Every finding on record at Maluhia

Based on interviews and record review, the facility failed to ensure safe handling and modified dressing protocols were used to protect one resident (R) 6, who had severe bilateral upper extremity (BUE) contractures and was totally dependent on staff for care. As result of this deficient practice, R6 suffered harm, a dislocated left shoulder. This was a facility reported event (FRI) #2745775, which the facility identified the noncompliance and conducted a Root Cause Analysis (RCA) and implemented a comprehensive corrective action plan that was fully verified as corrected on 07/17/2026, therefore, past noncompliance was determined. Findings Include:R6 is a [AGE] year-old male that has severe cognitive impairment and was totally dependent on staff for dressing, bed mobility, transfers, and had limited range of motion (ROM) due to severe BUE contractures and paralysis of his dominant left side from a stroke. At baseline he is unable to communicate. Final Event report dated 02/17/26 indicated On 02/12/26, observed by physical therapist (PT) prior to doing ROM that resident's left shoulder is not in alignment. X-rays were taken on 02/13/26 showed that R6 had a left anterior shoulder dislocation and an anterior humeral head dislocation. R6 was transferred to acute care for management and had a closed reduction (nonsurgical procedure used to realign dislocated joints without an incision). Review of the resident's care plan (CP), prior to the incident revealed a lack of specific, modified handling and dressing instructions specifically to protect his severe UE contractures during activities of daily living (ADL) care. The facility corrected the noncompliance prior to the start of the survey by implementing the following measures: 1) Root Cause Analysis (RCA, a structured process to uncover why issues arise by systematically evaluating contributing factors) was conducted on 02/24/26 by Compliance/Risk and Quality. The RCA focused on the high risk of injury when performing daily ADL care, including dressing, transferring, and performing passive ROM on residents with severe BUE contractures. 2) The facility action plan included: Implementation of adaptive shirts for R6 that fully open in the back to eliminate the need to forcefully extend or pull contracted or weak UEs during dressing. The facility purchased a Turn and Position System (TAPS) that helps staff to turn and position patients safely. 3) Education and Training: Training completed on passive ROM care, safe dressing protocols, safe handling repositioning, mechanical lift transfers, weekly skin assessment and the use of the new TAPS device. 4) CP revised on 05/17/26 to include Occupational Therapist (OT) to provide Inservice on proper dressing of upper body, positioning and transfers, and support & refrain from pulling/pushing of my left shoulder and my upper back. Continue passive, gently move me when doing care with at least 2 persons assist. On 05/20/26 the CP was revised to include I use the air tap for turning and positioning. Use appropriate sling size during transfers and shower me using shower gurney/bed. 5) Quality Monitoring: The facility implemented audits of weekly skin assessments, monitoring of CNA (Certified Nurse Aide) concerns regarding barriers to performing care and notifying licensed staff, using stop and alert, if Resident is not at baseline.

Based on observation, interview, and record review, the facility failed to ensure the care plan was revised for two Resident's (R) 27 and 72, of five sampled. 1) R27's care plan did not include interventions to prevent and treat scratches related to non-pressure skin conditions. 2) R72's care plan did not include additional interventions to prevent pulling out the Gastrostomy Tube (GT). As a result of the deficiency, R27 was at increased risk for worsening skin condition and R72 was at increased risk of the GT being pulled out. Findings Include: 1) On 07/07/25 at 08:22 AM, an observation of R27 and interview with Resident Representative (RR) 4 was done. Observed R27 in in her room in bed, her left hand had a blue latex glove on. RR4 spoke in English and in Korean, this surveyor was able to understand both languages, and reported she was wearing the gloves because she had scratches to her buttocks. Her nails get sharp and need to be cut daily. He no longer cuts her nails because of his poor vision but the facility has been cutting her nails. RR4 removed the gloves from R27's hand and her nails were observed to be neatly trimmed with pink nail polish. Review of R27's Electronic Health Record (EHR) documented in the most current skin assessment, dated 07/08/25, R27 had a facility acquired abrasion to sacrum since 05/27/25. Progress note documented on 07/01/25, R27 had self-inflicted scratches on the sacral area noted with slight bleeding. Cleanse the area with NS [Normal Saline], pat dry .Renew Bacitracin 500 units bid [twice a day] for 7 days. Apply Calmoseptine as ordered. Review of the physician's orders documented the following treatment for the abrasion to sacrum, topical bacitracin external ointment 500 unit, apply to sacrum topically every day and evening shift for abrasion for 14 days reordered on 07/08/25, and calmoseptine external ointment 0.44-10.6% (menthol-zinc oxide) apply to sacrum topically every shift for skin protection. Review of R27's care plan found no interventions or treatment to address R27's self-inflicting scratching. On 07/10/25 at 07:32 AM, an interview with Registered Nurse (RN) 12 was done. RN12 reported R27 tends to scratch her buttocks with her left hand when no one is around to redirect her. Staff cut her nails about three times a week but even with her nails short, her nails are sharp. RN12 confirmed an incident where RR5 cut R27's nails without staff knowledge and accidently clipped her skin, RR4 was educated not to cut her nails anymore and ask for staff assistance. RN12 reportedly inquired with RR4 to bring loose pajama pants and gloves to attempt to prevent R27 from breaking skin when scratching herself. RN12 confirmed the care plan should have been revised to include interventions or treatment to address R27's self-inflicting scratching. Review of the facility's policy and procedure for care plans dated 04/21/25 documented Each discipline will be develop, revise and ongoing follow up for care plans as related to their area of expertise to address resident's needs, wants, and preferences. Revise care plan anytime changes needed. 2) Review of EHR showed R72 was admitted on [DATE] with diagnosis including Stroke, Gastrostomy Tube, High Blood Pressure, High Cholesterol, Dementia. Review of progress noted dated 04/19/25 revealed that R72 pulled out the GT while waiting for transport back to the nursing facility. On 05/09/25 the GT spontaneously came out and the balloon was deflated. On 06/15/25 at 1725, resident pulled out the GT and was later sent to the hospital for GT re-insertion. A doctor's order was in place to perform the following interventions relating to pulling out the GT: Assess Pain, redirect, 1 on 1, refer to nurse's progress notes; Activity, return to room, toilet, give food, give fluids, change position, adjust room temperature, backrub, apply lotion, re-offer after 10 minutes, call family as needed. Review of the current comprehensive care plan did not include the interventions, from the doctor's order, relating to pulling out the GT. Staff interview on 07/10/25 at 08:30 AM, Charge Nurse (CN)3 acknowledged that the interventions, relating to pulling out the GT, should also be in the comprehensive care plan. CN3 said they will make the necessary changes.

