Every finding on record at Kauai Care Center

Based on interviews, document and record review, the facility failed to provide and document sufficient preparation to ensure that one Resident (R)1 of a sample size of three had the resources and support to meet his needs when discharged to the community. R1 had a Provider order for 24 hour supervision, but was discharged with a Private Hire (PH) two hours a day. There was lack of evidence that R1 was informed of the need for more supervision, or that the risks of refusing ordered services were discussed and understood. The post-discharge plan did not address resident limitations in ability to care for himself, which increased the risk of complications, and readmission to the hospital. This deficient practice could affect all Resident's being discharged to the community. Findings Include:1) On 10/15/25, the Office of Health Care Assurance received a concern that R1: 1) lived alone and did not have a caregiver, 2) due to physical or mental impairment, or both, could not perform essential tasks to care for himself, 3) had difficulty standing and frequent falls, 4) did not remember how to use his alert alarm, 5) had spoiled food in the apartment, and 6) had food and feces on the floor. R1 was an [AGE] year-old male admitted to the facility on [DATE] for medical management and rehabilitation after a stroke. His medical history included but not limited to encephalopathy (conditions that cause brain dysfunction, leading to symptoms such as confusion, and memory loss), muscle weakness, abnormalities of gait and mobility, Type 2 Diabetes Mellitus on insulin, non-pressure chronic ulcers of both heels, and hypertension. While at the facility, R1 had incontinence of bladder/bowel and wore disposable briefs. Prior to the stroke, he lived alone, was independent, had a Care Coordinator (CC) in the community assigned by his insurance company. He had been receiving meals on wheels, transportation and had a life alert system to call for help in an emergency. R1 had a neighbor who assisted with groceries, and a friend (F)1 who helped clean the house. He did not have a Power of Attorney. 2) Reviewed the Interdisciplinary Care Conference-V7 record for R1 dated 09/18/25, which included: D. Nursing Summary .Discharge home with family. G. Social Services Summary. A&OX2 (oriented to self and place), usually able to make needs know and understand others.He live alone.has community services and health coordinator .Return home with established services ., HH: PT/OT/NRSG (Home Health: Physical Therapy//Occupational Therapy/Nursing). I. Therapy and Restorative Care Summary (documented by MDS Coordinator) .Discharge home with family L. Discharge Planning .Lives alone.Private hire, .health coordinator (CC) will coord. This section documented that R1 had family, or a support network to provide assistance post discharge, and that that the primary caregiver was Wife. The discharge plan intervention checked was Evaluate and discuss with resident/family/caregiver the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum independence. This Care Conference was inconsistent and inaccurate. R1 did not have a family or wife, and the PH was arranged by the facility. There was lack of evidence that the facility had a discussion of the prognosis of independent living with minimal supervision, R1's limitations or that he fully understood the risks. In addition, there was no evidence that the provider was aware of the final discharge arrangements of minimal supervision. Record review revealed R1 made progress in PT/OT and on 09/23/25, his insurance issued him a notice of non-coverage with a discharge date of 09/26/25. R1 wanted to go home and did not appeal the discharge.Record review of Discharge Orders dated 09/23/25 revealed the level of supervision checked off was 24 Hour Care. The Home Health Services/Outpatient referrals included:1) Home Health PT), 2) HHOT, 3) HHST (Speech Therapy), and 4) HH/NSG (Nursing). A handwritten entry medication management was added. The document was signed by the Nurse Practitioner (NP)1 and dated 09/23/25.Reviewed the discharge MDS (Medical Data Set) assessment dated [DATE], which included the following: Section GG-Functional Abilities indicated R1 required partial/moderate assistance for toileting/hygiene, shower/bathe self, putting on footwear and personal hygiene. In addition, R1 was assessed as needing supervision or touching assistance for roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to chair transfer, toilet transfer, and walking. Section H- Bladder and Bowel documented R1 to be always continent of bladder and bowel. Reviewed documentation of R1's urinary continence/incontinence for the time period 09/19/25 to 09/26/25, which revealed he was incontinent of urine 21 times and incontinent of bowel nine times during that time.Reviewed the Physical Therapy Treatment Encounter Note dated 09/24/25. The plan was . Pt (patient/R1) to be seen for his final PT tomorrow. Pt is not safe to be home alone and PT recommending increased assist at home. Reviewed PT Discharge summary dated [DATE] by PT1, which included Patient is now ambulating and performing his mobility at a CGA/SBA (contact guard assist (provides occasional physical support to ensure safety))/stand by assist (present for safety but does not provide direct support) level. Reviewed Occupational Therapy Treatment Encounter Note(s) dated 09/24/25. The note included .home with 24/7 care and HHOT/PT on 9/26/25.Reviewed OT Discharge summary dated [DATE] by OT1, which included . Pt has made gains, however continues to need assistance and is recommended to have a caregiver at least 20 hours a week, per modified Barthel index score . R1's modified Barthel ADL score (level of assistance required for activities of daily living) score was 61 (Moderate dependence, including that the resident requires some assistance with most ADLs). Reviewed R1's nursing progress notes, which included: 09/23/2025 12:53 PM: Alert note: .Resident with persistent diarrhea and stomach upset. New orders received to collect stool for culture and O&P (test to detect presence of intestinal parasites) and add probiotic 1 capsule BID. 09/26/25 11:00 AM: Resident discharged home discharge instructions/summary given to caregiver. Review of R1's lab results revealed no results for the stool culture. A report from the laboratory was sent to the facility which notified them the test could not be done. The report said . Stool sample recvd (received) in sterile container not in stool media. Already passed stability to add to stool media. Spoke to .at Kauai Care Center, .resident no longer at facility, so no need to recollect. There was no documentation the provider, PMD, or Resident was notified that the test was not completed.3) On 02/19/26 at approximately 01:00 PM, during an interview with the Social Service Assistant (SS). She confirmed R1 did not have family or a full-time care giver. She said he had some services prior to admission and spoke with his community Care Coordinator (CC) to inform her R1 he received the notice of Medicare non-coverage, did not appeal the discharge and wanted to go home. The CC told the SS meals on wheels would resume on 09/29/25 and told her R1 had limited money, and that she would work on staffing for the ordered services, but that there was a staffing shortage. When asked SS who the caregiver was referenced in the nursing note at the time of discharge, she stated it was a Private Hire (PH) she (SS) was able to arrange. She went on to say she was concerned and knew he needed to be looked at every day and there would be a lag until other services could be arranged. SS said she did not know the qualifications of the PH, but R1 agreed to hire her two hours a day. SS knew R1 needed an insulin shot every day and said it would be nursing's responsibility to ensure someone was capable and competent do the injections. When asked if she or anyone else had any discussion with R1 about a Long-term care (LTC) facility or 24-hour supervision, she said she did not, but knew someone else did. SS said an 1147 (Hawaii form to determine level of care and at-risk evaluation to ensure appropriate level of supervision provided), would be done by nursing, or after he left the facility.On 02/20/26 at 12:25 PM, SS provided a Case Management Note from the hospital dated 09/03/25. The hospital note documented attempts to place R1 for rehab services, and included . discussed with patient (R1). Patient does not want LTC. Patient would like to return home after STR (short term rehabilitation) completed. SS acknowledged this discussion took place when he was in the hospital and that the facility did not have any documentation of any further discussion. During a second interview with SS, she said she spoke with R1's CC a couple of times, but did not document when or the content in the medical record. SS later provided a typed document she prepared retrospectively of the conversations with CC. The document included 9/23-9/24-I called CC to make her aware that he (R1) was going to be discharged on 9/26 d/t (due to) NOMNC) & his refusal appeal. CC told me that community services (meals on wheels) wouldn't resume until 9/29. CC did mention his money was limited, there was a staff shortage [sic]. 9/24 With Pt. permission: - I called a caregiver off the OEA (Office of Elder Affairs) . Services would be until his community services resume or long as he wants or needs. Care needs to include preparing meals, meds, ensuring insulin is taken, shower, taking him to f/u apt with PCP, chores.On 02/18/26 at 01:30 PM conducted a phone interview with F1. She confirmed she cleaned R1's house and was not a caregiver. F1 said R1 called her when he got to his apartment because he did not have keys to get in. She said the day of discharge, he struggled to get out of the chair. F1 said R1 knew when he had to go to the bathroom, but walked slowly and couldn't get there in time. F1 said there were accidents on the floor 24/7, and he could not figure out how to turn the insulin pen to the right units for his daily injection. She did not know how much help R1 actually had because they did not last. F1 shared that R1 had been hospitalized and was now in at a LTC facility. On 02/18/26 at 02:30 PM, interviewed Registered Nurse (RN)1 in the conference room, She reviewed R1's care plan and confirmed he was one person moderate assist for ADL's. On 02/19/26 at 09:50 AM, a telephone interview was conducted with the CC. She she spoke with SS on 09/19/25 about R1's dc planning, told her he had no support at home, and what services he currently had in place. She said there was no discharge date at that time. SS told CC that R1 was back to baseline. On 09/25/25, she spoke with SS again and was told a PT/OT referral would be made and again said he was back to baseline, ambulating on his own. CC said she reinforced R1 had no support at home, and that she arranged for a HH evaluation the day of discharge, with possibility of services starting on 09/29/25. On 02/19/26 at 12:32 PM, conducted an interview in the conference room with the Physical Therapist (PT)1. She confirmed the recommendation of 24-hour supervision as documented on the Discharge Recommendation/order and signed by Provider. PT1 said R1 had memory issues, would not be able to change his diaper and confirmed he was not at his functional baseline prior to the stroke. Reviewed the IDT conference notes and she said the notes id not accurately reflect the recommendations of PT/OT. On 02/19/26 at 01:52 PM interviewed the Occupational Therapist (OT)1, who confirmed R1 still needed assistance with verbal cues if continent, and toileting hygiene. She said if he was incontinent, he needed partial or moderate assistance to change his brief and had difficulty putting on the shoes he was supposed to wear when ambulating. On 02/19/26 at 03:00 PM, interviewed the Director of Nursing (DON) in the conference room. She said nursing is responsible to ensure the Resident can self-inject and if not, that there is an identified caregiver that is willing and trained to give the injection. The facility was unable to provide evidence R1 was competent and capable to self inject his insulin. The DON confirmed the stool culture and sensitivity had not been done, and that the provider should have been notified to ensure follow up post discharge.

Based on observation, interview and record review, the facility failed to protect the rights of one Resident (R) 198 of one resident sampled by ensuring the resident was treated with respect and dignity. R198 was receiving therapy from a staff member who spoke to her in a manner that R198 felt was disrespectful and demeaning, leaving R198 very upset. Findings Include:Facility Reported Incident (FRI) reviewed on 07/09/25 at 12:17 PM, intake #11576 for an incident that occurred on 03/12/25 at 02:41 PM involving a Physical Therapist (PT) 5 and R198. R198 reported to the facility staff that she was made to feel uncomfortable by PT5 regarding the way she spoke to her. R198 stated I was going to the toilet, and she came into my room and opened the curtain and stated, you are going to do therapy today, R198 told the PT5 that she was given a water pill and now must go to the bathroom more often. R198 stated that PT5 said you are always crying wolf, every morning you have an excuse. R198 said this is not the first time this has happened, but she did not want to say anything to get anyone in trouble. And said, I feel threatened by her and do not want to do therapy. The Nurse Practitioner, (NP), Medical Director (MD) and Inter-disciplinary team (IDT) made aware of the incident. Facility investigation report reviewed on 07/09/25. The facility responded by placing PT5 on leave immediately, reported to MD, Administrator, and the State Agency (SA). Adult Protective Services (APS) was notified on 03/12/25 of an allegation of verbal abuse. The resident was reassured of her safety. An investigation was completed that included interviews with PT5, and the Charge Nurse, (CN) that was on duty. PT5 was interviewed by the [NAME] President and Regional Directors of Therapy Operations and provided with training on professional conduct, patient rights, and abuse prevention. PT5 concluded by stating she had no idea the resident was feeling this way at all and felt horrible about this, did not recall having any type of disagreements with the resident and continued to work things out with her. She supported the resident by continuing to encourage self-directed, resident choice and preference during her care. Concurrently, other staff and residents along with family members were also interviewed, no other reports received, observed or witnessed with or by residents, witnessed with other staff members or by family members. all other residents interviewed stated they felt safe, no residents reported being harmed. Follow up interview made by the Social Services Director (SSD) with R198. R198 expressed that she (PT5) talks like the mainland, and it is hard for her to comprehend when she told her You're crying wolf, and thinks she needs to learn the ways in Hawaii. The resident was reassured that while it was not the intent of PT5 to offend her, it was not acceptable behavior or an acceptable practice of the staff here at the facility, R198 agreed and verbalized appreciation for all services received. R198 continued to state that she felt safe, was agreeable to continue to work with PT5 and all staff at the facility and will reside at the facility until she completed her short-term rehabilitation prior to returning to home, and verbalized understanding of her and all residents' rights of confidentiality and to report any further issues. R198 was placed on alert charting to monitor mood and behavior for possible psychological distress and signs and symptoms of psychological harm, the SSD made rounds on R198 to assess her emotional status and provide reassurance. Based on their investigation, the facility determined abuse did not occur. The facility concluded this was a misunderstanding of their standards of performance regarding acceptable customer service.The incident was reviewed by the Interdisciplinary Team (IDT) and it agreed immediate disciplinary action, training and a contingent performance plan was warranted. Random observations between 07/07/25 and 07/10/25 included interactions between PT5 and multiple residents in the Lokahi wing before, during and after therapy sessions. PT5 was observed to engage with the residents with a kind, caring and respectful manner. Observation and interview during a resident council meeting in the Lokahi dining room on 07/09/25 at 10:26 AM. The following residents were present: R3, R6, R14, R24, and R30. When asked if any staff treated them disrespectful or abusive. They all responded, no and that it is good here. They agreed that some of the staff are more friendly than others but they feel that the staff treat them well. On 07/10/25 at 10:07 AM, Administrator interviewed during the Quality Assurance Performance Improvement (QAPI) meeting in the conference room. When asked to explain the process that was put in place to ensure how the residents in the facility are provided with dignity and respect, and how the facility will monitor the effectiveness of the PIP, the Administrator explained that education of all the facility staff was included in the PIP. The staff education and sign in documents were reviewed. The Administrator discussed the PIP and provided a copy for review. The Administrative rounds were done weekly on 3/21/25; 03/24/25; 03/31/25; 04/07/25; 04/14/25; 04/22/25. No negative interactions were observed. Resident Rights Policy revised dated 11/2016 reviewed on 07/10/25. Facility will honor resident rights as listed below: .Resident has the right to receive treatment and care with respect and dignity in a manner and in a safe, clean and homelike environment that promotes maintenance or enhancement of his or her quality of life and individuality, regardless of his or her payer source.

