Every finding on record at Nuuanu Hale

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to ensure a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to ensure the following: Keep Urinary catheter tubing off the floor and tubing with visible sediment was cleaned or changed as required for of two of two residents (Resident (R) 8 and R53) sampled for urinary catheter care. Use Personal Protective Equipment (PPE) while providing catheter care to Resident (R) 53 who is on Enhanced Barrier Precautions (EBP).To implement the water management plan for legionella prevention and control.To dispose of trash promptly, instead piled trash outside of the trash bin. Findings Include: 1) On 02/24/26 at 9:28 AM, during an interview with R8, the surveyor observed the resident's urinary catheter bag on the floor inside a gray bin next to the bed. The catheter tubing was observed outside of the gray bin and in contact with the floor. The tubing contained visible discoloration and white sediment inside the tube. On 02/26/26 at 9:44 AM, R8 reported experiencing itchiness outside of her vagina and stated that her urinary catheter was leaking. On 02/26/26 at 9:48 AM, during an interview with Registered Nurse (RN) 22, asked whether she was aware that R8's catheter tubing contained sediment. RN22 stated she was aware and planned to contact R8's physician to request more frequent catheter changes, as the catheter was currently changed once a month. RN22 reported the tubing could be cleaned by irrigating it with saline. When asked if catheter tubing should be on the floor, RN22 stated it should not be on the floor for infection control reasons. On 02/26/26 at 3:21 PM, during an interview with the Infection Preventionist (IP), the surveyor asked how often nursing staff are to irrigate catheter tubing. The IP stated staff should irrigate the tubing when they notice the unit is not draining due to sediment. The surveyor showed the IP a photograph taken on 02/24/26 of the resident's catheter tubing on the floor and the condition of the tubing. The IP confirmed the tubing should have been changed and that the catheter tubing should not be on the floor due to the risk of infection. 2) Electronic Health Record (EHR) reviewed on 02/25/26. R53 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis includes Stroke, with impairments of his upper and lower extremities; Benign prostatic hyperplasia (Enlarged prostate) with lower urinary tract symptoms and requires an indwelling urinary catheter. He is dependent on staff for his personal care. R53 is on enhanced barrier precautions which indicates that staff put on personal protective Equipment (PPE) gown and gloves while providing any personal care or physical contact with the resident. Orders dated 06/27/25 reviewed. Catheter care every shift and PRN (as needed). Observation and interview with Registered Nurse (RN) 25 on 02/25/26 at 09:35 AM in R53's room at the bedside. Observed R53's catheter tubing laying directly on the floor. The bed was placed in the lowest position. When sharing the observation with RN25, she said it shouldn't be on the floor, and they need to place the bed in a low position but not too low so the catheter doesn't touch the floor. RN25 repositioned the bed and placed the tubing in the tray. 3) Observation in R53's room with Certified Nurse Aide (CNA) 15 on 02/26/26 at 10:01 AM. Noted a pungent odor like urine at R53's bedside near the urinary catheter bag. CNA15 put on gloves and completed the catheter care by emptying the catheter bag and cleaning the lower area of the catheter tube with an alcohol pad. After draining the catheter bag, she cleaned the area of the floor where the catheter bag is stored with wipes from the purple top. CNA15 was not wearing a PPE gown. The Infection Preventionist (IP) was interviewed on 02/26/26 at 10:42 AM in the conference room. Asked her if R53 is on enhanced barrier precautions. The IP said yes, because he has a foley catheter. Asked her if the staff should wear the PPE when doing the catheter care such as emptying the collection bag, she said yes, they should in case it splashes. Shared the observation made with CNA15 and that she was not wearing her PPE when she provided the catheter care. CNA15 interviewed on 02/26/26 at 10:56 AM outside of R53's room. Asked if she is supposed to wear PPE when she is providing care for the catheter. CNA15 answered yes. Asked where the PPE is located since it was not visible outside the room. CNA15 said it is over there and pointed down the hall to the PPE shelf on the wall. The IP was interviewed on 02/26/26 at 3:17 PM in the surveyor conference room. When asked if the staff are familiar with the PPE being located on the wall as opposed to having it stored outside of the room where it is readily available, she said they should, it was moved there two weeks ago and they were provided training. EBP policy revised: 01/03/25 reviewed. Definitions: EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. 13. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.14. High-contact resident care activities include g. Device care or use: urinary catheters, . 4) Water management plan program implemented date 12/25 reviewed on 02/26/26. 1. The water management team has been established in the guidelines to include the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. 