Every finding on record at Legacy Hilo Rehabilitation & Nursing Center

Based on observation, interviews and record review, the facility failed to provide the needed care in accordance to standard of practice to prevent a pressure ulcer (PU) in one Resident (R)88 of a sample size of three. R88 was at high risk of developing a new PU due to her immobility. She was totally dependent on staff for positioning to prevent a PU. There was no evidence in the medical record that staff frequently repositioned R88. As a result, she suffered harm and developed a Stage III (3) coccyx/sacral PU, which increased the risk of infection and complications. This deficient practice has the potential to affect any resident at risk of PU. Findings include: 1) Record review revealed R88 is an [AGE] year-old female that was a long-term resident at the facility with initial admission [DATE]. She had a medical history that included Guillain-Barre syndrome (GBS), paraplegia, spinal stenosis, neurogenic bladder and was cognitively impaired. On 02/03/26, R88 was sent to the hospital for respiratory distress hypoxia. She was readmitted to the facility on [DATE] after discharge from the hospital. On 02/24/26 at 11:00 AM, observed R88 in bed lying on her back. At that time, she said she had pain and pointed to her buttocks. Family members in the room said R88 had a PU on her sacrum. Review of R88's medical records revealed the following:Minimal Data Set (MDS), effective date of 02/16/26, included section GG (functional abilities) documented that R88 was totally dependent on staff for positioning and mobility and did not have the ability to roll from lying on back to left and right side, and return to lying on back on the bed. admission summary dated [DATE], included that R88 had MASD (moisture associated skin damage) to buttocks, zinc oxide cream applied during brief change. There was no PU at this time. Braden Scale (standardized tool to assess the risk of developing a PU based on numeric score) dated 02/13/26, was a total of 12, which signals high risk for pressure injury risk.Nursing note on 02/20/26, at 13:42, included Resident had skin breakdown to her coccyx area discovered during nurse management skin rounds. Resident with a Stage III . orders entered. On 02/26/26 at 01:00 PM, interviewed the Resident Care Manager (RCM), who confirmed there was no documentation of positioning R88 to prevent a PU. At that time the RCM also confirmed R88 did not have a PU at the time of admission, and that she currently had a Stage III PU on her coccyx. 2) Cross Reference F656: Comprehensive Care Plan The facility failed to develop and implement a comprehensive person-centered care plan for R88. The CP developed at the time of her initial admission on [DATE] did not include specific interventions to meet her needs and prevent the development of a new PU 3) Cross Reference F657: Care Plan Timing and RevisionThe facility failed to revise R88's CP in a timely manner after she developed a Stage 3 PU on her coccyx.

Based on observations, staff interview and review of policy, the facility did not follow proper sanitation practices in the kitchen. As a result of this deficiency, there was an increase risk for foodborne illness and quality of service. Findings include:During observation of the kitchen on 02/24/26 at 10:15 AM, a scooper utensil was left in the sugar container. Observation of the kitchen on 02/25/26 at 01:15 PM, Kitchen Staff (KS)1 and KS2 were not wearing hair restraints when working near the food preparation area. Staff interview, on 02/25/26 at 01:20 PM, Dietary Director (DD) acknowledged that the scooper utensil should have been taken out of the container and that the kitchen staff should have been wearing hair restraints at all times. Review of policy on Kitchen Sanitation read; . Policy, standard kitchen guidelines are to be followed as outlined . Procedures, the kitchen should have proper utensil storage and handling . Review of dietary policy on Dress Code read; . Policy, the intent of OPH Dietary Dress Code is for sanitation, safety and to represent the quality of service provided by the Dietary Department. Procedures . effective hair restraints are to be utilized while working in the Dietary Department . Departments should have hairnets, beard guards or bonnets on hand for staff to use. Hair restraint stations are located at each department entrance/exit. Bangs, pony tails should all be restrained under the hat/bonnet/hair net .

Based on observations, record review and interviews, the facility failed to develop baseline care plans (CP) and update with them to provide effective and person centered care to meet the immediate needs of four Resident's ((R)1, R2, R3,R4) of a sample size of five. As a result of this deficient practice, there is an increase risk of adverse events and lack of continuity of care. This has the potential to affect all new admissions to the facility. Findings include: 1) R1 was a [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnosis included sepsis (infection), pneumonia, diabetes, hypertension and transient ischemic attack. Reviewed R1's Admission/readmission Observation and Baseline Care Plan (nursing admission assessment) dated 04/02/26. The assessment documented R1 was cognitively impaired. Section N. Musculoskeletal System documented R1 had extreme weakness and required maximal assist from wheelchair to bed upon admission. Question 6. Are siderail(s)/bar(s) in use/requested? was answered Yes. Reviewed R1's admission MDS (minimal data set), dated 04/04/2026. Section GG, Functional Abilities documented she was totally dependent on staff for eating, oral hygiene, toileting hygiene, personal hygiene and rolling from side to side. The Skilled Note by nursing dated 04/02/26 included .On Ceftriaxone (antibiotic) 2 grams IV via PICC (peripherally inserted central catheter, used to deliver medicines directly to large central veins near the heart) line to right upper arm. On 04/20/26 at 10:30 AM, observed R1 in bed, and a noted a portable IV pump at the right side of her bed.On 04/20/26 reviewed R1's CP which revealed the following: Date initiated 04/10/26; The resident has an ADL (activity of daily living) self-care performance deficit. At the time of this review, there were no interventions in the CP to identify what the specific deficits were or how they would be addressed. A second review of the CP on 04/21/26, revealed the interventions for ADLs' was added on 04/21/26. In addition, R1's PICC line was not included in the baseline CP. On 04/21/26, reviewed additional copies of R1's CP that included resolved problems. On 04/03/26 the focus The resident is on antibiotic therapy (ceftriaxone IV) r/t infection: . was initiated with the resolved date of 04/13/26. This did not state R1 had a PICC line that requires specialized care. and monitoring. On 04/21/26 the CP was revised and resolved on the same date to include The presence of PICC line and risk for infection, occlusion, or dislodgment. The goal was PICC line to remain patent, intact, and free from infection or complications throughout duration of its presence. Interventions included: 1) Assess PICC site ., 2). Flush line per facility protocol ., 3). Monitor signs of complications ., and 4). Perform dressing changes per protocol. On 04/21/26 at approximately 10:45 AM, conducted an interview with the infection preventionist in the nursing station. She said they had just gotten an order to discontinue R1's PICC line.On 04/21/26 at 02:30 PM, conducted a phone interview with MDS coordinator (MDSC), who explained the admitting nurse completes the Admission/readmission Observation and Baseline Care Plan, which drives the baseline care plan. She said some of the issues will auto populate the CP, but others would have to be manually put in. The MDSC said she tracks admissions and on day three will look at orders and diagnosis to see if something needs to be added to the CP. She agreed it was important for residents' safety that the level of supervision and assistance needed should be in the baseline CP. 2). R2 was a [AGE] year-old male with a history of coronary artery disease, chronic kidney disease, insulin-dependent type 2 diabetic, spinal stenosis, and left eye blindness. He was admitted to the facility on [DATE] for rehabilitation after being hospitalized for pneumonia, multiple falls, progressive weakness and functional decline. Review of R2's nursing Admission/ readmission and Baseline Care Plan dated 04/09/26 documented he was alert and oriented, had no impairment of upper or lower extremities, amputation to the right great toe and 3rd/4th right toes, with contracture to the left hand. Question 6. Are siderail(s)/bar(s) in use/requested? was answered Yes. Reviewed the Side Rail/Enabler/Grab Bar Observation and Consent dated 04/02/26, which documented the Reason for side rail usage to be assist with transfer and bed mobility.On 04/20/26 at 11:00 AM, observed R2 sitting up in bed, and noted enablers attached on both sides. Review of R2's baseline CP revealed it did not include all the information to meet his immediate needs and was not updated as needs were identified in timely manner. The CP did not include 1) the enablers, 2) interventions and level of assistance to meet his ADL self-care performance deficits. The bathing/showering, bed mobility, dressing, eating, personal hygiene and transfer specifics were added 04/21/26, or 3). that he was on insulin. 3) R3 was a [AGE] year-old male with history of diabetes on insulin, coronary artery disease, hypertension, and left below the knee amputation (BKA). He was admitted to the hospital for non-healing stump and osteomyelitis (infection) of the left fibula. He was discharged from the hospital and admitted to the facility on [DATE] for rehabilitation and continued antibiotic therapy. Review of the hospital Discharge summary dated [DATE] revealed R3 was discharged with a PICC line in place and ceftriaxone planned for a six-week course.Review of the Admission/ readmission and Baseline Care Plan revealed R3 to have or requested to have an enabler.On 04/24/26 at 09:00 AM, observed R3 lying in the bed, which had enablers attached on both sides.Reviewed R3's baseline care plan which revealed the PICC line that was present on admission was not added to the CP until 4/22/26. In addition, the enabler was not present in the CP.4). R4 was a [AGE] year-old male admitted to the facility for rehabilitation on 03/30/26. He had a history of atrial fibrillation on Eliquis (anticoagulant), prior cerebrovascular accident, and diabetes managed with insulin. He was admitted to the hospital following a fall associated with generalized weakness and dizziness and was diagnosed with urinary tract infection. He required moderate assistance for transfers and mobility, and remained at a high risk, so he was discharged from the hospital and admitted for rehabilitation. Reviewed the nursing Admission/readmission Observation and Baseline Care Plan dated 03/30/26, which revealed R4 had or requested an enabler bar. R4's musculoskeletal system assessment documented no impairment to upper extremities, but lower extremity impairment on both sides with extremity weakness.Review of R4's provider orders revealed his orders included: Observe closely for significant side effects of Antidepressant medication (Duloxetine) including drowsiness, blurred vision, dizziness, nausea, fatigue, . Observe closely for significant side effects of Anticoagulant medication (Apixaban) including discolored urine, black tarry stools, nausea or vomiting .On 04/22/26 at 10:00 AM, observed enabler bars on both sides of R4's bed. Reviewed R4's baseline care plan that was initiated on 03/30/26. The baseline CP did not include the high alert anticoagulant or the antidepressant the provider ordered to monitor closely. These were added to the CP on 04/20/26. In addition, the enabler was not added to the CP.5). On 04/22/26 at approximately 10:00 AM, interviewed and concurrently reviewed the CP's of R1, R2, R3 and R4 with the Director of Nursing (DON) in the conference room. The DON confirmed the baseline CP did not include the items as noted above and that they should have been in the baseline care plan.

Based on observation, document, record review and interviews, the facility failed to have a policy based on professional standards of practice that addressed the use of enablers (device attached to bedframe that assists the resident with turning, repositioning and getting in and out of bed) to ensure residents are assessed to ensure effective and safe use. Four of a sample size of five Residents (R)1, R2, R2, R4)) reviewed had enablers attached to the bed. The facility failed to provide evidence of an assessment that included the the Resident's level of cognition and that they understood the use of the enabler to prevent injury. In addition, the consent forms are not signed by the Resident/Representative. r. As a result of this deficient practice, there is increased risk of injury to a Resident with impaired cognition.Findings include:1) R1 was a [AGE] year old female that was admitted to the facility on [DATE]. Her admitting diagnosis included sepsis (infection), pneumonia, diabetes, hypertension and stroke. Reviewed R1's Admission/readmission Observation and Baseline Care Plan dated 04/02/26, which documented she was cognitively impaired. Section N. Musculoskeletal System documented R1 had extremity weakness and required maximal assist from wheelchair to bed upon admission. Question 6. Are siderail(s)/bar(s) in use/requested? was answered Yes. Reviewed R1's admission MDS (minimal data set), dated 04/04/2026. Section GG, Functional Abilities documented she was totally dependent on staff for eating, oral hygiene, toileting hygiene, personal hygiene and rolling from side to side. Reviewed the Side Rail/Enabler/Grab Bar Observation and consent dated 04/02/26, which documented the reason for usage as bed mobility. On 04/20/26 at 10:30 AM, observed R1 in bed, lying on her back. There were enablers (U shaped) attached to both sides of the bed. R1 was noninterviewable due to her cognitive status.R2 was a [AGE] year old male with a history of coronary artery disease, chronic kidney disease, insulin-dependent type 2 diabetic, spinal stenosis, and left eye blindness. He was admitted to the facility on [DATE] for rehabilitation after being hospitalized for pneumonia, multiple falls, progressive weakness and functional decline. He was incontinent of bowel and bladder and wore briefs. Review of R2's nursing Admission/ readmission and Baseline Care Plan dated 04/09/26 documented he was alert and oriented, had no impairment of upper or lower extremities, amputation to the right great toe and 3rd/4th right toes, with contracture to the left hand. Question 6. Are siderail(s)/bar(s) in use/requested? was answered Yes. Reviewed the Side Rail/Enabler/Grab Bar Observation and Consent dated 04/02/26, which documented the Reason for side rail usage to be assist with transfer and bed mobility. On 04/20/26 at 11:00 AM, observed R2 sitting up in the bed and noted there were enablers attached to both sides of the bed. R3 was a [AGE] year-old male with history of diabetes on insulin, coronary artery disease, hypertension, and left below the knee amputation (BKA). He was admitted to the hospital for non-healing stump and osteomyelitis (infection) of the left fibula. He was discharged from the hospital and admitted to the facility on [DATE] for rehabilitation and antibiotic therapy on 04/10/26. Review R3's nursing Admission/ readmission and Baseline Care Plan documented he was alert and oriented, no impairment of the upper extremities and had the left BKA. Question 6. Are side rail(s)/enable bar(s) in use/requested? was answered Yes. Reviewed the Side Rail/Enabler/Grab Bar Observation and Consent dated 04/10/26, which documented the Reason for side rail usage to be assist with transfer and bed mobility. On 04/24/26 at 09:00 AM, observed R3 lying in the bed and noted enablers attached to both sides of the bed.R4 was a [AGE] year old male admitted to the facility for rehabilitation on 03/30/26. He had a history of multiple falls. The Admission/readmission Observation and Baseline Care Plan dated 03/30/26 documented R4 to disoriented- Some spheres some of the time and memory to be Impaired. R4's musculoskeletal system assessment documented no impairment to upper extremities, but tower extremity impairment on both sides with extremity weakness. Question 6. Are side rail(s)/enable bar(s) in use/requested? was answered Yes. The Nursing admission summary dated [DATE] at 10:50 PM documented R4 had received physical therapy (PT) once before he was discharged from the hospital and was able to get up to use a front wheel walker with moderate assistance. The note included Rehab request note inputted in Rehab mailbox for PT/T evaluation as well as a grab bar request. On 04/22/26 at 10:00 AM, observed enabler bars on both sides of R4's bed. 2) Reviewed the Facility form titled NSG (nursing): Side Rail/Enabler/Grab Bar Observation and Consent. The form was a template filled out by the nurse, and included:1) if a physician order is required? (only required if considered a restraint). 2). Medical symptoms requiring use of rail(s), 3) Are the rails a restraint?, 4) Reason for side rail usage, 5) Types of rails to be used, 6) Frequency of use, 6a) Detail frequency of use 7). Reason for observation. 8). Risks and benefits were explained to resident/family, including the risk of significant injury if a fall occurs. 9). Date the risk/benefits were explained. 10.) Full name of person(s) to whom they were explained. 11). Informed consent.: Resident/family signature. 11a). Informed consent date 12). Nurse signature and date, 13). Clinical Review indicates, and 14). Notification Details. The consent forms for the use of the enabler for R1, R2, R3 and R4 had the Resident/Representative names typed in the designated area for signature, but did not have a signature.3) On 04/21/26 at 02:30 PM, interviewed Registered Nurse (RN)1, who admitted R1 on 04/02/26. She confirmed she did the admission for R1 and that after she did her Assessment, she filled out a request for Physical therapy for the enabler. Asked if the facility required an order for enabler, and she said no. On 04/21/26, at 03:30 PM interviewed the Director of Nursing and the Administrator (ADM). The ADM said the facility did not have a restraint policy because they do not use restraints. Inquired if there was a policy or criteria for the use of enablers, and she said no. 4) To ensure safe and effective use of enablers there must be a policy with clear guidelines outlining the purpose and use of enablers. The policy should include assessment of the residents cognitive level to determine understanding of the device, documentation in the Resident's care plan and regular reassessment of their needs.

Based on interviews, observations and record/document review, the facility failed to ensure that the comprehensive care plan was reviewed and revised in a timely manner to reflect the current condition of two residents (R)2 and R88 of a sample size of three. As a result of this deficient practice, the care team does not have the current information needed to care for the resident's to ensure they reach their highest potential. Finding's include: 1) R2 was a long-term resident at the facility and requires 24-hour care. His medical history included End Stage Renal Disease requiring hemodialysis, Diabetes Type 2, Congestive Heart Failure, and stroke with left side weakness. He is dependent on staff for all Activities of Daily Living (ADL) and is a two-person transfer. On 02/25/26 at 08:10 AM, observed R2 in bed. He appeared comfortable and breathing easily. R2 was non interviewable. There was no sign outside the door that indicated R2 was on Droplet/Contact precautions. Record Review of R2's active care plan (CP) revealed he was on COVID Isolation Precautions R/T (related to) COVID + (positive for COVID infection). Interventions included: antiviral therapy if indicated, assist resident with donning mask as necessary, clarify orders for aerosol medications if indicated, complete symptom specific assessment as indicated, Evaluate for potential to be affected by the limited visitation ., Follow CDC (Center for Disease Control) protocol to obtain orders to start and start and discontinue transmission-based precautions. Special Droplet/Contact Precautions (full PPE with N95 mask and shield). On 02/27/26 at 08:25 AM, interviewed the Resident Care Manager (RCM) in the nursing station. When inquired if R2 had an active covid infection, she said he was diagnosed with a COVID infection on 10/03/25 but did not currently have COVID. At that time, reviewed R2's CP with the RCM and she acknowledged it was not accurate and should be updated. 2) R88 was an [AGE] year-old female that was a long term resident at the facility with initial admission [DATE]. She had a medical history that included Guillain-Barre syndrome (GBS), paraplegia, spinal stenosis, neurogenic bladder and was cognitively impaired. On 02/03/26, R88 was sent to the hospital for respiratory distress and when discharged from the hospital and readmitted to the facility on [DATE]. Due to her immobility, R88 was a high risk for developing Pressure Ulcer (PU). Review of R88's medical records revealed the following: admission (readmission) Summary dated 02/12/26, included R88 had MASD (moisture associated skin damage) to buttocks, zinc oxide cream applied during brief change. There was no PU noted at this time. Nursing note on 02/20/26, at 13:42, included Resident had skin breakdown to her coccyx area discovered during nurse management skin rounds. Resident with a Stage 111 (3) . orders entered. Reviewed R88's CP which revealed the CP was not revised to address the Stage 3 PU with interventions in a timely manner, and was not updated until 02/24/26. On 02/27/26 at approximately 10:30 AM, interviewed the RCM in the nursing station and reviewed R88's CP. The RCM confirmed she made the revisions to R88's CP on 02/24/26 to address the new Stage 3 PU to her coccyx after she did wound rounds with the external Wound Care Team.

Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for four of 21 residents (Resident (R) 6, 9, 88 and 104) in the active sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) R88 is an [AGE] year-old female that was a long term resident at the facility with initial admission [DATE]. She had a medical history that included Guillain-Barre syndrome (GBS), paraplegia, spinal stenosis, neurogenic bladder and was cognitively impaired. On 02/03/26, R88 was sent to the hospital for respiratory distress and admitted with diagnosis of Saddle embolus of pulmonary artery (life threatening condition where large blood lodges at the bifurcation of the main pulmonary artery, blocking blood flow to both lungs), bilateral pulmonary emboli and bilateral femoral deep vein thromboses. She was discharged from the hospital and readmitted to the facility on [DATE]. On 02/26/2026 at 12:11 PM, observed two family members (FM)'s of R88 in the hallway outside Resident's room talking to a staff member. Overheard a FM say R88 had not been turned in 3 days. Conducted an interview with FMs at that time. FM1 said they (FM1 and FM2) had been at the facility from 08:00 AM to 08:00 PM the past three days, and the staff never turned R88 the entire time. FM1 said she was very concerned because R88 had recently been in the hospital for blood clots and also had a pressure ulcer (PU). She went on to say they reported their concern to the Certified Nurse Aide (CNA) on duty 02/25/26, who agreed it was their responsibility to position her and that it should be done. FM1 also said the CNAs told her that R88's PU was getting bigger. Reviewed R88's Care Plan (CP) that which revealed the following: On 01/18/26, the CP focus was initiated: This resident is at risk for new pressure injury development r/t impaired mobility, decreased function, incontinence and MASD (moisture associated skin damage). The interventions included: 1) Follow facility policies/protocol's for the prevention/treatment of skin breakdown. and 2) Obtain and monitor lab/ diagnostic work . Reviewed the policy provided for prevention of PU's titled Skin Management System, effective date 11/07/25, which included 7. Initial interventions will be noted on the Baseline Care Plan as indicated. Ongoing problems and interventions will be captured on the Comprehensive Care Plan if indicated. The policy did not address interventions for prevention of PU's. On 02/27/26 at approximately 10:30 AM, interviewed the Resident Care Manager (RCM) in the nursing station and reviewed R88's CP. The PCM confirmed R88 was high risk for developing a PU, should be positioned and turned frequently, and confirmed the comprehensive care plan did not include specific interventions for prevention. She also confirmed that R88 has been immobile and was totally dependent on staff for positioning since her initial admission. 2) R104 was admitted to the facility on [DATE]. His medical diagnosis included history of traumatic brain Injury, constipation, and sepsis. He was incontinent of bowel and bladder, had limited physical mobility and required partial/moderate to substantial maximum assist for activities of daily living (ADL's). R104 had a pressure ulcer to his right heel and wound to right foot. On 02/25/2026 at 11:58 AM, observed R104, in bed with just a diaper on. He had a dressing on his right foot and noted to have lower leg contractures. Observed protective foot boot in the corner of the room. Attempted to interview R104, but he would not answer simple questions and started to get agitated and move about the bed, so the interview was stopped On 02/25/26, reviewed R104's CP, which included he had actual impairment to skin integrity that included a pressure ulcer to the right heel and wound to fight foot. The intervention for the wounds included: heel protectors to RLE (right lower extremity) while in bed/wheelchair. On 02/27/26 at approximately 01:15 PM, interviewed RCM, who confirmed that R104's care plan included heel protector to the right lower extremity. Reported that R104 had been observed without the boot every morning of the survey while he was in bed (02/24/26, 02/25/26 and 02/26/26). At that time, she said he often refused to wear the boot or kicked it off. The RCM said the CNAs are required to document the application of the boot and any refusals. Reviewed the progress notes and there was no documentation of refusals for the three days. Review of the Treatment Administration Record revealed documentation the boot was applied the day shift of 02/24/26, 02/25/26 and 02/26/26, which did not match actual observations. On 02/27/26 at approximately 01:30 PM, observed R104 in the hallway in a wheelchair with a shoe on the left foot, dressing on right foot, but no protective boot. Although R104's CP included the intervention of application of the boot to prevent further issues with the foot wounds, there was lack of evidence the staff attempted to apply the boot on a consistent basis, document refusals, or address the issue with the provider. 3) On 02/25/26 at 11:30 while interviewing R104's roommate, the roommate said he was very concerned about the staff's safety and said, No one should go in that room alone and care for him (R104) because of his behaviors. Review of R104's CP revealed it did not include any issue (Focus) of negative behaviors. The CP included an intervention/task to Monitor/document side effects of pain medication. Observe for. increased agitation, restlessness, confusion, hallucinations .Report occurrences to the physician. On 02/26/26 at approximately 11:30 AM, observed the Infection Preventionist (IP) prepare and perform the dressing change of R104's foot wound. While preparing supplies outside the room, she asked the RCM, who was going to assist to go into the room and clean the water off the overbed table because he had thrown water earlier in the day. At that time, asked the IP if R104 had known negative behaviors, and she replied yes, he throws stuff at people. On 2/26/26 at 01:45 PM, interviewed the CNA, who was assigned to R104. She said he became very agitated when she was in the room earlier, so she left and came back later. The CNA said, he has these behaviors now and then. Inquired if the CNA's document when the behaviors occur, and she said no. Reviewed R104's nursing progress notes that included the following entries of negative behaviors: 02/04/26 alert note resident expressing need to leave again and having behaviors at staff. 02/07/26 at 22:42, Behavior notes: Resident having negative behaviors toward staff and his neighbor. Resident was counseled and responded with more behaviors. Will continue with plan of care. On 02/27/26, a second record review revealed R104's CP was revised 2/26 to add The resident has a behavior problem of throwing items at staff. The interventions/tasks did not include monitoring the specific type of behaviors or how often they occurred. 4) R6 was a [AGE] year-old resident admitted to the facility for short-term rehabilitation services. Diagnoses included but not limited to atrial fibrillation (fast, irregular heart rhythm that causes blood to pool and increasing the risk for blood clots and stroke), history of transient ischemic attack (mini stroke) and cerebral infarction (medical condition caused by blockage of blood flow to the brain). On 02/25/26 at 11:20AM, an interview was conducted with R6 in his room. During the interview, observed some dried-up blood stains on the right side of his bed sheets. R6 said he has a small cut on his elbow but does not know how he got it and added that he is clumsy and bumps into things sometimes. Asked R6 if was taking anticoagulants to which he said, I've been on them (anticoagulants) for a long time. Review of R6's Electronic Health Record (EHR) revealed he was on Apixaban (an anticoagulant, medication that prevents or reduces the formation of clots) 5 mg (milligrams) twice a day. Review of current care plan revealed there were no plans or interventions related to R6's use of anticoagulants. 5) R9 was a [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to acute embolism and thrombosis of left femoral vein and history of falls. On 02/25/26 at 10:10 AM, an interview was conducted with R9 in her room. Observed old bruises on her right wrist and top of right hand. R9 said she has been taking anticoagulants for many years now. Review of R9's EHR revealed an order for Apixaban 5 mg twice a day, however, current care plan did not include care and interventions related to the use of anticoagulants. On 02/27/26 at 08:48 AM, a concurrent interview and record review was conducted with RN11 at the nurses' station. Reviewed current comprehensive care plans for both R6 and R9 with RN11 and confirmed there was no care plan to address the use of anticoagulants for both residents. RN11 added that a care plan should have been developed for both since they were admitted with an order for the anticoagulant.

Based on observation and interview, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: On 02/25/26 at 02:18 PM, inspection of the [NAME] Unit medication cart was conducted with Registered Nurse (RN)6. Observed an eye drop medication in a plastic bag with a label that stated, Refrigerate until opened. Discard 42 days after opening. Date opened: _____ (blank). Queried RN6 if the medication was currently being used and considered open. RN6 said, This is not my regular unit, so I'll check with the other nurse. RN6 asked RN11 and confirmed that the medication was currently being used and added that they would not know when it has been open for 42 days since the open date was not noted on the label.

Based on observation and interview the facility failed to ensure one of three residents (Resident (R) 62) sampled was free from accident hazards as evidenced by over the counter (OTC) medication, brought in by Family Member (FM)3, being stored in R62's room and administered by FM3 without notifying staff. This deficient practice created a risk for injury to R62 due to inappropriate and unsafe administration of the OTC medications by an unauthorized person.Findings include:On 02/24/26 at 10:46 AM, a bottle of Tussin Cough and Chest Congestion liquid and a bottle of Tylenol Extra Strength 500mg capsules were observed on R62's corner table.On 02/25/26 at 09:03 AM, FM3 was interviewed in R62's room. The bottles of Tussin and Tylenol Extra strength remained on the corner table. FM3 stated that he brought in the two medications, and while R62 has been in the facility, FM3 stated he had given the Tussin to R62 a couple times, approximately six months to a year ago, and Tylenol Extra Strength, the last time being six to eight months ago because R62 looked uncomfortable sitting in the chair. FM3 stated that he did not inform the Nurse that he gave these medications.On 02/26/26 at 03:30 PM, the Resident Care Manger (RCM)2 verified the Tussin and Tylenol Extra Strength bottles on the corner table in R62's room. RCM2 stated that medications should not have been stored in the resident's room unless the resident was assessed to be able to self-administer and the medications would need to be kept in a locked box. RCM2 stated that R62 was not a candidate for medication self-administration.On 02/27/26 at 10:27 AM, the Director of Nursing (DON) was interviewed and stated that the only reason medications could be stored in a resident's room is if the resident was assessed that he/she could self-administer medications safely and the medications would need to be locked.

Based on observation, interview and record review, the facility failed to ensure that two of 21 residents (Resident (R) 74 and R109) in the active sample were free from significant medication errors as evidenced by R74 being administered an inappropriate dose of short acting insulin via insulin pen and R109 was administered an insulin dosage via insulin pen based on a blood sugar taken after a meal. As a result of this deficient practice, R74's and R109's health and safety were jeopardized.Findings include:1) On 02/06/26 at 08:03 AM, Licensed Practical Nurse (LPN) 4 was observed preparing medication for R74 at the medication cart on the Kamakau unit. Reading from the Medication Administration Record (MAR), LPN4 stated R74 was due for 15 units of Lantus insulin via pen and results of blood sugar fingerstick taken at 06:51 AM was 143 mg/dl (milligram/deciliter). LPN4 proceeded to remove the insulin pen from the medication cart drawer, compared the label on the insulin pen to the MAR, and prepared the insulin pen to 15 units. LPN4 then asked the Infection Preventionist (IP) to double check the amount that was set on the pen. The IP asked how many units was to be given and LPN4 stated 15 units. The IP looked at the pen and confirmed it was set to 15 units. Upon returning to the medication cart after administering the insulin to R74, LPN4 stated that 15units of Novolog100u/ml flex pen was given to R74 instead of the Lantus. An order for sliding scale was noted on R74's MAR and based on the blood sugar result of 143 mg/dl, the Novolog insulin was to be held (Blood sugar 70-150 = 0 units).On 02/26/26 at 09:15 AM, LPN4 was interviewed on Lehua [NAME] unit and stated that the Nurse Practitioner (NP), who was at the facility, was notified and ordered recheck R74's blood sugar in one hour from the administration time and monitor for signs and symptoms of hypoglycemia. LPN4 stated that he did match the insulin pen to the order noted on the MAR but did not realize that the wrong insulin was provided to R74 until after it was administered. At 09:20 AM, LPN4 was observed rechecking R74's blood sugar via fingerstick with a result of 216 mg/dl and assessed R74 for signs of hypoglycemia. On 02/26/2026 11:55 AM, LPN4 was interviewed and stated that at 11:32 AM, R74 was assessed and displayed no signs of hypoglycemia and blood sugar was checked with a result of 118 mg/dl. On 02/27/26 at 08:50 AM, a review of R74's progress notes and February 2026 MAR, noted R74's blood sugar fingerstick was retaken on 02/26/26 at 01:16 PM with a result of 120 mg/dl and on 02/26/26 at 05:06 PM with a result of 172 mg/dl. No events of hypoglycemic episodes were documented for R74.A facility policy titled, Medication Administration General Guidelines with a date of 2007, stated, . Medication Preparation: .9. Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart, b. When dose is prepared, c. Before dose is administered .2) On 02/25/26 at 11:23 AM, R109's Family Member (FM) 5 was interviewed in the courtyard. FM5 stated that on 02/23/26 after R109 ate lunch and close to 01:00 PM, she went into the hallway from R109's room and informed LPN6 that R109 needed his folder for dialysis, lunch time medication, and his sugar checked. FM5 stated that LPN6 responded that R109 was going to dialysis and did not need the lunch medication, checked R109's blood sugar and gave insulin in the hallway.On 02/26/26 at 12:00 PM, LPN6 was interviewed in the Kamakua Unit. LPN6 stated that on 02/23/26, she was dealing with another resident emergency and did not get to pass her lunch medications as scheduled but could have asked for assistance from other facility licensed nurses. LPN6 confirmed the following:-R109's blood sugar fingerstick was done after he ate lunch with a result of 254mg/dl (milligrams/deciliter). Insulin was given per ordered sliding scale right before R109 left for dialysis. R109's February 2026 MAR documented Insulin Aspart 100 units/ml 6 units was given per sliding scale (241 -300 = 6 units).-R109's lunchtime oral medication was not given and documented on the Medication Administration Record (MAR) that it was not given.-LPN6 verbalized that she should have informed R109's physician's that the blood sugar was taken after lunch was eaten, insulin was given based on that blood sugar result, and R109's oral lunch medication was held.On 02/27/26 at 08:55 AM, R109's Physician Orders and February 2026 MAR were reviewed. A physician's order dated, 02/10/26 stated, Blood Glucose Monitoring before meals and at bedtime. A physician's order dated 02/10/26 stated, Calcium Acetate (Phos binder) Oral Capsule 667mg [milligrams].Give 3 capsule by mouth with meals. and scheduled for 1130. The entry for 02/23/26 was marked on the MAR by LPN6 with a code of 1. The legend on the MAR stated, 1 = Absent from home without meds however, the resident was still in the facility as evidenced by R109 being administered insulin by LPN6 before leaving for dialysis.A facility policy titled, Medication Administration General Guidelines, with a date of 2007, stated, . Medication Administration: 14. Medications are administered within 60 minutes of scheduled time .

Based on interviews, record and document review, the facility failed to develop and implement a discharge plan for the transition of post discharge care for one Resident (R)107 of a sample size of three. R107 had an indwelling urinary catheter (a medical device that helps drain urine from your bladder) at the time of discharge. The facility was not able to provide evidence that the Care Giver (CG) had the capacity, capability, or received education on how to preform catheter care. As a result of this deficient practice, there was increased risk of infection and complications related to the urinary catheter. This deficient practice could affect any discharged resident if the CG is not properly trained and capable to provide the after care needed. Findings include: On 12/10/25, the Office of Health Care Assurance received a report of concern that R107 did not have the resources needed after discharged home from the facility. It was reported that R107's CG could not safely manage the urinary catheter, which put her at increased risk of developing a urinary tract infection. R107 was a [AGE] year-old female admitted to the facility for short term rehabilitation due to generalized weakness on 08/26/25 after an acute care hospitalization. Prior to being hospitalized , she lived with her son, who was her support person and assisted her with her needs. R107's medical history included diabetes, spinal stenosis, chronic back pain, muscle weakness and abnormalities in gait and mobility. She had end stage renal disease and on dialysis. R107 was cognitively intact, was able to walk using a front wheel walker with CG assist and was totally dependent on staff (two-person assist) for transfers, requiring a mechanical lift (equipment used to transfer patients safely). While at the facility, she developed urinary retention and required an indwelling urinary catheter. The urinary catheter was not removed and was in place when she went home. R107 was discharged home on [DATE] with her son, who was the designated CG. Reviewed R107's nursing progress note dated 11/23/25 at 13:21, which included Resident discharged home with son, to be followed up by primary care provider as well as have home health services provided.son at bedside during dc (discharge) process. Resident transferred to son's car with staff assist. Per resident and resident's son will be able to transfer her out of vehicle upon arriving home.Education/Training Response as indicated: n/a.(not applicable) . There was no documentation that the CG was educated to manage the care of the Foley. On 02/27/26 at 11:00 AM, interviewed the Social Services Assistant (SSA), who reviewed R107's notes and contacted the Social Worker (SW) by telephone to inquire about the CG training. The SW said the vendor that delivers the mechanical lift does the CG training when they bring the equipment to the home, but he did not know if nursing provided the education on catheter care. He said the son had taken care of R107 prior to being hospitalized , but acknowledged R107 did not have a urinary catheter at home, prior to admission to the facility. On 02/27/26 at 12:30 PM, during an interview with the Administrator, she confirmed it was nursing's responsibility to assess what training the CG needed, provide and document the training. In addition, they should document the CG was willing, capable and had the capacity to provide the care to ensure the Resident's needs will be met. The facility failed to provide evidence of the CG training on Foley care.

Based on interview and Record Review (RR), the facility failed to ensure a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for four residents (Resident (R)41, R57, R35, and R56) sampled. Requested a copy of the sampled resident's transfer or discharge notice that was sent to a representative of the Office of the State Long-Term Care Ombudsman and the Administrator confirmed the facility has not been sending any copies of the notices to the Ombudsman. This deficient practice has the potential to affect all the residents who are transferred or discharged from the facility. Findings Include: 1) On 10/23/24 at 11:04 AM during interview with R41 he stated he went to the hospital this year to have my leg amputated. On 10/23/24 at 3:00 PM requested notice of transfer or discharge, bed hold and ombudsman notification for R41 from Administrator. Administrator provided a copy of the Notice of Transfer/Discharge for R41 on 10/24/24. Two copies were given, one was dated 05/31/24 and 06/24/24 and both included the bed hold policy. 2) On 10/23/24 during RR of R57's Electronic Health Record (EHR) found R57 was sent to the hospital on 10/21/24 after a fall and admitted to the hospital for a diagnosis of fall with left inferior pubic ramus fracture. On 10/23/24 at 3:35 PM requested notice of transfer or discharge, bed hold and ombudsman notification for R57 from the Administrator. Also requested facility policy for transfer and discharge. On 10/24/24 at 11:07 AM received Notice of Discharge/Transfer and bed hold form that was signed by R57 on 10/23/24. Resident returned to facility on 10/23/24 from the hospital and was readmitted to the facility. Awaiting copy of notification was given to Ombudsman from Administrator for R41 and 57. Administrator was able to provide a copy of the Transfer or Discharge Policy (Including AMA) which was last updated 10/22/2022. On 10/24/24 at 11:25 AM Administrator came to conference room to notify surveyor that the facility staff have not been sending copies of the notice of resident discharge/transfer to the Ombudsman. 42160 3) Reviewed R35's EHR which documented the resident was discharged to an acute hospital on 02/04/24. R35's EHR did not contain documentation of the facility's notification to a representative of the Office of the State Long-Term Care Ombudsman of R35's discharge. Requested documentation of the facility's notification to the Ombudsman for R35's discharge. On 10/24/24 at 01:07 PM, the Administrator confirmed a notice of transfer/discharge was not sent to the Ombudsman and a notice should have been sent. 4) Reviewed R56's EHR which documented the resident was discharged to an acute hospital on 07/23/24. R56's EHR did not contain documentation of the facility's notification to the Ombudsman of R56's discharge. Requested documentation of the facility's notification to the Ombudsman for R56's discharge. On 10/24/24 at 01:07 PM, the Administrator confirmed a notice of transfer/discharge was not sent to a representative of the Office of the State Long-Term Care Ombudsman and a notice should have been sent. Review of the facility policy Transfer or Discharge Policy (Including AMA) which was last updated 10/22/2022, states Policy Interpretation and Implementation 6. Generally, the notice must be provided at least 30 days prior to a facility- initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge. 7. The facility will maintain evidence that the notice was sent to the Ombudsman as applicable.

Based on interviews and record review, the facility failed to ensure controlled medication was reconciled for one of four medication carts sampled. Review of the Controlled Medication Reconciliation Log (CMR Log) documented on 10/02/24, nursing staff did not sign the log with the on-coming evening shift nurse indicating all controlled medications for medication cart was reconciled at change of shift and on 10/24/24 and 10/25/24, nursing staff pre-signed the CMR Log prior to reconciling and verifying the controlled medications count with the on-coming evening shift. As a result of this deficient practice, the facility is at potential risk for diversion of controlled medications. Findings Include: On 10/24/24 at 08:40 AM, conducted an inspection of medication cart # 4 with Nursing Staff (NS)3. Review of the CMR Log documented NS3 had already signed the box which indicated the controlled medication count was completed with the on-coming evening shift nurse which attested the count was accurate, prior to doing the actual count. Inquired with NS3 regarding when the CMR Log should be signed and if NS3 had pre-signed the form. NS3 stated that she was going to work a double shift, so she would be signing for both the off-going and on-coming evening nursing staff and would sign as the off-going nurse with the staff working the night shift. NS3 explained, she would have the keys for medication cart #4 for the entire day and evening shift, then count the controlled medications with the on-coming night shift. On 10/25/24 at 09:40 AM, reviewed the unit schedule which documented NS3 had worked until 06:00 PM on 10/24/24 and not the entire 8 hour evening shift as reported by NS3. On 10/25/24 at 11:15 AM, reviewed the CMR Log on medication cart #4. The CMR Log documented NS3 did not provide an additional signature attesting that the controlled medication was reconciled with the on-coming nurse to ensure all controlled medications for medication cart #4 was correct and there were no missing controlled medication(s). Also, NS23 had pre-signed the CMP Log prior to counting the controlled medications with the on-coming evening nurse. Inquired if NS23 was working the evening shift and NS23 confirmed he/she was not working the evening shift and would be conducting a count of the controlled medication with the on-coming evening nurse at change of shift later in the day. On 10/25/24 at 11:40 AM, conducted a concurrent interview and record review of medication cart #4's CMR Log with Resident Care Manager (RCM)8. Informed RCM8 of this surveyor's conversation and documentation on the CMR Log for 10/24/24 and 10/25/24 which showed both day shift nurses pre-signing the CMR Logs prior to counting the controlled medications with another licensed nursing staff. Inquired with RCM8 regarding the facility's practice for counting controlled medications between shifts and what is expected of the staff conducting the counts. RCM8 stated the CMR Log should be signed in the presence of the other licensed nurse during change of shift, when handing over the keys to the on-coming licensed nursing staff, after confirming the controlled medication count was accurate. RCM8 confirmed NS3 should have signed the CMR Log again and in the presence of the on-coming nurse after both staff confirmed the accuracy of the controlled medication count and NS23 should not have pre-signed the CMR Log. Reviewed the missing signature on the CMR Log for the day shift nurse on 10/02/24. RCM8 confirmed licensed staff should have signed the CMR Log in the presence of the on-coming licensed staff but did not. Review of the facility's Medication Storage, Controlled Medication Storage policy and procedure documented, 6. At each shift change or when the keys are surrendered, a physical inventory of all controlled substances, . is conducted by two licensed or approved individuals per state regulation and is documented on the controlled substances accountability record ore verification of controlled substances count report.

Based on observations, resident interview, staff interview, and review of policy, the facility did not have the call bell in reach for one Resident (R)14 out of six Residents sampled. As a result of this deficiency, R14s ability to call out for help was limited and the deficient practice has the potential to affect all the residents that uses the call bell for assistance. Findings Include: During observation and interview on 10/22/24 at 10:18 AM, R14's call bell was attached to the bed but was dangling and out of reach. R14 said that he/she had hard time finding the call bell to call out to staff. Observation and interview on 10/23/24 at 02:30 PM, R14's call bell was dangling over head of the bed and out of reach. R14 wanted to call to ask staff a question. Observation on 10/25/24 at 09:22 AM, R14 was sitting in a wheelchair next to the bed and the call bell was out of reach, dangling from the bed rail. R14 was trying to get the attention of staff. Staff interview on 10/23/24 at 02:51 PM, Certified Nurse Assistant (CNA)4 acknowledged that the call bell was out of reach and moved it closer to the resident. Review of policy on Call Light use read; Purpose, to respond promptly to resident's call for assistance, to ensure call system is in proper working order. Procedure, all facility personnel must be aware of call lights at all times . When providing care to guest/resident, be sure to position the call light conveniently for the resident to use, tell the guest/resident where the call light is and show him/her how to use the call light . Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand or clipped to the guest/resident or placed in reach when sitting up .

