewed. Problem: Potential for falls. R5 has impaired balance and unsteady gait which put her at risk for fall and injuries. Other risk factors for fall include weakness and fatigue, Parkinson's disease, poor safety awareness, impaired cognition and communication due to Dementia, use antidepressant, etc. She has history of falls prior to nursing admission. Found resident sitting on floor with back supported by the bed without visible injuries on 8/29/22, added safety fall mat to right side of bed . On 9/8/22 at 0135, found resident was kneeling with right knee on safety fall mat and holding enabler with both hands, no visible injuries noted. On 10/16/22, found on floor (FOF) with skin tear to right lateral eyebrow. FOF on 11/13/22 at opened bathroom door without visible injuries. FOF on 2/11/23 with sitting position without visible injuries, found resident sitting on floor right side of bed without injuries noted on 4/21/23. On 7/30/23, found resident lying on the floor without visible injuries. Noted R5 had seven falls within the last year. Requested a list of falls and dates for R5 for past one year from the Director of Nursing (DON) on 08/09/23 at 03:13 PM. Asked if there were any incident reports for R5, the DON said there were two. Whenever there is a fall we round with the quality assurance performance improvement team to discuss the fall and do a root cause analysis. We also track and discuss any falls during our QAPI meeting every month. Falls management system policy dated November 12, 2019, reviewed on 08/10/23 at 12:55 PM. Purpose B. 7. The goal of this program is to prevent or to minimize fall risk that might result in serious injury .II. Policy A. It is the policy .to provide each facility Resident .appropriate interventions to minimize the possibility of falls occurring. IV. Procedure A. Resident Assessment: 3. A Falls Risk Assessment score of 10 or above represents a high risk for falls .VIII. Risk factors associated with falls. A. 9. Bladder or bowel incontinence. 21. Fluid imbalance. C. Care Giver Factors: 2. Toileting schedule not maintained. 6. Rounds not made as required.

Based on observation, interview and record review, the facility failed to provide one resident (R)5 of one resident in the sample, adequate supervision, and assistance to prevent falls. R5 was not receiving adequate hydration (cross reference (cr) to F692 Nutrition and hydration) and timely assistance to use the bathroom (cr to F690 bladder and bowel incontinence). The deficient practice places the resident at risk for injury. Findings include: Observed R5 on 08/08/23 at 09:57 AM lying in bed with her eyes closed. Noted bed in low position, fall mat on the floor on her right side. When asked if R5 is alert and oriented or whether she gets out of bed, the Housekeeper (H)1 said she usually doesn't say anything or talk much. Sometimes she gets up to go to activities. During a telephone conversation with R5's family member (FM)1 on 08/08/23 at 2:05 PM. FM1 stated, I don't think she (R5) uses the bedside commode, and I don't think the staff are getting her up to go to the bathroom as often as they should be. She fell last week because she got up in the middle of the night to go to the bathroom. She's okay, the staff called me to tell me that she fell and has no injuries. They do take a long time to respond to my mom's call light when she needs help. Surveyor asked how many falls has she had in the last year? FM replied that R5 has fallen around four times. She didn't have any noticeable injuries, but she did have a lot of pain and soreness. Most of the time it's because she frequently needs to go to the bathroom. I've hired a private certified nurse aide (CNA) to come in during the evening because she is not drinking enough fluids or getting out of bed. They come in before dinner and stay until she goes to sleep. The CNA comes in and assists her at dinner and does her evening bath. Electronic medical record (EMR) reviewed on 08/08/23 at 3:35 PM. Care plan reviewed. Problem: Potential for falls. R5 has impaired balance and unsteady gait which put her at risk for fall and injuries. Other risk factors for fall include weakness and fatigue, Parkinson's disease, poor safety awareness, impaired cognition, and communication due to Dementia, use antidepressant, etc. She has history of falls prior to nursing admission. Found resident sitting on floor with back supported by the bed without visible injuries on 8/29/22, added safety fall mat to right side of bed . On 9/8/22 at 0135, found resident was kneeling with right knee on safety fall mat and holding enabler with both hands, no visible injuries noted. On 10/16/22, found on floor (FOF) with skin tear to right lateral eyebrow. FOF on 11/13/22 at opened bathroom door without visible injuries. FOF on 2/11/23 with sitting position without visible injuries, found resident sitting on floor right side of bed without injuries noted on 4/21/23. On 7/30/23, found resident lying on the floor without visible injuries. Noted R5 had seven falls within the last year. Requested a list of falls and dates for R5 for past one year from the Director of Nursing (DON) on 08/09/23 at 03:13 PM. Asked if there were any incident reports for R5, the DON said there were two. Whenever there is a fall, we round with the quality assurance performance improvement team to discuss the fall and do a root cause analysis. We also track and discuss any falls during our QAPI meeting every month. Falls management system policy dated November 12, 2019, reviewed on 08/10/23 at 12:55 PM. Purpose B. 7. The goal of this program is to prevent or to minimize fall risk that might result in serious injury .II. Policy A. It is the policy .to provide each facility Resident .appropriate interventions to minimize the possibility of falls occurring. IV. Procedure A. Resident Assessment: 3. A Falls Risk Assessment score of 10 or above represents a high risk for falls .VIII. Risk factors associated with falls. A. 9. Bladder or bowel incontinence. 21. Fluid imbalance. C. Care Giver Factors: 2. Toileting schedule not maintained. 6. Rounds not made as required.

