Every finding on record at Honoka'a Hospital & Skilled Nursing

Based on observation and staff interview, the facility failed to record hot water temperatures for manual washing of dishes/pots/pans and failed to completely record hot water temperatures for the dishwashing machine. Findings include: During observation of the kitchen on 11/19/24 at 10:25 AM, there were two different dishwashing sections; manual washing and dishwashing with machine. Review of hot water temperature logs showed no recording log for the manual washing, and missing temperature logs for the dishwashing machine. During staff interview on 11/21/24 at 08:20 AM, Kitchen Staff 1 revealed that the facility did not have temperature logs for manual washing and acknowledged that there were missing temperature logs for the dishwashing machine. The facility did not provide a related policy but said that they follow Hazard Analysis Critical Control Points (HACCP) which states temperature test logs should be maintained for each hot water sanitation dishwasher in the facility in order to follow HACCP-based record keeping standards.

Based on observation, interview, and record review, the facility failed to ensure 1 of 14 residents sampled (Resident 11) was free from accident hazards. Resident 11 was transferred using a mechanical lift transfer in a manner that placed her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all the residents at the facility who are dependent on mechanical lift transfers. Findings include: Resident (R)11 is an [AGE] year-old female admitted to the facility on [DATE]. On 11/19/24 at 12:02 PM, observations were made at the bedside of R11. Certified Nurse Aide (CNA)2 and CNA3 were transferring R11 from her bed to a standard wheelchair via a mechanical lift. Observed CNA3 positioned behind the wheelchair, tilting it up onto its back two wheels, leaving the front two wheels approximately a foot off the ground, while CNA2 operated the mechanical lift, lowering R11 into the tilted wheelchair. Interviewed both CNAs at the bedside as soon as the wheelchair with R11 in it had been lowered safely back down with all four wheels on the ground. CNA3 stated that they needed to tilt the wheelchair to lower R11 into it because she had a standard wheelchair that could not have the back lowered. Since R11 hung in a semi-reclined position on the mechanical lift, they felt they needed to ensure the wheelchair was in a semi-reclined position to receive her. On 11/21/24, a review of R11's comprehensive care plan (CP) for Potential for Decrease in ADL [Activities of Daily Living] noted that on 05/25/24, per PT [physical therapy] recommendation, . [mechanical] lift transfers . On 11/21/24 at 09:06 AM, an interview was done with the Assistant Administrator, who also served as the Regional Director of Nursing and the facility Infection Preventionist (IPC), in her office. When the observation was described to IPC, she agreed that it was not a safe transfer, either for the staff or the resident. IPC also agreed that she would have expected the CNAs to pull the sling of the mechanical lift to re-position the resident into the position required to lower her into the wheelchair, not the other way around. On 11/21/24 at 09:50 AM, a review of the Kwikpoint Patient Lifts Safety Guide, provided by the facility as training materials, noted that on page eleven (11), Lower the Patient instructs the mechanical lift user(s) to Slowly lower patient toward receiving surface. Move patient's body into correct position on receiving surface before releasing patient's weight. The Safety Guide includes an illustration where the staff member is repositioning a patient in the mechanical lift sling into an upright position as patient is being lowered into a standard wheelchair.

Based on observations, record reviews, and interview, the facility failed to protect a resident (Resident 310) from physical abuse. The facility did not de-escalate the situation between two roommates, resulting in Resident (R)50 going over and punching R310. This deficient practice has the potential to affect the residents' optimal physical and psychosocial well-being. Findings include: On 06/17/24, the facility submitted an Event Report regarding an allegation of abuse, resident to resident. On 05/18/24 at approximately 02:50 AM, Resident (R)310 alleged he was punched by his roommate, R50. The report documents at approximately 02:00 AM, Certified Nurse Aide (CNA)1 heard the residents yelling. R310 reportedly turned on the television and had the volume turned up, waking his roommate. R50 was heard telling R310 to go to sleep and turn off the television. Registered Nurse (RN)1 provided R310 with headphones to connect to his TV. After this, Licensed Practical Nurse (LPN)1 heard the television playing loudly again and entered the room to ask R310 why he wasn't using the headphones. R310 responded he could not hear the TV with the headphones on. Later R50 was again heard yelling for his roommate to go to sleep. LPN1 entered the room again and instructed R310 to use the headphones, but he did not. Shortly after that, LPN1 heard yelling from the room, He punched me! Upon entering the room, LPN1 saw R50 standing by R310's bed. Upon immediate assessment, RN1 found a small abrasion to R310's chin with minimal bleeding, and first aid was provided. R310 complained of pain to his jaw, a 9/10 upon pressing. R310 was provided with Tylenol and an ice pack. The facility documented in March 2024, R50 had a previous incident of punching and kicking a male CNA after accusing the staff member of being gay. The facility further indicated R50 becomes agitated when residents yell out and also had a conflict with a different roommate regarding his television being too loud, however, there had been no history of physical altercations. The facility developed interventions to address R50's agitation when other residents talk loudly, redirect me to where it is quiet and calm and do 15-minute checks. Observations on 11/19/24 at 11:46 AM, R50 was walking in the hall with staff, he was observed to constantly make verbal sounds. Subsequent observations saw staff members going in and out of resident's room. R50 refused lunch. On 11/21/24 at 08:47 AM, R50 was observed lying in bed, bed at lowest setting, and appeared to be asleep. On 11/21/24 at 12:16 PM, R50 observed in dining room waiting for lunch, dozing off in chair at table, seated next to female resident, and no yelling or behavior observed or overheard. At 12:24 PM, R50 was awake, and was moved next to a male resident. R50 was observed to display impulsivity and impatience, yelling out unintelligibly and looking around to get staff attention. Subsequent observation at 12:27 PM found R50 walking back to his room with a staff member. At 12:39 PM, three staff members were observed in the room with the resident, encouraging him to eat his lunch. One staff member remained behind to assist R50 with lunch, it was quiet, and the staff member was gentle and treated resident with respect and dignity. On the morning of 11/21/24 a record review was done. The alleged perpetrator, R50 was admitted to the facility from an acute hospital on 01/22/24 with diagnoses including dementia; schizoaffective disorder, behavior problem; and Alzheimer's disease. A review of his medication orders included buspirone, 5 mg twice a day (anxiolytic sedation); Lexapro, 20 mg daily (antidepressant); risperidone, 3 mg twice a day (antipsychotic); and trazodone 75 mg (antidepressant). A review of the Medication Administration Record (MAR) for the use of psychotropic medications identified the following behaviors related to the use of medication: trazodone and melatonin for sleeping; risperidone for auditory hallucinations, standing on bed, and talking to self and others; Lexapro for combative behavior, irritability and refusal of care; and buspirone for restlessness. A review of his admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/29/24 notes R50 is cognitively impaired. R50 requires supervision for sit-to-stand and is able to walk 10 feet with supervision or touching assistance. There were no noted behaviors documented. Immediately following the May 2024 incident, R50 was moved to a single room and care plan revision was done on 05/18/24. Revised interventions included: providing visual supervision at all times when out of his room due to history of altercation with other residents who are loud and please redirect me to where it is quiet and calm. A review of the alleged victim's record was also done. R310 was admitted to the facility on [DATE] and discharged on [DATE]. A review of the admission MDS with ARD of 05/17/24 noted R310 is cognitively intact. The social worker's note (dated: 05/21/24 at 11:02 AM) regarding R310's altercation with R50 noted R310 reported R50 became irritated because his television was too loud. R50 reportedly came over to grab the remote control, when R310 attempted to stop him, R50 punched him. R310 reportedly had pain to his jaw and informed the social worker that he feels safe in the facility and denied any concerns of anxiety. A review of the facility's policy and procedure, Freedom from Abuse/Neglect/Exploitation Long Term Care Residents was done. The definition of resident-to-resident abuse includes: A. Cognitive impairment or mental disorder does not preclude a resident from being abusive. B. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm . The definition of physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. On 11/25/24 a telephone interview was conducted with the Director of Nursing (DON). DON reported that she led the investigation for the abuse allegation and confirmed that abuse had occurred. DON reported R50 was physically able to get out of bed and walk over to R310's bed. R50 could also stand on his bed and squat down and up. DON reported R50 becomes agitated when other residents yell out or become disruptive. Inquired how does R50 express agitation? DON provided the following example: in the past R50 would become agitated by a former resident and there was an incident of R50 approaching the resident and appeared to make gestures to hit him. Staff members were able to prevent an altercation between the residents at that time. DON reported staff members keep constant watch of R50 when he is out of his room; he is escorted to the dining room and wherever else he goes. R50 also reportedly stays in his room alone, watching football. R50's room is close to the facility's nursing station to provide continuous monitoring of the resident. The observations, record reviews and interview, found the facility met the criteria of past noncompliance: at the time of the incident, the facility was not in compliance with the regulatory requirements; the noncompliance occurred after the exit date of the last standard survey (12/08/23) and before the current recertification survey; and there was sufficient evidence that the facility corrected the noncompliance, the facility revised and observations during the current survey confirmed, staff members were implementing R50's plan of care. To date, the interventions are effective, as evidenced by no subsequent incidents or allegations. The facility continues to monitor R50's behaviors (sleeplessness, auditory hallucinations, standing on bed, talking to self and others, restlessness, combative behavior, irritability, and refusal of care) as it relates to the use of psychotropic medication. The facility communicates R50's care plan revisions to staff via huddles and communication report. The facility also provided an in-service to all staff on 05/21/24 regarding the facility's policy and procedures for abuse and neglect.

Based on record review, staff interview, and policy review, the facility failed to monitor vital signs; blood pressure for one Resident (R) 57 of fourteen residents sampled. As a result of this deficiency, the facility put R57 at risk for further health complications. Findings include: Review of Electronic Health Record (EHR), on 11/21/24 at 08:25 AM, showed R57 admitted on [DATE] with diagnosis including recent Hip Fracture, Chronic Kidney Disease, Lymphedema, Paroxysmal Atrial Fibrillation, Hypertension, High Cholesterol, Venous Stasis. There was an active doctor order to take vital signs; blood pressure routine (monthly for this resident). Blood pressures were documented on the following dates: 11/12/24, 09/26/24, 09/13/24. During staff interview on 11/21/24 at 09:20 AM, Director of Nursing acknowledged that vital signs; blood pressures were not taken monthly as ordered. On 11/21/24 at 10:45 AM, review of policy for Extended Care Facility Vital Signs read Purpose, to assist in assessing resident's physiological parameters, early detection of disease process. Policy, Vital signs include temperature, pulse, respirations and blood pressure. Vital signs will be taken on all residents upon admission to Extended Care Facility. Thereafter, vital signs shall be taken as ordered by the physician, or as follows . Vital signs weekly on all skilled nursing facility patients and monthly for all intermediate care facility patients .

