Every finding on record at Life Care Center of Hilo

Based on interview and record review the facility failed to provide unopened mail to one of four residents sampled for mail delivered to them. Resident (R) 23 reported approximately six months ago four bank statements from her credit union and two personal letters that included checks made out to her were delivered opened to her. This deficient practice violates R23 resident rights and may cause undue emotional stress. Findings Include:On 07/01/2026 at 09:29 AM met with four Residents (R) 169, R130, R185 and R23 and two staff, Activities Director (AD) and Discharge Coordinator (DC), in the conference room to conduct the Resident Council interview. During this interview surveyor asked residents, Is mail delivered unopened and on Saturdays? R23 spoke up and said No. Inquired of R23 what happened and she stated she had four pieces of mail that were opened from her credit union with bank statements and two personal letters with checks that were coming to her for her to sign to give to the facility. Inquired when this occurred and R23 stated, This occurred about 6 months ago. Inquired of residents and staff who receives the mail when it is delivered to the facility and R23 stated the business office. Inquired who surveyor should speak to, the AD and DC stated the name of the Accounts Receivable staff. On 07/01/2026 at 10:22 AM met with the Business Office Accounts Receivable staff in the conference room. Inquired if the facility opens residents mail before they deliver mail to residents and she stated they do not open resident's mail. Inquired if there is ever a reason for facility staff to open resident's mail and she stated, Only for rep payees (if the facility is the rep payee for the resident). Inquired if she could provide surveyor with a list of the residents who the facility is the rep payee for. Staff also stated there is one resident who is not the responsible party and she will include this resident on the list. Business Office Accounts Receivable staff was able to provide the copy of the list of resident's names soon after and review of this list found R23 was not listed as having the facility as the rep payee for her. On 07/01/2026 at 2:53 PM met with and interviewed the Director of Nursing (DON) and Administrator in the Administrator's office. Inquired if resident's mail is supposed to be delivered to residents unopened and they confirmed this.

Based on record reviews, staff interview and review of policy, the facility did not show proof of discharge written notification for one Resident (R)11 of two sampled for hospitalization.Findings include:Review of Electronic Health Record showed that R11 was discharged to the hospital on [DATE]. Notice of Resident Transfer or Discharge form showed that the resident's representative was notified, via phone, of the transfer or discharge.During a staff interview on 07/01/26 at 2:35 PM, Social Services Director explained that the facility mailed R11's Transfer or Discharge form to the representative but could not provide any verification.Review of facility policy on Transfers and Discharges read; Policy, the facility will follow the limited conditions under which CMS has outlined how the facility may initiate transfer or discharge of a resident, the documentation that must be included in the medical record and who is responsible for making the documentation. Additionally, the facility will ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting is provided in accordance with federal guidance. The facility will also provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations.

Based on observations, interviews and record reviews, the facility failed to develop a written person-centered comprehensive care plan for two of three residents (Resident (R) 48 and R164) sampled for skin conditions. As a result of this deficient practice, staff did not have the information to adequately care for both resident's skin conditions. Findings include: 1) On 06/29/26 at 11:52 AM, observed R48 walking in the hallway with the assistance of the physical therapist. R48 had a dressing to his left shin. Queried R48 what happened to his shin. R48 said he had a wound that was slow to heal and was acquired before he was admitted to the facility on [DATE].Review of R48's Electronic Health Record (EHR) was conducted. R48 is a [AGE] year-old resident admitted to the facility for short-term rehabilitation services after sustaining a cervical (neck) fracture from a fall at home. R48 also sustained multiple bruises and wounds as a result of the fall. Further review of the EHR revealed that the wound on his left shin was cellulitis (bacterial skin infection that causes redness, swelling and pain in the infected skin and underlying tissues) and an order to cleanse it with normal saline, apply Mupirocin (topical antibiotic) ointment and apply a dressing to the wound was given by the provider on 06/23/26. There was no care plan implemented for R48's left shin cellulitis.On 07/01/26 at 1:04 PM, a concurrent interview and record review was conducted with Registered Nurse (RN)17 by the nurses' station. Queried RN17 if there was a care plan developed for the cellulitis to R48's shin. RN17 reviewed the current care plan in the EHR and confirmed that there was no care plan developed for the management of R48's cellulitis. 2) On 06/30/26 at 10:07 AM, an observation and interview were conducted with R164 in the main dining area on the third floor. During the interview, observed both of R164's feet were reddened, shiny and with small open wounds. Queried R164 about the condition of her feet. R164 said a few months ago, she had edema (swelling due to excess fluid in the body's tissues) to both legs and the top of her feet developed some open sores. R164 said the skin is shiny because the staff apply Aquaphor (skin-protecting ointment used to heal dry, cracked skin and minor cuts) after they cleanse it with normal saline.Review of R164's EHR was conducted. R164 is an [AGE] year-old resident admitted for long-term placement on 02/23/24. Diagnoses included but not limited to peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in the blood vessels), protein-calorie malnutrition and polycythemia vera (rare blood cancer where the bone marrow overproduces red blood cells that thickens the blood). Orders for the care of R164's feet included, saline wound wash every evening, application of Aquaphor, and covering the feet with gauze when in bed. There was no care plan found for the management of R164's skin condition of her feet. On 07/01/2026 at 09:43 PM, concurrent interview and record review was conducted with Licensed Practical Nurse (LPN) 13 in the nurses' station. LPN13 checked in the EHR and confirmed there was no care plan developed for the skin condition to R164's feet and added she will bring it to the attention of the interdisciplinary team.On 07/01/26 at 2:53 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. The DON confirmed that the care plans for R48 and R164 need to be updated to include care for their skin conditions.

Based on record review and interview the facility failed to assure one of five Residents, (R) 10, reviewed for unnecessary medication, had a completed Medication Informed Consent form that was shared with the resident's representative by phone which ensured the residents representative was informed of the risks versus benefits of R10 taking psychotropic medications. The deficient practice places residents at risk of the right to be informed of treatment. Findings Include:On 06/30/2026 at 3:01 PM record review of R10's Electronic Health Record found he is taking Citalopram Hydrobromide for a mood disorder secondary to his dementia, Trazodone at bedtime for sleep, Risperidone (an antipsychotic medication) twice a day for dementia with psychosis. Review of R10's consents for his medications found there was a Medication Informed Consent form partially filled out on 07/17/2025. The following three boxes of the form were left blank:The following non-drug approaches have proven to be ineffective:Reason why medication was prescribed:Expected benefits to resident: and the proposed course of the medication was not checked off. On 07/01/2026 at 2:53 PM an interview was conducted with the Director of Nursing (DON) in the Administrator's office with the Administrator present. Inquired if the medication consent form for R10's psychotropic medications should have been filled out completely prior to the nurse getting a telephone consent from R1's representative and she confirmed this.

Based on observations, interviews and record review, the facility failed to implement infection control policy related to Enhanced Barrier Precautions (EBP) for one of three residents sampled for skin conditions. The facility did not place Resident (R)48) on EBP who had a wound with cellulitis (a bacterial infection affecting deeper layer of skin) on his left lower leg. This deficient practice places the other residents in the facility at an increased risk of infection. Findings include:R48 was a [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to cervical (neck bone) fracture following a recent fall at home, diabetes and history of alcohol abuse. R48 was also admitted with multiple bruises and wounds to all extremities as a result of the fall. On 06/29/26 at 11:52 AM, observed R48 walking in the hallway with the physical therapist assisting him. Observe a dressing to R48's left shin. R48 said he has a wound that was slow to heal. Queried R48 if the wound was acquired at the facility. R48 said he already had the wound before he was admitted to the facility. Review of R48's Electronic Health Record (EHR) conducted. Entry under Progress Notes dated 06/30/26 at 10:12 AM stated, . Tx (treatment) orders in place-Mupirocin External Ointment 2 % (Mupirocin) Apply to L) [sic] (left) shin scab topically every day and evening shift for cellulitis for 10 Days (cleanse with NS, pat dry, apply ointment to scab and surrounding skin and cover with band aid/dry dressing. Dry scab remains with slight surrounding redness . On 07/01/26 at 07/01/26, Observed Registered Nurses (RN)17 provide wound care for R48's left shin wound in his room. No signage was noted at the room's entrance designating R48 to be on EBP. RN17 changed the dressing and applied Mupirocin cream to the wound as ordered. RN17 was not wearing a gown while providing care. Review of facility policy titled Enhanced Barrier Precautions dated 06/05/26 stated, .EBP are indicated for residents with . Infection or colonization . Wounds and/or indwelling medical devices . Examples of high-contact resident care activities requiring gown . Wound care: any skin opening requiring a dressing . On 07/01/26 at 2:53 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. The DON confirmed that R48 should be on EBP due to the wound being identified as cellulitis.

Based on interviews and record review, the facility failed to provide effective and timely pain management to a resident experiencing pain. Resident (R) 10 complained of pain 10 out of 10 (10/10 on the pain scale, indicating severe, intense agony) to the lower back after being in a wheelchair (w/c). The physician ordered an opioid medication at 01:47 PM, which was not administered until 09:00 PM, despite the resident's sustained pain level 8/10, which is severe. The delay in administration of an effective medication, the absence of non-pharmacological intervention, failure to seek higher level of care due to unrelieved pain caused R10 to experience unrelieved severe pain for 7.15 hours. As a result of this deficient practice, residents are at risk of physical harm. Findings include: Cross Reference to F609- Reporting of Alleged Violations & F610- Investigate Alleged Violations.On [DATE] at 09:06 AM conducted a review of R10's Electronic Health Record (EHR). R10 was admitted to the facility on [DATE] with diagnosis of [DATE] at 11:04 AM- documented the resident was in a wheelchair in the dining room and appeared comfortable. An interview with the author of the progress note on [DATE] at 01:59 PM, confirmed the note was written prior to R10 complaint of lower back pain and the resident was not tolerating being in the wheelchair, thus was transferred back to bed. At 12:54 PM the Medication Administration Record (MAR) documented Acetaminophen 650 milligrams (mg) was administered for 10/10 lower back pain. The Pain Scale also documented on [DATE] at 12:54 PM- 10/10, which indicates severe/intense agony pain. At 01:03 PM, a progress note documented R10 stated that Acetaminophen does not normally work but will take it and wanted stronger medication for pain management. At 01:23 PM, a progress note documented the follow-up evaluation of the Acetaminophen administered was 08/10 indicating severe debilitating pain. There was no documentation of non-pharmacological interventions implemented or attempted as a standard of practice. R10's pain scale documented at 01:23 PM- 8/10, indicating severe debilitating pain.At 01:47 PM, the Medication Administration Record (MAR) documented the physician ordered Hydrocodone- Acetaminophen 5-325 mg for pain which was not administered. At 05:00 PM, the pain scale documented R10's pain was an 8/10, indicating severe debilitating pain. Acetaminophen 650 mg and Hydrocodone-Acetaminophen 5-325 mg were not administered to manage the resident's severe pain. Also, non-pharmacological interventions were not implemented. At 09:00 PM, R10 was administered Hydrocodone-Acetaminophen 5-325 mg, approximately 8 hours after Acetaminophen 650 mg was given and 7.15 hours after the order for Hydrocodone-Acetaminophen 5-325 mg was ordered by the physician. At [DATE] at 01:50 AM, a progress note documented that R10 was pale and lethargic.Right Lower Extremity (RLE) inner leg below knee with extensive bruising. & (and) having pain with slight movement. Review of the hospital records documented obvious deformities to the right tibia, RLE and uncertain of how that occurred. R10 arrived at the emergency room at 02:39 AM and expired at 03:20 AM. An interview was conducted with Physician (P) 1 on [DATE] at 11:06 AM. P1 reported assessing the resident on [DATE] in the morning and the resident was not in any pain and appeared comfortable throughout the assessment. On [DATE] at 01:59 PM, conducted an interview with Registered Nurse (RN) 9. RN9 confirmed on [DATE], R10 was up in a wheelchair and became uncomfortable and was assisted back to bed. On [DATE] at 04:25 PM, conducted a telephone interview with Family Member (FM)2. FM2 confirmed R10 could not tolerate being in a wheelchair and had not been in one for approximately two years ago. R10 could not tolerate the wheelchair due to becoming dizzy and contractures which prevented her from sitting upright.

Based on interviews and record review, the facility failed to ensure an injury of unknown source was reported immediately to the State Agency (SA), but not later than 2 hours after the allegation was made, which resulted in serious bodily injury. Resident (R) 10 sustained a serious injury of unknown origin to the Right Lower Extremity (RLE). The facility did not report the injury of unknown origin to the SA. As a result of this deficient practice, residents are at risk for the potential of harm. Findings include: Cross Reference to F610: Investigate and F697: Pain ManagementOn 03/25/26 at 10:15 AM, reviewed the facility profile in the IQIES database. The database did not contain a Facility Reported Incident (FRI), initial or completed report, for the injury identified on R10's RLE. On 03/30/26 at 01:15 PM, conducted a review of R10's Electronic Health Record (EHR). The resident was admitted to the facility on [DATE]. The Nursing admission Tool completed on 02/02/26 at 12:50 PM, which is the nursing admission assessment, documented A. Skin Conditions documented a rash on the lower back, pink discoloration 15 x 14 cm, tip of nose 1.3 x 1 cm scab (malignant neoplasm) toenails with onychomycosis on the left greater toe avulsed toenail, and surrounding skin dry 3 x 3 cm. There was no documentation of bruising and swelling to the resident's RLE.A progress note written on 02/03/26 at 00:00 AM (midnight) documented staff called R10's Power of Attorney (POA) and informed her of bruising to the RLE. The RLE bruising was not documented on the Nursing admission tool (completed 02/02/26) used to assess R10 on admission, constituting a new injury, occurred after admission. No source of the injury was identified at the time the injury was reported by staff. A progress note on 02/03/26 at 05:00 PM documented, Resident was noted with a bruise to the RLE, below the knee (20 cm [centimeters] x 7cm in length). Resident does not recall how the bruise occurred. Although there are speculations as to the origin of the injury to the RLE, there is no documentation of an investigation conducted by the facility to ensure the injury was not a result of abuse or neglect. Thus, the facility should have conducted a formal investigation into the origin of the injury.A photograph taken on 02/03/26 at 05:03 PM, documented a dark red bruise to the RLE, below the knee which appears to measure the documented 20 cm x 7 cm. In addition to the dark red bruising, there was light yellow/purple bruising which encompasses R10's RLE from below the knee to the shin. On 04/01/26 at 123:37 PM, inquired with the Administrator if the facility reported R10's injury of unknown origin to the SA. Administrator confirmed the facility did not investigate or report R10's injury of the RLE to the SA due to family later reporting it could have happened when the transporting company brought the resident to the facility. However, an interview was conducted with Family Member (FM) 1 on 03/31/26 at 04:25 PM via telephone. FM1 informed that the facility insisted that the family stated the injury was a result of the resident's admission transfer with the transporting company. FM1 insisted that the family did not report that and it was a new bruise sustained after admission. The family provided a verified audio recording for 02/03/26 from approximately 06:45 PM to 08:35 PM. During this time the recording documents the family urging the facility to do x-ray sooner than the next day due to the severity of the injury to R10's RLE and did not mention the origin of the injury as being sustained from the admission transport to the facility. It is clear in the audio recording that the family is asking staff how the resident sustained this injury and if the resident was up in a wheelchair that day. The recording also documents family member repeatedly telling staff that something is wrong with R10; the resident was vomiting and cognition was declining. R10 is normally alert and oriented to person, place, time, and situation. However, the resident presented as alert and oriented to person only. Due to the unknown origin of the injury, the extent of the injury, and the potential for abuse and/or neglect to have occurred, the facility should have reported the injury to the State Agency.

