Every finding on record at Life Care Center of Kona

Based on interviews and record review, the facility did not employ a qualified Director of Food and Nutrition Services (DFNS). A qualified DFNS must be a certified dietary manager, or a certified food service manager, or hold national certification for food service management and safety, or who holds an associate's degree or higher in food service management or hospitality. This deficient practice has the potential to compromise the health and nutritional status of all residents at the facility.Findings include:On 01/12/26 at 09:35 AM, an initial tour of the kitchen was done with Dietary Aide (DA) 2 and the Registered Dietician (RD). The RD stated there was no current Food Service Manager.On 01/15/26 at 08:08 AM, the Administrator was interviewed in his office and stated that he was currently in charge of the kitchen. The Administrator confirmed that he did not have certification as a dietary manager or food service manager, did not have national certification for food service management and safety, or an associate's degree or higher in food service management or hospitality. The Administrator also confirmed that the RD's employment was part time status.On 01/15/26 at 12:19 PM, interviewed the RD in the Conference room. The RD confirmed her work status was part time. She stated that the Food Service Manager resigned in November 2025 and there was no formal discussion on how the responsibilities of the kitchen was going to be covered. The RD stated that without a Food Service Manager, the dietary staff can get the meals out but workflow issues are falling behind such as enforcement that required logs are completed. This was observed during the initial kitchen walkthrough with the RD and DA2 on 01/12/26. On 01/14/26 at 11:38 AM, posting of the dietary staff certifications outside of the RD's office was reviewed and no staff certification for a Certified Dietary Manager was observed. On 01/15/26 at 12:50 PM, the facility's Food Service Director-Certified Dietary Manager job description was reviewed and stated that the position required a current certification as Certified Dietary Manager in applicable State.

Based on observation, interview, and record review, the facility failed to store, monitor and maintain food items and kitchen equipment in accordance with professional standards for food service safety. Specifically, prepared food items and food items stored in containers in the refrigerator were not labeled, dated and/or expired, food items in the freezer were stored on the ground, chemical sanitization for the dishwasher was not completed for January 2026, refrigerator/freezer temperature logs missing entries for December 2025 and no recordings logged for January 2026, and expired food items found in the pantry. These deficient practices have the potential to compromise the health of all the residents and was a potential source of pathogen exposure at the facility.Findings include:On 01/12/26 at 09:35 AM, an initial walk-through of the kitchen was conducted with the Dietary Aide (2) and Registered Dietician (RD) and the following was observed:On 01/12/26 at 09:40 AM, a check of the refrigerator found the following food items:Cups with a prepared food item, which DA2 stated was prepared dessert, but no labeled identifying the food item or date prepared.Plastic storage containers of vegetables verbally identified by the RD as cut tomato and lettuce and mushrooms with no label identifying the food item and not dated.Plastic storage containers with protein items confirmed by RD as sausage, eggs, and another protein item, unable to be identified, all without a label identifying the food item and not dated.An expired plastic storage container of pineapple (labeled) with a use by date of 01/10/26.A facility policy titled, Food Safety with a revised date of 05/01/25 stated, Procedure: .The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by Date' is noted on the label or product when applicable.On 01/12/26 at 09:44 AM, observed a box of buns, bag of ice, and box of ice cream stored on the ground during the inspection of the freezer.A facility policy titled, Food Safety with a revised date of 05/01/25 stated, Cold Food Storage.Food in walk-in cooler/freezer is stored six inches off the floor.On 01/12/26 at 09:52 AM, the January 2026 Low Temperature Dish Machine log was blank. DA2 stated that the chemical sanitization should have been done but the chlorine test strips were not available since late December 2025. The December 2025 Low Temperature Dish Machine log could not be found. On 01/12/26 at 01:37 PM, the RD was interviewed and stated that the chemical sanitization for the dishwasher was important to ensure dishware was clean and to prevent potential spread of contamination.A facility policy titled, Ware Washing - Dish Machine/Manual Process with a revised date of 04/30/2025, stated, Low Temp Dish Machine.2. The temperature and parts per million (PPM) of the sanitizer (50-100 ppm for chlorine) will be recorded on the Low Temperature Dish Machine Log a minimum of three times per day. On 01/12/26 at 09:58 AM, a review of the Refrigerator/Freezer temperature log for December 2025 noted blank entries for the AM column for December 1 -15, 24, and 25 and PM column for December 1-8, 14, 20, 21,27, 28. No entries were for found for the January 2026 log.A facility policy titled, Food Safety with a revised date of 05/01/25 stated, Cold Food Storage.3. Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log.On 01/12/26 at 10:03 AM, a walk-through the pantry with the RD found cans of fruit labeled, Mandarin Oranges with an expiration date of 08/12/25. Large, canned goods labeled beets, carrots, cheddar cheese sauce, tomato sauce, diced tomatoes, and green beans with no date of receipt indicated and no identified expiration dates on the labels. Two bags of muffin mix folded over at the top of the bags with no identified date that they were opened and was not stored in a sealed container. Five containers of beef base with expiration dates of 12/30/25 were found. Storage bins with handwritten labels pasted on the slide out drawers:One storage bin was labeled Sweet and Sour with an expiration date of 12/12/25. Inside of the bin were individual sweet and sour packets with an expiration date unable to be located on the packets.One storage bin was labeled BBQ (barbeque) sauce with an expiration date of 11/06/25. Inside of the bin were individual BBQ sauce packets with an expiration date unable to be located on the packets.One storage bin was labeled Tartar Sauce with an expiration date of 12/14/25. Inside the bin were individual tartar sauce packets with an expiration date unable to be located on the packets.One storage bin was labeled Ketchup with an expiration date of 12/20/25. Inside of the bin were individual ketchup packets with an expiration date unable to be located on the packets.One storage bin was labeled Sugar with an expiration date of 12/12/25. Inside of the bin contained individual salt packets instead of sugar packets.A facility policy titled, Food Safety with a revised date of 05/01/25 stated, Procedure.2. Pre-packaged food.is labeled with the name of the contents.'Use by Date' is noted on the label or product when applicable.Dry Storage.2. Opened packages of food are resealed tightly to prevent contamination and 'use by date' will be used when applicable.Canned products are used within one year from delivery date.

Based on review of facility assessment and staff interview, the facility did not update the assessment annually, as required. As a result of this deficiency, the facility could not evaluate its resident population and identify resources needed to provide the necessary care and services.Findings include:During review of the facility assessment template on 01/14/26 at 02:10 PM, it showed the most recent review date of the following sections: Infection Prevention and Control 02/19/24, COVID-19 Resource Manual 02/19/24, Health Information Management 02/19/24, QAPI Manual 02/19/24, Wound Care Manual 02/19/24, Pharmacy Manual 05/23/23, Pharmacy Infusion Manual 05/23/23.During staff interview on 01/15/26 at 08:36 AM, Administrator said the facility assessment was recently discussed in their QAPI meetings and the six sections Infection Prevention and Control, COVID-19 Resource Manual, Health Information Management, QAPI Manual. as previously listed, were reviewed on 03/17/25. Administrator did acknowledge that the facility assessment was not completely updated annually as required.

Based on observations and interviews, the facility failed to maintain infection control practices to help prevent the transmission of communicable diseases/infections for two of four residents sampled for transmission-based precautions. As a result of this deficient practice, residents are at an increased risk of communicable diseases/infections. Findings include: 1) On 01/12/26 at 12:33 PM, Licensed Practical Nurse (LPN) 18 was observed walking out Resident (R) 20's room, designated for transmission-based precautions (TBP), specifically Aerosol Precautions, wearing full personal protective equipment (PPE) (gloves, gown, N-95 respirator and goggles). LPN18 doffed all her PPE she was wearing into the trash receptacle which was located outside of the room. On 01/12/26 at 12:46 PM, interviewed LPN18 who stated that the best practice was to take off gloves and gown inside of the resident's room, but the trash bin could not fit in the room. On 01/14/26 at 02:30 PM, Interviewed the Infection Preventionist (IP) in her office who stated that Aerosol precautions is synonymous with Airborne Precautions. She also stated for this precaution, proper removal of PPE would have been for removal of gloves and gown by the staff member inside of the resident's room and the trash receptable used to discard PPE should have been kept in the room. 2) On 01/13/26 at 08:15 AM, observed the Aerosol Precautions sign located on the outside of R20's room was removed and R20's room door was open. Registered Nurse (RN) 13 stated that R20 was now off TBP. On 01/14/26 at 08:30 AM, observed R20's room door closed and a TBP sign, specifically Droplet Precautions, was posted outside of the room. On 01/14/26 at 01:04 PM, IP was interviewed. IP stated that R20 developed symptoms of sore throat and cough on 01/11/26 and was placed on Aerosol precautions. The IP then stated that R20 was tested for Covid-19 and flu and results were negative. R20 was then retested on Day 3 for Covid-19, which was a standard procedure, and the result was negative. The IP then voiced that R20 still displayed respiratory symptoms and should have been placed on Droplet precautions but confirmed that R20 was mistakenly taken off TBP the morning of 01/13/26 and was not placed on Droplet precautions until the afternoon of that day. The IP confirmed that there was a risk of transmission of infection to other residents and staff from the time R20 was taken off TBP in the morning of 01/13/26 until it was resumed that afternoon. A facility policy titled, Chapter 4: Standard Precautions, Transmission based Precautions with a revised date of 09/18/2025, stated, Categories of Transmission-based Precautions.3. Droplet Precautions: a. The use of droplet precautions applies when respiratory droplets contain pathogens which may be spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. 3) On 01/12/2026 at approximately 12:15 PM, observed RN98 in Resident (R) 56's room with a nasal swab in one of her gloved hands wearing a mask. R56 was lying in bed with Certified Nurse Aide (CNA) 77 seated at the resident's bedside, waiting to assist R56 with lunch. CNA77 was not wearing a mask or any PPE. At 12:55 PM, inquired with RN98 about the nasal swab she was seen with in R56's room. RN98 reported the resident was not feeling good and she was swabbing for COVID-19 and rapid flu testing. On 01/15/2026 at 09:37 AM, during an interview the Director of Nursing (DON) was informed of the observation of RN98 after performing a nasal swab with a mask and gloves, but no gown. DON confirmed she was made aware of this incident by RN98, and RN98 should have been wearing a gown while obtaining the nasal swab. Also, the DON confirmed CNA77 should have been wearing at least a mask while assisting the resident with lunch to prevent the potential transmission of COVID-19 and/or the flu.

Based on interviews and record review, the facility failed to ensure the resident's right to formulate an Advance Health Care Directive (AHCD) for one (Resident (R) 6) of three residents sampled for AHCD. Findings include: On 01/13/26 at 9:58 AM, reviewed R6's Electronic Health Record (EHR). R6 was admitted to the facility on [DATE]. The EHR contained a Physician's Order for Life Sustaining Treatment (POLST) and a financial durable Power of Attorney (completed on 10/21/25). The EHR did not contain documentation of AHCD. Reviewed progress notes which did not contain documentation regarding the formulation or declination of formulating an AHCD. On 01/14/26 at 9:18 AM, reviewed documents provided by the Executive Director (ED) related to AHCD. Documentation provided was the financial durable Power of Attorney. Which does not authorize the agent to make health care decisions, only financial decisions. On 01/14/26 at 10:51 AM, conducted a concurrent interview and review of R6's EHR with Social Service (SS) staff. SS confirmed there was no documentation of the facility offering the resident assistance to formulate an AHCD.

Based on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident (R) 6) of five residents selected for medication regime review. Findings include: On 01/14/26 at 10:29 AM, conducted a review of R6's Electronic Health Record (EHR). Review of R6's physician orders documented an order for Trulicity Subcutaneous Solution, Inject 1.5 mg subcutaneously one time a day every Monday for obesity. Review of the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25, Section N. Medications, N0350. was marked 1. Indicating the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. On 01/14/26 at 12:04 PM, conducted a concurrent interview and record review of R6's EHR with MDS Coordinator (MDS) 1. MDS1 reviewed the Physician's Orders and quarterly MDS with an ARD of 11/21/25 and reported that Trulicity was a type of insulin. After discussion of the medication, MDS1 confirmed that Trulicity was not a form of injectable insulin and the MDS was erroneously coded R6 as having received an insulin injection.

Based on observations, record review and staff interview, the facility did not develop a comprehensive care plan for one (Resident (R) 57) of 15 residents reviewed. As a result of this deficiency, there was increased risk for complications related to R57's Peripherally Inserted Central Catheter (PICC) and colostomy.Findings include:During observation on 01/12/26 @ 11:00 AM, R57 was noted to have a PICC line in right arm, and colostomy to the abdomen. Review of the Electronic Health Record (EHR) showed that R57 was re-admitted to the facility on [DATE] with diagnoses including pressure ulcer of sacral region, malnutrition, osteomyelitis, resistance to multiple antimycobacterial drugs, high blood pressure, morbid obesity. Review of the comprehensive care plan did not have any focus, goal or interventions for R57's PICC line and/or colostomy. The care plan showed that it was last reviewed on 12/18/25. On 01/14/26 at 11:00 AM, the Director of Nursing (DON) was interviewed and acknowledged that R57's care plan did not have anything for the PICC line and/or colostomy.

Based on interview and record review the facility failed to perform annual performance reviews with their Certified Nurse Aides (CNAs) in identifying any weaknesses they may have and address them with in-service education. This deficient practice puts all the residents in the facility at risk for not receiving quality care from CNAs who have had their weaknesses identified and education provided that enhances the resident's life. Findings Include: On 09/25/24 at 11:04 AM an interview was conducted with the Director of Nursing (DON) and Administrator. Inquired if DON does annual performance reviews with CNAs and she stated, they are currently sitting on my desk. Inquired again, yes or no, if this was done and DON stated no. Requested from the Administrator a list of facility CNA names, date last performance review was done and next performance review is due. On 09/27/2024 at 01:39 PM an email was sent by the Administrator who provided a copy of the facility CNA names, date last performance review was done and when the next performance review is due. Review of the information provided revealed the following: Facility has 24 CNAs. 8 of the 24 CNAs are new hires and their annual performance review is due in 2025. 13 of the 24 CNAs are outdated with their annual performance review from the last time they had an annual performance review done, most as far back as 05/21. 16 of the 24 CNAs are outdated with their next review which was due either 05/24 or 06/24.

