Every finding on record at Kuakini Geriatric Care, Inc

Based on interview and record review, the facility failed to ensure that Resident (R) 9 received treatment and care in accordance with professional standards. This was evidenced by the failure to timely assess, treat, and notify the Medical Doctor (MD) 2 regarding R9's complaint of pain during repositioning in bed reported by facility staff on 04/27/26 night shift (11:00 PM - 07:30 AM) and 04/28/26 day shift (07:00 AM - 03:30 PM). This deficient practice had the potential of contributing to worsening injury to R9 as the resident was admitted to the hospital several days later for left hip fracture identified as injury of unknown source.Findings include:The Office of Health Care Assurance (OHCA) received a facility-reported incident (FRI) Intake #3004586 for R9, dated 05/02/26, documenting a left hip injury of unknown source. The State Agency (SA) entered the facility on 06/09/26 for an abbreviated survey where the FRI was investigated.R9 is an [AGE] year-old female with a most recent readmission date of 05/08/26 and diagnoses that included left hip hemiarthroplasty (partial hip replacement) on 05/04/26 and advanced Alzheimer's dementia. R9 required dependent care for all activities of daily living (ADLs) and speech was limited to a few words that are not clear (per 06/08/26 Medical Doctor (MD) 2 progress notes).On 06/10/26 at 08:00 AM a record review was done to investigate the facility's 05/02/26 report of left hip injury of unknown source.A nursing progress note found in the electronic health record (EHR) dated 05/02/26 at 03:17 PM documented, Staff noted resident grimacing when turn to right side.Notified MD.ordered left hip X ray. Another nursing progress note dated 05/03/26 at 12:44 AM stated, MD ordered to send resident to ER for acute left hip pain r/o [rule out] fracture.Resident was sent to ER at 2250 [10:50 PM]. R9 was admitted to the hospital on [DATE] and had left hip hemiarthroplasty on 05/04/26.The facility's investigation packet for the 05/02/26 incident contained lettergrams which was staff's written account/involvement regarding the incident. A statement at the top of the Lettergram forms stated, For inter-departmental communication only. A lettergram dated 05/12/26 written by Recreation Assistant (RA) 1 stated, During facetime call on 4/28/26 at 3pm, [Family Member (FM) 1] noticed his mom appeared to be physically different than during call two weeks prior. [FM1] remarked upon facial grimacing, clenched jaw, facial drooping.Throughout video call, [FM1] mentioned concerns re: pain. No documentation in R9's progress notes in the EHR regarding FM1's concerns, nursing assessment of R9 related to FM1's concerns, and notification to MD2 regarding R9's status was able to be found.A lettergram dated 05/13/26 written by Certified Nurse Aide (CNA) 33 who worked the 04/27/26 night shift [11:00 PM - 07:30 AM] stated, I was the one assigned with patient.while giving care I noticed that whenever I turn her.face is grimacing which is unusual with the patient. Notified RN [Registered Nurse (RN) 22] and CNA (day shift) [Certified Nurse Aide (CNA) 27] about the situation (28 April Tuesday AM).A lettergram dated 05/12/26 written by CNA27 stated, 4/28/26 Assigned to take care of [R9] AM shift. [Night shift CNA] endorsed pt was grimacing when I turned from left to right especially when you touched her hip. Last round pt need to be change her briefs pt still the same grimacing and loud whenever I turned. I notified my RN and [RN22] responded that MD was notified.No entry in R9's progress notes in the EHR could be found regarding CNA27 and CNA33's report of R9's pain, any assessment done by RN22, or any notification to the doctor regarding R9's complaint of pain. A review of R9's April 2026 Medication Administration Record (MAR) noted 0 (0 = no pain) documented for the night shift on 04/27/26 and day shift on 04/28/26 and there was no entry of any ordered as needed pain medicine being given on those dates. An MD2 note could not be found that documented being notified of R9's 04/27/26 and 04/28/26 complaint of pain.On 06/10/26 at 12:08 PM the Director of Nursing (DON) was interviewed in the first-floor conference room. The DON confirmed that there was no progress noted charted in the electronic health record regarding R9's pain reported by the CNAs working on 04/27/26 night shift and 04/28/26 day shift, and no note documented indicating that RN22 assessed R9 and notified MD2. The DON stated that R9 should have been put on alert charting to monitor R9's pain status and defined alert charting as charting every shift for a 72-hour time frame. The DON also confirmed that R9's pain status was not documented from 04/27/26 to 05/01/26 and that any significant resident medical status/changes, information, discussions and follow-ups should always be charted in the electronic health record.A facility policy titled, Documentation Related to Resident Care with a revision date of 03/2023 stated, Policy Statement:.changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. In addition to monthly charting, [facility] charts by exception meaning documentation is done whenever anything unexpected occurs for the resident. Documentation in the resident's progress notes should be completed in the following situations: a. there is significant change in the resident's mental or physical condition. b. any indication of illness or injury.

Based on interview and record review the facility failed to provide documentation that written notice of transfer or discharge was provided to the resident or resident's representative (RRP), a copy of the notice was sent to the Office of the State Long-Term Care Ombudsman, and documentation that written notice of bed-hold was provided to the resident or RRP for 5 of 6 residents (Resident (R) 2, R3, R4, R9, and R10) sampled for discharge process. This deficient practice has the potential to affect all residents needing to be transferred from the facility to the emergency room/hospital.Findings include: 1) On 06/10/26 at 02:13 PM, a review was conducted for 3 Resident charts (R4, R9, R10): R4 was sent to the Emergency Department (ED) on 02/25/26 and returned during the evening of 02/25/26. No documentation of a completed discharge/transfer and bed-hold notice was found in R4's electronic health record (EHR) or was able to be provided by the facility. On 02/26/26, R4 was again transferred to the ED. A facility form titled, Unplanned Discharge/Transfer Notice was reviewed and no documentation was found that written notice of transfer was provided to the RRP. No bed-hold notice was found in the EHR or able to be provided by the facility. R9 was sent to the ED on 05/02/26 and admitted to hospital. A facility form titled, Unplanned Discharge/Transfer Notice was reviewed and noted, Date Discharge Notice Given with a date of 05/03/26. However, documentation on how the written notice was provided to the RRP was not found or able to be provided by the facility. No documentation was found in the EHR or able to be provided by the facility that written bed-hold notice was provided to the RRP. R10 was sent the ED on 03/09/26 and admitted to the hospital. A facility form titled, Unplanned Discharge/Transfer Notice was reviewed and noted, Date Discharge Notice Given with a date of 03/09/26. However, documentation that written notice was provided to the RRP was not found or able to be provided by the facility. There was also no documentation that this form was sent to the Long-Term Care Ombudsman. No documentation was also found or able to be provided by the facility that written bed-hold notification was provided to the RRP. On 06/10/26 at 03:28 PM, the Director of Nursing (DON) was interviewed in the first-floor conference room. The DON stated that the Nurse who sends the resident to the ED should complete the Discharge/Transfer Notice and whichever Nurse calls the family/RRP regarding the transfer should ask about the bed-hold. The DON also stated the written notice for both the discharged /Transfer Notice and bed-hold notice is currently not being provided/sent to the resident or resident's RRP. 2) On 06/09/26 at 09:00 AM, record review of R3's EHR noted R3 was transferred to the ED on 05/15/26 for low blood pressure and hypoxia (a condition where the body's tissues do not get enough oxygen). There was no written bed-hold and discharge/transfer notification given to R3 or the RRP. On 06/10/26 at 10:00 AM, requested from the Director of Nursing (DON) the written bed-hold and discharge notification given to R3 or the RRP. On 06/10/26 at 12:44 PM, DON confirmed that there was no written bed-hold or discharge notification given to R3 or the RRP. 3) On 06/09/26 at 09:00 AM, record review of R2's EHR noted that R2 was transferred to the ED on 02/16/26 for right lower quadrant pain and difficulty breathing. There was no written discharge notification given to R2 or the RRP. On 06/10/26 at 10:00 AM, requested from the DON the written discharge notification given to R2 or the RRP. On 06/10/26 at 12:44 AM, DON confirmed that there was no written discharge notification given to R2 or the RRP.

Based on interviews and record reviews, the facility failed to document pertinent findings and interventions for 1 of 3 residents (Resident (R) 5) sampled for transfers to the emergency department (ED) due to abdominal pain. This deficient practice puts residents at risk for their needs not properly being identified and addressed. Findings Include:On 03/20/26 at 09:22 AM, the Department of Health, Office of Health Care Assurance (OHCA) received a complaint (intake #296005) from a family member (FM) 2 on behalf of R5. FM2 noted that R5 is a [AGE] year-old male who suffered a brain bleed and was admitted to the hospital on [DATE]. R5 was then transferred to the facility on [DATE] for rehabilitation. On 01/31/26, FM2 noted that R5 was complaining of severe stomachache, but the nurses thought it was just a bowel movement problem and just gave him medications. FM2 noted that R5 was in tears and kept begging to be sent to the Emergency Department (ED). R5 was sent to the ED on 02/01/26 where he was found to have pancreatitis and admitted . On 06/09/26 at 09:33 AM record review of R5's electronic health record (EHR) note that R5 was admitted to the facility on [DATE] at 02:25 PM and was not in any pain. At 06:19 PM, R5 complained of difficulty swallowing and could not eat dinner and was given medications for nausea. At 06:19 PM, Certified Nurse Assistant (CNA) reported to the charge nurse that R5 complained of difficulty swallowing and was noted to have vomited clear secretions and food particles and that R5 felt better after vomitus. There was no health note documented for the entire day on 01/31/26. Review of R5's medication and treatment administration record (MAR/TAR) noted that R5 was given Ondansetron (medication for nausea and vomiting) 4 mg (milligrams) at 02:27 AM, and 10:13 PM on 01/31/26. R5's pain level on 01/31/26 on the evening and night shift noted that he had mild pain, however, no Tylenol was given for the pain. There was no health note to indicate that R5 was experiencing any nausea, vomiting, or pain on 01/31/26 and why the Tylenol was not given. On 06/09/26 at 01:45 PM, interview with Director of Nursing (DON) confirmed that there should have been daily charting on R5 since he was a new admission and was not sure why this was missed. DON also stated that it is important to document significant findings and issues to identify if the residents are declining and for continuation of care purposes.On 06/10/26 at 09:20 AM, interview with Registered Nurse (RN) 14, confirmed that no health note was created on 01/31/26 for R5. RN14 agreed that R5's nausea, vomiting, and mild pain should have been documented and if medications given were effective. CN1 also noted that there should have been documentation of why the Tylenol was not given, i.e. R5 refused. RN14 also stated that for new admissions they are supposed to document and monitor residents for at least 72 hours and to chart any significant findings that happened during the shift. RN14 also stated if the RN assigned could not document, they should have relayed their findings to the Charge Nurse (CN) at the end of shift report and that the CNs would be the ones to document the information. RN14 admitted that sometimes the RNs are in a rush to go home and are sometimes busy on the floor with other residents that they forget to document. RN14 acknowledged that documenting and relaying pertinent information provides continuity of care. On 06/12/26 at 02:00 PM, interview with the Education Coordinator (EC) confirmed that all nurses have been trained to document head to toe assessments for newly admitted residents for at least 72 hours. EC also noted that the RNs should be documenting any change of condition, pertinent findings, and relaying it to the next shift. EC was not sure why there are documentation gaps but noted that there has been no audit to ensure documentation requirements are met. On 06/12/26 at 02:30 PM, review of the facility's Documentation Related to Resident Care policy, in the Policy Statement it notes, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial conditions, shall be documented in the resident's medical record. The medical records should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. In the Policy Interpretation and Implementation section, it reads, The following information is to be documented in the resident medical record a. objective observations; d. changes in the resident's condition.7.Documentation of procedures and treatments will include care-specific details including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual (s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated. In the Procedure section, it details, 3. In addition to the monthly charting, Kuakini Geriatric Care charts by exception meaning documentation is done whenever anything unexpected occurs for the resident. Documentation in the resident's progress notes should be completed in the following situations: a. there is a significant change in the resident's mental or physical condition, b. any indication of illness/injury.4. Documentation should also be completed for the following: c. SNF daily charting.

Based on interview and record review, the facility failed to do a thorough investigation post-fall for 2 of 5 Residents (Resident (R) 4, R10) sampled. This deficient practice placed the residents at risk for further falls and injury.Findings include: 1) R10 is [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include left femur fracture with repair on 12/28/25 and dementia. On 06/12/26 at 07:02 AM, a record review was done. A nurse's progress note dated 03/09/26 at 04:18 PM documented that R10 was found on the floor and was first seen by her daughter. R10 complained of left hip pain post-fall and Medical Doctor (MD) 1 was notified. R10 was sent to the emergency room and subsequently admitted to the hospital with a hip fracture. R10 was readmitted back to the facility on [DATE] after undergoing open reduction and intramedullary nailing of left femur (surgical procedure to treat long-bone fractures) and revision of the 12/2025 intramedullary nailing of the left intertrochanteric (top of the thigh bone) fracture. On 06/07/26 at 09:20 PM, R9 had another unwitnessed fall and was found on the floor on the right side of her bed. On 06/12/26 at 09:05 AM, Licensed Practical Nurse (LPN) 3 was interviewed at the 5th floor nurse's station. LPN3 stated that R10's baseline prior to fall incident on 03/09/26: Required assistance of one person for ADLs except for eating, which she could do independently, incontinent of bowel and bladder, primarily Korean speaking but could understand simple English words, was high risk for falls and had a bed alarm placed in her bed because she would attempt to dangle her legs on the edge of the bed. On 06/12/26 at 09:42 AM the Administrator and Director of Nursing were interviewed in the first-floor conference room. The DON presented a blank copy of the post fall investigation packet that contained: 1) Falls checklist, 2) Neurological flow sheet, 3) Post-fall Resident Assessment. The packet is used to determine the cause and circumstances of the fall, assess any injuries, communication to responsible party and MD, and identification of any new fall prevention interventions to prevent reoccurrence. The DON stated that the post-fall investigation packet for R10 could not be found. The Administrator stated that the investigation packet with the post-fall checklist and assessment along with any staff interviews/statements should have been completed. A facility policy titled, Fall Management Program with a date of 8/2018 stated, PROCEDURE.8) An incident report will be prepared by the person(s) knowledgeable about the incident. 9) A Post-Fall Resident Assessment/Staff Debriefing from will be completed and used to implement fall prevention interventions. A facility policy titled, Patient/Resident Event Management with an effective date of 07/2008 stated, 2. Event Reports will be reviewed and appropriate follow-up will be conducted in a timely manner. a.The respective management staff will conduct an investigation and take corrective action where appropriate to prevent reoccurrence. 2) R4 is a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of but not limited to left knee pain, unspecified fall, atrial fibrillation, and muscle weakness. On 06/12/26 at 08:39 AM, record review of R4's EHR noted that R4 had multiple falls since admission. R4 fell on [DATE] at around 04:45 AM and was found sitting on the floor and R4 sustained a laceration to the back of the head. The second fall happened on 02/26/26 at 03:55 AM, where R4 was found lying on the floor. There was no initial fall risk assessment completed on admission and no fall risk assessment completed after the 01/13/26 fall event. There was also no event report completed for R4's 02/26/26 fall incident. On 06/12/26 at 09:30 AM, requested from the Director of Nursing (DON) the initial fall risk assessment completed on admission, the fall risk assessment completed after the 01/13/26 fall incident, and the event report completed for fall incident on 02/26/26. On 06/12/26 at 10:16 AM, DON confirmed that there was no initial fall risk assessment completed on admission, no fall risk assessment completed for the fall incident on 01/13/26, and no event report for R4's fall on the 02/26/26. DON acknowledged the importance of completing fall risks assessments and fall incident report as it's a means of assessing what transpired and what needs to be changed and revised in the plan of care. On 06/12/26 at 01:37 PM, review of the facility's Fall Management Program, with a date of 08/2018, in the Procedure section, it reads, 1. At the time of admission, a Fall Risk Assessment record will be completed.8. An incident report will be prepared by the person (s) knowledgeable about the incident.9. A Post-fall Resident Assessment/Staff Debriefing /Staff debriefing form will be completed and used to implement fall prevention interventions.