Based on record review and interview with staff members, the facility failed to provide education regarding the benefits, risks, and potential side effects associated with COVID-19 immunization before offering the vaccine to staff member(s). Findings include: On 11/21/24 at 11:30 AM an interview was conducted with the Infection Preventionist (IPC). IPC reported the facility offered staff members the COVID-19 vaccination in October. A staff member, Kitchen Staff (KS)1 was randomly selected to verify the requirements for education and offering of COVID-19 immunization. IPC reviewed the spread sheet and reported the immunization was refused. Further queried if KS1 was provided with education on risks and benefits of the immunization. IPC reported the facility will provide a Vaccine Information Sheet (VIS) which includes education when vaccines are offered and administered, however, as the COVID-19 immunization is no longer required for staff members, the facility had not been providing the VIS. On 11/21/24 at 12:15 PM, KS1 was interviewed in the kitchen. KS1 was not sure whether the facility offered the COVID-19 immunization. KS1 reported not opting for the most recent COVID-19 immunization. At 12:22 PM, KS1 came to the conference room and reported the COVID-19 immunization was offered and she did not take it. KS1 confirmed that she was not provided with education, risks, and benefits of the COVID-19 immunization.

Based on review of Facility Reported Incident (ACTS 10975), record review, staff interview and review of policy, the facility failed to implement the comprehensive care plan for Resident (R)2. As a result of this deficiency, R2 was found in another resident's room showing inappropriate sexual behaviors. Findings include: Review of ACTS 10975 mentioned that R2 was found in another resident's room on 05/16/24 at approximately 03:20 AM displaying inappropriate sexual behaviors. R2 was directed back to room and placed on 1:1 supervision. Prior to this incident, R2 had a report of entering another resident's room on 11/22/22, and then on 12/02/22 there was another report of R2 exposing self in the room doorway. There were no other incidents thereafter until this current incident. Review of the Electronic Health Record showed that R2 was admitted on [DATE] with a diagnosis including Subarachnoid Hemorrhage, High Blood Pressure, Emphysema, High Cholesterol, Alcohol Abuse with Seizure. On 05/17/24 after the incident previously mentioned, R2 was discharged from the facility and admitted to the hospital for psychiatric evaluation and closer observation. Staff interview on 05/30/24 at 02:45 PM, Certified Nurse Assistant (CNA)1 said that R2 has never showed any behaviors of entering another resident's room or any inappropriate sexual behaviors. CNA1 said that R2 routinely stayed in bed and you could tell when R2 gets up only to stand in the doorway. R2 always likes to stay in bed most of the time. Review of Comprehensive Care Plan for R2, start date 02/23/23 read the following: Behavioral Symptoms; Problem, sometimes wander into the rooms of other residents and need to be redirected back to my own room. Outcome, will have fewer than three episodes each week of behaviors . behaviors will not cause harm to myself or others within the quarter. Policy of policy on Freedom from Abuse / Neglect / Exploitation Long Term Care Residents read Purpose, to advocate prompt and ample protection for victims and/or suspected victims, to provide a guide for accurate reporting and/or agency referrals of suspected crimes, including abuse, within the prescribed timeframes, while providing comprehensive and compassionate care to the alleged victim, without risking further danger, to keep residents free from abuse neglect and corporal punishment of any kind including involuntary seclusion, by any person . The resident's plan of care should be updated to include interventions to prevent further instances .

Based on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. Facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to two residents (Resident (R) 41 and 12) on Transmission Based Precautions (TBP). This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: 1) On 12/06/23 at 08:56 AM, observed signage next to R41's door indicating she was on Droplet Plus Precautions. R41 was sitting in a wheelchair with her breakfast tray on a table in front of her. R41 was not wearing a mask and was telling the staff that she wanted to come out of her room. Certified Nurse Aide (CNA) 3 entered the room to check on R41 without any PPE other than a surgical mask. CNA3 explained to R41 that she needed to stay in her room for now and asked her if she was done with her meal. R41 said she was done eating and CNA3 brought the tray to the cart that was out in the hallway. As CNA3 was walking out of the room, R41 tried to follow her out the room. As R41 approached the door, another CNA asked her to, Please stay in the room for now, we'll be right with you. At that time, Registered Nurse (RN) 3 was passing by the room and approached R41 by the door. RN3 was only wearing a surgical mask and was touching R41's shoulder to comfort her. Surveyor pointed out the sign by the door to RN3 and asked her if R41 was on TBP. RN3 replied, Yes. and started putting on gown, gloves, N95 mask and face shield. 2) On 12/07/23 at 12:52 AM, observed a Droplet Plus Precautions signage posted by R12's room. Restorative Nursing Assistant (RNA) 1 was helping distribute the lunch trays at the [NAME] Wing. RNA1 entered R12's room to bring her meal tray wearing only a surgical mask. RNA1 was in the room with R12 for approxiamtely three minutes as she set up her lunch on the bedside table. Review conducted of facility's infection prevention and control program last reviewed in June 2023. Stated under 10. Droplet Plus, . f. Perform Hand Hygiene and wear a N95 mask, face shield and gown upon entry into the resident room and when working within three feet of the resident. On 12/07/23 at 01:52 PM, interview with the Infection Preventionist (IP) was conducted in her office. IP confirmed that the staff entering any room where the resident is on TBP should be wearing N95 mask, gown, face shield and gloves.

Based on interview with a resident and record review, the facility failed to provide treatment and care in a manner that promoted his or her quality of life for one of 17 residents (Resident (R) 25) in the active case sample. This deficient practice has the potential to affect the resident's psychosocial well-being. Findings include: Record review noted R25 was admitted to the facility on [DATE]. A review of her quarterly Minimum Data Set with an assessment reference date of 10/13/23 documents R25 is cognitively intact. R25 also requires substantial assistance to roll from left and right and is dependent on helper to transfer to and from a bed to a chair (or wheelchair). On 12/06/23 at approximately 11:30 AM an interview was conducted with R25. R25 reported sometimes staff members are rough during care, specifically while providing incontinence care and during transfer via mechanical lift. R25 explained staff members push or pull her side to side while cleaning her. She also explained during transfer, staff will put her back on the bed or lift her without warning, stating this action could snap my neck. R25 clarified if staff would explain to her what they will be doing, she can brace herself or be prepared for the movement. R25 also shared that she had to wait 45 minutes for call light response, and she gets frustrated when nobody responds. R25 reported she usually calls for assistance at night as she wants to have her personal brief changed before going to sleep. R25 further reported that it would be fine if staff respond and let her know that they are currently helping another resident and will be back. R25 expressed concern that the facility seems to have only one sling for the mechanical lift. R25 explained that if her sling becomes soiled and sent to the laundry, she stays in bed and can't go out to activities. She also questioned why some staff can find an extra sling and there are times when she is told there is no sling available.

Based on interview with the resident council, the facility failed to ensure residents were provided ongoing communication regarding where to find the State Agency (SA) report with survey results and the facility's plans of correction, and information on how to file a complaint with the SA and Long-Term Care Ombudsman (LTCO) should they want to exercise these rights. Findings include: On 12/06/23 at 11:00 AM an interview was conducted with four resident council representatives. Asked the residents if the State inspection was available to read. The representatives were not aware of the location of the survey results, and that the report was available for them to review. Upon query, the representatives were not aware of where the LTCO's contact information was posted. Also, the representatives could not recall being provided with information on how to formally file a complaint with the SA. A review of the facility's hospitality book does not include information for reviewing the survey results, LTCO information, and how to file a complaint with the SA.

Based on observation and interview with staff, the facility did not assure a resident was provided with personal privacy during incontinence care. Findings include: On 12/06/23 at 08:56 AM observed the curtain was drawn to block view into the residents' room. Knocked at the door, peered around the curtain, and observed R48 lying on his right side with his left lower extremity exposed from the waist down. Further observed the curtain between the roommates was not fully drawn, R36 was sitting up in bed and could view his exposed roommate. Interview with Certified Nurse Aide (CNA)5 was done. CNA5 reported that she closed the curtain between the residents, however, R36 opened it. CNA5 reportedly told the resident not to open the curtain. Inquired whether R36 does this all the time, initially CNA5 responded yes. CNA5 then clarified, this was the first time she observed this behavior. Upon further query, CNA5 stated she would speak to the nurse. Subsequent observations on 12/06/23 at 10:08 AM and 01:02 PM found the curtain between the residents was fully closed.

Based on record review and interview with staff member, the facility did not ensure the notice of transfer/discharge contained the required contents; a copy of the notice is sent to the Long-Term Care Ombudsman (LTCO); and a resident transferred from the facility's long-term care/nursing to the critical access hospital was not provided written notice of transfer for 2 (Residents 54 and 55) of 2 residents in the sample. Findings include: 1) Resident (R)54 was admitted to the facility on [DATE] and discharged to an acute hospital on 08/13/23. R54 was readmitted on [DATE] and discharged on [DATE] to an acute hospital. On 12/07/23 at 01:29 PM the facility provided fax confirmation of notification to the LTCO of R54's discharges. The facility sent notice of the discharge log to the LTCO. Review of the discharge log documented the resident's admitted , discharge date , name of resident, and discharge disposition (discharge location) At approximately 02:15 PM, the facility provided copies of the transfer/discharge notices that were provided to R54. The LTC Transfer/Discharge Notice forms were reviewed. The content of the form did not include the following, a statement of the resident's appeal rights (including contact information and information on how to appeal); contact information for the LTCO; and for residents with intellectual and developmental disabilities and residents with a mental disorder the contact information of the state's protection and advocacy authorities. Also review of the notice dated 08/12/23 noted the form was incomplete. The effective date of transfer/discharge and transfer/discharge location were left blank. On 12/07/23 at 02:15 PM interviewed the Administrator. The Administrator reported notice is sent to the LTCO. Inquired whether the LTC Transfer/Discharge Notice with the required content is sent to the LTCO. Administrator was not sure whether the form was sent to the LTCO. Administrator deferred to the Social Worker (SW). On the morning of 12/08/23 SW was not available for interview. Left a message with the SW Assistant requesting to meet with the SW regarding transfer/discharge. Prior to exit, the SW was not available for interview. 2) R55 was admitted to the facility on [DATE]. R55 was transferred to the facility's critical access hospital for wound care. On 12/07/23 at 02:15 PM, the Administrator reported a written notification was not provided as the facility did not recognize the transfer from their long-term care facility to the critical access hospital as a transfer. A review of the facility's policy for Discharge/Transfer Notice does not include the required contents of the notice, specifically appeal rights, and contact information for both the LTCO and advocacy authorities for persons with developmental disabilities and/or mental disorder.