4. Water system description. The facility maintains: Central hot water system with recirculation. Cold water distribution system: hot water distribution system; ice machines located in designated areas. Shower and faucet fixtures in resident rooms. Hot water setpoints: Storage tanks: Greater than or equal to (>)140 degrees Fahrenheit. Distribution: > 124 degrees Fahrenheit .Monitoring Procedures include monthly hot water temperature by maintenance. Asked the Maintenance Director (MD) on 02/26/26 at 2:30 PM the location of the 140-degree storage tank. The MD said there are no storage/ water heater tanks with water with temperatures greater than 140 .8. Verification & Validation. Review monitoring logs monthly Review infection surveillance data and water testing results .9. The facility maintains: Temperature logs. Flushing logs. Cleaning scheduled Corrective action reports. Annual program review documentation. Approved on 02/06/26 by the Administrator. One month of temperatures were found for review in the binder for the resident rooms and water heaters (between 105 and 115 not to exceed 120) and does not pertain to the legionella prevention temperature guidelines from the Center for Disease Control and Prevention (CDC). There was no measure in place to disinfect potential contamination of water with the legionella pathogen. The IP was interviewed on 02/27/26 at 1:32 PM in her office. The IP stated that she just came into the position at the facility IP this month and the previous IP left last month. Asked who are the members of the water management team and has it been implemented. The IP responded that she was not familiar with the water management plan since she just started the position this month and the collaboration between the IP and maintenance director is non-existent. When asked if the risk assessment was completed and what type of control measures are in place. The IP said that no control measures are in place. The weekly monitoring of the flushing of the shower heads, faucets and the Monthly temperature monitoring is also not being done. 5) The Department of Health Office of HealthCare Assurance (OHCA) received an anonymous complaint regarding trash overload at the facility on 08/26/25. On 02/25/26 at 11:30 AM, observed three bags of thrash outside the facility next to the trash bin and multiple bags of thrash on the stairwell landing of the staircase outside of the facility leading to the second floor, blocking access to go up and down the staircase. On 02/25/26 at 01:30 PM, interview with Housekeeping Staff (HS) 1 responsible for the emptying trash on the second floor noted that she puts the collected trash bags in the bin at least every hour to prevent the overflow on the outside staircase, but sometimes needs to wait for the Maintenance Worker (MW) as he is the only one with the keys to open the bin. Interview with HS2 who is responsible for the thrash on the first floor noted that she will take the trash bags and leave it out by the bin at least twice a day, in the morning and afternoon. HS2 stated that the trash bags are too heavy for her to place in the bin so she would call the MW to place the trash bags in the bin. HS2 noted that she notified MW that there was trash to be placed in the bin about an hour ago, but not sure why it was still not placed in the bin. On 02/25/26 at 02:00 PM, interview with MW completed. When asked why the trash was still outside of the bin, MW noted that the aides told him to hold off putting it in the bin but was not sure why. On 02/26/26 at 09:30 AM, interview with Administrator confirmed the overflow of trash started back in May of 2025. The Administrator noted that they were using a waste management company who could not meet the scheduled pick-up frequency of three times a week, which caused the overflow. The Administrator stated that they have implemented changes to include switching over to a new waste management agency on 09/25/25 and acknowledged the importance of keeping the trash under control for infection control purposes. On 02/27/26 at 08:15 AM, interview with Maintenance Director (MD) confirmed that the housekeepers should be putting the trash in the bin more frequently but did not know why the first floor HS cannot put the trash directly in the bin and they cannot rely on or wait for the MW as he gets busy. MD acknowledged that the trash pile up can lead to unsanitary conditions that can affect the facility and neighborhood.

Based on record review and interview, the facility failed to provide a written notification to the resident representative of resident's transfer for three out of three residents (Resident (R) 66, R1, and R6) sampled for hospitalizations and failed to send a notification of the discharge to the long term care ombudsman's office for one of one resident (R68) sampled for discharges. The facility also failed to have the Ombudsman address and appeals right information noted on their notification form. As a result of this deficient practice, residents who are discharged /transferred from the facility are affected.Findings Include: 1) On 02/25/2026 at 01:00 PM, record review of R66's Electronic Health Record (EHR) noted that R66 was sent to the emergency room (ER) for critically low platelets on 11/28/25. R66 received blood transfusion and was admitted for subdural hematoma and remains hospitalized . On 02/25/26 at 01:00 PM, requested for the written discharge notification to family representative and Ombudsman from the Administrator. On 02/26/26 at 11:35 AM, no discharge/transfer notification received for R66. Concurrent interview with Social Worker Aide (SSA) 1 confirmed that no written notification to family representative and Ombudsman was completed. 2) 02/25/2026 at11:11 AM, interview with R1 noted that he went to the hospital couple of months ago for abdominal pain. On 02/25/2026 at 01:00 PM, record review of R1's EHR noted that R1 was admitted to the hospital on [DATE] for small bowel obstruction. On 02/25/26 at 01:00 PM, requested for the written discharge notification to R1's family representative and Ombudsman with the Administrator. On 02/26/26 at 11:35 AM, no discharge/transfer notification provided for R1. Concurrent interview with SSA1 confirmed that no written notification to family representative and Ombudsman was completed. 