Based on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for the water temperature to raise to 180 degrees Fahrenheit (F) or more during the final rinse cycle before processing the dishes from the conveyor belt, placing them on the storage racks of clean dishes, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents and staff, who eat their meals at the facility, at risk for foodborne illness. The State Agency (SA) identified an Immediate Jeopardy (IJ) at S483.60 (F812) on 01/05/25 at 08:44 AM. Findings Include: On 01/05/25 at 08:43 AM an initial tour was conducted with Food Services Supervisor (FSS)1. During initial tour of the kitchen found the kitchen uses a dishwasher with high temperatures to sanitize their dishware and silverware. Review of facility log for the dishwasher stated Standards: Wash - 140-160 degrees F and Final Rinse - 180-190 degrees F. If temperature is above or below range, please inform the supervisor. Logs of temperatures written in for 01/01/25 - 01/04/25 were all within the standard temperatures. Observed dishwasher at 08:44 AM with dishes loaded on the conveyor belt moving through the dishwasher and kitchen staff unloading the dishes onto a rack. During this time, the dishwasher temperature was checked by surveyor and the final rinse was at 172 degrees F. Inquired of the FSS1 what the final rinse temperature was at, and she stated 172. Inquired with the Food Service Worker 1 who also confirmed the temperature was at 172 degrees F. Inquired with Food Service Worker (FSW) 2 what the final rinse has to be at for the dishes to be sanitized and she did not respond, FSW2 continued to unload the dishes that had gone through the dishwasher. Inquired with FSS1 what the final rinse has to be at, and she told staff to stop what they were doing. She stated the final rinse has to be 180 degrees or more. Inquired with FSS1 if the dishwasher uses a chemical sanitizer to clean the dishes and she said it is done by heat. FSS1 showed surveyor where the dishwasher detergent was dispensed from that leads to the dishwasher and also showed the Temp Rinse All Temperature Drying Agent. On 01/05/24 at 10:00 AM returned to the kitchen to meet with the Administrator to discuss findings about the dishwasher use. Reviewed dishwasher detergent with Administrator who confirmed the Micro-Pak detergent by microTECH concentrates is not a sanitizer and he also confirmed the Temp Rinse All Temperature Drying Agent is not a sanitizer. On 01/05/25 at 10:35 AM, the facility Administrator was notified in writing of the IJ and provided with the IJ template. Administrator signed the template to attest receipt of the notice. 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). 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 01/05/25 at 01:04 PM requested kitchen use of dishwasher machine policy from Administrator which he provided. Review of policy titled Procedure for washing dishes by the use of a machine, Effective date: 01/10/18 states Purpose: To properly wash and sanitize dishware and silverware for its aesthetic value and to prevent the spread of harmful germs to patients, residents and staff. Scope: Food service workers Policy: All dishes, dishware and silverware shall be washed after each use. Dish machine [sic.] wash temperature should be 140-160 degrees F and final rinse temperature should be 180 degrees F and above. Procedure: . 5. In the event of any of the following conditions, the dishwashing procedures shall be stopped immediately. The food service worker shall inform the supervisor who shall call the Plant Operations department or the service representative. The supervisor shall direct the staff to use the dish machine [sic.] at Hale Pulama [NAME] b. Final rinse temperature is below 180 degrees - call Plant Operations. On 01/05/25 at 11:55 AM the facility presented an acceptable plan for removal of the immediate jeopardy. On 01/06/25 at 04:00 PM, the SA finalized onsite verification that the IJ Removal Plan, provided by the facility and approved by the SA, had been implemented. Immediately the facility utilized one time use disposable plastic utensils and paper tableware (plates, cups and trays) till IJ was lifted. The facility was able to provide inservice training with their kitchen staff on proper use of the dishwasher which included coverage of final rinse temperature to be reached when cleaning dishes in the dishwasher prior to processing dishes and placing them on the clean rack. Kitchen staff were reminded to notify the kitchen supervisor if the wash and rinse temperatures are not met when using the dishwasher. Facility consulted with vendor for sanitizer that could be used with heat sanitizing dishwasher but this was not something the vendor offers. Vendor informed Kitchen Manager the sanitizer would break down with the heat. Facility monitored residents for 72 hours for signs and symptoms of infection.

Based on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control measures for three out of twenty-three resident sampled. a. Resident (R)23 and (R)38 who were on isolation precautions did not have signage outside of their rooms at the door. b. The facility failed to assure staff to use proper personal protective equipment (PPE) when delivering a meal to a Resident (R)72 who was on droplet precautions. This deficient practice placed everyone at risk for developing preventable infections and other adverse health complications. Findings include: 1) R23 was a [AGE] year-old resident admitted to the facility for long-term care. Diagnosis included but not limited to Methicillin Resistant Staphylococcus Aureus, an infection that is resistant to many antibiotics, and had an order for contact isolation effective 08/03/24. On 01/05/25 at 10:57 AM, observed no signage was posted outside R23's room stating that he was on transmission-based precautions (TBP) instructing everyone to follow contact precaution and check with the nurse before entering the room. On 01/05/25 at 11:02 AM, an interview was conducted with Patient Care Coordinator (PCC)3 and confirmed that R23 is on TBP, and that signage should have been placed outside his door to alert everyone. When asked if facility is supposed to place the signage, PCC3 confirmed, Yes, that should be placed outside the resident's door. On 01/07/25 at 10:21 AM, an interview was conducted with Director of Nursing (DON) in her office and confirmed that a sign should always be placed outside resident's room if they're on isolation precautions to alert staff, family, and visitors to prevent spread of infections. Review of facility's policy on 01/07/25, Infection Control - Section 3.0 Body Substance Precautions stated, . a STOP sign is placed on the door to alert personnel and visitors to Check with the nurse before entering 37954 2) Cross reference to 656 Develop/ Implement Comprehensive Care Plan. Review of R38's electronic medical record found he returned to the facility and was readmitted on [DATE]. R38 had received antibiotics for a urinary tract infection (UTI) intravenously three times a day for Sepsis due to acute pyelonephritis and ESBL/UTI until 01/03/25 which was documented as completed on 01/03/25. Review of R38's Care Plan (CP) revealed staff are to utilize enhanced barrier precautions to care for resident related to history of ESBL. Interventions listed on R38's CP included Cart set up outside of patient's room and stocked with appropriate Personal protective Equipment (PPE) and trash can inside the room for discarding used PPE items or soiled items. Place an enhanced barrier isolation sign on resident room door. On 01/07/25 at 12:58 PM an observation was made outside of R38's room along with a concurrent interview with Certified Nurse Aide (CNA) 25. Surveyor observed inside and outside of R38's room and saw there was no signage or PPE cart posted outside of resident's room and no discard bin inside R38's room for used PPEs. Inquired of CNA25 where the EBP sign and PPE cart was and CNA25 stated he is not on EBP, she confirmed there was no sign and cart of PPEs outside of R38's room. On 01/08/25 at 10:49 AM interview with the Director of Nursing (DON) was conducted. Inquired about R38's CP which she confirmed has a CP for EBP due to his recent UTI with ESBL. She confirmed staff should be using PPEs and sign should be up outside the room door and cart should have been outside of the room with PPEs. 42160 3) On 01/05/25 at 11:50 AM, observed Certified Nurse Aide (CNA)32 in R72's room delivering lunch. There was signage on the entrance to R72's room documenting the resident was on Droplet Precautions. However, CNA32 only wore a surgical mask. Inquired with CNA32 as to why R72 was on droplet precautions. CNA32 reported R72 was on droplet precaution due to testing positive for Respiratory Syncytial Virus (RSV). On 01/08/25 at 10:30 AM, conducted an interview with the DON. Informed the DON of my observations and inquired what PPEs should staff wear while delivering a resident's meal who is on droplet precautions. DON confirmed staff should have been wearing a face-shield, gown, an approved mask, and gloves. .

Based on observations, record review and interviews the facility failed to properly label oxygen tubing when it was initiated for three of four Residents (R) 89, R19 and R216 sampled for respiratory care. The deficient practice placed the residents at risk of facility acquired respiratory infections. Findings Include: Cross Reference to F656 Develop/Implement Comprehensive Care Plan 1) On 01/05/25 at 11:56 AM an interview was conducted with R89 in her room. R89 was observed sitting in her wheelchair with a nasal cannula which was hooked up to the oxygen (O2) in the wall. Inquired of R89 if the oxygen was on and she confirmed it was on and at 2 Liters per minute (LPM) at all times for her shortness of breath due to her diagnosis of chronic obstructive pulmonary disease (COPD). Inquired of resident when does staff change the nasal cannula and she stated staff changes it out when she asks them to, when it gets dirty or wet inside the tubing. During the interview surveyor and R89 did not observe any sticker with the date the O2 tubing was implemented. Review of R89's Electronic Health Record (EHR) found she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, chronic obstructive pulmonary disease with (acute) exacerbation (persistent respiratory disease with respiratory symptoms significantly worsening); acute respiratory failure with hypoxia (not enough oxygen in the blood); acute respiratory failure with hypercapnia (too much carbon dioxide in the blood); emphysema (air sacs of the lungs are damaged), unspecified; and pulmonary fibrosis (scarring and thickening of the tissue around and between the air sacs in the lungs), unspecified. Review of R89's Admission Minimum Data Set (MDS) with an assessment reference date of 11/05/24 found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. Review of R89's physician orders found an order for Supplemental O2 (oxygen) 2-4L/min by nasal cannula with humidifier continuous to keep sats > (greater than) 90% every shift for COPD. On 01/06/25 requested and received oxygen use policy from facility Administrator. On 01/08/25 reviewed facility policy Respiratory Delivery Devices dated 01/24, Purpose: To set guidelines for the use of respiratory delivery devices in the facility which include nasal cannula, non-breather [sic.] mask, oxymizer pendant and bland aerosol administration. Scope: All qualified and trained Personal staff. Policy: Qualified and trained personal will utilize, treat, and monitor use of these respiratory delivery devices. Procedure: A. Nasal Cannula (1/4 - 6 LPM) . 3. Change nasal cannula weekly and PRN soiled. On 01/08/25 at 08:47 AM interviewed Registered Nurse (RN)33 outside of R89's room and inquired who changes the nasal cannula tubing and when is it done. RN33 stated night shift usually changes the tubing and sterile saline for residents on O2. They usually change it on Fridays. At this time inquired of R89 about her nasal cannula and she stated staff did change out her tubing on Sunday 01/05/25 when she asked them about it, after our first interview before lunch. R89 stated the sticker came off and she was able to put it on her bedside table. Sticker was dated 01/05/25 and timed at 1400 (02:00 PM). On 01/08/25 at 12:04 PM an interview was conducted with the Director of Nursing (DON). Inquired who changes the nasal cannula for those residents receiving O2. She confirmed the nasal cannula is switched out weekly by staff and as needed when it gets dirty. Inquired of DON if staff label the new tubing with dates and DON confirmed the nasal cannula tubing and bottle of sterile water should have had dates on them. 38870 2) On 01/05/25 at 02:10 PM observation in R19's room. R19 was lying in his bed with Oxygen (O2) at 3 Liters per minute (LPM) via trachea collar and connected to an aerosol bottle with a blue tube. There was no label on the blue tubing with a date to indicate when it was changed. Quarterly Minimum Data Set (MDS) with an assessment date of 07/19/24 was reviewed on 01/06/25. R19 is a [AGE] year-old male with a diagnosis that includes respiratory failure requiring Oxygen therapy and Tracheostomy care. Treatment Administration Record (January 2025) reviewed on 01/06/25. Apply trachea collar daily. On 01/08/25 at 11:30 AM, interviewed the Director of Nursing (DON) in her office with the Administrator. The surveyor asked the DON how often the respiratory tubing is changed and by whom. The DON discussed that the tubing is changed on night shift every Friday and that the tubing should be labeled to indicate that it was changed. Facility Respiratory Delivery Devices policy 01/2024 was reviewed on 01/06/25. C. T-Piece/Trach Collar with Aerosol (21-100% Fio2, Set Flow 6-10 LPM) .6. Change nebulizer, tracheostomy collar, and tubing set up daily and as needed (PRN). 3) Observation on 01/05/25 at 02:45 PM in R216's room who is on droplet precautions. R216 was lying in bed with his eyes closed and observed to have a deep productive cough. He was wearing a nasal cannula (NC) for O2 delivery. Observation of the O2 meter on the wall behind the head of the bed was not registering (in the off position). Observed the O2 tubing was not labeled with a date when the O2 tubing was changed. Observation and interview with Registered Nurse (RN) 25 in R216's room on 01/05/25 at 03:30 PM. The surveyor asked RN25 what the concentration of O2 is ordered for R216. RN 25 looked at the meter and said it's not on, but it's supposed to be at 2 L. RN25 turned the dial on the O2 meter until it reached 2 L. The surveyor asked RN25 when was the tubing was changed, by who and how often. She replied, its changed weekly by the Nursing staff, then looked closer at the tubing and said, there should be a label to note the date it was last changed, but there isn't one. Physician orders dated 01/04/25 reviewed on 01/05/25. Noted droplet precautions for the respiratory syncytial virus (RSV) positive (+).

Based on observations and interviews, the facility failed to provide appropriate care and services to prevent complications of enteral feeding (a way of delivering nutrition directly into the stomach or small intestine) for three of the 23 sampled residents (Resident (R)74, R50 and R59). The facility did not ensure the equipment used were properly cleaned and maintained. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications. Findings include: 1) On 01/05/25 at 08:46 AM, initial screening of the residents was conducted. R74 was observed lying in bed with head elevated. A pole was next to her bed with a feeding pump attached. A plastic container filled with liquid enteral feeding formula was connected to the feeding pump. Observed the feeding pump, base of the pole and floor had some residue of dried formula. On 01/06/24 at 09:01 AM, observed R74 lying in bed with head elevated. The drops of dried-up formula were still on the pump, base of the pole and floor. Returned to R74's room at 10:37 AM and drops of dried-up formula were still observed while the pump was running. On 01/06/24 at 03:37 PM, a concurrent observation and interview was conducted with Patient Care Coordinator (PCC)3 in R74's room. Showed PCC3 the drops of dried formula that were still on the feeding pump, base of pole and floor. PCC3 acknowledged that it does not look sanitary and could attract insect and other pests that could carry pathogens (organisms that cause diseases). PCC3 then proceeded to wipe off the dried-up formula. 37954 2) On 01/07/25 at 09:30 AM observed Registered Nurse (RN) 44 prepare medications for R50 to be given via G-tube. RN44 stated she was going to start R50's gastrostomy tube (G-tube) feeding after giving his medications. While in resident's room observed a pole next to his bed with a feeding pump attached. A plastic container filled with liquid enteral feeding formula was connected to the feeding pump. Surveyor showed RN44 the area on the feeding pump and pole that was soiled. Inquired of RN44 who is responsible to take care of the feeding pump and clean it. RN44 stated night shift takes care of it. RN44 tried to wipe the feeding pump and commented that it was dried on and hard to get off. On 01/08/25 at 09:04 AM an interview was done with the charge nurse, RN55. Inquired with the charge nurse who is responsible to process the feeding pumps and clean them. RN55 stated all the staff are to clean the machine when it gets dirty, the task is not assigned to anyone. Surveyor told the charge nurse that there is dried on formula on the poles the feeding pump hangs from and on the feeding pumps themselves. 42160 3) On 01/07/25 at 09:56 AM, conducted an observation of R59 lying in bed with a liquid filled bag of enteral formula which was connected to a feeding pump. The feeding set loop area of the pump was caked in a thickened layer of old feeding formula. A divided plastic tray positioned below the feeding pump had dried splatters of feeding formula. On 01/08/25 at 10:15 AM, observed the feeding pump had been cleaned and inquired with RN3 about the clean feeding pumps. RN3 confirmed the feeding pumps on the fourth-floor unit had been cleaned due to the soiled surfaces.

Based on interviews and record review, the facility failed to implement interventions to treat one of one Resident (R)79 in the sample for constipation. The deficient practice may affect the resident's quality of life due to increased pain and discomfort. Findings include: R79 was a [AGE] year-old resident admitted on [DATE] for long-term care. Diagnoses included but not limited to dehydration, muscle weakness and constipation. On 01/06/25 at 10:25 AM, an interview was conducted with R79 in her room. R79 said she has constipation at times since she is less active now. Asked R79 if she takes any stool softeners, to which she replied, Yes. but does not recall how often. Review of R79's Electronic Health Record (EHR) was conducted on 01/07/25. R79 had the following laxatives (medications that treat constipation) ordered: Senna 8.6 milligram (mg) tablet at bedtime, Lactulose 20 grams (gm) as needed if no bowel movement (BM) for two days, and Bisacodyl Suppository 10 mg if no BM for three days. Review of R79's Bowel Elimination log in the EHR revealed that on the following days, she did not have a BM: 12/14/24 to 12/15/24 (two days); 12/18/24 to 12/20/24 (three days), 12/26/24 to 12/27/24 (two days); and 01/01/25 to 01/03/25 (three days). Review of the Medication Administration Record (MAR) for December 2024 and January 2025 revealed that Lactulose was not administered for both months when R79 did not have BM for two days. On 01/07/25 at 09:11 AM, concurrent interview and record review was conducted with Registered Nurse (RN)6 at the third-floor nurse's station. Asked RN6 if R79 ever complained of being constipated. RN6 said there were instances and looked at the Bowel Elimination log in the EHR. Asked if laxatives were administered as ordered when R79 did not have any BM. RN6 reviewed the MAR and acknowledged some doses were missed in December and January when R79 did not have BM for 2 days. RN6 said, She's supposed to get Lactulose after two days without BM. When asked if R79 refused the medication when offered, RN6 said there was no documentation in the MAR that R79 refused.