Based on observation, record review and interview, the facility failed to monitor the temperature for the refrigerator and freezer to ensure the foods are stored in accordance with professional standards. The facility also failed monitor the disinfectant level for the dishwasher to ensure the dishes used to serve food were appropriately sanitized. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses. Findings include: On 09/22/24 at 10:01 AM, initial brief tour of the kitchen was conducted. Observed a document in a clear plastic sleeve on the wall between the walk-in refrigerator and freezer titled Refrigerator/Freezer Temperature Log. Month and year section of the log was blank but when asked [NAME] (C)6 if the log was for the current month, she said, Yes, it's for September. When asked how often they document the temperatures, C6 said, Twice a day. Observed missing entries for the morning checks on the following dates: 09/19/24, 09/20/24, and 09/21/24. Missing entries were also noted for the afternoon checks on the following dates: 09/11/24, 09/12/24, 09/18/24, and 09/19/24. Asked C6 what the importance is for checking the temperature, C6 said, To make sure the temperature is okay. On 09/22/24 at 10:13 AM, observed Dietary Aide (DA)7 loading the dishwasher. Observed a paper log a on the wall titled Low Temperature Dish Machine Log. Asked DA7 how often are they supposed to check and log the temperature and disinfectant level for the dishwasher. DA7 said three times a day when they use the machine. Asked DA7 if the dishwasher was used on the dates with missing entries on the log. DA7 said they use the dishwasher three times a day and the staff forgot to complete the log on those days. The log had missing entries for the following dates: 09/01/24, 09/02/24, 09/08/24, 09/09/24,.09/10/24, 09/15/24,.09/16/24, 09/17/24, 09/18/24, 09/19/24, 09/20/24 and 09/21/24. On 09/25/24 at 08:49 AM, an interview was conducted with the Nutrition Coordinator (NC) in the kitchen. NC confirmed that the staff are supposed to complete the refrigerator and freezer log twice a day, and the dishwasher log three times a day to ensure the temperatures and disinfectant levels are in range. Review of the facility policy titled Food Safety stated, . Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer . any problems will be reported immediately . Review of the facility policy titled Sanitation and Maintenance stated, . The temperature and parts per million (PPM) of the sanitizer (50-100 ppm for chlorine) will be recorded on the Low Temperature Dish Machine Log a minimum of three times per day.

Based on observations and interviews, the facility failed to ensure residents dignity for four residents (Resident (R)14, R156, R35, and R5) sampled. Residents were observed and/or reported having to wait 25 minutes or more for staff to address the resident's call lights and/or provide care as needed by the resident. As a result of this deficient practice, resident is at risk for more than minimal harm. Findings include: 1) On 09/22/24 at 10:58 AM, observed R14's call light on as this surveyor walked onto the unit. R14's room is the first resident room on the left after entering through the unit doors. No staff were visible in the hallway or at the nurse's station. At 11:15 AM, R14's call light was still on, and no staff were observed on the unit. This surveyor walked down the hallway and observed Licensed Practical Nurse (LPN)13 assisting another resident in the room. Then another staff entered the unit (through the unit doors), look up at R14's activated call light, then proceeded to go into the break room without checking in on R14. At 11:17 AM, LPN13 walked past R14's room, call light still activated, did not check on the resident or acknowledge the resident when walking past R14's room. At 11:19 AM, Certified Nurse Aide (CNA)6 entered the unit, walked past R14's room, did not look into the resident's room, and walked right past the door without acknowledging R14 or checking in to see if the resident was safe. At 11:21 AM, LPN13 entered R14's room and addressed R14. In a later interview with LPN13, it was confirmed there is not enough staff to provide care and/or address resident's call lights when staff are on their lunch break, especially on the weekends. Review of R14's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/24, Section C- Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 11, indicating R14 has moderate cognitive impairment. Section GG, Functional Abilities and Goals, documented R14 is dependent (helper does all of the effort) on staff for toileting hygiene, sitting to lying (ability to move from sitting on side of the bed to lying flat on the bed, and lying to sitting. R14 requires substantial/maximal assistance (helper does more than half of the effort) personal hygiene, rolling left and right, and upper and lower body dressing. 2) On 09/22/24 at 11:43 AM, conducted an interview with R156 in the resident's room. R156 was admitted to the facility on [DATE] for short-term rehabilitation and physical therapy after knee surgery. R156 was alert and oriented to person, place, time, and situation during the interview. R156 reported waiting 45 minutes to an hour for staff to answer the resident's call light. She stated that no one came in to check on what she needed and reported longer wait times on the weekend, especially on the evening and night shifts. R156 stated that she can tell when she must go to the toilet and requires staff's assistance to get to the bathroom but cannot hold herself for 45 minutes and ended up urinating in the bed. R156 said that she felt humiliated having to use the bathroom in her bed and she can't always get the help she needs when she needs it so she asked them for a bedpan so she wouldn't have to urinated on herself or in a diaper. R156 expressed worry that because there is not enough staff to help her up when she needs to go to the bathroom and less opportunities to get out of bed for short distances, it will lengthen her rehabilitation time. 3) On 09/23/24 at 09:35 AM, this surveyor was seated at the end of the hall, near R35's room and observed the resident's call light was activated as evidenced by the activated light about the room door. At 09:40 AM, observed Non-Certified Nurse Aide (NCNA)7 in another room changing the linen. From 09:35 AM to 10:01 AM, 13 staff, which included the Director of Nursing (DON) and the Administrator, passed by the resident's room with the activated call light and did not acknowledge R35 or check to ensure the resident was safe. At 10:01 AM, NCNA addressed R35's call light. During an interview with R35 on 09/23/24 at 10:36 AM, the resident confirmed he often waits 25 minutes or more for staff to answer his call light. R35 reported feeling frustrated because he can see staff walking past his room and hear him calling out, but staff keep walking by. R35 stated that on some occasions, he has had to wait for over an hour for staff to answer my call light, it makes me feel less than and like I don't matter. Review of R35's most recent quarterly MDS with an ARD of 09/19/24, Section C- Cognitive Patterns, BIMS score was 13, indicating the resident is cognition is intact. Section GG, Functional Abilities and Goals, documented R35 is dependent (helper does all the effort) on staff for toileting hygiene, shower/bath, transferring to any surface, and lower body dressing. R35 requires substantial/maximal assistance (helper does more than half of the effort) for personal hygiene, rolling left and right, and upper body dressing, 4) Review of R5's most recent quarterly MDS with an ARD of 07/18/24, Section C- Cognitive Patterns, BIMS score was 15, indicating the resident's cognition is intact. Section GG, Functional Abilities and Goals, documented. R5 requires substantial/maximal assistance (helper does more than half of the effort) for toilet transfer and transitioning from sitting to standing. During an interview with R5 on 09/22/24 at 11:58 AM, R5 reported that she often must wait a long time for staff to answer her call light and if staff are busy, staff do not communicate with the resident to let her know they are busy and will be right with her or check to make sure she was safe. R5 stated, My call light could be on, and staff will walk right past my room, I can see them walking past the door and they don't even check to see that I'm safe. I could've fallen and been hurt, and staff wouldn't know. R5 reported on the weekends and nights it is not uncommon to have to wait 30 minutes or more for staff to answer your call light or address you. R5 informed this surveyor that she is aware the facility is short on the weekends, but staff should at minimum check to see the resident is okay and what they need, instead of having the resident wait with no idea if staff are aware that her call light is on and provide a timeframe for when the staff will be able to help the resident.

