Every finding on record at Lanai Community Hospital

Based on policy review and interview, the facility failed to review its infection control plan on an annual basis. The deficient practice inhibits the facilities ability to effectively implement its infection control prevention plan and has the potential to affect all of the residents in the facility by placing them at an increased risk for illness. Findings include: On 04/01/26, review of the facility's Infection Control Pan 2024 noted a reviewed and revised date of 04/2024. In section 5.1, Plan Evaluation, 5.11.1 states In preparation for the annual planning and revision of the Infection Control Plan, all components of the current plan will be evaluated to determine compliance, trends, and continued applicability to the Infection Control Plan .On 04/01/26 at 2:11 PM, interviewed the Infection Preventionist (IP) in the surveyor conference room. IP was asked when the Infection Control Plan was last reviewed and IP noted he was not sure and would check and get back to the surveyor.On 04/01/26 at 2:46 PM, during an interview with the IP, he confirmed the Infection Control Plan was last reviewed on 04/2024 and was currently under review.

Based on interviews and record review, the facility failed to re-schedule a follow-up dental appointment for one of one resident (Resident (R), 7) sampled for dental services. This deficient practice has the potential to affect all residents currently residing in the facility.Findings Include:On 03/31/26 at 11:25 AM, interview with R7's family member (FM)1 noted that R7's teeth are getting worse and was not sure what could be done about it. FM1 stated she is worried that it will affect R7's eating. On 03/31/26 at 02:31 PM, interview with Charge Nurse (CN) confirmed that R7 did have an appointment with the health clinic on the island but initially refused. CN stated subsequent follow-up appointment could not be accommodated by the clinic, and the facility also failed to reschedule appointment. CN also acknowledged that R7's refusal and dental issues were not included in R7's care plan. On 03/31/26 at 12:00 PM, review of R7's Basic Oral Assessment flowsheet noted that on 12/23/24's assessment, R7 had plague and was referred for dental consultation and had an appointment on 06/15/25. Subsequent assessments made on 01/21/25 and 04/20/25, noted that R7 had plague and caries with dental appointment still scheduled for 06/15/25. The next assessment due date was scheduled for 07/28/25, but facility did not provide any further documentation of assessment being completed. On 03/31/26 at 01:00 PM, when asked what happened to the 06/15/25 dental appointment, CN provided a nursing note dated 06/16/25, written by Registered Nurse (RN) 1 that an email was received from the health clinic that they could not accommodate R7's dental appointment on 06/27/25. RN1 spoke with clinic staff who stated they would call the facility with a new dental appointment for R7, but according to CN no call back was received from the health clinic and facility staff missed re-scheduling R7's dental appointment.

Based on record review and interview, the facility failed to provide written notice of the discharge to the hospital to the resident's representative and provide a written notice to the office of the Long-Term Care Ombudsman (LTCO) for one of one resident (Resident (R) 6) sampled for hospitalization. The deficient practice potentially affects the rights of the resident and resident's representative to ensure protections are in place; and facility practices related to transfer and discharge are known to the office of the LTCO. Findings include: On 03/31/26, R6's electronic health record (EHR) was reviewed. R6 was discharged to the Emergency Department (ED) on 01/24/26 then admitted to the hospital per medicine history and physical note dated 02/04/26. admission date: 01/28/26. R6 is a [AGE] year-old female with a history of end stage renal disease (ESRD) and dementia who developed chest pain and was seen in the ED. It was felt that a pulmonary embolism (PE) needed to be excluded and she was transferred to the acute care hospital for further evaluation. On 03/31/26, review of the hospitalization information from the Administrator noted R6 was hospitalized from [DATE] to 01/28/26. The written notification of R6's discharge to the hospital that was sent to the resident's representative and the LTCO office was not provided for review. On 03/31/26, interview with the Administrator revealed there was no written documentation of notification sent to R6's representative or to the LTCO office. On 03/31/2026, review of The Patient Discharge - Long Term Care (LTC) Unit policy with reviewed date of 10/2022, states: To provide guidelines for documentation and care of patients transferred between units in the facility. The family shall be notified of the change of level and room .

Based on observation, interviews, and record review, the facility failed to develop a person-centered comprehensive care plan for one of one resident (Resident (R) 7) sampled for dental services and skin conditions.Findings Include:Cross-reference to F791R7 is a [AGE] year-old female, admitted to the facility on [DATE] with a primary diagnosis but not limited to stroke, hemiplegia affecting right side and aphasia. On 03/30/26 at 10:00 AM, observed R7 in bed, awake, able to mumble words when spoken to. R7's right hand flaccid with notable right-hand contracture. R7 with brief on, with no visible indwelling catheter assessed.On 03/31/26 at 11:30 AM, interview with R7's family member (FM) 1, noted that R7 is prone to having skin issues. FM1 stated that for the last couple of months, R7 seemed to have some kind of skin problem. FM1 also noted that she is worried about R7's worsening dental condition and was not sure what can be done about it. FM1 is afraid that R7's teeth issues may affect her eating. 1) On 03/31/26 at 12:00 PM, review of the facility's Alert Charting list noted that R7 had at least 16 documented skin issues from 11/25/25 to 03/11/26. R7 is prescribed Clobetasol 0.05% ointment twice a day and Triamcinolone Acetonide 0.1% ointment for rash/itching. Review of R7's care plan noted topical corticosteroids were not included as an intervention. 2) On 03/31/26 at 12:00 PM, review of R7's Minimum Data Set (MDS), a federally mandated assessment for all residents in Medicare or Medicaid certified nursing homes, indicated that R7 was incontinent of both bowel and bladder elimination and did not have an indwelling catheter on admission. Review of R7's care plan included goals and interventions for indwelling catheter care. 3) On 03/31/26 at 12:00 PM, review of R7's Basic Oral Assessment flowsheet noted that on 04/20/25, R7 had plaque and dental caries. Review of R7's care plan did not include any goals or interventions to address dental care. On 03/31/26 at 1:48 PM, interview with Charge Nurse (CN) confirmed that the topical corticosteroids and dental plan of care were missing. CN acknowledged that it should have been included in the care plan as it directs R7's care. CN also confirmed that R7 did not have any indwelling catheter since admission and catheter care should not have been included. CN also admitted that the care plan created for R7 was a bundled care plan (standardized care plan) chosen on admission and agreed that it should have been individualized based on R7 current needs.On 03/31/26 at 02:00 PM, interview with the Director of Nursing (DON) confirmed that the residents' care plans should be individualized and reflect current needs. On 04/01/26 at 10:00 AM, review of the facility's Care Planning policy, with a review and revised date of 02/2020, in the Purpose section, it reads, To provide an individualized plan of care for patients. In the Provisions/Procedures section, it states 5.2 The plan of care shall be individualized, based on the diagnosis and patient assessment.

Based on observations, interviews, and record review, the facility failed to revise the care plan for one of two residents (Resident, (R), 7) sampled for limited range of motion (ROM). The facility did not revise the care to include the application of a towel splint for R7's right-hand contracture. This deficient practice puts R7 at risk for worsening contractures.Findings Include:R7 is a [AGE] year-old female, admitted to the facility on [DATE] with a primary diagnosis but not limited to stroke, hemiplegia affecting right side and aphasia. On 03/30/26 at 10:00 AM, observed R7 in bed, awake with noticeable right arm flaccidity and right-hand contracture. No hand or towel splint applied.On 03/31/26 at 10:00 AM, observed right-hand contracture with rolled towel in place.On 03/31/26 at 01:00 PM, review of R7's care plan to address contractures did not include intervention of towel application to right hand. The care plan which was initiated on 11/12/25 also noted that R7 did not require a splint. On 3/31/26 at 01:48 PM, Charge Nurse (CN) confirmed that the care plan was not revised to include towel application to R7's right-hand contracture. CN also stated that they have been applying the towel to prevent moisture and accumulated sweat to R7's right hand. CN acknowledged that revising the care plan is important as it reflects the current needs of the residents. On 03/31/26 at 02:00 PM, interview with the Director of Nursing (DON) confirmed that the residents' care plans should be individualized and revised to reflect the residents' current needs. On 04/01/26 at 10:00 AM, review of the facility's Care Planning policy, with a review and revised date of 02/2020, in the Purpose section, it reads, To provide an individualized plan of care for patients. In the Provisions/Procedures section, it states 5.5 The plan of care shall be updated with revisions reflecting the reassessment of needs of the patient on a regular basis.