Based on observations, record review and interviews the facility failed to develop and implement a care plan (CP) for two of 23 residents sampled. Resident (R) 89 for the use of oxygen and R38 for a urinary tract infection with extended spectrum beta lactamase (ESBL), a bacteria that is resistant to many antibiotics. Findings Include: 1) On 01/05/25 at 11:56 AM interviewed R89 in her room. R89 was observed sitting up in her wheelchair and had a nasal cannula on that was attached to the wall oxygen. Confirmed with R89 that her oxygen (02) was at 2 liters (L) which she reported is on at all times. Resident stated she was diagnosed with chronic obstructive pulmonary disease (COPD) [AGE] years ago and only the last 2 years she has had symptoms of shortness of breath and needing to use oxygen. Review of R89's Electronic Health Record (EHR) found physician order for Supplemental O2 2-4L/min by nasal cannula with humidifier continuous to keep sats > (greater than) 90% every shift for COPD. Review of R89's CP dated 10/04/24 revealed the continuous use of oxygen order at 2-4 L for resident's shortness of breath related to her COPD was not in the care plan. On 01/08/25 at 11:37 AM a telephone interview was conducted with Nursing Assessment Specialist (NAS) 1. Inquired if R89's oxygen use should be included in the resident's baseline and ongoing care plan. NAS1 confirmed R89 had a doctor's order for oxygen and that oxygen use should be included in R89's care plan. Surveyor asked NAS1 to look at R89's CP for oxygen use for COPD and she confirmed the continuous oxygen use was not included on the resident's care plan. On 01/08/25 at 12:04 PM interviewed the Director of Nursing (DON) regarding R89's CP. Informed DON R89's continuous use of oxygen was not on her CP. Inquired if this is something that should be on R89's CP and DON confirmed this should have been included. 2) During a review of R38's EHR, he was readmitted to the facility on [DATE] and received antibiotics for a UTI intravenously three times a day for Sepsis due to acute pyelonephritis (inflammation of the kidney), ESBL/UTI until 01/03/25. Review of R38's CP revealed the focus included . staff utilize enhanced barrier precautions (EBP) to care for resident related to history of ESBL which was Created and Date Initiated on: 10/04/24. The goal for this focus states Resident will be free from ESBL infection through review date of target date: 04/05/25. Interventions included: a. Cart set up outside of patient's room and stocked with appropriate personal protective equipment (PPE) and trash can inside the room for discarding used PPE items or soiled items. b. Educate resident and residents' family/visitors on enhanced barrier precautions and when to utilized. c. Place an enhanced barrier isolation sign on resident room door. d. Staff will wear gown and gloves when performing high contact activities such as dressing, bathing, transferring, providing hygiene, changing linens, toileting, performing device care, or wound care. On 01/07/25 at 12:57 PM interview was done with Certified Nurse Aide (CNA) 25 outside of R38's room. Inquired if CNA25 uses EBP with R38 when working with him since he had been positive for ESBL. CNA stated no that there is no sign. Surveyor observed at this time there was no signage outside of R38's room and no cart with PPEs. On 01/08/25 at 10:49 AM interviewed DON and asked her about R38's CP for EBP use due to his history of ESBL. DON confirmed R38 has a CP for EBP due to his recent UTI with ESBL. She confirmed staff should be using PPEs and a sign should be up outside the room door and cart should have been outside of the room with PPEs.

Based on interviews and record review, the facility failed to ensure a resident's right to inform the resident's representative in advance, of the risk and benefits of proposed treatment one of five residents (Resident (R)72) sampled for unnecessary medication(s). As a result of this deficient practice, residents receiving psychotropic medications are at risk for more than minimal harm. Findings include: Review of R72's Electronic Health Record (EHR) on 01/07/25 documented the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/24, Section C. Cognitive Functioning, Brief Interview for Mental Status (BIMS) score was 6, indicating the resident's cognition is severely impaired. Review of Section GG. Functional Patterns documented the resident is dependent on staff for all care. Review of R72's Physician's Orders documented orders for: Trazodone hydrochloride (HCl) Oral Tablet 50 milligrams (MG) Give 0.5 tablet by mouth two times a day for dementia behavior and agitation (Started on 12/27/24); Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg by mouth two times a day hold if sleepy or respiratory rate is less than 11 (Started on 11/15/24); and Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for anxiety (started on 11/08/24). Review of the EHR did not contain documentation of R72's representative's consent for the use of psychotropic medications. Review of the R72's profile in EHR documented Family Member (FM)5 is designated to make health decisions for R72. On 01/07/25 at 01:48 PM, conducted a concurrent interview and review of R72's hard chart and the unit's psychotropic medication consent binder. Review of the binder did not contain documentation that FM5 consented to use of Trazodone, Seroquel, or Zoloft. RN3 confirmed there were no completed documentation in R72's EHR, hard chart, or the unit's Psychotropic Consent binder for R72. RN3 reported FM5 is off-island and consents are obtained through email and the unit supervisor or Director of Nursing (DON) is responsible for emailing FM5. On 01/07/25 at 02:30 PM, conducted an interview with the DON. Informed the DON that there was no documentation related to FM5 giving written consent for R72 to receive Trazodone, Seroquel, or Zoloft or had been informed that the facility is currently administering these medications to the resident and there was no documentation FM5 was informed of the risk versus benefits for receiving these medications. DON reported the employee responsible for contacting FM5 is on leave and the facility is unable to provide documentation that FM5 was informed of, consented, and received education on the medications previously listed prior to administering the medication to the resident.

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. Three residents reviewed, Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents in the facility, placing the residents at risk of harm, if the facility fails to protect resident's right to be free from abuse by staff. Findings Include: Cross Reference F580 - Notify of Changes (injury/decline/room, Etc.) 1) On 07/17/24 at 10:47 AM interviewed Registered Nurse (RN) 1. Inquired if she was working with R12 on 03/20/24 and she said yes, stated on March 20th it was resident's Care Plan day meeting and during the meeting they discuss with the family any concerns and they (the family member) mentioned R12 had told them that a staff had pushed her head down while she was showering her, that the staff had pushed her head against the wall. Family member was not sure what day this occurred. R12 told the family member that she did not like the agency staff who was black. RN1 spoke with R12 right after the phone call with R12's family member. The resident stated during her shower, not sure what day it was, the staff pushed her head down while she was showering her. RN1 asked staff working on 03/20/24 during day shift (7 AM - 3 PM) if they received any report from R12 regarding complaint of a staff member being rough with her in the shower. Staff stated no and RN1 reported it to Assistant Director of Nursing (ADON) and Director of Nursing (DON). On 07/17/24 at 11:54 AM interviewed Assistant Director of Nursing (ADON) confirmed he was present at R12's bedside with DON when they interviewed her. Resident stated CNA was rough handling her during her shower. Not sure if it occurred more than once. Not sure of the details. Resident was afraid but not physically hurt, looked a little upset and concerned. ADON stated R12 was worried that CNA in question would retaliate against her. ADON stated the CNA no longer works at facility, stated she was a contract worker and they canceled the remaining contract. 2) On 07/17/24 at 10:47 AM interviewed RN1. Inquired if she was working with R26 on 03/20/24 and she stated she was. RN 1 stated Certified Nurse Assistant (CNA) 1 reported that R26 had told her (CNA1) she has a concern about her care. CNA1 reported she asked resident what her concern was, R26 told CNA1 that she was sleeping and woke up and was like naked, the diaper was open and her gown was open. CNA1 told RN1 that R26 asked her why did the girl not tell me before doing it? RN1 reported to ADON (is the nursing supervisor during day shift if there is no supervisor) and DON. On 07/17/24 at 11:14 AM interviewed CNA1. CNA1 stated R26 was not assigned to her but remembers that morning, On 03/20/24 between 6:30-7:30 AM she heard resident crying out to her from her room. R26 stated she needed help. R26 had told her she did not want the black woman and resident told CNA1 what happened to her. CNA1 stated R26 stated she was rudely awaked by staff (night shift CNA) undressing her when the blanket was off and the brief was open, uncovered. R26 stated night shift CNA told resident she was wet. CNA1 contacted the charge nurse for the day, RN1. Resident repeated the same story of what occurred during night shift to CNA1 and RN1. RN1 reported the incident and ADON and DON came to the floor to investigate. On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. ADON stated the resident (R26) did not specify a time the incident occurred and reported that it was her night shift nurse aide that was in question. Inquired when night shift is and ADON stated our night shift is from 11:30 PM to 08:00 AM. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing. 3) On 07/17/24 at 11:54 AM interviewed ADON. ADON confirmed he was working this day (07/05/24) but had gone home by the time this incident occurred at 07:30 PM. There was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW). ADON stated the DON told him and the nursing supervisor that CNA4 could not work with R33. Inquired how the facility handles allegations of abuse by staff and he stated usually the staff would be reassigned to different resident or different location. After this incident CNA4 was not allowed to work on the 6th floor. On 07/18/24 at 09:30 AM interviewed CNA3. Inquired of CNA3 what occurred on 07/05/24 at 07:30 PM. CNA3 stated she came in early to work, went to use the bathroom that is located behind the nurse's station on the 6th floor. CNA3 stated once she came out of the bathroom she looked up and saw CNA4 step on R33's foot. Inquired if she thought it was a mistake or by accident and she said no. CNA3 stated R33 was sitting down, appeared very restless. CNA3 stated I saw with my two eyes that CNA4 stomped his foot. CNA3 stood up and stomped her foot on the ground to demonstrate what CNA4 had done. CNA3 stated I went to her and told her don't do that, that's not nice. CNA3 explained CNA4 was wearing crocs and R33 was wearing only socks when this occurred. CNA3 went to the charge nurse and told her to talk with CNA4 to tell her not to do that. CNA3 stated she spoke with CNA4 and CNA4 tried to lie saying that she only tapped the resident's foot softly but CNA3 stated she did it harder than that. CNA3 stated the supervisor had asked staff to write up what happened on a yellow sheet. On 07/18/24 at 11:07 AM interviewed RN2. RN2 stated she was working day shift (from 07:00 AM till 3:30 PM) when the incident occurred with R33 on 07/05/24 at 07:30 PM. RN2 stated she was working till 7 PM that day so that she could compete her admission. RN2 stated she was in the office when this occurred and did not witness the incident. RN2 stated she was told as I was leaving, I had clocked out. RN2 confirmed one of the CNAs (CNA3) who witnessed this incident told me about the incident, I think it was CNA3 who had come to work early. CNA3 told me that she actually saw CNA4 step on the resident's foot. I was clocked out and heading out and told the other nurses there to notify the supervisor and make sure there is an investigation. I also called the nursing supervisor to make sure too. Inquired who the nursing supervisor was and RN2 provided the name. On 07/18/24 at 02:55 PM interviewed nursing supervisor (NS)1. NS1 confirmed she was the nursing supervisor working on 07/05/24 at 07:30 PM when the incident occurred with R33. Inquired how she was informed and NS1 stated I just got a phone call on the supervisor's phone by the off going charge nurse (RN2) and she was leaving, cannot remember the exact time, almost 8 PM and she (RN2) said something happened and that you have to check regarding a staff and a patient, no details but to check with CNA3. I went up stairs from 3rd floor to 6th floor to talk to CNA3 to ask what happened, she told me that she was coming to start her shift early around 7-7:30 PM, she came to the nurses station, saw CNA4 with R33 who she was offering him pudding, she (CNA3) went to the bathroom, came out of the bathroom, and stated she (CNA3) saw CNA4 stomp on resident's foot, and CNA3 stated she told CNA4 don't do that. Inquired what NS1 did and she stated she spoke with CNA4 who stated the resident was trying to use his walker to hit CNA4's feet and she stepped on his foot to stop him from doing this. On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019 under Procedure page 6 of 10, I. Reporting/ Response C. Patient Care Coordinator/ Shift Coordinator (SC) responsibilities: . 2. In collaboration with the Charge Nurse, immediately initiate the action necessary to protect the client until the investigation is completed, including removing the suspected individual from direct contact with the affected client and from all direct care with clients.

Based on interview and record review the facility failed to consult with the physician for three residents reviewed when Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents at the facility and impede care the physician would order. Findings Include: Cross reference F600 - Free From Abuse and Neglect 1) On 07/17/24 at 11:54 AM interviewed ADON who confirmed he was present at R12's bedside with DON when they interviewed her. ADON reported resident stated CNA was rough handling her during her shower. ADON was not sure if it occurred more than once, not sure of the details. ADON reported R12 was afraid but not physically hurt, looked a little upset and concerned. ADON stated R12 was worried that CNA in question would retaliate against her. ADON stated the CNA no longer works at facility, stated she was a contract worker and they canceled the remaining contract. On 07/17/24 during RR of R12's EHR did not find a progress note from the licensed staff stating R12's physician was notified of R12's family's reported allegation of abuse by staff. On 07/19/24 at 12:25 PM interviewed R12's physician. Inquired if physician was notified of R12's family reported allegation of staff abuse and she stated she was on leave and would have to review her call log and would let the DON know. On 08/07/24 the DON sent surveyor an email stating R12's physician had emailed her the following response: No, I was not informed of this issue/ family concern. 2) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24 and reported that it was her night shift nurse aide that was in question. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing. On 07/17/24 during RR of R26's EHR did not find a progress note from the licensed staff stating R26's physician was notified of R26's reported allegation of abuse by staff. On 07/19/24 at 11:10 AM interviewed R26's physician and inquired if he was notified of R26's allegation of abuse by staff. Physician stated he was not notified. Inquired what he would have done if he had been notified and he stated he would have asked the DON to investigate this incident and to check for physical or psychological harm. 3) On 07/18/24 at 02:55 PM interviewed nursing supervisor (NS)1. NS1 confirmed she was the nursing supervisor working on 07/05/24 at 07:30 PM when the incident occurred with R33. Inquired how she was informed and NS1 stated I just got a phone call on the supervisor's phone by the off going charge nurse (RN2) as she was leaving. I went upstairs from 3rd floor to 6th floor to talk to CNA3 to ask what happened, she told me that she was coming in to start her shift around 7-7:30 PM, she came to the nurses station, saw CNA4 with R33 who was offering him pudding, she (CNA3) went to the bathroom, came out of the bathroom and she (CNA3) saw CNA4 stomp on resident's foot and CNA3 stated she told CNA4 don't do that. Inquired what NS1 did and she stated she spoke with CNA4 who stated the resident was trying to use his walker to hit CNA4's feet and she stepped on his foot to stop him from doing this. Inquired if R33's doctor was notified of this incident and NS1 stated she did not know if the resident's doctor was notified. On 07/18/24 during RR of R33's EHR did not find a progress note from the licensed staff stating R33's physician was notified of staff (CNA3) reported witnessed abuse by staff (CNA4). Review of completed report of Event Report submitted to Office of Health Care Assurance on 07/12/24 states R33's physician was not notified of this incident. On 07/19/24 at 01:47 PM Interviewed R33's physician who confirmed she had not been notified of R33's witnessed staff abuse. Inquired what she would had done if she had been notified and she stated she would have asked staff to notify the DON, do an incident report and then she (physician) would have seen R33 the next day. On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019. found under Procedure page 6 and 7 of 10, I. Reporting/ Response C. Patient Care Coordinator/ Shift Coordinator (SC) responsibilities: . 2. In collaboration with the Charge Nurse, immediately initiate the action necessary to protect the client until the investigation is completed, including removing the suspected individual from direct contact with the affected client and from all direct care with clients. 4. Notify the client's physician and family respectively.

Based on interview and record review the facility failed to assure staff accurately documented medication offered to and refused by resident (R)40. This deficient practice could affect all residents who receive medication in the facility if their medication administration is not documented accurately. Findings Include: On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Shift Coordinator for help and RN3 denied this. RN3 stated she gave CNA5 the medication cup and she (RN3) stayed at the resident's door as CNA5 offered the medication to R40. Inquired if R40 took the medication the CNA offered and RN3 stated R40 refused the medication. Record review on 07/19/24 of R40's Medication Administration Record (MAR) found RN3 had documented at 2113 R40 had taken her Tylenol 625 mg by mouth and Melatonin 3 mg by mouth.