Based on interviews and record review, the facility failed to investigate an injury of unknown origin to rule out the potential for abuse. Resident (R) 10 sustained a serious injury of unknown origin to the Right Lower Extremity (RLE). An investigation was not conducted into the origin of the injury and potential for abuse was not ruled out. As a result of this deficient practice, all residents are at risk for potential abuse until a thorough investigation is completed. Findings include: Cross Reference to F609- Reporting to the State Agency and F697- Pain ManagementOn 03/30/26 at 01:15 PM, conducted a review of R10's Electronic Health Record (EHR). The resident was admitted to the facility on [DATE]. The Nursing admission Tool completed on 02/02/26 at 12:50 PM, which is the nursing admission assessment, documented A. Skin Conditions documented a rash on the lower back, pink discoloration 15 x 14 cm, tip of nose 1.3 x 1 cm scab (malignant neoplasm) toenails with onychomycosis on the left greater toe avulsed toenail, and surrounding skin dry 3 x 3 cm. There was no documentation of significant bruising and swelling to the resident's RLE.On 02/03/26 at 05:00 PM a progress note documented, Resident was noted with a (new) bruise to the RLE, below the knee (20 cm x 7cm in length). Resident does not recall how the bruise occurred. The origin of the bruising and swelling are significant and warranted x-rays. Review of the resident's admission Assessment tool did not document a bruise or swelling to R10's RLE, indicating the injury occurred after the resident was admitted to the facility. On 04/01/26 at 12:27 PM, conducted an interview with the Administrator. Inquired if an investigation was conducted to ensure the new bruise was not a result of abuse. The Administrator confirmed an investigation was not conducted because the family thought the injury may have been from the resident's admission transfer the day before. However, an interview was conducted with Family Member (FM) 1 on 03/31/26 at 04:25 PM via telephone. FM1 informed that the facility insisted that the family stated the injury was a result of the resident's admission transfer with the transporting company. FM1 insisted that the family did not report that and it was a new bruise sustained after admission. The family provided a verified audio recording for 02/03/26 from approximately 06:45 PM to 08:35 PM. During this time the recording documents the family urging the facility to do x-ray sooner than the next day due to the severity of the injury to R10's RLE and did not mention the origin of the injury as being sustained from the admission transport to the facility. It is clear in

Based on observation, interviews, and record/document review, the facility failed to provide supervision to one resident (R)1, of a sample size of three, who was left alone in the facility van for an unknown period of time. As a result of this deficient practice, R1 was left in an unsafe environment with a high potential for negative physical and/or mental health outcomes. This deficient practice could affect any resident that used the transport van. After the event, the facility implemented interventions to reduce the risk of a similar event in the future and met the criteria for past noncompliance. Findings include: 1) R1 was a [AGE] year-old female resident at the facility since her readmission on 03/16/2022. Her past pertinent medical history included hypertension, Type 2 Diabetes Mellitus, dementia without behavioral disturbance, generalized weakness, and end stage renal disease. P1's BIMS (Brief Interview for Mental Status) on the MDS (Minimum Data Sheet) dated 03/22/2025 was five, which suggest severe cognitive impairment. She required one person assist to extensive assist to transfer and spent the majority of her day in a wheelchair (w/c). R1 was scheduled for dialysis treatments three time a week at an offsite dialysis center. The facility owned two vans and employed drivers/transport staff, who were scheduled to take residents to and from appointments outside the facility. R1 was transported to her dialysis appointments in her wheelchair, by the facility transport van. On 02/19/2025 at approximately 12:00 PM, when R1 returned to her unit after dialysis, she reported to staff when the van returned to the facility, the driver left her alone. 2) The facility encourages Residents/families to share concerns, and utilizes a form titled Concern and Comment Form to forward their concern to leadership. Reviewed the Concern and Comment Form, the Assistant Director of Nursing (ADON) completed for R1 on 02/19/2025 at 12:20 PM. The form included: Please include in detail your concern, comment, or commendation: He left me. I was all alone. I didn't know what to do (handwritten by ADON). Were you unable to report this concern/comment to a staff member? Yes, was checked. Was the staff member able to resolve the concern at the time it was shared? Yes, was checked. The Form included an area to document Facility investigation and response. The Executive Director (ED) handwrote the following on 02/26/2025: Investigation steps, SW (Social Worker) spoke with Family member (FM)1/ Power of attorney regarding setting up meeting in regards to transportation. Meeting scheduled for 2/26/25. Actions taken to resolve/respond to concern, See attached (meeting held with family on 2/26/25). Concerned party's response to the plan/outcome, Family expressed appreciation for meeting and satisfied with solution. 3) Reviewed R1's Pre/Post Dialysis Communication Forms for January 2025 to present. The form documents the resident's vital signs predialysis, at the dialysis center, and again on return to the facility, post dialysis. A total of 17 forms were reviewed. 16 of the 17 times documented for vitals (post dialysis) on return to the facility, ranged from 10:30 AM-11:35 AM. On 02/19/2025, the time post dialysis vital signs time were taken at 12:00 PM, which was the only time outside the range. Reviewed R1's Pre/Post Dialysis Communication Form, dated 02/19/2025, which revealed the following: 05:00 AM Pre-dialysis vitals: temperature (T) 97.1, pulse (P) 59, blood pressure (BP) 164/67, respirations (R) 17, and weight (Wt.) 109.6 lbs. 10:23 AM Dialysis Center vitals: T 90, P 62, BP 179/61, R20 Post-Dia (dialysis), Wt. 48.9 kg 107.8 lbs. 12:00 PM Post dialysis vitals: T 98.1, P 64, BP 182/62, R 22, Wt. 106.2 lbs. 4) Reviewed the Psychosocial notes,which included the following: 02/26/2025: QSW (Social Services), ED (Executive Director), and DON accommodated FM1, FM2, FM3, FM4, and FM5 by having care plan meeting today. Family updated on Resident's concern in regards to transportation. Discussed plan of care, having mental health speak with Resident, 2 man in van at all times. Resident with cell phone. Family providing cell phone. Family expressed appreciation for meeting. 03/04/2025: QSW met with R1 today to provide 1:1 social interaction for psychological well being. Resident displays pleasant affect, smiling, laughing and was able to carry out conversation in Ilocano and some English. Resident was oriented to self, but needed reminders to time and place.During the conversation, Resident express [sic] that she lost her voice and recalled when in the van calling out for assistance. Resident then states the person no longer works here and changed the subject. Resident was thankful of visit and was okay. 5) On 04/28/2025 at 12:00 PM, observed R1 in a w/c in her room. She was able to be understood and answer short questions. R1 confirmed she had just returned from her dialysis treatment, and getting ready to eat lunch. When asked about a previous concern with the van, she became upset, and indicated she did not want to talk about it, shaking her head back and forth. Inquired if she was OK, and she replied yes. 6) On 04/28/2025 at 01:15 PM, interviewed the ADON in the conference room. She said the staff came to get her on 02/19/2025 after finding out R1 didn't immediately come in from the van when it arrived back to the facility. She said usually there would be the van driver and a transporter, but sometimes there was only one. The ADON said she was unsure how long R1 had been alone in the van, but when she saw her shortly after arriving back to the unit, she was alert, verbal and pleasant. She said R1's blood pressure was elevated, which was not unusual for her. When asked about R1's clothes, she said they were dry, and her temperature was normal. On 04/28/2025 at approximately 02:00 PM, interviewed the House Supervisor (HS) that was working on 02/19/2025. She said after she was notified that R1 had been left in the van, she went and saw her on the unit. The HS said that when she saw R1, she was fine. She did not have any details of the event, but said there were two people scheduled that day and one likely had taken another resident back to their unit. On 04/28/25 at 02:35 PM, interviewed the DON and ED in the conference room. The ED said they had a concern (referencing the form) associated with this incident. She said it was brought to her attention that day, an investigation initiated, immediate action taken, and communicated with the family. She said they continued to monitor R1's emotional status, there was no physical harm, and she quickly returned to her routine. Inquired what had changed to prevent another incident from occurring, and she said the standard now is two people on the vans. The ED said they are monitoring the volume of the transports to ensure the correct staffing. She said there were two staff scheduled that day, but were unable to determine the exact location of the second person or the exact amount of time R1 was in the van alone. On 05/01/2025 at 08:29 AM, interviewed the DON again, in the conference room. She said the staffing for the van transport has changed. She explained prior to the event on 02/19/2025, at times they would have only one person, the driver on the van. The DON said although the full-time transporter would start with the van, she would often have to stay with a resident at a scheduled appointment, which left the driver alone. She said when the driver was interviewed, he said when he returned to the facility, he went to the bathroom, then went to get something to eat, when her realized R1 was still in the van. The DON said after this incident, the driver decided to retire from the job, and not return to the facility. On 05/01/2025 at 09:10 AM, interviewed Registered Nurse (RN)1, who often worked with R1. She said the staff get her ready to leave on dialysis days around 05:00 AM, and the pre-dialysis vitals are taken around that time. RN1 explained the transporter will come to the unit and take her to the van, usually leaving the unit about 06:00 AM. She said they work together, and the unit staff will assist with taking resident to and from the van as needed. RN1 said when R1 returns, they check the dialysis access site, and take vitals again. She stated on 02/19/2025, the CNA (certified nurses assistant) told her R1 was late getting back from dialysis. She said she thought maybe the van had to stop somewhere and was delayed. She said when R1 returned to the unit, she made a statement that the driver parked, closed the doors, and left her in the van. RN1 said R1 was flustered and very emotional at the time. After the event, they were able to calm her, and she returned to her routine, with a visit with her son that night. 7) On 04/30/2025 at 11:08 AM, observed the transport van arriving back to the facility. The driver backed into a space in front of the facility, parked, and immediately prepared the ramp to unload Residents. One Resident was ambulatory and accompanied by staff. The other two were in wheelchairs, and taken off the van in a timely, organized manner, each accompanied by staff. No resident was left alone at anytime. 8) The facility provided documentation of corrective actions taken to prevent a similar accident from occurring in the future, which included: Revised the orientation for new schedulers, drivers and transporters to include the transportation staffing policy. On 02/26/2025, a new policy was implemented to always have a minimum of two facility staff, a transporter and driver, on the van at all times. Depending on the type of appointments, three staff may be scheduled. On 02/26/2025, the DON directed the staff scheduler to implement the new policy and provided education as to the importance to ensure compliance. On 02/26/2025, the DON communicated verbally with transport staff, the new policy to have a driver with a transporter for each van and always have two staff to ensure residents are not left unsupervised. 9) Review of the van/transporter work schedule for May 2025, confirmed minimum staffing of one driver and one transporter.

Based on observations, interviews, and record review, the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being during meals times and during Activities of Daily Living (ADLs) for multiple residents on the second floor. Resident (R)203 reported having to wait up to an hour for staff to assist the resident to the bathroom due to insufficient staffing. An Anonymous Resident (AR) complained to Family Member (FM)1 about waiting for approximately 30 minutes for staff to answer the call light for assistance to the toilet, then staff rushing the resident off the toilet due to having to go and assist another resident, and staff not having enough time to assist the resident with meals due to the resident's slow pace of eating. Interviews with four anonymous direct care staff, on the second floor, confirmed there is not sufficient staff to assist residents on the second floor during mealtimes and with ADLs due to the high acuity and the amount of assistance the residents on the second floor require. Observations were made of residents being left unattended in the main dining room and residents having to wait for meals and/or assistance while other residents eat around them. As a result of this deficient practice, residents on the second floor are at an increased risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being and are at potential risk of harm. Findings include: 1) On 11/28/23 at 10:10 AM, observed the light (on the ceiling) directly outside of room [ROOM NUMBER] on (which is part of the call light system that visually alert staff of an activated call light). At this time, there were no staff in the hallway. At 10:14 AM, Certified Nurse Aide (CNA)48 exited room # 206, then entered room [ROOM NUMBER] (which is directly across room [ROOM NUMBER] and had an activated call light). CNA48 did not enter or address any resident in room [ROOM NUMBER] prior to entering or leaving room#202. From the entrance of room [ROOM NUMBER], this surveyor observed R203 seated in a wheelchair. R203 was alert and oriented to person, place, time, and situation during this interview. Inquired with R203 if the resident how long the resident has to wait for staff to address the resident and if the resident considered the wait time to be long, if the resident could recall the amount of time, he/she usually has to wait, and if this happens on any particular shift or the time of day. R203 stated, I know staff are busy and I know there are some residents who need more help than I do, but my room is at the very end of the hall, I have had to wait a long time for help to go to the bathroom, especially if it's around lunch or dinner time. R203 informed this surveyor, the longest he/she has had to wait for staff to respond to the call light was approximately 45 minutes and it was for assistance to go to the toilet. R203 reported if the resident had to wait any longer, the resident was just going to go to the toilet without staff because he/she did not want to have an accident. R203 confirmed every couple of days the resident waits at least 30 minutes for staff to answer his/her call light. During this occasion, R203 waited approximately 15 minutes for staff to assist the resident which was okay with the resident. On 11/28/23 at 11:53 AM, conducted a review of R203's Electronic Health Record (EHR), the resident's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/23 documented in Section C., the Brief interview for Mental Status (BIMS) was 13, indicating the resident is cognitive. Section GG. Functional Abilities and Goals documented (GG01115. Functional Limitation in Range of Motion) R203 has impairment of the upper extremity (shoulder, elbow, wrist, hand) and requires partial/moderate assistance for toilet transfer (the ability to safely get on and off a toilet or commode). 2) On 11/29/23 at 11:35 AM, a resident's Family Member (FM)1, requested to be anonymous along with the resident (AR), approached this surveyor and wanted to shared concerns AR has told him/her. FM1 reported AR complained of having to wait a long time for staff to answer the call light. AR activated the call light for assistance to the toilet and reported having to wait approximately 30 minutes. FM1 reported AR was upset about having to wait so long and was afraid of having an accident while in the wheelchair. FM1 reported once AR received assistance onto the toilet, AR reported staff hurried the resident off the toilet and the resident still felt like he/she had to defecate. FM1 reported at home AR need time on the toilet and because the resident is receiving pain medication, AR needs even more time on the toilet. FM1 denied AR being constipated due to the resident having bowel movements. AR informed FM1 staff told the resident, You have to hurry up, I cannot stay here with you too long, I have to go and help someone else. FM1 also stated that during meals which AR's family has been present, they did not feel as if there were enough staff to spend enough time with the resident which requires assistance. Asked FM1 to share observations of incidents which led FM1 to have that concern. FM1 reported AR informed the family that she was still hungry, but staff took away the resident's tray and told the resident other residents need help with their meals also. As a result of AR complaining to FM1, the resident's family attempts to come multiple mealtimes so they can ensure AR has the help he/she needs to eat due to the resident's low weigh. Inquired with FM1 if this concern was brought up to the facility. FM1 confirmed the facility was not made aware due to FM1 not wanting to get staff in trouble because he/she sees how hard staff are working, but there just enough staff to help all the residents who need help. On 11/29/23 at 01:12 PM, conducted a review of AR's EHR. Due to FM1's strong request to remain anonymous along with the resident certain information will be limited for the record review which could be used to identify the resident or FM1. Review of AR's EHR documented the resident requires staff assistance with transferring on/off the toilet. 3) On 11/30/23 at 09:14 AM, conducted a meeting with members of the resident council (R56, R160, R101, and R71). All residents were alert and oriented to person, place, time, and situation. R56, R160, R101, and R71 attend resident council meetings documented by the resident council attendance sheet. Inquired with the residents if they felt staff provided competent care in a timely manner. R56, R160, and R101 confirmed that it is not uncommon to have to wait a minimum of 30 minutes for staff to answer the resident's call light, especially during meal, due to not having enough staff to provide assistance to the resident who need help in addition to the resident who need help with eating their meals, R56 and R101 stated independently, There is just not enough staff during certain times. R160 reported there were several times when the resident had to wait so long that he/she almost didn't make it to the toilet. On 11/30/23 at 09:45 AM, conducted a review of R56, R101, R160, and R71's EHR. Review of R160's care plan documented the resident requires extensive to total assistance by one staff with toileting (last revision on 10/30/23) and requires limited to extensive assistance by one staff for transfers to the toilet. Review of R101's care plan documented the resident requires limited to extensive assistance by one staff for toileting (initiated 09/25/23). 4) During lunch observations on 11/28/23 at 11:02 AM, walked into the main dining room on the second floor and observed 31 residents to be unsupervised. Staff were assisting other residents into the main dining room. It was unclear as to how long the residents had been unsupervised prior to this surveyor entering the room. Approximately four minutes later, staff entered to room pushing a resident in a wheelchair. On 11/28/23 at 11:43 AM, two staff were seated in the main dining room assisting two residents with lunch while the other residents at the table watched and residents through the dining room sat waiting for their meals. The meals were in the dining room, however, there were no staff present to distribute the meals to the residents. At 11:59 AM, three staff entered the dining room and started distributing meals to the residents. Conducted interviews with four direct care staff throughout the second floor (staff requested to remain anonymous). Anonymous Staff (AS)1, AS2, AS3, and AS4 were all interviewed independently and confirmed that majority of the residents on the second floor are high acuity due to the amount of assistance the residents require with ADLs, especially with eating. AS1 reported in addition with requiring a lot of assistance with meals, the facility gets a lot of the residents out of bed and into the main dining room because it is their preference and it creates a homelike atmosphere where they get to see their friends and different faces, however, a lot of the resident require 1-2 staff to get out of bed and into the dining room. AS2 reported there is just not enough staff to be able to spend the amount of time with some of residents which require more time to eat, because it may take them up to 45 minutes to eat and there are other residents which need assistance with toileting also, there just isn't enough hands-on deck to do it all. On 12/01/23 at 09:13 AM, informed the Director of Nursing (DON) of observations and interviews with residents, resident representative, and with staff regarding insufficient staffing during mealtimes. The DON confirmed the level of acuity of the residents on the second floor is higher and the facility does try to ensure the second floor has more staff and explained that the facility is currently attempting to hire hospitality aides to assist with meals and will offer training as a CNA as an incentive. The facility is also offering to pay for CNAs to go to school for training as a licensed practical nurse (LPN), and for LPNs to go back to school to become a registered nurse. The DON confirmed more staff is needed during high care times, with meals and with ADLs, and is attempting to come up with creative way to fill those needs.

