Every finding on record at Leahi Hospital

Based on observations, staff interviews and policy review, the facility failed to: 1) Discard an expired container of Lemon Juice that was stored the kitchen refrigerator and 2) Label a supplement drink stored in the resident's kitchen refrigerator with the opened-on date once it was opened. As a result of this deficiency, the facility put residents at risk for foodborne illness.Findings Include:1) During the initial tour of the kitchen, on 07/22/25 at 08:50 AM, a one-gallon container of Lemon Juice, in the refrigerator, was labeled with an expiration date of 07/19/25. The container was half full and was located on the middle shelf. Staff interview on 07/22/25 at 08:52 AM, Kitchen Manager (KM) acknowledged that the Lemon Juice container was expired and should have been discarded. KM removed the Lemon Juice container and said they would discard it immediately. Review of facility policy on Food Labeling read; Purpose, to ensure that all foods served at the facility are fresh. Outdated foods that are kept beyond their allowed shelf life are not to be used in food production or served to residents and customers. Policy, Food & Nutrition Services will monitor the shelf life of the foods purchased, prepared and served to its residents and customers. A facility Food Storage Reference Table will be maintained by Food & Nutrition that lists the dates of foods used in the facility. Foods prepared for service will be labeled with date of service… III D. Manufacturer “Used by” or Expired dates – “Use by” of Expired dates stamped or printed on the original food container by the manufacturer. Unopened products with dates that have exceeded the “Best Used” by dates will be discarded… 2) On 07/22/25 at 12:54 PM observation of the resident's refrigerator on the fourth floor contained a TWO Kal supplement drink that was opened and did not have an opened-on date. Inquired with Registered Nurse (RN) 158 if the opened TWO Kal supplement drink has to have an opened-on date. RN158 confirmed the TWO Kal supplement drink in the resident's refrigerator should have been labeled with a date when it was opened.

Based on observation, interview, and review of the facility's Storage of Medication Policy, the facility failed to discard two vials of expired Influenza (flu) vaccine in Young 4's medication refrigerator. This deficient practice has the potential to affect all residents in the facility due for flu vaccination.Findings Include:On 07/24/25 at 08:15 AM, medication refrigerator was checked with Registered Nurse (RN) 9. Observed two vials of expired flu vaccine dated 06/2025 still in the refrigerator located on Young 4. RN9 said that it should have been discarded last month for safety purposes. On 07/25/25 at 08:30 AM, interview with Head Nurse (HN) 6 also noted that it should have been discarded and confirmed that discarding expired medications is for the safety of the residents and to ensure the efficacy of drugs given. Review of the facility's Storage of Medication policy dated 2007 on 07/25/25 at 11:00 AM, in the Procedures section, int notes, 14. Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal.

Based on record review and interview, the facility failed to provide the effective date of discharge in the discharge notice for one Resident (R) 98 of three residents sampled for the transfer discharge process when he was transferred to a hospital. The deficient practice has the potential misinform the representative of the Residents date of transfer. Findings include:On 06/03/25 progress notes reviewed. Resident (R) 98 was admitted to the facility on [DATE] for Physical Therapy (PT) and Occupational Therapy (OT) with a primary diagnosis of Pneumonia and Parkinson's disease. R98 was transferred to an acute care hospital three days later on 06/06/25 for respiratory failure secondary to recurrent aspiration pneumonia. On 07/24/25 reviewed the discharge and transfer notice with email documentation that was sent to the Long-Term Care Ombudsman (LTCO). The notice that was provided to the resident's representative and the LTCO did not have the date of the transfer written on the notice. On 07/25/25 at 10:30 AM, interview with the Social Services Director (SSD). Confirmed the date of the effective discharge on the transfer/ discharge notice was left blank.

Based on observation, interviews, and record review, the facility failed to implement the care plan for one resident (Resident (R), R38) sampled for accidents and R92, who was sampled for respiratory care. The deficient practice puts R38 at risk for falls that could result in harm if the mechanical lift is not used appropriately with two staff and puts R92 at risk for respiratory infection who already has compromised health. Cross reference to F689 1) On 07/22/25 at 08:30 AM, observed Certified Nurses Aide (CNA) 41 transferring R38 from bed to wheelchair using a mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6 and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for the resident's safety. HN6 also confirmed that this is noted in R38's care plan, which is accessible to all staff and should be followed as it directs the care of the resident. On 07/25/25 at 11:09 AM, record review of R38’s care plan noted in the “intervention” section for “Activities of Daily Living (ADL)-Transfers using mechanical lift with two staff assist.” Review of the facility’s “Goals and Objectives, Care Plans” policy, in the Policy Interpretation and Implementation section, it states “4. Goals and objectives are entered on the resident’s care plan so that all disciplines have access to such information…are derived from information contained in the resident’s comprehensive assessment…care plan goals and objectives are defined as the desired outcome for a specific resident problem…” 2) On 07/22/25 at 09:04 AM observed R92's oxygen (O2) concentrator in her room near the wall. On 07/24/25 reviewed R92's Electronic Health Record (EHR) which revealed she is receiving hospice services and has an order for oxygen use prn (as needed). Requested and received facility policy titled Oxygen Administration from the Director of Nursing (DON). Review of this policy found the following: Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation . 2. Review the resident's care plan to assess for any special needs of the resident. On 07/25/25 at 10:15 AM interviewed the Director of Nursing (DON) by phone regarding R92's care plan. Inquired if DON saw any care plan for R92's respiratory care that included oxygen as an intervention. DON reviewed R92's care plan and stated she could not find anything in the care plan for oxygen use, and confirmed the resident had an order for Titrate Oxygen per nasal cannula PRN.

Based on observation, interviews, and record review, the facility failed to ensure that one of one resident (Resident (R), R38) sampled for accidents was free from accident hazard when staff transferred R38 using a mechanical lift with only one person assist. This deficient practice has the potential to affect all residents requiring transfers using a mechanical lift.Findings Include:On 07/22/25 at 08:30 AM, observed Certified Nurse's Aide (CNA) 41 transferring R38 from bed to wheelchair using mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/22/25 at 09:00 AM, interview with Registered Nurse (RN) 9. RN9 said that transfers using the mechanical lift should be done with two staff for safety reasons.On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6, and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for resident's safety.Record review of the facility's Using a Mechanical Lifting Machine policy, revised July 2017, the General Guidelines section, notes, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.Review of the facility's Safe use of Mechanical Lifts training, in the Procedures and Safety section, 3. Determine if another person is needed to assist with the lift. Most lifts require two people: One person to operate the lift and one person to guide the sling. CNA41 completed the training on 04/09/22.

Based on observations and interviews the facility failed to label the oxygen tubing that was connected to the oxygen (O2) concentrator with the date if initiation for one of one resident (R) 92, sampled for respiratory care. This deficient practice put R92 at risk for infection. Findings Include: On 07/22/25 at 09:04 AM and on 07/23/2025 at 10:31 AM observed R92's oxygen (O2) concentrator in her room near the wall that had tubing connected to it which was not labeled with the date of first use. On 07/24/25 at 10:43 AM interviewed 4th floor Head Nurse (HN) 6 in R92's room. Inquired of HN6 if the O2 tubing, that was attached to the O2 concentrator, should have a date when it was initiated and she confirmed this.On 07/25/25 at 10:15 AM interviewed Director of Nursing (DON) by phone regarding R92's oxygen use. Inquired if R92 had an order for oxygen and the DON confirmed that the resident had an order for Titrate Oxygen per nasal cannula PRN . and confirmed the oxygen tubing has to be labeled with the date it was initiated (opened and attached).

Based on interview, record review, facility document review and facility policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI). Specifically, the facility failed to ensure corrective action was implemented and maintained to ensure sustained compliance with reporting and investigating alleged allegations of abuse. This had the potential to affect all residents that resided in the facility. Findings included: The Department of Health and Human Services Center for Medicare and Medicaid Services [CMS] Form CMS-2567's, dated 09/20/2021, 09/30/2022, and 09/14/2023, revealed the facility received deficiencies for F609 and F610 each year. The facility's Quality Assurance & Performance Improvement (QAPI) Plan 2023-2024, reviewed by the facility on 07/21/2022, revealed, Decisions will be made to promote excellence in quality of care, resident choice, person directed care, and resident transitions. Focus area will include systems that affect resident and family satisfactions, quality of care, and services provided, and all areas that affect the quality of life for persons living and working in our organization. The plan also indicated, The QAPIC [Quality Assessment and Performance Improvement Committee] has the responsibility to -Review quality improvement reports on identified quality deficiencies, such as survey findings, develop appropriate plans of action to correct identified and confirmed quality concerns, implement the plans of action, monitor the effectiveness of action plans and make revisions as needed. The plan revealed Attachment G included a Performance Improvement Project (PIP) Inventory with dates of review of 11/01/2018, 02/07/2019, 03/2020, 07/2021, and 05/2023. Further review revealed the inventory did not indicate there was a PIP for the area of abuse reporting and investigating. The plan revealed Attachment H included a Performance Improvement Project (PIP) Inventory with a date of review of 05/12/2022. Further review revealed the inventory did not indicate there was a PIP for the area of abuse reporting and investigating. During an interview on 08/01/2024 at 1:16 PM, the Director of Nursing (DON) said that all abuse allegations were discussed during the QAPI meetings, but it was not discussed whether the investigations were completed per the facility's abuse policy. During an interview on 08/01/2024 at 2:31 PM, the Quality Assurance (QA) Coordinator stated the facility QAPI plan was not effective if the facility was being cited for the same concerns each survey.

Based on record review, interview, and facility policy review, the facility failed to report abuse investigation results within five working days to the state survey agency for 2 (Resident #302 and Resident #28) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled IV. Procedure included 6. Within two (2) hours, the DON [Director of Nursing]/Administrator/Nursing Supervisor on duty shall notify by email, phone or FAX [facsimile] the following State Agencies as required by State law through established procedures of the reported incident and findings within five (5) working days from the day the discovery. The policy revealed the State Agencies listed to report the incident to included Adult Protective Services (APS) and Office of Health Care Assurance (OHCA). 1. An Admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, and visual hallucinations. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2023, revealed Resident #302 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene and chair/bed transfers. The MDS revealed the resident required substantial/maximal assistance from staff for bed mobility. Resident #302's care plan included a problem statement initiated on 05/30/2023 that indicated the resident used antipsychotic medications related to Parkinson's disease with psychosis and visual hallucinations. Interventions directed staff to administer psychotropic medications as ordered and to monitor for side effects and effectiveness every shift. Resident #302's Progress Notes, dated 11/03/2023 at 11:13 PM, revealed an entry that indicated Registered Nurse (RN) #6 had received a call from Resident #302's Power of Attorney (POA) during mealtime for RN #6 to call the spouse later from the resident's room regarding the resident's concern about day shift staff. The Progress Notes revealed RN #6 went to the resident's bedside, and Resident #302 stated that a day shift certified nurse aide (CNA) had been rough with them that afternoon. The Progress Notes revealed Resident #302 described that they were slapped on the right upper back by the shoulder blade about 15 times. The Progress Notes revealed RN #6 attempted to clarify with the resident if staff had been trying to help them to loosen their congestion, but the resident said they did not feel that way. The Progress Notes revealed Resident #302 indicated it happened around 2:00 PM but they did not report it to the day shift staff. The Progress Notes also revealed the DON was notified. A document titled, EVENT REPORT, contained an Initial Report of alleged abuse, dated 11/03/2023 at 6:50 PM. The document revealed a notation dated 11/07/2023 at 12:36 PM that indicated the final report of the incident would be forwarded once the result of the investigation was completed. An email dated 11/07/2023 at 12:55 PM sent from the DON to the state agency also indicated the final report would follow pending an investigation. A document titled, EVENT REPORT, contained a Completed Report, dated 01/03/2024 for the alleged abuse allegation dated 11/03/2023. An email from the DON to the state agency dated 01/03/2024 at 4:35 PM revealed the final report was sent to the state agency. During an interview on 07/31/2024 at 11:57 AM, the DON stated for an abuse investigation there was a two-hour window to report to the State agency, then the final was due within five days. The DON said the process was for her to complete the final report and if she was not at the facility, then it was the nurse supervisor's responsibility. During an interview on 07/31/2024 at 2:04 PM, RN #5 stated she assisted with the abuse investigation process by obtaining interviews and witness statements. RN #5 said the initial report was due to the state by two hours after the allegation. RN #5 stated the investigation started as soon as an allegation was reported. RN #5 said the DON was responsible for the final report. During an interview on 07/31/2024 at 2:52 PM, Social Worker (SW) #22 stated the DON was responsible for the two-hour initial report and the five-day final report. During an interview on 08/01/2024 at 8:44 AM, the DON stated the charge nurse called her that evening when Resident #302 reported that a CNA had done something to them. The DON said she went to the facility and started the investigation and completed the initial two-hour notification to the state. The DON said she was responsible for gathering the information for the investigation and the nurse manager helped with gathering statements from staff and the roommates and other residents. The DON said the CNAs were a part of a union, therefore; someone had to be brought in from the outside to investigate, and the facility had to wait for the union report. The DON stated the facility did not meet the required five-day timeframe because they were waiting for the final report from the other agencies. The DON stated her expectation was to have the five-day investigations completed and turned in timely. During an interview on 08/01/2024 at 9:26 AM, the Administrator stated that as soon as an allegation happened the facility reported to the state, then completed an investigation by the fifth day. The Administrator said if the facility had to call for an external investigation the state would be notified. The Administrator reviewed the provided documentation for Resident #302's internal investigation and stated the DON did not send the facility investigation on 11/07/2023 with the five-day notification. The Administrator stated she expected the internal investigation to be sent to the state by the fifth day, even if the facility was waiting for the external investigation. 29673 2. An Admission Record revealed the facility admitted Resident #28 on 04/07/2017. According to the Admission Record, the resident had a medical history with diagnoses that included quadriplegia, anxiety disorder, adjustment disorder with disturbance of conduct, anoxic brain damage, hemiplegia and hemiparesis (one-sided paralysis and weakness) following cerebral infarction affecting right dominant side, and dysphasia (difficulty with speech). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #28 had no physical or verbal behaviors directed towards others. Resident #28's care plan, included a problem statement revised on 11/09/2022 that indicated the resident had socially inappropriate behavior of talking loudly. Interventions directed staff to continue with therapeutic limits setting and include resident input to identify what could be done in place of minding other residents' business. A Progress Note dated 09/08/2023 at 4:17 PM, by Social Worker (SW) #22 revealed SW #22 heard Resident #28 screaming at a certified nurse aide (CNA) and was told by the charge nurse that the resident was yelling profanity to the CNA. The Progress Note revealed Resident #28 was very angry and said the CNA was acting like a monkey and saying profanity to the resident. The Progress Note indicated the CNA stated the resident slammed the bathroom door and yelled expletives at the CNA. The Progress Note also indicated Registered Nurse (RN) #6 called the nursing supervisor to speak with the CNA. During an interview on 07/30/2024 at 2:21 PM, SW #22 stated staff who heard of an allegation of abuse were to ensure the resident's safety, then notify the nurse supervisor. SW #22 stated the nurse supervisor checked on the resident and then called the Director of Nursing (DON), who was the Abuse Prohibition Coordinator. SW #22 stated the DON was responsible for reporting to state and other authorities and was responsible for the investigation. During an interview on 07/30/2024 at 3:27 PM, RN #6 stated that an accusation of abuse from a resident required the resident and the accused to be separated and the resident assessed for safety. RN #6 said she reported to her supervisor if the supervisor was in the building; if not, she called the DON and reported the allegation. She stated the DON was responsible for reporting to authorities and investigating the incident. During an interview on 08/01/2024 at 1:45 PM, the DON stated SW #22 submitted the initial report on 09/12/2023, and she submitted one on 09/17/2023. There was no evidence provided to indicate a five-day investigation was submitted. During an interview on 08/01/2024 at 10:08 AM, the Administrator said the internal investigation was expected to be turned in by the fifth day.

