Every finding on record at Kauai Veterans Memorial Hospital

Based on observations, interviews, and record review, the facility failed to ensure safe storage of perishable foods. As a result of this deficient practice, all residents have to potential to be exposed to harmfulfood-borne illnesses.Findings Include: On 02/24/26 at 08:29 AM, conducted a concurrent initial observation of the facility's kitchen and interview with the Hospital Executive Chef (HEC). The walk-in pantry (dry storage room) there were two (2) plastic containers, one contained curly egg noodle and the second one had dried shiitake mushroom; both plastic containers did not have labels. HEC was queried if containers should be labeled, after the original food packages were opened and the contents of the packages transferred to the plastic containers. HEC confirmed both plastic containers should have been labelled with the date of expiry written and employee number of the staff that printed the label when the packages were initially opened. On 02/26/2026 at 11:22 AM, conducted a follow-up interview and observation with [NAME] (C) 4. Observed minced garlic inside a plastic container inside refrigerator without proper label affixed, including missing expiration date and staff employee number. Toasted bread stored inside a pan covered with clear plastic saran wrap in the refrigerator with no label including employee number and date. Cook4 stated that the containers should have the date of expiry written on the plastic containers and staff employee number once the package was opened.On 02/27/2026 at 9:30 AM, conducted an interview with Regional Director of Nutrition (RDN). Inquired with RDN if food transferred from the original packaging to a different container, should the container the food was transferred to be labeled with an expiration date and employee number, RDN confirmed it should have been labeled. Reviewed facility's policy and procedure titled, Food Preparation and Storage with an effective date of 05/17/24. The policy instructs staff to ensure, .Items will be labeled with the date and food service employee number.

Based on observation and interviews, the facility failed to protect the confidential health information for one (Resident (R) 6) of six residents sampled for medication administration. This defecient practice has the potential to negatively impact the psychosocial well-being of residents.Findings Include: On 02/26/26 at 07:44 AM, observed Registered Nurse (RN) 2 take medications from the medication cart (located in the hallway), enter into the activity room, and give medications to R6. Observed the laptop computer on top of the medication cart had been left open and unattended, displaying R6's confidential health information from the resident's Electronic Health Record (EHR). While RN2 was administering the medication, observed three (3) staff, including non-direct care (i.e. housekeeping), with the opportunity to view R6's confidential health information. After RN2 administered the medication to R6, he/she proceeded back to the medication cart and prepare the next resident's medications, then signed off (locking) the laptop computer before walking away from the medication cart. At 07:46 AM, RN2 returned to the medication cart. Inquired with RN2 if the laptop computer should be locked/signed out of prior to leaving the medication cart to protect the resident's confidential health information. RN2 confirmed the laptop computer should not have been left open to ensure the protection of the resident's confidential health information.On 02/27/26 at 08:54 AM, conducted an interview with the Director of Nursing (DON) in the conference room. Informed the DON of an observation of the laptop computer left open with the resident's confidential health information left unattended and open. DON confirmed the laptop should have been secured and the resident's' confidential health information should be safeguarded and protected.Review of facility policy titled, Confidentiality/Privacy with an effective date of 02/10/26 stated, .Confidentiality of the patient record shall be maintained at all times by keeping the record closed when not in use.ensure that no other individual can read the screen and log-off the computer when not in use.

Based on observation, interview, and record review, the facility failed to ensure safe storage of medications. During medication administration, the medication cart was observed to be unattended, unlocked, and accessible to unauthorized individual(s).Findings Include: On 02/26/26 at 07:41 AM to 08:17 AM, observations conducted of medication administration with Registered Nurse (RN) 2 on the unit. Observed medication administration for Resident (R) 3, R10, R12, R13, R18, and R19. RN2 prepared a resident's medications, then left the medication cart unlocked as he/she went to administer the medication(s) to the resident. Observed multiple staff in the hallway with the opportunity to access the medications in the cart. After the last medication pass was completed, inquired with RN2 if the medication cart should have been locked prior to leaving the medication cart. RN2 confirmed the medication cart had not been locked prior to walking away from it and the medication cart should have been locked while unattended. Review of the facility's policy and procedure for Medications Security Maintenance on Nursing Units documented, All medications on all units shall be locked securely.

Based on interview and record review, the facility failed to ensure the Infection Prevention Control Program (IPCP) was reviewed annually. An interview with the Infection Preventionist (IP) was conducted and it was determined that the facility had not been reviewed and exceeded the annual (i.e. 12 months) requirement.Findings Include: On 02/26/26 at 02:20 PM, conducted an interview with the IP and the Regional Chief Quality and Compliance Officer (RCQCO) in the IP's office. Inquired when the Hospital-Wide Infection Prevention (Influenza, Pneumococcal and COVID Prevention Plan), Infection Control (LTC Antimicrobial Stewardship Program), and the Hospital-wide Infection Prevention (Infection Surveillance and Prevention) were last reviewed. IP reviewed the facility's internal policy review records and confirmed that the annual review of these policies and procedures had not yet been reviewed, and it has been more than 12 months since the last review. RCQCO was present during the review and became aware that these policies and procedures have not been reviewed annually, as required.