Based on observation, interview, and record review, the facility failed to ensure the Glucose Control Solutions used in the facility were labeled in accordance with professional standards and facility policy, and failed to ensure all drugs and biologicals are secured in a locked compartment. Proper labeling of Glucose Control Solutions is necessary to ensure the efficacy of the solutions used to test the facility's glucose monitors/test strips for accuracy. This deficient practice has the potential to affect all residents in the facility requiring point-of-care blood glucose tests. Findings include: 1) On [DATE] at 09:15 AM, the 3 South medication cart was inspected with Registered Nurse (RN)27 standing by. Observed an unlabeled box of Glucose Control Solution. RN27 validated that the box should have been labeled with the date it was opened as the solution(s) were considered expired 90 days after opening. RN27 stated he would discard the opened box and put a new one in the cart. 47783 2) On 11//,d+[DATE] at 09:28 AM, medication cart and medication storage for the first-floor South unit was inspected with Licensed Practical Nurse (LPN)11. Observed an open box of Glucose Control Solution with an illegible date, specifically the month, written on the box. Asked LPN11 if he could read the month noted on the Glucose Control Solution box. LPN11 said, It looks like a seven, but it can also be a nine. Asked LPN11 how long is the control solution good for from the date it was opened. LPN11 replied, 60 days, I'm not sure. On [DATE] at 11:46 AM, requested a copy of the facility's policy on the glucose meter testing and maintenance from the Director of Nursing (DON). At 12:05 PM, DON provided the staff training documentation for cleaning and disinfecting the Assure Glucometer and included the policy titled, Blood Glucose Monitoring and the cleaning and disinfecting instructions from the ARKRAY Prism Glucometer reference manual. Training records did not include performing control solution tests. Review of the ARKRAY Prism Glucometer reference manual revealed that the Glucose Control Solution is to be discarded three months after the open date. 3) On [DATE] at 08:27 AM, observed Resident (R)460 pacing in the hallway at the first-floor South unit. R460 then sat on the floor and laid down. LPN11 went to assist R460 back to his room and left the medication cart in the hallway unlocked. While the unlocked medication cart was unattended, four different residents walked past it. When LPN11 came out of R460's room, Surveyor pointed out that the medication cart in the hallway was left unlocked. LPN11 said, Yes, I realized I did that as I was walking back to the cart. LPN11 then locked the medication cart and pushed it back to the nurses' station.

Based on observation, interview and record review, the facility failed to ensure that records for controlled medications are in order and that an accurate account is maintained and reconciled. The staff did not document the actual amount of medication in the container, and signed off on medications not yet administered. As a result of this deficiency, there is a potential for the diversion of a controlled medication. Findings include: On 11/30/23 at 09:28 AM, inspection of the medication cart in the first-floor South unit was conducted with Licensed Practical Nurse (LPN)11. Review of the controlled medication log revealed that the remaining count for the sedative Lorazepam 0.25 milligrams (mg) was 48. The actual count in the blister pack was observed to be 49. LPN11 confirmed that the physical count and the amount documented in the log did not match. LPN 11 confirmed that he signed off on the medication when he gave it to the resident earlier in the morning but was supposed to give two pills. LPN11 added that he will give the other pill so the resident will get the full dose as ordered.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to be treated with respect and dignity for 2 of 10 residents (Resident (R)14 and R43) sampled for dignity. R14 was left unattended in his bed with a towel loosely tied around his neck. R14 was left in bed wearing a T-shirt and adult brief uncovered with privacy curtain open while his roommate had a visitor present in the room. Staff did not promote R43's dignity while dining as evidenced by lunch observations on 11/28/23 and 11/29/23 during which Certified Nurse Aide (CNA)48 stood over R43 while assisting the resident lunch. As a result of this deficient practice, resident's are at risk for more than minimal psychosocial harm. Findings include: 1) On 11/28/23 at 11:30 AM while rounding with residents observed R14 alone in his room, laying in bed with a towel tied loosely around his neck. Went to the corridor to find facility staff to inquire about this and found the Assistant Director of Nursing (ADON). Surveyor and ADON walked into R14's room and stood at his bedside, observing resident. Inquired of the ADON if a towel should be tied around a resident's neck such as it was with R14 and she stated this is not supposed to be done. On 11/28/23 after lunch ADON found surveyor to state she interviewed CNA7 who was assigned to R14 and ADON stated the CNA told her she showered the resident and during that time loosely tied the towel around his neck for the resident to use for when he drools. ADON stated this appears to be a comfort measure for the resident. ADON stated the towel should have been draped on his neck and left loose, not tied. ADON stated she did one on one training with staff to prevent this from happening again. On 11/28/23 Record Review (RR) of R14's Electronic Health Record (EHR) found his diagnoses include, but are not limited to, history of traumatic brain injury, muscle spasms, and contractures to the right and left hand. R14's Minimum Data Set (MDS) completed on 07/07/23 has him rated as being dependent on staff for his care. Concurrent observation of R14 found him erratically swinging his arms around as if to hit out at staff and surveyor. He was also observed picking at his towel, moving it around by tugging on it and throwing it onto the ground. On 11/29/23 at 12:22 PM walked into R14's room to observe him and noted he was in his bed without a top sheet or blanket, was only in his T-shirt and adult brief with his privacy curtain open and his roommate had a visitor present in the room with her back to R14. Found R14's blanket on the floor. During this observation the ADON came into R14's room. ADON saw R14's blanket on the ground and stated he threw it on the floor, that he does that with his sheet and blanket. On 11/30/23 at 02:11 PM interviewed CNA7, who stated that she got nervous while giving R14 his shower and forgot and left the towel loosely tied around his neck. CNA7 stated she did not do this before, and thought it would be best to do this since R14 was doing the hand motions with his right hand as if to hit someone. CNA7 stated she forgot and did not take off the towel when she was done showering him. CNA7 also explained ADON educated her right away that she is not supposed to do this and stated she knows this and will not do it again. 42160 2) During initial observations on 11/28/23 at 10:40 AM, R43 was lying in bed. R43 could not move his/her extremities, respond verbally or by any other means, or purposefully move. R43 appeared to be totally dependent on staff for care. On 11/28/23 at 12:15 PM, observed CNA48 standing on the left side of R43's bed, between the window and the bed, assisting the resident with lunch. CNA48 was observed scooping and feeding the resident with his/her right hand and in CNA48's left hand, he/she was holding the bowl of food in his/her palm with his/her fingers against R43's forehead, holding the resident's head up from falling to the side. The head of R43's bed was higher than a 45-degree angle. During lunch observations on 11/29/23 at 11:20 AM, a second observation was made of CNA48 assisting R43 with lunch while standing next to the resident's bedside, between the window and the resident's bed. On 11/29/23 at 02:30 PM, conducted a review of R43's EHR. Review of R43's most recent quarterly MDS with an Assessment Reference Date (ARD) of 10/21/23 documented that R43 is unable to eat independently and requires total assistance from staff with eating. On 12/01/23 at 09:13 AM, conducted a concurrent review of R43's EHR and interview with the Director of Nursing (DON). Shared observations of CNA48 standing at the bedside while assisting R43 with lunch on 11/28/23 and 11/29/23 and of CNA48 holding the bowl in the left hand while using his/her fingers on the resident's forehead to prevent the resident's head from falling forward. DON confirmed R43 is totally dependent on staff for assistance with eating and CNA48 did not treat R43 with dignity by standing at the resident's bedside while assisting the resident with lunch, or by holding the resident's head from falling forward with a couple of fingers. DON stated, CNA48 should have been seated next to the resident and should not have been holding the resident's head up by placing a couple of fingers on R43's forehead.

Based on observation and staff interview the facility failed to provide a clean environment for 1 of 35 Residents sampled, as evidenced by a portable fan positioned on the dresser of Resident (R)32 circulating air around his room, with a layer of dust on the front and back covers. In addition, the facility failed to provide a clean environment for the ground floor unit residents with water dripping from air conditioning ducts. Findings include: While doing rounds on the first day of survey, 11/28/23, observed that R32 had a portable fan in his room that was sitting on top of his dresser. Fan appeared dirty with dust noted on the front and back cover. On 11/30/23 at 09:57 AM, went back to R32's room to observe if the portable fan was still in his room. Observed R32's portable fan was on and circulating air around his room. The front and back cover of R32's portable fan had a layer of dust. At this time inquired with housekeeper(H)5 to see who cleans the residents' fans. H5 said the janitors are responsible to clean the fans, and stated that there are two janitors working every day. H5 stated she would take the fan to the janitor and fill out the form to have the fan cleaned. While walking in the corridor with H5 and the dirty fan, the Assistant Director of Nursing (ADON) inquired if we needed any help. Inquired at this time if ADON could explain the facility's process to have items such as a resident's portable fan cleaned. ADON explained facility staff fill out a form, a work order, and submit it to the janitors in one of their folders/box. On 11/30/23 at 01:19 PM, met with Janitor (J)1. J1 was able to explain that facility staff fill out a work order and leave it in their box. J1 also stated this procedure is the same for items such as drapes or privacy curtains. The janitor will then clean the item, such as a resident's fan. J1 was shown R32's portable fan and he said so dusty. Prior to leaving the facility on 12/1/23, requested a facility policy, schedule, or log that housekeeping and the janitors use to do routine cleaning. Facility Administrator provided their Daily Room Cleaning policy which was last reviewed on 07/19/2023. Review of this policy did not find any mention of cleaning resident's fans. 37229 2) Observation was made on the dementia unit on 11/30/23 at 08:39 AM. While walking in hallway, surveyor encountered a drop of water onto forehead. When surveyor looked up, noted that there was water dripping from various places on the air conditioning (AC)ducts. Further observations were noted that there were small puddles of water on the floor from three of the ducts on the dementia unit North. Observation was done on 11/30/23 at 08:40 AM of R42. R42 was walking down the hallway with a walker and socks. R42 walked past the three puddles in the middle of the hallways. Interview was done with Certified Nurse Aide (CNA) 27 on 11/30/23 at 08:45 AM. Queried CNA27 regarding moisture on the floor and the dripping that was occurring from the AC ducts. CNA27 stated that we always get condensation from the AC. Surveyor questioned this reply because on this day, the weather was a major flooding alert as compared to the day before when the sun was shining and there was no flooding. CNA27 responded with an oh. Interview was done 11/30/23 at 09:00 AM with maintenance staff (MS) #3. MS3 stated that it was AC condensation, and it happens all the time. We wipe it up when it does that. Observation done on 11/30/23 at 10:AM on dementia unit South. Observed that there were three puddles in the middle of the hallway. During an interview with the administrator on 11/30/23 at 12:00 PM. Surveyor brought to the attention the observations that were done on the dementia units South and North. Administrator stated that they did not have a protocol for this but would be looking into it. A record review of a facility policy, schedule, or log that housekeeping, and the janitors use to do routine cleaning was requested. Facility Administrator provided their Daily Room Cleaning policy which was last reviewed on 07/19/2023. Review of this policy did not find any mention of cleaning water puddles in the hallways.

Based on record review and interview, the facility failed to accurately complete a comprehensive assessment of medications for 1 of 35 residents (R) in the sample. Findings include: On 11/29/23 at 01:42 PM, during a record review of Resident (R)7's electronic health record (EHR), noted that on the Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/19/23, R7 had been documented as having taken insulin 1 day of the 7-day look back period. Further review of R7's EHR revealed no active, discontinued, or completed orders for insulin. On 11/30/23 at 03:43 PM, an interview was done with MDS Coordinator (MDSC)2 in the second-floor Conference Room. MDSC2 confirmed that he had completed R7's Admission Assessment. After a concurrent review of R7's EHR, MDSC2 confirmed that R7 had never been on insulin. MDSC2 could not explain why he marked R7 as having taken insulin, but agreed that he probably mistook another medication R7 was taking as insulin.

Based on interview and record review, the facility failed to effectively care plan and manage constipation for 1 of 2 residents (Resident 7) sampled. As a result of this deficient practice, Resident 7 experienced stool impaction(s) that had to be manually removed, causing her pain, distress, and embarrassment. This deficient practice has the potential to affect all the residents at the facility at risk of constipation. Findings include: Resident (R)7 is a [AGE] year-old female admitted to the facility on [DATE] following a urinary tract infection (UTI). Her admitting diagnoses include, but are not limited to, constipation, history of transient ischemic attack [(TIA) a temporary period of symptoms similar to those of a stroke], history of cerebral infarction (an area of tissue death in the brain caused by a blockage of blood vessels), chronic pain syndrome, and a history of falling. Admitting medication orders include: Senna 8.6 mg (milligrams)- One tablet as needed (prn) for no bowel movement (BM) after the second day; with a warning from the pharmacy: The daily dose of 1 tablet is below the usual dose of 1.7441 to 11.6279 tablets. Bisacodyl Suppository- One prn for constipation if no BM after the third day. Soap Suds Enema- Give prn for constipation if no results with the Bisacodyl suppository. Ferrous sulfate 325 mg- One tablet daily (common side effect of constipation). Oxycodone-acetaminophen 10-325 mg- One tablet every six hours as needed for pain (common side effect of constipation). Senna-docusate sodium 8.6-50 mg- One tablet twice a day for constipation. On 10/18/23 the order for Oxycodone-acetaminophen 10-325 mg was changed to one tablet every four hours as needed for pain AND one tablet three times a day for chronic pain. On 11/01/23 the previous Senna-docusate order was increased to two tablets twice a day for constipation. On 11/28/23 Polyethylene Glycol 3350- One packet by mouth once a day for constipation was added. On 11/28/23 at 01:02 PM, an interview was done with R7 at her bedside. R7 explained that she has been having problems with constipation. Reported having to have a digital extraction (manual extraction with a gloved finger) of stool twice yesterday. Tearfully described how she frequently has to be digitally extracted of stool, and explained how humiliating it feels. States that some staff are very kind, but others make her feel like they do not want to help her. On 11/29/23 at 11:50 AM, during an interview with R7 at her bedside, she stated that it has been weeks since she has had a BM normally. Reported the last suppository she had for constipation was two weeks ago and that she was told she could only have one suppository per week. When asked about an enema for constipation, R7 stated that she has never been offered or given an enema. Reports that she has informed the facility that she normally takes 6 Senna tablets a day at home and she has no problems with her BMs, but they won't listen to me. On 12/01/23 at 09:28 AM, a review of R7's electronic health record (EHR) was done. Noted that despite being admitted with a diagnosis of constipation, having at least four documented complaints of constipation to nursing staff, numerous medications prescribed that commonly cause constipation, and being prescribed five medications to address constipation, there was no care plan for constipation developed or implemented in her Comprehensive Care Plan. A review of the Nurse Progress Notes revealed the following: On 10/18/23 07:15 PM- Resident wishes to review the following with MD (physician): . laxative dosing (reports to taking 6 Senna S tablets all at once every day at home) . and . reports symptoms of constipation and that her stools have been hard and more difficult to pass . On 10/19/23 05:40 PM- . reports she continues with symptoms of constipation. She reports no results from PRN Senna yesterday; declined offer of Dulcolax suppository today, will accept PRN Senna . On 10/21/23 03:45 AM- Resident c/o [complaint of] constipation. On 11/28/23 11:39 AM- . resident with c/o constipation, has been needing to have digital extraction of her BM. A review of R7's medication administration records for October and November confirms that she has not been administered an enema since admission, and has not had a Bisacodyl suppository administered since 11/10/23. A review of a Bowel and Bladder Elimination report from 10/13/23 to 12/01/23 revealed the following: No BM 10/13/23-10/14/23 with no corresponding extra Senna tablet for no BM after the second day. No BM 10/16/23-10/20/23 with 1 extra Senna tablet given on 10/18/23, and no Bisacodyl suppositories given. No BM 10/23/23-10/27/23 with an extra Senna tablet given on 10/25/23, 10/26/23, and 10/27/23, and one Bisacodyl suppository given on 10/26/23. No BM 11/02/23-11/03/23 with no extra Senna tablet given. No BM 11/07/23-11/09/23 with an extra Senna tablet given on 11/09/23 and a Bisacodyl suppository given on 11/10/23. No BM 11/17/23-11/18/23 with an extra Senna tablet given on 11/19/23. On 12/01/23 at 10:48 AM, an interview was done with the Director of Nursing (DON) in her office. DON completely unaware that R7 had ever needed digital extraction of stool. Reports that her expectation is that if a nurse is doing that, they would document it in a progress note and notify her. Confirmed that she had not been informed by any staff that this was done.