Based on record review and interviews the facility was aware of Resident (R) 7's nut allergy but failed to document severity of nut allergy, failed to develop and implement a care plan for R7's nut allergy and failed to assure all recipes cooked in the kitchen were on the templates reviewed for food allergies before providing food to residents. The deficient practice resulted in harm to R7 who received food that contained nuts and having an anaphylactic response requiring transport to the emergency room for treatment. Findings Include: According to the United States Department of Agriculture (USDA) A food allergy is a potentially serious response to consuming certain foods or food additives. For those who are sensitive, a reaction can occur within minutes or hours, and symptoms can range from mild to life-threatening. The nine leading causes of food allergies identified in the US are milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, soybeans, and sesame. USDA's Food Safety and Inspection Service (FSIS) and the U.S. Food and Drug Administration (FDA) both have laws requiring that all the ingredients in a food product be listed on the food label. https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-allergies-big-9 Review of facility Event Report dated 03/19/25 for R7 submitted to State Agency (SA) revealed she ate a facility baked and provided dessert at about 01:00 PM and experienced an anaphylactic (severe allergic reaction) response to it. The following information was provided in the Event Report: On 3/19/25 at about 1300 (01:00 PM), resident (R7) called stating that she may have eaten something that she is allergic to. Noted resident's periorbital (refers to the tissues surrounding or lining the orbit of the eye) are slightly reddened. Called MD right away at 1300 (01:00 PM). Received and carried out order for Benadryl 25mg PO Q6 hours PRN (as needed). Called SRN (Nursing Supervisor) to get the Benadryl from the E-kit. VS (vital signs) at 1303 (01:03 PM) are 97.4F (temperature)-87 (pulse)-20 (respiratory rate)-130/67 (blood pressure)-94% (Oxygen saturation) on RA (room air). Noted resident (R7) was anxious and stayed with the resident. Administered the PRN (as needed) Benadryl as ordered upon receipt. Resident (R7) tolerated it. Resident (R7) c/o (complained of) itch to eyes and back. Noted periorbital swelling. Noted desaturation to 84% on RA. Administered oxygen via NC (nasal cannula) at 5L/min. O2 (oxygen) sat (saturation) increased to 94-96%. Updated MD at 1337 (01:37 PM). Received and carried out order to send to ER (emergency room) for anaphylactic shock. Writer called 911 at 1340 (01:40 PM) to give report. SRN (Nursing Supervisor) called the resident's son, at 1341 (01:41 PM) to update him and is agreeable with sending resident to the ER. Fire Department arrived at about 1345 (01:45 PM) followed by ambulance. Per ambulance, not sure what hospital they will go to yet. Resident left via ambulance gurney at 1350 (01:50 PM). On 04/23/25 review of R7's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, other intervertebral disc degeneration, thoracolumbar region; muscle weakness (generalized); unspecified asthma, uncomplicated; essential tremor; and dysphasia (impairment in the production of speech resulting from brain disease or damage). Review of R7's Minimum Data Set with an Assessment Reference Date (ARD) of 02/19/25 revealed her Brief Interview for Mental Status (BIMS) was 15 which indicates she is cognitively intact. Review of R7's care plan, initiated 02/13/25, did not include a care plan for R7's allergies and need for a therapeutic diet to exclude the food items R7 is allergic to, and did not include interventions to address what to do if R7 is exposed to allergen (food items). On 04/23/25 at 10:53 AM an interview was conducted in the kitchen with the Kitchen Manager (KM). Inquired of KM if R7 had food allergies on her diet and KM was unsure.KM stated following R7's incident, the facility stopped ordering nut items, they are currently a nut free facility. Tour of the kitchen found all nut items had been disposed of and no nut food items were found in the kitchen. Inquired about food item that had been cooked in the kitchen that had been given to R7. KM stated the facility was using a recipe (Jello Cream Cheese Square dessert), from 2019 that included nuts, but they no longer include nuts in this recipe after R7's allergic reaction. R7 was on transmission-based precautions, therefore, on 04/23/25 at 12:44 PM a phone interview was conducted. Inquired if resident had notified facility staff of her nut allergy, R7 stated she gave the list to the dietician and the dietician took notes. Dietician also asked the resident about her food preferences. R7 reported she ate an ice cream dessert with a cookie on the bottom and that was where the nuts were. R7 stated her nut allergy is her most violent allergy. R7 stated on her meal tray that day there was nothing indicating there was anything with nuts on her tray. R7 believes it was hidden with a very small amount in the cookie. R7 stated she reads all the labels on food before she eats anything because it can be lethal. On 04/23/25 at 02:28 PM met with the Administrator in the conference room and requested a copy of admission documents for R7. On 04/23/25 at 03:00 PM an interview was conducted in the conference room with Head Nurse Registered Nurse (RN)3. Inquired if the resident who has a severe allergy to nuts would have a care plan for this and she said yes. Inquired if R7 had a care plan for her nut allergies prior to her being exposed to nuts and she confirmed R7 did not have a care plan for her nut allergy. On 04/23/25 at 03:15 PM Administrator provided copies of requested admission forms filled out for R7. On 04/23/25 at 03:20 PM an interview was conducted in the conference room with the Day Shift Supervisor, RN4. Inquired of RN4 if she did R7's admission intake. RN4 stated she filled out the Pre-admission Notification form for R7. RN4 stated she had received admitting information from hospice which included R7's allergies but not the reaction to the allergens. Inquired who receives the Pre-admission Notification form and RN4 stated the team which included the DON, Social Worker, Doctor, Dietician, etc. Inquired if RN4 spoke with R7 and asked her reaction to her allergies (medications and foods) and she denied this stating this form is for pre-admission and the resident was not at the facility at that time. On 04/23/25 interviewed Dietician at 03:50 PM in the conference room. She provided a copy of R7's updated care plan that was initiated on 03/20/25. Inquired if dietician would initiate a care plan for resident's diet that included restrictions due to allergies and dietician stated she does not open any care plans for food allergies unless they (the resident) are not eating or are losing weight. Dietician stated normally she does not open the care plan for allergies unless it involves their nutritional intake. Dietician stated she talked to resident on 02/13/25 and resident stated she swells up if she eats nuts. Dietician was unsure if she shared this information in the IDT (Interdisciplinary Team) note. Dietician stated she jotted it down on her notes of what resident was stating such as mustard makes her sick, nuts make her swell up. Dietician stated this information was not shared in resident's chart (EHR or hard chart) or with the IDT in her assessment. Dietician explained food item served to R7 that caused the allergic reaction was not on the template used that would show all the ingredients used in the recipe, which would include nuts and that was how the dessert was able to be placed on R7's meal tray. Review of R7's admission documents revealed the Nursing admission Screening History dated and timed 02/13/25 at 14:42 (02:42 PM) did not include any reaction to R7's allergies for prescribed medications and food items resident is allergic to. A review of R7's admission orders dated 02/13/25 included R7's diet but no food restrictions related to her food allergies. R7's allergies were listed and included Famotidine, Penicillin, Phenobarbital, Sulfamethoxazole Trimethoprim, Levaquin, mayonnaise, mustard, nut. The admission orders included R7's allergies but date last reaction and specific reaction was left blank for all the medication and food allergies even though the form states List/circle specific reactions (DO NOT LEAVE BLANK): ______________ or anaphylaxis/rash/hives/wheeze/SOB (shortness of breath)/dizziness/CP/syncope (fainting)/N/V (nausea/vomiting) abdominal pain/diarrhea/bleeding/UNK (unknown). Review of Nutrition Assessment for R7 dated 02/25/25 included R7's diet 2/13/25: Regular diet, chopped texture, Regular thin liquids consistency, for Dysphagia; Dietician may order oral supplements as needed. 2/15/25 Regular diet, chopped texture, Regular thin liquids consistency, May have bread products for Dysphasia, unspecified. R7's Nutrition Assessment listed R7's allergies as Multiple nuts, Mayonnaise, mustard, spices, Curry, all salad dressings. R7's Nutritional Assessment did not include her reactions to her allergies. Review of R7's IDT Conf. Notes -V2 dated and timed for 02/14/25 at 08:58 did not include any mention of R7's allergy reaction to her list of medication and food allergies. A phone interview was conducted with RN5 on 04/24/25 at 09:21 AM. RN5 confirmed she was the nurse who did the admission intake for R7. Inquired if she inputted R7's allergies into the EHR and she denied this. Concurrent record review and interview with RN5 revealed Head Nurse RN6 had inputted R7's allergies in the EHR which included nuts. Inquired if other facility staff or R7's family told her R7's nut allergy is bad to the point the resident swells up and RN5 could not recall. A phone interview was conducted on 04/24/25 at 10:28 AM with R7's attending physician. Inquired if Medical Doctor (MD) was aware of R7's nut allergy and he confirmed he was. Inquired if R7 or her son had told MD of her reaction to nuts and he denied this, stated the allergy information was provided by hospice. Inquired of MD if he would have ordered medications such as Benadryl and an Epi pen prn (as needed) to have on hand if he knew of her allergy reaction to nuts and he confirmed this and stated these are in the e-kit (emergency kit). MD stated he believed R7 was exposed to trace amounts of nuts in the dessert she ate. On 04/24/25 at 03:11 PM an interview was conducted with Head Nurse RN6 in the conference room. Inquired of RN6 if allergies are included in the baseline care plan when residents are admitted . RN6 stated allergies are included in the allergy tab in resident's EHR but never put in the baseline care plan. RN6 confirmed she inputted R7's allergies into the EHR. Inquired if RN6 went over allergies and her reactions with R7 and RN6 denied this. RN6 stated they base it upon the discharge list that comes with the resident, it has a list and sometimes has information like GI upset or unknown response. Inquired about R7's care plan and RN6 stated the nut allergy was added to R7's care plan after she (R7) had the severe allergic response. Concurrent review of R7's baseline care plan revealed there is a diet section which only included R7's diet, not that the R7 has an allergy to nuts. On 04/24/25 at 04:45 PM an interview was done with R7 in her room at the bedside. Inquired if resident had told any facility staff about her reaction to her nut allergy. Resident explained she had met with a lady, believes she was a dietician, could not remember her name but explained she was very professional and knowledgeable and took notes down of her food preferences and resident explained her nut allergy was her most dangerous allergy. Inquired if any of the nurses inquired of her allergy reactions and resident said no. Inquired how long resident has had the allergy to nuts and she stated, since I was a baby, that her mother was afraid she would lose her because of it. On 04/25/25 at 09:20 AM inquired of Kitchen Manager (KM) for a copy of the Jello dessert recipe and received a copy of facility's recipe for Jello Cream Cheese Square. KM stated they use this recipe but no longer add nuts to the recipe since they have gone nut free. Review of the recipe found it contained Walnuts (minced) - 4 cups. On 04/25/25 at 10:09 AM an interview was conducted with the DON in the conference room. Reviewed R7's admission paperwork with DON who confirmed the nurse should have circled or wrote the reaction to R7's allergies on the admission Orders form. Inquired if nurses are expected to interview residents when they are admitted and ask what their allergy reactions are and DON stated the expectation was not to interview residents about their allergies, the facility would avoid it, for example if the resident were allergic to penicillin the resident would not get this medication. DON stated they would use the discharge summary as the communication from the hospital and enter the information into PCC (Point Click Care, electronic health record software). PCC will alert the doctor if they order a medication the resident is allergic to. Inquired who the pre-administration form is sent to, and DON stated everyone on the team. Review of R7's physician progress note dated and timed for 03/19/25 at 23:20 (11:20 PM) states: Note Text: Progress note: Subjective: Patient was transferred from Name of Nursing Facility to Name of Acute Hospital emergency room for anaphylaxis after she inadvertently consumed nuts that were in her Jell-O pudding dessert. She had periorbital swelling, shortness of breath, and desaturation. Upon transfer by EMS personnel, patient received epinephrine and diphenhydramine IV pushes. She did receive methylprednisolone IV in the emergency department. Allergic reactions completely resolved. Patient to return back to the nursing facility. Objective: Prior to transfer to Name of Acute Hospital emergency room: Vital signs: Temperature 97.4. Pulse 87. Respiratory rate 20. Blood pressure 130/67. Oxygen saturation 94% on room air. Subsequent desaturation to 84% room air. 94% on 5 L/min via nasal cannula. General: Patient appears to be in distress. HEENT: Periorbital edema. Lungs: Diminished. Cardiovascular: Regular rate and rhythm. Abdomen: Nondistended. Bowel sounds present. Extremities: No edema. No clubbing. No cyanosis. Neurologic: Unchanged. Assessment: Anaphylaxis secondary to inadvertent consumption of nuts with her Jell-O pudding dessert. Patient has underlying history of allergies to nuts. Allergic reaction has resolved after interventions which consists of diphenhydramine, epinephrine, and methylprednisolone IV. Patient is medically stable to be transferred back to Name of Nursing Facility. Plan: Patient returning from Name of Acute Hospital emergency room back to Name of Nursing Facility. Avoid administration of nuts in which patient is allergic to.

Based on record review and interview the facility failed to report the results of an allegation of staff to resident abuse, involving Resident (R) 5 and a Certified Nurse Aide (CNA), within five working days of the incident to the State Agency (SA). Findings Include: Review of facility's Initial Event Report submitted to the SA on 02/19/25 for R5 included the following information: Head nurse received call from R5's daughter, very upset and yelling that her dad was not treated properly by the CNA who was assigned to him about 7am this morning. I want to know now the CNA who was assigned to my dad, I want to report and call the social worker. My dad is crying and calling me that he wanted me to pick him up and go home. Head nurse went to talk to R5 and he was able to voiced out his concern. R5 was still very emotional and crying while telling head nurse what happened. I rather go home if you don't like me here. It happened about 7am, I asked the CNA what's her name, she did not tell me, she came to answer my call light but she seems mad and angry. She helped me with my shishi bottle. I told her that I usually have pain in my leg if not positioned properly. It's only her, all of you have been nice and telling me your names. There's always one that differs from the rest, I don't choose who take care of me as long as she don't do it again. On 04/23/25 at 02:28 PM interviewed Administrator in conference room. Inquired about CNA who was named in Event Report submitted to SA on 02/19/25. Administrator stated staff is out on leave, was put on leave the day the incident occurred, 02/19/25. Administrator stated CNA still has to be investigated which is an interview with the law firm the facility has contracted as the third party to perform the abuse/neglect investigations. Administrator stated she always has cases of abuse and neglect investigated by a third party because some of the staff have worked together for a long time with each other. Inquired when the investigation would be conducted as it is already two months since the incident occurred and she stated the law firm is busy but has been notified of the case. Administrator stated if the case is substantiated the facility will do disciplinary action with the staff in question. Administrator confirmed the incident has not been investigated and final report has not been sent to OHCA (Office of Health Care Assurance) within the 5 days per CMS regulation. Review of facility policy titled Abuse, Neglect and Exploitation of Residents, Participants, and Misappropriation of Property last reviewed 06/23/23 states . E. Reporting of actual, threatened, or alleged abuse or neglect, injuries of unknown origin and serious injuries 1. Office of Health Care Assurance (OHCA) (Attachment A) Report no later than two (2) hours from when a suspicion of crime has been determined to have been committed against a resident and that the resident sustained serious bodily injury as a result. Report within twenty four (24 hours) any of the following: . b. All allegations of or suspected abuse/ neglect of a resident . Submit preliminary report within 24 hours, and the final investigation report within 5 days.

