Every finding on record at Hilo Benioff Medical Center

Based on observations, interviews, and record reviews, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional infection control measures used when patients already have confirmed or suspected infections) by wearing the proper personal protective equipment (PPE) and adhered to standard precautions by performing proper hand and glove hygiene. In addition, the facility failed to have a surveillance plan for infections acquired outside of the facility. As a result of these deficient practices, staff and patient safety was compromised. Findings include: 1) On 01/27/25 at 11:14 AM, observed Droplet Precautions (transmission-based precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets) signage outside of North room [ROOM NUMBER]. The signage displayed the following instructions: EVERYONE MUST Clean hands, before entering & when leaving the room. Don gloves and gown BEFORE entering the room. Make sure their eyes, nose & mouth are fully covered before entering the room. Concurrent interview with Registered Nurse (RN)7 and Certified Nurse Aide (CNA)14 revealed beds A and C were on droplet precautions for the flu, and beds B and D were not. When asked what PPE would be appropriate when entering room [ROOM NUMBER], both responded that they would don (put on) full PPE (an N95 respirator, eye protection, a gown, and gloves) only for beds A and C. It was observed at this time, and confirmed by RN7 and CNA14, that beds A and C were the beds closest to the door. When asked for clarification, CNA14 reported that if she were entering room [ROOM NUMBER] for the residents in bed B or D, she would not need to don full PPE although she would be walking past beds A and C to get there. It was observed at this time that the privacy curtains around beds A and C were not drawn completely, they were drawn only enough to allow visual privacy from the beds next to them (horizontally). When asked what would be considered appropriate eye protection, CNA14 responded that it could be a face shield, goggles, or her eyeglasses (which were placed at the top of her head at the time). On 01/27/25 at 11:24 AM, observed Droplet Precautions signage outside of North room [ROOM NUMBER]. Concurrent interview with RN7 was done. RN7 stated that the resident (R) in bed A (R7) was on droplet precautions for the flu and was the only resident in the room (as far as he had received in report) that was on any type of transmission-based precautions (TBP). While interviewing RN7, observed CNA14 enter room [ROOM NUMBER] and approach the resident in bed C (R25) after donning an N95 respirator, gown, and gloves, with her eyeglasses still sitting on the top of her head. When asked about her PPE, CNA14 stated she had donned it and entered the room to see R7, however R25 had called her over as soon as she entered. CNA14 confirmed that she had received report that morning and was not told that R25 was on any type of TBP. After helping R25 reposition in bed, observed CNA14 doff (take off) her gown in the room, carry it out of the room, cross the hallway, and discard it in a trash bag hanging on the North pink medication cart. On 01/27/25 at 12:10 PM observed staff enter Resident (R)44's room. There were signs posted at the door to notify staff R44 is on droplet precautions. Certified Nurse Aide (CNA)1 was observed entering the room wearing a medical mask. From the door, observed CNA2 standing at R44's bedside. CNA1 then grabbed a blue gown from the dispenser and returned to R44's bedside, holding the gown in the crook of her arm. CNA1 was observed talking to the resident, then the resident handed her cellular phone to the CNA. CNA1 returned the phone to R44, walked over to the gloves. No hand hygiene was observed prior to putting on the gloves. While standing at bedside, CNA put on the blue gown. CNA1 pulled the privacy curtain and could be heard asking R44 if she wanted to call her daughter. CNA could be seen, she was wearing glasses and removed them to hook onto her scrub, then put glasses back on. CNA1 was also observed to place glasses atop her head. CNA1 requested assistance from Registered Nurse (RN)1 RN1 found there were no gowns in the drawer. RN1 rolled a cart from across the hall and placed it next to R44's door. RN1 was wearing medical mask, donned gloves, gown, and was wearing glasses. RN1 assisted R44. Upon exit, RN1 confirmed her glasses were eye protectors; however, CNA1 was wearing her regular glasses. RN1 confirmed CNA should have donned personal protective equipment (PPE) prior to entering R44's room. RN1 confirmed signage on the wall noted resident on droplet precaution (positive for the flu). On 01/27/25 at 11:29 AM, a second interview was done with RN7 regarding which residents in room [ROOM NUMBER] were on what type of TBP. Additional signage observed outside the room seemed to indicate there were at least two residents in the room on droplet precautions and one resident in the room on contact precautions (intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment). RN7 agreed that the signage outside the room was confusing, and he was not sure himself which residents were on TBP. After walking away and having a discussion with RN3, RN7 returned and confirmed that both R7 and R25 were on droplet precautions for the flu, and R8 had been placed on droplet precautions because she was at an increased vulnerability for the flu. On 01/27/25 at 12:12 PM, an interview was done with the Director of Nursing (DON) in her office. DON confirmed that eyeglasses were not acceptable eye protection. DON also confirmed that because droplet precautions were for airborne particles, they applied to the entire room, not specific residents within a room. DON agreed that full PPE should be applied before entering a room on droplet precautions, regardless of which resident within the room was being seen. On 01/27/25 at 12:59 PM, observation was done of CNA14 in North room [ROOM NUMBER], assisting R25 with no eye protection worn. On 01/28/25 at 07:20 AM, observation was done of CNA2 about to exit North room [ROOM NUMBER] with only a surgical mask on, no gown, and no eye protection. When asked where her PPE was, CNA2 stated that she was in the room only to assist R8, and so did not need to don the full PPE. On 01/28/25 at 04:10 PM, observation was done of CNA12 in North room [ROOM NUMBER] standing within 6 feet of R25 with only a surgical mask on. After exiting the room, asked CNA12 if he should be wearing full PPE in that room. CNA12 responded that he had only gone in the room to turn off R25's call light, and since he did not touch the patient, he did not need to don full PPE. On 01/29/25 at 10:25 AM observed housekeeping staff enter R44's room. Housekeeper was wearing a face mask and holding a spray bottle. At 10:29 AM, Housekeeper exited the room, did not change her mask, and was holding a plastic bin of cleaning of supplies. Queried whether she received infection control education, Housekeeper stated, yes. Asked when she received education, Housekeeper responded upon hire. Housekeeper reported she had cleaned the bathroom. Inquired whether she saw the sign by the door regarding droplet precautions. Housekeeper apologized and stated she did not see the sign. 2) On 01/28/25 at 10:45 AM, observed CNA2 and CNA14 performing pericare for R5. Following pericare, observed CNA2 touching R5's drawers, bedside table, and belongings, and brushing his hair, wearing the same pair of gloves used for pericare. On 01/30/25 at 10:12 AM, observed CNA11 performing pericare for R7. During pericare, observed CNA11 got stool on the gloves she was wearing. CNA11 wiped the gloves on the disposable underpad beneath R7 and proceed with finishing pericare. Following pericare, observed CNA11 touch R7's privacy curtains, and bedside table wearing the same pair of soiled gloves she used for pericare. RN6 was present at this time, applying medicated ointment to R7's perineal area. On 01/30/25 at 10:26 AM, an interview was done with RN6 at R7's bedside. RN6 confirmed that she would expect any CNA to change their gloves when going from dirty to clean. On 01/31/25 at 09:45 AM, an interview was done with DON at the nurses' station. When asked about monitoring of infection control practices, especially relating to PPE use and hand hygiene practices, DON reported that spot checks are done by the Charge Nurse and Clinical Coordinator as needed only. DON clarified that spot checks were usually done if they had an outbreak or if a breech in hand hygiene was observed and was documented on their Focus Rounds. The State Agency (SA) requested documentation of the Focus Rounds at this time. On 01/31/25 at 12:08 PM, an interview was done with DON in her office. DON stated that she could find no infection control practice monitoring logs, and that there was no documentation that Focus Rounds for hand hygiene or PPE checks had been done since the last COVID outbreak at the end of May 2024. Review of the facility policy and procedure, LTC: Infection prevention and control program, last revised 6/2024, revealed the following: Change gloves during resident care if the hands will move from a contaminated body site to a clean body site. 3) On 01/31/25 at 09:45 AM, an interview was done with DON at the nurses' station. A concurrent review of the facility matrix noted that 32 of 50 residents had been marked as being on an antibiotic but only 12 had been marked for infection. When asked about infection surveillance for infections obtained prior to admission, or outside the facility, DON stated that she was unsure how the facility monitored that but would check. On 01/31/25 at 12:08 PM, an interview was done with DON in her office. DON reported the facility had two current influenza infections in the facility, and one resident on antibiotics, confirming that the facility matrix was incorrect. DON also confirmed that the facility currently had no surveillance plan for infections acquired outside the facility, but agreed this was important for a complete picture of the infections in the facility at any given time. Review of the facility policy and procedure, LTC: Infection prevention and control program, last revised 6/2024, revealed the following: When there is a confirmed or suspected outbreak (2 or more ill residents) . such as influenza: 1. Conduct daily active surveillance for at least 1 week after the last confirmed case occurred.

Based on record review and interviews, the facility did not assure staff members received training for dementia management and resident abuse prevention, understanding expressions or indications of distress of residents to prevent abuse from occurring. This deficient practice has the potential to place at risk of resident-to-resident or staff to resident abuse. Findings include: Cross Reference to F600 - Free From Abuse and Neglect. The facility submitted event reports alleging resident-to-resident abuse, there were incidents of residents striking out, throwing items, and engaging in altercations related to inability to cope with other residents' behaviors of distress. A review of facility reported incidents found four allegations of resident-to-resident abuse. These incidents were investigated during the survey. The incidents occurred between 09/26/24 and 12/08/24. Resident (R)44 and R33 were involved in two incidents. The first documented incident occurred on 09/26/24 when two staff members on lunch witnessed R44 throwing rocks at R33. The second documented incident occurred on 12/08/24. R44 was seated on the lanai and R33 was seen going out to the lanai. Later, staff heard screaming and found R44 and R33 engaged in a physical altercation with R33 identified as the alleged perpetrator. R44 was also involved in another incident on 11/09/24. R3 is a cognitive resident and was screaming for help at 03:15 AM. R3 reported R44 threw a plastic mouthwash bottle at her. Registered Nurse (RN)3 documented R44 admitted to throwing the bottle at R3 as she would not shut up. An incident on 10/05/24 involves R37 and R14. Residents were seated in the dining room, R37 started making loud vocalizations, staff intervened, and he stopped. R37 started again, R14 reported he got irritated and ended up punching R37. Interviewed RNs and CNAs regarding staff training for abuse. Some staff members were able to recall having training recently, unable to specify the date as training reportedly is ongoing. Although staff were able to confirm they received training, they were unable to identify behaviors and provide examples of interventions that may prevent resident-to-resident abuse. Upon request of the latest training staff received for abuse/neglect, the facility provided the policy and procedure for Freedom from Abuse/Neglect/Exploitation Long Term Residents. Interviewed Administrator on 02/07/25 at 10:28 AM. Administrator reported part of the staff training included a review of the facility's policy and procedure. Further queried whether other training was provided. Administrator reported training is ongoing and provided during their huddle with the psychologist. This information is shared with the charge nurse via email. Inquired whether the CNAs and other staff are involved in this communication. Administrator was unable to confirm the information is shared with other staff members.