Based on observation, interview and record review, the facility failed to assist one Resident, (R)5 of one resident in the sample with enough fluids to maintain adequate hydration. The deficient practice placed the resident at a greater risk for dehydration, urinary tract infections and potentially increased the risk for injury (cross reference (cr) to F689 Free of Accident hazards/prevention/devices). Findings include: Observed R5 on 08/08/23 at 09:57 AM lying in bed with her eyes closed. When asked if R5 is alert and oriented or whether she gets out of bed, the Housekeeper (H) 1said, she usually doesn't say anything or talk much. Sometimes she gets up to go to activities. Noted the bedside table was out of reach close to the room divider. Did not note any cups or pitchers on the bedside table. Telephone conversation with R5's family member (FM)1 on 08/08/23 at 2:05 PM. Asked FM1 if her mom has had any urinary tract infections (UTI's)? She stated that she had received a call today from the staff there at the facility that reported that her mom's urinalysis result came back, and it was negative. She further explained that her mom has concentrated and smelly urine, so they tested her for a UTI. I think it is because she isn't drinking enough fluids throughout the day. I asked the staff if I can review her intake report to see how much she is drinking, but I didn't receive anything. She can drink fluids if she is offered some help. I don't think they have enough staff to make sure she gets enough fluids to drink or is getting up to go to the bathroom. to assist with meals and getting her extra fluids. She fell last week because she got up in the middle of the night to go to the bathroom. She's okay, they called me to tell me that she fell and didn't have any injuries (cr to F689). During an observation of R5 on 08/08/23 at 3:30 PM, noted R5 in her bed sleeping. Noted the overbed table was out of the reach and had a coffee cup with a lid. During an interview and record review with charge nurse (CN)10 on 08/09/23 at 09:49 AM Asked if R5 has a urinary tract infection (UTI), she looked in the EMR and replied that R5's urinalysis (UA) results were negative. We're pushing fluids with her, and the staff have reported that she is not having any more odorous urine. When asked if her fluid intake is being recorded, LN5 stated that her fluids are being measured at meals only and added that the fluids are also being given during the day, but they are not being measured. CN10 looked in the EMR to see how much she drinks and stated that she drinks about one to two cups of fluids per meal. CN10 said they are making rounds, but she usually sleeps. They don't want to wake her up to offer her fluids if she's sleeping, she may not be awake enough to swallow them. When asked when did she last have a UTI? he looked in the record and said it was last May of 2023. Reviewed electronic medical record (EMR). Care plan on 08/09/23 at 11:08 AM. Problem: R5 uses pads and briefs due to incontinent of bladder and bowel. She requires extensive assist with toileting. She has cognitive and communication deficits, functional impairment due to her multiple medical conditions. She is offered adequate fluids. Risks: UTI, skin breakdown, restlessness due to discomfort, etc. Staff continue to provide timely incontinent care as she does not call for assistance. She has urinary frequency, but no foul odor nor burning sense while voiding. UTI on 12/5/22 and 3/5/23. (Start date 08/09/23 Goal date: 11/07/23). Will be clean, dry, odor free and no signs and symptoms (s/sx) of UTI through next review date. Interventions: Monitor fluid intake daily and encourage fluid intake daily. Incorporate with nutrition care plan for hydration needs (cr F690). Reviewed facility policy & Procedures titled Hydration Program June 17, 2012. Policy: Residents will be provided fluids which meets daily requirements to avoid consequences of dehydration. Procedure: 2. Resident refusal of adequate fluid intake must be documented in the medical record. 3. Nutrition and hydration needs will be monitored. 4. Daily fluids will be provided at meals, refreshments, bedside water and when medications are administered.

Based on record review and interview with staff member, the facility failed to ensure one of five residents sampled were free from unnecessary psychotropic medication. Resident (R)265 was prescribed an as needed (PRN) antidepressant for agitation/insomnia without the diagnosed specific condition documented in the clinical record and the facility failed to appropriately monitor the effectiveness of the medication and the resident's sleep pattern. Findings include: R265 was admitted to the facility on [DATE] with diagnosis of Dementia associated with other underlying disease without behavioral disturbances. R265's diagnoses did not include insomnia. Review of R265's physician's orders included Trazadone 50 milligram (mg) tablet, give 12.5 mg PRN for 14 days for agitation and insomnia by mouth three times a day ordered on 07/28/23. Review of R265's care plan documented Takes as needed (prn) Trazadone for agitation and insomnia. No behavioral issues noted, however required use to help with sleep .Will be able to sleep at least 6 hours at night and remain free of drug related cognitive/behavioral impairment; hypotension .Administer and monitor effectiveness/side effect of medication .Monitor sleeping pattern and anxiety daily . On 08/09/23 at 03:54 PM concurrent record review and interview with Assistant Director of Nursing (ADON) was done. Inquired what is being monitored for R265 for the use of Trazadone, ADON stated agitation and insomnia. ADON reported the facility will monitor R265's ability to maintain and initiate sleep and the behavior log would be in the Treatment Administration Record (TAR). Concurrent review of R265's physician's order under behavioral monitoring, ADON confirmed R265's behavioral monitoring orders does not include monitoring for Insomnia, R265's sleep pattern and the effectiveness of the medication. Review of R265's Medication Administration Record (MAR) and TAR for July and August documented R265 was administered the antidepressant, Trazadone, on 07/28/23 at 07:08 PM and 07/29/23 at 08:00 PM. The TAR did not include any documentation of insomnia or agitation on those days. Review of R265's nursing notes on 07/28/23 and 07/29/23 do not document R265 having trouble sleeping and/or agitation on those days. Further review of R265's nursing notes leading up to the order of Trazadone does not include any non-redirectable indication of agitation or difficulty sleeping.