Based on observation and interview, the facility failed to ensure that the personal information and clinical records of resident (R)12 were protected. As a result of this deficient practice, residents are at risk of their health information not remaining private.Findings Include:On 03/31/26 at 01:00 PM, observed the computer terminal (located on the left-side corner of the activities room) with R12's electronic health record (EHR) left open and accessible to any passerby. The screen included R12's flowsheets, diagnosis, and other healthcare information. Concurrent interview with Certified Nurse Assistant (CNA) 1 stated that she left the EHR open and forgot to exit out when passing resident food trays. CNA1 acknowledged that closing out the chart is important for the protection of residents' health information and to comply with the Health Insurance Portability and Accountability Act (HIPPA).On 03/31/26 at 01:00 PM, interview with the Director of Nursing (DON), confirmed that the resident's chart should be exited out when it is not in use to comply with HIPPA requirements.On 04/01/26 at 09:00 AM, review of the facility's Premises Information Security and Privacy policy with a reviewed and revised date of 09/2023, in the 5.7 System/Device and Electronic Media Security section, it states MHS implements physical safeguards for computing systems/devices, medical devices, and electronic media used to access, transmit, receive and store non-public information.5.7.1c. Computing systems/devices and electronic media displaying non-public information must be positioned to minimize the viewing of such information by unauthorized persons. Physical barriers/devices such as screen guards or privacy screens should be utilized as appropriate and necessary.

Based on observations, interview and record review, the facility failed to ensure all medications and blood glucose testing supplies were labeled in accordance with professional standards. Proper labeling is necessary to promote safe administration practices and decrease the risk for medication errors. Proper labeling of blood glucose testing supplies is necessary to ensure the efficacy of the supplies used to test the blood glucose meter for accuracy. This deficient practice has the potential to affect all residents in the facility. Findings include: 1) On 10/15/24 at 08:26 AM, inspection of the medication cart was conducted with Registered Nurse (RN)1. Three insulin syringes were found in the top drawer of the cart. Asked RN1 if all three insulin syringes were currently being used for the residents, RN1 confirmed that they were. All three syringes had a red sticker where RN1 said they would write down the open and discard dates. Asked RN1 how long are the syringes good for once they are opened, RN1 said, 28 days. Observed one of the three syringes did not have the open and discard dates written on the red sticker. RN1 said the dates are supposed to be written on the sticker so they will know if they can still use the medication. On 10/18/24 at 08:25 AM, an interview was conducted with the Director of Nursing (DON) in his office. DON confirmed that the staff are supposed to write the open and discard dates of the insulin syringes on the red sticker. Review of facility policy titled Storage of Medications and solutions in Resident Care Areas stated, . Refrigerated insulins must be dated when opened and discarded after 4 weeks as per manufacturer's specifications . Humulin after twenty-five [sic] (28) days . 2) On 10/15/24 at 08:31 AM, inspected glucometer (device used to measure glucose in the blood), test strips and control solutions that were kept at the nurse's station with RN1. Observed test strips and both control solutions were not labeled with an open and discard dates. Asked RN1 how often do they test the glucometer. RN1 said they test it once a day. When asked if the test strip and control solutions in the case were being used to test the glucometer, RN1 said, Yes. Asked RN1 how long are the test strips and control solutions good for once opened. RN1 said 120 days for the test strips and 90 days for the control solutions. RN1 added that they should have written the open and discard dates on both the strips container and control solutions so they will know when to discard them. Review of the facility policy titled POCT (Point of Care Testing) Blood Glucose Bedside Testing stated, . Write the expiration date on every new Test Strip and Quality Control vial . Quality Control Solution will expire in 90 days from the date opened .

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately to determine if Resident (R)7 will have to be referred for a Level II evaluation. As a result of this deficient practice, there was a potential for R7 not receiving the appropriate care and services for his mental condition. Findings Include: Review of R7's medical records conducted. R7 was admitted to the facility on [DATE] for long term placement with a diagnosis of Dementia due to Pick's Disease. Review of the PASARR Level I Screen dated 12/11/20 under Part A revealed that for the second question, Does the SMI (Serious Mental Illness) individual have Dementia?, the box for No was checked. On 10/16/24 at 03:26 PM, a concurrent interview and record review was conducted with the MDS (Minimum Data Set) Coordinator (MDSC), Social Worker (SW) and Director of Nursing (DON) at the nurse's station. Asked MDSC and SW if a PASSAR Level II evaluation was completed for R7. Both MDSC and SW looked in the paper chart and Electronic Health Records (EHR) and were not able to find it. Reviewed PASSAR Level I that was in the paper chart and asked MDSC, SW and DON if the second question on Part A was supposed to be marked as No. DON and MDSC confirmed that since R7's primary diagnosis on the form stated dementia, the box for Yes should have been checked off. MDSC added that if Part A was completed accurately, it would have triggered Part C to be completed which would determine if a referral for Level II evaluation should be made.

Based on record review and interviews, the facility failed to ensure adequate monitoring was done for three of five resident (Resident (R)3, R4 and R6) sampled for unnecessary medications. The facility was not documenting if R3 was being monitored for signs and symptoms of bleeding and if R4 and R6 were being monitored for adverse effects of psychotropic medications. As a result of this deficient practice, these three residents were put at risk for avoidable adverse health complications related to her health condition and the use of anticoagulants and antidepressants. Findings include: Cross reference to F656 (Develop/Implement Comprehensive Care Plan) Facility did not implement interventions to monitor for adverse effects of psychotropic drugs and develop a care plan for the use of anticoagulant. 1) R3 is an [AGE] year-old resident on Eliquis (anticoagulant) 2.5 mg (milligrams) twice a day. Documentation of staff monitoring for the signs and symptoms of bleeding was not found in R3's chart. 2) R4 is an [AGE] year-old resident on escitalopram (antidepressant medication) 2.5 mg daily for major depressive disorder. Documentation of staff monitoring for the adverse effects of the medication was not found in the medical records. 3) R6 in a 71-year-pld resident on escitalopram 20 mg daily for depression. Documentation of staff monitoring for the adverse effects of the medication was not found in the medical records. On 10/17/24 at 03:49 PM, a concurrent interview and record review was conducted with Registered Nurse (RN)1 at the nurse's station. Asked RN1 if they monitor residents for sign and symptoms of adverse effects of medications like psychotropics and anticoagulants. RN1 said they monitor and document it every shift in the MAR (medication administration record). Reviewed MAR for R3, R4 and R6 with RN1. Documentation for adverse effects of psychotropics and anticoagulant were not found. RN1 said he will start including it in the MAR. On 10/18/24 at 08:25 AM, an interview was conducted with the Director of Nursing (DON) in his office. DON confirmed that the monitoring for signs and symptoms of bleeding for R3 and adverse effects of antidepressants for R4 and R6 should have been documented in the MAR every shift.