Based on record review and interview, the facility failed to protect the residents' rights to be free from physical abuse by another resident. The facility did not assure residents with a history of distressed behaviors were identified to be at risk for abuse. The facility did not ensure staff were provided with training to assess potential situations that may result in abuse (Cross Reference to F943 - Abuse, Neglect, and Exploitation Training). The facility did not assure residents with a prior incident were supervised and monitored on the lanai. The facility submitted reports alleging resident-to-resident abuse involving a cognitive resident (Resident 44) that had two incidents as the alleged perpetrator, one with a cognitively impaired resident (Resident 33) and a cognitive resident (Resident 3). There were two incidents involving Resident (R)44 and R33. This deficient practice has the potential to result in psychosocial harm and/or injury. Findings include: 1) ACTS #HI00011229 On 09/26/24 at 12:30 PM, the facility submitted an Event Report regarding an allegation of resident-to-resident abuse involving R44 and R33. R44 was identified as the alleged perpetrator and R33 as the alleged victim. The facility reported on 09/26/24 at 10:45 AM, R44 was observed by staff to wheel out to the lanai and began throwing garden rocks at R33. This was witnessed by two Certified Nurse Aides (CNA) who were eating lunch on the lanai. The CNAs stopped R44 and separated them. R44 accused R33 of taking her papaya the day before. R33 was noted with a bruise to the left forearm. The residents were separated, and the activities staff calmed R44. R44 requested papaya which was immediately provided by dietary. Subsequently, R33 noted with bruise (1.5 cm x .4 cm) on left forearm. R33 was unable to recall the event. Interviews with the staff present found R44 ate alone on the lanai and R33 ate in the dayroom. R33 went out on the lanai after lunch. Staff did not witness R33 taking food from R44 and R33 does not have history of taking food from others. Residents reportedly were kept apart, and no verbalizations of aggression or anger noted during investigation. In service was provided to all staff on abuse and neglect with focus on resident-to-resident altercation. Facility deemed altercation was substantiated as there were witnesses present at the time. On the morning of 01/27/25 observed R44 was on droplet precautions for the flu. R44 was quarantined to her room. On 01/28/25 at 08:00 AM, attempted to interview R44 at breakfast. R44 was visited at bedside. She was eating hot cereal, introductions were made R44 did not acknowledge my presence. As her mouth was full with cereal, informed her I'd wait until she swallowed her cereal, she looked up, made eye contact and took another spoonful of cereal. Requested an interview, R44 did not respond. On 01/30/25 at 10:26 AM observed R44 sitting alone on the lanai. It was difficult to see her as she was sitting to the side and could not be seen from across the activity/dining room. Record review notes R44 was admitted to the facility on [DATE] from an acute hospital. Diagnoses include cerebrovascular accident, hemiplegia, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) with assessment reference date of 11/12/24 notes R44 is cognitively intact, scored a 15 on the Brief Interview for Mental Status (BIMS). A review of Section D. Mood, the mood interview was conducted, R44 noted with the presence of the following mood symptoms: little interest or pleasure in doing things; feeling down, depressed, or hopeless, trouble falling or staying asleep or sleeping too much; poor appetite; feeling bad about yourself or that you are a failure or have let yourself or family down; and moving or speaking so slowly that other people could have noticed. R44 was not coded for exhibiting behaviors during the assessment period. R44 was seen by the psychologist on 10/17/24. The psychologist notes R44 tends to become agitated, and hoards (mostly food). R44 reportedly not on psychotropic or have psychiatric history. The recommendation/plan is to continue standard behavioral oversight and interventions to provide resident time to settle into her new placement. Review of the care plan for behavioral symptoms noted the following interventions, I can be impatient and have history of changing my own briefs while in my bed/room, remind to use call light and educate me on the importance of being patient and the risks of changing my own brief. Following the incident, the care plan was revised (09/26/24) to include, please ensure that I am not seated near resident in E2 (R33) during meals, as I think she stole food from me which made me upset. R33 was admitted to the facility on [DATE], diagnoses include but not limited to vascular dementia with behavioral disturbance, acute subdural hematoma, and insomnia. A review of the quarterly MDS with ARD of 12/10/24 notes, R33 scored a three (severe cognitive impairment) upon application of the BIMS. R33 noted with no mood or behavioral symptoms. On 01/27/25 at 01:09 PM interviewed R33 in her room. R33 was unable to recall any incident(s) with fell ow residents. Review of R33's care plan for behavioral symptoms included intervention when out in the dayroom staff will have visual on me at all times until further notice. Although facility noted R33 does not have a history of taking food from other, the care plan was revised, 09/26/24 to include I may take food that is left on table unattended, please redirect me. 2) ACTS #HI00011356 On 12/08/24 at 02:41 PM, the facility submitted an Event Report regarding an allegation of resident-to-resident abuse. This is second event between R44 and R33 while on the lanai. R44 was identified as the alleged victim and R33 as the alleged perpetrator. Report indicates on 12/08/24 at 12:26 PM, R44 was sitting outside on the facility's lanai. Activities Aide (AA) saw R33 heading out to the lanai on her wheelchair. Ten minutes later, AA heard screaming on the lanai, a Certified Nurse Aide (CNA)11 reportedly ran outside and called for help and upon arrival AA saw R33 pulling R44's hair. CNA11 indicated in the facility's investigation report while separating the residents, R44 turned to pull R33's hair and attempted to hit R33. The residents were immediately separated. R44 had scratch marks at the back of her necks and two small open areas to the right side of her neck. R44 was crying. R33 was assessed by the nurse and found to have one scratch and two open areas to the right hand and a scratch to the left forearm. Registered Nurse (RN)3 reported R44 indicated R33 scratched her when she would not allow her to take her phone and papaya. RN3 noted there was no papaya on the table but saw R44's phone on the table. RN3 indicated R44 told her R33 took her papaya. The Clinical Coordinator was documented as interviewing R44 on 12/09/24. R44 reported she was sitting her wheelchair on the lanai when another resident tried to grab her phone and took her papaya. R44 reported telling the resident not to take her things but the resident grabbed her by the hair. R44 further stated she had to protect herself and things. R44 was seen by the psychologist for evaluation on 12/11/24. The psychologist's impression was that the altercation with other resident has resolved but there could be a flare at any time due to the resident's impulsive tendencies and extreme guarding of her possessions. The psychologist recommendations includes watching R44 close for signs of upset with other residents when in common areas, particularly when on the back lanai as this seems to be the location of most conflicts and consider placing her bed to the far wall adjacent to the windows for security/privacy. R33 was seen for evaluation by the psychologist on 12/11/24. Psychologist noted R33 lacks capacity due to dementia and tends to wander and violate privacy/property of others, thus requiring close supervision. Psychologist further states R33 requires close supervision particularly when away from main common areas, as well as, minimizing interaction with R44. On 01/27/25 at 01:09 PM interviewed R33 in her room. R33 was unable to recall any incident(s) with fell ow residents. 3 ) ACTS #HI00011312 On 11/09/24 at 04:24 AM, the facility submitted an Event Report of an allegation of resident-to-resident abuse involving R44 and R3. This is R44's third involvement in resident-to-resident abuse. R44 was identified as the alleged perpetrator. The report documents on 11/09/24 at 03:15 AM R3 was on the bedside commode yelling for assistance, the privacy curtain was closed. The RN observed R44 in her wheelchair at the foot of R3's bed. R3 reported R44 threw a plastic mouthwash bottle at her. R44 admitted to throwing the bottle at R3 as she would not shut up. R3 with no visible injury. R44 was moved to another room. The completed report submitted on 11/18/24 at 03:33 AM notes the RN found the bottle at the side of R3's bed. Subsequent progress notes indicate on 11/12/23 R44 became furious at dinner time because she was looking for banana and papaya on her dinner plate, but it was not included. Staff explained that they don't have papaya now and R44 calmed down. Approximately 20 minutes later, she was noted to be shouting and crying and when asked what was wrong, she responded she didn't know and showed a video of kids and said, send me baby. Another progress note of 11/13/24 documents R44 with behavior while in the day room. R44 was seated at the table with other residents for a resident council meeting and when another resident attempted to back up and ran into R44, they began arguing. The other resident picked up a cup of water and threw it at R44. R44 attempted to take a swing at the other resident. This was R44's second incident with another resident. R44 was assessed by the psychologist on 11/23/24. Psychologist notes R44 presenting with status post cerebrovascular accident with aphasia, right hemiplegia (a condition that causes paralysis or weakness on one side of the body), and cognitive deficits. Psychologist notes managing R44's impulsive behaviors have been challenging and further complication includes language barrier English is not her primary language. R44 was happy being placed in a private room and has been provided a cooler to keep her papaya and banana in (related to earlier incident). Psychologist further notes the room reassignment to a private and quiet location has been well received by the resident who has not had an impulsive outburst since then. The update to the care plan included intervention for an appointment with the psychologist. R3 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease with hypoxia, history of falls and bipolar disorder. A review of a significant change MDS with ARD of 12/19/24 notes R44 is cognitively intact with a BIMS score of 15. R3 was not coded for exhibiting mood or behavioral symptoms. Review of the witness statement by Registered Nurse (RN)3 notes she entered the room when she heard R3 screaming for help. Upon entering the room, R3 was on the commode with privacy curtain drawn closed. R44 was at the foot of the bed yelling at R3. R3 reported to RN3 that R44 threw a plastic mouthwash bottle at her. The progress note of 11/09/24, created on 11/11/24 notes R44 admitted to throwing the plastic mouthwash bottle at R3 but denies the bottle hit R3. On 02/06/25 at 11:21 AM a telephone interview was conducted with RN2. RN2 was the Charge Nurse at the time of the incident. RN2 reported by the time she went to the residents' room, R3 was already back in bed. R3 reported having pain to the left arm. RN2 stated the plastic mouthwash bottle was found on R3's bed. RN2 reported there was no history of R44 and R3 not getting along or having a history of incidents. Interview with the Administrator and Social Services regarding R44's behavior. They reported working on finding placement for this resident and had R44 sign a behavioral contract. On 01/31/25, the facility provided a copy of the Behavior Contract for R44. The contract includes the following: 1. I will notify staff immediately when I have a concern regarding another resident here at facility; 2. I will NOT display/demonstrate any physical aggression with any residents here at facility; and 3. I will refrain from ANY negative verbal comments directed at other residents here at facility. The date of signature was illegible. On 02/07/25 at 10:13 AM, the Administrator and DON confirmed the contract was signed on 01/10/25, approximately one month from R44's last incident of 12/08/24. 4 ) ACTS #HI00011252 On 10/05/24 at 06:50 PM, the facility submitted an Event Report of an allegation of resident-to-resident abuse between R14 and R37. A review of the Event Report and facility's staff report notes on 10/05/24 at 05:00 PM, R37 was seated in his wheelchair in the dayroom. R37 could be heard screaming out for help when R14 stood up and yelled at R37 to shut up and punched R37 in the head twice. Review of staff witness report, CNA4 indicates he was assisting another resident with his meal in the dayroom. R37 was seated at a different table with two other residents, including R14. CNA4 saw R37 was done with his meal and began making several loud vocalizations which was noted to be a frequent observed behavior of R37. R37 was attended to, not needing immediate action. A few minutes later R37 made another series of vocal outbursts. At this time, R14 reportedly began a verbal exchange with R37. R14 was witnessed to stand and strike R37 in the face. R37 was removed and returned to his room. Another witness report by RN3 notes upon completion of assisting a resident with toileting, R37 was heard to call out (repetitive behavior). RN3 told R37 that his CNA would be with him in a few moments and to hang tight for a little while which R37 responded okay. While speaking to another staff member, R37 was heard to call out and RN3 witnessed R14 stand, yell at R37 and immediately hit him. Residents were separated. R14 was admitted to the facility on [DATE]. Diagnoses include, diabetes mellitus (insulin dependent), anemia, renal insufficiency, coronary artery disease, and anemia. Review of R14's quarterly MDS with ARD of 10/14/24 indicates he is cognitively intact as he scored a 14 on the BIMS. R14 was coded with symptom of mood, having little or pleasure in doing things over the past two to six days. R14 was not coded with behavior. R14 is coded with severely impaired vision (no vision). Following the incident, R14 was assessed by the psychologist on 10/17/24. The psychologist documents R14 was frustrated and impulsively became aggressive. The psychologist surmised this was an isolated incident, R14 recognized the inappropriateness of his behavior and gave verbal assurance he will address personal issues with staff and not lay hands on another resident. Review of R14's behavioral care plan includes intervention to monitor resident for presence of agitation, frustration, physical aggression, auditory hallucinations and intervene accordingly; updates of 10/10/24 includes when agitated with loud, repetitive stimulation, do not place me near anyone who is making loud, repetitive verbal stimulation, order for psychological consult due to physical altercation with another resident. Interviewed R14 on 01/28/25 at 09:36 AM in his room. R14 was able to recall the incident. He explained the guy yells every time and this time he got disgusted and punched R37. R14 stated that he would not do that again and the staff are aware that should R37 start yelling that they would move him away. R37 further stated that he doesn't like anything about R37 and he just don't like his ass. R37 shared that he doesn't know why he doesn't like R37 as he gets along with everyone else. A review of R37's record indicates he was admitted to the facility on [DATE]. Diagnoses include non-traumatic brain dysfunction and dementia. R37 has severe cognitive impairment, scoring a four on the BIMS. He was not coded for mood or behavior. A review of the psychiatric consult dated 10/01/24 notes diagnosis of dementia with behavioral disturbance - unstable, paranoid, and anxiety of being alone. Psychiatrist documents R37 is a reliable historian, he relayed to the psychiatrist they want me to stay here and has been screaming and yelling every day for the past 8 months. R37 noted to be agitated. Follow-up with psychiatrist was done on 10/14/24. R37 is seen for medication management. R37's care plan revision includes, but not limited to, 10/23/24, please bring me back to my room after meals in order to decrease overstimulation and frustration with noise. On 02/06/25 at 11:33 AM a telephone interview was conducted with RN3. RN3 reported R14 and R37 does not have a history of not getting along, they are usually okay together. RN3 recalled R37 has behavior or yelling and screaming out, he is being seen by a psychiatrist to correct the behavior. RN3 shared R37's behavior is attention seeking so when he calls out, staff need to go over and talk to him. At the time of the incident RN3 recalled R37 calling out, R37's assigned CNA responded to him. CNA attended to resident and left. RN3 heard R37 calling again, approached him and told him to hold on, his CNA is coming back. RN3 reported CNA4 no longer works at this facility. 5) The facility's policy and procedure titled, Freedom from Abuse/Neglect/Exploitation Long Term Residents was reviewed. The purpose of the policy and procedure is to keep residents free from abuse, neglect and corporal punishment of any kind, including involuntary seclusion, by any person. The type of abuse includes resident to resident abuse which notes cognitive impairment or mental disorder does not preclude a resident from being abusive; facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interaction (e.g. physical, sexual or verbal aggression; taking, touching or rummaging through another's property; wandering into another's rooms/space). The policy for training and maintaining staff's knowledge by providing education upon hire and at least annually includes but not limited to: Understanding behavioral symptoms of residents that may increase the risk of abuse and how to respond, including: i. aggressive and/or catastrophic reactions or residents; ii. Wandering or elopement-type behaviors; iii. Resistance to care; iv. Outbursts or yelling out; and v. difficulty in adjusting to new routines or staff. Also noted for preventing abuse, staff will be informed of the individual residents' care needs and behavioral symptoms, staff will identify, assess, and develop care plan interventions and monitor residents with needs and behaviors which may lead to conflict or neglect; and staff supervision will help to identify staff behaviors that may indicate potential for abuse or neglect. On 02/06/25 at 11:21 AM interviewed RN2 via telephone. Inquired what kind of training is provided regarding abuse. RN2 reported administration provides training on abuse and recently handouts were provided. Further queried what information was provided in the handouts. RN2 recalled it was a review of the process when there is suspected abuse, who to contact and to complete a report to the State Agency. Telephone interview with RN3 was done on 02/06/25 at 11:33 AM. RN3 was asked if she received training after the incident, she witnessed between R14 and R37 on 10/05/24. RN3 recalled they received training. Further queried what did she learn from the training, RN3 responded to round a little more, check on everybody, and assess before it gets worst. Further queried whether the facility provided training for providing care to residents with dementia or cognitive disabilities. RN3 recalled upon hire, training was done. Presently, RN3 stated she learns from other nurses on how to address behaviors. On 02/05/25 at 12:50 PM an interview was conducted with CNA5. Inquired what kind of training she received regarding abuse. CNA5 responded that she received in service training, which included review of the facility's policy and procedure. Further asked if the facility provided training on how to identify situations or behaviors that could lead to abuse. CNA5 responded, they were taught to remain calm and approach residents in a nice way. CNA5 is aware that if R37 becomes loud to take him back to his room. CNA5 also shared if residents become combative, they will inform the charge nurse, the resident may need medication. On 02/07/25 at 08:45 AM an interview was conducted with CNA1. CNA1 reported the facility has provided training on how to prevent abuse. CNA1 was asked what she looks for, CNA1 responded give resident water or something they want. Further asked how you ensure residents are not going to fight, CNA1 responded when they do you need to separate them. Requested documentation of the training that was provided to staff regarding abuse/neglect. The facility provided a copy of their policy and procedure, Freedom from Abuse/Neglect/Exploitation Long Term Care Residents with an attached staff sign-in form. Interview with Administrator was done on 02/07/25 at 10:28 AM. Administrator reported training is ongoing and includes review of the facility's policy and procedures. Further queried what kind of training is provided to staff to recognize behaviors that may put residents at risk for resident-to-resident abuse. Administrator explained residents' behaviors are discussed in their huddles meeting with the psychologist. Administrator was asked what if staff aren ' t' present. Administrator reported communication with the charge nurses are sent via email. Discussions are among the clinical staff.