Based on observation, interviews and record reviews, the facility failed to provide appropriate services to prevent urinary tract infections for one of the two residents (Resident (R) 34) in the sample. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter. Findings include: On 12/05/23 at 02:38 PM, observed R34 sitting up in a wheelchair in his room. R34 had a urinary catheter tubing connected to a collection bag placed in a dignity cover that was hung under the wheelchair seat. Both the urinary catheter tubing and collection bag were touching the floor. On 12/06/23 at 11:19 AM, review of Electronic Health Record (EHR) for R34 conducted. R34 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis (paralysis and weakness on one side of the body), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), and neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problem). R34 was also taking Ciprofloxacin (oral antibiotic) for a urinary tract infection. On 12/07/23 at 09:43 AM, observed R34 sitting in a wheelchair in the [NAME] room watching television. Urinary catheter tubing and collection bag were touching the floor. At 09:52 AM, Registered Nurse (RN) 8 pushed R34 closer to the medication cart that was in the hallway outside of the [NAME] room to administer oral medications. As RN8 transported R34, both the urinary catheter tubing and the collection bag were dragging on the floor. On12/07/23 at 01:50 PM, interview with the Infection Preventionist (IP) was conducted in her office. IP confirmed that both the urinary catheter tubing and collection bag are not supposed to be touching the floor for infection control.

Based on observation, interview with staff, and review of the policy and procedures, the facility did not assure drug records for controlled drugs were maintained. This deficient practice has the potential for possible drug diversion. Findings include: On 12/07/23 at 02:02 PM concurrent observation was done with Licensed Practical Nurse (LPN)8 and LPN9. A review of the Narcotic Count Medication Room/Lock Cabinet form found missing nurse signatures. Concurrent review of the log with LPN8 noted there were no nurse signatures for the off duty and on duty nurse for 12/06/23 at 11PM and no off duty signature for 12/07/23 at 7AM (the on duty nurse for this shift signed the log). Further review found missing signatures for 11/20/23 (off duty at 7AM); 11/10/23 (off duty at 3PM); 11/06/23 (on duty at 7AM and off duty 3PM); 10/28/23 (off duty at 7AM); 10/23/23 (off duty at 7AM); 10/22/23 (on duty at 11 PM); and 10/08/23 (off duty at 7AM). Inquired why is it important for the licensed nurses to sign the log for narcotic counts/reconciliation. LPN8 responded to show that the medications were counted. LPN9 responded to ensure there is no diversion of the medications. The facility provided policy and procedure, titled, Medication Storage - Controlled Medication Storage with the following procedure: At each shift change or when keys are surrendered, a physical inventory of Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medication at shift change. Procedure also includes, Current controlled medication accountability records are kept in MAR or narcotic book. When completed, accountability records are submitted to the director of nursing and maintained on file at the nursing care center. On 12/08/23 AM at 09:37 AM interview with the Director of Nursing (DON) confirmed there are some missing signatures on the log. DON stated she attributes some of the missing signatures to nurses working doubles and only signing it once.

Based on observation, interview and record review, the facility failed to assure the protection and freedom from sexual abuse of resident (R)1 who encountered several events of inappropriate touching and invasion of resident's privacy/room was witnessed by staff members on several occasions. Although suspicion of inappropriate sexual activity was perceived by staff, effective reporting and immediate action was not taken by the facility. This deficient practice has the potential to affect other vulnerable residents in the facility. Findings include. R1 was admitted to the facility on [DATE]. R1 has a diagnosis of advanced Alzheimer's dementia. R1 lacks the capacity to consent to a romantic or sexual relationship related to her diagnosis. Observation on [DATE] at 10:30 AM revealed R1 sitting up in wheelchair across from her room. Surveyor attempted an interview with R1. R1 was not able to answer questions. The name of the alleged perpetrator was mentioned, and no reaction or response was solicited from R1. During an interview and concurrent record review (RR) on [DATE] at 11:10 AM, staff member (SM)8 stated that on [DATE], S8 was working overtime and assigned to the dining area. R1 was in the dining area doing her activity of folding clothes. S8 stated that S10 came to dining area and asked S8 if she needed a break or needed to go to the bathroom. S10 started to help S8 fold clothes and was discouraged from doing R1's activities. S10 did not leave and turned his back to S8, blocking R1 from S8's view. I saw S10 grab R1's wrist and was trying to put her hand in S10's clothes. I don't know if it was S10's shirt or his pants. R1 pulled her arm back and stated no. S8 did this twice and has done this before and I felt something was wrong. S8 stated, I reported it to the team leader S7 on [DATE] and S7 instructed all of us to watch S10, keep him out of R1's room. My co-worker, S3 and myself noticed that S10 would show up all the time and be with R1. S10 was questioned on several occasions why he is in her room with the lights off and curtains drawn. S3 and I would get R1 up and S10 would come and put her back to bed, right after she was placed in the wheelchair for the day. After S10 put R1 back to bed, I stood outside of the curtain and looked under the curtain where S10 was standing over R1's bed with the curtain closed and light off. I heard him saying to R1 you feel good, you feel good? Interview on [DATE] at 11:51 AM was done with S2. I came in at 7:00 AM on the 16th of February 2023 and was doing a report with S7. After the report, when we were going to count, she said staff were watching S10 because he was spending too much time in R1's room. I told her if she felt that way, she needs to report it to the nurse manager. We went to report it to the nurse manager. S2 went on to say that S10 is slow and has a lot of health issues, his wife passed away and he must pay for his deceased wife's medical bills. S2 stated that she did a complete skin check on the 23rd but it did not involve a rape kit evaluation and/or a medical doctor or a trained professional to examine the resident for physical evidence of abuse on the 15th. An interview and concurrent RR on [DATE] at 12:00 PM was done with S3. S3 stated that she worked overtime on the 15th of February 2023 into the dayshift. The call light for 230B went on. She was requesting to be changed. I observed S10 in R1's room. S10 stated that he would be back to tend to R1. I decided to assist R1 with dressing and get her into the wheelchair into the hallway. I continued rounds and went into another room to assist S8. Upon finishing assisting S8, S8 and myself observed that S10 was taking R1 back to the room. As I walked past R1's room, I heard S10 asking R1 Is it good? or about something good. I reported this to team leader S7 and stated that it was uncomfortable and if team leader could check on S10. An interview on [DATE] at 12:20 PM with Assistant Director of Nursing (ADON) was done. ADON stated that when it was reported initially to me, it was not clear that there was sexual abuse involved. The report came in as S10 hiding in R1's room. Because S10 has a history of hiding and sitting in rooms because of his condition of being on light duty and health issues, I was not clued in that it was possibly sexual abuse. I talked with S10 on the 22nd of February 2023. S10 stated he was in R1s room because she was wheezing, and she needed support. I advised S10 that if he felt sick and/or needed a break, he should not be at work. Interview and concurrent RR was done on [DATE] at 01:00 PM with S7. S7 stated that on the morning of February 15, 2023, S3 came to me and asked me to check S10 who was in R1's room for a while. S3 stated she felt uncomfortable because S10 had taken R1 back to her room and this was not her normal routine of getting up in the wheelchair for the day. S7 went to the room and noticed the vital signs machine outside of R1's room. Upon entering R1's room, the curtain was closed, lights were off and S10 was holding both of R1's hands. S7 asked why R1 was taken back to the room because R1 had slept nine hours the night before. R1 was observed to be calm, smiling and holding S10's hands. S10 stated that R1 stated her eyes were sore and brought R1 back and turned the lights off. S7 stated she assessed R1's eyes and R1 stated that her eyes were not sore. S7 informed S10 that in the future, the nurse needed to know any complaints or concerns so that an assessment can be done by the nurse. S7 went on to state that on [DATE] after report , S8 informed S7 that she felt uncomfortable with S10's behavior the day before. There were two licensed on the nights and I had no idea what was going on the early AM of the 15th. I don't know if I told the supervisor the night of the 15th. When I returned on [DATE] , I went to talk to the supervisor S11. I informed S11 that S10 was spending a lot of time in R1's room and would close the curtain with the lights off. Even after instructing S10 to leave the room, do vitals on another wing, S10 would make his way back to R1's room. S10 seemed infatuated with R1. RR was done on [DATE] at 01:30 PM of the policy ID 4753018, dated ,d+[DATE], named Allegations of Abuse/Neglect/Exploitation: Acute Inpatient, Outpatient & Long-Term Care (LTC); page 2 of 11, (D) indicates For Long Term Care, the reporting must take place immediately, but not later than two hours after forming the suspicion if there is a possibility of abuse and/or serious bodily injury. (F) If the abuse allegation occurs after hours, the Nursing Supervisor or LTC Director of Nursing (DON)/Administrator has the authority to issue a letter to the alleged employee perpetrator explaining his/her rights to union representation during the preliminary investigation and that the employee is being placed on administrative leave until the investigation is completed (see Appendix J, Notice of Investigation). Continued RR revealed that the initial incident occurred on [DATE] with S10. Report of sexual allegation investigation did not occur immediately but officially reported on [DATE] to the state agency. S10 was allowed to work four days after initial incident reported, i.e., February 18, 20, 22 and 23rd (4 days in addition to initial observation of sexual abuse). Continued RR of policy, page 3 of 11, (2) indicates The patient/resident will be evaluated for physical and/or emotional signs of abuse/neglect/exploitation. Interview and concurrent record review was done on [DATE] at 09:16 AM with S6. S6 stated that S8 reported to her that things were feeling uncomfortable and S10 was exhibiting strange behaviors towards R1. I returned to work on [DATE]. S10 was informed not to come down to R1's room to take vitals as R1 was in isolation for COVID. It was morning shift, and we were documenting and S10 came straight down to R1's room. He pretended to take the vitals for R1 and wedged his way to the side of R1. He would squeeze himself between the table and his crotch was close to where he placed her hand. I went to the room and when I came out, S10 was on the side of her, and I witnessed him fix his pants and saw her hand drop down. I got upset and grabbed briefs and went into R1's room. I told S10 to let me in the room and he stood in the doorway and did not want to budge. I moved the table so he couldn't go into the room anymore and he was still there. I went to tell S7 that there was no reason for S10 to take vitals. When S7, our team leader told him to go, he did not want to go. I ended up going to see the assistant director of nursing that day because we could not keep watching S10 because it was stressful, and we had work to do. S6 went on to say that he was on light duty and R1 was total assist, so he could not do the extensive care that is required for her. He is slower and older. He tended to disappear a lot. An interview on [DATE] at 10:37 with Director of Nursing (DON) was done. DON stated that the social worker notified agencies to investigate the case on [DATE]. Because R1 had advanced dementia and interviews were not reliable, SW was not substantially involved because of R1's cognitive status. There was an initial report made to the nurse manager, but I was not aware of it. Another report was made on the 21st of February 2023. Both times, the interpretation of the report was that it was not sexual abuse. S6 persisted with ADON and myself that further investigation needed to be done regarding S10 and R1. Staff were reporting that something was not right and there were observations of inappropriate touching and closeness with R1. On February 24th, 2023, I contacted the administrator and human resources. S10 was not working on the 24th and was placed on administrative leave pending investigation. During an interview on [DATE] at 11:00 AM with the administrator, the administrator stated that because it was a nursing employee, I did not talk to anyone, and I believe that DON made the report to the authorities. Record review (RR) on [DATE] at 11:15 AM of the facilities Code of Conduct (COC) provided by the Human Resources Officer was done. COC indicates on page 19 that relationships of romantic or sexual in nature are unethical, prohibited and a violation.