Based on interview and record review, the facility failed to ensure one of three residents (Resident (R) 7) sampled for food allergies, was not served a food allergy. R7 was served mayonnaise on her lunch tray, a documented anaphylactic allergy, after R7's recent anaphylactic incident regarding a nut allergy that happened in the facility. This puts R7 at risk of allergy symptoms or anaphylaxis. Findings Include: On 04/25/25, an abbreviated survey was conducted for a facility reported incident (FRI), ACTs #11581. The facility was found not in compliance with requirements of 42 CFR 483, Subpart B, F684, Quality of Care. The facility was aware of R7's nut allergy but failed to document severity of nut allergy, failed to develop and implement a care plan for R7's nut allergy and failed to assure all recipes cooked in the kitchen were on the templates reviewed for food allergies before providing food to residents. The deficient practice resulted in harm to R7 who received food that contained nuts and having an anaphylactic response requiring transport to the emergency room for treatment on 03/19/25. In response, the facility submitted the following, but not limited to, plan of correction (PoC), ADMIN [Administrator] and FSM [Food Service Manager] re-educated .staff on 03/21/24 on the importance of double checking food allergies on ticket against what they plate during tray line .Completed 05/09/25, and DON [Director of Nursing], SRNs [Nurse Supervisors], HNs [Head Nurses], and EN [Education Nurse] conducted in-services from 03/27/25 to increase awareness/re-educate nursing staff on resident food allergies, importance of double checking allergies on Gerimenu ticket against what is served on meal tray, and yellow/colored tickets when passing meal trays. Completed 05/23/25. On 06/05/25, during the onsite revisit for the 04/24/25 survey, review of R7's Electronic Health Record (EHR) was done. R7's nursing progress note dated 05/21/25, documented a certified nurse aide [CNA] reported R7 called to let her know she was concerned with her meal tray. R7's care plan documented on 05/21/25, R7 was served salad with mayonnaise. Review of R7's list of documented allergies included mayonnaise, salad dressing, mustard, nuts, and teriyaki sauce with prior anaphylactic reactions. On 06/05/25 at 12:10 PM, an interview with R7 was done. R7 reported she has been checking her food due to her anxiety with receiving a food she is allergic to since the nut incident and that there was an incident in May with a salad having mayonnaise in it. R7 confirmed she is allergic to mayonnaise and a kitchen staff came down to apologize and reportedly stated it was their mistake. On 06/05/25 at 12:56 PM, an interview with Registered Nurse (RN) 19 was done. RN19 reported CNA11 served R7's lunch on 05/21/25 and answered R7's call light when R7 reportedly had concerns with mayonnaise on her salad in her meal tray. RN19 confirmed staff serving resident meals are to check their meal ticket, especially yellow meal tickets (indicating a resident has a food allergy), prior to bringing the meal tray to the resident. On 05/21/25 during lunch, RN19 confirmed it was not done and the facility started the yellow meal tickets in March. Review of R7's meal ticket on 05/21/25 documented R7 has an allergy to mayonnaise and menu instruction of CUBED PLAIN TOMATO SLD [salad], NO DRSG [dressing] / MAYO [mayonnaise]. On 06/06/25 at 09:40 AM, an interview with FSM was done. FSM reported after R7's anaphylactic incident with nuts, the facility changed their meal tickets to yellow for residents with food allergies. FSM stated the kitchen staff are supposed to check if any food allergies made it to a resident's meal tray during tray line, but on R7's meal tray on 05/21/25 for some reason, we didn't catch that. FSM admitted the meal ticket can be confusing due to it documenting NO DRSG/ MAYO and it would be better if it documented PLAIN because it can confuse staff when looking at the meal ticket briefly. On 06/06/25 at 09:53 AM, an interview with DON was done. DON confirmed the nursing staff are to check the residents with yellow meal tickets prior to going to the resident's room. DON further confirmed CNA11 was trained prior to the incident and should have checked the meal ticket. On 06/06/25 at 10:01 AM, an interview with Registered Dietician (RD) was done. RD stated, whatever is written in the meal ticket should be followed. Review of the facility's policy and procedure regarding allergies effective 05/14/25 documented under section E. Food Allergies, Meal Tickets will be printed on Yellow/colored paper to alert dietary staff when plating meals, so appropriate substitution can be made. Nursing staff will check yellow / colored meal ticket against the plated food before presenting to resident. If any discrepancy - clarify with dietary before serving food to resident.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience that was not required to treat the resident's medical condition for one of one resident sampled (Resident (R) 68). R68's reclined Geri-chair was not assessed as a restraint, although R68 forgets his physical limitations in standing and walking, R68 was observed to move his Geri-chair or attempt to get up and staff expressed they were unable to provide the constant supervision to prevent falls. Findings include: R68 was admitted to the facility on [DATE] with diagnoses, not limited to, Alzheimer's disease, dementia, weakness, and hemiplegia affecting right dominate side. On 06/30/24 at 09:34 AM to 10:12 AM, observed R68 in the hallway in a reclined Geri-chair. His upper body and head were tensed up not touching the reclined back of the chair, his left hand was holding the hallway rail, legs were reclined up and positioned toward the left side of the chair. Using his left arm, R68 was observed to swivel his chair back and forth in attempts to move it or sit up, while his left leg was moving off and hanging off the chair. R68 yelled and attempted to signal with his arm for unidentified people but no direct care staff were found in the hallway. At 10:12 AM, after surveyor signaled a staff member for R68, the staff member brought the resident closer to the Nurse's station and then where resident was attempting to signal the staff member where he wanted to go, closer to the activities room. During further observations of R68 on 06/30/24 and 07/01/24, in reclined Geri-chair, observed R68 sitting back comfortably in chair with legs reclined up and positioned toward the left side of the chair, not hanging off the chair. R68 was not attempting to move the chair or position himself upright. On 07/02/24 at 12:33 PM, observed R68 in the hallway in reclined Geri-chair with his right side closest to the hallway rail. R68's back of the chair was slightly reclined from a 90-degree angle and legs were reclined up and positioned toward the left side of the chair. R68 was moving his legs side to side, off the chair to back on the chair with slight forward rocking movement while making moaning noises. On 07/02/24 at 12:37 PM, an interview and concurrent observation with Certified Nurse Aide (CNA) 12 was done. CNA12 reported R68 can sit in his chair with legs slight reclined down but is more comfortable with his chair reclined up. CNA12 demonstrated by lowering the reclined position, during this R68 was rocking forward in a position to try to get out of chair. CNA12 reclined his legs back up and assisted another resident. On 07/02/24 at 12:43 PM, an interview and concurrent observation with CNA33 was done. CNA33 reported R68 likes to have his legs reclined up and if lowered down he may fall because he wants to walk but is unable to. CNA33 reported that they cannot watch him all the time because they need to help other residents. CNA33 lowered his legs down and R68 was observed to scoot himself towards the edge of the chair with slight rocking movement forward in a position to get out of the chair. CNA33 stayed by his side and redirected and repositioned him so he does not fall. CNA33 requested assistance from other staff members to bring R68 to his room. On 07/02/24 at 12:54 PM, an interview with Head Nurse (HN) 9 was done. Inquired with HN9 if the facility did a restraint assessment for R68's Geri-chair. HN9 reviewed the Electronic Health Record (EHR) and reported a restraint assessment was not done for the Geri-chair. HN9 further reported the Geri-chair would be considered a restraint if the resident is trying to get up on their own and it is restraining their movement. HN9 stated the Geri-chair is not a restraint for R68 because he does not have the ability to walk. HN9 confirmed that although R68 does not have the ability to walk he tries to get up and stand and is not aware of his limitations. On 07/02/24 at 01:56 PM, an interview with R68's resident representative (RR) 52 was done. RR52 reported R68 suffered a stroke and lost control of his right side of his body. R68 thinks he can get up and stand but has fallen from his bed a few times at the facility. The facility now puts him in a Geri-chair when he is restless and to give more social interaction. Review of the facility's event report for R68's falls on 02/21/24 and 05/17/24 was done. On 02/21/24, R68 was found on the floor in room next to his bed, documentation from staff members reports documented resident verbalized wanting to go home as a factor influencing the incident and to prevent the incident from happening again, place resident in recliner in a visible area for close supervision, if attempting to get up from bed. On 05/17/24, R68 was found on the floor next to his bed, documentation from staff members reported resident was restless. On 07/03/24 at 10:12 AM, an interview with Director of Nursing (DON) was done. DON stated she looked at R68 the other day and found him to be restless and uncomfortable. Inquired what is the facility's process in identifying possible physical restraints and devices, DON reported the facility would assess if there were a need for safety then get an order. The facility wanted R68 to get out of bed and use the Geri-chair for comfort and felt it was better to sit on for his safety because they do not want R68 to fall. DON further mentioned in the interview that the facility does not have the staffing for one-on-one supervision. Concurrent review of R68's INFORMED CONSENT FOR USE OF PHYSICAL RESTRAINTS signed and dated 01/14/24 mention Geri-chair as a type of restrained to be used. Review of the facility's policy and procedure PHYSICAL RESTRAINTS AND DEVICES effective 09/08/06, documents Restraints are to be used only when necessary under limited medical conditions or symptoms to prevent injury to resident and/or others .Restraints must not be applied for the purposes of discipline or staff convenience. Restraints must be ordered by the attending physician for a specified and limited period of time .Physical restraints include, but are not limited to .Geri chairs .A THREE-DAY ASSESSMENT PERIOD shall be implemented upon admission or use of new device to determine if the resident required the device to ensure resident's safety, increase function and/or to complete a medical treatment.

Based on record review and interview the facility staff failed to correctly document Resident (R) 6's facility acquired injury, progressing from Moisture-Associated Skin Damage (MASD) on his right gluteus to a stage 3 Pressure Ulcer (PU) on his coccyx, in R6's Discharge Assessment that was submitted to Center of Medicare and Medicaid Services (CMS) on 05/27/24. The deficient practice does not accurately reflect R6's injured skin status. The deficient practice could affect all residents who have an injury that has worsened over time. Findings Include: Cross-reference to F842 Resident Records - Identifiable Information. Based on record review and interview the facility failed to update R6's electronic health record (EHR) to accurately stage his facility acquired injury progressing from Moisture-Associated Skin Damage (MASD) to his right gluteus to a stage 3 PU on his coccyx. On 07/01/24 at 01:45 PM interviewed Minimum Data Set (MDS) coordinator 1 and inquired who stages the resident's skin injuries and she stated the nurses on the unit determine the type or stage of the injury. On 07/03/24 at 11:04 AM interviewed Head Nurse (HN) 9 on second floor. Inquired about R6's MASD and stated that it appears to be a PU. HN9 stated it is a stage 3 PU. HN9 explained R6's Nurse Practitioner, an outside provider, had identified the injury as a stage 3 PU in her documentation which was provided to the facility. HN9 stated the team met on 07/02/24 to discuss R6's injury and agreed the MASD had progressed to a stage 3 PU. At this time requested HN9 provide copies of R6's Care Plan (CP), doctor's orders, skin assessments, progress notes and NP Assessment. On 07/03/24 at 11:16 AM met with and interviewed DON who stated there was a meeting yesterday (07/02/24) and the team discussed R6's injury and concur it is no longer MASD but a stage 3 PU and the change should have been made in R6's EHR. On 07/03/24 review of R6's CP, doctor's orders, weekly skin assessments and weekly progress notes has documentation of R6's injury as MASD. During this review there was no documentation found that facility staff documented R6's PU progressed (got worse) from the MASD to a stage 3 PU on his coccyx with full thickness skin loss as documented by R6's NP on 05/14/24. During this review noted NP assessment had been faxed to the facility on [DATE] at 02:14 PM. NP documented on R6's injury Started as MASD but worsened with pressure. Review of R6's MDS found he had a Discharge Assessment that was submitted to CMS on 05/27/24, section M did not include R6 had an unhealed pressure ulcer (s) at Stage 1 or higher. No was checked off for this question. Other problem checked off included H. Moisture Associated Skin Damage (MASD).

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of 19 residents sampled (Resident (R) 68). R68's care plan did not include reclined Geri-chair in visible area for close supervision as an intervention to prevent R68 from falls when restless and expressing he wants to go home. Findings include: Cross Reference to F604. The facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience that was not required to treat the resident's medical condition for one of one resident sampled (Resident (R) 68). R68's reclined Geri-chair was not assessed as a restraint, although R68 forgets his physical limitations in standing and walking, R68 was observed to move his Geri-chair or attempt to get up and staff expressed they were unable to provide the constant supervision to prevent falls. On 07/02/24 at 01:56 PM, an interview with R68's resident representative (RR) 52 was done. RR52 reported R68 suffered a stroke and lost control of his right side of his body. R68 thinks he can get up and stand but has fallen from his bed a few times at the facility. The facility now puts him in a Geri-chair when he is restless and to give more social interaction. Review of the facility's event report for R68's falls on 02/21/24 and 05/17/24 was done. On 02/21/24, R68 was found on the floor in room next to his bed, documentation from staff members reports documented resident verbalized wanting to go home as a factor influencing the incident and to prevent the incident from happening again, place resident in recliner in a visible are for close supervision, if attempting to get up from bed. On 05/17/24, R68 was found on the floor next to his bed, documentation from staff members reported resident was restless. On 07/03/24 at 10:12 AM, an interview and concurrent record review with Director of Nursing (DON) was done. Inquired if R68's care plan included the Geri-chair, DON confirmed the Geri-chair was not care planned.

Based on interviews and record review, the facility failed to invite one of the sampled residents (Resident (R) 76) to attend and participate in her care planning meeting. This deficient practice has the potential to affect all the residents in the facility. Findings Include: R76 is a [AGE] year-old female admitted to the facility on [DATE]. A review of R76's Brief Interview for Mental Status (BIMS) with Assessment Reference Date (ARD) 04/17/24 was conducted. R76's BIMS score was a 14, meaning R76 was cognitively intact. Interview with R76 was conducted in her room on 07/01/24 at 09:28 AM. R76 stated that she had not participated in her care planning meeting, and she would have loved to go. R76 stated, I've never heard of them having a meeting about me. If someone told me, I would have remembered and I would go. A review of R76's Electronic Health Record (EHR) was conducted. The record noted a care plan meeting held on 04/24/24. R76's son was listed as an attendee. R76 was not on the list for attendees. Interview was conducted over the phone with the Social Worker (SW) 2 on 07/03/24 at 09:04 AM. SW2 stated that she does not recall inviting R76 to her care planning meeting. A review of the facility document titled, Comprehensive Care Plan Guideline, was conducted. The document noted, The resident and/or representative will be invited to attend the interdisciplinary Care Plan meeting during the Admission, Quarterly, Annual, and/or Significant Change Care Plan review meetings and upon request.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 06/30/24 at 08:42 AM, during an initial tour of the kitchen with [NAME] (C) 1, observed an opened and used large container of French salad dressing in the refrigerator. The salad dressing did not have an open/preparation date and a use-by-date. C1 was observed to immediately take the salad dressing out of the refrigerator and confirmed there should be a label for when the dressing was opened and when it should be discarded. Observed in a plastic container bin with a bag of oatmeal, a scooper on the bottom of the bin with oatmeal residue and unidentified debris. C1 confirmed the scooper should be hung and not touching the bottom of the bin. At 09:19 AM, observed C2 answer the phone, hang up the phone, put gloves on, and then his mask, before going back to prepping food, without washing his hands. Inquired with C2 if he washed his hands before putting on his gloves, C2 stated he did not. On 07/02/24 at 03:00 PM, an interview with Dietician (D) 3 was done. D3 reported staff should wash their hands prior to prepping food when touching other items to prevent foodborne illnesses. Review of the facility's policy and procedure Food Preparation and Handling effective 09/01/10, documented All food items, while bring prepared, are protected against contamination from dust, flies, rodents and other vermin unclean utensils and work surfaces, unnecessary handling, coughs, sneezes .and any other source of contamination .Foods will be prepared and served with clean tongs, scoops, forks .plastic gloves or other suitable implements to minimize handling and avoid manual contact of food at all point during preparation and service. Review of the facility's policy and procedure Hand Hygiene effective 02/03/23, documented Indications for Hand Hygiene .Before preparing or serving food .