Based on observations, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. In addition, the facility failed to ensure all medications used in the facility were securely stored in locked compartments in 3 of 4 medication carts. Proper storage and labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors and diversion of resident medications. Findings include: 1) On 01/30/25 at 08:37 AM, an inspection was done of the North Pink medication cart. Observation was made of an insulin glargine pen in the cart for Resident (R)152. The pen was not marked when it had been opened. A concurrent interview with Registered Nurse (RN)6 confirmed that the insulin pen should have been labeled when it was opened, otherwise there was no way to tell when it should be discarded. RN6 also confirmed that she had used the insulin pen that morning and had not noticed that it was missing an opened date. At 08:40 AM, observation was made of a Fluticasone nasal inhaler for R13 that had not been marked when it was opened. Concurrent interview with RN6 confirmed that it should have been labeled with an open date so that the discard date could be determined. When asked, RN6 stated that she was unsure how long the inhaler was good for after opening. A review of the manufacturer's insert revealed that Fluticasone nasal inhalers should be discarded thirty days after opening, or when the inhalation counter reaches zero, whichever comes first. 2) On 01/27/25 at 10:39 AM, observation was made that the North Pink medication cart had been left unlocked outside room [ROOM NUMBER]. Within two minutes, RN7 returned to the cart and validated that he should not have left it unlocked. On 01/27/25 at 02:29 PM, observation was made that the North [NAME] medication cart had been left unlocked. At 02:34 PM RN7 walked by the cart without noticing that it had been left unlocked. At 02:35 PM RN3 locked it. On 01/31/25 at 08:06 AM, observation was made of Licensed Practical Nurse (LPN)1 unlocking the East #2 medication cart then walking away into room [ROOM NUMBER] after a staff member called her, leaving the cart unlocked. Upon her return a minute later, LPN1 acknowledged that she should not have left the cart unlocked.

Based on confidential interview and record review, the facility failed to treat each resident with respect and dignity for one of one sampled resident reviewed for dignity. This deficient practice caused the resident distress and affected his mood. Findings include: Confidential interview was conducted with a resident on 01/27/25 at 11:15 AM. The resident reported that some of the staff are assholes, treating me bad. Asked how do they treat you badly, resident replied the staff member yells and cusses him/her out. The resident reported that this Certified Nurse Aide (CNA)2 is really loud, screaming and laughing, the resident finds it very disturbing. The resident reported residents are trying to rest and CNA2 is disrupting. The resident further reported the CNA is so loud it wakes him/her. Further queried whether CNA2 has been physical, resident replied no. The resident further shared that there have been times when, he/she yelled at CNA2 to shut up and used expletives. Then CNA2 will respond, is that how your mother taught you to act? Resident further stated taking offense to this statement as CNA is bringing involving a family member. Resident reported this gets him/her more frustrated and angry. Feels CNA is being antagonistic. Record review was done on 01/30/25 at 08:07 AM. A review of a quarterly Minimum Data Set (MDS) with an assessment reference date of 11/15/24 documents, the resident is cognitively intact and is coded with mood symptoms - having little interest in things, feeling down, moving or speaking slowly, and thoughts of being better off dead. Also reviewed progress which documents the resident's experience with the CNA. The staff member that entered the progress note documents the CNA the resident identified did not enter the resident's room and was not assigned to the resident.

Based on observations and interview, the facility did not ensure a resident's right to a safe and homelike environment was provided for one of one residents that expressed concern regarding their home environment. This deficient practice affects the resident's comfort and safety. Findings include: On 01/26/25 at 11:23 AM an interview was conducted with Resident (R)29. R29 reported the grab bar next to the toilet is tied up with plastic bags. Following the resident interview, observation of the bathroom found the grab bar to the left of the toilet was anchored with two plastic bags to the bar at the back of the toilet. Also observed a large area of the paint behind the toilet was blistered and peeling. On 01/28/25 at 08:34 AM concurrent observation was done with Licensed Practical Nurse (LPN)1. Inquired why is the bar tied up, LPN1 reported the resident has requested the grab bar to be out of the way to facilitate transfer to the toilet. Further queried whether the grab bar would stay up without it being tied. LPN1 was agreeable to undo the two plastic bags. Upon removal, observed when the grab bar is up and touched, it will disengage and fall. LPN1 was asked if the grab bar was broken, LPN1 responded there may be something missing that prevents the grab bar from locking in the upright position. LPN1 also confirmed the blistering and peeling paint behind the toilet. On the morning of 01/28/25 observed staff member touching up paint in the East hall. Concurrent observation was done with the staff member. The staff member confirmed the paint is blistering and peeling behind the toilet, as well as, an area by the toilet paper dispenser with peeling paint. The staff member reported the paint is on concrete and with moisture, the paint will peel off the wall. The staff member reported there was a work order regarding the peeling paint. Inquired when was the order submitted, the staff member was not sure. Requested the staff member provide a copy of the work order. The work order was not submitted prior to the survey team's exit.

Based on interviews and record review, the facility did not ensure the resident was apprised of the progress toward resolution of a filed grievance and prompt efforts were not made to resolve a grievance for one (Resident 1) of one residents that filed a grievance. This deficient practice resulted in the resident being unaware of the outcome of the grievance; therefore, five months have passed and Resident (R)1 continues without knowledge of the results of her grievance and an iPad. Findings include: On 01/29/25 at 01:03 PM, during the resident council interview, Resident (R)1 reported her iPad was damaged by a staff member. R1 shared the Certified Nurse Aides (CNA) was not careful during care, resulting in water damage to the iPad. R1 filed a grievance and reported she had not received a response from the facility on the disposition of the grievance. On 01/30/25 at 08:20 AM an interview was conducted with the Administrator. The Administrator was familiar with the grievance filed by R1 and stated the facility will replace the resident's iPad. Inquired whether the facility informed R1 of the outcome of the grievance. Administrator replied there is no written documentation R1 was notified of the facility's decision to replace the iPad. The Administrator also acknowledged the process for reimbursement is pending the State's accounting department. A review of the Grievance Form notes the day of the incident occurred on 08/21/24 at 05:30 AM. R1 reported the CNA was in a rush, accidentally dropped the resident's pitcher of water and when the CNA moved the over bed table, R1's iPad fell into the puddle of water. The iPad was wiped and R1 attempted to turn it on, but the iPad did not work. Subsequent document, Grievance Summary Report notes the grievance was received on 08/28/24. The facility's interview with the CNA notes while moving the bedside table, water spilled, iPad fell to the ground, then did not work. Further noted the recommendation was to replace the iPad and it was documented the grievance was resolved. The date of this document was 10/15/24. A Claim for Damage or Injury form was completed on 10/15/24. The amount of the claim for property damage was $205.00. A review of the facility's policy and procedures, LTC Grievance/Complaint provided by the facility on 01/29/25 at 03:13 PM notes the following: Written grievance decisions will be resolved promptly, but no later than 30 days from the filing of the grievance with the facility. Residents/representatives will be notified in writing of any grievance that takes longer than 30 days to resolution due to unforeseen circumstances or the nature of the specific grievance and will be provided an expected time-frame to completion. Further review notes under the facility's procedure, A summary report (attachment D) of the grievance will be completed in writing and made available to the resident/representative as per this policy. The summary will include: .5. A summary of the pertinent findings or conclusions; 6. A statement as to whether the grievance was confirmed or not confirmed; and 7. Any corrective actions taken or recommended by the facility .

Based on observations, record review, and interview, the facility failed to develop a baseline care plan that provided effective and person-centered care for 1 of 4 new admissions in the sample. Specifically, despite identifying that Resident (R)151 had psychotropic medication (medications that affect the mind, emotions, and behavior) needs, the facility failed to develop and implement a behavior-monitoring care plan. As a result of these deficient practices, the facility placed R151 at risk for avoidable declines or injury. Findings include: Resident (R)151 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of her electronic health record (EHR) noted she was admitted with diagnoses that include, but are not limited to, dementia with behaviors, generalized anxiety disorder (GAD), and cerebral atherosclerosis (when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls). As a result, R151 was admitted on Quetiapine Fumarate (an antipsychotic) 25 milligrams (mg) twice a day for agitation, and Escitalopram (an antidepressant) 10 mg daily for GAD. Observations made on 01/27/25 at 11:15 AM, 12:00 PM, 01:00 PM, 01:30 PM, and 02:15 PM, then again on 01/28/25 at 10:15 AM and 12:00 PM, noted R151 to be excessively sleepy. Review of her EHR noted her Psychotropic Drug Use Care Plan was created on 01/16/25 and included the following intervention: Complete behavior monitoring sheet every shift. Review of the Behavior Monitoring Flowsheet noted that it did not start until 01/27/25. On 01/30/25 at 12:59 PM, an interview was done with the Director of Nursing (DON) in the conference room. DON confirmed that the behavior monitoring flowsheet was created on 01/27/25 but should have been created upon admission on [DATE]. On 01/30/25 at 01:26 PM, an interview was done with the Clinical Coordinator (CC) in the conference room. CC acknowledged that the Psychotropic Drug Use care plan, along with the Behavior Monitoring Flowsheet, should have been created upon admission on [DATE].

2) Cross Reference to F692 (Nutrition Status Maintenance) and F710 (Resident's Care Supervised by a Physician). The facility failed to revise R10's care plan to reflect individualized preferences for foods and snacks. Record review found R10 had a significant weight loss. On 01/31/25 at 10:50 AM an interview was conducted with the Registered Dietitian (RD). RD confirmed significant weight loss occurred. Following identification of significant weight loss, RD reported she met with the resident to inquire what are his food and snack preferences are and discussed the use of dietary supplement. RD acknowledged the care plan was not updated to include the resident's preference as well as the interventions that were discussed. Based on record review and interview, the facility failed to review and revise the Comprehensive Care Plan (CP) for 1 of 1 resident (R) sampled for falls. Despite experiencing an unwitnessed fall with major injury, the facility failed to thoroughly revise R21's care plan to ensure his safety when alone. As a result of this deficient practice, R21 remained at risk for another fall. Findings include: The state agency (SA) received a facility-reported incident (FRI) regarding an unwitnessed fall with major injury for Resident (R)21. On 01/27/25, the SA entered the facility to investigate this event. Review of R21's electronic health record (EHR) noted that on 11/25/24, while attempting to ambulate unassisted to the bathroom, R21 fell and sustained a head laceration. The facility assessed him and transferred him to the emergency department where it was found that he had experienced the following injuries: an acute subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it), and small frontal lobe hemorrhages. R21 was admitted to the acute care hospital for seven days as a result. A review of the facility's fall report revealed it was unclear what caused the fall. A review of R21's current fall care plan revealed that despite being identified with impulsive behavior and repeatedly not calling for assistance out of bed, there was no intervention to ensure R21's bed was kept in the lowest position and with the wheels locked at all times. On 01/31/25 at 12:39 PM, an interview was done with the Director of Nursing (DON) in her office. DON acknowledged that keeping a resident's bed in the low and locked position is an important intervention for all residents, but especially for a resident at risk for falls. DON confirmed that the intervention was not a part of R21's care plan but should be. DON also confirmed that given his recent fall with major injury, the intervention should have been added if not already there.

Based on observation, record review and interview, the facility did not assure one (Resident 10) of one resident who is unable to carry out activities of daily living (ADL) receives the necessary services to keep his fingernails clean. This deficient practice has the potential to result in unsanitary practice which may lead to infections. Findings include: Resident (R)23 was admitted to the facility on [DATE]. Diagnoses includes but not limited to depression, anxiety, acute hypoxemic respiratory failure, chronic shortness of breath, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) with assessment reference date of 12/16/24 notes R23 is cognitively intact. In Section GG. Functional Abilities, R23 was coded as requiring substantial/maximal assistance for personal hygiene. Helper does more than half the effort. R23 has a care plan for potential for decrease in ADL with the goal to maintain/improve ADLs. The intervention for personal hygiene is for staff to assist resident. On 01/27/25 at 01:45 PM observed R23's left hand with reddish/brownish substance under his fingernails. Interviewed R23 on 01/27/25 at 02:14 PM. R23 reported a lady comes to help with nails but he hasn't seen her. R23 looked at his nails and started to pick the substance out from under his nails. R23 stated he was not sure what this was.