Based on interview and record review, the facility failed to ensure the Binding Arbitration Agreements ([NAME]) they asked the residents (or their representatives) to enter into, were explained in a form and manner that they could understand, and that the [NAME] explicitly granted the residents/representatives the right to rescind the agreement within 30 calendar days of signing it. This is evidenced by 1 of 3 residents (Resident 7) sampled stating she did not have the BAA explained to her in a way that she understood what it meant, 2 of 3 residents (Residents 7 and 101) sampled could not remember signing it or what it was about, and the Facility BAA granting residents only 10 days to rescind. Findings include: 1). On 11/29/23 at 12:08 PM, an interview was done with Resident (R)7 at her bedside. When asked about the BAA, R7 reported that the Director of Social Services (SSD) had visited her earlier that morning and asked her about the BAA as well, showing her a blank copy of the form. R7 stated that she told SSD that she could not remember signing the form and did not know what it was about. R7 stated the SSD did not explain the BAA to her at that time, despite informing her that she did not know what it was. After the State Agency (SA) explained the BAA to her, R7 stated she would never have agreed to sign a form like that if it had been explained to her. Asked R7 if the SSD had provided her a copy of the signed form after telling the SSD that she could not remember signing it. R7 answered no. 2). On 11/30/23 at 12:17 PM, an interview was done with R101 at her bedside. When asked, R101 confirmed that SSD had visited her the morning of 11/29/23, asked if she remembered the BAA form, and told her that she had signed it. R101 reported to the SA that she did not remember the BAA form, stating I signed so many forms when I got here, I can't remember what they were about. When asked if she was provided a copy of the signed BAA after informing SSD that she did not remember signing it, R101 replied no. A review of the list of residents who had signed [NAME] noted that R101 had declined. On 11/30/23 at 12:23 PM, an interview was done with SSD in the conference room next to the Social Services (SS) Office. When asked to describe SS involvement with [NAME], SSD stated we are not really involved with arbitration agreements at all, Admissions handles that. However, after further questioning, SSD confirmed that SS had assisted the Director of Admissions (ADMD) the previous day by visiting residents who were self-responsible, showing them a sample of the BAA, asking if they remembered signing it, and explaining it to them if they answered no. SSD admitted that most of the residents they asked had responded that they did not remember the form or what it was about. When asked, SSD reported that they did not provide any of the residents they spoke to with a copy of the BAA. SSD agreed that it would have been helpful to provide the residents with a copy of the BAA, either signed or blank, since most of the residents could neither remember signing it nor what it was about. 3). A review of the facility's Voluntary Agreement for Arbitration, last revised 03/18/13, included in the facility Admission Packet noted the following: . this Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution. An interview with ADMD was done on 11/30/23 at 01:10 PM in her office. The ADMD confirmed that the Facility's agreement should allow residents 30 days after signing to rescind, but only says 10 days. The ADMD stated that she had informed the Administrator that the agreement needed to be updated for that very reason.

Based on observation, interview, and record review, the facility failed to ensure 3 of 11 residents (Residents 7, 14, and 210) sampled for accidents were free from accident hazards. Specifically, the facility failed to ensure wheelchair footrests were applied before pushing R7 down a long hall to her room following a shower; despite identifying R14 as a High Falls Risk, the facility failed to ensure his bed was kept in the lowest position; and.the facility failed to provide adequate supervision/assistance to prevent an avoidable fall for Resident (R)210. Placing residents at risk of avoidable accidents and injuries by not providing the appropriate planning and monitoring, and/or implementing the interventions to meet their identified needs is a deficient practice that has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)7 is a [AGE] year-old female admitted to the facility on [DATE] following a urinary tract infection (UTI). Her admitting diagnoses include, but are not limited to, constipation, history of transient ischemic attack [(TIA) a temporary period of symptoms similar to those of a stroke], history of cerebral infarction (an area of tissue death in the brain caused by a blockage of blood vessels), chronic pain syndrome, and a history of falling. On [DATE] at 10:27 AM, observed R7 being wheeled back to her room from the shower room with no footrests on her wheelchair and R7 holding both feet barely above the ground. R7's room is positioned at the opposite end of the hall to where the shower room is located. Certified Nurse Aide (CNA)22 was pushing the wheelchair as CNA15 walked behind them. Asked CNA22 and CNA15 where her footrests were and CNA22 answered, I know, they're not here, she slid into the shower unexpectedly. On [DATE] at 10:32 AM, interviewed R7 at her bedside. R7 reported that earlier when CNA26 put her in the wheelchair, she did not offer or ask her if she wanted her footrests and R7 felt like it was too much hassle to ask for it because she has had issues with feeling like CNA26 did not want to help her in the past. Asked R7 if she did not like to use the footrests when she is being wheeled in the hallway. R7 answered that she does like to use the footrests because she often has pain in her knees which make it difficult to hold her feet up on her own. With certain staff however, she feels like she is being difficult whenever she asks for anything, so she doesn't ask. Confirmed with R7 that CNA26 is one of the staff members she was referring to. On [DATE] at 09:41 AM, during a review of R7's Comprehensive Care Plan for Activities of Daily Living (ADLs), noted the following recently added intervention: Resident's personal preference is not to apply footrests to wheelchair prior to and after showers. On [DATE] at 10:30 AM, interviewed R7 at her bedside and asked again if she preferred not using the footrests when she is being pushed for a distance such as to the shower room. R7 answered that she always prefers to use the footrests because of the pain in her legs. R7 stated that if it is offered, she will always say yes to the footrests when she is being pushed somewhere. Feels the only time she doesn't need the footrests applied is when she is sitting in one place (such as when she is waiting at the bedside for staff to change her sheets), because she is tall enough to comfortably rest her feet on the floor. 37954 2) Record Review (RR) of R14's Electronic Health Record (EHR) found his diagnoses include, but are not limited to, history of traumatic brain injury, other muscle spasms, contracture to right and left hand. Fall risk assessments (NRSG: Fall Risk Evaluation) for R14 were completed quarterly on [DATE], [DATE], [DATE] and [DATE] and all have resident rated as a high risk for falls with a score of 14 each time. On the NRSG: Fall Risk Evaluation, a score of 10 or more is considered a high risk for falls. R14's Quarterly Minimum Data Set (MDS) that was dated [DATE] has resident listed as dependent on staff for mobility. R14 is totally dependent on staff for his care. On [DATE] at 11:30 AM, entered R14's room and observed R14 was alone, no staff were present in the room with him. At this time, noted resident's bed was raised off the ground to almost hip height. After requesting the Assistant Director of Nursing (ADON) to come into R14's room, inquired why R14's bed was not left in the lowest position near the ground, and she responded that the lowest position is not care planned for because R14 is not at risk for falling out of his bed. On [DATE] at 12:14 PM, entered R14's room and noted his feet and lower legs hanging over the right side of the edge of his bed and his head was resting on the other side of the bed on the mid to upper left hand side. R14 had slid down in his bed and was becoming perpendicular with his mattress. During this time, R14's tube feeding was being administered by an electric pump. Walked to the corridor to get facility staff to reposition R14. ADON was available and came into R14's room. Once ADON saw R14, she asked if surveyor could stay with R14 while she asked another staff member to help her. Surveyor told ADON they would get staff to assist her. Surveyor walked to corridor and found R14's assigned nurse, Licensed Practical Nurse (LPN)4. ADON paused R14's tube feeding, then ADON and LPN4 were able to reposition R14 by centering him and lifting him up in his bed using the sheet under him. Afterwards, his tube feeding was turned back on. It was also noted upon finding the resident that his bed was not kept at the lowest position near the floor, instead it was raised at almost hip height. Surveyor told ADON R14 was observed yesterday and today unsupervised in his bed that was not left in the lowest position near the ground. Inquired with ADON why this was. ADON stated she had never seen him do anything like this before and stated that she would change his care plan to have his bed kept in the lowest position (when staff are not working with him). On [DATE] at 11:14 AM, RR of R14's care plan did not find any changes made to include bed to be put at lowest position before leaving resident unattended in his room. 47783 3) Review conducted of the completed Facility Reported Incident (FRI) document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10541. Type of incident was listed as Other, Fall. Details of the incident stated that on [DATE] at 08:00 PM, Resident self propelling [sic] wheelchair back onto second floor lanai area and fell . Initially resident was responsive. Staff provided assessment and comfort to resident while awaiting emergency rescue. Resident expired. Investigation initiated. Investigative notes included in the final report stated Certified Nurse Aide (CNA)26 observed R210 in his wheelchair attempting to self-propel back onto the second floor lanai area over a speed bump. CNA26 called out to R210 telling him to wait so he can be assisted but R210 continued to try to maneuver over the speed bump. R210 then fell backwards landing on the asphalt. CNA26 immediately called for help, the licensed nursing staff responded and 911 was called. R210 was trying to talk while the licensed nursing staff assessed him, but later became unresponsive. R210 was a [AGE] year-old resident admitted on [DATE]. Diagnoses included, but are not limited to, unspecified dementia, hypertension (elevated blood pressure), atrial fibrillation (irregular and rapid heart rhythm), hyperlipidemia (elevated cholesterol) and generalized muscle weakness. Review of the assessment tool Minimum Data Set (MDS) dated [DATE] revealed that R210 had moderate difficulty with his hearing, moderate cognitive impairment and requires limited assistance with the use of his wheelchair. R210 had a POLST (Provider Order for Life-Sustaining Treatment) on file and did not want to be resuscitated in the absence of pulse or breathing. On [DATE] at 11:10 AM, an interview was conducted with CNA26 on the third floor South Wing. According to CNA26, she was on her break and was going down the stairs from the third floor. CNA26 then saw R210 in his wheelchair coming from the parking lot and was trying to wheel himself over the speed bump that was separating the parking lot and the second-floor lanai area. R210 was not able to push himself over the speed bump on his first try so CNA26 asked him to stop since he was already tilting backwards. R210 continued to try and push himself over the speed bump and fell backwards. CNA26 said she started yelling for help and the second-floor nurse and the nurse supervisor responded. CNA26 said there were no other facility staff in the lanai area or the parking lot at the time of the incident. On [DATE] at 01:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4 in the second-floor conference room. LPN4 said R210 is able to propel himself in his wheelchair and is allowed to wheel himself outside to the lanai area without supervision. When asked if R210 was also allowed to go outside at night, LPN4 said Yes, sometimes he goes outside in the evening. On [DATE] at 03:20 PM, an interview was conducted with LPN2 by the second-floor nurses' station. LPN2 confirmed that R210 goes to the outside lanai in the evening and is able to open the door to let himself out. When asked if there are any staff members outside to monitor R210 when he goes out, LPN2 said the staff in the unit take turns checking on him every 10 to 15 minutes but do not stay outside with him. On [DATE] at 11:19 AM, an interview was conducted with the Director of Nursing (DON) in her office. DON stated that R210 was allowed to wheel himself around in the second-floor lanai and the parking lot. DON was not certain how often R210 goes out at night but said the staff inside the facility do visual checks every 10 to 15 minutes. On [DATE] at 12:49 PM, observed 2 residents in the second-floor lanai area. One of the residents was sitting in one of the chairs fronting the Administrator's office and the other resident was sitting in his wheelchair on the right end side of the lanai away from main entrance. There were no staff members observed on the lanai area.

Based on observation, record review and interview, the facility failed to monitor the temperatures to ensure the dishes used to serve food were appropriately sanitized in accordance with professional standards for food service safety. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses. Findings include: On 11/28/23 at 09:52 AM, initial tour of the kitchen area was conducted with Food Service Director (FSD). Observed clipboards on the wall by the dishwashing machine area. FSD said that was where the staff document the temperatures for the dishwasher. Review of the log titled High Temperature Dish Machine Log was done and noted an entry for 11/13/23 was missing. Below the space where the staff write the month and year for the log, the document stated, Check and record temperatures results before washing dishes. Wash needs to be per manufacturers' specification and rinse at 180 degrees to 194 degrees Fahrenheit. Asked FSD how often the staff record the temperatures on the log. FSD said the staff record it three times a day when the dishwashing machine is in use. FSD confirmed that the dishwasher was used after dinner on 11/13/23. Missing entry was pointed out to FSD and she said, We missed it that day.

