Every finding on record at Ka Punawai Ola

Based on record review and interview, the facility failed to identify and intervene for an acute change in a resident's condition related to infection for one Resident (R) 10 resulting in R10's family member initiating the transfer to the Emergency Department. The resident was admitted to the hospital with respiratory distress, pulmonary edema, and septic shock. There was no documentation of the resident's vital signs or notification of the change in condition to the physician which preceded the transfer to the Emergency Department, cross reference to F580. The deficient practice caused harm to the resident related to complications of sepsis. Findings include: Intake #2968720 reviewed on 04/21/26. R10's Family Member (FM) contacted the Office of Healthcare Assurance (OHCA) about an incident that occurred on 02/28/26 when R10 had a change in her condition that resulted in a transfer and admission to the hospital. R10's FM stated that R10 had a big bed sore that was identified on 02/27/26 and was told that R10 got it from an acute care facility the previous day when she went to have a blood transfusion on 02/26/26 where she sat for 5 hours. The FM stated no nurses told her about the bed sore. The FM said on 02/28/26 the Speech Therapist approached and told the FM that R10 was very weak that day. The FM wanted R10 to be sent to the ER due to her poor condition, and that the facility did not report that R10's status had changed and she was weak. The facility staff told her that R10 was cold that day asked for extra blankets. The FM demanded that her mom be sent to the ER. When the ambulance came and took R10's temperature she had a fever. R10 was taken to the ER after 5 PM on 02/28/26. R10 had a pressure ulcer that was 10 centimeters (cm), (a photo of the pressure ulcer was provided from the FM), and she was diagnosed with septic shock. The FM stated that R10 passed away on 03/08/26 in the hospital. Review of R10's Electronic Health Record (EHR) on 04/22/26. Resident (R10) is an [AGE] year-old female admitted to the facility on [DATE] for rehab services after a hospitalization. R10 had a seven percent (%) weight loss identified on 02/18/26 and acquired an unstageable pressure ulcer to the coccyx on 02/27/26. R10's diagnosis includes anemia (low red blood cells) requiring blood transfusions; difficulty in walking; muscle weakness; dysphagia (difficulty swallowing) and primary hypertension. R10 was transferred to the Emergency Department (ED) on 2/28/26 for high fever and heart rate and diagnosed with Sepsis. Minimum Data Set (MDS) discharge return anticipated with an Assessment Reference Date (ARD) of 02/29/26 reviewed. R10 requires substantial/maximal assistance with eating and was unable to ambulate or sit to stand. R10 had weight loss and was not on a prescribed weight loss regiment. R10 had one unstageable deep tissue injury to her coccyx that was identified on 02/27/26 the day before she was transferred out to the ED.Progress notes reviewed. 02/28/26 14:31 Skilled Note. Temperature (T) 97.5 02/28/26 07:19 Pulse (P) 90 02/28/26 07:19 Blood pressure (BP) 102/51 02/28/26 07:19 pain level 6 02/28/26 13:34 Pain scale: Numerical.No adverse effects noted on shift.On continous (sp) oxygen via nasal cannula 2 liters per minute (LPM) sating 93% and above; no SOB noted on shift.Signed by Registered Nurse (RN)28.02/28/26 17:07 Type: Orders - Administration Note. Acetaminophen Tablet 325 milligram (MG) Give 2 tablet by mouth every 4 hours as needed (PRN) for pain Acetaminophen. PRN Administration was: Unknown hospitalized . Signed by RN24.03/01/26 04:37 Type: Health Status Note. Resident to be admitted to Hospital for septic shock. Signed by RN36.Progress notes of R10's change in health status, with R10's vital signs and communication to the physician prior to the transfer to the hospital on [DATE] were not available for review in the EHR. The last vital signs that were documented were on 02/28/26 at 07:19 AM. eINTERACT (electronic) Transfer Form dated 02/28/26 reviewed. B. Transfer Details. 1. Sent To: Hospital listed was not the correct hospital. It was called in to EMS on 02/28/26 at 17:30 by RN24. The vital signs documented on the form were from the morning on 02/28/26 at 07:19 AM. An interview and record review was done with the Director of Nursing (DON) on 04/23/26 at approximately 12:30 PM in the surveyor conference room. The surveyor asked the DON to review the documentation in the EHR and look for information about R10's health status, when and why R10 was transferred to the ER. The DON looked in the EHR and confirmed there was no documentation that stated R10 declined and the doctor was notified of R10's condition or that the resident was sent to the ER. Asked the DON if there is a transfer/ discharge summary in the EHR with documented status date/ time, when resident was transferred, Doctor was notified, and family/ representative was notified. The DON looked in the EHR and said, there is a transfer/ discharge summary, but it's blank and confirmed there was nothing written to indicate when the resident went to the ER and the reason why. Asked the DON where the information about a resident's discharge/ transfer should be documented. The DON stated that the information should be documented in the progress notes and confirmed the notes were missing. Asked the DON if there is documentation that the vital signs were taken at the time R10 declined. The DON confirmed the vital signs were missing. An Interview and concurrent record review was conducted with the RN Supervisor (RNS) on 04/24/26 at 10:59 AM in the surveyor conference room. The surveyor asked RNS to discuss what occurred on 02/28/26 when R10 declined. RNS said it was on the evening shift. The Speech Therapist (ST) came to the desk and asked me to check on R10, and that she wasn't looking very good. I asked the evening nurse who was assigned to R10 if she had seen R10 and if she would go check on her. I went to check R10 with the ST. When I saw R10 she seemed ok. The FM came to me and said R10 isn't doing well, and this wasn't her baseline. We discussed that R10 wasn't eating well for the past few days, and the FM asked if R10 was getting fluids and felt like she needed more fluids. The FM asked what we do now and I told her we can call the doctor and offer her intravenous (IV) fluids. The FM said she wanted R10 to go to the ER. When asked what the vital signs were that day, she said she didn't remember. The RNS said she talked to R10's nurse, RN24 and she was new, she asked her if R10's family shared concerns about R10 and she said they did and she was going to go back to assess R10 but then she got busy with another resident and forgot to check back on her. RN24 went and did her assessment for R10, and the family insisted on taking her to the hospital. I think RN24 called the doctor to inform him. When asked the RNS what happens if there is a change in condition, she said, we inform the doctor then we implement our interventions and do our assessment and carry out any orders. Everything that happens gets documented in the progress notes, she looked in the EHR and said that she didn't see any notes documented there. Telephone interview with RN24 on 04/24/26 at 12:30 PM. Asked RN24 if she was assigned to R10's care on 02/28/26 and confirmed that she was assigned to her. Asked her to describe what happened on 02/28/26 prior to R10 transferring out to the ER. RN24 said she had just started her shift and the RNS came to her saying the family had concerns about the resident that she was very warm and wasn't feeling well. When she went to check R10, she felt warm, so she checked her temperature and it was 101 degrees. Her heart rate was also high, but she didn't remember what it was. RN24 said the family was there and they wanted R10 to go to the ER. The RNS and other staff helped get the paperwork together to send her out. Asked RN24 if the doctor was called to report the resident's fever. RN24 said she couldn't remember if she called the doctor and when asked if she documented the temperature and vital signs. She said she was busy and forgot to document the resident's vital signs. Asked her if she received report from day shift nurse she said yes, she did and they didn't report anything wrong with the resident, and everything was fine. Review of R10's hospital records on 04/24/26. ED Provider notes dated 03/01/26 at 1627 reviewed on 04/24/26. Diagnostic Impression: Pneumonia, bacterial Septic shock. Disposition: Admit. Chief complaint: Shortness of breath (brought in by ambulance from care at facility, staff states desaturation (low oxygen to the tissues) 88-89% generalized edema (swelling), shortness of breath.Tylenol given by staff prior to admission as per triage nurse.Vital signs Temp: 100.5, pulse 123, respirations 35 BP: 1-3/55, Saturation 93% on oxygen (O2). Hospitalist admission History and Physical (H&P) notes reviewed. In ER patient was found to be initially normotensive, tachycardic, and mildly febrile (normal blood pressure, high heart rate and fever) .Developed hypotension (low blood pressure) on monitor during my evaluation. I was asked to admit the patient for septic shock. BP 92/49, Pulse 93, Temp 99.4 Resp 23.large sacral decubitus ulcer (bed sore).2) EHR reviewed on 04/24/26. Progress notes reviewed. Type: Nutrition/ Dietary Note Date: 2/25/2026 14:39:13 Note Text: Resident with 7.0% significant weight (wt.) loss x 30 days likely related to poor oral intake mostly 0-50% with occasional refusals. Diet order: Reg, EC7 (easy to chew), Thin (liquids) with no added salt. ONS (on nutrition supplement): Med Pass 60 ml BID (twice per day) (takes 100%). Per resident appetite varies depending on the meal. Registered Dietician (RD) requested ST to determine if resident's texture can be upgraded to get the choice menu. The RD increased 90 ml three times per day (TID) & added orders to offer snacks TID. MD notified. Dietary care plan reviewed. Focus. At nutrition and hydration risk related to current health status including severe anemia.initiated 02/09/26. Interventions.Weekly weights x 4 weeks. Assistance with meals as needed.Weights reviewed: 02/05/26 13:30 138.0 lbs. Hoyer lift. 02/18/26. 17:23 128.5 lbs. Hoyer lift Resident had a significant weight loss of 7.2 % in 13 days. Telephone interview on 04/28/26 at 10:32 AM with Dietary Manager (DM) 2 Asked what interventions were in place prior to R10's weight loss. The DM2 said she was on a Liberalized (unrestricted) cardiac 2 Gram (GM) diet with no salt packets for fluid imbalance and edema. Asked the DM2 when the weight loss was identified. The DM2 said after she was admitted , the weekly weight didn't get done, there were weights done on 02/05/26 and 02/18/26. The DM1 was on leave until the 16th, and I stopped covering R10 on the 13th. It was hard for her to get out of bed, and she required a Hoyer lift. Once the DM1 discovered the weight loss, she added 2 Cal med Pass (a supplement) on the 16th and started the pro T gold 17 gm per 30 milliliters (ml), a supplement on the 27th when the pressure ulcer was identified.

Based on interviews, and record review, the facility failed to implement and develop interventions to prevent avoidable falls for one of three residents (Resident (R), 30) investigated for falls. R30 had four fall incidents ([DATE], [DATE], [DATE], [DATE]) and one near fall incident ([DATE]) from the time he was admitted to the facility on [DATE]. This deficient practice has the potential to affect residents with balance deficits and strength impairments.Findings Include:Cross reference to F656On [DATE] at 08:00 AM, the Department of Health, Office of Health Care Assurance (OHCA) received a complaint from R30's Family Member (FM) 2 that R30 sustained three falls at the facility. The FM2 stated that R30 was admitted to the facility on [DATE] and was going through rehab, working with therapist to strengthen his legs which never quite healed. The FM2 noted that for the first fall incident, R30 was able to crawl to the wheelchair before the staff got to him. The FM2 stated the second fall happened the same month but could not recall the specific dates and times, but R30 was working with the therapist when the fall happened. The FM2 recalls the third fall incident happened on [DATE] when a Certified Nurse Assistant (CNA) was helping him to the restroom but fell again and ended up fracturing his left ankle which required R30 to be transferred to the hospital for surgery and has been there since. The FM2 also mentioned that R30 injured his heel with one of the falls, with the heel getting infected and never healed. The FM2 stated that since R30's fall incidents, he has been going downhill and is now on comfort measures only. The FM2 stated that she was informed each time R30 fell and spoke with a Registered Nurse (RN) of what happened and what they were going to be doing to prevent further falls but felt that the facility may not have changed their processes to have prevented subsequent falls. On [DATE] at 09:00 AM, review of R30's electronic health record (EHR) noted that R30 is an 87-year male admitted to the facility on [DATE] with a diagnosis of but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle weakness, difficulty walking, heart failure, and diabetes. R30 prior to being admitted to the facility had two falls at home requiring hospitalization where he initially started physical therapy treatments (PTT) and continued with strength and conditioning at the facility. Review of the nursing admission assessment completed on [DATE] noted that R30's reason for admission was for rehabilitation and oral antibiotic therapy treatment, to include PTT and OT (Occupational Therapy). R30's cognition assessment on admission on ly notes that he had a hearing impairment and was oriented to person, place, and time, with primary means of communication to be verbal and can understand others and make himself understood. R30 was noted to have 3+ edema to left arm, none documented for lower extremity (LE) edema. R30 was continent for urinary status, however, needed extensive assistance for transfers, toileting, personal hygiene, and dressing. R30 was noted to require limited assistance with ambulation and/locomotion, but was found to have gait disturbance, unsteady gait, and balance issues due to right LE weakness. R30 had multiple skin condition with abrasion to bilateral knees and dorsum of left foot and right foot 2nd toe. R30 was noted to be a fall risk alert and review of R30's initial fall risk assessment on admission noted R30's mobility status was confined to chair and balance marked as not able to attempt test without physical help. R30 was also noted to have moderately impaired-limited vision but can identify objects, and R30's continent status was marked as elimination with assistance, which meant he was continent but needed assistance to use the bathroom.On [DATE] at 09:30 AM, review of the facility's Incidents by Incident Type Listing from [DATE]-[DATE] noted that R30 had three witnessed falls. The first fall was on [DATE] at 03:40 PM, the second fall on [DATE] at 08:05 AM, and the third fall at [DATE] at 07:10 AM. R30 was also listed as having one unwitnessed fall on [DATE] at 11:20 PM and a skin related injury on [DATE] at 11:00 AM. On [DATE] at 09:30 AM, a review of the fall incident reports that were provided by the facility was completed and with the following findings:1) Fall #1 was an unwitnessed fall, that happened on [DATE] at 15:40 PM in R30's room. This incident report was reported by RN1. The incident description is as follows:Nursing description: R30 opened his door, yelling Hey! RN1 went to check on resident, R30 was trying to sit back on his wheelchair, one wheel was not locked, and R30 fell on his bottom.Resident description: R30 stated, she told me she was going to get it ready so I can go to bed. RN1 explained it was too early for bed, R30 apologized and said he thought it was bedtime.Immediate action taken: RN1 helped R30 off the floor with CNA's assist. R30's vitals were wnl (within normal limits). R30 denied pain. A fall huddle was completed with new interventions put into place: Place sign at bedside as reminder to R30 to use call light and wait for assistance prior to ambulation/transfers, ST (short test of mental status) screen to address cognition.Injuries observed at time of Incident: No injuries observed at time of incidentMental Status: Oriented to Person/PlacePredisposing factors: OtherPredisposing physiological factors: Recent illness, gait imbalancePredisposing situation factors: Ambulating without assistOn [DATE] at 09:45 AM, review of the fall risk evaluation form completed on [DATE] for this fall noted R30's mobility status marked as ambulates without problems and with devices, balance marked as unsteady, but able to rebalance without physical support, continent status was now independent and incontinent, and visual status was marked as moderately impaired-limited vision, but can identify objects.On [DATE] at 10:00 AM, review of R30's care plan, cross reference to F656.There was no nursing intervention to address the wheelchair being unlocked or other interventions to address environmental hazards (i.e. bed in low position) noted in care plan with this fall incident. There was also no care plan found to address R30's moderately impaired vision (i.e. adequate lighting)On [DATE] at 11:00 AM, interview with the Director of Nursing (DON) completed. When asked about what the other was for the predisposing factor, DON noted that it could be the wheelchair but needed to confirm with RN1. DON acknowledged that the care plan should have been revised to include having the wheelchair locked and secure to prevent further falls/accidents and to address R30's visual impairment. On [DATE] 08:40 AM, interview with RN1 confirmed the fall incident on [DATE] and stated that R30 was calling for help and was able to open the door. R30 was confused about the CNA getting him something ready for bed and RN1 had to explain to R30 that it was too early for bed. RN1 further noted that R30 was able to walk back to his wheelchair to sit down but fell on his buttocks due to one of the wheels on wheelchair being unlocked. RN1 acknowledged that it is everyone's responsibility to ensure that the wheels are locked to prevent accidents. RN1 confirmed that locking the wheelchair was missed and the fall could have been prevented. RN1 also confirmed that the predisposing factors marked as other on the incident report was the wheelchair.On [DATE] at 09:00 AM, review of the physical therapy treatment (PTT) progress notes for dates of service from [DATE]-[DATE] indicated that for balance, R30 can stand unsupported with AD (assisted device) for 10 seconds. R30 was also noted to have a Tinetti balance (a health tool that screens elderly patients for balance and gait) score of 10/16, gait score of 9/12, for total score of 19/28, which indicated R30 had an increased risk of falling. R30 also had a mobility function score (ranges from 0-12; 12 being the highest function) of six, which indicates that R30 was generally dependent on mobility maneuvers and required help with basic ADLs (Activities of daily living) such as transfers, toileting, and dressing. 2) Fall #2 was an un-witnessed fall on [DATE] at 23:20 PM in R30's room. This report was prepared by RN2. The incident description is as follows:Nursing Description: RN2 was notified by CNA1 that resident fell. RN2 went to R30's room and found R30 lying on the floor, bed noted in lowest position. RN2 noted a bump on the occipital area and skin tear on R30's left rear upper arm, cold compress then applied on the bump and wound dressing done on the skin tear, no other injuries noted, denied pain. R30 is oriented to self, time, and situation (baseline). RN2 notified FM and MD (medical doctor).Resident Description: R30 verbalized, I feel so bad, I always use the call light but now I didn't. I wanted to go to the bathroom, so I got up to get to my wheelchair then my knees just gave out and then I hit the back of my head.Immediate Action Taken: Fall prevention sign placed on R30's room, brought R30 to the bathroom, made sure bed is in lowest position. Fall huddle complete with fall interventions added: Encourage toileting prior to bedtime and encourage/offer to toilet if see up at night.Injuries Observed at time of incident: No Injuries observed at time of incident (this is inconsistent with the nursing description).Mental Status: Oriented to person/situation/timePredisposing Physiological Factors: Gait Imbalance, Impaired MemoryPredisposing Situation Factors: Ambulating without assistanceOn [DATE] at 09:45 AM, review of the fall risk assessment completed on [DATE] for this fall noted R30's mobility status marked as ambulates with problems and with devices, balance marked as unsteady, but able to rebalance without physical support.Care plan review noted it did not include bed in low position as noted in the nursing description and no additional interventions to address impaired memory (i.e. hourly rounding, close monitoring)XXX[DATE] at 11:00 AM, interview with the DON noted that the bed in low position was not included to the care plan and frequent monitoring should have been implemented. 3) On [DATE] at 01:30 PM, review of R30's progress notes detailed a near fall incident that happened on [DATE] at 11:00 AM. A health status note was created by RN5, which read that CNA reported that as they were trying get R30's weight, R30's leg buckled which caused him to lose balance and scrape his left knee and stub his left great toe on the wheelchair, but the CNA was able to guide R30 back down to the wheelchair. RN and Unit Manager (UM) were made aware of the incident. Upon assessment, R30 had a skin tear to his left knee and left great toe.4) Fall #3 was a witnessed fall that happened in R30's room on [DATE] at 08:05 AM. This incident was reported by RN3. The incident description is as follows:Nursing Description: RN3 found patient sitting on the floor to his left side of his bed (witnessed fall by CNA), per CNA on duty, she assisted patient pulling R30's shorts up while standing, went to turn to pivot to R30's wheelchair then R30 grabbed CNA's shoulder and at that time R30's legs gave up. CNA assisted him slowly on the floor and R30 did not hit his head, and no new injury was noted.Resident description: R30 stated My legs gave up.Immediate Action Taken: R30 was put back to bed with three person assist, with no new injuries. MD and RP (resident representative) were notified. A new order from MD to increase Lasix to 20 mg (milligram) bid (twice a day) x7 days then 20mg daily for edema to his legs. Intervention: Change in diuretic medication to reduce swelling which is affecting R30's ability to stand and transfer to wheelchair.Injuries observed at time of incident: No injuries observed at time of incident.Mental Status: Oriented to person (this was a decrease in mental status in comparison to previous fall incidents)Predisposing Physiological Factors: Incontinent, Recent Illness, Weakness/Fainted, Gait Imbalance, Impaired MemoryOn [DATE] at 10:15 AM, review of the physician's orders noted TED (Thrombo-Embolus Deterrent) Hose to bilateral legs; on in am, and off in PM one time a day for edema and remove per schedule. R30 was also ordered fluid restriction of 1500ml/day starting on [DATE]. On [DATE] at 10:15 AM, review R30's care plan did not include the TED hose to bilateral legs application, the fluid restriction of 1500ml per day, or any nursing interventions to address LE edema. There was also no nursing interventions started to address R30's memory impairment, continued leg weakness, and gait imbalance. This was R30's second fall and third incident of his legs giving out and needing more than one person to assist him back to bed. No interventions or discussion noted that R30 would have benefitted from having two staff to assist him with ADLS due continued LE weakness and unsteadiness.On [DATE] at 10:30 AM, review of the fall risk evaluation completed for fall incident on [DATE], noted R30's mobility status marked as confined to chair, balance marked as Not able to attempt test without physical help.[DATE] at 11:00 AM, interview with the DON confirmed that TED hose application, fluid restriction, and other measures to address his LE weakness and knee buckling should have been included as it directs the resident's care and treatment. 5) Fall # 4 was a witnessed fall in resident's bathroom on [DATE] at 07:10 AM. This incident was reported by RN4. The incident description is as follows:Nursing Description: At about 07:08 AM, RN4 heard the CNA calling for help. Upon arrival at the room, R30 was sitting on the floor with his back by the CNA's legs. R30's left foot is against the wall. RN4 noticed blood on the floor, moved the foot to straighten and saw an open wound by the ankle joint. Per interview with the CNA, she was with R30 in the bathroom to do a brief change. R30 was holding onto the railing and was standing, with wheelchair locked and placed behind him. While R30 was standing, CNA pulled down R30's shorts and removed the soiled brief. R30 was still standing and lifted one leg as CNA inserted one hole of the new brief. When R30 put his leg down, that was when the fall happened. CNA was able to catch R30's head as he fell on his buttocks area. CNA felt the wheelchair push to the side. CNA then called for help and the nurse came. That is when they saw the fracture on R30's ankle. They called 911.Resident description: R30 stated he lost his balance and twisted his ankle.Immediate Action Taken: The weekend supervisor was informed and the facility called 911. While waiting, R30 was laid on the floor and started on 02 (oxygen) at 2LPM (liters per minute) with 96% 02 saturation. Vital sign taken: Temperature-97.8, Pulse 89, Respiration 20, and BP (blood pressure) at 106/66. R30 was transported via gurney and left at facility around 07:55 AM. R30 was brought to the hospital. MD was informed at 07:52 AM and approximately at 07:50 AM, FM was called 3x but there was no answer and mailbox was full. According to CNA, she took care of R30 before, and she was assisting R30 like how she does when she cares for him. R30 had prior falls related to buckling. In the ER (emergency room), R30 reported that he lost his balance and twisted his ankle. R30 was found to have a left open distal tibia and fibula fracture. R30 underwent left tibia and fibula reduction and remains in the hospital.Injuries Observed at time of Incident: Fracture, left inner ankleLevel of pain: 10.Mental Status: Oriented to Person/PlacePredisposing Physiological Factors: Incontinent, Recent Illness, Weakness/Fainted, [NAME] Imbalance, Impaired memoryPredisposing Situation Factors: Level 3 (individual-level risk factors)On [DATE] at 10:30 AM, review of the fall risk evaluation completed for the [DATE] fall noted R30's mobility status marked as ambulates with problems and with devices and balance marked as not able to attempt test without physical help.On [DATE] at 09:00 AM, review of the PTT summary of functional progress from 02/24-03/16 noted that R30 was downgraded (resident had plateaued) and was not able to make any more improvements in the areas of transferring and gait. The status of R30's ability to transfer and gait remained at supervision or touching assistance. Tinetti score of 21/28, although improved from initial baseline, remained as increased fall risk. Review of the PTT notes dated [DATE], a day prior to the [DATE] fall, R30 was found to have a pain intensity level of 5/10, with constant frequency to the right hand, right ankle, and right groin post therapy. It was also noted that R30 required extra time to process new information with this session. On [DATE], R30 had a PTT after the fall and post treatment results noted that R30 had a 6/10 pain intensity level with constant frequency to bilateral ankles. R30's response to treatment was met with unsteadiness on bilateral knees with knee buckling during transfer just before sitting. The PTT on [DATE] noted that R30's knee buckled again and R30 had to sit down. PT1 discussed with FM, R30's mobility level and recommended R30 to have 24-hour care at this time. R30's response to this PTT noted increased unsteadiness while standing with two episodes of knees buckling while standing.On [DATE] at 12:30 PM, interview with PT1 stated that they are aware of the residents' fall as they get a printout each day. They will take extra precautions and modify the treatment session considering the fall incident. PT1 was aware of R30's four fall incidents and noted that R30 made progress with treatments but later plateaued and could no longer improve in certain areas (gait and transferring) due to various factors to include, pain, skin issues, and the different medical conditions R30 has. When asked if R30's falls could have been prevented, PT1 stated that it is hard to predict when the fall is going to happen but stated that the CNAs should be knowledgeable and trained to assist residents with gait and balance issues to prevent the falls. When asked about how they communicate with nursing staff of any pertinent information that happened with residents during the PTTs, PT1 noted that they have daily rounds in the morning that is attended by nursing staff and the Director of Rehabilitation (DOR) but states the PT staff do not attend. When asked if he communicated R30's post-treatment response to PTTs regarding his pain intensity on [DATE], regarding increasing pain intensity level, unsteadiness on bilateral knees, and buckling during transfer on [DATE], regarding increased unsteadiness while standing with two episodes of knee buckling while standing on [DATE], and recommendation to have R30 with 24-hour, PT1 could not recall if he did. PT1 did acknowledge that this is significant information to communicate to nursing staff.On [DATE] at 01:10 PM, interview with DON noted that their primary means of communication with other departments is the daily grand rounds. The daily grand rounds are held Monday-Friday in the morning and the DOR attends and will present a list of concerns they may have with residents. When asked if the R30's pain level and increased unsteadiness and episodes of knees buckling during his therapy sessions on [DATE]-[DATE] was communicated to the nursing department, DON verbalized she did not remember it being presented in daily rounds. DON acknowledge that it should have been communicated right away so that appropriate nursing interventions could have been implemented and extra precautions made to prevent further falls. When discussing the plan of care revisions after this incident, DON noted that R30 expired about two weeks ago.On [DATE] at 02:00 PM, review of the facility's Fall Management policy with a reviewed date of [DATE], it states in the Policy section, The facility will assess the resident upon admission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. In the Avoidable Accident section, it reads, 1. Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. 3. Implement interventions, including adequate supervision.consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. 4. Monitor the effectiveness of the interventions and modify the care plan as necessary in accordance with current professional standards of practice. Risk-Refers to any external factor, facility characteristics (i.e. staffing or physical environment) or characteristics of an individual resident that influence the likelihood of an accident. Supervision/Adequate supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of staff, and the frequency of supervision needed. The determination is based on the individual resident's assessed needs. In the Procedure section, it states 4. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change.upon a fall event and as needed thereafter.6. The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history. One of these interventions may include safety checks.