Based on observation, interview with staff and record review the facility failed to assure a resident was free of significant medication errors. Findings include: On 08/09/23 at approximately 11:32 AM Registered Nurse (RN)5 checked resident (R) 263's blood glucose level and reported it at 170. RN5 administered 5 units of insulin from R263's Novolog Flex pen per sliding scale. On 08/09/23 at 01:01 PM medication error was found during R263'S record review of medication reconciliation. Surveyor noted physician's medication order for insulin matched the resident's Medication Administration Record (MAR) which read: Novolog Flex pen U-100 Insulin apart 100 unit/ml (3 mL) subcutaneous [Insulin apart U-100] Type M-Medication - Administer SQ every before meals per sliding scale (may replace to Novolin R until Novolog supply available). Call MD if BG less than 70 or more than 400. No cover-BG less than 151. 3 units - BG 151-200. 5 units-BG 201-250. 7 units- BG 251-300. 9 units- BG 301-350. 11 units- BG 351-400. For DM II. R263 was given 5 units of insulin instead of the ordered 3 units, receiving 2 units of insulin more than what was ordered. Surveyor reported medication error to RN5, RN6, Assistant Director of Nursing (ADON) and Director of Nursing (DON). Surveyor reviewed the printed copy of R263'S MAR with RN5 who confirmed the medication error. Upon further review of R263'S MAR it was found there were five other medication errors for R263 in administration of insulin on 07/07/23, 07/08/23 and 07/09/23. 07/07/23 at 08:00 AM with blood sugar documented at 268 and given 9 units of insulin instead of the ordered 7 units. 07/07/23 at 12:00 PM with blood sugar documented at 279 and given 9 units of insulin instead of the ordered 7 units 07/08/23 at 08:00 AM with blood sugar documented at 288 and given 9 units of insulin instead of the ordered 7 units 07/08/23 at 12:00 PM with blood sugar documented at 276 and given 9 units of insulin instead of the ordered 7 units and on 07/09/23 at 08:00 AM with blood sugar documented at 164 and given 5 units of insulin instead of the 3 units of insulin ordered. RN5 confirmed the medication errors. Surveyor questioned if this was a systems error and RN5 stated not as she was the only nurse with the medication errors. On 08/09/23 at approximately 08:00 AM during record review it was noted RN6 charted she notified R263'S doctor, pharmacist, and wife of the medication error.

Based on observation and staff interview the facility failed to assure a resident's insulin was labeled with the discard by date. Findings include: On 08/09/23 at approximately 11:25 AM Registered Nurse (RN)5 brought out Resident (R)263's insulin pen from the medication cart. The label of the insulin pen documented the open (first use) date of 08/06/23. There was no documentation of the discard date, the line was left blank. RN5 confirmed the discard by date had not been written. When questioned how long the insulin pen can be used RN5 stated she would check with her supervisor, that she did not want to say the wrong answer. RN5 returned and stated the supervisor said, 4 weeks. RN5 was able to calculate the discard by date from the open date.

Based on observation, interview and record review the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. Resident (R)263's drained bile from R263's gallbladder was left out in the resident's room and not discarded appropriately. Findings include: R263 was admitted the facility on 08/04/23 with diagnoses of Alzheimer's Dementia and acute cholecystitis requiring colostomy care. On 08/09/23 at 11:45 AM concurrent observation and interview with Registered Nurse (RN)5 was done. Observed one ounce of dark yellow liquid substance in a container partially closed on R263's nightstand. Inquired with RN5 what the substance was and after RN5 looked at the substance she stated she was not sure, she later stated it was bile from R263's colostomy drainage bag. RN5 reported the nightshift usually removes the bile from the drainage bag and discards the bile in the toilet and flushes the toilet after. On 08/10/23 at 10:05 AM interview with Infection Preventionist (IP) with Director of Nursing (DON)was done. IP reported when discarding a drainage bag with resident's bile staff are to discard it in the resident's toilet. If the bile was put into a sample container it should be discarded along with the container. Inquired the reason it should be discarded and not left on the resident's bedside table; IP stated it is infection control issue. We don't want to leave bile out in the open like that. Review of the facility's policy and procedure number DH-042 Infection Control revised on March 16, 2020, documented All body and blood fluids will be considered infectious .