Based on observations, record review, and interviews, the facility did not ensure a resident receives appropriate treatment and services to prevent further decrease in range of motion (how far a joint or muscle can be moved in various directions) for one (Resident 2) of four residents in the sample for residents with limited range of motion. The facility failed to apply soft posey splint and did not have an individualized program to perform passive range of motion. This deficient practice affects the resident's ability to obtain and maintain his highest functional goal. Findings include: On 01/27/25 at 10:51 AM observed Resident (R)2 lying in bed wearing headphones with laptop on his over bed tray. Both arms were drawn up to his chest and both hands were in a fisted. On 01/28/25 at 08:05 AM an interview was conducted with R2. R2 was wearing his headphones and was unable to raise his arms up to push it aside or remove them. A staff member assisted in removing the headphones. R2 was asked if he has a splint (device used to prevent and correct contractures, a permanent shortening of muscles, tendons, or ligaments, resulting in reduced range of motion). R2 replied he does not have splints. Further queried whether R2 receives range of motion (ROM) services (a type of therapy that helps people regain or maintain their ability to move their joints - active ROM, the resident will move the joint using their own muscles and passive ROM, another person will move the joint). R2 responded, it's useless. Record review was done on 01/30/25 at 12:59 PM and 02/06/25 at 09:52 AM. R2 was admitted to the facility on [DATE] with diagnoses which includes but not limited to quadriplegia (partial or total loss of function in all four limbs and the torso) due to a diving accident, decubitus ulcer to sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and diabetes mellitus. R2 was hospitalized from [DATE] to 06/26/24 for bowel obstruction. He was readmitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 10/22/24 notes R2 is cognitively intact. In Section GG. Functional Abilities, R2 is coded with functional limitation in range of motion to both sides of his upper and lower extremities. In Section O. Special Treatments, Procedures, and Program R2 was coded as not receiving restorative nursing services for passive ROM, active ROM, and splint or brace assistance in the last seven calendar days. A review of R2's care plan for prevention of skin breakdown includes the following, nursing staff to apply splints to my bilateral arms as recommended, and ROM to my upper extremities to be performed before putting them on. The care plan did not include specific interventions to address R2's limited range of motion/contractures. On 02/06/25 at 10:00 AM, an interview was conducted with Certified Nurse Aide (CNA)10. CNA10 works the night shift. Inquired whether she performs ROM for R2. CNA10 replied that ROM is performed when resident is dressed, and ROM is performed to both legs and hands. Further queried whether there is a program that specified what is required for R2's ROM exercises. CNA10 responded she exercises R2's legs and hands. CNA10 was asked how she knows what exercises are required for R2. CNA10 stated nobody has taught her, she goes by the years of experience. Inquired whether R2 has soft posey brace. CNA10 stated she doesn't know whether R2 has a brace. Accompanied CNA10 to R2's room to look for the brace. CNA10 stated she does not think R2 has a brace. On 02/06/25 at 08:55 AM, interview and concurrent record review was done with the Director of Nursing (DON). The DON reported R2 has Podus boots (a device designed to prevent and manage heel pressure ulcers by suspending the heel off the surface it rests on). Also noted a care plan for potential for decrease in activities of daily living which includes interventions for soft posey elbow extension brace end of evening shift and to remove start of day with monitoring for discomfort (dated 11/03/23) and assist to do ROM twice a day and PRN (as needed) to all extremities as tolerated (dated 12/02/24). Review of the electronic health record (EHR) with the DON documented ROM was being provided twice a day. Further queried whether R2's care plan included specific ROM or passive ROM for the aides to perform. Also, inquired whether R2 has the soft posey splints for his arms. DON was agreeable to follow up. On 02/06/25 at 12:10 PM, DON reported when R2 returned from the hospital in June 2024 there were no soft posey braces. DON also stated she would request a physical therapy screen for R2.

Based on observation, record review, and interview, the facility failed to assure one (Resident 10) of two residents reviewed for significant weight loss was evaluated by his physician and his care plan was revised to include person-centered interventions. This deficient practice has the potential to result in continued weight loss and the inability of the resident to maintain acceptable parameters of nutritional status. Findings include: Cross Reference to F710. The facility did not ensure Resident (R)10's physician was notified of the significant weight loss to further evaluate the resident and contribute to the care plan. Cross Reference to F657. The facility did not ensure R10's care plan was revised to include individualized interventions to maintain his current nutritional status. On 01/27/25 at 11:11 AM, observed R10 lying in bed. R10 immediately waved his hand at surveyor and said he was not interested. Subsequent observation on 01/28/25 at 09:33 AM found the privacy curtains were drawn closed. On 01/28/25 at 12:35 PM observed R10's lunch tray to consist of coffee, chocolate Ensure, entrée (covered), ground fruit, soup, and chocolate ice cream. A review of the facility's matrix noted R10 with unplanned excessive weight loss. Record review was done on 01/28/25 at 03:54 PM and 01/29/25 at 04:09 PM. R10 was admitted to the facility on [DATE]. Diagnoses includes but not limited to anemia; renal failure; arteriovenous malformation of brain, and squamous cell carcinoma of base of tongue. R10 was discharged from the facility on 10/15/24 to an acute hospital for aspiration pneumonia. He was readmitted to the facility on [DATE]. Review of the hospital record from 10/15/24 to 10/25/24, noted R10 weighed between 154 to 143 pounds (lbs.). Record review done on 01/28/25 at 03:38 PM found documentation on 10/25/2024, R10 weighed 159.6 lbs. On 11/30/2024, the resident weighed 135.2 pounds which is a 15.29 % Loss. Review of the facility's Registered Dietician (RD) progress note of 11/01/24 in the electronic health record (EHR) R10 was hospitalized for the past 10 days (10/15/24 to 10/25/24) for aspiration pneumonia and speech therapy assessment. The speech therapist recommended minced and thin liquids with Ensure (dietary supplement) one can two to three times a day. At this time, the RD's recommendation was to continue monitoring. R10 was assessed at low nutritional risk. The Weekly Skin/Weight Condition Review of 11/19/24 documents R10's weight ranged from 136 to 166 lbs. over the last six months, possibly due to scale discrepancy and poor food intake. RD noted R10 with 25% intake and seven meal refusals. Subsequent entry of 12/07/24 notes R10 with a 15.2% weight loss in one month and a 9.6% weight loss in six months (not significant). The recommendation was to continue current diet, honor resident preferences, continue to monitor weights monthly, and nutrition related labs per protocol. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/02/24 notes R10 was 70 inches in height and weighed 140 lbs. R10 was coded for weight loss (5% or more in last month or 10% or more in last 6 months) and not on physician-prescribed weight-loss regimen. A review of the care plan for Nutrition Risk with goal for no significant weight change documents the following interventions: provide diet as ordered and food consistency as best tolerated, provide preferences as verbally or observed; monitor monthly and prn weights, discuss in interdisciplinary team meeting as needed; and notify physician and RD of significant weight loss and assess possible cause of weight loss. There was notation care plan reviewed 12/04/24. On 01/31/25 at 10:50 AM concurrent record review and interview was conducted with the facility's RD. RD acknowledged R10 had a significant weight loss. Inquired what contributed to the resident's weight loss. RD responded R10 is cranky about being weighed and has pain with poor appetite and poor intake. R10's diet order is minced and moist and he receives supplement. RD reviewed supplement consumption and reported intake ranges from 25% to 100% with many refusals. The care plan was reviewed with the RD. The interventions included: provide diet as ordered and food consistency as best tolerated, provide preferences as verbally or observed, monitor monthly and prn weights, discuss in IDT meeting as needed, and notify physician and RD of significant weight loss. RD noted the documentation that the care plan was reviewed on 12/10/24. Inquired if there were care plan revisions. RD was not aware of any changes and the history of the interventions. RD reported following identification of R10's weight loss, she visited the resident weekly to ask about food/snack preferences and supplement intake. RD confirmed there is no documentation in the care plan of the resident's food/snack preferences. RD noted R10's ideal body weight is 166 lbs. RD stated R10's weight loss started on readmission from acute hospital in October, then there was further loss in November and December. Further queried whether R10's physician was notified of the significant weight loss. RD replied she did not notify the resident's physician; nursing may have notified R10's physician. On 01/31/25 at 11:18 AM interview was conducted with the Director of Nursing (DON). Inquired whether R10's physician was notified of the significant weight loss. The DON reported residents are discussed in weekly meetings with the physician. The DON confirmed there is no documentation R10's physician was notified of the significant weight loss.

Based on observations, interviews, and record review the facility failed to label resident's nasal cannula with a date when first used for one of one resident in the sample. This failure has the potential to result in illness due to bacterial/viral buildup in the plastic tubing. Findings include: On 01/27/25 at 11:09 AM, Resident (R)23 was asleep. R23 was wearing a nasal cannula (a thin, flexible tube that goes around the head and into your nose to deliver oxygen). There was no label on the nasal cannula to document when the nasal cannula was changed and/or first used. Second observation on 01/27/25 at 01:19 PM staff were transferring resident from bed to wheelchair. R23 was connected to an oxygen canister. Did not observe the nasal cannula was labeled with a date. Resident interview was conducted on 01/26/25 at 01:44 PM on the lanai. Inquired how often does the staff change the nasal cannula tubing. R23 responded once a month the facility changes the whole thing. Third observation on 01/28/25 at 10:12 AM observed no date label on the nasal cannula. At 10:20 AM concurrent observation was done with Licensed Practical Nurse (LPN)1. LPN1 confirmed the nasal cannula was not labeled with a date to indicate when it was changed. LPN1 reported the nasal cannula is changed weekly or if it is gunky. On 01/30/25 at 11:10 AM the Director of Nursing (DON) was interviewed in her office. Inquired when is nasal cannula changed? DON reported she will need to follow up. Further queried why is it important to change the nasal cannula, DON responded to prevent infection and ensure it doesn't get dirty. Requested a copy of the facility's policy and procedure for oxygen use. On 01/30/25 at 12:05 PM, the DON provided a copy of the policy and procedure, Oxygen Administration. DON reported the nasal cannula is to be changed weekly. The policy and procedure did not include procedures to label nasal cannula with the date it was changed and how often to change it.

Based on record review and interview, the facility failed to notify the resident's physician of a significant weight loss for one (Resident 10) of two residents sampled for significant weight loss. This deficient practice resulted in the lack of physician oversight to evaluate and manage causes of the resident's weight loss, inability to contribute to the resident's assessment and care planning, and ensure resident is maintaining acceptable parameters of nutritional status. Findings include: Cross Reference to F657. The facility did not revise the resident's care plan to ensure person-centered interventions were implemented. Cross Reference to F692. The facility failed to ensure a resident maintained acceptable parameters of nutritional status as evidenced by significant weight loss. Record review done on 01/28/25 at 03:38 PM found documentation on 10/25/2024, Resident (R)10 weighed 159.6 lbs. On 11/30/2024, the resident weighed 135.2 pounds which is a -15.29 % Loss. On 01/31/25 at 10:50 AM concurrent record review and interview was conducted with the facility Registered Dietitian (RD). RD noted R10's weight loss started on readmission from acute hospital in October, then there was further loss in November and December. Further queried whether R10's physician was notified of the significant weight loss. RD replied she did not notify the resident's physician; nursing may have notified R10's physician. On 01/31/25 at 11:18 AM interview was conducted with the Director of Nursing (DON). Inquired whether R10's physician was notified of the significant weight loss. The DON reported residents are discussed in weekly meetings with the physician. The DON confirmed there is no documentation R10's physician was notified of the significant weight loss.

Based on observations, record review and interviews, the facility failed to ensure the pharmacy recommendations were addressed for one (Resident 27) of five residents reviewed for unnecessary medication when the physician did not respond to the pharmacist's recommendation for dose reduction of psychotropic medications. This deficient practice could potentially result in residents receiving unnecessary medication. Findings include: Record review done on 01/31/25 at 09:01 AM notes Resident (R)27 was admitted to the facility on [DATE]. Diagnoses includes but not limited to anemia; dementia, senile delusions; emotional lability, mood disorder; metabolic encephalopathy; and major depressive disorder, recurrent severe without psychotic features. A review of the medication orders noted R27 is prescribed with bupropion (anti-anxiety), Prozac (antidepressant) and risperidone (antipsychotic). The pharmacist Medication Regimen Review (MRR) documents from 12/12/23 to 01/10/25 were reviewed. There was a note for 08/13/24 the MRR was completed and see report. Requested a copy of the report. On 01/31/25 at 11:28 AM, the Director of Nursing (DON) provided a copy of the Consultant Pharmacist's Medication Regimen Review dated for recommendations created between 08/01/24 and 08/13/24. The pharmacist notes, R27 has been taking the antipsychotic Risperidone, 1 mg, daily since 07/20/23 for diagnosis of paranoid delusions. Further noting it is time for documentation of an annual review of this psychotropic medication and to consider a dose reduction. There was no documentation of a response from R27's physician. Review of the quarterly Minimum Data Set with an assessment reference date of 10/18/24 notes in Section N. Medications, R27 coded as receiving an antipsychotic and antidepressant on a routine basis. Also noted, a gradual dose reduction was not attempted and there is no documentation by the physician a gradual dose reduction would be clinically contraindicated. Subsequent interview with Director of Nursing (DON) on 01/31/25, the DON confirmed there is no documentation of physician's response to document need for dose reduction or to indicate a dose reduction would be clinically contraindicated.