Based on an interview and document review, the facility failed to establish a water management program as part of an infection prevention and control program to prevent the transmission of disease associated with water-borne pathogen. The facility was unable to demonstrate its measures to minimize the risk of Legionella and other water borne opportunistic pathogens in building water systems in a documented water management program. This program must be based on nationally accepted standards and include an assessment to identify where Legionella and other water borne pathogens could grow and spread and measures to prevent the growth of opportunistic water borne pathogens and how to monitor for pathogens. As a result of this deficiency, resident are potentially at risk for infections related to water-borne pathogens. Findings include: Definition of Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires' disease which is typically characterized by fever, myalgia, cough, and clinical or radiographic pneumonia; and Pontiac fever, a milder illness without pneumonia (e.g., fever and muscle aches). Legionellosis is caused by Legionella bacteria. Legionella can grow and multiply in a building's water system, water containing Legionella can spread in droplets small which individuals can breathe in and develop Legionnaires' disease or Pontiac fever. On 04/04/24 at 11:36 AM, conducted a concurrent interview and RR with the Maintenance Staff (MS)3. Inquired with MS3 regarding the facility's water management program for facility assessment of the building's water system and potential areas Legionella can grow and multiply and how the facility monitors for Legionella water system and areas identified in the assessment. MS3 reviewed the facility's maintenance binder, then confirmed the facility did not complete an assessment of the building's water system and does not have a plan for monitoring the water system for the presence of Legionella and other opportunistic water-borne pathogens. MS3 stated he/she was unaware that facility needed to complete an assessment of their water system and monitoring for Legionella and other water-borne pathogens.

Based on interviews, observation, and document review, the facility failed to meet regulatory requirement for having a designated Full-time (working 40 or more hours a week) director of nursing. The individual identified by the facility as the DON was also designated as the infection preventionist, and responsible for the Infection Prevention and Control Program (IPCP). As a result of the designated DON not being able to allocate 40 hours or more a week to oversee the nursing department, there is the potential the quality of care provided, and resident outcomes may be impacted and could affect all residents living at the facility. Findings include: The facility is licensed for 52 beds, Review of the facility assessment included: B.2. Acuity - Care Requirements (page (pg.)15): Staff/Personnel required: . DON . Infection Preventionist, . C.1. Cognitive - Care Requirements (pg. 18): Staff/Personnel required: .DON, . D.4. Cultural - Care Requirements (pg. 22) : Staff/Personnel required: .DON.Infection Preventionist. Reviewed the survey binder provided on entrance. The binder included documents related to infection prevention and control. The facility identified the DON as the Facility's Infection Preventionist. It also listed a facility Regional IP Consultant, (IPC)1. The binder included infection prevention training documents for the DON, IPC1 and five other individuals. These individuals later were identified by the DON and Administrator as corporate resources available to the corporate facilities. Reviewed a policy titled Infection Preventionist, revised date 10/2027. The Procedure included: 1. The facility Infection Preventionist will be identified by the Director of Nursing Services. On the morning of 04/03/2024, conducted an interview with DON, also identified as the facility's IP, to review the facility's IPCP. DON stated her job roles is the current director of nursing and the infection preventionist. DON informed this surveyor of her intent to train a new registered nurse to assist her with the facility's IPCP. Inquired which staff are qualified to function as the infection preventionist and who were the individuals listed in the survey binder with completed infection preventionist training. DON replied, the individuals listed in the survey binder with completed infection preventionist training were corporate staff (not actual staff currently working as a registered nurse at the facility) and prior to her employment at the facility, a corporate staff was on-site as the infection preventionist and the others (in the survey binder) are corporate resources staff, consultants, as needed by the facility. DON stated the corporate resource staff also cover other infection preventionist positions, due to vacancy and vacations, at other facilities owned by the parent corporation. DON confirmed she is solely responsible for the facility's IPCP, and the duties are not shared with any corporate resource staff. DON stated corporate resource staff have access to the computer program used and will occasionally contact her to ask if she had seen something, but there is no delineation of duties. DON admitted to trying to maintain eight hours a day, Monday through Friday, 40 hours per week. When asked to estimate the amount of time she consistently spends on infection control, DON stated, 50 percent. On 04/04/2024 at approximately 12:30 PM, during an interview with the Administrator (ADM), confirmed DON has full responsibility for the IPCP program at the facility. ADM reported the facility has access to resources at corporate, but corporate resource staff do not complete any daily duties/tasks in an attempt to assist the DON in her role as the infection preventionist. The ADM confirmed the training documents in the survey binder were those of the corporate staff, and that there was no one else in the facility currently assisting the DON with IP duties. On 04/04/2024 at 10:30 AM, observed the CN11 drop a narcotic pill on the floor during a med pass. Because CN11 was the only licensed staff on the unit, she needed to request the DON's presence to waste the narcotic. Observed the DON assist with the process, witnessing the waste of the narcotic and the documentation. On 04/04/2024 at 12:00 PM, observed and interviewed the DON at the nursing station on Laulima. She confirmed she is covering the unit floor for the licensed staff who was at lunch. Due to the fact the facility has one licensed staff on each unit, the DON often needs to cover breaks and assist with tasks and resident care. Reviewed the job description of the Director of Nursing. The position summary read: The Director of Nursing will plan, organize, develop, and direct the overall operation of the facility's nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, as may be directed by the Executive Director to ensure that the highest quality of care is maintained at all times. Essential Position Duties included, but not limited to: - The Director of Nursing (DNS/DON) is responsible for the delivery of nursing services to include planning, implementing, and evaluating the care plan of each resident to maximize resident quality of life and quality of care . - The Director of Nursing develops and evaluates with the health care team and Executive Director, resident care goals and policies in order to assure that adequate resources and services are provided to residents, reviews logs, and medical records on an ongoing basis ensuring the highest practicable care is being delivered. - Observes, mentors, and trains new and current staff . and holds staff accountable for duties assigned. - Perform other related duties as assigned. Reviewed the job description of the Infection Preventionist, last revised 8/7/2022. The position summary read: The Infection Preventionist evaluates the quality of resident care and outcomes as they relate to Healthcare Acquired Infections (HAI) and Community Acquired Infections (CAI) in accordance to Presents infection data and makes recommendations for actions. Monitors Employee compliance with infection control standards through . Prepares and presents education for the staff, residents, and families. Serves as a resource to all departments and personnel related to infection control practices. Essential Position Duties included, but not limited to: -Responsible for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services. -Responsible for collecting, analyzing, and providing infection data and trends to nursing staff and health care practitioners. -Identifying when and how isolation should be implemented for a resident including the type and duration of isolation, . -Accountable for surveillance of healthcare acquired and community acquired infections including outbreak investigates. -Adherence to the facility antibiotic stewardship. -Conduct routine facility rounds to evaluate staff compliance with hand hygiene, linen handling, standard precautions, transmission-based precautions, use of PPE, disinfection of reusable equipment, disposal of single-use items and appropriate aseptic technique. -Complete clinical reviews of documentation for newly prescribed antibiotics to ensure appropriate treatment, dose, duration, and indication .

Based on observations, interviews and document review, the facility did not ensure the wrist blood pressure (BP) patient care monitor was used according to manufacturer's recommendations. Specifically, the monitor is recommended for in-home use only. To ensure accuracy, it should be used according to manufacturer's guidelines. This has the potential to affect any resident that had their BP taken with the wrist monitor. Findings include: On 04/03/2024 at 10:10 AM, observed a wrist blood pressure (BP) monitor on the top of the medication cart. At that time interviewed the Resident Care Manager (RCM), who was administering medications. She said they keep the piece of equipment on the cart and use it to check resident BP prior to administering hypertension medications with range limits. The unit is used on multiple residents and wiped down between residents. On 04/04/2024 at 10:00 AM, observed CN11 use the wrist BP monitor on R5 prior to administering her BP medication. On 04/03/2024 at 11:20 AM, during an interview with DON, inquired what the manufacturers recommendations were for use and cleaning the wrist strap. She stated they wipe down the monitor and strap after each use. DON said she thought the units were old and had not purchased any since she was hired. Request make for manufacturer guidelines. The DON provided the wrist blood pressure user guide which she located on the Internet at approximately 02:30 PM, later that day. The wrist blood pressure monitor (Model MDS4003) was manufactured by Medline Industries. Review of the User Guide dated 2019, included the following: Page 4: Indications for Use .It is intended for adult in-home use only. Page 6: Page titled Caution. Bullet one: This device is intended for adult, in-home use only. Bullet two: The device is not suitable for use on . patients with implanted electronic devices, patients ., premature ventricular beats, atrial fibrillation, peripheral, arterial disease and patients undergoing intravascular therapy . Page 7: .To verify the calibration of the automated sphygmomanometer, please contact manufacturer. Page 8: It is recommended that the performance should be checked every 2 years and after maintenance or repair. There was no process in place to check the performance of the wrist blood pressure monitor according to manufacturer's guidelines.

Based on observation, interviews, and RR, the facility failed to revise the care plan for one of 14 residents sampled (R12). R12's care plan (CP) was not revised to include an updated oxygen administration order. R12's care plan did not include a new order to maintain R12's oxygen saturation be maintained between 88%-92%. Failure to revise care plans to reflect new orders could potentially lead to resident's not receiving appropriate nursing and medical care which has the potential to harm resident(s). Findings include: Cross Reference F-684: Quality of Care R12 is a [AGE] year-old female with diagnosis that include but not limited to severe persistent asthma, muscle weakness, acute and chronic respiratory failure, hypertension, pulmonary hypertension (increased blood pressure in the arteries of lungs, which causes shortness of breath, and swelling of legs), anxiety disorder, seizure disorder and gastrointestinal hemorrhage. On 04/01/2024 at 10:20 AM, observed R12 resting with her eyes closed, in the resident's assigned room. The resident's bed was against the wall. R12 was in a seated-position, perpendicular to the bed, with her back against the wall and feet hanging off the side of the bed and had several pillows behind her back which propped the resident up. Observed the resident receiving 3 liters of oxygen by nasal cannula via concentrator located at her bedside. On 04/04/2024 at 11:00 AM, observed R12 in the activity/dining area in a wheelchair at a table. The resident was receiving 3 liters of oxygen from a concentrator located next to her. While conducting an interview with R12 on 04/04/2024 at 11:15 AM, the resident stated she always uses the oxygen and cannot go without it. She was able to speak full sentences with mild shortness of breath. Reviewed R12's CP, which identified on 09/02/2023 she had Alteration in respiratory status r/t (related to) Asthma. Interventions included The resident has O2 via nasal prongs/mask @ 2-4L (liters per minute) continuously with humidifier, dated 09/02/2023. Reviewed R12's EHR. On 03/12/24, the Director of Nursing (DON) revised R12's oxygen administration order. The order summary documented, Oxygen: 2-3 liters per minute Delivery: cannula to keep sats between 88-92%, every shift for COPD (chronic obstructive pulmonary disease). Review of R12's CP documented it was not revised to reflect this order.

Based on observations and interviews, the facility failed to ensure a safe environment for residents, staff, and the public. Observation of the facility's industrial dryers used by the facility documented the lint traps were not cleaned and the facility's formed used to document staff cleaned the lint traps was blank, indicating staff did not clean it. Interviews with staff confirmed the environment was unsafe for residents, staff, and the public due to the fire hazard of the amount of lint contained in both industrial dryers. Also, the facility is physically located in a dry and hot climate which would make it easier for the fire to spread and affect the residents, staff, and public resulting in Findings include: On 04/04/24 at 11:24 AM, conducted a concurrent interview and inspection of the facility's laundry room and services with the Housekeeping/Laundry Supervisor (HLS). At 11:29 AM conducted an inspection of the lint traps for two of three industrial dryers used by the facility (the third dryer was out of order). HLS opened the bottom panel (where lint in collected) of dryer (D)1. As HLS opened the panel, lint was immediately observed due to a portion of the lint was partially connected to the opened panel. The entire lint screen was covered with lint which was approximately half an inch thick. HLS opened the panel for D2, there was lint on the bottom of the dryer and the entire lint screen was covered with lint which was approximately one inch thick and contained lint on the bottom of the dryer. HLS confirmed the lint catch for both dryers should have been cleaned because it is a fire hazard but had not been cleaned. At 11:31 AM, Laundry staff (LS)71 entered the laundry room, informed this surveyor he/she was not currently working in the laundry room on this day, but worked in the laundry room yesterday (04/03/24). LS71 stated the lint portion of the dryer should be cleaned after each use, because the lint can cause a fire and the facility climate the of the county is dry and hot, which would allow the fire to spread to surrounding structures quickly. At 11:33 AM, LS4 entered the laundry room and confirmed he/she was working in the laundry room this shift. LS4 initially stated the lint was being cleaned from the dryer after each use and was informed by HLS that both dryers were not cleaned and there was lint. Reviewed a form posted on the dryer which is used by staff to document when staff cleaned the lint with HLS, LS71, and LS4. HLS stated there is a form on the dryer that staff are supposed to sign/initial as an attestation that the lint trap of the dryers were cleaned. HLS, LS71, and LS4 reviewed the lint trap cleaning form and confirmed on 04/03/24 and 04/04/24, responsible staff did not sign/initial the form, indicating the dryer's lint trap had not been cleaned on those days.