Based on record review, staff and administrator interviews, and policy and procedures review, the facility failed to assure that all alleged violations of mistreatment, neglect, abuse or injuries of unknown origin were thoroughly investigated and reported immediately to the facility administrator, and to other officials in accordance with the State law for 9 of 10 residents (Residents # 2, 3, 4, 5, 6, 7, 8, 9, and 10) between the dates of April, 2008 and [DATE]. As a result, the facility failed to protect the residents from further potential abuse, and failed to implement the facility policy and procedure for abuse and neglect. Findings include: On [DATE] the Hawaii State Survey Agency (SA) received a report of alleged abuse involving a facility certified nurse assistant (CNA) and a resident which occurred on [DATE] at 4:15 P.M.. The facility reported that the identified assistant (CNA #2) was alleged to have struck Resident #1 on the head with a hair brush, and grabbed his/her left arm while the resident was seated in a wheelchair. CNA #2 was removed from the facility on the evening of [DATE] pending the outcome of an internal investigation. The facility initiated an internal investigation of the allegation on [DATE] which included staff interviews. During the interview process, four CNAs made allegations of abuse involving CNA #2 and 8 additional facility residents (Residents #2, 3, 4, 5, 6, 7, 8, and 10) which had taken place prior to [DATE]. According to the four CNAs, several residents (Residents #3, 4, 5 and 10) were involved in multiple episodes of alleged mistreatment by CNA #2. CNA #2 was terminated by the facility on [DATE]. Eight additional reports of alleged abuse involving CNA #2 and 8 facility residents were forwarded to the SA between ,[DATE] - [DATE]. During the SA site visit on ,[DATE] and [DATE], interviews and record reviews located additional unreported incidents of suspected abuse, or suspicious events. One of the incidents was found during the review of CNA #2's personnel file, and involved an allegation of mistreatment involving Resident #9. This allegation had been reported to the DON and a facility administrator, but was not reported to the SA. (Cross reference to findings in F226 for the unreported allegations of mistreatment.) Based on the SA interviews with staff, and review of records, the allegations of mistreatment between CNA #2 and facility residents are described below. A. On [DATE] at 4:00 P.M. CNA #1 reported to the charge nurse that CNA #2 was "...unnecessarily rough" with Resident #1 while providing care. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. He/she required one person assist with activities such as bathing and transferring, but was able to feed him/herself. Record review noted that Resident #1 was at times agitated and physically and verbally aggressive with the staff. The SA team interviewed CNA#1 on [DATE] at 2:23 P.M. He/she stated that Resident #1 was being assisted out of bed and into a wheelchair by CNA #1 and CNA #2 at 4:00 P.M. on [DATE]. As CNA #1 was adjusting the footrests on the stationary wheelchair, CNA #2 was standing behind the wheelchair in which Resident #1 was seated. CNA#1 then saw and heard CNA#2 strike Resident #1's head "hard" with a hairbrush three times. CNA#1 instructed Resident #1 to tell CNA #2 to stop it. The resident then stated, "Stop it!" at which time CNA #2 smiled. Resident #1 then stated, "Don't touch me." at which time CNA #2 grabbed the residents left arm in a "forceful" way. (CNA #1 demonstrated the way in which CNA #2 moved the residents arm upwards during the interview.) CNA#1 stated that the resident then, "...got more crazy.", and appeared upset. CNA#1 completed care for Resident #1, and reported the incident to the charge nurse. CNA#2 was removed from the floor, and sent home. The interaction was then reported to the facility administrator on call. Examination of Resident #1 found no visible injuries. According to facility records, the resident could not recall these events when interviewed on the evening of [DATE]. B. Resident #2 was admitted to the facility on [DATE]. Review of the chart noted that [DIAGNOSES REDACTED]. The treating physician noted on ,[DATE] that he/she witnessed the resident behavior including "swearing at the staff...nonstop screaming...and increasingly paranoid". Additional chart notes reviewed indicated Resident #2 was on occasion combative during care. An interview was conducted with CNA #6 on [DATE] at 4:11 P.M. CNA #6 alleged that CNA #2 struck Resident #2 during the evening shift around 9:00 P.M. sometime between April and July of 2008. On the evening of the alleged mistreatment, Resident #2 was being re-positioned during a brief change. CNA #2 and CNA #6 were on opposite sides of the bed moving the resident onto his/her side. CNA #6 described him/herself as holding onto the residents right shoulder and right knee when CNA #2 was on the opposite side of the bed performing care. Resident #2 then attempted to strike the CNAs, and reached backwards toward CNA #2. At that point CNA #2 struck Resident #2 on the right buttock with an open hand. (CNA #6 demonstrated the slap during the interview.) CNA #6 stated that the slap left a visible hand imprint on the residents buttock. CNA #6 told CNA #2, "Don't do that.". CNA #6 did not report the incident as CNA #6 stated that CNA #2 was frightening, and made fun of CNA #6's English language skills. C. Records were reviewed for Resident #3 who was involved in two alleged episodes of mistreatment involving CNA #2. His/her [DIAGNOSES REDACTED]. A recent hospital admission (from ,[DATE] - [DATE]) for Ogilvie's Syndrome included the surgical placement of a feeding tube on [DATE]. The chart noted that the resident was non-verbal between [DATE] and [DATE], but that Resident #3 could move his/her mouth in response to cues although no sound emerged. 