Based on observations, record review, and interview with staff members, the facility did not assure their infection control program for enhanced barrier precautions (an approach to expand the use of personal protective equipment, the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-Resistant Organisms [MDRO] to staff hands and clothing) were implemented. Findings include: On 01/08/24 observed posted signage at the facility's entrance alerting staff and visitors of COVID-19 outbreak. The instructions were to use an N95 face mask and face shield. On 01/08/24 at 10:30 AM during initial screening of residents on the unit, observed some residents had signage posted for enhanced barrier precautions (EBP). Interviewed the Director of Nursing (DON) regarding the need for personal protective equipment (PPE). DON reported PPEs for residents on EBP are required only when providing treatment and/or care and not needed if you do not have contact with the resident. Observation on 01/08/24 found signage for EBP for Resident (R)19. R19 was observed lying in bed watching television. R19 had a tracheostomy and ventilator. On 01/08/24 at 11:38 AM while walking through the unit, observed a staff member standing on the resident's right side with back facing the door. The staff member was observed to be wearing gloves, a face mask, and goggles. Staff member was seen leaning over the resident, stood upright, and removed goggles. The resident could be heard with gurgling sounds and holding a clear tube up to her mouth. At 11:45 AM, staff member exited the resident's room wearing face mask and goggles were hanging from the neckline of the scrub top. Upon exiting the resident's room at 11:45 AM, interviewed the staff member. Staff member was a Respiratory Therapist (RT)1. Inquired what kind of care was provided to R19. RT1 responded, treatment was not being provided. RT1 clarified the resident has a tracheostomy and was being assisted to speak by capping the tracheostomy tube. Second observation on 01/08/24 at 02:26 PM observed an x-ray technician in R19's room. The staff member was wearing gloves and a face mask. The staff member took the x-ray. After taking the x-ray, the technician walked over the left of the resident and removed a rectangle plate that was wrapped in plastic from under the resident. The technician was not wearing a gown. Third observation on 01/10/24 at 09:40 AM observed a lab technician and Charge Nurse (CN)1 in R19's room. The CN wore a face mask, face shield, gloves, and gown. The lab technician was not wearing a gown. Registered Nurse (RN)1 was observed in the hall and reported lab technician was inserting an IV as the resident requires fluids and was also drawing blood for lab tests. Concurrent observation was made with RN1. RN1 confirmed the staff member was not wearing a gown and should wear a gown to protect the resident. Record review on 01/10/24 at 11:59 AM noted R10 was admitted to the facility on [DATE]. A review of R19's comprehensive medical history dated 06/22/22 notes resident has history of MRSA (Methicillin-resistant Staphylococcus aureus is a group of gram-positive bacteria that is responsible for several difficult-to-treat infections in humans) and ESBL (extended spectrum beta-lactamase are enzymes produced by some bacteria that may make them resistant to some antibiotics) R19 was admitted to the acute hospital in April 2022 with diagnoses of acute chronic hypoxic respiratory failure secondary to aspiration pneumonia requiring intubation with ventilation, status post tracheostomy and PEG (percutaneous endoscopic gastrostomy is a procedure to place a feeding tube). R19 currently on antibiotics due to diagnosis of urinary tract infection. On 01/10/24 at 01:58 PM, the DON was interviewed. The observations of the three staff members were shared with the DON. The DON confirmed the respiratory therapist should have been wearing a gown. It was further explained it is difficult when staff come from the hospital to provide services as EBP is not required there. DON stated the respiratory therapists have been re-inserviced on the use EBP. The DON also confirmed the x-ray technician, and the lab staff should wear a gown while providing services to R19. Review of the facility's policy and procedures for Enhanced Barrier Precautions which was provided by the facility on 01/10/24 at 01:38 PM. EBP applies to residents with an indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Further noted to perform hand hygiene and wear gloves and a gown for high-contact resident care activities, device care or use, and wound care. High-contact was defined as care activities which included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. Devices include central line, urinary catheter, feeding tube, and tracheostomy.

Based on record review and interview, the facility failed to ensure an environment free of accident hazards for one resident (Resident (R)32) and/or receives adequate supervision to prevent accidents for one resident (R142) sampled. As a result of this deficiency, both residents had falls and R142 experienced harm that required the resident to be transported to an acute hospital on another island and had emergency neurosurgery (brain surgery) and a long hospitalization with further complications. Findings include: 1) On 10/21/22 at 10:04 AM, reviewed the facility reported event that was received via email to the Office of Healthcare Assurance (OHCA) on 06/29/22 at 4:00 PM. R142 is a [AGE] year-old female with a history of [CONDITION(S)] and on [CONDITION(S)] with a left below the knee amputation and was taking anticoagulants (blood thinner's). On 06/28/22 at 07:02 AM, R142 was found in the room, on the floor, laying on the right side. She was noted to have swelling to her right eye and vomiting. On 06/29/22, R142 was noted with an altered level of consciousness and was transferred to the Emergency Department (ED) at the acute care hospital. While in the ED, she had a computerized tomography (CT) scan of the head that showed a right-side Subdural Hematoma (SDH) (bleeding under the skull in the brain) with a right to left midline shift (swelling that causes pressure that pushes the brain tissue to one side). The treatment plan was to transfer the resident to an acute care hospital in Honolulu for possible surgical intervention. On 10/21/22 at 10:42 AM, a concurrent interview and review of R142'sElectronic Medical Record (EMR) was conducted with the Assistant Director of Nursing (ADON). R142 was admitted to facility on 06/27/22 with diagnosis that included SDH, dysphagia (difficulty swallowing), embolic stroke (blood clot in the brain), End Stage Renal Disease ([CONDITION(S)]), [CONDITION(S)], ascites, and [CONDITION(S)]. R142 also had a below the knee amputation (BKA) with a prosthetic leg and required a wheelchair to get around. R142 was at the facility for physical therapy/ occupational therapy (PT/OT) rehabilitation. Queried the ADON if R142 had a history of falls? The ADON replied she did not know and recalled R142 had used a call bell, although not consistently, and yelled out as well for staff. On 10/21/22 at 12:00 PM, reviewed Admission Note dated 06/27/22 at 7:00 PM. Registered Nurse (RN)10 documented Pts. (patient) awake and alert. Pt oriented to person and place. Able to speak and understand some English, but unable to understand concepts, unable to answer complex questions. Here for Physical therapy (PT)/Occupational therapy (OT). On 10/24/22 at 09:15AM, conducted a review of R142's Baseline Care Plan. Cognition: checked confused; Safety: History of falls; Activity of Daily Living (ADL's): transfer assist of 2+ (two or more staff); Walking: total dependence; Toileting: total dependence, wheelchair and side rails x 2; and eating, grooming, and bathing the resident is total dependent on staff. On 10/25/22 at 12:00 PM, conducted a review of nursing progress notes: -On 06/28/22 at 07:36 AM, RN 10 documented, at 07:02 AM, noted pt. and room mates' call light on. Went to room and found pt. on the floor laying on her right side. Observed redness and mild swelling to right eye and intact shear wound to lateral eyebrow. Also noted mild bruise to right knee. Prior to fall, pt. calling frequently. At 05:15 AM, pt. wanting to sit up at the edge of bed. Assisted to sitting position. At the change of shift pt. reported nausea and vomitus in basin noted post fall. - On 06/28/22 at 9:00 PM, RN15 documented, after dinner around 7:45 PM, R142 vomited a large amount undigested food. Neuro check done, left eye pupils responsive unable to assess right side due to swelling. R142 only answered simple questions with a few words. Bilateral (both) hand grasps fair and right foot push fair. -On 06/29/22 at 09:46 AM, RN 10 documented, at 09:30 AM, pt. awake and alert, but observed pt. not speaking with writer. Hand grasp to right very strong, but left, weak. pt. with vomiting throughout morning, pt. refusing to eat. CT of head with contrast ordered. -On 06/29/22 at 12:39 PM, R142's spouse visited the resident, after being informed of the incident, and reported since yesterday (06/28/22) R142's level of consciousness (LOC) changed, and the resident had an increase of vomiting and generalized weakness from the previous day. Pt. not eating or drinking, per physician (MD) okay to send to ED. Pt. to ED at 11:30 AM. -On 06/29/22 at 3:01 PM, a Nursing Progress Note, The ED Care Coordinator (from the acute hospital) informed the facility that the acute hospital was attempting to transfer R142 to another acute hospital in Honolulu. On 10/25/22 at 09:10 AM, conducted a review of R142's EMR. Review of R142's Hospitalist History & Physical, dated 08/01/22, documented R142 (admit and exam date: 08/01/22 at 4:57 PM) returned to East Hawaii Hospital for ongoing care after prolonged hospitalization in Honolulu at acute care hospital. Patient presented originally at the East Hawaii ED on 06/29/2022 with Altered Mental Status (AMS) after ground-level fall. She was on [MEDICATION(S)] and Aspirin (blood thinners) at that time. Work up in the ED found her to have a large right-sided SDH with mass-effect and midline shift. She is emergency transfer to a Honolulu Hospital for further care on 06/29/2022. She had a long-complicated hospital course while at the hospital in Honolulu. She was found to be aphasic (unable to speak) and unable to swallow anything safely. A gastrostomy tube (G-tube) was placed on 07/12/22. She remained intubated post G-tube placement and follow up head CT showed worsening of the right to left shift in the brain. On 07/13/22 she had embolization (removal of a blood clot) of the right middle meningeal artery (in the base of the brain). On 07/14/22 she had a craniotomy with evacuation of the hematoma. She remained intubated. On 07/17/22 she was found to have a new right frontal hemorrhage. 2) (Cross Reference to F656- Implement Care Plan and F657- Care Plan Revision) On 10/19/22 at 10:12 AM, conducted a record review of R32's Electronic Medical Record (EMR). R32 was admitted to the facility on [DATE] with diagnosis that included Dementia with behavioral disturbances, [CONDITION(S)], chronic kidney disease, stage 4, and various heart valve insufficiencies. Review of R32's admission Minimum Data Set (MDS) with an Assessment Reference Date of 01/06/22, documented a Brief Interview of Mental Status (BIMS) score was 1, indicating R32's cognition was severely impacted. Progress notes documented R32 had multiple falls on: 1) 02/12/22- Unattended/assisted fall on day shift, out in dayroom, no injury 2) 02/14/22- Unattended fall on day shift, hematoma to head 3) 03/03/22- Unattended fall on night shift, no injury 4) 03/29/22- Unattended fall at 1820- no injury 5) 05/20/22- Unattended fall with no injury 6) 09/01/22- Unattended fall with skin tear 7) 09/27/22- Unattended fall with skin tear 8) 10/06/22- Unattended fall with injury (hematoma to left side of head) Review of Physical Therapy notes written on 02/22/20 at 1:20 PM by Physical Therapy staff (PT)1 documented a physical therapy evaluation was ordered to treat was received to assess patient status post witnessed fall on 02/12/22. PT recommended for staff to continue to utilize sara lift and geri-chair for trunk support and recline and to provide constant supervision while seated in chair due to occasional agitated and unsafe behaviors. Review of the resident's comprehensive person-centered care plan documented a fall care plan with interventions for visual supervision during morning report, every 30-minute checks, and R32 was on close watch. Review of R32's assessments did not contain documentation that the facility conducted an assessment for R32's risk of falls and/or accident hazard of the use of the geri-lounger for the resident. On 10/21/22 at 09:35 AM, conducted a concurrent record review of R32's EMR and interview with the Director of Nursing (DON). DON stated R32 prefers to be in the geri-lounger as she does not like to be in a regular wheelchair or in bed and is in the geri-lounger out in the day area for most of the day. DON confirmed majority of R32's falls occurred when the resident was seated in the geri-lounger out in the day area and confirmed staff was not always present when the falls occurred. DON confirmed PT did not conduct an evaluation for risk of falls and/or accident hazard related to R32's use of the geri-lounger.

Based on observation and interview, the facility failed to provide meals that were at the desired temperature based on the resident's preferences. As a result of this deficiency, there is the potential to affect the resident's nutritional status, hydrations status, and could exposure the residents to food-borne illness and has the potential for harm. Findings include: During a Resident Council meeting on 10/19/22 at 03:10 PM, Resident (R)156 stated the food is often cold. The trays come between 12:00 PM-1:00 PM and many times the food is cold. Another resident, R163, reported the hot food is not always hot and sometimes the cold food is not cold and gave an example of ice cream being completely melted by the time the resident received his/her tray. On 10/20/22 at 11:30 AM, conducted a review of the kitchen. Two (2) kitchen staff were plating the food for the unit's lunch meal. Staff plated and placing the covered plates onto a tray, then into the meal carts (used to transfer the meals from the main hospital to the facility) which were identified as Cart One, Cart Two, and Cart Three. The process of transporting the meal carts from the hospital required the meal carts to be transported one at a time, outside the acute hospital, then down a walkway to the facility via a motorized cart by the kitchen staff. The meal carts were attached directly to the motorized cart for the purpose of transport and did not have internal heating to keep the food warm throughout the transportation process. While in the kitchen at the hospital at 11:30 AM, this surveyor a test tray to be sent down to the facility. A test tray was placed on the bottom of the Cart Two and marked test tray. When the meal carts arrived at the facility, nursing staff informed the surveyors that the kitchen had sent two (2) test trays instead of one (1). Test tray #1 arrived on the East Unit meal cart and test tray #2 arrived on the South Unit meal cart. At approximately 12:02 PM, meal Cart One and Three arrived at the East Unit, and meal Cart Two was the last to be delivered from the kitchen. At 12:24 PM, after the last tray was delivered to the residents, the surveyors removed both test trays from the meal carts and took the internal temperature with a thermometer (provided by the facility) and tasted the food for quality and palatability. The meal consisted of a Char [NAME] chicken thigh, one scoop of brown rice, green beans (canned), and a bowl of chicken noddle soup. Test Tray (TT) #1 was on the second meal cart delivered to the facility. The temperatures recorded with the internal thermometer documented: - Char [NAME] chicken= 151.0 degrees ( ) Fahrenheit (F) - Chicken and rice soup= 148 F. - Taste test identified both dishes tasted hot and deemed appropriate by this surveyor. TT #2 was on the third and last meal cart to arrive at the facility and was delivered to the South Unit. The temperatures recorded with the internal thermometer documented: - Char [NAME] chicken = 121.8 F - Chicken and rice soup was 122.0 F - Taste test identified the food on TT#2 was noticeably cooler that the first TT. The Char [NAME] chicken tasted warm and the Chicken & rice soup tasted lukewarm. The palatability of this TT was not as enjoyable as TT#1 and could clearly identify with the resident's concerns regarding the temperature(s) of the meals. On 1020/22 at 1:00 PM, conducted this surveyor spoke to the Kitchen Manager (KM) and reported the internal food temperature and taste test results of the two TTs. KM was informed that there was a difference of 30 degree F between TT#1 and TT#2, validating the resident's report of the hot food not being hot and cold food not being cold for regular scheduled meals.