3) EHR reviewed on 02/26/2026. R68 was admitted to the facility from an acute care hospital to Hospice care on 09/17/25. Diagnosis included alcoholic cirrhosis of the liver. R68 was discharged home on [DATE] on hospice care. The Ombudsman discharge notices binder was reviewed on 02/27/2026 at 07:17 AM, R68's notification was not found. SSA2 was interviewed on 02/27/2026 at 10:08 AM. Asked if there was a notice sent to the Ombudsman when R68 was discharged on 12/12/25. The SSA2 confirmed there was no discharge notification sent to the Ombudsman and added that he was the only SSA who was covering at the facility during the time the resident was discharged . Typically, the SSA2 sends a fax notice to the Ombudsman. 4) During record review of R6's Electronic Health Record (EHR) on 02/25/26 found R6 was discharged and returned to the facility in December 2025 and February 2026. R6 was transferred to the emergency room (ER) for further evaluation on 12/14/25 when he had a change of level of consciousness (LOC). R6 was admitted to the hospital for Acute Hypoxemic Respiratory Failure / on oxygen (O2). R6 was readmitted to the facility on [DATE] and his Principal diagnosis was Methicillin-resistant Staphylococcus aureus (MRSA) septicemia due to Central Venous Catheter (CVC) infection. On 02/12/26 R6 was sent to the ER when he became unresponsive. R6 was admitted to the hospital on [DATE] for sepsis. R6 returned to the facility on [DATE]. Review of R6's EHR revealed there was no documentation in writing that the resident or his representative was given notification of these transfers/discharges and there was no documentation the Ombudsman was notified of the transfers/discharges. On 02/27/26 at 10:02 AM interviewed Social Services Aide (SSA)2 in the conference room. Inquired of SSA2 if he had given written notification of transfer to R6 or his representative and he stated he did not. Inquired if the Ombudsman had been notified of R6's discharge to the hospital in December 2025 and he stated he had not notified the Ombudsman, that the facility was catching up with this. SSA2 stated the Ombudsman requested to be notified monthly and the February 2026 discharges will be sent to the Ombudsman in March.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure that food items stored in the walk-in freezer and refrigerators were labeled properly and old food discarded. This deficient practice places residents in the facility at risk of foodborne illness.On 02/24/26 at 08:20 AM, during the initial walkthrough of the kitchen with Dietary Lead (DL), observed frozen vegetables and meats without any labels in the walk-in freezer. The refrigerator also had vegetables and soup base items not labeled with receive and discard date. Observed a minced onion container in with a Best used by date of 01/26/26 still in the refrigerator. Concurrent interview with DL confirmed that in the freezer they have not been labeling the food items with received/discard date and for the refrigerator they only label food with the discard date. At 10:00 AM, interview with the Dietary Manager (DM) noted that they do not label food items in the freezer as they order items based on usage. DM noted that frozen foods are used, consumed, and ordered on a weekly basis. DM provided invoices for several food items that were ordered through the facility's food vendor on the following dates:Invoice # 3447933 was ordered on12/17/25, but it did not indicate a received by and date received information.Invoice # 3470342 was ordered on 02/11/26, but it did not indicate a received by and date received information.Invoice # 3473185 was ordered on 02/18/26, but it did not indicate a received by and date received information.Invoice #34735132 was ordered on 2/19/25, but it did not indicate a received by and date received information.Only invoice #02481435, dated 02/18/26 had a received by signature and a received date of 02/18/26. When DM was asked what system did he have in place to ensure that food are discarded appropriately when there are no receive/discard date labels on them, DM noted that he uses the trust system, stating that his employees have over 30 years of experience and would look at the food for their appearance, smell, and taste and if appeared spoiled would discard them. DM also provided a Custom Culinary Julain Code explanation for the beef base containers that were not labeled but had difficulty noting what the discard date would be. Requested from DM their Food Storage and Labeling policy but stated they did not have one. On 02/25/26 at 09:30 AM, interview with Administrator confirmed that they should have a Food Storage Policy and acknowledged there should be a system in place for food labeling and discarding of food and not just based on trust.On 02/27/26 at 09:30 AM, walkthrough of the freezer with the Administrator confirmed that there were no labels for food items stored in the freezer. Administrator stated that she saw labels on the items two days ago, but she was not sure why they do not have them today. Administrator acknowledged that labelling of food items is important to prevent foodborne illnesses.On 02/27/26 at 09:00 AM, review of the facility's Labelling Food policy, dated 10/2017, it notes in the Purpose section, all potentially hazardous food items shall be labelled to assure safe consumption and prevention of food borne illness. In the Protocol section, it notes: 1. All perishable food items will be labelled by dining services staff using two dates which indicate the date the product was opened initially and secondly indicating that date by which the item must be discarded, i.e: 7/1/15-7/4/15. 2. Food items not easily and/or visually identifiable and not in the original carton/packaging, labelling may indicate name of item, date initially opened and date by which item must be discarded, i.e: pureed chicken, 7/1/15-7/4/15.All non-perishable foods will be stored in the kitchen storage area and labelled with the date of receipt/delivery of items .