On survey entry, a request was made for a copy of the facility specific Infection Prevention Control Plan (IPCP) and surveillance policy within one hour. The surveillance policy was provided at the end of day three after a conference call with Corporate regarding an Immediate Jeopardy. The IPCP, review date 09/2022, was included with abatement documents on survey day four, 05/22/2023. Based on observations, interviews and document review, the facility failed to ensure staff were familiar with and aware the written facility specific IPCP and surveillance policy existed. In addition, 1) visitor policy was interpreted differently by staff, 2) there was no system established for ongoing process monitoring of staff compliance with personal protective equipment (PPE-items worn to protect from cross-transmission), 3) a root cause analysis (RCA) was not completed timely after COVID infection spread to the third unit, and 4) the facility did not have a system to record actions taken to control the spread of infection. These deficiencies resulted in an Immediate Jeopardy as there was a high potential of another outbreak which could result in harm or death. Findings include: 1) The Office of Healthcare Assurance (OHCA) received an anonymous complaint on 04/26/2023 regarding the COVID situation at the facility. The complainant felt the infection spread quickly and did not feel aggressive measures were being taken to minimize the spread. 2) The facility had an outbreak of COVID-19 beginning on 04/09/2023. The infection affected three units and the facility was cleared of COVID infection on 05/19/2023. A total of 76 residents had tested positive and 17 staff. The timeline provided by the infection preventionist (IP)1 was as follows: 04/09/2023: First resident tested COVID-19 positive (+) on one the first floor memory care units (N1). This type of unit creates challenges for infection control because it may be difficult to restrict residents to their room . 04/14/2023: First resident COVID + on the other first floor memory care unit (N2). 04/20/2023: First resident COVID + on a second floor unit (S2). 05/19/2023: Facility cleared of COVID infection. 3) On 05/17/2023 conducted survey entrance at 10:30 AM with the Executive Director (ED) and Director of Nursing (DON). At that time, provided a list and reviewed requested documents for the survey. Documents requested within one hour included, but not limited to, Facility policies for: 1) Infection Prevention and Control Program, include surveillance. The facility had two Infection Preventionists (IP), IP1 was new to the organization and started 04/10/2023, one day after the outbreak, and IP2, who was the Educator, had been in the IP role and was precepting IP1. The ED provided several organization-wide policies and the organization-wide IPCP with review date 06/01/2022. The facility uses an electronic policy management system, with all policies online. Day one, two and three of survey included interviews with both IP's and DON. Each were asked for facility IPCP and surveillance policy. After the ED was informed of an IJ in F880, she asked if the survey team would speak to someone from corporate. The corporate representative was confident there was a written surveillance policy, and again at this time requested it. As the survey team was leaving the facility 05/19/2023, the ED provided the surveillance policy. On 05/22/2023 the facility specific IPCP dated 09/23/2022 was provided with other abatement documents. The facility had not been able to provide the IPCP or surveillance plan after multiple requests. 4) The facility did not have an organized system or written guidelines for investigating, and recording the corrective actions taken by the facility, and did not adequately document their actions during the outbreak. On survey entrance a request was made for all documents related to the investigation of outbreak and timeline of interventions taken to prevent the spread. On 05/17/2023, at 11:56 AM, the ED provided a copy of the Centers for Disease Control and Prevention (CDC) guidance and recommendations for COVID 19-outbreak, and stated, Our interventions were based on these CDC guidelines. Inquired further if there was documentation of what specific actions were taken and when. The ED said she would ask IP1. 05/18/2023, asked IP1 if she had a timeline of actions. She later provided a two page undated document titled COVID-19 Outbreak Timeline. IP1 said she had put it together using other notes and resources. Review of the timeline revealed it did not include documentation of key interventions, i.e. when N95 mask and face shields were implemented on the third unit, or monitoring of staff compliance with PPE use. Inquired if the facility had a Quality Meeting or Infection Committee meeting to discuss the outbreak, conduct root cause analysis/investigate and plan interventions. The ED said they met on 04/10/2023, the day after the first case and did a RCA. She provided a one page undated, titled Root Cause Analysis of Covid-19 Outbreak. The document listed potential contributing factors, and included the summary, Root cause is believed to be an increase of community rates of Covid-19 March through April. Community events resulted in an influx of tourists to the island and Holidays with large group/family gatherings. Since the identified outbreak facility has taken measures to prevent the spread. The facility implemented recommendations from CDC (Center for Disease Control) and Local Health Department. Associate/Family/Visitor education provided. Audits for compliance surrounding infection control/CDC recommendations. There were no actions documented on this document. During an interview with IP1, she said to her knowledge, the facility had not discussed if they would be monitoring community rates after the outbreak and RCA had been completed. Requested documentation of notifications to staff regarding changes (i.e. required PPE, testing, staffing) throughout the outbreak. The ED said the facility sends information to staff via text system, and she would have to see what could be retrieved. The ED provided a one page document titled Communication/Memo's related to COVID. The document listed eight dates she said information had been sent to staff between the 04/17/2023 and 05/17/2023. The document did not include the specific information sent. The ED said she was unable to pull all the information requested retrospectively from the system. 5) The facility visitor screening was passive, with the exception of a few hours during the survey, a staff member was noted to be at the entrance. There were two kiosks for visitors to check in and out of the facility. Each kiosk had masks, hand sanitizers available and an organization-wide sign posted with symptoms of COVID, visitor guidelines, and how to prevent spread of infection. This sign directed visitors to check with the staff on the unit regarding PPE requirements. The entrance kiosk had three additional signs. 1) Please sanitize your hands before and after using the kiosk. 2) .Face masks are required at all times during your visit and are available at the kiosk, and 3) Lastly, change into a provided mask.Face Mask required. The second kiosk, inside the lobby did not have the sign directing visitors to change into provided mask. Observations of visitors presenting to facility on 05/17/2023 included the following: 10:56 AM: visitor checked out at kiosk. Noted to have a black mask on, which is not what is provided by the facility. 11:00 AM: two visitors presented, each put on a facility provided mask. The one who used the kiosk did not sanitize hands before or after using the kiosk. 11:04 AM: two visitors used second kiosk. One put mask facility on, the other had a black mask on and did not change into a facility mask. 11:08 AM: visitor sanitized hands, had mask on when arrived, but did not change into new mask. 11:15 AM: staff with face mask and face shield was posted at the main kiosk. 11:25 AM: visitor presented with black mask on, sanitized hands, used kiosk, sanitized hands after and entered resident unit. Staff at kiosk did not ask to change mask. 11:30 AM: visitor presented with mask, did not sanitize hands prior or after using kiosk and did not change mask. Staff did not ask to change the mask. 11:31 AM: two visitors presented. One sanitized hands, but the one who used the kiosk, did not sanitize after using the kiosk. Both had black masks on and did not change into facility masks. Staff did not ask to change the mask. 11:32 AM: visitor with black mask presented, sanitized hands, but did not change mask. Staff did not ask to change the mask. 11:40 AM: visitor with black mask presented, sanitized prior to using kiosk, did not sanitize after or change mask. Staff did not ask to change the mask. 12:30 PM: visitor presented with black mask, did not sanitize after using kiosk,or change mask Staff did not ask to change the mask or sanitize. 01:49 PM: No staff at kiosk. Three visitors arrived, one female, child and elderly man with a walker. Child and lady put on masks. Elderly man had mask on, but did not change it. 02:41 PM: While Surveyor on the second floor unit, observed visitor approaching the nursing station with no mask. The DON saw the visitor, handed him a mask and informed him he had to wear one. On 05/17/22 at 4:16 PM observed licensed nurse (LN)1 go in to a room to give a resident medication, LN1 did not sanitize hands after leaving the residents room. On 05/19/23 at 09:53 observed a resident sitting with a visitor who was wearing a black mask. On 05/19/2023, the signage on both kiosks were updated and changed to be consistent. On 05/18/2023, during an interview with IP1, she said visitors were to put on a facility mask. On 05/19/2023, during an interview with the DON, she said that visitors were suppose to change into a facility mask. On 05/19/2023, during an interview with IP2, she said visitors could leave their community mask on, but should put a facility mask over it. When asked what she felt the standard for healthcare facilities would be for visitor masking during outbreak, she said they should put our mask on. 6) On 05/18/23 at 09:15 AM, during an interview with IP1, when asked about the surveillance policy and procedures, IP1 talked about the surveillance they were conducting with the staff re monitoring the residents for symptoms. If the Certified Nurse Aide (CNA) sees something, they report to the nurse who assesses the resident and follows up with the physician for orders. We are educating the CNA's regarding the symptoms to look for and when to report. The facility written surveillance plan and CNA training documentation was requested. On 05/18/23 at 09:28 AM interview with LN2 when asked if any of the residents were being monitored for COVID 19 symptoms, responded, I understand they were surveilling the residents who were positive. Now as far as I know there is not any type of surveillance going on. Interviewed LN3 at 09:45 AM asking the same question. LN3 responded that there isn't any surveillance going on right now. The requested surveillance information was not available for review. 7) An Implementation Plan-COVID Outbreak dated 04/20/2023 was developed as a collaborative effort with CMS (Centers for Medicare & Medicaid Services) Quality Improvement Organizations and the facility. The plan included but not limited to 1) Develop audits specific to RCA (e.g. personal protective equipment (PPE) compliance) 2) Determine audit frequency and auditors and provide training. Assign audits to be conducted over 24/7 periods with immediate reeducation for noted violations of practice standards. On 05/18/2023, during an interview with IP1, she said she had been doing PPE compliance observations, but did not document them until recommended to do so after the RCA. She said she was the only one that did the observations and had not yet had time to set up a system for ongoing monitoring that would include 24/7. IP1 provided documentation of 18 observations from the time period 04/19/2023 to 05/03/2023 (first COVID positive on third unit 04/20/2022). Review of the observations revealed the following: All observations were made on the day shift. Nine of the 18 observations were to check the supplies were available. Nine observations were for staff PPE compliance. Five of the nine observations included IP1' s' comments of feedback/education to staff when they did not adhere to the standard.

Based on observation, medical record review (MRR) and staff interviews, the facility failed to ensure that female residents were not subjected to sexual harrasment from a male resident in the same locked special care unit. Findings include: Interviewed Staff #136 on 6/13/17 who stated that R#249 continues to follow the female resident and continues to try to touch and be close. A couple of the female residents are disturbed by the resident's behavior. When sitting in their chairs and R#249 approaches them, they will fold their arms across their bodies and not make eye contact. They also try to move away but he follows. Staff #136 further stated that two female residents in particular do not like anyone in their space. One female resident is easily agitated with anyone and everyone and R#249 needs constant redirection. This is a dementia unit. Moods change as soon as you drop a pen on the floor. Some residents like their space. It is not black or white. Medical record review on 6/15:17 at 8:32 A.M. for resident(R) #249 was conducted, and it was noted that the resident was admitted to the facility in 10/2016 for custodial care and behavioral management. R#249 was admitted with a history of [MEDICAL CONDITION], aggressive behaviors towards males and liked touching females. Pharmacy along with the MD were adjusting medications to control behaviors in the months of March and April In March, gradual dose reduction (GDR) was looked at by the behavior enhancement committee and GDR was attempted. R#249 did have a dose reduction of his [MEDICATION NAME] in March from 1 mg Am/1 mg midday/2mg at night to 1 mg three times a day. Review of Psychopharm Committee Minutes dated 5/11/17 discussed R#249 and suggested increasing [MEDICATION NAME], adding Tylenol, monitor 3-4 weeks behavior per MD. It stated that R#249 continues to approach female residents personal space. Staff to redirect and effective. A note written by MD on 5/17/17 noted that staff had noticed increase in behavioral disturbances since [MEDICATION NAME] and [MEDICATION NAME] were reduced. Record review for the months of May and June revealed R#249 exhibited aggressive and desire to touch females on the following dates: 5/20/17 - Hanging around females, trying to touch the females. 5/21/17 - Trying to touch the females 5/24/17 - Trying to touch females, touching hair, trying to kiss. 5/25/17 - Trying to touch females. 5/26/17 - Trying to touch females On 6/2/17 - R#249 [MEDICATION NAME] was increased to 1.5 mg at lunch. 6/18/17 - Trying to touch females. 6/19/17 - eating others food if not supervised and trying to touch females. 6/10/17 - Trying to touch females. 6/12/17 - R#249 punch a resident in stomach 6/14/17 - R#249 grabbed a females buttocks. Psychopharm Committee Minutes dated 6/8/17 were reviewed. Documentation for R#249 per the minutes stated that R#249 is hyperactive, sexual behaviors (touching). The team was recommending to continue medication [MEDICATION NAME] along with interventions. Redirect resident when approaching female residents personal spaces, provide snack. Have staff ask resident if he needs assist with something. Interview on 6/15/17 at 10:18 A.M. with Staff #136 to clarify R#249's behaviors, and staff member related that R#249 gets jealous. For example, one of the incidents that occurred was of the female unit manager talking with another male resident in the hall and R#249 came walking by and without provocation, hit the other male resident in the stomach, out of jealousy as he was talking to the female unit manager. R#249 seemed to get aggravated and jealous. Staff#139 further stated that R#249 likes to hang around woman and protect them, however, the resident has been getting better with medications. Interview with Staff #167 regarding R#249 and asked what the goal was for R#249. Staff #167 stated our goal is for R#249 to be able to wander about the unit safely to prevent and decrease incidents of any altercations because of his impulsiveness. When asked if there is a care plan for R#249, Staff #167 stated I don't see a specific care plan for the touchy feely with the females. They should be charting on the behavior monitor sheet. A review of the Behavior Monitoring Form demonstrated the behaviors documented in the progress notes of the records did not collaborate with the care plan. This form lists codes for behavior, location code, intervention code and resident response. The form also had not been updated since May 10, 2017 although the recommendation to monitor for 3-4 weeks per MD in psychopharm committee minutes was suggested on May 11, 2017. This was pointed out to a staff member who did not have any answer except yea, we're supposed to document on that form. The female residents in the same secured unit as R#249 were subjected to unwelcome touching and attention from this male resident. The facility failed to provide care and have safe-guards in place to ensure these female residents were not subjected to sexual harrasment and inappropriate sexual behaviors. The facility staff stated that the female residents have dementia and their cognitive deficits make them unaware if anything untoward happened. The facility practice was harmful to these female resident's who should have been safe from inappropriate sexual behaviors towards them and ensured their psychosocial well-being.