Based on observation, record review, and interview the facility failed to assure kitchen staff used non-expired Hydrion test strips to test the kitchen's three-compartment sink for proper sanitizer level to assure sufficient concentration of sanitizing solution is present to effectively clean and sanitize dishware and failed to assure the kitchen dishwasher water temperature was used and logged at 180 degrees Fahrenheit (F) or more during the rinse cycle, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents, staff, and visitors, who eat their meals at the facility, at risk for foodborne illness. The State Agency (SA) identified an Immediate Jeopardy (IJ) at 483.60 (F812) on [DATE] at 10:12 AM. The facility failed to follow the proper sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as evidenced by final rinse temperatures of the water in the High Temperature Dishwasher (using heat sanitization) that were below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda.gov/media/110822/download), in addition to not monitoring that the proper temperatures were being maintained. Widespread serious harm is likely to all residents using facility dishware and/or utensils due to risk of transmission of enteral pathogens related to improper sanitization. On [DATE] at 12:41 PM, the Regional Chief Nursing Executive and the Regional Chief Quality Officer were notified in writing of the IJ and provided with the IJ template. Both signed the template to attest receipt of the notice. On [DATE] at 02:23 PM, the SA finalized onsite verification that the IJ Removal Plan, provided by the facility and approved by the SA, had been implemented. Although the SA confirmed IJ Removal, a pattern of level 2 deficient practices at F812 remained. Findings include: On [DATE] at 10:00 AM, started initial tour of the kitchen with Food Service Manager (FSM) and Executive Sous Chef (ESC). At 10:03 AM observed the three-compartment sink that was just filled up with water and sanitizer solution. At this time, requested staff test the sanitizing solution. Kitchen staff had a container of Hydrion test strips that she used that did not have the picture of the colored strip to compare the test strip to, she stated it got lost. Requested ESC get another packet of the Hydrion test strips for testing. New test strips ESC brought out were found to be expired with expiration date of [DATE]. On [DATE] at 10:12 AM, observed the kitchen dishwasher running a wash and rinse cycle. Dishwasher showed the temperature of the washing cycle was at 150 degrees F temperature or higher, and the rinse cycle showed P2. Reviewed temperature logs for the dishwasher at this time and noticed staff wrote P2 for rinse temperature on the log for all of [DATE] and [DATE], up to today's date ([DATE]). Inquired of ESC what P2 meant, and ESC stated she did not know. Observed thermometer behind the dishwasher appeared broken as it was not registering the high temperature water running through the dishwasher. ESC stated, maintenance is working on this. ESC used a meat thermometer in the dishwasher to test the rinse temperature and found the thermometer did not register past 178 degrees F. SA requested ESC to call maintenance staff to come to the kitchen for an interview. Interview was conducted with Maintenance Staff (MS)1 and inquired if thermometer on dishwasher was broken, and he stated he has to replace the heat line and has the parts but has not had time to do it. MS1 was able to show the second boiler booster, which is located under the counter to the right of the dishwasher. Thermometer for the booster is located above the booster and at this time found it was at 170 degrees F. MS1 stated staff have to run the dishwasher one or two times for the temperature to raise up to 180 degrees F or more. Requested copies of August and September dishwasher temperature logs from ESC which she provided. On [DATE] at 11:45 AM ESC provided copies of Dishmachine Temperature Records from [DATE] which found staff started writing P2 on the dishmachine temperature rinse on [DATE]. Review of the monthly records found temperature rinse had temperatures below 180 degrees F from [DATE] to [DATE]. P2 was documented for temperature rinse logs from [DATE] and ongoing through [DATE]. Dishmachine Temperature Records states Temperatures (150 F and above for Wash) (180 F and above for Rinse). The [DATE] - [DATE] Dishmachine Temperature Records did not have any Re check Temp. or Plan of Action (Maintenance Notified) filled out for the out of range temperatures or P2. On [DATE] at 12:05 PM requested facility policy for dish washing from the kitchen manager. On [DATE] at 12:20 PM kitchen manager provided a copy of facility policy Washing Dishes with an effective date of February 23, 2021 which states III. Procedure: 6. The supervisor must maintain a dish machine temperature log to ensure that temperatures meet the established standards. Temperatures are taken by the food service employee as [sic.] a designated time and logged.

Based on record review and interview the facility failed to identify and report, within 14 days, a significant change and decline in activities of daily living (ADLs) for 1 of 12 residents sampled (Resident (R) 11). This deficient practice has the potential to affect other residents who have a decline in health status. Findings include: On 09/05/24 record review of R11's Electronic Health Record (EHR) Minimum Data Set (MDS) Annual assessment dated [DATE] and Quarterly review dated 04/26/24 revealed she had the following declines in functional limitations: limitations progressing from one lower extremity to two lower extremities, now requires substantial/maximal assistance with upper body dressing when she was previously partial/moderate assistance, and went from being able to roll left and right with partial/moderate assistance to roll left and right requiring substantial/maximal assistance. Review of R11's MDS assessments submitted to the Centers for Medicare and Medicaid Services (CMS) revealed no Significant Change in Status assessments. On 09/06/24 at 09:43 AM, interviewed the Minimum Data Set Coordinator (MDSC) and inquired if R11 had a significant change with her ADLS requiring more assistance with care. R11's MDS assessments submitted on 01/28/24, 04/26/24, and 07/21/24, were reviewed by MDSC who confirmed R11 did have a significant change with her ADLS that was identified and should have been reported to CMS .

Based on record review and interview the facility failed to accurately document the health status of two residents reviewed, Residents (R)20 and 11. R20 was incorrectly identified as taking insulin for one day and R11 was incorrectly identified as having a diagnosis of Alzheimer's Disease when she has a diagnosis of severe vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. This deficient practice has the potential to affect all the residents at the facility if their health status is not correctly identified. Findings include: 1) On 09/05/24 record review of R20's Electronic Health Record (EHR) revealed R20's Minimum Data Set (MDS) Admission assessment dated [DATE] identified her taking insulin for 1 day. Review of R20's EHR medication orders did not find any insulin orders. On 09/06/24 at 09:33 AM, interviewed Minimum Data Set Coordinator (MDSC) who confirmed resident does not take insulin and confirmed this was an error. MDSC believes it might have been a different injection she received such as an immunization. 2) On 09/06/24 record review of R11's EHR revealed she had a diagnosis of severe vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. Review of R11's Minimum Data Set Quarterly review dated 07/21/24 found R11 had Alzheimer's Disease checked off. On 09/06/24 at 09:33 AM, interviewed Minimum Data Set Coordinator (MDSC). MDSC reviewed R11's MDS Quarterly review dated 07/21/24 and saw R11 had the Alzheimer's Disease box checked. MDSC stated this was an error on the resident's MDS and confirmed that R11 does not have an Alzheimer's Disease diagnosis.