Based on interviews and record review, the facility failed to ensure the resident's right to be free from abuse for two (Residents (R)8 and R5) sampled. R8 informed two different staff that R23 had run over her feet twice with his wheelchair, then cursed at R8 when she responded verbally to R23. On 07/16/24, an incident occurred where R5 informed staff that the Alleged Perpetrator (AP) caused her pain by handling the resident's gait belt roughly when transferring the resident to the toilet, AP yelled in R5's ear causing the resident numbness in her ear canal, and AP told R5 that the resident is fussy and that's why no one (staff) wants to work with her in response to the resident informing the staff of her preferences for transferring on and off the toilet. R5 reported because of R5 not doing what the staff wanted, AP deliberately called the resident fussy and told her no one wanted to help the resident, who is dependent on staff to transfer on and off the toilet. As a result of this deficient practice, residents are at risk for the potential of more than minimal harm. Findings include: Willful, as defined at 483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Guidance for 483.12(a)(1) documents, All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population. A facility cannot disown the acts of staff, since the facility relies on them to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment .It is also not acceptable for an employee to claim his/her action was reflexive or a knee jerk reaction and was not intended to cause harm. Retaliation by staff is abuse, regardless of whether harm was intended . Cross Reference to F609 Reporting of Alleged Violation 1) On 09/22/24 at 01:05 PM an interview was conducted with R8. Inquired if any resident had ever hurt or abused her and R8 stated a resident comes over here sometimes and has run over my feet twice and he called me an F'n bitch. Inquired if she had reported this to any staff at the facility and she stated she reported it to two staff, the Activities Director and the Social Worker. Inquired when this occurred and R8 was unsure of the date. Inquired if the resident still lives in the facility and R8 was not sure. On 09/22/24 Record Review (RR) of R8's Electronic Health Record (EHR) revealed she is a [AGE] year-old admitted to the facility on [DATE] with a diagnosis that include, but are not limited to, acute respiratory failure with hypercapnia (higher than normal levels of carbon dioxide in the blood), Type 2 diabetes mellitus, chronic pain syndrome, muscle weakness and difficulty in walking, not elsewhere classified. R8's Minimum Data Set (MDS) completed on 08/27/24 identified her as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 identifying her as cognitively intact. On 09/24/24 at 08:45 AM requested facility investigation for reported resident to resident abuse (R23 towards R8) from Administrator. Administrator stated there was no investigation for this incident because it had been reported by staff as an accident. On 09/25/24 at 11:15 AM interview was conducted with the Administrator who stated yesterday (09/24/24) she reported the incident to the State Agency Office of Health Care Assurance (OHCA). Administrator stated she interviewed R8 and called the police to ask them to come and take resident's statement. Administrator stated she was not previously aware of the allegation(s) of abuse that occurred from R23 to R8, she had not been informed this incident was abuse, she was told it was an accident. On 09/25/24 at 09:53 AM interviewed Human Resource Director (HRD). Inquired of HRD when staff do abuse training and she stated upon hire and annually. Requested a copy of all staff's current abuse training dates. She stated she would provide the dates of staff's abuse training. On 09/27/24 at 01:39 PM Administrator provided a copy of staff's dates for abuse training by email. On 09/27/24 review of facility staff abuse-training data revealed a total of 76 staff listed, 25 staff were not current with this training making this 33% of staff outdated with their abuse training. Review of facility policy found the following Protection of Residents: Reducing the Threat of Abuse & Neglect . Position Statement & Guidelines . Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. Policy . This facility has procedures in place to provide protection for the health, welfare, and rights of each resident residing in the facility. These procedures include, but are not limited to, the following seven components: 1. Screening 2. Training 3. Prevention 4. Identification 5, Investigation 6. Protection 7. Reporting and Response . Reporting and Response . 2. All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. 3. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g. bruising and skin tears) will be immediately reported to the administrator and/or director of nursing. 10. The administrator, director of nursing, or designated representative will complete an investigation of the incident including a written summary of the findings no later than five (5) working days after the reported occurrence. 42160 2) Cross Reference to F609 Reporting of Alleged Violation and F610- Investigate / Prevent / Correct Alleged Violation Review of R5's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/24 and most recent quarterly MDS with an ARD of 07/18/24 documented, Section C. Cognitive Patterns, scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition is intact. Section GG. Functional Abilities and Goals. GG.0170 Mobility, documented R5 requires substantial/maximal assistance- Helper does more than half the effort for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), Chair/bed-to-chair transfer (ability to transfer to and from a bed to a chair/wheelchair), toilet transfer (the ability to get on and off a toilet or commode), and Tub/shower transfer (the ability to get in and out of a tub/shower. Review of a Facility Reported Incident (FRI) #11120 (initial report date 08/06/24; completed report date 08/09/24), dated 08/06/24, for an allegation of staff to resident abuse which occurred on 07/16/24 at 02:00 PM. The report documented on 08/06/24, R5 reported to the Director of Nursing and the Executive Director that she felt as though she had been abused by AP. An abuse investigation was initiated, and AP has been suspended pending investigation. The completed report (08/09/24) documented, R5 reports that she felt as though the CNA(AP) abused her on 08/09/24 although the incident happened on 07/16/24. The facility documented that it wasn't until the 08/06/24 incident that they became aware of how R5 felt about the incident on 07/16/24. The report documented on 07/16/24, AP was assisting R5 to the bathroom and there was a discrepancy between how AP was completing the transfer and the resident's preference of only locking one side of the wheelchair to transfer in a manner which the resident felt comfortable and safe. As a result of the disagreement on mode of transferring the resident, AP claimed R5 was yelling at her, and AP made a comment about R5 being fussy and this is why staff do not want to work with her. R5 felt as if AP was shaking the resident while assisting her with maneuvering in the pivot disc which caused her pain. After the encounter R5 then asked to see the manager and AP assisted R5 to Registered Nurse (RN)32. RN32 reported the incident to the DON and the DON reviewed customer service with AP and reported she was better. The next few days R5 continued to improve and seemed to be back to her normal self. Social Service Director (SSD)1 spoke to R5 on 07/18/24, no concerns were brought to her attention. On 08/06/24, R5 overheard staff saying AP said R5 refused lunch, when in fact R5 had not refused lunch and was waiting for it to be delivered. R5 became upset about the situation and while the nurse attempted to deescalate the situation, R5 reported that she was upset because the incident that happened on 07/16/24, she then added in the pieces about being yelled at and shaken around making her feel abused. The nurse notified the DON, an abuse investigation was promptly started, AP was suspended pending investigation, police, and Adult Protective Service (APS) was notified. The facility continued the investigation by conducting interviews with the resident and staff. no concerns were related to AP, additional education was completed with AP regarding communication and care are without concerns. Informed AP she would not be assigned to R5 in the foreseeable future. On 09/22/24 at 12:08 PM, conducted an interview with R5 in the resident's room. The interview with R5 and the facility's completed report were different. R5 stated on 07/16/24 she was abused physically and verbally when AP assisted the resident to the toilet. R5 stated she had not been feeling good (in good health) that day and took a nap. At approximately, 02:00-02:30 PM, AP entered the room and assisted the resident to the bathroom to use the toilet. R5 stated that upon entering the room, AP appeared to be upset about something and was grumbling about something under her breath which R5 could not understand and was mumbling prior to helping R5 to the bathroom. During the transfer, R5 requested for AP to lock only one wheel of the wheelchair instead of two due to the set-up of the bathroom and the way the wheelchair needs to move in relation to the pivot disc. R5 reasoned that with both wheels locked it is a difficult position for R5 and she does not feel safe before she sat into the wheelchair. AP informed the resident that she had to lock both wheelchair wheels and R5 insisted on her preference to only lock one wheel. R5 reported AP became frustrated over R5's insistence of locking one wheel only and AP began to get louder out of frustration, to the point AP began to yell in R5's ear. R5 explained when AP picked her up using the gait belt, AP was rougher than normal and shaking the pivot disc bars in a manner which caused R5 to experience pain in her back. R5 reported she had not been handled in this manner by AP or other staff before when using the pivot disc and did not feel safe with AP. R5 recalled that AP is normally louder than other staff, but it wasn't that she was speaking loudly or AP's positioning to the resident, it was more than that, she was yelling in her ear, and she asked AP to stop yelling in her ear. AP then told R5,You know that meeting was all about you. You're so fussy, that's why no one wants to work with you. R5 recalled that all she wanted to do was to get safely into her wheelchair to get away from AP. R5 reported that as soon as she got into her wheelchair, she began wheeling herself out of the room and AP followed behind the resident, waving her hands in the air, mockingly yelling in the hallway, Yeah here she comes, coming to complaint about me, I didn't do anything. R5 reported the incident to Registered Nurse (RN)32 and RN32 took the time and care to calm R5 down. R5 reported AP was yelling in her ear as she wheeled herself out of the room. I was just telling AP of my preferences, what works for me, and how other staff transfer me. I felt like she was abusing me with her words, yelling into my ear, and her attitude towards me, and then shaking me with the gait belt which caused me pain. R5 stated that when she reported this incident on 07/16/24 to the nurse, the Director of Nursing (DON) or the Administrator did not come to talk to me to get my side of what happened or to see how I was feeling after the incident. It's like they did not believe me. R5 said that she told SSD1 about the incident and SSD1's response to her was that there were no marks or bruises to support the resident's claim that she was abused. Inquired if the DON or Administrator spoke with her (R5) after the incident on 07/16/24. R5 confirmed the DON did not speak to her to see what happened, she only spoke to AP. R5 stated she repeatedly inquired with the DON about the education and/or training AP received because of the 07/16/24 incident. R5 stated the DON informed her that AP received training but refused to provide the resident with the materials used in the training. R5 reported she felt unsupported, and the DON and Administrator did not believe or was interested her version of events on 07/16/24 and that the DON had already made up her mind that AP did not abuse her. R5 stated when AP told her Nobody wants to work with her it really affected her mood, R5 expressed she started to feel depressed and sad. R5 said, I depend on staff to go to the toilet, for my food, and care and to hear staff say that to you makes you feel less than and when the DON had already made up her mind and couldn't be bothered, how do I trust the DON to have my best interest in mind. I have nowhere else to go, this is my home, and it doesn't feel good to be treated this way and not liked by staff. During this interview, R5 was visibly affected by the 07/16/24 incident. R5's voice was shaky, cried, appeared to be in low spirit, and took breaks to compose herself. R5 stated, I know that I am particular about somethings, but those things don't change, and they are not unreasonable, for example, I only like to drink filter water, because of the quality of the unfiltered water, I don't feel like that is a new or unreasonable request. On 09/25/24 at 08:22 AM, conducted an interview with the DON and Administrator in the conference room regarding the incident on 07/16/204 with AP and R5. DON stated she was notified of the incident on 07/16/24 by RN32. DON confirmed she only spoke to AP about the incident and did not conduct an interview with R5 to get the resident's perspective. DON confirmed AP admitted that she told R5 that she was fussy, and no one wanted to work with her. Asked the DON if AP's statement to R5 could be identified as potential verbal abuse due to AP making a non-professional statement that any reasonable person would be offended by, there was conflict within the situation between R5 and AP, and the resident was dependent on staff to maneuver onto the toilet. DON stated she did not see it as verbal abuse because the resident is known to be picky about what she likes and how she wants things done, for example, she only likes filtered water and R5 gets upset when she's given another type of water. DON was firm that AP making that statement was not verbal abuse by AP and it was a customer service matter. Referred to the report which documented it took a few days for R5 to return to her baseline behavior. Inquired about the type of education and training AP received because of this incident. DON stated AP received education and training. Requested for the DON to provide a copy of the material used to educate and train AP. DON then stated, there was no formal education or training, when the DON spoke to AP about the incident, AP was informed to stay away from the resident and that was not an appropriate way to speak to a resident. On 09/25/24 at 08:56 AM, conducted an interview with SSD1 regarding the incident. SSD1 confirmed she spoke to R5 a couple of days after the incident. SSD1 stated that when there is an investigation, it was her role to speak to the residents. SSD1 reported AP was educated on customer service because of the incident but did not know what the education was comprised of. SSD1 confirmed R5 told SSD1 that AP abused her and confirmed that she did not see any marks on the resident and discounted the resident's allegation of abuse because the DON was handling the incident as a customer service issue. SSD1 confirmed R5 was upset about what AP said to her. On 09/25/24 at 09:31 AM, conducted an interview with RN32. RN32 recalled the incident and stated she saw R5 wheeling down the hallway and AP was following behind R5, saying that R5 is going to complain about her now. RN32 stated R5 was visibly upset and told AP to give the resident some space. RN32 confirmed R5 reported AP was yelling in her ear so loud the resident stated her ear canals were numb, AP told the resident she's so fussy and that's why no one wants to work with her, and that when AP was maneuvering the resident on the pivot disc, she was doing it in a manner that hurt the resident. RN32 stated, R5 was so upset over the incident that it took RN32 approximately 35 minutes to deescalate R5 after the incident.

Based on interviews and record reviews the facility failed to report allegations of abuse of two residents (Residents (R)8 and R5) of 51 residents at the facility, to the facility administrator and/or state agency within two hours of being reported to staff by the resident. During the review of R8's allegation of abuse two facility staff were notified by R8, and the facility administrator was not notified abuse had occurred. Initial report of R8's allegation of abuse was submitted by the facility to the state agency on 09/24/24. The facility did not identify R5 allegations as having the potential for abuse and classified the incident as a customer service issue and did not report the incident within the two-hour timeframe. This deficient practice could affect all residents in the facility who have a reported or witnessed incident of abuse and the facility fails to notify the state agency within two hours. Findings include: 1) On 09/22/24 at 01:05 PM interviewed R8 and inquired if she has had any confrontations with other residents at the facility and she stated R23 comes over here sometimes and has run over my feet twice and called me an F'n bitch. Inquired what facility did about this and R8 stated they told me that they talked to him about it. Inquired who they were and R8 stated Social Worker and Activities Director. Inquired when this occurred and R8 was unable to recall the date this occurred and could not confirm if the resident still lived at the facility. On 09/22/24 Record Review (RR) of R8's Electronic Health Record (EHR) revealed she is a [AGE] year-old admitted to the facility on [DATE] with diagnoses that include, but are not limited to, acute respiratory failure with hypercapnia (higher than normal levels of carbon dioxide in the blood), type 2 diabetes mellitus, chronic pain syndrome, muscle weakness and difficulty in walking, not elsewhere classified. R8's Minimum Data Set (MDS) completed on 08/27/24 identified resident as having a Brief Interview for Mental Status (BIMS) of 15 identifying her as cognitively intact. On 09/24/24 at 11:15 AM requested from Administrator investigation that was conducted for R8's allegation of abuse from R23. Administrator stated she had not been told the incident was abuse, that it had been an accident. Surveyor explained R8 had reported R23 had run over her feet with his wheelchair two times and cursed at her when she said something to him. On 09/25/24 at 08:43 AM Administrator stated yesterday (09/24/24) she reported R8's allegation of abuse to State Agency Office of Health Care Assurance (OHCA). Administrator stated on 09/24/24 she interviewed R8 and called the police to take resident's statement. At this time inquired and Administrator confirmed she was not previously aware of the allegation of abuse from R23 to R8, she had not been informed this incident was abuse by staff and had been told it was an accident. 42160 Cross reference to F600, F610. On 09/22/24 at 12:08 PM, conducted an interview with R5 in the resident's room. R5 informed this surveyor that on 07/16/24, R5 reported an incident to Registered Nurse (RN) 32 which included allegations of staff causing her intentional physical pain while using the pivot disc to transfer to and from the toilet. R5 confirmed she does not usually experience pain when using the pivot disc and reported the Alleged Perpertrator(AP) was willfully handling the resident roughly. R5 also reported that AP, who is normally speaks in a loud volume, was yelling in the resident's ear in a manner which caused her ear to feel numb and requested several times with AP for the staff to stop yelling in her ear. In addition to being handled in a rough manner and yelling in the resident's ear, R5 reported AP was upset and grumbling under her breath prior to assisting the resident and became increasingly more irritated with the resident and told the resident, You are so fussy, that's why no one wants to work with you. and informed the resident that there was a staff meeting about her. R5 also stated that she informed the Social Service Director (SSD) 1 that she felt like she was being abused by AP, two days after the incident occurred. R5 reported, she felt like SSD1 did not believe her and asked the resident if she had any bruises or marks, R5 replied she did not have physical evidence, but at the time AP did hurt her physically, was emotionally hurt by what the staff said to her, and felt like staff did not believe the resident or asked the resident about her account of the incident. R5 confirmed that facility did not interview her about the 07/16/24 incident with AP, it was only after she complained about the staff again on 08/06/24. During an interview with RN32 on 09/25/24 at 10:42 AM, staff stated the first time she became aware of the situation was on 07/16/24, when R5 rolled herself out of her assigned room quickly with AP following behind the resident's wheelchair, waving her hands, and loudly saying, I didn't do anything to her, she's (R5) going to complaint about me. RN32 also confirmed AP did not wheel R5 out of her assigned room and the resident was telling the staff to get away from her. RN32 stated it took approximately 30 minutes or more to verbally deescalate R5 because the resident was extremely upset about the incident between R5 and AP. After conducting an interview with RN32, both R5 and RN32's account of the incident was aligned and similar. RN32 stated that her first action was to separate R5 and AP, so AP was reassigned to another section of residents. Then, RN32 called the Director of Nursing (DON) and informed her of the incident. Then RN32 attended to R5 and calmed the resident down. RN32 reported that R5 was extremely upset and affected by the incident with AP and required a lot of time and attention to calm down R5. Also, it took R5 a couple of days to get back to her normal self and R5 regularly ruminated on the incident. During an interview with the Administrator and DON on 09/25/24 at 08:22 AM. During the interview, the DON confirmed she did not identiy the incident with R5 and AP on 07/16/24 as a potential abuse but viewed the situation as a customer service issue. DON reported R5 did not have any identifiable marks and did not tell staff she was abused. Inquired if DON was aware that AP called R5 fussy and told resident that was why no one wanted to work with her. DON confirmed AP admitted to saying this to R5 on 07/16/24 when she interviewed AP over the phone. DON stated she informed AP that it was not okay to speak to the residents in this manner and still did not identify it as potential abuse. Inquired if DON was aware that RN32 spent more than 30 minutes directly after incident to calm and deescalate R5. DON confirmed she was aware the RN32 spent time calming the resident down, and confirmed she did not identify that R5 could have potentially experienced psychosocial harm and stuck to her decision to treat the incident on 07/16/24 as a customer service issue. DON confirmed the incident on 07/16/24 was not reported because it was not identified as having a potential for abuse. Review of the Facility Reported Incident (FRI) #11120 (initial report date 08/06/24; completed report date 08/06/24) included the incident from 07/16/24.