Based on observations, interviews and record review, the facility failed to provide care consistent with professional standards of practice for the resident (Resident (R)3) who received hemodialysis (treatment to remove waste and excess fluids from the blood) treatments. Specifically, the facility did not provide post hemodialysis treatment care for R3's vascular access (a way to reach the blood for hemodialysis). This deficient practice could result in preventable vascular access complications that could cause serious adverse health conditions. Findings include: Cross Reference to F656 (Develop/implement Comprehensive Care Plan) - instruction to remove pressure dressing to vascular access not included in care plan. On 10/14/24 at 02:55 PM, Certified Nurse Assistant (CNA)2 said R3 has her hemodialysis treatments on Mondays, Wednesdays and Fridays at the dialysis clinic on the ground floor. On 10/15/24 at 08:39 AM, observed Registered Nurse (RN)1 administer medication to R3 in her room. R3 had two separate dressings to her left upper arm where her vascular access was. RN1 said the dressings were applied by the staff at the hemodialysis clinic after her treatment on 10/14/24. On 10/16/24 at 01:55 PM, observed RN1 administer medications to R3 in her room. R3 still had the dressings to her vascular access. Asked RN1 if they were the same dressings that were observed on 10/15/24. RN1 said they were and that he will remove them before she goes down for her treatment that afternoon. Review of R3's medical records conducted. Reviewed communications between the hemodialysis clinic and the facility. A document dated 08/08/24 from the hemodialysis facility stated, . After a 24-hour period please remove pressure dressing . On 10/16/24 at 03:13 PM, a concurrent record review and interview was conducted with the Director of Nursing (DON) and RN1 at the nurse's station. Showed the 08/08/24 communication to DON and RN1, both confirmed that the dressing should have been removed on 10/15/24 to prevent possible complications to R3's vascular access.

Based on observations, interviews, and record review, the facility failed to ensure comprehensive person-centered care plans were developed and/or implemented for three residents (Resident (R)3, R4 and R6) in the sample. Specifically, care plans were not developed or implemented to monitor for adverse effects of medications taken for all three residents and to care for the vascular access (a way to reach the blood for hemodialysis) post hemodialysis (treatment to remove waste and excess fluids from the blood) for R3. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: Cross Reference to F698 (Dialysis) - pressure dressing not removed as communicated by dialysis facility. Cross Reference to F757 (Drug Regimen is Free from Unnecessary Drugs) - monitoring for adverse effects not documented. 1) R3 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses included but not limited to stage 5 chronic kidney disease (kidney failure) and atrial fibrillation (irregular fast heartbeat). Review of medical records revealed that R3 was getting hemodialysis treatments three times a week and is taking Eliquis (anticoagulant medication used to prevent blood clots) twice a day. Observed R3 with the same dressing on her left upper arm on 10/15/24 and 10/16/24. Review of R3's care plan conducted. There were no care plans documented for the use of an anticoagulant and how to care for her vascular access after hemodialysis treatments. On 10/17/24 at 03:49 PM, a concurrent interview and record review conducted with Registered Nurse (RN)1 at the nurse's station. RN1 confirmed that R3's comprehensive care plan did not include interventions to monitor for signs and symptoms of bleeding or bruising and the instruction for the care of R3's vascular access after hemodialysis treatments was not implemented. 2) R4 is an [AGE] year-old resident admitted to the facility on [DATE]. Diagnosis included but not limited to alcohol related dementia with behavioral disturbances. Review of medical records revealed that R4 was on escitalopram (antidepressant medication) 2.5 milligrams (mg) daily for major depressive disorder. Comprehensive care plan included monitoring for common side effects like trouble sleeping, nausea, sweating, tiredness and sleepiness. No documentation of monitoring was found in the medical records. 3) R6 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnosis included but not limited to depression. Review of medical records revealed that R6 was on escitalopram 20 mg daily. Comprehensive care plan included monitoring for signs and symptoms of adverse effects to the medication. No documentation of monitoring was found in the medical records. On 10/17/24 at 03:49 PM, a concurrent interview and record review was conducted with RN1 at the nurse's station. Asked RN1 if they document the monitoring for adverse effects of escitalopram for both R4 and R6. RN1 said they document it in the MAR (medication administration record) every shift. Reviewed MAR with RN1, documentation only included behavior monitoring and not for signs and symptoms of adverse effects. RN1 said he will start including specific adverse effects of the medications in the log for both R4 and R6. During an interview with the Director of Nursing (DON) in his office on 10/18/24 at 08:25, DON confirmed that monitoring for the side effects of medications needed to be documented in the MAR, and instructions from the dialysis facility regarding post hemodialysis care for R3's a vascular access should have been added to the comprehensive care plan and implemented.

Based on interviews and record reviews, the facility failed to ensure an allegation of financial exploitation was reported immediately, but not later than 24 hours after the allegation is made, to the State Survey Agency (SA), Office of Health Care Assurance (OHCA)), Adult Protective Services (APS), and the authorities, or submit a completed report of all investigations in accordance with State law, to OHCA, within 5 working days of the incident for one Resident (R)9 sampled. Findings include: On 10/23/23 at 04:24 PM, the State Agency (SA) contacted the State Long Term Care Ombudsman LTCO assigned to the facility to inquire about any concerns. LTCO reported there was a complaint involving an employee of the facility that was filed by a resident's Financial Power of Attorney (FPOA) regarding financial exploitation, cross reference (cr) to F602 free from Misappropriation/exploitation. On 10/23/23 at 04:45 PM, this surveyor and the currently assigned Medicare Certified Officer (MCO) checked the Aspen Complaints/Incidents Tracking System (ACTS) and the state agency email which is used by the facilities to submit reportable incidents to OHCA. There was no documentation that the facility reported the allegation or any documentation informing the SA OHCA office of the incident. On 10/24/23, conducted the entrance conference with the Administrator at 12:42 PM, requested the facility abuse and neglect policy documentation regarding the investigation of resident financial exploitation, cr F607 Develop/implement abuse/neglect policies. While conducting the entrance conference with the Administrator on 10/24/23 at 12:42 PM, Asked when the Administrator first became aware of the allegation of financial exploitation by R9's POA. The Administrator stated he first became aware of the incident when he received a letter from R9's POA's attorney on 09/19/23. Requested for the Administrator to provide the facility's investigation of all allegations of abuse, neglect, or exploitation within the last year. Inquired with the Administrator twice (10/25/23 at 01:03 PM and on 10/26/23 at 10:15 AM) and was not provided the requested documents. On 10/26/23 at 01:26 PM, an email provided by the Administrator documented the Administrator filed a police report on 10/04/23 at 09:52 AM, which was 15 days after receiving a compliant of financial abuse from the family's attorney. The Administrator provided the requested investigation documentation on 10/26/23 at 04:00 PM. Inquired with the Administrator if the facility reported the allegation to OHCA, APS, and the police. The Administrator stated he emailed the report to OHCA and filed a police report, but did not report the incident to APS, as his understanding of the reporting duties were only to OHCA and the police; he reported it to the Ombudsman and stated it was the Ombudsman's responsibility to report the allegation to APS. The Administrator provided an email copy dated 09/30/23 at 12:07 PM, that was sent to the SA to an incorrect email address. The Administrator's initial email was sent 11 days after receiving notice of the allegation from the family's attorney. On 10/27/23 at 03:00 PM, during a telephone call with APS office, inquired if the facility had filed a report with the APS office. APS specialist (APSS)1 reviewed their database and confirmed there was no report of the incident documented. This surveyor made an official report of the allegation of financial exploitation regarding R9.