Based on interview, record review, and facility document and policy review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #302) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled, I. Purpose included, B. To report and conduct a thorough investigation of all incidents within specified timelines and provide appropriate corrective actions and preventive measures. The policy also specified that when investigating allegations of abuse, investigators will, e. Conduct and document all necessary interviews with staff, witnesses, resident, and alleged perpetrator as deemed necessary. An Admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease (COPD), and visual hallucinations. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2023, revealed Resident #302 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene and chair/bed-to-chair transfers. The MDS revealed the resident required substantial/maximal assistance from staff for bed mobility. Resident #302's care plan included a problem area, initiated on 05/30/2023, that indicated the resident used antipsychotic medications related to Parkinson's disease with psychosis and visual hallucinations. Resident #302's Progress Notes revealed a communication note, dated 11/03/2023 at 11:13 PM, that indicated Registered Nurse (RN) #6 received a call from Resident #302's Power of Attorney (POA) during mealtime requesting RN #6 to call the POA later from the resident's room regarding a concern about day shift staff. The note indicated RN #6 went to the resident's bedside, and Resident #302 stated that the day shift certified nurse aide (CNA) had been rough that afternoon. The note indicated that Resident #302 described that they were slapped on their right upper back by their shoulder blade about 15 times. According to the note, the RN attempted to clarify with the resident if CNA was trying to help them loosen their congestion, and the resident said they did not feel that way. The note revealed Resident #302 reported the incident happened around 2:00 PM but they did not report it to day shift staff. A document titled, EVENT REPORT contained an Initial Report of alleged abuse, dated 11/03/2023 at 6:50 PM. The document indicated that Resident #302 alleged that CNA #8 was rough with them. The document indicated that the resident reported that CNA #8 slapped them on their right shoulder blade area 15 times on 11/03/2023 around 2:00 PM. The document indicated the final report of the incident would be forwarded once the result of the investigation was completed. A document titled, EVENT REPORT contained a Completed Report, dated 01/03/2024. The document indicated that, when asked, Resident #302 did not feel like the staff member was trying to help loosen their congestion. The document indicated that a complete head-to-toe assessment was completed, and no injury was noted. The document indicated that CNA #8 was suspended pending the investigation. The facility's Daily Nursing Assignment Sheet for the day shift on 11/03/2023 revealed four CNAs (including CNA #8), RN #7, and Licensed Practical Nurse (LPN) #10 were working at the time the incident allegedly occurred. The facility provided documentation of Employee/Resident Quality Assurance Reports and a Supervisor's Quality Assurance Report that reflected documentation of interviews and statements related to this allegation. These reports reflected that as part of the investigation into the allegation, the facility obtained information from CNA #8, RN #6, and RN #5. There was no evidence provided to indicate the facility interviewed or obtained statements from the other staff members working at the time of the alleged incident, including the remaining three CNAs, RN #7, and LPN #10. The facility also provided documentation of two resident questionnaires, dated 11/08/2023. The facility did not provide evidence of any additional resident interviews or evidence to indicate that residents who were not interviewable were assessed for signs or symptoms of abuse. During an interview on 07/31/2024 at 2:04 PM, RN #5 stated that the abuse investigation process included obtaining interviews and witness statements. RN #5 stated an investigation started as soon as an allegation was reported, and staff followed a checklist to not miss any steps. RN #5 stated they then gathered information from anyone who may have heard or witnessed anything. Per RN #5, residents, family, and staff members were asked to complete witness statements during the process. She stated witness statement were obtained from for Resident #302's roommate and another resident for whom the CNA had provided care that day. RN #5 read over her report and stated if she had not documented it, then there were no head-to-toe assessments performed on residents who were not interviewable. RN #5 indicated the DON was responsible for the final report. During an interview on 08/01/2024 at 8:44 AM, the DON stated the charge nurse called her when Resident #302 reported that the CNA had done something to them. The DON indicated she went to the facility and started the investigation. The DON indicated she was responsible for gathering information for the investigation, and the nurse manager helped with gathering statements from staff, the roommates, and other residents. The DON stated they did not talk to any other residents and did not assess residents who were not interviewable for signs or symptoms of abuse. The DON indicated it was the facility policy to do those things for a thorough investigation. During an interview on 08/01/2024 at 9:26 AM, the Administrator indicated the investigation for Resident #302 had been completed. The Administrator stated that as soon as an allegation was made, the facility reported to the state survey agency, then completed an investigation by the fifth day. The Administrator indicated a thorough investigation usually included speaking with the residents in the room of the alleged incident, if they were alert, and talking to any other residents who were in the area. The Administrator indicated they also usually talked with other staff working at the time. The Administrator stated she did not know if that occurred for this investigation.

Based on record review, interview, and facility policy review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disorder, or related condition, to the state-designated mental health or intellectual disability authority for review. The deficiency affected 2 (Resident #9 and Resident #39) of 2 residents reviewed for Pre-Admission Screening and Resident Review (PASARR; PASRR) services. Findings included: A facility policy titled, Preadmission Screening Resident Review (PASRR), dated 06/07/2018, revealed the section titled II. Policy, included, E. Social Services will be contacted for assistance with Level II evaluations and for any significant mood or behavior changes that may necessitate a Level II evaluation at any time throughout the resident's stay at [the facility]. The policy revealed the section titled, IV. Procedure, included, C. Nursing Supervisor, Unit Manager and Social Worker will review PASRR for Part C exceptions for individuals with MI [mental illness] or ID [intellectual disability]/DD [developmental disability] (i.e. [id est; that is], physician certification for less than 30 day stay that is required for condition which they were hospitalized for ); and will follow up within the accepted time frame if additional action is necessary, such as Level I re-evaluation and Level II evaluations and appropriate review by the state agencies. Further review revealed, I. When observing any significant decline in mood and behavior in a resident with SMI [serious mental illness], IDT [interdisciplinary team] will determine if a significant change minimum data set (MDS) assessment is warranted. Care plan(s) will be revised, if appropriate. If the resident does not stabilize within 21 days, Level II evaluation will be initiated and submitted to AMHD [Adult Mental Health Division] through the ePASRR [electronic PASRR] website. 1. An Admission Record indicated the facility admitted Resident #9 on 06/15/2004. According to the Admission Record, Resident #9 had a medical history that included a diagnosis of psychotic disorder (onset 10/03/2017). Resident #9's Preadmission Screening Resident Review (PASARR) Level I Screen, dated 05/15/2004, revealed the resident did not have a mental disorder, which included psychotic disorder. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #9 had an active diagnosis of psychotic disorder. Resident #9's medical record revealed no evidence that indicated a referral was made to the appropriate state-designated authority after the resident's diagnosis of psychotic disorder. 2. An Admission Record indicated the facility admitted Resident #39 on 06/06/2017. According to the Admission Record, Resident #39 had medical history that included diagnoses of delusional disorders (onset 08/09/2018) and paranoid personality disorder (onset 08/09/2018). Resident #39's Preadmission Screening Resident Review (PASARR) Level I Screen, signed by a physician on 06/06/2017, revealed the resident did not have a serious mental illness, such as psychotic disorder or delusional (paranoid) disorder. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #39 had active diagnoses of psychotic disorder other than schizophrenia and paranoid personality disorder. Resident #39's medical record revealed no evidence that indicated a referral was made to the appropriate state-designated authority after the resident's diagnosis of psychotic disorder. During an interview on 08/01/2024 at 8:10 AM, the Director of Nursing (DON) stated the facility did not update Level I PASARRs after the residents had been admitted to the facility.

Based on observation, interview, and facility policy review, the facility failed to ensure medication carts were locked when not within the line of sight of facility staff for 2 of 6 medication carts. Findings included: A facility policy titled, MEDICATION: Unit Storage; Expiration Dating; Inspection, dated 03/02/2005, specified, All medications/medication storage areas are locked when not observed by nurses. During an observation on 07/30/2024 at 11:31 AM, upon entrance to unit Young 4, a medication cart (Team 2 cart) was located between room [ROOM NUMBER] and room [ROOM NUMBER] and was not locked. There was no staff in the hallway. At 11:32 AM, Registered Nurse (RN) #2 exited room [ROOM NUMBER] and stated the medication cart should have been locked because it was out of her line of sight. During a concurrent interview RN #2 said the medication cart should have been locked when she walked away for medication safety. Some of the medications observed in the cart included lisinopril (used to treat high blood pressure), metoprolol (used to treat high blood pressure), trazodone (an antidepressant), Remeron (an antidepressant), Coumadin (an anticoagulant), Buspar (anti-anxiety), and insulin syringes. During an observation on 07/30/2024 at 1:29 PM, upon entrance to unit Young 5, a medication cart (Team 2 cart) was between room [ROOM NUMBER] and room [ROOM NUMBER] and was not locked. RN #3 exited room [ROOM NUMBER] and stated the medication cart should always be locked. During a concurrent interview RN #3 stated she was in a rush to administer medications to a resident but should not have left the medication cart unlocked. RN #3 stated the medication cart should be locked because there were medications inside and if it was unattended then it should be locked. Some of the medications observed in the cart included citalopram (an antidepressant), Depakote (an anticonvulsant), Seroquel (an antipsychotic), metoprolol tartrate (used to treat high blood pressure), levetiracetam liquid (an anticonvulsant) and insulin syringes. During an interview on 07/30/2024 at 3:47 PM, the Director of Nursing (DON) stated if the nurse left the medication cart that it should be locked. During an interview on 07/31/2024 at 10:45 AM, RN #5 stated if a medication cart was not attended then it should be locked. During an interview on 07/31/2024 at 10:58 AM, RN #1 stated if the medication cart was not visible to the nurse, then it should be locked. During an interview on 08/01/2024 at 8:41 AM, the DON stated she expected for staff to lock the medication cart if the cart would be left unattended. During an interview on 08/01/2024 at 9:29 AM, the Administrator stated she expected for the medication cart to be locked at all times when the nurse was out of sight.

Based on record review, staff interview and review of policy, the facility failed to provide written notice of discharge for two Residents (R)R32 & R90) out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of discharge. Findings include: 1) Review of the Electronic Health Record (EHR) indicated that R32 was admitted to the hospital on 06/27/23 with diagnosis including Stroke, Diabetes, High Blood Pressure and discharged from the hospital on 07/03/23. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 09/13/23 at 01:50 PM, Social Worker (SW1) acknowledged that the facility did not provide written notification of discharge to R32 and/or representative. The Discharge/Transfer Notice form for R32 showed the family, representative was verbally notified by phone of discharge but there was no written notification given. 2) On 09/12/23 at 10:19 AM, conducted a review of R90's EHR documented the resident was transferred to the hospital on 05/26/23 due to the potential of sepsis related to unstable vital signs and increased fever. The Discharge/Transfer Notice form was not documented in the resident's EHR. During staff interview on 09/13/23 at 01:50 PM, SW1 acknowledged that the facility did not provide written notification of discharge to R90 and/or representative. Review of facility policy titled Transfer/Discharge Requirements and Documentation read Purpose; to ensure transfer and discharge requirements are met and documented in the medical record, as well as written notice provided to the resident and resident's family and/or resident's representative for transfer or discharge from the facility. Policy; Residents will be transferred or discharged from the facility for the following reasons: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . A written notice will be given to the resident, resident's responsible party, and/or resident's legal representative at least 30 days or as soon as practicable prior to, or upon, transfer or discharge of the resident. The notice must be in a language and manner understandable to the resident, and will include the reason for transfer/discharge, the effective date of transfer or discharge, location to which the resident was transferred/discharged , right of appeal, and information on how to notify the Ombudsman and appropriate protection and advocacy agencies .