Based on observation, staff interviews and review of the dishwasher temperature logs, the facility failed to maintain the dishwasher temperature gauge was in safe operating condition. This deficient practice puts residents at risk for foodborne illnesses.Findings Include:On 02/24/25 at 08:30 AM, initial walkthrough of the kitchen with Dietary Lead (DL), observed dishwasher machine temperature daily log at 125 for the entire month of January until 02/24/26. Facility has a low temperature dishwasher where the recommended wash temperature should be at a minimum of 120 . Requested for Dietary Aide (DA) to complete a wash cycle. Observed throughout the wash and rinse cycle, the dishwasher temperature gauge did not move and stayed at 100 throughout the entire process. Concurrent interview with DA acknowledged that she has not been physically checking the temperature gauge daily and just noting 125 degrees on the log. Concurrent interview with DL noted they did not know the gauge was broken and will inform the Maintenance Director (MD) to fix it. On 02/24/25 at 10:00 AM, a follow-up observation to the kitchen noted the dishwasher temperature gauge showing 120 . Per DL, MD came to fix it. Premium (vendor the facility is contracted with to do kitchen equipment repairs) Representative (PR) was called to get a better understanding of the dishwasher functions and when temperature settings should be checked.At 11:00 AM, PR assessed the machine and ran the dishwasher for one cycle and noted that there was nothing wrong with the temperature gauge. The temperature gauge showed 130 .On 02/27/26 at 08:15 AM, interview with MD stated that he did not fix the dishwasher temperature gauge as it is not an equipment that he is responsible for repairing. MD noted that it is the Dietary Manager's (DM) responsibility to keep track of and call the vendor to fix it. MD also stated that he has told the dietary staff to check the dishwasher temperature with a thermometer until the gauge is replaced or fixed. MD stated he was not sure how long the gauge was broken.At 11:30 AM, observed PR showing Administrator and DA that the dishwasher gauge was now working properly and voiced that he was not sure why it was not working during the initial kitchen walkthrough. PR confirmed that once the start button is pressed, the dishwasher temperature gauge should start increasing in temperature and fluctuating throughout the cycle, but it should not go below the recommended temperature setting of 120 . DA confirmed that the temperature gauge did not move at all during the wash cycle during the initial kitchen walkthrough and it stayed at 100 the entire time. PR stated he could not recall when he last came to the facility to do preventative maintenance on dishwasher.At 12:00 PM, reviewed dishwasher temperature daily log for the months of October, November, and December of 2025, and for both AM/PM temperatures noted the temperature to be documented consistently at 125 . On 02/27/26 at 02:00 PM, review of the facility's Sanitation, policy, under the Cleaning and disinfection of utensils, dishware, pots, and pans section, it notes, When a chemical dish machine is utilized, the above items will be washed at a minimum 120 F using soap or detergent.NOTE: A preventative maintenance schedule shall be maintained and documented. Water temperatures will be monitored and documented daily. In the Equipment and supplies section, it reads, 1. Equipment used for cleaning of food and for proper dishwashing shall be maintained in working order. A preventative maintenance schedule shall be maintained and documented.