Based on interviews and record review, the facility failed to ensure all alleged violations are thoroughly investigated, in response to an allegation of abuse for one (Resident (R)5) sampled. On 07/16/24, R5 reported an incident that the Alleged Perpetrator (AP) was rough with the resident's gait belt when assisting the resident during a transfer, yelling in the resident's ear, and told the resident she was fussy and that's why no one wanted to work with her. RN23 reported spent approximately 30 minutes deescalating R5 after she reported the incident to the Director of Nursing (DON). The DON conducted an interview only with AP, did not interview the resident, did not conduct a thorough investigation, did not identify the incident as having a potential for abuse (physical, verbal, and psychosocial harm), and classified the incident as a customer service issue. Two days after the incident, R5 informed the Social Service Director (SSD)1 that she felt like AP abused her on 07/16/24 and the facility did not initiate an investigation. As a result of this deficient practice, residents are at risk for more than minimal harm related to the facility not identifying the potential for abuse and conducting an immediate thorough investigation. Findings include: Cross Reference to F600- Free from Abuse, Neglect, and Misappropriation and F609- Reporting of Alleged Violation On 09/22/24 at 12:08 PM, conducted an interview with R5 in the resident's room. R5 informed this surveyor that on 07/16/24, R5 reported an incident to Registered Nurse (RN)32 which included allegations of staff causing her intentional physical pain while using the pivot disc to transfer to and from the toilet. R5 confirmed she does not usually experience pain when using the pivot disc and reported the Alleged Perpetrator (AP) was willfully handling the resident roughly. R5 also reported that AP, who is normally speaks in a loud volume, was yelling in the resident's ear in a manner which caused her ear to feel numb and requested several times with AP for the staff to stop yelling in her ear. In addition to being handled in a rough manner and yelling in the resident's ear, R5 reported AP was upset and grumbling under her breath prior to assisting the resident and became increasingly more irritated with the resident and told the resident, You are so fussy, that's why no one wants to work with you. and informed the resident that there was a staff meeting about her. R5 also stated that she informed the Social Service Director (SSD)1 that she felt she had been abused by AP, two days after the incident occurred. R5 reported, she felt like SSD1 did not believe her and asked the resident if she had any bruises or marks, R5 replied she did not have physical evidence, but at the time AP did hurt her physically, was emotionally hurt by what the staff said to her, and felt like staff did not believe the resident or asked the resident about her account of the incident. R5 confirmed that facility did not interview her about the 07/16/24 incident with AP, it was only after she complained about the staff again on 08/06/24. During an interview with RN32 on 09/25/24 at 10:42 AM, staff stated the first time she became aware of the situation was on 07/16/24, when R5 rolled herself out of her assigned room quickly with AP following behind the resident's wheelchair, waving her hands, and loudly saying, I didn't do anything to her, she's (R5) going to complaint about me. RN32 also confirmed AP did not wheel R5 out of her assigned room and the resident was telling the staff to get away from her. RN32 stated it took approximately 30 minutes or more to verbally deescalate R5 because the resident was extremely upset about the incident between R5 and AP. After conducting an interview with RN32, both R5 and RN32's account of the incident was aligned and similar. RN32 stated that her first action was to separate R5 and AP, so AP was reassigned to another section of residents. Then, RN32 called the Director of Nursing (DON) and informed her of the incident. Then RN32 attended to R5 and calmed the resident down. RN32 reported that R5 was extremely upset and affected by the incident with AP and required a lot of time and attention to calm down R5. Also, it took R5 a couple of days to get back to her normal self and R5 regularly ruminated on the incident. During an interview with the Administrator and DON on 09/25/24 at 08:22 AM. During the interview, the DON confirmed she did not identify the incident with R5 and AP on 07/16/24 as a potential abuse but viewed the situation as a customer service issue. DON reported R5 did not have any identifiable marks and did not tell staff she was abused. Inquired if DON was aware that AP called R5 fussy and told the resident that was why no one wanted to work with her. DON confirmed AP admitted to saying this to R5 on 07/16/24 when she interviewed AP over the phone. DON stated she informed AP that it was not okay to speak to the residents in this manner and still did not identify it as potential abuse. Inquired if DON was aware that RN32 spent more than 30 minutes directly after the incident to calm and deescalate R5. DON confirmed she was aware that RN32 spent time calming the resident down, and confirmed she did not identify that R5 could have potentially experienced psychosocial harm and stuck to her decision to treat the incident on 07/16/24 as a customer service issue. DON confirmed the incident on 07/16/24 was not investigated thoroughly because it was not identified as having a potential for abuse. Review of the Facility Reported Incident (FRI) #11120 (initial report date 08/06/24; completed report date 08/06/24) included the incident from 07/16/24.

Based on interview and record review, the facility failed to provide proper notification of transfer/discharge for two of four residents sampled for hospitalization (Residents (R)1 and R8). Specifically, the facility failed to provide written notification of transfer/discharge to the residents or their representatives. This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: 1) R1 was admitted to the facility on [DATE]. On 07/16/24, R1 was transferred to an acute care hospital for gastrointestinal bleeding. Review of the Electronic Health Record (EHR) was conducted, and no documentation was found of the facility providing a written notification of transfer to R1 or his representative. Asked Administrator if a written notification was sent to R1's representative. Administrator said she will check the paper files. On 09/25/24 at 10:27 AM, Administrator was interviewed in the conference room. Administrator said she was not able to locate document to show written notification of R1's discharge was provided to R1's representative. 37954 2) On 09/22/24 at 01:27 PM interviewed R8. Inquired if resident had been hospitalized while she lived at the facility and she stated, a couple of times. Asked R8 why she went to the hospital, and she stated one time when she was found unresponsive and in the in ICU for a couple of days and can't remember why for the other time she went to the ER and was admitted to the hospital. On 09/22/24 record review of R8's EHR found she is a [AGE] year-old admitted to the facility on [DATE]. Review of R8's Minimum Data Set (MDS) revealed she was admitted on [DATE], discharged on [DATE] and returned to the facility on [DATE] and discharged on [DATE] and admitted back to the facility on [DATE]. Review of R8's progress notes revealed she was discharged from the facility on 08/09/24 and sent to the emergency room for SOB (shortness of breath) and further evaluation. R8 returned to the facility on [DATE] and had been hospitalized for COPD (Chronic obstructive pulmonary disease). R8 was discharged on [DATE] when she was found unresponsive but breathing by facility staff. R8 was transferred to the emergency room and admitted to the hospital ICU (intensive care unit). R8 returned to the facility on [DATE] and had been hospitalized for acute-on-chronic hypoxemic and hypercapnic respiratory failure (occurs when there is not enough oxygen and too much carbon dioxide in the body leading to breathing to stop). On 09/25/24 at 08:45 AM requested from the Administrator copies of R8's discharge/transfer notification that was provided to R8 or her representative for her discharges on 08/09/24 and 08/17/24. On 10/10/24 at 01:02 PM in an email reply by the Administrator she was able to provide a copy of the discharge/transfer notice that was given to R8's representative for the 08/17/24 transfer. Administrator, stated in her email response, that she was not able to find the transfer notification form for 08/09/24.

Based on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to three of four residents sampled for hospitalization (Residents (R)1, R30 and R8). This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital. Findings include: 1) R1 was admitted to the facility on [DATE]. On 07/16/24, R1 was transferred to an acute care hospital for gastrointestinal bleeding. A review of the Electronic Health Record (EHR) was conducted, and no documentation was found of the facility providing a written notification of the bed hold policy to R1 or his representative. 2) R30 was admitted to the facility on [DATE]. On 07/01/24, R30 was transferred to an acute care hospital for an abscess to his AV (arteriovenous) fistula (surgical connection made between an artery and a vein used to access the blood for dialysis). A review of the EHR was conducted and no documentation was found of the facility providing a written notification of the bed hold policy to R30 or his representative. On 09/24/24 at 10:03 AM, requested from Administrator a copy of written notifications given to both R1 and R30 regarding the facility's bed hold policy when they were transferred to an acute care hospital. Administrator said she will check the paper charts. On 09/25/24 at 10:27 AM, Administrator said she was not able to locate the written notifications of the bed hold policy give to R1 and R30 in the paper charts. Review of the facility policy titled Bed-Hold Policy stated, . The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital . to ensure that the residents are made aware of the facility' bed-hold and reserve bed payment policy before and upon transfer to the hospital . notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. 37954 3) On 09/22/24 record review of R8's EHR found she is a [AGE] year-old admitted to the facility on [DATE]. Review of R8's progress notes revealed she was transferred to an acute care hospital two times in August 2024, once on 08/09/24 for SOB (shortness of breath) and further evaluation and on 08/17/24 when R8 was found unresponsive but breathing by facility staff. During this record review no documentation was found of the facility providing written notification of the bed hold polity to R8 or her representative. On 09/25/24 at 08:45 AM requested from Administrator copies of R8's written notifications of the bed hold policy for the transfers/discharges that occurred on 08/09/24 and 08/17/24. On 09/27/24 at 01:39 PM Administrator sent an email to surveyor stating she was unable to locate the bed hold policy forms for R8's transfers/discharges that occurred on 08/09/24 and 08/17/24.

Based on observation, record review (RR), and interview the facility failed to develop and implement a comprehensive care plan for two residents (Resident (R)8 and R32) sampled. R8 has a physician's order for 2 (two) liters/(per) minute of continuous oxygen via nasal cannula and a care plan was not developed for this medical intervention. R32 has a physician's order for an opioid pain medication and R32's care plan did not include non-pharmacological pain-relieving interventions. The deficient practice could affect all residents at the facility if the facility fails to develop and implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical well-being. Findings include: 1) On 09/22/24 at 01:05 PM, observed and interviewed R8 in her room with O2 (oxygen) tubing connected to an O2 concentrator and oxygen administered via nasal cannula at 2L/minute. Resident did not appear to be in distress. Tubing was noted to be long enough to go into the bathroom with her. On 09/25/24 at 08:10 AM during RR of R8's Electronic Health Record (EHR) found resident was admitted to the facility on [DATE] with the diagnosis of acute respiratory failure with hypercapnia. R8's Brief Interview for Mental Status (BIMS) score is 15 which identifies her as being cognitively intact. During this RR found R8 does not have a CP for her continuous O2 use. Review of R8's physician's orders found she has the following order: Oxygen at 2 liters/minute continuously per nasal cannula. Document every shift for sleep apnea, obesity hypoventilation syndrome which was written on 09/23/24. On 09/25/24 at 09:03 AM, reviewed with Administrator who confirmed R8 does not have a CP in place for her O2 use. 42160 2) Review of R32's EHR documented, the resident has an order for, Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain, which is an opioid analgesic pain medication which acts on the central nervous system to relieve pain. Review of R32's care plan documented interventions did not include non-pharmacological interventions. On 08/25/24 at 08:22 AM, during an interview with the Administrator and the Director of Nursing, it was confirmed the CP did not include non-pharmacological interventions as an option for treatment of the resident's pain and it should have been included.

Based on observation and interview the facility failed to provide adequate supervision for one Resident (R)52 who was found outside of the facility sitting in her wheelchair, by herself, at a table with her back facing the facility door. The deficient practice puts residents at risk for accidents if they are not provided proper and adequate supervision. Findings Include: On 09/23/24 at 04:30 Surveyors were leaving the facility and noticed a female resident was sitting outside of the facility in her wheelchair with her back facing the facility door. R52 called out I need help! Can you help me? Surveyor inquired what she needed and R52 stated she wanted to go back inside. Surveyor buzzed the front door and asked for staff to come and assist R52 back into the building. Facility staff came out to help R52 back into the unit. On 09/24/24 record review of R52's Electronic Health Record (EHR) found she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, history of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke with weakness on the right side), difficulty in walking and legal blindness, as defined in USA. R52's Minimum Data Set (MDS) completed on 09/03/24 has her Brief Interview for Mental Status (BIMS) score at 13 out of 15 identifying her as Intact/borderline cognition. On 09/24/24 at 11:19 AM an interview was conducted with the Administrator. Inquired what had occurred with R52 the previous day (09/23/24) when she was left by herself outside the front of the facility. Administrator reported hospitality aide and the resident had an understanding when the resident was to return to the unit. Administrator reported the resident wanted to be in for dinner which is at about 5 PM. The resident meant go in at 4:00 PM for dinner. Inquired of Administrator how do residents notify staff inside if they need assistance when the resident is left outside the facility by themselves. Administrator confirmed the resident would not be able to notify staff because she is not able to move herself in her wheelchair and the facility does not have any signaling device outside the facility that communicates with staff inside the building. On 09/24/24 at 11:55 AM interviewed Hospitality Aide (HA). HA stated yesterday she took R52 outside after lunch to sit in front of the facility. Inquired what time this was and HS was not sure exactly when she took R52 outside and stated resident wanted to come back inside the facility at 4 PM. HA stated she finishes at 3 PM and she told the nurse before she left for the day. HA stated she checked on resident one last time at 2:57 PM and came back to the unit and told the nurse R52 wants to come in at 4 o'clock for dinner and HA said nurse stated ok staff would bring her in. On 09/24/24 at 12:27 PM, interviewed R52 who thanked surveyor for helping her. HA told them to bring me inside at 4 PM but they forgot. They always forget me. Inquired if this has happened before and R52 confirmed it has and stated When someone passes me outside, I ask them for help. It has happened before, but I cannot remember how many times. Inquired if she can notify staff that she wants to go inside if she is outside sitting at the table by herself and R52 stated I have no way of telling them. Only when someone passes by I ask them for help. R52 stated It is wonderful here but there are not enough people . to coordinate to bring me in on time. Sometimes we have three nurses and then none.

Based on interview and record review, the facility failed to ensure an account of all controlled drugs is maintained. Reconciliation of the controlled medication reconciliation sheet and the medication documented a discrepancy between the count of the medication and the number of actual pills. As a result of this deficient practice, there is the potential for more than minimal harm. Findings include: On 09/24/24 at 09:57 AM, conducted an inspection of a medication cart with Licensed Practical Nurse (LPN)13. Review of R41's-controlled medication reconciliation sheet for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) documented 38 tablets. Counted the actual pills stored in the locked compartment with LPN13 which documented only 37 pills. Reviewed R41's Medication Administration Record (MAR) with LPN13. R41's MAR did not contain documentation the medication was administered to the resident. LPN13 reported R41 was administered Oxycodone HCl 5 mg at 07:30 AM for the resident's complaint of a pain level, 5 out of 10. LPN13 confirmed she should have updated the Controlled Medication Reconciliation sheet when the medication was initially removed from the locked container and the administration should have been documented in the MAR but was not. Review of the facility's policy and procedure, Administration of Medications (Reviewed 09/16/2024) documented, .f. Right Documentation .Controlled substances should be signed out from the descending count sheet and documented on the MAR for each routine and PRN (as needed) dose of medication administered.