Based on interviews and record reviews, the facility failed to ensure alleged verbal abuse and an injury of unknown source resulting in serious bodily harm, were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and other officials, including to the State Survey Agency (SA) and Adult Protective Services (APS) for two residents (Resident (R)82 and R31) sampled. As a result of this deficient practice, all residents are at a risk of harm, including psychosocial harm. Findings include: The facility's Policy, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, effective date: 11/03/21 was reviewed. Residents, et al. shall not be humiliated, harassed ., it is the facility's policy to report alleged complaints and/or violations involving abuse, neglect, involuntary seclusion, injury of unknown origin and misappropriation of property immediately to the Administrator and the DON of the facility and shall be reported to the State agencies within specified timelines. (Cross Reference to F610: Investigate/Prevent/Correct Alleged Violations) 1) Review of the State Agency's (SA) Aspen Complaints/Incidents Tracking System (ACTS) documented the Director of Nursing (DON) emailed an Event Report of an allegation of abuse injury of unknown origin to the SA on 07/16/23 at 03:32 AM. The initial Event Report documented on 07/15/23 at 03:05 PM, a Certified Nurse Aide (CNA)1 reported to Licensed Nurse (LN)56 that R82 was displaying symptoms of pain to the lower left abdominal area. Upon assessment, NS56 documented R82 was lying in bed guarding the left side. LN56 called and included an interpreter language service via telephone to communicate with the resident. The nurse instructed the interpreter to ask the resident where does it sore? The resident initially answered, The lady with pain went away. The resident was asked a second time, where does it sore? R82 answered, Someone kicked her. The resident refused to go to the hospital, LN56's head to toe physical assessment documented no redness, no swelling, and no ecchymosis (discoloration of the skin resulting in bleeding under the skin, typically caused by bruising). The physician was notified and ordered an x-ray of the left lower rib cage. On 09/13/23 at 2:58 PM, conducted a concurrent record review of R82's electronic health record (EHR) to include the facility's completed investigation of the allegation of abuse and interview with the Director of Nursing (DON). Review of R82's x-ray results documented R82 sustained acute lateral 7th and 8th rib fractures, the physician interpreting the x-ray findings signed the results on 07/15/23 at 08:34 PM and staff wrote Noted 07/15/23 which was initialed by staff acknowledging receipt of the x-ray results. During the interview, the DON stated she was not notified by Nursing Supervisor (NS)29 of the incident within 2 hours of the incident but could not recall or provide documentation of the exact time. The DON also confirmed there was no documentation of the time the Administrator was notified of the incident. Inquired why was there a delay in NS29 informing the Administrator and the DON. DON stated, NS29 did not identify the incident as an allegation of abuse because staff know the resident has cognitive deficits and did not believe that someone kicked the resident. The DON confirmed NS29, and the DON made an initial determination that R82's allegation was not credible prior to reporting the allegation and of have been treated as an allegation of abuse and/or injury of unknown origin. Thus, the event was not reported to SA with in the 2-hour period and confirmed the facility did not report the incident to APS as required by federal and state regulation. On 09/13/23 at 04:38 PM, conducted an interview with the Administrator. Inquired when did the Administrator first become aware of R82's allegation of abuse. The Administrator reviewed the investigation and phone records and confirmed she was not immediately notified of the incident, but once she became aware, she informed nursing staff and the DON that R82's incident is a reportable event, and the SA and APS should be notified, and a complete investigation should be conducted. The Administrator confirmed NS29 did not immediately notify the DON and Administrator as soon as the resident verbalized the allegation of physical abuse but did not. On 09/14/23 at 02:50 PM, conducted an interview with NS29 regarding R82's allegation of abuse. NS29 confirmed the resident has cognitive deficits and her assessment of the resident and what the resident was saying to the interpreter, in her opinion, did not constitute as a credible report of abuse. NS29 could not recall or provide documentation of when she notified the DON and the Administrator of the event. 2) On 09/11/23 at 08:58 AM, conducted an interview with R31 at the resident's bedside. R31 stated, Last week a male CNA (CNA23) was really mean to him and his roommates. and CNA23 called the resident a motherfucker and treated me like a dummy. R31 also reported that he was upset because CNA23 handled his roommate, who is totally dependent on staff, roughly and he did not like that. Inquired if R31 had reported the incident to staff. R31 confirmed the facility knows about the incident and that CNA23 continued to work on the same floor as the resident. R31 reported feeling extremely upset at just the sight of CNA23 and in addition to speaking to the resident. On 09/14/23 at 10:52 AM, conducted a concurrent record review of R31's EHR and interview with Nurse Manager (NM)5. Inquired about the incident R31 reported to this surveyor. NM confirmed she became aware of the situation on Monday, 09/11/23. LN56 documented the incident as R31 having a behavior of swearing at CNA23. NM5 stated R31 reported that CNA23 called him the name of an actor that does not have teeth or hair, which upset R31. R31 felt like CNA23 was teasing him. NM5 stated LN56 called NS29 to address the situation. On 09/14/23 at 10:14 AM, conducted a concurrent record review and interview with the DON regarding R31's allegation of abuse. The DON reviewed the facility's documentation and stated she was first informed of the incident on 09/12/23 when an event report was created and confirmed NS29 did not identify R31's reports of abuse by CNA23 as an allegation of abuse. The DON confirmed NS29 made an initial determination whether the allegation is credible before reporting the allegation. As a result of NS29 initial determination that the allegation of abuse was not credible, the DON and Administrator was not immediately made aware of the situation, CNA23 should have been sent home to protect the resident and/or other resident from the potential of abuse, and the SA and APS should have been notified within the 2-hour timeframe but was not. On 09/14/23 at 12:33 PM, conducted a concurrent record review and interview with Social Worker (SW)1 regarding R31's reported incident. SW1 stated on 09/08/23, SW1 heard a commotion in the hallway involving R31. SW1 took R31 into the solarium to calm the resident down and find out what was going on. SW1 recalled that she had not seen R31 this mad before and R31 informed SW1 that CNA23 told the resident Okininam, which means fuck you in Ilocano. While in the solarium with R31, SW1 reported CNA23 came into the room and began arguing with R31 about what happened, then CNA23 stormed off. SW1 stated she was concerned about CNA23's behavior and interaction with the resident. SW1 stated that she informed LN56 and NS29 that the incident between CNA23 and R31 was possibly abuse, that CNA23 should not be working on the floor until an investigation is completed, and the DON and the Administrator should be notified immediately. SW1 reported that CNA23 informed NS29 that he wanted to go home and did not want to work due the allegations of abuse, but NS29 informed CNA23 that if he went home, he would be fired for resident abandonment. CNA23 was reassigned to another part on the same floor and worked the rest of the shift. On 09/14/23 at 2:23 PM, conducted an interview with NS29 regarding R31's allegation of verbal abuse by CNA23. Inquired if NS29 identified the incident as an allegation of verbal abuse. NS29 stated she did not identify the incident involving R31 and CNA 23 an allegation of abuse because the resident is well known will harass staff. NS29 denied that SW1 had informed her that the incident could potentially be abuse and needed to be handled according to the the facility's policy and procedure for abuse. NS29 stated she handled it as a grievance, informed CNA23 he could not leave, and did not inform the Administrator or the DON of the incident. NS29 confirmed the incident should have been handled as an allegation of abuse but did not.

Based on observations and interviews, in response to an allegation of abuse the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further abuse while the investigation was in progress. As a result of this deficient practice, residents are at risk of abuse and experiencing harm. Findings include: (Cross Reference to F609: Reporting of Alleged Violations) On 09/13/23 at 02:58 PM, conducted a concurrent record review of R82's electronic health record (EHR) of the facility's completed investigation of the allegation of abuse with the Director of Nursing (DON). Inquired with the DON about the details of the investigation related to R82's report that someone kicked her in response to Licensed Nursing Staff (LN)56 assessing the resident's lower left abdomen for pain. The DON confirmed as a result of Nursing Supervisor (NS)29's determination that R82's allegation of being kicked in response to questioning regarding lower left abdomen pain as not being a credible allegation, the incident was not thoroughly investigated, but should have been. DON stated R82's physician determined that the resident's fractured ribs was a result of Osteopenia and not from being kicked. Inquired if R82 had a known diagnosis of Osteopenia at the time the allegation was made. The DON confirmed R82 did not have a diagnosis of Osteopenia or sign/symptoms prior to the allegation of abuse. DON stated Certified Nurse Aide (CNA)1 identified R82's symptoms of pain in the lower left abdomen when the resident was lying in bed (the resident has three mattresses side by side which are placed on the floor for the resident's safety) and when LN56 assessed the resident there was no observable trauma. Inquired about the resident's cognition and the DON confirmed that although the resident does have cognitive deficits the resident is able to make needs known at the resident may have been able to discern if a person was the cause of the injury. Reviewed staff 's written statements and inquired about CNA34's statement that the resident had signs and symptoms of pain while assisting CNA1 with transferring the resident from the shower, prior to returning the resident to her bed. The DON confirmed she was not aware that CNA34's statement and did not investigate the resident's activities prior to LN56 assessing R82 in the bed. Inquired if the DON confirmed she had not interviewed the staff involved and used the completed witness statements and progress notes as the source of information for the investigation. After reassessing the details of the investigation, the DON confirmed a thorough investigation had not been conducted and it is possible that R82 could have sustained the fractured ribs during transfer or other means which were not investigated due to staff discrediting the resident's allegation before conducting a thorough investigation. Reviewed the facility's policy and procedure for investigating an allegation of abuse and the DON confirmed the procedure for investigating allegations was not implemented and should have been. On 09/14/23 at 02:50 PM, conducted an interview with NS29 regarding R82's allegation of abuse. NS29 confirmed the resident has cognitive deficits and her assessment of the resident and what the resident was saying to the interpreter, in her opinion, did not constitute as a credible report of abuse.

Based on observations, staff interview and review of policy procedure, the facility failed to post staffing information for one Nursing Unit, 4th floor Young, out of three Nursing Units sampled. As a result of this deficiency the facility failed to follow regulation to make nurse staffing data available to the public for review. Findings include: During observation of the 4th floor Young Nursing Unit on 09/11/23 at 10:15AM, the staffing information form posted at the nurse's station was not completed. There was no information to show the total number and actual hours worked by licensed and unlicensed nursing staff as required. During staff interview on 09/11/23 at 02:30PM, the Director of Nursing acknowledged that the staffing information was not completed as previously mentioned. Review of facility procedure on Revised Procedure for Staff Posting read the following: Effective immediately, units are required to complete the Daily Staff Posting sheet by 0700 hours and post in the designated area (white board). At the beginning of each shift, the Charge Nurse for the on-coming shift will verify the census and staffing, and make changes as needed on the Daily Staff Posting sheet. The sheet will be changed at 0700 hours daily and submitted to the Nursing Supervisor/Nursing Office for record keeping .

Based on observation and interview, the facility failed to assure a safe, clean, and comfortable homelike environment for two of five sampled residents (Resident (R)37, and R43). Findings include: On initial tour of facility 09/11/23 at 09:56 AM, at the bedside of R43's, equipment was observed. Surveyor noted that the tube feeding pole and parts of the bed were splattered with spilled/spots of questionable formula which smelled like milk. Also noted were areas of the bed with black stain and/or questionable dirt. An observation on 09/11/23 at 12:18 PM, tube feeding was in progress for R 37. Noted fresh formula and a dried crusty substance was spilled on the pole where the formula bag hangs. On 09/12/23 at 08:44 AM, surveyor observed R43's bedside table, feeding machine, pole, and bed were splattered with a milky and crusty substance. Noted an odor that smelled like formula. On 09/13/23 at 09:44 AM, an interview with nursing supervisor (NS)1 was done. Surveyor and NS1concurrently observed the soiled equipment and the smell of milk. NS1 agreed that cleaning is needed for rooms of R37 and R43.

Based on observations, interviews, and record review, the facility failed to perform proper hand hygiene and follow infection control protocol. This deficient practice places the residents and visitors at risk for the development and transmission of communicable disease and infections. Findings include: 1) Observation was conducted on 09/11/23 at 07:54 AM on the first-floor visitor check-in station. A Health Screener (HS) was observed conducting self-swab Covid testing on three state surveyors. After the first surveyor performed self-swabbing, HS collected the test swab and placed it on the table. HS then removed his gloves and threw them in the trash can. HS proceeded to don new gloves without hand hygiene and assisted the second surveyor with self-swabbing. Once the second surveyor finished self-swabbing, HS collected the test swab and placed it on the table. HS then removed his gloves and placed it in the trash can. HS proceeded to perform tasks near the table containing the test kits. A couple minutes later HS walked away from the testing station. 2) Observation was conducted on 09/13/23 at 08:50 AM on the fourth-floor hallway. A Registered Nurse (RN) 1 was prepping medications at the medication cart with gloves on. RN1 entered room [ROOM NUMBER] with the same gloves and administered medication via gastrostomy tube to R34. Following medication administration, RN1 removed the gastrostomy tube dressing and threw it in the trash. RN1 also removed her gloves at the same time and walked out of the room. A minute later, RN1 returned to the room and donned new gloves to finish the dressing change. She applied ointment and new dressing on the gastrostomy tube site. Once dressing change was completed, RN1 proceeded with medication administration without removing and changing her gloves. Interview was conducted on 09/13/23 at 09:46 AM in the fourth-floor hallway. RN1 stated that facility staff are supposed to change their gloves when performing different tasks. Interview was conducted with the facility's Infection Preventionist (IP) on 09/13/23 at 10:17 AM via telephone. IP stated that facility staff should be performing hand hygiene in between glove changes and change gloves when performing different tasks. A review of the facility policy titled, Hand Hygiene, dated 02/03/23 was conducted. The policy indicated, Indications for Antiseptic Hand Rubbing or Antiseptic Handwashing .before putting on and after removing gloves (wearing gloves is not a substitute for hand hygiene) .before administering medications .Before performing sterile or clean procedures such as but not limited to urinary catheterizations, IV insertions, dressing changes .

Based on observations, staff interview and review of policy, the facility failed to secure a padlock that was attached to the medication refrigerator door on the 3rd floor Young Nursing Unit. As a result of this deficiency, the facility failed to properly store the refrigerated medications. Findings include: During observation of the 3rd floor Young Nursing Unit, on 09/11/23 at 11:20AM, the medication refrigerator was not secured. There was a padlock there to secure the door, but the padlock was not locked. There was no staff in the immediate vicinity, and anyone could remove the padlock and have access to the medications in the refrigerator. Staff interview on 09/11/23 at 11:45AM with the 3rd floor Head Nurse acknowledged that the padlock should have been locked and always secured. Head Nurse then locked the padlock and secured the refrigerator. Review of policy on Storage of Medication read Policy; Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Procedures; In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken .

Based on observations, interviews, and record reviews, the facility failed to properly assess and treat the mobility issues and provide for the dementia care needs of one resident (R)77 out of a sample of one, that could have potentially prevented R77's fall. This deficient practice has rendered harm to R77 who sustained a pelvic fracture that cannot be surgically corrected, with subsequent pain, decreased mobility, decreased appetite, and overall decreased quality of life. This has the potential to affect all residents with dementia and mobility issues in the facility who need timely rehabilitation (PT/OT) screening and individualized dementia care. Finding includes: On 09/27/22 at 09:48 AM, an initial observation of R77 was made. R77 laid in bed on his back with a blue blanket covering him up to his neck. R77's bed was on the floor, up against the wall, with a floor mat alongside the left of the mattress (facing into the room). R77's room was dark. Subsequent observations of R77 at 11:00 AM, and 12:03 PM, revealed R77 laid in the same position on his bed in his darkened room. State agency (SA) initiated conversation by asking him if he was cold and he stated, No, and closed his eyes. On 09/28/22 at 06:50 AM, observed R77 lying on his back sleeping. A follow up observation was made at 09:44 AM and R77 was found lying in the same position with his eyes closed. No response was made by R77 when he was greeted. On 09/28/22 at 08:37 AM, an initial record review (RR) of R77's EHR revealed in the Progress Notes, no Nurse Note documented on 09/27/22 regarding R77's status. A Nurse Note documented on 09/28/22 at 04:52 AM stated, .Slept good no behavior. A Fall Note was documented by Registered Nurse (RN)9 on 06/13/22 at 07:37 AM which stated that R77 was walking back and forth without an assistive device in the hallway of a nursing unit in the early morning of the night shift. RN9 held his hand assisting him with walking, when he firmly grasped RN9's hand, pulling RN9 towards him, let go of his grip from RN9, lost his balance, and fell on to his buttocks. R77 hit his head on a wheel of a cart on his way down to the floor. On 09/29/22 at 07:13 AM, R77 was observed to be lying on his back on his bed, sleeping. A subsequent observation at 08:03 AM, found R77 lying in the same position with music playing in his room. At 10:27 AM, R77's room was quiet, and he laid in the same position on his bed with his eyes closed and did not respond to any greeting. On 09/29/22 at 12:14 PM, R77's electronic health record (EHR) was reviewed. R77's medical diagnosis screen revealed that R77 is a [AGE] year old resident admitted on [DATE] for [CONDITION(S)], post COVID-19 condition, diabetes, depression, restlessness and agitation, and anxiety. R77's primary physician documented in R77's admission note sent to the facility on [DATE] at 1:20 PM, the following: .Unsteady, muscle weakness, high risk for fallsPoor [sic] memory and safety awareness . and .certify that patient meets criteria and needs to continue care at the [facility] nursing home at the ICF [intermediate care facility] level of care for PT [physical therapy]/OT [occupational therapy] rehab [rehabilitation] . Reviewed R77's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/17/22. Under Section C Cognitive Patterns, R77's Brief Interview for Mental Status (BIMS) score was three, rating his cognition as severely impaired. Section G Functional Status, R77 needed 3. Extensive Assistance - resident involved in activity, staff provide weight-bearing support with 2. One person physical assist with walking. Mobility devices used by R77 were identified as a walker and wheelchair. Fall Risk Assessment 2 documentation of 05/11/22 at 2:00 PM, scored R77 with a fall risk score of 6, which directs the facility to initiate Fall protocol I. On 09/29/22 at 12:30 PM, the facility's Fall Prevention policy and procedure (P&P) was reviewed. It stated, .B. All residents will be considered at risk for falls and standard care protocol (Protocol I) shall include the following: .4. Reinforce use of assistive devises [sic], if used, and keep within reach . 7. Consider rehabilitation screen, if appropriate, and maintenance exercise to maintain strength, ambulation and function. Continued RR of R77's EHR revealed in .Interdisciplinary Team Conference [IDT] Notes - V4 of 05/17/22 at 1:30 PM stated for the Social Worker summary: Resident is transitioning to new environment, and will often need frequent reminders due to poor safety awareness. Resident is confused and has difficulty remembering why resident is at [facility]. When resident was first admitted resident was alert, and engaged in conversation well. As resident has been at [facility] for a couple of days getting used to environment, resident's affect is flat, and is restless and makes frequent attempts to get out of chair. Resident does well when other persons are around, and will need close supervision . No PT nor OT summary notes were documented in the IDT conference notes. The Orders screen showed PT/OT eval. [evaluation] was ordered on 06/17/22. There was no documentation by the rehabilitation department (PT/OT) until 06/17/22 at 3:12 PM which stated the following: .Per 6/13/22 x-ray, acute fracture of left acetabulum [sudden break in the left hip socket]; Per 6/15/22, left inferior ramus fracture [broken lower pelvic bone] .Rolling left and right with 2 person max assist due to pain. Lower body dressing extensive to total assist. Review of Orthopaedic [sic] Surgery consult note dated 06/17/22 revealed R77's pelvic fracture was .a non-surgical type fracture of the pelvis . On 09/29/22 at 1:54 PM, the Director of Nursing (DON) was queried if R77 was ever assigned care to be provided to him by one caregiver (one to one) due to his behaviors and she stated that he was never provided care solely by one caregiver but was always kept in the line of sight of staff. Continued RR of R77's EHR revealed in . Interdisciplinary Team Conference Notes - V4 of 09/06/22 at 2:00 PM under the .E. Dietary Summary .m. Problems/Needs: .Resident w/ [with] decline in ADLs [activities in daily living], including feeding; requires mostly extensive assist per records; previously fed self after set-up. Resident w/ decline after fall 6/13/22, harder to sit up with head up, needing more assist w/ meals per records ., and .F. Recreation Summary .A significant change assessment is warranted at this time, due to a decline in ambulation, transfer, locomotion on/off unit, and incontinence. Bladder [urine] Elimination task flowsheet from 06/01/22 to 09/28/22 was reviewed. In the month of June 2022, before R77's fall on 06/13/22, R77 had six episodes of incontinence and 46 episodes of continence. After his fall, R77 had 45 episodes of incontinence and six episodes of continence from 06/14/22 to 06/30/22. In July 2022, R77 had 79 episodes of incontinence and six episodes of continence. The month of August 2022 showed R77 being mostly incontinent with one episode of continence and in September 2022 until 09/28/22, R77 was totally incontinent of urine. A Weight Change Note documented on 07/05/22 at 3:32 PM stated, .Resident had weight loss of 16.8 lbs [pounds] (-9.82%) since last month. The (Rehab) ADL - Walk in Corridor task flowsheet showed that R77 ambulated 185 feet with the use of a walker from 08/15/22 to 08/25/22. In the month of September 2022, R77 only ambulated on 09/27/22 for 20 feet with a walker. Both involved LIMITED ASSISTANCE - Resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. On 09/30/22 at 10:02 AM, Nurse Manager (NM)7 was interviewed. NM7 stated that after R77's admission into the facility he was restless and was always moving - sliding to the floor from his wheelchair, lying on the floor, walking in the hallways, he often refused to use his wheelchair and walker. R77 loved surfing and liked to watch sports. R77 spent 20 days on the unit she managed, and he became familiar with the staff. NM7 stated that R77 was transferred to another nursing unit after finishing his quarantine for 20 days. R77 was stable before he was transferred to the other nursing unit. NM7 stated that R77's dementia rapidly progressed. R77 was transferred back to her unit after his fall on 06/13/22 due to the smaller census of residents and the capability to provide more one to one supervision. NM7 described R77 now as being more moody and partially attributes his decline to the pain he is experiencing after his fall. NM7 stated that all ICF residents should receive a PT/OT screen on admission. On 09/30/22 at 11:19 AM, interviewed NM4 in her office concurrently with RN9 on NM4's cell phone. R77 was transferred to NM4's unit on 06/09/22, had his fall on 06/13/22, and transferred back to NM7's unit on 06/14/22. NM4 stated that RN9 would call the nursing supervisor if RN9 needed help with R77. RN9 stated that R77 was more agitated than usual on her shift before his fall and that the nursing supervisor was unable to assist with R77 because she was busy doing another task. NM4 stated that she does notice that residents with changed environments become more restless after the change and that a slower transition is needed to help accommodate them and their needs. Reviewed R77's care plan with last care plan review on 09/20/22. R77's problems of refusing to utilize his walker and wheelchair for mobility, his unsteadiness, muscle weakness and rapidly progressing dementia, were not addressed. Reviewed facility's policy and procedure, Evaluation & Therapy for Inpatient/Residents, effective date 08/30/06, .II. Policy All patient/residents who have received a physician's order for evaluation or who have been identified through the initial screening assessment as candidates for therapy will be scheduled for an evaluation. Reviewed the Dementia Care policy, identified by the DON as Major neurocognitive disorder (dementia), identifying and managing resident safety risks, long-term care revised on 02/18/22. It stated, Introduction .A resident with major neurocognitive disorder living in a long-term care facility typically has difficulty adapting to the unfamiliar environment. Daily interactions with multiple staff members can cause stress, further compromising the resident's safety and welfare . and .Managing behavior .Observe the resident's behavior to identify triggers that lead to agitation. Behavior is a way in which residents with major neurocognitive disorder communicate their needs and desires . and .Preventing falls .Collaborate with a physical therapist, if needed, to determine whether the resident may benefit from strengthening exercises, use of an assistive device, or safe seating training . Based on observations, record review, interviews, and facility policy review, the facility failed to ensure an assessment was completed to determine if a chair alarm and seat belt were medically necessary, safe, and appropriate for 1 (Resident #14) of 1 sampled resident reviewed for restraints. Findings included: Review of a facility policy titled, Physical Restraints and Devices, dated 03/06/2008, revealed the following: - Definitions: A physical restraint is any manual method or physical or mechanical device, material, or equipment that is attached or adjacent to the resident's body that the resident cannot easily remove by him/herself and restricts the resident from freedom of movement or normal access to his/her own body. - Procedure: A. Responsibilities: 1. The Nursing staff shall: a. Determine through documented assessment that the device is needed to improve the resident's well being [sic], is medically necessary, and its benefits outweigh potential harmful effects. b. Select a restraint to be used only after other less restrictive measures have been found to be ineffective to protect the resident from harm. - B. Assessment/Care Planning: 1. A THREE-DAY ASSESSMENT PERIOD shall be implemented upon admission or use of new device that may be considered a physical restraint to determine if the resident requires the device to ensure resident's safety, increase function and/or to complete a medical treatment. 2. During the THREE-DAY ASSESSMENT PERIOD: a. The Nurse shall observe and assess the resident for risk for falls or injury. b. The observations and assessment must be documented in the Interdisciplinary Progress Notes (IPN) every shift. c. Documentation to include medical condition, functional ability, medications, cognitive status and psychological impact related to use of the device/restraint. d. The nurse will utilize alternatives for restraint use and document interventions tried. - 5. After less restrictive devices or alternatives have been tried and found ineffective in protecting the resident from harm, the Nurse will: a. Complete the Restraint Assessment/RAP Review form on the computer for each device. Print a copy, sign and file in chart. b. Determine if the device is a restraint or not on page 2 of the form. Review of an Admission Record revealed the facility admitted Resident #14 on 06/17/2022 with diagnoses that included Alzheimer's disease, anxiety disorder, and [CONDITION(S)]. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #14 scored zero on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS indicated the resident required extensive assistance for transfer, was totally dependent for locomotion, and used a wheelchair for mobility. According to the MDS, the resident used a bed and chair alarm daily and used no restraints. Review of a care plan, dated as initiated 06/17/2022 and revised 08/05/2022, revealed Resident #14 was at high risk for falls related to incontinence, vision/hearing problems, antihypertensive medication, and psychoactive medication. Interventions included a Posey alarm with splitter while in bed, so the call light was activated if the resident tried to get up unassisted; and a wheelchair Posey alarm with a speaker, to remind the resident to sit and wait for help, to be on at all times when the resident was in the wheelchair. Review of a Progress Note, dated 07/05/2022 at 1:54 PM revealed the resident kept insisting on going home and trying to get out of the wheelchair and going down to floor. The nurse noted that she called the resident's family member and left a message. Review of a Progress Note, dated 07/05/2022 at 2:33 PM, revealed the nurse obtained verbal permission from the resident's family member to apply a seat belt when the resident was sitting in the wheelchair. During an observation on 09/29/2022 at 10:15 AM, Resident #14 was sitting in a wheelchair with a Velcro waist belt applied. During an observation on 09/29/2022 at 2:04 PM, Nurse Manager (NM) #5 asked Resident #14 if he/she could remove the Velcro belt. The resident was confused and stated he/she did not want to take it off and that it belonged to him/her. During an observation on 09/30/2022 at 9:00 AM, NM #5 asked Resident #14 to remove the belt and the resident was able to remove it. The alarm did not sound. NM #5 stated it was supposed to have a recording that remined the resident, The nurse is here to help. NM #5 stated the alarm was not activated when Resident #14 removed the belt. During an interview on 09/29/2022 at 10:01 AM, Certified Nursing Assistant (CNA) #1 stated Resident #14 had a seatbelt when in the wheelchair. CNA #1 stated Resident #14 had it because he/she would try to stand up, and it stopped the resident from standing. CNA #1 stated Resident #14 knew how to open the belt and that it was a reminder. During an interview on 09/29/2022 at 1:22 PM, Licensed Practical Nurse (LPN) #1 was not sure when the Velcro belt was put in place or whether other interventions were tried before implementing the belt, but stated that Resident #14 knew how to turn off the alarm. During an interview on 09/29/2022 at 1:43 PM, NM #5 stated was not sure if there was a documented evaluation done to determine if the Velcro belt was a restraint for Resident #14. During an interview on 09/30/2022 at 3:26 PM, the Director of Nursing (DON) stated that when a resident had a device put in place that could potentially be a restraint, the resident would be assessed for the need for the device. The DON stated there was a paper assessment that was included in the facility policy. The DON stated he/she would have to read the policy to know if an assessment should have been done for Resident #14's potential restraint. During an interview on 09/30/2022 at 3:26 PM, NM #5 stated no assessment was done for Resident #14's Velcro belt. During an interview on 09/30/2022 at 3:26 PM, the Administrator stated the facility had an assessment to determine if a resident needed a device, assess whether the resident could remove it, and indicate the goal of the device. The Administrator stated the facility needed to do the assessment to rule out a device being considered a restraint.

Based on interviews, document review, and facility policy review, the facility failed to promptly respond to requests and grievances from the Resident Council and maintain records to demonstrate the response. The failed practice had the potential to affect all residents. Findings included: Review of a facility policy titled, Resident Rights and Responsibilities, dated 01/01/2009, revealed, The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings. When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility. Review of an undated facility document titled, Resident Council Tool Kit revealed, The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility must demonstrate their response and rationale for such response. However, this does not mean the facility must implement every request of the resident or family group. The document also indicated, d. All grievances raised during the meeting should be recorded in the minutes. e. Responses to grievances should be received in a timely manner as indicated in the facility's grievance policy. f. Responses should be specific and should be reflected in subsequent minutes. Review of an Agenda Resident Council Meeting, dated 01/26/2022, revealed the residents wanted a suggestion box to enable them to provide comments and feedback. Review of a March Resident Council Satisfaction Survey revealed the residents requested and/or reported the following: - In response to a question regarding the type of activities the residents desired, the residents indicated they would like to have a movie party, live music, a book club, a consistent exercise schedule, and more artwork projects, like painting by numbers. - In response to a question regarding whether residents were satisfied with the meals provided by the facility, the residents indicated the flavors of the food were not good; the food always tasted the same; they serve the same five meals and mix my vegetables with my food. The residents' suggestions for the food they would like to see on the menu included pizza, chili, more fresh fruit options, tacos/ soft burritos. - In response to a question regarding whether residents felt their calls for assistance were answered in a timely manner, the residents' comments indicated night shift canceled the call light, then returned later without helping; staff always stated they were short-staffed; had to wait a long time, then staff would use the intercom to ask if the resident needed help; it takes a long time in the mornings. - In response to a question regarding whether the residents would like to provide suggestions to improve their care, the responses included that the facility always seemed shorthanded, mostly in the evenings and night shift. Additionally, there was a suggestion for more opportunities to shower. Review of an Agenda Resident Council Meeting, dated 05/25/2022, revealed the residents shared interests in having more opportunities to socialize via Zoom; that residents would like to have a suggestion box for comments and feedback; that the Director of Nursing attend the next meeting; that church services be resumed via the Activities Department; and that a movie be shown in the Young 1 activity room. A review of Resident Council Meeting Minutes, dated 07/27/2022, revealed the residents shared an interest in understanding the Emergency Preparedness Plan due to the recent events of high surf along the southern coast and hurricane season. Review of the July 2022 Resident Council Satisfaction Survey Results revealed that in response to a question regarding whether the residents would like to provide suggestions to improve their care, 70% of the responses were yes. However, the residents' suggestions were not documented. Review of Resident Council Meeting Minutes, dated 09/21/2022, revealed the residents requested to have the Emergency Services Preparedness Team provide them with the plan to be implemented in the event of a natural disaster. During an interview on 09/29/2022 at 12:05 PM, Social Worker (SW) #1 stated residents were asked questions about whether their needs were being fulfilled and if they had any concerns they wanted to discuss. SW #1 stated that at every other meeting, a survey was completed, which should have been recorded in the minutes. SW #1 stated SW #2 would have the information on this. During an interview on 09/29/2022 at 12:27 PM, SW #2 stated that when a concern was brought up in the meetings, the department responsible for the concern would be notified. SW #2 stated the only concern brought up in the September 2022 meeting was that the residents wanted the meetings to be held in person. SW #2 stated dietary was a special guest at the meeting in January 2022, as the residents had a lot of concerns for dietary. During an interview on 09/29/2022 at 1:12 PM, SW #2 stated there had not been any grievances from the council in the last six months, and there were no dietary concerns. During an interview on 09/30/2022 at 10:05 AM, Resident #51 and Resident #64 stated they did not know how to file a grievance. During an interview on 09/30/2022 at 10:19 AM, Resident #51 stated he/she brought up concerns in the council meeting when dietary attended, and other residents brought up dietary concerns in the meeting as well. Resident #51 stated the dietary concerns were not resolved. Resident #51 stated he/she thought having a suggestion box was important, but the council never received a response on that request. Resident #51 stated the council never received a response to the requests for information on emergency preparedness, and a lot of residents were nervous about the big waves. During an interview on 09/30/2022 at 10:40 AM, Resident #51 stated he/she brought up a suggestion about mail delivery during a Resident Council meeting and never received any response. During an interview on 09/30/2022 at 1:09 PM, SW #1 stated there were dietary concerns brought up in the Resident Council meetings. SW #1 stated the surveys that showed the resident concerns were not saved, but they probably did have concerns during the Resident Council meeting about dietary, and that was why dietary attended a meeting. SW #1 stated resident concerns were written in residents' individual records, and the concerns were not written down during the Resident Council meetings. SW #1 stated the concerns should have been documented in the meeting minutes. SW #1 stated that Resident #51 had brought up the suggestion of having a suggestion box, and there was no documentation of follow-up on that request. When asked about the concern of the night shift cancelling call lights, SW #1 stated that concern was sent to the nursing department. SW #1 could not say whether any follow-up was completed on that issue. When asked about the resident who requested more opportunities to shower, SW #1 stated that issue was followed up on; however, when asked if there was documentation of the follow-up, SW #1 did not know which resident wanted more opportunities to shower. SW #1 indicated she did not know what the residents' suggestions were when 70% of residents responded they wanted to provide suggestions to improve their care. During an interview on 09/30/2022 at 1:58 PM, SW #1 stated the Resident Council format had been changed; it should have included the actions taken. SW #1 stated she did not know what the follow-up was to any of the council's concerns. During an interview on 09/30/2022 at 2:11 PM, the Director of Nursing (DON) stated there had never been a nursing concern brought up in Resident Council meetings. The DON denied any knowledge of the concern brought up in the March 2022 meeting about call light response and was unaware that a resident stated he/she wanted more opportunities to shower. During an interview on 09/30/2022 at 3:06 PM, the Administrator stated if residents had concerns, an interdisciplinary team (IDT) meeting would be held to discuss the concerns with the related department. The Administrator stated the grievance log was only used if a complaint could not be resolved, but there should have been a complaint log. The Administrator stated whatever was expressed in the council meeting should have been written in the minutes, and the results should have been reported at the next meeting. The Administrator stated Social Services had a responsibility to follow up on the concerns.