Based on interviews and record review the facility failed to assure a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice. This deficient practice could affect all residents and put them at risk for harm if licensed staff delegate tasks to unlicensed staff such as medication administration, which is outside their scope of practice. Findings Include: On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility. On 07/18/24 at 2:25 PM interviewed Certified Nurse Aide (CNA)5 who confirmed she worked on 02/07/24. Inquired if she was asked by Registered Nurse (RN)3 to give R40 her bedtime medication. CNA5 stated she was directly involved, she took care of the resident and stated she did her best to provide care and that R40 was very irritated. CNA5 stated R40 was demanding her bedtime medication and CNA5 stated she told R40 that RN3 was helping another resident and that she would tell RN3 that she is requesting her medication. CNA5 told RN3 that R40 wanted her medication and RN3 handed CNA5 the medication cup with the pills inside and told her to give R40 the medication. CNA5 stated she took the medication into R40 and R40 asked CNA5 why is she giving her the medication and not the nurse. R40 refused to take the medication. Inquired if CNA5 knew she was not supposed to do this because she is not a nurse and CNA5 confirmed she knew this. On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 confirmed she is not supposed to do this, that it is outside her scope of practice. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Nursing Supervisor (Shift Coordinator) for help and RN3 denied this, stated she was busy on the other floor testing residents. RN3 stated she gave CNA5 the medication cup and she (RN3) stayed at the resident's door as CNA5 offered the medication to R40. Inquired if R40 took the medication and RN3 stated she did not take her medication that night, she refused it. On 07/19/24 review of facility policy titled Administering Medications states Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretations and Implementation 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.

Based on interview and record review the facility failed to provide sufficient nursing staff on 02/07/24 and 07/05/24 during their second shift (03:00 PM - 11:30 PM) on the skilled nursing unit. The deficient practice puts the residents at risk for harm such as abuse by staff and staff working outside of their scope of practice. Findings Include: Cross Reference F600 - Free From Abuse and Neglect and F726 Competent Nursing Staff On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility. Continuation of interview with ADON confirmed he was working on 07/05/24 but had gone home by the time this incident (staff to resident abuse) occurred at 07:30 PM. ADON explained there was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW). On 07/19/24 review of the facility's staffing matrix (per facility is Intended as a guideline for staffing levels. Specific resident care needs will always dictate actual staffing requirements.) and facility Census/Staffing forms found on 02/07/24 during the evening shift (03:00 PM - 11:30 PM), the Skilled Nursing Facility (SNF) floor had 37 residents and per the staffing matrix should have had 2 Registered Nurses (RNs), 2 Licensed Practical Nurses (LPNs) and 4 or 5 Certified Nurse Aides (CNAs). On 02/07/24 there were 2.5 RNS, no LPNs and 3.5 CNAs which means the floor was short 1.5 LPNs and short 0.5 - 1 CNAs for this shift. On 07/05/24 the SNF floor had 31 residents and per the staffing matrix for the evening shift (03:00 PM - 11:30 PM) should have had 1 RN, 2 LPNs and 4 or 5 CNAs. Review of the facility Census/Staffing form dated 07/05/24 found the facility had 2.5 RNs, no LPNs and 4 CNAs. The unit was short 0.5 LPN and up to 1 CNA.

Based on interviews and record reviews the facility failed to report allegations of abuse to the state agency within two hours of being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). During the review of two Residents (R) 26 and 33 allegations of abuse were reported to a NS, or ADON and DON. Initial reports submitted by the facility were sent to the state agency two days after the incidents were reported to the CN, NS, or ADON and DON. This deficient practice could affect all residents in the facility who have a reported or witnessed incident of abuse and the facility fails to notify the state agency within two hours. Findings Include: Cross Reference F600 Free From Abuse and Neglect 1) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. ADON stated the resident (R26) did not specify a time the incident occurred and reported that it was her night shift nurse aide that was in question. Inquired when night shift is and ADON stated our night shift is from 11:30 PM to 08:00 AM. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing. On 07/17/24 review of the Facility Reported Incident (FRI) for R26 found it was sent via email to the Office of Healthcare Assurance (OHCA) on 03/22/24 at 05:00 PM with the following boxes checked off staff to resident and mistreatment. On 03/20/24 at 11:15 AM R26 reported the allegation of abuse to the CNA who reported it to charge nurse and two days later the incident was initially reported to the state agency. 2) On 07/17/24 at 11:54 AM interviewed ADON. ADON confirmed he was working this day (07/05/24) but had gone home by the time this incident, witnessed staff abuse of R33, which occurred at 07:30 PM. There was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW). On 07/18/24 review of the FRI for R33 was sent via email to the state agency on on 07/08/24 at 3:30 PM with the following boxes checked off staff to resident and mistreatment. Staff to resident abuse occurred on 07/05/24 at 07:30 PM. Almost three days later the facility initially reported the incident to the state agency. 07/19/24 at 01:30 PM interviewed DON who confirmed she interviewed residents who had reported allegations of abuse by staff. Inquired about reporting FRI's to the state agency and she stated she had been told the reports were submitted, she had not been informed they were submitted days later. On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019 under Procedure I. Reporting/ Response on page 6 and 7 of 10, E. Director of Nursing or designee (Patient Care Coordinator/ Shift Coordinator) responsibilities: 2. Notify State Officials in accordance with State law. a. Notify Department of Health, Office of Healthcare Assurance and Department of Human Services, Adult Protective Services and Honolulu Police Department per regulatory guidelines. b. Complete question #1 of the Notification of Event Memorandum,. and fax it to the Department of Health, Office of Healthcare Assurance (DOH, OHCA), (See Attachment G) within 24 hours or by the shorter time-frames noted in the KGC Reporting a Suspected Crime under the Federal Elder Justice Act Policy number 02-0401C5 if a KGC-ICF or SNF resident is the alleged victim.

Based on interviews, record review (RR) and observation, the nursing staff failed to demonstrate the competence and skill sets to provide safe nursing care in a manner to meet one resident's (R)2 physical needs. Specifically, the Certified Nurse Assistants (CNA) had been administering oxygen (O2), which is outside their scope of practice. In addition, the nursing staff administered oxygen to R2, who had Chronic Obstructive Pulmonary Disease (COPD) when her oxygen saturation level (sat) was outside the parameters ordered by the physician. Due to this deficient nursing practice, there was high likelihood that a Resident with COPD and oxygen administration parameters would be administered oxygen by licensed or unlicensed staff outside the order parameters and suffer harm. When identified by the facility, this deficiency was found to be corrected immediately the following day, and at the time of survey met the criteria for past noncompliance. Findings include: 1) R2 was a [AGE] year old female with a history of end stage emphysema recently started on home oxygen and was hospitalized [DATE] to 11/09/2023 for chronic respiratory failure. At that time, she was diagnosed with a pulmonary embolism and started on an anticoagulant (blood thinner). R2 was transferred to Kuakini Geriatric Center (KGC) for short term rehabilitation with the goal to return home with family. 2) Reviewed R2's Physician (MD)1 notes, which included the following: Encounter date 11/09/2023: Respiratory insufficiency/Emphysema resp (respiratory) status improved, pt (R2) feels comfortable on 2L(liters) NC (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy. Encounter date 11/22/2023: .Emphysema resp status improved, pt feels comfortable on 2L NC at rest.monitor O2 sats & resp status during therapy, goal of supplemental O2 is to keep sats 88-93% Reviewed R2's orders, which included: 11/13/2023 by MD1; Titrate /adjust O2 to keep O2 sats between 90-93%. 11/21/2023 by MD1, Titrate /adjust O2 to keep O2 sats between 90-93%. 3) Reviewed an event report regarding R2, which read: On 11/28/2023, R2's Family Member (FM) contacted the Social Worker (SW) and reported that MD1 recently put parameter's on pt's oxygen levels and there is a sign in pt's room stating those parameters.At some point that night (11/27/2023 to 11/28/2023), a nurse turned off pt's oxygen. Per FM, this morning right before breakfast was served, a nurse notified that the oxygen was still off and her (R2) oxygen levels dropped to the 70's. FM spoke to a nurse .today, and the nurse told FM that she will tell the other nurses to check the sign and check on her more frequently if the oxygen is turned off. FM told SW that he is still concerned as the sign was up, but yet the nurses left the oxygen off for an unknown period of time, letting pt's oxygen drop to the 70's., pt refused therapy with PT .today d/t (due to) being tired/fatigued. The report included: At that time MD1 provided rationale for that order and that chronic respiratory residents require a lower O2 flow in order to maintain optimal O2 levels, (risk of hypercapnia (too much carbon dioxide in blood that can lead to respiratory failure.)) The resolution comment included: Investigation is ongoing. It was determined that there was miscommunication between what was said about staff actions and what actually happened. Staff education included, Titration of O2 should only be completed by licensed personnel (RN) as oxygen is considered a medication; any changes in O2 regulation, should be followed by an assessment by of the resident reaction/tolerance to change. In addition to reading the pulse oximetry, the assessor should be noting the resident's symptoms e.g. pursed lip breathing, use of accessory muscles etc. The severity level on the event form was documented as D. Harm-Intervention Needed. Reviewed the event report hand written attachments of the staff who had knowledge of the event, which included: Lettergram (written communication tool) dated 11/29/2023 by RN1 read: On 11/27/2023 morning shift @ 9:00 AM, received a call from MD1 that she saw the SPO (oxygen saturation) entry in PCC (electronic medical record) always 99-100% with 2 Liter of oxygen, she told me that that it is in the PCC order to titrate 88%-93% Inform and supposed to be no need oxygen if above 93%. Inform [sic] my med nurse. She titrate and monitor the patient. I write and post information on the wall to titrate the O2 at 88% to 93% . Lettergram dated 11/28/2023 written by CNA1 included: Found oxygen is low as 73-77% when I was taking my morning v/s (vital signs) and check the O2 regulator is off. So I reported it to the medicine Nurse. Lettergram dated 11/30/2023, written by night RN2 include: CNA1 was taking V/S for day shift and overheard her saying O2 sat low 70% and she said she put O2 on and she (R2) was ok. I went to check + she had it (O2) @ 4L with sat at 97% so I lowered it to 1 liter with 93-94 % saturation. Lettergram dated 11/29/2023,written by CNA2 included @ 5:45 AM did last round .asked her (R2) permission to changed [sic] and check her bottom.She said I can't breathe. I told her I'm gonna put the O2 to 2 lit (liters/L) while changing diaper immediately then after I did checked her O2 sat and was 92%, . Reviewed Nursing Progress Notes which revealed there was no documentation by either the night shift staff or day shift staff (11/27/2023 to 11/28/2023) of R's O2 saturation level dropping to the 73-77%, or documentation of notification of the physician of the event. The legal medical record did not accurately reflect R2's condition and/or treatment, or meet the standard of nursing documentation. On 11/29/2023, R2 was transferred to the Emergency Department about 09:10 AM for respiratory failure. Review of R2's Vitals Summary, revealed R2 was administered oxygen 22 times during the time period of 11/22/2023 to 11/28/2023, when it was outside the parameters ordered (keep oxygen saturation between 90-93%). 11/21/2023. The DON stated she was unable to provide the liters per minute that were administered on the printed report, so reviewed progress notes to obtain LPM and respiratory status if documented, and provided in hand written document. Review revealed the following entries: 11/22/2023 07:13 AM 96% (Oxygen via Nasal Cannula), LPM (L) not documented. 11/22/2023 09:11 AM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/22/2023 05:42 PM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 06:39 AM 98% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 09:10 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 02:42 PM 97% (Oxygen via Nasal Cannula), 0.5L- no SOB/Respiratory distress. 11/23/2023 08:24 PM 96% (Oxygen via Nasal Cannula), 0.5L no SOB/respiratory distress. 11/23/2023 04:52 PM 96% (Oxygen via Nasal Cannula), 0.5L- No SOB/Respiratory distress 11/24/2023 05:31 PM 98% (Oxygen via Nasal Cannula), LPM not documented. 11/24/2023 06:06 PM 98 % (Oxygen via Nasal Cannula), 0.5-1/0 LPM No SOB/Respiratory distress. 11/25/2023 03:06 AM 97% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/25/2023 06:59 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 09:12 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 10:58 AM 100% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/25/2023 04:52 PM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 09:32 PM 94%(Oxygen via Nasal Cannula), 0.5-1L No SOB/respiratory distress 11/26/2023 06:40 AM 97% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/26/2023 01:24 PM 97%(Oxygen via Nasal Cannula), 1-2 L (Progress note: .increased resp rate 33 and SOB at 11:50 AM .O 1 sat 95% on 1 L increased oxygen to 2L/min 11/27/2023 09:51 AM 97% (Oxygen via Nasal Cannula), LPM not documented 11/27/2023 04:25 PM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/28/2023 05:04 AM 95% (Oxygen via Nasal Cannula), 0.5L 11/28/2023 02:19 PM 94% (Oxygen via Nasal Cannula), LPM not documented. 3) During an interview with the DON on 02/29/2023 at 9:30 AM, she confirmed the CNA's had been administering oxygen. She went on to say she immediately addressed the practice when she found out. The Facility provided documentation of education provided to staff 11/30/2023 and 12/01/2023. 4) On 02/29/2023 at approximately 09:45 AM, observed the oxygen regulator that controls the liter flow in an empty Resident room. The room had wall oxygen with a flow meter regulator. Due to the low flow rate of .5L, it was very difficult to identify the specific location of marking on the regulator. Inquired if other residents had orders for .5L, and she said no, it was unusual for a flow rate that low. 5) Cross Reference F657: R2's CP was not revised in a timely manner to include the new order dated 11/21/2023, to titrate the oxygen to keep saturation between 90-93%. In addition, the focus notes created on 11/09/2023 was not changed and continued to read R2 was on continuous oxygen at 3 LPM/NC. 6) These deficiencies met the criteria for past noncompliance. R2's oxygen administration resulted in a grievance from a family member, which resulted in an investigation, action plan and implementation of that plan. The facility was found to have corrected the deficiency and was found to be in compliance at the time of this survey. Actions taken included: - All CNA's educated to scope of practice, and cannot adjust oxygen. - All nursing staff educated to the importance of tight oxygen control and the need for oxygen administration parameters in the resident with COPD. - All staff educated to the importance of accurate, timely updates to the CP. - Reviewed the current oxygen regulator with all licensed staff to identify .5 L flow.