Based on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan that was individualized to address the needs for one of three residents (Resident (R), 30) to prevent falls and failed to implement the use of floor mats for one of three residents, R20 investigated for falls.Findings Include:1) On 04/21/26 at 09:00 AM, review of R30's electronic health record (EHR) noted that R30 is an 87-year male admitted to the facility on [DATE] with a diagnosis of but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle weakness, difficulty walking, heart failure, and diabetes. R30 prior to being admitted to the facility had two falls at home requiring hospitalization where he initially started physical therapy treatments (PTT) and continued with strength and conditioning at the facility. Cross reference to F689. a)On 04/21/26 at 09:00 AM, review of R30's physician orders included Fluid Restriction: 1500 ml (milliliters)/day, with a start date of 01/31/26, TED Hose to bilateral legs; on in am, off in PM one time a day for EDEMA and remove per schedule, which was ordered on 02/04/26 could not be found in the care plan.b) On 04/21/26 at 09:10 AM, review of the facility's initial fall risk assessment noted that R30 had moderately impaired vision, however, there was no care plan found to address visual impairment.c)On 04/21/26 at 09:30 AM, review of the facility's Incidents by Incident Type Listing from 02/01/26-04/22/26 and the fall incident reports provided by the facility noted that R30 had three witnessed falls and one near fall incident resulting in skin injury. The first fall on 02/03/26 at 03:40 PM, which was witness by staff was due to one of the wheels on the R30's wheelchair not locked. The second fall on 02/26/26 at 11:00 AM was unwitnessed and the cause of the fall was determined that R30's knees gave out when attempting to get on his wheelchair. The third fall that happened on 02/26/26 at 08:05 AM, was a witnessed fall and R30's legs gave out, while CNA was helping him. The fourth fall occurred on 02/28/26 at 07:10 AM, a witnessed fall where R30 lost his balance and twisted his ankle, while being helped in the bathroom by a CNA, resulting in major injury and requiring hospitalization and surgery. The near fall incident happened on 02/22/26 were a CNA reported that as they were trying get R30's weight, R30's leg buckled which caused him to lose balance and scrape his left knee and stub his left great toe on the wheelchair. On 04/21/26 at 10:00 AM, review of R30's care plan noted the following:Focus: RISK FOR FALLS: R30 is at risk for falls as evidenced by fall risk present as determined by fall risk evaluation with a score of > 10 on admission. Functional problem: presents with balance deficits and strength impairments and in consideration of history, personal factors, and functional limitations, with s/p (status post) fall at home, leading to dx (diagnosis) of intraparenchymal hemorrhage-right occipital, left cerebellum, with history of DM (diabetes), HTN (Hypertension), HfpEF (Heart failure), A. Fib (Atrial Fibrillation).this focus was initiated on 01/19/26 and revised on 02/04/26.Goal: R30 will not sustain serious injury requiring hospitalization through the review date. Goal was initiated on 01/19/26 with a revised date of 02/07/26, with target date of 04/19/26.Interventions/Tasks: Assist with ADLs (Activities of daily living as needed)-initiated on 01/19/26Call light within reach-initiated on 01/19/26Complete fall risk assessment-initiated on 01/19/26Encourage toileting prior to bedtime and encourage/offer to toilet if see up at night- initiated on 02/11/26.Increase diuretics to decrease swelling to lower extremities-initiated on 02/27/26Orient resident to room-initiated 01/19/26Place sign at bedside as reminder to R30 to use the call light and wait for assistance prior to ambulation/transfers-initiated on 02/03/26ST screen to address cognition-initiated on 02/04/26There was no nursing intervention to address the wheelchair being unlocked or any interventions to address environmental hazards. The care plan did not include additional interventions to address R30's memory impairment, i.e. hourly rounding, sitting or close monitoring, or safety checks. Nursing interventions to address R30's continued LE edema, weakness, unsteady gait, legs giving out, and the need for adequate staffing to meet the R30's needs were not developed.04/23/26 at 11:00 AM, interview with the DON acknowledged that R30's care plan could have been more comprehensive and individualized to address R30's ongoing and increasing needs.2) R20 is an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of but not limited to left knee idiopathic gout, moderate-protein calorie malnutrition, muscle weakness, dysphagia and cognitive communication deficits. On 04/21/26 at 09:30 AM, review of the facility's Incidents by Incident Type Listing from 02/01/26-04/22/26 noted that R20 had two unwitnessed falls, 04/15/26 at 12:15 PM and 04/18/26 at 12:20 AM.On 04/21/26 at 10:00 AM, review of R20's care plan noted Focus: At risk for falls r/t (related to) deconditioning and functional dependence s/p hospitalization. Goal: The resident will not sustain serious injury requiring hospitalization through review date. Interventions: Bilateral fall mats when in bed, call light and frequently used items within easy reach, assist with ADLs (Activities of daily living) as needed, and completed fall risk assessment.On 04/24/26 at 10:30 AM, observed R20 asleep in bed with bed in low position, but with no fall mats on the bedside floor. The fall mats were flushed against the wall in front of the entrance of R20's room. On 04/24/26 at 01:10 PM, interview with DON acknowledged that the floor mats were not in the right place and it does not do the resident any good having it flushed against the wall. On 04/24/26 at 02:00 PM, review of the facility's Comprehensive Care Plan and Revisions policy, with reviewed date of 08/29/25, in the Policy section, it reads, The facility will ensure that the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team who has the knowledge of the resident and his/her needs. In the Procedure section, it states 1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered care plan.

Based on record review and interview, the facility failed to notify the physician when one Resident (R) 10 of three sampled for hospitalizations, had an acute change in condition that resulted in a transfer to the Emergency Department (ED). Findings include: Cross reference to F684 Quality of Care. Review of R10's Electronic Health Record (EHR) on 04/22/26. R10 was admitted to the facility on [DATE] for diagnosis including severe anemia dependent on blood transfusions. 03/01/26 04:37 Type: Health Status Note. Resident to be admitted to Hospital for septic Shock. Signed by RN36.Care plan reviewed. Focus. R10 is at risk for rehospitalization due to chest pain, shortness of breath (SOB) and acute pneumonia and other comorbidities revision 02/23/26. Interventions. Staff to provide timely communication to physician/ Nuse Practitioner (NP) regarding any change in resident condition. 02/05/26.An Interview and record review was conducted with the Director of Nursing (DON) on 04/23/26 at approximately 12:30 PM in the surveyor conference room. The surveyor asked the DON to review the documentation in the EHR to find the notes about R10's change in health status when she declined on 02/28/26. The DON looked in the EHR and confirmed there was no documentation that stated R10 declined, the doctor was notified of R10's condition, or that R10 was sent to the ER.An Interview with the Advanced Practice Registered Nurse (APRN) 5 on 04/24/26 at 11:00 AM at the [NAME] nurses station. Asked him if the nurse called him to inform him of R10's decline and transfer to the and said they may have called the on-call practitioner since it was on the weekend.During a Telephone interview with Registered Nurse (RN) 24 on 04/24/26 at 12:30 PM to discuss R10, asked RN24 if she called the doctor or APRN on 02/28/26 when R10 wasn't feeling well to report R10's change in condition. RN24 said she couldn't remember.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident. Findings include: (Cross Reference to F692: Nutrition Status Maintenance) On 03/31/25 at 11:10 AM, conducted a review of R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 pounds (lbs). On 03/07/25 and 03/09/25, R42 weighed 143.2 lbs, which is a -7.01 % loss in one month. Review of R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Reviewed the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to a loss of 5% or more in the last month, indicating R42 did not have a significant weight change. On 04/02/25 at 12:12 PM, conducted a concurrent review of R42's EHR and interview with Dietician (D)1. D1 reviewed R42's weights on 02/08/25, 03/07/25, and 03/09/25, then confirmed R42 did lose more than 5% in one month. D1 confirmed he/she did was not aware that R42's weight loss was significant. D1 reviewed R42's quarterly MDS with an ARD of 03/27/25, Section K. and confirmed the MDS should have coded R42 for a weight loss of 5% or more, but did not.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for one of three residents (Resident (R)294) sampled for pressure ulcers. Staff failed to report R294's refusal to be turned every two hours which delayed the implementation of new interventions to prevent the development of a new pressure ulcer. As a result of this deficient practice, R294 developed a Stage 2 pressure ulcer to her coccyx area and has the potential to affect other residents who are high risk for developing pressure ulcers. Findings include: Cross-reference to F726. (Competent Nursing Staff) R294 is an [AGE] year-old female who was admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to muscle weakness, unspecified protein-calorie malnutrition, and depression. During an interview with her Family Member (FM) at the bedside on 03/31/25 at 12:40 PM, FM stated that R294 had no skin problem or pressure ulcer prior to her admission. FM explained that R294 is now complaining of pain to her coccyx. FM stated that she visits every day and stays in the facility for up to six hours, and did not observe the staff repositioning R294 every two hours. FM stated most of the time R294 refuses to be moved. On 04/02/25 at 10:29 AM, review of R294's Electronic Health Record (EHR) was conducted. Care Plan Report dated 03/19/25, stated R294 was . at risk for break in skin integrity . Skin assessment upon admission done on 03/19/25 documented skin condition as, . coccyx - brown discoloration . admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/25, Section M, documented R294 is at risk of developing pressure ulcers/injuries. R294's Braden Scale assessment with a completion date of 03/26/25, noted a score of 12, which identified R294 as high risk for developing pressure ulcer and mobility as Very Limited. Physical Therapy treatment encounter notes for 03/25/25 to 04/01/25, documented the resident's resistance to care. On 03/26/25, . Resistive to sitting edge of bed . Documentation for 03/27/25 stated . Attempted to have the patient stand but she was combative . Documentation for both 03/28/25 and 03/29/25 stated . exhibits heightened anxiety w/ activity . Documentation for 04/01/25 stated . She was agreeable for therapist to assist with mobility but then would resist movement or want to return to bed. On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. Asked how often CNA9 assist R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. When asked what should staff do if R294 refuses to be turned, CNA9 stated that she is supposed to report to the nurse. Then asked CNA9 if R294's refusal to be repositioned was reported to the nurse. CNA9 confirmed the resident's refusals was not reported until the open area was noticed on R294'c coccyx on 03/31/25, which is 12 days after the resident was admitted . Conducted a concurrent interview and record review with the Director of Nursing (DON) on 04/03/25 at 10:17 AM in her office. DON confirmed there was no documentation about resident being repositioned every two hours or the resident's refusals. DON confirmed that CNAs should have repositioned the resident every two hours but did not. Review of the facility's policy and procedure manual on 04/03/25, titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management stated, . 3. A skin assessment/inspection should be performed weekly by a licensed nurse . a. Skin observations . Any changes or open areas are reported to the Nurse . a. reposition at least every 2-4 hours .

Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident. Findings include: (Cross reference to F641 Accuracy of Assessment) On 03/31/25 at 11:10 AM, conducted a review of R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 lbs. On 03/07/2025 and 03/09/25, R42 weighed 143.2 pounds which is a -7.01 % loss. Review of R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Review the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to a loss of 5% or more in the last month. On 04/02/25 at 12:12 PM, conducted a concurrent review of R42's EHR and interview with the Dietician (D)1. D1 reviewed R42's weights on 02/08/25, 03/07/25, and 03/09/25 then confirmed R42 lost more than 5% in one month. D1 stated he/she was aware that R42 was losing weight, but did not identify the weight loss as being more than 5% in one month. D1 reported adding supplemental nutrition to R42's meals and confirmed he/she may have given the resident more calories and monitored the resident more closely had he/she identified R42 loss more than 5% in one month.

Based on interviews and record review, the facility failed to provide competent nursing services for two residents (Resident (R)249 and R246) in the sample. Staff did not report to the Registered Nurse (RN) when R249 refused to be repositioned and R246 was given a higher dose of pain medication for the pain level reported by the resident. As a result of the deficient practice, the two residents were placed at risk for avoidable injuries and adverse health conditions. Findings include: Cross-reference to F686. (Treatment to Prevent/Heal Pressure Ulcers) 1) Reviewed of R294's Electronic Health Record (EHR), Task records performed from 03/19/25 through 04/02/25 for bed mobility, noted check marks indicating the resident was repositioned every two hours three times a day. On 04/01/25, the task was checked only twice and there was no documentation in the progress notes of R294 refusing to be repositioned every two hours. On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. When asked how often CNA9 assist R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. CNA9 also stated that she is supposed to report to the nurse when the residents refuse care, but did not report anything to the nurses until she noticed the open area on R294's coccyx on 03/31/25, 12 days after the resident was admitted . Conducted an interview with the Director of Nursing (DON) on 04/03/25 at 10:17 AM, in her office. Asked if CNAs should report the resident's refusal to be turned or repositioned, DON confirmed it should be reported to the nurses. 47783 2) On 04/02/25 at 07:57 AM, observed RN7 during medication administration. RN7 asked R246 what her pain level was. R246 said, Six out of 10. RN7 opened the computer on the cart, logged R246's pain level and checked the medication to be given. RN7 then prepared Hydrocodone-Acetaminophen (opioid pain medication) 10-325 mg (milligrams) tablet and administered it to R246. After giving the medication, RN7 documented on the computer. Review of R246's Electronic Health Record (EHR) was conducted. The following orders for pain were noted: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg every 6 hours as needed for severe pain and Hydrocodone-Acetaminophen Oral Tablet 5-325 mg every 6 hours as needed for moderate pain. On 04/02/25 at 10:11 AM, a concurrent interview and record review was conducted with RN7 just outside R246's room. Asked RN7 what numeric pain level is considered severe. RN7 said, Seven to 10 is considered severe. Asked RN7 if the pain medication dose given to R246 earlier in the morning was correct. RN7 checked in the computer and said R246 should have been given Hydrocodone-Acetaminophen 5-325 mg since her pain level was only at six and considered moderate. On 04/02/25 at 10:20 AM, an interview with Unit Manager (UM)3 was conducted at the nurse's station. UM3 confirmed that a pain level of six out of ten is considered moderate.

Based on interview and record review, the facility failed to provide food that accommodates the food allergies for one of the two residents in the sample. Resident (R)294 is allergic to eggs and was served eggs for breakfast more than once. As a result of this deficient practice, residents are at risk for more than minimal physical harm. Findings include: During breakfast meal observation on 04/02/25 at 08:52 AM, inside R294's room, Family Member (FM) reported on two separate occasions (03/202025 and 03/29/2025), R249 was served breakfast with scrambled eggs. FM stated that she notified the Food Service Director (FSD) about the incidents and R249's food allergy included eggs. Reviewed R294's Electronic Health Record (EHR) on 04/02/25. R294's clinical resident profile included list of allergies, created on 03/19/25, documented, Allergies: Aspirin, metronidazole, Eggs . Nutrition Assessment, dated 03/20/25 at 04:47 PM, also identified eggs as a food allergy. Conducted an interview with the FSD on 04/02/25 at 10:32 AM, FSD verified R294's food allergies included eggs, but the resident was served eggs on 03/20/25 and 03/29/25. The FSD said it should not have been given to resident.

Based on observation, resident interview, staff interview and record review, the facility failed to maintain a functioning clock for one Resident (R)143 out of three residents sampled. As a result of this deficiency, R143 did not know the time of day when referring to that non-functioning clock. Findings include: Review of Electronic Health Record (EHR) showed R143 was admitted on [DATE] with diagnosis including Stroke, Aphasia (language disorder that affects the ability to communicate), Urinary Tract Infection. During observation of R143's room on 04/01/25 at 10:30 AM, a wall clock showed the time as 08:25 and was not functioning. Observation of R143's room wall clock on 04/02/25 at 08:45 AM showed the same time 08:25 as previously mentioned and still not functioning. Resident interview on 04/02/25 at 08:50 AM, R143 said he wished the wall clock worked because it was located on the wall right in front of him. R143 said he told the staff about the clock not working a day ago. Staff interview on 04/03/25 at 09:15 AM, Unit Manager (UM)1 acknowledged that the clock was not functioning and said they will have someone come and fix it.

Based on observation and interview, the facility failed to treat one of 2 residents sampled Resident (R)292 with respect and dignity by staff not responding in a timely manner to R292's request for assistance with food replacement. This deficient practice has the potential to affect all residents in the facility. Findings include: During breakfast meal observation on 04/02/25 at 08:52 AM, inside R292's room, R292 asked the Certified Nurse Aide (CNA)3 to replace toasted bread with a freshly toasted bread for her breakfast. On 04/02/25 at 10:20 AM, observed Activities Assistant (AA) brought in freshly toasted bread inside R292's room, one hour and 20 minutes after R292 requested for a replacement. Conducted an interview with Food Service Director (FSD) on 04/02/25 at 10:32 AM, FSD confirmed an hour and 20 minutes was too long for the toasted bread replacement to be delivered, and was not done in a timely manner.

Based on record review, staff interview, and review of policy, the facility failed to report an allegation of abuse for one Resident (R)27, out of one resident reviewed, to other officials including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow further review of the abuse allegation by APS. Findings include: Review of Facility Reported Incident (FRI), allegation of abuse for R27 stated that the facility did not contact APS for the incident. During staff interview on 04/02/25 at 01:30 PM, Administrator acknowledged that this allegation of abuse was not reported to APS. Administrator said they were not aware of the obligation to report all cases to APS and will make the change going forward. Review of policy on Abuse, Inservice Training read Policy; the facility will maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property and dementia management, that is appropriate and effective, as determined by staff need and the facility assessment . Staff, includes for the purposes of the training guidance, all facility staff (direct and indirect care and auxiliary functions), contractors and volunteers. Procedure; staff orientation and training . Facility procedures and Federal and State requirements for reporting abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources, timeframes for reporting and to whom staff and others must report their knowledge related to any alleged violation without fear of retaliation .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment for one of six medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings include: On 04/02/25 at 08:02 AM, observed Registered Nurse (RN)7 as she was administering medications. RN7 walked to the medication cart to log into the computer to check the orders. After checking the orders, RN7 took the medications from the other cart that was being used by RN5 and brought it to her cart. RN7 then prepared the medications and placed the blister packs back in RN5's cart. As RN7 walked to the resident's room, observed the medication cart was not locked, and three other staff members were walking around the hallway. After giving the medications to the resident, RN7 went back to the cart, signed off on the medications on the computer and walked back to the other section of the unit. The medication cart remained unlocked. On 04/02/25 at 10:11 AM, shared observation of the cart not being locked and left unattended with RN7. RN7 said she did not notice it since she did not open the cart, only used it to prepare the medications and document on the computer. RN7 added that the cart was being used by two other RNs helping to pass medications for day shift. On 04/02/25 at 10:20 AM, an interview was conducted with Unit Manager (UM)3 at the nurse's station. Shared observation of the unlocked medication cart with UM3. UM3 confirmed that medication carts should always be locked and secured when not in use. A review of the facility policy titled, Medication Storage stated, . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 04/23/24 at 08:06 AM, during the initial tour of the facility's kitchen with Food Service Director (FSD), inquired with FSD if the facility labels food items when the arrive at the facility, FSD reported they label food items when they arrive and when they open them. Observed in the small prep-refrigerator, juice refills of apple juice, orange juice, cranberry juice, and passion orange guava juice for a juice dispenser without a label when the juice arrived. Inquired if the juice had a use-by date, FSD was not able to locate the date on the juice refills. Further observed three boxes of fudge brownie mix, with no use-by-date or date when the facility received the items. Review of the facility's policy and procedure, Food Safety revised on 04/26/23 documented The First In, First Out (FIFO) method is used in food storage or according to state regulations .Food is labeled with the date received if not already indicated on the item.