Based on record review (RR), staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure that information populated in the Minimum Data Set (MDS) was accurate for one of two residents sampled (Resident (R)51). R51's electronic health record (EHR) documented the resident was discharged home. Review of R51's discharge MDS documented the resident was discharged to an acute hospital. Failure to complete the MDS assessment accurately could potentially lead to missed opportunities for generating appropriate care plans and possibly not providing needed services, which could result in harm to the resident. Findings include: During record review of R51's discharge MDS, Assessment Reference Date 02/05/24, Section A Identification Information, A2105. Discharge Status, documented 04. Short-Term General Hospital (acute hospitals, IPPS) indicating R51 was discharged from the facility to acute hospital. Review of R51's progress notes documented R51 was discharged to home on 02/05/24. During staff interview on 04/04/24 at 12:30 PM, Executive Director confirmed R51 was discharged home and the resident's RAI, discharge MDS inaccurately documented the resident was discharged to an acute hospital. Executive Director stated that they would do the necessary correction. Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on observations, interviews, and RR, the facility failed to provide the needed care within the professional standards of practice that met the needs for three of 14 residents sampled (R8, R12, and R17). As a result of this deficient practice, all residents at the facility are at risk of the potential for harm due to not achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: 1) R17 is a [AGE] year-old female transferred to the facility on [DATE]. Her diagnosis included, but not limited to Type 2 diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, spinal stenosis, and morbid obesity. She is bedbound and uses a Hoyer lift with two staff assistance for transfers and positioning in bed. R17 is alert and oriented. Her active medications for diabetes management include Levemir Flex Pen subcutaneous 100 unit/ml (milliliters), 3 units in the evening, Novolog Flex Pen subcutaneous 100 unit/ml, 2 units before meals, Jardiance 10 mg (oral) every morning and Glimepiride (oral). On 04/01/2024 at approximately 11:30 AM, observed R17 lying comfortably in bed when the Charge Nurse (CN)11 came in to check her blood sugar (BS). Her BS sugar was 215. CN11 proceeded to give R12 her scheduled injection for diabetes. At that time, interviewed CN11, who said R17's BS was very unpredictable and often fluctuated over 200. Reviewed R17's Blood Sugar Summary for the month of March 2024. The results revealed R12's lowest BS was 145 on 03/03/2034, and the highest BS was 389, on 3/24/2024. It was not unusual for R17's BS to run over 200. Review of R17's lab results revealed her last hemoglobin A1C (tells average BS sugar over the past 2-3 months) was on 01/13/2023, which was resulted at 7.1%. RR of R17's Provider (P)1 notes dated 03/04/2024 revealed the plan for R17's diabetes included -Monitor A1C q (every) 6 (six) months if at goal /q 3 months if not at goal. Goal is less than or equal to 7.5% in the healthy elderly, and less than or equal to 8% in the [sic] those with multiple comorbidities, and less than or equal to 8.5% in the very complex/ill with limited life expectancy. On 04/04/2024 at 11:10 AM, during an interview and concurrent RR of R71's EHR with the DON in the nursing station, reviewed R17's provider note dated 03/04/2024. She reviewed R17's lab orders and results to confirm there had not been an A1C drawn since the note was written and the last time R17 had one done was 01/13/2023. The DON notified surveyor later she had contacted the provider to clarify the order, and confirmed the providers intent was to have an A1C drawn at the time she wrote the progress note, and then ongoing monitoring of A1C based on those results. The DON went on to say the provider stated she had given a verbal order to the nursing staff the day she wrote the progress note, but the staff failed to follow through with the order. The staff was no longer at the facility for interview. 2) R12 is a [AGE] year-old female admitted to the facility on [DATE] for rehabilitation after hospital admission. She has been re-hospitalized twice since her admission. The last hospitalization was on 02/28/2024 for aspiration pneumonia. She returned to the facility on [DATE] to continue rehabilitation. R12 has extremity weakness and right shoulder pain. She does not ambulate independently due to unsteady gate and uses a wheelchair. R12 requires one person assist for dressing, toileting, bathing, and transfers. Her diagnosis includes, but not limited to severe persistent asthma, muscle weakness, acute and chronic respiratory failure, hypertension, pulmonary hypertension (increased blood pressure in the arteries of lungs, which causes shortness of breath, and swelling of legs), anxiety disorder, seizure disorder and gastrointestinal hemorrhage. R12 has chronic shortness of breath and uses oxygen (O2) continuously via nasal cannula. On 04/01/2024 at 10:20 AM, observed R12 sleeping in her room. The side of her bed was against the wall, and she was propped up with her back against the wall with several pillows and her legs were off the side of the bed. R12 was sleeping and was on 3 liters (L) of oxygen by nasal cannula via concentrator located at her bedside. Reviewed R12's O2 saturation (amount of oxygen in blood) level summary for March 2023, which revealed her oxygen saturation (sat) level was never documented to be below 95%. Reviewed R12's active orders, which revealed her oxygen administration order was revised on 03/12/2024. The new order read: Oxygen: 2-3 liters per minute Delivery: cannula to keep sats between 88-92% every shift for COPD (Chronic Obstructive Pulmonary Disease (O2 should be controlled due to risk of too much carbon dioxide in blood resulting in respiratory failure)) Cross Reference F-657: Care Plan Revision. R12's active CP included the intervention initiated on 09/02/2023 The resident has O2 via nasal prongs/mask @ 2-4L (liters per minute) continuously with humidifier. The CP was not updated to reflect the revised order of O2 at 2-3L to maintain O2 sat range of 88-92%. On 04/03/2024 at 10:30 AM, during an interview with the Resident Care Manager (RCM)1, outside R12's room, she said she frequently cared for R12. She said R12 had continuous oxygen and has not been tried to wean due to her chronic condition. She went on to say R12 becomes very anxious without her oxygen. RCM1 was asked to review R12's current oxygen order, and when confirmed the O2 sat range was to be maintained at 88-92%, she commented, But she's always over 96%. RCM1 also confirmed R12 did not have a diagnosis of COPD. She acknowledged she had not been aware of the specifics of that order and would contact the provider for clarification. On 04/04/2024 at 11:00 AM, during an interview with the DON, reviewed R12's oxygen order revised on 03/12/2024. The DON stated she was the one who reviewed the orders from the hospital when R12 was readmitted to the facility and entered them in the medical record. She said the process is to discuss the orders with the facility provider, confirm the orders and enter them as verbal orders. The provider would then sign off on the orders. The DON said she made an error and entered them incorrectly as prescriber written, which resulted in the order not being authenticated and signed by the facility provider. RR revealed a new oxygen administration order for R12 was entered on 04/03/2024 at 07:00 PM by P1. The order read Oxygen 2-3 liters per minute: Delivery: cannula to keep sats above 90%. Directions every shift for Severe Asthma, SOB, or difficulty breathing. On 04/04/2024 at 11:00 AM interviewed R12 in the activities room/dining area. She was in her wheelchair (w/c) pulled up to a small dining table with the oxygen concentrator set at 3L, next to her. R12 said she uses the O2 all the time and does not take off. She was able to speak in full sentences. The revised oxygen administration order with restricted O2 sat range had been in place since 03/12/2024. The nursing staff failed to identify the order was not the standard of care because R12 did not have a diagnosis of COPD and should have notified the provider for clarification. 42160 3) During an interview with R8 on 04/02/24 at 09:30 AM, the resident informed this surveyor that she was feeling dizzy and activated the call light. Certified Nursing Aide (CNA)99 responded to the call light. The resident informed CNA99 that she was feeling dizzy. CNA99 replied, I will let the nurse know. On 04/02/24 at 02:43 PM, conducted a review of R8's EHR which documented, R8 was admitted to the facility on [DATE]. R8 has diagnosis which include, but are not limited to hypertension, hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side, Type 2 Diabetes Mellitus, and chronic migraines. Review of R8's most recent quarterly MDS with an ARD of 02/09/24, Section C. Cognitive Patterns, R8 has a Brief Interview for Mental Status (BIMS) scored of 13, indicating the resident's cognition is intact. Review of R8's physician orders documented an order to monitor the resident's blood glucose, document the results, hypo/hyperglycemia protocol, and an order for a sliding scale dose of insulin Aspart Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart), to be administered subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications and an order to monitor blood glucose. Review of R8's blood glucose levels documented prior to the resident reporting feeling dizzy, the most recent blood glucose level was taken on 04/01/24 at 05:52 AM, 92.0 mg/dL (milligram per deciliter). Following R8 reports of feeling dizzy at 09:30 AM, the resident's next blood glucose was completed at 12:41 PM (141.0 mg/dL). Review of the times nursing staff completed blood glucose checks indicated staff regularly did the checks four times a day. Review of R8's April 2024 medication administration record (MAR) documented CN11 did not document a blood glucose value or number of units administered to R8 on 04/02/24 at 06:45 AM. Review of R8's March 2024 MAR also documented on 03/19/24, staff did not document a blood glucose value or the number of units, if any, were administered to the resident for the 06:45 AM administration time. On 04/03/24 at 11:52 AM, conducted a concurrent review of R8's EHR and interview with the DON. Informed the DON of the observation of R8 reporting to CNA99 of feeling dizzy and the missing blood glucose testing. DON reviewed R8's EHR and confirmed the resident's blood glucose level was not documented for the 06:45 AM administration time and there is no other place staff would document these values. DON reviewed R8's MARs (April and March), then confirmed on 03/19/24 and 04/02/24 at 06:45 AM, day-shift staff is responsible for this administration time, and staff did not carry out R8's physician's orders as prescribed by the physician. DON also confirmed the blood glucose value taken at 05:52 AM was not valid to be used for the 06:45 AM administration time due to the length of time between 05:52 AM and 06:45 AM, it would not be safe or a standard of practice to administer insulin an hour after the blood glucose level after it was taken. DON stated the expectation of staff is to take the blood glucose level immediately prior to administering insulin, then administer the insulin as prescribed by the physician. DON also confirmed staff should have taken a blood glucose reading to ensure the resident was not experiencing a hypo/hyperglycemic episode but did not. On 04/04/24 at 09:05 AM, conducted a follow-up interview with R8 in the resident's assigned room. R8 confirmed CN11 did not take the resident's blood glucose level on 04/02/24 at 06:45 AM as scheduled and did not take a blood glucose reading after she complained of feeling dizzy to CNA99.

Based on observation, interviews, and RR, the facility failed to ensure drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. As a result of this deficient practice, there is the potential for diversion of controlled medication(s). Findings include: 1) On 04/03/24 at 09:21 AM, conducted a concurrent observations and interview of the controlled medication reconciliation for the medication cart with the RCM1. The facility implemented a Narcotic Count sheet (located in the medication cart binder) which is used by licensed nursing staff to document the reconciliation of controlled medication(s) between shift to account for all controlled mediations and to mitigate the diversion of controlled medications. Review of the facility's Narcotic Count sheet documented it was not signed/initialed on 04/01/24 and 04/02/24 for the On 0700-1900 and OFF 07/1900 portion of the sheet. Inquired with RCM1 regarding the blank portion of the Narcotic Count sheet. RCM1 confirmed the Narcotic Count sheet should have been signed with the off-going nurse and the on-coming nurse immediately after staff confirm the count of controlled medications listed on Narcotic Count sheet matches the actual count and both staff should initial/sign the form in the presence of each other, but staff did not initial/sign the Narcotic Count sheet. On 04/03/24 at 11:49 AM, conducted an interview with the DON. DON stated the Narcotic Count sheet is used to reconcile controlled medications between shifts, should be initialed/signed immediately after verifying the count is correct with another licensed nurse, and it should be initialed/signed in the presence of the licensed nurse the count was completed with as part of the facility's process to mitigate the diversion of controlled medications and confirmed staff did not implement the facility's procedure. DON stated the licensed staff responsible for not initialing/signing the Narcotic Count sheet was called in to sign it. Review of the facility's policy and procedure, Medication Administration, Controlled Substances, 01/23, documented the procedure, 7. At each shift change, a physical inventory of controlled medications, as defined by state regulations, is conducted by two licensed clinicians and is documented on an audit record. 2) On 04/03/24 at 09:25 AM, conducted a reconciliation of the narcotic medication for the medication with RCM1. RCM1 reported three residents was administered controlled medication(s) and the administration was documented on the electronic medication administration record (EMAR) but had not yet documented the administration on the resident's (individual) pharmacy count sheet (documents the count of the number/amount medication which should be stored in medication cart). RCM1 stated R41 was administered one tablet of Tramadol 50 mg, R5 received one tablet of Lacosamide 100 mg, and R30 was administered one tablet of Lorazepam 1 mg. All the controlled medications stored in the medication cart were reconciled and confirmed RCM1 did not sign the pharmacy count sheet for R41, R5, and R30 at the time the medication(s) were removed from the medication cart. On 04/03/24 at 11:51 AM, conducted an interview with the DON regarding RCM not documenting the removal of the medication from the medication cart. The DON stated staff sign the pharmacy's count sheet after the resident takes the medication. Review of the facility's policy and procedure, Medication Administration, Controlled Substances, 01/23, documented the procedure, 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from the controlled storage .

Based on interviews, observation, and RR, the facility failed to ensure a resident (R)12 is free from an unnecessary drug (antibiotic). R12 was prescribed an antibiotic (Levaquin) by a consultant at the time of an off-site office visit. Neither the prescribing consultant or facility provider documented adequate indications for the antibiotics use. As a result of this deficient practice, the antibiotic may be unnecessary and increase R12's resistance to antibiotics and put her at risk for adverse reactions to the medication. Findings include: R12 is a [AGE] year-old female with upper extremity weakness and right shoulder pain. She does not ambulate due to unsteady gate. R12 uses a wheelchair and requires one person assist for dressing, toileting, bathing, and transfers. Her diagnosis includes, but not limited to severe persistent asthma, muscle weakness, acute and chronic respiratory failure, hypertension, pulmonary hypertension (increased blood pressure in the arteries of lungs, which causes shortness of breath, and swelling of legs), anxiety disorder, seizure disorder and gastrointestinal hemorrhage. R12 has chronic shortness or breath and uses oxygen continuously via nasal cannula. On 04/01/2024 at 10:20 AM, observed R12 sleeping in her room. Her bed was against the wall, and she was sitting in the bed with several pillows behind her back propping her up with her back against the wall and legs off the side of the bed. She was sleeping and was on 3 liters (L) of oxygen (O2) by nasal cannula via concentrator located at her bedside. On 04/04/2024 at 11:00 AM, observed R12 in the activity/dining area in a wheelchair at a table. She had her oxygen on at 3L, with the concentrator next to her. On 03/26/2024, R12 went off site for a visit to a Pulmonologist. Reviewed the Pulmonologist hand written consult notes sent with R12 when she returned to the facility after the office visit. The notes included the following: Chief complaint: Shortness of breath and cough with green sputum. Findings, Assessment, Plan: + (positive for) wheezing, +edema, +JVD (jugular vein distention) . levaquin 500 mg. (milligrams) po (orally) daily x 10 days then D/C (discontinue). MD1's typed progress notes included: R12 is .here for follow up of shortness of breath. Since the last visit, R12 was hospitalized with pneumonia twice, the [sic] had Covid infection. She has a cough with green sputum, but has no hemoptysis (coughing up blood). She reports no aspiration symptoms . Past medical history included asthma. Assessment and Plan: Shortness of breath with hypoxia (below normal level of oxygen in your blood), with persistent symptoms in a patient with severe pulmonary restriction and reactive airway disease. ROS (review of systems) included: No recent fever or chills. Visit Diagnosis included shortness of breath, uncomplicated severe persistent asthma, and hypoxemia. The Pulmonologist did not order a diagnostic chest x-ray or a culture and sensitivity prior to the start of the antibiotic. RR revealed R12 had the order for the antibiotic placed on 03/27/2024. The order summary read Levaquin Oral Tablet 500 mg (levofloxacin). Give 1 tablet by mouth one time a day for PNA (pneumonia) for 10 days. Reviewed R12's care plan, which revealed revisions on 03/27/2024 after the visit with pulmonologist. The Focus was ABT (antibiotic therapy) r/t (related to PNA (pneumonia). The goal included: Resident will have no adverse reaction from antibiotic therapy use. During an interview with the Infection Preventionist (IP), she said the facility uses the McGeer Criteria for Infection Surveillance. The IP said, although the licensed staff do not use a form or checklist, the criteria is posted in the nursing station. R12 had not been identified by the staff as having a potential new infection based on the McGeer criteria. The IP said she was familiar with R12, the antibiotic order, and said the pulmonologist did not want a chest x-ray or sputum culture and sensitivity (C&S) to identify the most effective antibiotic), but that the facility had done a C&S. The facility uses exception charting, which is a method of medical notation in which nurses only document notes if there are deviations from a patient's norm or baseline. Review of R12's nursing progress notes from 03/20/2024 to 03/26/2024, revealed there were no entries of deviation from R12's baseline. There were no notations of increased cough or colored sputum. Her oxygen saturation remained at baseline (96-99%) and there was no fever, increased respirations, or changes in her mental or functional status. On a second interview, the IP said she had been mistaken, and that on further investigation, the facility provider had given a verbal order for the sputum C&S, but nursing did not record or complete the test. The IP (DON) said she was trying to reach the Pulmonologist to inquire what the indications were for the antibiotic, and if there was a diagnosis of infection. The IP confirmed there was no diagnosis of pneumonia documented. RR revealed R12's last chest x-ray was taken on 02/28/2024 for shortness of breath. The findings included There are increased reticular opacities in both lungs (comparison chest x-ray 11/27/2023 and CT 12/14/2023.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment which would help prevent the development and transmission of communicable disease and infections. Findings include: Observation was made on 04/11/23 at 9:54 AM of med passing at the nursing station and TV activity area. Observation was made of staff nurse 2 (SN)2 passing meds. SN2 was not using hand sanitizer (HS) between rooms when passing meds on a nursing unit. SN2 also was pouring medications into bare hands and then into a cup. SN2 went to nursing station and opened cupboards to grab meds at nursing station, then walked to front door to grab a gown and then went back to isolation cart to gown up before entering room. Outside of the room [ROOM NUMBER]A, SN2 gowned up, applied gloves without hand sanitizing, walked into room with medications she obtained initially. All this activity without handwashing or hand sanitization. Observation on 04/11/23 at 10:08 AM was done of SN2. SN2 was observed leaving room [ROOM NUMBER]A and doffing occurred outside of the room. SN2 then cleaned with hand sanitizer (HS) Observation was made on 04/11/23 at 10:44 AM. SN2 entered the resident's room with the blood pressure machine. SN2 did not HS hands or blood pressure machine. Observation was made on 04/11/23 at 10:50 AM of SN2. SN2 grabbed gloves without HS and entered room. When SN2 came out of room and did not HS. SN2 cleaned the blood pressure machine. Record review (RR) was done on 04/13/23 at 10:00 of policy of hand hygiene (HH). According to HH policy, 5th paragraph states Hand hygiene: Either soap and Water or alcohol-based hand rub: . When coming on duty . Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Before and after performing any invasive procedure (finger sticks) . Before and after entering an isolation precaution area. . Before and after assisting a resident with personal care (e.g., oral care, bathing) . Upon and after coming in contact with a resident's skin (vitals, lifting) . After blowing or wiping nose . After removing gloves or aprons . After handling soiled equipment or utensils. On 04/13/23 at 1:30 PM, interview was done with Nurse Manager (NM). Observations were discussed with NM regarding hand sanitizing, hand washing, doffing, hand sanitizing and glove removal and observations. Nurse manager acknowledged that this is not best practice. This deficient practice can affect all the residents in the facility and can lead to poor outcomes with infection control spread and outbreaks.