Based on observation, record review, interview with staff members and review of the facility's policy and procedures, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for 2 residents (Resident #324 and #3). Findings include: 1) Closed record review and interviews with staff members were done to investigate this complaint. Closed record review was done on the afternoon of 6/29/16 and on the morning and afternoon of 6/30/16. Cross Reference to F226. This allegation of neglect was not reported to the State Agency. On 12/4/15 the State Agency received a report from the state's adult protective agency for Resident #324, regarding caregiver neglect. An anonymous caller contacted the adult protective agency on 12/3/15 to register an allegation of neglect. The caller reported on 11/30/15 during a visit with Resident #324 the resident appeared to have red eyes and a fever, later the resident had a [MEDICAL CONDITION] (became stiff and rigid for 15 to 20 seconds) and when the caller placed the resident on his side it was found he did not have a personal brief on and a large bedsore was found on his buttock. The reporter informed an aide who reported it was the first time to see the sore. The licensed nurse was informed and was not aware of this sore. Subsequently the Director of Nursing (DON) was called and viewed the sore, responding I'm so sorry. This allegation of caregiver neglect was investigated during the facility's recertification survey. Resident #324 was admitted to the facility on [DATE]. The resident was admitted from another nursing home. A review of the transfer summary from the previous nursing home dated 10/20/15 was done. The resident resided in the previous nursing home from 2/2/12 through 10/19/15. The resident's [DIAGNOSES REDACTED]. The resident was noted to require total care, incontinent of bowel and bladder and on regular diet with pureed consistency and pudding thick liquids. The admission history and physical (H&P) dated 10/20/15 notes Resident #324 with advanced dementia to the point of being nonverbal, non-communicative and requires total care. At the time of admission, the resident was 62 inches in height and weighed 151 pounds. The goal was to provide care for comfort, no routine medications and assess need for routine pain medications. A review of the resident's admission Resident Assessment Instrument (RAI) with assessment reference date (ARD) of 10/26/15 notes Resident #324 is severely impaired in the area of cognitive skills for daily decision making. In Section G. Functional Status, the resident is documented to be totally dependent with two person assist for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Resident #324 was also noted to be totally dependent with one person physical assist for dressing, eating, toilet use, personal hygiene and bathing. The resident was also coded to be always incontinent of urine and bowel. The resident's active [DIAGNOSES REDACTED]. In Section M. Skin Conditions, the resident was not admitted with a pressure ulcer or other wounds. The resident was admitted with pressure reducing device for chair and bed. A significant change RAI with ARD of 12/12/15 was completed by the facility. The resident is noted to require more support for dressing, toilet use and personal hygiene. The resident was coded to have an indwelling catheter. In Section M. Skin Conditions, the resident noted to have open [MEDICAL CONDITION] other than ulcers and moisture associated skin damage (i.e. incontinence, perspiration, drainage). The skin and ulcer treatments now include: pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, application of nonsurgical dressings and application of ointments /medications. The resident's care plan was reviewed. The facility developed a care plan for Skin Integrity with onset date of 10/19/15 with actual skin breakdown to coccyx on 11/18/15. The approaches include the following: do skin head to toe assessment weekly, notify PCP for skin issues; Braden scale assessment quarterly and prn; offer fluid intake in between and during meals; do not massage bony prominence; dietician to evaluate resident's nutritional status prn; treatment/monitor as ordered; 12/1/15 air mattress; and frequent turning. An acute care plan was developed on 11/18/15 for excoriation to coccyx. The approaches include: treatment as ordered by MD; reposition every 2 hours; and weekly skin checks. A review of the Braden Scale for Predicting Pressure Sore Risk found assessments for 10/19/15 and 10/26/15 note the resident was at high risk for pressure sores. The resident yielded a score of 14 (moderate risk) on 11/2/15 and 11/9/15. Subsequent assessments yielded score of 9 and 6 (very high risk) on 12/1/15 and 12/8/15 respectively. The resident's nutrition for 10/25/15 and 10/27/15 was noted to be excellent. A review of the Weekly Skin Integrity Data Collection prior to the documentation of the three wounds first observed on 12/1/15 was done. The resident was noted to have intact skin on 11/1/15, 11/8/15 and 11/15/15. On 11/22/15 the resident was noted to have excoriation buttocks, Sensicare with no indication of site (the site was not indicated on the diagram) or the measurement of the excoriated area. Subsequent documentation on 11/29/15 notes the resident has excoriation to buttocks with Sensicare (cream). The diagram shows an elongated circle to the left buttock close to the gluteal cleft with no measurement of the affected area. The data for 12/5/15 and 12/6/15 notes excoriation to buttocks with no new open areas, bruises. The assessment for 12/9/15 indicates excoriation to buttock with an elongated circle to the left buttock close to the gluteal cleft. On 12/13/15 it is noted the resident has excoriation to the tip of the penis, wound to left buttock with excoriation and wound to the coccyx. A review of the Non-Pressure Skin Condition Record found documentation of a skin related area on the lower coccyx measuring 1.6 x 0.6 cm. dated 11/18/15. The diagram shows an x to the left of the gluteal cleft. The next documented assessment was don on 12/8/15 (19 days later). This skin condition was not documented in the Weekly Skin Integrity Data Collection, the documentation of 11/22/15 notes excoriation to buttocks with Sensicare. Subsequent documentation (12/15/15, 12/21/15, 12/29/15, 1/5/16, 1/12/16, 1/21/16 and 1/28/16) documents improvement to the skin. The documentation of 1/28/16 notes the area healed. Further review found documentation of three non-surgical skin conditions with date of first observation 12/1/15 (Non-Pressure Skin Condition Record). The body diagram documents the letter A written on the left buttock with an arrow drawn from the left buttock away from the body with BC written in a circle. Site A to the left buttock measured 13 x 7 cm with 1.0 cm in depth. The wound was noted to be red, pink and black and the wound appearance was [MEDICATION NAME] and necrotic (dead tissue). Site B to the left buttock measured 5.4 x 4.4 cm, black in color and the wound appearance was necrotic. Site C to the left buttock was noted to be 2.4 x 1.3 cm and 1.0 cm in depth and pink in color. Subsequent assessment on 12/8/15 notes the following: Site A, measured 10 x 7 cm with 1.0 cm in depth with the wound appearance was light yellow in color with [MEDICATION NAME], granular and necrotic; Site B measured 4.3 x 2.8 with wound appearance of soft brown necrotic; and Site C measured 6.2 x 1.2 with 1.0 cm in depth. All wounds noted to be improving. The assessment done on 12/15/15 combined Site B and C together. The assessment done on 12/22/15 combined all three sites (A, B and C). The assessment noted on 12/29/15 combined Sites A and B and separated Site C. The Non-Pressure Skin Condition Record with start date of 12/29/15 notes the type of the wound as Moisture Associated Skin Damage (MASD). The assessments performed on 1/5/16, 1/12/16 and 1/21/16 continued to combine Sites A and B and separated Site C. On 1/12/16 Sites A and B was noted to have tunneling. However, all sites were documented with improvement. After the discovery of the three wounds, the facility continued to conduct the following assessments: Weekly Skin Integrity Data Collection (excoriation of left buttock), Non-Pressure Skin Condition Record (lower coccyx) and Pressure Ulcer Status Record (start date of 1/21/16) of the left buttock separately. On 12/3/15, the physician ordered physical therapy consult to assist with wound management of left buttock moisture associated skin damage. An interview and concurrent record review was done with the Director of Rehab (DOR) on 7/1/16 at 8:25 A.M. The DOR confirmed Resident #324's first session was on 12/8/15 for debridement and positioning. On 7/1/16 at 8:45 A.M. an interview and concurrent review of record was conducted with the Physical Therapist (PT). The PT recalled the wound was not healing, very sloughy, foul odor with purulent and serosanguineous drainage. The Plan of Treatment notes the measurement was 7.4 cm x 4.0 cm x 1.0 cm to the left buttock area. Also noted the open area to the left buttock had necrotic tissue and foul smell. The PT reported during cleaning, the wound was found to have undermining which could not be seen as the necrotic tissue was covering the area. Inquired how does this happen, the PT replied incontinence of bowel and bladder puts a resident at higher risk, if there is excoriation and the skin is always damp or too much moisture, the skin will erode. The PT reported necrotic tissue is a by product of the body healing itself and it can occur fast when there is moisture related to urine, fecal material or sweat. The physician ordered [MEDICATION NAME] concentrate 100 mg/mL (20 mg/mL) oral solution PO 3x per week 0.5 mL prior to each PT wound treatment in addition to the current prn order. The start date was documented as 12/14/15. The physician ordered a referral to the wound clinic on 12/1/15 and 12/7/15. The DON provided documentation on 6/30/16 regarding the referral to the wound clinic noting on 12/3/15, the resident's public guardian requested to hold off on the consult until the resident's condition stabilized. On 1/20/16 Resident #324 was seen by wound consultants, a physician and a licensed nurse. The report notes the resident had a buttock pressure ulcer since December with Mesalt packing and dry dressing daily along with debridement. At this time the resident had not eaten for 52 days with IV fluids. The wound was described as being very close to the anus, < 1 cm. The impression was a decubitus ulcer of left perineal ischial region, Stage 4 which measured 4 cm x 3 cm with a depth of 3 cm. The ulcer was also noted to have large amount of serosanguineous drainage. The recommendation was to continue with Mesalt and dry dressing daily and PRN with air mattress, turning schedule and discontinue debridement. Following the consultation with the wound specialists, the facility initiated a Pressure Ulcer Status Record which was initiated on 1/20/16 (date of first observation). On 1/21/16 there is documentation of a Stage IV pressure ulcer measuring 4.8 x 2.2 and 2.2 in depth to the left buttock with moderate drainage and tunneling 5.5 at 1200. The assessment of 1/28/16 notes improvement; however, the resident is now in pain as evidenced by moaning. A review of the nursing notes found documentation for 12/1/15 noting at Resident #324 had two episodes of [MEDICAL CONDITION] at 0001. Initially the Certified Nurse Aide (CNA) heard a loud noise and upon entering the room the resident was found to have whole body and extremities shaking, [MEDICATION NAME] less than one minute. The second episode was observed by the licensed nurse, a loud noise was heard and the resident had twitching facial and eye lids with total body shaking including upper and lower extremities [MEDICATION NAME] less than one minute. Two more [MEDICAL CONDITION] were noted on 12/1/15, [MEDICATION NAME] less than a minute with facial, mouth and eye lids twitching, a total of 4 (four) episodes of [MEDICAL CONDITION] activity. There is documentation on 12/1/15 the Public Guardian was called at 1125 with an update of [MEDICAL CONDITION] overnight and buttock wound with stat labs, wound treatment and antibiotic. The nursing staff also documented the resident had a rectal temperature of 100.6 which was rechecked at 1329 and it was 101.1 and emesis was noted with scant bright red blood. Subsequent documentation on 12/1/15 notes a full thickness wound noted to the left buttock (see non-pressure skin condition record for measurements). An interdisciplinary team note dated 12/8/15 was reviewed. The progress note documents the resident has discoloration and skin changes which are consistent with a history of prior skin breakdown. The resident also noted to have skin breakdown near the coccyx on 11/18/15 which was treated with Sensicare. Subsequently on 11/27/15 the resident was noted to have excoriated area on the left buttock with application of topical Sensicare. The wound opening and eschar formation was noted to be related to the [MEDICAL CONDITION] activity on 12/1/15. The resident was noted to be on comfort care and terminal with the expectation of no improvement to his condition. A review of the physician note dated 12/1/15 notes Resident #324 was seen for follow up visit for [MEDICAL CONDITION] and buttock wounds. The physician was notified on 12/1/15 that the resident was having brief but recurrent [MEDICAL CONDITION] which started around midnight, he has no known history of [MEDICAL CONDITION] and the physician. The physician notes the resident has a significant wound to his left inner buttock that is quite extensive. The physician noted this is not typically a pressure wound as it is very close to the anal opening and subject to moisture and feces. The orders for 12/1/15 include the following: [MEDICATION NAME] concentrate prn every 15 minutes prn for refractory [MEDICAL CONDITION], respiratory distress, discomfort related to end stage dementia; air mattress; for buttock wound, pack with Mesalt daily with Sensicare to the surrounding tissue daily; additional [MEDICATION NAME] 5 mg. IM now then increase to [MEDICATION NAME] 10 mg IM every 15 minutes as needed for [MEDICAL CONDITION]; refer to wound clinic for assessment and assistance in wound management; and [MEDICATION NAME] 5 mg IM every six hours routine for intractable [MEDICAL CONDITION] related to end stage dementia (this in addition to the current [MEDICATION NAME] 10 mg IM prn). On 12/2/15 Resident #324 is diagnosed with [REDACTED]. An order was made for IV [MEDICATION NAME]. The progress note for 12/3/15 notes the resident's wound on the left inner buttock has a pink wound bed with some clear drainage, eschar and wound margins appear to be better. The resident's [MEDICAL CONDITION] activity diminished overnight with both IV [MEDICATION NAME] and [MEDICATION NAME]. A Foley catheter was inserted for moisture associated skin damage. The physician also ordered for physical therapy consult to assist with wound management of left buttock moisture associated skin damage. IV fluids were also started as the resident was unable to tolerate eating by mouth. On 12/4/15 the physician notes the resident has not had improvement in his neurologic condition and essentially unresponsive. The physician also notes per nursing investigation the buttock wound started as an excoriation noted on 11/27, at that time the Sensicare that was being used for the coccyx excoriation was extended to the left buttock but the the wound worsened to the condition it was on 12/1/15. Based on the resident's POLST artificial feeding by tube was not indicated. The physician notes for 1/7/16 documents on 1/6/16 the wound was showing signs of increased drainage with more of a foul odor. The physician's examination found the wound margins looked clean but there was some greenish malodorous drainage noted. An order was made for [MEDICATION NAME] for wound infection. The physician also ordered labs for wound infection. The lab results with report date of 1/14/16 (collected 1/11/16) notes specimen from left buttock found culture of 3+ proteus mirabilis and 1+ [MEDICATION NAME] faecalis. A brief interview was done with the DON on the morning of 6/30/16. The DON stated the findings of their investigation related to the allegation of neglect found a break in the process and procedures. The DON reported a nurse found excoriation below the coccyx and thought it was all one big excoriation and applied Sensicare to the whole area and reported the finding to the supervisor. This was documented in the book on a Friday to update the physician; however, he was not updated until the following Tuesday. The DON further reported this event was not reported to the State Agency as their investigation found procedural issues. On 6/30/16 at 2:30 P.M. an interview was done with the Administrator, Physician, DON and Licensed Nurse. The Administrator reported the resident was admitted with no known history of [MEDICAL CONDITION], then on the night of 11/30 through 12/1/15 the resident had multiple [MEDICAL CONDITION]. It was further reported the NOC nurse checked the resident and there was no open areas and the next morning when the resident's niece came to visit, he had another [MEDICAL CONDITION], the niece turned him to the side and noticed the opening on his bottom. Inquired how did the resident's skin breakdown so quickly, the Physician responded that Resident #324 had an area of weakness related to a history of rectal abscess and a rectal fistula and combined with series of grand mal [MEDICAL CONDITION], the friction and force of [MEDICAL CONDITION] caused the skin to open. The Physician reported the wounds were not pressure ulcers as it was not over a bony prominence. The Physician reported the use of antibiotics was ordered as a [MEDICATION NAME] to prevent infection. The DON reported the resident was being treated for [REDACTED]. Subsequently, the CNA reported a pink area under his buttocks and the licensed nurse assessed the area and thought it was connected to the coccyx area wound and applied the Sensicare on the buttock area. On 7/1/16 at 9:45 A.M. an interview was done with a Licensed Nurse (LN). Although the LN was not working when Resident #324 had the onset of [MEDICAL CONDITION] activity. The LN reported she did observe a few [MEDICAL CONDITION] which lasted a few seconds, the resident's body stiffened and there were tremors of the hand. Inquired what is the response to a resident when a grand mal [MEDICAL CONDITION] is observed. The LN reported the resident would be turned to the side to prevent aspiration and ensure the patient's safety. Following the [MEDICAL CONDITION], vitals would be done as well as checking the mouth. The LN confirmed that she performs weekly skin assessments. Inquired what is the training process, the LN replied they are required to watch videos and must do head to toe check for bruises and redness. The LN reported Sensicare cream was being applied to Resident #324's buttock. The LN explained that the Sensicare is used as a moisture/protective barrier. The LN further reported at times the cream is applied so thickly that the skin isn't always visible for assessment and the concern is that if it is scrubbed the skin will become more irritated. The LN stated she will try to clean skin but can't get it (cream) all off to really see what's happening with the skin. The LN offered to show the surveyor what the cream looks like, the LN squeezed some cream from the tube, the cream was white in color and appeared opaque. On 7/1/16 at 10:45 A.M. the QAA (Quality Assessment and Assurance) interview was conducted with the Administrator and DON. The DON reported the facility has addressed skin issues. The facility discontinued the use of soakies, acquired pressure relieving mattresses, changed the moisture barrier cream (as they found some staff members applied the cream on too thickly) and provided inservice to staff. The facility will have the Unit Managers (UM) do the weekly skin rounds and currently have two UMs that have completed wound training. The Administrator provided documentation entitled Corrective Action Taken following the survey team's exit conference. The corrective action includes: staff education (12/10 and 12/11/15) on the importance of identifying and reporting of any skin issues upon discovery; CNAs were educated on importance of utilizing INTERACT Stop and Watch form to alert/communicate to the nurse any skin conditions identified during their care; CNAs and nurses were educated on the importance of documenting all skin issues on their unit zone sheets upon discovery of any skin issue; nurses were educated on importance of conducting an assessment of all skin issues reported to them upon notification; nurses were educated on documenting all administered skin treatments in the treatment record; development of clinical competencies to accurately document weekly skin check, how to accurately document the initial data collection tool for each resident and how to properly assess a resident's skin condition; and CNA competencies were conducted to ensure the identification of any type of skin condition that may be presented and where to look for common areas of skin conditions on a mannequin. The facility failed to accurately assess and treat Resident #324's skin excoriation to the left buttock close to the gluteal cleft first noted on 11/22/15 (the facility identifies the first observation of skin excoriation on 11/27/15) resulting in three open wounds first observed on 12/1/15. Per the Administrator's report, on 11/30/15 the NOC shift nurse assessed the resident's skin and found no open areas; however, on 12/1/15 the resident was noted with three moisture associated skin damage with necrotic tissue to the left buttock. It was reported Resident #324's skin was compromised and following multiple grand mal [MEDICAL CONDITION] on 12/1/15 the resident acquired the (MASD) wounds. The report from the adult protective services agency indicates the facility had no knowledge of these wounds. The report from the state's adult protective agency and interview with the Administrator confirms the resident's niece discovered the wounds on 12/1/15. The resident's wounds were noted to be necrotic with [MEDICATION NAME] tissue by the time of discovery. As a result of the three moisture wounds, a Foley catheter was inserted on 12/3/15, debridement of the wound was needed to be rid of the necrotic tissue (dead tissue) beginning 12/8/15 and development of an infection to the wound which was treated with antibiotic on 1/7/16. Although the facility reports the resident's skin was compromised and the [MEDICAL CONDITION] activity was a causal factor to the actual breakdown of the skin, the documentation and diagrams of Resident #324's skin integrity prior to 12/1/15 indicates excoriation to the left buttock next to the gluteal cleft; however, the subsequent diagram of the three wounds to the left buttock appears to encompass the whole left buttock. The documentation does not support the extent of the resident's compromised skin that would lead to the development of the three wounds with necrotic tissue. Resident #324 was first noted to have excoriation to the left buttock on 11/22/15 which was treated with Sensicare cream. This Sensicare cream was acknowledged by the licensed nurse doing weekly skin assessments to create a barrier to assessing residents' skin when applied too thickly. The DON also stated in an interview a nurse found excoriation below the coccyx and thought it was all one big excoriation and applied Sensicare to the whole area. There was no documentation/assessment of increased excoriation to the left buttock to require application to the whole area. The DON also confirmed the facility has changed the moisture barrier cream as it was found some staff were applying the cream too thickly. No documentation of the efficacy of Sensicare cream to address the excoriation. 2) ON 06/30/2016 at 8:33 AM reviewed R#3's the electronic medical record (EMR). The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The care plans included, Self care deficits secondary to impaired mboility and profound dementia; with the goal that the resident will be clean, dry and her daily needs will be anticipated and be met daily over the next 90 days; and review date of 08/30/2016. The care plan interventions included: Total assist with daily care per as directed in care directives; Provide rest periods during care; Report a decrease in joint mobility or pain with movement to the nurse. On 06/30/2016 at 2:05 PM observed a dressing change to R#3's left (L) hip area. The LN gathered the supplies that included clean gauze squares that were placed into two separate plastic cups (for soap and water), Allevyn classic dressing, clean gloves and hand sanitizer. Followed the LN to R#3's bed and the CNA assisted by turning R#3 to the right to expose the L hip area. The LN used aseptic technique as he removed the soiled Allevyn dressing and cleaned the excoriation to the L hip area. Asked the LN what caused the excoriation and he replied, Probably pressure. On 07/01/2016 at 8:04 AM interviewed the Unit 3 south charge nurse. She stated that the nurse unit managers (UM) monitored the wounds on each unit and gets the treatment orders from the doctors. A head to toe skin check is done for all residents upon admission to the facility and the LN's are to call the UM when a pressure ulcer(PU)/wound is found on a resident. Interviewed the UM for unit 3 south and she stated that R#3's L hip denuded area was first seen on 05/21/2016 and provided the treatment administration record (TAR) that documented, Denuded area L hip. Cleanse with NS. Aloe Vista PRN. 5-21-16. When informed the UM of the discrepancy of the treatment observed and treatment on the TAR, she stated that she was acting as nurse supervisor on the date written on the TAR and another UM took over monitoring of PU/wounds. Reviewed R#3's medical record and the, Weekly Skin integrity Data Collection form documented: 06/09/16 Old L hip denuded; 06/16/16 Dry, open area other L hip noted pink, blanchable, old, noted, on 06/15/16; 6/23/16 Dry, old excoriations buttock; 06/30/16 Dry, old excoriation to buttock. The Non-Pressure Skin Condition Record form documented that, Site A Excoriation date first observed was 6/15/16 L inner buttock with measurement of 0.5 cm x 1 cm. Site B Excoriation date first observed 06/15/16 R inner buttock with measurements of 0.5 cm x 0.5 cm. On 07/01/2016 at 8:52 AM interviewed the UM who documented on the TAR and Non-Pressure Skin Condition Record form for clarification. According to this UM the non-pressure wound that increased in size on 06/24/16 was located at the L inner buttock with noted documentation for measurements of 1.2 cm x 1.4 cm [MEDICAL CONDITION] cm; pink; no drainage; [MEDICATION NAME]; and deteriorated. The nursing notes dated 06/24/16 also noted, Excoriation to L inner buttock clean,pink and moist. Resident yells out and pulls away during treatment. Requires total assistance for all care. Incontinent of bowel and bladder. See chart for measurement. According to this UM she used Allevyn dressing for the wound as noted above. Pointed out to the UM that the TAR documented, Sensicare BID and PRN to buttock excoriations x 1 wk then reassess dated 6/20/16. Treatment was provided from 06/20/16 to 6/26/16. On 06/27/16 the treatment to the buttock excoriation was changed to, Cleanse with soap and water apply Allevyn classic dressing change every 3 days et PRN x 14 days then reassess daily. On 07/01/2016 at 10:05 AM observed the UM from each unit, the charge nurse for unit 3 south and and the MDS Coordinator at R#3's bedside to look at the PU/wound dressing that was observed on 06/30/2016. The LN's removed the Allevyn dressing from the L hip denuded area. The UM from unit 2 south stated that the L inner buttock now looks healed and there's another area below the L buttock that was pink and uncovered. Discussed with the LN's that documentation of excoriations and non-pressure related wounds are inaccurate and treatment was provided to the wrong wound. Although the facility developed a corrective action plan and provided documentation of their plan to address their residents' wounds, the deficient practice related to accurately assessing and providing treatment to wounds continued as evidenced by the observation of the care provided to Resident #3.