Based on interview and record review the facility failed to assure staff treated one of one resident, Anonymous Resident (AR)1, with respect and dignity when caring for them while providing care with Activities of Daily Living (ADLs). This deficient practice has the potential to affect all residents in the facility who require assistance with ADLs. Findings Include:On 02/24/26 at 02:20 PM a family interview was conducted with AR1's representative. Inquired if AR1 was treated with respect and dignity and AR1's representative stated sometimes the staff talk rough to AR1. AR1's representative stated they tell staff that they are talking rough to AR1 when they witness this. Inquired if they told the unit manager or Director of Nursing and the resident representative said they did not, they chose to say something directly to the staff who was talking rough with AR1 at the time it occurred. Inquired what happens afterwards and the representative said the staff stops talking. Resident representative stated they are afraid for AR1, worried that this behavior might be happening when AR1's representative is not at the facility. Inquired the staff's name but AR1's representative was unable to state the staff's name. During this interview inquired of AR1 if they felt safe in the facility and they confirmed they did. On 02/27/26 at 11:51 AM in the conference room inquired of the Acting Director of Nursing (DON) if there has been reports of staff talking rough with the residents and she stated yes and it's in the reports, At this time reviewed event report that occurred on 07/31/25 when a resident reported a staff member was rough during care and ignoring her when she pressed her call light. DON investigated and found Certified Nursing Assistant (CNA) had worked with resident, provided care and shortly after the resident called her and CNA reported she rounded with her other residents first and then went back to her. Resident requested education for CNA and verbalized that she wanted to continue to work with this CNA. Unable to interview this resident as she was discharged to the hospital on [DATE]. Inquired of Acting DON if staff are to treat residents with respect and dignity, she confirmed this. Review of facility policy titled Resident Rights - Freedom From Abuse, Neglect & Exploitation with a reviewed and revised date of 04/11/18 states, Name of facility shall assure that all residents are fully aware of and able to exercise their rights during their stay at this facility and are treated by staff members, family members, friends, visitors and other residents in accordance with the rights to which they are entitled under applicable Federal and State regulations. Procedure for preventing resident abuse . 8. Any use of oral, written or gestured language, including disparaging and derogatory terms a resident to a resident that can result in intimidation, threat, harm, mental anguish and fear. Describing residents in a derogatory way regardless of their age, ability to comprehend or degree of disability is also prohibited. (Verbal Abuse)

Based on interview and record review, the facility failed to ensure residents were informed of their right to formulate an Advanced Health Care Directive (AHCD) for two of six residents (Resident (R) 64 and R4) reviewed for AHCD. This failure placed R64 and R4 at risk of not having their health care preferences known or honored, potentially resulting in care that is not consistent with their wishes. Findings Include: 1) R64 was admitted to the facility on [DATE] with diagnoses including, but not limited to, peripheral vascular disease, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, venous insufficiency, atherosclerotic heart disease of native coronary artery without angina pectoris, cardiomyopathy, chronic obstructive pulmonary disease, polyneuropathy, epilepsy, acquired absence of right leg and left leg above the knee, hypertension, and hyperlipidemia. Review of R64's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/12/25, documented a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of R64's Electronic Health Record (EHR) revealed no AHCD on file. On 02/25/26, a request was made to the facility for a copy of R64's AHCD. On 02/26/26, the facility provided a Social Services progress note dated 12/12/25 documenting that R64 was oriented to person, place, time, and circumstances. The note stated: Resident does not wish to designate POA [Power of Attorney] at this time, wishes to continue to make her own decisions. POLST is Full Code, no change requested to plan of care. On 02/26/26 at 10:07 AM, an interview was conducted with R64. R64 stated that someone came quarterly to ask about her POLST. She reported that she had expressed a desire to change it to Do Not Resuscitate (DNR) and had requested the paperwork. R64 stated that no one had asked her about formulating an AHCD and that she did not know what it meant to formulate one. R64 further stated she would like to complete an AHCD and designate her daughter to assist with healthcare decisions if she becomes incapacitated. On 02/26/26 at 10:53 AM, an interview was conducted with Social Services Aide (SSA) 1. During concurrent review of the progress note, SSA1 confirmed that designating a POA is not the same as offering, educating, and formulating an AHCD. 2) R4 is a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis metabolic encephalopathy, muscle weakness, and pneumonitis. On 02/24/26 at 01:00 PM, reviewed R4's Electronic Health Record (EHR). There was no Advance HealthCare Directive (AHCD) or supporting documentation about formulating or obtaining an AHCD found in the progress notes or Care Plan (CP). On 02/25/26 at 01:00 PM, a copy of the AHCD and/or supporting documentation for R4 was requested from the Administrator. On 02/26/26 at 11:00 AM, no documentation was received. Concurrent interview with Social Services Aide (SSA) 1 confirmed that the AHCD was not completed for R4. On 02/27/26 at 11:44 AM, review of the facility's Residents' Rights Regarding Advance Directive policy dated, 12/2025, it reads, It is the policy of this facility to support and facilitate a resident's rights to request, refuse, and/or discontinue medical or surgical medical treatment and to formulate advance directives. In the Policy Explanation and Compliance Guidelines section, it reads, 1. On admission, the facility will determine if the resident has executed and advance directive, and if not, determine whether the resident would like to formulate an advance directive.