Based on interviews and record review, the facility failed to exercise reasonable care for the protection of the property from loss or theft for one out of 22 sampled residents (Resident (R) 9). As a result of this deficiency, R9's psychosocial wellbeing was negatively affected. R9 did not think the facility took his statement seriously. This deficient practice has the potential to affect all the residents whose property is lost or missing. Findings Include: Interview was conducted with R9 on 10/22/24 at 01:45 PM in his room. R9 stated that a couple of months ago, five bottles of supplements went missing after taking just one pill. R9 explained that a family member had ordered the supplements for him and had it delivered to the facility. R9 had informed a couple of the facility staff of the missing items and staff had helped him search for it. R9 was not sure if the staff had taken his statement seriously. R9 did not think the facility had opened an investigation regarding his missing items because no one had spoken to him regarding the missing bottles. Interview was conducted with R9's family member by phone on 10/24/24 at 01:19 PM. R9's family member confirmed that he had ordered 5 bottles of supplements for R9 two months ago and had it delivered to the facility. Interview was conducted with Registered Nurse (RN) 10 on 10/24/24 at 01:27 PM at the nurse's station. RN10 stated that R9 had informed her of his missing supplements a couple of months ago and RN10 searched for it with other staff. RN10 was not sure if the facility social worker was aware of R9's missing items. RN10 did not inform the social worker that R9 was missing his supplements. Interview was conducted with Social Worker (SW) 1 on 10/24/24 at 01:29 PM at the nurse's station. SW1 stated that once a resident's item is reported missing, staff begins a search for it. If the item is not found, the facility fills out a lost item form and begins the investigation process. SW1 confirmed that she was not aware that R9 had missing items a couple of months ago. Therefore, investigation for R9's items was not started. A review of the facility policy titled, Theft and Loss Program, last updated on 01/01/2010, was conducted on 10/25/24. The policy noted, 8. If a resident, responsible party or staff member become aware that an item is missing, they will initiate a theft and loss form and forward immediately to Social Services.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 22 sampled residents (Resident (R) 66). R66 experienced frequent pain and the facility failed to develop a care plan for R66's pain. The deficient practice has the potential to negatively affect R66's wellbeing and has the potential to affect all the residents who experiences pain in the facility. Findings Include: R66 is a [AGE] year-old female admitted to the facility on [DATE]. R66 has medical diagnosis that includes, but not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, aphasia, low back pain, and pain. Observation and interview were conducted with R66 on 10/23/24 at 09:53 AM in R66's room. R66 was observed rubbing/massaging her left thigh area. R66 stated that she experiences constant pain in her left thigh area and needs to take medications for it. A review of R66's Minimum Data Set (MDS) dated [DATE] was conducted. Section J in R66's MDS noted that R66 has frequent pain. A review of R66's current care plan was conducted on 10/23/24. R66's care plan did not include a plan of care for her frequent pain. Interview was conducted with the Director of Nursing (DON) on 10/24/24 at 10:35 AM in the DON's office. DON confirmed that R66 had frequent pain and was aware that R66 takes medications to alleviate the pain. DON confirmed that R66 should have had a care plan for pain. A review of the facility policy titled, Pain Management Policy, with a revision date 07/12/2023, was conducted. The policy noted, 3. An individualized Care Plan will be developed to identify a resident's pain and interventions to assist with care of the resident and updated with any changes in interventions.

Based on observation, interview and Record Review (RR) the facility failed to assure one of the sampled residents (Resident (R) 132) received appropriate treatment and services with care for his urinary indwelling catheter. The deficient practice included R132's urinary catheter tubing being left on the ground, urinary catheter flush for blood in the tubing performed by licensed staff without a physician order, and licensed staff not performing proper hand hygiene before flushing R132's urinary catheter. This deficient practice has the potential to affect all the resident with urinary catheter. Findings Include: Cross-reference to F880 Infection Prevention & Control On 10/22/24 at 11:30 AM R132 was observed sitting in his wheelchair near his bed with his urinary catheter tubing on the ground. Interview was conducted with the Certified Nurse Assistant (CNA) 1 who was working with R132. Inquired if the tubing should be on the ground and she confirmed it is not supposed to be left on the ground and she put on gloves and lifted the tubing off the ground and moved it to the side of R132's wheelchair. On 10/23/24 at 10:01 AM observed R132 sitting in his wheelchair outside of his room and Registered Nurse (RN) 5 was talking with resident. Interview was conducted with RN5 at this time. Inquired about the blood that was observed in the urinary catheter tubing of R132 and RN5 stated she was going to flush the urinary catheter. R132 was transferred into his bed by RN5 and maintenance staff (who is a CNA). RN5 continued using the same gloves as she flushed R132's urinary catheter. Afterwards RN5 was interviewed and asked if she should have taken off the dirty gloves, performed hand hygiene and then put on clean gloves before flushing R132's catheter, and she confirmed that she should have done that. On 10/23/24 a RR was done of R132's Electronic Health Record (EHR) which revealed he is an [AGE] year old male who was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; Type 2 diabetes mellitus; personal history of malignant neoplasm of prostate; chronic kidney disease, stage 3a; and urinary tract infection, site not specified. Continued RR found there was no physician's order for R132 to have his urinary catheter flushed by licensed staff. On 10/24/24 at 03:00 PM interviewed RN6 inquired if nurses are required to have a doctor's order to perform a urinary catheter flush and she confirmed this. On 10/24/24 at 03:05 PM interviewed RN5 and inquired if she had a doctor's order to flush R132's urinary catheter tubing prior to doing this on 10/23/24. RN5 reviewed R132's doctor's orders. RN5 stated she did not find an order to flush R132's urinary catheter tubing. Inquired if nurses need to have the order to be able to do this and RN5 confirmed she needed a doctor's order. RN5 stated she would contact the doctor. RR on 10/25/24 of R132's EHR revealed a doctor's verbal order with a created date of 10/24/25 at 04:12 PM which stated May flush urinary catheter when urine output is bloody or urine output is decreased. Every shift - PRN PRN 1, PRN 2, PRN 3

Based on observations, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. This deficient practice has the potential to affect all the residents in one of the four units in the facility. Findings Include: Concurrent observation and interview were conducted on 10/22/24 at 11:00 AM. One of the facility's medication carts was observed unlocked and unattended. The cart was assigned to Licensed Practical Nurse (LPN) 10, who was observed in one of the resident's rooms. Once LPN 10 exited the resident's room, she was asked about the unlocked and unattended medication cart. LPN10 confirmed that the medication cart should not have been left unlocked and unattended. Concurrent observation and interview were conducted on 10/23/24 at 03:17 PM. One of the facility's medication carts was observed unlocked and unattended. The cart was assigned to Registered Nurse (RN) 11. Once RN11 came back to the nurse's station, she was questioned about the unlocked and unattended medication cart. RN11 confirmed that the medication cart should not have been left unlocked and unattended. A review of the facility policy titled, Storage of Medication, dated 01/24 was conducted on 10/23/24. The policy noted, 3. 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 medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation, Record Review (RR) of Resident's Electronic Health Record (EHR) and interview, the facility failed to assure one of the sampled resident's (Resident (R) 132) urinary catheter tubing did not rest on the ground, failed to have staff remove dirty gloves, perform hand hygiene and put on clean gloves before flushing R132's urinary catheter, and perform hand hygiene after disposing of dirty gloves before putting on clean gloves during a dressing change for R58. The deficient practice puts the residents at risk for facility acquired infections. Findings Include: 1) On 10/22/24 at 11:30 AM R132 was observed returning to his room in his wheelchair with staff pushing his wheelchair. R132 was observed in his wheelchair near his bed and his urinary catheter tubing was observed resting on the ground. Inquired with Certified Nurse Assistant(CNA) 1, if the tubing should be on the ground and she stated it should not be on the ground. CNA1 put on gloves and moved the tubing so that it was not resting on the ground. On 10/23/24 at 10:01 AM observed R132 sitting in his wheelchair outside of his room. An interview was conducted at this time with Registered Nurse (RN) 5. Inquired with RN 5 about blood that was observed in R132's urinary catheter tubing. RN5 stated she was going to flush it. Observed RN5 push R132 in his wheelchair from the hallway to his bedside. RN5 and Maintenance Staff (MS) 1 (who is also a CNA) transferred R132 from his wheelchair to his bed. During the transfer RN5 was wearing gloves. After transfer RN5 did not dispose of dirty gloves and perform hand hygiene. RN5 proceeded to flush R132's urinary catheter which had blood and urine in the tubing. Resident tolerated it well. Afterwards RN5 changed her gloves, threw away dirty gloves and put on clean gloves and did not perform hand hygiene. RN5 placed a holder (STAT LOCK) on resident's right leg which she stabilized R132's urinary catheter tubing in. Inquired of RN5 if she should have disposed of dirty gloves and perform hand hygiene prior to flushing R132's urinary catheter and RN5 confirmed she had not done hand hygiene and did not change her gloves prior to flushing R132's urinary catheter which she acknowledged she should have done. 2) On 10/24/24 at 10:11 AM observed suprapubic catheter dressing change for R58 done by RN5. R58 was laying in his bed, no distress, was cooperative with dressing change, reported to nurse that he does not have any pain. Site was clean, no drainage and no inflammation. RN5 disposed of old dressing and washed her hands. RN5 donned clean gloves and cleaned site with saline. RN5 took off her gloves and threw them away, no hand hygiene was performed before putting on clean gloves. Ointment was applied to the site with a sterile q-tip and dressing gauze was applied with paper tape. On 10/24/24 at 08:45 AM requested Hand Hygiene policy from Administrator which she provided that day. Review of facility policy titled Handwashing and Hand Hygiene Policy with a revision date of 05/23/23 states Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: . c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). t. Before donning and after doffing gloves and PPE.

Based on record review and interview, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing services that assured resident (R) safety for 1 of 6 residents sampled (R1). As a result of this deficient practice, R1 was placed at risk of a decrease in her physical well-being related to receiving morphine sulfate (a strong narcotic most commonly used to treat moderate to severe pain) on a routine basis, scheduled every one hour, as opposed to being used as needed. Findings include: Resident (R)1 was an [AGE] year-old female admitted to the facility on [DATE]. On 05/23/24, R1 was admitted to hospice for end-of-life care. On 05/28/24, R1 passed away at the facility while on hospice. On 06/24/24, the State Agency (SA) received an anonymous complaint (ACTS #11034) regarding the care R1 received at the end of her life. Amongst the allegations made was a concern that R1 had received too much morphine sulfate on 05/26/24. On 07/09/24, a review of R1's electronic health record (EHR) revealed the following progress notes: 05/26/24 Hospice Nurse Progress Note: . On-call Visit . ORDERS: Morphine 10 mg [milligrams] Q1H [every one hour] PRN [as needed] . 05/26/24 02:59 PM Facility Nursing Progress Note: New Orders Hospice nurse . spoke to APRN [advanced practice registered nurse] . from Hospice with the following recommendations: . Roxanol [morphine sulfate] 10 mg Q1H prn for pain/SOB [shortness of breath]. The Roxanol order was updated. Further review of R1's EHR revealed the following physician orders entered for morphine sulfate: 05/24/24: Morphine 20 mg/ml (milligrams per milliliter) 0.25 ml (5 mg) every one to two hours PRN (as needed) for pain and shortness of breath (order was discontinued on 05/26/24 at 02:53 PM). 05/26/24 02:53 PM: Morphine 20 mg/ml 0.5ml (10 mg) every one hour for pain and shortness of breath. 05/26/24 09:39 PM: Morphine 20 mg/ml 0.5ml (10mg) every one hour as needed for pain and shortness of breath. A review of R1's medication administration record (MAR) revealed that on 05/26/24, between 02:53 PM (when R1's morphine sulfate order was doubled from 5 mg to 10 mg and changed from as needed to scheduled every one hour) and 09:39 PM (when the order was clarified and changed to as needed), R1 was given morphine sulfate at 04:32 PM, 05:00 PM, 06:31 PM, and 09:00 PM. The MAR documents that her family declined/refused the 07:00 PM and 08:00 PM doses and requested that the order be clarified. After the order was clarified and changed to as needed (at 09:39 PM), R1 did not receive any further morphine sulfate until the next morning. On 07/10/24 at 11:01 AM, an interview was done in the Conference Room with Resident Care Manager (RCM)1. RCM stated that there was a data entry error made on the 05/26/24 02:53 PM order, and that the order should have reflected that it was PRN and not scheduled every one hour. At a second interview done at 11:25 AM, RCM1 agreed that he would expect a nurse to question/clarify any order scheduled for every one hour, but especially a narcotic. On 07/11/24, a review was done of the Nurse Competency checklists for the Licensed Practical Nurse (LPN)1 who took and incorrectly transcribed the morphine sulfate order on 05/26/24, and the Registered Nurse (RN)1 who administered the morphine sulfate every hour times 3 hours, without clarifying the order until it was questioned by a family member. LPN1, employed at the facility as an LPN since 03/03/24, had been initialed off in every topic area on the checklist, including Documentation of Telephone/verbal orders, by RCM1 on 03/04/24 and 03/05/24. What was noted to be lacking on the checklist, however, was that none of the individual skills within each topic area had been checked off as completed, and neither were the assessment methods (i.e., verbalized understanding, return demonstration, observed in clinical area, documentation review). RN1, employed at the facility as an RN since 04/08/24, had been checked off in every skill area under the topic of Medication Management, by the Staff Development/Educator on 04/10/24, however, the only assessment method checked was Verbalized understanding. On 07/11/24 at 10:27 AM, a phone interview was done with the Staff Development/Educator (SD). During a concurrent review of both Nurse Competency Checklists, SD agreed that neither checklist had been completed as it should be. For LPN1, SD stated, everything should be checked off [with regard to the individual skills within each topic area], and agreed that some type of assessment method should also be checked off. For RN1, SD verified she was the one who checked off every box under each topic area and individual skill, however, she did not provide the one-on-one training, so did not feel comfortable checking off any of the assessment methods. SD agreed that for the topic of medication management, the preferred assessment methods to ensure competency would be observed in clinical area or return demonstration. SD confirmed that the assessment method(s) should have been checked off by her one-on-one trainer. SD could provide no explanation why RN1's one-on-one trainer had not been the one to check her off on each skill, or why she, as the SD, had checked/initialed off on all the individual skills when she was not the one-on-one trainer.

Based on record review and interview, the facility failed to ensure pharmacy services included a thorough process to assure accurate reconciliation and accounting for all controlled medications in order to promptly identify loss or potential diversion. Findings include: Resident (R)1 was an [AGE] year-old female admitted to the facility on [DATE]. On 05/23/24, R1 was admitted to hospice for end-of-life care. On 05/28/24, R1 passed away at the facility while on hospice. On 06/24/24, the State Agency (SA) received an anonymous complaint (ACTS #11034) regarding the care R1 received at the end of her life. Amongst the allegations made was a concern that R1 had received too much morphine sulfate on 05/26/24. On 07/09/24, while investigating the complaint, a review of R1's medication administration record (MAR) and progress notes was done while comparing it to the Controlled Drug Record (log) for the morphine sulfate. Several discrepancies were found while attempting to reconcile the MAR and log. The MAR documents 0.50 milliliters (mls), equivalent to 10 milligrams (mg) of morphine sulfate was administered on 05/26/24 at 09:00 PM, however there is no corresponding sign out on the log between 06:30 PM (administered at 06:32 PM) and 12:55 AM the next morning. Progress notes and the log indicate 0.50 mls (10 mg) was signed out, half the dose was wasted per family request, and 5mg was given on 05/27/24 at 12:55 AM. Review of the MAR reveals the first dose administered on 05/27/24 was documented as given at 07:50 AM, but the charted date [and time] in the comments for that dose is 05/27/24 02:04 AM. No 12:55 AM dose was documented on the MAR. On the back of the log are documentations of refusals of half the ordered dose, requiring a waste of half of what was signed out, three times on 05/27/24 and twice on 05/28/24. The MAR reflects a half dose was administered only once on 05/27/24 and no occurrences on 05/28/24. On 07/10/24 at 11:01 AM, an interview was done with Resident Care Manager (RCM)1 in the Conference Room. When asked what the process was for narcotic reconciliation and accounting, specifically who should be reviewing the narcotic logs, RCM1 stated that it is the responsibility of the RCM to review and reconcile all the narcotic logs at the end of every month. RCM1 confirmed he did not review/reconcile the narcotic log for R1's morphine sulfate and stated that he should have.

Based on record reviews, interviews and observation the facility failed to ensure R8 was being protected from further verbal abuse from R11 after an incident on (MONTH) 13, 2019 where R11 was verbally abusive and aggressive towards R8 endangering R8 of psychosocial harm. Findings include: Complaint On 05/16/19 an anonymous complaint was filed with the State Survey Agency (SSA) reporting that R8 had been verbally abused and threatened by R11 and the facility had failed to put in place interventions to protect R8 from further verbal abuse and threats from R11. Event Report 1) On 05/15/19 at 06:19 PM, the facility transmitted an Event Report (ER) to the State Survey Agency (SSA) regarding an allegation of resident to resident abuse. The allegation involved Resident R11, the alleged perpetrator and R8, alleged victim. On 05/13/19 at approximately 06:20 PM, R8 stated that he wanted to go home. At this time R11 (who was seated approximately 7 feet away from R8) stated Go on and cry, you [***] ing Crybaby, that's why your mom doesn't want you. Registered Nurse (RN)1 intervened with a verbal warning to R11. R11 responded in a raised voice, I don't give a [***] about him he's a [***] ing Jap piece of[***] RN1 wheeled R11 away from the nurses' station, as well as, the other residents who were present. On the way to her room, R11 continued screaming, I don't give a [***] , you [***] ing jap piece of[***] I'll kill you. R11 began raising her voice to the RN, stating, [***] you you cunt, don't tell me what to do. R11 was taken to her room and continued to yell profanities at RN1. 2) On 05/17/2019 at 07:20 PM the facility transmitted a completed report on the incident of verbal abuse (resident to resident) that occurred on 05/13/19. The report stated that the ombudsman had been contacted and informed the facility to assess the two residents in regard to their ongoing relationship: if R8 wanted R11 relocated to the other side of the building; if R8 felt verbally abused; and whether they felt the need to contact Adult Protective Services (APS) to make a formal report. The facility asked both R8 and R11 if they wanted to make a report to APS and both residents verbalized they did not. The completed report went on to to say that R11's care plan had been updated to reflect that she may use vulgar language when speaking to each other, use of racial slurs & demeaning phrases at times: staff to approach (R11) in a calm manner & re-approach at a later time if agitated or uncooperative; do not take what (R11) may say out of anger or irritation personal as this is a way that she lets her feelings out. R8's care plan was updated to reflect that he & his female friend speaks w/ vulgar language, racial slurs, & demeaning phrases - they have been speaking that way to each for the past 3 - 4 years: separate the two pals if it seems to get out of hand: at times he may get upset & feel lonely & state that he wants to go home: he likes to talk story w/ the staff using profanity & staff may use profanity back at him. Investigation 3) On (MONTH) 28, 2019 a review of R8 and R11's medical records was conducted. R11's medical record listed admission [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. 4) Some of the admission [DIAGNOSES REDACTED].; Presence of Cerebrospinal Fluid Drainage Device; Hypertension; Dementia without Behavioral Disturbance; and Presence of Prosthetic Heart Valve. 5) Further review of R8's medical record on 05/28/2019 had documented in the Kardex under Behavior/Mood Allow my female friend to speak to me with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what she says. If it seems that its getting out of hand, please separate us. 6) Further review of R11's medical record on 05/28/19 had documented in the Kardex under Behavior/Mood Allow my male friend and I to speak to each other with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what he says. If it seems that its getting out of hand, please separate us. 7) A phone interview was conducted with R8's attending physician on 05/30/19 at 10:50 AM. This physician has been R8's attending physician since the resident's admission in (MONTH) (YEAR). The physician stated R8 has poor ability to comprehend and understand what is being said to him, R8 is able to understand simple commands, answer simple questions with simple replies and that R8 functions at the level of a 5-6 year old. 8) After the incident on 05/13/19 at approximately 06:20 PM, the facility had determined that corrective action would be to move R11 to another room, away from the alleged victim. The move did not occur and reasons varied from one of the residents was asleep, and there were not enough staff available to move R11. It was also reported that R11 and R8 were in agreement not to make a room change. 9) Lunch time dining observation was made by two surveyors on 05/28/19 who observed R8 and R11 seated at the same table. Interviews with Certified Nursing Assistant (CNA) and Registered Nurse (RN)1 on 05/28/19 validated that R8 and R11 have continued to be seated at the same table for all meals since the incident on the evening of 05/13/19. On the afternoon of 05/28/19, R8 and R11 were observed by two surveyors sitting side by side outside of the nurses station. No one was present to supervise their interactions. 10) Interviews conducted on 05/28/19 with CNA and RN, and then on 05/29/19 with the Minimum Data Set Coordinator (MDSC), RN2, SSA, DON, and Administrator all confirmed the incident that occurred on the evening of 05/13/19 was an occurrence of resident to resident verbal abuse. The facility did not provide any documentation or evidence that corrective action was taken to separate the alleged perpetrator away from the alleged victim. During an interview with CNA on 05/28/19, she stated that R8 had once told her that R11 is mean, she is just mean, and I friend, so just taking it. Interviews with both the CNA and RN1 on 05/28/2019 stated that they had never heard R8 swear, use racial slurs or berate anyone. RN1 stated R8 has the mentality of a ten year old boy and someone needs to advocate for him. RN1 went onto to say the nurse who witnessed and diffused the incident was trying her best to advocate for the residents and ensure the residents were safe and the correct reporting procedures were being followed. 11) On the morning of 05/28/19, R11 was interviewed and she admitted to the use of bad words towards R8 and is aware this is not okay. R11 was more concerned that she was not being allowed visitation with her boyfriend that she wants to marry. R8 was interviewed on 05/28/2019 and stated he feels sad when R11 uses bad words towards him. When R8 was asked what abuse was he replied I don't know. R8 was interviewed again on both 05/29/19 and 05/30/19 and asked what abuse was, both times R8's response was I don't know. 12) On 05/29/19 a phone interview with the legal guardian/mother of R8 was conducted. She stated she had been notified of the incident on the evening of 05/13/19. She expressed her concern that R8 continues to sit at the same table for meals with R11 and is often left sitting beside R11. She states she has witnessed while visiting R8, R11 being bossy and swearing towards R8 and also behaving in this manner to other residents and staff. She also expressed her distress that the facility continues to allow this to occur as her family does not and has never used swear words in their home. 13) Observations were done by two surveyors of R8 interacting in activities on 05/29/19, 05/30/19, and 05/31/19. During these observations it was observed that R8 would repeat anything that was being said twice. This occurred during each observation. During observation and conversation with R8 during these times, R8 would repeatedly state I wanna go home. At no time did the two surveyors during observation, interview or conversation with R8 hear R8 use any profanity. 14) During interviews with all the staff noted in point (10), they were able to articulate what abuse is, the different types of abuse and the need to separate the perpetrator from the victim to avoid further incidents of abuse occurring to prevent any harm occurring. Interviews conducted on 05/29/19 with MDSC, Administrator, and MD who all acknowledged that the incident that occurred on the evening of 05/13/19 was verbal abuse, stated that updates to the Kardex reflected the resident's choices and preferences and further corrective action was not required as that is the way they always talk to each other, and talking that way was a local culture thing. The failure to take corrective action to protect R8 from further verbal abuse from R11 may result in serious psychosocial harm to R8. All residents in the facility are at risk of psychosocial harm from the behaviors and language used by R11. In addition, R11's behavior puts her at risk as another resident may take offense which may result in an altercation/abuse (physical/verbal).