Based on interviews and record reviews, the facility failed to implement policies for the feedback, data collection, monitoring, performance improvement for high-risk, high-volume, or problem-prone areas, and conduct an improvement project at least annually. The Administrator was unaware of the high-risk/high prone issues, how the facility was addressing identified issues such as adverse event reporting, and results or adjustments made to implemented measures in a good faith attempt to reconcile these issues related to the facility's Quality Assurance Performance Improvement (QAPI) program as a result of this deficient practice, residents are at a potential risk for physical, mental, and/or psychosocial harm. Findings include: On 10/27/23 at 10:45 AM, conducted a concurrent record review of the facility's Quality Assurance and Performance Improvement (QAPI) program and interview with the Administrator. The Administrator had printed out the facility's QAPI notes and explained that the facility does not conduct an individual QAPI meeting but is part of a larger system and is incorporated into a larger QAPI review. Requested for the Administrator to: 1) identify and explain how the facility identifies, report, track, investigate, and analyze adverse events, and high risk, high volume, and/or problem-prone concerns. 2) What are some of performance improvements that the QAA team has identified high risk, high-problem areas? 3) How did the facility decide on what issues to work on? 4) How did the facility know that the corrective actions implemented, is effective, and improvement is occurring? The Administrator responded, I gave you the minutes, you can look and see what the areas are. This surveyor requested for the Administrator to explain the QAPI minutes because there were only graphs and no explanation of the graph's data. On some of the graphs, there was no indication of the value/identification of what was being graphed. The Administrator was unable to answer any of questions related to the facility's QAPI program, could not identify any high-risk, high-problem areas, could not speak to any performance improvement projects currently being implemented, and did not know when the last QAPI meeting was and/or what was discussed.

Based on interview and record review, the facility failed to implement screening procedures to protect resident(s) from financial exploitation, report and thoroughly investigate an allegation of financial exploitation for one resident (Resident (R)9) sampled. The Administrator failed to report the allegation of financial abuse to the appropriate authorities and to the State Agency (SA). This deficient practice placed the residents in the facility at risk for financial exploitation. Findings include: On 10/23/23 at 04:24 PM, the State Agency (SA) contacted the State Long Term Care Ombudsman LTCO assigned to the facility to inquire about any concerns. LTCO reported there was a complaint involving an employee of the facility that was filed by a resident's Financial Power of Attorney (FPOA) regarding financial exploitation, cross reference (cr) to F602 free from Misappropriation/exploitation. On 10/24/23, conducted the entrance conference with the Administrator at 12:42 PM, requested the facility abuse and neglect policy documentation regarding the investigation of resident financial exploitation, cr F609 reporting of alleged violations. The abuse policy was not provided to the surveyor for review. On 10/26/23 at 09:05 AM, requested AP employee folder. The folder provided by the Administrator did not contain documentation of a background check or pre-employment screening was completed for the AP. A second request for the Administrator to provide AP's full employee file to include any documentation of a background check or pre-employment screening was conducted. The Administrator provided an additional employee file for AP which included training modules but did not contain documentation of a background check or pre-employment screening. Inquired with the Administrator a third time, at which point the Administrator confirmed the facility does not have documentation that a background check or pre-employment screening was conducted for AP. The Administrator stated he had spoken with the Human Resource Office (HRO), located on another island, and confirmed the facility was recently acquired and the acquiring owners grand-fathered in staff who were currently employed by the facility and did not conduct any form of screening or ensure employees had been appropriately screened before grand-fathering staff into the facility. The Administrator confirmed there was no documentation that AP was screened appropriately or had conducted a background check and could not confirm AP's appropriateness for employment.

Based on interviews and record review, the facility failed to ensure the designated Infection Preventionist (IP) worked at least part-time at the facility. The facility's IP works full-time at another facility on another island and is not present at the facility at least half-time. As a result of this deficient practice, residents are at risk for more than minimal potential for harm. Findings include: On 10/24/23 at 1:15 PM, conducted an interview with the Administrator regarding the facility's IP. The Administrator confirmed the IP works full-time on another island for another facility and primarily works remotely. Inquired as to when the IP is physically present at the facility. The Administrator did not know when the IP is scheduled to be at the facility, could not provide documentation of any past or future schedules of the IP on-site in the facility. Requested to speak with the IP and was informed by the Administrator that the IP was at a conference and/or vacation and was not available to the surveyor. The Administrator reported that the facility has another Registered Nurse (RN)5 with infection control qualifications. Conducted an interview with RN5 and RN5 confirmed that although he/she has completed the necessary courses/training for infection control preventionist, RN5 is a full-time nurse in the emergency room adjacent to the facility and has not functioned as an infection preventionist for the facility. Additionally, during the survey, the Administrator announced RN5 would be assisting the facility in the capacity of the Director of Nursing, because the appointed Director of Nursing had handed in a letter of resignation and had not worked in the facility for, approximately, the past month. On 10/26/23 at 03:10 PM, conducted interviews with RN1 and RN2 regarding the presence of the designated IP at the facility. RN1 and RN2 confirmed IP is not present at the facility at least part-time and reported that although the IP is available by phone, the IP is not in the facility weekly, and could not confirm that the IP is in the facility at least monthly. RN1 and RN2 also confirmed there was no other staff that is designated as the facility's IP. During a meeting with the Administrator on 10/27/23 at 10:45 AM, the Administrator confirmed the IP works full-time on another island and is at the facility once a month and as needed. Inquired when the IP was last at the facility, the Administrator did not know and did not provide any documentation of when the IP was last at the facility.