Based on interview and record review, the facility failed to develop and/or implement a resident-centered Comprehensive Care Plan (CP) for 2 of 13 residents (Residents 5 and 1) in the sample. Both residents (R) are insulin-dependent diabetics, yet neither had an active diabetes care plan. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F689 Accident Hazards. A review of R5's CP revealed no active care plan developed for Activities of Daily Living (ADLs), which would include interventions addressing her mobility and transfer needs. Resident (R)5 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her active diagnoses include insulin-dependent diabetes, and chronic kidney disease. A review of R5's electronic health record (EHR) revealed that she had a stroke with functional decline on 08/05/24. A review of R5's CP noted no resident-specific care plan for her diabetes and/or diabetes management. A review of her CP history revealed a resident-specific diabetes care plan titled: LTC [long term care] Diabetes Mellitus IPOC [individualized plan of care] that was discontinued on 06/04/24. On 09/10/24 at 09:26 AM, a concurrent interview and record review was done with the MDS (Minimum Data Set) Coordinator (MDSC) in Conference Room C. After reviewing R5's CP, MDSC confirmed that R5's diabetes care plan had been discontinued on 06/04/24 but could not explain why. MDSC stated she would look into whether R5 had a diabetes care plan between 06/04/24 and her stroke on 08/05/24. On 09/10/24 at 10:57 AM, an interview was done with MDSC at the Nurses' Station. When asked about CP management, MDSC stated that she oversees the residents' care plans, but any licensed staff can initiate and discontinue them. When asked what oversees entails, MDSC responded that she reviews each resident's care plan at least every 90 days. On 09/10/24 at 11:03 AM, during a concurrent record review and interview with the Quality Management Nurse (QMRN) at the Nurses' Station, QMRN confirmed that R5 had no Diabetes Care Plan since 06/04/24. QMRN showed MDSC and the State Agency documentation in the EHR that revealed that although a Diabetes Care Plan had been entered into the EHR on 08/15/24, it had never been initiated, so was not active. Review of the facility's Comprehensive Care Plan policy and procedure, last updated 01/25/24, noted the following: C. The planning for care, treatment and services shall include the following . Individualized to meet the needs of the resident with measurable objectives describing the steps towards achieving the resident's goals . 37954 2) On 09/04/24 during review of R1's EHR found she is a [AGE] year-old who was admitted to the facility on [DATE]. Review of R1's medications revealed she is receiving insulin daily with her morning meal to treat her diabetes. Review of R1's CP did not reveal a current CP and no interventions for resident's diabetes. On 09/09/24 at 11:30 AM, requested a copy of R1's Diabetes CP from the MDSC. On 09/10/24 at 11:15 AM, MDSC provided a copy of R1's CP. Review of R1's CP found R1's LTC Diabetes Mellitus IPOC (Completed) and had Last updated on 08/24/23 at 12:15 HST by MDSC name. Outcomes and Interventions were either discontinued or met for R1. Concurrent interview with MDSC confirmed R1 did not have a Diabetes CP.

Based on observation, interview, and record review, the facility failed to ensure 1 of 13 residents sampled (Resident 5) was free from accident hazards. Despite having a history of falls, an identified recent stroke with functional decline, and requiring a two-man assist for transfer, staff failed to lower Resident (R) 5's bed until her feet were touching the floor prior to manually transferring her from her bed to a shower chair, placing her at risk for an avoidable fall and/or injury. In addition, the facility failed to develop and implement a care plan for R5 that included/addressed her mobility and transfer needs. This deficient practice has the potential to affect all residents at the facility who require assistance to stand or transfer. Findings include: Resident (R)5 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her diagnoses include diabetes (added to diagnosis list at admission), chronic kidney disease (last updated on diagnosis list [DATE]), recurrent falls (last updated in 2019), decreased transfer ability (last updated in 2023), and history of stroke (last updated in 2022). During a review of R5's electronic health record (EHR), the following was noted under a PT (Physical Therapy) Evaluation and Treatment done on [DATE]: . requires MAX A [maximum assistance] today for sit to stand and stand pivot transfer secondary to RLE [right lower extremity] weakness . at an increased high fall risk than she was previously . While the following was noted under an OT (Occupational Therapy) Evaluation done on [DATE]: Toilet Transfer: [needs] Total assistance . Shower Transfer: [needs] Total assistance . currently max A [maximum assistance] - [to] dependent for ADLs [activities of daily living such as transferring] . On [DATE] at 08:46 AM, an observation was done of Certified Nurse Aide (CNA)2 and CNA5 getting R5 ready to be transferred from her bed to a shower chair. R5 was noted to be wearing a t-shirt, an adult disposable brief, and a pair of sneakers, as her feet dangled above the floor while seated at the edge of the bed. While CNA5 supported R5 under her right armpit, CNA2 supported R5 under her left armpit. CNA2, being the closest to the bed controls, lowered the bed to a height where R5's feet remained dangling above the floor. As CNA5 and CNA2 readied to lift R5 off the bed from under each armpit, this Surveyor stopped them and asked if the bed could be lowered any more as R5's feet were not touching the floor. CNA2 lowered the bed until R5's feet touched the floor, then they transferred her to the shower chair lifting her under both armpits. On [DATE] at 08:50 AM, an interview was done with CNA2 at the bedside while CNA5 took R5 to the shower room. When asked if they usually lower a resident's bed to the lowest setting prior to assisting a resident for transfer, CNA2 responded, not always, because the bed goes really low, and it can become difficult for a resident to stand [from the lowest setting]. While CNA2 did agree that the bed should be lowered enough so that the resident's feet can touch the ground, she explained that she didn't do that for R5 because she cannot bear weight. When asked if they should be using a mechanical lift for safety when transferring a resident that cannot bear weight, CNA2 stated that sometimes R5 can bear a little weight and assist with a transfer, but most times she cannot, so they make sure they have two (2) staff to transfer her at all times. When asked again about using a mechanical lift when they know a resident cannot assist with the transfer, CNA2 responded they haven't recommended mechanical transfers for her yet. When asked if an order or a recommendation for a mechanical transfer was necessary in order to use a mechanical lift, CNA2 answered no, and agreed that they can use it whenever they feel it is necessary. On [DATE] at 11:34 AM, an interview was done with the Minimum Data Set Coordinator (MDSC) at the Nurses' Station. MDSC confirmed that R5 had a stroke on [DATE] and as a result experienced a decline in functional abilities. MDSC also confirmed that since [DATE], at times R5 can assist with a transfer in and out of bed, but most times she cannot. While MDSC agreed that staff should use their judgement to use a mechanical lift to transfer a resident safely, she stated that 2-man manual transfers can be done safely with R5 if staff lift her under the arm and under the leg on each side. A review of R5's Comprehensive Care Plan (CP) revealed no active care plan developed for ADLs, which would include interventions addressing mobility and transfer needs. A review of the facility's Safe transfers With Use of Mechanical Lift policy and procedure (P&P), and Safe Transfers Without Use of Mechanical Lift P&P, revealed the following: Mechanical lifts are to be used for all residents that cannot assist with transfers.

Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards, including medication parameters for administration. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: 1) On 09/06/24, beginning at 08:00 AM, medication pass observations were done with Registered Nurse (RN)6. At 08:01 AM observed RN6 preparing medications for Resident (R)11, who had a blood pressure that morning of 82/45 and when rechecked, 88/51. Observed the Metolazone 10 milligrams (mg) that RN6 prepared had a medication label on the blister pack that read: HOLD FOR SBP [systolic blood pressure] < [less than] 100 OR SYMPTOMATIC HYPOTENSION [low blood pressure]. Handwritten in red pen next to that was the following: SBP<80. Observed the Furosemide 40 mg that RN6 prepared had a medication label on the blister pack that read: HOLD FOR SBP<90. Handwritten in both black and blue ink to the left of the medication label was the following: FYI: Hold < SBP 80. At 10:23 AM, concurrent record review and interview was done with RN6 at the medication cart. Regarding the Metolazone, record review confirmed that the order decreasing the parameter from an SBP<100 to an SBP<80 was changed on 06/27/24. RN6 confirmed that the medication blister pack she used that morning was sent from the pharmacy on 08/01/24. Regarding the Furosemide, record review confirmed that the order decreasing the parameter from an SBP<90 to an SBP<80 was also changed on 06/27/24. RN6 confirmed that the medication blister pack she used that morning was sent from the pharmacy on 08/19/24. RN6 could not explain why the pharmacy labels on the medications did not match the provider order(s) from over a month ago. 2) On 09/06/24 at 08:31 AM, observed RN6 preparing medications for R18, who had a blood pressure that morning of 145/58. Observed that the Losartan 100 mg that RN6 prepared had a medication label on the blister pack that read: HOLD FOR SBP<100. At 10:19 AM, concurrent record review and interview was done with RN6 at the medication cart. Record review confirmed that the original order for the Losartan on 10/30/23 was with parameters of Hold for SBP<110. RN6 confirmed that the parameters had never been changed. RN6 also confirmed that the medication blister pack she used that morning was sent from the pharmacy on 08/25/24. RN6 could not explain why the pharmacy label on the medication did not match the provider order. A review of the facility's Medication Administration policy and procedure, last updated 01/14/23, revealed the following: . RN [registered nurse] . Acknowledges and verifies orders in Electronic Medical Record (EMR). . Pharmacist . Independently verifies the Physician's order at the time of validating medication into the patient profile.

Based on observations, interviews, and record review, the facility failed to provide safe storage for delivered food items placed into the kitchen's chiller and the dietary aides failed to perform appropriate hand hygiene while delivering meal trays to residents. These deficient practices have the potential to cause harm to their residents, staff, and visitors due to the possibility of contracting a food borne illness. Findings include: 1) On 09/19/23 at 10:32 AM, conducted a concurrent observation and interview with the kitchen chef (KC) of the kitchen's chiller located outside, across from the freezer. The chiller contained a box of sour cream tubs on the floor to the left and the right side contained crates with gallons of milk and juice. KC stated that they received the delivery of those items at 10:00 AM. On 09/19/23 at 10:45 AM, conducted a concurrent observation and interview with the Director of Food Services (DFS) of the same chiller. DFS stated that the delivery personnel will alert staff that the items were placed into the chiller. DFS further confirmed that the kitchen staff should have put the items away on the shelves of the cart right away as the items should be stored at least 6 inches off the ground. Record review of policy and procedure from the Department of Nutritional Services on Infection Control, Policy No.: 140-300-1 with effective date 02/17/21. It stated, . III. PROCEDURE: . 6. Food must be stored at least eighteen (18) inches above the floor . 2) On 09/19/23 at 11:48 AM, conducted initial lunch observations. Dietary Aide (DA)1 delivered a lunch tray to resident (R)12 in R12's room. DA1 moved items on R12's tray and touched the bedside table while conversing with R12. DA1 exited the room without taking off his gloves and performing hand hygiene. DA1 proceeded to deliver the rest of the lunch trays to residents in the day room and residents in their rooms. On 09/20/23 at 12:05 PM, conducted follow up observations of lunch tray deliveries. DA2 wore gloves when delivering a tray to a resident in the day room. DA2 was back at the meal tray delivery cart when his cell phone rang in his pants pocket. DA2 proceeded to take out his cell phone from his pocket, looked at it, and then put it back into his pants pocket. DA2 did not remove his gloves and hand hygiene before taking out another lunch tray to deliver. On 09/22/23 at 09:13 AM, interviewed the Infection Preventionist (IP) in the conference room, IP was notified of lunch tray deliveries by DA1 and DA2. IP stated she expects glove removal, hand hygiene, and new gloves donned to have occurred after DA1 touched the items on R12's tray and bedside table before delivering the rest of the lunch trays. IP also stated that DA2 should have also removed his gloves, performed hand hygiene, and donned on a clean pair of gloves after placing his cell phone back into his pants pocket. IP stated that she has not done any hand hygiene audits of the kitchen staff. Record review of policy and procedure from the Department of Nutritional Services for Personal Hygiene, effective date 02/23/21, Policy No.: 140-400-5. It stated, . HAND WASHING . 3. Wash hands frequently, including after . the use of cellular phones .

Based on record review and interview, the facility failed to ensure that the family or resident representative of one resident (R)19, out of three residents sampled, was notified of R19's transfer to the emergency room (ER) for an acute condition. This deficient practice fails to protect residents from possible inappropriate facility-initiated discharges from the facility. Finding includes: On 09/21/23 at 11:54 AM, progress notes revealed that R19 was transferred to the ER due to a low blood count. On 09/22/23 at 11:11 AM, conducted a concurrent observation of R19's electronic health record (EHR) and interview with the MDS Coordinator (MDSC) at the nursing station. MDSC confirmed that R19 was transferred to theER on [DATE] as evidenced by an ER physician note documented on 08/13/23 at 09:21 AM that R19 refused her hemodialysis treatments (medical process to clean toxins out of the blood and to remove excess fluids) on Friday and Saturday. Progress notes revealed further that R19 was transferred from the ER to the intensive care unit (ICU) on 08/13/23 at 01:59 PM. There was no documentation in the progress notes found about a written notification being sent to R19's family. On 09/22/23 at 12:18 PM, interviewed the Social Worker (SW) in her office. SW stated that no written notification are sent to the resident representative or Long Term Care Ombudsman for residents that are transferred to another provider for higher levels of care.

Based on interview and record review, the facility failed to ensure that quarterly comprehensive assessments were completed no less frequently than once every 3 months for 2 of 2 residents (R) in the sample. As a result of this deficient practice, the facility placed R1 and R16 at risk of not having their needs met. This deficient practice has the potential to affect all the residents at the facility for long-term care. Findings include: On 09/21/23 at 03:00 PM, during a review of Resident (R)1's electronic health record (EHR), it was noted that R1's last quarterly Minimum Data Set (MDS) assessment had been completed on 05/20/23. The most recent MDS assessment showed an assessment reference date (ARD) or target date of 08/17/23, but had not been completed. On 09/21/23 at 03:24 PM, an interview was done with the MDS Coordinator (MDSC) at the Nurses' Station. Reviewing a Final Validation Report provided by the MDSC, it showed the assessment due on 08/17/23 had a Completion Date of 09/21/23. The MDSC confirmed that some of the care area assessments had been completed more than 14 days after the ARD, making them late. The MDSC also verified that the completion date of 09/21/23 was correct, making the assessment more than 92 days since the last.