Based on record review and interview the facility failed to assure two residents reviewed, of the 18 sampled, had accurate information placed in their Electronic Health Record (EHR). Review of R20's Advanced Health Care Directive (AHCD) found it was signed by the agent the resident had selected to be his decision maker and not by the resident. R2's physician documented resident as [AGE] years old over a three-year span, identified the resident as full code when he is a Do Not Resuscitate (DNR) and documented resident did not have any allergies when he is allergic to Clindamycin. The deficient practice puts all residents at risk if the resident's AHCD is not filled out correctly prior to it being utilized by the facility and resident's health status is not accurately documented by the physician. Findings Include: 1) On 09/23/24 during record review of R20's EHR found there is a copy of his AHCD which shows his agent, the person named as the one making healthcare decisions for R20 signed the form where R20 should have signed. On 09/24/24 at 12:05 PM, interviewed Administrator. Shared R20's AHCD was not signed by him instead was signed by his agent. Administrator reviewed AHCD for 20 and confirmed he should have signed the AHCD and not his agent. 2) On 09/24/24 during record review of R2's Electronic Health Record (EHR) found Practitioner Notes written by R2's physician stating resident as a [AGE] year-old male for all the provider notes he completed from 03/12/21 - 09/11/24. Physician also has documented in Practitioner Notes R2's Allergy List: No known medication allergies. No known allergies. but EHR lists Clindamycin as an allergy. R2's EHR also shows he is a DNR (Do Not Resuscitate) with Comfort Measures with a Physician Orders for Life Substantiating Treatment (POLST) filled out and signed by his guardian and physician on 02/17/21. R2's physician's last Practitioner Note dated 09/13/2024 lists resident's Code Status: Full Code. On 09/26/24 at 03:35 PM an interview was conducted with R2's physician who confirmed he had not updated R2's age as he got older, physician confirmed the software used to write the Practitioner Notes does not interface with Point Click Care (PCC) and the updates are not done automatically such as a resident's age or changes that are made in PCC such as the resident's allergies and code status. Physician stated these were errors he made.

Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to Resident (R)1, who was on Enhanced Barrier Precautions (EBP), and performing hand hygiene between glove changes. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: On 09/22/24 at 10:43 AM, observed a sign by the entrance of R1's room that stated, Enhanced Barrier Precautions . Everyone Must: . Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing . Transferring . Wound Care: any skin opening requiring a dressing . On 09/23/24 at 11:00 AM, observed RN (registered nurse) Care Manger (CM) and Certified Nursing Assistant (CNA)23 change the dressing to R1's open wounds to his back and buttocks. CM and CNA23 entered R1's room without wearing a gown. CM placed the supplies on the bedside table, performed hand hygiene and donned a clean pair of gloves. CM then removed the old dressing, assess the wound, removed her gloves and donned new gloves without performing hand hygiene. CM then cleaned the wound, applied a cream, measured the wound and changed gloves again without performing hand hygiene. After applying a new dressing to the wound, CM changed gloves again without performing hand hygiene and helped CNA23 change R1's clothes and transfer him from the bed to his wheelchair using the mechanical lift. Both CM and CNA23 were not wearing a gown. On 09/24/24 at 02:41 PM, an interview was conducted with the Infection Preventionist (IP) in her office. IP confirmed that both the CM and CNA23 should have been wearing a gown while changing the dressing, changing R1's clothes and transferring him to his wheelchair. IP added that staff were trained to perform hand hygiene with either the alcohol-based hand rub or soap and water after removing their gloves. Review of facility policy titled, Enhanced Barrier Precautions stated, . indicated for residents with the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized . Review of facility policy titled hand Hygiene stated, . perform hand hygiene (even if gloves are used) in the following situations: . After removing personal protective equipment (e.g., gloves, gown, eye protection, face mask) .

Based on observations, record reviews and staff interviews, the facility failed to ensure adequate supervision and assistance to prevent accidents for two Residents (R)8 and R36 sampled. As a result of these deficient practices 1) R8 fell and sustained a hematoma to the right side of her forehead and swelling of the right side of her face and 2) R36 was placed at risk for falling when being transported in a wheelchair that had no footrests. Findings include: (Cross Reference to F656: Develop/Implement Comprehensive Care Plan) 1) On 09/17/23 at 11:17 AM, observed R8 in her room sitting up in her wheelchair. R8 had a dressing on the right side of her forehead. When asked what happened to her head, R8 said I fell in the bathroom. Review of electronic health record (EHR) for R8 conducted. Progress note dated 08/17/23, 08:51 AM revealed that R8 had an unwitnessed fall in the bathroom after the CNA left her alone to get the vital signs tower from the nurse's station. As a result of the fall, R8 sustained a hematoma to the right side of her forehead and was sent to a nearby acute facility emergency room for evaluation. The following were also documented in the EHR under Progress Notes: 08/18/23 at 08:39 PM, . Right eye swollen shut and hematoma on right side of forehead. 08/19/23 at 07:07 PM, . Raised area to right forehead has small multiple blisters now. R (right) eye lid still swelling and blue and purple in color now. 08/19/23 at 07:37 PM, . R (right) eye lid still swelling with bruising that starts at the top of her head and continues down the right side of her face and I noted there is blood pooling down in her neck. 08/20/23 at 04:58 PM, . Edema from fluid from trauma came down to [sic] cheek and chin area today. 08/23/23 at 01:36 PM, . resident noted to have knot on R (right) upper forehead with a laceration and bruising to site. 08/23/23 at 05:34 PM, . Large raised bump to right side of head with purple/black bruising down right side of face and neck. 08/29/23 at 09:55 AM, . resident continues with knot on R (right) upper forehead with a laceration and bruising to site. 09/01/23 at 10:02 AM, Large pocket of blood drained from residents [sic] head wound. New dressing applied to site. 09/03/23 at 06:58 PM, . Light red bleeding from R (right) forehead continues little by little. Raised area decreased and flat, and area discolored like large size scab. 09/05/23 at 04:27 PM, . Noted area has dry eschar with slightly milky appearance to the discharge. Wound bed is clean and beefy red, refer to WOT (wound observation tool) for measurements. Wound measurement was 4.5 X 4.5 centimeters (cm) and 0.8 cm deep on 09/05/23. On 09/20/23 at 10:23 AM, observed Unit Care Coordinator (UCC) change the dressing to wound, current measurements were 3.6 X 4.5 cm and 0.1 cm deep. Review of latest care plan dated 08/17/23 documented interventions for ADL (activities of daily living) self-care performance deficit included, TOILETING SCHEDULE: Request voiding with check and change as needed. DO NOT LEAVE ALONE IN BATHROOM. Initiation date for intervention was 03/08/22. 39754 2) During observation on 09/18/23 at 11:00AM, R36 was sitting in a wheelchair and Hospitality Aide (HA)1 was pushing the wheelchair forward through the hallway from the facility entrance to the Ka'u Nursing Unit. The wheelchair had no footrests, R36 had to lift both feet/legs off the ground, and there was an increased chance of R36 falling forward out of the wheelchair. Review of the EHR showed that R36 was admitted to the facility on [DATE] with a diagnosis including Alcohol Dependence, Difficulty Walking, Malnutrition, Asthma, Hypertension, History of Falling, Anxiety.

Based on interviews and record review, the facility failed ensure competent skills to assure resident safety and maintain the highest practicable well-being for two Residents (R)40 and R34 sampled. Nursing Staff (NS)99 delayed treatment by not immediately informing the physician after R40 fell from the bed sustaining redness and pain to touch (5/10) on the resident's left shoulder to ensure a physician evaluated the resident's overall condition(s), laboratory test, treatment of the resident was under the care of a physician. Approximately four to five hours after the fall, R40 had an acute mental status change and was transferred then discharged to an acute hospital for further treatment. Staff did not properly place R34's catheter bag while transferring the resident which resulted in bleeding from from the catheter insertion site down the length of the cateter tubing, pain, and dark red blood in the catheter collection bag indicating tissue trauma. As a result of these deficient practices R40 and 34 experienced harm. Findings include: 1) While conducting observations of residents on 09/18/23 at 08:38 AM, observed two Emergency Medical Service (EMS) staff enter the facility and go into R40's room. The resident on bed, on his back, with uncontrollable involuntary movements. The resident's movements were rapid and spastic which made it hard for the resident to safely remain on the bed. EMS staff and facility staff were talking to the resident, and although the resident made jokes, it was apparent the resident was not at baseline and appeared to have an altered mental status from this surveyor's previous interaction with the resident. Reviewed R40's diagnosis which included Diabetes Mellitus (DM2) with polyneuropathy, Major Depressive Disorder (MDD), adrenocortical insufficiency, acute embolism, and thrombosis of superficial veins of left upper extremity, and orthostatic hypotension. Review of the physician's orders documented R40 had orders for: - Accuchecks in the morning every Wednesday related to type 2 Diabetes Mellitus without complications, Notify MD (physician) if BS (blood sugar) is less than 60 or greater than 400; (09/06/23 BS=98 and 09/13/23 BS=90) - Implement a hyperglycemia/hypoglycemia protocol with parameters of greater than 400 and less than 60, respectively. - Blood glucose check every Wednesday - Aspirin EC tablet delayed release 81 milligrams (mg), give by mouth one time a day for deep vein thrombosis prophylaxis - Heparin sodium flush lock 100 Units (U) /(per) 5 milliliters (ml) Use 5 ml intravenously every day shift every 4 weeks on Friday, last given on 09/15/23 - Bupropion HCl ER (XL)tablet 24 hour extended release 300 mg, give by mouth 1 tablet 1 time a day, which was increased from l50 mg daily on 09/15/23 - Citalopram Hydrobromide tablet 40 mg, give 1 tablet by mouth one time a day for depression, which was increased form 20 mg on 09/03/23 - Glucagon (rDNA) Kit 1 mg, inject 1 mg intramuscularly every 15 minutes as needed for Blood sugar less than 60. - Encourage resident to drink house shake on meal tray. One house shake at breakfast, two house shakes at lunch with meals for weight gain. R40 did not have an order for insulin control (oral or subcutaneous). Review of R40's meal intake documented: 09/16/23 Breakfast: 0-25 percent (%) Lunch: Refused Dinner: 0-25% Shake: Breakfast- 100 % Lunch 0%, Dinner: 100% Breakfast:0-25% Lunch: 26-50% Dinner: 0-25% Shake: Breakfast- 0 % Lunch 100%, Dinner: 50% R40 did not have adequate nutritional intake. On 09/18/23 at 02:48 PM, conducted a concurrent review of R40's EHR and interview with Nursing Staff (NS)27 regarding the events which lead up to R40's transfer to an acute hospital that morning. NS27 stated she came on at 06:00 AM and the report from the off-going night nurse of R40's fall had not mentioned any complications because of the fall. The first documented neuro check was documented at 03:15 AM and review of neuro check assessment documented no abnormal results. Reviewed a progress note written on 09/18/23 at 04:12 AM, which documented, residents (R40) roommate called facility to alert Nurse that his roommate needed assistance. Upon entering room, this Nurse found Resident on ground to the right side of his bed. Resident was on his back. Resident stated he was trying to reach a book on his bedside table and fell off the bed. Resident stated he hit left shoulder on the ground. This Nurse immediately obtained vital signs (VS) and assessed for injuries. Red, painful to touch area noted to left shoulder. Resident c/o (complained of ) 5/10 pain to area. PRN (as needed) Tylenol given, and ice pack offered. Neuro checks initiated, and all WNL (within normal limits) of Resident. Intervention will be to make sure his bedside table is always within easy reach. Resident educated on using call light if he cannot reach items around his bed. Nurse manager notified. MD notified in communication binder. Will alert AM Nurse to notify Residents power of attorney (POA) during daytime hours. Call light within easy reach. Reviewed a progress note (written on 09/18/23 at 09:00 AM) documented EMT (emergency medical transport) reported BS (blood sugar) was 38 (dangerously low which can lead to a coma and even death). NS27 confirmed R40's blood sugar was not checked at the facility and the resident's intake has been low. Review of the physician orders documented the physician ordered lab test (CBC with diff, CMP, ammonia) on 0918/23 at 08:04 AM. Progress noted documenting updates of R40 in the acute hospital documented: 09/18/23 at 12:12 PM, R40 currently being treated with Dextrose, Rocephin for a urinary tract infection; 09/18/23 at 04:10 PM the acute hospital will be admitting R40 due to blood sugar under 100 with dextrose and lunch. Inquired if the physician is notified after a resident fall. NS27 stated, The doctor is called only as needed. Asked for situational examples of when nursing staff would call the physician. NS27 responded, the doctor would be called if the resident had an injury, if the neuro checks were abnormal, or if the resident had an observable change in condition. Summarized the progress note which R40's roommate had to alert facility staff of the fall, there is no way to verify for certain if the resident hit his head because the fall was unwitnessed, R40's left shoulder was red and reported pain 5/10, receives Aspirin 81 mg daily which increases the resident's potential for bleeding, R40's Bupropion dose was doubled on 09/15/23 and inquired if R40's event was an accident involving a resident which resulted in injury and had the potential for requiring a physician's intervention. NS27 confirmed a note left in the physician's binder was not sufficient, the physician was not immediately notified and should have been due to the circumstances of R40's fall. On 09/20/23 at 09:49 AM, conducted a concurrent review of R40's EHR and interview with the Director of Nursing (DON). After reviewing R40's chart, the DON confirmed the physician should have been immediately contacted. DON added the physician should be contacted after every fall regardless of the nurse's assessment and the physician has also informed the staff to call. 2) During an interview with R34 on 09/17/23 at 12:19 PM, the resident reported when staff was transferring him to the bed using the Hoyer lift, they forgot about the bag and when they moved me the catheter tubing was pulled, and I started bleeding all over the place. R34 reported being in a lot of pain and saw blood in the catheter collection bag after the incident. R34 stated that staff rush while providing care and don't pay attention. On 09/19/23 at 02:53 PM, conducted a review of R34's EHR. A progress note written on 09/16/23 at 02:53 PM documented, Patient (R34) was being transferred via standing Hoyer and while doing so foley catheter was pulled so hard that some bleeding to foley catheter was noted. Bleed bright red was scattered the length of catheter tubing. This RN (Nursing Staff (NS) 26) monitored throughout the rest of night shift; urine in collection bag with lightly tinged dark red bleed. No bright red bleed noted. Will inform DON and (physician) via unit binder .). Conducted a comprehensive interview and record review with the DON on 09/20/23 at 09:49 AM. DON confirmed staff did not provide competent care while transferring R34 with the Hoyer lift to ensure the resident's catheter tubing is not pulled to avoid harm to the resident.