Based on observations, interviews and record reviews, the facility failed to implement interventions to prevent a pressure ulcer and provide necessary treatment to prevent infection for R73 who was at risk for developing pressure ulcer/pressure injury (PU/PI) due to the presence of contractures. This deficient practice caused R73 to develop an unstageable PU/PI which was avoidable if the facility provided proper care. Findings include: R73 is a [AGE] year-old admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R73 also presents with MASD to the GT site, buttock and labia and a left great toe unstageable ulcer that requires a daily dressing change. Per R73's MDS assessment dated [DATE], R73 is non-verbal and rarely/never understood in her ability to express ideas, wants, and understanding verbal content and requires total assistance for activities of daily living. On 09/14/21 at 8:30 AM in R73's room, R73 was observed contracted lying in bed on her back. Head of the bed was up at 45 degrees. A pillow was behind R73's head, a pillow behind each of R73's shoulders, and a pillow behind her back. Both of R73's arms were bent towards the chest, with a rolled bath towel in both elbow creases between each arm and trunk. Both of R73's fists were clenched around a paper towel. R73's knees were bent towards the chest with a pillow placed underneath the knees and between the legs. R73 also wore a brief. Both feet had foam heel protectors that were touching the bed. R73 eyes were closed and did not respond to surveyor's greeting. Surveyor observed R73 in the same position on her back on 9/14/21 at 10:30 AM and at 11:39 AM. On 09/16/21 at 11:09 AM and 09/17/21 at 9:17AM in R73's room, surveyor observed RN20 perform a daily dressing change to her left toe wound. Surveyor observed R73's feet turned inward in a [NAME]-toed fashion when heel protectors were opened. PU/PI to left great toe was located on right side of the toe and appeared to have dry black and white tissue with no drainage. Entire left great toe was colored deep pink compared to R73's other toes which were pale. R73's knees and legs closed together tightly after the pillow in between her legs was removed. On 09/16/2021 at 11:09 AM at the unit's medication cart, RN20 stated that R73's PU/PI Started with a blister. R73 presses both feet together which is how she probably got the blister. She was on [MEDICATION(S)] antibiotics for infection. On 09/16/2021 at 1:51 PM at the unit's nursing station, in an interview with NM3, she stated that in R73's care plan, intervention of Check positioning at least every two hours as needed meant that patient needs to be physically turned to a different position. When surveyor showed NM3 R73's turn and position flowchart with multiple entries for the same time, NM3 stated that They (certified nursing assistants) might not chart in real time, so entries are put in late and only records the time that they inputted the entry not the actual time the patient was turned. A record review (RR) was done on 9/16/21 at 1:00 PM of R73's care plan dated 06/21/21. It stated that for the problem of left great toe unstageable, the intervention is to alleviate and minimize friction/shearing during repositioning. For care plan problem: the resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] impaired mobility (Decrease Range of Motion to Bilateral Upper and lower extremities) impaired cognition Dx. [diagnosis] Alzheimer's dementia, the intervention is to check positioning at least every two hours as needed. R73's task flowchart for Turn and Reposition, revealed that turning and repositioning of R73 was completed on 09/14/21 at 06:34 AM, 07:44 AM, 9:08 AM, 12:50 PM, 2:01 PM, 8:01 PM, 8:01 PM, and 8:01 PM. Surveyor did not observe the repositioning and turning of R73 from 08:30 AM to 11:39 AM as evidenced by R73 being in the same position. From 09/03/21 thru 09/15/21 except for 09/11/21, R73's flowchart for turning and repositioning indicated that R73 was turned and repositioned at the same time 53 out of 164 total entries. According to RR on 09/17/21 at 11:30 AM, Nursing note for 08/05/21 at 10:30 AM stated, .PCP [primary care physician] notified and new orders obtained for transfer to green zone and lt. [left] great toe tx. L/M [leave message] with podiatrist office for podiatry consult .Resident transferred via her bed to Y4 [Young 4] at 1030. On 08/05/21, clinical physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Measuring 1.2 cm (centimeter) x 1.8cm. Cleanse with normal saline, pat dry, and apply skin prep daily. Clinical physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet via GT two times a day for left great toe infection until 09/13/21. Weekly skin assessment note on 09/13/21 states Left first toe Unstageable. Area 1.0 cm x 1.4 cm with 50% dry dark scab and 50% dry white tissue. Toe swelling and redness decreased. Tx. [treatment] Cleanse left great toe unstageable wound with NS [normal saline], pat dry, apply sorbact dressing and cover with dry dressing daily. Improving. In a RR done on 09/17/21 at 12:00 PM, the facility's Policies and Procedures for Skin Care and Pressure Injury Prevention effective 11/08/17, stated that in Section D. Protection from Friction, Shear and Pressure, #11. For residents who are unable to turn or shift their weight, reposition every 2 to 3 hours.

Based on interviews and record review, the facility failed to ensure the resident's right to be free from neglect and abuse for one resident, R335, sampled. Staff did not accurately assess the extent of R335's hearing impairment upon admission and was administered a rectal suppository without being fully aware and/or informed of the route of administration, reason for administration, or alternative choices prior to administration. After the rectal suppository was administered, R335 called FM crying and reported an allegation of sexual abuse. FM contacted the facility and reported the allegation to the NS4. NS4 spoke to the resident who was upset and crying, and the resident's blood pressure became elevated which required a medication intervention. RN10 worked the rest of the shift and continued to provide care for R335, despite FM reporting the allegation of sexual abuse to NS4. Although the facility's investigation did not substantiate the allegation of sexual abuse, the facility did not identify staff administering the medication without consent of the resident as a form abuse; or R335's verbal reports feeling scared, sad, and violated to various staff as psychosocial harm; and direct care staff neglected to provide appropriate trauma-informed services (until the resident could be seen by a psychiatrist) to aid in the resident's overall well-being at the conclusion of the State Agency's investigation. Findings include: R335 is a [AGE] year-old resident who was admitted to the facility on [DATE], for rehabilitation, after falling at home and fracturing his/her pelvis. At the time of the survey, the MDS assessment was in progress and a baseline care plan was implemented. Review of the facility's interoffice communication documented R335 is very hard of hearing but coherent. Through interviews with FM (on 09/20/21 at 4:25 PM), R335 (09/14/21 at 09:29 AM), and anonymous staff, confirm R335 has significant hearing impairment, has no cognitive impairment and is capable of making appropriate decisions related to the resident's care and preferences. Review of R335's MR on 09/15/21 at 11:59 AM and the facility's investigation documented the following timeline for events on 09/07/21: At 2:30 PM: R335's Nursing Assessment documented R335 arrived at the facility at 2:30 PM. Upon admission, R335's blood pressure (BP) was 128/65, System Assessment of Communication/Sensory documented; No problems, difficulty with: hearing, slightly impaired (RN10 wrote in slightly impaired). At 4:19 PM: RN10 administered [MEDICATION(S)] (medication to treat constipation) Suppository 10 mg, rectally. At 6:06 PM: RN22 spoke with FM regarding R335's medications. At 6:36 PM: Interoffice communication documented; R335 spoke to FM. Crying, R335 reported to FM, he/she had been left unattended, outside by an elevator and feeling violated when the nurse administered the rectal suppository. FM contacted the Nursing Supervisor (NS)4 and reported the incident. A conversation was held over speaker phone with FM, NS4, and RN10 during which RN10 chuckled while FM queried the staff of the incident. FM became upset due to RN10 laughing. NS4 informed FM he/she would check on R335. NS4 documented he/she knocked on the door, but R335 seemed to not hear the knock and proceeded to gently tap the resident on the right upper arm and R335's eyes immediately opened. R335 did not understand NS4 when the staff verbally introduced themselves to the resident. NS4 exited the room and got a sharpie and paper to communicate with R335. NS4 wrote to the resident and introduced himself/herself and inquired how the resident was feeling and if the resident needed assistance with dinner. R335 stated, I can't eat, I feel so bad and sad. She (RN10) put her finger in my ass (made a swirling motion with her left finger), in my vagina too. NS4 apologized and explained to R335 that she needed the suppository to have a bowel movement (BM) and it's been 4 days since the resident had a BM. R335 got tearful, asked if FM was going to pick the resident up, and reported having a headache. FM was on the phone during NS4 interaction with R335. NS4 told FM the conversation was going to end and would be tending to R335. FM replied that staff should check the resident's blood pressure due to high blood pressure which was the result of RN10 administering the rectal suppository and the resident could have a stroke. At 7:30 PM: R335's BP was 178/122, all other vital signs were stable. NS4 instructed RN10 to call the physician. The resident denied chest pains and shortness of breath but had expiratory wheezing while saying I just feel so bad, holding his/her chest with facial grimacing. At 8:29 PM: The MAR documented R335 received 1 inch of Nitro-Bid Ointment 2% ([MEDICATION(S)]) transdermal (topical, medication is absorbed through the skin) for BP greater than 170 for elevated blood pressure. Staff documented R335's BP was 180/98. At 11:01 PM: RN10 documented in a progress note a summarized the resident received [MEDICATION(S)] (medication to treat constipation) suppository (endorsed by the day shift) with good results. Review of R335's progress notes (on 09/07/2; 09/08/21 at 2:41 PM; at 11:01 PM; 09/08/21 at 10:45 PM; 09/15/21 at 8:47 PM) documented R335 refused care during HS (night) round and at last round (on the date of the allegation), the resident verbalizing feeling scared, wanting to go home, wanting the lights to remain on due to feeling afraid, and inability to sleep due to feeling scared. Reviewed R335's care plan (CP). After the event, R335's CP was updated to include communication with appropriate interventions. The resident's needs and preferences related to the route medications would be administered or any form of trauma informed care for direct care staff was developed or implemented despite the resident's verbalizing feelings of being scared and afraid, violated, wanting the light to stay on, requesting to go home, or the resident's psychosocial well-being in relation to the event. On 09/17/21 at 3:00 PM, conducted a review of the facility's investigation. Review of interoffice communication, an interview SW1 confirmed the facility did not immediately identify and treat R335's allegation of sexual abuse per the facility's policy and procedure and immediately notify the Administrator/Designee of the allegation or report the allegation to the State Agency as required by federal and state laws. Review of the facility's investigation documented the facility did not conduct a review of R335's medical chart, ask the resident the same questions as the staff, or establish the resident's baseline cognition as part of the investigation. R335's MAR and factor in R335 had two scheduled medications ([MEDICATION(S)] Sodium capsule and [MEDICATION(S)] Powder) at 5:00 PM for constipation. The investigation did not identify staff did not accurately assess R335's hearing impairment accurately on the Nursing Admission Assessment form (completed upon admission). The facility did not conduct a psychosocial assessment of R335 post event in order to provide appropriate trauma informed care and ensure R335's over-all mental well-being. Despite the facility not substantiating R335's allegation of sexual abuse, review of interoffice communication documented the facility was aware R335 is very hard of hearing and did not understand what RN10 was telling the resident. The facility acknowledged if R335 still feels that the resident is being violated the facility should send a report to the State Agency before FM files a formal complaint to the State Agency. The facility proposed to write a good intervention of counseling RN10, review abuse prevention protocols, and resident's rights. The facility acknowledged R335 is very hard of hearing, but coherent, which posed a problem for the facility in handling the situation and R335's FM. The facility also confirmed RN10 did not confirm if the resident heard or understood RN10 before the suppository was administered which is a violation of the resident's rights and is a form of mental and physical abuse. (Refer to F552 Right To Be Informed/Make Treatment Decisions, F585 Grievances, F600 Free from Neglect, F609 Reporting Alleged Violations, F610 Failure to Prevent Further Abuse, F641 Accuracy of Assessment)