Based on interviews and record reviews, the facility failed to ensure the resident's wishes and preferences were considered in the exercise of the rights of the representative for 1 (Resident (R)10) of 2 residents sampled. Findings include: On 10/19/22 at 2:12 PM, conducted a record review of R10's Electronic Health Record (EHR). Review of R10's Advance Health Care Directive (AHCD) documented the resident's wishes were to be resuscitated, receive pain medication, receive artificial hydration and nutrition, and identified a designated Healthcare Decision Maker (HDM). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R10' AHCD and POLST were conflicting. This surveyor could not locate documentation in R10's EHR that indicated the facility was aware of this discrepancy and the physician had addressed the discrepancy with the HDM. On 10/20/22 at 10:39 AM, conducted a concurrent interview and record review of R10's EHR with SW. SW reviewed R10's AHCD and POLST and confirmed the R10's AHCD documented the resident wanted to be resuscitated but the POLST documented the resident was not to be resuscitated. Inquired with SW if there was documentation that the discrepancy between R10's AHCD and POLST was addressed with the HCM by the physician. SW reviewed R10's EHR but was unable to provide documentation that the physician discussed the discrepancy between the AHCD and POLST with the HDM. On 10/20/22 at 11:25 AM, conducted an interview and concurrent record review of R10's EHR with AA. Informed AA of the discrepancy between R10's AHCD and POLST and provided AA with an opportunity to provide documentation that the physician reviewed the AHCD and POLST with HDM. AA and this surveyor reviewed a nursing progress note that on admission (01/07/22), HDM designated R10 as DNR on the POLST and nursing staff informed the physician of HDM decision. The nursing progress note did not document the physician was aware of the discrepancy between R10's wishes documented on the AHCD and HDM designating R10 as DNR and there was a discussion with HDM of discrepancy between the documents. Review of the facility's policy and procedure for Advance Directive/POLST (last revised on 03/2022) documented 3. If the resident has an existing AD (advance directive), the physician or APRN (advanced practice registered nurse) should ensure the content is consistent with those indicated on the POLST and B. When possible, the physician or APRN should review the POLST for with the resident or his/her surrogate when: 2. The resident is transferred from one setting to another.

Based on observations, interviews, and record review, the facility failed to ensure was the comprehensive person-centered care plan (CP) was implemented to maintaining the resident's highest practicable physical well-being for one (1) resident (Resident (R)32) sampled. Findings include: (Cross Reference to F657- Care Plan Revision and F689- Accident/Hazard) Observations were made on 10/18/22 at 1:15 PM, 10/19/22 at 09:25 AM (surveyor #2 also witnessed), and 10/20/22 at 09:55 AM (surveyor #2 also witnessed), of R32 in the day area (in front of the nursing station), unattended (no visible staff in the area), seated in a geri-lounger recliner. R32's feet were elevated in the recliner and the resident's head was reclined down (approximately 45 degrees) in a laying position on the lounger. On 10/19/22 at 10:12 AM, conducted a record review of R32's Electronic Medical Record (EMR). R32 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R32's admission Minimum Data Set (MDS) with an Assessment Reference Date of 01/06/22, documented a Brief Interview of Mental Status (BIMS) score was 1, indicating R32's cognition was severely impacted. Progress notes documented R32 had multiple falls on: 1) 02/12/22- Unattended/assisted fall on day shift, out in dayroom, no injury 2) 02/14/22- Unattended fall on day shift, hematoma to head 3) 03/03/22- Unattended fall on night shift, no injury 4) 03/29/22- Unattended fall at 1820- no injury 5) 05/20/22- Unattended fall with no injury 6) 09/01/22- Unattended fall with skin tear 7) 09/27/22- Unattended fall with skin tear 8) 10/06/22- Unattended fall with injury (hematoma to left side of head) Review of Physical Therapy notes written on 02/22/20 at 1:20 PM by Physical Therapy staff (PT)1 documented a physical therapy evaluation was order to treat was received to assess patient status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive person-centered care plan documented a fall care plan with interventions for visual supervision during morning report, every 30-minute checks, and R32 was on close watch. On 10/21/22 at 09:35 AM, conducted a concurrent record review of R32's EMR and interview with the Director of Nursing (DON). Informed the DON of this surveyor's observations of R32 seated in the geri-lounger in the day area with no staff within visible sight of the resident. DON confirmed majority of R32's falls occurred when the resident was seated in the geri-lounger out in the day area and confirmed staff was not always present when the falls occurred. Reviewed R32's CP, Physician Orders, Progress Notes, Post-Fall Reports, and assessments. DON acknowledged this surveyor and surveyor2's observation and stated staff should have been within the line of sight of R32 due to her high risk of falls and the number of falls the resident has had.