Based on record review and interview the facility failed to update Resident (R) 6's electronic health record (EHR) to accurately stage his facility acquired injury progressing from Moisture-Associated Skin Damage (MASD) on his right gluteus to a stage 3 Pressure Ulcer (PU) on his coccyx. This deficient practice could affect all residents who have skin injuries that are not being documented correctly. Findings Include: On 07/01/24 at 10:09 AM during record review of R6's EHR found he had a newly in-house (facility) acquired MASD injury documented on his skin assessment dated [DATE]. Weekly skin assessments for R6 were filled out from 03/19/24 - 06/19/24 documenting R6 had MASD on his Right Gluteus that at times was deteriorating, stalled or improving. Weekly progress notes for Skin/Wound Notes, written by facility Registered Nurses (RNs), dated from 03/16/24 - 06/26/24 also had documentation that R6 had MASD and not a stage 3 PU to his coccyx. Review of pictures provided in R6's EHR showed R6's injury was deeper than superficial. On 07/01/24 at 01:45 PM interviewed Minimum Data Set (MDS) coordinator 1 and inquired who stages the resident's skin injuries and she stated the nurses on the unit determine the type or stage of the injury. On 07/03/24 at 11:04 AM interviewed Head Nurse (HN) 9 on second floor. Inquired about R6's MASD and stated that it appears to be a PU. HN9 stated it is a stage 3 PU. HN9 explained Point Click Care (EHR software) does not give the facility an option to change the documentation from progression of MASD to a PU. HN9 explained the MASD would have to be resolved and then the PU put into the EHR. HN9 explained R6's NP, an outside provider, had identified the injury as a stage 3PU in her documentation which was provided to the facility. HN9 stated the team met on 07/02/24 to discuss R6's injury and agreed the MASD had progressed to a stage 3 PU. At this time requested HN9 provide copies of R6's Care Plan (CP), doctor's orders, skin assessments, progress notes and NP Assessment. On 07/03/24 at 11:16 AM met with and interviewed DON who stated there was a meeting yesterday (07/02/24) and the team discussed R6's injury and concur it is no longer MASD but a stage 3 PU and the change should have been made in R6's EHR. On 07/03/24 review of R6's CP, doctor's orders, weekly skin assessments and weekly progress notes has documention of R6's injury as MASD. During this review there was no documentation found that facility staff documented R6's PU progressed (got worse) from the MASD to a stage 3 PU on his coccyx with full thickness skin loss as documented by R6's Nurse Practioner (NP) on 05/14/24. During this review noted NP assessment had been faxed to the facility on [DATE] at 02:14 PM. NP documented on R6's injury Started as MASD but worsened with pressure.

Based on observations, interviews, and policy review, the facility failed to ensure proper hand hygiene procedures were followed by a staff member during medication administration. This deficient practice promotes the development and transmission of communicable diseases and infections. The deficient practice has the potential to affect all the residents in the facility. Findings Include: Concurrent observation and interview were conducted on 07/02/24 at 08:16 AM. Registered Nurse (RN) 10 was observed preparing medications for Resident (R) 8. After placing the pills in the cup, RN10 walked to the refrigerator for apple juice. RN10 could not find apple juice so he/she used the telephone to call the facility kitchen. RN10 then walked back to the medication cart and poured laxative powder into a cup. RN10 then walked back to the refrigerator and grabbed cranberry juice to add to the laxative powder. After mixing the laxative and cranberry juice, RN10 entered R8's room. RN10 then proceeded to administer whole pills to R8, followed by the laxative and cranberry drink. RN10 was not observed performing hand hygiene throughout the different tasks. RN10 was asked if he/she should have performed hand hygiene prior to R8's medication administration. RN10 stated hand hygiene should have been done prior to giving R8 her medications. Interview was conducted with the Director of Nursing (DON) on 07/02/24 at 01:50 PM. DON confirmed that RN10 should have performed hand hygiene prior to administering medications to R8. A review of the facility policy titled, Hand Hygiene, dated 08/01/10, was conducted. The document noted, Indications for Hand Hygiene (Alcohol Based Hand Rub or Handwashing) .Before administering mediations.

Based on observations and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodations to one of 18 residents sampled (Resident (R) 57). As evidence by, not ensuring R57's call light was within reach and assessable. This deficient practice has the potential to negatively contribute to resident outcome. Findings Include: R57 is an [AGE] year-old male admitted to the facility on [DATE]. He is Cantonese speaking but understands a small amount of the English language. Observation was conducted on 07/24/23 at 08:46 AM. R57 was in his room, awake, and sitting at the edge of his bed having breakfast. He greeted this surveyor with a wave. R57's call light was wrapped up and hanging on the wall. The placement of the call light was not within reach for R57. Observation was conducted on 07/24/23 at 01:30 PM. R57 was asleep in his room and his call light was still hanging on the wall. Observation was conducted on 07/25/23 at 07:37 AM and 01:11 PM. R57 was lying in bed and his call light was still hanging on the wall, not within reach for the resident. Observation was conducted on 07/26/23 at 10:18 AM. R57 was up in bed finishing his meal. His call light remained hanging on the wall. Interview with Registered Nurse (RN) 53 was conducted on 07/26/23 at 10:20 AM in the nurse's station. RN53 was asked if the call lights should be near residents and be accessible to the residents. RN53 stated that the call light should be near and accessible to all the residents. Informed RN53 that R57's call light has been hanging on the wall and has been inaccessible to the resident for the past 3 days. RN53 stated that the call light should be accessible to R57 even though he probably wouldn't use it.

Based on observation and staff interview, the facility failed to maintain a clean environment as evidenced by a supply shelf, in the second-floor storage room, found covered with spider webs. As a result of this deficiency, the facility increased the risk for infestation. Findings include: Observation on 07/25/23 at 08:30 AM of the supply storage room on the second floor revealed a shelf covered with spider webs. The shelf contained a seat cushion and a splint. The shelf below contained boxes of disposable gloves. During staff interview on 07/25/23 at 08:35 AM, Registered Professional Nurse (RN)29 acknowledged that the shelf was covered with spider webs. RN29 said that they would have housekeeping immediately remove the spider webs and have the room cleaned.

Based on observations, interviews, and record review, the facility failed to implement interventions in a care plan to provide effective and person-centered care that meet professional standards of quality care for two of the 18 residents sampled (Resident (R) 22 and R30). This deficient practice has the potential to negatively impact the resident's quality of life. Findings Include: R22 has a medical history that includes but not limited to cerebrovascular disease with hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness), and dementia. R22 has also been receiving hospice care since 06/14/23. Observation and interview were conducted on 07/26/23 at 07:53 AM in R22's room. R22 just finished having her breakfast and was lying in bed. This surveyor asked R22 how she did in bingo yesterday. R22 responded that she didn't win anything but was happy to be out of her room since she has been in isolation for the past 10 days. R22 was informed by this surveyor that there was another bingo activity scheduled for 10:00 AM that morning. R22 became excited and expressed interest in wanting to go. Observation and interview were conducted on 07/25/23 at 10:15 AM in R22's room. R22's curtains were drawn, and she was receiving personal care from Certified Nurse Aide (CNA) 32. This surveyor asked through the curtain why R22 was missing bingo. CNA32 responded, She already went yesterday. Interview was conducted on 07/27/23 at 07:45 AM with R22 in her room. R22 explained that she had missed bingo the day prior because she was told by staff that it was not her turn to go and that it was her roommates turn. R22 stated she wanted to go because she likes playing bingo. Interview was conducted with CNA32 on 07/27/23 at 08:20 AM on the third-floor hallway. CNA32 explained that residents are assisted to get up every other day. R22 was assisted to get up into a recliner to attend bingo on 07/25/23. On 07/26/23 it was another resident turn to get up into the recliner. Therefore, R22 missed bingo on 7/26/23. Interview was conducted on 07/27/23 at 08:20 AM with Recreational Aide (RA) 12. RA12 explained that there is usually a list of residents that request to attend bingo. RA12 indicated that R22 was not on the list. RA12 also explained that one of her tasks is to go around and let the residents know bingo was an activity for the day. RA12 stated she did not go into R22's room on 07/26/23 to invite her to bingo. RA12 also added that any resident that wants to come to bingo are accommodated and are not denied participation. Interview with Registered Nurse (RN) 53 was conducted on 07/27/23 at 08:47 AM. RN53 stated that RA12 usually does the inviting of the residents for facility activities. She also added that there is no limit to the number of resident participants because everyone should be accommodated. RN53 stated that R22 should have been able to attend bingo on 07/26/23, especially since it's on R22's care plan. A review of R22's Electronic Health Record (EHR) indicated, I [R22] make daily decision, just invite and escort me when I am available to any group activities for meeting my emotional, intellectual, physical, and social r/t CVA with right sided weakness. These activities are my favorite and very important to me i.e. bingo, Catholic mass/service, keeping up with the news, music, and being with group of people. 42871 On 07/24/23 observations of R30 were made. At 08:45 AM, R30 was observed lying in bed on her right side, a pillow propped under the left side of her back. R30 was very thin and frail and slowly responded to her name by nodding. At 10:00 AM, R30 laid on her back in bed with her eyes closed. At 11:38 AM, R30 was observed still lying on her back, sitting up with the head of bed raised. R30 was grimacing. On 07/25/23 at 07:30 AM, R30 was observed to be sitting up in bed eating breakfast. No verbal response was made when state agency (SA) greeted her. On 07/25/23 at 09:48 AM, interviewed R30's family member (FM) via phone. FM stated that R30 needed to exercise her upper extremities because of her limited mobility. Record review of R30's electronic health record (EHR) revealed a Transfer/Discharge Report documenting that R30 was an [AGE] year old resident admitted to the facility on [DATE]. R30's diagnoses included Adult Failure to Thrive, Mild Cognitive [brain] impairment of Uncertain or Unknown Etiology, and Traumatic Subarachnoid Hemorrhage [bleeding in the brain] . Review of the Progress Notes documented on 06/22/23 by the respective therapists, revealed that R30 was not appropriate for physical therapy (PT) and occupational therapy (OT) interventions due to her . frail condition, and limited activity tolerance . and recommended a maintenance program for upper and lower extremity range of motion (ROM) exercises. Care plan problem, I am at risk for further falls and fall related injury associated with my medical condition, impaired mobility and cognition and history of falls prior to admission, had the intervention of maintenance OT/PT for upper and lower extremity ROM . Tasks revealed that active ROM and passive ROM were to be done by the Certified Nurse Aide (CNA) on every shift. Active ROM flowsheet for 06/28/23 to 07/21/23 showed exercises were done with R30 on three days and R30 refused one day out of the 24 days documented. Not Applicable was marked for the rest of the 20 days. Passive ROM flowsheet for 06/28/23 to 07/21/23 indicated that it was done on seven days, refused by R30 for eight days, and marked Not Applicable for 15 days. On 07/27/23 at 10:54 AM, a concurrent review of the task flowsheets for active and passive ROM and interview were done with Registered Nurse (RN)19. RN19 stated that the expectation is for R30 to have these exercises done with her every day on every shift and documenting an entry Not Applicable was unacceptable.