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be informed of and participate in his/her care in a manner the resident can understand for one (1) resident, (R)335, sampled. Staff did not use auxiliary aids or written communication to inform R335, who has impaired hearing, that a medication would be administered rectally and was not informed of options and/or alternatives prior to staff administering the medication. As a result of not understanding medications would be administered rectally, R335 reported an allegation of sexual abuse to a family member (FM). As a result of this deficiency, R335's blood pressure elevated and required intervention, the resident has experienced feelings of being physically violated, fear of the staff member, difficulty sleeping at night, and sadness indicating psychosocial harm. Findings include: R335 is a [AGE] year-old resident who was admitted to the facility on [DATE], for rehabilitation, after falling at home and fracturing his/her pelvis. At the time of the survey, the Minimum Data Set (MDS) assessment was in progress and a baseline care plan was documented. On 09/14/21 at 09:29 AM, this surveyor knocked on R335's room door then proceeded to enter the room. R335 was lying in bed, resting, and the resident's eyes were closed. Surveyor stood approximately 2 feet from the resident's bed and called the resident by name. The resident's eyes did not open and remained resting. On 09/14/21 at 12:05 PM, surveyor knocked on the resident's door and announced her presence, however, the resident did not open his/her eyes and remained resting. On 09/15/21 at 10:50 AM, this surveyor proceeded to enter the resident's room again in the same manner (knocking and announcing her presence). As surveyor entered the room, the Nurse Manager (NM)9 stated the resident cannot hear and directed surveyor to the erasable whiteboard and/or an amplifier, located in the room, to communicate with R335. R335 had just had an interview with the Ombudsman and appeared to have been crying. This surveyor sat at the resident's bedside (approximately 1 foot from the bedside) and verbally introduced herself. R335 stated What?! I cannot hear you. I cannot tell what you're saying, you have to use the whiteboard and write it down cause I have bad hearing. Inquired with R335 (using the whiteboard to write questions and the resident verbally replied) regarding the allegation of sexual abuse reported by the resident's FM. R335 stated on the day the resident was admitted , the nurse put something up the resident's ass and in the resident's vagina. They (the facility staff) said that the nurse said she told me and showed me the medicine, but she didn't. If they asked me, I would have told them NO! I don't want anything up my ass. It feels like they raped me. I feel so violated. R335 confirmed the Registered Nurse (RN)10 worked the remainder of the shift and provided care to the resident after the Nursing Supervisor (NS)4 became aware of the allegation of sexual abuse. R335 stated that she felt afraid all night and could not sleep. The resident reported to this surveyor feelings of being scared (especially at night), difficulty sleeping, sadness, scared, and fearful due to RN10 administering the rectal suppository without the resident understanding the route of administration. Throughout the interview with this surveyor, R335 was alert and oriented to person, place, time, and situation. The resident responded to questions in a coherent and manner, appropriately. R335 cried periodically throughout the interview and reported feeling emotionally upset and traumatized regarding the incident. This surveyor offered to stop the interview due to the emotional response by R335, but the resident declined and stated she did not want this to happen to anyone else. During an interview with RN10 on 09/17/21 at 3:21 PM, RN10 confirmed staff only verbally communicated with R335 and did not use any auxiliary devices or other means of communication to ensure the resident understood what staff was saying and reported working the entirety of the shift after R335 reported the allegation of sexual abuse to the Nursing Supervisor (NS) 4. RN10 stated the resident had just been admitted around the change or shift. The day shift nurses endorsed during transfer communication with the nurses from the transferring facility, they were informed that the resident had not had a bowel movement and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN10 confirmed R335 did have pain but declined pain medication stating it made the resident feel sick. RN10 stated after the medication was administered, the resident asked to call FM and was assisted in making the call. RN10 reported he/she became aware of the allegation when FM later spoke with NS4 on the unit. Conducted a record review of R335's medical record (MR) on 09/15/21 at 11:59 AM. Review of an acute facility's Hospitalist Discharge Summary, date of service on 09/07/21 at 10:50 AM, the physical exam on discharge documented R335's abdomen was soft, nontender, non-distended, with normal bowel sound. Review of R335's MR and facility investigation documented the following timeline of the sequence of events on 09/07/21: At 2:30 PM: R335's Nursing Assessment documented R335 arrived to the facility at 2:30 PM. Upon admission, R335's blood pressure (BP) was 128/65, System Assessment of Communication/Sensory documented; No problems, difficulty with: hearing, slightly impaired (RN10 wrote in slightly impaired). At 4:19 PM: RN10 administered [MEDICATION(S)] (medication to treat constipation) Suppository 10 mg, rectally. At 6:06 PM: RN22 spoke with FM regarding R335's medications. At 6:36 PM: An interoffice email documented; R335 spoke to FM. Crying, R335 reported to FM, he/she had been left unattended, outside by an elevator and feeling violated when the nurse administered the rectal suppository. FM contacted the Nursing Supervisor (NS)4 and reported the incident. A conversation was held over speaker phone with FM, NS4, and RN10 during which RN10 chuckled while FM queried the staff of the incident. FM became upset due to RN10 laughing. NS4 informed FM he/she would check on R335. NS4 documented he/she knocked on the door, but R335 seemed to not hear the knock and proceeded to gently tap the resident on the right upper arm and R335's eyes immediately opened. R335 did not understand NS4 when the staff verbally introduced themselves to the resident. NS4 exited the room and got a sharpie and paper to communicate with R335. NS4 wrote to the resident and introduced himself/herself and inquired how the resident was feeling and if the resident needed assistance with dinner. R335 stated, I can't eat, I feel so bad and sad. She (RN10) put her finger in my ass (made a swirling motion with her left finger), in my vagina too. NS4 apologized and explained to R335 that she needed the suppository to have a bowel movement (BM) and it's been 4 days since the resident had a BM. R335 got tearful, asked if FM was going to pick the resident up, and reported having a headache. FM was on the phone during NS4 interaction with R335. NS4 told FM the conversation was going to end and would be tending to R335. FM replied that staff should check the resident's blood pressure due to high blood pressure which was the result of RN10 administering the rectal suppository and the resident could have a stroke. At 7:30 PM: R335's BP was 178/122, all other vital signs were stable. NS4 instructed RN10 to call the physician. The resident denied chest pains and shortness of breath but had expiratory wheezing while saying I just feel so bad, holding his/her chest with facial grimacing. At 8:29 PM: The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff documented R335's BP was 180/98. At 11:01 PM: RN10 documented in a progress note a summarized the resident received [MEDICATION(S)] (medication to treat constipation) suppository (endorsed by the day shift) with good results. On the morning of 09/17/21, conducted an interview with anonymous staff. Staff confirmed R335 is alert and oriented to person, place, and time and is reliable. Staff reported R335 was deeply affected by the incident with the suppository as evidenced by the resident reported being scared especially at night, R335 appears to be depressed, observed the resident crying. Additionally, staff verbalized this incident negatively impacted the resident's emotional and psychological well-being. On 09/17/21 at 3:00 PM, conducted a review of the facility's investigation. Review of interoffice communication confirmed R335 has impaired hearing, was coherent and able to make a choice, and RN10 did not confirm R335 heard or understand staff was going to administer a rectal suppository which was a violation of the resident's rights. (Refer to F585 Grievances, F600 Free from Neglect, F609 Reporting Alleged Violations, F610 Failure to Prevent Further Abuse, F641 Accuracy of Assessment)

Based on observations, interviews and medical record reviews, the facility failed to ensure that there were sufficient qualified nursing staff available to meet each resident's needs for nursing care in a manner and in an environment which promotes each resident's highest practicable physical, mental and psychosocial well-being for enhancing their quality of life. Findings include: 1. There is non-compliance with this regulation based on the cumulative deficient findings/outcomes in the various regulatory groupings which include Resident Assessment, Resident Behavior and Facility Practice, Quality of Care, Quality of Life, Nursing Services, etc. The cumulative findings are cross-referenced at their cited regulatory tags at F164, F225, F226, F241, F242, F257, F272, F278, F279, F280, F282, F309, F314, F315, F318, F323, F328, F329 and F514. 2. Additional findings include: On 08/14/2017 at 12:09 PM, an initial dining observation on the Young 4 unit was done. Staff #40 said several of the residents sitting in the solarium needs assistance with eating. At 12:25 PM, Res #12 had his food tray placed in front of him, but it was not until 12:39 PM that Staff #137 starting taking the food off his tray onto a placement. Then she sat next to Res #12 to feed him. In addition, when Staff #59 was asked about the number of residents who required closer supervision, cueing and/or feeding assistance on this unit, she stated she had the most. The list she provided included 14 total residents for feeding assistance. Staff #59 acknowledged there should be staff in the solarium to supervise the residents, when there was none. Staff #59 then queried the surveyor and asked, How do the other facilities do it? It was found the residents in the solarium were left unattended with many of them requiring feeding assistance by staff who were not available to help. For Res #118's in-room dining, it was found that by 1:05:57 PM, her meal tray had been left in her room from the time the meal cart had arrived onto the unit. The resident still had not been fed. The three CNAs available during lunch were busy assisting the other residents to eat in the solarium. At 1:09:08 PM, CNA #137 said, I'm going to feed her now and went into Res #118's room. Thus, it took one hour before this resident was assisted to eat. It was also later found during an environmental rounds tour that this resident's room temperature was hot and close to 90 degrees Fahrenheit. Cross reference to findings at F257. Her meal tray had been sitting in the hot, unventilated room for one hour. 3. Then on 08/15/2017 at 8:28 AM, there were five residents in the solarium but with no staff present. One of the residents began dumping out her thickened juice onto the table with a spoon. Staff #59 observed this when the surveyor asked her to do a concurrent observation. Staff #59 reiterated they have a lot of residents who require feeding assistance. She said although they had their maximum number of CNAs (five), she acknowledged for one other resident (Res #93), her meal was hardly touched. Staff #59 said this resident needs a lot of encouragement as she will not just sit down and eat. Again, there was no staff in the solarium to assist this resident to eat, while the other resident was dumping out her thickened liquid onto the table. There was not enough staff to consistently assist these residents as part of their overall dining experience. 4. On 8/15/2017 during a Stage 1 family interview, the family member for Res #116 stated in response to the staffing and notification of change questions, that this facility did not have enough staff. He/she stated Res #116's fall was because the staff was not there to answer (resident's) call light and she ended up being hospitalized with a wrist, collarbone and rib fractures. The family member stated Res #116 told the family she called to get up to go to the bathroom, but no one responded. The family member said for the bed alarm, We could be there and pretty much standing her up, but no one would come. So why have a bed alarm when no one comes? So this one night she called, no one came so she tried to get out of bed on her own to go to bathroom and she fell . So that night we got a call that (resident) fell and they said they're going to monitor her. No, she suffered through the night with all these broken bones and after all of that, (another family member) goes over the next day and she's in all this pain and they downplayed it but said that she may have fractured something but it's up to you folks if you want to call 911 and take her to the hospital because we're not. The family member also expressed that because of what had transpired, and the way things were communicated to them, another family member has been vigilant about visiting the resident almost daily and believed this has helped to keep staff more aware of the resident's needs. 5. On 08/16/2017 at 1:58 PM, a telephone interview of Staff #141 was done concerning the care she provided for Res #116 on the evening of 11/16/17. During her interview, she stated in response to what the staffing was that evening, Uh, I cannot recall, but just to tell you the truth, most of the time we are short of CNAs, but the CNA really assigned to this patient was on break. So the other CNA (Staff #99) was the reliever because 1 person will go break and the other CNA is the reliever. Four CNAs split two and two each side, but only one licensed. I'm the only RN for 38 residents. This is on Young 5 at the time. And despite the fact she stated in her interview that she continued to check the resident's neurological status and her pain, these were quality of care areas which were found not have been done due to the lack of clinical documentation. Additionally, Staff #141 acknowledged that being short of staff, Yeah I think it's a factor too, because we cannot help it, we have to help the resident from falling. I need to drop what I'm doing to help the patient who is falling. One person falls down, it will hold me up so I'm trying my best to help the aides--especially the restless patients. We understand staffing get enough, but we have sick calls, so that's how ended up being short. 6. For the fall incidents related to Res #116, #38 and #114, the facility failed to ensure they reviewed the staffing patterns and failed to complete thorough root cause analyses of their falls, albeit the residents sustaining serious physical injuries.

Based on observation, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 3 of 32 residents (Res #116, #38 and #114). Findings include: 1) Res #116 was admitted to the facility on [DATE]. Res #116 was found to have sustained multiple fractures from an unwitnessed fall on 11/14/16 at 7:30 PM. As a result of this fall, she sustained six right rib fractures, a comminuted fracture of the right midclavicle, and a right radius fracture. The facility submitted their completed event report to the State Agency (SA) on 11/15/16. Cross-reference to findings at F225. Res #116's clinical record found her Minimum Data Set (MDS) admission assessment showed her BIMS score at 12. The resident also signed her own Advanced Health Care Directive and other admission forms including the 10/27/16 Conditions of Admission for Leahi Hospital. After admission, a 11/4/16 SBAR report by Staff #59 to the resident's attending physician noted this resident used to attend their adult day health center and was ambulatory with a walker with supervision. The recommendation at that time was to add maintenance physical therapy as nursing noted a decline in her ADL function and believed she could benefit from maintenance therapy. The 11/4/16 IDT conference notes also stated, Can ambulate with walker with supervision. Has brace on right hand due to previous fracture. Her fall assessment on admission found prior to admission she had a right wrist hairline fracture, with a Fall risk score of 8, triggering an initiation of the fall protocol level 2 Falling Star program. She initially came in for long term care placement with no skilled therapies at the time. However, per interview with Staff #59, the maintenance therapy did not occur for this resident before the resident fell on the evening of 11/14/16. The resident's fall was investigated by the SA during this survey. It revealed that a thorough investigation had not been conducted for this resident who sustained multiple fracture injuries on 11/14/16. The staff interviews revealed discrepancies in the details of the resident's fall and differed from what was submitted on the facility's final ERF to the SA. There also was no documentation of the investigation which was verified by both the DON and Staff #59 during their interviews. In addition, the licensed staff who attended to Res #116 after the fall, failed to initiate post-fall monitoring checks, which included vital signs, pain scoring, neurological or neuro checks and blood pressure checks as there was no Nursing Observation Flowsheet found. Thus, Staff #141 who found the resident post-fall, failed to ensure Res #116 received the necessary clinical care, treatment and services to ensure she was being monitored for changes in her condition which should have started with checking the resident every 15 minutes for the first hour, and if stable, progress to 30 minutes x 2, and if stable then, every hour x 2 and so forth. The lack of this documentation was verified by the DON and Staff #59. Staff #141 also failed to document her physical assessment of the resident and her assessment of the resident's pain levels throughout her shift. She also failed to document the actual fall and status of the resident in her progress note. In addition the fall risk assessment to be done post-fall was not dated. Yet, Staff #141 scored the resident with a fall risk of 7, which was an improvement in her fall risk score from her admission score of 8. On admission the resident was known to be able to ambulate with an assistive device with supervision reflected in her 10/31/16 assessment. However, the second undated entry by Staff #141 showed a zero for assistive device use to ambulate and/or transfer. The RCA done post-fall by Staff #59 also failed to identify nor address any of this. By Staff #59's admission that she did not conduct a thorough investigation nor conduct a thorough RCA, it further demonstrates failure by the facility to ensure Res #116 was provided with adequate supervision and monitoring when she was known to be a Falling Star fall risk since her admission. In addition, post-fall, there was no review of antecedent factors, such as whether the resident had access to her front wheel walker at bedside, whether there was a bedside commode and whether her call light or bed alarm were adequately functioning. This is where no query was done by Staff #59 as part of her RCA. In fact, the DON stated, this is not a RCA when she reviewed it. 2. Res #38 sustained a fall in the facility on 2/24/17 resulting in a right hip fracture. On 08/21/2017 at 9:20 AM, the DON said her review of the record found the resident was sent to ED. The resident was admitted to the hospital for a right proximal intertrochanteric femur fracture with right proximal cephalomedullary nail fixation done secondary to the fall. The resident was readmitted to the facility on [DATE], but yet again sustained another fall on 3/27/17. This second fall was an unattended fall from her wheelchair while she tried to wheel herself back to her bed. Then on 4/1/17 the resident was transferred to the hospital again for swelling to her right thigh with pain. Her CT results showed she had a minor avulsion fracture, non-operative and was most likely due to her 3/27/17 fall. A doppler with ultrasound also showed deep vein thrombosis (DVT) with a psuedoaneurysm at the femoral artery and the resident was sent out to the hospital again on 4/12/17. She was again readmitted to the facility on [DATE]. During an interview with Staff #59 with the DON present, she stated at first this resident was ambulatory, and after the first fall, although she received limited skilled rehabilitation therapy, she had a second fall. After the second fall, she developed leg swelling (hematoma), a DVT and was sent to the hospital again. Yet, the RCA done on 3/29/17 stated the recommended actions/solutions with measurable outcomes/indicators to be: close supervision, frequent visual. The DON and Staff #5 were asked if a thorough investigation and RCA was done for this resident's two significant falls, and the DON replied, we are now putting the interviews into the root cause analysis. That's why it's only root cause. Staff #59 stated the process had changed but was unaware of the date it happened. The DON stated, It's not completed. No sufficient documentation on the RCA with the second fall . The DON said even the RCA for the first fall, same thing, it should be a team approach but it was not done. On 08/21/2017 at 10:40 AM, the DON stated, We didn't do enough with the first fall, then the second fall .then a decline in her adl function. Oh my god. The facility failed to ensure the residents received adequate supervision, care and assistive devices to have prevented an accident and is evidenced by a lack of clinical documentation and a failure to conduct a thorough investigation to further ensure there was no neglect for Res #116 and Res #38's who both suffered significant fall related injuries. On 08/15/2017 at 9:54 PM the facility faxed an incident report to the State agency for R#114's fall on 12/31/2016 that resulted in an injury. The resident sustained [REDACTED]. This was the 4th fall occurence for R#114 since admittance to the facility in September 2016. The facility completed a fall assessment after each fall. Fall assessments done on the dates of 12/31/17, 03/05/17 and 07/01/17, did not include the resident's restlesness which would have increased the fall risk assessment scores by a point and corresponding fall risk assessment scores should have been 10, 11, and12. On 08/16/2017 at 3:30 PM met Staff#116 and showed her R#114's care plan (CP) which had written interventions Seat belt alarm when in W/C, Bed alarm when in bed and Bilateral fall mats. Staff#116 stated that the interventions were written by her and recognized the hand writing as her own. The staff member could not remember when she wrote it in R#114's CP as there was no start date for these interventions on the CP. Staff#116 also stated that the facility used a CP template and the intervention, Staff to follow procedures as specified in Leahi policy for Physical restraints #110-3-14, with a start date of 09-12-16, was not removed although R#114 was never put into restraints. Validated with Staff#116, interdiciplinary progress notes that specified that R#114 should be monitored for a minimum of 72 hours per facility policy after a fall. There should have been 9 consecutive nursing progress notes by shift each time the resident fell but this was done only once out of the 6 times that the resident fell . Queried Staff#116 about the missing nursing progress notes and she stated, I don't know why. When queried if there is any oversight to nurses documentation and Staff#116 didn't provide oversight for nurses documentation in the medical records.