Based on observations, record review, and staff interviews, the facility failed to ensure adequate interventions were provided to establish proper nutrition for one (Resident (R) 17) of three reviewed for nutrition in a total sample of 14 residents. The facility failed to re-weigh R17 per facility policy when a significant weight loss was first identified, failed to immediately assess R17's nutritional status after a significant weight loss, and failed to immediately notify R17's physician of the significant weight loss. Findings include: Review of an undated document provided by the facility titled Patient Registration Form, indicated R17 was admitted to the facility 03/23/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan provided by the facility, dated 03/23/21 indicated R17 was nutritionally at risk. The care plan directed staff to encourage R17 to eat and drink, to monitor monthly and as needed weights, to discuss in the interdisciplinary team (IDT) meetings, and to notify the physician and Registered Dietician (RD) of significant weight loss or gain. Review of a document provided by the facility titled, New Nutrition Assessment/MDS (Minimum Data Set) Note dated 03/31/21 documented R17 weighed 157.7 pounds on 03/23/21. Review of a document provided by the facility titled Weight History, dated 05/02/21 indicated R17 weighed 156.5 pounds. Review of R17 significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/19/21, revealed the resident had a Brief Interview for Mental Status (BIMS), score of two out of 15, indicating severe cognitive impairment. The assessment revealed the resident was independent with eating with set up from staff. The assessment revealed the resident weighed 157 pounds and the resident's height was five feet, six inches. The assessment indicated the Care Area Assessment (CAA) triggered under nutrition and directed the staff to develop a care plan. Review of a care plan provided by the facility, dated 05/26/21 indicated R17 was nutritionally at risk and the resident was on a mechanically altered diet. The care plan indicated staff were to notify the physician and RD of significant weight loss or gain for R17. Review of a document provided by the facility titled IDT (Interdisciplinary Team) Meeting Notes, dated 06/02/21 indicated R17's weight remained stable over a 30-day period. The document indicated the resident was on a regular/chopped diet, received Ensure Plus three times a day, was eating approximately 50 percent of his meals, and was consuming 100 percent of his nutritional supplements. The document indicated R17 voiced he had a poor appetite since his stroke. Review of a document provided by the facility titled Weight History, dated 06/02/21 showed R17 weighed 153.2 pounds, indicating a 2.85 percent loss since 03/23/21. Review of documents provided by the facility titled Nurse Note, for the months of July 2021 and August 2021 failed to address changes in R17's weight. Review of a document provided by the facility titled Weight History, dated 07/09/21 showed R17 weighed 150.6 pounds, indicating a 4.5 percent loss since 03/23/21. Review of a document provided by the facility titled Weight Chart, dated 08/08/21 indicated R17 sustained significant weight loss of 13.8 pounds from the last recorded weight of 150.6 pounds. The resident's current weight of 136.8 pounds indicated a 9.16 percent loss since 07/09/21. The document revealed a Registered Nurse (RN) was notified of the weight loss of over three percent. There was no indication of what steps were taken by the RN after the electronic notification alert was made in the medical record. There was no evidence to show R17 was re-weighed or that weekly weights were implemented by nursing. Review of an updated care plan provided by the facility, dated 08/23/21 indicated R17 was nutritionally at risk. The care plan did not address that R17 sustained a significant weight loss. The care plan indicated the staff were to encourage the resident to eat during mealtimes, provide nutritional supplements and snacks as ordered, and to notify the physician and RD of a significant weight loss or gain. Review of a document provided by the facility titled IDT Quarterly Screen, dated 08/26/21 indicated a chart review was conducted and R17 continued to require setup assistance for self-feeding. The form failed to address R17's significant weight loss as identified on the 08/08/21 Weight Chart. Review of a document provided by the facility titled, Nurse Note dated 08/26/21 documented R17 was started on antibiotics for a Urinary Tract Infection. A document provided by the facility titled Nutrition Assessment, dated 09/16/21, was completed by RD9. The form documented R17's last weight was on 08/08/21 with a result of 136.8 pounds. The note continued and indicated if that weight was accurate, R17 sustained a significant weight loss of 12.6 percent. This would indicate a total loss of 20.9 pounds over the past six months, or a 13.3 percent overall change in the resident's weight. The note indicated the resident required 1550 to 1870 kilocalorie (kcal; 1 kilocalorie equals 1000 calories) per day. RD9 wrote R17 received Ensure Plus three times a day which provided the resident 350 kcal and 13 grams of protein each (Three Ensure Plus supplements would provide a total of 1050 kcal per day). RD9 documented the resident consumed 20 percent of his meals and approximately 75 percent of supplements. RD9 recommended the resident remained on a regular chopped diet with texture as tolerated, and to continue to offer him Ensure Plus three times a day. There was no evidence the resident's physician was notified of the significant weight loss at this time. Review of a document provided by the facility titled Weight History, dated 09/19/21 showed R17 weighed 127.2 pounds, indicating a 19.34 percent loss since 03/23/21. The document provided by the facility titled IDT Meeting Notes, was signed by the physician on 09/21/21, indicating he was made aware of R17's significant weight loss 44 days after it was identified. The form documented R17 weighed 136.8 pounds on 08/08/21 and his body mass index (BMI) was 22.1, which fell within acceptable range for his age. The IDT notes continued, and indicated if the 08/08/21 weight was accurate, the resident lost 13.8 pounds over one month which was a 9.2 percent weight loss and would be considered a significant weight loss. The form lacked evidence that new orders were received from the physician at that time. Review of a document provided by the facility titled Weight History, dated 09/27/21 showed R17 weighed 128.2 pounds, indicating an 18.71 percent loss since 03/23/21. Review of a document provided by the facility titled Nurse Note, dated 09/29/21, revealed staff notified R17's physician was of the resident's decreased appetite and received new orders to increase the resident's [MEDICATION(S)] (an appetite stimulant/mood stabilizer) to 15 milligrams (mg) to be administered daily at bedtime. Review of a document provided by the facility titled Weekly Skin/Weight Condition Review, dated 10/01/21, indicated R17 sustained a significant weight change, received a regular chopped meal, was noted to be refuse more meals, and received Ensure Plus three times per week, as well as Magic Cup twice a day at 2:00 PM and 8:00 PM. Review of a document provided by the facility titled Weight History, dated 10/03/21 showed R17 weighed 125.9 pounds, indicating a 20.16 percent loss since 03/23/21. Review of a document provided by the facility titled Weekly Skin/Weight Condition Review, dated 10/08/21, showed R17's was 124.8 pounds, indicating a 20.86 percent loss since 03/23/21. RD9 documented food preferences were discussed with R17, and she updated his menu. The document revealed R17's received Ensure Plus with meals and snacks, totaling six times daily. The recommendations were to continue weekly weights. Review of a document provided by the facility titled Weight History, dated 10/17/21 showed R17 weighed 128.6 pounds, indicating an 18.45 percent loss since 03/23/21. Review of a document provided by the facility titled Nutrition Assessment, dated 10/19/21 indicated R17's last weight was 128.9 pounds as of 10/17/21, and he had a BMI of 20.8, which fell below the resident's optimal range for his age. The entry revealed R17 had a noted decline in intake noted over the past three months. The document revealed R17's Ensure Plus was increased from three times daily to six times a day on 10/06/21 due to continued weight loss with consistent supplement intake. The form documented R17 had a weight loss of one percent over the last 30 days, 16.4 percent over the last three months, and 20.1 percent over the past six months. Review of an updated care plan provided by the facility, dated 10/21/21 indicated R17 was nutritionally at risk and had sustained a significant weight loss. Review of a document provided by the facility titled Weekly Skin/Weight Condition Review, dated 10/21/21 indicted R17's current weight was 128.6 pounds. The document indicated R17 consumed more supplements than actual food. The document revealed the resident's physician was notified and the current treatments for the resident were to provide Ensure Plus six times a day. RD9 indicated she met with R17 and addressed food preferences and updated the menu. During an observation on 10/26/21 at 12:07 PM, staff delivered R17's meal tray which included a bottle of Ensure Plus. The staff member set up R17's meal, opened the bottle of Ensure Plus and, handed it to the resident. R17 was observed to drink the Ensure Plus. R17 was served a regular chopped meal, he was able to feed himself, and consumed approximately 90 percent of the meal during this observation. During an interview on 10/26/21 at 1:36 PM, RD9 stated R17's appetite was not good, and he had been eating less. RD9 stated R17 received supplements which were increased from three times a day to six. RD9 stated R17 had an increase in [MEDICATION(S)], and she had addressed the resident's food preferences following the noted weight loss. RD9 stated she kept track of residents' weights on a monthly basis and if a resident was identified with a significant weight loss, they were added to a weekly meeting for review. The meeting included the Director of Nursing (DON), RAI Coordinator, and the Assistant Administrator. During an interview on 10/27/21 at 9:39 AM Certified Nursing Assistant (CNA) 8 stated the staff could see a resident's weight change in the medical record and if there was a weight loss staff were to notify the nurse. During an interview on 10/27/21 at 9:36 AM, Registered Nurse (RN) 11 stated the CNAs were to inform the nurses if there was a weight loss for a resident. The nurse then needed to determine if there was a discrepancy. If there was a question about a discrepancy, the resident would be re-weighed. Nursing should notify the physician and the RD immediately if a weight loss was identified so they could investigate causes and develop interventions. During an interview on 10/27/21 at 10:05 AM, RD9 stated R17 should have been re-weighed by nursing after 08/08/21 since the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/27/21 at 11:59 AM, RD10 confirmed he was the supervisor of RD9. He stated he reviewed RD9's documentation and confirmed RD9 did not address R17's weigh loss until 09/24/21. During an interview on 10/28/21 at 9:04 AM, RD9 and RD10 were both present. RD9 stated she would review residents' weights monthly to identify significant weight changes. RD9 stated if a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . RD9 stated nursing was to re-weigh the resident if the resident had a three percent or more weight loss to ensure accuracy. RD9 stated R17 had consistent weights until 08/08/21 and staff did not re-weigh or implement weekly weights per the facility's protocol. RD9 stated she was on leave multiple times during August 2021. RD10 stated RD9 missed a QAPI meeting while on leave, which was normally the process used for notifying the physician of a weight change. RD10 further stated typically another RD from the hospital side would step in and address the basic needs of a resident when the assigned RD was not available. RD10 stated since they were in a rural area, RD positions were short. During this interview, both RD9 and RD10 reported they were unable to locate documentation to show the physician was notified of the significant weight change when identified. RD9 stated she increased R17's nutritional supplement on 10/06/21 to address the resident's significant weight loss. During an interview on 10/28/21 at 12:22 PM, the Regional Nursing Director stated she reviewed the clinical records for R17 and confirmed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Nursing Director stated if the resident was recognized as having a weight loss or gain staff were to implement weekly weights. The Regional Nursing Director stated she was aware, the clinical record lacked evidence that interventions were implemented when R17's weight loss was identified. She reported her expectations would be for the RD to be involved and review the services being provided to the resident on a weekly basis. The Regional Nursing Director confirmed there was a lapse before anything was done for R17 after the significant weight loss. During an interview on 10/28/21 at 1:07 PM, the Medical Director stated he believed he became aware of R17's weight loss approximately two months ago (September 2021). The Medical Director stated a nurse manager informed him of the weight loss of R17. Once he was made aware, he ordered blood work and a CT (Computed Tomography) scan of the resident's brain. The Medical Director stated the dietary supplements were not really effective and the decline in R17's weight was possibly related to his dementia diagnosis. The Medical Director stated the facility attempted to find an etiology and measures to increase the resident's caloric intake to possibly reverse the weight loss. Review of a document provided by the facility titled LTC (Long-Term Care) Skin & Weight Meeting, dated October 2021, indicated the purpose was .To evaluate residents with significant weight changes.and to ensure timely intervention by the facility Interdisciplinary Team.Skin & Weight meeting will be conducted by the facility on a weekly basis.Residents who demonstrate a significant change in condition, significant weight loss/gain or gradual, consistent weight loss will be placed on weekly weights until stability is demonstrated and maintained for at least four weeks. Review of such residents will be documented using the Skin/Weight Condition Review form and placed in the LTC Skin and Weight note in the EMR (electronic medical record). The nursing staff will ensure the attending physician and/or ANP (Advance Nurse Practitioner) is informed of the skin/weight change.The Skin/Weight Condition Review placed in the resident's records will serve as documentation of each resident reviewed. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, record and policy review facility failed to protect resident's right to be free from any type of abuse that results in, or had the likelihood to result in physical harm, verbal abuse, or mental anguish in four Resident's (R) 10, R20, R22, and R30 in the sample of 16. The facility failed to provide care planning interventions and supervision to prevent three incidents involving R30. An incident on 08/09/2018 resulted in R22 striking R30 after verbal confrontation with R30. On 11/04/2018, R30 and R20 had an abusive verbal confrontation that required staff to render a show of force to prevent a physical confrontation. On 11/12/2018, R10 was involved in a verbal confrontation with R30, when he felt R30 was loud and rude to staff. This deficient practice caused harm for R30 resulted in high potential to endanger the other 24 residents residing in the extended care facilitl section. Findings Include: During initial screening of residents on 11/13/2018, R25 expressed she would like to discuss concerns about R30. During a brief interview on 11/14/2018 at 10:50 AM, R25 stated, R30 upset the blind man (R22) to the point he went after him. He is verbally obnoxious. I give the staff credit as they are kind to him. During an interview with resident council members (R10, R22, R25, and R29) on 11/14/2018 at 10:45 AM R22 stated. There's a guy (R30) here who I got into it with. He talks all the time and goes on and on. A couple of months ago I was in the same room and got sick of it and punched him. R10 stated, He is bad to the staff how he talks to them and obnoxious. R29 stated, He was kicked out of bingo and has to know everything about everyone's business. R10 said, He has no respect for women. R25 stated, He (R30) asks one of the CNA's if she'll marry him. She told him she was married, and he tells her to divorce and marry me. When asked if the resident's present felt safe, they replied yes. R10 stated, He's not safe in our environment. When asked to explain, R22 said, Concerned someone will get upset with him because he's so obnoxious, always swearing and in everyone's business. Shared that R30 had been observed to be sitting alone in the dining room this morning. R10 responded. Staff have asked him to stay away, but he gets up and goes to the tables anyway and starts talking. During an interview with Director of Nursing (DON) and Administrator on 11/15/2018, about R30's behavior, AHA described him as Portuguese and very talkative. He is not offensive to everyone. Asked what interventions have been put in place to prevent further altercations involving R30, and AHA stated, We are working with them one to one to help them understand R30's communication style and separate them in the dining area. The residents committed to notify the staff if they feel frustrated with R30's conversation prior to addressing it directly with him. There has not been a second incident with these resident's (R10, R20 and R22). The concern regarding R30's safety discussed at Resident's Council interview was discussed. AHA stated, No one will be able to remain here if threats are made. Clarification made, and it was reiterated that the statements made were not made as a threat but interpreted as [MEDICATION NAME] concern that due to the ongoing verbal persistence of R30, any resident might unexpectedly react and harm R30. The level of frustration verbalized at Resident's Council interview revealed the interventions to date were not adequate and concern expressed for further occurrences. During a brief interview with AHA on 11/16/2018 , additional records were requested for care plans after the three incidents. AHA was asked if there was anything that could have alerted them or factors that could have been foreseen to prevent the incident on 08/09/2018 when R30 was struck. AHA replied, No, there was nothing. EMR reviewed R30 was known and identified on the baseline care plan as having difficult behavior, demanding and verbally abusive communication. On 08/09/2018 RN55 was made aware by R22 that he was upset with R30 and needed to talk. R30 and R22 were left in the room unsupervised resulting in a physical altercation. Interventions put in place after the incident were not effective in reducing behaviors resulting in a second and third incident involving R30. A behavioral contract was not developed with R30 until after the third incident on 11/19/18. On 08/09/2018 at 05:20 PM, an altercation occurred between R30 and R22. The incident report completed by RN55 documentation includes the following: R22 stating earlier that he wanted to talk to R30 about squealing to MSW (Master of Social Work). R22 states MSW talked to him and R10 during the day about complaints of them being mean to R30. Upset R30 went behind his back to talk to MSW instead of saying it to his face, stated he wanted this writer to be there as witness because R30 was lying to MSW. Notified R22 that he can talk to resident but not argue or do anything physical, to call this writer when he was ready to talk. R30 was sleeping when this writer left room at 1700. Notified by Certified Nursing Assistant (CNA)16 at 17:20 that .R22 who was hitting . R30 during dinner. R22 said he brought up the issue of R30 squealing on him then R30 said used profanity. R22 states he lost it got up and started swinging his arms trying to hit R30 who was in bed. R22 is blind and states he just went toward R30's voice. RN55 told R22 he, should have called this writer like he promised. CNA16 states R22 was hitting the left side of R30's body, she pulled R22 away. R30 was moved to another room after the incident. Review of R30's Social Services notes by Social Worker (SW)1 include: On 08/10/2018 at 07:30 AM. R30 again stated he had no physical pain but said he was emotionally hurt. The SW responded the staff would keep him safe. On 08/10/2018 at 02:35 PM. At approximately 12:30 PM the resident said he did not feel safe, and felt restless and not normal. further describing the event as a trauma. The SW said to the degree he could, R30 should try to maintain a normal routine and be involved in activities within the group. R30 said, What if he comes in my room after me? The SW reassured R30 that R22 was not prone to this and, with the two men being in separate spaces, it was not at all likely to happen. On 08/10/2018 at 02:53 PM. R30 stated he felt safe but expressed anger at his former roommate who had hit him. On 08/13/2018 at 02:00 PM. R30 spoke several times with the SW throughout the day. He complained that his former roommates were being mean to him. He described looks and them whispering. The SW said he would attempt to address it with the other men but said the (sic) he needed to give that situation time since there had been overt conflict that previous week. Review of SW1 follow up notes for R22 include: On 08/10/2018 at 07:45 AM. R22 said he was upset the SW had spoken to him about R30's concerns with him (R22). Other residents reported that R22 shouted for R30 to shut up loudly in the dayroom on 8/8/18. R22 said I no care you kick me out of here. The resident (R22) said, I tell him you come to me if you got a problem with me. He said, Don't hide behind other people Brah. The SW also pointed out that three roommates had come and gone with R22 and the third roommate R10. The SW said that such physical attacks could not happen, as all residents needed to feel safe. On 08/24/2018 Subjective findings in R30's progress notes by Advanced Practice Registered Nurse (APRN) reviewed: We discussed the interpersonal challenges he has been having with peers and staff. He has been in 7 care homes. APRN's assessment included Borderline personality disorder-continues to have interpersonal problems, however willing to practice communication strategies with staff and distancing strategies with unfriendly peers. On 11/04/2018 an Office of Healthcare Assurance ([NAME]HA) report revealed a second incident involving R30. The event was described as follows: R20 was heard swearing at R30. Staff heard R20 state in a very loud voice, what! What!; As R20 was swearing, he was approaching R30. (Both men utilize front wheeled walkers for mobility assistance.) R30 was seated with other residents; facing the front of the .building, R30 was reacting to R20 and also began to curse at him. Staff approached both men and asked them to stop their behaviors. R20 appeared to be preparing to strike out at R30, as he was bringing his right hand backwards. However, staff was able to place themselves in a position to gain R20's attention and state, Stop. You need to go back to your room and calm down. R30 continued his taunt. R20 began to become more upset. He was becoming more difficult to redirect. Along with the staff aide, the activity aide, as well as the housekeeper was able to render a show of force, which successfully dc-escalated (sic) the situation. R20 returned to his room. R30 was advised not to approach or antagonize R20. The report documents, There were no issues prior to this event; as these residents had not associated with each other prior to this encounter. Causal factors identified by the facility were documented as: R30, had settled in to the facility; he continues to have a tendency to repeat self; making persistent verbal requests of others. R20, does have instances of verbal outburst that lends to his self-isolation. There were noted precipitating factors that could explain the incident. On 11/06/2018 an email From CNA26 was sent to the Director of Nursing (DON) which said R20 was only inches away from R30's back and ready to swing his hand on his back. R20 were about to turn around when R30 started to talk and teased him to fight. R20 got more upset and unable to redirect.' R20 had no plan to stop attacking R30. On 11/12/2018 a verbal altercation occurred between R30 and R10. The [NAME]HA initial report describes: R10 was trying to stop R30 from speaking loudly and rudely to the Recreational Aide. Survey team was on site 11/13/2018. RN56 nurses notes dated O7/24/2018 stated Resident's daily routine People say I talk too much and identified potential barriers to his discharge/ goals as: Hx difficult behavior, and demanding + verbally abusive. Comprehensive care plan dated 07/25/18 reviewed, no evidence of interventions to address identified difficult behavior and demanding, verbally abusive behavior noted. On 08/10/2018 at 10:34 AM, R30's comprehensive care plan revised after the incident on 08/09/2018, to include the following interventions: Please remind me if my verbal persistence is upsetting others. Let me know what good behaviors look like. Approach me in a gentle sensitive manner. Talk calmly. On 08/14/2018 Additional interventions include: Please ask me if I am upset. Offer me reassurances, but also encourage me to distract myself in places I feel safe, such as my new room or in common areas with staff. Allow me to vent over my feelings of frustration or anxiety, but direct me if I repeat themes after reassuring me this will not re-occur. My feelings get hurt if no one talks to me. On 09/17/2018 Please encourage me to resume my daily routine (out for activities, engaging others in conversation, out for meals etc. Remind me that others may not respond the way I expect them to. On 11/04/2018 After second incident, care plan revised to include: Changed to every 15 minute monitoring due to altercation. On 11/12/2018 after the third incident, care plan revised, I will be monitored so that another resident(s) I had a verbal altercation with will not be in the dayroom at thie(sic)same time as I am until further notice. On 11/16/2018 care plan revision, I will have 1:1 visit with my SW/LTC Administrator to verbalize my feelings and any concerns that I have. On 11/17/2018 care plan revision I am receiving 1:1 supervision due to verbal altercation I had with another resident (R10). 11 dc' d (discontinued) 11/20/2018. On 11/19/2018 NHA (Nursing Home Administrator) informed of behavioral contract developed and R30's agreement and signature provided.