Based on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for two residents (R)13 and R26 out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication. Findings include: Cross reference to F625. The facility did not provide written notice of bed-hold policy. Review of the Electronic Health Record (EHR) indicated that R13 was discharged to the hospital on 09/07/22. Further review did not show any written notice of discharge to the resident and/or representative. Review of the EHR indicated that R26 was discharged to the hospital on 02/25/23. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 04/12/23 at 2:30 PM, Social Services Director acknowledged that the facility did not provide written notification of discharge for R13 and R26. Review of facility policy on Admission/Transfer/Discharge read the following: Policy, it is the policy of this facility to provide direction and guidance in accordance with state and federal regulations for admissions, transfer, and discharge of residents . Transfer/discharge policy . 3. Prior to a facility-initiated discharge or transfer, the facility must provide notice of transfer or discharge and reasons to the resident, resident representative, and State Long-Term Care Ombudsman. Copies of these notifications will be retained in the resident record.

Based on record review, staff interview, and review of policy, the facility failed to provide written notice of bed-hold policy for two residents (R)13 and R26 out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication of the facility's bed-hold policy. Findings include: Cross reference to F623. The facility did not provide written notice of discharge. Review of the Electronic Health Record (EHR) indicated that R13 was discharged to the hospital on 09/07/22. Further review did not show any written notice of bed-hold policy to the resident and/or representative. Review of the EHR indicated that R26 was discharged to the hospital on 02/25/23. Further review did not show any written notice of bed-hold policy to the resident and/or representative. During staff interview on 04/12/23 at 2:45 PM, Admissions Coordinator acknowledged that the facility did not provide written notification of bed-hold policy for R13 and R26. Review of Bed Hold Policy and Agreement Form provided to residents and/or representatives on admission read the following: A resident who is temporarily absent from the facility as a result of a transfer or a therapeutic/social leave may apply for a bed-hold to ensure his or her bed is preserved for the resident's anticipated return. The right to exercise a bed-hold when the resident is temporarily away from the facility is applicable to all residents and may not be used as a condition for admission or re-admission . Each resident being discharged to the hospital (or the resident's legally authorized representative) will be offered the option of holding the resident's current bed under this policy. At the time of discharge to the hospital, the discharging nurse gives the resident and representative a copy of this Bed-Hold Policy and Agreement. The resident/representative who chooses a bed-hold must sign this Agreement below acknowledging the charges for a bed-hold.

Based on record review and staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of a confirmed case of COVID-19 as required by regulation. Findings include: A review of the facility staff COVID-19 testing records showed a positive case on 03/20/23. During staff interview on 04/14/23 at 08:55 AM, the Infection Preventionist acknowledged that not all residents, their representatives, and resident families were notified of the confirmed case of COVID-19 by 5:00 PM the next calendar day as required by regulation.

Based on interviews and record review, the facility failed to provide assistance in obtaining routine dental care for 2 out of 6 sampled residents (R) R16 and R20. Findings include: Interview was done on 04/12/23 at 10:11 AM with R16. R16 stated that she has not seen a dentist. Interview was done with R20 on 04/12/23 at 10:47 AM. Queried R20 if a dental exam had been done. R20 was not able to answer this question. Record Review(RR) on 04/12/23 at 2:00 PM revealed no order for a routine dental exams for R16 and R20. Interview was done on 04/12/23 at 2:48 PM with nurse manager (NM) on the unit. NM stated that seeing a dentist is on an as needed basis and if they come to us or let us know, we make arrangements with their dentist or find someone. We attack it at a holistic approach. If they complain of pain or they want to see someone, we make arrangements. This deficient practice can affect all the residents in the facility for routine dental services.

Based on observation, interview and record review, the facility failed to report the results of an investigation of alleged abuse (invasion of privacy) for two of two sampled residents (R)20 and R21. Findings include: 1)The facility was asked if they could provide the results and followup of a complaint investigative report. The report was not available for R20. Observation and concurrent interview with administrator on 04/14/23 at 10:30 AM were done. A query was made with the administrator regarding missing final reports sent to the state agency. Administrator stated that I was not here when that was happening. It was the other administrator that was here. Administrator was not able to confirm that the completed investigation was done to verify if the appropriate corrective action occurred. 2) The facility reported an initial event report (#10015) on January 5, 2023. No completed report or followup was received. These deficient practices have the potential to affect all residents in the facility if alleged regulatory violations are not thoroughly investigated and reported.

Based on observations, interviews, and record review, the facility failed to provide non-pharmacological methods to help alleviate depression for one resident (R)11. This hinders R11's ability of attaining his highest practicable physical, mental, and psychological well-being. Finding includes: Cross reference to F740 Behavioral Health Services. The facility did not appropriately manage R11's depression. On 04/11/23 at 11:20 AM, observed R11 sitting in the dining room by himself listening to music. 04/12/23 at 09:31 AM, R11 was interviewed in his room. R11 frequently stated that he was lonely and sad. R11 stated that the activities provided by the facility were not tailored for his age group. R11 stated that he liked going out and enjoys pet therapy. R11 further stated that he was missing his two favorite cats, one of which had a birthday at the beginning of the month. On 04/13/23 at 10:41 AM, observed R11 alone in his room lying on his bed. R11 stated that he sees a psychiatrist. On 04/13/23 at 3:11 PM, observed R11's roommate and other residents were in the common area eating their afternoon snack while R11 stayed in his room. Record review of R11's Admission Record revealed that he is a [AGE] year old resident admitted to the facility on [DATE] for low blood sodium level, Parkinson's Disease, and recurrent major depressive disorder. R11's Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 11/13/22 revealed under Section D Mood a PHQ-9(C) (Patient Health Questionnaire-9 to determine the severity of depression) score of 6 signifying mild depressive symptoms. Section F Preferences for Customary Routine and Activities noted under F0500. Interview for Activity Preferences that it was important for R11 to be around pets. Review of R11's careplan did not identify that R11 enjoyed pet therapy and did not identify specific activities that were compatible with his physical and mental capabilities.

Based on observation, interviews and record review, the facility failed to update and revise the care plan to include interventions and treatment for a suspected hairline fracture of the left 5th proximal phalanx. The facility failed to update and revise the care plan for one of one sampled resident (R)20. Findings include: Resident(R)20 with an admitted [DATE] with a history of falling and care planned on falling. Observation was done on 04/11/23 of R20 at 12:30 PM sitting in activity room watching TV. R20 answers occasionally appropriate answer to queries. No walker boot noted to foot. Record review(RR) done on 04/11 at 1:30 PM on nursing unit was done. RR revealed that the resident sustained a fall on 03/28/23. R20 complained of neck pain and was sent to the ER for cervical neck x-rays. R20 did not complain of foot pain at that time. Interventions were put in place for cervical pain. RR done on 04/12/23 at 11:30 AM of the falls care plan. Care plan states that resident is at risk for falls r/t poor vision, unsteady gait/balance, history of falls, poor safety awareness and impulsiveness. Fall 3/30/23 with left foot hairline fracture nondisplaced, 5th digit. Interview was done on 04/13/23 at 1:06 PM with Registered Nurse (RN)1. RN1 stated R20 started mentioning foot pain after returning from ER about her foot. Eight days later, on 04/04/2023, nursing staff noted some erythema of the foot. R20 went back to x-ray and then it was discovered that she had a hairline fracture of her left foot, 5th proximal phalanx. Further review of orders revealed that three days later, on 04/07/23, advanced practice registered nurse (APRN) ordered a walker boot to left foot to be worn when patient is out of bed. This order for a walker boot did not transcribe to the care plan. The new order stated for a walker boot when patient is out of bed. Interview was done with the Rehab director (RD) on 04/13/23 at 1:23 PM. RD stated that a boot was ordered a week ago, but it has not come in. RD stated that she has been buddy taping it/gauze left foot 4th and 5th digits to protect the 5th toe hairline fracture. RD also provided another supportive orthopedic shoe until walker boot comes in. RD confirmed that this treatment was not transcribed in the care plan. This deficient practice could affect all the residents in the facility if the care plans are not updated to assure continuity of care.

Based on observations, record review, and interviews, the facility failed to appropriately provide the necessary behavioral health care and services for one resident (R), R11, to attain his highest practicable physical, mental, and psychological well-being. The facility failed to recognize R11's depressive symptoms and provide non-pharmacological interventions to help alleviate R11's depression. Finding includes: Cross reference to F656 Develop/implement Comprehensive Care Plan. The facility failed to identify and provide individualized interventions to manage R11's depression. On 04/11/23 at 11:20 AM, observed R11 was sitting in the dining room by himself listening to music. 04/12/23 at 09:31 AM, R11 was interviewed in his room. R11 frequently stated that he was lonely and sad. R11 stated that the activities provided by the facility were not tailored for his age group. R11 stated that he liked going out and enjoys pet therapy. R11 further stated that he was missing his two favorite cats, one of which had a birthday at the beginning of the month. On 04/13/23 at 10:41 AM, observed R11 alone in his room lying on his bed. R11 stated that he sees a psychiatrist. On 04/13/23 at 3:11 PM, observed R11's roommate and other residents were in the common area eating their afternoon snack while R11 stayed in his room. Record review of R11's Admission Record revealed that he is a [AGE] year old resident admitted to the facility on [DATE] for low blood sodium level, Parkinson's Disease, and recurrent major depressive disorder. R11's Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 11/13/22 revealed under Section D Mood a PHQ-9(C) (Patient Health Questionnaire-9 to determine the severity of depression) score of 6 signifying mild depressive symptoms. Section F Preferences for Customary Routine and Activities noted under F0500. Interview for Activity Preferences that it was important for R11 to be around pets. Review of the progress notes revealed an Alert Note written on 04/09/23 at 04:06 AM stating that R11 was being monitored due to the increase of his trazadone (antidepressant medication) dosage. The Order Summary revealed an order for trazadone 50 mg (milligrams) written on 04/06/23 to be increased from one tablet to one and a half tablets. There was no documentation by psychiatry and the Advanced Practice Registered Nurse (APRN) found in the progress notes to explain why the dosage was increased. On 04/13/23 at 2:39 PM, queried the Social Services Director (SSD) as to why there were no psychiatry notes in R11's chart. SSD stated that the psychiatry office did not want to release them to the facility. On 04/13/23 at 4:02 PM reviewed R11's psychiatry notes that were requested from the psychiatry office on behalf of the state agency (SA). Psychiatry notes on 04/06/23 revealed that R11 was feeling more depressed during the week because he was missing his cats and remembered that April 1st was their birthday. On 04/14/23 at 08:32 AM, interview was done with the APRN. She stated that R11's trazadone was increased because he was experiencing more depressive symptoms at the beginning of this month. APRN does not know what happened to the progress note she documented in the electronic health record (EHR) so all staff may not be aware of R11's current state. On 04/14/23 at 09:45 AM, SSD was interviewed. SSD stated that if she knew the outcome of R11's psychiatry visits, SSD would have followed up with him frequently. SSD stated that R11 was currently on an outing to the pet store to pick up parakeets for him to look after.