Based on observations, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the resident's choices, for 5 of 21 Residents (R32, R231, R22, R2, and R47) sampled. As a result of this deficient practice, the residents were placed at an increased risk for avoidable declines and/or injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation (rehab) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status (BIMS) exam, reflecting a determination of cognitively intact. On 04/24/24 at 11:02 AM, an interview was done with R32 at her bedside. R32 complained that sometimes no bowel movement for 5 days, they do nothing, then all of a sudden they come in 3 times a day. When asked to elaborate, R32 explained that she has had a problem with constipation since before admission, and regularly takes medication at home for it. Since she got here, she has had days go by with no bowel movement, has experienced and complained of abdominal discomfort, but felt like the staff doesn't really pay attention to that. R32 stated that once she had 5 days of constipation and not much was done. A review of R32's electronic health record (EHR), specifically her bowel movement log, revealed that there was no bowel movement documented from 04/07/24 to 04/13/24 at 05:17 PM, a period of more than 6 days. A review of her physician orders noted the following: Bisacodyl (a laxative) Suppository 10 milligrams (mg) as needed for constipation if no results from Lactulose. Lactulose (a laxative) 30 milliliters (ml) as needed for constipation if no bowel movement for 3 days. Polyethylene Glycol (a laxative) Powder 17 grams once a day for constipation. Senna Plus (a laxative plus stool softener) 8.6-50 mg two times a day for constipation. Tap water enema 240 ml rectally as needed for constipation if Lactulose and suppository are ineffective. A review of R32's Medication Administration Record (MAR) for April notes the as needed Lactulose was given once on 04/10/24 and twice on 04/12/24. All 3 doses were marked as ineffective [in resulting in a bowel movement]. Also noted was that there were no Bisacodyl suppositories or Tap Water enemas administered in the month of April. On 04/26/24 at 12:08 PM, an interview was done at the Nurses' Station with Unit Care Coordinator (UCC)3 regarding R32. UCC3 agreed that given her opioid pain medication, admitting diagnosis of constipation, and that she was not ambulating very much, constipation should be expected and monitored for. During a concurrent review of R32's bowel movement log, UCC3 expressed surprise that R32 had gone 6 days with no bowel movement in April. UCC3 agreed that either a Bisacodyl suppository should have been administered on 04/10/24 after the Lactulose had been marked as ineffective, or there should be documentation as to why it was not administered. After a review of the MAR and nurse progress notes, UCC3 confirmed there was no indication/documentation that the constipation the Lactulose had been given for three times in April, had been treated and managed as it should have been. A review of the facility's Bowel Protocol policy and procedure, last revised 09/12/23 revealed the following: The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement. 2) R231 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehab. Review of her EHR noted she was admitted with lower leg edema (when the tissues or blood vessels in your legs hold more fluid than they should) at a level of +4 (the most severe type of edema), as determined by the Nurse Practitioner (NP)1 at her admission assessment. On 04/23/24 at 09:44 AM, an interview was done with R231 at her bedside. R231 stated she had been at the facility for 2 weeks. Observed R231 with a cast to her lower right leg and moderate to severe swelling visible to both feet. R231 was sitting up in bed with the head of the bed at an 80-degree angle, with both lower legs extending straight out from her hips in approximately a 90-degree angle, resting on the bed. When asked about elevating her lower legs because of the swelling, R231 pointed to one flattened pillow at the foot of her bed and stated that was all she was given to elevate her lower legs and that just doesn't cut it, so she hadn't bothered putting it under her legs. On 04/23/24 at 03:52 PM, observed R231 sitting outside in the sun in a wheelchair with no footrests. When asked about the footrests so that she might elevate her feet while sitting, R231 stated she (facility staff) took them back to the room. R231's left ankle was still visibly swollen along with her right foot and toes. On 04/24/24 at 08:23 AM, a review of R231's EHR noted that despite being admitted with edema, numerous nurse progress notes documenting edema to both lower legs, and being sent out to the emergency roiagnom on [DATE] for increased edema, there was neither a care plan initiated for the edema, nor were there active provider orders to address the edema such as to keep her lower legs elevated, monitor and document level of edema, or apply compression stocking(s). On 04/26/24 at 11:04 AM, an interview was done with the Director of Nursing (DON) in the Conference Room. The DON agreed there should have been a care plan initiated for R231's lower leg swelling, especially considering that the facility did identify the swelling as a problem. The DON explained that when she spoke to staff, they told her they always encouraged R231 to elevate her legs, however she confirmed that the documentation did not reflect that. The DON also agreed that the nursing staff should have been consistently monitoring and documenting the amount of swelling instead of only documenting its presence. A review of Patient Education: Edema (swelling) (Beyond the Basics), by [NAME] H [NAME], MD, found at https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print, and current through August 2023, revealed the following: Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. 37954 3) On 04/23/24 at 01:38 PM interviewed R22 who is a [AGE] year old resident admitted to the facility on [DATE]. Inquired if R22 ever has constipation or diarrhea and she stated she has had diarrhea, sometimes it takes her two times for her to use the toilet to empty her bowels. On 04/24/24 Record Review (RR) of R22's last quarterly Minimum Data Set (MDS) dated [DATE] found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. During RR of R22's last quarterly MDS dated [DATE], found she is continent (uses the toilet) of bowel and bladder and rated 02 = Substantial/maximal assistance - Helper does MORE THAN HALF the effort for toilet transfer, making R22 dependent upon staff to assist her onto the toilet. R22's diagnoses include, but are not limited to, constipation, unspecified, history of falling, and heart failure unspecified. During RR of R22's EHR found the resident had the following physician's ordered medication to help prevent constipation: polyethylene glycol 3350 powder give 17 gram by mouth one time a day for constipation with breakfast. Dissolve in 8 oz of liquid. Hold for loose stools ordered on 08/11/23 and Senna-Docusate Sodium Oral tablet 8.6 - 50 mg (Sennosides-Docusate Sodium) give 1 tablet by mouth one time a day for Constipation hold for loose stools ordered on 11/08/23. Both medications were given every day from 04/01/24 - 04/24/24. Review of R22's documented bowel movements (BM's) found she had four loose BM's on 03/31/24 at 11:03 AM, 04/02/24 at 10:02 AM, 04/14/24 at 03:37 PM, and 04/23/24 at 06:27 PM. On 04/25/24 at 08:34 AM observed medication pass by Licensed Practical Nurse (LPN) 5 to R22. LPN5 gave R22 her Senna-Docusate Sodium Oral tablet 8.6 - 50 mg tablet and polyethylene glycol 3350 powder 17 gram that was dissolved in water. At this time LPN5 did not ask R22 if she had any loose stools and was not observed reviewing R22's EHR for documentation of her last BM. On 04/25/24 09:07 AM interviewed LPN5 and asked if she would ask the resident if she had loose stools before giving medication that states hold for loose stools. LPN5 said no that R22 knows her medications and would tell her if she had a loose stool and that R22 is very vocal. LPN5 stated the CNA's (Certified Nurse Assistants) report if the residents have loose stools to her. 4) On 04/24/24 at 09:46 AM interviewed R2 who is a [AGE] year old resident who was admitted to the facility on [DATE]. Inquired if she has a history of constipation or diarrhea. R2 stated sometimes she has diarrhea and has told staff she does not want to take the Miralax (brand name for polyethylene glycol 3350 powder) but the staff give it with her medications. On 04/24/24 RR of R2's last quarterly MDS dated [DATE] found she had a BIMS with a score of 15 out of 15 identifying her as cognitively intact. Review of R2's functional abilities, under section GG of the MDS, found she was rated 01 for toileting hygiene which means she is dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. R2's EHR found her diagnoses include, but are not limited to, constipation, unspecified, unspecified glaucoma, history of falling and muscle weakness (generalized). During RR of R2's EHR found the resident had the following physician's ordered medication to help prevent constipation: polyethylene glycol 3350 powder (polyethylene glycol 3350 (bulk)) give 17 gram by mouth two times a day for Constipation HOLD for loose stools ordered on 02/13/24 and senna oral tablet 8.6 MG (Sennosides) give 1 tablet by mouth in the evening for Constipation; HOLD for loose stools ordered on 08/25/23. On 04/26/24 at 10:43 AM Review of R2's documentation of BM's found from 04/01/24 - 04/25/24 she had 33 loose stools and 7 putty like BM's. During this time reviewed R2 did not have any formed bowel movements. A review of her medications found she received 42 of 51 doses of polyethylene glycol 3350 from 04/01/24 -04/25/24 with 9 doses held and not given. Review of R2's Senna oral tablet given in the evening found R2 received 23 of 25 doses with only 2 doses held and not given. On 04/15/24 R2 received 2 doses of polyethylene glycol 3350 powder and a dose of senna and had four documented loose stools that day at 05:55 AM, 09:41 AM, 11:41 AM and 07:05 PM. R2 also received the 2 doses of polyethylene glycol 3350 powder and a dose of senna the next day. R2 had loose stools 21 days out of 25 days reviewed from 04/01/24 -04/25/24. 04/26/24 at 10:54 AM interviewed Registered Nurse Unit Care Coordinator (UCC) 2 and reviewed R2's documented BM's with her. UCC2 confirmed R2's documented BM's showed R2 had loose stools documented for almost all of April 2024. Inquired if she would ask R2 if she had a loose BM prior to giving medication that states hold for loose BM and UCC2 confirmed she would ask the patient, assess if she had a loose stool before giving these medications. On 04/26/24 at 11:17 AM interviewed DON. Reviewed R2's BM's for April 2024 and she confirmed the resident should not have been given the medications (polyethylene glycol 3350 powder and senna oral tablet) because of the documented loose stools. On 04/26/24 at 01:35 PM interviewed UCC2. Inquired what would happen to the resident if R2 continued to have loose stools and UCC2 stated the resident could experience dehydration. 42160 5) On 04/23/24 at 08:32 AM, smelled a strong urine odor as this surveyor approached the entrance to R47's room. While at the doorway, observed R47 had a covered catheter bag hanging from the bedframe (on the side closest to the doorway) and the catheter tubing was visibly cloudy. After entering the R47's room, the strong urine odor intensified, observed R47 sitting upright in bed, doing a nebulizer breathing treatment. Made a closer observation of R47's catheter tubing which revealed the entire catheter tubing was cloud with multicolored (white, gray, brown, and reddish) sediment the entire length of the visible catheter tubing. Inquired with R47 about the strong urine smell and the resident confirmed the urine odor was strong and stated, I think it's coming from the catheter. R47 confirmed all meals are eaten in the room and the smell is always there, I just got used to it, but maybe my visitors might not want to stay as long with that smell. R47 confirmed the Foley catheter is for long-term use because the resident has difficulty breathing, especially when having to lay flat when changed due to incontinence. R47 looked at the tube and stated, It's dirty (catheter tubing), they haven't changed it in awhile. On 04/24/23 at 11:08 AM, observed the hospice nurse (HS)1 in R47's room finishing up a physical assessment of the resident. R47's catheter bag and tubing remained unchanged, and the strong urine odor was still present. On 04/24/24 at 02:13 PM, conducted a review of R47's EHR which documented the resident was admitted to the facility on [DATE] and started receiving hospice services on 04/12/24 with diagnosis which include end stage COPD, abnormal weight loss, and a lung mass with the life expectancy of less than six (6) months if disease progresses as expected. Review of R47's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/24, Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 15, indicating the resident's cognition is intact and is a reliable source of information. Section H. Bladder and Bowel, documented R47 has an indwelling catheter. Review of the physician's orders documented an order for Indwelling catheter to straight drainage size 18 Fr (French) bulb: 10 cc. Change for leakage or obstruction every day shift starting on the 20th and ending on the 20th every month for Foley care (ordered on 06/22/23 and started on 07/20/23). Other orders related to providing care for R47's Foley catheter included, change for leakage or obstruction, catheter care with warm water and soap, flush with 100cc of sterile water for increased sediment/low urine output, and implementation of enhanced barrier precautions for the resident's Foley catheter. Review of R47's March 2024 and April 2024, Medication Administration Record (MAR) documented on 03/19/24 and 04/20/24 the indwelling catheter was changed. On 04/25/24 at 02:00 PM, conducted a concurrent interview and record review of R47's EHR with Registered Nurse Unit Care Coordinator (UCC)2. Inquired with UCC2 when R47's Foley catheter bag and tubing was last changed. UCC2 reviewed the April 2024 MAR and confirmed nursing staff documented the Foley catheter bag and tubing was changed on 04/20/24. UCC2 stated according to the orders the Foley catheter is not changed unless it is obstructed or leaking and there is an order to flush with sterile water for sediment. At 02:08 PM, UCC2 and this surveyor went to look at R47's Foley catheter bag and tubing. Prior to entering the room, inquired about the strong urine odor coming from and in the resident's room. After investigating the dirty linen bins in the hallway and the soiled laundry room, UCC2 concluded the urine smell was coming from the catheter bag privacy cover. UCC2 stated the privacy bags are not routinely changed and if the clamp is not sealed tightly or there is residual urine in the tubing when it is placed back into the privacy bag, the inside of the privacy bag could be soiled with urine. UCC2 confirmed the strong urine odor in R47's room was not a homelike environment for R47, especially because the resident eats all meals in bed and rarely leaves the room. UCC2 inspected the Foley catheter tubing and confirmed the tubing had a lot of sediment, so much sediment that it could potentially have a negative outcome for the resident and needed to be changed immediately. Then UCC2 pulled the catheter bag out of the privacy cover and the bag was labeled, Change foley set 3/19/24. UCC2 confirmed during review of the April 2024 MAR, staff documented the catheter was changed on 04/20/24. Also, R47 showed us the sticky pad (used to adhere secure a portion catheter tubing to the resident's leg to minimize damage to the resident's urinary structures which are in contact with the catheter) on the resident's left thigh was starting to peel off of the resident's leg. UCC2 confirmed the R47 could potentially be harmed if the catheter tubing was to be forcefully pulled on. UCC2 followed-up with staff who documented (on the April 2024 MAR) the Foley catheter was changed on 04/20/24 and this surveyor was informed, the responsible staff did not change the Foley bag and tubing because there was no obstruction or leakage, and the MAR was marked as done to indicate the Foley catheter was inspected for obstruction and leakage. UCC2 confirmed staff signing off on the MAR indicated the Foley catheter system was changed. UCC2 also confirmed R47's physician orders only addressed changing the Foley catheter for obstruction and leakage but did not include clinical indications, such as visible sediment in the catheter tubing. The facility contacted the nurse practitioner and got a new physician's order which included changing the Foley catheter for clinical indication. Review of the facility's policy and procedure, Indwelling Urinary Catheter (Foley) Management (last reviewed on 08/24/23) and the Center for Disease (CDC) guideline for the prevention of Catheter-Associated Urinary Tract Infections (CAUTI), III. Proper techniques for Urinary maintenance, documented, .it is suggested to change catheter and drainage bags based on clinical indication. However, literature review on the National Institutes of Health (NIH) indicated the long-term use (one month or more) of indwelling catheters should also include the manufacturer's recommendations, which may include recommended changes every 30-days.

Based on observation, interview, and record review, the facility failed to support and honor the food preferences of one resident (R) in the sample, and one unsampled resident. This deficient practice has the potential to impact all the residents at the facility with food preferences. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited to, congestive heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD). Review of R33's Minimum Data Set (MDS) initial 5-day assessment with an Assessment Reference Date (ARD) of 04/01/24 noted that R33 was evaluated as having a score of 13 out of 15 for her Brief Interview for Mental Status (BIMS) exam, reflecting a determination of cognitively intact. On 04/23/24 at 11:25 AM, an interview was done with R33 at her bedside. When asked about unintended weight loss, R33 stated [I] think I lost 6 - 8 pounds since getting here. R33 explained that sometimes she cannot eat the food she is given because the texture is off-putting. R33 stated that for example, she gets oatmeal and mush [a hot porridge] for breakfast a lot, and she will not eat it. R33 stated she has told staff 4-5 times that she doesn't eat oatmeal/mush and has asked that they stop giving it to her, but she still gets it. A review of R33's electronic health record (EHR) revealed her measured weight on admission was 186.4 pounds. Her last measured weight taken on 04/22/2024 was 180.6 pounds, reflecting a 5.8 pound or 3.11% weight loss in less than a month. On 04/25/24 at 08:27 AM, concurrent interview and observation was done with R33 at her bedside. R33 stated there was mush on her breakfast tray, I told them no put mush, they still give me. Observation of R33's meal ticket sitting on her breakfast tray noted that on the left side of the ticket, under Allergies/Dislikes, CEREAL was bolded and at the top of the list. On the right side of the ticket, under Preferences, NO CEREAL was bolded and the second item on the list. On 04/25/24 at 04:04 PM, an interview was done with the Food Service Director (FSD) in his office. FSD confirmed that he was aware that R33 does not like cereal. When asked what cereal means with regards to facility meals, FSD answered that cereal could mean either oatmeal or a hot porridge. FSD stated that he checked the meal tickets himself as the trays were being made that morning and confirmed that R33 should not be receiving oatmeal or hot porridge on her tray. On 04/26/24 at 08:52 AM, conducted a second interview with FSD in his office. FSD explained that with regards to R33's meal ticket, because cereal was listed on the ticket in two places (under Dislikes and Preferences), it shows that it was already a problem of not honoring that preference. Ideally, it should just be there one time, but when there are complaints of it not being followed, he adds it to the ticket in two spots to increase the chance of it being seen. FSD stated he has now added the no cereal preference to R33's meal ticket in a third spot. 43414 2) On 04/23/24 at 11:51 AM, during a tray line observation in the kitchen, observed an unsampled resident's order form with ordered diet, dislikes, likes, and preferences indicated on the form. The form included the preference service sandwiches on hot plate. Observed the sandwich on the resident's tray not on a hot plate. Registered Dietician (RD) 1 was observed to check the order form twice prior to announcing the cart was ready to go on the unit at 12:15 PM. After RD1 announced the cart was ready to go, inquired with RD1 if the resident's plate was on a hot plate and if it was her preference, both RD1 and FSD reviewed the order form and FSD announced to dietary staff at the tray line that they did not put the sandwich on a hot plate.

Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures to prevent the transmission of communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and performing the proper form of hand hygiene at all appropriate times while caring for Resident (R)33. In addition, the facility failed to assure staff performed hand hygiene between glove changes while performing perineal care (cleaning genital and anus area) for R131. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited to, congestive heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD). On 04/21/23 R33 was placed on contact enteric precautions for a symptomatic and confirmed clostridium difficile infection (C-diff a highly transmissible bacterial infection that can cause diarrhea and an inflammation of the colon). On 04/23/24 at 09:24 AM, observed a contact enteric precautions sign posted outside R33's room door. The sign provided the following instructions: Everyone Must: Clean hands with sanitizer when entering room and wash with SOAP AND WATER upon leaving the room. Doctors and Staff Must: Gown and glove at door. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. On 04/23/24 at 12:30 PM, observed Registered Nurse (RN)1 deliver lunch tray to R33 as she took in her noon-time medications. Observed R33's lunch was not in disposable containers and was carried in on a non-disposable tray. On 04/23/24 at 02:48 PM, observed Certified Nurse Aide (CNA)3 doff her PPE at the doorway prior to exiting R33's room, however she did not wash her hands, and instead used alcohol-based hand rub (ABHR) to clean her hands after she exited. Surveyor stopped CNA3 and asked her what type of hand hygiene should be performed before exiting R33's room. CNA3 apologized and stated she should have washed her hands with soap and water. On 04/24/24 at 11:17 AM, observed RN21 administer medications to R33 in her room, doff his PPE at the doorway prior to exit, then walk out of the room with no hand hygiene at all. Surveyor immediately stopped RN21 and insisted he return to R33's room to wash his hands. RN21 acknowledged the importance of proper hand hygiene due to R33's level of TBP, apologized, and returned to the room to wash his hands. On 04/25/24 at 09:20 AM, informed CNA31 that R33 had requested ice and explained that due to her TBP, her water pitcher could not be carried out of her room, so the ice had to be carried in separately. At 09:23 AM, observed CNA31 carry R33's water pitcher out of her room, take it to the nourishment room to fill it with ice, then return to R33's room with the same pitcher. As she re-entered R33's room, R33 did not don a gown, only a pair of gloves. Observed R33 deliver the water pitcher filled with ice, then pick up R33's non-disposable breakfast tray from her bedside table and exit the room without performing any type of hand hygiene. CNA31 carried the breakfast tray across the hall and discarded all the disposable containers that were on the tray into the trash can. At 09:26 AM, interviewed CNA31 in the hall outside of R33's room as she held the now empty non-disposable breakfast tray. Inquired what PPE should be worn when entering R33's room. CNA31 answered that because R33 had C-diff, she only needed to don a gown when she was toileting her. Asked about hand hygiene, CNA31 admitted that she did not wash her hands and would do it right away. At 09:28 AM, followed CNA31 from our interview in the hall, down the hallway to the kitchen where she returned R33's non-disposable breakfast tray. CNA31 still had not washed her hands and observed her touching door handles and doors along the way. On 04/25/24 at 10:08 AM, an interview was done with the Infection Preventionist (IP) in her office. IP confirmed that staff should be donning gown and gloves when entering R33's room for any reason and should always be washing their hands with soap and water prior to exiting. IP agreed that CNA31 should not have carried R33's water pitcher out of the room and should have instead carried the ice in. IP also explained that R33's meals should be delivered in disposable containers on a disposable tray, however for transport from the kitchen to the room, the entire tray was placed on a non-disposable tray. IP reported that staff should know to leave the non-disposable tray on the transport cart and only take the disposable meal items into the room. A review of the facility's policy and procedure, Clostridium (Clostridioides) Difficile (CDI), last revised 06/20/23, revealed the following: 2. A resident diagnosed with CDI should be placed in a single room on Contact Precautions. 7. Meal trays should be bagged prior to removal from the room . 8. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. 9. Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by C-diff. a.Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile .) is likely to have occurred. 37954 2) On 04/23/24 at 12:38 PM overheard a nurse request Certified Nursing Assistant (CNA) 24 help change R131's adult brief. CNA24 went to R131's room and told resident she will help her right after she assists another resident. CNA24 went to help deliver a resident's lunch tray and open it up for him. CNA24 performed hand hygiene by using the hand sanitizer. On 04/23/24 at 12:42 PM CNA24 returned to R131's room and was observed putting on gown, gloves and mask for Enhanced Barrier Precautions (EBP) with this resident. At this time interviewed CNA24 and asked why R131 had EBP and she stated R131 has EBP for open wounds. On 04/23/24 at 12:46 PM observed CNA24 provide perineal care and adult brief change for R131. CNA24 gathered her supplies. During the interaction CNA24 asked resident if it was ok to lower her back and raise her bed. Curtains were drawn for privacy. During perineal care CNA24 was observed taking off a glove and then putting on a new one, no hand hygiene was performed. On 04/23/24 at 12:58 PM interviewed Registered Nurse (RN) Unit Care Coordinator (UCC) 2 and inquired if staff are to perform hand hygiene between glove change and she confirmed staff are expected to do hand hygiene once they take off gloves and throw them away. On 04/23/24 at 01:01 PM interviewed CNA24 who confirmed she is supposed to use hand sanitizer after she takes her glove off, before putting on a new glove.

Based on observation, interview, and record review, the facility failed to identify, support, and honor one Resident's (Resident 32) preference to be informed of a time range that rehabilitation therapy services would occur. As a result of this deficient practice, R32 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility receiving therapy services. Findings include: Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (therapy) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status exam, reflecting a determination of cognitively intact. On 04/24/24 at 11:07 AM, an interview was done with R32 at her bedside. R32 complained that she never knows when therapy will be. She thought she was supposed to have therapy in the morning, but it had not occurred yet. R32 stated that she does not like waiting the whole day. She likes to prepare herself for therapy and wants the ability to plan her day. R32 explained that her grandson wanted to visit in the afternoon, and she did not want to cut the visit short because of therapy. R32 stated that she had asked the therapists repeatedly to give her a time range of when they would visit, but they have not honored her request. On 04/25/24 at 09:05 AM, observed a therapy slip (piece of paper) at R32's bedside indicating that she was scheduled for physical (PT), occupational (OT), and speech therapy (ST). R32 stated that she gets the therapy slips every morning that let her know what type of therapy was scheduled for the day, but I don't know when [what time of day], that's bad! R32 complained again that she would like to know a time range of when therapy would occur, especially when there were multiple types of therapy scheduled for the day. R32 explained that in addition to being able to plan her day with regards to visits and activities, she would like to be able to request pain medications prior to PT, now that she was doing more. It would be nice to be able to do that [pre-medicate]. On 04/25/24 at 02:31 PM, an interview was done with the Director of Rehab [rehabilitation] (DOR) in the Conference Room. The DOR explained that the therapy schedules are printed the afternoon or evening before and provided to the nursing staff. The night shift nursing staff then make the therapy slips for the following day. When asked about R32 specifically, DOR agreed that she was aware that R32 preferred a set routine regarding the schedule and confirmed that the therapy staff do not schedule residents for specific times or time blocks.

Based on record review and interview the facility failed to follow-up and ensure residents were informed of their right to develop an advance health care directive (AHCD); or periodically reassessed in his/her decision-making capacity to do such according to State Law, for four of ten residents sampled (Resident (R) 2, R16. R40 and R7). As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. Findings include: 1) On 04/24/24 at 09:55 AM during record review of R2's Electronic Health Record (EHR), R2's advanced health care directive was not found. R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. Review of R2's Care Plan (CP) found she has a Focus identified as DISCHARGE PLAN: Resident's Name wishes to discharge home after therapy is completed. Code Status: DNR (Do Not Resuscitate), Comfort measures only, No artificial nutrition by tube. Advanced Directives: Resident's Name (R2) has a completed POA (Power of Attorney) which first representative as daughter's name (daughter) and secondary representative as son's name (son). This problem was initiated on 02/21/23 and revised on 03/23/23. Review of R2's last quarterly Minimum Data Set (MDS) dated [DATE] found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. On 04/25/24 at 04:10 PM met with and interviewed Social Worker (SW) who provided a copy of R2's POA and found it was for financial powers. SW confirmed the POA is for finances only. SW also provided a copy of the Declaration of Authority to Act As A Surrogate form. The front page of this facility form was filled out and the back was left blank. The back part of this form is filled out by the physician which identifies the resident as not having capacity to make their own healthcare decisions. SW explained facility uses the Declaration of Authority to Act As A Surrogate form internally for residents to fill out with resident identifying who will make healthcare decisions for them if they cannot. SW stated residents either cannot afford or refuse to do the AHCD when it is offered instead choose to use the Declaration of Authority to Act As A Surrogate form. R2 is cognizant and has not been identified by her physician as being incapacitated. Requested SW to provide documentation she met with R2 to discuss AHCD as a follow up. On 04/26/24 at 09:42 AM interviewed SW who was unable to provide any documentation of follow up regarding a meeting to discuss R2's options for AHCD. 2) On 04/23/24 at 03:03 PM reviewed R16's hard medical record for AHCD and none was found. On 04/24/24 at 10:05 AM during record review of R16's EHR R16's AHCD was not found. R16 is a [AGE] year old resident who was admitted to the facility on [DATE]. Review of R16's CP found he had a Focus identified as DISCHARGE PLAN: Mr. Resident's Last Name wishes to remain in the facility as ICF level. Code Status: Full Code which included the following: Advanced Directives: Mr. Resident's Last Name reported resident's Aunt's first name, Aunty, has copy of AHCD and she is listed as the first agent. KPO surrogate formed [sic.] completed by R16's Aunt's name (Aunty). This problem was initiated on 12/19/2022 and revised on 01/23/2024. Review of R16's last quarterly MDS dated [DATE] found he had a BIMS with a score of 15 out of 15 identifying him as cognitively intact. On 04/25/24 at 04:24 PM interviewed SW, who had provided a copy of R16's AHCD. Review of R16's AHCD found it was not filled out completely, was not signed by two witnesses or notarized when he signed it on 7/10/19. SW confirmed R16's AHCD was not fully filled out and she stated she would ask R16's Aunt for a copy of his AHCD if she has a copy that is fully filled out as she is the person named as his decision maker for healthcare. On 04/26/24 at 09:44 AM interviewed SW who stated she met with R16's Aunt on 04/25/24. R16's Aunt did not have a fully filled out copy of R16's AHCD. SW stated she provided a blank copy of the AHCD and R16's Aunt was receptive to have two witnesses come to the facility to sign the document when the resident fills out this form. 3) On 04/24/24 at 10:30 AM reviewed R40's EHR and hard medical record for AHCD and none was found. R40 is an [AGE] year old resident admitted to the facility on [DATE]. Review of R40's EHR found his diagnosis includes, but is not limited to, vascular dementia, unspecified severity, with agitation. Review of R40's last quarterly MDS dated [DATE] found he had a BIMS with a score of 00 out of 15 identifying him with severe impairment. On 04/26/24 at 09:30 AM met with and interviewed SW who was able to provide a copy of R40's POA which is only for financial. SW confirmed R40 did not have an AHCD. Reviewed copy of Declaration of Authority to Act As A Surrogate form which the front is only completed, back of the form, which the physician would fill out to state resident does not have capacity, is not filled out. SW confirmed R40's copy of Declaration of Authority to Act As A Surrogate form was not fully filled out with the back of the form left blank. SW confirmed there is no documentation the physician was asked to fill out the form. 43414 4) R7 is an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of, but not limited, to vascular dementia. During R7's stay she was hospitalized twice on 03/04/24 and 03/21/24. On 04/25/24 at 10:56 AM, review of R7's electronic health record (EHR) found no copy of her AHCD. The EHR included a progress note documenting on 01/25/24, Resident has a Hawaii Advanced Health Care Directive/Power of Attorney, she [daughter] will provide copy once found. Copy of Power of Attorney (POA) documentation was not found in the EHR. No further follow-up was found. On 04/26/24 at 09:43 AM, an interview with Social Worker (SW) was done. SW confirmed the facility does not have a copy of R7's AHCD or POA and did not follow-up with R7's daughter to receive a copy. Review of the facility's policy and procedure Advanced Directives and Advance Care Planning under resident transfers, .If the resident leaves the facility temporarily (e.g., ER visit, hospital stay, or diagnostic procedure), a copy of the advance directive is sent with the resident .Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning information.