Based on interviews and record review, the facility failed to ensure an allegation of financial exploitation was thoroughly investigated and reported to the State Agency, within 5 working days of the reported incident, for one resident (Resident (R)9) sampled. Legal counsel of R9's health care and Financial Power of Attorney (FPOA) reported an allegation of financial exploitation of the resident by a facility staff to the Administrator on 09/19/23. Review of the facility's investigation during the State Agency's (SA) recertification survey revealed the facility had not completed an investigation more than a month after the allegation was reported. Findings include: On 11/25/23 at 12:10 PM, requested for the Administrator to provide documentation of the investigation completed for an allegation of financial exploitation made by R9's health care and FPOA on 09/19/23, cross reference to F602 free from Misappropriation/exploitation. Review of the facility's investigation on 10/26/23 at 11:10 AM revealed there was no completed investigation report. This surveyor requested for the Administrator to provide documentation of the facility's submission to the SA. No documentation of the facility's submission to the SA was provided to the surveyor. Review of the SA's complaint and facility reported incident database did not contain documentation of a completed investigation report. The investigation which was completed by the Administrator was an interview with the AP. There was no documentation of staff interviews, interviews of R9's POA, no review of the facility's processes, and no review of R9's financial receipts and/or money and checks at the facility. The Medicare Certification Officer (MCO) reviewed the State Agency (SA) database on 10/26/2023 and verified the facility had not reported the allegation of financial exploitation to the Office of Health Care Assurance. During an interview with the Administrator, he confirmed the AP was cleared and would be returning to work but would be reprimanded for not disclosing a conflict of interest despite the lack of a complete and thorough investigation. Review of the SA complaints and facility reported incident (FRIs) database confirmed a completed report had not been completed or provided to the SA.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to be free from misappropriation of a resident's property for one Resident (R)9 sampled. The Alleged Perpetrator (AP) was an acquaintance with R9 prior to the resident's admission to the facility and worked in the business office. The AP used his/her position as the Patient Access Services Lead and is responsible for handling financial matters. AP used her position to gain access to R9's bank account and personal property. This deficient practice placed the residents in the facility at risk for misappropriation of property. Findings include: On 10/23/23 at 04:24 PM, the State Agency (SA) contacted the State Long Term Care Ombudsman LTCO assigned to the facility to inquire about any concerns. LTCO reported there was a complaint involving an employee of the facility that was filed by a resident's Financial Power of Attorney (FPOA) regarding financial exploitation. LTCO reported the facility's Administrator had received an email from the resident's FPOA alleging an employee the AP influenced a resident to change his/her power of attorney from the resident's family member and attempted to sell R9's residential home to his/her child at a price below market value. LTCO confirmed that he did not know the name of the employee or resident involved in the allegation and was given minimal information by the Administrator about the alleged incident. At 4:45 PM, the SA's database, Aspen Complaints/Incidents Tracking System (ACTS) was reviewed and did not have an intake for the alleged incident from the facility or any other reporting agency to the SA. During the entrance conference on 10/24/23 at 12:42 PM, with the Administrator, requested the following documentation for the alleged incident: The name of the resident and AP; documentation of the date and time the facility successfully submitted the event report to the SA; the facility's complete investigation of the event; documentation of the facility's report to Adult Protective Services (APS) and police. Conducted a telephone interview with the Family Member (FM)1 who is the FPOA on 10/25/23 at 10:41 AM. FM1 reported being concerned that R9 was being taken advantage of financially and described the resident as being vulnerable and easily influenced. FM1 stated that prior to being admitted to the facility, R9 was in an acute hospital (on another island) and was deemed not competent to make decisions. At that time, FM2 was designated as the surrogate decision maker. FM1 reported that while R9 was in the acute hospital, the family needed to get access to R9's advanced healthcare directive (AHCD) and FPOA documents. At that time, FM1 learned that the AP had keys and unsupervised access to R9's home. FM1 requested for AP to retrieve R9's AHCD and FPOA documents from R9's home and was told that the AP was unable to find those documents. FM1 and FM2 also learned that R9's vehicle was given to one of the AP's children and had been in an accident. FM1 reported that when they went to the home, the majority of the furniture was missing, along with financial documents that included stocks, bonds, and deeds to properties that were owned by R9, and the AHCD and FPOA documents. R9 informed FM1 that the AP had cleaned the house and did not know of the location of any of the documents in question. FM1 reported that on a subsequent visit to the facility a couple of months after R9's admission, they became concerned the AP was overstepping boundaries and infringing on R9's financial matters. FM1 enlisted a real estate agent (REA)4 to sell the home. REA4 informed FM1 that the AP met with her and sought to sell the home to one of the AP's children for a price below the current market value ($725,000). The process was discontinued once REA4 discovered the property was in a trust. FM1 reported at this point R9's family became aware of the AP's intentions and believed that R9 was being manipulated by AP for her and her family's personal financial gain. FM1 confirmed the facility did not provide a monthly statement of any sort and as a result of her concern that R9 was being taken advantage of, the family hired an attorney, and the facility was served with a formal complaint which was sent and confirmed as delivered by United States Postal Service (USPS and email) to the facility's Administrator on 09/19/23. The complaint claimed that FM1 was R9's health care and financial POA, has and will continue to act in the best interest of the resident, and included documented issues and concerns related to the AP's unethical behavior which included the following: 1) R9 needs to be assessed for capacity due to the resident's decline in mentation, due to R9 making erratic changes to plans that have been known and in place for the safety of the resident, a lack of capacity making R9 susceptible to being influenced by the AP, and that AP has been blocking the family's request for a capacity assessment. 2) The AP had control over R9's finances and checkbook. 3) AP had attempted to purchase R9's property. 4) AP cleaned out R9's residential property and destroyed legal documents and conspired to change R9's estate documents. 5) AP trying to influence changes to R9's estate planning: AP indicated to FM1 that she is actively working with an attorney for R9 to update her estate planning documents. Initially, AP was going to be the POA but once the family questioned AP's employment at the facility, another friend AP(2) was named as the POA. Additionally, the AP has the key for R9's P.O. Box and is accessing the resident's mail. FM1 (the current financial POA and health care decision maker) is requesting that AP be removed from accessing and handling any financial affairs for R9 due to a conflict of interest and the unethical behavior of the AP to ensure R9 is not financially exploited and for the resident's safety. Surveyor called the AP on 10/26/23 at 04:15 PM to attempt an interview and was told that AP was on leave and was unavailable for an interview. During an interview with the Administrator stated the Director of Nursing (DON) has been on leave for the past 3-4 weeks, has turned in his/her resignation letter and is not expecting the DON to return to the facility prior to the designation date. Contact information for the DON was not provided by the Administrator. Also, Social worker (SW)1 and SW2 are no longer employed by the facility and not available for interview. On 10/26/23 at 05:23 PM, conducted an interview with Registered Nurse (RN)1 and RN2 regarding the AP's handling of the financial affairs for R9. RN1 and RN2 both confirmed they did not know that the AP and R9 were friends prior to the resident's admission to the facility. RN1 and RN2 confirmed AP had unsupervised access to the resident's checkbook and bank card. Staff stated they trusted AP due to her position and did not provide supervision over what AP was doing with R9's checkbook and bank card. RN1 stated prior to R9's family coming to the facility and requesting R9's checks and bank card, AP had the items in her possession, and it was not with the resident or in the resident's room. RN2 recalled when R9's family came to the facility in August, AP gave the items to RN2 to be logged into the resident's belongings. RN1 and RN2 reviewed R9's belonging's log which documented the resident's checkbook and bank card being entered into the locked box on 08/01/23. RN1, RN2, the Administrator, and this surveyor reconciled the check numbers logged into the resident's belongings with the actual checks in the locked box (stored in the medication cart which only the nurses have access to). It was documented R9 had 3 check books logged and there were only 2 check books present, the resident did not have the missing check book in her room. Also, four checks (#7038, #7039, #7040, and #7041) which were not logged into the resident's belongings were documented in the check ledger. RN1 and RN2 confirmed AP had been writing out R9's checks and having the resident sign it and the handwriting on the check ledger book was identified as AP's handwriting. The Administrator confirmed he was unaware that all the resident's checks and moneys were being kept in a locked box in the nurse's medication cart and the facility's process was for the nurses to be responsible for this. The Administrator stated that it was not appropriate for the nurses to be handling or to be responsible for resident's checks and money. RN1 and RN2 confirmed they trusted AP with the resident's checks and money due to her position at the facility and were unaware of what was going on. On 10/27/23 at 10:09 AM, conducted an interview with two business office staff (BO1 an BO2). Requested to review R9's financial records and review any receipts in the resident's financial file. BO1 and BO2 confirmed that AP is the only staff that can access the receipts, AP is not supervised and there is no oversight provided. BO1 and BO2 were able to print up a Cost Share Statement which documented a payment to the facility Check #7033 for $1,500 paid on 07/27/2023. BO1 and BO2 reported that there was another payment for $2000 which is not reflected in the statement. On 10/26/23 at 02:15 PM, conducted a review of R9's Electronic Health Record (EHR). Physicians admission orders documented R9 was admitted to the facility on [DATE] with a diagnosis which included Alzheimer's disease, metabolic encephalopathy, dysphagia, anemia, aspiration pneumonia, history of ischemic TIA, hypertension, and chronic kidney disease on the physician's Admission Orders. Review of the R9's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/23, documented, Section C. Cognitive Patterns, the brief interview for mental status (BIMS) score was 10, indicating moderately impaired cognition. The admission MDS, with an ARD of 01/20/23, Section C. Cognitive Patterns, C0500. documented the resident BIMS score was 6, indicating severe cognitive impairment. The facility also conducted four Mini Mental State Examination (MMSE) which is a tool used to systemically assess mental status and is not required by federal regulations. It is an 11-question measure that test five areas of cognitive function: orientation; registration; attention and calculation; recall and language. The maximum score is 30. A score of 23 or lower is indicative of cognitive impairment. Review of the completed MMSE conducted for R9 revealed that the resident consistently did not score any points in the attention and calculation portion of the test, indicating the resident is unable to do numeric calculations. -01/15/23- R9's total score was 20, indicating cognitive impairment. -02/13/23- R9's total score was 17, indicating cognitive impairment. -05/03/23- R9's total score was 24. -08/05/23- orientation (10 points). Staff documented, Resident refused to so the rest of the test. Review of R9's AHCD was signed and notarized, Durable General Power of Attorney (DGPOA), delegating administrative functions (banking, trust power, custody and safe keeping of assets, record keeping, and accounting), general management and investments, collections, litigation matters, bank accounts, safe deposit boxes, and acquisitions and conveyances power granted to Family Member (FM)1, and power granted to FM2 upon the disability or death of FM1, was notarized on March 10, 2009. Review of Social Worker (SW)1 progress notes documented on 01/17/23 at 10:03 AM, documented R9 had a Durable Power of Attorney on file; Support System: AP, friend; and Accountable accompanying adult: FM2. SW1's progress note on 05/01/23 documented, R9's initial MDS assessment with an ARD of 01/20/23, completed by the Director of Nursing (DON), R9 triggered for Cognitive Loss/ Dementia. Health Care Decision Making: Per note dated 12/19/2022 and completed by SW2, resident's health care agent/sister-in-law FM1 is unable to continue as the agent for R9 due to family health issues and other challenges. On 12/20/22, FM2 became R9's health care surrogate while family was searching for an Advance Health Care Agent (AHCD) document. The surrogacy was scanned into Epic on 12/22/22 by an acute hospital social service clerk. On 02/23/22 and AHCD dated 03/10/09 was scanned into R9's chart. R9's sister-in-law, FM1 was the assigned agent. The document also stated that if FM1 was unwilling or unable to serve as the agent, niece FM2 would become the agent. SW1's progress note on 08/01/23 at 11:53 AM documented, R9 has an AHCD on file and .when the surrogate was completed, a physician certified that resident DOES NOT have the ability to understand the significant benefits, risk, and alternatives to proposed health care and DOES NOT have the ability to make and communicate health care decisions . Currently, the resident's attending is reassessing R9's capacity to make health care decisions. If it is determined R9 can make his/her own health care decisions, SW1 will discuss completion of an AHCD with resident. 08/02/23- Teams meeting was facilitated by SW1, present were the DON, RN1, R9, FM1, and FM2. FM1 reported that someone else has been writing out R9's checks and R9 has been signing the checks. 08/03/23- SW1 conducted a Peacetime meeting with R9 and Registered Nurse (RN)1. R9 is requesting a new Durable Power of Attorney to be completed and would like the (AP) to become the new financial agent. SW1 discussed conflict of interest and reminded her that FM2 is the alternate financial agent. Review of bank statements from 11/01/22 to 10/25/23. While R9 was in the facility, unexplainable charges to the resident's financial institution included but are not limited to: - 02/10/23 Target: $29.67 - 02/13/23 Target: $29.68 - 02/14/23 Check-bank card $500.00 -03/10/23 Check-7008- Bank card $500.00 -05/10/23- Bank card- $500.00 -06/15/23- Bank card- $500.00 -06/15/23- 7013- home health agency provider- $500.00 -07/11/23 check 7027- bank card- $500.00 It was noted that bank card withdrawals of $500.00 which occurred on 02/14/23; 03/10/23; 05/10/23; 06/15/23; 07/11/23 were all documented as bank card and no other transactional description was provided and was documented in AP's handwriting in R9's check ledger. Review of the facility policy and procedure for Resident Trust Accounts, documented the residents have the right to manage their own financial affairs. Their personal funds will be deposited in the Individual Resident Trust Savings Account if the resident or legal representative request in writing. Procedures include the facility maintains a separate interest-bearing checking account, request for funds can be made by the resident or resident representative, request are written in an expense book, accurate and quarterly accounting to be completed, copy of the receipts are maintained and given to the resident representative, withdrawals are documented on resident's Safekeeping Account Withdrawal Record Form, and all banking records will be kept for a minimum of 3 years.