Based on observation, interview, and record review, in response to a COVID-19 outbreak (one positive direct-care staff member) identified on 05/16/22, the facility failed to ensure appropriate protective and preventive measures for COVID-19 were executed, as evidenced by the facility failing to follow and implement their infection prevention and control policies and procedures, including the transmission-based precautions and testing procedures of their COVID-19 Plan to control and prevent the spread of COVID-19. Due to the Centers for Disease Control (CDC) moving the COVID-19 Community Level to HIGH on 05/14/22, failure to follow the facility policies and CDC recommendations related to COVID-19 had the potential to contribute to the transmission and spread of COVID-19 in the facility's vulnerable population. As a result of this deficient practice, staff and patient safety was compromised and an immediate jeopardy (IJ) was identified. In addition, the facility failed to ensure a systematic screening and thorough testing process, failed to ensure staff conducting point-of-care (POC) COVID-19 testing in the facility were properly trained, and that they conducted the testing per CDC and manufacturer guidelines. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. The State Agency (SA) identified Immediate Jeopardy (IJ) on 05/18/22 at 10:43 AM. On 05/18/22 at 11:24 AM, the Administrator and Administrator-in-Training (AIT) were notified of the IJ at 483.80 (F880) and provided with the IJ template. The Administrator signed the template to attest receipt of the notice. The facility did not implement standard transmission-based precautions to contain possible spread of COVID-19 upon identification of a direct-care staff member symptomatic and positive for COVID-19. The community positivity rate for COVID-19 has been exponentially increasing (20% positivity). The facility failed to ensure all staff with exposure to a positive staff member were tested for COVID-19, failed to ensure staff members followed facility guidelines for the universal wear of N-95 respirators and face shields, failed to provide an on-site Infection Preventionist (IP) to conduct the outbreak investigation, and failed to physically distance un-masked residents in communal areas. The deficient practice has the potential to result in adverse outcomes (spread of COVID-19) to residents and staff members in the facility. On 05/18/22 at 03:22 PM, the facility provided a removal plan. The removal plan consisted of ensuring facility-wide testing was conducted and continued per CDC guidelines, providing a dedicated screener at the facility entrance to ensure a more systematic screening process, ensuring residents wore masks and were physically distanced in communal areas, and ensuring staff wore the appropriate personal protective equipment (PPE) consistently and properly by beginning PPE compliance audits. On 05/20/22 at 12:03 PM, the SA verified the IJ was removed, however a pattern of deficient practices at F880 remain. Findings include: Cross-reference to F882 Infection Preventionist Qualifications/Role. The facility failed to designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention and Control Program and works at least part-time at the facility. Cross-reference to F886 COVID-19 Testing - Residents and Staff. The facility failed to thoroughly conduct COVID-19 testing following the identification of a direct-care staff member diagnosed with COVID-19 in the facility and failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests. On 05/17/22 at 09:30 AM, observations were done at the facility entrance as the SA tried to enter. Rang doorbell next to facility main entrance at least four (4) times, and knocked on the door, with no response. No staff members were visible through the entrance door or window. Opened and entered door as it was unlocked, no alarm sounded. As SA stood in the entrance, approximately ten (10) un-masked residents were visible, many within 2 feet of each other, sitting in the activity area next to the entrance. Still did not observe any staff members. SA walked into activity area and observed Certified Nurse Aide (CNA)4 sitting right around the corner leading into the dining area. CNA4 alerted the Administrator-in-Training (AIT) of the SA presence, and the AIT informed the SA that we would need to wear an N95 respirator and eye protection in order to enter. CNA4 guided the SA through the computerized screening process. It was observed at this time that the AIT was wearing a KN95 mask and CNA4, although wearing an N95 respirator, was wearing it incorrectly with both rubber bands of the respirator secured around the lower back of her head. On 05/17/22 at 02:00 PM, observations were made in the conference room of a facility memo, dated 05/16/22, informing staff of a .staff Covid-19 outbreak ., with .a reminder that it is required for you to wear a N95 mask and shield or stoggles Moving forward we will begin written corrective action if a staff member is found not wearing the appropriate PPE [personal protective equipment] . At approximately 02:10 PM, observed several staff members approach the time clock wearing KN95 masks, red-colored or black-colored masks, or wearing their N95 respirator incorrectly. At 02:15 PM, during an interview in the conference room with the AIT, the AIT stated that the facility provided white N95 respirators for staff, and that the expectation was that staff wear only those respirators provided. Requested fit-testing documentation for staff. 05/17/22 at 02:25 PM, conducted a random audit of PPE use among staff. Observed one activities aide, and the Activities Director (AD) wearing KN95 masks as they sat in the back dining room with six residents. No one was physically distanced at the time, and all of the residents were un-masked. On the unit, observed one CNA wearing a KN95 mask as she exited room [ROOM NUMBER], and one Registered Nurse (RN) wearing a black mask as she walked through the unit. On 05/18/22 at 08:40 AM, observed Licensed Practical Nurse (LPN)1 providing direct care to un-masked residents in the activity area without wearing proper eye protection. LPN1 and the staff member conducting screening at the entrance were both wearing their N95 respirators improperly as well, with both rubber bands secured behind the lower back of their heads. On 05/18/22 at 08:55 AM, during an interview with RN1 at the upstairs nurses' station, it was observed that although RN1 was wearing her N95 respirator properly, it was slipping off of her nose and she had to repeatedly pull it back up into place. During an interview with the AIT on 05/18/22 at 08:57 AM in the DON Office, the AIT stated it was CNA1 that tested positive on 05/16/22. When CNA1 arrived to work he tested positive and was immediately sent home. The AIT did not know when CNA1 worked last (prior to testing positive). When asked about contact tracing, the AIT stated that the facility was not conducting any contact tracing, but that everyone was tested on Monday (05/16/22). The AIT explained that staff had already been on a twice a week testing schedule prior to CNA1 testing positive, so that was being continued. On 05/18/22 at 11:24 AM, the Administrator and Administrator-in-Training (AIT) were notified of the IJ at 483.80 (F880) and provided with the IJ template. On 05/18/22 at 03:22 PM, the facility provided an IJ removal plan. The Administrator confirmed that in the physical absence of a DON and IP, no one had been conducting infection control audits. The AIT stated and provided documentation that staff training and in services on [COVID-19] Outbreaks, Standard and Transmission-Based Precautions, Linen Handling, Resident Equipment Sanitation, Donning and Doffing PPE, and Hand Hygiene had all been conducted at the end of April 2022 by their Maintenance Director. The facility could not provide the SA with documentation of the Maintenance Director's training and qualifications in infection control as requested. A review of the facility's COVID Reopening [sic] Policy, revised on 03/24/22, the following was noted under Core Principles of COVID-19 Infection Prevention: Physical/social distancing as least six feet between persons, in accordance with the CDC. Appropriate staff use of Personal Protective Equipment (PPE). These core principles are consistent with the .(CDC) guidance .and should be adhered to at all times. The following was noted under PPE and Source Control: Staff must wear eye protection for all resident care encounters when the community transmission rates of their county are high . The following was noted under Indoor Visitation: If the facility or nursing home's county COVID-19 community level of transmission is substantial or high, all residents or visitors, regardless of vaccination status, should wear face coverings or masks, and physically distance, at all times. During a review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated on 02/02/22, the following was noted: Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). On 05/18/22 at 08:38 PM, during a review of the facility's Resident COVID-19 vaccination status, it was noted that six residents were not up to date and one resident was completely unvaccinated. On 05/20/22 at 09:00 AM, during an interview with LPN1 at the nurses' station, LPN1 confirmed that she had no knowledge of which residents were up to date on their COVID vaccinations or not. LPN1 was aware of the one resident who had not been vaccinated but did not know of any special treatment or restrictions required for her care. LPN1 also confirmed that there were no residents on quarantine during the outbreak investigation started on 05/16/22.

Based on observations, record reviews, interviews with staff and family representative, and review of the facility's policy and procedure, following an incident of sexual abuse (04/30/22), the facility failed to consistently implement interventions to reduce unsafe wandering behavior. The facility also failed to monitor interventions for efficacy. This deficient practice placed female residents of the facility at risk for sexual abuse and placed the Resident (R)21 at risk for altercation with other residents. On 05/19/22 at 10:54 AM, Immediate Jeopardy was called. The facility leadership was informed and the State Agency (SA) requested immediate action to prevent repeat of this failure. The facility provided a removal plan on 05/19/22. The SA accepted the removal plan. Implementation of the removal plan was validated onsite through observations and interviews with staff members. The Immediate Jeopardy was removed on 05/20/22 at 12:06 PM. Findings include: Cross Reference to F600. R21 has a known history of wandering into other residents' rooms, resulting in R21 entering R40's room and found rubbing her stomach and groin area. On 05/17/22 at 11:45 AM, observed R21 sitting on the side of his bed eating his lunch. There were multiple bottles of water on his overbed tray. The forward wheel walker was placed next to his bed. R21 was not observed to participate in activities or have meals in the dining room. On 05/18/22 at 09:50 AM, 12:15 PM, 01:25 PM and 02:45 PM observed R21 in his room, asleep. R21 was not observed in the dining/activity room or living room area. At 04:08 PM, R21 was observed in the dining room, seated in a recliner with an overbed tray placed in front of him across the nurses' station. A forward wheel walker was placed next to him. On 05/19/22 at 09:30 AM observed R21 seated in the living room area. His t-shirt was raised up to his chest, exposing his stomach. R21 ate lunch in the living room area. On 05/20/22 at 09:12 AM observed R21 seated in the living room, he got up and was observed ambulating with Certified Nurse Aide (CNA)8 following him. CNA8 stated she was going to provide a shower. R21 used his forward wheel walker to ambulate. A handled bell was tied to the area where the horizontal and vertical bar of the walker intersects. R21 and CNA8 were followed back to his room. Observed the bell was leaning against the bar, not allowing it to swing and ring. The ring was barely audible and was heard intermittently. At 10:20 AM, R21 was observed in group activities. As R21 entered the room, the sound of the bell was inaudible. He was not seated next to female residents and participated in balloon toss (using a fly swatter). On 05/17/22 at 12:01 PM a record review was done. R21 was admitted to the facility on [DATE]. R21's diagnoses include but not limited to [CONDITION(S)] with behavioral disturbance and major depressive disorder, recurrent. A review of the Order Summary Report notes R21 has physician orders for [MEDICATION(S)] tablet, 20 mg in the morning for behavioral exacerbation, increased libido, decreased mood related to [CONDITION(S)] with behavioral disturbance (start date of 05/03/22); [MEDICATION(S)] tablet Delayed Release, 125 mg by mouth in the morning related to [CONDITION(S)] with behavioral disturbance (start date of 03/10/22); [MEDICATION(S)] tablet Delayed Release, 250 mg in the evening for increased moods, agitation, exit seeking, and [CONDITION(S)] related to [CONDITION(S)] with behavioral disturbance (start date of 03/09/22); donezepil HCI tablet, 10 mg at bedtime related to [CONDITION(S)] without behavioral disturbance (start 03/05/22); and [MEDICATION(S)] tablet, 6 mg by mouth at bedtime for therapeutic use for [CONDITION(S)] (start date of 03/05/22). A review of the quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 04/16/22 notes R21 yielded a score of three (severe cognitive impairment) when the Brief Interview for Mental Status (BIMS) was administered. R21 was coded to require supervision with set up for walking in room (how resident walks between locations in his room) and walking in corridor (how resident walks in corridor on unit). R21 requires supervision with one-person physical assist for locomotion on and off unit. In Section E. Behavior, R21 was coded to exhibit behavioral symptoms one to three days during the seven day look back period: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing other sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R21 was not coded for wandering. Review of elopement assessments (Elopement Review - V2) found R21 was assessed on 01/12/21, 04/10/21 and 07/10/21. R21 was coded to be at risk for elopement. There were no subsequent assessments. The assessment dated [DATE] include the following interventions, anticipate and meet resident's needs, encourage resident to remain in supervised area when out of bed, monitor whereabouts Q15 [every 15] minutes and PRN [as needed], resident knows how to open doors and lift gates off of hinges & secure all doors and gates both coming and going from facility, provide structured activities, toileting, ambulation inside and outside and snacks, redirect resident back to wife's room when wandering, resident responds to wife giving direction and re-orientation. A review of the facility's map found R21's new room (room 10) is in a separate unit, at the back of the facility. This unit does not have a nurses' station. The facility's nurses' station, activity room, and dining room is located at the front of the facility. There is no visual to the R21's unit. A review of the map shows in order to return to his former room (room 10 to room 14 which is separated by a breezeway/courtyard), R21 would have to exit out the door to the right of his room at the end of the unit, walk across the breezeway/courtyard on a cemented pathway, and enter the unit through another door. This path does not cross the nurses' station. Another pathway would involve R21 to walk down the hall of his unit via tilted ramp, pass rooms 9 and 8, make a right turn to pass through the corridor (past rooms 3, 4, and 5), then walk past the nurses' station to the back to reach his former unit. A review of the progress notes found an entry dated 04/30/22 at 08:44 AM documenting after the incident, R21 was moved from room 14 to room 10. Documentation of 04/30/22 at 08:59 PM notes R21 wandered into room 8 which is occupied by two female residents. Room 8 on the map is located at the end of the unit. R21 would have to exit right out his door, head down a corner, and walk past room 9. Room 8 is located before the ramp down to the front of the facility. Subsequently, on 05/03/22 there is documentation that at 08:45 PM, R21 was found back in his old room. Progress notes of 05/05/22 at 07:08 PM, documents at 06:45 AM, resident was seen by staff wandering in other resident's room. The note of 05/07/22 at 07:43 PM, R21 made three attempts at wandering into rooms but staff was able to re-direct. The progress note does not indicate which room R21 attempted to enter. A review of the CNA monitoring documents R21 was entering other resident's room/personal space on the 05/04/22 at 10:32 AM and 05/05/22 at 07:58 PM. There is no documentation of which room R21 entered. A review of R21's care plan found no interventions to address R21's wandering behavior. Following the incident, the facility initiated a care plan, dated 04/30/22 for inappropriate sexual behavior towards staff r/t [CONDITION(S)] with behavior disturbances e/b grabbing staff in private areas, making sexual gestures. The interventions with a revision on 05/01/22 included, if resident is attempting to touch, tell resident to stop and walk away, sit resident away from female residents keep at least chair space in-between, and when possible, stand arm's length away from resident. On 05/18/22 at 11:15 AM interview was done with Licensed Practical Nurse (LPN)1 at the nurses' station. LPN1 reported R21 is good in ambulating with the walker and a bell has been placed on R21's walker to determine his whereabouts. LPN1 reported the facility has implemented Stop banners across residents' rooms to prevent R21 from entering and 15-minute checks are performed. LPN1 further reported since R21's move he has not been found in another residents' room. On 05/18/22 at 09:55 AM interviewed R60, R60 resides in room 9 (kitty corner to R21's room). Observed a Stop banner hanging from the door, inquired what is that for, R60 replied she doesn't know. Inquired how long has the banner been in use, she replied the facility put it on last night. R60 reported she is aware that a man is going into residents' rooms and this is to prevent the man from touching you. On 05/18/22 at 12:10 PM an interview was conducted with R50 and R41 in their unit. R50 reported that he has observed R21 go into R40's room and sleep with her. Inquired how did he see this, he replied, from the door. R41 is R40's roommate, she reported when she saw R21 in the room she screamed and acknowledged she saw them in bed together. On 05/18/22 at 01:37 PM an interview was conducted with Registered Nurse (RN)3. RN3 reported R21 has a history of going around and usually can be re-directed. RN3 reported after R21 was moved from room 12 to room 14 he was seen going into the room across from him (occupied by females). Inquired what interventions are being implemented to prevent R21 from entering other residents' rooms. RN3 replied check on him frequently as he is incontinent and will take his brief off on his way to the bathroom and protect female residents with the Velcro Stop signs across their door. Inquired whether an alarm is used, RN3 replied she is not sure. Further queried when are the Velcro signs affixed across the doors. RN3 responded in the evening at last round as staff go in and out frequently to provide care. RN3 reported R21 is monitored from the nursing station through the windows across the courtyard. On 05/18/22 at 02:00 PM an interview was conducted with Certified Nurse Aide (CNA)1. Queried CNA1 whether he observed R21 enter other residents' rooms. CNA1 reported seeing R21 go into R40's room (room 12) but never witnessed him touching R40. CNA1 also reported finding R21 sleeping on the bed in room 12. Further queried what interventions were implemented to deter R21 from entering residents' rooms. CNA1 responded they would close the door and use the Stop banners. CNA1 was asked if R21 can remove the banner, CNA1 responded R21 can remove the banner. A review of the facility's investigation documents interviews with six staff members (dated 04/30/22) documents R21 was observed to wander into other residents' rooms. There is no documentation of which rooms staff members observed R21 enter. The interviews with residents found four of five residents saw R21 enter another residents' room. There is no documentation of which room R21 entered. R46 (room 4) reported R21 entered her room and she told him to get out. On 05/19/22 at 08:45 AM an interview was conducted with the Administrator in Training (AIT) and Director of Nursing (DON). The DON participated via conference call. The staff members were asked whether the interdisciplinary team (IDT) met after the incident (04/30/22) to discuss and update R21's care plan. AIT responded they met in the morning to discuss. Requested documentation of the IDT's meeting/discussion. AIT reported this was not documented. Inquired what interventions were added to address R21's unsafe wandering behavior (wandering into other residents' rooms, exit seeking). Staff members reported two alarms are being utilized, alarms are placed under the resident's hips while he is in bed and one alarm has been placed on the exit door to the breezeway (the breezeway leads to the unit R21 was moved away). The DON clarified two alarms are placed under the resident's hips while he is in bed, it is tucked in so when he gets off the bed, it will alarm. The DON added a few days ago, a bell has been placed on R21's walker. Concurrent review of the care plan was done with the AIT, the AIT confirmed these interventions were not included in R21's care plan. The DON reported she can see the updated interventions on R21's care plan in the electronic health record (EHR). DON reported the bell on the resident's walker was initiated on 04/30/22 and the DON edited the care plan on 05/18/22. DON was agreeable to send a copy of the updated care plan. Review of the updated care plan with revision on 04/30/22 was provided by the AIT. The care plan addressing wandering and exit seeking behaviors related to [CONDITION(S)] with behavioral disturbances was updated on 04/30/22 (date initiated was 01/13/21) and inappropriate sexual behavior towards staff related to [CONDITION(S)] with behavior disturbances evidenced by grabbing staff in private areas and making sexual gestures was initiated 04/30/22. The following interventions were included for wandering and exit seeking behavior: check on resident whereabouts q15 minutes (revised on 05/01/22); direct resident to sit outside or sit in common area where he can be visually monitored by staff (initiated 04/30/22); divert behaviors with activity of interest (newspaper, word search puzzles, jigsaw puzzles, group activities) in common area (revised 05/01/22); monitor triggers for wandering, consider time of day, location, persons involved and situation, remove triggers for wandering if possible (initiate 04/30/22); place bell on resident's walker to notify staff of resident's whereabouts, ensuring resident does not enter another resident's room (initiated 04/30/22); place two call bells under patient's hips while in bed to notify staff of resident's movement to prevent resident from entering another resident's room (initiated 04/30/22 and revised on 05/19/22); provide seating and reading materials outside in breezeway closer to his room, resident enjoys sitting outside (initiated 04/30/22); and when resident wakes in the morning between 5:45-6:45 escort him out to common area, provide snack, drink and reading materials (initiated 05/05/22). The following interventions were included for inappropriate sexual behavior towards staff: if resident is attempting to touch, tell resident to stop and walk away (initiated 04/30/22); place bell on resident's walker to notify staff of resident's movements to ensure he is not entering another resident's room (initiated 04/30/22); place two call bells under patient hips to notify staff of resident's movements ensuring resident does not wander into another resident's room (initiated 05/19/22); sit resident away from female residents, keep at least chair space in-between (initiated 04/30/22); and when possible stand arm's length away from resident (initiated 04/30/22 and revised on 05/01/22). On 05/19/22 at 10:00 AM concurrent observation was done with AIT and Registered Nurse (RN)2. The exit door in the hallway leading to the breezeway/courtyard to the resident's previous unit was opened by the AIT. This alarm was not activated. Inquired why the alarm was not activated, AIT responded that if there are staff members providing care, it is not necessary. There were no staff members providing care on the unit. Although the DON reported using a door alarm on the exit, this was not included in the resident's care plan nor was it implemented as the alarm was not engaged. AIT asked RN2 to assist in the demonstration of the alarms placed in R21's bed. R21 was out of bed at this time. Observed two touch call lights clipped to the resident's left, toward the edge of the bed. RN2 reported one call light is placed at the hip and the other by the resident's arm. RN2 explained the call lights are placed by hip and arm so it will activate when R21 turns to get out of bed. The call light was not placed in accordance with R21's care plan or as reported by the DON. RN2 also reported a bell is placed on R21's walker so staff can hear him in the facility. Observed another walker in the resident's room without a hanging bell. RN2 confirmed R21 has two walkers and the walker in his room did not have a bell on it. Requested manufacturer's use of call light pad as an alarm. The AIT provided a flier for specialty call cords. The facility is utilizing a mechanical pad as an alarm system to notify staff when R21 gets out of bed. The mechanical pad is a nurse call device, it is a flat surface approximately the size of a hand that can be clipped to the bed linen. Further queried whether the use of the mechanical pad is approved by the manufacturer as an alarm system. AIT was agreeable to follow-up. On 05/20/22 at 12:10 PM, AIT provided a copy of an email that notes the manufacturer was contacted and they don't have a manual for this product. On 05/20/22 at 10:41 AM attempted to conduct an interview with the Doctor of Nursing Practice (DNP) regarding the pharmacological interventions that have been implemented. Inquired if she was aware of the incident and the behaviors R21 was exhibiting. Inquired what were the behaviors that R21 was exhibiting? DNP responded [MEDICATION(S)] dosage was increased as a gradual dose reduction was not effective. Reviewed the order summary of the [MEDICATION(S)] dosage with DNP and inquired whether this was an increase. DNP responded she wouldn't know because the record is not in front of her and commented, you can look at the summary. The [MEDICATION(S)] order was dated 03/09/22 (prior to the incident). Queried regarding the addition of [MEDICATION(S)] (behavioral exacerbation, increased libido, decreased mood) and how this medication works. DNP stated it affects the frontal lobe. Further queried how long does it take for this medication to reach therapeutic levels, DNP responded it varies for individuals. The interview was discontinued as DNP appeared uncooperative. The progress notes of 04/30/22 at 08:59 AM documents R21 wandered into room 8 where R80 and R81 live. On 05/18/22 at 10:00 AM observed no stop banner across the door of room 8. Also observed a female resident asleep in room 8. R21 was observed asleep in his room. Record reviews for the female residents living in room 8 was done. The female residents residing in room 8 are both vulnerable residents. On 05/18/22 at 08:48 AM record review was done for R80. R80 was admitted to the facility on [DATE] with diagnoses including but not limited to displaced intertrochanteric fracture of right femur, cognitive communication deficit, and dysphagia. A review of the MDS with an ARD of 04/18/22 notes R80 has short and long term memory problems with severe cognitive impairment. R80 has not walked in her room and requires extensive assist with one-person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Record review for R81 was done. R81 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus and low back pain. A review of the admission MDS with ARD of 03/06/22 notes R81 with severe cognitive deficit. R81 requires limited assistance with one-person physical assist for bed mobility and transfer. R81 is able to use a walker for ambulation and with supervision and limited assistance is able to walk in room and corridor.