Based on record review and interviews, the facility failed to communicate necessary discharge information to the resident, resident representative and/or family member (FM), and provider(s) for one resident (R), R74, out of a sample of two residents. Inadequate information was documented by R74's physician detailing R74's course of stay at the facility and incomplete information was noted in the nursing discharge instructions and discharge care plan. Finding includes: Record review of R74's electronic health record (EHR) revealed a Social History And Assessment document that stated that R74 was a [AGE] year-old resident. R74 did not want to prolong her life and a discussion was made with the FM regarding hospice care. R74 has lived in a foster home for one and a half years and wants to return there. Transfer/Discharge Report noted that she was admitted on [DATE] and discharged on [DATE] to a foster home. Read Skilled Charting - V2 document dated 05/18/23. R74 needed total care with her activities of daily living (ADL) and had impaired balance and was weak. R74 was not eating well due to difficulty swallowing, was incontinent of bowel and bladder, and used oxygen delivered through tubing to her nose. R74 was referred to hospice care. Reviewed Discharge Summary Report, written by R74's physician. A handwritten word next to Diagnoses, three handwritten lines after Physician Summary, and a handwritten date of documentation were all difficult to decipher. Discharge Instructions had no notation under Treatments, Last Meal, Last BM [bowel movement], Follow-up Visits, Physician Name, Phone Number, Appointment Date/Needed, Ambulation Status, Transfers, Other, and entries listed under Social Services (Community referrals, Social/Emotional/Behavior Status, and Coping Mechanisms/Reaction to Discharge. There were only the discharge medications noted on the document and not the medication regimen R74 was admitted with, indicating changes made in R74's medication during her course of stay at the facility. The discharge care plan did not state that R74 was referred to hospice services and did not describe the care to be received at her foster home. On 07/27/23 at 10:23 AM, a concurrent review of R74's EHR and interview were done with Registered Nurse (RN)19 at the unit's nursing station. RN19 stated that the physician describes the resident's course of stay at the facility in their discharge summary. Reviewed Discharge Summary Report with RN19 and she could not decipher the physician's handwriting and confirmed that it was also incomplete because it did not summarize R74's course of care received at the facility. During the concurrent review of the nursing Discharge Instructions, RN19 stated that residents are discharged with instructions reviewed with the resident and/or resident representative containing any follow-up appointment(s) with the provider(s), therapy to be received and with instructions on how to perform them (as appropriate) and the resident's current medications with instructions. RN19 stated that the document was not complete because all blank spaces pertinent to R74 should have been completed and they were not. As a result of both incomplete documents, the foster home care operator, R74 and FM, will not know the regression of R19's health in the facility and the needed care that R74 is to receive. On 07/27/23 at 11:14 AM, interviewed Social Worker (SW)2 via phone. SW2 confirmed that R74's discharge care plan was incomplete because it did not state that R74 was referred to hospice care and any needed treatments or care. Record review of Transfer/Discharge Requirements and Documentation policy and procedure with effective date 01/07/18. It stated, . IV. Procedure . C. A comprehensive discharge care plan must be developed by the social worker as appropriate based on the resident and/or resident representative preferences, goals, and needs . H. Staff will provide sufficient preparation and orientation to the resident to ensure a safe and orderly transfer or discharge from the facility including providing discharge instructions that outline post-discharge care (prescribed and over the counter medications and treatments) and summary of arrangements made for follow up and post discharge services as applicable and agreeable by resident and/or representative.

Based on record review and interview with staff member the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for two of five residents sampled (Resident (R) 27 and R32). The facility failed to monitor R32's and R27's behaviors and use the appropriate diagnoses related to psychotropic medications. Findings include: 1) Review of the facility's policy and procedure Psychotropic Drug Use effective 09/01/18, documented a .physician's order must be obtained for use of any psychotropic medication and the order must include Indication and clinical need on measurable diagnosis or condition for the medication and specific .behavior targeted. The policy and procedure further documented There must be documented monitoring of episodes of symptoms or behaviors . 2) During review of R32's Electronic Health Record (EHR) on 07/26/23 at 09:12 AM, R32's physician's orders include an antipsychotic medication, Seroquel, 6.25 milligrams (mg) once a day effective 06/09/23, and an antidepressant medication, Sertraline, 50 mg in the evening effective 02/11/22. Both for Dementia with Behavioral Disturbance. Documentation of the monitoring of the behaviors related to the use of the psychotropic medications were not found. Review of R32's nursing notes documented on 07/05/22 Resident's behavior such as asking for enema at all times, fixated on going to the ER [emergency room ] and fixated on not having a bowel movement has not been observed for the past 5 months of her behavior monitoring review. We will reactivate behavior monitoring as we observed such behavior. On 12/19/23, Verbalizing wanting to die behavior has not been observed for the past several months of her behavior monitoring review. We will reactivate behavior monitoring as we observed such behaviors. R32 continued to be administered the psychotropic medications after behavior monitoring was discontinued. Further review of R32's nursing notes documented on 06/09/23, Resident was seen by .[the physician] .on 6/8/23 for follow up via telehealth. Received telehealth notes today. APRN .[Advanced Nurse Practitioner], covering for MD .[Medical Director] .and was updated of the recommendation. Signed consent for the use of psychoactive medication. We will continue to monitor resident's behavior. On 07/26/23 at 02:23 PM interview and concurrent record review with Registered Nurse (RN) 53 was done. RN53 confirmed R32 was prescribed Seroquel, an antipsychotic, and Sertraline, an antidepressant. RN53 reported the behaviors that were monitored for Seroquel were not having a bowel movement and accusing daughters of bulling her. RN53 confirmed behavior monitoring was discontinued because she no longer exhibited the behaviors for several months. RN53 reported due to R32 not exhibiting behaviors related to the Seroquel the dose had gradually decreased from 50 mg to currently 6.25 mg. RN53 further reported for Sertraline, R32 was admitted with a dose of 25 mg but was increased to 50 mg on 02/11/22 due to expressing she is better off dead and did not want to be a burden to her family. RN53 reported R32 has not expressed negative statements of wanting to die since the dose change and the behavior monitoring was discontinued. 42871 2) On 07/24/23 at 11:33 AM, interviewed R27 in his room. R27 laid in bed and responded appropriately to inquiries. R27 stated that he takes an antidepressant and would like to see a psychiatrist because he stated, This is not the best living situation. Record review of R27's electronic health record (EHR) revealed under Orders, directives for Escitalopram (medication to treat depression) 20 mg (milligrams) one tablet daily, Mirtazapine (medication to treat depression) 7.5 mg one tablet at bedtime, and Trazodone (medication to treat depression) 50 mg one tablet at bedtime for insomnia. There were no behavior monitoring documentation by the licensed nurses found in R27's EHR which indicated if R27's depression improved or if his depression continued or became worse with the use of the three antidepressant medications. There was also no documentation noting any follow up on the effectiveness to treat R27's insomnia with the administration of Trazadone. There also was no consent signed by the resident for the use of Trazodone. Care Plan stated an intervention under R27's depression, . Administer Lexapro, Trazodone, Mirtazapine . as ordered. Monitor for . effectiveness . On 07/27/23 at 11:33 AM, concurrent review of R27's EHR and interview were done with Registered Nurse (RN)19 at the unit's nursing station. RN19 confirmed that there was no behavior monitoring notation done by the licensed nurses to indicate the effectiveness of the antidepressants for R27's depression and insomnia (Trazodone). RN19 also stated that the diagnosis of insomnia for Trazadone was unacceptable and that the diagnosis should be for the usage of Trazadone as an antidepressant. RN19 searched in R27's EHR and paper chart for the consent to use Trazodone and none was found.

Based on record review and interview with staff member the facility failed to evaluate one of five residents sampled (Resident (R) 32) for gradual dose reduction (GDR) for a psychotropic medication prescribed to treat behaviors that are no longer monitored and exhibited. Findings include: Cross Reference to F757, the facility failed to ensure each R32's drug regimen was free from unnecessary drugs due to not monitoring R32's behaviors related to psychotropic medications. On 07/26/23 at 09:12 AM review of R32's Electronic Health Record (EHR) was done. R32 was admitted to the facility on [DATE] with a physician's order of Sertraline 25 milligrams (mg), one tablet in the evening. On 02/11/22, R32's Sertraline dose was increased to 50 mg, one tablet in the evening. Behaviors that were monitored related to the antidepressant but discontinued were fixated on not having a bowel movement, asking for enema, and fixated on going to the emergency room were discontinued on 07/05/22. Making up stories/accusatory, crying, feeling unhappy and getting mad/throws tantrums were discontinued on 09/05/22. Verbalizing wanting to die was discontinued on 12/19/22. Review of a consent form for the antidepressant dated 02/11/23 documented increase Zoloft [Sertraline] to 50 mg in the evening for target behavior feeling unhappy verbalizing wanting to die. Review of a nursing note on 12/19/23 documented Verbalizing wanting to die behavior has not been observed for the past several months of her behavior monitoring review. We will reactivate behavior monitoring as we observed such behaviors. On 07/26/23 at 02:23 PM interview and concurrent record review with Registered Nurse (RN) 53 was done. RN53 confirmed R32 is currently prescribed Sertraline 50 mg in the evening. RN53 reported R32 was admitted with a dose of 25 mg but was increased to 50 mg on 02/11/22 due to expressing she is better off dead and did not want to be a burden to her family. RN53 reported R32 has not expressed negative statements of wanting to die since the dose change and the behavior monitoring was discontinued. RN53 confirmed it has been more than 6 months since the facility discontinued the behavior monitoring and the facility has not attempted or evaluated for a GDR for the antidepressant during R32's stay in the facility and after increasing the dose more than a year ago. Review of the facility's policy and procedure Psychotropic Drug Use effective 09/01/18 documented Within the first year in which a resident is admitted on a psychotropic medication .or after the facility initiated an psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinical contraindicated.

Based on observations, interview, and facility policy review, the facility failed to properly store medications in a manner that facilitates considerations of precautions and safe administration in one out of two medication carts sampled. This deficient practice has the potential to promote medication administration error to one resident in the facility. Findings Include: Observation and interview were conducted on the third-floor hallway near the nurse's station on 07/25/23 at 01:52 PM. A medication cart contained a resident's medication blister pack labeled, Senna 8.6 mg tablets. On the blister pack was a handwritten note indicating, Discard after 5/23. Registered Nurse (RN) 6 was questioned about the medication blister pack. RN6 confirmed that the medication should not have been in the cart and should have been discarded. Record review was conducted on the facility's document titled, Medication Storage, dated 01/23. The document indicated, Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observations, record review, and interviews the facility failed to ensure a resident's (Resident (R) 55) menu met her preferences. Findings include: R55 was admitted to the facility on [DATE]. R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/23 documented R55 scored a 15 (cognitively intact) during the Brief Interview for Mental Status (BIMS). On 07/24/23 at 09:18 AM interview with R55 was done. R55 stated she prefers to have lots of fresh vegetables with her meals. R55 reported she likes to have a bite of fresh vegetable after eating a piece of meat because she does not feel good when she eats too much meat. R55 reported she did not get any vegetables with her breakfast and during lunch and dinner her salad is very small. On 07/24/23 at 01:32 PM observed a small salad with R55's lunch. Observed R55 to eat all her salad. R55 stated she got lettuce, but it was not enough, and she wanted more lettuce. R55 further reported during her dinners she receives only a little bit of fresh vegetables. On 07/25/23 at 08:11 AM observed no vegetables with R55's breakfast. R55 stated she did not get any vegetables with her breakfast. On 07/25/23 at 12:07 PM observed R55 eat all her small salad but did not touch her chicken or cooked carrots and ate a small portion of her rice. Inquired why R55 did not eat the other food, R55 stated she does not really like the food and reported she ate all her salad. On 07/26/23 at 12:05 PM observed R55 eat all her small salad, fruit, a portion of her rice and soup but did not touch her chicken with gravy and cooked vegetables. Observed Staff Member (SM) 3 ask R55 if she is done with her meal and inform R55 she will take her back to her room. Inquired with SM3 if she is usually in the dining room providing supervision, SM3 stated she rotates with other staff members. Inquired if R55 does not eat much of her meals, SM3 stated she usually does not. Further inquired if SM3 knew the reason why, SM3 stated she was not sure. On 07/26/23 at 12:27 interview and concurrent record review with Registered Dietician (RD) 1 was done. RD1 explained the admission process to ensure the facility gathers information on residents' preferences. RD1 reported during admission and annually her assistant will use the worksheet Assistant to Dietitian New Admission/Annual Worksheet to help determine preferences. Inquired if a form was done with R55, RD1 stated it was not done with R55 and it was not documented that her assistant attempted to meet with R55 and if R55 refused. RD1 reported she spoke with her son about the resident's preference because R55 may speak another language which may have been challenging for her assistant. Inquired if the facility uses interpretor services, RD1 confirmed they do, and it was not documented interpreter services was attempted to be used with R55 to ensure her preferences were considered.