Based on interviews and record review (RR), the facility failed to revise Care Plans (CP) of two Residents (R)1 and R2, of a sample size of three in a timely manner. The facility did not 1) update R1's CP to include use of the abduction pillow or the skin condition on right forearm, and 2) did not update R2's CP in a timely manner to include parameters for oxygen administration when ordered. As a result of this deficiency, there was the potential the residents may not meet their highest potential of physical and mental well-being. This deficiency had been corrected prior to the survey, and met the criteria for past noncompliance. Findings include: 1) R1 was a [AGE] year old female admitted to Skilled Nursing Facility on 10/28/2023 for rehabilitation services following right hip surgery after sustaining a right hip fracture from a fall at home. She was COVID + on admission. R1's medical history included but not limited to Diabetes mellitus, hypertension, congestive heart failure, Stage 3b chronic kidney disease and atrial fibrillation. She was hard of hearing, had very fragile skin, incontinent of bowel and bladder, and required two person assist for bed mobility and transfers. R1 required one person assist for other activities of daily living. She was on an anticoagulant and at risk for bleeding. R1 may have had a component of dementia, but family believed her cognition was intact and her deficits due to her hearing deficit. On admission to the facility she had a Stage 2 Pressure Ulcer to the sacral area, which was noted in her comprehensive CP. Reviewed R1's Physician (MD)2 notes which included: 11/06/2023: Pain and swelling of right forearm unclear etiology. May be related to previous trauma. Appearance does to appear to be consistent with an infection, but the area remains painful. 11/07/2023: Right forearm pain, swelling, skin tears. Family member (FM) reports that the patient sustained some right forearm skin tears at some point. One of them received a Steri-Strip, but the other is still open to air. 11/14/2023: (discharge summary) The patient was noted to have swelling and bruising on her right forearm. The etiology of this is unclear; there have been reports that this was related to IV (intravenous) infiltration in the hospital, but alternatively it has been speculated that this could be an injury from her previous fall. Of note, there is also a dark, well circumscribed, raised area of unclear etiology that may be a large seborrheic keratosis (common noncancerous skin growth).She was subsequently evaluated by wound care and was started on Medihoney and a dressing. Reviewed R1's CP, which revealed the following entries: Created 10/28/2023: Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk. Goal: Residents Skin will remain intact. Created 11/06/2023: .All staff to maintain right hip precautions for resident when in bed: Use hip abductor pillow between legs to prevent legs from crossing over. Keep leg in abduction (away from the midline of your body). Support entire leg with pillows when turning in bed. R1's CP was not revised to include the right forearm skin condition. During an interview with the Director of Nursing (DON), she said she updated the care plan the same day or day after she spoke with R1's FM who expressed care concerns that included the staff did not consistently use the abduction pillow as recommended by Physical Therapy. At that time, the DON confirmed the staff had been inconsistent with placement of the pillow, and acknowledged the forearm issue should have been in the CP. 2) R2 was a [AGE] year old female with a history of end stage emphysema recently started on home oxygen (O2) and was hospitalized [DATE] to 11/09/2023 for chronic respiratory failure. At that time, she was diagnosed with a pulmonary embolism and started on an anticoagulant (blood thinner). She was transferred to Kuakini Geriatric Center for short term rehabilitation with the goal to return home with family. Reviewed R2's Physician (MD)1 notes, which included the following: Encounter date 11/09/2023 Respiratory insufficiency/Emphysema resp (respiratory) status improved, pt (patient) feels comfortable on 2L (Liters/flow rate) CN (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy. Encounter date 11/22/2023 included: .Emphysema resp (respiratory) status improved, pt feels comfortable on 2L NC (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy, goal of supplemental O2 is to keep sats 88-93% Reviewed R2's orders, which included: 11/13/2023 by MD1, Titrate/adjust O2 to kep O2 sats between 90-93% 11/21/2023 by MD1, Titrate/adjust O2 to keep O2 sats between 90-93%. Review of R2's care plan (CP) initiated on admission 11/09/2023 included the following information: Created on 11/09/2023. Focus: The resident has an ADL self-care deficit r/t (related to) Emphysema, COPD (Chronic Obstructive Pulmonary Disease) with nodule in the lungs.No SOB (shortness of breath) or respiratory distress. Resident on continuous oxygen at 3 LPM (liters per minute)/NC (nasal cannula), . Created on 11/28/2023. Focus: The resident has potential of pain r/t pneumonia, COPD. Intervention: O2 via nasal cannula PRN (as needed) SOB. May titrate as needed to maintain O2 Sat 92% or above as needed . Created on 11/28/2023. Focus: The resident has altered respiratory status/difficulty breathing r/t LOBAR PNEUMONIA, OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE EXACERBATION) EMPHYSEMA, pulmonary fibrosis, respiratory failure, other pulmonary embolism . She is at risk for SOB, respiratory distress . Intervention: Titrate/adjust O2 Keep O2 sats between 90-93%, humidifier for O2. The CP was not revised in a timely manner to include the order to titrate the oxygen to keep saturation between 90-93%. In addition, the focus notes created on 11/09/2023 was not changed and continued to read that R2 was on continuous oxygen at 3 LPM/NC. 3) These deficiencies met the criteria for past noncompliance. The facility took action and corrected the deficiency prior to the survey. The facility plan of correction included: R1's CP was revised appropriately and timely after a FM brought concerns to leadership. The changes included the abductor pillow for body alignment and specific requests for bathing and oral care. R2's oxygen administration resulted in a grievance from a family member. As part of the action plan developed from that investigation, all nursing staff were educated on the reason and importance of oxygen parameters in Residents with COPD and ensuring they are reflected in the CP. In addition, a recertification was conducted at the facility January 12, 2024, which identified a deficiency in ( F657) in Care Plan Timing and Revision. A desk revisit was conducted on February 27, 2024, which found the deficiency had been corrected on 02/16/2024 with ongoing monitoring. The facility Plan of Correction (POC) included 1. In-servicing the licensed staff, 2. MDS coordinator and interdisciplinary team of the requirements of accurate and timely review and revisions to the care plan. 3. The Patient Care Coordinator or Shift Coordinator were designated the responsible individual to update for any new medications. 4. The IDT will conduct quarterly review of all care plans and update as needed, and 5) The PCC or designee will conduct monthly audits of 25% of the residents for accuracy and report findings to the quarterly Quality Assurance Committee.

Based on interviews and document review, the facility failed to ensure the grievance policy included all the required elements. In addition, the facility was unable to provide documentation that Residents were informed they have the right to file a grievance anonymously and the right to obtain a written decision regarding the grievance. There was lack of documentation of the pertinent findings or conclusions regarding the care concerns of two Residents (R), R1 and R2. As a result of these deficiencies, there was the potential residents do not know how to file an anonymous complaint and grievance findings may not be adequately communicated to the complainant, resulting in dissatisfaction. Findings include: 1) Review of the facility policy titled Resolution of Patient/Resident grievances, complaints, and concerns, effective date 02/2023 revealed the following: 1. The policy did not include a reasonable timeframe the resident can expect a completed review of the grievance; 2. The policy did not identify the grievance official who was responsible for overseeing the grievance process, receiving and tracking grievances through their conclusions; 3. The policy did not include the written grievance decision requirements; 4. The policy did not specifically say a grievance/complaint could be made anonymously, orally or written. 5. The policy did not include the complainant could request a copy of the grievance findings and decision. Reviewed the material provided to resident/representative at the time of admission, which included a document titled Resident/Family/Caregiver Complaint Procedure. The document did not include how to file an anonymous complaint. The admission packet also included a document titled A Matter of Rights. This document included information on the Grievance Procedures, but also did not include an anonymous complaint could be filed. The procedure in this document stated You have the right: . to voice concerns and complaints either orally or in writing, . The facility has five different signs posted with resources for residents/representatives to contact if they would like to file a grievance. There was one titled Long Term Care Ombudsman, which included Your call will be kept confidential, but there was no directions of how to file an anonymous complaint with the facility. 2) On 02/27/2024, during an interview with the Director of Nursing (DON), she said she did not know who the grievance official was, but thought it may be Patient Relations. On 02/28/2024 at 01:45 PM, during an interview with Patient Relations (PR), she said she was not sure who the grievance official was, but thought it was the Risk Manager. She explained the PR role and said she receives complaints from the facility staff and physicians and does some follow up. She went on to say she and the Risk Manager (RM) work together, and if a chart needs clinical review, she will send it to the RM, who gets information for her after the Nursing Manager investigates. PR said a complaint is more of a service recovery, and would not get a follow up letter as would be considered resolved, but a grievance should receive a written follow up. On 02/28/2924 at 02:15 PM, during an interview with the Risk Manager (RM), she said they do not use the term Grievance Official, but the functions fall under Patient Relations. She explained they (PR) work together as a team, and would send anything that needed to be investigated to the Director of Nursing (DON) for follow up and resolution. At that time, reviewed the facility policy and the RM said the policy was fairly new, and some of the missing requirements were in the old policy, but had been deleted. 3) Reviewed facility documentation regarding grievance from R1's FM, which revealed the issue was unresolved to the complainant's (Family Member (FM))'s satisfaction and there was no written response with follow up regarding the investigation findings/summary, actions taken, or if the concern was substantiated. Reviewed the Current Summary of R1's complaint entered on 11/11/2023. The description read I (Shift Coordinator) was notified by my Administrator that there was a concern coming from family member (FM) of resident (R1) in regards to care received from Certified Nurse's Assistant (CNA) this past NOC (night) shift. It was communicated to this writer that the party involved a male CNA. I was asked to speak with family and investigate the issue further. When calling the unit to talk privately to SNF (skilled nursing facility) Charge Nurse in regards to the situation, it was discovered that the FM had already voiced her complaint to her earlier. Charge nurse apologized to FM and explained she (R1) could be cared for by 2 person assist and offered her Posey sleeves to provide cushioning and skin protection to her bilateral arms. Separately, this writer went in to talk to FM and it appeared FM was trying to explain the incident, but said she was only relaying on what her mother verbalized to her what happened during this past night a .woman cared for her and was rough with her when she turned her. Patient said when she was turned and using a nudging motion of her right arm she mentioned that's when she hurt. Resident did not suffer any injuries from incident but there is a Mepilex dressing to right foreman, which according to nursing was applied for a skin tear treatment. Originally only had steri strip dressing, but FM requested something with more protection and so the treatment was changed. Unbeknownst to FM regarding new treatment, she believed that dressing may now be a new skin issue as well. On 11/17/2023, the file was updated by PR, to include Patient (R)1 transferred to acute unit (hospital)/PCU. Met with FM to acknowledge her recent KGC (Geriatric Center) complaint, she commented that she was not there when the encounter with nurse happened, however mother told her what happened. FM also shared had a recent talk with the Interim Administrator (IA) and the [NAME] President (VP) to address . complaints. I reassured her that the KGC nursing administration will do a follow-up. The Resolution and Outcomes of this complaint/grievance was marked as Satisfied. Outcome notes read DON and ADON (Assistant Director of Nursing) completed investigation and reported to the administrator. Refer to attached files. The attached files were handwritten notes made by the DON dated 11/06/2023. During an interview with the DON, She said she was unsure who was responsible to send follow up letters after the investigation was completed. She said the investigation findings were that R1's pain and concern regarding rough treatment most likely occurred when staff were moving her when positioning in bed. The DON said she did not have a follow up conversation with FM as to the findings. During an interview with PR, she said she had one contact with R1's FM after she was transferred to the hospital and wanted to establish a rapport with her because she was aware there had been concerns regarding the care, which included rough treatment when in KGC. She said she marked the event form satisfied because she could not personally address the issue and knew it had been escalated to the Interim Administrator and Senior [NAME] President. PR said she agreed this should have been handled as a grievance with documentation of closure. It was unclear to her who and what process would be used to do that. During an interview with the Interim Administrator, she said she and the Senior [NAME] President (SVP), did have a conversation with R1's FM, but did not realize there was an unresolved concern related to KGC. She confirmed there was no letter or follow up from either of them on this grievance. 3) R2's family member (FM) called the Social Worker (SW) regarding an event that occurred on 11/28/2023. Review of the event included the following notes: Per PCC (Patient Care Coordinator), Shift Coordinator (SC) and DON were addressing the situation today with pt (R2's) FM. PCC states that she does not know the whole story and instructed SW to reach out to either SC or DON to address the situation. On 11/28/23, FM had approached nursing staff; he had spoken with nursing supervisor. Administrator, DON, ADON and SNF PCC were informed. An investigation was performed, and staff were interviewed to determine the validity and the timeframe of the event Resolution Comment: Investigation is ongoing. During an interview with the DON, she said the issue was that the FM was concerned that even with a sign posted by R2's bed about oxygen administration, R2 went without oxygen for a period of time the night before. She went on to say the investigation was completed, and actions taken to prevent future occurrence, but she had not discussed her findings with FM, and to her knowledge, no written follow up had been done. During an interview with the Risk Manager (RM), she said she was familiar with the event, and had been on leave at the time. She went on to say when she reviewed the investigation notes, she had unanswered questions and sent it back to the DON for further clarification. The RM considered this investigation still open. This grievance was not closed in a timely manner.

Based on interviews and record reviews, 1) the facility failed to ensure the attending physician reviewed and responded to the identified irregularities on the pharmacist Medication Regimen Review (MRR) for one of five residents R91) sampled for medication review. The pharmacist identified an irregularity for a resident prescribed a psychotropic medication without a diagnosis and recommended a gradual dose reduction (GDR). This placed the resident at risk for harm including negative side effects of the psychotropic medication, experiencing a fall, mental status changes, or sustained negative psychosocial outcomes. The medical record did not show evidence that the attending physician had reviewed and responded to the pharmacist MRR recommendation. 2) The facility failed to ensure the facility developed policies and procedures that included time frames for the different steps in the monthly drug regimen review process. Pharmacist MRR recommendation for October 2022 identified to GDR a psychotropic medication for R91 that was not reviewed and responded to until January 2023. Due to inadequate medication management immediate action is required to avoid adverse consequences for residents on psychoactive medications in the facility. Findings include: Cross Reference to F657- Care Plan Revision, F689- Free from Accident Hazard, and F758- Free from Unnecessary Psychotropic Medication 1) On 01/09/23 at 3:11 PM, conducted a record review of R91's Electronic Medical Record (EMR) that documented R91 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbances, diabetes mellitus type 2, and hypertension. Review of R91's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/22 documented in section C. Cognitive function, R91 has a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident has severe cognitive impairment. Review of the R91's physician orders documented an order for Mirtazapine 7.5 milligrams (mg) at bedtime for sleep disturbances that started on 07/18/22. R91 had a total of seven falls since admission. As a result of one of the falls R91 sustained a fractured left hip and fractured right humerus (upper arm bone) and required surgical interventions for both injuries. Multiple observations (on 01/09/23 at 08:57 AM, 09:28 AM, 10:17 AM, 11:05 AM; 01/10/23 at 08:11 AM, 09:15 AM, 10:32; 01/11/23 at 09:30 AM and 10:45 AM; 01/12/23 at 09:15 AM, 10:15 AM, 1:45 PM) were made of R91 sleeping throughout the day. On 01/12/23 at 10:36 AM, conducted an interview with Unit Supervisor 5 (US)5 regarding observations sleeping in the mornings. US5 confirmed R91 is usually sleeping in the mornings. On 01/11/23 at 11:20 AM, conducted a review of R91's hard chart on the unit with Registered Nurse (RN)88. Reviewed R91's hard chart for the pharmacy's MRR. This surveyor was unable to locate the pharmacy's MRR in the resident's hard chart. Inquired with RN88 and requested to review all the pharmacy's MRRs and the review and responses from the attending physician. RN88 could not locate the pharmacy MRR or documentation that the attending physician reviewed and responded to the MRR recommendations and confirmed there were no documents located in R91's medical chart (hard chart and EMR). Inquired what the process was for pharmacy MRR recommendation and the physician's review and responses to the recommendations. RN88 stated the pharmacy MRR do not come to the unit individually, the units receive an email, the email is printed out, and staff follow-up with the physicians. RN88 showed this surveyor stapled printouts from the contracted pharmacy (PMA) titled Recommendation Summary for DON & Medical Director. RN88 explained that on the side column follow-through staff will write if the pharmacist MRR was followed up with the attending physician. RN88 stated some attending physician verbally inform unit staff or send a fax, but the fax does not go to the unit, the fax goes to the 6th floor. RN88 and Unit Clerk (UC1) confirmed that unit staff do not see the physician's responses if they fax it. Requested with UC1, RN88, Nursing Staff (NS)22, and US5 to provide any form of documentation that could identify that there was any documentation of the pharmacist MRR recommendations and that the attending physicians reviewed and responded to any recommendations. RN88 stated there was a binder at the nurse's station that contained all of the MRRs and physician responses. UC1, RN88, NS22 and US5 searched the unit and could not locate the binder or any past MRR recommendations or physician responses. UC1 stated the previous unit clerk had retired and they were not sure what happened to the binder. US5 confirmed there was no other system in place on the unit to recover those documents. Requested for US5 and RN88 to review all documentation in R91's medical chart for documentation that the attending physician reviewed and responded to the pharmacist's MRR recommendation for October 1-31, 2022. US5 and RN88 confirmed R91 medical chart did not contain any documentation that the attending physician reviewed and responded to any pharmacy MRR recommendations. US5 and RN88 also confirmed R91's medical chart did not contain physician progress notes (encounter notes) for October 2022, November 2022, and December 2022. This surveyor was informed by RN88 and US5 that the Consultant Director of Nursing (CDON) would have the pharmacy MRR recommendations and was unsure where the attending physician's responses to the recommendations were located. On 01/12/22 at 10:05 AM, this surveyor revisited the unit and inquired with RN88 and UC1 if staff was able to locate the binder of MRR recommendations with physician responses or the physician progress notes (encounter notes) for October, November, and December 2022. RN88 and UC1 confirmed staff did not have the binder or the physician progress notes. RN88 lost the stapled printout of the pharmacy MRR recommendations (for December 2022) that she/he was using the day before and had no way to identify which MRR recommendations were reviewed, if changes were made, or what the changes were. On 01/11/23 at 11:15 AM, conducted an interview with the Consultant Pharmacist (CP1) regarding the MRR recommendations and the timeframe for attending physician to respond to MRR recommendation(s). CP1 stated that he/she conducts monthly audits and send recommendations to the facility. The attending physician should review and document in the resident's chart whether they will implement the recommendation, and if not then they should provide a rationale if they choose not to implement the recommendation. CP1 stated monthly percentages are provided to the facility regarding their rate of compliance for attending physicians responding to monthly MRR recommendations (percentage of compliance in listed below (Executive Summary of Consultant Pharmacist's Medication Regime Review)). CP1 also stated the attending physicians do not provide documented responses directly to the pharmacist and there is no streamline system to ensure the recommendations are reviewed and responded to. Inquired with CP1 if R91 had a diagnosis or clinical indication for the use of Mirtazapine to the resident. CP1 confirmed R91 did not have a diagnosis of depression or other diagnosis that would clinically indicate the use of a psychotropic medication for the resident. Inquired whether R91's attending physician reviewed or responded to the GDR for Mirtazapine. CP1 confirmed there was no documentation that the attending physician reviewed or responded to the MRR recommendation. On 01/11/23 at 11:50 AM, conducted an interview with the CDON regarding the pharmacy MRR. CDON stated the pharmacy MRR recommendations are emailed to the units and a printout is provided to the units, faxed to the physicians, and should be stored in a binder on the unit for the attending physicians to review. Informed CDON that the 5th floor staff confirmed the unit could not locate or provide the binder to this surveyor, there were no pharmacy MRR recommendations or the responses from the attending physician to any recommendations from the pharmacy located in R91's medical record. Request a copy of the pharmacy MRR recommendations starting from October 2022. On 01/11/23 at 12:05 PM, received and reviewed the Executive Summary of Consultant Pharmacist's Medication Regime Review forms for July 2022 to December 2022 (report prepared by the Consultant Pharmacist (CP1) documented the facility's follow-up of the last visit's recommendation out of 100% was: July- 19.5%. August- 60.8% September- 32.1% October- 29.8% November- 80.2% December- 66.0% On 01/11/23 at 12:29 PM, received the Recommendation Summary for DON & Medical Director form (for October and November 2022) from CDON and reviewed the documents. A recommendation was made in October and November 2022 for R91 was, This resident continues to receive Mirtazapine 7.5 mg QHS (bedtime) for sleep disturbance and Melatonin 9 mg QHS for sleep disturbance. Please evaluate the current doses and consider a dose reduction. Kindly consider a trail gradual dose reduction of the Mirtazapine to 3.75 mg QHS (no response was documented on the forms). On 01/12/23 at 2:05 PM, conducted a telephone interview with R91's attending physician. Inquired with AP2 if he/she had reviewed and responded to CP1's MRR recommendation from 2022 to decrease R91's dose of Mirtazapine. The attending physician did not have access to resident records and could not answer questions specifically related to R91. On 01/12/23 at 02:15 PM, this surveyor went into the CDON's office and requested with the CDON, Senior [NAME] President (SVP), and Chief Nursing Officer (CNO) to provide any documentation that the pharmacist MRR recommendations are part of R91's medical chart and documentation that R91's Attending Physician (AP)2 reviewed and responded to the pharmacist MRR recommendation to GDR Mirtazapine from 7.5 mg to 3.75 mg. On 01/12/23 at 4:12 PM, CDON came down into the surveyor's conference room and stated he/she spoke to the AP2 and confirmed AP2 did not review or respond to CP1's MRR recommendation to GDR R91's Mirtazapine prior to this day (01/12/23) but has decided not to change the order. On 01/13/23 at 08:30 AM, CDON came into the conference room and stated the facility audited the MRR recommendations and there was no documentation that AP2 reviewed or responded to the October 2022 GDR recommendation. The facility had reviewed all MRRs recommendation for October and November 2022 for completion and identified other residents that the attending physician did not review or respond to. CDON stated the facility does not know what happened on a system level that the MRR recommendations were not reviewed or responded to in a timely manner. The facility was notified of the Immediate Jeopardy (IJ) on 01/13/23 at 09:21 AM. The facility provided an acceptable plan for removal of the immediacy IJ on 01/13/22 at 10:33 AM to the survey team. The corrective measure included: 1) Review of all Pharmacy Recommendations completed. All Pharmacy Consultant recommendations responses received 100 % and the signed Pharmacy Consultant for were filed in the Medical Record. 2) The facility will review all Pharmacy Consultant recommendations. All letters to the MD (medical doctors) will be faxed to the physician for review and recommendations. Physician will fax the letters back to the facility and units with their recommendations. Facility staff and Patient Care Coordinators or designee will track all the recommendations on a daily basis and will call the Geriatrician if no response is received within a week. All Pharmacy Consultant letters will be filed in the resident's medical record. 3) The facility Patient Care Coordinators will maintain a log for all Pharmacy Consultant reviews to ensure compliance. Audits will be completed on a monthly basis to ensure 100% compliance and submit to QAA committee. The IJ immediacy was abated on 01/13/23 at 10:50 AM. 2) Review of the facility's policy and procedure, Medication Regimen Review and Reporting Section 8.1 dated 10/07 documented Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. And 8 .Recommendations shall be acted upon within a reasonable timeframe. The policy and procedure do not specifically address what is an appropriate and timely fashion timeframe for attending physician to review and respond to recommendations. On 01/12/23 at 11:15 AM, conducted an interview with the Consultant Pharmacist (CP1) regarding the MRR recommendations and the response of the attending physician regarding the recommendation(s). CP1 stated that he/she conducts monthly audits and send recommendations to the facility. Inquired with CP1 if the facility implements a timeframe for the attending physicians to review and respond to the pharmacist MRR recommendations to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and to prevent or minimize adverse consequences related to medication therapy. CP1 stated that although there is a timeframe implemented for the pharmacist, there is no timeframe implemented for the attending physician to review and respond. Inquired with CP1 if there was documentation in R91's medical chart (hard chart and EMR) that documents the attending physician reviewed and responded to October 2022 and November 2022 MRR recommendation to decrease Mirtazapine 7.5 mg to 3.75 mg. CP1 confirmed there was no response from the attending physician regarding the recommendation to decrease the Mirtazapine dose made in October 2022. On 01/13/23 at 08:30 AM, CDON came into the conference room and stated the facility audited the MRR recommendations and there was no documentation that AP2 reviewed or responded to the October 2022 GDR recommendation. The facility had reviewed all MRRs recommendation for October and November 2022 for completion and identified other residents that the attending physician did not review or respond to. CDON stated the facility does not know what happened on a system level that the MRR recommendations were not reviewed or responded to in a timely manner.