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by uncomfortable temperatures in Resident (R) 283's and R284's room(s), and splatters on the kitchen ceiling. In addition, the facility failed to exercise reasonable care for the protection of one resident's clothing from loss, as evidenced by Resident (R)32's complaint that so many of her clothing pieces were not returned to her from laundry that she now had her family doing her laundry. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 04/23/24 at 09:39 AM, made observation of R283 and R284 in their room. R283 was observed to have at least four blankets covering her with a blanket covering her head. R284 was observed sleeping covered with two blankets up to her neck. The blow of the cold air conditioner could be felt when entering the room. The thermostat read 71 degrees Fahrenheit (F). On 04/23/24 at 12:43 PM, observation and interview with R283 and R284 was done in their room. Observed the air conditioner to be off. R283 reported she seems to be always cold, especially at night and early morning. It gets so cold she covers her face and uses multiple blankets. During the day, currently, it is usually comfortable. R284 concurred the room gets very cold during the night and in the early morning. On 04/24/24 at 11:03 AM, made observation of R283 and R284's room. R283 was not in her room, but R284 was sleeping with two blankets covering her from neck to toes. The blow of the cold air conditioner could be felt when entering the room. The thermostat read 71 degrees F. On 04/25/24 at 08:42 AM, observation and interview with R283 and R284 was done in their room. Observed the air conditioner to be off. R283 reported she believes a staff member turns on the air conditioner when providing assistance to them because it is too hot for the staff member, but then does not turn it off, making the room very cold at times. R284 reported she does not mind having the air conditioner on but wants it at a comfortable temperature and not blasting cold air. R284 stated 76 degrees would probably be more comfortable. On 04/25/24 at 01:46 PM, an interview with Certified Nursing Aide (CNA) 31 was done. CNA31 stated R283 and R284's will report the room is cold to her and had noticed R283 blankets covered all the way to her head. On 04/25/24 at 01:48 PM, an interview with Registered Nurse (RN) 12 was done. RN12 reported R283 and R284 will complain if the temperature is too cold and had to turn it down for them yesterday. RN12 noticed R283 wears a lot of blankets. Review of the facility's policy and procedure Resident Rights reviewed on 09/25/23, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. 2) On 04/23/24 at 08:06 AM, during the initial observation of the facility's kitchen with Food Service Director (FSD), observed multiple, various sized light brown splatters, some as big as a quarter, on the ceiling around the speaker in the kitchen. Inquired with FSD what the splatters were, FSD reported he did not know but called someone to clean it this morning. On 04/25/24 at 11:51 AM, a second observation of the kitchen was done. Observed the splatters from the ceiling to be cleaned. Inquired with a dietary staff member, how long had the splatters been there. The dietary staff member stated, a couple of months and someone had been called to help clean the splatters after this surveyor pointed it out on 04/23/24. Inquired with Registered Dietician (RD) 1, the kitchen cleaning schedule, concurrently observed the cleaning schedule on the bulletin board with weeks not completely signed off. The cleaning schedule did not include cleaning the ceiling, inquired with RD1 if maintenance is responsible for cleaning the ceilings if there are food splatters, RD1 reported it would be dietary staff. Review of the facility's policy and procedure Cleaning Schedule reviewed on 04/25/23, The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietician, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times. 43245 3) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (therapy) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status exam, reflecting a determination of cognitively intact. On 04/24/24 at 10:57 AM, and interview was done with R32 at her bedside. R32 stated that when she was first admitted , the facility would wash her clothes for her. She quickly realized that several articles of clothing were not returned to her. When she reported it to facility staff, she was told that she or a family member could go to the laundry room and look through the missing clothes kept there. R32 stated that her daughter had gone to look a couple times but never found her missing items, so now her daughter takes all her clothes home to wash. On 04/26/24 at 01:22 PM, an interview was done with the Housekeeping Director (HD) in the laundry room. HD explained that residents are instructed to label their own clothing. Sometimes the facility staff may assist residents with labeling their clothes. When asked to show a sample of a properly labeled clothing item, HD provided Surveyor with a woman's top that had the resident's name written in faded black ink on the inside behind the neck area. HD confirmed they recommend using a black permanent marker for labeling. When asked about the process, HD reported that if clothes are 'unlabeled [with a name]', they are placed with the 'missing laundry.' HD explained that missing laundry is placed on a large metal cart, both hanging and folded, of clothing and linen, kept in the back of the laundry room. HD stated that the items stay on the cart for 3 months, then if unclaimed, they are donated to the facility. HD further explained that when a resident says they have missing laundry, laundry staff check the missing laundry cart for the missing items. If the missing items are not on the cart, they let the resident know and invite the resident or family to come in and look for themselves. HD reported that he does not keep track of or log which residents were missing laundry, or what their missing items were. On 04/26/24 at 02:45 PM, an interview was done with the Social Worker (SW) in the Conference Room. When asked about what process is followed when a resident reports missing laundry, SW explained that usually it is a Certified Nurse Aide (CNA) that gets report of missing laundry. The CNA then would notify nursing staff and the unit managers (UMs), and they would look for the missing items. If not located, the Director of Nursing (DON) or UM would notify SW. SW stated she would then investigate the missing item(s) and document the incident on a blue comment card. If it is appropriate to replace the missing items, SW would be responsible for that. SW stated she could not recall being notified that R32 was missing laundry and confirmed that she did not fill out nor did she see a blue comment card for her. A review of the facility policy and procedure, Closet Search - Lost and Unmarked Clothing, last revised 09/24/21, revealed the following: 1. A concern and comment form [blue comment card] should be completed, as appropriate, and turned into the Environmental Services Director [HD] or Social Services [SW] . 2. Using the description given for the lost article of clothing, the Laundry Department will go to each room and search through every closet. Of note is HD seemed unaware of a closet search and only described checking the missing laundry cart when interviewed by the Surveyor.

Based on record review, staff interviews and review of the facility's inservice documents, the facility failed to ensure that a resident receives optimal care and services in accordance with professional standards of practice in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one resident (Resident #1). Finding includes: 1) Cross-reference to findings at F157 and F514. Resident #1 (Res #1) was admitted to the facility on [DATE] from an acute hospital. His admitting [DIAGNOSES REDACTED]. The resident's clinical record revealed that during his acute hospitalization , he had been started on a [MEDICATION NAME] drip for his [MEDICAL CONDITION] flutter, but upon discharge, was prescribed aspirin 81 milligram (mg) as he was noted to be a poor candidate for anticoagulation given his history of falls and gait instability. Upon entry into the facility, the social service assessment of 12/29/16 found Res #1 to be alert and oriented x 3 (name, place and date), aware of his environment and knew his reason for being in the facility. He was also receiving rehabilitation services (physical and occupational therapy or PT and OT)) and the resident's family member helps resident with personal and legal matters. Resident will be discharged to home. Review of the daily OT rehab report found from the time of Res #1's initial OT evaluation, whereby he was a moderate to maximum assist, he eventually progressed such that by 1/6/17, he was primarily contact guard to minimal assist for his therapeutic activities. However, it was revealed by 1/8/17, Res #1 required maximum assist in performing all the tasks with significant change in assistance .Pt (patient) required MaxA (maximum assist) to complete transfer with max cues for correct sequencing. Therapist notified nursing staff of change in functional ability and increased level of assistance required for transfers today. Interview with Staff #3 on 5/1/17 at 9:00 AM revealed that she was familiar with Res #1. She verified her clinical entry of 1/8/17 and stated she worked with Res #1 quite frequently and had worked with him the week prior to Res #1 being emergently transferred out of the facility to the hospital on [DATE]. Staff #3 said she worked with him on functional transfers, bed mobility, strengthening exercises to get his legs stronger and walking. Staff #3 stated, He was progressing, he was contact guard assist for transfers. For ambulation, we weren't walking too far yet because of his [MEDICAL CONDITION], but that Res #1 was motivated to progress in therapy, worked very hard at it, and wanted to go home. However, when she returned to work on Sunday, 1/8/17, she saw a definite change to his legs with a noticeable decline in his function. She said, I worked Sunday through Thursday with (Res #1) and then I was off on Friday and Saturday. So when I came back on the 8th (1/8/17), a Sunday, my biggest concern was more discoloration that was mid-calf and it was a noticeable change and it was cool to touch and my concern was that there was some circulation stuff going on. Regarding the change to Res #1's level of function, she said, To get him in and out of bed was a like a max assist and I had to give him about 75% to stand him up so I wasn't sure if he was really fatigued and that was the biggest thing for me. Usually he was 25% or under and I would just give him contact guard assist that whole week. CGA or contact guard assist means you are touching them but not giving or assisting much, it's more like verbal cues and sequencing, like where to put his hands and all. Staff #3 said for her, it was a significant change seeing the resident like this. She said, Yeah, big time for me, because during that whole time he was at CGA and it was consistent. She said the resident denied being in pain but said he never complained of pain to her and was a coherent individual. She said he denied feeling cold and recalls he did not like having the bedsheets on himself as a personal preference. Staff #3 was aware the resident came in with discoloration to his lower extremities. Staff #3 was shown Res #1's 12/28/16 admission weekly skin assessment diagram. Upon reviewing the diagram and how it was generally circled, Staff #3 said the discoloration during the time she worked with him and before 1/8/17, was lower and more to the resident's bilateral feet and above the ankle region. She said it was not how it was drawn as one large circle to both of the resident's lower legs (shin region) with dark discoloration written by nursing staff. Further, she said by Sunday (1/8/17), although the discoloration was still below the knee, it was front and back, both shin and calf and it was going up to the calf area. But it wasn't as concerning as Monday (the day the resident was transferred out). She said on Sunday the noticeable change was that it was a little bit darker but rising up the right calf. However, on the next day when she went in to see him, she said, Monday, it was very dark purple and cold to touch. Staff #3 also recalled that on Sunday, 1/8/17, We finished our treatment and I reported it to his nurse (Staff #4) after therapy and told her to come look at his leg and the discoloration went up a little more. She came in and wasn't too concerned about the leg. Staff #3 also stated although Staff #4 felt the resident's leg, her response was that he did not usually have his sheets (bedsheets) on and attributed that as a reason why the resident's right leg felt cool. Staff #3 said Staff #4 then took his vital signs and although Staff #3 recalled asking her, What about the coloring? It looks like it's going up and it's colder to touch and it compared to the resident's left leg. Staff #3 said she also told Staff #4, I'm a little worried there may be some circulation problems going on. Staff #4 did not say anything back, but after taking the resident's vital signs, Staff #3 said Staff #4 told her the resident may be having an off day with the maximum assist he was needing. Staff #3 said Staff #4 did not say anything more about the discoloration and coolness to his legs. Staff #3 confirmed she touched and felt the resident's right calf and had Staff #4 touch it too. Of note, review of the facility's weekly skin assessment flowsheet did not document anything more about the initial dark discoloration found on the 12/28/16 admission assessment diagram to the resident's front bilateral lower extremities. Thus, by the next weekly skin assessment of 1/3/17, there was no documentation whether the dark discolorations to his bilateral lower extremities had resolved, diminished or was being monitored by the nursing staff. There was no description of the characteristics of the dark discoloration to the resident's lower legs, including the color, size/measurements and specific location of the noted dark discoloration circled around both lower legs on the diagram. Staff #3 repeatedly affirmed that her observation was the resident had discolorations to his lower extremities and that a noticeable darker discoloration was going up the right calf with coolness to touch when she saw him on 1/8/17. Nursing staff failed to address this. Then by 1/9/17, Staff #3 said she brought the resident his breakfast tray as he was going to have therapy in bed. And I saw his leg, it was very dark, it was like an icebox to my touch and told (Staff #4) about it. I think she was busy at the time, and I went straight to our communication log and wrote down change in color and cold to touch. Staff #3 said because it was very disconcerting she escalated her concerns to her directors. Staff #3 stated she did not hear of what happened to the resident thereafter, and denied having any type of inservice after this incident. Record review found Staff #4 had no entry of any assessment she performed on 1/8/17, and her next entry on Res #1 was on the day of his transfer on 1/9/17 at 12:13 PM. There also were no other clinical entries to state that the resident's lower right leg was being monitored. Staff #4's sole entry stated, Resident found this morning with cyanotic right lower leg. Cool to touch, dark color, toe color purple. Unable to palpate pedal pulses .Staff reported tarry stool and amber color urine, NP (name) notified and assessed at 0930. 911 called @ 0945 with (NP's) confirmation. Spoke to resident's (family) and nurse (name) from (hospital) emergency room at 1000. EMC arrived and pick up resident @ 1015 . Staff #4 has since left her employment at this facility and could not be interviewed. 2) On 5/1/17, during an interview with Staff #2 at 10:10 AM, she recalled Res #1 complaining of pain and believed the pain level to be 5 on a scale of 1 to 10 (10 being the worst pain). Staff #2 was asked whether Res #1 described what kind of pain he was having. Staff #2 said, No, I didn't ask him. She verified she gave Res #1 pain medication twice on 1/6/17, once at 9:30 AM for right hip pain and then again at 1:00 PM for his right leg pain. She said from what she remembered, Res #1 was complaining of pain to the right lower leg. She acknowledged the prior night shift nurse documented giving pain medication at 3:05 AM that morning for right leg pain. Thus, there were 3 occasions which pain medication was given to the resident within a 12 hour period. However, when Staff #2 was further queried if R #1's pain was significant because it was a different location (unlike the left leg or back pain he was admitted with), she did not have a clear response but stated she left her shift and endorsed it to the on-coming shift. Staff #2 was asked about her assessment of the resident on 1/6/17 and was asked if she looked at the resident's legs. She replied, No, I don't believe so. I just asked him his pain level. I didn't look or touch his legs. He was just in bed She verified she passed it off on report for the last pain medication she gave. She verified the NP was also there on 1/6/17 to the see resident but did not remember why. Staff #2 also stated ever since this incident, I really do do the assessment. Not just for him, but I changed my assessment. She said she was inserviced after this incident by Staff #1 and recalls it was about the documentation, or better assessment. 3) During the entrance on 4/28/17, Staff #1 told the SA that she remembered this incident because the resident went to the hospital and she did an in-service specific to that unit. She produced the content, Expectation of Charge Nurse - Proper Documentation re: (Res #1) and other residents. Staff #1 said, If it's not documented, it's not done. The overall failure by the facility to critically assess/monitor Res #1's lower extremities from admission, and the failure to recognize a need to intervene by 1/6/17 through 1/8/17 until his emergent discharge to the hospital on [DATE], is such that the harm (right leg amputation) may have been avoidable. This resident's hospitalization and admission history indicated he was at risk for potential [MEDICAL CONDITION] events, and although facility staff did have nursing encounters with him based on their interviews, these assessments were not documented in his clinical records. Thus, the resident potentially could have had interventions placed sooner than having a negative outcome of having his right leg amputated above the knee. During the interview with the NHA on 5/1/17, the NHA was informed that based on the staff interviews, it was revealed the resident had started complaining of pain to his right leg (new onset) on 1/6/17 with ensuing shortness of breath and [MEDICAL CONDITION](rapid heart rate) that same day. Although he had also been seen by Staff #2, the NP and the ADON on 1/6/17, there were no clinical entries/notes to describe or endorse to the oncoming shift what had occurred and what they should assess for, including any changes in the resident's condition with the start of a new heart medication. Then by 1/8/17, other notable changes were witnessed by Staff #3 of his decline in his functional level with increased discoloration to his lower right leg, which she reported to the resident's nurse caring for him, but again, was not documented or assessed as a concern. The NHA stated she was aware Res #1 was transferred to the hospital on [DATE] with subsequent amputation to his right leg.