Based on observation, record review, interviews and review of the facility's policies and procedures, the facility failed to protect and ensure residents have the right to be free from any physical restraints imposed for purposes of discipline or convenience for 3 of 44 residents (Residents #87, #178 and #45). There also was neglect in the failure to provide care and services necessary to assure the residents' needs were met. This resulted in Resident #87, who is continent of bowel and bladder, having to vocalize with loud pleas to be let out of her geri chair because she wanted to void. For Resident #178, the harm was being unable to freely get out of bed as a result of various devices/equipment staff placed around her bed to prevent her from getting out. Resident #45 was found to be left in the hallway in her geri chair with a lap tray for restless behavior for several hours, without being toileted, without activities and no medical reason to substantiate the use of being in a geri chair for an extended length of time. Findings include: On the afternoon of 8/5/15, an Immediate Jeopardy was found at the facility. There was harm due to the failure of staff to recognize for three cognitively impaired residents (Res #87, #178 and #45), that these residents were physically restrained as a method of staff convenience, and these devices were not used in order to enhance the residents' quality of life or for their safety, and did not promote the highest practicable well-being or level of function to them. The facility's policy (No. 110-3-14) Physical Restraints and Devices states: Restraints are to be used only when necessary under limited medical conditions or symptoms to prevent injury to resident and/or to others. The decision to apply restraints shall be based on a comprehensive assessment and care planning that shall include assessment of the resident's capabilities, causes of behavior and evaluation of least restrictive alternatives and ruling out of their use.and the right to refuse/accept restraints shall be addressed by informed consent. Restraints may not be applied for the purpose of discipline or staff convenience. Restraints must be ordered by the attending physician for a specified and limited period of time.A physical restraint is any manual method or mechanical device, material, or equipment that is attached or adjacent to the resident's body THAT THE resident cannot easily remove by him/herself and restricts the resident from freedom of movement or normal access to his/her own body.Physical restraints include, but are not limited to, the following:.Geri chairs; Lounge chairs/beds; Lap tables/Lab Buddies; Other chairs and/or position of chairs that prevent the resident from rising; Any physical barriers that prevent voluntary movement. Review of the facility's abuse policy (No. MPAT0003) Freedom From Abuse And Neglect states: 3. Mental abuse includes, but is not limited to,.deprivation. Psychological abuse.Deliberate ignoring of a resident by staff member.In addition, Psychological abuse may be indicated if a resident exhibits the following manifestation: Helplessness (being unable to manage oneself; defenseless; lacking power). Hopelessness (despair; feeling trapped).Neglect means the failure to provide the goods or services which are necessary to avoid harm; mental anguish.or failure of a staff member to provide such goods, or services. 1. Neglect and harm suffered by Res #87 by the use of a physical restraint (geri chair). On 8/5/15 at 5:08 AM, surveyors entered the facility to observe the night shift based upon an anonymous complaint and allegations that residents were being placed in geri chairs on all units and and some were being restrained with equipment. Upon arrival on the 2 Makai unit, there were two Residents (Res #45 and #87) placed in geri chairs in the hallway fronting the nursing station. Res #87 was heard from the elevators repeatedly calling out loudly for help and saying over and over, Hayaku, hayaku, onegai, shonben[***]i. This meant hurry, hurry, please, I need to urinate. (Surveyor understands Japanese). At 5:13 AM, surveyor observed that Res #87 continued to plead and motioned with her hands to lower the geri chair's foot rest. The foot rest was raised so the geri chair was in a semi-recumbent position, yet the resident was sitting up with her knees bent. She reached out with her arms, put her hands together in prayerlike fashion, and kept motioning and stating, Sagete kudasai, kore and Onegai, onegai, shonben[***]i. The resident continued to say, Hey, hey, please lower this; please I want to urinate. At the time, there was a licensed nurse (LN #4) in the adjacent hallway and two CNAs on the unit. However, Res #87's vocalizations could be heard throughout the unit as it resonated loudly. This was verified by another surveyor who came to the unit after touring the 2 Mauka wing. On 8/5/15 at 5:20 AM, surveyors met LN #4, who said he was the 2 Makai unit charge nurse. He had been standing at the medication cart, which was parked right around the corner of the unit by the nurse's station. Around that time, LN #3, the night shift supervisor TA, also came to the unit, saw and heard Res #87 and said to LN #4, She likes the feet down. LN #4 replied back, Oh no, it's not safe, we have an order for [REDACTED]. LN #3 walked away shortly thereafter and left the unit. LN #4, the supervising registered nurse on duty, did not attempt to stop and assess Res #87, who was still calling out. The resident's distress was evident by her clear vocalizations for help and constant pleading in Japanese. At one point, she tried to get out of the recliner by pushing her hands against the armrest to lift herself, but could not. LN #4 continued to say he had a doctor's order for use of the geri chair and pulled the resident's chart. He read that it was for a recliner and said it was for restless behavior, I reported this to the doctor. Of note, the 2015 August Physician order [REDACTED]. It did not state to place the resident in the geri chair for restless behavior. LN #4 was queried about the resident's continuous calling out for help and he replied, I ask her many times if she's in pain, and [MEDICATION NAME] was given at 11:30. Well, usually she calm down. Also, we have language barrier and she speaks Okinawan language. I don't understand the language. He was asked if this has been going on all night long and he replied, Yes, pretty much. Only tonight she started making noise around 15 mins to 5 mins ago. By 5:21 AM, the resident was still calling to be toileted. LN #4 was asked if he even attempted to get her out of the geri chair and he said, I heard her screaming and yelling and (CNA #1) was with her. He was asking if you want to make shi shi (urinate) earlier, but she said no. Sometimes in past, she says, shi-shi shi-shi but she makes nothing--there's past history for this. She's screaming and yelling and agitated. I told (CNA #1) to recline it to make sure that it is safe. At 5:29 AM, CNA #1 was asked if Res #87 was able to void on her own. He said, Yes, with extensive assist. He then wheeled the resident into her room and then CNA #1 assisted her to use her own bedside commode where she voided urine. Afterward, he placed her back into the geri chair in an upright sitting position with a pillow behind her back. At 5:47 AM, continued observation noted Res #87 remained in the geri chair in the hallway, but her demeanor was calm after having voided. She did not yell, plead nor cry out for help. CNA #1 and CNA #5 both confirmed they did not understand what the resident asked for and said they had no translation cards/tools to effectively communicate with her. She remained in the geri chair sitting upright when the day shift arrived. On 8/5/15 at 5:49 AM, a re-interview with LN #4 was done. He confirmed he gave the resident [MEDICATION NAME] once at bedtime. He was asked when Res #87 has restlessness and agitation, what does he assess. He said, It could be potty. I did ask for pain, I did ask if she's hungry, thirsty. This shi shi episode--before you came in (CNA #1) did ask her, but she didn't want to go. I guess I should try harder and ask her what she really wants. Because she speaks Japanese most of the time and I don't understand her and her past fall events-I just try to avoid her falling on floor. And we do have the Elder Justice Act that we have to call the police if there's a severe injury with a fall. Also, yes, being [MEDICATION NAME], and meeting the needs of resident. At 5:00 when (CNA #1) was asking her, I really felt I met my duty as nurse because he asked her. I should have asked her several more times if she want to make shi shi. LN #4 made no attempts to assess the resident during the entire time surveyor observed the resident. LN #4 was insistent the resident had been asked to be toileted and that he did not want to lower her footrest because he had an order. LN kept referring to the resident's past history of restless behavior and agitation and said about the geri chair, Well, it's not a restraint, this is really for safety. This is my unit so I know how she is. Interview of LN #3, the night shift nursing supervisor, was done on 8/5/15 at 6:09 AM. She said regarding Res #87, she told LN #4 earlier to put down the feet of the recliner because I thought that was what was making her noisy, she was pointing to it that's why. He said no because she'll try to get out of the recliner when you put down the foot of the recliner. I have to leave because I have to post the (nursing) schedule, yeah, because morning shift coming. LN #3 said for Res #87, I should have stayed and did it myself. She was uncomfortable. So is this a concern for you? Yeah it is. LN #3 said she was up on the unit earlier, but when she made her second rounds around 4:00 AM, her feet wasn't up. She recalled the other resident (Res #45) was also up at that time too. LN #3 was asked what she looked for while making her rounds. She replied, If there's problems like that I need to address it. She then told CNA #1, Keep an eye on (Res #87) and left the unit. On 8/5/15 at 7:15 AM, CNA #1 was interviewed regarding Res #87. He stated the 3-11 shift endorsed this resident to him and she was already in the geri chair. Yes ma'am, she was up in recliner all night. Did you attempt to toilet her? Yes, I toilet her 2x before at 2:45, toileted her last one when you came around 5:15 I think. Surveyor observed the resident was still pleading out loud to be toileted at that time. CNA /#1 acknowledged he heard the resident yelling out about something, but said he was in room [ROOM NUMBER] caring for another resident. 2. Neglect and potential physical harm (i.e., by falling or by entrapment when climbing over the geri chair) by the use of physical restraints for Res #178. Initial observation of this resident during Stage 1 on 8/4/15 at 3:21 PM found that a staff did not want to place the resident back into bed but had her color in the center of room while she sat in her wheelchair. At that time, Res #27 called out to surveyor and stated, Today I got worried because they didn't put the lounge chair next to the side of her bed. They also use the small table (overbed table) and put it on the other side of the bed to prevent her from getting out. But it's probably because you folks are here--you're called the surveyors right? Well, that's why they're probably not putting the chair there. Usually, they put it on the side of her bed so she can't climb out. Because they can't tie her down right? That wouldn't be right. Res #27 said the staff have been placing the equipment around Res #178's bed and felt it was needed for her safety. Res #27 said, I feel responsible for her. I don't want her to get hurt. She's [AGE] years old, but boy, when she's determined to get out, I've seen her climb over the lounge chair as well. Although she has bed alarms, by the time the alarm goes off, she's standing on her feet! She further said, The usual routine is to put her back to bed in the afternoon and they put the lounge chair on the left side and the table on the right side. But today, it's not there and that's why I was worried that she would fall out or something bad would happen to her. Upon arrival of the 2 Makai unit at 5:08 AM on 8/5/15, it was found that Res #178 was asleep in her bed. Her bed however, was surrounded with 4 pieces of equipment: a bedside commode, a geri chair, an overbed table and a walker. The barricade was made with the bedside commode placed at the head of bed on the left side, with a geri chair next against the left side of her bed, and the overbed table at the foot of her bed. The walker anchored it so that the 4 items formed a backward L shaped configuration around her. On 8/5/15 at 5:11 AM, Res #27, who was already up, said, They brought her in around 1:30 AM. She's been restless and now she's sleeping. They've been putting the geri chair next to the bed since the time she came here. Res #27 said she thought the barricading was started by one of the CNAs. On 8/5/15 at 5:56 AM, LN #4 said he has not seen a geri chair next to the bed of Res #178. By that time, the geri chair had been moved and CNA #1 had the curtains drawn and was attending to the resident. LN #4 said, Oh, I don't know, I don't see it. LN #4 denied having seen equipment around her bed. On 8/5/15 at 7:15 AM, CNA #1 was interviewed about Res #178. He said, Her behaviors, sometimes she wants to get out of bed, she has tendency to get out of bed. Oh yeah, the recliner ma'am, I'm sorry. When I just came in the recliner is in there already. What I mean is that one is for the safety because her leg is--she's always putting down her legs because last night she was restless and she was sitting in the recliner and I just put her back in bed and I put the recliner. CNA #1 was asked why he put the recliner up against the bed with all the other equipment. He stated, Because she's always putting down her legs and always getting bruises right here, on her left side so if she's restless, but when I put her down, she's sleeping. He confirmed he put the recliner against her bed. He was asked if this was something he has been doing and he replied, To tell you the truth, yes. Why? Because since I came over here, that's what they're doing already. From evening shift too. Did you ever report this? No. And I'm very sorry, I know that's not supposed to be there. Just for the protection of the patient. How long has this been going on? Like long time already that one. Did you ever bring it up to the nurse at night (LN #4)? No, ma'am. I'm very sorry. 3. Neglect and harm by the use of physical restraints for Res #45. On the morning of 8/5/15 at 5:08 AM, Res #45 was observed sitting in a geri chair with a lap tray. She was placed next to Res #87 in the hallway. Res #45 was observed to be calm and just smiled and said What? when asked how she was. She had a magazine and some bangles on her lap tray, but primarily held and looked at her knit blanket on her lap tray. She was also observed to periodically rub the top of the lap tray with her hand, or just looked down and picked at her blanket. During the interview with LN #3 on 8/5/15, the night shift supervisor, she said Res #45 was already in the geri chair when she made her rounds at 4:00 AM. During the interview with CNA #1 the same day at 7:15 AM, he stated Res #45 was already outside and in her recliner when he started his night shift. He said it was endorsed to me by 3-11 shift. She is restless, she's trying to get out of the bed and so we put her into recliner. She has lap tray too. Can she remove that? I don't think so ma'am. He stated she is incontinent unlike Res #87 so they had to change her. We toileted her around 2 am something. I ask her if she wants to go bed, but she didn't want to, she just likes to stay in the recliner. From LN #3's and CNA #1's account, the resident had been placed in the geri chair for several hours in the night. Surveyor observed the resident was there from 5:08 AM, but did not see the night shift staff, nor the day shift staff interact with this resident. The breakfast cart then arrived on the unit; yet, the resident had not been taken out of the geri chair or had her lap tray removed. In addition, when the day shift arrived, many staff passed by her in the hallway, but staff did not ask or see what she was doing or if her needs were being met. No one asked how long she had been sitting in the geri chair. Then by 7:14 AM, Res #45 was in her room, sitting in the geri chair and eating her breakfast. She did not exhibit restless behavior and only called out someone's name in the early morning, but otherwise, had picked at her knit blanket, looked at a white piece of paper, or [MEDICATION NAME] over the top of the lap tray with her hands. 4. An interview of CNA #3 was done on 8/5/15 at 10:02 AM. She has been with the facility for approximately [AGE] years. She stated for Res #178, she has never witnessed a geri chair to barricade the resident's bed. She stated it was against the law because it's a restraint and it would be dangerous if you put it here. She can get up from the bed, she can stand if she likes to. I saw her getting out of bed like that during the day-early morning she's getting out of the bed already. She denied seeing a geri chair next to the resident and denied suggesting/ placing a chair next to the resident's bed. CNA #3 said the resident's geri chair is for her comfort because the wheelchair is too high because she cannot reach the food. There was no order for the use of [REDACTED]. For Res #45, CNA #3 said the resident had some behaviors of yelling and banging the geri chair. She said, The geri chair is mostly for her comfort, not for restraint. She said, but supposed to be less than 2 hours, cannot leave her longer than that. Because it's not good for their buttock and we need to reposition. She said the endorsement she received from LN #4 this morning was that Res #45 had been restless and that was why she was in the geri chair. This resident had an order written [REDACTED]. Yet, the resident was not restless, the lap table was not removed at any point during surveyor's observation and, longer sitting tolerance is not a medical reason to place a resident in a geri chair for several hours with no staff monitoring or documenting it. 5. On 8/5/15 at 12:51 PM, interview with the Director of Nursing (DON) was done. She said there was a nursing supervisor (TA) every shift Mon-Friday for 10 hours a day. She was asked how she assured residents' needs were met, especially during the night. The DON said she did not make rounds at night, and said, very rare on night shift but relied on her nursing TAs for this. The DON was then informed of the early morning observations found on the 2 Makai unit for Res #87, #178 and #45. She stated, a restraint would be if their freedom of movement was impeded. It would be a restraint. At 1:13 PM, the DON was informed that based on the findings for the 3 residents on the 2 Makai unit, an Immediate Jeopardy (IJ) was identified at this facility. The DON was informed that she and her team would need to formulate an abatement plan to ensure that any further harm would not occur, as a result of the residents being physically restrained. 6. On 8/5/15 at 5:53 PM, the survey team reviewed the initial preliminary IJ abatement plan. On the morning of 8/6/15, the final IJ abatement plan was accepted by the survey team. On 8/6/15, surveyor arrived at the facility at 9:15 PM and toured all four units to ensure the IJ abatement concerning systemic changes to address all residents had occurred as outlined. 7. On 8/6/15 at 10:15 AM, the geri psychiatrist (Physician #1) reviewed one of the resident's (Res #87's) 2011 order which was, Recliner PRN safety and better comfort. He was asked about the definition of PRN safety. He said he did not write this order, but agreed the wording for the PRN use was not clear and essentially how staff could misunderstand the use of placing the resident in a geri chair, thus becoming a restraint. He also was unaware of the numerous entries with which Res #87 was also being administered [MEDICATION NAME] at night. Physician #1 stated he would be reviewing her record and called the resident's family as well. Cross-reference to findings at F329. 8. On 8/6/15 at 10:17 AM, interview with the 2 Makai head nurse (LN #1) was done regarding the three residents. She verified for Res #87 and #178, there was no informed consent for use of the geri chair, but that Res #45 had one. She said for Res #87, the recliner was used if she was getting out of bed compulsively and if she was uncomfortable using the wheelchair. LN #1 said her expectation was to see documentation by staff before the transition from the wheelchair to the geri chair occurred. LN #1 confirmed her staff did not and said, There is no documentation as to the step by step things to be done before using the recliner. Once she's on the wheelchair, she has the ability to move around on the wheelchair (self propel). If she stays too long in there (wheelchair), then she gets restless or irritated, or the language barrier. We will offer if she would like to go to the geri chair then. Yet, conversely, the resident was never observed to have been offered a wheelchair on the morning of 8/5/15, if she was restless in the geri chair, to allow her to self-propel herself around the unit. She had an ADL care plan which noted she could do this. LN #1 also stated for those residents placed in geri chairs, my staff to still check on them to attend to their basic needs and that every 1-2 hours, if they're incontinent, uncomfortable, is there anything there and to provide immediate actions if there is any discomfort or any concerns. We still treat them like if they're on the bed, or if they want to have activities. If it's a language barrier, we have to use our cards or pointing onto words or drawings to better communicate to residents to make needs known. This was not done for either Res #87 or Res #45. LN #1 verified that Res #87 was also continent. Yes, she is continent of bowel and bladder--although she has dementia, that's one thing she is not forgetting. LN #1 was then asked when the geri chair became a restraint. She stated, It becomes a restraint when it restricts movement and she wants to move around and she wants to use the bathroom and no one to help her and address her needs. Even though she is continent, she is still dependent on us for mobility issues. Someone has to be with her and putting her on the commode. LN #1 stated as a result of what occurred, they would be reviewing all care plans, one by one--why are we using the geri chairs, it's not because they're restless you put them in. I tell them everyone has to have an individualized care plan and it works differently on them. She said they were also going to discontinue use of the geri chair for Res #87. Regarding Res #178, LN #1 said, She's the one with the barricade. She said this resident used the bedside commode and the overbed table. She denied having seen a barricade during her rounds or spots checks during the day. She said the resident is extensive to total assist in mobility, and occasionally incontinent. LN #1 denied having knowledge of the resident climbing out of bed, but maybe to extend her lower extremities to get out of bed. Maybe to extend and she slides down. During an interview of Res #178 thereafter via translation, the resident stated, I just stay in my bed. One time I get out and I overturned. One time I fall down when I try to close the window, and said something about landing on the grass. 9. Record review of Res #27 revealed she is verbally alert, responsive, very pleasant and conversant; able to make her needs known very well. A social services report dated 3/2/15 noted, This resident scored 29/30 on the MMSE and 3 on the PHQ-9, positive for having trouble sleeping daily. She reported roommates were disruptive at times, with one being restless and will try to get out of bed. The resident needed to call the nurses at times when the roommate.is trying to get out of bed. She reports she is not tired during the day and is not disrupted enough to move out of the room. Follow-up interview with Res #27 on 8/7/15 at 10:35 AM was done. She said, they haven't been putting the chair next to her (Res #178's) bed anymore. I had to call the nurse several times last night because she was getting up, but she did not fall to the floor or anything like that. I worry because she's so tiny that her bones will break like a picture window. It was noted no geri chair or other device was placed by Res #178's bedside, except her bedside commode. 10. On 8/6/15 at 10:17 AM, LN #1 said for Res #45, they were going to change the written order to separate the use of the geri chair so the use of the lap top was more defined. 11. Record review found LN #4's 8/5/15 nursing entry at 0715 for Res #87 noted: Received resident in recliner exhibiting restlessness and agitation. Several episodes of shouting at staff observed. [MEDICATION NAME] 25 mg po prn at 2330 for her [MEDICAL CONDITION] and restlessness without relief. Offered drinks and snacks but resident refused. Continue to monitor safety by nursing station. For Res #45, LN #4's entry at 0705 was similar to Res #87's and stated: Received resident in recliner exhibiting restlessness and agitation. Several episodes of yelling/shouting at staff and names of family members observed. Refused to take antianxiety meds prn. Offered drinks and snacks but resident also refused. Continue to monitor safety by nursing station. LN #4 did not have a nursing entry for Res #178 on 8/5/15. During the interview with the DON, she was not aware of the repetitive clinical entries being written for these residents, including restless behavior without descriptors of the behavior, or that non-pharmacologic approaches were not being documented prior to medicating the residents. The DON acknowledged they had a lot of work to do as part of their corrective measures.