Based on interviews and medical record review, the facility failed to ensure Resident #8 was served the correct specialized diet that resulted in the resident choking on his food and developing aspiration pneumonia. Findings: A medical record review was conducted on 08/15/2018 and the following was found documented in the record, that a speech therapist report dated 11/30/2017 had documented that Resident #8 required a puree diet with nectar thick fluids as he was at risk of aspiraton. The specialized diet ordered for this resident has not changed since the date of that report. A nursing note dated 07/21/2018 had documented that the Resident #8 had a continuous wet moist cough, gurgling, rales all four lobes, spitting whitish thick saliva after dinner. The doctor was notified and gave an order to send Resident #8 to the emergency room . They also documented that the Director of Nursing (DON) and Administrator were notified. The patient history that was documented on the Emergency Department report dated 07/21/2018 stated that the patient had arrived from Legacy via AMR transport and that patient had been given the wrong texture diet for dinner. Soon afterward Resident #8 had a course cough and increased dyspnea and his oxygen saturation was registering 84%. The clinical impression on the Emergency Department report had documented Aspiration pneumonia due to food (regurgitated). Further documentation on the Emergency Department report had documented, Normally he gets a pureed thickened meal although was given a regular diet. He was noted to have been choking and EMS was called. A diagnostic imaging report dated 07/21/2018 showed findings of bilateral basilar lower lobe consolidations, greater on the left than right with impression documented Bibasilar airspace disease suggestive of aspiration pneumonia. Documented date 07/23/2018 by the doctor at Legacy stated, Patient seen for follow-up aspiration pneumonia. I was called over the weekend that he was given the a regular tray for dinner instead of his modified diet and after dinner on Saturday was noted to have wet moist cough and gurgling. The doctor had also documented that Resident #8 had been sent to the Emergency Department, with intravenous antibiotics ordered for the next 7 days and oxygen therapy as required. On 08/15/2018, the food service manager was interviewed and stated he had been informed that Resident #8 had been incorrectly given a regular diet tray, and before staff were able to swap it out, that Resident #8 had started to eat the regular diet. The doctor was also interviewed on 08/15/2018 and confirmed that she had been notified that the resident had been incorrectly served a regular diet, choked on it, developing a moist cough and gurgling. She ordered that he be sent to the Emergency Department were he was diagnosed with [REDACTED].

Based on record review and interview with staff members, the facility failed to ensure 2 (Resident 69 & Resident 141) of 3 sampled residents were free from accident hazards. Findings include: 1) On 4/27/2018 an anonymous caller filed a complaint with the State Agency (SA) reporting Resident 69 (R69) had a fall which resulted in a [MEDICAL CONDITION]. At the time of the fall, the facility reportedly did not have a nurse to watch the falls. R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review done on 5/9/2018 at 12:15 PM noting R69 was heard yelling for help on 4/24/2018 at about 2:25 PM. The resident was found on the bathroom floor. The resident reported she had a fall after using the toilet and requested the paramedics to be called. At 6:15 PM the paramedics picked up R69. R69 was admitted to the acute hospital. Subsequent progress note documents the facility was informed R69 passed on 5/2/2018. Further record review found a quarterly Minimum Data Set (MDS) with an assessment reference date of 2/19/2018 documenting R69 yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was conducted. In Section G. Functional Status, R69 requires limited assistance with One-person physical assist for toilet use (how resident uses the toilet, transfers on/off toilet) and was coded to be always continent of bowel and bladder. The resident was also noted to be not steady while moving on and off the toilet, only able to stabilize with staff assistance. A review of Section N. Medications notes R69 received antidepressants and hypnotics during the last 7 (seven) days and opioid in the last six days. In Section O. Special Treatments, Procedures and Programs, R69 was noted to receive [MEDICAL TREATMENT]. On 5/21/2018 at 11:58 AM, R69's medical record was reviewed at the acute hospital with the assistance of the Quality Manager. On the afternoon of 5/21/2018, copies of the ED notes, nursing progress notes and death summary was obtained from the hospital. A CT scan of the pelvis was done on 4/24/2018 at 7:26 PM. The impression included displaced [MEDICAL CONDITION] iliac wing, fractures of the right pubis and superior pubic ramus, and moderate free fluid within the pelvis. An x-ray was done on 4/24/2018 at 7:32 PM. The impression was fractures of the right pubis and right superior pubic ramus. A chest x-ray was done on 4/24/2018 at 7:34 PM. The results found cardiomegaly and mild vascular congestion with suspect of small right pleural effusion. R69 was admitted to the hospital. The progress note of 4/25/2018 at 3:55 AM documents R69's was not well controlled and she was asking for pain medication approximately every hour. Subsequent nursing note of 4/25/2018 at 7:25 PM documents the pain control was the main issue during the shift. R69 received [MEDICAL TREATMENT] on 4/26/2018, 4/27/2018, and 4/28/2018. The nurse's note for 4/29/2018 documents R69 was lethargic with decreased respiratory rate, [MEDICATION NAME] was administered. At 4:30 PM, R69 was agitated and [MEDICATION NAME] was administered for agitation. The documentation of 5/1/2018 at 2:37 PM documents pain control was still an issue and R69 lets pills sit in her mouth or chews them, even when prompted to drink water. At 9:17 PM R69 took medications that were crushed with jello. On 5/2/2018 at 12:28, the nursing assistant notified the nurse it was difficult to get a blood pressure on patient during vital sign check. The nurse arrived to assess R69, R69 took her last breath, unarousable to sternal rub, no heart beat and pulse. At 12:29 AM the physician confirmed R69's death. A review of the Death Summary notes the immediate cause of death, pelvic fracture as a result of dementia with end stage [MEDICAL CONDITION] and [MEDICAL CONDITION] as contributory causes. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]., one tablet three times a day related to diabetes mellitus with foot ulcer (start date of 3/15/2018); [MEDICATION NAME] capsule, 15 mg, by mouth at bedtime related to [MEDICAL CONDITION] (start date 11/13/2017); and [MEDICATION NAME] Tablet 5-325 mg., one tablet by mouth every 8 hours as need for breakthrough pain related to diabetes mellitus with foot ulcer (start date 3/14/2018). On 5/22/2018 at 8:24 AM an interview was conducted with the resident's daughter. The daughter reported her parent missed two [MEDICAL TREATMENT] treatments, went to [MEDICAL TREATMENT] and fell upon return from [MEDICAL TREATMENT]. The resident's daughter further shared that her parent did not know what happened and while hospitalized was not talking as much. The daughter reported her parent had difficulty with transferring as her parent had a stroke and is unable to use one side of her body. Inquired whether the resident had a previous fall, the daughter replied that she was not aware of other falls. A review of the care plan provided by the facility was done on 5/22/2018 at 11:12 AM. The care plan for activities of daily living notes R69 uses the toilet with limited to extensive assist of one staff member and requires extensive assist of one staff member for all transfers. A care plan was developed for falls, noting the resident is at risk for fall related to the following: chronic medical condition; [MEDICAL CONDITION], Stage 5; right side weakness; falls risk score of 17 (high); history of falls; and weakness/deconditioning. Also documented is on 3/22/2018 at midnight here was a change in elevation, unwitnessed. Further review on the afternoon of 5/22/18 found a progress noted dated 3/23/2018 at 6:21 AM which documents R69 was on alert charting for status [REDACTED]. The resident approached the nurse's station requesting a dressing for bleeding to her left upper arm at approximately 0000 (midnight). The resident reported to the staff member that while attempting to transfer from the toilet back the wheelchair, she slipped and landed with her butt on the toilet seat twice. The resident acknowledged she is aware that she needs to call for help and was apologetic for not doing so. Subsequent entry dated 3/23/18 at 9:36 AM documents the resident reported she transferred herself, lost balance and fell . The resident reported that she able to care for herself without staff assistance and did not need to speak to staff concerning the need for transfer assistance. The staff member reminded R69 that safety is the primary concern. The staff member documented to continue with care plan presently in place. Further review could not find documentation of a root cause analysis following the first fall and there was no revision to the care plan. On 5/22/2018 at 11:16 AM, concurrent record review and interview was done with Staff #8. The staff member reported the facility had a falls nurse to review residents falls and identify risks. A request was made to the staff member to find documentation in the record of a progress note regarding possible factors that contributed to the resident's fall and whether the facility revised the resident's care plan to prevent future falls. The staff member confirmed there was no documentation in the electronic record of a root cause analysis related to the fall in (MONTH) (YEAR) or a care plan revision based on an assessment. On 5/22/2018 at 2:05 PM an interview was conducted with the Administrator and Director of Nursing (DON). Information related to the resident's non-compliance with [MEDICAL TREATMENT] before the falls and the resident fell while independently using the toilet despite the identified need for limited to extensive assist for toilet use were shared with the staff members. The DON acknowledged the resident's history contributed to the situation by refusing [MEDICAL TREATMENT] and was terminal with confusion which placed her at risk for falls. The DON also acknowledged that the resident was transferring to the toilet without calling for assistance which also contributed to the risk for falls. The DON stated the resident may have benefited from being monitored more closely. The Administrator reported that a pattern or trend surrounding the falls were indicated and the fall nurse should have assessed the fall and prepared an incident report. 2) On 05/21/2018 the State Agency received an anonymous complaint with concern that Resident 141 (R141) eloped. The complainant reported on 04/22/2018, R141 was found outside of the facility in the parking lot. R141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the facility found the front entrance to the facility automatically opens and closes when the sensor is triggered. There is a reception counter in the front which is staffed by one person. There are other doors in the facility which chimes when opened and closed. On 05/10/0218 at 1:30 PM R141 was observed out of bed, the resident's room is near the nurse's station (the first room next to the nurse's station). The bed was placed in a low position and a candy cane rail was up. R141 was found in the activities room with other residents. The resident was seated in a wheelchair at the table manipulating small rectangular blocks. On 05/21/ at 10:20 PM, R141 was observed in the large activity room playing BINGO with the assistance of another resident. There was a wheelchair alarm attached to the back of the chair. Subsequent observation at 11:00 AM and 11:25 AM found R141 was participating in BINGO. An observation at 1:30 PM found R141 in the activities putting the blocks back into the box and subsequently at 2:15 PM the resident was observed in the small activity room folding small bath towels. On 05/22/2018 at 2:08 PM and 2:55 PM, R141 was observed in his room, seated in the wheelchair looking at a newspaper. Observation on 05/23/2018 at 11:05 PM, R141 was seated at a table in the courtyard with other residents. He was folding towels while other residents engaged in individual activities. At 12:51 PM the resident was in the dining room, he had finished his lunch On 05/24/2018, R141 was in his room visiting with his son. The resident's son reported it was his father's birthday and later the family will have a celebration lunch with R141. The resident's son comes to visit his father and states his father can walk in his room for short distances independently. At 9:10 AM, R141 was observed to wheel himself out of his room, the staff member at the nurse's station saw the resident emerge from his room and approached the resident. The staff member asked a Certified Nurse Aide (CNA) to take the resident for a walk around the unit. The CNA wheeled R141 around the unit and then took him to the activities room. At 1:01 PM, the resident was observed to be parked in his wheelchair by the nurse's station. On the afternoon of 05/21/2018 a record review was done. R141 was admitted to the facility from home. A review of the resident's admission Minimum Data Set with assessment reference date of 03/23/2018 notes R141 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. In Section E. Behavior, R141 was not coded to have indicators for [MEDICAL CONDITION], behavioral symptoms, rejection of care, and wandering. R141 was noted to require extensive assistance with one-person physical assist for bed mobility and transfer, locomotion on and off unit did not occur and mobility devices included a wheelchair. The resident was not coded to have functional limitation in range of motion of the upper and lower extremities. A review of the progress notes found no documentation of R141's elopement/wandering to the parking lot. There was no care plan to address resident's elopement/wandering. Interviews were conducted with R141's direct care staff members on the afternoon of 05/21/2018. At 2:10 PM, Staff #1 was not aware R141 eloped from the facility. At 2:12 PM, the Activities Director (AD) stated she was not aware of R141 exiting the facility. The AD reported R141 can propel himself in the wheelchair; however, he is always engaged in activities. An interview was done with Staff #2, the staff member reported R141 can stand and ambulate and can propel his wheelchair if he wants to do it. Upon query, the staff member responded that she is not aware of R141 wheeling himself out of the building. At 2:20 PM, Staff #3 was interviewed. The staff member reported R141 can stand but not independently and requires close supervision. The staff member was not aware of an incident of the resident leaving the building. At 2:20 PM, Staff Member #4 stated R141 has never left the building but tries to go down the hall to look outside (the door by the therapy room). An interview was done with Staff #5 at 2:25 PM. The staff member reported having knowledge of R141 being found at the front door and was not sure when this occurred; however, the resident did not exit the facility and was escorted back to his unit. The staff member further reported R141 wants to check on his car in the garage. The staff member shared that most of the time there is a staff member at the reception counter at the front door; however, there may be times when the reception counter is not staffed. The staff member reported the front door is locked at 8:00 PM and opened at 7:00 AM and the staff watch the resident and work together. The staff member stated it was Staff #6 who found R141 at the front door. Staff #6 was observed standing at the reception counter with Staff # 5. The staff member was asked about finding the resident at the front door. The staff member reported she did not remember this incident, Staff #5 insisted Staff #6 found R141 at the door. Again, the staff member could not recall this incident. Subsequently, on 05/22/2018, Staff #5 stated thinking back, it was not Staff #6 that found R141 at the door, it was Staff #7 and this staff member is on leave. Staff #5 reported she learned about the incident during a stand up meeting and reiterated, the resident did not leave the building. The staff member further reported the resident can propel himself for a short distance and has not been identified as a wanderer. On 05/21/2018 at 2:45 PM an interview and concurrent record review was done with Staff #8. The staff member confirmed there was no documentation in the progress notes related to elopement or finding the resident at the front door of the facility. The staff member has no knowledge of the incident; however, stated if the interdisciplinary team members were aware of this incident, an assessment and care plan would be developed. On 05/24/2018 at 8:45 AM an interview was conducted with R141's son. The son reported his father is doing good at the facility, he has not had any falls. Inquired whether the facility notified him of any significant event related to his father. Inquired what notifications has he received from the facility, he replied the facility called him when his father's bed sore healed. The resident's son also showed the surveyor a bandage on his father's knee and explained the facility's process for labeling the sore. The resident's son was asked whether his father wanders, the son reported his father likes to stand up and wants to go and check on his car. A review of the standup minutes found no documentation of R141 eloping or managing to independently propel himself to the front entrance of the facility. Interview was done with Staff #7 on 05/25/2018 at 8:50 AM. This is the staff member that was identified by Staff #5 to have witnessed R141 at the front entrance of the facility. Staff #7 responded that she did not find R141 at the front entrance of the facility, she further reported that she has not observed R141 off the facility units. The staff member is able to identify R141.