Based on observation, record review, staff interview and review of the facility's policy and procedure, the facility failed to ensure for the safety of residents and to prevent accidents, including physical injury to two residents, who were unsupervised by staff upon leaving the facility on 8/25/14 and 8/26/14, respectively. Both residents #248 and #22 did not sign out of the facility and staff did not monitor this nor followed up with what off premise activities these residents engaged in as a clear safety measure. As a result, this was the Immediate Jeopardy situation identified for both residents. Findings include: 1) On 08/25/14 at 8:50 AM observed R#248 sitting in the wheelchair dressed in a hospital gown and sweater smoking a cigarette on the sidewalk the gas station adjacent to the facility. The resident was accompanied by his/her spouse who was also smoking. The surveyor introduced self and asked if the resident lives at the facility. The R#248 questioned, "Why?" Informed R#248 that the facility was being surveyed and inquired if they cannot smoke at the facility. The R#248 stated that the facility is smoke-free and claimed, "Staff know that I come here to smoke and nobody does anything." On 08/25/2014 at 9:00 AM, facility Adminstrator (Adm) came into the conference room to deliver the alphabetical resident list and inquired about the facility's smoking policy. Adm stated that facility smoke-free and if resident wants to smoke will not be accepted at the facility because unable to meet their needs. Only those residents that want to use nicotine patches for smoking cessation will be accepted. For residents that go out on pass and smoke off campus, the family would have to sign out resident, and inform the nurse. Requested that the Adm accompany surveyor to the nursing unit to look at sign-out log for those residents with a pass. The R#248 was not signed out, and pointed out resident to Adm, as R#248 was being wheeled back to his/her room by spouse. The medical record review (MRR), for R#248, found a physician order, (PO), written on 8/01/2014, "1. May go out on pass PRN x 72 hours. RN to document in and out of the facility." The smoking CP dated 08/01/2014, under: Problem: ___wishes to smoke in facility property, given education about facility policy - non compliance; Goals: Will smoke safely at designated area(s) with spouse and during out on pass through next review date; Target Date: 10/25/2014 Approaches: Educated (res name) about (facility name) free smoking facility. Offered other alternatives such as nicotine patch however declined. (R#248) spouse to bring her out on pass for therapeutic needs with MD order. Reiterated to (R#248) that (facility name) grounds are not designated smoking areas. On 8/25/2014 at 10:10 AM a group interview was conducted with the Adm, DON, ADON, LN#3, and Admission Dir, (AD), regarding R#248 leaving the facility grounds to smoke. According to the AD, the resident was informed of no smoking policy upon admission and no smoking policy reiterated on day of admission. The alternative offered to residents is smoking cessation. At admission on 7/12/2014, both R#248 and spouse were informed of non-smoking policy. On 08/01/2014 the AD observed R#248 smoking under the tree in front of the facility. The AD reminded the resident about the non-smoking policy at the facility and discussed with the DON about offering R#248 the nicotine patch. The R#248 informed the AD that he/she smokes twice a day, after breakfast and lunch only, because the family goes home in the evening. The DON confirmed that had a conversation with the AD but doesn't recall the specifics of R#248 wanting to smoke twice a day. The facility's physician was aware of the resident continual smoking, and a physician order [REDACTED]. The unit nurse (LN#6), that was on duty on this date (8/25/2014), was not aware that R#248 was going out of the facility. According to LN#6, the resident's spouse is a frequent visitor and will roll R#248 around the facility grounds alot, but was not aware that spouse was taking the resident off of facility grounds to smoke. The unit manager, LN#3 stated that residents are free to roll around the facility grounds, and don't have to report to the nursing staff or sign-out. The Adm provided the facility's policy and procedure, (P&P), for, "Tobacco-Free Environment." The P&P provides that, ..." smoking and/or the use of any tobacco product is not allowed throughout Life Care's corporate campus in Cleveland as well as division and region offices nationwide effective September 1, 2004." The P&P under procedure, "1. Associates and visitors who wish to smoke and/or use tobacco products must exit Life Care property...." The Adm also provided from the Life Care of America, Inc., Environment of Care Manual, Chapter 3: Utilities Management Program, page 3-25, Smoking: "The smoking policy of the facility is no smoking within 50 feet of the entrances and only in areas designated for smoking. All construction associates must comply with this policy. Any contractor not complying with this policy will be asked to leave the facility grounds permanently." At 12:15 PM went to interview R#248 and according to LN#6, the resident was taken by the spouse to the outside lanai fronting the facility . The surveyor went to the area and observed the couple returning to the facility crossing the driveway in front. Asked couple if they came from the gas station after smoking. The spouse stated that they were advised to not smoke at the service station because surveyor reported them. They instead went to the loading zone between the facility and gas station to smoke. According to the spouse, LN#3 suggested that the couple go to the park, (a block away), to smoke but spouse stated, "It's too far to walk." At 12:25 PM interviewed the DON regarding the above observance. The DON stated that trying to adjust to Hawaii rules and where she comes from residents can go to the park close by without needing physician orders [REDACTED]. Further MRR on R#248, revealed that the medications column of the resident's MAR had written on 08/01/14, "May go out on pass, (OOP), x 72 hours. RN to document in and out." The date column for 8/5/2014 had STOP written vertically in the column. On the 8/2/14 column the times marked for OOP were 10 AM and 1 PM; on the 8/3/14 column the times marked were for 12:30 and 1:30 PM; on 8/4/14 no times were marked. The sign-out log sheet at the unit nursing station revealed that R#248 signed out on: 8/2/2014 at 0945 for the purpose of riding; 8/3/2014 at 1230 for the purpose of walking; 8/4/2014 at 0910 for the purpose of walking; and, 8/5/2014 at 0900 for the purpose of walking. The AD provided the facility's, Resident Admission Agreement booklet, that included rules and regulations for smoking on page 13, section 10. An orange loose leaf flyer was also included with the booklet for, "Important Information," and, "This is a SMOKE Free Facility Thank You for Not Smoking," printed below the heading of the flyer. The EMR documentation in the nurses progress notes dated 08/01/2014 and e-signed by the DON noted that R#248 was smoking outside facility under tree with spouse per AD. The AD reiterated to the couple that facility non-smoking facility and couple verbalized understanding. The 08/01/2014 nursing notes at 6:32PM noted that the MD was updated and will document how many times R#248 will go OOP within 72 hours. The resident didn't go out during that shift. On 08/02/2014 the nursing notes reveal that R#248 was OOP with family from 10 AM and returned at 12:00 noon. On the 08/03/2014 nursing notes at 6:37 PM it revealed that R#248's family came to visit, and the resident, up in wheelchair, spent time outside with family in the PM. On 08/25/2014 at approximately 1:00 PM, informed the Adm that an IJ situation existed due to R#248 being wheeled to the gas station to smoke by his/her spouse and staff unaware of the resident's whereabouts. The physical environment with cars constantly entering and exiting the gas station, and adjoining car wash, with the busy street between the gas station, fast food chain and the facility was a potential for serious harm to the resident. The facility provided the finalized plan of correction, (POC) on 08/25/2014 at 5:38 PM to remove the IJ citation. The Abatement Written Plan was rewritten four times before acceptance of the finalized form. Corrective Action Taken on 08/5/2014 for R#248 included: Resident assessment included: ? Elopement risk and Cognitive status Resident's CP was revised to reflect: ? Passes will be supervised by staff when spouse or responsible party not available ? Resident#248 and responsible party will be escorted/supervised by a (facility name) associate for smoking. ? Resident would like to smoke 4 times per day as follows: Before breakfast, before therapy, after lunch, and after dinner. ? Resident will sign in and ot on the facility's sign in and out log book ? Resident and spouse were educated on the sign in and out requirement and risks associated with smoking in an inappropriate area Identification of others ? Residents currently exercising their rights to leave the facility out on pass and who have a physician's orders [REDACTED]. ? All staff currently working in the facility will receive education on the importance of following/re-enforcing the facility's pass protocol and recognizing residents that may be at risk for elopement. Staff who are not currently in the facility on 08/25/14, will be educated on the importance of re-enforcing/following the facility pass protocol and recognizing any residents who might be at risk for elopement prior to their next working shift. Systemic Changes ? Any resident wanting to go out on pass, must have a physician's orders [REDACTED]. ? Residents will need to sign out in the sign out book wen leaving the facility, this will include name, who they are with and the anticipated time of return. ? Residents going out onpass will have facility's contact information on their person to assist them in contacting the facility should they need assistance while out ? The sign in and out log book will be maintained at each nurse's station ? Nursing administration will review the sign in and out book to ensure it is being utilized according to protocol. Monitoring ? All residents' physician orders [REDACTED]. ? A list of resident's with privileges will be maintained in the sign out book to assist staff with knowlege of which residents have pass privileges and to ensure use of the log. ? Monthly, the nursing administration team will submit to the performance improvement committee, resident who have orders for passes, frequency of passes taken and compliance with the facility's pass protocol. This information will be provided to the committee for input and review or until sustained compliance is achieved. 2) On 8/26/14 at 10:17 A.M., R #22 was observed asking to be signed in at the nurse's station. The resident sat in a motorized scooter and held a nearby fast food chain's (JIB's) coffee cup. The resident had signed out in the Day Pass Sign Out Log at 7:20 A.M. and returned at 8:10 A.M. However, there was no sign out time for this activity. Surveyor also noted Res #22 had several JIB coffee cups stacked in his room. On 8/26/14 at 1:31 P.M., the resident agreed to be interviewed about his outings as an Immediate Jeopardy (IJ) situation was identified on 8/25/14 for Res #248 who was found off the facility's premises without staff knowledge and smoking at a nearby gas station. R #22 stated he frequented JIB to obtain his coffee on his scooter after signing out. He left from the front door and went right to JIB from the driveway, but stated, "sometimes the sidewalks don't connect from the sidewalk to the street walk. If I get into any trouble the people get out of their car and help me to the sidewalk." He also said people would pay for his purchases at JIB. Res #22 said his physician told him he "could go anywhere I wanted to." Sometimes when he needed to buy powder he would go to a drug store across the street to a strip mall on his scooter. "Sometimes I'll stop--there is a lane that turns left." He also said about 3 years ago, he backed over a board at the entrance of the facility, lifted on his wheel whereupon the scooter landed on him, smashing his hip. He said he had "to put a new hip-the most painful operation." Record review found this [AGE] year old resident had an accident involving his motorized scooter on 4/27/12. The resident fractured his right hip and required surgery. Currently, R #22 has functional limitations to his lower extremities, requires a lift for transfer and is unable to walk per LN #1 and LN #2. The resident was also observed to use a scarf to band his lower legs together for adduction while on his motorized scooter. Other [DIAGNOSES REDACTED]. The resident's identified problem areas in his current care plans included alteration in mood state, sad mood, belligerent; impaired cognitive skills, potential risk for recurrence for extension of stroke related to a history of stroke and atrial fibrillation, at risk for [DIAGNOSES REDACTED]/ hyperglycemia, at risk for falls related to poor balance due to history of multiple falls, stroke with loss of voluntary movement and limitation in range of motion complicated by decreased endurance, with extensive assistance needed. Interview with LN #5 on 8/26/14 at 2:20 P.M. revealed that R #22 went to JIB frequently and was instructed to sign out in the log book. She said the resident was medically stable, "I know he has a heart condition," rode a scooter to get around and had pain to his legs. "Sometimes he complains of chest pain, and it's probably twice he complained of chest pain since I've been here (9 months)... I think physical therapy did a re-eval and felt that he's pretty stable to go to JIB. I don't know if he's gone to (drug store), but if he does go further, he would have to let us know." How would you know if he ventured further? LN #5 replied, "He would say though, he would say I'm going to (drug store). I think last time he wanted to go to (drug store) was to get alcohol wipes." LN #5 said if the resident didn't come to her by a certain time when she was passing meds, she would get concerned and start looking for him. She also did not know why the previous escort was discontinued. "That I'm not too sure but that he was re-assessed and clear to go." She did not know what safe route was established for the resident to take to get to JIB when he left the building on his scooter. During an interview with LN #1 on 8/26/14 at 2:53 P.M., she stated R #22 had OOP privileges and cleared to use the Handivan without an escort. She said the resident however, did not use the Handivan, although the 11/8/13 physician's OOP orders allowed the resident to do so, and without an escort unless it was medically contraindicated. LN #1 said before the resident had an escort, "but he talked to the doctor that he wanted more JIB, but one of our social services goes but then he gets too like ah--she wanted to go (leave). We did assessment and then he did pretty good." LN #1 further said, "He usually goes to JIB, and I know he goes to (drug store) across the street because sometime he came back with their bags." She confirmed the resident has been able to go OOP from November 2013, and verified it was her handwritten entry on the care plan where they discontinued the escort. "I'm pretty sure if he can go alone. But he knows that he can go to (drug store) by himself since this order." LN #1 said the resident could go anywhere, even the other shops in the shopping complex. (Note: The resident would need to cross a busy intersection of a 4 lane highway to get to the shopping complex and traverse a busy parking lot. Once crossed over, the left sidewalk was paved only up to a portion with grass thereafter. Thus, if resident was on his motorized scooter, he would need to back up or risk getting stuck as there was no sloped paved ramp that extended into the parking lot). LN #1 further said, "He get his cell phone, he knows our number. For me I have never received any call; no incident report. He has his personal phone, but no one checks (if it's charged daily). Suppose to have his name band. The accident with the scooter, he fell , a fall from the scooter trying to reach something-- I'm not too sure if he get injuries. Two years ago, not pretty sure...scooter fell on top of him. He was readmitted in May 2012. He also had episode of angina and we transferred him too." LN #1 was asked if this raised any concerns and she replied, "We don't--where to keep on track of him when he goes out, but he tells us though. Because he's alert enough." What about his angina if that should occur? LN #1 replied, "That was like a couple of years, since I started here. I don't have an episode yet." Has it been assessed where he can go for his safe areas? LN #1 replied, "I know the resident is very alert and he is not going to cross and there's these stoplights." What is the facility doing to ensure his safety then? Are you relying on his personal cell phone for him to call if anything happened? And, if therapy assessed him, did they also check on this? LN #1 replied, "We wouldn't know where he goes after he tells he's going JIB." Review of the 11/12/13 rehabilitation services screening tool noted changes to R #22's functional abilities such as requiring maximum assist in bed, mobility, transfers, decline in ambulation with RNA secondary to lower extremity (LE) pain and complaints of bilateral LE pain with mobility. In addition, it noted, "MD cleared pt for I (independent) community mobility with scooter, need to assess/address safety." The OT plan of treatment (SOC date 11/14/13) noted, "2. Safety awareness - Skill not assessed during evaluation (patient reports he already went to nearby fast-food restaurant earlier this am)." The original plan was to have the resident use the Handivan for longer community outings and reintegration training; however, LN #1 stated the resident did not even use the Handivan. Staff interviews revealed that R #22 was to sign out each time he left the facility. Yet, it was found the resident had no entries of his outings in the facility's Day Pass Sign Out Log from March 2014 until the first entry on the morning of 8/26/14. The facility's policy, "Pass Privileges" stated, "2. Residents are asked to sign out in the sign out book when leaving the facility. This documentation will include name, who they are with, and the expected time of return." Thus, staff failed to monitor the resident's whereabouts and he was able to leave the facility unsupervised. Additionally, the facility's policy, "Elopement" provided on 8/25/14, stated, "Definition of Elopement: An incident in which a resident leaves the facility grounds without staff knowledge; the resident has impaired decision making abilities and is unaware of his/her own safety needs...Factors to consider may include the following: a. In some facilities, residents are at high risk just leaving the building due to busy streets/highways or the presence of railroads, rivers, ponds, and/or drainage ditches...d. Sensory, auditory, or physical impairments." R #22's risk for elopement summary review (month illegible)/25/14 documented, "Pt has impaired cognitive skills d/t (due to) short term memory problem and vascular dementia. Pt has alteration in mood. Pt uses motorized scooter." Record review also found no resident assessment, and thus no care plan which addressed a safety plan even though the attending physician, "cleared pt for independent community mobility with scooter..." On 8/26/14 at 4:30 P.M., after the facility was informed of the identified IJ situation involving Res #22 and the potential for serious harm due to the resident's unsupervised outings on his motorized scooter. There was: - A high potential for serious harm, injury, impairment or death to occur to R #22 as the facility was not monitoring the whereabouts of the resident who had not been signing out in the facility's log book. This met the facility's policy and definition of elopement. - The facility had no emergency plan for the resident if he had a medical emergency while he was OOP by himself. - The facility had no safety care plan for the resident who traversed the road fronting the facility and further crossed a busy intersection to get to the shopping complex unaccompanied. The facility also had prior knowledge the resident's motorized scooter, per the incident report and resident's recollection, was a causative factor for his right hip fracture in 2012, but had no emergency plan developed. The facility provided its initial IJ abatement plan to the survey team on 8/26/14 at 6:30 P.M. This was a Safety care plan developed on 8/26/14. The identified problem was: "At risk for injuries or any other problems during out on pass (i.e.: going to JIB or (drug store) by himself," with a target date of 11/26/14. The approaches were discussed with the DON, who agreed it needed to include additional interventions. Also on 8/26/14 at 6:30 P.M., the Administrator and DON informed surveyor the resident's attending physician walked with the resident to JIB and that the therapy staff was involved too. The Administrator confirmed they did not have a safety care plan in place for this resident. Immediate Jeopardy Removed, Deficient Practice Corrected on 8/27/14: On 8/27/14 at 6:35 A.M., the DON presented a revised Safety care plan which included the following 8 approaches: - Therapist to assess for safety to make sure he can maneuver a safe route from (facility)grounds to established off premises locations and vice versa; - (Resident) will sign in and out during pass; - (Resident) requires assistance from staff while out on pass at established off premises locations and other community areas for safety precautions; - (Resident) requires staff assist (activities staff or unit staff to go with him via van or scooter); - (Resident) has an established safe route to established off premises locations and will be accompanied by a staff member; - (Resident) is aware if an case of an emergency that staff who accompany him will contact facility or call 911; - If bad weather, facility staff will make arrangements with (resident) to escort with an umbrella or van to destinations. Staff will encourage (resident) to reconsider his outing at that time or offer alternative activities; - PT as ordered - therapy Thereafter for the remainder of the survey, the resident was found to be accompanied by staff on his outings and was signing out and in beginning 8/26/14. This was evidenced by an entry by the resident who signed out at 5:18 P.M. to go to JIB, then again at 6:44 P.M.. After signing in upon return to the facility, the staff also initialed the OOP entries. On 8/27/14, the resident signed out at 10:30 A.M. to go to the drug store, which he said he frequented at least once a week. Nursing documentation from 8/26/14 after the IJ was identified revealed, "a new order for resident may go out on pass with an escort for safety concern and for therapy to establish a safe route for resident to travel with scooter to JIB..." In addition on 8/26/14, the DON's entry noted, "Resident re-educated on sign out for pass policy when leaving facility campus, resident stated he can go out when he is ready per MD order and I verified to he that it is true but reiterated that he has to sign out when leaving campus, resident verbalized understanding. Resident was also educated on process if off campus and an emergency arises, he was provided with a business card with facility phone to contact if away from campus and reminded he can always call 911 if cases of medical emergency. Resident verbalized understanding of process." The 8/27/14 entry stated, "New ordesr (sic) noted and carried out: PT eval and Rx.PT clarification order: PT 5x/wk x 1 week for therapeutic activities, community reintegration, training, w/c fitting and management ..." On 8/29/14 at 8:35 A.M., during an observation of Res #22, he stated, "They put another string around my neck. Now I can't even go over to feed the birds anymore across the front but I have to stay inside thanks to you folks." The IJ was removed and the deficient practice corrected with the implementation of the new Safety care plan with the interdisciplinary team following the new orders to ensure the resident's safety.

Based on record reviews, staff interviews and a review of the facility's policy and procedure, the facility failed to ensure nursing services provided by the facility met the professional standards of clinical practice for the assessment and treatment of [REDACTED]. Findings include: a) Residents #231, #223, #49, #212 and #222 were triggered for closed record reviews as they were admitted with and/or developed in-house pressure ulcers. The outcome of the investigation of the residents' pressure ulcers found the facility's former regional director of clinical services (RDCS) instructed various licensed staff to "backstage" or reverse stage pressure ulcers (i.e., a Stage 3 to a Stage 2), and/or "cluster" pressure ulcers into a single one. Interviews with licensed staff involved in the care/assessment of these residents verified this. The licensed staff who did this reverse staging and wound clustering however, failed to report this practice for alleged fear of reprisal from the RDCS. The additional harm done for these residents with pressure ulcers is that licensed staff, despite having the knowledge that this was not the clinical standard of practice, continued to assess the residents in this manner and further noted the residents' pressure ulcers "healed" within 2-3 weeks, with no clinical entries or evidence of it. b) To demonstate this deficient practice, selected examples of findings for residents #222 and 231 are included below. Also, cross-reference to additional findings at F279, F314, F501 and F514: On 8/27/2014 at 3:32 P.M., during a concurrent record review of R #222's chart with LN #2, she said, "it looks like she only has one on the sacrum from 5/13. On 6/2--looks like she clustered." R #222 was admitted on [DATE] with one Stage 3 pressure ulcer to the coccyx measuring 5.0 x 3.0 centimeters (cm) (no depth) and two Stage 2 pressure ulcers to the right and left buttocks, both measuring 1.0 x 2.0 cm according to LN #2. Yet on 6/2/14, the three ulcers became one Stage 3 cluster on the Pressure Ulcer Status Record and measured 9.0 x 7.0 centimeters (cm). LN #2 was asked what a "cluster" meant, but she hesitated in her reply and said the clustering of wounds happened when their RDCS was at this facility. Further record review found LN #2's 8/8/14 clinical entry which stated, "Resident has Stage II wound to sacrum, with two open areas. Areas on left sacrum measures 2.5 cm x 1.5 cm. No depth odor,...Open area to right of sacrum measures 1 cm x 1 cm. No depth odor...Treatment NS, santyl cover with foam dressing and [MEDICATION NAME]. Treatment frequency increased...Continue with current POC." R #222 came in with a Stage 3 pressure ulcer to the coccyx, which was then combined with 2 other pressure ulcers. According to this entry, it also became a Stage 2 pressure ulcer with reverse staging evident. On 8/29/14 at 9:35 A.M., during a concurrent record review of R #231's pressure ulcer status with LN #1, she stated for this resident's pressure ulcers, their RDCS said she could back stage and cluster the resident's pressure ulcer wounds. LN #1 drew a picture showing how three wounds got "clustered" as one wound. In addition, the pressure ulcers for R #231 were initially recorded as Stage 2s (one to the sacral and one to the buttock area) on 6/7/14. But by 6/12/14 the right buttock ulcer was restaged to a Stage 3, then restaged again to a Stage 2 on 6/18/14. Then on 6/25/14, the same ulcer was noted to be "Healed" with no staff signature for this entry. The sacral ulcer followed this same pattern of staging and on 7/18/14 it was also "Healed" with no staff signature. A new Stage 3 pressure ulcer was also documented five days after admission to be 6.0 x 6.0 cm (no depth). By 6/25/14, it too was noted as "Healed." c) On 8/29/14 at 10:46 A.M., MDS Coordinator (MDSC #1) said she became aware of this problem when LN #1 told her to reverse stage based on the RDCS's direction. MDSC #1 stated, "it was direction from (the RDCS) and we had discussion that we can't reverse and she said, 'do you want to challenge me, this is insubordination.'" MDSC #1's reply to her was, "this is what have to do (follow the RAI)." MDSC #1 stated regarding the combining or "clustering" of multiple pressure ulcers, "My knowledge about clustering wounds--this is the first time in my practice. My clinical knowledge--it is not a standard of practice. I left it alone because she is the RDCS and because of the challenge." MDSC #1 said she and two other nurses went to the Administrator "about being challenged about the RAI and that's when (the RDCS) stayed away." MDSC #1 stated, "I did not pull out the NPUAP." She acknowledged the National Pressure Ulcer Advisory Panel (NPUAP) is referenced in Section M of the Resident Assessment Instrument (RAI) for pressure ulcer identification and coding and they followed this as well as the corporate pressure ulcer guidelines. d) On 9/2/14 at 10:32 A.M., MDSC #2 said R #222 was a skilled nursing resident when she was admitted on [DATE]. She coded the pressure ulcers the resident came in with according to the Minimum Data Set (MDS) rules and how they were taught to stage pressure ulcers. She said she questioned the clustering of the pressure ulcers. "I did. When I asked nurses they said they were taught by our regional nurse to cluster the wounds." She has never "clustered" pressure ulcer wounds. On the resident's 5 day MDS admission assessment, she said it was the unstageable pressure ulcer to the resident's right heel (8.0 x 2.0 cm) which she coded. The resident had 2 suspected deep tissue injury (DTIs) to both heels and the right heel was the largest on admission. However, by day 14, she stated there was only 1 suspected DTI and that this R heel ulcer had "healed" on 6/2/14. MDSC #2 said, "there's no documentation on how this healed. I looked." She said when wounds heal, "there should be documentation." MDSC #2 said, "Yeah, I did" have a hard time tracking the documentation and, "(The RDCS) threatened my job and I stopped." She also said she had brought it to the attention of another ADON. e) On 9/3/14 at 11:32 A.M., during an interview with the ADON, she said the RDCS was at their facility from January to June 2014 and did some training. "We were talking about the wound staging and she said she was a wound care nurse. I didn't know she was back staging the wound. I know for myself we don't restage the wound being an RN. If the wound gets worse or better, it stays the same stage. The Medical Director did talk about it in a QI meeting. I didn't discuss it one on one with him. I was unaware of the changing of stages; when I looked at the report I wasn't able to match, I wasn't aware. No one from MDS told me. My expectation now? They should have brought it up in a meeting at grand rounds." f) On 9/3/14 at 9:24 A.M., the Administrator said she confirmed with their regional corporate office that they did not have any credentials of their former RDCS regarding her wound care certification outlined in her curriculum vitae (CV) or professional profile. The RDCS's CV stated she was "Certified under AIS for MDS 3.0, clear understanding of coding of Section "M" and one of her accomplishments included, "Have had no in-house acquired pressure soars (sic)." Yet, the corporate office was unable to provide this documentation although her CV was produced. The Administrator was made aware on 9/3/14 the residents with pressure ulcers were provided with clinical nursing services that did not meet the professional standard of care found in the RAI Manual and their corporate Pressure Ulcer Guide. In addition, the facility and corporate office were unable to produce documentation of the RDCS's certification as a wound care specialist. Licensed staff implemented the reverse staging and clustering of pressure ulcers despite having resources, clinical knowledge and skills to know that the assessments and treatments for these residents with pressure ulcers did not follow the professional standard of care. As a result, their lack of action to stop it was neglectful and harmful to these residents while they were admitted for skilled nursing care at the facility. The Medical Director stated during his interview on 9/3/14 at 1:30 P.M., this was "basic nursing 101" and licensed staff were not to have reversed staged and clustered wounds. He was also informed there was no clinical documentation when the pressure ulcers healed in the duration of time documented in the records, but stated he was not aware of all this.