Based on review of an event report submitted by the facility, record reviews, interviews with staff members, residents, and family members, and review of the facility's policy and procedures, the facility failed to ensure a resident was free from sexual abuse. Findings include: Cross Reference to F689. Resident (R)21 has a history of wandering into other residents' rooms. The facility failed to monitor interventions for efficacy and consistently implement interventions to prevent the resident from wandering into other residents' rooms. On 05/02/22 at 01:23 PM the facility sent an Event Report to the State Agency (SA) via facsimile regarding resident-to-resident abuse. The facility documented on 04/30/22 at 06:31 AM, the night shift Charge Nurse (CN1) called to report Resident (R)21 was in R40's room standing next to her bed and touching her near her stomach and groin area with his hands on the outside of the resident's blanket. The facility submitted a completed report on 05/03/22 at 02:34 PM via facsimile. A review of the completed report was done. Following the incident, on 04/30/22 at 08:45 AM, a room change was done for R21, he was moved to another unit of the facility. The facility also implemented 30-minute checks for wandering behavior and room change alert. On 04/30/22 at 09:49 AM, Administrator in Training (AIT) interviewed R40. R40 confirmed someone entered her room earlier and identified R21 as the person that entered her room. R40 denied R21 climbing into her bed and laying down with her. She reported he was standing over me and touching me all over my body, it was like he was patting me all over. R40 also reported to AIT that R21's hands were outside of her blanket. AIT informed R40 that R21 had a room change and is now in another part of the building, R40 reportedly stated that she hopes he is okay. R40 reportedly stated she is fine and appreciates everything everyone does for her. R40 continues to eat 75-100% of her meals, continues to participate in activities of choice and remains on alert charting with no changes to mood/behavior or activities of daily living. The facility reported in addition to room change and 30-minute checks, interventions were updated to include, two alarm placed under resident when in bed, an alarm was installed at resident's door for when he exits the room, when he is ambulating on the unit to direct him to sit outside or common area where he can be visually monitored, and to provide resident with activities. The facility provided an in-service to Certified Nurse Aides (CNAs) that provide care to R21. The facility noted R40 resides in the room R21 previously shared with his wife. R21's wife passed away on 08/14/21 after [AGE] years of marriage. The facility surmised R21 may have awoken that morning in a confused state and wandered into the room he shared with his wife to look for her. A review of the progress notes found an entry dated 04/30/22 at 05:37 AM by CN1. CN1 documented she responded to call bell in room [ROOM NUMBER]. CN1 found R21 already in R40's bed with his left hand touching her groin area and right hand rubbing her stomach. R21 was observed to attempt to go on top of her but this writer and other staff members were able to anticipate. Subsequent note at 05:40 AM documents R21 was found sitting down on the side of R40's bed. R40 reported R21 touched her but stated she was fine and did not appear to be in distress. CN1 asked R40 if she feels threatened/afraid and R40 stated that she felt safe and was not afraid. On 05/18/22 at 09:50 AM an interview was conducted with R41, R40's roommate. R41 was unable to state her name, however, nodded head yes when her name was identified (printed on a book). Asked her if she knows R21, she nodded head for yes. Asked if R21 came into their room. She responded, no. On 05/18/22 at 11:00 AM an interview was conducted with R40's daughter via telephone. R40's daughter could not remember the date of the incident, however, was informed by the facility of the incident. R40's daughter reported somebody went into her mom's room and was touching her mom inappropriately. R40's daughter was aware her mom currently resides in the room that R21 shared with his wife. Inquired whether she spoke with her mom about the incident, she reported Mom is probably embarrassed about the incident. R40's daughter further shared she has refrained from talking about it as she does not want to further traumatize mom. Further queried whether she thought the touching was consensual, R40's daughter replied, no. Inquired if she has observed any changes in her mom. R40's daughter replies mom seems different; she reports mom isn't as perky and the last time she visited mom was tapping on the wall with her fingers. She asked her mom what she was doing, mom reportedly told her she does this so they'll hear me. R40's daughter also reported, mom's eating has declined and now consuming 25% of her food. The facility has requested R40's daughter bring food from home. She has been bringing sushi, namasu, and pork tofu for her mom. R40's daughter expressed the incident may have affected her mom's change or it may be due to advanced age (going to be [AGE] years old in June). On 05/18/22 at 11:45 AM an interview was conducted with R40. R40 was eating lunch, asked her if she recalled an incident with a man. R21 responded he touched me. Inquired whether she was scared, she said yes. Further asked if he tried to get into bed with her, R40 replied man do that. Further inquired and stated she did not want him to touch her. R40 was asked if she is afraid of him, she replied no. On 05/18/22 at 12:10 PM interviewed R41 and R50 as they were sitting together in the atrium. Inquired if they would see R21 enter other residents' rooms. R50 said he has seen R21 enter room [ROOM NUMBER] (R40 and R41 reside in this room). R50 stated he is aware of one time when R21 slept with the lady in bed. Asked how he knows this; states he can see in the room. On 05/18/22 at 08:17 PM, a telephone interview was conducted with CN1. CN1 reported, R40's roommate pressed the call button at approximately 04:50 AM. CN1 responded and found R41 (roommate) pointing to R40 and R21. CN1 observed R21 sitting on R40's bed touching her groin and stomach area. Inquired whether R21 attempted to get on top or lay next to R40. CN1 responded he tried to get on top of R21 and with assistance from CNAs was able to stop him. Inquired whether R40 wanders into other residents' rooms. CN1 replied R40 goes into rooms [ROOM NUMBERS]. CN1 reported female residents reside in these rooms. CN1 stated a Stop banner is placed across the doors of rooms [ROOM NUMBERS]. Further queried whether R40 can remove the signs, CN1 replied R40 is able to remove the signs. CN1 reported R40 is ambulatory, able to get up himself. Asked if R40 can get back to his old room, CN1 responded, he is able to get back to his old room, however, a bell has been placed on his walker and you can hear him. CN1 reported this is the first time R40 exhibited this behavior. On 05/18/22 at 09:00 AM, a record review was done for R40. R40 was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) was done. The quarterly MDS with an assessment reference date (ARD) of 05/08/22 notes R40 yielded a score of 10 (moderately impaired) when the Brief Interview for Mental Status was administered. A comparison of the significant change evaluation with an assessment reference date (ARD) of 02/05/22 and the quarterly assessment with an ARD of 05/08/22 was done. In Section D. Mood, the significant change assessment found no mood indicators were present. The subsequent quarterly assessment (ARD of 05/08/22) documents R40 with indicators of mood. R40 exhibited the following mood indicators, feeling tired or little energy in the past 12-14 days (nearly every day) and poor appetite/overeating in the past 2-6 days (several days). The quarterly assessment also documents R40 exhibiting behavior of having trouble concentrating on things in the past 2-6 days. Further review found the Interdisciplinary Care Conference V-4 dated 05/02/22 was incomplete with an error message. On 05/17/22 at 12:01 a record review was done for R21. R21 was admitted to the facility on [DATE]. R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his quarterly MDS with ARD of 04/16/22 notes R21 has severe cognitive impairment. R21 was coded to require supervision with set up for walking in room and walking in corridor. R21 requires one-person physical assist for locomotion on and off unit. On 05/18/22 at 09:15 PM review found an entry by Doctor of Nursing Practice (DNP) dated 05/02/22. R21 noted to weigh 200.4 lbs. and was seen due to increased libido. R21 was noted to have been on an antidepressant along with [MEDICATION(S)]; however, a gradual dose reduction was down without a gradual return of previous behaviors. Resident was prescribed [MEDICATION(S)] for mood and behavior. Subsequent entry dated 05/18/22, DNP notes R21 tolerating [MEDICATION(S)] well with reduced hypersexuality and libido episode. Staff informed DNP resident has not been exit seeking recently and has been easy to re-direct. On 05/20/22 at 10:41 AM attempted to conduct an interview with DNP regarding the pharmacological interventions that have been implemented. Inquired if she was aware of the incident and the behaviors R21 was exhibiting. Inquired what were the behaviors that R21 was exhibiting? DNP responded [MEDICATION(S)] dosage was increased as a gradual dose reduction was not effective. Reviewed the order summary of the [MEDICATION(S)] dosage with DNP and inquired whether this was an increase. DNP responded she wouldn't know because the record is not in front of her and commented, you can look at the summary. The [MEDICATION(S)] order was dated 03/09/22 (prior to the incident). Queried regarding the addition of [MEDICATION(S)] (behavioral exacerbation, increased libido, decreased mood) and how this medication works. DNP stated it affects the frontal lobe. Further queried how long does it take for this medication to reach therapeutic levels, DNP responded it varies for individuals. The interview was discontinued. On 05/19/22 at 08:45 AM an interview was conducted with AIT and the Director of Nursing (DON). The DON participated via telephone. Inquired whether the interdisciplinary team (IDT) met after the incident to discuss and update the care plan. AIT responded the IDT met the next morning, requested to review the IDT notes, AIT responded there is no documentation of the IDT discussion. Inquired whether this incident was identified as sexual abuse, AIT responded absolutely not. The definition of sexual abuse from the facility's policy and procedure was read aloud, AIT did not acknowledge this was an allegation of sexual abuse. Reviewed the progress note written by CN1 of R21 attempting to get on top of R40 and shared during the interview, CN1 witnessed R21 sitting on R40's bed. AIT responded R21 would not be able to get on top of R40, he can barely sit in a chair and R40 has a low bed. AIT further commented there is no way he can try. A review of the facility's policy and procedure titled, Abuse/Neglect/Misappropriation/Exploitation with revision date of 05/2019 notes the definition of sexual abuse is means any form on non-consensual contact, including but not limited to unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing and sexual harassment.