Based on observations, medical record reviews and interviews the facility failed to provide sufficient preparation and orientation to Resident 140 (R140) to ensure a safe and orderly discharge from the facility. Findings Include: On 04/30/2018 the State Agency received a complaint with concern that R140 had been discharged from the facility on 09/08/2018 in an unsafe manner. On 09/08/2017 R140 was discharged at 05:30PM to Manago Hotel. According to Google maps, Manago Hotel is located 86.7 miles from the facility and is estimated at being a 1 hour and 48 minute drive from the facility. Manago Hotel was established in 1917 and still maintains the original building as the functioning hotel. Surveyors visited the Manago Hotel on 05/08/2018. The building is the original wooden structure that consists of various narrow ramps that incline upwards or downwards as well as many steep staircases between the different levels. There are no elevators in the building. One of the hotel workers was interviewed on 05/08/2018. They recalled R140 arriving at the hotel that evening at approximately 07:30 PM in a vehicle driven by a LYFT driver. The hotel worker stated, he was very lethargic, unable to walk on his own and one of his feet was purple, but she could not remember which one. She stated that R140 did not fully understand why he was coming to the hotel from Hilo. He was unable to exit the vehicle himself. He was assisted by the LYFT driver and the hotel manager into the wheelchair that had been sent with him along with boxes of his belongings. The hotel worker stated they offered him food, but he did not respond so they gave him a sandwich. She also stated that a reservation had been made that day by the facility for one night and that no plans for payment had been made. She also stated that R140 had no identification, credit card/s or money on him, or any documentation from the facility. She stated it was evident he was unable to care for himself or mobilize independently, so the LYFT driver called EMS to take him to the local hospital. On 05/08/2018/, surveyors went to the local hospital where R140 was taken to review his medical record. The physician who completed an assessment of R140 in the Emergency department on 09/08/2017 documented in the medical record of R140 that he was a poor historian, unable to give details of his medical history, and inform them what medications he was currently taking. The hospital physician contacted the facility physician who informed him that he had a psychiatric evaluation that determined that he had capacity to make his own decisions. He demanded discharge, and stated he wanted to go to this Hotel. According to this physician, nursing discharge managers told her that he had a source of income, and a place to stay at this hotel. She did recently workup the foot pain, with an MRI for osteo[DIAGNOSES REDACTED] which was negative for osteo[DIAGNOSES REDACTED]. The physician had also documented that the previous care home had refused to have him back. The EMS report dated 09/08/2017 had documented Pt relates being transported from Legacy Hilo Rehabilitation and Nursing Center via Lyft driver to Manago Hotel with all his belongings. Pt relates Legacy Rehab center told pt that they had set up a room for him to live in and seek treatment for [REDACTED]. Pt and hotel staff were unaware of the situation, hotel staff then activated 911. Upon EMS arrival pt complaining of bilateral foot pain. Lyft driver then tried to contact Legacy Rehab Center with no success. HPD was contacted for possible abandonment case. On 09/08/2017 a Registered Nurse in the Emergency Department had documented in the medical record of R140, I was able to speak with the physician who had been caring for him at the skilled nursing facility. The patient has apparently been refusing all of his medications for the past 4-6 weeks. He has been violent with the staff there, injured other residents, and assaulted nursing aides with his cane. He had a psychiatric evaluation that determined that he had capacity to make his own decisions. He demanded discharge, and stated he wanted to go to this Hotel. Documentation for Admission History and Physical in the medical record dated 09/09/2017 stated that R140 's presenting chief complaint was Altered mental status. Further documentation stated He was evaluated by psychiatry and thought to have at least moderate dementia and lacked capacity. On 09/09/2017 a psychiatry consult note was documented in R140 ' s medical record at the hospital. The documentation stated, Insight is poor. Judgment is poor On Cognitive exam, the patient is Oriented x 1 only. He does not know where he is or what kind of place he is in. He cannot give the date, or year. Cannot name the president or the governor. assessment: The patient is significantly demented. He is unable to perform ADLs, manage finances or care for himself. DX: Dementia, severe. In my opinion, he lacks capacity to make medical decisions. R140 was admitted to inpatient medical-surgical with a [DIAGNOSES REDACTED]. Case management had documentation in the medical record of R140 throughout his admission at the hospital until appropriate placement was found for him. On 09/11/2017 it was documented, patient discharged from Legacy and sent to Kona in a taxi to Manago Hotel. Per Manago there was no reservation for patient. Patient was confused upon arrival and sent to hospital. Patient shares he was living at Regency for a long time. He verbalizes he does not know why he had to leave, patient shared, I don't know why they sent me to Manago Hotel, why didn ' t they send me home? The hospital made requests to the facility on ,[DATE] for R140's medical records with follow up phone calls daily. Documentation on 09/13/2017, DON spoke again to Legacy owner who consulted with his lawyer re: case. Per lawyer recommendation, if currently treating MD feels patient does not have capacity and a note documenting as such is provided to Legacy then to benefit the patient discharge planning, records will then be able to be shared. Owner requests once documentation completed to please forward to his email for review and he will forward it to his facility with instructions to forward records as requested. Spoke to hospitalist who agrees presently patient does not have capacity and records will be most beneficial for pt care. On 09/14/2017 fax was received from facility to hospital that included admission record, discharge summary and admission History and Physical for R140's stay at the facility. On 09/15/2017 it was documented in the case management notes that the owner of the facility had been informed of what had been received so far at the hospital and notified him that the case manager (CM) had called medical records requesting additional information. Further documentation stated, No faxes or return calls from Legacy Medical records department so far today, called again this afternoon, no answer, left a VM at 13:30 requesting again the psych evaluation conducted by psychiatrist, SW notes, CM notes and nurses notes for the last week leading up to pt discharge. On 09/18/2017, CM had documented, called direct line for Legacy, rang unanswered, unable to leave VM, rang approximately a dozen times and went straight to off hook signal. Attempted again with same result . On 09/19/2017 CM had documented, call to Legacy to follow up. No answer, was able to leave a VM requesting return call. Called Legacy direct line, transferred to SW, confirmed her direct line. Per SW patient left facility AMA, however records received so far include a discharge summary. Inquired SW re:d/c summary which instructs patient to follow up with PCP in a week, asked if she knew who patient PCP was, as it was not listed in d/c information and if a post d/c appointment had been made for him prior to leaving. Per SW patient PCP is a Nurse Practitioner (NP). CM asked if pt PCP was located in Kona or Hilo, she shared PCP in Hilo. Inquired again, if pt was discharged knowingly to Kona, is it regular practice to not assist patient with establishing primary care in the area patient is discharging to? SW then directed CM to follow up with facility DON, as she was present during pt discharge, direct contact number obtained. The Legacy DON was called and a VM requesting a return call. CM called Legacy medical records to state they were still awaiting requested records and requested again psych evaluation completed by psychiatrist noting R140 to have capacity. CM also requested a return phone call if the requested records could not be found. CM asked medical record staff at Legacy if a patient leaves AMA at their facility as SW believes patient was, if there was an AMA form signed by patient. If so they would like a copy of the AMA form. The requested documentation was received on 09/19/2017. Also documented on 09/19/2017 by the CM was that R140 arrived at the hospital with no ID, insurance cards, bank cards, cash and no medications. On 09/21/2017, CM documented in the R140's medical record, received copy of patient current ICF L[NAME] 1147. 1147 indicates patient has noted impairment of vision and hearing, has a problem with both short term and long term memory, needs supervision and/or assistance with feeding, has difficulty communicating his needs or wants, is disoriented and/or disruptive, aggressive and/or abusive, requires minimal/standby assist with transferring, able to walk with minimal assistance, ambulates with a device but unsteady and subject to falls, patient is continent of bowel with cues, incontinent of urine at least once a day, unable to bathe without total assistance and patient requires physical assistance for dressing and personal grooming on a regular basis. On 09/22/2017, CM documented in R140's medical record, discussion with Corporate and strong feelings from Medial staff confirming that patient discharge from Legacy was unsafe and put a vulnerable, demented elder at risk, it is recommended that an APS report be filed. On 09/29/2017, CM documented in R140's medical record that patient was under the protection of APS and they will be managing his finances and assist with safe discharge. an order for [REDACTED]. R140 was discharged from the hospital to another Long Term Care facility on the Big Island. The discharge summary from the hospital dated 02/28/2018 had documented , 76 yo M h/o HTN, DM, who was brought to the ER due to confusion. Please see H&P for details of his presentation, but in short, he had been deemed competent and discharged from Legacy SNF, send to Manago hotel by Lyft. As they did not have vacancy, and as the patient has dementia he was sent to the ER. During his prolonged hospital stay, there have been no acute medical issues besides situational [MEDICAL CONDITION]. He does not have capacity to make medical decisions for himself and has little to no insight into his circumstances. He is overall surly and stubborn, not agreeing to physical examination, and only answering few and simple questions. On 05/10/2018 the Manago Hotel manager was interviewed via a telephone interview. The Manager stated staff #11 called on the same day R140 arrived to make a reservation for one night. They did request on a room on the second floor. The manager stated a credit card number was given for the reservation along with an email address. The email address was rejected and they could not verify the reservation at the hotel. The manager stated when R140 arrived at the hotel at approximately 07:30 PM that evening, he stated there was major problems with his leg, it appeared black and looked like his foot was dead and he had no ID on him. There was a wheelchair and several boxes of belongings that had accompanied R140 to the hotel. The hotel manager stated R140 was confused and did not know what was going on and he was unable to do anything for himself. The hotel manager went onto to say that the facility had not communicated the needs of R140 to them. The hotel manager stated they attempted to call facility with no success. The hotel manager and the LYFT driver assisted R140 into the wheelchair. The hotel gave R140 a sandwich to eat and the LYFT driver called EMS for R140 as the hotel was unable to accommodate his needs. The hotel manager stated, To someone in his condition and just being dumped. On 05/10/2018 the LYFT driver was interview via a telephone interview. The LYFT driver stated late on the afternoon of 09/08/2017 he received a transfer request from Legacy from a woman (whom he could not recall the name of) for a resident to go to Kona. He went onto say when he arrived at the facility and that a staff member met him with the resident in a wheelchair and 2-3 boxes of the resident's personal belongings. The driver stated, the woman running the show had other people to help load him in the car. The LYFT driver stated he asked the facility staff if the resident had been fed and toileted and the staff responded with a yes. He said he asked the staff if there was any paperwork for the hotel, and the staff responded there was not, and that the hotel was expecting him, and everything was taken care of. The LYFT driver went onto say as he was leaving the parking lot of the facility, R140 stated to him if they are not home you will have to take me back and the driver asked what he meant, he replied you taking me to my family. The driver stated he informed R140 he was taking him to the Manago Hotel and resident insisted he was taking him to see his family. The driver stated he went and asked female staff member where he was going, and the staff replied that he was not going to family and that he was just confused. The female staff had one of the other staff go and talk to R140 and the driver once again requested paperwork but there was none. The driver stated they arrived at the hotel 2 ½ hours later and it was dark and raining. The hotel manager met them and stated he had a reservation but no funds to pay for the hotel. R140 had no credit card, ID or money on him, stated he was unable to care for himself and he appeared to be wheelchair bound. The driver stated he called EMS for R140 and also called Police for elderly abandonment. EMS arrived and took R140 to local hospital. The LYFT driver stated he made several calls to the facility asking for on duty manager, but no one called back. The driver stated, I felt that person was put in car for me to take him 100 miles plus as far away as possible. The driver also stated, The result was a dangerous situation for an elderly person for dumping this elderly person at hotel. He was a nice little guy. On 05/10/2018 the facility physician was interviewed. The physician stated R140 was constantly stating he wanted to leave to go to a place in Kona, but staff were unable to find this place. Staff then informed physician that he wanted to go to Manago Hotel. The physician stated her role in discharging residents was to ensure they were stable, have a PCP in place, home help if needed and to write up discharge summary. The physician stated R140 was a higher risk due to his status and that it was not a well-planned discharge. The physician went onto to state we have to allow people to make bad decisions as part of their rights. The physician stated she was informed R140 called a taxi himself and the DON informed her that he was demanding to leave, and everything was in place. The physician did not remember who the PCP was for R140. The physician was asked if he was demanding to leave why didn't they do an Against Medical Advice (AMA) and she responded, Making AMA causes insurance issues. The physician was asked if she thought it was a safe discharge and she responded by saying she felt she was misled about the circumstances and does not feel she was told the full story and if she knew what she knows now then, she would not regard it as a safe discharge. On 05/10/2018, staff #5 was interviewed. She stated the week before R140 left that he got nasty, calling her names. Staff #5 stated she did not have anything to do with R140's discharge but recalls he refused to sign discharge paperwork and that he was given Crisis Access telephone number and contact for a PCP. Staff #5 stated it was a planned discharge and the facility conducts discharge meetings for residents with upcoming discharges. When staff #5 was asked who was responsible for completing discharge summary, she replied it was the nurse completing the discharge to do so and continued to state she had nothing to do with his discharge. Staff #5 was asked why her digital signature was on all of the discharge summary items in the electronic medical record (EMR). She stated whoever opens the note and closes the note, it locks with their name. Staff #5 was asked if it was a planned discharge, why did it occur at 05:30 PM and she responded she got word of the discharge at 05:00 PM, that an aid took R140 to the front door and he got in a taxi. Staff #5 returned a little while after interview to state she had helped the RN with the discharge and believed he had been given medications at discharge. On 05/11/2018 the social worker (SW) was interviewed. The SW stated for those residents planning to return to the community, discharge planning commences on admission for them. The SW stated he remembered R140 coming to the facility around (MONTH) (YEAR) and had expressed desire to be discharged back into the community or an adult foster home. The SW stated that he had been informed that R140 was demanding to be discharged on [DATE] and that the notes had stated R140 had ambulated using a forward wheel walker (FWW) to the front door that day. The SW was asked if he thought it had been a safe discharge for R140 and he responded No. Medical record review or R140's record was conducted on 05/09/2018. The Minimum Data Assessment (MDS) completed on admission, had documented that R140 had a BIMS (Brief Interview for Mental Status) score of 6 out of 15. A score of 0-7 is indicative of a person being severely cognitively impaired. Documentation dated 08/17/2017 in R140's care plan stated that pre-discharge plan to be established with patient and caregivers and to be revised a week before resident is discharged . This never occurred. Staff #5 had documented on the 09/08/2017 in R140's EMR, Resident declined to sign d/c summary & inventory sheet prior to d/c today. Resident continues with inappropriate verbal and attempted inappropriate physical behaviors up until departure today w/o remorse. Resident did however leave this facility ambulatory w/FWW in stable condition. No documentation could be found in the medical record to support that discharge planning had occurred during his stay at the facility.

Based on observations, medical record review and facility staff interview, the facility failed to provide the adequate supervision and necessary safeguards to maintain the safety and well being of 2 residents resulting in actual harm (Resident 46) and an immediate jeopardy (IJ) (Resident 85). 1. Resident 46 was not provided two person staff assistance during bed mobility resulting in him falling and sustaining a laceration to his left forehead and subsequent hospitalization for metabolic [MEDICAL CONDITION], aspiration pneumonitis with hypoxemia and urinary tract infection. 2. Resident 85 was not provided staff supervison while ambulating outside of the facility while using his walker with O2 tank. Findings include: 1) On the morning of 3/13/18 at 10:30 A.M. Resident 46 was found lying in bed in his room. The resident stated incomprehensible words and was attempting to get out of his low bed with mats on both sides. He appeared disoriented and confused and calling out for assistance. A Certified Nurses Aide (CNA) arrived at Resident 46's room to assist him. An observation of Resident 46 on the morning of 3/15/18 at 9:30 A.M. found him seated in his wheelchair near the nurses station. He was alert and nonverbal. Over a period of one and a half hours, Resident 46 made several attempts to get out of his wheelchair while seated in the hallway. On one occasion Resident 46 was attempting to get out of his wheelchair and a CNA ran over to assist the resident. Several times from 9:30 A.M. to 11:00 A.M., Resident 46 was alone in the hallway without any supervision. A medical record review for Resident 46 on the morning of 3/15/18 revealed he was first admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the morning of 3/15/18, a review of Resident 46's fall risk assessments (dated 10/29/17 to 1/4/18) found scores ranging from 11.0 to 14.0, all of which are considered moderate risk for falls. Resident 46 had two witnessed falls on 10/31/17; one unwitnessed fall on 11/7/17; and one witnessed fall on 12/26/17. On the morning of 3/15/18, a review of the Falls huddle report for Resident 46 noted his fall on 12/26/17 occurred when a CNA changed the resident's brief without assistance. According to the Resident Assessment Instrument (RAI) dated 11/29/17, Section G (Functional Status) Resident 46 required 2 person assistance for bed mobility. Review of Licensed Nurse's note dated 12/26/17, 12:24 P.M. found, Reminded CNA that resident requires 2 person assist with bed mobility. On 3/15/18 at 2:00 P.M., a review of Resident 46's care plans found one for Activities of Daily Living (ADL) self-care performance deficit and/or limited physical mobility related to . impaired functional mobility. For bed mobility, the care plan stated, I require extensive assist by two staff to turn and reposition in bed. The intervention was initiated 10/30/17 and revised on 11/2/17. On 3/15/18 at 2:06 P.M., an interview of the Falls Nurse revealed Resident 46 experienced multiple falls. The Falls Nurse stated the facility determined the resident was accustomed to sleeping on the floor which was his preference in his home. The Falls Nurse reported Resident 46 often slid to the ground where he felt more comfortable as was his cultural practice. The Falls Nurse confirmed that Resident 46 required 2 person assist with bed mobility, which the CNA caring for him on 12/26/17 failed to do. The Medical Director noted on 10/31/17 that Resident 46 was high risk for falls and therefore stated, Given his behaviors and multiple falls, I do not feel that anticoagulation is safe. The risks clearly outweigh the benefits and since he has had multiple falls and only 3 days I believe I will have to take him off of the Eliquis. Will start him on low dose baby aspirin 81mg daily. A review of the Medication Administration Record (MAR) on the morning of 3/16/18 at 11:00 A.M. found Resident 46 refused the baby aspirin thirteen days in (MONTH) (YEAR) and twenty one days in (MONTH) (YEAR). There was no documentation to indicate the nursing staff notified the Medical Director of Resident 46's refusal of medications. A medical review on the morning of 3/14/18 at 10:00 A.M. found a Licensed Nurse's note dated 12/26/17 and stated Resident 46's brief was being changed by a CNA at 05:45 A.M. The CNA reported the resident was grabbing at the curtain on his left side and rolled over the bed and landed on the landing mat. The resident fell to the floor, hitting the left side of his head and sustained a 0.7cm laceration to his left eyebrow. The Medical Director saw Resident 46 on 12/26/17 at 11:13 A.M. for the fall when she noted he was no longer on blood thinners due to the high fall risk. She noted he was supposed to be on baby aspirin daily but reviewed the MAR and found he had not taken the aspirin in a week. At the time of her assessment, Resident 46's vital signs were stable and his neuro exam was unremarkable. Further review of Resident 46's medical record found a note dated 12/26/17 at 02:05 P.M. when the wound nurse noted, 0.7cm skin tear to left eyebrow. Small amount of drainage noted, no s/sx (sign and/or symptoms) infection as well. New order to cleanse with NSS, pat dry, apply hydrogel and cover with sheer bandage daily x 21 days. Another licensed nurse documented on 12/26/17 at 02:34 P.M., On alert for fall. Resident denies pain from fall. Skin tear to left eyebrow with saturated band aid, changed and applied new band aid. Neuro checks WNL (within normal limits). There was no documentation indicating the amount of drainage the Licensed Nurse found at 2:34 P.M., 29 minutes after the wound nurse changed the bandage when there was a small amount of drainage. Another licensed nurse created an entry dated 12/26/17 at 06:24 P.M. (over 12 hours since his fall) which stated, CNA notified LN (licensed nurse) that resident was not his usual self. Obtained blood pressure 166/64, heart rate 87, respiratory rate 20, temperature 99.1 degrees Fahrenheit axillary and oxygen saturation 95% on room air, blood sugar 217. Resident was alert, looked worried, drooling on side of mouth, pupil fixed and able to verbalize but not understandable. MD informed at 05:50 P.M. and got order to sent to emergency room .Resident left facility with medics at 06:15 P.M. A review of the hospital record on the morning of 3/15/18 revealed Resident was transported to the emergency roiagnom on the evening of 12/26/17 and admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. The emergency report specifically noted Resident 46 was brought to the emergency room unresponsive, concerning as a stroke activation. The source of information stated, emergency room records. Old records are not available, no records from (LTC) facility. No family is available. An interview of the Falls Licensed Nurse (FLN) on the afternoon of 3/15/18 at 02:06 P.M. revealed Resident 46 fell on the morning of 12/26/17 while a CNA was providing care to him. The FLN reported the CNA independently provided care to Resident 46 without assistance from another CNA. The FLN confirmed Resident 46 requires 2 person assistance for bed mobility. A review of the facility's policy titled, Fall Prevention and Management Program with revision date of 7/5/17 noted Resident 46 was a level II fall risk and noted, C. Maintain at least limited assistance with resident while ambulating or moving about the facility as available; and D. Initiate interventions for fall precautions and management as appropriate. 2) On 03/15/18 at 10:55 AM Resident 85 was observed walking at a fast pace by self outside of the facility on the sidewalk going around the building pushing their Rollator Walker with portable O2 tank. Surveyors inquired with Resident 85 where he/she was going. Resident 85 stated that it was a nice day and that they were getting their exercise done by walking around the outside of the facility. During this time there were no facility staff present escorting Resident 85. On 03/15/18 at around 11 AM inquired with staff 85 if they knew where Resident 85 was and they escorted surveyor to Resident 85's room. Resident was not found in room. Staff 85 inquired with CNAs assigned to work with Resident 85 if they knew where Resident 85 was and they were also unaware of Resident 85's location. On 03/15/18 at 11:18 AM met with staff 72 who stated that Resident 85 notified staff 146 that they were going to go walk. Staff 72 also stated that res is cleared to walk with O2 tank and walker outside of the facility. Review of Resident 85's Electronic Medical Record (EMR) on 03/15/18 at 11:30 AM found that they were admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident 85's physician order's found an order, dated 05/22/2017, for O2 continuously @ 2L via nasal cannula every shift related to [MEDICAL CONDITION], Unspecified. Resident 85 had a new order dated 03/15/18, Mat (sic) walk up the hill with CNA or activities staff escort with O2. After review of Resident 85's physician orders [REDACTED]. Some interventions listed were: Place me in a supervised area when out of bed and up ambulating with my FWW. Please have the staff assist me with all ambulation, and assist me with pulling my O2 tank, tubing and O2 caddy to all destinations and back. Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for signs/symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. It was noted that Resident 85 also has a problem, on CP, for at risk for falls related to Acute Illness- [MEDICAL CONDITION] to feet/toes (healed), history of falls at home with injuries, 06/13/17 @1300 witnessed fall, no injuries/ fell in therapy room/ tripped over O2 tank. Intervention noted for this problem included I ambulate with a Rollator Walker or no equipment independently to an from dining room and all destinations. Please have staff check my portable O2 daily and to see if it is secure as I need. One new intervention initiated on 03/15/2018 was To increase my physical activity my PCP has given me an order that I may ambulate up the hill with an activity aid or CNA with my oxygen secured to my Rollator Walker. Review of Fall Risk Evaluation, for Resident 85, dated 02/28/18, scored resident Moderate Risk for falls with with a score of 6. Review or Resident 85's Minimum Data Set ((MDS) dated [DATE] for Quarterly Review rated resident as 1 for Supervision-oversight, encouragement or cueing for Locomotion on and off unit. On 03/15/18 at 11:49 AM met with staff 87 and staff 103, who interviewed facility staff to inquire if anyone knew of Resident 85's plan to walk by themself outside of the facility and found that staff 145 notified staff 54 but this information was not told to Resident 85's assigned licensed nurse or CNAs. Staff 103 stated that Resident 85 had met with their doctor that day and had discussed choices regarding walking outside. Staff 103 concurred that Resident 85 should have had supervision while walking outside. An Immediate Jeopardy (IJ) was identified with F 689 Free of Accident Hazards/ Supervision/ devices on 03/15/18 at 1:14 PM and the facility administrator was notified. An abatement plan for the IJ was accepted by the SA on 03/15/18 at 5:15 PM.