Based on interview and record review, the facility failed to provide a Director of Nursing (DON) on a full-time basis. The same staff member covers both the long-term care (LTC) facility and the Critical Access Hospital (CAH) as the DON. Findings include: On 08/10/22 at 01:45 PM, Administrator reported the facility's Director of Nursing (DON) oversees the LTC facility and the CAH. On 08/11/22 at 02:46 PM, the facility provided a job description for the LTC DON via secure email. The job title is Director of Nursing - Critical Access. The job summary includes providing leadership and on-going management of the hospital's daily administrative services and responsible for staffing, planning, development, implementing, controlling and evaluation of the hospital's operations to ensure quality patient services are provided. On 08/15/22 at 11:15 AM, the facility provided a snapshot of the facility's organizational chart. The staff member in the DON position is listed as the DON for the LTC facility and the Critical Access Hospital.

Based on observation and interview, the facility failed to ensure pharmacy services included a thorough process to assure the accurate reconciliation and proper disposition of all drugs and biologicals necessary to meet the potential needs of the residents. As a result of this deficient practice, the safety and efficacy of Emergency Kit (E-Kit) medications and devices were compromised. This deficient practice had the potential to affect any patient who required immediate use of a medication or device in the E-Kit. Findings include: On [DATE] at 02:57 PM, an inspection of the long-term care medication cart was done. In the bottom drawer of the cart, a sealed E-Kit (Emergency Kit) labeled COVID-19 EKIT EXPIRES: [DATE], was found. Labeling indicated that the E-Kit had been restocked in [DATE]. The E-Kit inventory sheet attached to the sealed container listed the following contents: 2 - Aerochamber Plus Flow-[NAME] (a valved holding chamber that helps residents inhale metered dose inhaler medications correctly), with an expiration date of ,d+[DATE]. 2 - Ventolin HFA 90 mcg (micrograms) Inhaler (used to prevent and treat wheezing and shortness of breath), with an expiration date of ,d+[DATE]. 2 - 24-count Dexamethasone 2 mg (milligrams) Tablets (a steroid used to prevent the release of substances in the body that cause inflammation), with an expiration date of ,d+[DATE]. On [DATE] at 03:26 PM, an interview was done in the Treatment/Activity Room with the Administrator and the Director of Nursing (DON). The Administrator stated the E-Kit was for COVID only and they never would have used it. Both the Administrator and DON confirmed that the facility Nurses are responsible to check the cart for outdated medications on a daily basis and that the facility Pharmacist should also be checking the cart every month. The Administrator agreed that someone should have pulled the expired E-Kit out and either sent it back to the Pharmacy or destroyed it.