Based on interviews, observations, and record review (RR), the facility failed to provide adequate supervision to prevent elopements from the unit and/or facility for two of three resident's (R's) sampled. R1 eloped from the facility on 08/09/20 and was not located for approximately 90 minutes. R2 left the unit (4th floor) unaccompanied nine times since August 2019. In addition, all residents did not have documentation that a risk of elopement assessment had been completed. Findings include: 1. The Office of Healthcare Assurance (OHCA) received an incident report (ACTS # 8423) that R1 eloped from the facility on 08/09/20. The report documented, .CNA (Certified Nurses Assistant) at around 15:35 to 15:40 was doing her second check with R1 and noted that R1 was not in his/her room nor around the nurses station. By 15:55 R1 was not found in ICF5 (unit on the 5th floor where R1 resided), so by 16:00 CNA/LN (licensed nurse) called the other units to [NAME] the search, at 16:04 Shift Coordinator (SC) and Security Officer (SO) had been alerted to start the search within the property grounds. Around 16:45 police were called to file a missing person report by the SC with the subsequent notification to call the responsible party. During that time, the LPN (licensed practical nurse) reported that he/she had just spoken to R1's family member (FM), who informed LPN that R1 was with FM and that he/she would drive R1 back within 10-15 minutes. The FM reported that R1 was driven by an individual to his/her place of residence who found R1 around Vineyard Boulevard after having had a fall. Upon return to Kuakini Geriatric Care (KGC), the LPN met R1 in front of the Hospital ER and was seen to have had small bruises on his/her forehead, both knees and right elbow .Resident was taken directly to the ER for evaluation of medical condition.R1 .returned to the KGC, was placed in a room by himself/herself .for further monitoring, observation and COVID19 testing. Covid19 test result was negative and an additional low back X-ray completed on 8/13/20 due to complain of mild pain and revealed negative result. 2. R1 was a [AGE] year old admitted to the facility on [DATE]. R1's had poor cognitive status related to dementia and disoriented to place and time. At baseline, R1 walked around with no device, but used a wheelchair for longer distances. R1 was well conversant, but forgetful and repetitive. R1's diagnoses include dementia without behavioral disturbance, and the MDS (Minimum Data Set) dated 08/20/20 Section C, Cognitive Patterns assessed his/her to have a Brief Interview for Mental Status (BIMS) summary score of 11. The interpretation of this score indicated R1's cognition was moderately impaired. 3. Review of the Emergency Department Physician Record of R1's visit on 08/09/20 included documentation that, patient complained of left knee pain, but doesn't recall injury. Denies hitting head, despite obvious abrasion/hematoma of forehead. History limited by dementia . The record also documented frequently reporting left knee pain, with moderate pain to face and left knee. R1 also had a 4 x 4 cm (centimeter) hematoma a proximal tibia/patella (lower leg/knee) and a 1 cm faint ecchymosis (bruising), minimal swelling to right knee area. Clinical impression was Contusion Left knee, and Acute head injury. Review of the Emergency Department Triage note revealed the chief complaint was, Patient brought to ER to be evaluated for fall patient was found by bystander at Vineyard Blvd. Abrasions/bruise noted to forehead. 4. On 08/13/20, MD1 saw and evaluated R1 during a telemedicine encounter. RR revealed, Recent fall with back pain after presumed fall pt (patient) recently escaped from facility and found with extracranial head injury and knee contusion. Pt. reported back pain last night to nurse and during visit pt. is heard complaining of lower back pain while walking to bathroom . Patient does report being tired right now which nursing reports is different from baseline where she usually walking around at this time of day. MD1 ordered [MEDICATION(S)] 4% patch to back for pain. 5. On 05/25/20 R1's risk elopement assessment determined R1 was a medium elopement risk. The risk elopement assessment documented the following: Question (Q)3. Does the resident have a history of escape or elopement? Are there relevant factor from the residents history? Consider elopement from previous home, history of leaving the premises unsupervised Staff documented: Yes, with the comment, wander out of .in 2016, out of ICFS 2 years ago 2018, wander out of ICFS to 1st floor to go to activities. Q8. Does the resident say that he/she wants to leave, to go home, etc? Staff documented: States usually to go to church, a meeting, he/she thinks he/she works in KGC, no verbalization of going home. Q11. Please list elopement deterrents in place for this resident: Staff documented: Daily activities; 1:1 socialization with staff during working hours when walking around the unit. Offer magazines/books to read. Offer food/fluids. Check 15 min to 1 hour and check for location. Related diagnosis was dementia. Assessment indicated R1 is easy to redirect. Additional comments: Pt. does not exit seek or observed to have exit seeking behavior. On 08/18/20 (elopement 08/09/20): another assessment was completed that determined R1 was a medium elopement risk. The risk assessment documented the following: The elopement that occurred 08/09/20 was not noted on the assessment form. Q8. Does the resident say that he/she wants to leave, to go home, etc? Staff documented: States usually to go to church, a meeting, he/she thinks he/she works in KGC, no verbalization of going home. The risk assessment was the same as the previous assessment with the exception of the following: Q11. Added attends 9:30 AM and 1:30 PM activities daily. Additional Comments: Above assessment is based on 1:1 documentation from 08/09/20 to present. 6. On 08/11/20, RR of R1's progress notes revealed the following entry, . Patient (R1) continuously said, Please take me home. 7. Review of the facility event log provided by Risk Management revealed an entry (# ) dated 04/06/20 that read: Saw the resident (R1) talking to the security guard by the security kiosk. Said he/she wanted to go to the store. Brought him/her back to ICF5 (fifth floor, R1's home) and notified the Charge Nurse. The security kiosk was located on the ground floor by the exit door. This incident was not noted in R1's progress notes, Care Plan, or on either of the Elopement Risk Assessments. In addition, the Interdisciplinary Team (IDT) quarterly Care Plan Conference Record dated 05/19/20 did not include any reference to the 04/04/20 event when R1 left the unit unaccompanied and wandered to the first floor. 8. On 08/19/20 observed at the main entrance, KGC is to the left, and the hospital was to the right. Due to COVID-19 the facilities do not allow visitors. At both facility entries, a desk was set up where everyone, including staff that enter sign in and are screened prior to entry. These desks are manned until approximately 05:00 PM, when the KGC table is taken down, and everyone is screened by the staff at the hospital screening table. The Security Manager (SM)said the security kiosk located in the hallway close to the hospital screening table is staffed every night from 08:30 PM until approx 05:00 AM. Review of a memorandum dated April 21, 2020 with the subject: Basic Instructions for Entry Monitor (EM), states the EM must be able to control the entry point and enforce entry restrictions . The memorandum provides details of who may enter and the general health screen to be performed, but does not have any reference to individuals exiting. Review of the screeners (EM) job description titled Clerk Receptionist-Security Services, dated 05/18/20 does not list monitoring individuals exiting the facility as a duty or essential function. 9. On 08/20/20 at approximately 9:00 AM, completed a tour of the facility entrances and exits, observed the video monitoring system, and conducted a reenactment of the elopement route with the SM. It is unknown exactly where R1 fell , but he/she walked a minimum of .5 miles before reaching the street where reportedly picked up. During that time, the SM stated one of the fire exit doors on the ground floor did not have an exit alarm. 10. On 08/20/20 during a tour of the fourth and fifth floor, observed due to the layout and location of the elevators, the elevators are not visible to the nursing station, and there are several blind spots that staff were unable to see a resident enter an elevator unless they were in that immediate area. An ambulatory or self propelled wheelchair resident could enter an elevator and leave the unit without being seen. 11 On 08/20/20 at 10:45 AM, during an interview with a family member (FM) of R1, the FM said voices were heard outside the door, and when the door was opened, R1 was outside with an unknown man. The man said he found R1 on Vineyard Blvd after R1 had fallen. R1 told the man he/she was going home. He gave R1 a ride, and relayed he had a some difficulty finding the house and wanted to make sure it was right place before he left. He did not want to give his name. The FM said the house is at lease a 15 minute drive from KGC. No-one really knows what route he/she took or exactly where he/she was found. The FM put R1 in the car and drove him/her back to the facility. FM stated, while in enroute, I called the facility and they told me they were just trying to call me. They met me at the door and took him/her to the ER. FM said he/she did not receive a phone call that night regarding R1's status, or ER disposition. FM said he/she wanted to participate in the scheduled care conference, and asked for administration to be present because he/she had a lot of questions regarding the incident. Like how does a [AGE] year old not wearing a mask walk out of the facility unnoticed? I asked if they had any procedures to monitor for people leaving the building, and was told no. The nursing station has direct view of only four to six rooms. The rest can't be seen, and no-one is stationed near the elevators. FM said R1 could not remember a fall or details of the event. 12. Review of Social Service Progress Record dated 08/11/20 at 15:30 revealed the following documentation: FM questioned how people who enter/exit KGC are being monitored. FM was informed that surveillance who enter/exit KGC are being monitored. FM informed that surveillance is being done in compliance with the State and CDC (Center for Disease Control and Prevention) guidelines in response to COVID-19 pandemic. FM was informed that during higher traffic hours, there are two check in desks (one located right outside the Hale Pulama [NAME] building (KGC entrance) and one closer to the hospital entrance by the ER) During slower traffic time-check in table is consolidated to one table (the one closer to the ER). FM questioned if people entering KGC are required to wear a mask and present ID, why wouldn't they also monitor people who are leaving the facility to require mask and ID as well. FM was informed there is no expectation of visitors to sign out.FM expressed his/her concerns about the floor plan and suggested the nursing station should be closer to the elevators FM aware resident with dementia and dementia is a progressive disease. FM informed KGC is not capable of providing ongoing 1:1 sitter however KGC is and will continue to make every effort to accommodate changing needs as long as it is within the scope of what KGC can provide. 13. R2 was a [AGE] year-old with a past medical history of cerebral ischemia, vascular dementia with behavioral disturbance and frequent falls. R2 was admitted to the facility on [DATE] and was able to ambulate with a walker and supervision. R2's BIMS score assessed on 06/08/20 indicated his/her cognition was moderately impaired. 14. RR of R2's progress notes revealed multiple accounts of R2 wandering off the unit between 08/16/19 to 08/23/20. Complete progress notes for the time period of 02/2020 to 05/2020 were not in the medical records. The DON, said these records could not be located, and were not available at the time of survey exit. Entries in the progress notes available included: 08/16/19: .Nursing staff provided 1:1 assistance from 3-7 pm .Resident wanted to wait for her 2 son's downstairs .resident keep insisting today is his/her birthday & he/she wanted to wait downstairs .Resident went downstairs by herself, .staff brought him/her back to the unit @5:15p. 1:1 assistance provided for resident's safety. 09/21/19: .Resident wandered around unit with over 20-25 attempts to go down-stairs. Made it into elevator 3 times . 09/22/19: .Around 12:30 PM found the resident in front of ER. 09/27/19: Resident found by Physician wandering in the lobby. MD escorted resident back to the unit. 09/30/19: Family is aware resident wanders and knows about resident's multiple elopements 10/09/19: .Co-resident reported that resident went down to the lobby .Staff went down & accompanied resident back the unit . 10/15/19: .Resident found by security guard in the lobby. Escorted back to unit . 10/22/19: .Pt wandered down to the 1st floor today . 11/29/19: .Has some wandering behavior, gets on elevator, but now more redirectable to come out and go back to the floor. Last episode of elopement/wandering was today when pt. was found in the 3rd floor 11/30/19: .At 7:30 AM during endorsement, resident found by the housekeeper @ cafeteria. Per resident he/she don't know where he/she going and what to do 08/07/20 Nutritional Progress note: .Found resident trying to get out of elevator on 1st Fl (floor) 08/21/20: .CNA noted that resident went to elevator and press down, CNA redirect 08/23/20: .At approximately 14:00 resident started walking towards elevator. Per resident she will walk to country club .Resident repeatedly verbalized she is going to dinner to country club .Nurse alerted all staff to monitor for elopement. 15. Review of the IDT (Interdisciplinary Team) MDS/Care Plan Conference Record dated 06/08/20 documented the comment: Redirect as necessary. Wandering or elopement was not documented as a problem at this meeting and the IDT did not have establish a goal for R2 related to wandering. 16. Review of the facility event log revealed an entry (# ) on 11/30/19: at 730 AM, while doing spot check we noticed resident (R2) not in his/her room. Resident found in the cafeteria by the housekeeper. Per resident he/she don't know where he/she going and don't know what to do . The other times R2 left the unit unaccompanied were not listed on the event report. 17. RR of the Geriatric Medicine Recertification Note dated 04/14/20 revealed the following: Though still a fall risk, pts function is much improved from admission. Discussed with DHPOA (power of attorney) that pt. will likely be better served in a dementia facility that has wander guards and has a locked unit to prevent elopement as it is not advisable to keep medicating pt. to keep him/her sedated enough to dampen her desire to walk. 18. Review of R2's admission Elopement Risk of assessment dated [DATE], indicated R2 does not have a history of escape or elopement and is not exit seeking. It was noted that resident wanders aimlessly on occasions and concluded R2 was a medium risk for elopement. The Facility re-assessed R2 on 08/19/20 with changes indicating R2 was exit seeking and included: Resident has a tendency to wander around the unit constantly. He/She attempts to take the elevator downstairs and continues to wander aimlessly. The re-assessment concluded elopement risk was medium. 19. On 08/19/20 at 02:30 PM observed R2 to ambulate well without assistance in the hall using a front wheel walker. During a period of time approximately 10 minutes, the nursing station redirected R2 twice. 20. RR of R2's care plan indicated R2 was at risk of leaving the unit. The intervention read, When resident is ambulating in the hallway make sure personal alarm is on and monitor more closely to prevent him/her from leaving the unit. During an interview with the DON, it was confirmed the facility did not have a personal alarm system that residents wear, and he/she felt the staff were referring to a bed or wheel chair alarm that alarms with someone is getting out of the bed or a wheel chair. 21. On 08/20/20 at 08:00 AM observed COVID-19 EM at the entrance of the facility screening individuals entering the facility. There was no staff was in the visitor center desk located in front of the main elevators to facility floors. At that time during an interview, the EM stated there is a binder at the security station (kiosk) with pictures of residents who are an elopement risk. EM said he/she would not be able to recognize all residents who are wandering or eloping out of the facility because there are too many to remember. 22. Review of facility Policy/Procedure titled Wandering and Missing Resident (Elopement) dated 04/2018 includes the following: Wanderer: A resident who has shown a history of straying out of view and monitoring of staff and requires a high degree of staff monitoring and oversight to ensure the resident's safety. All residents will be assessed for risk of wandering/leaving the facility. Any staff noting an increase in at risk behavior (verbalizations, increase in actions, etc.) will notify CN (Charge Nurse) and Shift Coordinator (SC) . An additional assessment will be completed by the IDT team to determine the degree of risk for elopement or wandering. Additional safety measures will be initiated and care planned as appropriate. 23. On 08/19/20 RR completed on the 4th floor to validate all residents had an elopement risk assessment completed. The sample on the 4th floor included 38 residents. It was immediately noted that several residents did not have an elopement risk assessment in the designated binder. During an interview at approximately 02:00 PM, with the Unit Manager (UM), it was brought to his/her attention several residents did not have documentation of the assessment. Inquired what the facility policy was, and how residents were assessed for elopement risk. The UM was unable to verbalize the policy/process and stated, We assess the resident's that we think are an elopement risk. UM completed an audit for compliance at that time, and results revealed 18 of the 38 residents had a documented elopement risk assessment in the medical record . The DON later informed surveyor that the assessments were completed on residents admitted after 2018, when the policy went into effect, and validated the facility had not done the assessments on the other residents. The DON stated he/she would address the issue, and provided documentation of completion prior to exit. 24. Review of the Facility assessment dated ,d+[DATE], listed psychiatric/mood disorders that may be screened for facility included: [CONDITION(S)], impaired cognition, mental disorder, depression, anxiety, behavior disorder, behavior that needs interventions, and neurological system disorders that included Alzheimer's Dementia, and Non-Alzheimer's Dementia. The facility assessment did not indicate the facility did not have the capability or resources to care for a resident that wanders. It is not uncommon individuals with these conditions or diagnoses wander or to be at risk of elopement.