Based on interview and record review, the facility failed to report an alleged sexual abuse violation to the State Agency within two hours of receiving reports of inappropriate touching, invasion of privacy and space from staff members for Resident (R)1. Allegations of sexual abuse were reported initially on 02/15/23. An official report was received at the SA on 02/24/23. The facility also failed to report to the designated representative within 5 working days of the incident. This deficient practice could place vulnerable residents at the facility at risk for jeopardy or harm due to untimely reporting process for abuse allegations. Findings include: During multiple interviews done during 03/14/23 through 03/15/23 by the state agency, staff members reported observations were made of inappropriate touching and behavior of staff (S)10 towards R1. The following observations were observed on the following dates: On 02/15/23, S8 and S3 observed inappropriate touching and behavior of S10. On 02/16/23, S7 reported to charge nurse inappropriate behavior of S10. On 2/22/23, S6 reported to lead charge nurse inappropriate touching and behavior of S10 towards R1. (REF F600) Record review (RR) on 03/15/23 at 09:50 AM revealed that the official report made to the State agency, resident representative and other agency were not made until 02/24/23. An interview on 03/15/23 at 10:37 AM with Director of Nursing (DON) was done. DON stated that the social worker notified agencies on 02/24/23. Because R1 had advanced dementia and interviews were not dependable, SW was not substantially involved because of R1's cognitive status. There was an initial report made to the nurse manager, but I was not aware of it. Another report was made on the 21st of February 2023. Both times, the interpretation of the report was that it was not sexual abuse. S6 persisted with ADON and myself that further investigation needed to be done regarding S10 and R1. Staff were reporting that something was not right and there were observations of inappropriate touching and closeness with R1. On February 24th, 2023, I contacted the administrator and human resources. S10 was not working on the 24th and was placed on administrative leave pending investigation. (REF F600)

Based on record review, interviews, and facility policy review, the facility failed to ensure planned fall prevention interventions were promptly and consistently implemented to minimize the risk of falls/fall-related injury for 1 (Resident #22) of 2 sampled residents reviewed for falls. Findings included: Review of a facility policy titled, Fall Prevention and Management, revised 03/2022, revealed the steps for post-fall management included, g. Complete post-fall huddle. h. First responder to complete First Responder Form. i. Clinical follow-up for care plan additions/changes as indicated through outcomes of daily stand-up and falls meetings discussions. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #22 was severely impaired in cognitive skills for daily decision-making, per a staff assessment for mental status. According to the MDS, the resident had active diagnoses including hypertension, Alzheimer's disease, and a history of falling. The MDS indicated the resident required extensive assistance with bed mobility and transfer, did not walk during the assessment period, was totally dependent with locomotion on and off the unit, and used a wheelchair for mobility. Per the MDS, the resident had experienced two falls with no injury since admission, reentry, or prior assessment. A review of Current Orders revealed Resident #22 had a physician's order dated 07/22/2020 for, Precautions: Fall Prevention Protocol ACTIVE. Additionally, the resident had a physician's order dated 08/28/2020 for alarms to be on at all times. The order did not specify the type of alarms to be used. Review of a care plan, dated as initiated 07/22/2020, revealed Resident #22 was at high risk for falls related to a history of falls and a diagnosis of dementia. The care plan indicated the resident had experienced falls on 07/10/2021, 07/23/2021, 07/29/2021, 09/16/2021, 10/17/2021, 01/30/2022, 05/06/2022, 06/11/2022, 07/23/2022, and 09/12/2022. Interventions included monitoring the resident's sleep patterns (07/23/2021); having the physician complete a medication evaluation (07/29/2021); having a staff member stay with the resident during periods of restlessness (01/30/2022); replacing the wheelchair alarm due to a malfunction and checking the alarms every shift to ensure they are activated (02/10/2022); placing the resident next to staff, due to the resident's tendency to stand without asking for help (05/06/2022); checking on the resident every 15 minutes (06/11/2022); ensuring the bed alarm is secured with Velcro to ensure proper placement (07/23/2022). Review of a Nurse Note w/ [with] Vitals, dated 07/23/2021, revealed Resident #22 had an unattended, witnessed fall. The resident's alarm sounded, and staff saw the resident stand, attempt to sit down, and miss the wheelchair. The resident fell to the floor and landed on their buttocks. The wheelchair brakes were locked, the resident's shoes were on, and the floor was dry. The resident reported, I am looking for my companions. No injuries were noted. Review of an LTC [Long-Term Care] IDT [Interdisciplinary Team] Note, dated 07/23/2021, revealed a falls meeting was conducted, and an intervention to monitor the resident's sleep patterns was developed. Review of a Monitoring Sleeping Pattern form revealed the facility monitored Resident #22's sleep pattern from 07/23/2021 to 09/31/2021. There was no documentation in the resident's medical record of any conclusions or interventions that were developed as a result of the sleep pattern monitoring. Review of a Nurse Note, dated 07/29/2021, revealed the resident had an unattended fall. The note indicated a certified nursing assistant (CNA) heard the resident's bed alarm sound and upon entering Resident #22's room, found the resident on the floor between the bed and side drawer. The resident was supine (lying on back) with the right leg flexed upward and the left leg straight. The resident reported attempting to check the food that I'm cooking. No injury was noted. The note indicated the bed was in the low position and locked at the time of the fall. Review of an LTC IDT Note, dated 07/30/2021, revealed a falls meeting was conducted, and an intervention was developed to have the physician complete a medication evaluation and to assess the resident's medications during a [CONDITION(S)] meeting. Review of a [CONDITION(S)] Committee Meeting note, dated 08/03/2021, incorrectly indicated Resident #22's last fall occurred on 04/13/2021. According to the note, Resident #22's physician did not attend the meeting. Review of a Nurse Note, dated 01/30/2022, revealed Resident #22 had an unattended fall from the wheelchair. The note indicated the resident was found on the floor in the hallway in front of the wheelchair. The resident reported wanting to go back to bed. According to the note, the wheelchair alarm was on but did not sound. No injury was noted. Review of an LTC IDT Note, dated 01/31/2022, revealed a falls meeting was conducted, and an intervention was developed to have a staff member stay with the resident during periods of restlessness if the assigned CNA had to attend to another resident; however, based on review of the Nurse Note below, the resident fell again 10 days later after exhibiting signs of restlessness. Review of a Nurse Note, dated 02/10/2022, revealed Resident #22 was found on the floor near the hallway, in front of the wheelchair. According to the note, the alarm was on but did not sound. The resident reported wanting to go home. Staff reported they had toileted the resident and placed the resident in bed, but the resident got up twice, so had been placed in the wheelchair. Review of an LTC IDT Note, dated 02/11/2022, revealed a falls meeting was conducted, and the wheelchair alarm was replaced due to malfunction. An intervention to check the alarms every shift was added. Review of a Nurse Note, dated 05/06/2022, revealed Resident #22 had an attended fall. According to the note, the resident slipped from the chair to the floor. CNAs attempted to catch the resident but were unsuccessful. The resident reported wanting to go home. No injury was noted. Review of a Nurse Note, dated 05/10/2022, revealed a falls meeting was conducted, and an intervention was developed to place the resident next to staff due to the resident's tendency to stand without asking for assistance. Review of a Nurse Note, dated 06/11/2022, revealed Resident #22 had an unattended witnessed fall. Staff heard the resident's alarm sounding and went out in the hall to see the resident sliding slowly to the floor, onto the buttocks. The wheelchair was at the resident's back, and the side table was upside down in front of the resident. The resident was unable to explain what they were attempting to do. No injury was noted. Review of an LTC IDT Note, dated 06/15/2022, revealed a falls meeting was conducted, and an intervention was developed to check on the resident every 15 minutes. Review of CNA documentation for close watch revealed 15-minute checks were initiated on 06/26/2022, eleven days after the intervention was developed. Review of a Nurse Note, dated 07/23/2022, revealed Resident #22 had an unattended fall. According to the note, the resident was found on the floor, facing the door to the room, with the slippers under the resident's right leg. The note indicated the bed alarm did not trigger. The nurse noted that the resident's doll was under the large body pillow on the resident's bed, and when the doll was removed, the alarm sounded; therefore, the nurse surmised the combined weight of the doll and the pillow prevented the alarm from triggering. Review of an LTC IDT Note, dated 07/26/2022, revealed a falls meeting was conducted and an intervention was added to check the resident's alarms every shift to ensure they were activated. Additionally, the bed alarm was secured with Velcro to ensure proper placement. The note indicated the body pillow weight was considered; however, it was determined the pillow was not heavy enough that removal of the pillow would trigger the alarm., Review of a Nurse Note, dated 09/12/2022, revealed Resident #22 had an unattended fall. According to the note, the resident was found in the bathroom, soiled with urine, and lying on the right side with legs extended. No injury was noted. The CNA stated the resident's alarm was delayed and was not sounding when the CNA entered the resident's room and found the resident's wheelchair unoccupied. The note indicated the alarm would be replaced. Review of a Fall Risk Assessment, dated 09/12/2022, revealed Resident #22 had fall risk factors including confusion/dementia, unsteady gait, frequent toileting needs, a history of falls in the past three months, a language barrier, and poor hearing. The resident's fall risk assessment total score was 75. The form indicated a score of 15 or greater indicated a fall risk. Observation on 10/11/2022 at 10:30 AM revealed Resident #22 in a wheelchair in their room, with an alarm in place. The resident's roommate stated the alarm sounded frequently. During an interview on 10/12/2022 at 2:44 PM, CNA #1 stated he checked on Resident #22 every 15 minutes. CNA #1 stated he also checked to ensure Resident #22's bed and chair alarm were functioning by checking the batteries. During an interview on 10/13/2022 at 8:50 PM, Licensed Practical Nurse (LPN) #1 stated the Director of Nursing could answer questions related to fall interventions for Resident #22. During an interview on 10/13/2022 at 9:43 AM, the Director of Nursing (DON) stated she did not see a physician's note to indicate a medication review was conducted as indicated after the 07/29/2021 fall. The DON acknowledged the date of the last fall listed on the 08/03/2021 [CONDITION(S)] meeting notes was incorrect. The DON stated she could not find documentation regarding a discussion about Resident #22's sleep monitoring and did not know what was determined from the monitoring. The DON was asked about the planned intervention to place the resident next to staff and when that intervention was discontinued. She stated, What they do is they try to make sure [resident] is visible where staff can see [gender]. The DON stated for the 05/06/2022 fall, staff was facing a different direction and staff were told to keep the resident where they could see the resident. She stated if a staff member had to go in another resident's room, the resident might be left alone but as much as possible they preferred to have eyes on the resident. The DON was asked why, if staff were to keep the resident in sight, the 15-minute checks were put in place after the fall on 06/11/2022. She stated if the resident was with staff, they are just checking on the resident and, if staff had to go and help another resident, the expectation would be to do a visual check on the resident every 15 minutes. The DON stated this was documented on the close watch task. The DON stated close watch monitoring was only documented every 30 minutes until 06/26/2022 because, while the frequency had had been updated on the care plan, it also needed to be corrected in the task list. During an interview on 10/13/2022 at 10:57 AM, Registered Nurse (RN) #1 stated she did not recall the results of the sleep review for Resident #22. The RN stated in addition to the alarms, staff were also with the resident when the resident was in the hallways, and if the resident was in bed, then the 15-minute checks were done. During an interview on 10/13/2022 at 11:54 AM, the Administrator stated nurses on the floor were responsible for ensuring care planned interventions were carried out. The Administrator did not recall Resident #22's sleep pattern study and did not know the outcome. The Administrator did not know the details regarding the occasions when the resident's alarm failed to function. The Administrator stated there should be a fall meeting for each fall, during which the fall and the resident's chart were reviewed comprehensively. Based on this review, the team would gather data and look at the care plan to determine if new or different interventions were needed. Regarding the 15-minute checks, the Administrator indicated if staff were doing constant supervision of the resident and switched to 15-minute checks, there should have been clarification that the 15-minute checks were to be done while the resident was in bed. During an interview with the DON and Administrator on 10/13/2022 at 1:33 PM, the DON stated there was no fall meeting documented after the 10/17/2021 or 09/12/2022 falls. She stated the team talked about the falls in stand-up meetings but must have forgotten to document. The Administrator stated she was not aware there was not a fall meeting after those falls.