Based on clinical record review and interview with staff, the facility failed to ensure that a comprehensive assessment of a resident who displays mental or psychosocial adjustment receives appropriate treatment and services to correct the assessed problem for Residents #1 and #2. Findings include: Resident #1 is diagnosed with [REDACTED]. Throughout his stay at the facility, resident displayed signs of psychological decompensation, reports of being in "utter despair", teary-eyed, and verbalizing a plan to hurt himself. The facility did not ensure appropriate interventions were implemented, nor reassess the efficacy of the interventions that were being provided to this resident and revise the plan of care accordingly which resulted in resident's attempt to commit suicide by hanging. Following the event, the facility did not follow their practice of investigating and implementing corrective actions. During the survey Resident #2 was identified as an individual that would be affected by this deficient practice. Resident #2 is diagnosed with [REDACTED]. 1) An event report was submitted to the Office of Health Care Assurance on 7/6/09 by the facility. The report noted on 7/4/09 at 1400 "resident found in room with blanket around neck and tied above to ceiling. Nurse unwrapped blanket and resident taken to emergency room ". Prior to resident's attempt to hang himself, resident was crying and complained of depression, "I want to hurt myself". Physician was notified again and ordered to have resident sent to emergency room . Nurse reported while giving report to the emergency room nurse, resident returned to his room and attempted to hang himself with a blanket - found standing on his bed with blanket around his neck and tied to the ceiling bracket. Resident #1 was transferred from an acute hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 7/28/09 at 2:10 P.M. found progress note entry of 6/21/09 at 0240 by licensed nurse that resident's behavior was "very unusual", resident was talking to himself incoherently, entering residents' rooms, touching residents' sheets and putting his head down on their nightstands. Resident's sister who is also a resident in the facility reported that her brother "voiced wanting to hang himself this evening at 2200 on lanai ...sister stated she thinks res got drugs from outside from 2 visitors ...res has hx of smuggling drugs and syringes into hospital ..." On 6/21/09, resident complained of sore throat, the physician was contacted and gave a prescription for sore throat and ordered a urine drug screen. Review of ER Coder Chart View dated 6/21/09 notes resident presented at emergency room at 10:35 A.M. with complaint of headache, generalized 'achy' feeling, and sore throat. Resident refused chest x-ray and left the emergency room against medical advice, stating he want to return to the facility to smoke. Resident returned to facility at 1225. Resident was evaluated by psychiatrist on 6/22/09. The consultation report was not in the resident's clinical record provided by medical record. Upon request, consultation report was provided by Long Term Care Supervisor. The psychiatrist reported this resident has a "long history of drug abuse, IV and otherwise, with overdoses and indiscriminate use, often resulting in psychiatric hospitalization s here. He is a poster child for the serious drug abuser and personality disturbed person, who is dependent and over-utilizes the mental health system." Psychiatrist also noted resident has "many psychiatric symptoms, chronic severely depressed mood, sleep disturbances, appetite disturbances, anhedonia, [MEDICAL CONDITION], chronic pain, and suicidal thinking, which he carries out by injuring himself". The resident's [DIAGNOSES REDACTED]. The recommendation was to increase [MEDICATION NAME] and [MEDICATION NAME] and continue [MEDICATION NAME] and [MEDICATION NAME] as prescribed. On 6/26/09 resident was seen by the social worker. A review of the Social Services Intake/Critical Assessment for Long Term Care dated 6/26/09 notes resident has no thoughts of suicide and does not have a plan. Resident reported that he is on the brink of "thoughts of suicide". The plan was to continue to monitor, assess reports of depression and another appointment was scheduled for 6/29/09. Progress note entry of 6/28/09 at 1345 by RN Case Manager notes resident requested transfer to acute as the facility is "depressing 'seeing dead people wheeled out and constantly being around my sister'". RN Case Manager recommended resident "try to acclimate to new surroundings, involve self in activities; read a book, use computer, etc." The plan was to discuss with social worker tomorrow. Subsequent entry on 6/28/09 at 1515 by LPN notes resident requests to talk to someone about being "utterly depressed". Also states that there are too many people at the facility that makes him anxious. On 6/29/09 the social worker documented meeting with resident at 8:30 A.M. At this time resident was teary eyed and reported being in "utter despair". Subsequently, resident requested to meet with social worker again. The social worker met with resident at 1440. The resident noted to be teary eyed and reported "I can't take it anymore". He reported feeling anxious, not wanting to live anymore, and felt like hurting himself. He informed social worker that he did not have a plan and requested to see someone. The social worker referred resident for behavioral health assessment. Review of the "Behavioral Health Assessment" dated 6/29/09 at 2245 notes that resident feels depressed and suicidal with thoughts of hanging himself. Resident requested to go to the psychiatric unit to protect him from himself. Resident spent the night at emergency room . At the time of discharge resident denied suicidal ideation and verbally contracted for safety. Resident returned to the facility. There is no documentation of when the resident returned to the facility. Progress note entry of 6/30/09 at 1400 by the RN found resident stated "he's been thinking of how he's going to hang himself or cut his wrists or try to hurt himself so that he can get someone's attention to try and help him". RN informed resident he/she will try to contact the psychiatrist for a second consult. RN asked resident "if he could confirm not to hurt himself until IDT tomorrow when we can discuss other options, resident stated 'I cannot promise, I'll try'". The plan was to monitor closely and await call back from the psychiatrist. At 1515 behavior responder was contacted, responder recommend resident contact clinic for follow up appointment to prepare for discharge to home. The plan was to monitor and allow resident to express feelings, pending reply from psychiatrist and will continue to monitor for increased suicidal ideation, will contact physician and send to emergency for re-evaluation. Review of the Interdisciplinary Team (IDT) report found team met on 7/1/09. Resident declined to attend. The recommendation was close supervision and monitoring secondary to signs and symptoms of depression. There was no documentation in the resident's clinical record regarding his attempt to hang himself. Review of the ER Coder Chart dated 7/4/09 documents resident "was found trying to secure a sheet around his neck in attempt to hang himself. states that he does not want to live anymore". At the emergency room , resident became agitated, banging his head against the wall, requiring "take down of patient with 5 security guards to get patient in bed. Chemically restrained patient after patient was in restraints". Reviewed assessments done by the facility and the consultants. The "Depression Rating Scale LTC" was completed on admission (6/17/09). Resident yielded a score of 13 (severe). The item for initiate care plan was checked. A review of the "Suicide Risk Evaluation" done on 6/29/09 notes a score of 16, Risk level I. Noted on form "When score of 14 or greater provide safety precautions and notify MD". A subsequent evaluation was done on 6/30/09, the residents was scored at 13 (low risk); however, the section regarding "lethality or plan" was not scored and included in the total score, it was left blank. Review of the "Depression Evaluation Form" dated 6/29/09 was found in the clinical record. The evaluation was not completed. Review of the care plan found a care plan #1 for potential for injury to self secondary to depressed mood. The care plan was developed on 6/30/09. Although the results of the "Suicide Risk Evaluation" done on 6/29/09 resident yielded a score of 16, safety precautions were not included in the plan of care and documentation of implementing safety precautions could not be found. An approach listed was to refer to MSW depressed mood care plan; however, there was no documentation care plan addressed resident's suicidal ideation with a plan or safety precautions. Of note was a blank page in the care plan labeled #2 behavior. The surveyors met with the Chief Nurse Executive (CNE) and Surgical Services Supervisor (SSS) on 7/28/09 at 3:40 P.M. The CNE reported that whenever the resident expressed [MEDICAL CONDITION] he was sent for assessment for acute episode. The team reported that resident's behavior was related to drug seeking behavior. The team reported that the resident was under close supervision during his stay at the facility. The surveyors requested facility provide documentation of the psychiatrist's evaluation of 6/22/09, the emergency room reports as these items were not in the clinical record provided. Surveyors also requested the facility's policy and procedures for addressing residents with suicidal ideation and plan, and how the facility defines close monitoring. On 7/29/09 at 8:00 A.M. the surveyors met with the facility's team CNE, SSS, Long Term Care Supervisor (LTCS), Quality Management Director (QMD), and Risk Manager (RM) at 8:00 A.M. The CNE reported that the facility did everything to protect the resident, the facility followed their policy, there was nothing new that they could have done or added to the resident's care plan, and the resident was being closely monitored. Surveyors inquired whether resident's room was evaluated for safety (items/objects resident could use to hurt himself were removed?). Facility's team could not confirm this was done. Surveyors also inquired about how the facility defines "close monitoring", the facility responded that 1:1 would have been an option if the resident had exhibited behaviors. Facility team reported the resident's care plan was not revised as there was no recommendation by the physicians or consultants to do so. CNE reported they should have kept documentation by the physicians and consultants that there was no need for change. Review of the facility's "Performance Improvement Form" found it was a recapitulation of the report submitted to the Office of Health Care Assurance. The reported checked block "Feedback requested". The portion identified "Manager Assessment for Process Redesign - what needs to happen on your unit to improve patient safety and decrease these types of errors?" had written "OHCA report completed". Interviewed Chief Nurse Executive, Risk Manager, Quality Management Director, Long Term Care Supervisor on 7/29/09 at 8:00 A.M. The facility team reported that this event was not brought to the facility's quality assurance committee/quality management for review and consideration for corrective actions. Subsequent interview with facility staff on 7/29/09 at 2:40 P.M., staff reported the event was not recognized as a sentinel event to be reviewed by the risk management and quality management department. Immediate Jeopardy was abated on 7/29/09 at 4:00 P.M. 2) Resident #2 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Interview with Charge Nurse on one unit identified Resident #2 is depressed and had suicidal ideation. Concurrent review of the clinical record on 7/29/09 at 9:25 A.M. noted progress note dated 6/2/09 at 1530 by the licensed nurse that resident stated "I may as well die, I'm in jail, I just eat sleep,[***] No more woman, no more drink. I may as well die". Resident refused tube feeding and stated "No want to eat, I die, I die". Subsequently, the RN called the psychiatrist at 1520 and left a message regarding resident's verbalizing that he wants to die. Progress note of 6/3/09 at 0900 documents the psychiatrist called and agreed to see resident at the next round. The psychiatric consult note of 6/4/09 documents [DIAGNOSES REDACTED]. The recommendation was to: discontinue [MEDICATION NAME]; increase [MEDICATION NAME]; and ask if resident can "eat for comfort". Psychiatrist noted resident has been refusing care and talks about dying. There is no assessment whether resident has a plan, lethality of plan, or history of suicide attempts. The Charge Nurse recalled that the suicidal ideation was precipitated by a failed discharge plan. Resident #2 was scheduled for discharge home on 5/18/09 and on the day of his discharge, his mother reported she could not care for him and discharge was cancelled. The Charge Nurse confirmed that the social worker was not informed of resident's statement and could not find documentation that the care plan was revised to address suicidal ideation.

Based on clinical record review and interview with staff, the facility failed to utilize assessments to develop, review and revise the Resident #1's comprehensive plan of care following episodes related to suicidal ideation and suicidal ideation with a plan. Finding includes: Cross Reference F319. Clinical record review found resident had episodes of [MEDICAL CONDITION] and ideation with a plan, resident reported to staff that he was thinking of hanging himself or cutting his wrists. On 6/21/09 resident's sister reported to staff that her brother stated he is thinking of hanging himself. On 6/26/09, resident reported to social worker that he is on the brink of suicidal thoughts. Resident reported to social worker on 6/29/09 that he feels like hurting himself. Assessment by behavioral health on 6/29/09 documents resident had thoughts of hanging himself. Progress notes of 6/30/09 documents that resident reported to staff that he is thinking of how he will hang himself, cut his wrists, or something to hurt himself. Assessments done following resident's report of suicidal ideation with plan were incomplete. The "Suicide Risk Evaluation" done on 6/30/09 did not score the lethality or plan and the "Depression Evaluation Form" was incomplete (sections of the protocol was not completed by assessor). A care plan for depression was developed on 6/26/09; however did not include approaches to address resident's [MEDICAL CONDITION] and how to ensure resident's safety when he reports having a plan. Following an episode on 6/30/09 a care plan was developed for #1 Behavior - Potential for injury to self secondary to depressed mood. The care plan did not address resident's actual threats to commit suicide or approaches for ensuring resident's safety by clearing environment of items/objects that could be used to harm himself or increasing the monitoring of resident more than once every shift when he threatens to harm himself or considering utilizing 1:1 supervision. Subsequently on 7/4/09 resident attempted to commit suicide by hanging himself.

Based on clinical record review and interview with staff, the facility failed to ensure that Resident #1's environment remained free of accident hazards and received adequate supervision to prevent attempted suicide. Finding includes: Cross Reference F319. Resident #1 was admitted to the facility on [DATE]. Throughout resident's stay, resident decompensated and expressed to staff suicidal ideation with a plan to hang himself, cut his wrists, or find another way of harming himself. Subsequently on 7/4/09 at 1400, resident was found standing on his bed trying to secure a sheet/blanket around his neck in an attempt to hang himself. Review of the resident's clinical record on the afternoon of 7/28/09 found a "Suicide Risk Evaluation" done on 6/29/09 in which the resident yielded a total score of 16, a score of 14 or greater it is recommended that safety precautions be provided. Subsequent evaluation done on 6/30/09 found resident yielded a total score of 13; however, the assessment was incomplete. The section regarding "lethality or plan" was left blank and not scored. Interview by surveyors with facility staff on 7/29/09 at 8:00 A.M., staff member reported that the facility followed their policy and everything was done to protect the resident. Surveyor inquired whether resident's room was evaluated for safety (items/objects that could be used to hurt himself were removed). The facility's team could not confirm this was done. Although resident informed facility staff that he was suicidal, the facility did not increase monitoring of this resident. Surveyors inquired how the facility defines "close monitoring", the facility responded that 1:1 supervision is an option if the resident had exhibited behaviors. Facility staff confirmed resident was being monitored once per shift and provided documentation of monitoring. Review of the "Behavior Monitoring Chart" found monitoring was not documented for 3-11 shift on 6/29/09 and 11-7 shift on 6/30/09. Documentation was not provided for the month of July.