Based on observations, medical record reviews (MRR) and staff interviews the facility failed to ensure that 3 of 32 residents (R#38, R#116, R#46), obtained optimal improvement and/or did not deteriorate within the limits of their recognized pathology and the normal aging process, and, each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in the Stage 2 sample. Findings include: 1. On 08/15/2017 at 2:39 PM, Res #38 was observed in bed with her lower legs uncovered. It was found her right lower shin area had a dressing applied to it and her left shin area had a large bruise-like area to it. The resident is non-interviewable. On 08/17/2017 at 12:53 PM, record review found Res #38 was readmitted to the facility on [DATE] after a hospital stay post-fall. Her initial skilled nursing admission record however, found she was originally admitted on [DATE]. In the 2013 clinical record, there was documentation showing resident's BLE (bilateral lower extremities) with small faded bruises was assessed, but without baseline measurements. During an interview with Staff #59 and Staff #72 on 08/17/2017 at 1:21 PM, Staff #72 said the resident does not have bruises, but that it was her usual skin discoloration. She stated, has been that way ever since she was here--years. She was on aspirin before but not anymore ever since she developed a hematoma. Always had the discoloration, but it's her skin that's discolored, but no swelling or anything .She was with us, went to another floor, and then came back to us. Her shins have been like that for awhile. Both staff were queried with the resident's readmission, if a baseline measurement of the bruising or discoloration which their nurses have been documenting since 2016 in the progress notes was ever done. They reviewed the 2013 skin assessment note that showed the same leg areas with only small faded bruises. Staff #59's reply was, When she came back, we knew she already had that, but it should be somewhere in the older record. Staff #72 said, Myself, I never measured it, but has always been her whole shin area, right down here. Both staff were further queried if a readmission baseline skin assessment was not done, how could nurses, therapists, etc. determine whether Res #38's skin condition was improving or worsening, and/or what changes were actually being monitored for. Staff #72 said as nurses they see the resident every day so they can tell if it's an old discoloration versus a new bruise. When surveyor again asked if this monitoring is being done, when did the resident's bilateral lower extremity skin condition change from being small faded bruises to a larger discoloration. Finally Staff #59 was asked, Where's your baseline measurement for this discoloration? There is none? Staff #59 nodded affirmatively that there was none. On 08/17/2017 at 1:21 PM, per Staff #59, she said resident's skin discoloration has been that way ever since she was here--years. She was on aspirin before but not anymore ever since she developed a hematoma. Always had discoloration, but it's her skin that's discolored, but no swelling or anything. She was with us, went to another floor, and then came back to us. Her shins have been like that for awhile. On 08/17/2017 at 1:39 at PM, the DON said Res #38's weekly skin assessment shows bilateral old bruises, but no baseline documentation for it. On 08/17/2017 at 3:00 PM, during the infection control task meeting, Staff #115 and another licensed staff stated for wounds, skin conditions, etc., for Res #38 bilateral lower extremities, the nursing staff should have baseline measurements. They concurred it was basic nursing practice to do so. On 08/21/2017 at 7:59 AM, the DON told Staff #59 she wanted Res #38's legs to be covered with leg protectors and whether there were issues with positioning of the resident. Staff #59 said the attending physician did not know about the lower leg extremity and although nursing has been monitoring it all this time, Staff #59 said the attending physician has never documented on it. The DON asked, what's causing all this? If (attending physician) could only write and do a consult. So all this time . The DON expressed, I want them to further look at the area, the condition of the affected area. So protection of skin to prevent from breakdown. Go beyond the assessment, yeah. Then of course we want to know the cause of this. On 08/21/2017 at 9:00 AM, surveyor asked the DON to clarify the 8/17/17 measurements obtained by her nursing staff. It had stated, Left leg shin area with discolored measured: Length 29 cm and width 9 cm. Photo taken per . The DON said this skin assessment was not acceptable. The DON and two other licensed staff went to re-do the skin assessment to obtain what would be the initial baseline measurements. The DON provided this revised 8/21/17 skin assessment which stated, Resident with brownish discoloration to Lt leg shin measuring 24.0 cm x 9.0 cm with small dark bluish discoloration (dime-sized) approx 1.0 cm x 0.75 cm within the brownish discolored area on upper lateral lt. shin and another reddish discoloration approx. 3.0 cm x 1.0 cm within the brownish discolored area on lower lt. shin. No swelling or [DIAGNOSES REDACTED]; resident denies pain or discomfort. The DON acknowledged the size of it was pretty large. It was pointed out the 2/28/17 photographs of resident's left lower extremity showed what appeared to be macerated skin with open areas. Yet, there were no measurements and the photographs were pictured on a totally blank wound care measurement and assessment form. In addition, surveyor pointed out the original 7/25/2013 documentation noting the resident was admitted with bilateral lower extremities small faded bruises was not what was assessed to be her current status as evidenced by the wound measurements obtained on 8/21/17. Thus the facility failed to ensure Res #38's skin condition had noticeable optimal improvement as there was no concise assessment starting with basic measurements of its size to know what, if any, were related to recognized pathology and the normal aging process versus an injury or unknown origin. 2) Res #116 sustained multiple fractures after she fell on [DATE]. On 08/21/2017 at 8:47 AM, the DON and Staff #59 verified the neurocheck flowsheet was not done by Staff #101 and she also failed to initiate a pain monitoring flowsheet and complete her documentation on the MAR for the Tylenol she gave to the resident at 8:50 PM on 11/14/16. Cross-reference to findings at F225, F323 for Res #116. 3. On 08/15/2017 2:17:02 PM, the MRR on R#46 found that the resident was admitted to the facility on [DATE] for respite care with approved form 1147 (authorization request) for 29 days ( 04/17/17 to 05/15/2017). The level of care (L(NAME)) evaluation form(DHS 1147) notes that R#46 primary [DIAGNOSES REDACTED]. The resident was assessed and determined to have complete absence of speech, unable to communicate wants/needs; disoriented (partially or intermittently)required supervision; tube fed; did not assist in transfer or is bedfast; unable to walk; incontinent; cannot bathe without asst; requires total help in dressing, undressing , and grooming. The required skilled procedures for R#46 were: non-ventilator dependent tracheotomy care/suctioning 6 times/day; tracheotomy care; and, therapeutic diet of [MEDICATION NAME] 1.2 kcal, 1 can 5 x/day. The skilled procedures for decubitus ulcers (Stage III and above) and decubitus ulcers (less than Stage III); wound care was marked N ( not applicable /Never). The adult residential care home (ARCH) from where R#46 was transferred from, also faxed over the resident's individualized service plan (ISP), that included, Impaired skin integrity risk, follow skin breakdown prevention protocol ( position, change, keep clean & dry), proper nutrition. On 08/16/2017 at 7:09 AM continued MRR on R#46 and on the long term care facility transfer form dated 04/17/17, documentation included: no pressure ulcers; medications reviewed and renewed on 02/21/17; .[MEDICATION NAME] ointment apply to buttock area with each diaper change PRN for skin breakdown. The facility's interdisciplinary admission care plan (CP) dated 4/17/17, for CP#4 Potential for Skin Breakdown/Skin Breakdown, included interventions of: Encourage resident to turn every 2 hours or assist resident to to turn every 2 hours; Assess resident's skin every week and document findings; Report skin breakdown to Skin Care Nurse for consult . The facility's interdisciplinary progress notes dated: 4/23/17, #4 At risk for skin breakdown, documented that R#46 had a small cut on left side of lip. 4/27/17, #4 at risk for skin break down (buttocks), the progress notes documented that the resident had 3 open areas on his/her buttock measuring 2 x 1 cm and 1 x 1.5 cm to L buttock; and, 2 x 2.5 cm. [MEDICATION NAME] was applied to the area and resident was turned side to side as much as possible. 05/03/17 the wound care nurse documented that buttock/coccyx breakdown noted 04/27/17; contacted me 05/03/17. The facility's CP dated 4/27/17, problem #4 (SKIN) At risk for pressure ulcers due to limited bed mobility (including inability to reposition self and body parts) and exposure to excessive moisture from fecal incontinence; with measurable goals, Intact skin on buttocks and perineum without evidence of redness, irritation, or maceration; goal date 05/29/17. On 08/16/2017 at 8:18 AM interviewed Staff#70 and queried why staff waited 6 days before informing the wound care nurse. The DON stated that the wound care nurse was monitoring R#46's pressure ulcers and that by the resident's discharge date the wounds were healed. On 08/16/2017 at 10:36 AM a telephone interview of R#46's home caregiver (CG) was done. The CG stated that the resident was placed at the facility for respite care and at the time of discharge back to her care home, facility staff apologized that the resident had skin breakdown at the facility. The CG stated that the resident has been in her care home for 7 years and never had pressure ulcer or skin breakdown. The CG related that resident is incontinent of bowel/bladder and is changed right away when brief is wet to prevent skin breakdown. CG also stated that DOH comes to inspect her care home and in care home records this resident never had pressure ulcer under her care. On 08/17/2017 at 9:13 AM interviewed Staff#98 to discuss R#46's skin breakdown while in the facility. According to Staff#98, the resident's pressure ulcers (PU) were not staged because buttock area has no bone so not considered PU. Staff#98 further stated that R#46 was admitted to facility with [MEDICATION NAME] ointment and discoloration on resident's buttocks shows that resident had skin breakdown before. Staff#98 diagnosed skin breakdown as incontinence associated [MEDICAL CONDITION] and not PU. The nursing staff were instructed on how to treat incontinence associated [MEDICAL CONDITION] (IAD) and may be reason why staff reported skin breakdown to her on 05/03/17 and not on 04/27/17 when discovered. Staff#98 last saw R#46 on 5/08/17 and determined then, that within several days skin breakdown would be healed. The wound care measurement and assessment forms dated: 4/27/17 included a picture of reddened areas on the residents buttocks, with no exudates and normal wound edges; 5/3/17 included a picture of the L buttock and coccyx, with wound type described as single thickness wound, no exudates, normal wound bed, surrounding skin color, and wound edges. The measurements written at the bottom were, #1 L butt - 3.0 x 2.0; #2 coccyx 1.0 x 1.0; 5/8/17 included a picture of the L butt, single thickness 3.5 x 2.0 cm, no exudates, wound bed [MEDICATION NAME] tissue, normal surrounding skin color and wound edges. Written at the bottom of the sheet, coccyx healed. On 08/21/2017 at 2:49 PM the MRR on R#46 found on the Leahi Hospital SBAR REPORT dated 5/3/17; To: R. Gries; From: Y3 Leahi Hospital; Situation/Assessment (SBAR); Resident's buttocks with skin breakdown (excoriation) TX done per Leahi protocol; [MEDICATION NAME] ointment TID & PRN; Background: DX: [MEDICAL CONDITION]; Assessment/Recommendations: Pls assess & any recommendations. The May 17 Physician order [REDACTED]. The admission orders [REDACTED]. The Daily system Assessment Performed (sheets) documented on these dates and times day(D), evening (E), and night (N): 4/17-24/17 skin intact, warm and dry 4/25/17 (D) L buttock denuded [MEDICATION NAME] apply; (E) L corn of lip scab 4/26/17 Buttocks excoriated on (D,E, N) 4/27/17 D) buttocks excoriated, calasime applies; E) [MEDICATION NAME] applied to buttock 4/29/17 Buttocks still excoriated/open areas 4/30/17 D) Buttocks still excoriated, continue to apply [MEDICATION NAME]; E) buttocks still excoriated [MEDICATION NAME] applied 5/1/17 D) buttock excoriated 5/2/17 D) buttock still moist, cont reposition Q 2 hr & apply [MEDICATION NAME]; N) Buttocks remain open The facility did not provide the necessary skin care and services consistently to maintain R#46's skin integrity to prevent IAD.