Based on interviews and record review, the facility failed to ensure staff reported an injury of unknown source that resulted in serious bodily injury no later than two hours after discovery to the facility Administrator for one of one resident (Resident (R) 70) reviewed for abuse. Specifically, staff were aware that R70 had a large bruise on left hip and thigh, first observed on [DATE], but the injury was not reported to the Administrator and State Agency until [DATE]. Findings Include:Cross reference to F726, Competent Nursing Staff. The facility failed to ensure licensed nursing staff demonstrated the appropriate competencies and skill set to provide a thorough and accurate skin assessment of R70 after observing a large bruise on the resident's left hip and thigh. R70 was admitted to the facility on [DATE] and deceased with hospice services on [DATE]. R70's diagnoses included, but not limited to, hereditary ataxias/[NAME]-[NAME] disease, dementia with behavioral disturbance, lumbar spinal stenosis without neurogenic claudication, lumbar disc degeneration with discogenic back pain, hyperlipidemia, hypertension, venous insufficiency, anxiety disorder, major depressive disorder with psychotic symptoms, bilateral keratoconus muscular dystrophy, agoraphobia with panic disorder, and sciatica.Review of the initial facility reported incident (Intake #2578903), received on [DATE], documented that staff observed a bruise on R70's left hip and left thigh. A completed report submitted on [DATE] documented that a Certified Nurse Aide (CNA) working the night shift observed the bruise on [DATE] but forgot to report it to the Charge Nurse and instead relayed the information only to the incoming day shift CNA on [DATE]. The day shift CNA informed the Registered Nurse (RN) on duty. Upon assessment, RN noted that bruise appeared purple in color with location at left thigh (posterior). Resident did not remember how it happened and denied any pain or discomfort. When RN assessed resident, she assumed bruise was already reported to a licensed staff and did not need to make an initial entry. The Director of Nursing (DON), Administrator, physician, resident, representative, and State Agency were not notified until [DATE]. Review of RN10's written response in the facility's investigation, dated [DATE], stated I am unsure of how the bruise may have occurred. During the transfer from wheelchair to shower chair. [Restorative Nurse Aide (RNA)] .relayed to me that.[CNA30] .had alerted her about the bruise. This was the first time it was reported to me. [RNA] .relayed the bruise was not from today but another day.Given that. [CNA30] .was aware I assumed. [CNA30] .reported the bruise to the assigned license nurse on her shift.On [DATE] at 08:20 AM, a telephone interview was conducted with CNA30. CNA30 could not recall the exact date she worked when she observed the bruise. Review of the facility's July CNA schedule showed CNA30 worked from 11:00 PM to 7:00 AM on [DATE] into [DATE]. CNA30 reported that around 12:00 AM on [DATE], she observed a big, dark bruise on R70's thigh. CNA30 confirmed she did not notify the night shift nurse due to being busy and forgetting, but she told the day shift CNA during shift change. She could not recall which CNA she endorsed the bruise to. CNA30 acknowledged she made a mistake by not reporting to the nurse on duty.On [DATE] at 08:37 AM, an interview was conducted with RNA. RNA reported she first became aware of the bruise on [DATE] while assisting CNA8 with R70's care. The RNA described the bruise as large and located in the lower hip area. The RNA confirmed with CNA8 that the on duty nurse, RN10, had been informed. The next day, on [DATE], the RNA observed another large bruise on R70's thigh and reported it to Licensed Practical Nurse (LPN) 3.On [DATE] at 08:45 AM, a telephone interview was conducted with CNA8. CNA8 stated she first saw and heard about the bruise on a Thursday, possibly [DATE], while assisting R70 with a shower. CNA8 reported she informed the RNA and RN10, who were assisting with care.On [DATE] at 11:29 AM, an interview was conducted with Administrator. Administrator acknowledged that staff did not report the bruise timely to ensure she and the State Agency were notified within required timeframes.Review of the facility's abuse policy and procedure, revised on [DATE], documented An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property and shall be immediately report.Allegations that involve abuse or result in serious bodily injury shall be reported immediately, but not later than 2 hours after the allegation is made.The Administrator or designee shall be notified immediately, who will immediately initiate the report. to state agencies.

Based on observation, record review and interview the facility failed to develop a care plan for bed rail use for one of six residents sampled for accidents, Resident (R) 38. The deficient practice puts all residents in the facility who have bed rails and do not have a care plan for bed rail use at risk for injury.Findings Include:On 02/25/26 at 09:05 AM observed R38 lying in her bed with bilateral upper quarter bed rails up on her bed. Inquired of R38 about the bed rails and she said she uses if she needs to hold onto it and the staff use it.Record review of R38's Electronic Health Record on 02/25/26 found R38's care plan did not include use of bilateral upper quarter bed rail use.Interview with Acting Director of Nursing (DON) on 02/27/26 at 10:42 AM was conducted in the conference room. Inquired of Acting DON if R38 had a care plan for bed rail use and she confirmed resident did not have a care plan in place for bed rail use and confirmed this should have been included.