Based on observations, interviews and record reviews, the facility failed to ensure the resident's right to voice grievances to the facility or other agency/entity that hears grievances. Residents were unaware of how to file a grievance/complaint and the contact information of independent entities (pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system) with whom grievances may be filed was not made available to all residents. As a result of this deficiency, residents are at risk for negative psychosocial impacts on their quality of life. Findings include: During an interview with Resident (R)16 on 05/25/21 at 12:56 PM, the resident stated multiple complaints were made to direct care staff (registered nurses (RN) and certified nursing assistants (CNA)) regarding the aspects of the resident's care. Inquired on how the resident would go about filing a grievance with the facility and if the resident was aware of his/her right to contact the State agency. The resident was not aware of how to file a grievance and stated he/she had just been complaining to staff and no one has addressed the resident's verbal complaints. Furthermore, R16 was unaware of the right to contact the State agency, the Office of Health Assurance (OHCA), and did not have access to OHCA's or the Adult Protective Service's contact information. Inquired if the resident attends resident counsel or leaves the room. R16 stated he/she never leaves the room due to the resident's health condition. This surveyor did not observe any posting for information of grievances or any State agency's contact information. On 05/27/21 at 11:15 AM, review of R16's admission Minimum Data Set (MDS) with an assessment reference date of 03/09/21 documented R16's Brief Interview for Mental Status (BIMS) score was 14 indicating the resident is cognitively intact. R16 was admitted to the facility on [DATE]. On 05/25/21 at 1:20 PM, requested a list of grievances for the past 6 months from the Administrator. The following day, the Administrator stated that the facility did not have any grievances from the residents. 2) An observation on 05/26/21 at 09:07 AM was made in the Ha'ole Room of the Board of information that includes the Ombudsmen's, grievance information and the States, OHCA contact information. This board was in an inconspicuous area in the dining room of the Ha'ole Room. The board was blocked by a white screen, in the corner next to the bathroom. Interview on 05/26/21 at 10: 07 AM with the Administrator - there have been no grievances for over a year or longer. On 05/26/21 at 1:30 and 2:01 PM, respectively interviewed Residents (R)5 and 26. R5 and R26 stated that they do not come out of their rooms, do not know the board in the Ha'ole Room, and do not know how to file a grievance. An interview with the Social Worker (SW) on 05/27/21 at 10:04 AM. SW stated that the charge nurses go over the admission packet with the residents which includes the grievance procedure process. The SW coordinates the resident council meetings. Review of the resident council minutes dated May 2020, we discussed the Ombudsman as old business. The new business was resident rights. SW showed this surveyor the attendance form which showed 5 residents that attended the meeting in May of 2020, which was the last discussion in resident council regarding ombudsman, grievances and resident rights. SW further stated that I do a memory and mood assessment every three months during which the SW asks residents if they have any concerns, any complaints, in care plan conference. On 05/27/21 at 02:02 PM, surveyor interviewed Registered Nurse (RN)1 who is the charge nurse. RN1 was asked to go over the admission packet with this surveyor and duplicate the process when doing an admission to the facility. RN1 referred to the concern form in the admission packet and stated if you have questions in regard to disability or resident rights, you will call that number. Information such as ombudsman, resident centered care, grievances was skipped over. This surveyor went over their paperwork with RN1 named Got a Concern? Who to call? The concern form includes ten State resource departments that include phone numbers as well. When surveyor asked RN1 if she knew that the states OHCA number and ombudsman's number was on their sheet for regulatory, licensing concerns and grievances, RN1 stated she was not aware of this. RN1 stated that the bulletin in the Maika Rooms has a list of resident rights. There are grievance forms outside of the Maika Room and before you turn to [NAME] unit. There is also a bulletin board in the Hau'oli room Interview and concurrent observation on 05/27/21 at 03:29 PM with Assistant Administrator (AA) who was shown the board of Information in the Ha'ole Room. The board was covered by a white screen in the back of the room. AA stated Yes I agree no one can see this board. It needs to be moved.