Based on record reviews and interview with staff members, the facility did not assure 2 (Residents 10 and 1) of 9 residents in the sample received an accurate assessment for the use of antibiotics and accurately code a resident's activities of daily living abilities in bed mobility and transfer. Findings include: 1) Resident (R)10 was admitted to the facility on [DATE] from an acute hospital. Diagnoses include cerebrovascular accident, diabetes mellitus, and hypertension. Record review of R10's comprehensive/annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/24/22 notes R10 was coded for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) as requiring extensive assist with two plus person physical assist. Review of the subsequent quarterly MDS with an ARD of 06/23/22 documents R1 was coded as dependent with two plus person physical assist for bed mobility and transfer, indicating a decline in self-performance. Interview with Resident Assessment Instrument Coordinator (RAIC) was done on 08/09/22 at 03:44 PM, inquired what contributed to R1's decline in self-performance for bed mobility and transfer. RAIC was agreeable to review certified nurse aides' charting. RAIC explained extensive assist would indicate the resident could bear some weight (stand-lift) and using a Hoyer lift for transferring would indicate the resident is dependent. At 04:23 PM, RAIC reported R10's record was reviewed back to December 2021 and R10 has always been dependent in self-performance for bed mobility and transfer. RAIC acknowledged this was a coding error and not a decline. 2) R1 was readmitted to the facility on [DATE] after being treated for COVID-19 and a urinary tract infection (UTI). Diagnoses include unspecified dementia without behavioral disturbance. Record review found a physician progress note dated 08/08/22 documenting R1 has recurrent UTI with staghorn calculus in the right kidney which requires surgery. The recommendation was antibiotic suppression, administration of Vantin (antibiotic) either continuously or until surgery can be scheduled. A review of the Medication Order for August 2022 notes a physician's order for cefpodoxime 200 mg tablet (for Vantin) once daily continually for diagnosis of UTI. The start date was 04/28/22. A review of R1's annual/comprehensive MDS with an ARD of 06/14/22 in Section N. Medications, R1 was coded as receiving antibiotic once during the last seven days. Review of the care plan revealed no plan/interventions for the long-term use of an antibiotic. A review of R1's Medication Administration Record (MAR) for June documents cefpodoxime (Vantin) was administered daily as ordered. On 08/10/22 at 10:00 AM, an interview and concurrent record review was done with the RAIC. RAIC reviewed the MDS and MAR and confirmed there was a coding error. R1 should be coded 7 (seven) indicating R1 received an antibiotic medication for seven days during the assessment period.

Based on observation, record review, and interview with resident and staff members, the facility failed to ensure a resident, Resident 9 was assessed to determine the resident's capacity to safely smoke unsupervised. R9 has a [DIAGNOSES REDACTED]. Findings include: Resident 9 (R9) was admitted to the facility on [DATE] following an acute hospitalization . The [DIAGNOSES REDACTED]. On 09/18/18 at 12:00 PM, R9 was observed exiting the unit via a motorized scooter. The surveyor accompanied R9 out through the facility's Emergency Department (ED) door. R9 parked at the back of the facility. There were staff members sitting at a table and greeted R9. An interview was conducted with the resident. R9 reported four cigarettes are allowed per day and the time for smoking is in the morning, after lunch, after dinner and at night. R9 further reported she holds her own cigarettes and showed the surveyor the ashtray in the basket of her scooter. As the ED door is secured, R9 will press the buzzer for the ED staff/lab staff to let her back into the facility. The resident did not smoke at this time. Subsequent observation at 2:44 PM found the resident going by the nursing station, stating she was going out for a smoke. The resident was unaccompanied by staff and exited the double doors of her unit. R9 was observed to go out of the facility unaccompanied and was not wearing a smoking apron. R9 shared that she continues to have delusions and will go to her room, close the door and rest until it stops. A record review was done on the afternoon of 09/19/18. The quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 08/01/18 found the resident yielded a score of 14 (cognitively intact) on the Brief Interview for Mental Status. The resident was also coded to have delusions and feeling down, depressed, or hopeless. R9 noted with functional range of motion to one side of the upper and lower extremities. In section J. Health Conditions, the resident was coded to have had a fall with injury. A review of the physician orders [REDACTED]., three tablets (7.5 mg) daily to stabilize mood; and okay to give [MEDICATION NAME] and [MEDICATION NAME] the same time. On 07/29/18 R9 was seen by the psychiatrist for hallucinating and requesting more medication. The resident's [DIAGNOSES REDACTED]. At this time R9 complained of poor sleep and appetite with pain related to arthritis. Further review found no documentation of an assessment regarding R9's capabilities and/or deficits to determine whether R9 required supervision while smoking outside of the facility. There was no documentation of a care plan related to the resident's smoking (i.e. approved times for smoking, the designated smoking area, the need for supervision). On 09/20/18 at 8:45 AM an interview was done with the Charge Nurse (CN). The CN was asked whether the facility assessed R9 for safe smoking without supervision and/or developed a care plan. The CN reported the resident's cigarettes and lighter are held at the nurses' station and R9 is allowed to smoke four times a day. The CN further reported R9 is safe as the hospital staff members will check on R9 and the resident can be seen from the back door (the ED door). The CN stated the facility did not assess R9 for smoking and based on the assessment developed a care plan. On 09/20/18 at 9:33 AM, the Director of Nursing, CN and Accreditation Regulatory and License (ARL) staff member were notified of immediate jeopardy. R9 was observed to exit the unit unsupervised to smoke. The smoking area is located at the back of the facility to the side of the ED entrance/exit which requires a code to re-enter the facility. R9 was not assessed to determine whether she has the capability of smoking unsupervised or what precautions are required to be in place to ensure the resident smokes safely. The facility was aware the resident was smoking unsupervised; however, failed to assess the resident for safety and develop a care plan. The failure to assess and care plan resulted in potential for harm without immediate correction. On 09/20/18 at 2:51 PM a correction/abatement plan was provided to the State Agency. The facility provided the following documents: Plan of Correction; Smoking Rules; and Acknowledgement of Smoking Risks. The facility completed a Smoking Assessment which determined R9 is not safe to smoke unsupervised due to the side effects of [MEDICAL CONDITION] medications. A care plan was developed to include intervention for supervised smoking, donning of smoking vest and smoking items to remain in locked location. Observation with the CN found the resident's cigarettes and lighter were stored in a locked cabinet. On 09/20/18 at approximately 3:00 PM R9 was observed requesting cigarettes, the staff member offered the resident the smoking apron. R9 was heard saying the apron was absurd, refusing to wear the apron. R9 was not allowed to go out to smoke. On 09/20/18 at 3:21 PM, the State Agency validated that the immediate jeopardy abated.