1. After being re-admitted to the facility on [DATE], Resident #3 was started on tube feeding. An interview was conducted with CNA #4 on [DATE] at 2:30 P.M. CNA #4 alleged mistreatment of [REDACTED]. CNA #4 reported that Resident #3 had been readmitted from the hospital and had an intravenous line infusing fluids with more frequent bowel activity taking place. Care for Resident #3 included turning him/her every 2 hours, and given the residents [MEDICAL CONDITION] this involved two staff to accomplish. At one point during the evening shift, CNA #4 and CNA #2 went to reposition Resident #3, and discovered that a brief change was also needed. CNA #4 then saw CNA #2 put his/her hands on his/her hips, and heard CNA #2 address Resident #3, "Again? Mister, why do you do this to us again?" CNA #4 stated that CNA #2 then pulled on and twisted Resident #3's nose. CNA #4 told CNA #2, "Just stop it." at which time CNA #2 laughed, stopped the nose pulling, and said, "I'm sorry. I'm just joking." 2. An interview was conducted with CNA #6 on [DATE] at 4:11 P.M. CNA #6 stated that sometime between April and July, 2008 at approximately 2:30 P.M. ,CNA #6 alleged an episode of mistreatment took place involving Resident #3 and CNA #2. The resident was awake as CNA #2 and CNA #6 entered the room. CNA #2 approached Resident #3, and struck his/her left facial cheek "hard" with an open palm after which he/she tapped the end of the residents nose on both sides several times calling out the residents name. CNA #6 stated that CNA #2 was laughing while touching the resident in the described manner, which CNA #6 demonstrated to the SA team. During the SA chart review for Resident #3, notes were found indicating a medication error had taken place and was discovered at 5:45 P.M. on [DATE]. Facility policy # "Medication Errors and Drug Reactions" effective [DATE] stated: Report all medication errors and drug reactions immediately to the attending physician, Director of Nursing Service and Administrator." Interviews with the Interim Executive Director on [DATE] at 10:45 A.M. and 12:20 P.M. noted that the attending physician was notified, however, the DON and/or Administrator had not been notified. The administrator stated, "Clearly, we need to do some major re-training with staff." The chart review found no reported injury to Resident #3 from the alleged instances of mistreatment or the medication error. D. Resident #4 was involved in two alleged incidents of mistreatment with CNA #2. One was reported to the SA, the second was noted during the on site visit. Record review for Resident #4 found that [DIAGNOSES REDACTED]. Nursing notes stated that Resident #4's behavior was occasionally combative with staff, and that one person assist was needed for daily care and transfers to the wheelchair. 1. An interview with CNA #3 was conducted on [DATE] at 3:00 P.M. CNA #3 alleged that sometime between April and [DATE] during the evening shift, CNA #2 mistreated Resident #4. CNA #3 stated that while assisting the resident to dress, he/she saw CNA #2 pinch both of Resident #4's nipples with both hands. The resident responded to CNA #2 by trying "...to fight back and hit". CNA #3 then told CNA #2, "Stop it! Don't do that to her." CNA #3 stated that CNA #2 laughed in response, and stopped the pinching. 2.. An interview with CNA #1 was conducted on [DATE] at 2:23 P.M. at which time he/she alleged that an episode of CNA #2 doing "...the same nipple pinching thing" with Resident #4 took place during the first week of June, 2009 at around 3:30 P.M. CNA #1 and CNA #2 were assisting Resident #4 in dressing when CNA #1 witnessed CNA #2 touching the residents nipple. Resident #4 stated, "Stop it! What are you doing?" CNA #1 stated that Resident #4 "teared up" immediately afterward. CNA #1 covered the residents upper body, and both CNAs left the room. Review of the chart found no entry of injuries to Resident #4. E. Resident #5 was involved in two alleged episodes of mistreatment with CNA #2. One was reported to the SA, the second was noted during the on site visit. Record review of Resident #5 found [DIAGNOSES REDACTED]. The record included the following: "extensive assistance with activities of daily living, transfers and mobility". Resident #5 was noted to have episodes of restlessness, occasional combative behavior and severe cognitive impairment. 1. CNA#1 was interviewed on [DATE] at 2:23 P.M., and alleged that he/she witnessed two abusive interactions between CNA #2 and Resident # 5. CNA #1 reported that Resident #5 required the assistance of ,[DATE] staff to prepare her for bed at night. The first took place sometime around mid May, 2009 at 9:00 P.M.. CNA #1 saw CNA #2 lift resident #5's top, pinch her left nipple, and laugh. Resident #5 stated, "Stop it! Leave me alone!" CNA#1 then covered the residents upper body, and left the room with CNA #2. CNA #1 stated there was no visible injury to residents body at that time. 2. CNA #1 reported the second alleged incident took place approximately one week after that noted above at around 9:30 P.M. Both CNA #1 and CNA #2 entered Resident #5's room. CNA #1 saw CNA #2 lift Resident #5's top and pinch her nipple. CNA #1 stated that the resident "...got all crazy" and told CNA #2 to stop doing this. CNA #2 then reportedly laughed. Due to the resident being visibly upset, CNA #1 