Based on observation, interview, and record review (RR), the facility failed to protect and promote quality of life for four residents (R)30, R50, R27, and R22, by ensuring that they were treated with respect and dignity. As a result of this deficient practice, these residents have experienced embarrassment, ridicule, sadness, frustration, and defeat, and have been prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all residents in the facility. Findings include: 1) R30 was a [AGE] year-old male admitted on [DATE] for long-term care with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Since his admission, R30 had been isolated in a single room in the facility, leaving his room only to attend outside doctor appointments. On 05/26/21 at 09:41 AM, during an interview and concurrent observation with R30 in his room on the Lehua Unit, R30 described several situations where he felt staff had treated him disrespectfully. R30 reported that many of the Certified Nurse Aides (CNAs) on the morning shift were rude and lazy, grumbling when he asked for help, ignoring him as they talk[ed] story over him, sometimes speaking in Filipino and laughing while changing his incontinence brief, and gossiping about other staff and residents as if he was invisible. When he has asked them to stop, he was ignored. R30 stated that sometimes when he asks to be turned, cleaned, or repositioned and pulled up in bed, the CNAs have treated him roughly and carelessly, leaving him uncomfortably positioned on his side longer than necessary, dropping his legs, grabbing his arm to turn him instead of using the draw mattress, or insisting that he is fine positioned the way he is. The thing that bothers him the most is how careless they are with positioning the draw mattress under him. R30 stated that it is always too high, so that when it is inflated, he is hanging off it from the hips down. When he asks the morning CNAs to fix it, they usually either tell him that it does not need to be fixed, or that they will fix it later. The poor positioning of the draw mattress was confirmed through direct observation. There was noted to be approximately two feet of the deflated draw mattress hanging down off the head of the bed. R30 stated that when positioned correctly, the top of the draw mattress should be behind his shoulders. When asked, R30 stated that he had shared some of what had been going on with Restorative Nurse Aide (RNA)2. On 05/27/21 at 09:45 AM, during a phone interview with RNA2, RNA2 confirmed that R30 had discussed some of the morning CNAs with her. RNA2 stated that R30 had complained to her that some of the CNAs make him feel uncomfortable and that they do not position him properly. RNA2 shared that she had observed times when the draw mattress was not positioned correctly, or R30 had a wet incontinence brief, and she would call the CNAs in to fix it, R30 would ask her to please stay and watch the CNAs to make sure they did it right. RNA2 also stated that once she had observed a CNA grab R30's hand to pull him for turning and she had immediately intervened and instructed the CNA on how to turn him safely using the draw mattress. RNA2 stated she did not document any of this but had reported some of it to the Assistant Administrator. On 05/27/21 at 12:54 PM, an interview was done with the Assistant Administrator in her office. The Assistant Administrator acknowledged that RNA2 had come to her with some of R30's concerns, but the way it was presented to her, she was unaware that R30 had complaints of specific nursing staff and took the relayed concerns as a need for additional education of all nursing staff. The Assistant Administrator stated that she did speak to R30 twice to assess whether he had any complaints against specific staff, and twice he denied it. As a result, the assessments and denials were not documented anywhere, but additional education pertaining to R30's positioning, pain, and disease management was provided to nursing staff. 2) R50 was a [AGE] year-old female admitted on [DATE] for long-term care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/25/21 at 01:09 PM, an observation and interview were done of R50 in her room on the [NAME]. R50 was observed with an indwelling catheter with dark yellow urine in the tube, draining into a urinary bag with no privacy cover that was hooked under her bed. R50 stated she spends much of the day in her room, but usually gets out of bed and goes out to the Solarium every morning. On 05/26/21 at 11:30 AM, during an interview of R50 in her room on the [NAME], R50 tearfully described several situations where staff have treated her disrespectfully. R50 reported that sometimes staff yells at her, and when she asks, why are you yelling at me?, staff tells her she is the one yelling. Other times staff have treated her roughly when they were changing her incontinence brief, or they have teased her when they turn her onto her back, exposing her privates, and saying oh look, the bushes, the bushes, pointing and laughing. When R50 has asked staff to stop the disrespectful behavior, staff has denied the events happening. R50 stated that she receives a bed bath three times a week but would like to be bathed more frequently. When she has requested more baths, they told me I was too heavy. R50 also reported that sometimes the CNAs [certified nurse aides] don't want to come into the room to help me, sometimes it makes me upset, and I start crying, sometimes I don't know who really to talk to. On 05/26/21 at 11:49 AM, an observation and concurrent interview was done with licensed practical nurse (LPN)2 at the bedside of R50. R50's urinary collection bag for her indwelling catheter remained uncovered and was positioned flat on the floor under her bed. When pointed out to her, LPN2 agreed that the catheter bag should have a privacy cover and should not be on the floor. LPN2 immediately left the room to grab a privacy cover and a container for the bag to sit in. On 05/27/21 at 12:25 PM, a RR was done of R50's Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/20/21. It was noted that R50 had yielded a score of 15 (cognitively intact) for her Brief Interview for Mental Status (BIMS). 3) R27 was a [AGE] year-old male admitted on [DATE] for long-term care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite the tremors in both hands related to his diagnoses, R27 could still eat his meals independently with minimal assistance. On 05/25/21 at 01:17 PM, an observation and interview were done with R27 in his room on the [NAME] as he was eating his lunch. R27 was observed having difficulty cutting his piece of chicken with both hands shaking uncontrollably, inadvertently pushing food off his plate. Milk could be seen dripping down R27's beard and the front of his shirt. When asked if he needed any help, R27 looked embarrassed, wiping his beard with his hand saying, I usually keep my napkin right here [pointing towards his chest], but they didn't give me one today and then they left before I could ask. 4) R22 was a [AGE] year-old non-verbal male admitted on [DATE] for long-term care, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 was completely dependent on staff for all his activities of daily living (ADLs). On 05/27/21 at 01:21 PM, an observation was done in R22's room on the [NAME]. R22 was lying awake in bed, alone in his room, just after having his incontinence brief changed. At the foot of his bed directly below his feet was a balled up, soiled incontinence brief and two dirty incontinence wipes. On 05/27/21 at 01:47 PM, RNA1 was observed at R22's bedside, working with him using a stand exerciser. The soiled incontinence brief and dirty wipes had been removed from the foot of the bed. RNA1 stated she discarded the items when she saw them and agreed that the CNAs should not have left them there.

Based on interviews and observations, the facility failed to ensure the resident's right to a safe, clean, and comfortable environment for everyday living. In various rooms throughout the facility paint was worn and peeling from the walls, an air conditioner was leaking in a room, air conditioner hose laying on the ground, a ceiling tile was cracked/loose, and there were black marks along the interior of the wall. Findings include: 1) On 05/25/21 at 11:51 AM, conducted an interview with Resident (R)4 and quiered the resident regarding the cleanliness of the resident's room. R4 stated for two months housekeeping has not cleaned this resident's side of the room. However, housekeeping has cleaned the R4's roommate's side of the room. On 05/25/21 and 05/26/21 during the day shift, while on the [NAME] Unit this surveyor did not observe housekeeping staff. An interview was done 05/27/21 at 11:30 AM with Maintenance worker (M)1. M1 stated, we (the facility) have only three housekeepers, and now we are hiring utility workers. Utility workers are able to work in housekeeping, kitchen (do not handle food), and maintenance departments. 2) On 05/27/21 at 12:00 PM, while on the [NAME] Unit, an observation was made of a ceiling tile open in the hallway and an air conditioner (AC) leak (which was contained with a dumpster). Upon inquiry of the observation, Licensed Nurse (LN)1 stated there an AC unit was leaking and maintenance was fixing it. LN1 also stated it happens all the time and that is why we have the portable along the hallway. A tour of the facility was done on 05/27/21 at 1:23 PM. This surveyor observed the following: wall paint wear and tear in Rooms 115 A/B, 116A/B, 117A/B, 119, 121A; leaking and stained ceiling panels were noted near Room 210; cracked ceiling tile noted near Room 238; black skid marks on walls in Rooms 236 and 234; ceiling panel loose at area of Room 230; worn down pain and black stain on wall of Room 236; black skid marks on wall of Room 218-220; and a portable AC hose laying on the ground near the wall of Room 226 and 228. LN1 stated the portable AC hose laying on the ground fell down and is not connected. On 05/27/21 at 02:00 PM, conducted an interview with M2. M2 stated, We (the facility) are trying to replace units (AC) one at a time. We are looking at our [NAME] wing to upgrade. I change units all the time and the ceiling tile. We can only do one job at a time. We have been doing this since 1995. Bottom line is that everything costs money.

Based on observation, interview, and record review (RR), the facility failed to accommodate the needs of two residents in the sample, as evidenced by not providing resident (R)22 with a call light that he could activate, and not providing R30 with a geriatric chair for mobility and/or a wheelchair for transport. As a result of this deficient practice, R22 was placed at risk of not having his needs identified and met in a timely manner, and R30 was confined to either his bed or a gurney since his admission. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) R22 was a [AGE] year-old non-verbal male admitted on [DATE] for long-term care, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/25/21 at 12:00 PM, an observation was done of R22 in his room on the Lehua Unit ([NAME]). R22 was noted to have contracted elbows, wrists, and fingers and could not move his hands. There was a regular button-style call light placed at R22's right hip. On 05/27/21 at 09:01 AM, an interview was done with LPN2 in the hall outside of room [ROOM NUMBER]. LPN2 stated that R22 communicates with his eyes. To call for help, LPN2 explained that R22 cannot extend his fingers, hands, or elbows, but he could hit the triangular red sensor call light by bumping it with his fist or elbow . On 05/27/21 at 09:09 AM, an interview was done with Registered Nurse (RN)2 in R22's room on the [NAME]. RN2 stated that R22 should have a triangular red sensor call light that he can activate by hitting it with the lateral surface of his fist, or with his elbow, however she could not locate it in the room. Upon observing the regular button-type call light placed near his right hip, RN2 confirmed that R22 would not be able to activate it. The Nurse Manager (NM)1 was notified that R22 needed a sensor call light, and it was installed within two hours. 2) R30 was a [AGE] year-old male admitted on [DATE] for long-term care with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Since his admission, R30 had been isolated in a single room in the facility, leaving his room only to attend outside doctor appointments. On 05/26/21 at 10:00 AM, an observation and interview were done with R30 in his room on the [NAME]. R30 was observed sitting upright in bed, with the head of the bed up approximately 75 degrees. R30 was wearing a ventilation mask and head gear, his breathing was unlabored, and there were no support pillows or wedges observed under his arms, at his sides, or under his knees or ankles. R30 was on a regular mattress with no devices for off-loading [pressure] observed. R30 stated that he cannot reposition himself independently and requires assistance to move anything below chest level. R30 explained that he spends all his time in bed, except for when he leaves the facility for a doctor's appointment, for which he is transferred to a gurney. R30 then stated that the reason he is transported on a gurney is because the facility does not have a wheelchair large enough to fit him. R30 expressed that he does not like, nor does he feel safe being transported on a gurney, especially since the transport service used by the facility does not have a vehicle that the gurney can be safely secured in. He is aware that the facility is working with an ALS organization to obtain a power wheelchair for him but does not understand why there is nothing else he can use to sit in or be transported in for the meantime. Further observations were done of R30 in his room on the [NAME], on 05/27/21 at 08:30 AM, 01:30 PM, and 03:10 PM and on 05/28/21 at 08:30 AM, 09:20 AM, and 10:00 AM. At each observation, R30 was sitting up in bed with the head of his bed between 75-90 degrees, with no trunk support, head support, or neck support noted. At some times, R30 was observed eating or drinking, and he was noted to feed himself, chew, swallow, and speak without difficulty. On 05/28/21 at 09:00 AM, an interview was done with the Director of Nursing (DON) in her office. The DON confirmed that the facility does not have a manual wheelchair large enough for R30, so he must be transported to outside appointments on a gurney. The DON then stated that the facility was working on obtaining a power wheelchair for R30, which would enable him to be independent with his mobility, but she was unaware of any other mobility or transport devices available that R30 could use while waiting for the power wheelchair. On 05/28/21 at 10:45 AM, an interview was done with NM1 in the conference room. NM1 stated that due to his trunk instability, it had been determined that a manual wheelchair would not be appropriate for R30. Documentation of this assessment and specific determination was requested but not received. On 05/28/21 at 11:00 AM, a RR of R30's Physical Therapy Note, dated 11/28/20 (late entry from 11/25/20), by Physical Therapist (PT)1 noted the following: .[R30] is able to tolerate sitting at edge of bed supported by bilateral UE's [upper extremities] with [NAME] [minimal assistance] for 15 minutes, chair transfers deferred at this time secondary to lack of appropriate chair . No documentation found in the Physical Therapy Notes regarding any issues of trunk instability, poor head control, or poor neck control since being discharged from Physical Therapy on 11/25/20.