Based on interviews and record review (RR), the facility failed to provide the needed care and services that were resident centered, in accordance with one resident's (R)1 preferences, goals for care and professional standards of practice. There was lack of documentation of R1's choices, preferences and goals to support not treating his critical medical condition related to his blood dyscrasias. Although this may not have been the sole contributing factor, R1 had four falls during [DATE] to [DATE] with progressive functional and cognitive decline that resulted in a transfer to the hospital where he was treated with blood [CONDITION(S)] and diagnosed with a subdural hemorrhage (bleeding in the brain) that required surgical intervention. R1 recovered from the surgery, but later expired as a result of complications during that hospital stay. Findings include: 1) R1 was a [AGE] year-old male with a past medical history significant of [CONDITION(S)] (AML-very rare type of blood cancer), pancytopenia (combination of low levels of all types of blood cells including red blood cells, white blood cells, and platelets), [CONDITION(S)] (blood disorder with abnormally low levels of platelets which help your blood clot properly), hypertension, diabetes mellitus type 2 and cognitive communication deficit. He was undergoing [CONDITION(S)] for AML and required special blood products that needed to be flown from Honolulu. R1 was admitted to the facility on [DATE] for care and rehabilitation therapy after his hospitalization ([DATE] to [DATE]). Severe pancytopenia can cause symptoms including but not limited to: shortness of breath, pale skin, fatigue, weakness, fever, dizziness, easy bruising, bleeding and fast heart rate. Serious symptoms include severe bleeding, severe shortness of breath, confusion and loss of consciousness. The main goal of treatment is to prevent death and disability caused by bleeding. Dangerous internal bleeding can occur when your platelet count falls below 10,000 platelets per microliter. 2) RR of R1's hospital discharge summary by the Hospitalist (MD)1 dated [DATE] revealed the following documentation: Patient is pancytopenic and now also neutropenic (abnormally low white cells which increase the risk of infection). Patient has antibodies necessitating specific blood products to be flown in from Honolulu and requires irradicated blood. Received 2 PRBC's (packed red blood cell [CONDITION(S)]), HG (hemoglobin/Hgb) 7.4 > 9.6 as well as platelets. -Transfuse PRN (as needed) based on labs. Should get biweekly labs. [CONDITION(S)]. Related to underlying AML. Received 2 PRBC's with irradicated PRBC, now stable [CONDITION(S)] .Patient with recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Was pancytopenic prior to induction of [CONDITION(S)] and has required transfusion of irradiated PRBCs, .-Transfuse as indicated (given platelets and PRBCs while hospitalized ) -will require labs twice a week. Hospital Course: .on [CONDITION(S)] with pancytopenia and RBC transfusion dependent who was admitted for PRBC infusion . He also received platelet transfusion with irradiated platelets for [CONDITION(S)] with platelets less than 10 (units 10(9)/L).He will require labs twice a week for close monitoring. The patient was transferred to SNF (skilled nursing facility) for continued assistance with rehabilitation and care. Discussion regarding hospice care was initiated after patient expressed frustration with need for transfusion. This can be further discussed on an outpatient basis as the patient would like time to think about it. Pertinent Recent labs in the hospital: [DATE] WBC (white blood cells) 1.43 Hemoglobin (Hgb) 7.4, Hematocrit (Hct) 22.6, PLT (platelet) 23(units 10(9)/L) [DATE] WBC 1.35, Hgb 7.9, Hct 23, PLT 9 (units 10(9)/L) [DATE] WBC 1.37, Hgb 9.6, Hct 27.8 PLT 8 (units 10(9)/L) Condition improved.Condition on Discharge: fair and terminal. 3) Clinical labs of Hawaii reference range of normal lab values WBC 3.8 -11.2 (units 10(9)/L) Hgb 13.,d+[DATE].2 (units g/dl) Hct 40.,d+[DATE].3 (units %) PLT: ,d+[DATE] (units 10(9)/L) 4) RR revealed the facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 5) Labs at the facility: [DATE] WBC 1.0, Hgb 8.4, Hct 24.2. PLT 15 (units 10(9)/L). Critical Value called to facility by the lab [DATE] WBC 0.8, Hgb 7.8 Hct 22.6, PLT 5 (units 10(9)/L). Critical Value called to facility by the lab [DATE] lab draw refused. 6) RR of the R1's Physician's (MD2) progress notes included the following: [DATE] History and Physical: .Following clinical and symptomatic stabilization, he (R1) was deemed appropriate for transition to SNF status and transferred .to undergo a course of rehabilitation therapy. The patient is feeling generally weak, but feels he is gaining strength. His appetite is improving . He is contemplative regarding the plan of care with regards to his AML given his poor tolerance for [CONDITION(S)]. [DATE] .Today, surveillance serologies collected on [DATE] are reviewed and discussed with the patient and nursing.complete blood count is exhibitive of chronic stable normocytic [CONDITION(S)] with Hemoglobin level of 8.4 [CONDITION(S)] (PLT) is noted with level of 15.Neutrogena/pancytopenia in the setting of malignancy and [CONDITION(S)], symptomatically stable, febrile, repleting potassium. The remainder of medical management remain unchanged. [DATE] .Generally speaking, he is feeling Okay, but has experienced periods of extreme anxiousness.A review of chart reveals that hemodynamics and heart rate are within normal limits.Leukopenia is present with WBC of 0.8 and .RBC's are depleted at 2.61. Hemoglobin and hematocrit are decreased to 7.8 and 22.6 respectively. [CONDITION(S)] is present with platelet count of 5.Deferring changes to medical management at this time. Continuing to monitor the patient closely in the setting of severe neutopenia. There was no additional documentation of any discussions with R1 or his representative regarding a decision to specifically not receive further lab work or blood [CONDITION(S)]. He continued to take his [CONDITION(S)] medication. 7) RR of R1's Minimum Data Set (MDS) assessment dated [DATE] included the following: Section C Cognitive: BIMS (brief interview for mental status) score of 11(moderate cognitive impairment). Section G Functional Status: set up assistance only for eating and one person physical assist for transfers, toilet use, and bed mobility. Section H Bladder and Bowel: Occasionally incontinent of urine, and always bowel continence. 8) Review of R1's Advanced Directive (AD) and POLST (Provider Orders for Life Sustaining Treatment - a portable medical order that records patients treatment wishes so that emergency personal know what treatments the patient wants in the event of a medical emergency) revealed the following: R1 prepared and signed an AD dated [DATE]. The directive Part 1 designated his two daughters agents (POA) to make healthcare decisions for him. B. Agents authority: My agent is authorized to make all healthcare decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration, and all other forms of healthcare to keep me alive.C. My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions unless I mark the following box (the box was marked and read): my agent's (POA) authority to make health-care decisions for me takes effect immediately. Part 2 Instructions for Health Care A1 was marked -I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainly, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the benefits. The POLST was completed over the telephone by R1's daughter on [DATE] with the Admissions Director (ADMD). The POLST included: Do not attempt resuscitation and in Part B, Medical interventions, it was marked Limited Additional Interventions includes care described above (comfort measures), use medical treatment, antibiotics and IV fluids as indicated. Do not intubate. May use less invasive airway support. Transfer to hospital if indicated. Includes intensive care. Part C indicated to provide long-term artificial nutrition by tube. 9) On [DATE] at 02:25 PM during an interview with the ADMD, she said her role included developing a POLST with the resident or family if they did not have one. She went on to say her practice was to go to the Residents room and see if they were able to complete the POLST. If she felt the Resident was not able to understand, she checked with the nurses to see if she should call the family to complete it. The ADMD said she couldn't recall specifics, but always does the same thing, and said I believe I did go into the room. She remembered a discussion with the daughter about medical interventions (artificial nutritional), but did not recall anything specific about blood [CONDITION(S)]. The ADMD said she does not discuss the AD and would not have asked about [CONDITION(S)] as she does not have a medical background. 10) Reviewed the facility policy titled Advance Directives and Advance Care Planning last revised [DATE]. The policy purpose read: The ability of a person to control decisions about medical care and daily routines has been identified as one of the key elements of quality care at the end of life. The process of advance care planning is ongoing and affords the resident, family, and others on the residents interdisciplinary health care team an opportunity to reassess the resident's goals and wishes as the resident's medical condition changes. Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation of the residents desires on a routine basis and when there is a significant change in the resident's condition. The process can help the resident and interdisciplinary team prepare for the time when a resident becomes unable to make decisions or is actively dying. The procedure included: 3. The Admissions Director or designee interviews the resident and/or family upon admission to determine the need and knowledge relative to advance directives and advanced care planning.The discussion should be to determine Goals of care related to advanced directives i. Prolonging Life-focusing on care most likely to help the person live longer ii. Maintaining Functioning- focusing on care most likely to help the person stay strong and do as much as possible independently iii. Comfort Care-focusing on care most likely to improve the person's comfort level and quality of life. 4. Other Treatment Restrictions -Indicates that the resident, legal guardian, health care proxy, or representative does not wish for the resident to receive certain medical treatments (e.g , but not limited to, blood [CONDITION(S)], tracheotomy, respiratory intubation). 8. Each time the resident is admitted to the facility .and when a change in condition noted the resident condition, the facility should review the advance directive and advance care planning information. a. This review should focus on if the existing advance directives .match the current goals of the resident. 11) RR of Care Management notes revealed the following: [DATE] at 10:45 AM: 48 hour meeting held with resident, daughter via phone and CM (Case Manager).Care Plan reviewed. Discharge plan is undetermined. Resident wants to go home with caregivers. Family wishes for resident to complete CA (cancer) treatments prior to discharge home. Code status reviewed.There was no documentation of discussion of any treatment restrictions ([CONDITION(S)]). [DATE] at 02:57 PM: Status meeting held with daughters via phone. OT (occupational therapy) and CM reviewed current functional status including decline x1 week both functionally and cognitively. Discussed continuing further CA treatment (Tx) and blood [CONDITION(S)] versus comfort measures. Family still hopeful that Tx will be effective. MD2 aware of decline and labs ordered. MD to f/u with family. Possible end of life visit scheduled with daughter ,d+[DATE]. 12) Review of Nursing progress notes revealed the following pertinent entries: [DATE] 10:05 PM: unwitnessed fall to find Res (R1) lying on floor, parallel to bed, with head facing foot of the bed. Res awake and alert when found. Reported trying to use the restroom. [DATE] 06:13 AM: unwitnessed fall to find Res sitting on the ground, leaning against the wall facing the bed and window. Res awake and alert when found. Reported to have ambulate to restroom, lost balance on the way back to bed, leaned against way [sic] for stability and lowered self to ground. [DATE] 10:45 AM: .1 person max assist with toileting and transfers, voids in urinal but is forgetful and tries to get to bathroom. [DATE] 03:35 PM: Severe confusion noted this shift [DATE] 05::59 PM: very weak; unsafe to stand and obtain weight [DATE] 11:02 PM: Res has moments of confusion during shift. Unable to fully make needs known. [DATE] 11:21 AM: .tolerating chemo moderately; very weak this shift with noted increased confusion. Severe bruising to abdomen noted. There were no other entries about the bruising or if it was reported to MD2. [DATE] 11:46 PM: A&O ,d+[DATE] at baseline. Increased confusion noted this shift. MD aware. Res (R1) had 1 episode of anxiety. Administered PRN [MEDICATION(S)] with some effect .episode of increased HR (heart rate) of 138. MD aware. 1 time dose of [MEDICATION(S)] 25 mg and NEW order for [MEDICATION(S)] BID (twice a day) with parameters. [DATE] 11:34 PM: Currently on [CONDITION(S)] with Ventoclazx TAB 100V MG daily. On neutropenic precautions .observed to have increased weakness at times [DATE] 03:05 PM: Unwitnessed fall at bedside. Reports since ,d+[DATE] saying resident is having increased confusion, possible new baseline reported ,d+[DATE] HR (heart rate/pulse) elevated ,d+[DATE]'s, no new orders. [DATE] 03:33 PM: at 14:15 alerted by CNA (certified nursing assistant) staff, this nurse found resident lying on right lateral side on the floor next to his bed. Res is unable to state if head hit floor. denied knowing what happen, when prompted orientation resident states no.no obvious injuries noted. 2 person assist was required to assist R off floor and on to bed. Gown was wet but briefs dry. Previous notes mention change in mental status since ,d+[DATE], and again on ,d+[DATE] with MD aware. OC (on call ) MD was notified, no new orders. Continuing resident on Neuro Fall protocol. [DATE] 12:20 PM: CBC with diff, CMP on [DATE] then every Monday. Resident refused, attempted by this nurse and lab services. [DATE] 01:40 PM: MD2 was made aware of residents decline in overall health, and refusal of labs from this morning. MD2 reported no new orders and will assess resident further today also MD reported will speak to family regarding residents' current status. [DATE] 02:38 PM OT note documented not able to communicate needs. Pocketed food. [DATE] 04:51 PM: .responds to yes or no, reported by skilled therapy services of decline in activity, MD notified . requires 1:1 assistance with feeds d/t (due to) decline in health, required frequent reminders to swallow, observed pocketing food in mouth.incontinent of bowel and bladder. [DATE] 07:33 PM: Resident was found on the floor next to his bed, unable to recall events leading up to incident. Two-person max assist required to transfer .MD2 made aware, ordered to monitor for elevated temperatures and notify MD2. [DATE] 05:30 AM: Resident on alert charting for fall at 17:50 on [DATE]. Resident lethargic, but able to take his HS (night) medications whole with thin liquids answered slowly with clear speech to yes or no questions. Neuro checks done during night shift. got slightly agitated with neuro checks. Incontinent of urine and bowel. [DATE] 08:26 AM: rec (received) call from MD2 to transfer to ER for further evaluation r/t worsening condition. This morning he is unable to answer questions appropriately. [DATE] 09:40 AM: AMR (ambulance) transferred to ER at 08:50 AM. 13) On [DATE] at 12:45 PM during an interview with MD2, discussed the process for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD2 said this works well with straight forward cases such as a [CONDITION(S)], but R1 had complex management issues at hand. MD2 said the orders are drafted by the nursing staff and that he reviews the discharge summary and any other documents sent prior to the residents admission, revises the orders as needed signs off. MD2 said he admitted ly was working on his documentation as this environment (SNF) was a fairly new to him. 14) On [DATE] at 09:40 AM, the Administrator provided a written communication from MD2 addressed to surveyor explaining his medical decision making. The letter included the following: .He (R1) had undergone several rounds of [CONDITION(S)] and extended hospital stays, and as indicated by the H&P dated [DATE], the patient had not tolerated [CONDITION(S)] well and was considering discontinuation of therapy. As per his wishes, the patient was treated conservatively. Surveillance lab work was drawn [DATE] and indicated worsening in known [CONDITION(S)]; the patient had recently been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent lab work drawn [DATE] demonstrated further worsening [CONDITION(S)], to the level that would require admission to the hospital, an extended course of treatment, and likely multiple [CONDITION(S)], the patient declined transfer. He was aware that declining treatment might result in this passing, as evidenced by indications on his POLST that he would not like life-saving measures undertaken (a transfusion would certainly fall under this category). Given his decision, it was felt that any further lab studies would not be undertaken as they would be non-contributory and result in discomfort on the part of the patient. Over the next several days his mental status declined to the point that he was unable to make decisions for himself. From a medical and ethical standpoint, it would have been quite reasonable and appropriate to transition the patient to comfort measures at this time. However, decision making was transitioned to his family, who elected to have the patient transported to the emergency department, and ultimately Honolulu. There was no documentation in the medical record by MD2 of any discussions with R1 regarding a refusal to transfer to the hospital after the [DATE] lab results, or decision not to do lab work or receive [CONDITION(S)] as indicated. The only documented note was [DATE] when MD2 documented R1 is contemplative regarding his plan of care with regards to his AML given his poor tolerance of [CONDITION(S)]. In addition, there was no mention of this during MD's interview. 15) During a telephone interview with R1's daughter (POA), when inquired if she completed a POLST over the phone with facility staff, and she said she did not know what a POLST was. Informed her the POLST had been completed with her over the phone with the ADMD on [DATE], and reviewed the content with her. The POA said she called the facility on [DATE] and spoke with the CM who said R1 was getting weaker. After that, she was contacted after the fall on [DATE]. The POA said she did not recall the date, but she spoke with the CM and someone else and discussed her concerns. She told them she really was not worried about R1 walking 150 feet as felt that it was unrealistic, but was concerned about his lab work and [CONDITION(S)]. The POA said she told them she wanted them to continue the [CONDITION(S)] and [CONDITION(S)]. The POA said she was not notified when the critical lab values came back on [DATE], or any discussions that may have occurred with R1 and MD2 about not having [CONDITION(S)]. The POA said she did not feel R1 fully understood the situation. She was under the impression R1 was to have labs twice a week to monitor the need for [CONDITION(S)] and this was part of the plan as discussed with her at the hospital. The POA was not contacted by the physician or facility about refusing to go to the hospital after said discussion of his lab results on [DATE]. She said ultimately I would want to honor my father's wishes, but was not aware of any change or that he really understood the situation. 16) Cross reference to F689 Free of Accidents The nursing staff failed to provide adequate supervision to R1 to prevent a fall on [DATE]. R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Although it was documented R1 showed increased signs of confusion,neurological, and functional decline, the nursing staff did not monitor or supervise him adequately or implement appropriate interventions to prevent another fall. 17) Cross reference to F726 Competent Nursing Staff The facility failed to ensure all nursing staff had the behaviors and or knowledge to perform their role to monitor, assess and document findings of R1's status after he fell to ensure his safety. There was a gap of 13 hours and 20 min. of documentation that neuro checks and assessments were performed ([DATE] at 05:00 AM until [DATE] at 06:20 PM). R1 fell a second time on [DATE] at 05:50 PM during the time he should have been monitored more closely. 18) R1's Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . As early as [DATE]) R1's lab values indicated dangerously low PLT and indicated the need for transfusion. With the documentation of R1's cognitive impairment and documentation of increased confusion, the POA should have been notified of the critical lab values for a discussion with the MD and R1 if able, to decide to treat or not treat with [CONDITION(S)]. When the POA verbalized to the facility on [DATE] she wanted to continue the [CONDITION(S)], [CONDITION(S)] and hospitalization as needed, it would have been appropriate to transfer R1 in a timely manner to the hospital based on his declining condition and lab results. He was not transferred to the hospital until after another fall on [DATE] with further decline. Transfer did not occur until [DATE] at 08:50 AM. 19) Review of R1's death certificate dated [DATE], documented Cause of Death: a) [CONDITION(S)] complicated by subdural hemorrhage Due to, or as a consequence of b) Probable [MEDICATION(S)] force trauma.