Based on record review, observations, and interviews, the facility failed to ensure one of three residents (Resident (R) 63) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts R63 at risk of a decline in ROM and further contractures.Findings Include:R63 is a [AGE] year-old male, admitted to the facility on [DATE] with a primary diagnosis of dysphagia following cerebral infarction. On 02/24/26 at 08:28 AM observed R63 with right (R) hand and R foot contracture. No splint applied to R hand/R foot. At 10:32 AM, no splint applied to R hand/R foot. AT 01:07 AM, no splint applied to R hand/R foot.On 02/25/26 at 07:33 AM, no splint applied to R hand/R foot.On 02/25/26 at 01:00 PM record review of R63's Electronic Health Record (EHR) noted orders to assist R63 to wear splint (R hand and R foot splint) for 4 hours minimum as tolerated daily from 07:15-15:15. The Care Plan (CP) approach noted for R63 to perform ROM exercises to upper body and lower body 2-3x/week as tolerated and to continue donning soft ankle foot orthosis and resting hand splint 4 hours minimum.On 02/26/26 at 09:00 AM, observed R63 in bed with no R hand/R foot splints applied. On 02/26/26 at 09:15 AM, interview with Restorative Nurse Aide (RNA) confirmed that R63 should have splints applied. RNA stated that she did not get to apply the splints because of being busy doing certified nurse aide's (CNA) job when the facility is short. RNA also stated that CNAs and license staff can also apply splints. RNA also confirmed that she has only been able to provide R63 active/passive ROM once a week. RNA acknowledged the importance of applying splints and performing ROM exercises to help prevent further contractures.On 02/26/26 at 09:50 AM, interview with Acting Director on Nursing (DON) and Registered Nurse (RN) 1 confirmed that R63 should have had splints on and confirmed that according to R63's CP, he should have been getting 2-3x q week restorative nursing treatments. On 02/26/26 at 11:30 AM, record review of R63's restorative treatment records noted that he only had once a week treatment on 01/29/26, 02/06/26, 02/15/26, 02/19/26, and 02/25/26. Records also showed splints were not applied on 02/08-02/11, 02/13-2/14, and 02/22-02/24/26.Review of the facility's Restorative Nursing Programs policy, it notes in the Definition: Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. In the Policy Explanation and Compliance Guidelines: 2. The interdisciplinary [NAME], with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve the resident's abilities in accordance with the resident's comprehensive assessment, goal, and preferences. 4. All residents will receive maintenance nursing.as needed, by certified nursing assistants.5. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include a. Passive or active range of motion. B. Splint or brace assistance. 10. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form.

Based on record review and interview the facility failed to monitor one resident's fluid intake for one of one resident sampled for dialysis, Resident (R) 6. This deficient practice put R6 at risk for fluid overload and complications with his dialysis. Findings Include:On 02/25/26 record review of R6's Electronic Health Record revealed R6 was readmitted to the facility on [DATE] and receives dialysis three times a week on Tuesday, Thursday, and Saturday. R6 was ordered a Renal diet; puree texture consistency; Thin liquid (Fluid restriction 1200 mL/day). Review of meals and fluid intake found the Certified Nursing Assistants (CNAs) documented this at each meal for R6. Review of R6's Medication Administration Record (MAR) found there was no monitoring of R6's fluid intake with medication administration. On 02/25/26 at 03:25 PM interviewed Licensed Practical Nurse (LPN)3 at the nurse's station. Inquired about R6's fluid restriction. Inquired how nurses know how much fluid he drinks each day. LPN3 stated resident has fluids measured out and provided with his meals and medication pass. On 02/27/26 at 11:37 AM interviewed Acting Director of Nursing (DON) in the conference room. Inquired if a resident is ordered fluid restriction if the resident would have his fluids documented with each medication pass and she confirmed a resident who is on fluid restrictions would be monitored and this information documented. Reviewed resident's MAR with the Acting DON and she stated R6's order for fluid restriction monitoring was discontinued on 02/12/26 when he was discharged to the hospital. Acting DON stated the resident returned to the facility on [DATE] and there was no new order to start monitoring his fluid intake from that time and this should have been ordered when he returned.