Based on observations, medical record review and staff interviews the facility failed to provide one of four residents, Resident #19, with the necessary care and services to avoid a stage 4 pressure ulcer. Findings include: Resident #19 was admitted to the facility from an acute care facility with [DIAGNOSES REDACTED]. A review of Resident #19's history noted he was admitted to the long term care (LTC) facility from an acute care facility (1/24/17-5/1/17). The history further noted he was admitted to the acute care facility in septic shock due to multiple stage 4 pressure injuries with osteo[DIAGNOSES REDACTED]. The wounds were infected with bacteria and contained maggots. During his acute care stay, Resident #19's left lower leg was unsalvageable from complications of a wound on his left ankle and required a [MEDICAL CONDITION]. Resident #19's acute care stay was further complicated with antibiotic resistant bacterial infections which required management by an Infectious Disease Specialist. Resident #19 was finally discharged from the acute care facility on 5/1/17 when he was admitted to the LTC facility. Resident #19 was being reviewed for hospice services during stage 2 of the QIS survey. Resident #19 was admitted to hospice services on 5/12/17. During the hospice investigation, Surveyor identified concerns related to Resident #19 developing a pressure injury after admission to the LTC facility. Observation of Resident #19 on the afternoon of 9/20/17 found him lying in bed watching TV. He was nonverbal and unresponsive to questions. He made eye contact. Observation of Resident #19 on the morning of 9/21/17 found him lying in bed watching TV. Resident #19 was unresponsive but made eye contact. During the morning of 9/21/17, an observation of dressing change for Resident #19 found he had a healing stage IV pressure injury on his left hip. The stage IV pressure injury on Resident #19's left hip appeared to have significantly improved and was noted to be clean, dry and the tissue appeared healthy. During the dressing change, it was observed that Resident #19 also had a pressure injury on his right hip along with 2 additional pressure injuries on his right foot. The Wound Nurse noted Resident #19 developed a pressure injury on his right hip and two pressure injuries to his right foot after being admitted to the LTC facility. The Wound Nurse further noted the pressure injury on Resident #19's right hip was a stage IV. On the morning of 9/21/17 at approximately 10:30 A.M. a medical record review found Resident #19 developed the pressure injury on his right hip on 6/8/17. The initial pressure injury assessment dated [DATE] noted the right hip wound was a stage II and measured 1.0 cm length x 1.0 cm width x 0.1 cm depth. The plan noted: Initial assessment of pressure injury; Hospice notified for air mattress order; New treatment in place. A review of the Weekly Pressure Injury Assessments found one dated 7/6/17 where Resident #19's wound deteriorated to an unstageable pressure injury and the wound measurements increased: 3.5 cm length x 2.0 cm width x 0.1 depth. The plan noted, Hospice nurse notified for possible treatment of [REDACTED]. The Weekly Pressure Injury assessment dated [DATE] noted Resident #19's pressure injury was a stage IV pressure injury (previously unstageable) and measured 3.0 cm length x 2.0 cm width x 0.8 cm depth. The plan noted, Majority of slough not present this assessment. Able to see red granulated wound bed. Further review found Resident #19 developed two pressure injuries to his right foot on 6/30/17. The Wound Nurse assessed the wounds as suspected deep tissue injury without signs or symptoms of infection and measured 1.5 cm length x 1.5 cm width x 0 cm depth. The Plan stated, 2 deep tissue injuries located to lateral right foot both 1.5 cm length x 1.5 cm width, light brown in discoloration and skin intact. The Weekly Pressure Injury Assessment of the resident's right foot pressure injuries dated 7/12/17 noted the wounds deteriorated and measured 1.8 cm length x 3.0 cm width x 0 cm depth. Plan stated, Continue floating right foot. Another Weekly Pressure Injury assessment dated [DATE] noted the right foot pressure injuries had deteriorated and measured 1.0 cm length x 1.5 cm width x 0 cm depth. Plan stated, Continue to offload pressure of right foot. Despite 75-100% meal intakes, Resident #19's last documented weight was on 8/9/17, 69 pounds. A review of the facility's Skin Check Body Diagram noted the following: 6/19/17 No new skin changes noted this shift. Wounds to bilateral hip dressing changed by Wound Nurse. Dressing clean, dry, intact; 7/3/17 No new skin changes noted this shift. Wounds had been changed and assessed by Wound Nurse on day shift to bilateral hips. Darkened pressure sites to right lateral foot is present and open to air. Skin is intact. Dressings are clean, dry, intact; 7/10/17 No new skin issues noted at this time. On the morning of 9/21/17 at approximately 11:00 A.M. a review of the physician's history and physical (5/2/17) for Resident #19 noted he was admitted to the LTC facility for wound care and antibiotics (skilled nursing) then long term care. The physician's note dated 5/2/17 indicated Resident #19 eats well but required total assistance with feeding. She noted Resident #19 ate well but didn't gain weight. Resident #19's [MEDICATION NAME] level (necessary protein which is effected from malnutrition and helps practitioners determine a person's ability to recover from severe chronic illness) on 2/27/17 was 24 indicating a normal level (15-36). On 5/5/17, Resident #19's [MEDICATION NAME] level was 39.8. On 5/9/17 the physician noted Resident #19 had dehydration. The physician noted the nursing staff was providing pudding thick liquids even though Resident #19's order stated thin liquids. Starting around 6/11/17, Resident #19 began experiencing fevers and the physician's note dated 6/13/17 stated that Resident #19's left hip pressure injury appeared to be infected. The note stated Resident #19's left hip pressure injury was noted to have white material obscuring the view of the wound during the dressing change on 6/13/17 with purulent drainage and a foul odor. A wound culture was obtained and found to have [MEDICAL CONDITION] (MRSA) and Resident #19 was placed on contact isolation. A comprehensive review of all the physician's progress notes found she did not acknowledge that Resident #19: Developed a stage II pressure injury to his right hip on 6/8/17; and Developed two suspected deep tissue injuries to his right foot on 6/30/17. A review of the physician's notes dated 6/13/17 through survey date found she did not document assessments of Resident #19's wounds on his right hip and right foot. Additionally, the physician did not indicate the treatment plans for the new wounds or the fact that the wound on Resident #19's right hip deteriorated from a stage II on 6/8/17 to stage IV on 8/11/17. Interview of the Wound Nurse on the afternoon of 9/21/17 at 4:25 P.M. revealed Resident #19 was admitted to the LTC facility with a stage IV pressure injury on his left hip with the tendon showing. The Wound Nurse was asked whether the development of the stage IV pressure injury on Resident #19's right hip was avoidable. The Wound Nurse responded that the staff, including the Certified Nurses Aides (CNAs), were very focused on healing the resident's left hip wound. The Wound Nurse stated the staff were focused on offloading Resident #19's left side. He noted that from the frequent offloading of the left side, impaired skin integrity occurred on the right side. The Wound Nurse was asked if weekly skin assessments would demonstrate a breakdown in skin such as discoloration; redness; blanchiness; mushy feeling; or blisters prior to the development of a stage II pressure injury. The Wound Nurse stated that skin assessments would note such things as discoloration, redness, blanchiness, or blisters prior to breakdown to stage II pressure injury. The Wound Nurse was unable to explain how Resident #19's right hip was discovered at a stage II pressure injury without first having some visible skin breakdown prior to opening. The Wound Nurse reported the Hospice agency was able to provide Resident #19 with an air mattress at the end of June 2017, almost two months since his admission. When asked if the air mattress assisted with wound healing and potentially prevented development of pressure injuries, the Wound Nurse replied yes. He further noted they did not provide an air mattress for Resident #19 upon admission until he found out the Hospice would provide them. Resident #19's history of multiple pressure injuries, emaciated stature, and deteriorating health placed him at high risk for skin breakdown. Despite these risk factors, the facility failed to implement all necessary interventions to maintain the integrity of Resident #19's skin. The combination of Resident #19's risk factors and the lack of vital interventions resulted in the development of three new pressure injuries. One of the three wounds progressed from a stage II to a stage IV in a matter of 9 weeks. The physician failed to document any assessments or plans for the three facility acquired wounds. The facility's failure to maintain an aggressive approach to the prevention of additional skin breakdown resulted in Resident #19 developing a stage IV pressure injury on his right hip and two deep tissue pressure injuries on his right foot.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to provide sufficient nursing staff based on the staff's inability to provide needed care to residents to enable the residents to reach their highest practicable physical, mental and psychosocial well-being. Findings include: 1) The cumulative findings in the areas of Resident Behavior and Facility Practice, Quality of Care and Quality of Life determine there is a pattern of harm, in addition to other regulatory areas, which are interdisciplinary and includes nursing and administrative services related to the lack of the quality care care and services to the residents. This is evidenced and is cross-reference in the findings at: F164, F225, F226, F241, F242, F246, F248, F249, F278, F279, F280, F281, F282, F309, F312, F323, F325, F329, F334, F364, F366, F371, F441 and F520. Furthermore, interviews with residents, family members and staff validated the lack of the delivery of necessary provision of care and services to the residents at this facility. There is also the failure by administration to ensure their staff are trained and knowledgeable in the care plans of each resident to be able to deliver the individualized care required to achieve the highest practicable physical, mental and psychosocial well-being for each resident, current and/or discharged . Again, this was not found as evidenced by the deficient practices found in each citation noted above. Moreover, the facility did not have its own developed policy for care planning, which is the basis by which comprehensive assessments are formulated to ensure each resident's care needs are identified and met through outlined care planning goals and outcome measurements. 2) On 9/14/2016 at 3:33 P.M. after completion of a medication pass observation with Staff #2 for R #53 the residents shared the following: evening shift they are so short, I go to the bathroom by myself or sometimes I just make in my pull ups and pad, then I change it myself, my daughter tells me to call for help but I don't. When the resident was asked, How do you feel, about that? R #53 responded, I don't feel anything, what am I suppose to do? By the time they get here it's too late, they have to take care of the other side. They are short on evenings and nights. R #53 was seated in an overstuffed chair reading a paperback novel, with a front wheeled walker within reach and a side table with several paperback novels stacked. Review of the R #53's 5/31/2016 MDS showed a BIMS of 14. R #53's toileting assessment documents the following: frequent incontinent; one person physical assistance for toilet use. The facility fails to provide staffing service for the resident's toileting needs.

Based on observations, EMR and MR reviews and staff interviews the facility failed to ensure that 1 of 3 sampled residents (R #72 of the 38 residents in the Stage 2 sample, was provided nutritional care and services for impaired nutrition and unplanned weight change. Findings include: On 09/15/2016 at 8:14 A.M. observed R #72 in bed with Staff #12 sitting on the bed feeding resident a pureed diet. The resident stated that food taste junk. Queried if food was warm and Staff #12 commented, No taste that's why. The Staff #12 tried to give the resident water but the resident wanted [MEDICATION NAME] orange juice instead. When Staff #12 left the room asked R #72 if food was warm and the resident shook head, No.Informed R #72 that staff can be asked to warm up food but resident stated, No need, no make difference food no taste. Asked resident if not feeling well and resident stated feel dizzy and upset stomach.Asked Resident if Doctor told him/her about condition and Resident stated, Doctor doesn't even come. On 09/15/2016 at 11:31 A.M. reviewed R #72's EMR, and noted that the last physician exam was done on 06/27/16 by the facility's previous medical director (MD). The resident was diagnosed and assessed for diabetes mellitus (DM) type 2, with fasting blood sugars ranging from 130-200 with a hemoglobin A1c of 6.1 done on 04/04/16. The physician assessment/plan further documented that R #72 was currently on insulin at 20 units provided in the AM with improvement in [MEDICAL CONDITION], and that the AM blood glucose was mostly within normal limits. The resident was on a carb controlled, low-fat, low cholesterol diet due to [DIAGNOSES REDACTED]. The resident also had a [DIAGNOSES REDACTED]. The physician plans was to monitor R #72's blood glucose and adjust the insulin as needed and to recheck the HGB A1c with other pertinent lab work. On another MD note text dated 6/27/16 it documented, Transfer of Care to the facility's new MD due to an administration change. As of 6/28/2016, care of this patient has been transferred to Dr. ___. Dr. ___ has been notified of this transfer of care on 6/27/2016 by myself via telephone conversation. He has accepted care and states he and his care team of physicians will resume care as of 06/28/16. he states that he will get patient history via the chart. This has been the plan laid out by the current administrator ___. Dr. ___has been given my cell phone number should he, or the members of his team, have any questions. Patient has been personally notified of this transfer of care by me. Under the EMR assessment tab Reviewed R #72's nutrition assessments, and the weekly Nutrition at Risk Review dated 04/15/2016 with a lock date of 04/20/2016, noted that R #72's wt on 04/12/2016 was at 142.6 lbs and the 03/31/2016 admission wt was 145.6 lbs. The Res food intake for breakfast, lunch and dinner was from 51-75% and fluid intake for all meals was 75%. The nutritional factors affecting R #72's nutrition status was checked at feeding ability/changes; medical causes; and, swallowing. The goals and interventions noted that the Res was recently admitted to the facility under ICF level of care for long term care placement. The Res was alert and oriented x3; history [MEDICAL CONDITION] speech and swallowing abilities; required extensive to total assistance with meals; on ground texture diet, and nectar thick liquids; noted with an insignificant wt loss of 2% since admission; and, free from pressure-related skin impairments. The plan was to continue with current plan of care, and review weekly to monitor wt trending and skin integrity. The Nutrition Risk assessment dated [DATE], (quarterly), used the most recent wt taken on 05/01/2016 of 139.8 lbs; body mass index (BMI) of 26.4; and food intake met 76-100% of estimated needs. Under the lab values section, Abnormal lab values, were marked, and in the comment section was written: alb 3.3, Na 131. The summary and recommendations section noted that R #72's estimated needs were based on an adjusted wt of 115 lbs that calculated for 1300 calories, 50 g protein, and >1500 ml fluid. The Res had overall good meal intake; liquids were downgraded to honey thick by SLP; and no noted swallowing issues with mechanical soft/honey diet/liquid consistency. Documentation included, No significant wt changes noted but last wt was on 05/01/16. Will request res to be reweighed. Appropriate to continue current nutrition plan of care and monitor progress. The weights found under the Weights and Vitals tab of R #72's EMR were: 07/13/2016 130.2 lbs (10.58% wt loss from admission wt of 145.6 lbs on 03/31/16) 07/24/2016 125.4 lbs 08/24/2016 124.0 lbs 09/07/2016 123.0 lbs (15.5% wt loss in <6 months from admission) On 09/15/2016 at 12:27 P.M. observed R #72 in restorative dining and refusing to eat pureed diet. Staff #6 explains that Res was coughing with mechanical soft diet and now on pureed diet. The resident refused to eat and stated, No sub, sub, sub.Resident told Staff #6 that the food all tastes the same because same texture (pureed) dog food. The Staff #6 replied that R #72 being comical. Staff #6 explained that SPT ordered pureed diet and that the resident goes between pureed and mechanical soft, with mechanical soft only with RNA present. Observed Staff #6 feeding resident papaya that she got from the kitchen. Staff #6 asked resident if wanted to eat more of pureed meal and Res replied, No, dog food. On 09/15/2016 at 12:47 PM reviewed R#72's EMR and care plans (CP) included: I am at nutritional risk r/t I have thickened liquids, dysphagia, and have a mechanically altered diet/therapeutic diet, initiated on 04/03/2016. The goals were: I will have no significant wt changes of 5% in 1 month and/or 10% in 6 months. Interventions included: · I have built up utensils to promote self feeding. Assist me as needed, revised on 07/15/2016; · Monitor my weight per facility policy. Report significant wt changes to my physician. Discuss my wt in Skin/Wt meeting and consult my RD as needed to assess my wt changes, initiated 04/03/2016; · My RD will evaluate and make recommendations as needed, initiated 04/03/2016; · Obtain and monitor my lab/diagnostic tests as ordered. Report findings to my physician for follow up, initiated on 04/03/2016; · Provide and serve my diet as ordered. Monitor and record my meal and fluid intake, initiated 04/03/2016. The facility's new administration initiated CP, Resident started on Restorative program for restorative dining & PROM to LUE with splinting d/t increase strength, general weakness & to facilitate self feeding, on 07/16/16 and revised on 08/30/16. The goal initiated on 08/30/16 was for, Restorative dining program to facilitate self feeding & contracture management. The interventions initiated on 09/02/2016 and revised on 09/07/2016 were: · Provide quiet environment for meals; · Restorative Eating program: RNA to assist feeding with meals 7 days a week as tolerated 1. Mechanical ground diet with honey thick liquids. (If no RNA pureed diet d/t high risk for aspiration). 2. close supervision for all meals. 3. Upright position for all meals. 4. 1/2-3/4 tsp bite size max 5. small sips (no straws) 6. slow rate of intake 7. make sure she swallows 1-2 x prior to taking another bite/sip On 09/16/2016 at 8:34 A.M. interviewed the Dining Svcs Manager (DSM), and queried how the DSM knew what type of diet and/or diet texture was required for each resident in the facility. The DSM stated that upon admission to the facility, he will be given the heads-up on the diet order for the resident. Any changes to a resident's diet is provided by the in-house nurses who alert him via the communication form. The Registered Dietitian (RD) also updated the DSM and would send same order recommendation to the MD. Asked the DSM about R #72's diet and he accessed his computer to look under Diet tab; and, documentation for R #72 on 09/02/2016 was CCHO (consistent or controlled carbohydrate), pureed, honey-thick consistency. Asked if the DSM received any diet order & communication form on 09/02/2016, and the DSM looked through a pile of forms and found one for R #72 for that date. On the diet order form it was noted that R#72 could have a mechanical soft diet when in RNA dining. The DSM looked at R #72's physician orders [REDACTED]. Queried the DSM further and he stated that the last RD diet assessment for R #72 was on 07/12/16. The DSM stated that he tracks residents for weight loss and emails RD to give her a heads up as the RD came to the facility 3 times a week. Asked to see email that DSM sent to the RD to communicate R #72's wt loss. The DSM's recent email to the RD for residents being monitored, included that R #72: · on a weekly/weight monitoring for triggered weight loss -22.6 lbs/15.5% x · for 6 months; · Meal intake: 50-100% · Fluid intake: [PHONE NUMBER] cc/day fluid intake. With these recommendations written by the DSM, Resident has unanticipated but beneficial weight loss. Resident is now at ideal BMI. Restorative dining increased to 5-7 times a week ordered 8/30. Diet downgraded to puree texture 9/2. Resident weights remain stable x4 weeks. Recommend to discharge monthly weight monitoring and continue monthly. Asked the DSM how he came to the conclusion that R #72's weight loss was beneficial. According to the DSM, he had a food and science degree which qualified him to be a nutritionist. When the DSM was asked if R #72 was on a physician planned weight loss diet in consultation with the RD and whether pertinent labs were also part of the nutrition evaluation. The DSM replied that the RD looks at labs quarterly unless nursing and/or MD alert her otherwise, and that he referred to the physician order [REDACTED]. The PO diet order written for R #72 was, CCHO (ADA, Diabetic. No added sugar, NCS) diet, mechanical soft and Pureed texture, honey-like consistency. The DSM stated that he didn't know when R #72 was in RNA dining and needed mechanical soft diet. Also, that nursing staff should have informed him of Resident's refusal of pureed diet and wanting mechanical soft diet. The DSM stated that he had no communication past several days of Resident's refusal of pureed and/or in RNA dining. Informed DSM that observed R #72 in RNA dining during lunch and the menu was of turkey stir fry, steam rice, green peas, and chocolate pudding. Observed that the resident refused the pureed diet but ate the chocolate pudding. Asked if the chocolate pudding was sugar-free. The DSM stated that the facility had a limited supply of sugar- free foods and there was no sugar free chocolate pudding, and he was in the process of ordering more sugar free foods. Also, observed that the resident was given juice several times. The DSM stated that he was still looking for sugar free beverages to order but there were juices lower in sugar content (e.g. apple, cranberry,orange) and that sweeter juices were [MEDICATION NAME] orange, and grape. Informed him that R #72 asked and was given [MEDICATION NAME] orange juice during observations. On 09/16/2016 at 9:27 A.M. interviewed Staff#2 who started working at the facility in July. According to Staff #2, the OT/SPT will refer residents to the RNA program and teach RNA staff the recommended feeding techniques along with special utensils if needed. Staff #2 stated that she spoke with the SPT last week, and informed him that R #72 chokes on minced diet, and that she recommended that R #72 be given only pureed diet and no longer be able to feed self. The Staff #2 stated that she was scared to feed her mechanical soft/minced diet because the resident continued to choke but maybe today will try soft diet as resident feeling better. According to Staff #2 the resident never told her that pureed food is dog food and when fed pureed diet the resident never complained. The R #72 had bouts of nausea and dizziness and was mostly fed in bed by CNA staff because the CNAs can only feed pureed diet to resident. On 09/16/2016 at 10:06 A.M. reviewed R#72 EMR for lab reports, pertinent lab results for the Resident's nutritional status was not within the normal parameters. Glucose H 173 (70-99) Calcium L 8.3 mg/dL (8.6-10.3) [MEDICATION NAME] L 3.5 g/dL (4.0-5.1) alk Phos H 135 U.L Triglyceride H 248 mg/dL (<150) hemoglobin A1C H 8.8 % (<5.7) TSH with Reflex FT4 L 0.10 uIU/mL (0.34-5.60) RBC L 3.86 10(12)/L (3.9-5.2) Hemoglobin L 11.2 g/dL (11.6-15.1) On 09/16/2016 at 12:00 P.M. interviewed the SPT, and he related that months ago he picked-up R #72 on his caseload and when SPT evaluation is done usually tries for less restricted diet to balance quality of life for resident. Recently within the past month, SPT received reports from staff that R #72 impulsive when feeding self mechanical soft/ground diet and one of the RNAs reported that Res was still choking on mechanical soft diet/ground. The R #72 also spoke with SPT and told him that didn't want pureed diet and wanted to advance diet to mechanical soft/ground diet. The SPT no longer had the resident on his caseload and used his professional judgment that R#72 is alert and oriented with good cough reflex and could tolerate mechanical soft/ground diet if supervised by RNA staff. The SPT then went to huddle with the RNA staff and the DON to discuss R #72's diet and restorative dining recommendations. The DON came up with the directive that R #72 could have mechanical soft/ground diet when fed by RNA staff and pureed diet when self-feeding, and RNA staff are unavailable. The SPT further elaborated that at the time of R #72's discharge from SPT, self - feeding was not an issue and the resident was able to self feed. The SPT felt that It was not a therapeutic issue but more a staffing issue as one of the RNA staff stated that R #72 didn't cough when fed mechanical soft/ground diet. The SPT couldn't justify reevaluation of R #12 because RNA supervision was more of a staffing problem. Also, the SPT couldn't write orders if R #72 wasn't on caseload and on 09/02/16 resident wasn't on SPT caseload, so nursing had to implement and/or revise restorative dining care plan. On 09/16/2016 at 12:19 P.M. interviewed Staff #2 and queried her on who made decision that R#72 cannot self feed pureed diet. Staff #2 stated that the SPT made that recommendation when she informed him that Res was coughing with ground texture. Informed Staff #2 that just spoke with SPT and SPT documentation in MR did not reflect that. The Staff #2 stated that she must have mistaken about recommendation. On 09/19/2016 at 12:36 P.M. interviewed the RD via telephone call. The RD stated that the last time she assessed R #72 was on 07/12/16, and last weight noted then was 139.8 lbs taken on 05/01/16, with the next weight of 130.2 lbs, taken on 07/13/16. The RD calculated that from 04/10/16 to 07/13/16 the resident had a 5.6% weight loss; and, from 04/10/16 to 09/07/16 a 10.8% weight loss in 5 months, and stated that it was a significant weight loss. The RD further elaborated that the facility's Skin and Weight Committee did not alert her of R #72's weight loss. The RD stated that the last Skin and Weight Committee report on 05/05/16, there was no significant weight change to report. The Skin and weight committee team makes decision to consult RD or not and it would have been beneficial for them to consult with RD to see what was going on. The weights were not being done and not being reported and would have been caught if there were weights done between June and July. The RD further stated that the 9/12/16 Skin and wt committee report mentioned that wt loss is beneficial because the resident is now within BMI for height and weight. Since July resident's weight has been stable and will probably order new labs to make sure residents receiving proper nourishment. When asked if RD was aware of R #72's diet texture and whether resident should be fed or not, the RD stated that It is something that the DON needs to educate the RNA staff on regarding mechanical soft versus pureed diet. The RD stated that she knows that the Resident eats better on mechanical soft diet. In summary, the facility did not ensure that R #72 maintained acceptable parameters, to the extent possible, of nutritional status based on a comprehensive assessment. Also, the DON, RD, DSM and/or MD, did not recognize, evaluate and address that the resident was experiencing impaired nutrition. The nutritonal care and services provided to R #72 were inconsistent that resulted in negative outcomes of actual harm that included, but are not limited to: · Significant 10.58% weight loss at 3 months from admission (03/31/2016 to 07/13/2016); · Inadequate food/fluid intake due to restricted diet and downgrading the food consistency without accommodating the resident's preferences in accepting related risks; · Failure to provide a therapeutic diet that took into account the Resident's clinical condition and preferences, when there is a nutritional indication.