Based on medical record reviews, staff and resident interviews, the facility failed to evaluate and revise care plans for 2 of 44 residents in the Stage 2 survey sample. Findings include: 1) On 08/06/2015 at 9:40 AM the medical record review (MRR), on R#14 found that the resident's most recent readmission was on 05/29/15. The Medicaid assessment done on 06/01/15 dcoumented that R#14's primary [DIAGNOSES REDACTED]. The resident's other [DIAGNOSES REDACTED]. The resident was also a right (R) side above the knee (AKA) [MEDICAL CONDITION] and had a new R groin Permacath that was first used for [MEDICAL TREATMENT] treatment on 05/29/2015. A. On 08/06/2015 at 2:02 PM interviewed LN#2 and asked what staff were doing to prevent [MEDICAL CONDITION]. LN#2 replied that staff are given directive for proper hand-washing and referred to care plan (CP) #6 Risk for DM and [MEDICAL TREATMENT] (HD) related complications; and intervention 12. Collaborate with _____ [MEDICAL TREATMENT]. LN#2 also stated that if R#14 displayed any abnormal temperature, and/or vital signs, staff would call the MD right away. The resident also had another CP #4 Risk for further skin breakdown related to impaired mobility due to PAD, Severe [MEDICAL CONDITIONS] R [MEDICAL CONDITION], DM, [MEDICAL CONDITION], hx of R AKA and amputation of toes to left foot, on ASA and incontinent, AV fistula on R groin. On 08/07/2015 at 9:36 AM interviewed R#14 to ask how the staff cares for his/her R groin Permacath access site and how it is kept dry when given a bath. The resident showed that the access site was covered with gauze, and stated that the CNAs cover the access site with plastic when given a shower. After talking with R#14 went to LN#2's office and the facility's infection control coordinator (ICC) was also there to look at R#14's CPs. Asked LN#2 if there was a CP for bathing R#14. LN#2 stated that how R#14 was given a bath was not in the CPs. LN#2 further stated that the access site was covered with gauze and changed after a shower. Informed LN#2 that R#2 said the CNA's covered the access site with plastic. The ICC went to ask CNA#2 to show what supplies were being used for R#14's baths. The CNA brought a small gray plastic bag and spool of tape that staff used to cover R#14's access site during showers. Asked CNA#2 how she knew what to do and she replied that the LN's provided instruction. The ICC looked at R#14's CP#6 and stated that there were no interventions specific for resident's high risk for infections. Discussed with the ICC and LN#2 the close proximity of R#14's new HD access site for soiling with urine and feces. The ICC asked LN#2 if the HD staff provided any recommendations to care for the Permacath access site. LN#2 stated that facility staff were instructed to reinforce gauze dressing if it became loose. Asked what staff would do if the dressing became soiled and LN#2 stated, Would have to change. The ICC stated that staff should be instructed on how to change soiled dressing. LN#2 picked up the phone and called [MEDICAL TREATMENT] to ask for instructions on how to care for R#14's Permacath site. B. The CP#6 Risk fo DM and [MEDICAL TREATMENT]-related complications for R#14 also had written under Measurable Goals .resident name will consume at least 900 ml/day and within fluid restriction of 1200 ml/day. On 08/06/2015 at 10:54 AM interviewed LN#2, due to the HYDRATION ALERT WORKSHEET for R#14 documenting >1200 ml/day on several days from 07/30/2015. According to LN#2, the resident brings back bottled water from the HD facility and hides them in his/her bag. Queried LN#2 how accurate are the staff in calculating the fluid intake for R#14 if the resident sneaks and drinks. LN#2 stated that staff will count the amount of fluid when they see the resident with a bottle of water. Asked LN#2 whether staff adjust fluids on the meal tray if they know that the resident had a bottle of water. LN#2 stated that they haven't done that. Discussed with LN#2 that the 1200 ml/day fluid restriction, was for dietary to provide 960 ml/day for meals, and 240 ml day for medpass; and, the hydration sheet showed that R#14 received more than 240 ml/day during medpass. LN#2 replied that she plans to talk with nursing staff to make adjustments. 2) The facility failed to monitor, reassess and update the care plan for Resident # 79 (Res #79)on a pureed diet. On 8/04/2015 at 11:26 AM Res #79 was observed seated in a wheelchair with a bedside table in front of her. A family member placed a napkin onto the bedside table then placed french fries on the napkin. Res #79 was observed picking up and eating the french fries placed on the napkin. When asked about dental concerns the family member stated she has dentures but does not use them. A meal observation was done on 8/06/2015 at 12:01 PM in Res #79's room. CNA #4 sat next to the resident and stated She really needs a lot of cueing; we feed her, she can hold the cup but she doesn't want to scoop with the spoon. Res #79 was noted to have an enlarged neck, when asked CNA#4 stated, she has an enlarged [MEDICAL CONDITION] according to family she was suppose to remove it but became scared and left the hospital, that's why she is on a pureed diet. A review of Res #79's speech/swallowing therapy evaluation stated, Medical History dementia, goiter. Comments: oral dysphasia dated 6/12/14, signed by a Speech Language Pathologist. On 8/06/2015 at 2:32 PM Licensed Nurse #9 (LN #9) was interviewed about the Res #79's diet and the observation of the resident eating french fries. LN#9 stated, We remind family she cannot eat that, sometimes the family brings for husband and he give to her, sometimes the brother give the soft rice, the husband keep on insisting, he say you eat, you eat, sometimes when they give the cake it is hard. A concurrent review of Res #79's care plan was done with LN #5. Res #79 Care Plan states, Problem #6 Risk for aspiration due to dysphasia. Intervention 6. Provide pureed diet, no bread products thin liquids. On 8/06/2015 at 4:16 PM the Registered Dietician (RD) was interviewed regarding the Res #79's meal observation, interview with nursing staff, and review of the resident's care plan. The RD stated, I will contact the speech therapist and nurses. I will tell the family to hold off, do a swallow evaluation and speech therapy recommendation, update the care plan on nutrition and at risk for aspiration. 3) The facility failed to update the care plan for Resident #45 (Res #45) who was prescribed trazadone as needed for [MEDICAL CONDITION]. Res #45 had the following as needed orders: trazadone for [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], and [MEDICATION NAME] for agitation. A review of Res #45's Care Plans did not find a care plan or interventions for [MEDICAL CONDITION]. On 8/6/2015 at 10:31 AM a concurrent medication review was done with Licensed Nurse #10, from July 14 to July 31, 2015 the resident was given trazadone 8 days out of 18 calendar days for [MEDICAL CONDITION]. When asked about the frequency of trazadone use for [MEDICAL CONDITION] LN #10 stated, she keeps moving and moving she is a fall risk, because of her dementia. On 8/6/2015 at 10:42 AM a concurrent medication review and interview was held with Physician #1 for Res #45. Within those 18 days when the resident received 8 doses of trazadone the resident was not given [MEDICATION NAME] or [MEDICATION NAME]. The concurrent review of the residents Behavior/Intervention Monthly Flow Chart documents that after each dose of trazadone outcome was 0 or unchanged. Physician #1 stated, my expectation when the resident is given an as needed medication like trazadone is they write down why it was given and non pharmalogical measures taken. Later that afternoon LN #10 stated, Physician #1 recommended we continue the [MEDICATION NAME] for sleep as needed; discontinue the [MEDICATION NAME]; and eventually discontinue the trazadone. We are going to monitor for about a week and follow up with Physician #1. This should have been done sooner because it was not working.