Based on observation, interview, and record review, the facility failed to ensure one resident (R) in the sample was free from accident hazards. Despite being unsteady on her feet and requiring at least a two-man assist to stand, staff failed to lock R11's shower chair before having her stand for a transfer, placing her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all residents at the facility who require assistance to stand or transfer. Findings include: Resident (R)11 is an [AGE] year old female admitted to the facility on [DATE] with admitting diagnoses that include age-related physical disability, Diabetes, Hypertension (high blood pressure), Heart Failure, and Morbid Obesity. A review of R11's most recent quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 08/13/23, shows that for Balance During Transitions and Walking, as well as Surface-to-Surface Transfer (transfer between bed and chair or wheelchair), R11 was marked as Not steady, only able to stabilize with human assistance. Further review noted that under Mobility, for Sit to Stand: The ability to safely come to a standing position from sitting in a chair or on the side of the bed; and for Chair/bed-to-chair transfer: The ability to safely come to a standing position from sitting in a chair or on the side of the bed, R11 had been marked as needing Substantial/maximal assistance - Helper does MORE THAN HALF the effort. On 09/20/23 at 09:34 AM, an observation was done at R11's bedside. Registered Nurse (RN)6 had just completed a dressing change on a wound to R11's left shin following her shower. RN6, Certified Nurse Aide (CNA)9 and CNA8 were preparing to transfer R11 from the shower chair she was sitting on, to her wheelchair, however R11 still needed to don (put on) an adult disposable brief and her pants. Prior to having her stand, CNA9 stated she made doo-doo (defecated) [in the shower], she still get, and grabbed some moistened absorbent wipes. As RN6 and CNA8 got ready to assist R11 from sitting in the shower chair to standing, CNA8 suggested using a gait belt. CNA9 stated, no, she no like. As RN6 and CNA8 grabbed R11 under either armpit, an observation was made that the shower chair, with CNA9 standing by, had not been locked. Surveyor asked, do you want to lock the shower chair [to keep it from moving], to which CNA9 responded no, I need to move it fast that's why. RN6 and CNA8 had R11 grasp the bed rail while they assisted her to stand. As she stood, CNA9 moved the shower chair out of the way, wiped R11's buttocks with the absorbent wipes, pulled R11's adult disposable brief and pants up (all while positioned behind her), then moved her wheelchair into place where RN6 and CNA8 helped her sit. Upon further questioning regarding the safe transfer of residents, RN6 and CNA9 reported that R11 is normally a 2-person assist for transfers. Since there were three staff members present however, they did not/do not lock the chair she is transferring from because they need to move it out of the way quickly because she [R11] cannot stand long. CNA9 further explained that because they used three people for the quick transfer, they didn't lock the shower chair, but they usually do when transferring other residents. On 09/22/23 at 10:18 AM, an interview was done with the Director of Nursing (DON) in her office. The DON explained that the staff members had shared the incident with her. After the Surveyor described the observations made on 09/20/23, the DON stated it was her understanding that it was a quick transfer, meaning the shower chair was immediately switched out for the wheelchair and the resident was seated. Given the length of time R11 stood while her buttocks were wiped and her brief and pants were pulled up, the DON agreed that the shower chair should have been locked for safety. Upon further discussion, the DON agreed that all movable equipment should be locked for safety during transfer.

Based on observation, record review, and interview, the facility failed to recognize the need for closer monitoring and additional interventions to manage a significant change in physical condition for one resident (R) in the sample. Although R4 was identified with a serious, potentially life-threatening wound infection that required extended intravenous (IV) antibiotic therapy, placement of a central line (IV access into a large central vein near the heart), and an upgrade of her status to a skilled nursing level of care, the facility failed to assess the impact the infection had on her functional needs, or to refer her to the appropriate specialists for her condition. As a result of this deficient practice, the facility placed R4 at an increased risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents in the facility with worsening wounds. Findings include: Cross-reference to F637 Comprehensive Assessment after Significant Change. The facility failed to conduct a comprehensive assessment of functional capacity within fourteen (14) days of identifying a significant change in physical condition for Resident (R)4. Cross-reference to F692 Nutrition/Hydration Status Maintenance. The facility failed to provide care and services to prevent significant weight loss or to identify the need for closer monitoring and timely interventions for R4. R4 is a [AGE] year-old female admitted for long-term care on 03/29/22, then upgraded to a skilled nursing (SNF) level of care on 08/03/22. Her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's electronic health record (EHR) noted that what began as a blister-like lesion on her right great toe in April 2022 had progressed to [CONDITION(S)] and gangrene (dead tissue due to a lack of blood flow or a serious bacterial infection) of her right big toe and hallux metatarsal phalangeal (MTP) joint, or her big toe joint. On 08/31/22 at 12:55 PM, further review of R4's EHR noted that despite extensive documentation beginning in May 2022 about the worsening wound(s) on her right foot, prolonged wound infection(s), and [CONDITION(S)], no referrals were found to have been made to a wound specialist, an infection disease specialist, or a vascular disease specialist. On 09/01/22 at 10:26 AM, observations were done of Certified Nurse Aide (CNA)3 and CNA6 transferring R4 from her geriatric chair (Geri-Chair) to her bed. With the Geri-Chair in the fully upright position, it was observed that R4's feet dangled approximately four (4) inches above the ground. Both CNAs attempted to waken R4 as she slept sitting up, with no success. Observed CNA3 and CNA6 each use one arm to hook under one of R4's armpits and use their remaining free hand to grab the back of R4's elastic-waist pants. They then proceeded to lift R4 from the Geri-Chair to the bed with no assistance from her. After R4 was safely in the bed, an interview was done with both CNAs at the bedside. When asked why a mechanical lift was not used, both CNAs stated that R4 is a 2-man assist for transfer because she can bear weight on her good [left] foot and assist with the transfer when she is not sleepy. When it was pointed out that R4 was very sleepy and could not even lift a hand to assist with the transfer, nor could she bear weight on her good foot when her feet did not touch the floor, CNA3 explained that is why they transferred her the way they did. On 09/01/22 at 10:38 AM, an interview was done with Registered Nurse (RN)1 outside of R4's room. After describing the transfer that was just observed, RN1 agreed that when R4 is sleepy, as she has been lately, the safer option for both resident and staff would be to transfer her utilizing a mechanical lift. RN1 stated that all staff should be using their own judgement to ensure transfers are safe and that an order is not needed for mechanical lifts. On 09/01/22 at 02:30 PM, the DON was interviewed at the NS. After a discussion regarding R4's increased transfer, mobility, dietary, and wound healing needs, the DON agreed that R4's functional needs had to be reassessed. On 09/02/22 at 09:13 AM, an interview was done in Conference Room C with the Chief Quality Officer (CQO). The CQO confirmed that although R4's condition had been followed by two different Podiatrists (a medical professional devoted to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, and interview, the facility failed to store, label, and serve food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: 1) On 08/30/22 at 09:50 AM an initial tour of the kitchen was done with Kitchen Staff (KS)1. Observations found the three-door refrigerator contained a plastic container of balsamic vinegar dressing and a plastic container of miso labeled with a used by date of 08/23/22. In the reach-in refrigerator there was a container of chickpeas that was not labeled to identify the food item and the use by date. The reach-in freezer found a plastic bag of frozen food that was not labeled. Inquired what was in the plastic bag, KS1 replied she did not know and threw out the food item. Upon entering the walk-in freezer, observed frozen red liquid on the floor close to the door jam with frozen red liquid trailing down an empty plastic container. Asked KS1 what is that? KS1 responded it is probably frozen blood and further states this is the area where raw hamburger is stored. Also observed a box on the floor of the walk-in freezer. KS1 confirmed this was a box of frozen chicken that was just delivered. 2) On 08/31/22 at 09:50 AM a confidential resident interview was conducted. The resident reported the dishware (plates, bowls, cups) are oftentimes chipped. The resident reported that this is not sanitary. On 09/01/22 at 08:15 AM observed breakfast meal, there were three plates (white in the center with grey trimming) with chips on the perimeter. At 08:20 AM, concurrent observation and interview was done with Certified Nurse Aide (CNA)5 as she was clearing the tables. Inquired whether she noticed if there were chips in the ceramic dishware. CNA5 stated she has not noticed, however, confirmed there was a chip in the plate. On 09/01/22 at 12:55 PM concurrent observation of the dishware was done with the Kitchen Manager. Observation found five white plates with fluted edges with chips on the rim. The Kitchen Manager reported the chipped plates allow particles to permeate the plates and is not a good infection control practice. The Kitchen Manager stated she will go through the dishware and check for chips. 3) On 08/30/22 at 11:02 AM, observations were done in Resident (R)8's room as the Certified Nurse Aide (CNA)2 prepared to feed him his lunch. Observed CNA2 stir R8's pureed rice with a spoon, then stick her right index finger in it, wipe the finger on his napkin, and continued to stir. When asked about sticking her ungloved finger in his food, CNA2 explained that she was ensuring the food was cool enough to feed to the resident. As she explained what she was doing, CNA2 demonstrated the process by sticking her right index finger into R8's pureed main dish twice, in between stirring it with a spoon. When asked about hand hygiene, CNA2 explained that she washed her hands with soap and water before she left to pick up R8's lunch tray, then used an alcohol-based hand rub when she returned with the food, before she began feeding him.