Based on observations, interviews and record reviews, the facility failed to provide care to one Resident(R)1 within professional standards of nursing practice between 05/08/21 to 05/21/21. R1 did not receive routine treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff failed to assess and report R1's severe bilateral lower extremity [CONDITION(S)] that resulted from the application of an occlusive wrap to R1's bilateral extremities (calf). The deficient practice caused increased pain and suffering for the resident and did not provide care that was at the highest practicable physical and emotional wellness. Findings include: Surveyor reviewed a complaint report of an incident that occurred on 05/20/21 when the complainant went in to see R1 at the facility and made some observations that were of great concern. R1 is a [AGE] year-old female resident who has skin cancer and fragile skin. Surveyor observed a photograph of R1's left facial profile on 05/25/21 at 3:30 PM provided by the complainant. The photograph showed a picture of R1's left ear with a dirty gauze dressing marked with a date of 05/? The dressing was soiled with a plastic occlusive dressing covering the gauze. The edges of the occlusive dressing were stuck in the resident's hair and on the back of her neck. The report revealed that when the complainant tried to remove the dressing from R1 she was crying out that it was very painful. [MEDICATION(S)] (narcotic pain killer) needed to be given to R1 so that her dressing could be changed. Surveyor observed a second photograph on 05/25/21 at 3:40 PM of R1's right lower leg with bright blue Coban adhesive tape wrapped from the mid foot all the way up over the right knee. The left leg showed a sock covering the foot with a Coban wrap covering her shin up to just under the knee. The resident's knee appeared swollen with a large purple bruise. The left foot had +3 [CONDITION(S)] (moderate swelling, on a scale from +1, trace to +4, severe); her first and third toes had purplish discolorations. Further review of the report revealed that R1 complained of pain to her swollen foot when the complainant touched them. When the complainant removed the Coban wrap from R1's legs, her skin flaked off in excessive amounts and R1 complained of her legs feeling very itchy. The complainant applied lotion to R1's legs and R1 stated that her skin felt much better. Surveyor reviewed R1's electronic medical records (EMR) on 05/26/21 at 11:02 AM. Surveyor noted there were no orders found to apply the Coban adhesive wrap to R1's lower extremities. Surveyor also noted there were no nursing notes in the progress notes that Coban was being applied to R1's lower extremities. There were no orders found about the daily dressing change to the left ear until 05/22/21. There were no progress notes found about the condition of the left ear wound or that the dressing was changed until 05/21/21. Physician orders: 05/04/2021 07:00 Monitor skin tear with steristrips [medical tape that help wound edges heal together] 5cm [centimeter] long. change dressing daily . 05/09/2021 15:00 [3:00 PM] Change dressing to skin opening to right calf daily. Cleanse site, apply [MEDICATION(S)] [antibiotic] ointment, cover with nonadherent gauze, secure with Kerlix [gauze bandage roll]. 05/09/2021 15:00 Change dressing to skin opening to right calf daily. Cleanse site, apply [MEDICATION(S)] ointment, cover with nonadherent gauze, secure with Kerlix. 05/22/2021 15:00 [MEDICATION(S)] Ointment 500 UNIT/GM [gram] Apply to left ear topically in the evening for prevention of infection. Cleanse w/NS [normal saline], apply thin layer of [MEDICATION(S)] ointment and cover w/gauze and occlusive dressing once daily. Progress notes reviewed: 05/03/2021 11:50:51 AM APRN noted -Skilled nursing to continue to provide wound care and notify if signs of infection occur such as increased [CONDITION(S)] [redness], drainage, or fever ect. [etcetera] If wound does not heal or worsens notify provider. 05/09/2021 12:10 Skin/Wound Note: Resident's skin tears assessed and cleansed. Applied steri-strips to old skin tear to left lower extremity and right knee. Resident has skin opening to right calf, moderate amount of sero-purulent [serum and pus] drainage, redness to surrounding skin, and foul odor. Notified provider via Daiya communication book. Resident denied pain at the time of her dressing change but stated sometimes it hurts. Wrapped both legs in thick gauze and applied leg protectors. Care plan (not dated) reviewed and stated under Alteration in Skin Integrity r/t [related to] altered nutrition status, thin fragile skin, musculoskeletal weakness and [CONDITION(S)] [cancer] of left ear: Assess/record/monitor wound healing per policy. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [medical doctor] (as applicable) Surveyor interviewed the Advanced Practice Registered Nurse (APRN) on 05/27/21 at 09:45 AM in the employee's lounge. The APRN stated that she was the acting primary care provider (PCP) in the facility. Surveyor asked APRN if she knew the resident was wearing the Coban on her legs, she responded that she never saw them. Whenever she evaluated R1 she never had [CONDITION(S)], she said she would not use the Coban but would order a kerlix wrap or a Geri sleeve or a padded boot to protect the skin. They have to go through with what works for them. The only reason they would put the Coban is to keep the kerlix in place. I never saw her with the teal Coban. She always had the white kerlix on and she never had the [CONDITION(S)]. The facility administrator asked me to check on R1 on 05/21/21. Surveyor asked the APRN if the nursing staff reported that resident was having [CONDITION(S)] and if she wrote the orders for the Coban, she responded No. The APRN further stated, I went in to see her after the hospice nurse came in on May 20th, by then the Coban was removed. The acrocyanosis [discoloration of the feet caused by slow circulation] may cause the feet to be purple. I didn't see any additional concerns and wrote that I would continue to see her monthly. Hospice would write the orders to remove the Coban and for other skin protectants. She refused some of the skin treatments. At 08:50 AM, observations of R1's left ear and bilateral lower extremities were made with RN10 in R1's room. RN10 removed a clean dry gauze dressing with an occlusive cover over the ear. The skin under the bottom lobe is with thin, clear drainage, no pus; wound pink/red with yellow slough. The wound measured approximately three inches by one and a half inches. Observations of R1's lower legs revealed: skin moisturized, no flaking or dry skin. R1 with no leg protectors on, sheep skin booties on both feet. RN10 removed booties. Top of right foot had a bruise approximately two and a half inches long by one and a half inches wide. Purple color. Right shin had some purple discoloration in two areas. Skin otherwise intact. The left lower leg had steri strips; one steri strip over a skin tear and another skin tear with three steri strips over it. It was located above the first one. Skin otherwise looked hydrated and intact. Above the left knee had three small purple discolorations quarter size and three small purple discolorations dime sized. Upper back of the left lower extremity (calf) had an area with five steri strips and a piece of gauze in place. Skin and strips look clean dry and intact. RN10 was unable to locate the leg protectors, looking in the bedside drawer and bathroom. RN10 noted padding on R1's wheelchair and on the side of the bed was in place to help prevent skin tears during transfers to wheelchair and bed. Surveyor interviewed the facility's Executive Director (ED) and Director of Nursing (DON) on 05/27/2021 at 11:10 AM in the employee's lounge. Surveyor asked when was the left ear dressing change and was it done prior to May 20, 2021? The DON replied, We change it every day. Surveyor asked where was the nursing documentation regarding the dressing change in the record prior to May 20, 2021, and where was the order to apply the Coban wrap. Surveyor showed the color photos received from the complainant to both the ED and DON. The DON stated, There was a daily dressing change, and necrotic tissue was removed daily. It is cancerous, that's why it looks like that. Her skin is fragile. Surveyor repeated the questions and asked, Where were the progress notes about this? No notes were found. The DON left the room. Surveyor asked the ED if this looks like prudent nursing care, and she stated No. The DON returned with some papers and gave them to the surveyor. It was the Hospice nursing notes from the May 20th visit. The DON stated that she tried everything with R1, and nothing worked, not leggings or arm sleeves. She further stated, I discussed it with the Hospice nurse, and she said it was okay. Surveyor asked the DON if it was the nurse's responsibility to notify the doctor if it was like this? (Showing picture of [CONDITION(S)]). The DON stated, Yes, if they saw it and it was bad. The Coban was a bad idea, but what can we do for this poor lady?

Based on record review and interviews the facility failed to ensure basic life support was provided to one of three residents immediately according to the resident's requested code status signed in the POLST. Findings: Record review reflected documentation that the resident was found unresponsive, not breathing and appeared pale in the living room in a high back chair on (MONTH) 29, (YEAR). Time this occurred was not reflected in the medical record with the writer stating they last sighted the resident at approximately 10:30 AM, whom at the time requested to change the blanket. The Resident Care Manager (RCM) and the Director of Nursing (DON) were immediately notified. A nursing note in the progress notes dated [DATE] written at 04:01 PM stated Resident in DNR status. Contacted Power of Attorney (POA)(NAME)x1 no answer, called spouse no answer, left message to both numbers. Called POA again and no answer. Received call from POA (daughter) instructed that resident to be a Full Code and transport to the ER. CPR initiated immediately, 911 called, CPR continued until medics arrived and took over from nursing staff. The Hawaii EMS Report dated [DATE] had documented in the Narrative: DISPATCHED TO KAUAI CARE CENTER FOR A 79 YO MALE WITH CPR IN PROGRESS PER STAFF PAT HAD AN ADVANCE DIRECTIVE THAT DNR SO CPR INITIAL NOT STARTED UNTIL THEY SEEN A POLST STATING DAUGHTER WANTED EVERYTHING DONE. CPR STARTED ,[DATE] MINUTES LATER. The medical record contained an Advanced Directive dated [DATE]. On this Advanced Directive under Section 6. End-of-Life Decisions, Choice Not to Prolong Life is ticked off. Stated in this section is: I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical uncertainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits. In Section 7 of the Advanced Directive, Choice to receive nutrition and hydration is ticked off and states in this section: I do want my life prolonged by artificial nutrition and hydration. The medical record contained a POLST with a prepared date on it of [DATE] and signed by a physician on [DATE]. In section A (Cardiopulmonary Resuscitation (CPR)) of the POLST, Attempt Resuscitation/CPR was ticked off. In Section B (Medical Interventions) Full Treatment was ticked off. Full Treatment includes care described in Section A. Use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. The POLST was signed by legally authorized person (daughter) for the resident. In the medical record there was a physician order [REDACTED]. No documented conversation about change in code status with resident's legal representative or resident was found in the medical record. There was no care plan present in the medical record pertaining to code status for the resident. An interview with the Registered Nurse (RN) that was working that day was conducted on [DATE] at 10:30 AM. The RN stated she last saw the resident at about 10:30 AM on [DATE] and the resident was requesting a blanket. The RN stated the Certified Nurse Assistant (CNA) informed her that the resident was unresponsive, and the RN called for help and checked the physician order [REDACTED]. The RN stated the resident was unresponsive with no respirations or pulse and CPR was not commenced at that time. The RN stated they called the wife and daughter twice and there was no response from either one. The RN stated the daughter called back approximately ,[DATE] minutes later and stated to do CPR on him. The RN stated the resident was wheeled back to his room and placed in his bed, prior to daughter calling back. CPR commenced by facility staff and 911 was called. The distance was measured from the living room where resident was located to the resident's bed by maintenance and measured 154 feet. A progress note dated [DATE] by the DON stated the resident was pronounced at 12:27 PM on [DATE]. A Quality Assurance performance Improvement Committee Plan was commenced on the [DATE] in response to this incident to ensure in the future no discrepancies would be present in the medical record of any resident pertaining to resident's desired code status. It was identified on [DATE], that there were discrepancies between physician orders [REDACTED]. Director of Nursing Services (DNS) or designee will initiate POLST discussion upon admission/readmission, review existing POLST, or initiate a new one. In addition, the DNS or designee will assess if an ACHD has been completed, which should reflect the resident's wishes. Any conflicting information be addressed and documented. 2). POLST will be signed by resident, AHCPOA, or surrogate. 3). DNS or designee will place a copy of the POLST in the Medical Doctor (MD) box. 4). DNS or designee will contact MD for telephone confirmation of orders. 5). DNS/RCM will be notified to Un-queue orders. 6). DNS/RCM will check order against actual POLST. 7). Copy of signed POLST and Advanced Health Care Directives (AHCD) will be placed in the Disaster Binder at the nurses stations. 8). Medical Records (MR) will scan copy of signed POLST under documents in the Electronic Medical Record (EMR). 9). DNS or designee will be notified to supervise the POLST process when a resident makes a decision to change their POLST. 10). Once admission orders [REDACTED]. They must check the POLST orders against the Physician order [REDACTED]. MR will conduct admission order audit and check POLST against physician orders [REDACTED]. Orders will be reviewed at every morning meeting and confirmed that POLST and physician orders [REDACTED]. 13). DNS or designee will review the POLST, the physician order [REDACTED]. In addition, the ACHD will be included in the discussion if non is on file or any conflicting information that needs to be addressed. 14). DNS or designee will document information in the care conference notes. This is to include documentation follow up on AHCDs if pending or none, the resident's response to the discussion and a timeline of when the next follow will be and completion time. 15). When competing weekly order summaries, the DNS will review the POLST and physician orders [REDACTED]. 16). In-services will be conducted regarding these new processes. 17). The signed green POLST will be placed in front of each disaster binder after scanned by MR. 18). Green copy of POLST will be placed in MD box for signing. 19). Physician order [REDACTED]. 20). Progress note to be documented by nurse receiving information regarding code status, verbal orders to be confirmed with MD. 21). If POA/Legal representation to sign POLST, must have signed and activated AHCD or surrogacy. 22). If there is no AHCD, encouragement to be given to obtain resident's response , and timeline of process to be completed including follow-up. 23). Quarterly M[NAME]K Code Checklists implemented to identify opportunities for improvement. 24). Automated External Defibrillator (AED) systems in place. 25). Nursing to use Admissions Checklist to ensure resident's POLST/AHCD are reviewed and documented. 26). MR checklist to ensure code status orders are in place and copies of POLST/AHCD are readily available. 27). Admission Liaison to evaluate the residents POLST/AHCD status prior to or upon admission and provide nursing with the documentation to effectively initiate an appropriate discussion with the resident/representative (HCPOA or surrogate) confirm code status, and retrieve MD orders as necessary. 28). Admission's nurse to check off POLST/AHCD items appropriately on the admission checklist: adding in comments if needed for further follow up. 29). MR will utilize an admission's audit checklist to ensure code status order that hads been inputted into PCC matches the POLST. 30). Nursing shift report to review code status and changes to order. 31). Copies of the POLST will follow the resident when out of the facility. Documentation was obtained that all the above mentioned interventions were conducted and are ongoing. Mandatory in-services were conducted with all staff, including the attending physician, by a lawyer bought in by the facility to educate staff on the differences between an Advanced Health Care Directive and a POLST. Inservices will continue on an annual basis along with with being part of the orientation process for new staff. Observations and documentation reviews conducted during the abreviated survey reflected that the incident that occured was due to past non-compliance with no current non-compliance evident.