told CNA #2, "I guess I can't put her to bed already." Resident #5 transferred to a different facility in late June, 2009. F. Resident #6 was involved in one alleged abusive incident with CNA #2. The SA team found two entries of unexplained bruising while reviewing the residents chart. These two unexplained bruises were not reported to the SA. 1. Record review of Resident #6 found that current [DIAGNOSES REDACTED]. The Monthly Nursing Summary notes stated that Resident #6 required assistance with daily activities, transferring to the wheelchair, but he/she was able to eat independently if the food was arranged within reach. a. CNA #1 was interviewed on [DATE] at 2:23 P.M. He/she stated that Resident #6 was being assisted into pajamas sometime around the beginning of June, 2009 at 9:30 P.M. when CNA #1 alleged that CNA#2 pinched the nipple of Resident #6. Resident #6 then "...went all crazy kicking her legs", and stated, "Make him stop! What are you doing? Get the hell out!" CNA#1 stated that CNA#2 laughed, and left the room. b. The SA record review found the following chart entry dated [DATE]: "CNA reported RFA 3.5 cm ecchymosis @ 1500. Resident is unable to explain what it happened." c. The record review noted a report on [DATE] from the residents family of a bruise to the left inner leg around the size of a quarter. Items "b" and "c" were not investigated or reported to the SA. G. Record review of Resident # 7 found admitting [DIAGNOSES REDACTED]. Chart notes stated that this resident was forgetful, but alert, and he/she required extensive assistance from the staff for daily activities. An interview with CNA #3 was conducted on [DATE] at 3:00 P.M. He/she witnessed an alleged instance of mistreatment involving Resident #7 and CNA #2. Sometime between April and [DATE] during the evening shift, he/she alleged that CNA #2 struck Resident #7 on both facial cheeks with an open hand. Resident #7 responded by stating, "What are you doing?" CNA #3 then told CNA #2 that his/her help was not needed, at which time CNA #2 laughed and left Resident #7's room. H. Records were reviewed for Resident #8 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Coding on the MDS noted that his/her cognitive skills were severely impaired ("3"). Resident #8 was dependent on staff for all daily activities. CNA #3 was interviewed on [DATE] at 3:00 P.M. at which time he/she alleged that CNA #2 mistreated Resident #8. Unable to recall the exact date in May, 2009, CNA #3 saw CNA #2 place both of his/her hands on Resident #8's nipples and pinch them while CNA #2 was assisting Resident #8 into bed. Review of the chart found no documented injury. Resident #8 was deceased on [DATE]. I. During the SA visit to the facility, record of an alleged abusive episode between CNA #2 and Resident #9 was found in CNA #2's personnel file. This included a cover memo from the DON indicating that the statements could be discarded. Interview with the Human Resources manager on [DATE] at 9:35 A.M. found that the documents were kept in the file because he/she was not sure what to do with them. Resident #9 was admitted to the facility on [DATE], and record review noted [DIAGNOSES REDACTED]. He/she needed full assistance from the staff for daily needs, and had "combative behavior" at times when staff were helping him/her. On [DATE] CNA #2 reported that he/she went into Resident #9's room and offered to bathe him/her. Resident #9 refused and stated that CNA #2 had slapped his/her face the day before. This allegation was reported to the facility administrator who was passing in the hallway, and also to the charge nurse, who reported this to the DON. The DON instructed the charge nurse collect written statements from 6 staff on duty, and gave no further instructions. CNA #2 remained on duty. (Cross reference to findings in F226 for unreported allegations of mistreatment.) The charge nurse was interviewed on [DATE] at 3:14 P.M. He/she recalled the reported allegation, and contact with the DON. He/she could not recall if he/she examined Resident #9 for injury. The charge nurse confirmed that neither the DON nor the facility administrator examined the resident for injury. Resident #9 was transferred to another facility on [DATE]. J. During the SA visit to the facility, interviews with staff found two allegations of verbal abuse between CNA #2 and Resident #10. Resident #10's [DIAGNOSES REDACTED]. Resident #10 required assistance from staff for some daily activities. An interview with CNA #4 was conducted on [DATE] at 2:30 P.M. CNA #4 alleged that on two separate occasions (exact dates unknown) Resident #10 asked for CNA #2 to be removed from the room after asking personal questions. CNA #4 said that CNA #2 asked the resident, "How come you were never married, huh?" several times. Resident #10 turned to CNA #4 and said, "Would you please get this boy out of this room?" at which time CNA #2 left. CNA #4 stated that Resident #10 seemed "upset" by this type of question on several occasions. Review of the chart for Resident #10 found no entries of injury from these interactions which were not reported to the SA. Based on the above information gathered during the SA visit on site, the facility failed to assure that allegations of mistreatment of [REDACTED]. In the instance when CNA #2 self-reported an allegation of abuse to the facility administrator (Item I. above) the SA team noted that CNA #2 was not removed from the facility, nor was the SA notified of the incident until the site visit found a record of the occurrence. (Cross reference to findings in F226 for unreported allegations of mistreatment.)