Based on observation, interviews and review of the facility's policy and procedure, the facility failed to ensure that all alleged violations involving potential abuse and neglect, including injuries of unknown origin are thoroughly investigated with evidence of it for 1 of 32 residents (Res #116) in the Stage 2 sample. Finding includes: 1) Res #116 was found to have sustained multiple fractures from an unwitnessed fall on 11/14/16 at 7:30 PM. As a result of this fall, she sustained six right rib fractures, a comminuted [MEDICAL CONDITION] midclavicle, and a right radius fracture. The facility submitted their completed event report form (ERF) to the State Agency (SA) on 11/15/16. On 8/15/17, a family interview was done as this resident remains in the facility and was in the Stage 1 sample. The family member stated in response to the staffing and notification of change questions that this facility did not have enough staff. He/she stated Res #116's fall was because the staff was not there to answer (resident's) call light and she ended up being hospitalized with a wrist, collarbone and rib fractures. The family member stated Res #116 told the family she called to get up to go to the bathroom, but no one responded. The family member said for the bed alarm, We could be there and pretty much standing her up, but no one would come. So why have a bed alarm when no one comes? So this one night she called, no one came so she tried to get out of bed on her own to go to bathroom and she fell . So that night we got a call that (resident) fell and they said they're going to monitor her. No, she suffered through the night with all these broken bones and after all of that, (another family member) goes over the next day and she's in all this pain and they downplayed it but said that she may have fractured something but it's up to you folks if you want to call 911 and take her to the hospital because we're not. The family member stated the resident was taken to a nearby hospital where she was admitted and then later returned back to this facility. The family member said only upon readmission to the facility was she moved closer to the nurse's station. The family member said, Here's a [AGE] year old woman that was saying she wants to die because of it--and I thought that was just really unnecessary that she had to go through all that. She also recalled being told the night of the fall from a staff who called that she did not need to come to the facility because they would be addressing resident's pain with Tylenol. The family member expressed because of what had transpired, and the way things were communicated to them, another family member has been vigilant about visiting the resident almost daily and believed this has helped to keep staff more aware of the resident's needs. On 08/15/2017, review of the ERF submitted by Staff #59 was done. Staff #59 was asked whether her completed investigation included documented interviews of staff who worked the night and morning of 11/14 and 11/15/16. On 08/16/2017 at 10:44 AM, per the DON, she said with Staff #59 standing next to her, There is no written investigation of the staff involved. Unfortunately she did not do a follow-up. Staff #59 was asked how then did she conclude on the ERF that no abuse/neglect was found given for a [AGE] year old resident with an unwitnessed fall and multiple fractures requiring hospitalization . Staff #59 said, It was whatever staff gave me information verbally. Yes, that's how I completed the report. She confirmed she had no documentation of witness statements. Review of the facility's policy and procedure, Prevention of Resident Abuse, Neglect, ., Policy No. LPAT0003, eff. 1/01/09, it stated, I. Purpose B. To report and conduct a thorough investigation of all incidents and provide appropriate corrective actions and preventive measures .III. G. NEGLECT means failure to provide goods and services necessary to avoid physical harm, mental aguish or mental illness .IV. Procedure B. Step 3. Assessment & Complaint Documentation 1. Staff shall complete an Event Report form to document the initial complaint and/or witnessed information, including a list of personnel on duty or pertinent witnesses .3. The Charge nurse will perform a physical assessment of the resident and document findings in the resident's medical record. 4. The DON or designee will gather further information and begin a confidential folder. 5. All documentation including preliminary reports to the State agencies will be routed to the Administrator. C. Investigation .3. a. Review the resident's medical record .b. Review the background information .c. Review records of work schedules and staff and resident assignments .e. Conduct and document all necessary interviews with staff, witnesses, resident .g. Submit a written report to the Administrator detailing findings and recommendations . The SA's on-site investigation of the resident's fall included the following: a) On 08/15/2017 at 2:39 PM, an interview with Res #116 was done in Japanese by the surveyor. The resident is an alert [AGE] year old resident who was able to reply back in Japanese. She said she used to be able to walk before but once she became bedridden, she has been unable to walk. She did not recall the fall in November 2016. She denied being in any pain at this time. She said one family member visits her every day and said she's uncertain what each day brings when she awakens. b) On 08/16/2017 at 1:58 PM, a telephone interview of Staff #141 was done. She completed the SBAR fall event report as she was the licensed nurse on the 11/14/16 evening shift when Res #116 fell at 7:30 PM. She stated while she passed medications that night she heard a loud noise and when she went to check on the resident with a CNA, they found Res #116 on the floor lying on her side. Staff #141 recalled the resident talking and she said she likes to use the bedside commode at that time and the commode to one side, but tipped over. She was on the ground by bedside. So we needed to assess her, get her up, back to bed, check vital signs, neuros, and I called the doctor and he told me to continue check neuros and I called family to let them know about the incident. I asked if she's in pain, and she said she was in pain, but sometimes she says no, but she was able to help us, able to move her extremities. Surveyor asked Staff #141 what did you do, range of motion? She replied, I checked her leg if able to bend it, extend it. What about the right side? Staff #141 replied, She's able to move her hand. Throughout the night? Staff #141 replied, Uh-huh. And I even check on her and able to grab my hand, squeeze my hand. She cannot really tell me 1-10, can speak simple English too. Staff #141 said, she's not frowning, no moaning, no crying, so I assuming she's comfortable because she didn't show any signs of pain. I am not sure if I gave--I can't remember too much because I'm a floater. Did you send her out? Staff #141 replied, I think not. Did anyone else interview you about this? Staff #141 replied, I think my head nurse actually asked me about the incident. I don't know what happened to (resident). I just heard from there that this patient was sent out. So I don't know exactly what happened, if it happened on my shift. No, nobody followed up with me. When I give the report, (Staff #59) asked me what happened and I told her what happened. Did this patient use her call light? Staff #141 replied, That time I couldn't remember for sure if she used the call light. Did you hear an alarm or anything? Staff #141 replied, I cannot remember if there's alarm. What was staffing that night? Staff #141 replied, Uh, I cannot recall, but just to tell you the truth, most of the time we are short of CNAs, but the CNA really assigned to this patient was on break. So the other CNA (Staff #99) was the reliever because 1 person will go break and the other CNA is the reliever. Four CNAs split two and two each side, but only one licensed. I'm the only RN for 38 residents. This is on Young 5 at the time. Staff #141 recalled speaking with a family member to let them know their policy and procedure was to call as well as the doctor. Staff #141 was asked for a [AGE] year old resident with a fall, did she consider sending the resident to the ED? She replied, We can consider that too, but she didn't have any signs of fracture and I didn't really realize she need to go to the emergency at that time and I continued to check her neuros and pain at that time. My shift ended at 11:30 (PM) and then every time I go home, I reported to incoming shift about her fall and continue to monitor. Staff #141 was asked what the purpose of the bed alarm was for this resident. Staff #141 replied, For us to know if patient gets up, to go and check the patient for their safety. So everytime, I was passing medicine and close to that room, one door away so I heard the loud noise, so if the call light is on, I will drop everything and answer the call light, because if she does press call light, i could have been there and help her right away. Have there been falls because short staff? Staff #141 replied, Yeah i think it's a factor too, because we cannot help it, we have to help the resident from falling. I need to drop what I'm doing to help the patient who is falling. One person falls down, it will hold me up so I'm trying my best to help the aides--especially the restless patients. We understand staffing get enough, but we have sick calls, so that's how ended up being short. Note: Record review found Staff #141 did not do neurological checks, failed to initiate and document the resident's pain level, etc. Cross-reference to findings at F309 and F323. c) On 08/16/2017 at 2:25 PM an interview of Staff #59 was done. She said for her investigation and ERF report to the SA, she did not do any interviews of the staff who worked the night and morning shifts of 11/14/17. She stated she did not have any documentation other than the ERF and the root cause analysis (RCA) form regarding Res #116's fall. The RCA was reviewed and Staff #59 was asked to explain it. She stated, I try to determine what caused the fall. So the cause is toileting, maybe she wasn't checked or toileted before this happened and maybe she tried to stand up and this happened. When I did interview with them this is what I found out that she was found with urine and BM in her diaper. So, the recommendation is prompted toileting, which means CNAs have to check her every 2 hours and check if she's incontinent or to use the bathroom. Staff #59 said she completed this on the next day, 11/15/16. Staff #59 was asked what other things would have been considered in doing the RCA, and she replied, Consider environment, lighting. What about your staffing at that time? Staff #59 replied, Less supervision when there's less staff. Surveyor asked if she was aware that one CNA had been on break when Res #116 fell . Staff #59 said, Yes. I missed that. She also confirmed Res #116 was able to ambulate prior to the fall, but after the fall, she is unable. d) On 08/16/2017 at 2:48 PM, an interview with Staff #99 was done. She recalled on the evening shift of 11/14/16, she came to the aid of Res #116 who had fallen. She recalled coming off her break. She said they did not hear the resident's call light when she went to aid the resident. She said Staff #141 assessed the resident, and after that the two of us asked other staff and she came to help us and we picked her up and we took her to the bathroom. Staff #99 was asked to clarify this and said, So two of us carried her (resident) into the wheelchair and took her to bathroom toilet. Staff #99 said the resident was not soiled at all when they found her on the floor. She said the resident actually sat on the toilet, not the bedside commode. Then afterward they put the resident back to bed. Staff #99 said she did not think the resident was in any pain, Because she was able to handle it, seems it was fine. And then after that the charge nurse took over. Staff #99 stated she was not interviewed by anyone after this incident nor wrote an account of what happened. Staff #99 said she spoke to the charge nurse only but not to Staff #59. Staff #99 also recalled their staffing that evening prior to resident's fall. She said, We are four that day and we are good for that. But it falls under during the break, but I was there close by to respond. Staff #99 was asked if the resident was ambulatory before the fall and she replied, The resident was able to stand up and assist before the fall. Note: The SA found the ERF submitted to the SA stated the resident had been found on the floor incontinent of urine and bowel. Staff #99 also stated she did not speak to staff #59 after this incident. e) On 08/17/2017 at 7:00 AM, interview of Staff #106 was done. He said he was familiar with Res #116 and verified his nursing entry of 11/15/16. Staff #106 stated he worked the night shift and recalled at first the resident had no pain. But at 1:45 AM she complained of pain. Pain to her right side. He did not fully recall the details of the fall, but stated, I want to test if the Tylenol gonna work and felt it was effective. He verified it was his sole entry on the Pain Monitoring Flow Sheet. Staff #106 said Res #116 told him verbally what her pain was. I let her describe from 1-10. Can you rate your pain from 1-10, 10 being the most painful and 0 being no pain. And she said 9. She's a times 2-3 (alert) and there are some occasions that she's confused. Staff was asked if he would have used the PAINAD scale for her. He replied, No, I wouldn't use that one for her because she's really conversant at that time and can tell me. He said that scale was used for those with dementia those who cannot really verbalize. He stated the nurses are supposed to use the Pain Monitoring Flow Sheet. Staff #106 was asked if Res #116 was able to use her call light, and he replied, Yeah, she's the one who use her call light. Even if she wants to be changed already, she calls. Sometimes she requests water. She can really verbalize her needs. Prior to the incident, she could walk. He repeated, She does use her call light. Even with turning she helps. Note: Record review found Staff #106 also did not follow the nursing observation neurological checks as there was no documentation found by either Staff #141 and #106. In addition, the ERF completed by Staff #59 mentioned unable to rate pain using the PAINAD. Staff #59 was asked why she wrote, Unable to to rate pain using the PAINAD on the completed ERF, as she stated she would not have considered using it for this resident. Staff #59 said she did not remember why she put it in there. She acknowledged the PAINAD scale is used for those residents who are with severe to advanced dementia. This resident scored a BIMS of 12 and was able to self-report her pain. f) On 08/17/2017 at 10:14 AM, a re-interview of Staff #59 was done. She stated she recalled on the day Res #116 was transported out to the hospital, she spoke to family members. She said, I explained to them she's in a lot of pain so that's why transferring out. She could not recall if the family members had questions about the fall injuries after the mobile x-ray was done. Staff #59 could not recall if she even saw the results. Like I said we were busy transferring patients down to this unit. But every time we have tests like this, I do want to see it and make sure we call the doctor .Yes now I remember. I wanted to call the doctor, for the abnormal results. I talked to the family and the doctor and the doctor wanted to order some type of narcotic pain medication. No, the family just wanted her to go to the hospital already. Staff #59 was asked why was there such a lag time before the ambulance was called, especially since Staff #59 stated she was in a lot of pain. She replied, I cannot recall anymore, yes, she was only getting the Tylenol. She was asked why there was no on-going clinical documentation about the resident's condition. Staff #59 stated, Only whatever my charge nurse wrote is it. Staff #59 stated, Yes, it is a significant fall with fractures. She was asked if her investigation included ruling out the potential for abuse and neglect. She replied, Oh yes, if unusual situations like this. I did talk to the CNAs that were working that evening, but because I didn't go deeper. I should have. You really need to find out how did it happen and what the situation was, what was the resident doing at the time and even prior to the event report. However, she affirmed she had no documentation except for the RCA she prepared. She was asked again, if she even considered neglect given the extent of the resident's injuries and the staffing for the evening. She replied, Oh yes, yes. I think so. Well resident is alert and she can ambulate and if she was checked before that, then maybe it could have prevented the fall. But then again the staffing, we only had 3 CNAs that time. But the thing I know is one CNA was helping the RN already. Staff #59 was asked whether the night shift supervisor was involved in this at all, and she replied, No mention of it. Because even when I talked to the RN, she should have sent her out already because she was in pain. Staff #59 said when she looked at the record, she felt the resident should have gone out and not waited until the next morning. I could have expected the evening shift, the time it happened, I told her that, my charge nurse, you should have just sent her out already. I'm not sure she remembers, but I told her that, yes. Staff #59 verified after reviewing the resident's record, the 11/14/16 evening charge nurse who found the resident on the floor failed to initiate and document on: 1) the Nursing Observation Flowsheet, 2) the Pain Monitoring Flow sheet, 3) the Medication Administration Record [REDACTED]. Staff #59 also said she would not have considered using the PAINAD scale for this resident because, she's alert and this one only for those that are confused. I told her why did you not send her out. g) On 08/21/2017 at 8:17 AM, during another interview with the DON and Staff #59, the DON agreed the RCA was not done as it lacked an in-depth review to see what the antecedent factors preceding the resident's fall may have been, which staff were present and whether was there enough staff available at the time this resident wanted to be toileted, as well as what their witnessed and documented accounts were. The DON reiterated, This was not done. Staff #59 also confirmed that Staff #141 was supposed to have documented a follow-up note. She stated she expected a physical assessment to have been done by Staff #141, but said there was nothing documented about it. On 08/21/2017 at 8:47 AM, the DON and Staff #59 re-verified the neurocheck flowsheet was not done by Staff #141 and also failed to initiate a pain monitoring flowsheet and complete her documentation on the MAR for the Tylenol she gave to the resident at 8:50 PM on 11/14/16. h) On 08/17/2017 at 06:40 AM, Staff #129 said the nurse who sent the resident to the hospital on [DATE] was unavailable for interview as she was out on extended leave. Thus, for this resident who sustained numerous physical injuries, declined in her functional ability to walk, coupled to a lack of a thorough investigation to rule out neglect, the facility failed to ensure this resident was provided the necessary care and services. This is further evidenced by the lack of clinical documentation by the licensed staff regarding the fall, no neurocheck flowsheet, no on-going pain monitoring and an incomplete RCA. By the time resident was discharged to the hospital, the documentation only included Staff #106's entry, the x-ray result of 11/15/16 at noon, one vital sign entry on 11/15/16 at 2:20 PM and the discharge/transfer note of 11/15/16 at 3:15 PM.

Based on clinical record review and interview with staff members, the facility failed to ensure that a resident who is fed by gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for Add-On Resident #1. Findings include: The facility submitted an Incident Report (IR) on 3/28/11 to the State Survey Agency reporting on 3/25/11 at 1425, the resident's gastrostomy tube ([DEVICE]) was changed by the registered nurse (RN). The RN reported difficulty with insertion as the resident was "contracting abdominal muscles". A 16 French [DEVICE] was inserted with 30 ml inflate. The "order in place for [DEVICE] change every 3 months and PRN with 14 Fr 15 ml inflate". Tube feeding was started at 1500 hours by the Personal Care Technician (advanced aide) who verified the placement. At 1515 hours resident presented as "pale, clammy, moaning, facial grimacing and restlessness". The feeding was discontinued. The physician was notified and ordered to transfer the resident for evaluation. A follow up call from the acute hospital on [DATE] notified the facility that the resident has a [DIAGNOSES REDACTED]. Clinical record review done on 4/5/11 at 12:30 P.M. noted resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of the "physician's orders [REDACTED].#14 FR with 15 ml NS inflate Q 3 months and prn for obstruction and dislodgement". An interdisciplinary progress note by the RN dated 3/25/11 at 1530 hours documented "GT changed routinely & inserted 16 Fr with 30 ml balloon w/ difficulty. (He/She) was contracting abdominal muscles while GT was inserted". Subsequent nursing note dated 3/25/11 at 2300 hours noted "at 1500, TF was given, was stopped and held for 1600 feeding schedule. Resident awake but abdomen was hard, tympanitic, and no bubbling sounds when auscultated to see the placement of the tube. Skin was cool and clammy. Resident was in pain due to facial grimacing and pain behavior noted". At 1515 the resident was noted to be "pale, moaning and restless". The physician was notified at 1625 and ordered to transfer resident to an acute facility. The resident left the facility at 1725 via ambulance. A physician called to notify the facility at 1910 that the resident "is sick and tube is not in place". The physician also notified facility that the resident went for surgery. On 4/5/11 at 1:15 P.M. an interview was conducted with the Chief Nursing Executive (CNE). The CNE confirmed the physician's orders [REDACTED]. The CNE also reported that a 14 Fr was available in the facility for use at the time of the incident. The CNE stated that the annual inservice/competency for changing of [DEVICE]s is usually done annually; however, it was not done this past year. The CNE reported the change of [DEVICE]s is a practice of the facility and following the incident a "Nursing Services Directive" dated 3/29/11 was disseminated to all registered nurses and licensed practical nurses of the facility that "Effective immediately, RNs and LPNs employed by (facility name) are not authorized to perform gastrostomy tube changes for resident care". The CNE shared that the resident had a perforated viscus and continues to be in the medical intensive care unit.