Based on record review (RR) and staff interview the facility failed to assess resident (R)83 for safe Geri chair use prior to using a Geri chair, ensure R83's environment was free of accident hazards and received adequate supervision while sitting in a Geri chair to prevent an accident which resulted in harm to the resident, requiring a visit to the emergency room . This deficient practice had the potential to affect the other 79 residents at the facility who have been identified on the matrix with a [DIAGNOSES REDACTED]. Based on observation, staff interview and record review the facility failed to maintain safe water temperatures ranging from 100 to 120 degrees Fahrenheit facility wide placing the residents are risk for burns. This deficient practice had the potential to affect the 155 residents at the facility. Based on observations, staff interviews, and resident interview, the facility failed to identify foreseeable accident hazards from a bed mattress placed on the floor (in place of a bed mat) for 16 of 43 residents reviewed. As a result of this deficient practice, the facility put the safety and well-being of not only the residents, but the public and the staff at risk for accidents. Findings Include: 1) R83 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On 09/13/18 at 09:23 AM interviewed Registered Nurse (RN)1 regarding R83's fall on 09/10/18 which he stated occurred at approximately at 09:10 AM near the nurse's station on the fourth-floor unit. RN1 stated the fall was from a Geri chair in the reclined position and it was an unwitnessed fall. Prior to the fall, R83 was assisted into the Geri chair after she pulled down the privacy curtain and 2 ceiling tiles in her room. This caused damage to the privacy curtain rail and had to be fixed by maintenance staff. RN1 stated R83 was yelling, stating she wanted to get out of the facility, was angry and trying to grab RN1. RN1 stated when R83 grabs him it's a tight grip and he has to pry her hands off of him. Inquired with RN1 if R83 was on 1:1 supervision and RN1 stated no, R83 was left near the nurse's station unsupervised sitting in a reclined Geri chair. RN1 stated this was done so facility staff would be able to see R83 and react to help her if it was needed. This was reported by RN1 as something normally, routinely done on the unit. Inquired if R83's physician was notified of R83's behavior and RN1 confirmed that he reported the worsening behavior at 08:05 AM on 09/10/18 and an order was given for a one time dose of [MEDICATION NAME] 0.25 mg p.o. (by mouth) which was given to R83 while she was sitting in her Geri chair, prior to the fall, and this medication was documented and reported as ineffective. RN1 stated injury was sustained to R83's face from the fall with bleeding from her nose and pressure was applied to stop the bleeding. RN1 stated about an hour after the fall R83 started coughing up blood. Upon RR of R83's medical record with RN1 it was noted RN1 documented in R83's progress note, dated 09/10/18 at 10:30 AM, At approximately 10:30 AM, resident started coughing up blood, slimy and thick in appearance. RN1 stated R83 had a complete blood count (CBC) with differential lab draw done and RN1 stated R83's white blood count (WBC) lab result came back abnormally high. RN1 notified R83's physician immediately of this and the physician decided to send R83 to the emergency room (ER) for evaluation. R83 was transferred to an acute hospital ER at 11:00 AM. R83 was seen in the ER and moved to the Progressive Care Unit (PCU) afterwards. R83 was returned to the fourth-floor unit on 09/11/18 at 03:00 PM with Final [DIAGNOSES REDACTED]. Continued staff interview on 09/13/18 with RN1 found R83's [MEDICATION NAME], a medication that reduces anxiety was initially ordered at 7.5 mg p.o. BID (by mouth twice a day) then decreased to just daily and then discontinued on 09/10/18. RN1 stated R83's behavior appeared to have gotten worse as she was taken off the [MEDICATION NAME]. During interview, a review of physician orders for R83 did not reflect an order for [REDACTED]. Devices that need assessment and must be care planned and consents signed shall be used. These include: Bed rails, Reclining chair/Geri chair, Wheelchair seat buckle/Velcro belts, Wheelchair/reclining chair, Gurney straps/belts, Positional change (bed and chair) alarms. RR of R83's care plan (CP) found a CP in place for Resident has a need for Geri-chair usage for postural support while OOB (out of bed) to improve comfort. CP was initiated by RN1 on 07/18/18. RR found that R83 had a Bed Rail/ Other Device Assessment Record form completed by RN1 on 08/06/18 for Top bed rails. It was noted that Reclining chair was not checked as assessed for R83. Inquired with RN1 regarding this and he confirmed the assessment was only for bed rail use and should have included Geri chair use. RN1 confirmed that R83 did not have an assessment completed for Geri chair use. Inquired of RN1 if R83 should have had a completed Geri chair assessment prior to using a Geri chair and he confirmed this. On 09/13/18 during RR of R83's CP found Care Plan - Severe Behavioral Disturbances R/T Dementia under intervention 4. If the resident becomes restless and decides to roam the hallways, provide 1:1 assistance as necessary to maintain safety . Inquired with RN1 why R83 was not supervised on 1:1 as stated in her CP as she was agitated, exhibited aggressive, destructive behavior, and appeared restless and RN1 stated that they did not have any staff they could use to watch R83. Inquired if RN1 requested 1:1 staff for R83, to maintain her safety, from DON or supervisor and he stated no. Inquired of RN1 if R83 should have been supervised on 1:1 to maintain safety and RN1 concurred that R83 should have been monitored 1:1 for her own safety on 09/10/18 prior to her fall. 09/14/18 at 08:09 AM interviewed RN2 and inquired if she was asked to monitor R83 on 1:1 for her safety on 09/10/18 prior to R83's fall. RN2 stated she was not asked to observe R83 1:1 Monday, 09/10/18. RN2 confirmed that she started to monitor and observe R83 1:1 on 09/12/18 at 07:00 AM. RN2 stated she assessed R83 when she was helping the CNA help R83 with Activities of Daily Living (ADLs) and stated she felt R83 required 1:1 observation due to her restlessness. RN2 stated that she observed R83 1:1 from 07:00 AM - 01:20 PM on 09/12/18, with no breaks except to use the bathroom. RN2 stated this was the longest she has spent with a resident doing a 1:1 observation for the resident's behavior. On 09/14/18 at 09:36 AM interviewed Director of Nursing (DON) who confirmed that she was notified that R83 had pulled down her privacy curtain and two ceiling tiles but could not say if R83 was being monitored on 1:1 with staff when asked. DON confirmed that she was notified of R83's fall from the Geri chair soon after this occurred as she was on rounds with the facility administrator. Inquired why R83 was not monitored on 1:1 DON stated it is hard to find staff, staffing office tries by making phone calls and it is not easy, usually they have to take one staff off the floor and that floor would work short. DON explained R83 has had scheduled 1:1 monitoring in the past. DON stated that she has done one shift as a 1:1 with R83 in (MONTH) (YEAR) but unsure what day that was. When asked about how the facility determines staffing needs DON stated that it is based on numbers/census of the unit using the staffing matrix. DON shared a copy of the facility staffing matrix and noted that it states Intended as a guideline for staff levels. Specific resident care needs will always dictate actual staffing requirements. On 09/14/18 at 10:10 AM interviewed administrator regarding R83's fall that occurred on 09/10/18. Administrator stated she was doing rounds with DON on the unit after R83 had fallen from her Geri chair. She stated they went to the room to see R83. R83 had been assessed by the nurse and was being transferred to the ER. R83 was in bed with two CNAs in her room. Administrator stated R83 has had 1:1 staff in the past when she became agitated and confused. When asked why R83 was not placed on 1:1 that day prior to the fall and administrator stated I don't think that they anticipated that she needed 1:1 that day, 1:1 can happen any time. Administrator explained staff would notify management which is the DON and the staffing office, of the need for a 1:1 staff and staff could be pulled from another floor. Administrator stated the Patient Care Coordinator (PCC) could sit with the resident, and management could sit with her. Administrator stated she did 1:1 observation with R83 when she was first admitted , around late June. R83 was not as strong, not as agitated at that time. Review of R83's medical records progress notes and assessments found the facility did not assess safe Geri chair use with R83 prior to using the Geri chair, putting R83 at risk for harm. Review of staff interview found on 09/10/18 that R83 was agitated, exhibited aggressive, destructive behavior, and appeared restless prior to her fall requiring a one-time dose of an antianxiety medication to help her calm down. R83 was assessed by an RN on 09/10/18 prior to her fall but was not placed on 1:1 supervision based on shortage of staffing at the facility even though staffing requirements are based on specific resident care needs as stated on the facility's staffing matrix. The facility failed to provide a safe environment for R83, failed to provide adequate supervision while using a Geri chair resulting in harm to the resident, requiring an ER visit. 2) On 09/11/18 during initial walk through of the fourth-floor unit it was noted the water in the resident's room sinks were very hot to the touch when the hot water was turned on. At 04:15 PM met with maintenance staff (MS)1 to test water temperatures in the resident's rooms. tested rooms 404, 419, 420 and 423 and found water in room [ROOM NUMBER] was 122.3 degrees Fahrenheit using a digital thermometer. Rooms 404, 420 and 423 water temperature range were from 112.8 degrees Fahrenheit to 120 degrees Fahrenheit. On 09/12/18 at 11:10 AM met with facility maintenance manager to discuss spot checks of hot water temperatures and he showed his Daily Hot Water Temp Log from 06/01/18 - 09/10/18. Review of the log found hot water temperatures ranging from 112-127 degrees Fahrenheit. Facility maintenance manager was reminded that facility was cited last year for exceeding the safe hot water temperature as the facility's water temperature was also recorded above 120 degrees Fahrenheit during the (YEAR) survey. Inquired what was done with the room sinks that went over 120 degrees Fahrenheit on the logs that he shared with me, facility maintenance manager stated that his boss quit last month and that his boss was responsible for that part of the plan of correction. Upon observation, staff interview and review of hot water logs found the facility failed to maintain resident's hot water temperatures between 100-120 degrees Fahrenheit even after having been cited the previous year for this. This deficient practice puts the 155 vulnerable residents at risk [MEDICAL CONDITION] the elderly residents' skin are thinner, some of the residents are mute and unable to state that the water is too hot and 80 of the 155 residents have been identified with dementia on the facility matrix and might not be able to communicate to staff that the water is too hot or that they have hurt themselves with the hot water. 3) During an observation of Hale Pulama Mau 3rd floor, on 09/14/18 at 08:22 AM, 16 out of 43 residents had a bed mattress placed on the floor (floor mattress) next to their regular bed. According to the charge nurse (CN)1, the floor mattress was used to provide a soft pad in the event of a resident falling off their bed. CN1 also stated the staff would have to move the floor mattress out of the way whenever residents, staff, or visitors needed access to that space. During an interview with Resident (R)68 on 09/14/18 at 08:26 AM, R68 said he had concerns about the mattress being on the floor next to his bed. R68 said that he didn't want that mattress there and that it could cause an accident, mostly with the staff falling over it. During staff interview with Clinical Nurses Assistant (CNA) 4 on 09/14/18 at 08:45 AM, CNA4 relayed that it was a hassle to always move the floor mattress whenever they wanted access to the resident. CNA4 further stated that one couldn't just step on the floor mattress because that would be very dirty. Staff interview with CNA6 on 09/14/18 at 01:23 PM revealed a concern for extra clutter in resident's room along with the continued concern of residents and/or visitors falling over the floor mattress. CNA6 stated that when there are two residents assigned to one room, the floor mattress really took up a lot of space and that may cause anyone to trip and fall. Staff interview with licensed nursing staff (Nurse) 5 on 09/14/18 at 01:35 PM revealed a concern for potential accident hazard during emergency situations. Nurse 5 stated that the floor mattress always got in the way when you want to have access to the resident. Nurse 5 particularly stated that in emergency situations, the only option would be to step on the mattress and that may cause anyone to trip over the mattress and fall.