Based on review of facility policy and procedure, interviews with staff and administrators, and record reviews, the facility failed to implement written policies and procedures that prohibit mistreatment and abuse of residents in 3 of 10 incidents. This included failures to investigate, protect, and report allegations of abuse. Findings include: Review of the facility policies and procedures pertaining to abuse and/or neglect reporting and investigation was done on 7/1/09. This included Policy # "Abuse, Investigating and Reporting of Resident Abuse, Suspected Abuse & Neglect" which stated: "All suspected abuse will be investigated in a timely and thorough manner." Policy # "Incident/Accident Reporting and Investigation" was reviewed which stated: "An event is any incident which includes by (sic) not limited to, bruises, skin tears, burns, resident to resident alterations, unexpected death, witnessed & unwitnessed falls, and alleged abuse." During the SA visit to the facility, record of an alleged abusive episode between CNA #2 and Resident #9 was found in CNA #2's personnel file. This included a 1/1/09 note from the DON stating: "...if you do not want...please discard". Interview with the Human Resources manager on 6/30/09 at 9:35 A.M. found that the documents were kept in the file because he/she was not sure what to do with them. Resident #9 was admitted to the facility on [DATE], and record review noted [DIAGNOSES REDACTED]. He/she needed full assistance from the staff for daily needs with noted "combative behavior". On 10/28/09 CNA #2 reported that he/she went into Resident #9's room and offered to bathe him/her. Resident #9 refused and stated that CNA #2 had slapped his/her face the day before. This allegation was self reported to the facility administrator who was passing in the hallway, and also to the charge nurse, who reported this to the DON. The DON instructed the charge nurse to collect written statements from 6 staff members on duty. CNA #2, the staff member alleged to have abused Resident #9, remained on duty on the same floor as Resident #9. The charge nurse was interviewed on 6/30/09 at 3:14 P.M. He/she recalled the reported allegation, and contact with the DON. He/she could not recall if he/she examined Resident #9 for injury. The charge nurse confirmed that neither the DON nor the facility administrator examined the resident for injury. The incident was not investigated further by facility staff or administrators, and was not reported to the SA. The failure to implement facility policy was evidenced by the facility not removing the alleged abusive staff from further contact with residents, not conducting a thorough investigation, and not reporting the allegation of abuse to the SA. Allegations of abuse involving CNA #2 were submitted to the facility DON and/or administrator on 8/21/08, 10/27/08, and 6/13/09. The investigation of the 6/13/09 allegation brought 13 additional and previously unreported allegations of abuse involving CNA #2 and facility residents. The SA team reviewed the facility's development and implementation of policies and procedures regarding abuse including record reviews, interviews and policy and procedure reviews of facility screening, training, prevention, identification, investigation, protection and reporting activities in the allegations of abuse involving CNA #2. A. Screening of potential employees for a history of abuse, neglect or mistreating residents was performed when CNA #2 was screened prior to employment. Review of CNA #2's personnel file found a search had been done for a history of criminal charges with no charges found. The Red Cross registry of certified nurse aides reported no prior notifications of abuse. The Human Resources manager was interviewed on 6/30/09 at 9:35 A.M. , and confirmed that after a reference check was done, CNA #2 was employed at the facility on 3/13/07 as a full time CNA. B. Training of employees with reference to abuse prohibition practices through orientation and on-going sessions was confirmed through staff and administration interviews, and record reviews. The Director of Nursing (DON) confirmed during an interview on 6/30/09 at 11:06 A.M. that he/she personally oversaw the first two weeks of new employee orientation to assure the competency of new hires. Additionally, annual training topics for all facility staff routinely included "Abuse of the Elderly" and "Resident Rights". The SA review of CNA #2's personnel file found confirmation of CNA #2's attendance at this training on 3/18/09. All CNAs interviewed during the SA on site visit provided a basic definition of abuse in the facility setting, and facility guidelines for handling potentially abusive incidents. Record review found that all facility CNA staff had been required to "read and sign" facility policies involving resident's rights, and investigating and reporting of resident abuse. This followed the facility's internal investigation of a prior allegation of abuse involving CNA #2 in August, 2008. Two CNAs (CNA #1 and CNA #6) stated during the interviews that they were personally afraid of CNA #2, and that this influenced their reporting events in which they allegedly witnessed CNA #2 mistreat residents. C. Prevention of abuse was explored during interviews with staff, record and policy and procedure reviews. Interviews with the DON, facility administrators, licensed staff and CNAs confirmed that a number of residents were known to have aggressive reactions in response to care measures. CNA interviews confirmed that interventions for dealing with these reactions were known to them through training. Review of records for several residents (Residents #1 and #2) confirmed that appropriate care planning was in place for identified behaviors. Observations and interviews confirmed the existence of an anonymous suggestion box wherein staff could report concerns. The DON confirmed during an interview on 7/1/09 at 3:40 P.M. that there was "always" a written response to notes in this box, and action would be taken if warranted. Interviews with 5 staff members validated that the suggestion box was a known avenue of reporting concerns in the work environment. The DON confirmed that supervision of staff for behavior was ongoing. During an interview with the DON on 6/30/09, he/she said that CNA #2 worked well on his/her own, and with the team. Further that CNA #2 was a "hard worker who was willing to pick up extra shifts", and that there was "no reason to doubt" his/her performance. An annual performance appraisal for CNA #2 dated 3/10/08 was reviewed on 6/30/09 with no deficiencies noted. D. Interviews and record reviews into facility identification of events was done also. Policy # "Incident/Accident Reporting and Investigation" was reviewed which stated: "An event is any incident which includes by (sic) not limited to, bruises, skin tears, burns, resident to resident alterations, unexpected death, witnessed & unwitnessed falls, and alleged abuse." Prior to the 6/13/09 allegation of abuse, the facility reported one previous allegation of abuse to the SA between CNA #2 and a facility resident. This took place on 8/21/08 at 6:00 A.M. when Resident #11 claimed