Based on observations, staff interviews, hardcopy and electronic medical record reviews, the facility failed to implement consistent routine and individualized pressure ulcer, (PU), prevention and treatment for 2 residents (R#58 and R#280), in the Stage 2 survey sample. Findings include: Cross to F280 1) Resident #58 was 1 of 2 residents with a Stage IV PU in the facility during the survey. This PU was acquired in the facility and assessed on 05/20/2013 as a Stage II PU to the mid back, and measurements were (5.3 W x 3.0 L x 0.l D cm), as written on the Pressure Ulcer Status Record, (PUSR). On 05/28/2013 the PU wound was assessed as unstageable with measurements of (6.01 W x 2.5 L x ?D), and appearance described as, "...wound bed is 90% black eschar, 10% red with pale yellow slough. The PUSR on 08/23/2013 documents the unstageable PU wound assessed as Stage IV with measurements of (4.1 W x 2.0 L x 1.0 D), with undermining, (1.7 at 12-5), and described as, "change in wound stage due to decrease in slough, able to see underlying tissue. The PUSR documented the PU treatment, (TX), as wet to moist from 05/20/2013 until a new order (written on the 03/21/2014 PUSR), dated 03/17/2014 for "[MEDICATION NAME] 0.1% top BID - on order at this time - still unavailable. Continue with saline moist gauze packing." The PUSR documented on 04/18/2014 that TX with [MEDICATION NAME] packing BID was started. According to the MDS 3.0. for R#58, admittance to the facility was on 6/29/2006, with [DIAGNOSES REDACTED]. The MDS 3.0 also coded R#58's cognitive pattern to be severely impaired, unable to participate in daily decision making or to make needs known, and totally dependent for all activities of daily living, (ADL). The quarterly review on 09/30/2013 under skin conditions noted that R#58 had an unhealed Stage 4 PU, and dimensions were, (01.8L x 01.6W x 00.8D). The most recent quarterly review on 03/24/2014 noted the Stage 4 PU with dimensions of, (00.8L x 00.8W x 00.4D). On 05/13/2014 at 1:31 PM, interviewed LN#8 regarding R#58's current status of the PU, and she provided that R#58 just received new PU TX order, as recommended by the facility's regional DON. The new TX order read, "D/C previous orders for [MEDICATION NAME] TX. Stage IV mid back wound care: Cleanse with normal saline. Apply skin prep to peri-wound. Pack wound with [MEDICATION NAME] ag and cover with foam drsng daily x 14 days then evaluate." According to LN#8 the PU TX was changed because the PU wound wasn't improving. Went to observe R#58 and saw that the resident was lying on his/her side facing towards the left. On 05/14/2014 at 10:50 AM, observed LN#4 do R#58's PU TX, using the new order for [MEDICATION NAME] ag. The LN#4 provided the wound measurements as (0.7 cm x 0.4 cm depth and tunneling 4.3 cm) on this date. The LN#4 probed the wound tunneling with a cotton tip applicator soaked in normal saline, (NS). Asked LN#4 if R#58 was provided pain meds before TX or were vital signs taken. The LN#4 stated that she doesn't notice grimacing or other signs of pain during PU wound TX and dressing change. The LN#4 also stated that R#58 had a [MEDICATION NAME] on, so no other pain reliever was needed. On 05/15/14 at 9:57 AM, did MRR on R#58, and interviewed LN#8 to query if there were other skin assessments or nursing documentation prior to R#58 being diagnosed with [REDACTED]. The "Pressure Ulcer Risk Assessment Tool" dated 5/09/13, documented: "Risk Factors: Hx of PU and Existing PU; Comments: Reposition freq to side lying position. Moisture barrier d/t incontinence. PU 1st obs 5/20/13 with measurements of ( 5.1L x 3.0W x 0.1D) dark purple reddened tissue at Stage 2 ; Wet to moist drsng started." The Pressure Ulcer Status Record, (PUSR), dated from 5/20/13 to 5/9/14 documented the course of R#58's Stage II PU wound, as first observed on 05/20/13, to the mid back area that measured in size (5.3L x 3.0W x 0.1D). The wound nurse, (LN#4), primarily used the PUSR to document the assessment of the PU wound and TX being used. The PUSR documented these changes to the PU TX throughout the year of the initial Stage II PU: 5/28/13; change in stage unstageable; 6.0x2.5x?; wet/moist; 8/23/13 change in wound stage, Stage IV; 4.1x2.0x1.0; undermining 1.7 at 12-5; in the appearance column it was written, "change in wound stage due to decrease in slough, able to see underlying tissue; wet to moist; 8/30/13 start TX with moist gauze pack wet to moist; 9/27/13 TX of moist loose packing; 3/17/14 new order for [MEDICATION NAME] 0.1% topical bid- on order at this time- still unavailable. Continue with saline moist gauze packing, (written under 3/21/14 TX date); 4/18/14 [MEDICATION NAME] packing BID. The PUSR had the attending physician's signature at the bottom of the form and LN#4's signature was countersigned by the clinical care coordinator's, (LN#2) signature on: 5/28/13, 06/28/13, 7/19/13, 7/31/13, and 9/18/13. On 05/15/14 at 10:27 AM interviewed LN#4, (wound nurse), to discuss how R#58's PU wound was first assessed at Stage II, and whether the CNA's report any skin changes to the LN's. According to LN#4, due to R#58's frailty and lying on his/her back the wound was found at Stage II, and although it would be ideal to assess the PU at Stage I, it was difficult with the resident's condition and frail skin. The LN#4 further stated that the CNA's try their best and if they see a reddened area, they will alert the wound nurse or charge nurse. The LN#4 believed that the PU, "probably happened overnight due to R#58's frail condition," because the resident's back is visible to the CNA's when they provide care. Also queried LN#4 on how and when she collaborated with the physician, DON, and/or Supervisor regarding the PU TX, or if assessed that the TX was not working or the PU wound was worsening. According to LN#4, she informs the DON or the charge nurse, (LN#8), and would document in the nursing notes when consults with her supervisor, (LN#2), or the physician, but sometimes communicates verbally. The LN#4 was unable to provide documentation on consulting or collaborating with the physician, DON or Supervisor regarding R#58's PU TX. The LN#2 accessed the electronic medical record, (Softcare), and found documentation dated 05/28/13, that the physician was updated on the wound status as assessed by the wound nurse, "90% blackened eschar and 10% red with pale yellow slough. Continue with wet to moist drsng BID. Dr.___ updated." There was a CP dated 08/23/13, "A Potential for Skin Breakdown." The CP approaches included: weekly skin assessments during showers; reposition resident every round and prn; place resident in skin-breakdown-prevention program; and, place pressure relieving products on bed/chair/other prn. There were changes written all over the CP when the TX was changed or there was a change in the wound status. Another CP dated 10/24/12, " Potential for Pain, Pain AEB grimacing;" with a target date for 03/27/14; included these approaches: "Anticipate res needs; activities as tolerated; obs res for signs of pain with all care and every interaction ie: facial, grimacing, scared , fearful or alarmed expression, moaing/groaning;" "Analyze and document factors that precipitate pain and what may reduce it;" "Provide total asst with repositioning;" " Move res slowly;" and, "7/27/13 [MEDICATION NAME] 25 mcg/hr [MEDICATION NAME] apply 1 patch Q 72 hrs and change Q 3 days." On R#58's PO for May 2014 there was an order dated 07/22/2013, "[MEDICATION NAME] 25 mcg/hr [MEDICATION NAME] Patch - Apply 1 patch Q 72 Hours and change Q 3 days." The PO for the new order of [MEDICATION NAME] 0.1% was dated 03/25/14, but this "new order," was written on the PUSR on 3/17/14. On 05/15/14 at 11:20 AM in the Learning Lab, interviewed the physician, the Clinical Care Coordinator,(LN#2), the staff development/quality assurance nurse, (LN#3), and the wound nurse, (LN#4), regarding the PU wound management at the facility. According to the physician, he will look at the PU with LN#4 periodically, and "if there's a sense that the PU wound is worsening." The physician stated that he documents these encounters into the facility's EMR, (Softcare). The LN#2 that provides supervision to LN#4, stated that when she reviews the PUSR she countersigns after LN#4's signature, and sometimes will look at the PU with LN#4. As LN#4 is the wound nurse for the facility, the PU TX was primarily determined by her. When queried whether it is standard wound care protocol to use wet to moist dressing for three months to debride the PU wound, the LN#4, stated that from 5/28/13 when R#58's PU went from Stage II to unstageable and then to Stage IV on 8/ 23/13, the moist to wet dressing TX was kept because she believes in that TX. The LN#4 further stated that the debridement action worked, and that Santyl is too expensive to use. The physician stated that R#58 was in such a debilitated condition, that a more "hospice- like," approach was used. Also, due to R#58's advanced dementia, the resident would often "lock jaw," refuse to eat, and his/her arms tightened into a fetal position, and that R#58 was on a "roller coaster," in response to interventions. The recommendation then, was to keep the wet to moist dressing. The physician stated that the nursing staff knows more about wound care than himself, so usually he goes along with their recommendations. The physician notes dated 05/29/14 documented, "Res stopped talking and eating, noncommunicative (2/2013). Res eats ensure pudding btw meals, puree diet and liquids. Occ will clamp jaw and refuse foods for 3 days and than starts eating again." In the EMR, (Softcare), with a date of 05/29/2013 at 3:34 PM, under, "Care Note History," the physician documented, "patient has a pressure ulcer on coccyx which has evolved in to an eschar, patient has endstage dementia with contractures and failure to thrive with poor intake, given terminal condition, wound will not heal and focus should be on comfort, basic dressings." Queried LN#4 on why the TX was changed on 5/13/14 to use [MEDICATION NAME] ag, and she stated that the facility's regional DON suggested to change the treatment for 14 days because the regional DON "believes in [MEDICATION NAME] ag." According to LN#4, the regional DON is said to be a certified wound nurse. On 05/15/14 at 1:34 PM, interviewed LN#4 to query whether the PT who is also certified to do wound care and sharp debridement, was ever consulted regarding R#58's PU management. According to LN#4, she did not recommend sharp debridement for R#58, due to the physician placing the resident on palliative care, and in retrospect wouldn't have asked the PT to do sharp debridement because of the resident's condition. Also, Santyl was not considered as TX option. On 05/15/14 at 1:45 PM, interviewed CNA#1, who identified self as responsible for providing personal care to R#58 during day shift. The CNA#1 stated that he/she ensures that R#58 is repositioned at least every two hours, and when providing personal care will assess the resident's skin. Queried if CNA#1 saw any skin changes prior to R#58 assessed with [REDACTED]. According to CNA#1, R#58 had acquired a PU wound to the mid back during the time he/she was on a week-long vacation. 2) Reviewed the MDS 3.0 for R#280 and found that the resident was admitted to the facility on [DATE] with an unstageable pressure ulcer with 50% necrotic tissue (diameter 3.5 x 2.0), that required debridement, and the PU wound was classified at Stage IV. The MDS 3.0 also coded R#280 as total dependent for bed mobility and transfers. On 05/13/14 at 1:35 PM interviewed R#280 in the facility's rehab therapy room. The resident stated that the PU wound was acquired during his/her stay at a Honolulu rehab therapy facility. On 05/14/2014 at 12:40 PM, LN#4 informed surveyor that the PT was unable to perform continuous pulse irrigation, (CPI) for PU TX because the bag that catches the water did not come in. According to the LN#4 the bags were ordered but delivery had been delayed. The PT informed LN#4 that there would be a flood without the special bag to perform CPI TX. The LN#4 stated that the order was changed, and she will do PU wound TX at 1:00 PM. On 05/14/14 at 1:23 PM observed LN#4 perform the PU wound TX for R#280. The LN used proper hand hygiene, placed supplies on an overbed table covered with white drape paper covering, poured normal saline over a stack of 4x4 gauze, (placed directly on the white paper drape), and used the moistened gauze to clean inside of wound, in place of the CPI TX. The LN#4 used all of the moistened 4x4 gauze including the last gauze on the wet white drape covering the table. After performing hand hygiene, the LN#4 donned clean powder free gloves, and with her gloved index finger wiped Santyl ointment into the PU wound bed. The LN finished the wound TX by ensuring that the foam pieces and wound vac was placed correctly and comfortable for the resident. The wound measurements were: 4.0 x 3.5 cm outer wound; 3.5 x 3.0 cm crater wound, Depth 1.7 cm; undermine 2.0 cm at 12:00; 2.0 cm at 1:00-3:00; 2.7 cm at 9:00-11:00. Queried LN#4 on process for setting up supplies on overbed table, and she stated that Sani-wipe was used to sanitize table before placing supplies onto clean white drape covering table. Also wiped scissors with Sani-wipe before using to cut foam and adhesives. On 05/15/14 at 9:27 AM, interviewed the PT regarding alternatives for CPI TX for R#280's PU wound with bags on order. According to the PT, the CPI bags order was placed on 05/08/2014 with delivery usually within a week but not received to this date. The PT stated that an alternative to the CPI TX would be to irrigate the wound with NS using a syringe instead of using 4x4 gauze moistened with NS. The PT stated that he didn't use the syringe to irrigate R#280's PU because LN#4 is the wound nurse, and responsible for PU TX. On 05/15/14 at 1:35 PM, interviewed the Clinical Care Coordinator (LN #2), and the Staff Development/Quality Assurance, (LN #3), and the Wound Nurse, (LN#4), regarding use of the syringe to irrigate R#280's PU wound with NS versus the use of the 4x4 gauze moistened with NS. According to LN#4, the facility's regional DON advised her not to use the syringe to irrigate the PU wound because LN#4 is not a certified wound nurse, and may cause more trauma to the wound bed tissue. According to LN#4, she attended PU wound seminars in Hilo 4 yrs ago, and the facility provided inservices by wound consultants within the last 2 years. Also, the facility has no specific criteria for the title of Wound Nurse. The PT is a certified wound care provider and able to do sharp debridement and CPI wound TX. The PT did the sharp debridement for R#280. The MRR found that the PUSR that LN#4 used to document R#280's PU TX, documented that on 3/26/14 the TX was, "CPI by PT then Santyl oint cover with gauze dry." On the 4/7/14 PUSR it was documented, "CPI by PT wound vac started." The PU TX from 4/18/14 to 5/9/14 was, "wound vac with Santyl." The physician order [REDACTED]." Also, PO on 04/07/2014, "Wound vac therapy 125 mm/Hg continuous to stage IV sacral wound, change dressing Monday, Wednesday and Friday Daily." The electronic PO dated 05/12/2014, "Santyl 250 unit/gram topical ointment three times a week, apply to coccyx wound three times a week on wound vac days q Monday Wednesday and Friday." There was no PO for PT to do CPI wound TX. The CP's for R#280 included, "Resident has pressure ulcer - unstagable to Sacrum," with onset date of 04/08/2014; under the Approaches column (written in pen ink) on page (7 of 11), "4/28 'No' Santyl," and on page (8 of 11), "4/4 Juven 1 pck PO daily," and "4/7/14 Wound vac 125 mm/change dressing MWF; CPI Therapy by PT." The CP revisions written in pen ink were not initialed or signed.