Based on medical record review (MRR, staff and resident interviews, the facility staff failed to ensure that 1 of 44 residents (R#14), was provided the necessary care to maintain his/her highest practicable level of physical well-being in accordance with the plan of care. Findings include: Cross to F280 On 08/06/2015 at 9:40 AM a MRR on R#14 was done. The social services notes documented that the resident lived at the facility since 08/13/2002. After the most recent readmission to the facility on [DATE] a Medicaid assessment dated [DATE] noted that R#14 had a primary [DIAGNOSES REDACTED]. The secondary [DIAGNOSES REDACTED]. At the bottom of the form, XX. Additional information concerning patient's functional status ____requires total assist for all __ ADL except for eating that ___ requires limited assistance; related to [DIAGNOSES REDACTED]. Staff provides after care after [MEDICAL TREATMENT] to promote quality of life and comfort. The hospital discharge report dated 0 5/29/15; 5. Followed with Dr. _____ (nephrology). Pt started on CRRT during hospitalization while __ was in septic shock, which helped to resolve the patient's electrolyte derangements. ___ improved dramatically. ___ was eventually restarted on regular HD TTHS, which ___ has been tolerating well through the L groin vascath and subsequent replacement HD catheters. resume HD on Saturday 5/29/15 via new right groin perm cath. On 08/06/2015 at 2:02 PM interviewed LN#2 and asked what staff were doing to prevent [MEDICAL CONDITION]. LN#2 replied that staff are given directive for proper hand-washing and referred to care plan (CP) #6 Risk for DM and [MEDICAL TREATMENT] (HD) related complications; and intervention 12. Collaborate with _____ [MEDICAL TREATMENT]. LN#2 also stated that if R#14 displayed any abnormal temperature, and/or vital signs, staff would call the MD right away. The resident also had another CP #4 Risk for further skin breakdown related to impaired mobility due to PAD, Severe [MEDICAL CONDITIONS] R [MEDICAL CONDITION], DM, [MEDICAL CONDITION], hx of R AKA and amputation of toes to left foot, on ASA and incontinent, AV fistula on R groin. On 08/07/2015 at 8:16 AM looked at R#14's previous MR admissions: On a transfer summary to the facility dated 11/13/14 from an acute hospital, it was noted that R#14 was hospitalized , 10/31/14 for chest pain; and temperature of 101 degrees F with [MEDICAL CONDITION]; blood culture result was Staph aureus from drainage cultured from RUA AVF; apparently HD nurse reported drainage from the fistula site that was subseq. cultured 11/1. On re-admitted [DATE], the transfer summary from an acute hospital noted that on 12/27/2014 the resident was hospitalized due to profuse bleeding from R AV fistula & could not be stopped. The preoperative [DIAGNOSES REDACTED]. The transfer form noted the transfer [DIAGNOSES REDACTED]. The assessment plan noted, infected AV graft removed; [MEDICAL CONDITION]; AV graft; small amount staphyloccous [MEDICAL CONDITION]. On 03/08/15 R#14 was transferred for acute hospitalization and on March 11, 2015 at 5:19 PM, the Final Report; 65 yo ___ well-known to myself from HD access attempts with recent removal of infected avgraft right upper arm, now presents with infected permacath [MEDICAL CONDITION]. Her right arm wounds are nearly healed. She has had extensive surgery in left upper extremity to axilla and is s/p right AKA. She has severe PAD and an attempt at av access in left lower extremity likely would be followed by major amputation. Other option would be a 'neckless' type avgraft from [MEDICATION NAME] artery to [MEDICATION NAME] vein. Will consider but check venous duplex to ensure central vein patency. Thanks. Will follow. On 08/07/2015 at 9:36 AM interviewed R#14 to ask how the staff cares for his/her R groin Permacath access site and how it is kept dry when given a bath. The resident showed that the access site was covered with gauze, and stated that the CNAs cover the access site with plastic when given a shower. After talking with R#14 went to LN#2's office and the facility's infection control coordinator (ICC) was also there to look at R#14's CPs. Asked LN#2 if there was a CP for bathing R#14. LN#2 stated that there was no CP for bathing R#14. LN#2 further stated that the access site was covered with gauze and changed after a shower. Informed LN#2 that the resident said the CNA's covered the access site with plastic. The ICC went to ask CNA#2 about the supplies that were being used for R#14's baths. The CNA brought a small gray plastic bag and spool of tape that staff used to cover R#14's access site during showers. Asked CNA#2 how she knew what to do and she replied that the LN's provided instruction. The ICC looked at R#14's CP#6 and stated that there were no interventions specific for resident's high risk for infections. Discussed with the ICC and LN#2 the close proximity of R#14's new HD access site for soiling with urine and feces. The ICC then asked LN#2 if the HD staff provided any recommendations to care for the Permacath access site. LN#2 stated that facility staff were instructed to reinforce gauze dressing if it became loose. Asked what staff would do if the dressing became soiled and LN#2 stated, Would have to change. The ICC stated that staff should be instructed on how to change soiled dressing to the access site. LN#2 picked up the phone and called [MEDICAL TREATMENT] to ask for instructions on how to care for R#14's Permacath site. The ICC also asked to speak with the social worker at the [MEDICAL TREATMENT] center to set-up a collaborative CP meeting in the near future. The CP #6 Risk fo DM and [MEDICAL TREATMENT]-related complications for R#14 also had written under Measurable Goals .resident name will consume at least 900 ml/day and within fluid restriction of 1200 ml/day. On 08/06/2015 at 10:54 AM interviewed LN#2, due to the HYDRATION ALERT WORKSHEET for R#14 documenting >1200 ml/day on several days from 07/30/2015. According to LN#2, the resident brings back bottled water from the HD center and hides them in his/her bag. Queried LN#2 how accurate are calculations for R#14's fluid intake if the resident sneaks and drinks. LN#2 stated that staff will count the amount of fluid when they see the resident with a bottle of water. Asked LN#2 whether staff adjust fluids on the meal tray if they know that the resident had a bottle of water. LN#2 stated that they haven't done that. Discussed with LN#2 that the 1200 ml/day fluid restriction, was for dietary to provide 960 ml/day for meals, and 240 ml day for medpass; and, the hydration sheet showed that R#14 received >240 ml/day during medpass. LN#2 replied that she plans to talk with nursing staff to make adjustments. Review of R#14's previous MR admissions found that the resident was transferred to an acute hospital on [DATE] with principal [DIAGNOSES REDACTED]. The discharge summary with date of discharge on 06/24/2014, noted under the heading, Hospital Course; #[MEDICAL CONDITION] exacerbation - possibly dietary noncompliance. Clinically overvolumed, she might have drunk excessive water per history. Overvolume was evidenced by XR, BNP>1000. Had hx of drinking waters despite [MEDICAL CONDITION] on HD status.This [MEDICAL CONDITION] is more from volume overload. We consulted outpatient nephrologist ______, and had ultrafiltration on 6/23, and will do regular HD after discharge as outpatient on 6/24. The facility's Long Term Care, Outpatient [MEDICAL TREATMENT] Service Agreement, under 2. The Company's Obligation:.d. To provide the Facility information on all aspects of the management of the Resident's care related to the provision of [MEDICAL TREATMENT] services, including directions on management of medical and non-medical emergencies, including but not limited to, bleeding/hemorrhage, infection/bacteria, septic shock, and care of shunts, fistulas and catheters.

Based on observation, record review and interviews, the facility failed to ensure that the resident's environment remains as free of accident hazards and each resident receives adequate supervision to prevent accidents for 1 of 44 residents in the Stage 2 sample. Finding includes: Resident #178 was observed on 8/5/15 at 5:08 AM on the 2 Makai unit asleep in bed. Her bed however, was surrounded with 4 pieces of equipment: a bedside commode, a geri chair, an overbed table and a walker. The barricade was made with the bedside commode placed at the head of bed on the left side, with a geri chair next against the left side of her bed, and the overbed table at the foot of her bed. The walker anchored it so that the 4 items formed a backward L shaped configuration around her. The potential for physical harm due to an accident, such as the resident climbing over the geri chair existed and was confirmed by interviews conducted with Res #27 as well. Cross-reference to F221 for further details.