Based on Medical Record Reviews, interviews and observations the facility failed to provide care and services to prevent pressure ulcer development and promote healing of pressure ulcers for 3 out of 3 residents. Findings: 1) Resident #1 was admitted to the facility on [DATE]. He was discharged on /,[DATE] for 1 night and was readmitted [DATE]. His [DIAGNOSES REDACTED]. Care Plan Conference Conducted on [DATE] had documented that Resident #1 is at risk fro pressure ulcer because he had a history of [REDACTED]. Review of Skin assessments for (YEAR) and (YEAR) showed documentation of reoccurring pressure ulcers during this time. Skin check completed on [DATE] had documented that skin was intact and no skin issues noted. On [DATE] the skin assessment had documented an open area to the right buttock that was covered with DD. Also dry healing abrasion to right upper thigh measuring 2 x 3 cm, 2 x 2 cm and 0.5 x 0.5 cm. This was after a one day hospital admission to Hilo Medical Center. APRN documented in a miscellaneous note on [DATE] that resident had a stage II pressure ulcer he got during his hospital stay and noted resident was on an air mattress and ordered Vitamin C BID and Zinc 220mgs PO daily and [MEDICATION NAME] supplement BID. Skin assessment on [DATE] had documented the coccyx area was open to air and pinkish in color with no open areas noted. On [DATE] the skin assessment had documented 2.3 cm x 3.2 cm pressure ulcer with possible deep tissue injury to left ishial tuberosity. The wound nurse was notified and examined the site, ordering duoderm to be applied every Monday, Wednesday, Friday and PRN. Resident had a speciality mattress. [DATE] miscellaneous note by APRN noted the wound to the left ischium measured 3 cm x 3 cm, circular with a black soft cap over 75% of the wound with 25% pink base. Yellow drainage with no odor. Dressing orders changed to mesalt after irrigating wound with normal saline. Mesalt was to cover black cap of wound only and then cover with folded ABD pad to cushion wound daily. [DATE] APRN documented in miscellaneous note that the resident had 3 pressure ulcers, 1 on his left ischium and the other 2 on the left side of the coccyx. Treatment ordered for all three pressure ulcers was Safegel and dry dressings. [DATE] APRN documented in miscellaneous note that the resident had another deep tissue injury located on the right trochanter. This area measured 5 x 5 cm with an open center that measured 2 x 2 cm. Serous sanguineous drainage was noted and was unable to stage at that time. Orders were to clean with normal saline and apply a [MEDICATION NAME] dressing to the open area and pad entire ulcer with an ABD pad daily. [DATE] is was documented on the skin assessment that there were three pressure wounds, on on the left ischial 1 x 1 cm with pink wound bed and minimal drainage with safgel dressing covered by dry dressing, one on right ischial 5.2 x 3.3 cm blackened wound bed no odor and minimal drainage unstageable wound with safe gel and dry dressing and one on the sacrum 1 cm x 1.2 cm with pink wound bed with minimal drainage and no odor being treated with safe gel and dry dressing. [DATE] had four pressure ulcers documented. one on the coccyx measuring 1 x 2 cm partial thickness with pink base. Minimal serous drainage, cleaned with normal saline, patted dry, [MEDICATION NAME] applied and covered with dry dressing. Second pressure wound was on sacrum 0.5 x 1 cm partial thickness area with pink wound bed, minimal serous drainage, cleaned with normal saline, [MEDICATION NAME] applied and covered with dry dressing. Third pressure wound was on right trochanter, unstagable 5 x 4 cm with eschar and scant amount of slough. No drainage or odor was noted. Fourth pressure wound was on left ischium measuring 0.5 x 0.5 cm with pink bed and no drainage or odor. [DATE] was documented on the skin assessment that the left ischium, sacrum and coccyx wounds had resolved. The wound to the right trochantar continued with 5 x 4 cm black eschar boggy center with slough to the edges. Wound was being cleaned with normal saline. [MEDICATION NAME] was being applied to wound and covered with a dry dressing. [DATE] it was documented on the skin assessment that the sacrum stage II wound had reopened 0.2 x 0.2 cm with pink wound bed. [DATE] it was documented on the skin assessment that the right trocahntar unstagable pressure ulcer had 100% yellow gray slough, measuring 3.7 x 3.5 x 0.1 cm with moderate amount of brownish drainage with mild odor. Left trochantar stage II pressure injury had reopened measuring 1.5 x 1 cm with pink wound base and no drainage. Sacrum area remained resolved but fragile. [DATE] it was documented on the skin assessment the right trochantar pressure injury measured 1 0.5 0.5 cm with pink wound bed. Minimal serous drainage and no odor. Wound was cleaned with normal saline, patted dry, saturated 2 x 2 with safe gel and applied to wound bed, covered with folded 4 x 4 secured with tape and then covered with [MEDICATION NAME]. Left trochantar there were no open areas or discoloration and duoderm was applied to the area. Buttocks had no open areas or discoloration, [MEDICATION NAME] #3 applied as ordered for protection. [DATE] it was documented on the skin assessment that the right trochantar pressure injury was resolved and duoderm had been applied for protection. [DATE] it was documented on the skin assessment that the resolved right trochantar pressure injury area was dry and intact. When the duoderm was removed a small skin tear was noted and new order was obtained to pain area with [MEDICATION NAME] BID. Old pressure area to left trachantar remained resolved with scar tissue present. Skin prep was applied to the area. A new stage 2 pressure injury to the right sacrum measuring 2 x 2 cm. an order was obtained to cover with [MEDICATION NAME] and secure with duoderm. [DATE] skin assessment had documented that no openings in the skin at this time. [DATE] skin assessment had documented that the left trochantar had a stage 1 pressure injury measuring 0.5 x 0.5 cm. The area was cleansed with normal saline, skinprep applied and was covered with duoderm for protection. [DATE] skin assessment had documented that on left side of buttocks there was an opening measuring 1 x 1 cm with pink wound bed and no drainage or odor. [MEDICATION NAME] #3 being applied QID. There was another superficial open area top of butt crack measuring 0.5 x 0.5 cm with pink wound bed with nor drainage or odor. [MEDICATION NAME] #3 applied as ordered. A third opening was on right side of sacrum measuring 0.5 x 0.5 cm with pink wound bed and no drainage or odor. [MEDICATION NAME] #3 was applied. [DATE] skin assessment had documentation that there was a stage II pressure injury to left ischium measuring 1.7 x 1.3 cm with pink wound bed with no drainage and sensicare was applied. Also present was an unstagable pressure injury to the sacrum measuring 4.5 x 3 cm open area. To the right side of the open area there was dark slough/eschar present. Left side of open area was pink to bright red with small amount of drainage with no odor. Wound was cleansed with normal saline and dried. [MEDICATION NAME] was applied to wound and covered with duoderm. [DATE] skin assessment had documented the stage II pressure injury to the left ischium measured 1.5 x 1 cm with pink wound bed with no drainage. Sensicare was applied as ordered. Unstagable pressure injury to sacrum measured 4.5 x 3 cm open area with dark/slough/eschar to right side of wound and pink to bright red area on left side of the wound. There was a small amount of drainage with no odor. [MEDICATION NAME] was applied to the wound and covered with duoderm. A third open area measuring 0.5 cm was noted on the site of the old right trochantar pressure injury area. Duoderm was applied. [DATE] wound assessment had documented that the resident continues to be monitored for old wounds to coccyx and ischium and no new skin issues were noted at this time. On [DATE] it was documented on the skin assessment that the resident refused wound care and skin assessment that shift due to nausea and vomiting. The next wound assessment completed ten days later on [DATE] had documented that the old right trochantar pressure injury remained closed, a stage IV pressure injury to the sacrum measuring 1.5 x 1.5 x 0.5 cm with tunneling at 12 o'clock. Wound bed pink to bright red with moderate amount of sero-sang drainage and no odor. Wound was irrigated and gently dried. Skin prep was applied and silver cel was packed into the tunneling and was to be changed every Monday, Wednesday and Friday. Documentation by APRN on [DATE] states Patient's condition continues to deteriorate and skin breakdown has become unavoidable. On [DATE] and [DATE] a physician had documented pressure injuries are unavoidable and development of pressure ulcers is not only inevitable but unpreventable. With this information documented along with documentation from care plan conference on the [DATE] the facility failed to ensure weekly skin assessments were maintained to help prevention and promote healing of pressure injuries. On [DATE] it was documented on the skin assessment that a skin assessment was unable to be done that shift due to resident being out of facility. Next skin assessment was completed [DATE] after this time. Previous one was conducted on [DATE] leaving 21 days with no skin assessment being conducted on a high risk resident. Again on [DATE] skin assessment was not completed to resident refusing at time and next skin assessment was completed on [DATE] with previous one completed on [DATE] leaving 12 days with no skin assessment being completed on a high risk resident. Lab results for right hip wound culture on [DATE] showed 2 organisms were present. Organism 1 was [MEDICATION NAME] Avuim Group D and Oraganism 2 was Staphylococcus Aureus. Wound culture taken from buttock wound on [DATE] showed two organisms present. Organism 1 was Staph [MEDICAL CONDITION] and organism 2 was Entercoccus faeculis. Interview with Staff #8 who is the wound clinic nurse for the facility last saw Resident #1 on [DATE]. With Resident #1 being a high risk pressure injury resident, deteriorating in month of (MONTH) and had a documented Stage IV pressure injury to his sacrum, the wound nurse should have been overseeing the management of this wound on a more frequent basis to prevent deterioration of the pressure injury and be actively working towards healing. Resident was transferred to North Hawaii Community Hospital on [DATE]. He arrived at the hospital at 1824 hrs. Medical record notes from North Hawaii Community Hospital have documented on [DATE] that He was initially admitted with a chronic small bowel obstruction which was due to adhesions from [MEDICAL CONDITION] ulcer surgery many years ago. Patient had perforated ulcers and had to be allowed to heal by secondary intention. He started taking a turn for the worse yesterday becoming more and more confused blood pressure dropping. Patient has some draining decubiti on his pelvis which appear to be infected. He is hypotensive. He is also somewhat hypoxic. He appears to be septic. [DATE] at 9:57 PM it was documented in the medical record of Resident #1 a [DIAGNOSES REDACTED]. Documentation in the Medical record at North Hawaii Community Hospital on [DATE] at 0301 hrs stated He had multiple potential sources of this [MEDICAL CONDITION] his small bowel obstruction he had infected decubitus ulcers an he also had masses in the right lung which were surrounded infiltrate which could be infectious. Resident was full code status and was intubated in the emergency room before being transferred to the ICU. He was listed as critically ill. Patient expired at 1452 hrs on [DATE]. Discharge summary completed [DATE] at 1514 hrs stated patient [DIAGNOSES REDACTED]. He has received 2L IV bolus and started on maintenance fluid. Lactic acid 2.8>1.7. Source at this time could be post-obstructive PNA vs aspiration PNA, infected decubitus ulcer, [MEDICAL CONDITION], GI with SOB. Patient has a suprapubic catheter in place. -comfort is primary goal of therapy. Documented in medical record is the presence on admission of an unstageable sacral decubitus ulcer with purulent drainage and a second decubitus ulcer was present. Based on this information the facility failed to monitor through weekly skin assessments development of pressure injuries and progress of healing of present pressure injuries on a regular frequent basis. The facility to have their wound nurse monitor and oversee the care and monitoring of a resident who was assessed as being high risk for pressure injuries and had a documented history of reoccurring pressure injuries. The facility failed to prevent a facility acquired pressure ulcer/injury from becoming infected with various bacteria causing osteo[DIAGNOSES REDACTED] and may have contributed to the Resident developing Septic Shock. . 