Based on record review (RR) and interviews the facility failed to provide adequate supervision to one resident (R)1 to prevent several falls in spite of the resident being a high fall risk related to his medical diagnosis. After R1 had a fall on 12/13/2020 he was on alert charting and frequent neurological checks to monitor his condition for signs/symptoms of any potential neurological decline. Although it was documented R1 showed increased signs of confusion, lethargy, and functional decline, the nursing staff did not monitor him appropriately. During that period of time R1 fell again. This deficient practice of the lack of monitoring and supervision resulted in harm from avoidable fall's and the eventual decline and death of R1. Findings include: 1) R1 was a [AGE] year-old male had a past medical history significant of [CONDITION(S)] (AML-very rare type of blood cancer), pancytopenia (combination of low levels of all types of blood cells including red blood cells, white blood cells, and platelets), [CONDITION(S)] (blood disorder with abnormally low levels of platelets which help your blood clot properly), hypertension, diabetes mellitus type 2 and cognitive communication deficit. He was undergoing [CONDITION(S)] for AML and required special blood products that needed to be flown from Honolulu. R1 was admitted to the facility on [DATE] for care and rehabilitation therapy after his hospitalization (11/29/2020 to 12/02/2020). 2) RR of R1's Medical Data Sheet (MDS) dated [DATE] Section C, Cognitive Patterns, revealed he had a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment and did not have any altered level of consciousness. Section G indicated R1 was not steady and only able to stabilize with staff assistance. 3) RR of R1's care plan (CP) revealed he was at risk for falls related to debility. The goal was R1 will not sustain serious injury requiring hospitalization through the review date. The CP documented R1 had unwitnessed falls on 12/02/2020, 12/03/2020, 12/13/2020 and 12/14/2020. After the fall on 12/13/2020, the CP was revised to add a Flat call light as an intervention. On 12/15/2020 (fall occurred 12/14/2020), the CP was revised to add Floor mats to both sides of his bed. R1's care plan interventions were added after he had three falls. No CP revisions occurred after the first unattended fall on 12/02/2020. 4) RR of nursing progress notes included, but not limited to the following entries: 12/05/2020 at 11:02 PM: Res (resident/R1) had moments of confusions during shift. Unable to fully make needs known. 12/06/2020 at 11:05 PM: Very weak this shift with noted increased confusion. 12/07/2020 at 11:46 PM: A&Ox2-3 (alert and oriented to self, place and time-not alert to situation) baseline. Increased confusion noted this shift. MD aware. Res had 1 episode of anxiety. 12/10/2020 at 06:04 AM: .voids in urinal but is forgetful and tries to get up to bathroom. 12/11/2020 at 09:21 PM: Continue with confusion, A&Ox1-2. Possible new baseline .Observed to have increased weakness at times. 12/12/2020 at 06:04 AM: . voids in urinal but is forgetful and tries to get up to bathroom. 12/13/2020 at 03:05 PM: Communication with Physician: .Reports since 12/07/20 stating resident is having increased confusion, possible new baseline reported 12/11/20. 12/13/2020 at 03:22 PM: Daughter/POA made aware of resident's change in mental status as well as unwitnessed fall. 12/13/2020 at 03:33 PM: At 14:15, alerted by CNA (certified nurse assistant) staff, this nurse found resident lying on his right lateral side on the floor next to his bed. Resident unable to state if head hit floor, denied knowing what happen, when prompted orientation resident states, no. No obvious injuries observed. 2-person Max (maximal) assist was required to assist resident off floor and on to bed. Gown was wet but briefs dry. Previous notes mention change in mental status since 12/7, and again on 12/11 with MD aware.Continuing resident on Neuro Fall protocol. 12/13/2020 at 11:49 PM: .Resident was incontinent of bowel and bladder during night shift. 12/14/2020 at 12:29 PM: lab draw refused by resident, attempted by this nurse and lab services. 12/14/2020 at 07:33 PM Event Note: Resident was found on the floor next to his bed, unable to recall events leading up to incident. 12/15/2020 at 05:30 AM Alert note: Resident on alert charting for fall at 17:50 on 12/14/2020. Resident lethargic, but able to take his HS (hour of sleep) medications whole with thin liquids. No difficulty swallowing noted. Answered slowly with clear speech to yes and no questions. Neuro checks done during night shift. 12/15/2020 at 08:26 AM. Received telephone order from MD3 to transfer resident to hospital for further evaluation r/t worsening mental state. This morning unable to maintain eye contact or answer questions appropriately. 5) Cross reference F726 Competent Nursing Staff: The nursing staff failed to assess, monitor and document neuro checks and assessments on R1 according to standard of care and facility's policy. The nurses skipped several neurological assessments and did not perform them correctly when they documented sleeping twice. 6) Cross reference F684 Quality of Care: Review of R1's death certificate dated January 7, 2021, documented Cause of Death: a) [CONDITION(S)] complicated by subdural hemorrhage Due to, or as a consequence of b) Probable [MEDICATION(S)] force trauma.

Based on a facility reported incident (HI 619), and subsequent onsite investigation that included record review and staff interview, the facility failed to ensure that Resident (R)24 received adequate supervision to prevent accidents. As a result, R24 fell and sustained harm, two fractures of the right side of the face, and a right eye injury. Findings include: Record review reflected that R24 was a known fall risk, had fallen on 11/03/14, 02/11/15 and 02/08/17 without injury, and fallen 02/10/18, and 08/12/18 with injury. The resident had also been care planned for falls and interventions prior to the fall that occurred on 08/12/18. Interventions included falls risks assessments, reporting falls to primary care physician and responsible party, reporting to primary care physician any side effects associated with resident medication use, place items frequently used within reach, offer snacks and monitor closely and provide activities to reduce agitation, provide opportunity to transfer out of bed and use toilet during rounds at night, and resident door to room will remain open. Following the 08/12/18 fall, the care plan added that two staff members will perform all activity of daily living while resident is in bed. The resident's [DIAGNOSES REDACTED]. Resident's [DIAGNOSES REDACTED]. During interview with facility Director of Nursing (DON) and Nursing Home Administrator (NHA) on 08/30/18 at 10:39 AM, the DON confirmed that the facility was aware that the resident was at risk for falls prior to the 08/12/18 fall, that all care plan interventions were maintained, the fall was avoidable, because the Certified Nurse Aide (CNA)25 had raised the bed to a high position, and should not have turned her back on R24 while gathering supplies, and could not prevent the resident from falling from the bed while resident called out that she was falling. DON went on to say that after the facility completed their investigation, they had determined that it was a training issue, the nurse aide needed education and corrective action, treated the incident like an immediate jeopardy incident, put together a performance improvement plan to ensure that no other residents were at risk. DON said, If I were a state surveyor I would treated it as a harm. DON said that moving forward that she monitors care of residents in bed to ensure care is provided safely, did competencies with CNAs after this occurred to ensure this would not happen.