Based on interview with resident council representatives, the facility did not assure residents are aware of the contact information for the State Long Term Care Ombudsman and not aware of how to contact the State Survey Agency to file a complaint. Findings include: On 08/31/22 at 09:30 AM an interview was conducted with six resident council representatives. Residents were asked if they are aware of where the Ombudsman's information is posted. Resident (R)13 was aware of the Ombudsman's name but not sure where to find the contact information. Resident (R)15 responded it is probably posted on the bulletin board. The representatives were asked if they were aware they can contact the State Survey Agency to file a complaint. The representatives could not confirm knowledge of contacting the State Survey Agency to file a complaint.

Based on interview with resident council representatives, the facility did not ensure residents were aware of the right to examine the results of the most recent survey conducted by the State surveyors. Findings include: On 08/31/22 at 09:30 AM an interview was conducted with six resident council representatives. The representatives were asked if they are aware that the State Survey Agency report is available for review. None of the representatives were aware a State Survey Agency report is available to review and they did not know where it is located.

Based on observation and interview, the facility failed to ensure a safe, clean, homelike environment for the residents at the facility, as evidenced by half of Resident (R)13's room being used for storage, and residents being taken to use the toilet and shower in the Isolation/Compassionate Care Room, a room which was also filled with storage. As a result of this deficient practice, the residents were placed at risk for avoidable decline and injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 08/30/22 at 10:36 AM observed Resident (R)13 does not have a roommate. R13's bed was placed close to the wall with a nightstand and chair next to her bed. The other half of the room was filled with seven wheelchairs, a mechanical lift and other equipment (bolsters) stacked on the nightstand. On 08/30/22 at 12:47 PM R13 was observed sitting in her room. Inquired about the stored equipment in her room. R13 explained the facility had to use a room for a resident so all the items in that room were brought to her room. R13 commented that this is a warehouse and would prefer items not be stored in her room. On 08/30/22 at 02:12 PM observed a staff member enter R13's room to get a wheelchair. R13 was sitting in her room and staff member did not acknowledge R13 upon entering her room. On 08/31/22 at 08:55 AM observed R13 was not in her room and a staff member entered her room to return a wheelchair. 2) On 09/01/22 at 08:40 AM, observed Certified Nurse Aide (CNA)1 walking a resident out of the Isolation/Compassionate Care Room (ICCR) at the end of the hall. Observation of the inside of the room noted it was filled with storage items such as wheelchairs, a bed, walkers, wedges, and nightstands, with many items piled on top of each other. A narrow path had been created between the storage that led from the room entrance to the bathroom. When asked about using the room, CNA1 stated that sometimes they will take residents to the bathroom in the ICCR because it was closer to the activity room than their own rooms. An interview with CNA6 at the same time revealed that the shower in the ICCR was used to shower all the residents in the back half of the hall. While the residents from the front half of the hall were taken to the shower room through the double doors at the beginning of the Unit. On 09/02/22 at 11:07 AM, an interview was done with the Infection Preventionist (IP) in Conference Room C. When asked about the storage in the ICCR, the IP stated that those items were stored there because there was nowhere else to put them. When the ICCR needed to be used as a Compassionate Care Room, some storage would be moved into the resident's room, who would then occupy the vacated space in the ICCR (as was the case for R13's room, whose roommate was moved into the ICCR). When asked what the facility would do if they needed to clear out the ICCR to be used as an isolation room, the IP stated that they would need to find another place to put the storage. When asked to clarify where that would be, the IP confirmed that a space had not been identified yet.