Based on record review, staff interviews and review of the facility's policies and procedures, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing and prevent new sores from developing for 5 of 35 residents included in the Stage 2 sample. Findings include: Cross-reference to additional findings at F279, F281, F501 and F514. 1) Resident #222 (R #222) was admitted to the facility on [DATE] with one Stage 3 pressure ulcer to the coccyx measuring 5.0 x 3.0 centimeters (cm) (no depth) and two Stage 2 pressure ulcers to the right and left buttocks. On [DATE], during a concurrent record review, LN #2 stated both buttock ulcers measured 1.0 x 2.0 centimeters (cm) with no depth. Yet, it was found on the [DATE] Pressure Ulcer Status Record that the right buttock, documented as Stage 2, measured 5.0 x 2.0 x 0 cm (length x width x depth) and not 1.0 x 2.0 cm. The record also noted on [DATE] the left buttock Stage 2 measured 5.0 x 5.2 x 0 cm. The resident also came in with suspected deep tissue injuries (sDTIs) to both heels. The [DATE] record found the right heel measured 3.0 x 2.0 x 0 cm and the left heel measured 2.0 x 2.0 x 0 cm. However, the Minimum Data Set (MDS) Admission assessment ([DATE]) coded the pressure ulcer with the largest surface area to be the right heel ulcer at 8.0 x 2.0 cm. MDSC #2 was asked about this discrepancy in size, but she verified she coded it according to what she found talking with the nurses and her chart review. LN #12's [DATE] nursing entry stated: "Both heels noted with DTI and measures from left heel 2.5 cm x 2.0 cm, and right heel 8.0 cm x 2.0 cm". The attending physician's history and physical of R #222 further noted, "DTI (B) (deep tissue injury bilateral) heels, no rashes," but failed to include the other three pressure ulcers in her physical assessment and overall plan of [DATE]. In addition, the [DATE] pressure ulcer care plan only addressed one Stage 3 pressure ulcer to the sacrum, although the initial interim care plan of [DATE] included the other pressure ulcers to the buttocks and heels. On [DATE] at 3:32 P.M., during a concurrent record review of R #222's chart with LN #2, she said, "it looks like she only has one on the sacrum from ,[DATE]. On ,[DATE]--looks like she clustered." The documentation also showed the three ulcers became one Stage 3 cluster on the Pressure Ulcer Status Record and became 9.0 x 7.0 centimeters (cm) (no depth). Then on [DATE], there were 4 clusters to the left buttocks with measurements of 1 x 1.2, 2 x 1.5, 1.5 x 1 and 1.0 x 1.5 cm, although the description of the site was the initial "sacrum" area of [DATE] measuring 5.0 x 3.0 cm. The next entry of [DATE] reverted to having a Left 1.7 x 2.2 cm and a Right 1 x 1.3 cm Stage 3 pressure ulcer on the same record. This was one of the examples of how this resident's pressure ulcer documentation was inaccurate, being "clustered" and overall, did not follow the professional clinical standard of practice. Other evidence found entries of reverse staging such as the [DATE] clinical entry which stated, "Resident has Stage II wound to sacrum, with two open areas. Areas on left sacrum measures 2.5 cm x 1.5 cm. No depth odor,...Open area to right of sacrum measures 1 cm x 1 cm. No depth odor...Treatment NS, santyl cover with foam dressing and [MEDICATION NAME]. Treatment frequency increased...Continue with current POC." The resident came in with a Stage 3 pressure ulcer to the coccyx, then clustered with 2 other pressure ulcers, and according to this entry, became a Stage 2 pressure ulcer, with reverse staging evident. On [DATE] at 10:46 A.M., MDS Coordinator (MDSC #1) stated regarding the combining or "clustering" of multiple pressure ulcers, "With clustering, this is the very first time. It is not the standard of practice." MDSC #1 acknowledged that although she was aware of this, "I left it alone because she is the regional director" who had instructed the licensed staff to reverse stage and/or cluster wounds. In addition, for Res #222's MDS admission assessment (5 day), it was an unstageable right heel pressure ulcer that was coded to be 8.0 x 2.0 cm. The resident had 2 suspected deep tissue injury (DTIs) to both heels and the right heel was the largest on admission. However, by day 14, during an interview with MDSC #2, she stated there was only 1 suspected DTI and that this R heel ulcer had "healed" on [DATE]. MDSC #2 said, "there's no documentation on how this healed. I looked." She also said for wound healing, "There should be documentation." There were no nursing entries that described the clinical healing of the right heel wound. Review of the facility's policy and procedure, "Assessment and Monitoring of Healing," (Chapter 3: Treatment Pressure Ulcer Care Guide, Last Rev: [DATE]), found: "Purpose - To gather data for the purpose of planning and implementing wound care treatment procedures (nursing care plan), To evaluate outcomes, rationale, frequency...Policy - With each dressing change, the pressure ulcer is observed for developments that may indicate the need for change in treatment such as: Wound deterioration or improvement...The physician, resident, and family/caregiver are kept informed of the progress (or lack of progress) toward healing. The resident is reassessed if the ulcer does not show signs of healing as expected...Procedure...5. Measure the wound (surface area and depth) following the steps on the "Measurement of Pressure Ulcers" quick reference card...12. Look for general signs of healing: Decreased length, width, and depth of the ulcer...16. Document your findings. Include a narrative description of the wound, including its physical characteristics, in the medical record to avoid miscommunication or misinterpretation... Note: Never backstage a wound...Other Documentation: Chart observations and assessments on the flow sheet weekly. Document significant findings or changes in the interdisciplinary/nurses' notes. Document physician notification. MDS Coding: For the MDS, select the best description of the most severe type of tissue present in any pressure ulcer bed. Healed Pressure Ulcers: completed closed, fully [MEDICATION NAME] red, covered completely with [MEDICATION NAME] tissue or resurfaced with new skin, even if the area continues to have some surface discoloration. Do not backstage. Current clinical standards do no support reverse staging or backstaging. For example, a Category/Stage IV pressure ulcer that has been healing (is now less deep, wide, and long), and has healed to the depth of a Category/Stage II pressure ulcer is considered a healing Category/Stage IV pressure ulcer. It is not reclassified a a Category/Stage II pressure ulcer." The licensed staff had access to this policy but failed to follow it. 2) On [DATE] at 8:45 AM the discharged MRR for R#49 noted that the resident was admitted to the facility on [DATE] with a Stage II PU to the coccyx that healed on [DATE]. The R#49 was admitted for hospice care and deceased on [DATE]. The hospice progress notes dated [DATE] documented that a dressing change was done for Stage II PU on coccyx. The facility's skin assessment form dated [DATE] documented that the PU to coccyx measured 1.0 cm x 1.2 cm, and on [DATE], PU on coccyx healed. The EMR progress notes for [DATE] had no documentation that a skin assessment was done. Interviewed MDSC#2 and reviewed skin assessment sheet with her and inquired about Stage II PU to coccyx documented as healed but no other descriptions. Inquired whether MDSC#2 could provide documentation of skin assessment in nursing progress notes to that described PU was healed. According to MDSC#2, LN#1 could possibly provide that information as she was the wound nurse for R#49. On [DATE] at 9:30 AM interviewed LN#1, who stated that she was not present for R#49's admission to the facility on [DATE] (Saturday), so she did not do initial assessment. When LN#1 reported to work on [DATE] (Monday), LN#8 requested that LN#1 look at R#49's PU on coccyx because there was no PU. According to LN#1, the PU dressing was used only as a protection pad. The LN#1 stated that staff should have documented on the TAR on that date ([DATE]), to note that the PU healed. The skin assessment sheet documented that the PU to the coccyx healed on [DATE] because that was the day R#49 was scheduled for a skin assessment. The LN#1 further stated that progress notes should have documented on ,[DATE] that PU on coccyx healed and skin intact; discontinue skin treatment and family notified. 3) On [DATE] at 1:00 PM discharge MRR for R#212 on the survey admission sample revealed the resident was admitted to the facility on [DATE] with a pressure ulcer to the coccyx. The Initial Data Collection Tool/Nursing Service form under the General Skin Condition, on the human diagram was a dark circular mark on the coccyx with a line drawn to document Stage IV pressure ulcer. The Pressure Ulcer Status Record, (PUSR) dated [DATE] documented, Unstageable Coccyx 6.5 x 9.5 cm (LxW) x 0 (depth), scant drainage, odor none, color red, tunneling none, slough appearance of wound; on [DATE], Unstageable, 4.75 x 1.2 x 0 both entries signed by LN#2. On [DATE] the PUSR documented "Healed," with no signature and corresponded with the Weekly pressure ulcer report that LN#1 documented on [DATE] for PU on coccyx "Healed." Interviewed LN#2 on [DATE] at 2:00 PM, regarding the PUSR for R#212 that noted PU, "healed" on [DATE] with no description of PU or signature, and nurses notes on EMR dated [DATE] at 6:38 PM. The EMR nurses notes signed LN#2, "Notes: New order. DC treatment to RLE and buttock. Cleanse with NS, pat dry, apply [MEDICATION NAME] to wound bed then skin prep around wound to RLE, cover with [MEDICATION NAME] foam daily. ...Cleanse with NS pat dry apply wound gel to left inter buttocks Stage II then cover with [MEDICATION NAME] foam daily, PRN for soilage. Re assess in 10 days. Skin prep to bilateral buttocks Stage I q shift and PRN for soilage for 10 days then re-assess." Inquired of LN#2 whether PU to coccyx was healed on [DATE] because documentation on PUSR, Weekly Pressure Ulcer Report and nurses progress notes didn't correlate. According to LN#2, when PU healed will continue to treat [MEDICATION NAME]. LN#2 was not sure if she wrote "Healed" on [DATE] but the wound was considered healed on that date. Further MRR noted on CP that Coccyx PU healed on [DATE] also noted on TAR. Other PUs to buttocks healed [DATE] and corresponds to nursing progress notes dated [DATE]. On [DATE] interviewed LN#1 at 4:02 PM as LN#2 stated that she took over wound care of R#212 from LN#1. According to LN#1, the unstageable PU to coccyx was healed on [DATE] and changed to Stage II inner buttock PU. LN#1 was accompanied by the ADON who was the DON in [DATE]. According to both LN#1 and the ADON, the former RDCS advised LN#1 to re-stage the wound. LN#1 stated that she shouldn't have re-staged the wound then, but was told that the RDCS was a certified wound specialist hired by the corporate office, so complied. The ADON didn't know that the RDCS was going in that direction and had no authority to question the RDCS. LN#1 went to an Advanced Wound Care conference in July and learned from experts there that an unstageable wound should not be back-staged. LN#1 had that knowledge in [DATE] but felt compelled to follow the directions of the RDCS because staff could not question her authority. 4) On [DATE] at 11:00 AM, the discharge MRR for R#223 was admitted to the facility on [DATE] from an acute hospital with admission primarily for rehabilitation and aftercare for healing traumatic fx of vertebrae. On the facility's history and physical assessment form dated [DATE] documentation for, "Plan of care: short term course of Pt and OT to improve functional status." The Initial Data Collection Tool/Nursing Service form dated [DATE] documented under the Physical Functioning heading, that R#223 required assistance to reposition self, needed 2 person assistance, understood and was able to recognize the need to wait for assistance to get out of bed; and, under the General Skin Condition heading it was marked that R#223s skin was warm and intact, with bruises to the surgical site area. The EMR found a CP "Risk for Pressure Ulcers" dated [DATE], and on [DATE] a CP "Pressure Ulcer, to the left buttock Stage II related to decreased strength and endurance, decreased standing tolerance balance and pain...incontinence." The CP goal date of [DATE] included interventions to assist with turning and repositioning while in bed or in wheelchair as needed. The EMR progress nursing notes on: [DATE] at 11:04 PM, "Notes: Res on bed, alert and verbally responsive....Open area noted on left buttocks, flexicol applied. Res cont to assist with ADL and transfer. Call light within reach and cont current POC." [DATE], "Notes: Res on bed, alert and verbally responsive. ...Dressing change on left hip, clean and dry. Flexicol applied to left buttocks, with open area noted 1 cm x .5 cm. Resident cont to asst with ADL and transfer. Call light within reach and cont current POC." [DATE], "Notes: Stage II to L buttock measures 1.6 x 1 cm. No depth, drainage, or odor. Wound bed is pink with [MEDICATION NAME] tissue. Treatment changed to : NS, pat dry apply foam dressing daily and PRN. Pressure relieving interventions: check and change, turn to sides frequently. No complaint of pain during dressing change. Pain assessment, Braden scale, and education updated. Continue to monitor resident and cont with current plan of care. On [DATE] at 9:01 AM, the EMR for RITA, that the CNA staff document their daily task was reviewed for the monthly flow report on R#223. The R#223 Daily care monthly flow sheet for the task of,"Repositioned every 2 hours," documented with a check mark for the date and shift during: [DATE]= ,[DATE] N, ,[DATE] D, ,[DATE] N; [DATE]= ,[DATE] D, ,[DATE] E, ,[DATE] E, ,[DATE] N, ,[DATE] D & E, ,[DATE] D&N, ,[DATE] E&N, ,[DATE] E, ,[DATE] D; [DATE] = ,[DATE] E, ,[DATE] E, ,[DATE] N, ,[DATE]E, ,[DATE] E, ,[DATE]N, ,[DATE]N, ,[DATE]D, ,[DATE] N, ,[DATE]D. On [DATE] at 9:43 AM, interviewed LN#2 and inquired how the nursing staff check whether resident's that need assistance to be repositioned are repositioned every 2 hours. The LN#2 stated that the CNA staff are instructed to reposition those residents every 2 hours. Asked LN#2 whether CNA staff need to document in the RITA EMR. The LN#2 was not sure because the RITA system was just changed yesterday ([DATE]). Asked LN#2 to access the RITA EMR to see if a current resident with a PU was being repositioned every 2 hours per their CP. The LN#2 went on RITA and looked at a monthly flow sheet for res with PU and the Daily Care sheet for Repositioned Q 2 hrs did not have a check mark consistently throughout the month of August. Inquired how nursing staff would know that CNA staff following CP intervention for repositioning of a resident with a PU. LN#2 went to call LN#12 to explain how nursing staff monitor the CNA staff and RITA input. According to LN#2 she is the facility's nursing supervisor and not sure how nursing staff monitor CNA staff for RITA input. The LN#12 explained that when the shift ends she asks the CNA staff that worked with her to print-out their RITA reports to ensure nothing missing. The LN#12 also stated that she monitors the CNA staff to ensure that residents with PU are off-loading and that the CNA's are using the draw sheet to reposition residents. The LN#12 stated that it was standard practice for her but couldn't comment on what other nursing staff do. 5) A closed record review was done on [DATE] at 1:30 P.M. for Resident #231 (R #231), admitted [DATE] with [DIAGNOSES REDACTED]. On admission the resident's skin condition was recorded as open [MEDICAL CONDITION] to the sacral and (R) buttocks; multiple pressure sores, quantity: clustered. The body map had two circled areas demarcating the (R) buttocks and sacral area, both labeled Stage 2. However there were three pressure ulcers noted in the resident's care plan on [DATE]. The care plan noted, "Problems: (Resident) has pressure ulcers to sacrum, right buttock and right ischial tuberosity." On [DATE] the Stage 2 (R) buttock ulcer had no documented measurements. By [DATE], the ulcer was restaged to Stage 3, measuring 2.5cm x 2.0 cm, no depth. By [DATE] the ulcer was restaged to a Stage 2, and measured at 2.5cm x 2 cm no depth. Then 7 days later on [DATE], the ulcer was "Healed," but there was no staff initial or signature for this entry, and no documentation of the wound healing status. On [DATE] the resident's sacrum ulcer was documented as a Stage 2 pressure ulcer. It measured 4 cm x 7 cm with no depth. By [DATE], it too was restaged to a Stage 3 and measured 3.0 x 6.9 cm with no depth. Documentation of the weekly skin integrity data on [DATE] found an entry, "open area saccral - unstageable; coccyx 'dark discoloration'". Yet by [DATE], the sacral wound was "Healed," with no staff initial or signature for this entry, and no documentation of the wound healing status. Then 5 days after admission, the resident's record show an entry on [DATE] for a (R) ischial tuberosity pressure ulcer Stage 3, that measured 6 cm x 6 cm, no depth. Yet, by [DATE] this Stage 3 ulcer was marked "Healed"; and again with no staff initial/signature for this entry and no documentation of the wound healing status. Also noted was a physician's orders [REDACTED]. The order was for Santyl 250 unit/gram topical ointment, "Cleanse with NS, pat dry. Skin prep around wound and apply Santyl ointment to wound bed, cover with foam dressing to Sacrum, right buttock and right ischial tuberosity. Topical daily and prn soilage RE-assess in 14 days." Surveyor interviewed MDCS #1 on [DATE] at 10:46 A.M. and she stated, "We go by if it is documented, it is there. If it is not documented, it is not there, not done." MDSC #1 also reviewed the [DATE] physician order [REDACTED].#231 with the entries for the (R) ischial tuberosity. MDCS #1 looked at the electronic MDS record for resident #231 and confirmed the resident's (R) ischial tuberosity wound was a new pressure ulcer dated [DATE]. On [DATE] at 8:21 A.M., surveyor interviewed LN #2; regarding the sacrum ulcer documentation. LN #2 stated, "The [DATE] stage 2 restaging to stage 3 is an error. It is a whole different pressure ulcer if restaged. We were going through a transition of staffing and positions during this time. This is also the time the RDCS was coming in and a lot of changes made." On [DATE] at 8:55A.M., surveyor interviewed LN #1 regarding the restaging of the (R) buttock pressure ulcer. She stated, "I based on the stage 2 with admission; I still had a lot of confusion. I have the RDCS with me, when we changed saying that's a stage 3. For the [DATE] R ischial tuberosity, this is the day I went to assess, somebody must have seen this one on the 11th and get the order then I went there on the 12th and started the treatment. For me when I went over there; I should have put over here ,[DATE], it should have started on ,[DATE] because it is noted here on the care plan. My observation-- this pressure ulcer because it is clustered-- clusters means it is spread." LN #1 drew three small circles to demonstrate how she clustered the wounds. She stated, "I know now that each wound needs to be measured individually. The RDCS said I could change the stage. Clustering was told to me from my RDCS." On [DATE] at 10:46 A.M., surveyor interviewed MDSC #1 who stated, "(Corporate) Center has a policy to follow the National Pressure Ulcer Advisory Panel (NPUAP) with follow up on staff development on what is being taught, until management changed about a year ago. We had a RDCS that came around. I let her know that we can't reverse. She said, 'Do you want to challenge me, this is insubordination.' I reported to our executive director being challenged with MDS. We went to the Administrator and according to policy this is what we have to do. When we (LN #1) was discussing the wound, she said we can restage. I said we cannot reverse stage, but she said it was under the direction of the RDCS. After with the MDS challenging, the RDCS told me insubordination I backed up and we went to the DON. I did not say anything about the back staging because the DON said it was from the regional. I did not pull the NPUAP to back up my knowledge. My knowledge about clustering wounds--this is the first time in my practice. My clinical knowledge--it is not a standard of practice. I left it alone because she is the RDCS and because of the challenge." During an interview with DON and Administrator on [DATE] at 11:15 P.M., the DON said they do not cluster the wounds nor reverse stage pressure ulcers. The Administrator said they recognized they had problems with the pressure ulcers. The DON also acknowledged the same and said with the findings of this survey, they would be "moving on."

Based on record reviews and staff interviews the facility leadership failed to collaborate with the medical director to help develop, implement, and evaluate resident care policies and procedures to reflect current standards of care that are related to the provision of services by physicians and other licensed health care practitioners. Findings include: Cross to F314 On 09/03/2014 at 1:30 PM, interviewed the facilities medical director, (MD), regarding the implementation of pressure ulcer (PU) wound care assessments and treatments by the former RDCS during the month of June 2014. The MD was apprised of how the licensed wound nurses were told by the RDCS to back-stage PU wounds and/or to "cluster," wounds, (e.g. 3 PU wounds adjacent to one another measured as 1 larger PU wound). The MD stated that in basic PU wound care, the PU is never back-staged and he never heard of "clustering," wounds. The MD further stated that the facility's wound nurses have been doing PU wound care for a number of years and should have the basic knowledge of wound care. The MD stated that he was never notified that PU wound assessment and treatments proposed by the RDCS were implemented, and would not have permitted this inappropriate directive. The MD stated, "the nursing staff should have let me know." The MD was informed that the licensed staff could not question the authority of the RDCS as she was hired by the corporate office to supervise the facility. Also, the RDCS would state that the nurse was being insubordinate when her instructions to back-stage and/or "cluster" the PU wounds were questioned. The licensed nurses felt that they would lose their jobs because the former RCDS was hired by the facility's corporate office to provide supervision. From January to June 2014, the RDCS went weekly to the facility to provide supervision. According to the MD, he is frequently at the facility and the staff will call him if the resident's attending physician is unavailable or in an emergency to provide them direction. The MD also meets with the facility's physician once a week which he stated is an informal process. The facility's attending physician attends the PU and nutrition committee meetings and usually keeps the MD informed of any issues.

Based on record review and interviews, the facility did not ensure clinical records were maintained on each resident that were accurate and complete, in accordance with accepted professional standards and practices, including the facility's own policies and procedures. Findings include: Cross-reference to various findings: 1) For R #222, LN #2 stated the nurses should be documenting if they do a dressing change for the wound, and for a Stage 3 pressure ulcer, treatment is done at least daily. On the Treatment Administration Record (TAR) for [DATE] and [DATE], it was found too the licensed staff did not sign off on these two dates and thus, the lack of documentation meant it was not done, which was affirmed by LN #2. The findings at F 314 show the professional standard of nursing care in the treatment of [REDACTED]. Cross-reference to findings at F314, F279 and F281. 2) On [DATE] at 8:45 AM the discharged MRR for R#49 noted that the resident was admitted to the facility on [DATE] with a Stage II PU to the coccyx that healed on [DATE]. The R#49 was admitted for hospice care and deceased on [DATE]. The hospice progress notes dated [DATE] documented that a dressing change was done for Stage II PU on coccyx. The facility's skin assessment form dated [DATE] documented that the PU to coccyx measured 1.0 cm x 1.2 cm, and on [DATE], PU on coccyx healed. The EMR progress notes for [DATE] had no documentation that a skin assessment was done. Interviewed MDSC#2 and reviewed skin assessment sheet with her and inquired about Stage II PU to coccyx documented as healed but no other descriptions. Inquired whether MDSC#2 could provide documentation of skin assessment in nursing progress notes to that described PU was healed. According to MDSC#2, LN#1 could possibly provide that information as she was the wound nurse for R#49. On [DATE] at 9:30 AM interviewed LN#1, who stated that she was not present for R#49's admission to the facility on [DATE] (Saturday), so she did not do initial assessment. When LN#1 reported to work on [DATE] (Monday), LN#8 requested that LN#1 look at R#49's PU on coccyx because there was no PU. According to LN#1, the PU dressing was used only as a protection pad. The LN#1 stated that staff should have documented on the TAR on that date ([DATE]), to note that the PU healed. The skin assessment sheet documented that the PU to the coccyx healed on [DATE] because that was the day R#49 was scheduled for a skin assessment. The LN#1 further stated that progress notes should have documented on ,[DATE] that PU on coccyx healed and skin intact; discontinue skin treatment and family notified. 3) On [DATE] at 1:00 PM discharge MRR for R#212 on the survey admission sample revealed the resident was admitted to the facility on [DATE] with a pressure ulcer to the coccyx. The Initial Data Collection Tool/Nursing Service form under the General Skin Condition, on the human diagram was a dark circular mark on the coccyx with a line drawn to document Stage IV pressure ulcer. The Pressure Ulcer Status Record, (PUSR) dated [DATE] documented, Unstageable Coccyx 6.5 x 9.5 cm (LxW) x 0 (depth), scant drainage, odor none, color red, tunneling none, slough appearance of wound; on [DATE], Unstageable, 4.75 x 1.2 x 0 both entries signed by LN#2. On [DATE] the PUSR documented "Healed," with no signature and corresponded with the Weekly pressure ulcer report that LN#1 documented on [DATE] for PU on coccyx "Healed." Interviewed LN#2 on [DATE] at 2:00 PM, regarding the PUSR for R#212 that noted PU, "healed" on [DATE] with no description of PU or signature, and nurses notes on EMR dated [DATE] at 6:38 PM. The EMR nurses notes signed LN#2, "Notes: New order. DC treatment to RLE and buttock. Cleanse with NS, pat dry, apply [MEDICATION NAME] to wound bed then skin prep around wound to RLE, cover with [MEDICATION NAME] foam daily. ...Cleanse with NS pat dry apply wound gel to left inter buttocks Stage II then cover with [MEDICATION NAME] foam daily, PRN for soilage. Re assess in 10 days. Skin prep to bilateral buttocks Stage I q shift and PRN for soilage for 10 days then re-assess." Inquired of LN#2 whether PU to coccyx was healed on [DATE] because documentation on PUSR, Weekly Pressure Ulcer Report and nurses progress notes didn't correlate. According to LN#2, when PU healed will continue to treat [MEDICATION NAME]. LN#2 was not sure if she wrote "Healed" on [DATE] but the wound was considered healed on that date. Further MRR noted on CP that Coccyx PU healed on [DATE] also noted on TAR. Other PU's to buttocks healed [DATE] and corresponds to nursing progress notes dated [DATE]. On [DATE] interviewed LN#1 at 4:02 PM as LN#2 stated that she took over wound care of R#212 from LN#1. According to LN#1, the unstageable PU to coccyx was healed on [DATE] and changed to Stage II inner buttock PU. LN#1 was accompanied by the ADON who was the DON in [DATE]. According to both LN#1 and the ADON, the former RDCS advised LN#1 to re-stage the wound. LN#1 stated that she shouldn't have re-staged the wound then, but was told that the RDCS was a certified wound specialist hired by the corporate office, so complied. The ADON didn't know that the RDCS was going in that direction and had no authority to question the RDCS. LN#1 went to an Advanced Wound Care conference in July and learned from experts there that an unstageable wound should not be back-staged. LN#1 had that knowledge in [DATE] but felt compelled to follow the directions of the RDCS because staff could not question her authority. 4) On [DATE] at 11:00 AM, the discharge MRR for R#223 was admitted to the facility on [DATE] from an acute hospital with admission primarily for rehabilitation and aftercare for healing traumatic fx of vertebrae. On the facility's history and physical assessment form dated [DATE] documentation for, "Plan of care: short term course of Pt and OT to improve functional status." The Initial Data Collection Tool/Nursing Service form dated [DATE] documented under the Physical Functioning heading, that R#223 required assistance to reposition self, needed 2 person assistance, understood and was able to recognize the need to wait for assistance to get out of bed; and, under the General Skin Condition heading it was marked that R#223s skin was warm and intact, with bruises to the surgical site area. The EMR found a CP "Risk for Pressure Ulcers" dated [DATE], and on [DATE] a CP "Pressure Ulcer, to the left buttock Stage II related to decreased strength and endurance, decreased standing tolerance balance and pain...incontinence." The CP goal date of [DATE] included interventions to assist with turning and repositioning while in bed or in wheelchair as needed. The EMR progress nursing notes on: [DATE] at 11:04 PM, "Notes: Res on bed, alert and verbally responsive....Open area noted on left buttocks, flexicol applied. Res cont to assist with ADL and transfer. Call light within reach and cont current POC." [DATE], "Notes: Res on bed, alert and verbally responsive. ...Dressing change on left hip, clean and dry. Flexicol applied to left buttocks, with open area noted 1 cm x .5 cm. Resident cont to asst with ADL and transfer. Call light within reach and cont current POC." [DATE], "Notes: Stage II to L buttock measures 1.6 x 1 cm. No depth, drainage, or odor. Wound bed is pink with [MEDICATION NAME] tissue. Treatment changed to : NS, pat dry apply foam dressing daily and PRN. Pressure relieving interventions: check and change, turn to sides frequently. No complaint of pain during dressing change. Pain assessment, Braden scale, and education updated. Continue to monitor resident and cont with current plan of care. On [DATE] at 9:01 AM, the EMR for RITA, that the CNA staff document their daily task was reviewed for the monthly flow report on R#223. The R#223 Daily care monthly flow sheet for the task of,"Repositioned every 2 hours," documented with a check mark for the date and shift during: [DATE]= ,[DATE] N, ,[DATE] D, ,[DATE] N; [DATE]= ,[DATE] D, ,[DATE] E, ,[DATE] E, ,[DATE] N, ,[DATE] D & E, ,[DATE] D&N, ,[DATE] E&N, ,[DATE] E, ,[DATE] D; [DATE] = ,[DATE] E, ,[DATE] E, ,[DATE] N, ,[DATE]E, ,[DATE] E, ,[DATE]N, ,[DATE]N, ,[DATE]D, ,[DATE] N, ,[DATE]D. On [DATE] at 9:43 AM, interviewed LN#2 and inquired how the nursing staff check whether resident's that need assistance to be repositioned are repositioned every 2 hours. The LN#2 stated that the CNA staff are instructed to reposition those residents every 2 hours. Asked LN#2 whether CNA staff need to document in the RITA EMR. The LN#2 was not sure because the RITA system was just changed yesterday ([DATE]). Asked LN#2 to access the RITA EMR to see if a current resident with a PU was being repositioned every 2 hours per their CP. The LN#2 went on RITA and looked at a monthly flow sheet for res with PU and the Daily Care sheet for Repositioned Q 2 hrs did not have a check mark consistently throughout the month of August. Inquired how nursing staff would know that CNA staff following CP intervention for repositioning of a resident with a PU. LN#2 went to call LN#12 to explain how nursing staff monitor the CNA staff and RITA input. According to LN#2 she is the facility's nursing supervisor and not sure how nursing staff monitor CNA staff for RITA input. The LN#12 explained that when the shift ends she asks the CNA staff that worked with her to print-out their RITA reports to ensure nothing missing. The LN#12 also stated that she monitors the CNA staff to ensure that residents with PU are off-loading and that the CNA's are using the draw sheet to reposition residents. The LN#12 stated that it was standard practice for her but couldn't comment on what other nursing staff do. 5) A record review was conducted on [DATE] at 1:30 P.M. R#272 was admitted to the facility on [DATE]. He came in with a [DIAGNOSES REDACTED]. There was an order of 1500 ml of fluid restriction per 24 hour period on [DATE]. This amount was divided between nursing and dietary department. The dietary department had 1020 ml and nursing had 480 ml of fluids. There was no documentation on how the resident ate during breakfast on [DATE]. And, there was no documented amount of AM snack consumed from [DATE] to [DATE]. And, was 0% during PM and HS snack from [DATE] to [DATE]. The "Intake/Output Record" for the licensed nurse to document how much fluid were given during medication administration were as follows: No documentation for [DATE] and [DATE]. On [DATE]: ,[DATE] shift = 0, ,[DATE] shift = blank, ,[DATE] shift = 120 ml; [DATE]: ,[DATE] shift = 120 ml, ,[DATE] shift = blank, ,[DATE] shift = blank; [DATE]: ,[DATE] = 0, ,[DATE] shift = blank, ,[DATE] shift = blank; [DATE]: ,[DATE] shift = 120 ml, ,[DATE] shift = blank, ,[DATE] shift = blank; [DATE]: ,[DATE] shift = 60 ml, ,[DATE] shift = blank, ,[DATE] shift = blank; [DATE]: ,[DATE] shift = 120 ml, ,[DATE] shift = blank, ,[DATE] shift = 240 ml; [DATE]: ,[DATE] shift = 60 ml, ,[DATE] shift = blank, ,[DATE] shift blank; [DATE]: ,[DATE] shift = 60 ml, ,[DATE] shift 100 ml, ,[DATE] shift = 80 ml; [DATE]: ,[DATE] shift 120 ml, ,[DATE] shift = 120 ml, ,[DATE] shift = blank; [DATE]: ,[DATE] shift = 30 ml, ,[DATE] shift = 240 ml, ,[DATE] shift blank and; [DATE]: ,[DATE] shift = 30 ml. The 24 hour section of the intake/output record were left blank and the documentation were incomplete. LN#3 was interviewed, she stated the facility's computer program does not calculate the 24 hour fluid intake of the residents. An observation was conducted when the resident's wife came to visit on [DATE] at 11:15 A.M. She was observed checking the resident's bag at the bedside. She found two old sandwiches with foul odor, and a small container of mandarin oranges in a Ziploc plastic bag. These were his food while at the treatment center. There was no documentation in the pre and post-[MEDICAL TREATMENT] checklist that R#272 had sandwich and mandarin oranges to eat while at the treatment center and how much the resident had consumed.