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. While residing in the facility, Resident #3 developed a Deep Tissue Injury (DTI) on her right and left heels. Over a six month period, the DTIs resolved and formed on both of Resident #3's heels. At the time of this abbreviated survey, Resident #3 had a DTI on her left heel with the right heel DTI being resolved. An observation of Resident #3 on the morning of [DATE] found her lying in bed wearing mid calf high foam boots to bilateral legs. Resident #3 was unable to turn herself and was aphasic, being unable to make her needs known. Resident #3 had a dark, large (approximately 6 cm x 7 cm) round eschar patch on the bottom of her left heel. Foam boots were placed on both feet and rose to mid calf. Resident #3 had upper and lower extremity contractures and wedges and pillows were utilized to maintain comfortable positions. A review of Resident #3's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] on the morning of [DATE] revealed she was totally dependent on staff for bed mobility (2+ person assistance), transferring (2+ person assistance), eating (1 person assistance), and bathing (1 person assistance). The [DATE] MDS further noted Resident #3 had severely impaired cognitive skills for daily decision making and short and long term memory problems. A review of Resident #3's body diagram assessment on the morning of [DATE] revealed her fluctuations in the resident's skin which ranged from being intact, to stage 2 pressure injury, to Deep Tissue Injury (DTI) over a six month period (July to (MONTH) (YEAR)). The Electronic Medical Record (EMR) was difficult to navigate and to gather information. Facility staff (Administrator, Director of Nursing (DON), and Nurse Manager) were all available to surveyors to obtain/print information from the EMR. The facility initiated the use of Multipodus Boots on [DATE] with the body diagram assessment noting, Right lateral leg no open areas, dry flaky skin. [MEDICATION NAME] #3 applied. New Multipodus boots in place. Highlights from review of the body diagram assessments found discrepancies from one week to the next. For example, the assessment dated [DATE] noted , No skin issues, while on [DATE] the assessment noted, Continues with DTI to right heel. On [DATE] the body diagram assessment noted, Left heel discoloration with 1.5 L x 1.5 W (cm) soft area; No discoloration noted to area but area remains to be soft and boggy to touch. This note indicated Resident #3 was beginning a new DTI on her left heel. The following body diagram assessment dated [DATE] noted Resident #3 Continued with left heel DTI; Podus boot in place; Wound Nurse aware and will continue to monitor. On [DATE], the body diagram assessment noted, Right plantar heel blanchable light purple discoloration, indicating the right heel was again breaking down. The body diagram assessment dated [DATE] noted, Left plantar heel DTI and right plantar heel DTI. The assessment on [DATE] indicated Resident #3's right plantar surface DTI had progressed to two stage 2 pressure injuries. A week later, Resident #3's body diagram assessment dated [DATE] noted, Left plantar heel DTI continues. Dry hard stable eschar measures 5.5 cm x 5 cm. Painted with [MEDICATION NAME] per order. Right plantar heel resolved. A review of Resident #3's Pressure Ulcers care plan found an entry dated [DATE] indicating, Per Wound Nurse, Multipodus boots discontinued. The Wound Nurse's last visit with Resident #3 was on [DATE]. A late entry for the [DATE] visit was noted on [DATE], when the Wound Nurse stated, Wound to patient's right heel assessed today. Patient has hard stable eschar on the right heel due to medical device, Podus boot. Recommend patient not use Podus boot and continue with [MEDICATION NAME] twice daily to keep eschar stable. Heel boots were also recommended. Please see wound record for wound description. A late entry by the Physical Therapist dated [DATE] (for [DATE] visit) noted, (Resident #3) had right heel deep tissue injury develop during treatment episode. An interview of the three Certified Nurses Aides, CNAs, on the morning of [DATE] at 11:45 A.M. revealed Resident #3 developed the DTIs/stage 2 pressure injuries to bilateral heels after use of the Podus boots. The CNAs all noted Resident #3's Podus boots remained on her heels without removal all day during their day shifts. The CNAs reported that they did not receive instructions to remove the Podus boots during the day shift hours. An interview of the Nurse Manager on the morning of [DATE] at 9:33 A.M. revealed Resident #3 had a history of [REDACTED]. After admission, Resident #3 has had recurring DTIs and pressure injuries. The Nurse Manager reported that Resident #3 was referred for Occupational Therapist (OT) screening due to her contractures. The OT recommended the use of Podus boots, which was used to prevent skin breakdown but instead caused skin breakdown for Resident #3. When asked when the boots were removed to allow her skin to rest, the Nurse Manager reported the boots remained on 24 hours per day. The Nurse Manager stated that the Podus boots were discontinued due to the DTIs and reported the resident now used foam boots. On the morning of [DATE] at 9:33 A.M., the Surveyor asked the Nurse Manager to provide a copy of Resident #3's physician's orders [REDACTED]. Resident #3 started use of the Podus boots on [DATE], when the skin on her heels were intact. From use of the Podus boots, she developed a DTI on her right heel on [DATE] (first documented note). Since developing a DTI on her right heel, the facility continued use of the Podus boots despite the initial skin breakdown. Podus boots were discontinued on [DATE], three months since start of use. The facility failed to provide the necessary treatment and services for Resident #3 to prevent new DTIs and pressure ulcers from developing on both heels. 3) Cross Reference to F641. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. Record review done on [DATE] found an admission Minimum Data Set with assessment reference date of [DATE]. In Section C. Cognitive Patterns, the Brief Interview for Mental Status was conducted. Resident #2 yielded a score of 15 (cognitively intact). In Section M. Skin Conditions, Resident #2 was documented with unhealed pressure ulcer, Stage 1 or higher with one Stage 1 pressure ulcer and one Stage 2 pressure ulcer (dated [DATE]). In Section G. Functional Status, Resident #2 was found to require extensive assistance with two person physical assist for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). The resident was not coded with a life expectancy of less than six months (J1400. Prognosis). A review of the resident's care plans (provided by the facility on the afternoon of [DATE]) found a care plan for potential for skin breakdown and pressure ulcers. The potential for skin breakdown notes the resident is at risk for skin breakdown related to dependence on staff for mobility and [DIAGNOSES REDACTED]. Interventions included: reposition every 2 hours in bed and weight shift when in wheelchair; use pillows to keep heels off bed and to aid in positioning; consult dietary as needed; and keep resident hydrated per dietitian. The care plan for pressure ulcers (Stage 2 to coccyx, admitted with and [DATE] DTI to left heel) found the following interventions: left heel DTI - [MEDICATION NAME] swab BID; coccyx - duoderm change every 4 days and prn; foam boots while in bed; APP mattress; measure weekly; turn every 2 hours; and refuses to use the foam boot. The documentation of [DATE] notes, Resident #2 was admitted with a Stage 2 pressure ulcer to the coccyx (measurement was 6 cm x 7 cm). On [DATE] the ulcer measured 6 cm x 7 cm with superficial opening, measuring 1 cm x 0.8 cm. Subsequent documentation for [DATE], [DATE]/ [DATE] and [DATE] does not document further measurements, description of wounds or whether the Stage 2 pressure ulcer to the coccyx healed. On [DATE], the weekly skin assessment notes three Stage 1 pressure injuries to the lower back, each measures 3 cm x 1 cm, non-blanchable. The progress note for [DATE] notes three Stage 1 pressure injuries that the resident was admitted with continues, each red and non-blanchable, measuring 3 cm x 1 cm On [DATE] an air mattress was provided. Further documentation on [DATE] notes the pressure injuries to the lower back resolved. Resident #2 was also noted to have deep tissue injury (DTI) to left heel. The first documentation was dated [DATE] which measure the injury as 2 cm x 2 cm. On [DATE], the injury was measured as 1.8 cm (length) x 2.0 cm (width), [MEDICATION NAME] was ordered (swab twice a day). Subsequent note of [DATE] notes deep tissue injury to left heel continues, open area to left ear continues with foam boots and [MEDICATION NAME] to left heel area. The note dated [DATE] by the Registered Dietitian (RD) was reviewed. The RD notes Resident #2 with good intake (75% of meals) but does not accomplish kcal/protein needs at this time due to increased protein needs with wounds. The recommendations included magic cup three times a day with meals; speech therapy consult; wound supplements added, [MEDICATION NAME] twice a day and zinc sulfate for increased wound healing. A review of the care plan identifies Resident #2's problem as nutritional risk due to ill-fitting dentures, mechanically altered diet, advanced age, increased needs due to wounds and BMI <22. The care plan included nectar-thickened mighty shake at bedtime to decrease night-time hunger and provide nutritional supplements as ordered. The physician order [REDACTED].M. for wound care found no order for the supplements recommended by the RD ([MEDICATION NAME] twice a day and zinc sulfate). On [DATE] at 9:30 A.M. an interview and concurrent record review was done with Staff Members #7 and #8. Queried whether Resident #2 was provided with the supplements ([MEDICATION NAME] and zinc sulfate) as recommended by the RD. The staff member reported if there is an order for [REDACTED]. Following review of the record, Staff Member #7 stated it healed, based on the note that there are no open areas. Inquired whether the wound assessments should include the measuring of the injury/ulcer, Staff Member #2 confirmed that the assessor should document the wound measurements and confirmed this was not being done. Staff Member #2 commented when Resident #2 was admitted , the facility considered placing the resident on hospice. The facility failed to provide care/services for the treatment of [REDACTED]. The facility failed to accurately assess the resident's skin as the resident was admitted on [DATE] and four days later ([DATE]) there is documentation of three Stage 1 pressure ulcers on admission to the resident's lower back. Also the facility failed to ensure thorough assessment of the wounds were done to include size, description of wound (exudate present, color and type of tissue, slough or eschar present) and pain assessment.