Based on record review, staff interviews and review of the facility's policy and procedures, the facility failed to ensure services provided met professional standards of quality and/or clinical practice for Resident #1. Resident #1 sustained a fall with injuries and experienced neurological changes while in the care of a licensed staff. As a result of the lack of accurate and immediate notification of the resident's condition to the physician and on-call nurse, and the lack of on-going clinical documentation/initiation of standard nursing measures, the resident's status deteriorated whereby he subsequently became unresponsive and later expired approximately 5.5 hours after he fell . Findings include: The Hawaii State Survey Agency (SA) completed an abbreviated survey at the facility on [DATE] related to an incident which occurred on [DATE] involving Resident #1 (Res #1), a [AGE] year old resident admitted to the facility on [DATE] for skilled rehabilitation services. On [DATE], at approximately 1:30 A.M., the resident fell in the hallway outside his room and sustained head and skin injuries. Approximately 5.5 hours after his fall, around 7:00 A.M., Res #1 was found unresponsive and transported to the hospital, where he later expired. Cross-reference to findings at F 309. The record review revealed Res #1 had discharge plans which was to return to an assisted living facility with a prior level of function. His resuscitation status was, "Code B - Full Therapy Short Of Resuscitation, Hospital If Necessary - Maximum therapeutic effort not including resuscitation. May be discharged from the facility to the hospital for evaluation on order of the physician..." The SA's investigation found a licensed nurse (LN #1) was assigned to Res #1's unit on [DATE]-[DATE]. Clinical record review found that after the resident fell , a neurological (neuro) assessment flow sheet was started by LN #1 on [DATE] at 1:45 A.M. Review of LN #1's [DATE] nurse's note at 4:30 A.M. noted the resident was, "Found on floor of hallway after hearing unusual noise at 0130. No LOC (loss of consciousness). Has 7x4 cm contusion to the back of cranium. Ice pack applied intermittently & HOB (head of bed) elevated after helped back to bed. R pupil ,[DATE] mm and briskly rx. L pupil initially 2+ & sluggishly reactive. Face symmetrical. MAE (movement to all extremities) x 4 spontaneously. Alert, but responds erratically to commands &/or questions, possibly (secondary) dementia. Later L pupil appeared to react WNL - remains slightly larger than R pupil in diameter. Has 6? x 4 cm ragged skin tear to L neck and a 4 x 3 cm skin tear to top of L shoulder. Wounds cleansed & bandaged. (Physician) notified per FAX. On/call nurse...notified at 0205 per TC...Neuro checks protocol initiated. Will continue to monitor closely." The SA found this was the only clinical entry by LN #1 for the entire 5.5 hour period aside from the neuro flow sheet. Interview of the Assistant Director of Nursing (ADON) on [DATE] at 9:15 A.M. revealed the ADON was the on call nurse on [DATE]. She said LN #1 called her around 2:00 A.M., and LN #1 told her that Res #1 had a fall with small cuts/skin tears. The ADON said based on that, she told LN #1 to follow the neuro check protocol and call back if there were any changes. However, when another nurse (LN #2, a day shift nurse) saw the resident in the morning and reported it, the ADON said, "her assessment was different. I had no knowledge about the big lump, the gash...she (LN #1) didn't call me to tell me about that. What she (LN #2) assessed and seen was not the same thing when (LN #1) called me about the fall, that there was more stuff that (LN #1) didn't report." The ADON confirmed based on LN #2's initial morning assessment, the resident was already unresponsive and transported via ambulance to the hospital. The ADON confirmed the resident expired on [DATE], but did not know the actual time nor had an autopsy report. The ADON said she completed the resident's skin assessment afterward as LN #1 did not do it before the end of her shift. The ADON's [DATE] skin data diagram showed that Res #1 sustained injuries to his body, which included a bump to the back of his head measuring 6.5 x 5 centimeters (cm), and 4 skin tears: a 7 x 4 cm skin tear to the left side of his neck, a 4 x 3 cm skin tear to the top of his left shoulder, an approximate 1 cm skin tear to one of his left fingers and an approximate 1 cm skin tear to the inner aspect of his left knee. LN #1's [DATE] 4:30 A.M. nurse's note however, only documented the head contusion and two skin tears, and did not include the other two skin tears. It was found that LN #1 documented the two additional smaller skin tears in her [DATE] witness statement form at 4:05 A.M., but failed to include a finding in her nursing note that the resident also had blood on his lips and that he may have bitten his tongue. LN #1 wrote she was unable to assess it well. The measurements of the head contusion and the largest skin tear however were different. Interview of LN #2 on [DATE] at approximately 1:15 P.M., revealed she was the day nurse who found the resident unresponsive. She verified she called the physician on [DATE] at 7:00 A.M. LN #2 said Res #1 was already non-responsive when she entered his room. She quickly assessed his injuries and found him non-responsive to painful stimuli. A day CNA (no longer at the facility) came to report to the day charge nurse that Res #1 was not responsive during her rounds. LN #2 said she then offered to do the assessment and reported her findings to the ADON thereafter. LN #2 verified her 8:00 A.M. nursing entry followed LN #1's entry. LN #2's documentation of her assessment was: "VS: 99.6, ,[DATE],115, 18, O2 Sat 90% on RA (oxygen saturation level at 90% on room air). Neuro check not WNL (not within normal limits) at 0715. Res. unresponsive with pupils non-reactive, Biot's breathing ...laceration to left neck with dressing change secondary saturation, bleeding clotted at this time..911 called with estimated arrival time of 0745. Ambulance transfer at 0750..." LN #2 said her expectation of any licensed staff was, "to notify the physician if a change has occurred. I know it as standard procedure, to notify the physician of an injury...If I couldn't reach (physician), I would have sent him out. I'd also try to get hold of our Medical Director. So always there's a nurse manager on call...we have four nurse managers really to contact too..." LN #2 said Res #1's resuscitation status alone, "a B, would help you send out a patient without a physician...If Code A or B, you can automatically send them out." A review of the [DATE] neuro flow sheet revealed the entries at 4:00 and 4:30 A.M., were the third and fourth 30 minute neuro checks. LN #1 initially had documented "N" for Res #1's respiratory pattern at 4:00 and 4:30 A.M., which denoted the resident's respiratory pattern was normal, easy, quiet breathing with the rate of ,[DATE] breaths a minute. However, LN #1 had written over those times and changed the resident's respiratory pattern to a "B," which denoted Biot's breathing of deep or shallow breathing alternating with irregularity recurring periods of apnea. At 5:30 A.M., LN #1 then documented a third "B" at the start of the hourly neuro checks. LN #1's [DATE] nurse's note included a notification to the physician via facsimile (fax), but there was no evidence or documentation of it in the clinical record. Of note, LN #1 chose to notify the physician by fax (actual time unknown), instead of calling the physician. During a telephone interview of a Certified Nurse Aide (CNA #1) on [DATE] at 4:40 P.M., he stated he worked the [DATE] night shift with LN #1 and he recalled Res #1's fall. CNA #1 said he took all the vital signs on Res #1 after the fall and documented it on the neuro flow sheet. He was not sure if LN #1 did the neuro checks as he and his partner were busy attending to other residents. However, CNA #1 noticed a change in the resident's status at 4:00 A.M. "I gave report to her (LN #1) time to time to check (Res #1) because his snoring getting louder and louder." CNA #1 said this was unusual for this resident. CNA #1 said Res #1, "he was not talking back to me like before. The nurse came down--squeeze my hand (to resident) and told me he's still squeezing but not that much." He said LN #1 however, did not share information about the resident's breathing. CNA #1 reiterated to the SA he told LN #1 about Res #1's snoring because it was unusual and got louder and louder. On [DATE] the SA's review of CNA #1's written statement of the events on [DATE] at 1:30 A.M. found his entry about Res #1's fall: "He was fine when he just fell down and for the next 2 more hours, but suddenly after 2 hours, (partner CNA) and I heard (Res #1's) personal alarm so went check on him, he was trying to get up again but unusually he doesn't look good and don't even talked back when we tried to talked to him. He was all confused and resisting but finally we get him to bed in couple of minutes and after that's the time that he fell asleep until our shift ended. During/while he was asleep, we heard unusual snore coming from (Res #1) and that's the time I/we reported to (LN #1) (partner CNA) and I was trying say that we should send him to the hospital but then (LN #1) assessed on him and said 'He's fine because when I asked him about holding/ pressing/squeezing my hands tight and he did it.' So stating that from a charge nurse made me relieve a little bit but I continue to keep an eye on (Res #1). Then I reported every time I saw (LN #1) the same thing that (Res #1) is snoring louder and louder (illegible) is unusual." Interview with the Director of Nursing (DON) on [DATE] at 3:00 P.M. revealed she was on vacation when this incident occurred. Upon her return, she reviewed the chart and acknowledged she noted a concern about the [DATE] neuro flow sheet entries, specifically the 4:00 A.M. entry. The DON said there was a change in the resident's respiratory pattern. She said with that sort of change in respirations, she would have watched it for a short period of time along with the vital signs. If she thought the resident was having respiratory distress, the physician or the nurse on call would be notified. The DON said she would have called the physician because there was a change with Res #1. If the resident continued to have that type of breathing, she would have initiated closer checks on him, such as every 15 minutes and called the physician. Yet, there was no documentation that LN #1 called the physician at 4:00 or 4:30 A.M., and per the DON, "this is not okay." The DON said the licensed nurse had two options: Call the physician and assume to send the resident to the hospital and/or call 911. "A nurse does not have to call us. If there's an emergency, they should be able to handle it. If there's any questions, they know to call the nurse on call and myself." Further record review noted from the time of LN #1's 4:30 A.M. nursing note and the neuro flow sheet, there was no other on-going documentation by LN #1 of the resident's condition. The change in the resident's respiratory pattern, from normal to Biot's breathing was recorded at 4:00 A.M., and remained Biot's throughout per the 4:30 and 5:30 A.M. neuro checks. There was no clinical documentation that oxygen saturation levels or the administration of oxygen was performed by LN #1. In addition, the resident's systolic blood pressure (SBP) remained higher than compared to his daily baseline SBPs. Of note, on the neuro flow sheet, at 3:00 A.M., his BP was recorded as ,[DATE], at 3:30 A.M. it was ,[DATE], at 4:00 A.M. (Biot's breathing noted) it was ,[DATE], at 4:30 A.M. it was ,[DATE], at 5:30 A.M. it was ,[DATE], and the last taken was ,[DATE], when he was also found to be [MEDICAL CONDITION] at 115 bpm with a temperature at 99.6 degrees Fahrenheit. The resident's daily baseline SBPs generally ranged in the 100's to 130's, and he did not have a [DIAGNOSES REDACTED]. Yet, there was no clinical documentation by the end of LN #1's shift at 6:00 A.M. about these changes, or of CNA #1's report of his observations of the loud, unusual snoring and decreased responsiveness of Res #1 at 4:00 A.M., which he stated he informed LN #1 of. Additionally, the neuro flow sheet documented Res #1 was confused at baseline, although initially assessed to be alert after his fall at 1:30 A.M. LN #1 also had assessed the resident to be drowsy beginning at 2:00 A.M. on the neuro flow sheet, which indicated a change from his initial status where he opened his eyes spontaneously at 1:45 A.M., but only to speech by 2:00 A.M. and thereafter. There was no on-going documentation by LN #1 as to what her assessment findings were for this resident who had no loss of consciousness at the time of his 1:30 A.M. fall, but within a half hour later, was assessed to be drowsy for the remainder of the neuro checks. The neuro flow sheet also noted Res #1's motor responses became "localized" at 4:00 A.M., which was when his breathing pattern changed to Biot's. Again, there was no documentation by LN #1 about this nor what his "localized" responses were. Additionally, LN #1's neuro entries noted the resident's movement to all extremities (MAE x 4) remained spontaneous and strong throughout her shift. However, query as to how LN #1 assessed this since there was no documentation of asking the resident any questions related to his fall, how he was feeling or what steps she took to elicit his responses. Further, LN #1 wrote in her nursing entry she would closely monitor Res #1, which as a standard nursing measure would be warranted for a resident who was a new fall on her shift with a head contusion and skin injuries; yet again, there was a lack of documented on-going clinical observations/findings about the care to indicate measures were being done for the resident. Res #1 was also a new status [REDACTED].#1 described in her [DATE] witness statement form as ragged skin tears. She also wrote the resident reacted as if his left knee hurt and that a bruise would likely develop. However, there was no documentation that a pain assessment was performed by LN #1 during her shift. Notably too, there were no entries by LN #1 on whether she checked Res #1's oxygenation status, offered fluids, administered or applied medications, performed dressing changes or provided any type of supportive care throughout her shift. The CNAs stated they initially applied the ice pack to the resident's head; again, there was no entry by LN #1 about observations related to the head contusion or left knee to check for increased swelling, tenderness, pain, bleeding, etc., to those and his other skin injury sites. There was no follow-up found whether LN #1 rechecked the resident's bloody lip or tongue based on what she had noted in her witness statement. In fact, LN #2 said during her interview that the resident's dressing to his neck was "saturated" or soaked with blood when she found him unresponsive, so she changed the dressing. LN #1's last documented neuro check of Res #1 was at 5:30 A.M. Yet, query the degree to which she assessed or observed the resident if his dressing had been so saturated. There also was no documentation that LN #1 attempted to contact the physician or other licensed staff prior to end of her shift at 6:00 A.M. Then, approximately 5.5 hours after the fall, the resident was found unresponsive and per LN #2, the resident died after being transferred to the hospital. During a [DATE] telephone interview with the Regional Chief Nurse Executive (CNE) at 1:00 P.M., she concurred that LN #1's sole entry at 4:30 A.M. on [DATE] portrayed Res #1 as being stable, and concurred the resident did have neurological changes with significant injuries. She stated her review of the record found LN #1 "downplayed" the full extent of Res #1's injuries when she contacted the ADON around 2:00 A.M. on [DATE]. The Regional CNE also said if there were abnormal changes after a fall, such as the change in breathing at 4:00 A.M., LN #1 should have reported it immediately. She said the expectation of any of their licensed staff was to have done this, as well as to listen to the CNAs. The CNE said she also questioned LN #1's neuro assessment because this resident had a change in respirations, but then was "full blown" (pupils non-reactive and resident non-responsive) two hours later. On [DATE], a facility policy on Neurological Assessment noted one purpose was, "To provide guidelines for observation and communication of trends and changes over a period of time...Pertinent Changes and Interventions, The nurse shall document and report any pertinent changes in the resident's neuro status immediately to the physician..." The policy was produced by the staff development coordinator. In addition, the facility's "Competency-Based Position Description and Performance Review" for Registered Nurses noted the RN, "delivers care to residents ensuring all applicable laws, regulations and (facility's) standards are met. Reports to Director of Nursing (DON)." The specific requirements for an RN included, "Must possess the ability to make independent decisions when circumstances warrant such action; must be knowledgeable of nursing practices and procedures, as well as the laws, regulations, and guidelines governing nursing functions in the long-term care facility...Must understand and follow company policies..." In addition, the responsibilities, standards, and competencies included for direct nursing care stated the RN, "knowledgeably and completely delivers basic nursing care to residents; assesses residents comprehensibly and responds accurately to on-going assessments...evaluates resident's needs through ongoing assessments and revises care plan based on changes in resident's condition; supervises answering of call lights and responds personally as required; demonstrates ability to handle emergency situations; communicates appropriately with physicians and follows physician's orders [REDACTED]. [DATE]). As such, the SA's investigation found LN #1's failure to provide quality, standard of care services as a licensed registered nurse caused harm to Res #1. LN #1 failed to meet the professional standards of clinical practice in the delivery of care and services by having failed to follow the facility's policy and standard clinical nursing practice for a resident who was status [REDACTED]. There was the lack of on-going clinical assessment and documentation, a failure to immediately call a physician and/or nursing supervisors, a failure to accurately report clinical findings related to the resident's injuries, a failure to identify and document changes in neurological status from baseline findings, and a failure to implement standard nursing measures, such as concise, on-going pain assessments, monitoring of oxygenation status, and other standard nursing practices beyond what the neuro flow sheet encompassed. Thus, the investigation found that as a result, Res #1's condition declined and became unresponsive approximately 5.5 hours after his fall, only to be transferred out of the facility when a physician was notified at 7:00 A.M. and dying sometime thereafter.