Based on observation, record review, staff interviews and a review of the facility's policy, the facility did not ensure the resident's environment remained free of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents for 7 (Residents #45, #107, #66, #36, #68, #12 and #122) of 9 residents sampled for accidents of the 38 residents in the Stage 2 sample. As a result, one resident sustained [REDACTED]. Findings include: 1. R #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 8/20/16 MDS quarterly assessment has her BIMS score at 15, and during the resident interview, the resident was alert and oriented to person, place and time. On 09/14/2016 at 08:18 A.M., the resident related she fell on [DATE] after having missed the bed and fell to the ground. She confirmed she fractured some of her ribs as a result of this fall. She said after the incident happened, she was told to wait for staff to take her to the bathroom. The resident stated, During day I can go by myself, but at night, sometimes I have to wait long time, so sometimes I think to myself I rather walk and go, but when I had the dizzy spells, scary. Only one time I fell , and hit the left side (points to rib cage). I came back from the restroom that night and those days, I used to go by myself and I trying to get inbetween the (overbed) table and bed and the table slipped away and I hit my rib. Now, they want me to call for everything, but they're so busy, I feel I can do but when i call, they don't come right away. The resident said, Some nights only 2 girls maybe working and it's hard when I want to go, they're so busy. Only once i made shi-shi, slipped out and wet the bed. I call and I wait sometimes over 15 minutes. When you want to go yeah, it can be long time. Record review found the care plan was not updated to include resident had a fall with significant injury of the left eighth, ninth, and tenth non-displaced rib fractures,as reported on the facility's self-reported incident report. In addition, the facility failed to follow their Fall Prevention policy as it did not indicate whether the resident was a Level I or Level II fall risk. In addition, the facility's self-reported incident report for the resident's 7/19/16 fall with rib fractures did not indicate what interventions were done for her during the time this event happened, with an initial reporting to the SA on 7/26/16 and submission of the final report on 8/2/16. The resident's fall care plan did not indicate the interventions as an update to this injurious fall with rib fractures she sustained. 2. R #45 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Observation of the resident on 9/14/16 at 11:23 A.M. revealed the resident sustained [REDACTED]. The skin tear was bleeding and needed to be dressed by licensed staff immediately. Cross reference to F441. Another smaller skin tear to the resident's left inner forearm measured 0.3 x 0.2 cm. The resident acknowledged by nodding it was sore. Review of the resident's incident report noted Staff #5 last saw the resident on 9/14/16 at 11:00 A.M. Staff #5 involved in the incident documented that R #45 was trying to lay down in chair he was very close to sliding off I tried to hook him under his arms, he got all stiff. I got my arms under him and pulled him up. he did it again when I helped him I noticed blood so I called the nurse. This had occurred in the activity room. R #45's record review found this resident had several falls on 6/15/16, 6/24/16 and 7/7/16 and susceptible to skin tear due to his dry, fragile skin and aspirin use. On 6/15/16, the resident had a fall and was placed on alert charting by nursing; however, there was no nursing entry for the actual fall he sustained. On 6/24/16, he had an unwitnessed fall on the evening shift and was found in a fetal position on the floor in front of his bathroom. He was found to be resistive to care and combative to staff. On 6/25/16, nursing entry noted the resident sustained [REDACTED]. Then on 7/7/16, the resident fell in the evening shift and was found on the floor with his head against the wall and feet toward the bed. His brief had small soft bowel motion in it. On 7/14/16, a nursing entry noted a blister to his right knee and on a later entry at 10:20 P.M., that the resident also sustained a dark discoloration to his right forearm with an old skin tear that reopened. No wound measurements were documented. A 7/15/16 entry at 3:31 A.M. noted a skin tear to the resident's left upper arm. No other documentation is noted about it. Then a 7/16/16 entry at 5:20 A.M.noted the family was informed of the bilateral skin tear to the space between the thumb and first finger. Geri sleeve is in place with the cloth between the thumb and first finger cut. Another entry for 7/22/16 at 11:03 A.M. notes the skin tear to upper left arm open to air with three steri-strips and that he also has a large scab to the posterior portion of his left hand. There was no documentation to note how long R #45 also had the existing surrounding discoloration measuring 7.7 x 4.0 cm that was documented by Staff #3 on the day he sustained the new large skin tear to his right inner forearm region on 9/14/16, and based on surveyor observation. Review of the resident's fall care plan, initially copied on 9/14/16 and concurrently reviewed with Staff #3 on 9/14/2016 at 1:52 P.M., revealed this resident, after having multiple falls in the prior months, did not have an updated care plan for falls, nor was there an update to the care plan for skin impairment although R #45 sustained multiple documented skin tears per the nursing alert charting notes. Staff #3 also stated this resident had a tendency to always slide and then said, not always but that everyone knew this is what he does, which is to slide down from his wheelchair. She said, Today, according to the activity aide, he was sliding, and when they moved him to reposition, his arms were outside and got caught on the wheelchair. This was not what the witnessed event report documented in the incident report turned in to the DON, who signed off on it on 9/14/16. There was also no query whether the staff involved in the injury to the resident needed retraining or re-education as this resident is known to slide by everyone. In addition, review of the resident's care plans show there is no intervention for safe transfers on his ADL care plan for self-care performance deficit and limited physical mobility related to his generalized weakness. There was a failure by nursing staff to update R #45's care plan, after the multiple falls and skin tears he sustained in the prior months. Nor was the resident's care plan updated to include whether he was a Level 1 or Level II Fall Risk per the facility's Fall Prevention and Management Program policy that was provided by Staff #4 on 9/15/16. Further, on 09/16/2016 at 8:59 A.M., interview with Staff #4 revealed for R #45, the care plan should have been updated and stated this resident was brought up in stand-up, but yet, Staff #4 acknowledged there was no consideration whether rehab services would assess his wheelchair and positioning if he was known to slide out. Staff #4 stated,They just informed everyone that his treatment is in place. Staff #4 validated he is not aware of what Level I or Level II means as he did not know the facility's falls policy yet. When he was asked if he knew what the color coded stickers meant, he said red was high risk for falls. Then he acknowledged that for Res #45, this resident is a high risk for falls and could have ensured to have a care plan in place related to his new large skin tear. The facility's Fall Prevention policy also states as an intervention seating aids such as wedge cushions and postural supports should be used for persons likely to fall or slide from a chair. Random observations of this resident often found him to be sleepy while in his wheelchair and slouching down. Thus, if staff knew the facility's Falls prevention policy, and updated care plans had been in place, this resident's multiple falls and skin tears should have been preventable. Of note too, the facility specific policy and procedure on care planning for residents produced by the administration was not their policy, and thus, they have none. Cross-reference to F279, F280. 3. R #107 was admitted to the facility on [DATE] as a short term stay resident for SNF rehab services. Observation of this resident found she appears to have left sided [DIAGNOSES REDACTED], but may be due to her brain cancer and is status [REDACTED]. This resident was found to have four falls during the month and a half of residing in the facility. Record review found on 9/9/16 on the evening shift, the resident had a witnessed fall. There is no nursing documentation about this fall, but an incident report noted it happened at 7:00 P.M. It involved a certified nurse aide who was toileting the resident but had turned away from the resident while she was sitting on the toilet. The resident slid off the toilet and landed on her buttock at that time according to the witness statement. The 9/1/16 fall incident occurred at 10:35 P.M. where the resident was found on the floor with her head nearly under the bed, with her feet up to her chest in a fetal position. The resident complained of pain to her right ankle and stated she wasn't going anywhere, but was waving someone to help and slid off the bed. This fall had clinical documentation by nursing in the alert charting notes. However, the care plan for falls was not updated after these two falls. In addition, the fall care plan had only been developed on 8/29/16, after the resident's second fall (left on toilet by friend) since her admission into the facility. Yet, review of the resident's MDS admission assessment of 8/6/16, PPS 14-day assessment of 8/12/16 and both PPS assessments of 8/15/16 and 8/23/16 all coded the resident to require extensive assist with a two person physical assist. This had not been care planned and no documentation was found that the friend had been educated about the resident's functional status and ADLs. Missing from the fall care plan was the documentation by nursing after the 8/29/16 fall that it was a Level 2 fall. Thus, the resident's care plan had not been updated and the facility did not follow their Falls Prevention Policy. Further, an interview with R #107's friend on 09/15/2016 at 12:15 P.M., revealed,Maybe she falls, because they take long to come when she trying to get up to go to the bathroom. But sometimes, the staff might be busy, so she cannot wait I guess .So when she's left alone in the room, she cannot wait, but you gotta understand the fact, if the staff is busy on something else, they may not get to her right away. The resident who was in her wheelchair softly stated, Four times .why? and closed her eyes. The resident was observed to be able to stand during her PT session on 9/15/16, but required two person assist by rehab to stand with cues to stand up straight, look ahead, etc. The 9/9/16 Fall Risk Evaluation notes confusion, disoriented x 2, history of falls or 3 or more in the past 3 months (but with four documented falls in a month and half of short term rehab stay), requires regular assist with elimination, gait/balance not normal with a balance problem while standing/walking/needs safety reminders, requires use of assistive device, unsafe for ambulation/transfer/impulsive and with 1-2 predisposing medical conditions including medications taken currently and/or within last 7 day. None of these factors were placed into the resident's fall care plan as preventive fall recurrence measures from this assessment. R #107 was also coded to be frequently incontinent of urine and occasionally continent of bowel on her PPS 14 days MDS assessment of 8/12/16, but had been always continent of bowel on her admission assessment. This information was not accounted for in her fall care plan or risk assessment. There also was no ADL plan of care developed for this resident. In addition, on 09/15/2016 at 2:32 P.M., Staff #15 stated that therapy was not involved during the Aug fall incidents as the resident had been undergoing radiation treatments and was weak. Staff #15 said, Usually if there is a fall while on caseload we look at factors contributing to the fall and see what other therapeutic interventions need to be provided. A lot of times, the fall is the reason for therapy. However after the 9/9/16 fall incident, Staff #15 stated therapy was not made aware of this fall while she was on their caseload. Staff #15 the way they become aware of the resident falls is only through the nursing report at daily standup, but there is no documentation on it. During an interview with Staff #1 on 09/16/2016 at 10:43 A.M., she said, It's the truth that it's not updated. I know some of them (referring to nurses) they don't know how to access the resident care plans. I started at the end of June and didn't know how to do the care until the end of July. R #107) is one of them I never go to yet. I told the nurses at least they got to start with 3 problems for me-told all the nurses but some of the new ones, we got to sit down and show them how Staff #1 was asked why are they on the floor if they don't know how to develop care plans. Staff #1 replied, Well, they know how to assess, and shrugged her shoulders. Staff #1 said she was going to take the fall for this. In addition, the DON was asked several times to provide the licensed nurse skills checklist for all nursing staff. The DON stated they used a skills checklist for all new hire nurses. Thus, the SA's purpose was to see whether the facility's current licensed staff were evaluated before caring for residents on the units, coupled to what Staff #1 said. However, the DON did not provide any template or completed skills checklists of her nursing staff to show it was being done. 4) Cross Reference to F280. On 9/14/16 at 10:45 A.M. R #36 was observed laying in bed, subsequently she was observed ambulating in the hallway with the assistance of a forward wheel walker. At 11:35 A.M. Staff #22 (Certified Nurse Aide) was asked where is R #36. The staff member responded the resident went down the hallway and pointed to the direction. The observation found the resident in the hallway ambulating. On 9/14/16 at 2:07 P.M. the resident was observed ambulating in the hallway of her unit. On 9/15/16 at 12:45 P.M. R #36 was observed ambulating from her room to the dining hall. The resident sat in a chair outside of the dining hall across the nursing station. At 1:00 P.M. R #36 was observed visiting with her son. At 2:45 P.M. while sitting in the conference room, R #36 could be heard shrieking. Upon exiting the conference room, R #36 was observed walking toward the lobby. The resident was followed, the receptionist saw the resident and invited the resident to sing and accompanied the resident back to the unit. At 5:45 P.M. the resident was out on pass with her son. On 9/16/16 at 8:30 A.M., Staff #18 (Certified Nurse Aide) was asked where is R #36, the staff member responded the resident was down the hall. Observation found the resident ambulating down the hall. Subsequently an alarm was heard at 8:50 A.M., Staff #19 (Registered Nurse) looked over to the doorway. The staff member reported she was checking if a resident went out the door but saw a staff member enter the building. The staff member also reported the doors on the periphery of the building is armed with an alarm and when the alarm is heard, staff members will check. Random observations on 9/14/16 and 9/15/16 also found R #36 ambulating with staff members or family members. A record review was done on the morning and afternoon of 9/15/16 for R #36. R #36 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The review found a progress note dated 6/24/16 at 3:41 P.M., the resident wandered out the front doors today, the receptionist called for staff to bring the resident back to the unit. Alert charting was done for three days with no attempts to leave the building. A subsequent progress note dated 8/4/16 at 11:04 A.M.notes the Social Worker (SW) was informed R #36 was involved in a resident to resident altercation. A resident reported R #36 scratched another resident. A review of the physician's orders [REDACTED]. A review of the resident's care plan (provided by the facility on 9/15/16 at 2:05 P.M.) found a plan for at risk for behavior symptoms related to history of behavior symptoms physical aggression (pinching) and verbal outbursts (yelling) with an initiation date of 6/8/16. Interventions included: administer medications as ordered; ask me to sing my favorite songs (You are my sunshine, Japanese nursery rhymes) and sing with me as this helps to redirect me; identify pattern of wandering, is wandering aimless? is resident looking for an exit; ask where are you going? please answer as this helps to redirect me; monitor behavior episodes to identify triggers, consider location, time of day, persons involved and situation, when possible remove behavior triggers; and monitor triggers for wandering, consider time of day, location, persons involved and situation and remove triggers for wandering if possible. On 9/15/16 at 3:15 P.M. an interview was done with Staff #3 (Registered Nurse). The staff member was asked how do you ensure the safety of other residents in the facility related to R #36's behaviors, the staff member reported they keep R #36 away from other residents and they apply mittens so she doesn't scratch the other residents. On 9/15/16 at 3:20 P.M. an interview was done with Staff #23 (Certified Nurse Aide). The staff member was asked whether she was aware of R #36's behavior. The staff member responded the resident attempts to scratch and punch staff when they attempt to provide care so two people are available and/or the resident's sons assist. The resident's family has provided mittens to prevent their mother from scratching others. The staff member stated the mittens are removed during incontinence care and change of clothes. Also, the staff member shared the resident is able to remove the mittens. The staff member also reported the staff ensure the resident is kept at a distance from other residents as she may try to grab and pinch other residents so they will move the resident away from the others. The staff member also reported all staff members are aware of the resident's wandering on the unit and keep an eye on the resident. Also, the resident tends to wander to the same rooms so those doors are kept closed. Although staff members are implementing interventions to address R #36's behaviors, there is no documentation of care plan revisions based on an assessment (identifying triggers, patterns, etc.) of R #36's behaviors that are specific to this resident to prevent further accidents. 5) R #68 was initiated for a review of accidents during Stage 2 of the QIS survey based on an incident report submitted to the Hawaii State Survey Agency (SA). The Incident Report alleged that Resident #68 experienced multiple falls while in the facility. R #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to home on 8/19/16, before the survey. Therefore, a closed record review was completed for R #68. A review of the facility's Incident Reports (IRs) on the morning of 9/15/16 revealed R #68 experienced multiple falls while a resident at the facility. On 5/3/16 R #68 was found on her knees in her room. She complained of right knee pain. The IR noted the resident's skin was intact and she did not sustain any injuries. R #68 was moved to a room closer to the nurse's station. On 5/4/16 R #68 was found on the floor laying on her side. She sustained a 4.0 cm x 0.8 cm bruise on her left knee and no other injuries. On 6/19/16, R #68 felt weak and lowered herself to the floor of the bathroom. She did not sustain any injuries. On 6/20/16 R #68 was found on the floor kneeling facing the bed. She was confused and did not sustain injuries. On 7/30/16 R #68 was being assisted to the bathroom near the shower room by a Certified Nurses Aide, CNA. The CNA reported the resident was left in her wheelchair for less than 30 seconds while she went to retrieve gloves. When the CNA returned, the resident was on the floor of the bathroom. The IR noted the resident did not sustain any injuries. On 8/14/16 R #68 apparently slid out of bed. The IR noted she did not sustain injuries. On 8/17/16 R #68 had an unwitnessed fall in which she did not sustain any injuries. On 8/18/16 R #68 had an unwitnessed fall. The resident was found on the floor in her bedroom where she stated she fell from her bed. She was transferred to the hospital for evaluation where they did xrays and the results indicated she did not have any injuries. On 8/19/16 R #68 experienced another fall and the IR indicated she did not sustain any injuries. Of all the IRs reviewed for R #68's falls, only the fall dated 5/3/16 addressed/identified a root-cause analysis for the fall. The other 8 IRs did not have a root cause analysis to identify factors contributing to the resident's falls. A review of R #68's Minimum Data Sets (MDS) 3.0 found 2 quarterly assessments. The MDS Coordinator was unable to find MDS's dated prior to the change of ownership on 4/1/16 which is why a comprehensive assessment was not available at the time of survey. A review of the first quarterly assessment with an Assessment Reference Date (ARD) of 6/18/16 indicated the facility was unable to complete a Brief Interview of Mental Status (BIMS) for R #68 because she was rarely/never understood. The staff noted that she had moderately impaired cognitive skills for decision making. The resident required extensive 2-person assistance for most of her activities of daily living (ADLs) such as bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene. Under item J1800, Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? The facility answered, No. However, as previously noted, the resident sustained [REDACTED]. A review of R #68's discharge MDS with ARD of 8/19/16 noted she had a BIMS score of 6/15 indicating severe impairment in cognitive patterns. She occasionally experienced disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). R #68 had behavioral symptoms directed towards self (hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days during the look back period. The resident rejected care for 1 to 3 days during the look back period. The resident wandered 1 to 3 days during the look back period. The resident was noted to still require extensive assistance with bed mobility, transfer, locomotion on unit, dressing, toilet use, and bathing. Under item J1800, the facility answered, Yes. For item J1900 Number of falls since prior assessment, the facility noted 2 with no injuries and 1 with injury (except major, such as bruising). According to the IRs, R #68 experienced 6 falls (as opposed to 2 reported on the MDS) without injuries and 1 fall in which the resident sustained [REDACTED]. Record review for R #68 found the facility did a Falls Risk Assessment when she was admitted on [DATE] where she scored 10 (moderate risk). Thereafter, R #68 had the following Falls Risk Assessments: 3/20/16, score was 15 or moderate risk; 5/3/16, score was 14 or moderate risk; 5/4/16, score was 14; 7/30/16, score was 14. An interview with the Staff #2 on the morning of 9/15/16 at approximately 10:00 A.M. revealed that the staff was expected to complete a Falls Risk Assessment after each fall. The facility failed to complete a Falls Risk Assessment after each of R #68's falls. The Falls Risk Assessment was not completed for the falls which occurred on 6/19/16, 6/20/16, 8/14/16, 8/17/16, 8/18/16, and 8/19/16. A review of R #68's care plans found a care plan titled, I am at risk for falls related to fall risk score 15, fall on 3/20/16. I have decreased safety awareness. The care plan was initiated on 3/20/16. The resident experienced multiple falls after the initiation of the care plan but only a few interventions were added: 5/4/16 - I am sometimes impulsive and will attempt to transfer myself to my wheelchair from my bed or get out of bed without calling d/t my medical [DIAGNOSES REDACTED]. Keep my wheelchair out of my reach while I am in bed so as to not tempt me to go into it; 5/10/16 - I have agreed to have visual reminders in my room to remind me to call for nursing to assist me with my needs. Verbally remind me to not get up by myself as I am confused at times; 5/10/16 - I have agreed to move into Room 159A, which is closer and in my line of sight for me to call for assist when I require help; 4/4/16 - Please do not leave me unattended while toileting. Please standby until I am transferred to and from toilet and assist me back from restroom for prevention of falls. During the review of the IRs as noted above, the resident was left alone in the bathroom and experienced a fall on 7/30/16. On the morning of 9/16/16 at approximately 10:00 A.M., an interview with Staff #2, who was familiar with R #68, found that after a resident experienced a fall, the staff was expected to: Complete an incident report; Figure out what happened; Complete a Falls Risk Assessment; and Update the care plan to avoid/prevent more falls. Staff #2 further stated, When patients fall, we investigate the patient's needs to assist in avoiding more falls. With her, landing mats were hard. She had weakness on one side. The facility failed to perform root cause analyses for R #68's falls. R #68 experienced multiple falls during her admission to the facility. The resident's care plan did not reflect effective interventions as evidenced by the resident's continued falls. 6) On 09/13/2016 at 12:29 P.M. observed R #12 in the Restorative dining room. The R #12 was sitting in a wheelchair at the table, eyes were closed and didn't respond when spoken to Hello, ____. The Staff #6 sanitized the resident's hands and her own and tried to waken R #12 by stating, It's time for lunch. The Staff #6 cuts up the chicken mushroom with gravy lunch that was served on a regular dinner plate. The Staff #6 placed a fork into R #12's hand and rubbed his/her shoulder to try and waken resident. The Staff #6 placed a spoonful of rice to the resident's lips but resident didn't open mouth. The Staff #6 placed the spoon down and told R #12, It's lunch time, are you hungry. The Staff#6 than provided passion orange juice by putting the cup up to R#12's lips and the resident slowly sips juice but eyes remained closed. Staff#6 stated, Can you open your eyes? R #12's eyes remained closed and Staff#6 continued to try to have resident hold fork and eat by rubbing the resident's arm and hand and asked Are you hungry ____? The Staff #6 tried to lift R #12's R hand holding fork up to the plate but Res doesn't comply and eyes remain closed. Staff #6 states, ____ your juice, will you drink? R #12 doesn't open mouth and Staff #6 spooned a pear cube into resident's mouth after rubbing the spoon along the resident's bottom lip for Res to open mouth. The R #12 eats the pear cube with eyes closed. The Staff#6 placed another piece of pear into the resident's mouth and walks out. With eyes still closed, R #12 swallows pear. The Staff #6 returned to the dining rm and continued to feed R #12 fruit cocktail as resident chewed with eyes closed. On 09/14/2016 at 11:31 A.M. reviewed R #12's EMR and hard copy medical record. The care plan focus, Resident started on Restorative Program due to maintain or increase level of activity with feeding self, I'm in the Restorative dining program to encourage independent feeding for meals. The CP had an initiation and revision date of 08/01/2016, with the goal of, Restorative dining for meals to promote & encourage self feeding; and interventions of, Provide quiet environment when eating meals; Restorative dining program to promote indedpendent feeding with meals daily. The physician order [REDACTED]. Diet type: Regular Diet texture: Regular Fluid Consistency: Thin Order type: Standard Dietary-diet The Occupational Therapy (OT) Evaluation & Plan of Treatment form dated and signed by the OT on 07/11/2016, with physician signature dated 08/05/16, included short-term goals #1.0 Patient will safely perform self feeding tasks with Min (A) with use of Scoop dish w/ plate guard 25% Tactile Cues for initiation/termination of tasks in order to increase (I) in self feeding, with target date of 07/25/2016. On 09/16/2016 at 9:07 A.M. interviewed the Dining Svcs Manager (DSM) and asked how he would know whether a resident required special utensils. The DSM stated that either the OT, registered dietitian (RD) and/or nurses would communicate to him using the Diet Order & Communication form. The DSM went through the pile of communication forms on his desk and was unable to find one for R #12. The DSM went to R #12's MR and found a communication form dated 06/18/16 with, Communication: New Resident checked; Diet Order: Regular checked; and, Food allergies [REDACTED]. The DSM stated that OT recommendation should be on R #12's tray cart ticket; went to check resident's tray cart ticket for OT recommendation of scoop dish with plate guard, and was not included on ticket. According to the DSM, he started at the facility on 08/04/16 and OT recommendation was done in July 2016 and signed by the physician on 08/05/16. On 09/16/2016 at 9:49 A.M. interviewed the Rehab Director and she stated that if special eating utensils were recommended it would be communicated with nursing and DSM via the communication form. She stated that the communication form currently being utilized may not have been implemented in July 2016. The R #12's CP did not include outcome objectives when staff use tactile cues for initiation and termination of self-feeding tasks, and the OT's recommendation for a scoop dish with plate guard. Also, the CP did not attempt to manage the resident's risk factors of reduced cogniti