Based on observations and interview the facility failed to ensure there was sufficient nursing staff to provide services according to the residents assessments and comprehensive care plans and physician orders. Findings include: 1) Residents were observed having 8 AM medications administered at 10.30 AM -11 AM daily for the duration of the survey. Interview with Staff #109 and Staff #148 confirmed their core nursing staff was currently down in required numbers due to a large number of nursing staff resigning from mid January through to March 2017. This left gaps in required number of nursing staff required on a daily basis as reflected on the daily staffing sheets from 1 April, 2017- 3 May, 2017. 2) On 05/05/17 at 12:52 PM, during an interview with the DON, she stated, A lot of the 8:00 morning meds are averaging around 10:00 AM. We are in the process of trying to get it more directed for the patient care coordinators (PCCs) to review instead of just wandering the floor with the new management observation sheet. And these sheets will be brought to the weekly meeting for review with reference to the staffing concerns and late medication administration found during survey. Cross-reference to findings cited at F176, F333, F431 and F514. On the afternoon of 05/08/17, during the interview of the Medical Director, she stated their physicians are looking into the medication administration times for long term care residents and a plan to adjust some of the routine medication administration times. Although she stated the medical care is excellent, it is the SA's cumulative findings with the IJ, that the overall failure of the facility to identify these substantive issues has affected the residents' care and well-being, and was corroborated by resident, family and staff interviews, including the lack of sufficient staffing as a contributory factor. 3) On 05/02/17 at 11:47 AM, observation was started for the lunch meal service with the delivery of the food carts on the 5th floor. At 12:03 PM, Res #103 had not received a meal tray yet, as well as several other residents. Staff #58 informed surveyor that those residents who needed to be fed, we leave them (trays) in the cart. She said these residents were always fed last. At 12:36 PM, Staff #58 was feeding Res #527 beef stew and rice, but she had no green tea to drink as listed on her menu. Staff #58 did not realize the resident was missing this from her tray and was only spoon feeding her the entree. Surveyor queried whether the resident can have liquids in between, and that's when Staff #58 said, I will go get yeah fast kine and left to get the tea. Another staff, Staff #60 said, because we have plenty who need assist! and that was why they felt rushed even though they had 4 CNAs passing the trays and feeding residents. One CNA was dedicated to the Solarium to observe those residents. At 12:42 PM, Staff #50 said was finishing up with another resident and said once Staff #60 was finished in the Solarium, she was going to feed Res #103. However, by 12:45 PM, Res #103 still had not been fed, which was approximately an hour later by then. On 05/03/17 at 8:02 AM, Staff #67 was feeding one resident in the TV room. She had four other residents with her, one who could eat by himself, and one she was assisting. Staff #67 admitted that she still had two more residents to feed, even though the food cart arrived at 7:30 AM. She said before they had 6 CNAs, but now 5 CNAs. Yet, another resident, Res #216 did not know she had eaten and said, I ate already. Res #216's meal tray however was left untouched and Staff #67 said the resident does not remember. Staff #67 was not able to assist Res #216 since she was feeding someone else, but yet stated she would have to in addition to two other residents she still had to feed. At 9:16 AM, Staff #67 said it took her until 9:10 AM to finish feeding the three residents their breakfast, which was about an hour and 45 minutes after the meal cart was brought up. On 05/04/17 at 8:01 AM, Staff #62 and Staff #135 said they used to have six CNAs for 50 residents with three licensed staff. They said now there is only two licensed staff with three to four CNAs. They said sometimes, they have one CNA for 16 residents and only one licensed staff on the weekend. They both said, It's really bad and Staff #62 felt we're running and the families always say that to us too. Staff #135 confirmed they had 20 residents who are dependent in feeding, four with tube feeding and for the remaining residents, she said, although they can eat they still require supervision. Almost all need assistance. When she was asked why are the residents who required feeding assistance were fed last, she said, Because they have to go one at a time with them .But the food usually cold by then and so staff have to reheat it. On 05/04/17 at 8:28 AM, a family member of a resident who requested not to be identified, stated the reason why he/she came to help feed the resident was because if he/she did not, (resident) won't get fed timely. The family member said he/she feels sorry for the CNAs because they're always running and they're always short staffed. Even sometimes the patients are crying out loud too, like where's my food, where's my food. The family member said lately too, the meal carts were being delivered half an hour later, and the meals trays are mixed up. The family member shook his/her head acknowledging this. On 05/04/17 at 8:33 AM, an interview of Staff #121 was done. She was asked what quality measures were identified and what improvement measures were being implemented on her nursing unit. She stated there was a decrease in the number of falls due to the changes she made to the break hours for the night shift, as I was reviewing the trends, it was much improved, instead of 2 (staff) at a time, only 1 goes on break at a time. When asked about her observations of the residents' dining service on her unit, the PCC stated, We do get them up for lunch and dinner and how to feed residents and to be on the eye level. When further queried about the meal service itself, such as the delivery of the meal trays and if residents were fed timely, she stated, So far it's been good. Staff #121 was then asked again if she observed the meal trays coming up to the unit and the delivery of the trays to the residents to ensure timely meal service and consumption. She replied, No, not really. She was unable to identify the number of residents who were dependent on feeding assistance by the staff, but then said it was around 10. She acknowledged their ICF census had not changed that much. Staff #121 was also asked why the residents who required feeding assistance, such as Res #103 was always fed last. She was queried if it was because the cognitively impaired residents were less likely to complain if their meal was served to them an hour later and colder. Staff #121 had no comment and then acknowledged because she has not really observed the dining experience for her unit, she did not know. On 05/04/17 at 8:59 AM, Staff #36 stated she often has to help the CNAs with assisting the residents. She said, it's pretty bad and even though we attend the staff meetings, nothing has changed. Even family members will complain, but the families say, 'Oh no sense we say anything because nothing is going to change.'

Based on observation, record review, interviews and review of the facility's policy and procedure, the facility failed to ensure the resident was comprehensively assessed to safely self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate for 1 of 37 residents (Resident #39) in the Stage 2 sample. Finding includes: Cross reference to findings at F280, F333, F353, F514. On 05/04/17 at 12:52 PM, an interview was conducted with Resident #39 (Res #39). During the interview, the resident stated, Sometimes I wait an hour before the nurse can come to help me, like my 8 o'clock medication, yeah, the morning one. I don't get it until 10:30 or 11:00 am. Today I had it earlier because you guys are here (her other routine medications). That's why I have to hang onto my sprays, I have to give myself, my [MEDICATION NAME], because I can't wait on them. I need it for my breathing. I told them I need to be responsible for my own health. Res #39 said one of the nurses had given her the inhalers to keep at her bedside but did not recall who it was. Res #39 said it has been around a month or so that she's been self-administering her own inhalers. The resident was observed to have both her [MEDICATION NAME] disc and ProAir inhaler at the foot of her bed. She said she kept it there so I can grab it and use it. She denied ever being taught by licensed staff how to use her inhalers. She denied that staff watched her when she used her inhalers on her own and said, I know how to do it. They're always late, that's why I have to keep it here. On 05/04/2017 at 1:36 PM, the resident went out on an appointment and was not in her room. A concurrent observation was made with Staff #99 on 05/04/17 at 1:39 PM of Res #39's room. It was observed that both the [MEDICATION NAME] and ProAir inhalation medications were left unsecured, on the top of her bed mixed in with baby powder, sugar packets in a tub, books, a small Kleenex box, etc. Staff #99 said, We never ask doctor if may keep medication at bedside. It is our fault. We never ask doctor. Staff #99 was queried whether she observed the resident doing her own self administration of medications and whether the resident was using them properly and dosing correctly for both the inhalers. Staff #99 also said, She's alert and I observed her inhaling, but to be honest, but I haven't seen her use it at lunch time. Staff #99 said the resident's ProAir order was to use four times a day and the [MEDICATION NAME] was twice daily. Staff #99 said she would ask Res #39, I ask have you done your cough? and based on what the resident said was how she documented it on the Medication Administration Record [REDACTED]. On 05/04/17 at 1:44 PM, during an interview with Staff #57, she acknowledged documenting on the MAR indicated [REDACTED]. Staff #57 said only last month for the [MEDICATION NAME] and admitted not administering the medication nor watching/observing whether Res #39 did her inhalations. Yet, Staff #57 documented that those medications were administered to the resident by her when in fact, she did not. Staff #121, the unit's patient care coordinator (PCC) was also present and said she was not aware that Res #39 was self administering her medications. Staff #121 said it was not acceptable what the licensed staff were doing. She acknowledged the lack of monitoring and risk for overdose by the resident. Staff #121 also said, We are not following what's in the policy and patient safety. She acknowledged it was a concern that licensed staff were signing off on the MAR indicated [REDACTED]. It was later reported to the State Agency (SA) that two other residents were found to have medications at the bedside which should not have been left there. On 05/04/17 at 3:20 PM, during a re-interview with Res #39, she stated, The nurses came in and took away my medication and said they also have to teach her how to correctly self-administer the inhalers. She shook her head and said, I told them it's because you don't give it to me on time. For my 8 o'clock medication, they give it to me at 10:30 or 10:45. I need it. They don't watch, no, no. I do it myself, I know I can and I know how much I have left (doses), but they don't look. Before this, they never watch. She said she had a stroke in 2008, has [MEDICAL CONDITIONS], a [MEDICATION NAME] asthma condition and had to be on continuous oxygen all the time via nasal cannula. The resident had an H tank at her bedside and portable oxygen. On 05/04/17 at approximately 2:00 PM, the State Agency (SA) team identified an immediate jeopardy (IJ) situation at the facility. The IJ was for the facility's failure to protect the resident from the potential harm from adverse effects of self administering medications, as evidenced by a lack of assessment, a lack of a physician's orders [REDACTED]., although they were aware, of providing the resident her prescribed medications timely, and yet, documenting on the MAR indicated [REDACTED] The policy on Medication Administration Self-Administration by Resident (10/07, Section 7.3) was provided by the facility on 5/4/17 at 1:20 PM. It stated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process .5. The resident is instructed in the proper cleaning of inhalers where applicable, proper storage and the necessity of reporting each medication dose used to the nursing staff. The completion of this instruction is documented in the resident's medical record. The nursing staff, as deemed necessary, undertakes periodic review of these instructions with the resident .7. If the interdisciplinary team determines that bedside or in-room storage of medications would be a potential safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. The medication nurse will provide the medication to the resident in the unopened package, when appropriate, for the resident to self-administer. The nurse then records such self-administration on the MAR indicated [REDACTED] On 5/4/17 at 3:35 PM, the DON and the Vice President/CAO were notified of the IJ situation. The facility provided an initial acceptable abatement plan by 5:11 PM. The facility's abatement plan included notifying Res #39's attending physician, an inspection of all residents' bedrooms with implementation of a bedside tracking log, in-service of licensed staff, a house wide investigation, monitoring of actual times medications were being administered compared to the scheduled times, and the implementation of a daily nursing management rounding sheet.

Based on review of facility event report, observation, interviews and record review, the facility did not ensure that one resident had the right to be free from any physical restraints imposed for purposes convenience, and not required to treat the resident's medical symptoms, as evidenced by the use of a vest restraint that wrapped around the resident's neck and caused her to be slightly cyanotic. Finding include: An abbreviated survey was completed from 10/18 to 10/19/11 at the facility based on an Event Report the facility forwarded to the Office of Health Care Assurance. The Event Report noted that a licensed practical nurse(LPN) doing rounds on the floor heard gasping noises coming from the resident's room. The resident was found laying half on her bed mattress and half on the fall mattress on the floor at 4:50 AM on 9/21/11. He found the resident slightly cyanotic and face flushed. She had a vest restraint wrapped around her neck. The restraint straps were tied on the bed frame. The vest restraint appears to have slid up towards the head of the resident when she scooted down towards the foot of the bed, causing it to bunch up around her neck. After releasing the restraint, her skin color returned to normal. Upon assessment, red marks were noted around resident's neck. Interview with the Director of Nurses (DON) on the morning of 10/18/11 noted that a vest restraint had been ordered by the resident's physician. The reason for the vest restraint was that the resident had uncontrollable movement of her extremities and would get out of bed and scoot on the floor with her knees. Resident would not remain in her bed, and was out of bed scooting on her knees. She had developed [MEDICAL CONDITION] as a result of the constant rubbing of her knees on the floor. In order to stop her getting out of bed and to prevent reoccurrence of [MEDICAL CONDITION] her physician had ordered a vest restraint. At 9:10 AM on 10/18/11 the DON confirmed that the vest restraint was not on the approved list of restraints to be used on residents in this facility. She stated that the vest restraint should not have been used. Secondly, the C.N.A. assigned to care for the resident on that shift on 9/21/11 did not follow the resident's plan of care as the C.N.A. did not release her restraint for 10 minutes every two hours, and visual check the resident every 30 minutes. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident resides in a private room in the facility. Observations during lunch on 10/18/11 had the resident eating a chopped meal and being fed by a C.N.A. Resident responses to the questions of the DON could not be understood. The DON reported that the resident does not have recognizable speech. Resident's room had several mats on the floor surrounding her bed. The DON and charge nurse reported that the resident was able to scoot off her bed and scoot around the room on her knees. She was again observed in a Geri chair on the morning of 10/19/11 in the hallway next to the nurses station. There was movement of her arms and legs, and she was somewhat curled up in the chair. After a period of 5 minutes she stopped moving and closed her eyes. Record review was done on the afternoon of 10/18/11 with the assistance of the DON. The DON located the Physicians Order dated 11/10/09 for the use of the vest restraint, PRN agitation when up in reclining chair/bed. Release every 2 hours, during care, meal time and when family or staff is available. A new order was done on 8/16/10 for the vest restraint. Apply vest restraints when up in bed and reclining chair. Release every 2 hours during routine care, meal time and when family and staff available. The Minimum Data Set with the ARD of 8/22/11 coded the resident as " 1 " for memory problems for short and long term memory, and " 3 " as severely impaired for daily decision making. Resident was coded as dependent for her activities of daily living. Section P was coded as " 2 " for trunk restraint and " 3 " for other restraint. Physical Restraints was triggered on the CAA and checked for addressed on the care plan. There was a consent for the vest restraint signed by the resident's husband on 11/13/09. There was an Interdisciplinary Team AMDS/Care Plan Conference Record dated 8/22/11 which noted the "vest restraint when in bed". Copies of the Restraint Monitoring Log for the months of July, August and September 2011 were provided by the DON, who reported that this form was custom designed for this resident as she had a vest restraint. The form noted the identified restraint as a vest restraint. Facility was fully knowledgeable of the use of the vest restraint and was not in compliance with the facility's policy for restraint use. Review of the facility's investigation of the vest restraint incident included interviews with staff who were working on the unit at the time of the incident. A facility document titled "Employee Action Report" for the C.N.A. who was assigned to care for the resident on 9/21/11 was reviewed. It contained the hand written statement from the LPN who found the resident with the vest restraint around her neck. The LPN noted he was on the 11-7 shift and at or about 0450 he was making his rounds and heard somebody gasping for air. He went into the room and found the resident on the mat on the floor. Her legs were on the mat and the restraint was around her neck with restraint tied to bed. She was slightly cyanotic and crying. He had to physically lift the resident back on bed because the restraint was too tight. After placing the resident back on the bed he released the restraint and her skin color came back to normal. They were not able to get vital signs because of her agitation. It appeared that the resident scooted down to the end of bed and the restraint slid around her neck. The investigation included an interview with the C.N.A. assigned to the resident's care during that shift. This interview took place on 9/22/11. The C.N.A. reported that her last rounds were about 0145 when she checked on the resident, and resident was not wet so she readjusted her vest and made sure it was on good because it was loose. At 5 to 10 minutes prior to the choking event the C.N.A. reported that she walked past the resident's room on her way to the next room, and that she didn't go into the room to provide care. Thus, the C.N.A.'s last check prior to the 4:50 AM incident was at 1:45 AM. This was almost a 3 hour time period, instead of the 2 hour check and release of restraint as required as a standard of care by the facility. The DON provided a copy of the policy and procedure titled "Physical Restraint/Other Devices. Under the section titled "Policy" it noted under #7 that "Approved Devices-Only approved restraint devices shall be used. These include: Bed rails; Hand mittens; Reclining chair; Wheelchair seat buckle/Velcro belts, Wheelchair/reclining chair lap table; pillow or bar; Guerney straps/belts; Cloth wrist/limb holders." Interview with the DON and Managing Director during the morning of 10/18/11 confirmed that the facility reviewed their policy for restraints and affirmed that vest restraints are not approved for use. All vest restraints were removed from the nursing floors, and inservices on restraint policy and procedures were held with all nursing staff on 10/3/11. A resident was found with a vest restraint around her neck, lying half off her bed. She was found slightly cyanotic and crying, and was subsequently agitated. The facility did not conduct a thorough assessment of the use for the restraint, as evidenced by utilizing a restraint that was not approved by the facility. Secondly, the facility failed to fully implement the plan of care for a resident with the use of a restraint by not checking the resident and releasing the restraint every two hours.