Based on interview and record review, the facility failed to provide care and services to prevent significant weight loss or to identify the need for closer monitoring and timely interventions for one Resident (R)4, as evidenced by a weight loss of 5.571% in one month. As a result of this deficient practice, the facility placed this resident at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility. Findings include: Resident (R)4 is a [AGE] year-old female admitted for long-term care on 03/29/22, then upgraded to a skilled nursing (SNF) level of care on 08/03/22. Her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's electronic health record (EHR) noted that what began as a blister-like lesion on her right great toe in April 2022 has now progressed to [CONDITION(S)] and gangrene (dead tissue due to a lack of blood flow or a serious bacterial infection) of her right big toe and hallux metatarsal phalangeal (MTP) joint, or her big toe joint. On 08/31/22 at 12:55 PM, further review of R4's EHR revealed that on 07/25/22, R4 was documented as weighing 104.1 pounds. One month later, on 08/29/22, R4 was documented as weighing 98.3 pound, reflecting a 5.571% weight loss. On 08/31/22 at 02:06 PM, a phone interview was done with R4's family representative (FR). FR shared that R4 had initially gained weight when she was admitted to the facility and told her that she enjoyed the food. As time passed, with the development of the right foot wounds, FR stated that R4 has not seemed to be eating as much and has been sleepier than usual. FR expressed that she is concerned about R4 losing weight, stating that R4 is not even interested in her favorite foods that FR brings from home. When she asks the facility about R4 losing weight, FR stated that she is told that R4's weight is stable. On 09/01/22 at 03:20 PM, additional review of R4's EHR was done. The following was noted regarding her nutritional assessments and interventions: Nutrition Evaluation done on 04/10/22 documented a regular diet, thin liquids, weight stable with an Average Meal Consumption Per Day: 75-100%. Nutrition Evaluation done on 07/07/22 documented a chopped diet with thin liquids, overall beneficial weight gain, with an Average Meal Consumption Per Day: 50-74%. No changes were made to R4's nutritional plan at that time. No nutrition/dietary referrals, notes, or assessments found between 07/07/22 and 08/12/22, despite a change in condition identified on 08/03/22. Nutrition Note done on 08/12/22 documented the following: Discussion of wounds with Interdisciplinary Team on 08/11/22 . Nutritional concerns d/t [due to] resident with wounds. High protein needs d/t ulcer to promote wound healing. Resident with recent decline in oral intake . Per RN [Registered Nurse] notes on 08/08 - [08/]09, poor oral intake AEB [as evidenced by] ate only 25% of her meals, ate only 3 bites and 100ml of her fluids for breakfast, stated, I wanna die, I don't wanna eat . The interventions implemented were to add eight (8) ounces of a nutritional shake three times a day with meals, and a recommendation to continue encouragement and cueing at meal times [sic]. Nutrition Consultation done on 08/16/22 documented the following: Consult: Weight Difference .Resident continue with poor oral intake AEB RN Notes (08/12 - 08/15) detailing meal intakes are 25% or less, refusal of supplement, poor appetite, requirement of much encouragement to eat and drink .Resident on regular, bite sized, thin liquids .Continue to encourage oral intake. Will continue to monitor. Further review found no indication on the frequency of the monitoring that would be done, no calculation of caloric, hydration, or protein needs, and no changes in interventions ordered. It was also noted that there was no dietary/nutrition referrals, notes, or assessments between 08/16/22 and 09/01/22, a period during which R4 lost 5.5 pounds, or 5.298% of her body weight. On 09/02/22 at 09:13 AM, an interview was done in Conference Room C with the Chief Quality Officer (CQO). The CQO reported that R4 had been assessed by the Registered Dietician (RD) the previous day and moved to the Medical-Surgical Unit so that she could receive Total [MEDICATION(S)] Nutrition (TPN), a method of feeding done by IV, bypassing the gastrointestinal tract, and providing most of the nutrients the body needs. After concurrent record review of R4's EHR, the CQO agreed that the RD referral and review of R4's weight and dietary intake was delayed.

Based on observations, staff interviews, and record review, one of three Facility Reported Incidents (FRI) was substantiated. The facility failed to provide adequate supervision and assistance to prevent an avoidable fall. As a result of this deficient practice, (Resident (R) 6) sustained a fall with injury. Findings Include: 1. During staff interview on 06/27/18 at 11:00 AM, Staff Member (SM) 15 recalled the incident and remembered that R6 fell while posing for a picture. SM15 said that two staff members were standing alongside R6 but that did not prevent the fall from happening. 2. During observation on 06/28/18 at 07:45 AM, it was observed that outside staff (referred to as Regional Staff) came for part of the scheduled day to work with the Kauai Veterans Memorial Hospital (KVMH) residents. This regional staff would spend the remaining part of the scheduled day to work with other residents from(NAME)Mahelona Memorial Hospital. During an interview with regional staff on 06/28/18 at 07:50 AM, SM14 acknowledged that they did work with residents from two different facilities and that they were not in-serviced or familiar with any of the KVMH resident's recommended activity orders. 3. During an interview with the Physical Therapist (PT) on 06/28/18 at 01:42 PM, SM4 stated when there are new or updated PT activity recommendations, that not only gets typed in the chart for everyone to view, it is subsequently communicated directly to KVMH staff by either a short in-service or through verbal communication. However, SM4 acknowledged that these recommendations may not always get communicated to every staff member, including regional staff, as they should. In relation to the investigated FRI, record review showed that R6 had an updated activity recommendation by Physical Therapy almost four months prior to the incident. This activity recommendation included that the resident be provided Min Assist or Minimal Assistance. According to SM4, Min Assist included a waist belt be applied to the resident, and a hand on the resident was to be provided at all times for support. This was not done. Based on observations and staff interview, the facility failed to secure the Emergency Cart (Code Cart), which is shared between the Long-Term Care unit and the Obstetric (OB) unit. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. On 06/27/18 at 09:31 AM, during an observation of a Code Cart (located on the OB unit), it was noted that all the drawers were locked except the top drawer. The top drawer contained various venipuncture supplies such as needles, syringes, tubing, tape, and laboratory tubes for blood draw. Also, there was no one in the immediate vicinity to prevent the residents or general public from getting ahold of the various venipuncture supplies. During staff interview on 06/27/18 at 09:40 AM, Staff Member (SM) 5 acknowledged that the drawer should have been locked and the contents secured.