Based on observation, record review, interviews and review of the facility's policies and procedures, the facility failed to ensure it is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Finding includes: There is non-compliance with this regulation based on the negative outcomes related to the findings cited in the areas of Quality of Life and Quality of Care with substandard quality of care identified with the immediate jeopardy (IJ) and harm. This is evidenced and cross-referenced to the findings at: F164, F226, F248, F250, F279, F280, F282, F309, F314, F323, F325, F353, F371, F441 and F520. Based upon the interviews, record reviews, record reviews, and review of the facility's policies and procedures, it was found the administrative oversight, which should have been provided by the Medical Director and the Administration, remains ineffective and failed to ensure that each resident's health and safety was maintained in order for each resident to reach his/her highest level of functioning. An simple example of this involves the observation of the lack of plates for all residents, in addition to a family member's interview about this, concomitant to what the surveyor observed to evidence this: On 11/03/2016 at 12:25 PM, Res #17 was observed eating her lunch while in bed. Her food was in a Styrofoam take out container. Res #17's roommate, Res #13, also had her lunch in a Styrofoam container. CNA #1 who was in the residents' room was asked why these residents' meals were being served in take out containers, and whether it was an infection control issue. CNA #1 said, Really I did not know, and denied it was an infection control problem when further queried. She said for Res #17, she thought it was maybe because she liked to take things off her regular plate and this way her whole tray would not be taken away from her. Then, at 12:34 PM, during the dining room observation, it was found that Res #146 and this resident's sister, who also resides at the facility, were eating on the same dining room table. Res #146 was being assisted to eat by the MDS-C. Both of the residents were eating out of Styrofoam containers while other residents in the dining room were eating on regular plates. The MDS-C was asked why some residents had disposable containers while others had their meals on regular plates. She replied, Should be coming in. She was asked, What should be coming in? You mean plates? There's not enough plates? Her only reply was, You have to talk to (NHA). On 11/4/16 during a meeting with the DON and NHA for the IJ, the NHA said the plates were on a back order, which has been cancelled. The NHA said they are in the process of purchasing more plates locally. The NHA and DON were questioned whether they maintain at the very least, par levels for not just the food plates, but also for other resident care/use items, as the previous recertification survey found they even ran out of Sani-Cloths. Their response was that the census increased. The DON and NHA were informed this affects resident care outcomes, and based on this revisit survey, this should be evident as more of their own staff, more residents and more family members are bringing up these concerns regarding the inadequate and/or lack of care and services being provided.

Based on observations, record review, interviews and review of facility policies, the facility failed to maintain a quality assessment and assurance (QA&A) committee consisting of a physician designated by the facility and demonstrating active participation in the facility's QA&A program. In addition, the QA&A committee did not have a quality assurance program that showed specific standards for quality of care and outcomes, nor have documentation to identify and show the study and improvement of processes to better resident care services and outcomes, or to prevent/decrease problems identified with respect to which quality assessment and assurance activities have been necessary to correct identified quality deficiencies. Findings include: During an interview with the NHA and DON on 09/16/2016 at 11:28 A.M., they were asked to describe the facility's QA&A program and what has been identified as performance improvement processes or measures. The DON initially stated she goes off of CMS's indicators, such as pain, falls, skin and weight, nutrition, infections, etc. Upon query as to how then their resident care policies and procedures outlined a systematic process for the care of residents with areas such as falls, dementia, weight loss, etc., the DON's response was they followed the nursing assessment criteria of identifying it, observing it and implementing it and evaluating it based on resident outcome. However, a review of the resident care policy found the facility produced policies which belonged to another company, which were for Care Planning for Residents and for Standard Precautions, as evidenced by the policy titles. The facility did not have their own policies. Cross-reference to F279, F280. The SA also asked the NHA and DON how their QA & A committee monitored for consistent development and implementation of their policies and procedures for residents specific to falls in the facility and for those residents with recurrent falls. The DON stated the incident reports were given to her and at their daily stand up meeting, they become aware of who has fallen. She said then the CNAs huddle and check the veracity of the incident reports and then they look at other causal factors. She explained the falls were placed on a calendar with the time of the falls and she looked for the frequency and pattern of falls and causal factors. The DON was asked if she had documentation for this and replied the charge nurses documented it and that they do root cause analysis with their falls committee. Cross-reference to F323. When the NHA and DON were asked how their QA & A committee has provided monitoring and oversight for the care and services for residents with falls and the care plan process, as it was one of the areas of concern during the survey, the DON stated for the care plans, with each intervention, the care plans are updated. I'm following up, we have a lot of new nurses we're working with. She also said staffing vigilance as process--as our census has grown, our staffing has grown, and that has decreased the number of falls to date. However, the DON stated she has no trending, for the SA to see. Yet, during the meeting, the DON said she did have a QA falls binder and stepped out of the meeting to look for the falls QA binder. At 11:45 A.M., upon her return to the meeting, she said she could not find the falls binder which had all of her QA falls material in it. Cross-reference to F278, F279, F280, F281. In addition, the NHA and DON were asked if they had identified issues with staffing and resident dining. The SA said dining observations found periods of time when there was no staff in the dining room and residents were waiting, and some residents needed full assistance to eat but were not provided with it. The DON replied, We need more carts. It will look less chaotic and they'll be more individuals assisting. Right now I have meals being wheeled in and 2 carts, so I need to have more staff to feed. The DON was asked about the RNA dining program and how the program was being implemented and monitored. She stated, I'll be observing and checking with (RNA Nurse) to see if the resident is increasing their level of participation with self feeding. Then she was asked, what if the resident had weight loss, and her response was, Then we have to re-evaluate what we're doing and get the dietitian to help me. She stated the Nutrition at Risk committee meets weekly and they have identified those residents and they do a new assessment and the monitoring of it and we track what's happening with the individual. For a resident who has had significant weight loss, the DON said documentation would be found in the PCC (their electronic health record system) and it's under nutrition risk, which tracks the resident's weights. Related to facility staffing concerns and with so many new hire nurses, they were asked how the QA&A committee may have identified any quality deficiency areas related to the care of residents as a means for improvement, including the tools used to monitor that residents are getting the provision of care and services in some of the identified areas such as fall prevention, care planning, dining service and assistance, weight loss monitoring, etc. The DON stated it was done by providing education, whether of the staff or educating families, monthly inservices and by doing daily huddles where they discussed what was going on with individuals and residents and the separate shifts. As to the staffing concerns, the DON said, Some family members came to (the NHA) and said that I'm glad you have more staff. The DON said, I haven't started implementing them, but now that we have case managers, I do have rounds and checklists to validate that. I don't have anything at this point, other than my word. I go in and check on the residents too. For an identified problem, the NHA said that some people say they need more rehab. The DON said also that the food served was cold on occasion, with some residents wanting more ethnic dishes and more avocados. You're right I haven't written it down, was the response to the SA. Cross-reference to F353. The NHA and DON were asked about their Medical Director's involvement in the QA & A. The DON explained how a resident's voice was heard in her dying process, and said, quality of life? Is that a QA problem? We have our share of hospice--those who are on hospice and had to work with (Medical Director) and get to another level. Is it documented, no, other than nursing notes, I don't know. They were asked if they could provide the SA with any other QA & A activities/programs they have implemented for process improvement. Their collective response was that they just got a skin nurse and the other care manager is a wound certified nurse. On 09/16/2016 at 12:44 P.M., Staff #2 brought the QA falls binder which she said she got from the DON to give to a surveyor. Staff #2 confirmed this is the only binder of falls and she had worked on alphabetizing all of the resident fall related incident reports. Although the DON stated during the interview they have had a decrease in the number of falls by having had increased staff, the last fall meeting of 9/7/16 included signatures of four licensed staff plus the DON and the topics of discussion included implementing fall mats for two residents, possibly moving one resident to a closer room or add a roommate and implementing a fall checklist. There was no other data to indicate how the resident falls rate was being recorded, analyzed and how the facility was looking to specifically address it using quality metrics. Thus, with the collective review and findings in the areas of resident behavior and facility practice, quality of life and quality of care, resident assessment, dietary services, infection control, etc., and with no documentation to show how quality metrics or other clinical standards and practices were being implemented by the facility, demonstrated the fact that this facility does not have a current, on-going and intact quality assurance and management program.

Based on a complaint, record review and interviews, the facility failed to provide services for a resident (Resident #39) to attain the highest practicable psychosocial well-being. Findings include: On 8/12/16 a complaint was filed alleging the facility did not administer a prescribed medication (sleep aid) for R #39. On 9/14/16 at 2:00 P.M. an interview was conducted with R #39. The resident reported there was a couple of times in July when the facility did not administer her medication which helps her to sleep. R #39 further reported following the death of her spouse the medication has helped her to sleep at night. A record review done on 9/14/16 at 2:50 P.M. found a physician order [REDACTED]. to 5 mg.) every night with a start date of 11/25/2015. A review of the Medication Administration Record [REDACTED]. Also noted was a row to document SLE with entries ranging from 0 (zero) to 8. The medication time was specified for 2100. On 9/14/16 at 3:15 P.M. an interview and concurrent review of the MAR indicated [REDACTED]. Inquired what does SLE mean and what are nurses documenting in this row. Staff #3 reported SLE is probably for sleep and the numbers indicate how many hours the resident slept as there is documentation of 8. Further queried whether the documentation of 0 indicates the resident didn't sleep at all and what shift is responsible for ensuring the documentation is completed. The staff members were unable to explain the process. Inquired why the entries for 6/18/16, 7/20/16 and 7/27/16 were blank. Staff #3 further reported R #39 is aware of the medications given and if it was not given will ask for it. On 9/14/16 at 3:25 P.M. Staff #24 was asked what does SLE mean and what does a 0 indicate on the MAR indicated [REDACTED]. On 9/14/16 at 3:25 P.M. the MDS Coordinator (MDS-C) was interviewed. The MDS-C reported a blank entry would indicate the medication was not administered. On 9/15/16 at 12:55 P.M. an interview and concurrent record review was done with Staff #3. A review of the Controlled Drug Record for June 2016 found documentation [MEDICATION NAME] administered on 6/18/16. The drug record for July 2016 could not be located. Staff #3 reported the two missing entries for July 2016 may be due to the shut down of the facility's electronic medical record for maintenance. The staff member was agreeable to locate documentation of the shut down of the EMR. Prior to the exit conference, the staff member did not provide documentation of the shut down of the facility's system for maintenance. A review of the resident's care plan focusing on impaired sleep patterns due to my medical [DIAGNOSES REDACTED]. every night as ordered by the resident's physician. The facility failed to administer R #39's medication ([MEDICATION NAME]) as ordered by the physician to aide in sleeping to maintain the resident's highest practicable physical and psychological well-being.

Based on observations, resident and staff interviews, and medical record review, the facility failed to provide the necessary services to prevent pressure ulcers and infection for one resident, Resident #42, resulting in the avoidable onset of two pressure ulcers. Findings include: Resident #42 was being reviewed for unnecessary medications during a revisit survey, following the facility's recertification survey on 9/19/16. During a record review for Resident #42, it was discovered that he had acquired two pressure ulcers to his bilateral heels while a resident in the facility. A stage 3 pressure ulcer was discovered on Resident #42's left heel on 10/27/16. Several days later, on 11/2/16, the facility identified another pressure ulcer on his right heel which was unstageable, with signs of infection. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #42 on the afternoon of 11/3/16 found him sitting up in bed with both heels propped on 2 pillows - 1 for each heel. The resident's TV was on. The resident was asked if he gets out of his room to attend activities or go to the dining room for meals. He reported he would like to get out of his room but was never given the opportunity. Observation of Resident #42 on the morning of 11/4/16 found him sitting up in bed with both heels propped up on 2 pillows - 1 for each heel. The resident's TV was on. When asked how he was doing, Resident #42 reported he had been experiencing pain in his heels. At present, the resident denied having any pain. He stated the facility provided pain medication as needed to control the pain. Resident #42 was pleasant and socially appropriate with the surveyor. An interview with Licensed Nurse #1 on the afternoon of 11/3/16 at approximately 2:10 P.M. revealed that a staff member found the left heel pressure ulcer on 10/27/16. The Wound Nurse or Resident Care Manager, RCM #1, assessed Resident #42 on 10/27/16 and found a Stage 3 pressure ulcer on his left heel. Approximately 6 days later on 11/2/16, the night shift supervisor found another pressure ulcer on Resident #42's right heel. The RCM #1 assessed Resident #42's right heel and found the pressure ulcer was unstageable with signs of infection. Resident #42 was started on Bactrim DS 800-160 mg tablets twice per day on 11/2/16 for the right heel infection. A medical record review on the afternoon of 11/3/16 revealed Resident #42's pressure ulcers were located on both heels. The Initial Skin Ulcer Assessment for the left heel was dated 10/27/16 and noted the wound was facility acquired and measured 1.5 cm length x 2.0 cm width x 0.3 cm depth. The nurse's note indicated: the Wound bed had 90% granulation tissue with a top layer of 10% eschar; Small amount of serosanguinous drainage; and the Periwound was red, blanchable and mushy. Shortly after the discovery of the left heel pressure ulcer, on 11/2/16, another pressure ulcer was found on Resident #42's right heel. An Initial Skin Ulcer Assessment was completed on 11/3/16 which noted the pressure ulcer on Resident #42's right heel was unstageable. It noted that Resident #42 acquired the right heel pressure ulcer in the facility and it measured 2 cm length x 3 cm width x unknown depth. The assessment further noted the wound showed signs of infection: Small amount of purulent exudate/drainage; 100% viable non-granular wound bed; Non resolving [DIAGNOSES REDACTED]; and the Wound bed color was not visible. Additionally, the assessment noted a 5 cm x 4 cm purple boggy area to peri wound area. The treatment plan for the right heel was float heels. A Weekly Skin Ulcer Measurement Wound Evaluation was completed on 11/3/16 for Resident #42's left heel. The 11/3/16 evaluation noted the wound measured 1.5 cm x 2.0 cm width x 0.2 cm depth with a small amount of serosanguinous drainage and no signs/symptoms of infection. A review of Resident #42's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/9/16 noted under Section C (Cognitive Patterns) that he had short and long term memory problems and had severely impaired cognitive skills for daily decision making. Under Section G, it noted Resident #42 required extensive assistance with 2 staff assistance for bed mobility, transfer, and toilet use. For bathing, he was totally dependent and required 2 staff assistance. Under Section D, Resident #42's score was 00 meaning he did not exhibit any mood symptoms. Under Section E Behavior, Resident #42's scores were 0's indicating the resident did not display any behavior symptoms and was cooperative with care. Resident #42 had a care plan titled, At risk for further skin breakdown r/t incontinence, needs physical assist with Activities of Daily Living (ADLs) and co-morbidities, with onset date of 6/16/16. The care plan included interventions: Do weekly skin head to toe assessment. Notify MD for skin issue. The interventions did not include frequent turning or repositioning of Resident #42. The facility added the problems, (11/2/16) Right heel wound. Left heel wound. No further changes were made to the care plan. The facility created another care plan titled, I have a pressure ulcer to my left foot with onset date of 10/27/16. The interventions noted the treatment orders for the left heel pressure ulcer and to notify the Registered Dietician. A separate care plan was titled, I have an acute infection for right heel infection with onset date of 11/3/16. The interventions included: Antibiotic treatment; Nurse to assess right heel for improvements; and Notify the MD/FNP for changes. A concurrent record review and interview of the Resident Care Manager (Wound Nurse), RCM #1, on the afternoon of 11/3/16 at approximately 3:50 P.M. revealed that he was notified of Resident #42's left heel pressure ulcer on the morning of 10/27/16. The RCM #1 stated that the pressure ulcers on Resident #42's heels developed from his heels touching the bed. The RCM #1 further reported that Resident #42 preferred staying in bed which would contribute to skin breakdown. The RCM #1 was asked whether the pressure ulcers on Resident #42's heels were avoidable or unavoidable. The RCM #1 replied that he would need to confer with the physician to determine if Resident #42 had any underlying medical conditions. Further interview of the RCM #1 revealed that he expected the nurses to complete a weekly skin assessment for all residents. The RCM #1 reported that the skin assessments were kept in a binder at the nurses station. The RCM was unable to find any skin assessments in that binder. He noted that the skin assessments were probably not done. The RCM noted that the nurses may have documented the skin assessments in the Electronic Medical Record (EMR), where he looked but was unable to find any. The RCM found two forms of the Braden Scale for Predicting Pressure Sore Risk: 1) 6/4/16 - Score 17; and 2) 9/19/16 - Score 14 (13-14 = moderate risk; and 15-18 = at risk). The RCM #1 noted that CNA staff were required to turn/reposition residents every two hours. However, he was unable to find documentation for turning/repositioning of Resident #42 by CNA staff. The RCM was again asked whether the pressure ulcers on Resident #42's heels were avoidable or unavoidable. The RCM #1 stated that both pressure ulcers on Resident #42's heels were avoidable. In summary, the facility was aware of Resident #42's risk for skin breakdown: lack of mobility, impaired cognitive skills for daily decision making, and his need for extensive to total assistance for ADLs. The facility caused harm for Resident #42 based on their negligence with conducting skin assessments and the failure to provide appropriate interventions to prevent skin breakdown.

Based on a complaint investigation, interview with resident and family members and record review, the facility failed to provide medically-related social services for 1 of 1 (Resident #58) residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Finding includes: Cross Reference to F323. Resident #58 was admitted to the facility on [DATE]. The complainant noted Resident #58 is fearful of Resident #36 who wandered into her room and is known to scratch, pinch and hit other residents and staff members. The resident also reported incidents of feeling that Resident #36 would knock her over in the hallway. However, there is no documentation of the Social Worker (SW) providing support to this resident or developing a plan to find options to meet the resident's emotional needs. Record review notes the resident was admitted to the facility on [DATE]. A review of the admission Minimum Data Set with assessment reference date of 3/21/16 notes Resident #58 is cognitively intact. The Resident Mood Interview was conducted with the resident. Resident #58 reported feeling down, depressed or hopeless and feeling tired or having little energy for several days. The admission note dated 3/21/16 documents the resident appears to be adjusting to the facility as evidenced by attending activities, eating her meals in the dining room and socializing with staff and peers. There was no noted mood or behavior indicators. A review of the physician orders [REDACTED]. every 12 hours as needed). An incident occurred in June 2016 when Resident #36 wandered into Resident #58's room. As a result, Resident #58 became afraid of Resident #36 and had to close her door to prevent the resident from entering without permission. Resident #58 reported life was miserable and her family member reported the closing of the door resulted in claustrophobia. Although the resident did not label herself as having claustrophobia, she reported she didn't feel like herself, it affected her body and brought about a change of attitude. Further review found there was no documentation of the SW providing support services to address Resident #58's fears and uneasiness. Also, there was no documentation of a care plan with interventions to address Resident #58's feelings. On 11/4/16 at 1:00 P.m. the NHA confirmed there was no documentation of SW services. The facility failed to provide social services to ensure Resident #58 felt safe in her new home after an incident with another resident which resulted in actual harm, chronic fear. The resident resided in her home from approximately 6/27/16 (as evidence by first documentation) through 10/15/16 in fear of another resident.