Based on observation, record review, and facility staff interviews, the facility failed to revise/update a care plan for 1 resident, R #17, of 3 residents reviewed during the follow up visit to the facility. Findings include: Cross reference to F 323. Record review for R #17 on the morning of 7/1/14 at approximately 11:00 A.M. found an "At Risk for Falls" care plan with an onset date of 2/15/13. The resident had actual falls on 10/16/13 without injury, 3/23/14 without injury, and on 5/4/14 without injury. The care plan had handwritten dates for when it was reviewed: 5/15/13 (yellowed out), 7/29/13 (yellowed out), 11/1/13 (yellowed out), 1/28/14 (yellowed out), 4/28/14 (yellowed out), and 7/29/14, (next review date). On the afternoon of 7/1/14, Licensed Nurse, LN #1, stated that the 2/15/13 Falls care plan was the most current and up to date care plan. Approximately 30 minutes later LN #2 stated the Falls care plan was the most up to date and current care plan. On the morning of 7/1/14 record review found the facility completed a Fall Risk Evaluation for R #17: 3/23/14 with a score of 22; and 5/4/14 with a score of 22. The total score noted, "A resident who scores a 10 or higher is at risk. Consider environmental risk factors in resident's interventions". Despite the resident's actual falls on the above dates, the facility did not revise/update the interventions/approaches to ensure R #17's safety. The facility's negligence placed the resident at risk for future falls/accidents. Interview of the Falls Committee Chairperson, LN #2, on the afternoon of 7/1/14 at approximately 2:00 P.M., revealed the facility met weekly to discuss falls. The committee reviewed a dashboard which looked at history, underlying acute medical problems, medications, underlying chronic medical problems, functional status, sensory status, psychological status, and environmental issues. The LN #2 stated the R #17 was discussed at their weekly meeting after each of her falls. However, the LN #2 stated the interventions/approaches were not revised/changed. The LN #2 again stated the Falls care plan in the medical record dated 2/15/13 was the current updated care plan. The LN #2 stated she's had some difficulty because of staff turnover in the Rehab department. The LN #2 stated they needed to "tighten up" their Falls Committee. On the morning of 7/2/14 at approximately 9:50 A.M., the Regional Director of Clinical Services, RDCS, approached the surveyor and stated that R #17's care plan for falls was in the learning lab and that the staff didn't know it was there. The RDCS stated they had been revising numerous care plans and the staff didn't know that the actual updated care plan for R #17 was there. The RDCS then asked if she could give the surveyor a copy of the Falls care plan. Surveyor informed the RDCS that it was a revisit survey to ensure the facility was back in compliance with their citations. The care plan provided to the surveyor on 7/1/14 was the most current, according to LN #1 and LN #2. Surveyor then informed the RDCS that the care plan must have been revised after it was brought to the staff's attention. The RDCS stated the care plan had been there all along but the staff didn't know. The RDCS stated, "It's hard to update care plans for 200+ residents in less than 30 days". On 7/2/14 at approximately 10:05 A.M., the RDCS again approached the surveyor, along with a Corporate Interim Administrator, CIA. The RDCS explained that the facility was in the process of reviewing and revising care plans for all the residents. She then provided a copy of the "actual, updated" care plan for Falls for R #17. The RDCS stated that LN #1 and LN #2 were unaware that the care plans were being revised and therefore didn't know where they were located. Another surveyor informed the RDCS that she, too, found information in another resident's care plan which wasn't included in the care plan during the 5/16/14 survey. The RDCS stated that was why they were requesting an Independent Informal Dispute Resolution (IIDR). When asked how the staff were to provide care to the residents if the care plans were not available to them, the RDCS stated that she and the CIA were providing education to the staff. The RDCS stated she and the nursing staff stayed late on 7/1/14 to discuss how to make changes to the care plans. On 7/2/14 at approximately 11:30 A.M., the RDCS approached the survey team regarding R #17's revised care plan. She informed the survey team that she had nothing to do with care plans. She stated she didn't touch the care plans. She informed the surveyor the care plan she reviewed on 7/1/14 was, "the most accurate care plan for you." When asked what that meant, she stated the care plan being provided to the surveyor on the morning of 7/2/14 was the actual, updated care plan and was in another location. She further explained the licensed nurses didn't know about it because they had been working hard to update multiple care plans. The surveyor again asked when the 7/2/14 care plan was created. The RDCS replied that the falls care plan for R #17 was revised and printed on the evening of 7/1/14. The surveyor then clarified, "the 7/2/14 care plan was not in R #17's record on the day of 7/1/14"? The RDCS stated the care plan was revised on the evening of 7/1/14 but noted the same onset date of 2/15/13 (which gave the appearance like it was in the record all along). The difference between the care plans was there were handwritten review dates on the 7/1/14 care plan and none on the 7/2/14 care plan. Also, the approaches on the 7/2/14 care plan were different from the approaches on the 7/1/14 care plan. The surveyor informed the RDCS that there is concern for resident well being when the falls committee chairperson, LN #2, didn't seem to grasp the concept of root-cause analysis when reviewing residents with falls/accidents. The RDCS and CIA both agreed that they're working on teaching the LN #2 how to conduct root-cause analyses. The RDCS stated they did a revision of R #17's Falls care plan on the evening of 7/1/14 after the surveyor discussed the resident and her care plan with LN #2. The RDCS also noted on the morning of 7/2/14 that a root-cause analysis needed to be performed for R #17's falls. The RDCS stated the root-cause analysis was conducted the night before with the licensed nurses. On the morning of 7/2/14, a review of the facility's policy for "Falls Management" revealed, "1. Assessment of Fall Risk & Care Plan Development: e) The care plan is reviewed throughout the course of treatment by the interdisciplinary team to assure the most recent, updated, and resident specific fall reduction interventions have been incorporated as necessary into the plan of care". Furthermore, the policy noted under "2. Management of Falls: j) The charge nurse will review and update the care plan as needed to reflect the resident's present mobility, safety needs, and will communicate fall reduction interventions to care givers on the unit and in shift report". On the morning of 7/3/14, the facility was asked to provide any additional documents before the exit. At the time of exit on 7/3/14, the facility did not provide any additional documents.

Based on staff interviews, hardcopy and electronic medical review, the facility failed to ensure that the pressure ulcer (PU), care plan, (CP), for 2 residents (R#58 & #280), with Stage IV pressure ulcers, in the Stage 2 survey sample, were individualized, evaluated, and revised using an interdisciplinary approach. Findings include: Cross to F314 1) On 05/14/2014 at 10:50 AM, after observing R#58's Stage IV PU wound tx done by LN#4, reviewed the resident's CP in the medical record. The CP with onset date of 08/23/13, under problem column noted "Potential for skin breakdown: res has a change in stage to Stage IV d/t visible base of wound to mid back." Under the goals column it noted, "Maintains intact skin integrity over the next 90 days," with a target date of 03/27/2014. The CP was revised by staff writing in with a pen in the onset date column, "Actual Skin Breakdown," that was initialed, and an illegible date crossed out. The goal also written in pen noted, "Wound will decrease in size free from S/S of infection over the next 90 days," with a target date of 7/25/14. All across the first page (Page: 2 of 3), of the CP there were revisions written in pen ink for dates of: 3/8/14 0020 " L)1st & 2nd knuckles reddened & slight swollen;" 3/25/14 "Stage I to (R) lateral foot change in stage 4/17/14;" 4/17/14 4/12/14 , "change in wound status for (R) lateral foot stage I - Currently stage II;" under this it is written with bracket and dated 5/13/14," Added approaches, Wound care mid back Stage IV: Daily - Cleanse with NS. Apply skin prep to peri wound Pack wound with [MEDICATION NAME] ag. Cover with foam dressing. x 14 days then re-evaluate, Skin prep q shift and prn to B heels and L hip as preventative measure. Wound care Stage II R foot : Cleanse with NS & apply skin prep q shift & prn . x 14 days the re-evaluate." The second page, (Page: 3 of 3), also had CP revisions written in pen ink in the approach column and along the bottom of the page: 1/9/14- "For Stage 4 wound to back, cleanse wound pack with moisten gauze & cover with dry gauze daily;" 3/17/14 - "New 'O' for Stage IV - [MEDICATION NAME] apply to lesion to back bid;" 1/9/14 - continues under the above revision, "has hx of Stage II pressure ulcer to L) hip: apply large padded all over for protection only. Change PRN. healed 2/10/14" 3/25/14 "New order midback wound care 1) Flush wound with 1/2 bottle saline & 60 syringe, 2) Moisten 1 2x2 gauze with saline & apply [MEDICATION NAME] onto gauze than loosely pack into wound..." 3/28/14, 4/17/14 ("since 4/12/14"), and 4/17/14 were revisions written in ink regarding foot protection and than a foot wound. The CP revisions written in pen ink, were done in different handwritings, and written on the CP in no particular order, with illegible initials or none at all. The last e-signed date was 12/26/2013 by social services staff, with the physician's name printed in the right hand corner of each page. On 05/15/14 at 9:57 AM, interviewed LN#8 and discussed the PU CP for R#58. The previous CP with onset date of 10/24/2012 was retrieved from the medical records staff, with the problem statement, "A Potential for skin breakdown," with goals, "Maintain intact skin integrity over the next 90 days," and a target date of 01/24/2013. The staff revised this CP by writing in pen ink on the dates of: 5/20/13, "Stage II wound to mid back;" 5/28/13, "Change in stage to unstageable due to black eschar; 8/23/13, "Change in Stage to IV due to visible base of wound midback;" 9/27/13, "Stage II wound L hip and R hip -healed 10/10/13." The last target date written in pen ink was 3/27/14, and the last approach date was 9/27/13, "wet/moist dsg BID R hip." The last e-signed date was 10/27/2012 by the MDS Coordinator. 2) On 05/13/14 at 1:35 PM met R#280 in the rehab therapy room and asked him/her about the Stage IV PU on his/her sacrum. The resident stated that when admitted to this facility, he/she already had a PU, that was sustained while receiving rehab therapy at a Honolulu facility. On 05/14/2014 at 9:15 AM reviewed the MDS 3.0 for R#280 and it was noted that he/she was admitted with an unstageable PU covered with eschar that measured 4.5L X 4.5W in centimeters. The CP problem, " Res has PU- unstageable to sacrum," with an onset date of 04/08/2014. The PU treatment was found under the approaches column with other instructions for the goal of "Pressure ulcer will exhibit signs of healing evidenced by decrease in size, improved appearance and be free from signs and symptoms of infection by next review date" and "Resident will not develop any new areas of skin breakdown through next review date, " with both having a target date of 7/08/2014. The treatment approaches included: 4/28- "No Santyl," (written in pen ink on page 7 of 11); on third page of CP (page 8 of 11) in print type, "Wound care as ordered by physician (see current Wound Treatment and Progress Record)," and written under this with a pen was, "4/7/14 Wound Vac 125 mm/ change dsg MWF; CPI Therapy by PT." An electronic physician order [REDACTED]." Another electronic PO written on 05/12/2014 at 12:04 PM, to modify the Santyl order read, "Santyl 250 unit/gram topical ointment Topical three times a week apply to coccyx wound three times a week on wound vac days q Monday Wednesday and Friday. On the "Pressure Ulcer Status Record," dated 4/7/14 it was written, "CPI by PT Wound Vac started 4/7/14." The physician signature was at the bottom of this form, that the wound nurse used to document the ongoing status of the PU TX and assessment. On 05/14/14 at 12:40 PM, LN#4 stated that PT was unable to perform continuous pulse irrigation (CPI), to PU because the bag that catches the water did not come in. The bag was on order and LN#4 stated that the PT informed her that there would be a flood without the special bag needed to perform CPI. On 05/14/14 at 1:23 PM observed LN#4 do the PU dressing change for R#280, and in place of the CPI treatment, she cleansed the wound with 4 x 4 gauze moistened with normal saline, and with clean gloves on used her finger tip to apply Santyl ointment inside of the wound bed. On 05/15/14 at 9:27 AM, interviewed the PT who is also certified to do wound care, regarding the CPI bag not being available. According to the PT the order for the CPI bag was placed on 05/08/14 and the order usually takes a week to come in. He further stated that an alternative to the CPI treatment would have been to irrigate the wound bed with NS using a syringe. He didn't attempt to use the syringe method because the wound nurse determines the treatment. The CPI therapy by PT was added to the CP on 4/7/14, but could not determine by whom, and there was no PO written for PT to do CPI on R#280.