Based on record review and interview with staff members, the facility failed to ensure 3 (Residents#22, #3 and #12) of 5 residents selected for medication review received monitoring for anticoagulant and insulin. Findings include: 1) Medical record review on 1/25/17 at 2:30 P.M. Resident #22 (Res#22) was admitted to the Skilled Nursing Facility on 9/9/16 for an extended course of physical therapy (PT). Res#22 has a history of End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT] three times per week. He also has a history of [MEDICAL CONDITION] Fibrillation (AF) for which [MEDICATION NAME] was prescribed. Lab work done on 9/8/16: Hemoglobin (HGB) and international normalized ratio (INR) was 10.2 and 1.29 respectively. The reference range for HGB on lab report dated 9/8/16 is 13.4-17.2 g/dL. and the INR therapeutic range on lab report dated 9/8/16 was 2.0-3.0. According to lab report HGB of 10.2 and INR of 1.29 were within the normal parameters. Medical record review on 1/27/17 at 10:00 A.M. revealed that on 9/30/16, Res#22 was at the [MEDICAL TREATMENT] center. Res#22's HGB was drawn and reported to be 5.0. Res#22 was sent to the Emergency Department by the doctor at the [MEDICAL TREATMENT] center. He was hospitalized for [REDACTED]. Lab report dated 9/30/16 states CBC Comment: Critical value called: HH low report to (Staff Name) at 1300 hours. On 9/30/16 INR value of 4.21 with the following comment: Critical value called, readback done and verified as correct at 1310. Interview on 1/26/17 at 10:30 A.M. with the Nurse Manager (NM) and concurrent record review was done. The NM produced admission orders [REDACTED] Monday - 5 mg Tuesday - 2.5 mg Wednesday - 5 mg Thursday - 5 mg Friday - 5 mg Saturday - 2.5 mg Sunday - 5 mg Record review done on 1/26/17 at 10:30 A.M. with NM revealed admission orders [REDACTED]. Clarification orders dated 9/9/16 at 1500 did not specify any lab orders to be drawn to monitor [MEDICATION NAME]. NM was not able to produce a care plan for Res#22 for the 21 days at the facility, starting 9/9/16. NM was not able to show any lab work to track Res#22's INR levels. NM was not able to show any interventions or teaching to monitor for side effects of [MEDICATION NAME]. A query with the NM and LN#1 on 1/26/17 at 13:00 was done. LN#1 and the NM contacted the [MEDICAL TREATMENT] center for the Facility to Facility Communication Form (FFCF see below). The NM and LN#1 stated that the [MEDICAL TREATMENT] facility had drawn labs on 9/28/16 and the [MEDICAL TREATMENT] MD was aware of a HGB at 5.9. The NM further stated that she was not made aware of this low HGB by telephone or by the FFCF. The FFCF form did document that Res#22 voided dark urine. NM stated that it was not until Res#22 was admitted to theER on [DATE] that she was aware of Res#22's critical HGB and INR. Interview on 1/26/17 at 4:30 P.M. with NM, LN#1, CNE and QO was done (facility representatives). The facility representatives were advised and queried for any documentation showing that the facility had designed a care plan for Res#22 to monitor adverse effects, any lab work to track INR levels or HGB levels. On 1/27/17 at 7:30 A.M., interview with facility representatives stated that they had not developed a care plan or interventions to monitor for adverse effects or lab work to track INR levels. It was not done. The facility stated that the [MEDICAL TREATMENT] center was aware of the drop in HGB on 9/28/16; however, this was not communicated to them on 9/28/16 on the communication form or by telephone. On 1/27/17, the facility representatives provided the contract between the [MEDICAL TREATMENT] center and the facility. The Scope of Services outlined for A. Responsibilities of Skilled Nursing Facility stated on line 2: Communicate changes to the [MEDICAL TREATMENT] facility regarding the resident's status, medications, including but not limited to vital signs, weight, medications, diet and psychosocial needs, by initiation of the Facility to Facility form to be sent with the resident for completion and return. B. Responsibilities of [MEDICAL TREATMENT]: 2. Monitor the resident's response to [MEDICAL TREATMENT] and also develop and implement care plans and communicate such interventions necessary for continuity of care. Such communication of changes will be the Facility to Facility form. The Facility to Facility form will accompany the resident back to the nursing unit for final record keeping in the medical record chart. In summary, the facility was aware that Res#22 was on alternating doses of [MEDICATION NAME], dialyzes three times a week, and yet, there was no care plan developed to monitor the side effects of [MEDICATION NAME]; the hemoglobin and INR levels were not tracked between the nursing facility and the [MEDICAL TREATMENT] unit until Res#22 had a low critical value of HGB of 5.0 and was admitted to the hospital to receive blood [MEDICAL CONDITION]. 2) Cross Reference to F279. Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 1/25/17 a record review was done. A review of the physician's orders [REDACTED]. twice a day; [MEDICATION NAME] 100 unit/ml subcutaneously, inject five units in the morning and at bedtime; and [MEDICATION NAME] (sliding scale). Further review found lab results dated 12/29/16 documenting an A1C result of 7.3 (high). A review of the resident's care plan provided by the facility on 1/26/17 at 12:52 P.M. notes an expected outcome for blood sugars will be managed within MD parameters. The plan of care included instructions to administer medications as ordered diabetic medications as ordered ([MEDICATION NAME] and [MEDICATION NAME]); monitor for effectiveness and side effects of report to Charge Nurse (side effects of mentoring - metallic taste to mouth, mild anorexia, nausea, abdominal discomfort and diarrhea); and monitor for effectiveness and side effects of insulin - pallor, palpitation, [MEDICAL CONDITION] headache, and confusion. Upon further review, there was no documentation that the physician reviewed the lab results, including the high result of the A1C. An interview and concurrent record review with Licensed Nurse #1 (LN #1) was done on 1/26/17 at 10:21 A.M. The licensed nurse confirmed there is no documentation that the physician reviewed the resident's lab results. The LN #1 also confirmed based on the lab results, there is no documentation whether a change to the current orders were needed or to continue with the current order. 3) Cross Reference to F279. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The results noted glucose of 192 (high) and A1C of 8.5 (high). A review of Resident #3's care plan documents an expected outcome for blood sugars will be managed within MD parameters. The instructions included: monitor blood sugars as indicated per protocol, per order; and administer medication as ordered by physician, [MEDICATION NAME] to prevent [MEDICAL CONDITION]. There was no documentation of the resident's physician reviewing the lab results or indication whether a change in order is warranted or no changes to the order. On 1/26/17 at 9:23 A.M. LN #1 confirmed there is no documentation of the physician reviewing the resident's lab results. The Nurse Manager (NM) provided a copy of the facility's policy and procedure for Acute Care Patient Assessment/Documentation on 1/26/17 at 1:00 P.M. The procedure for Lab Work notes the date and time the physician is notified of the results is documented. The NM also confirmed there is no documentation the residents' physicians were notified of the lab results. The facility failed to demonstrate residents (Residents #12 and #3) with orders for insulin received monitoring for efficacy of the present insulin dosage and failed to establish a monitoring process, identifying who is to communicate with the prescriber and when to ask the prescriber to evaluate and consider modifying the medication regimen to ensure residents achieved their highest practicable level of functioning. The facility also failed to identify blood sugar parameters for Residents #12 and #3. The care plan is not specific for each resident.