Based on observations, resident and staff interviews, and policy review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies and failed to develop and implement appropriate plans of action to correct the deficiencies. Findings include: Part 2 of the Quality Assessment and Assurance (QAA) review was conducted on the afternoon of 5/28/13. In attendance were the IA, Administrator, DON, and the RDCS. The QAA Committee met monthly, was chaired by the DON, and included all department heads. The DON stated the IA worked with her to co-chair the QAA Committee. The IA was questioned as to his role as the Interim Administrator. The IA stated that everyone had a piece of the QAA and they discussed bigger facility concerns. The IA further stated that he had only attended 2 or 3 meetings over the past 10 months. He indicated that it was coincidental that the QAA meetings occurred while he returned "home" in another state. The IA stated he knew, for example, "there was a concern about phone coverage after hours and so they talked about getting cell phones, what doctors bring up,...so stuff like that". The DON then went over a listing of areas reviewed during QAA meetings. Such topics included falls, pressure ulcers, indwelling foley catheters, tube feedings, physical restraints, nutrition, behaviors, psychoactive medications, pain management, blood thinning medication use, etc. The facility maintained that care area goals were enforced by the corporate office, which set thresholds for the facility. In reference to oversight of CNA staff, the DON stated they expect CNAs to do rounds every couple hours. The IA stated they also discussed the Interact Tools and the Medical Director and Corporate Office were interested in implementing it. The purpose of the Interact Tools was to assist nursing homes with Quality Assurance and Performance Improvement (QAPI). The Interact Tools were not being utilized during the survey period. The survey team coordinator shared some of the negative findings from the survey up until 5/28/13. The issues included: Communication between the nursing staff and the physicians; Dignity - food and shower preferences, call lights being answered in a timely manner and being respectful to residents; Choices; Nursing issues - clinical documentation, assessments, general resident care, physicians orders, incomplete documentation on Medication Administration Records (MARs); CNAs - Documentation (accuracy, supervision/oversight - actual sponge baths on every shift?) and supervision of CNAs; Social services - adjustment to the facility, discharge planning, psychosocial issues; Accidents; Unnecessary medication use - behavior monitoring; Hydration - no bedtime snacks being offered; Resident behavior and facility practice - Responses to complaints/concerns, accurate reporting, and documentation of incidents. Due to the abuse allegation, the Abuse Prohibition Review was triggered which required the facility to provide a minimum of 3 alleged violations since the last survey. The facility provided the only 2 alleged incidents reported. The fact that they only had 2 alleged incidents was inconsistent from the many complaints and general dissatisfaction expressed by residents, families, as well as observations/findings during survey. The survey observations found several reports of residents who got into verbal altercations with staff and residents/families expressing their dissatisfaction. Further investigation of the reports revealed the facility failed to document or demonstrate in writing what, if anything, had been done to remedy the issues/concerns. Interviews with involved staff members revealed the facility was made aware of the problems/concerns. The facility failed to show a good faith effort to resolving the problems. Refer to the following citations: F224, F226, F241, F242, F309, F353, F490, and F514. The IA responded by saying some of the concerns raised by the survey team should have been placed on the facility's Comment & Concerns Cards (CCCs). The purpose of the CCCs was to gather information from residents/families for quality improvement. The cards provided the administration insight into the residents' experiences and was used as documentation of how the facility addressed the issues. The IA further stated that some of the concerns have been very small and minor. He stated, "So do I spend half my day writing these things down? But there are things we could have." He further stated, "We do not have anything documented, because if we did we'd give it to you. We do not." The RDCS stated the facility worked to decrease falls and pressure ulcers. The Medical Director did rounds with the Wound Nurse to collaborate on skin care. The IA stated that when there were concerns brought to his attention, he would talk to family members and staff. He stated, "In terms of bigger system things in place, but how much I've been able to oversee all this...(he trailed off)...because I'm month to month." He worked with the DON on increasing admissions. A surveyor then asked if the DON was taking on the administrative and DON duties. The IA stated the DON had taken on a lot of things. The IA then said that some of the issues brought forth from the survey were new to him and not part of their QAA. He further indicated that they came up with action plans over the past week regarding communication. The IA said the facility conducted a mock QIS survey in April 2013. The survey triggered abuse. In response to the abuse allegations, the IA stated the residents who made allegations were "unable to provide a time, staff name, or specify the incident". The mock survey also triggered above the thresholds for Admission/Transfer/Discharge, Choices, Nutrition, Care Plan, and Resident Property. The facility did not create or initiate an action plan to address the issues/concerns stemming from the mock QIS survey. The RDCS discussed the facility's "dashboard" which looked at various topics such as pressure ulcers, etc. and their associated thresholds. The facility utilized a red, yellow, green light system to determine how they would manage things. In conclusion, the facility failed to demonstrate a working system to identify and address concerns/issues, resulting in noncompliance with the QAA regulation.

Based on observations, resident and staff interviews, the facility failed to maintain the dignity and respect for 15 of 24 residents. Findings include: Interviews and observations were made during both Stages 1 and 2 of the Quality Indicators Survey (QIS) and revealed a multitude of issues/concerns related to dignity and respect. 1) Interview of a Resident, R #333, on the morning of 5/21/13 revealed that a Certified Nurses Aide, CNA #7, treated the resident roughly and was rude to her. During the interview on 5/21/13, R #333 was alert and oriented to person, place, and time. The R #333 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident stated, "When I first came, I couldn't walk. I couldn't even move off the chair. The CNA was so rough, she pushed me around to make me move. I couldn't. She forced me to go to bed. She's short tempered. She complained that I was too demanding. I didn't demand anything. She's just mean and nasty." The resident further explained that this occurred every night that CNA #7 was on duty. The R #333 stated that she would use her call light to go to the bathroom and would wait long periods of time before the CNA would tend to her. The R #333 stated she was in the Day Room on the Keolamau unit one evening when she wanted to return to her room to go to bed. The resident stated the CNA #7 was sitting at the nurse's station, drinking water, and took her "sweet time". The R #333 stated she waited approximately 30 minutes before the CNA #7 got up to assist her back to her room. The R #333 stated the CNA #7 was caring for her when she stated (in Filipino), "You're a pain in the neck. Every time I come here you make more work for me". The resident was upset and stated to the surveyor, "I don't want her near me. I don't want her taking care of me anymore." The R #333 stated that she was planning on talking to someone about this. As of 5/21/13, the resident did not share these concerns with any other staff members. The resident stated the CNA #7 hadn't worked over the past 2 evenings. The R #333 reasoned that the CNA #7 was likely to return that night (5/21/13) since she had been off the past 2 nights. She stated, "I think she's coming back tonight and I refuse to let her touch me. I don't want her near me". The R #333 stated she wasn't afraid of the CNA and that she would tell her to leave her alone. The resident was able to describe what the CNA looked like: Body frame, Ethnicity, height. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/21/13 during the afternoon of 5/21/13 found R #333 had a Brief Interview for Mental Status (BIMS) score of 15/15. The resident was able to tell the surveyor where she was (facility), the city where her home was located, the reason for admission to the facility (rehabilitation), and how long she had been in the facility (7 days). Interview of the Administrator and Director of Nursing (DON) on the afternoon of 5/21/13 revealed the Administrator recently started working at the facility and had only been on the job for one week. The DON and Administrator both stated they were unaware of R #333's allegations of abuse. The DON and Administrator stated they would immediately investigate the allegations. The Administrator and DON interviewed R #333 on the afternoon of 5/21/13, during which the resident spotted the alleged perpetrator and was able to verbalize, "You stay away from me. I don't want you touching me." The Administrator and DON stated she was pointing to CNA #7. The CNA #7 was immediately suspended pending investigation. Interview of the Adminstrator, Interim Administrator, DON, Chief Nurse Executive (CNE) on the afternoon of 5/22/13 revealed they were almost done with their abuse investigation. They had to interview the alleged perpetrator, CNA #7, and a rehab therapist was writing a statement. The DON expressed her shock at the fact that CNA #7 was being accused, as the CNA was recommended by a family member for outstanding performance. The Adminstrator further expressed that the resident, "needed re-education on appropriate transfer techniques". The Administrator consulted the Physical Therapist, who informed her that the resident needed frequent reminders about proper transfer technique. The CNA #7 was interviewed by the DON on evening of 5/22/13, when the CNA denied the allegations. According to the DON, the CNA #7 was inconsistent with her stories. The facility substantiated abuse. The CNA #7 submitted a letter of resignation on the morning of 5/23/13. 2) Interview of R #333 on the morning of 5/21/13 revealed that she was admitted on [DATE] and still hadn't received a shower. Record review confirmed that R #333 did not receive a shower since her admission. The "Montly Flow Report" revealed R #333 received sponge baths on the evening and night shifts on 5/14/13; Day, evening and night shifts on 5/15/13; Day, evening and night shifts on 5/16/13; Evening and night shifts on 5/17/13; Day, evening and night shifts on 5/18/13; Day and Night shifts on 5/19/13 and 5/20/13; and Night shift on 5/21/13. Interview of the Assistant Director of Nursing, ADON, on the afternoon of 5/23/13 revealed that showers were usually given shortly after breakfast or soon after the evening shift began. Unless a resident requested, the night shift usually didn't provide showers. Their night shift was from 11 P.M. to 7 A.M. The ADON explained that sponge baths included a head to toe wipe down in bed. When asked whether the night shift provided sponge baths to residents, the ADON responded, "Yes, probably". The DON and MDS-Coordinator (MDS-C #1) were notified on the afternoon of 5/21/13 that R #333 had not received a shower since her admission. The DON stated she would look into it. On 5/22/13 at 12:45 P.M., R #333 stated she still hadn't received a shower. She stated, "I feel dirty. I want to take a shower". The resident didn't receive a shower until the late afternoon on 5/22/13, 8 days after she was admitted to the facility. The facility had a Bath List for Keolamau which indicated R #333 was supposed to receive showers on Wednesdays and Saturdays. The Bath List noted, "Please don't make any changes unless approved by (DON) or (staff nurse)". On the afternoon of 5/23/13, the ADON stated that residents had the ability to choose the frequency of their showers. If they wanted daily showers, they would try to accomodate them. 3) A Unit Clerk, #1, wheeled R #333 out to the lanai on the morning of 5/21/13 to meet with the surveyor. While being wheeled out, R #333 asked the Unit Clerk #1 if she could get a newspaper to read. The Unit Clerk #1 informed the resident that the Activities staff went over the current events with residents in the Day Room and she could get the paper after they were done with it. Interview of R #333 revealed that she was purchasing her own newspaper over the past week since she was admitted but the resident has since run out of money. The R #333 stated she had loose change in her bedside table but ran out so she now had to wait for her daughter to buy her a newspaper. Interview of the MDS-C #1 on the afternoon of 5/21/13 revealed that the resident was entitled to receiving a newspaper if she requested one. The MDS-C #1 stated the staff should have provided the R #333 with a newspaper. 4) On the morning of 5/21/13 interview of R #328 found that she was disrespected and felt her dignity was compromised. The resident explained that she previously went to the dining room for meals but stopped because of the way she was treated. The resident explained that while in the dining room, the staff would provide her with her food tray after everyone else got served. The resident stated the staff would bring the trays to persons who required assistance with eating, and uncover all their food items then walk back to the food cart to pass out the remainder trays without feeding them first. The R #328 stated she and another resident were the last to receive their trays. She stated that she asked to get served earlier but was ignored. By the time she received her tray, the hot food had already cooled off and the cold items weren't cold. The R #328 stated that she asked for toast one day and was told, "No". She stated that she didn't have any dietary restrictions that would prevent her from a liberal diet. She stated, "Now I stay in my room. I don't want to make a scene. I feel more comfortable and my TV is on." Record review for R #328 revealed a physician order [REDACTED]. Interview of the ADON on the afternoon of 5/23/13 found that residents were able to receive additional food items per their requests if within their dietary restrictions. 5) Interview of Resident, R #334, on the morning of 5/21/13 revealed she experienced long wait times for the call light to get answered. She stated that she looked at her clock and she often waited 15-20 minutes for assistance. The R #334 stated that 15-20 minutes is really long when you have to go the bathroom. The resident stated that she told the facility staff that they're slow. The R #334 told facility staff, "We paying big money. They tell us they have other patients. They take so long to come. Sometimes they're outside laughing. Sometimes you don't know what they're saying because they're talking Filipino." The R #334 stated that during the late morning one day last week they had something (ex. movies or other activity) in the Day Room on Keolamau. The R #334 and 3 other residents were waiting in the Day Room for approximately 30 minutes for the staff to take the resident back to her room. The resident observed one staff member walking back and forth. The R #334 went to the nurse's station and said something to the staff about ignoring the residents in the day room and making them wait for long periods of time. The resident stated that one resident was sleeping in the Day Room. One of the CNAs just stood there and looked at her. It wasn't in an intimidating way. Another staff member took them back to their rooms. The resident stated she often had to use her call light to assist her roommate, who was not alert and oriented. Record review for R #334 on the afternoon of 5/22/13 revealed a Brief Interview of Mental Status score of 15/15, indicating she was alert and oriented. The resident was admitted for rehabilitation and was being discharged on [DATE]. 6) During an interview with Resident #161 on 5/20/13 11:33 A.M., she stated when the staff approached her, "they don't tell who and what going to do." She said for instance, CNA #4 who came to take her to bathroom, just started to comb her hair while she was sitting on the toilet. Resident #161 also stated when she used her call light, the staff failed to answer in a timely manner, but when they did, her sense was that staff were uncaring or unfriendly and did not properly introduce themselves. Resident #161 also stated she had a problem with one of the CNAs about her showers. Cross-reference to findings at F226 and F224. 7) Observation of Resident #326 on 5/21/13 at 9:36 A.M. found the resident sitting in his wheelchair (W/C) with head in his hands. He was situated by the foot of his bed with the privacy curtain drawn. The resident declined to be interviewed, but said, "I like go home, I like go home," and teared up. It was also observed his call light was not within his reach. It was hung on an IV pole at the head of his bed. A social worker (SW) consultant passing by was asked to come see the resident and when she did, the SW failed to fully assess the resident's condition/needs when he sat there with his hands to his face, stating he wanted to go home. Instead the SW consultant told the resident that the therapist, who had walked in to talk with the resident's roommate, was going to schedule the resident's next therapy appointment. The resident acknowledged that; however, as the SW was going to leave his side, surveyor asked about his call light. The SW said, "oh yeah," saw the call light hanging on the IV pole, obtained it and told the resident she was going to clip it to his shirt. CNA #4 walked in then and the SW told her the call light had been hung on the pole and then left the room. The SW did not tell CNA #4 anything about how she found the resident. CNA #4 kneeled down next to the resident and asked him in his native dialogue, "Who put you here?" and the resident replied he did not know. CNA #4 said, "We usually don't put him here by himself." She said the resident tries to get up by himself and was not supposed to have been placed there with no call light within reach. After a few more questions, the resident said he wanted to go to bed and the CNA assisted him to bed. 8) During multiple random observations of Resident #329, the resident was found dressed in a white tee shirt and blue adult briefs. On 5/24/13 at 8:28 A.M., the resident was observed from the doorway laying in bed wearing blue adult briefs and a white tee shirt. The resident's right hand was in his brief and did not have a blanket or sheet covering him. The resident was in full public view from the doorway. Interview with CNA #6 revealed the therapist had just finished working with the resident. CNA #6 said, "oh no, he no like sheet." Surveyor explained the resident was visible to the public, but then CNA #6 opened up the folded white bedsheet and immediately covered him and said, "Someone maybe don't like," and drew the privacy curtain around the bed. At 9:00 A.M., therapist #2 said CNA #6 told him he did not cover the resident after working with him. Therapist #2 acknowledged with the resident being in blue adult briefs and visible to public view was not dignified. He was asked if there were shorts that the resident could wear, and he said, "Oh yeah." However, in the afternoon, the resident still had the blue adult briefs and his thighs and legs were fully exposed. He did not have any shorts or other type of undergarment to cover the adult blue briefs. 9) Cross Reference to F353. Interview with residents during the survey found residents' reporting that they did not receive the assistance they require for toileting and managing pain. A) Interview with Resident #172 was done on 5/21/13 at 9:50 A.M. The resident reported that there has been times when she uses the call light for assistance to use the restroom and will have to wait a long time for assistance. Inquired how long she has to wait, the resident responded sometimes an hour or she has to wait so long that she forgets what kind of assistance she needs. She also reported that sometimes she waits so long that she loses the urge to use the toilet. The resident also shared that the staff will tell her that its okay if she wets the bed/urinate in her personal brief; however, the resident stated that after 3 to 4 times it gets uncomfortable. Record review done on 5/24/13 at 2:00 P.M. found an "Initial Data Collection Tool/Nursing Service" dated 12/19/12 documenting the resident is continent of bowel and bladder and occasionally incontinent. Review of the quarterly Minimum Data Set with assessment reference date notes the resident is frequently incontinent of urine and always continent of bowel. Resident #172 requires extensive assistance with one person physical assist for toileting and is not steady and only able to stabilize with staff assistance for moving on and off the toilet. B) Resident #44 was interviewed on the morning of 5/21/13. When asked whether the staff treats him with respect and dignity, he replied no. He reported that there is not enough staff available to assist him when he wants to use the toilet and he has to yell for help. Review of the resident's annual MDS with assessment reference date of 1/21/13 notes he requires extensive assistance with one person physical assist to use the toilet. The resident was also noted to be always incontinent of urine and frequently incontinent of bowel. The subsequent quarterly evaluation with assessment reference date of 4/8/13 notes the resident is always incontinent of urine and bowel. Resident #44 scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). C) Resident #292 was interviewed on 5/21/13 at 10:15 A.M. The resident reported that when his legs are sore and he asks for help, the staff doesn't come right away. He stated he is told "there's plenty patients beside me, so they come when they get a break. They say, yeah, yeah we coming, we coming. But when they say they gonna come back, by the time they come, I'm suffering already." On 5/22/13 at 10:30 A.M., Resident #292 reported that he sometimes has to wait for medicine a long time and he gets mad when staff tell him they will be right back and two hours later they come back. He shared that he has burning and needs help to reposition himself or no longer wants to sit and staff tell him to take a deep breath. The resident commented that this is "bull[***]. While interviewing the resident, the resident's wife arrived and requested to add her comments to the interview. The resident's wife reported that although her husband presses the "red button" nobody comes, it takes a very long time. The resident's wife also reported that her husband had to ring the call light for his roommate when he fell . D) During resident interview done on 5/21/13 at 8:00 A.M., Resident #162 responded that she has to wait a long time for staff to receive care and assistance that she needs. The resident clarified that sometimes she has to wait so long for staff to assist her with toileting that she will "pee" in her pampers. Record review found a quarterly MDS with assessment reference date of 3/11/13 noting Resident #162 scored a 13 (cognitively intact) on the BIMS. She was noted to require extensive assist with two plus person physical assist for toileting. She was also noted to be occasionally incontinent of urine and frequently incontinent of bowel. E) During interview with Resident #135 on 5/20/13 at 11:00 A.M. the resident reported that she sometimes has to wait two hours for assistance. She reported that at night it is really bad and the facility is short of staff and the people out there don't want to work and say they are very busy. Resident #135 reported that her bed gets wet. Record review done on the afternoon of 5/24/13 found an annual MDS with assessment reference date of 4/2/13 documenting the resident scored a 15 (cognitively intact) on the BIMS. Resident #135 requires extensive assist with one person physical assist to use the toilet. She was also noted to be frequently incontinent of urine and always incontinent of bowel. 10) On 5/21/13 at 7:30 A.M. observed Residents #12, #186 and #162 seated on their unit with bath towels wrapped around their upper body, covering their chest and back. Interview with Resident #162 found that she wears the towel because she is cold. Inquired whether she has a sweater, she responded that she has a sweater; however, it is in the laundry. Observation on 5/22/13 during breakfast found the three residents having breakfast in the dining room with the bath towels wrapped around their upper body. On the morning of 5/28/13 Licensed Nurse #5 was asked why the residents have towels draped on their upper body. LN #5 replied it is because they are cold. Inquired whether these residents have sweaters. The licensed nurse responded that they have sweaters and would look into why they are not wearing their sweaters. 11) On 05/21/13 at 8:04 AM during Stage 1 of the survey, R#165 was interviewed. When asked the QIS question, "Has staff yelled or been rude to you?" The resident answered, "Yes." The resident further elaborated that staff are impolite sometimes, and that he/she felt hurt when staff said, "This is your medicine, you supposed to take it." The resident stated that he/she is educated and not a moron that doesn't know things. Med record review on 5/22/13 at 8:45 AM revealed that R#165 was admitted to the facility on [DATE] for a short-term course of physical and occupational therapy, to improve functional status. The resident's previous lifetime career was in insurance sales. R#165 was prescribed an anti-depressant with behavior monitoring for, "sad mood," and "sad face, " and in the Month of May 2013, a "0" was written each day to document that the resident did not display signs and symptoms of depression. On 05/22/13 a facility, "Concern and Comment, " card was completed by LN#3, due to R#165 becoming upset that LN#3 wanted to provide insulin by subcutaneous injection while he/she was eating breakfast. The outcome of the facility investigation concluded that LN#3 would no longer provide services to R#165, as resident requested, ("He does not understand me."); and, LN#3 was provided education on appropriate treatment times. 12) On 5/21/2013 at 8:00 AM during Stage 1 of the survey, interviewed R#327 for QIS interview. The resident stated that the staff cleans his/her dentures daily, but not if he/she was to ask as needed. The resident related that on 05/20/13 in the evening, he/she wanted to rinse dentures in the bathroom sink, and requested assistance from the CNA that delivered the dinner tray. The CNA's reply to R#327 was that he/she was too busy with the dinner meal service. The resident resorted to rinsing his/her dentures in hot miso soup that was on the dinner tray and gargled with water to rinse. The resident stated that had to do whatever could be done for him/her self; because "There are a lot of, ' Schwarzenegger ' s, ' that work here." When asked to clarify, R#327 stated that whenever he/she requests help from staff their reply is, "I'll be back." The resident was a quadriplegic and admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R#327 required extensive assistance for all activities of daily living, (ADL), due to generalized weakness. The resident's May 2013 monthly flow sheet for daily care documented under the "Dentures Cleaned," section, that there were no check marks between and on the days of 5/18-20/2013.

The facility failed to provide sufficient nursing staff based on the staff's inability to provide needed care to residents that enable them to reach their highest practicable physical, mental and psychosocial well-being. The survey was extended due to substandard quality of care. Findings include: Cross to F 224 Based on observation, record review, resident, family and staff interviews, and a review of the facility's policy and procedure, there was a failure to provide services necessary to avoid mental anguish and a potential for a decline in health status for 1 of 32 residents included in the Stage 2 sample. Cross to F 226 Based on interview with staff and review of facility's documents, the facility failed to implement policies and procedure to identify, investigate and report allegations of mistreatment, neglect, and abuse of residents and misappropriation of resident property. Cross to F 241 Based on observations, resident and staff interviews, the facility failed to maintain the dignity and respect for 16 of 24 residents. Cross to F 242 Based on resident interviews, record reviews, and staff interviews, the facility failed to provide 5 of 40 residents the ability to choose their preferred shower schedules. Cross to F 280 Based on observations, record reviews, and interviews, the facility failed to ensure the residents' care plans were revised and/or updated to reflect the residents' current status for 2 of 32 residents (Residents #292 and #329) in the Stage 2 sample. Cross to F281 Based on observations, record review, staff interview and review of the facility's policies and procedures, the facility failed to ensure professional nursing standards of practice were followed for 4 of 32 residents in the Stage 2 sample. Cross to F 309 Based on observations, resident and staff interviews, and medical record reviews, the facility failed to ensure that 2 of 32 residents in the Stage 2 survey sample, (R#152 and R#161), received the necessary care and services to help these residents attain or maintain the highest practicable level of well-being by preventing or managing pain. Also for R #152, the facility failed in managing the interchange of [MEDICAL TREATMENT] information. Cross to F 312 Based on observation, interviews with family members, residents and staff members, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 3 of 3 residents sampled for ADL care. Cross to F 314 Based on record review and interview with staff members, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that it was unavoidable for 1 of 2 sampled residents of the 32 residents who were included in the Stage 2 sample. Cross to F 322 Based on observation, record review, staff interview and review of the facility's nursing standard of practice, the facility failed to ensure labeling of the enteral nutrition (EN) formula was complete and accurate for 1 sampled resident who received tube feedings (TF) of the 32 residents in the Stage 2 sample. Cross to F 329 Based on record review and intervview with staff members, the facility failed to ensure 1 of 10 sampled residents drug regimen was adequately monitored. Cross to F 368 Based on observation and interviews, the facility failed to ensure that snacks were offered to residents at bedtime daily for 1 of 32 residents in the Stage 2 sample. Cross to F 441 Based on observation, record review and interviews, the facility failed to ensure a safe, sanitary environment to help prevent the development and transmission of disease and infection, and failed to conduct data analysis toward detecting unusual or unexpected outcomes to determine the effectiveness of infection prevention and control (IC) practices. Cross to F 514 Based on record review and interviews, the facility did not ensure clinical records were maintained on each resident that were accurate and complete, in accordance with accepted professional standards and practices, including the facility's own policies and procedures.

Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to effectively maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: The survey team determined the facility was providing substandard quality of care and actual harm. An extended survey was initiated. During entrance conference on the morning of 5/20/13 the survey team determined that the Administrator was new to the position, with her just starting work at the facility the week before, 5/13/13. The facility was under the direction of the Interim Administrator (IA) over the past 10 months. The Director of Nursing (DON) was responsible for the Quality Assessment and Assurance (QAA) in addition to her other responsibilities. 5/22/13 INTERVIEW WITH KEY PERSONNEL: During an interview with key personnel: IA, Administrator, DON, and 2 Medical Directors on 5/22/13 at approximately 3:30 P.M., the IA explained that he was not involved in the QAA process since he was only temporary. He explained that he coincidently "went home" to another State when the QAA meetings were scheduled. He stated that he missed all but 2 QAA meetings. Interview of the DON revealed that she was left to manage all nursing staff and perform administrative duties and activities, including QAA meetings. On 5/22/13, the IA explained that the facility conducted a mock Quality Indicators Survey (QIS). Their mock survey results found many areas above the acceptable threshold. The areas which scored above the threshold included: Abuse, Admission/Transfer/Discharge, Choices, Nutrition, Care Plan, and Resident Property. When asked what the facility did with the survey information, the staff were unable to discuss interventions/plans to modify/improve the facility practices. When questioned about interventions for the Abuse (since threshold is 0%), the IA stated the residents were unable to give "a specific date, time, or staff name". The facility concluded it's abuse investigation based on the fact that the residents were unable to provide more information. A root-cause analysis was not discussed regarding the mock survey results. The facility provided the survey team with a copy of the mock survey findings. Attached to the survey findings were 4 of the inconclusive abuse interviews of the residents. One resident's response noted that staff weren't rough but "rowdy". When asked what "rowdy" meant, the resident responded that one staff member did things "loudly and slammed doors". The staff asked that resident if he had been injured, to which the resident replied, "No, I did not break any bone or hurt my muscle". No further intervention was was provided. During the interview with the key staff on 5/22/13, the IA stated they provide a "Circle of Service", which provided residents with a mentor or coach who would provide one-on-one attention for the first 72 hours following admission. The Circle of Service provided staff with the ability to maintain contact with the resident and provided the facility with an understanding the residents' "experience". After 72 hours, the facility followed up with the residents' needs during the Care Plan meeting 14 days following admission. The facility had no procedural ways to monitor a resident's adjustment to the facility. They typically had the Social Worker do an assessment followed by monitoring by 2 contracted Social Workers. The IA explained that the Director of Social Services had 2 Social Services Designees (SSD), 1 full time and 1 part time. The full time SSD walked out on the Director followed by the part time SSD. The SS Director resigned last week. The facility was in the process of hiring an SSD, who would start the following week. Please reference the following citations for more details: F224 F241 F353 F493 F520

Based on observations, resident interviews, and staff interviews, the facility failed to designate a Nursing Home Administrator (NHA) to establish and implement policies to manage and operate the facility. Findings include: On the afternoon of 5/28/13, the current NHA stated he was the "Interim Administrator" (IA). He stated his position was temporary and "month to month". The IA further determined that he really didn't want to "dig my heels into anything big", and explained that he wouldn't be able to complete any projects. The Regional Director of Clinical Services, RDCS, indicated she was unaware the IA was on a month to month assignment. The IA further explained that the administrative oversight came from the Regional Executive Director, RED, who was located on another island and was not on sight daily. The IA stated the RED made visits to the facility weekly. The IA and the newly appointed Administrator were both licensed in other States and not with the State of Hawaii. Cross reference to: F241 F353 F490 F520

Based on observation, record review, resident, family and staff interviews, and a review of the facility's policy and procedure, there was a failure to provide services necessary to avoid mental anguish and a potential for a decline in health status for 1 of 32 residents included in the Stage 2 sample. Findings include: Cross-reference to additional and related findings at F226, F241, F242, F309, F312 and F323. During an interview with Resident #161 on 5/20/13 at 10:55 A.M., the resident stated she felt afraid because of the way she and/or other residents were treated. The resident conversed both in Japanese and English and said she was admitted to the facility for short term rehabilitation following a surgical procedure. She said, "I have asthma" and that there was an incident with her breathing which made her fearful and afraid since. The resident said one night she had chest pain/discomfort and could not breathe good. The night nurse just gave her some pain medication and told her, "Good night, you can go sleep" and never came back to check on her. The resident said her chest felt painful, but said it was because of the asthma. She said in Japanese, "Tasukete, iki dekinai kara" or "Help me, because I cannot breathe" and said she had to plead to a male nurse aide who came into the room. She told him, "I need inhaler, something, I cannot takey my breath." She said the pain killer did not do anything because it was not the problem. She felt the nurse just wanted her to sleep. The resident said, "How can be a nurse?" and shook her head during the interview. The resident also said the male aide did tell the nurse and only then did that nurse return after 35-45 mins later to give her a breathing treatment. The resident said she felt "really, really afraid" because she could not breathe. The resident also stated during the interview that some staff have "no feeling" towards her. She said at night after toileting, when she has to lay back down, the staff do not assist or help her back to bed. She said they just leave her at the bedside and it was mostly the female staff. The resident said there were some staff who cared, but others were not and rude in their manners. She said her roommate was a new admission and about 4-5 nights ago around 3:00 A.M., her roommate started crying out for help. She said they both used their call lights, but the staff who came into the room said, "Wow, wow!" The resident said she told the staff her roommate needed help, but was told, "No, she's okay," although her roommate could not sleep. The resident said she felt sorry for her and because she was also coughing, she called the nurse again. She asked the nurse if she could give her neighbor something for the cough, and this made her think how bad it was when the staff did not seem to care. She said, "patient so new--they don't even take care. I cannot sleep too--I worry for her, but cannot speak to her (language barrier)." In addition, the resident said even though her family member meets with the staff about the issues related to her care, the communication was not good and did not feel clear answers were being provided. She stated she did not even know how she was doing with her illness and felt saddened by it. She stated, "I just likey go home already" and dabbed her eyes with tissue. Clinical record review on 5/22/13 found the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 14 day MDS assessment with an ARD of 5/8/13 noted her BIMS was not done in Section C, but Section B coded the resident as having clear speech, made self understood, able to usually understand and had adequate vision. The resident was also capable of hearing and responded appropriately to surveyor's questions during the 5/20/13 interview with her. On 5/24/13 at 2:10 P.M., during an interview with the resident's family member, the family member stated one problem was the Administration. He/she stated, "there's no communication--it's the little things that's not being reported. There's no communication." The family member also gave an example regarding a shower incident involving the resident and said, "(resident) didn't even have a chance to clean up well after the shampoo was dumped on her head. Another instance the aide didn't wipe her down well. And the staff says to her, 'I'm doing my best!' in a heightened tone of voice. Different nurses come in and say what can she do? What?! So, they don't even know her level of care? It's just the communication, lots of improvement needed. And a lot of staff are rude, grouchy, but this is their job, their profession they chose. It shouldn't be like this."

Based on observation, resident and staff interviews, and facility policy review, the facility failed to have sufficient nursing staff to provide nursing and related services to maintain or attain the highest practicable physical, mental and psychosocial well-being of each resident. Findings include: 1) Cross reference to F241 for details. 2) Cross reference to F311 Items #1 and #5 for details. 3) Cross reference to F323 Item #1 for details.

Based on observation, interviews, record reviews, and policy review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 4 (Resident #4, #6, #22, #23) of 23 residents in the case sample and 4 additional residents (Random Sample Resident (RSR) #3, RSR #4, RSR #5, RSR #6). Findings include: 1) Review of the facility's incident report submitted to the SA on 11/10/10 and record review was done for Resident #4 of the case sample on 12/28/10. The report noted that Resident #4 was found on the floor near the bathroom door on left side lying position on 11/09/10 by RN staff walking in the hallway at 5:35 p.m. RN staff immediately assisted resident. When RN staff inquired what happened, Resident #4 replied, "Going to the bathroom." Resident also stated that (s)he forgot to call for assistance. A fall assessement of Resident #4 noted resident complaint of left hip pain with guarding, facial grimacing and moaning. M.D. was notified and ordered X-ray to left hip stat. X-ray impression reported an oblique fracture of the left superior pubic ramus. Resident #4 also sustained a bruise to the left upper lip with slight swelling due to the fall. Resident #4 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Resident #4 was provided comfort care with weekly hospice services provided by a contracted hospice agency. Upon admission resident required assistance with activities of daily living (ADL) and transfers. Resident #4 was admitted to the facility on pain medications that included: MS Contin (Morphine) 60 mg every 12 hours and MS IR 15 mg every 4 hours as needed for pain. The care plan developed upon admission included: monitor resident every 2 hours and as needed; provide safe environment; and keep bed at lowest position. Facilities post-fall interventions included placing fall alarm to wheelchair, pressure bed alarm kept on at all times, 1/2 partial rails for security, and gentle transfer. The physician increased Resident #4's pain medications on the day of fall to: MS Contin 60 mg three times a day and MS IR from 15 mg to 30 mg every 4 hours as needed for pain. During interview of Resident #4 on 12/28/10 at 8:45 a.m., resident stated that (s)he fell down on 11/09/10 because (s)he tried to grip the bathroom door knob but it was slippery and (s)he could not hold on to prevent from falling. Resident #4 complained that when he/she requested assistance there was a long wait time, and preferred using the toilet when possible. Record review of Resident #4's complaints were documented in the social work progress notes dated 12/09/10 and 12/23/10. In the hospice volunteer clinical notes dated 12/19/10, resident cried that a person was rough with her. The facility did not keep Resident #4 safe, as there was no documentation of monitoring resident every 2 hours or as needed according to the care plan. Post-fall social work progress notes documented Resident #4 reporting that (s)he was unable to receive assistance as needed. 2) Record review of Resident #6 of the active case sample was done on 12/28/10. Late documentation on 11/24/10 in nursing notes, documented that Resident #6 fell three times on the same day, 11/23/10. Resident #6 was found lying on his/her left side on the resident's room floor at 5:45 p.m. on 11/23/10. Resident #6 was assessed and there were no fractures and/or skin tears. An hour later at 6:45 p.m. Resident #6 was found kneeling on the ground, and nursing notes documented no injuries or pain. Resident #6 was complaining of having wet underwear and was placed back to bed for change. Although nursing notes on 11/24/10 documented that Resident #6 fell 3 times there were only 2 falls described. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Admission Minimum Data Set (MDS) with assessment reference date (ARD) of 12/09/10 indicated the resident required 1-2 person assist for transfer and ambulation due to abnormal gait and no strength. Resident had noted bruises on knees with skin tears on toes and left forearm. The Fall History of the MDS with ARD of 12/09/10 indicated no history of falls, but the hospital transfer document noted that the resident fell at home prior to hospitalization and transferred to the facility. Based on the MDS the facility failed to include high-risk for falls in Resident #6's care plan. After the first fall, the facility failed to determine the risks and hazards to prevent further injury. (S)he fell a second time and no change was documented in the nurses notes nor the care plan. After the 3rd fall occurred on 11/23/10 sometime after 6:45 P.M. the facility then documented in the nurses notes that Resident #6 was placed in a wheelchair with a lap buddy in front of the nurses station. 3) Review of facility's incident report submitted to the SA on 8/30/10 and concurrent closed record review was done for Random Sample Resident #3 on 12/29/10. The report indicated that on 8/28/10 at 9:30 P.M., the resident returned to her room after visiting with someone out on the lanai. "At 9:45 P.M. the resident was given her routine medications. At 10:05 P.M., the resident was found on the floor in left lying position. Her left leg was extended and (right) leg flexed. Resident stated she stood up to close her curtains because she wanted to go to sleep. States that she lost her balance and fell . The resident was unable to lift her left leg and complained of pain to that side". The resident was sent to the hospital for evaluation and x-ray noted "minimally distracted fracture of the intertrochanteric region of the left femur". Resident discharged from facility on 8/28/10. Record review noted the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission Minimum Data Set with assessment reference date of 8/27/10 indicated the resident was independent in cognitive skills of daily decision making; required extensive assistance with activities of daily living skills. Review of the form titled "Fall Risk Evaluation" documented a total score of 10 on 8/21; scored 11 on 8/23 and a score of 14 on 8/28/10. "A resident who scores a 10 or higher is at risk" for falls. Review of nurse's notes dated 8/23/10 at 12.23 P.M. found entry "Witnessed fall with pt in room while sitting up at EOB. Pt slid to floor on (R) side of bed". Entry dated 8/28/10 10:55 P.M. "Resident found on the floor in back lying position crying with left hand holding the left hip and (R) hand holding her head with (R) leg flexed @ an angle. Resident not able to move her leg". Review of "Resident Care Plan" dated 8/21/10 "At risk for fall related to poor mobility, poor balance, unsteady gait". Care plan updated following fall on 8/23/10 noted approaches included "falling star program, and fall alarm on". Further review of the record and the facility's "Incident Follow-Up & Recommendation Form" for incident dated 8/28/10 could not find documentation that the fall alarm was in place while the resident was in the wheelchair. There was no indication that the call light was within reach. Interview with the Director of Nursing (DON) on 12/30/10 at 7:15 A.M. and concurrent record review revealed that the resident was in the wheelchair at the time of the fall and there was no indication that the fall alarm was in place. The DON stated that the resident was noncompliant with safety, however, that was not indicated on the care plan. 4) Review of the facility's incident report submitted to the SA on 9/8/10 and concurrent closed record review was done for Random Sample Resident #4 on 12/29/10. The report noted that on 9/5/10 at 5:35 A.M., CNA heard a fall alarm ringing in resident's room and found resident on the floor in a (R) side lying position. Resident reported that she wanted to use the bathroom. Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] following a fall and complaints of left leg pain. Admission Minimum Data Set (MDS) with assessment reference date of 8/13/10 noted the resident was coded as independent in cognitive skills of daily decision making; required extensive assistance with activities of daily living skills. The MDS coded the resident as continent of bowel and usually continent of bladder. Review of the "Fall Risk Evaluation" form documented a total score of 7 on 8/6/10; scored 14 on 8/15/10 and a score of 16 on 9/5/10. "A resident who scores a 10 or higher is at risk" for falls. Review of nurse's notes dated 8/15/10 at 8:30 A.M. found entry "Resident s/p unwitnessed fall @ 3:30 A.M. Resident found sitting on the floor by the bathroom door. No injuries noted". Entry in nurse's notes dated 9/5/10 at 8:30 A.M. documented "At 5:35 A.M. (CNA) heard fall alarm ringing and found resident in a (R) sided lying position on the floor of pt's room to the left side of the bed". Per resident "I wanted to go use bathroom". The resident was incontinent of stool and provided peri-care by staff. Review of care plan dated 8/6/10 "At risk for actual/repeat falls due to history of falls at home prior to admission, episodes of dizziness, syncopal episode, TIA, adverse effects/side effects of (medication), cognition problem, seizure, dementia. Actual fall noted 8/16/10, 9/5/10". There was no documentation of care plan update following the actual falls. Interview with the DON on 12/30/10 at 7:15 A.M. and concurrent record review confirmed there was no documentation to indicate when the care plan was updated. There was no indication the call light was within reach for resident to call for assistance. The resident did not have the hip protector as indicated on the care plan. Review of the facility's "Falls Management" policy stated "An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions". 5) Review of complaint submitted to the SA on 2/22/10 and concurrent closed record review was done for Resident #22 of the active case sample on 12/29/10. The complaint alleged that the resident had fallen 5 times since his/her first admission to the facility (1st admitted [DATE]). Record review of the most recent readmission date of [DATE] (Resident was discharged [DATE] to a hospital and readmitted on [DATE]) revealed that the resident had multiple falls noted on the care plan - 1/7/10, 1/8/10, 1/18/10, 2/11/10, 2/13/10, and 2/15/10. The care plan was revised once on 1/7/10 and stated "Bed place near the nurse's station for closer monitoring." Closed record review for Resident #22 stated the following admitting diagnoses(1/4/10): Major depressive disorder, acute renal insurfficiency, altered mental status, hypertension, neuropathy, anorexia, diabetes mellitus, and peripheral vascular disease. The facility failed to keep Resident #22 safe by not identifying, evaluating, implementing interventions, and monitoring the effectiveness and modifying interventions for the hazards and risks. The facility was aware of Resident #22's frequent falls history as evidenced by documentation in the record and the care plan. The facility was aware that the resident was able to remove his/her fall alarm but made no changes to the plan of care. 6) Review of the facility's incident report submitted to the SA on 4/10/10 and concurrent closed record review was done for Resident #23 of the case sample on 12/29/10. The report noted that Resident #23 was in rehabilitation therapy when (s)he complained of pain to his/her left ankle. Resident's spouse then informed the facility that before therapy, resident's spouse had assisted the resident to the toilet without staff assistance. When the resident was transferring from the toilet to the wheelchair, (s)he lost his/her balance and his/her left ankle was in a twisted position while his/her knees were bent as in a squatting position. Resident's spouse did not inform the staff until the resident was in therapy and complained of pain. The resident had an x-ray done on 4/11/10 which revealed, "1) Slight irregularity at the tip of the medial and lateral malleoli which could be post-traumatic and small chip fracture fragments are not excluded otherwise there is no evidence of acute bony injury; and 2) Soft tissue swelling more marked medially." Closed record review revealed the resident was admitted to the facility on [DATE]. Upon admission, the facility created a care plan dated 3/23/10 and was titled, "At risk for actual/repeat falls due to history of falls; Adverse effects/side effects of meds (currently on Lexapro); Contributing factors include [DIAGNOSES REDACTED]." Actual falls documented on this care plan were noted on 4/10/10, 5/16/10, and 6/10/10. The care plan was revised on 4/12/10 with, "Encouraged and reminded resident and (spouse) to call for assistance when needed. Refer to rehab as needed for further caregiver training for resident's spouse if appropriate." The PT note dated 3/31/10 under "Evidence of Skilled Service: The patient's condition is such that the skills of a therapist are required to safely render treatment due to left neglect impacting the safety of ambulation and increasing the burden of care. Caregiver training for safe ambulation and transfers as required in discharge location. Therapist skills needed to adjust techniques to facilitate progress toward patient goals." Under the section "Caregiver education: Educated pt on the importance of working with and initiating movement of left side of body to increase muscle recruitment." The Nurse's notes revealed that resident's spouse was at resident's bedside on a daily basis. Resident #23's spouse also transported the resident to and from dialysis three times per week. There was no documentation of education for resident's spouse to assist with transfers/ADLs. The facility did not keep Resident #23 safe by providing appropriate and adequate caregiver education on proper transfer techniques. The facility did not provide adequate supervision/assistance with ADLs. The facility failed to update/revise the resident's Falls care plan. Subsequently, the resident experienced multiple episodes of falls on 4/10/10, 5/16/10, and 6/10/10. Review of the facility's "Falls Management" policy on 12/29/10 stated "An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions". 7) A review of the facility's self reported incident reports submitted on 8/25/10 and 9/14/10 to the SA, as well as the closed record review for Random Sample Resident (RSR) #5, was completed on 12/30/10. The completed incident report noted that on 8/15/10 at 10:30 A.M., the resident was "found on the floor in a sitting position by the foot part of the bed with left leg flexed, left arm holding onto the bed with FWW (front wheeled walker) flipped over on the floor near the resident." The report stated that the resident indicated that (s)he was trying to change the TV channel but the TV's remote was not working. "On assessment resident noted with skin tears to the left arm and left shin with bruising noted." The resident initially denied pain but later complained of generalized pain, and was medicated as ordered for pain. The facility replaced the resident's TV remote control. Physical therapy staff screened and evaluated resident after the fall and "no changes in ROM (range of motion) or strength noted." The incident report noted that on 8/21/10 the resident "complained of severe body pain and was yelling out because of pain." The resident insisted on going to the hospital because (s)he couldn't tolerate the pain and was transferred to a local hospital emergency room . The CT Pelvis (CT KUB) done on 8/21/10, compared to the CT KUB on August 13, 2010, revealed a "new fracture at the left inferior pubic ramus." The resident returned back to the facility in the evening with orders for pain medication as needed. Closed record review noted "9/1/10 actual fall" in the care plan and also a fall on 9/13/10. The incident report for the fall on 9/13/10 was received by the SA on 9/14/10. The incident report and the closed record review noted at 1:25 A.M. the "resident was found on the floor in a lying position in the BR (bathroom) by the toilet, (R) hand holding onto the grab bar, head not touching the floor, both legs flexed. Per resident, (s)he tried to go to toilet to urinate but lost (his/her) balance, FWW found on the floor beside the resident." The resident sustained [REDACTED]. Physician was contacted and ordered a (L) hip X-ray in the morning. The resident was medicated for pain as ordered. X-ray done at 7:30 A.M. revealed "relatively non-displaced intertrochanteric fracture of left femur." The physician was notifed and ordered to have the resident transferred to a local hospital emergency room . Closed record review and staff interview on 12/30/10 revealed that prior to the fall on 9/1/10, RSR #5 was "alert and verbally responsive, oriented (times) 3; resident requires assistance on ADLs and transfer; resident on continuous (oxygen) therapy... Resident seen by staff ambulating in her room and hallway on several occasions without calling for assistance and resident also seen and reported going to the (bathroom) on her own. Staff continuously encouraged and reminded resident to call for assistance when needed and to use the call light; resident aware on how to use call light, at times resident uses call light when (s)he wants (his/her) pain medication;... resident able to turn off bed alarm; staff seen bed alarm in the bedside drawers, staff placed pressure alarm/bed sensor alarm back on resident's bed; resident refuses to keep pressure alarm on, per resident, "It drives me crazy."... per CNA's, resident able to remove fall guards/hip protectors... the resident said, "It's too hard."... "Resident still not compliant in calling for assistance and keeping fall alarm on and wearing hip protectors at all times - despite staff continuous encouragement and reminders." Staff interview on 12/30/10 noted that RSR #5 needed a "lot of balance retraining." The resident understood his/her limitations but "still wanted to be mobile." The resident was receiving physical and occupational therapy. The facility tried different alarm systems but the resident was able to disarm the alarms. When the resident returned to the facility after surgery, the facility provided "1 to 1 sitter" for RSR #5 upon readmission. The facility failed to keep RSR #5 safe knowing that the resident was able to disarm the alarm systems and ambulate without staff assistance. The facility was aware of the resident's behavior of getting out of bed without assistance and the resident's previous history of falls, yet the facility was not able to keep the resident safe and free of accidents by implementing interventions including adequate supervision to reduce the risk of falls/injury as well as monitoring the effectiveness of the interventions. 8) On the afternoon of 12/29/10 and morning of 12/30/10 review of the incident report for random sample resident (RSR) #6 revealed the resident sustained [REDACTED].M. The report noted "nurse heard a fall alarm ringing. When another resident screamed, (RSR #6) stood up from (his/her) bed and found on the floor lying on (his/her) right side with legs extended." "Resident stated that ((s)he) wanted to get up & brush (his/her) teeth. Resident's bed was placed near the (Wailani Unit) nurses station for close monitoring." "Nurse was on the phone @ (at) the nurses' station when she (nurse) heard the fall alarm and a resident scream, when nurse looked up, resident was already on the floor. Resident assisted to bed and assessed." a. A review of the 9/16/10 x-ray results revealed "IMPRESSION: 1. Fracture of the base of the neck of the femur with medial angulation of the distal fragment. 2. Patellar spurs present." b. RSR #6's care plan was reviewed on the morning of 12/30/10 noted the "Problem Onset 8/26/10 (also admitted )" for "risk for actual/repeat falls due to: history of fall." The Problem/Need column noted "Cognition problem Alzheimer's Disease, dementia. Contributing factors include [DIAGNOSES REDACTED]...8/31 Actual Fall." In the column of "Approaches...provide diversional activities to minimize the potential for falls such as TV, snacks, and music...Assist with transfer and position..." "Approaches dated 8/31 frequent visual checks, fall alarm in place when in bed...at all times...place resident on falling star program...bed outside nurses station at HS (bedtime) for close monitor." c. Review of the 9/15/10 8:50 P.M. Nurse's Notes revealed "Resident found on the ground lying to (his/her) right side with both legs straight by RN staff-Resident states "((s)he want to brush her teeth...Addendum-Resident found on the ground near (his/her) bed at the nurses station." There was no documentation in the record as to how the frequent visual checks were being monitored, how and whether the resident was being monitored when the nurse was on the telephone since the bed was located at the nurses station, or if diversional activities were encouraged/implemented before the fall. Interview with the Falls Committee which consisted of the Administrator, the DON, and the Rehab Manager on 12/29/10 revealed that the team met weekly and were involved with all falls. The Administrator stated that he implemented a "Proactive Fall Risk Assessment" which was started on 5/12/10. The Administrator stated that he had become very involved in all falls occurring in the facility and he was committed to increasing patient safety. The facility's goal was to reach a 10% (census) threshhold, which would be approximately 11 falls per month or less. The Administrator stated that the facility was able to reach the threshhold in October 2010 when they had a total of 11 falls. The DON was responsible for determining which steps to take based on what was already in place. The Rehab Manager was responsible for determining which devices to use/try. The DON would collaborate with the Rehab Manager and Administrator in determining causes, risks, and the need for staff training.