Based on observations, medical record review and staff interviews, the facility failed to maintain the necessary nutritional requirements for two residents (R7 and R1) who experienced weight loss Findings include: 1) Resident 7 (R7)was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Due to the disease process of PSP, R7 experienced anticipated declines in her ability to swallow. R7 was unable to swallow independently which lead to unplanned weight loss in (MONTH) (YEAR). Over a six month period from 03/1/18 to 08/1/18, R7 experienced a severe weight loss (greater than 10%) - 11% of her body weight. R7 was sent to a hospital on [DATE] for gastric tube ([DEVICE]) placement to provide formula nutrition. Upon return to the facility the same day, 08/13/18, R7 was started on tube feedings: Fibersource HN 160 ml/hour at 5:00 AM, 10:00 AM, 3:00 PM and 8:00 PM. Observation of R7 on the morning of 09/18/18 found her laying in bed awake. She was not connected to her [DEVICE] feeding at the time. The Formula bag did not have a label to include resident's name, name of the formula and amount to be infused and date/time the formula was hung. Observation of R7 on the morning of 09/19/18 found the formula bag with the resident's name, formula name and infusion amount and frequency. R7 was awake and non responsive to questions. Observation of R7 on the afternoon of 09/19/18 found her seated in a recliner chair in the activities room. She was seated facing the TV where a movie was playing. On the morning of 09/19/18 a concurrent medical record review and staff interviews found R7 returned to the facility on [DATE] with a [DEVICE]. She was 106 pounds on 08/01/18 and lost 3% over the next three weeks, weighing 103 pounds on 08/21/18. R7 was weighed again on 09/01/18 when she weighed 101 pounds or 5% over the past month. The next weight on 09/13/18 found R7 at 98 pounds (decrease of 14% over 6 months) or 3% in 12 days. The final weight noted in R7's medical record found she remained at 98 pounds on 09/19/18. From 02/01/18 to 08/01/18, R7 experienced a decrease of 12% of body weight. An interview of the Registered Dietician (RD) on 09/19/18 at 9:26 AM revealed R7's [DIAGNOSES REDACTED]. In addition to R7's difficulty swallowing, she would refuse to eat (prior to tube placement). R7's spouse would come for every lunch meal to assist with feeding her. The RD had the Speech Language Pathologist (SLP) do a swallow evaluation which found her difficulty with swallowing which also contributed to her not wanting to eat. The RD stated the staff should have been weighing R7 at least weekly since her [DEVICE] was placed on 08/13/18. A review of the RD's note dated 08/10/18 noted her recommendation to weigh R7 weekly for four weeks after [DEVICE] placement. The RD noted that if weekly weights had been obtained, she was likely to have intervened earlier to avoid additional weight loss. An interview of the Charge Nurse revealed the staff weighed R7 every 2 weeks after her [DEVICE] placement despite the RD's recommendation for weekly weights. On the morning of 09/19/18 a review of R7's Minimum Data Set ((MDS) dated [DATE] found he was totally dependent with one person assistance for bed mobility and eating. The MDS further noted she was totally dependent with toileting requiring two person assistance. On the morning 09/19/18 at 10:00 AM an interview of the Charge Nurse noted R7 was experiencing constipation with possible bowel obstruction over the past few weeks. The Charge Nurse noted the physician ordered [MEDICATION NAME] 15 ml per day on 09/2/18 to aide with constipation. On 09/13/18 an additional dose of [MEDICATION NAME] was added for bowel obstruction found on x-ray taken 09/13/18. On 09/19/18 a suppository was added due to R7 having diarrhea. On 09/18/18 R7's bowel obstruction was cleared. On the morning of 09/19/18 at 11:00 AM found R7's orders for enteral feeding were changed as follows: 08/26/18 80 cc/hr four times daily; 09/05/18 160 cc/2 hours four times daily; 09/11/18 200 cc/one hour 45 minutes four times daily. On the morning of 09/19/18 a review of R7's care plan found one for Enteral Nutrition with a start date of 08/16/18 noting one goal as, Stable weight for next 2 months with gradual gain. Interventions included, Dietician will review weight and feeding orders monthly and as needed. Weight monitored monthly with review by nurse and dietician. The care plan did not reflect the RD's note dated 08/10/18 which recommended weekly weights after [DEVICE] placement (08/13/18). The facility did not implement necessary interventions as recommended by the RD to weigh R7 weekly. R7 experienced an unplanned severe weight loss despite being on a controlled, consistent diet of enteral nutrition. 2) Resident 1 (R1) was a long time (several years) resident of the facility. The resident experienced complications after a J-tube placement was attempted in June/July (YEAR). R1 was sent to the hospital to resume his former tube style - J[DEVICE]. R1 was readmitted to the facility on [DATE] after J[DEVICE] (re)placement. R1 was on comfort care. On the afternoon of 09/19/18 at 3:37 PM, a concurrent medical record review and RD interview found R1 recently experienced a slight weight loss. R1's weight changed from 181.3 pounds on 06/01/18 to 176.1 pounds on 09/01/18 (3% loss). The RD's note dated 06/05/18 noted she received reports from the Nursing staff relating R1 was unable to meet his tube feeding goal rate. The nursing staff further noted R1 does not have residual gastric contents but nursing staff were unable to give medications due to formula coming out. R1 also with large liquid bowel movements daily. The RD made a recommendation for R1 to have a gradual weight loss and optimize tube feeding tolerance. The RD recommended slow weight loss to his usual weight of 170 pounds. The RD specified her recommended weight loss plan as 4% by 07/05/18 to 174 pounds and 2% by 12/05/18 or 170 pounds. On the afternoon of 09/19/18 at 3:12 PM, a concurrent medical record review and Charge Nurse interview found R1's weight loss was planned and done in collaboration with the RD and physician. However, the Charge Nurse was unable to find the physician's orders [REDACTED]. Additionally, R1's care plan did not reflect the facility's plan for physician prescribed weight loss. The Charge Nurse stated since R1 experienced complications with the J-tube, she didn't want to risk R1 experiencing more weight loss than they could handle. Therefore, R1's physician prescribed weight loss program was discontinued to avoid additional problems. The RD was present during this interview and noted she was unaware of the discontinued weight loss program. A review of R1's annual MDS dated [DATE] found he required extensive assistance with bed mobility with one person assist. He was noted to be dependent with two person staff assistance for transfer and toileting. The facility failed to ensure appropriate orders, goals and interventions to obtain a safe, consistent approach to R1's weight loss plan.

Based on medical record (MR) and electronic medical record (EMR) reviews and staff interviews, the facility failed to ensure that 1 of 9 residents (R#1) on the survey census sample, received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being. Findings include: On 02/26/2016 at 8:20 AM reviewed R#1's Medication Administration Record [REDACTED]Levetiracetam 500 mg tab #30; 1 tab PO twice daily - DX: [MEDICAL CONDITION]. The RN stated that the circled dates meant that R#1 didn't receive the medication on those dates and the reason why would be written on the back of the MAR. On the back of the MAR indicated [REDACTED]. Queried nursing staff on ordering of medications and the RN stated that the night shift RN usually orders all medications because the day shift RN is usually too busy to order. The RN provided the facility's Pharmerica order sheet on 2/7/2016, and Levetiracetam 500 mg's with instructions to Refill-out of stock showed that the facility received the medication on 2/9/16. Reviewed R#1's EMR with RN staff for the dates of missed [MEDICAL CONDITION] medications and documentation on 02/09/16 at 18:10 in the nurse notes tab included, Pt becoming agitated prior to dinner. [MEDICATION NAME] 1 mg PO given at 1700 with dinner meds. Pt had grand mal [MEDICAL CONDITION] 1715 while laughing with other residents. [MEDICAL CONDITION] lasted 45-90 secs. Pt post ictal for 3 mins. Scant amount of blood in saliva, no wound seen in mouth. Pt uncooperative when writer attempting to assess tongue. Pt no longer bleeding from mouth . Pt slightly drowsy but alert . Dr. Janikowski called and updated. Will move pt to ER if second [MEDICAL CONDITION] occurs. Lab called for antiepileptic blood levels. Verbal order for 2nd dose [MEDICATION NAME] obtained. Second dose administered 1750. Documentation in the nurse notes tab on 02/09/2016 at 18:42 noted, Lab in to collect blood. Name,RN, will F/U with Dr (name) in am regarding specific labs to be ordered. AA/DON, aware that pt missed 7 doses of Levetiracetam. No incident report necessary as per AA/DON medication arrived this evening, 1700 does (sic) given at 1800. Requested to review the facility's policy/procedure (P&P) for ordering of medications and the AA/DON stated that there was none because, should be common sense for nurse to order. The AA/DON elaborated that the night nurse was responsible for ordering meds. The AA/DON stated that she didn't know that R#1 was out of [MEDICAL CONDITION] medication until she was notified on 02/09/2016 that he/she had a grand mal [MEDICAL CONDITION]. The AA/DON further directed the RN staff to find out whether out of stock written on the MAR meant that the pharmacy was out of stock and so the facility could not get a refill. On 02/26/2016 at 10:10 AM a telephone call to the pharmacy was made and spoke with the pharmacist who stated that the pharmacy always have medications. The pharmacist further stated that the order of Levetiracetam for R#1 was received by the pharmacy on 02/08/2016 and sent on the plane from Honolulu on 02/09/2916. The pharmacist shared that there are no automatic refills and that the facility is responsible for re-ordering medications.