that he/she was "punched" by CNA #2. The investigation was closed when the facility fact finding did not confirm the allegation. In addition to the discovery of the second allegation of abuse involving CNA #2 noted above, other instances of alleged abuse were noted in the process of staff interviews during the SA on site visit. These included allegations of two episodes of verbal abuse involving Resident #10. . CNA #4 alleged that on two separate occasions (exact dates unknown) Resident #10 asked for CNA #2 to be removed from the room after asking personal questions. CNA #4 said that CNA #2 asked the resident, "How come you were never married, huh?" several times. Resident #10 turned to CNA #4 and said, "Would you please get this boy out of this room?" at which time CNA #2 left. CNA #4 stated that Resident #10 seemed "upset" by this type of question on several occasions. Review of the chart for Resident #10 found no entries of injury from these interactions which were not reported to the SA. Record reviews found two entries of unexplained skin bruises to Resident #6. A chart entry dated 3/23/09 stated: "CNA reported RFA 3.5 cm ecchymosis @ 1500. Resident is unable to explain what it happened." And the residents family reported on 6/20/09 that there was a bruise to the left inner leg around the size of a quarter. Neither of these charted skin bruises were investigated or reported to the SA. E. Investigation of alleged violations, and reporting results to the proper authorities were examined through policy and procedure and record reviews. Policy # "Abuse, Investigating and Reporting of Resident Abuse, Suspected Abuse & Neglect" was reviewed which stated: "The Administrator and/or Director of Nursing Services shall assure that the Resident's medical needs are met and immediately initiate a thorough investigation of the allegation." The allegation of abuse involving CNA #2 and Resident #11 on 8/21/08 was investigated by the DON. After CNA #2 underwent a 30 day supervised review/monitoring employment period, he/she was returned to unsupervised, full time employment. In a letter to the SA dated 8/25/08, the DON reported that "no valid reason" was found to discharge CNA #2. The second allegation of abuse involving CNA #2 was reported to the DON and administrator on 10/28/08. A record of the incident was found by the SA during the on site visit when CNA #2's personnel file was reviewed. The investigation consisted of six written statements from staff on duty on 10/28/09, the date following the alleged date of the abuse which was 10/27/08, and involved an allegation of abuse from Resident #9 who alleged that CNA #2 had slapped him/her. The charge nurse on duty on 10/28/08 was interviewed on 6/30/09 at 3:14 P.M. He/she confirmed that on 10/28/08 CNA #2 self-reported a comment from Resident #9 who alleged that CNA #2 had slapped him/her on 10/27/08. CNA #2 added that he/she was assigned to another floor within the facility on 10/27/08, and was not assigned to the care of Resident #9. The charge nurse was unable to recall if he/she personally examined Resident #9 for injury on 10/28/08. Resident #9 was described by the charge nurse as "paranoid", and under the care of a psychiatrist at the time of the allegation. That evening the charge nurse notified the DON of the allegation by phone. During that conversation, the DON asked the charge nurse if CNA #2 was working on 10/27/08, and what floor he/she was assigned to work. After the DON was advised CNA #2 had worked on another floor within the facility on 10/27/08, the charge nurse was instructed to obtain statements from the staff on duty. Both the DON and the charge nurse confirmed during their respective interviews that no further instructions were given in handling the allegation. CNA #2 continued working on the floor that evening, and intermittently thereafter. In an interview with the DON on 6/30/09 at 11:06 A.M. he/she was asked about the investigation and handling of the 10/27/08 allegation. The DON confirmed that CNA #2 self reported the allegation, but that staff confirmed that he/she was not assigned to Resident 9's floor on 10/27/08. The investigation, according to the DON, was confirmed to be the 6 written statements from staff on duty on 10/28/08. The DON confirmed that the allegation was not reported to the SA. The SA team reviewed the payroll records and the daily assignment sheets for the two floors involved in this allegation. The payroll record confirmed that CNA #2 was working on 10/27/08, and the daily assignment sheet noted that he/she was assigned to a floor different from Resident #9's. The DON confirmed that passage between the two floors was possible via elevator or connecting stairs, and that CNA #2 was not permanently assigned to one of the two floors. Policy # was reviewed and stated: "Interview the person reporting the incident to clarify what he/she saw and heard...Assess the Resident for physical signs of abuse." The DON said that Resident #9 was neither interviewed nor examined in regards to the alleged abuse. During the interview with the SA team on 6/30/09, the DON said that Resident #9 was not "cognitively complete". Under these circumstances, the DON concluded that he/she did not believe it necessary to remove CNA #2 from the facility, nor look into the matter further. F. Facility policy # was reviewed regarding resident protection: "Immediate action will be taken to protect the resident from retaliation and harm. The accused perpetrator will be immediately removed from the resident. The accused perpetrator will be relieved of duty until the investigation is completed." In the 10/28/08 allegation of abuse outlined above, this policy was not followed. The DON said in an interview with the SA team on 6/30/09 that he/she did not believe removal of CNA #2 was necessary in the scenario alleged by Resident #9. G. Review of the facility Policy # noted the following: "The Administrator/Designee shall report all alleged violation ...(to)...the Department of Health Office of Health Care Assurance (OHCA)...A written report, complied (sic) by the DON or her designee, needs to be faxed. A completed form must be submitted to OHCA within five calendar days." In both conversations between the DON and the SA team there was discussion regarding facility policy in reporting allegations of abuse. In an interview on 6/30/08 the DON said that the reporting of the 10/27/08 allegation of abuse was not done and that, "This one slipped through our hands." The DON confirmed that he/she was usually the initial contact for allegations of abuse, and that "staff report things to me all the time." He/she had also instructed the staff to "...go up the chain of command" if they believe the DON did not provide a proper response to an allegation of abuse. Based on the above findings, the facility failed to consistently identify, investigate, and report allegations of abuse (Residents # 9 and 10), and unexplained skin bruising (Resident #6). The facility failed to protect the residents by not removing CNA #2 from further contact with residents until an investigation was completed after an allegation of abuse was reported on 10/28/08 (Resident #9).