Based on record reviews, observations and interviewed the facility failed to provide the necessary care and services to attain and maintain the highest practical physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 4 of the 30 residents in the Stage 2 Sample. Findings include: 1) The facility failed to assess and reinforce the fluid restriction orders for a resident on [MEDICAL TREATMENT]. On 7/29/2015 at 9:39 AM a record review was done for Resident #68 (Res #68). Res #68's care plan included 8. Alteration in hydration fluid restriction 1000cc daily. Interventions: 1. fluid restriction 1000 ml in 24 hours by MD order; 3. Monitor fluid intake and output closely and document. The fluid restriction order was dated 7/20/15. Res #68's fluid intake and output record was reviewed. On for 7/23/15 fluid intake was 1210 ml; on 7/26/15 fluid intake was 1500 ml; 7/28/15 fluid intake was 1200 ml. Nursing notes reviewed found no documentation by licensed staff about fluid intake on the days when Res #68 went beyond the recommended 1000 ml. On 7/29/2015 at 10:33 AM a concurrent record review was done with the Director or Nursing (DON) on Res #68's fluid intake. When asked about the policy for days when the Res#68 went beyond the 1000 ml fluid restriction, the DON stated CNA's are suppose to tell the LN. The LN should be writing about her going over, looking at her weight; lungs - I don't see that in here. On 7/29/2015 at 10:56 AM a concurrent review of the fluid intake for Res #68 was done with Licensed Nurse #1. LN#1 stated on the days when fluid intake is more than the 1000 ml the procedure is to talk to my staff, I should write on the days 'fluid restrictions not met' and the staff should look after him/her. 2) During stage 1 and stage 2 observations, R#48 was observed to have bruises on both forearms. There was no documentation in the progress notes in regards to the bruises and there was no care plan developed. During the interview with the RCM on 7/30/15 at 09:03 A.M. she acknowledged that it should have been assessed and care planned. 3) Res #47 was observed to have bruises to both forearms on 7/27/15 during the Stage 1 review. On 7/29/15, he was seen lying in a recliner and was noted to have skin tears to his posterior right upper arm with steri strips applied. CNA #6 said the resident often got restless, became combative at times and would bang his arms. She said, that's why it's like that noting the large, deep purplish bruising to his forearms and the skin tears. She said he did not have any sleeve protectors either, but now, I will go and ask for one. Record review noted the resident was admitted on [DATE] with a history of multiple recurrent falls with head injury, loss of consciousness, severe neck pain due to repeated trauma, malignant hypertension, agitated [MEDICAL CONDITION] possibly due to [MEDICAL CONDITION] related to his head injuries with multiple head CTs and labs done. His [DIAGNOSES REDACTED]. On 7/29/15 at 10:30 AM, during a concurrent record review with LN #1, it was found there was no care plan developed for the resident's bruises to his forearms. At 10:36 AM, interview with he DON confirmed the resident did not have a care plan. The DON verified there was nothing about the skin tear in the TAR and failed to recognize the concern related to the number of bruises documented on the TAR, which the licensed staff were only monitoring daily. The extent of the documented injuries included the following: 7/5/15 - Bruise to Lt (left) elbow 4.5 x 2.5 7/5/15 - Bruise to Lt (left) FA (forearm) with skin tear 11.5 x 10 cm 7/5/15 - Bruise to Lt (left) top hand 7 x 3.5 7/5/15 - Scattered bluish bruise to Rt (right) inner upper thigh - 2.5 x 2 cm, 1 x 1, 0.5 x 0.5, 0.6 x 0.6 Monitor skin tear LFA 7/6/15 - Monitor Rt (right) side of face pinkish 7/23/15 - Monitor bruise to middle of back 3 x 1¾ in length. On 7/29/15 at 10:59 AM, the charge nurse, LN #1 confirmed the entries in the TAR should be separate and not combined as it was written for the bruise with skin tear 11.5 x 10 cm. She was queried as to what the cause of the bruises and skin tears were from, but surveyor received no response from LN #1 except that she was monitoring every day and, he's on aspirin. On 7/29/15 at 3:38 PM, the resident was in the dining room doing a table activity. He now had bilateral orange cut-out looking sleeve protectors on. However, his wheelchair remained the same without any protective padding to it. The DON acknowledged they had just put in an order for [REDACTED].>A re-interview of CNA #6 was done on 7/30/15 at 8:32 AM. CNA #6 said the resident got restless, was impulsive and thought that he got the bruises sometimes in his own wheelchair he bangs, and he cannot keep still so it gets banged out, he spreads his arms out and pretending he has something in his hand. Sometimes, he used to get those bruises. She had been on vacation, but when I come back this past Monday, it's the first time I see it. She said, The nurses know, I asked them how come he get all that again, and they said he's so restless, combative. No, nothing protective--they just put on (protector sleeve). That's why we put him in the recliner because the armrest is soft. Because if he stays in regular chair, he gets banged up. CNA #6 said they would always report the bruises to the charge nurse and thought it was written in the TAR. On 7/30/15 at 9:07 AM, interview and concurrent chart review was done with the RCM. She stated she would have created a care plan for alteration in skin integrity and review his medications for anticoagulants that could contribute to the bruises. She said she would have spoken to the resident too about what happened in addition to interviewing the CNAs. This was not done. The RCM was then asked to review the TAR entries about the resident's multiple bruises. She replied, Something is not right. These are on the same day (7/5/15). The RCM said she also did not know who wrote the 7/5/15 TAR entries because they were not initialed. The RCM could not find any clinical entry in the record as well for the multiple bruises and skin tears, and said at that time, there was another RCM who oversaw the unit and is no longer employed at the facility. The RCM also said an incident report would have been done for something like this. This was not done. In addition, LN #1 who was present, stated she was aware of it and stated, they were there referring to the TAR entries. LN #1 continued to sign off on many of the TAR entries daily from 7/5/15 and this was confirmed by the RCM. The RCM said as the charge nurse, LN #1 would have been responsible to complete an incident report for injuries of this extent and report it to DON as well for further investigation. The RCM also verified the attending physician was not notified the bruises documented on the 7/5/15 TAR entries. She verified there was no clinical documentation in the resident's record and said, there's nothing on 7/5, but on 7/3, the resident was combative and then the 7/5/15 entries (TAR) all clustered on one day, and no one initials it. The RCM acknowledged with the multiple bruises/skin tears noted on the TAR, licensed staff failed to query whether the bruising was due to potential abuse and neglect. She also said, one entry to mean the bruise and skin tear was of 11.5 x 10 cm--with the way it's written in the TAR, yes I would read it to be the size of the skin tear. The RCM stated the size of the bruise and the skin tear should be separate clinical entries and confirmed there no treatment orders for the skin tears as well. The RCM also confirmed the multiple documented injuries were not reported to the attending physician after reviewing the record. She said, I can't find it. She verified within their 24 hour communication book, they also did not have any documentation about the bruises/skin tears. She said the clinical expectation is that licensed staff were to report it either written or verbal. 4) R#10 L great toe injury, bruises and skin tears A. On 07/28/2015 at 09:37 AM interviewed R#10 for the Stage 1 resident survey sample. When asked of R#10 if she had any pain, she/he stated, My big toe nail on my L foot broke off and painful. Asked LN# to remove R#10's foot covering and as LN removed the foot covering the resident made guarded movements with his/her foot, and said, Ow-ow. The L great toe nail was lifted off at the tip and appeared swollen with some redness covered with ointment and strip of tape to the base of the nail. The LN#4 explained that the resident's toe nail started to lift on Friday (7/24) and tried to schedule a podiatry appt. but the next podiatry appt was in December (Dec), because there is only one podiatrist on the island. The LN#4 further stated that R#10 toe nails tend to curve in and may have fungal growth underneath the nail, which makes it difficult for staff to cut. At 10:06 AM interviewed the DON, who stated that she just found out on Monday (7/27) about R#10's L great toe nail coming off. The DON reiterated that there was only 1 podiatrist on island and the next appt was in Dec. Queried the DON why R#10 would have to wait until Dec to see a podiatrist,and she stated that she just found out yesterday afternoon and wasn't going to make R#10 wait until Dec but was going to call his/her physician. The DON picked up the telephone and called the MR to schedule an appt with the physician. After the DON got off the phone, she stated that, MR, will sched an appt for today as much as possible instead of tomorrow. When asked the DON what was the plan when she was informed on 7/27, and she stated that it was for R#10 to see her physician instead of wait until December and she wasn't sure whether the MR tried to make an appt yesterday. The DON also stated, I didn't receive an incident report. The LN#4 reported to her yesterday afternoon (7/27), and she thought that she told LN#4 to write an incident report. The DON went to get the 24 hour staff communication book and nothing was written on 7/24/15 regarding R#10's L great toe nail coming off. On 07/28/2015 at 1:33 PM interviewed LN#4 and she stated on Friday (7/24), she was alerted at 6:30 AM by a CNA (who quit working at the facility on the same day of the incident), that R#10 was complaining of toe nail pain. LN#4 assessed that the L great toe nail was beginning to lift but there was no swelling or redness. LN#4 stated that she Pushed the toe nail down and secured it with band-aid and R#10 had no complaint after that. LN#4 didn't inform the DON on Friday (7/24) and didn't have a reason why. On Monday (7/27), she informed the DON that R#10's toe nail was detaching but attached at the base. The DON told LN#4 to make an incident report today (7/28). When asked of LN#4 for the facility's process for reporting injuries, she could repeat the process; Call CM, MD, write IR, tell DON. B. During R#10 resident interview on 7/28/15, R#10 was asked about the bruises on his/her arms and he/she said that staff were rough when placing him/her back to bed. During the interview of LN#4 asked her about R#10's bruises and she stated that R#10's skin assessments are done by 3-11 shift LNs, so she did not report on the bruises and skin tears on the resident's arms. In R#10's medical record (MR), nursing progress notes on 06/9/15 at 2200 documented that at 1615 a CNA noticed reddish purple bruise to R FA 1) 7.5 x 4 cm; 2) 2.2 x 1.2 cm when transferred R#10 from recliner to wheelchair. The resident denied any pain or discomfort to affected area and had + ROM . The PCP was notified via fax . The resident denied scratching to the area and didn't remember what happened. There was Alert Charting for R#10 in the medical record, and on the 7/14/15 , 24 hour report, under the change of condition report and in the Night Shift column, it was written, R#10 restless at times crying out loud; -skin tear L arm 1.9 cm long. There was no documentation in the nursing progress notes, asked LN#3 if there were other skin assessment sheets available and she responded the treatment administration record (TAR). Looked at the treatment administration record (TAR)sheet for R#10 and documentation on: 06/26/15 - no new skin issues noted, skin remain warm, dry and intact; bruise to R FA stable. 7/15/15 - skin tear to Lt lower arm, sterstrips applied, monitor for infection, 1.9 cm long 7/22/15 - Monitor bruise to LFA 4.2 cm x 5 cm 7/24/15 - Monitor L great toe. Toe nail lifting off. Applied drsg & change daily. 7/26/15 - Monitor R mid toe - inner ingrown sm. nipped with trimming. s/s infection +/-. A head to toe skin assessment dated [DATE] documented, Res alert & confused at times. Able to make needs known. No facial grimacing noted - yelling & demanding to staff after dinner- Res needs attended by staff. Took all ___ meds w/o problems. Bruise to L FA (old) x2 4.8 x 6 cm; 1.6 x 1.4 cm. Bruise to R FA 2 x 1.6 cm , old skin tear with steristrip to L FA & L upper still persist. On 07/29/2015 at 11:52 AM interviewed LN#2 and he stated that he noticed bruise to R#10's L FA on 7/23/15 at approx 9 AM, and wondered why the night shift didn't mention anything about the bruise during shift change. LN#2 completed an IR and placed it into the 24 hour communication binder. From his recollection, R#10 stated that bruise was from a male CNA's wife (CNA walked off the job on 7/24/15 at 6:38 AM). LN#2 stated that CNA wasn't married so surmised that R#10 may be talking about a female CNA that was working with him. LN#2 asked R#10 twice about how he/she got bruise and both times replied from CNA's wife. Later, R#10 stated that CNA's placed him/her into bed roughly and bruised arm. On 07/29/2015 at 12:19 PM interviewed the DON, re: investigation for root cause of R#10's bruises. The DON investigated this AM (7/29) and spoke with CNA#1. CNA#1 told the DON that a gait belt is used to transfer R#10 back to bed so the resident's arms are not touched. The DON documented on IR, in summary that ecchymotic bruise probably from pressure of doll head. DON stated that R#10 doesn't move much in w/c and always has 2 dolls in his/her arms and also sleeps with dolls. On 07/29/2015 at 3:05 PM interviewed LN#3 as she worked NS from 7/01-18/15; and asked how R#10 is transferred from w/c to bed. According to LN#3, R#10 requires 2 man assistance and demonstrated that how assistance was provided by holding under arms to help R#10 stand to walker. Asked LN#3 about use of gait belt and she stated that gait belt used also but R#10 able to stand so sometimes CNA's will hold her arms to assist the resident. Interviewed LN#2 on how R#10 was given assistance back to bed. LN#2 stated that he will lift R#10 under her armpits to help him/her to stand because the resident is able to stand and walk to the bed with assistance. Asked LN#2 if a gait belt is used and he stated that a gait belt is also used sometimes. On 07/29/2015 at 2:44 PM interviewed CNA#1, who stated that R#10 requires 2 person assistance for transfers. CNA#1 stated that the resident can stand to the walker and the gait belt used to lift him/her from the w/c as R#10 pivots to sit on bed. One CNA will help her upper body and the other CNA will lift her legs onto the bed. A pink pull sheet is used to pull R#10 up in bed. Asked about bruises to R and L FA and CNA stated that R#10 sleeps with her dolls and always holds dolls in his/her arms. Asked about skin tears and CNA stated that she heard that R#10 fought with a CNA. When asked on what date, CNA couldn't remember details and said, That's what I heard but I'm not sure. That happened a long time ago and I think there was an incident report. CNA also stated that she works mostly day shift and on-call for night shift (NS), but mostly day shift and didn't work on 7/22 NS. On 07/30/2015 at 12:48 PM the DON provided IR's for event date 7/22/15 for bruise on L FA 4.2 x 5 cm and event date 7/24/15 L great toe nail avulsion.