Based on observations, record review and interviews the facility failed to assess the risk of entrapment from bed rails prior to installation for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. This deficient practice could place R56 and R38 at risk for harm from bed rail use. The deficient practice could affect all residents in the facility who are using bed rails if a risk assessment is not completed prior to use of their bed rails. Findings Include:Cross-reference to F909 Resident Bed. The facility failed to implement a regular maintenance program to identify areas of possible entrapment with bed rail use for residents observed using bed rails, Resident (R) 56 and R38. 1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed.On 02/25/2026 during record review, of R56's Electronic Health Record (EHR), found she is [AGE] years old and her last admission occurred on 12/05/2024. R56's diagnoses include, but are not limited to, unspecified dementia, unspecified severity, with agitation and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Continued record review found R56 has a signed consent by her son for use of bed rails, alarms and call light which was signed on 07/10/19. Review of R56's Minimum Data Set (MDS) submitted on 12/04/2025 with an Assessment Reference Date (ARD) Observation end date of 11/18/2025 revealed R56 was coded as requiring substantial/maximal assistance when rolling left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Reviewed R56's care plan and found a care plan for bed rail use that stated, Placed side rail padding/pillows and frequent checks to ensure that any part of body is not in between rail and mattress/bed and gaps in the bedrail. Reviewed assessments completed for R56 and found there was no risk assessment completed for bed rail use. On 02/27/2026 at 10:42 AM interviewed Acting Director of Nursing (DON) in the conference room. Inquired if residents with bed rails needed a risk assessment to be completed prior to use of bed rails and Acting DON confirmed this. Inquired if R56 had one completed and she confirmed R56 did not have a risk assessment completed for bed rail use and this should have been done prior to using bed rails with R56. 2) On 02/25/2026 at 9:05 AM R38 observed lying in her bed which has bilateral upper quarter bed rails which were up in use. Inquired of R38 about the bed rails and she said she uses it if she needs to hold onto it and the staff use it.On 02/25/2026 at 3:05 PM interviewed Licensed Practical Nurse (LPN)3 at the nurse's station. Inquired about R38's bedrails and LPN3 stated R38 uses the bed rails to help with repositioning in her bed. On 02/25/2026 record review of R38's EHR found she is [AGE] years old and her last admission occurred on 02/03/2026. R38's diagnoses include, but are not limited to, acute diastolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Continued record review revealed R38 has a signed consent for use for grab bar or assist rail dated 02/03/2026.Reviewed assessments completed for R38 and found there was no risk assessment completed for bed rail use. On 02/27/2026 at 10:42 AM interviewed Acting DON in the conference room. Inquired if R38 had a risk assessment completed for bedrail use and she confirmed resident did not have a risk assessment completed prior to bedrail use.

Based on record review and interviews, the facility failed to ensure licensed nursing staff demonstrated the appropriate competencies and skill set to perform a timely, thorough, and accurate skin assessment for one of one resident (Resident (R) 70) reviewed for abuse. Specifically, staff were aware that R70 had a large bruise on left hip and thigh, first observed on 07/30/25, but an initial assessment was not conducted, and subsequent skin assessments did not document the presence, location, size, characteristics and/or progression of the bruise. This deficient practice places R70 at risk for unrecognized injury progression and delays in appropriate monitoring, intervention, investigation, and implementation of protective measures to safeguard the resident's health and safety.Findings Include: Cross Reference to F609, Reporting of Alleged Violation. The facility failed to ensure staff reported an injury of unknown source that resulted in serious bodily injury, large bruise to left hip and thigh, no later than two hours after discovery to the facility Administrator. The injury was first observed on 07/30/25 but was not reported until 08/01/25. Review of the initial facility reported incident (Intake #2578903), received on 08/01/25, documented that staff observed a bruise on R70's left hip and left thigh. A completed report submitted on 08/07/25 documented that a Certified Nurse Aide (CNA) working the night shift observed the bruise on 07/30/25 but forgot to report it to the Charge Nurse and instead relayed the information only to the incoming day shift CNA on 07/31/25. The day shift CNA informed the Registered Nurse (RN) on duty. Upon assessment, RN noted that bruise appeared purple in color with location at left thigh (posterior). Resident did not remember how it happened and denied any pain or discomfort. When RN assessed resident, she assumed bruise was already reported to a licensed staff and did not need to make an initial entry. On 08/01/25 a day shift Licensed Practical Nurse (LPN) observed the bruise on left hip and thigh and notified the physician. An X-ray was ordered and it revealed AP [Anteroposterior] and lateral views obtained. There is no acute fracture or dislocation. Joint spaces are aligned and maintained. There are no bony lesions. Mineralization is normal. Soft tissue swelling is noted. Impression: Soft tissue swelling without acute osseous abnormality.Review of RN10's written response in the facility's investigation, dated 08/01/25, stated I am unsure of how the bruise may have occurred. During the transfer from wheelchair to shower chair. [Restorative Nurse Aide (RNA)] .relayed to me that.[CNA30] .had alerted her about the bruise. This was the first time it was reported to me. [RNA] .relayed the bruise was not from today but another day.Given that. [CNA30] .was aware I assumed. [CNA30] .reported the bruise to the assigned license nurse on her shift.On 02/26/26 at 09:25 AM, an interview was conducted with LPN3. LPN3 stated skin assessments are done weekly, routinely, and when a new skin issue is observed. LPN3 confirmed she observed a large purplish bruise from R70's lower hip to the thigh on 08/01/25 and did not measure the bruise. LPN3 confirmed she found no assessment or event note prior to 08/01/25, identifying the bruise, prompting her to create an event and notify the Director of Nursing (DON). When asked if weekly skin assessments should include the unresolved bruise, LPN3 stated the bruise should be documented in the skin assessment.Review of the weekly skin assessments on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 by RN10 revealed no documentation of the bruise on the left hip and thigh. The skin assessment was documented the same including skin description, that there were no new onset skin impairments, describing only Dry scattered scabs to bilateral shins and on Medihoney gel- areas are dry and healing except for which CNA assisted with the assessment.Review of the event report initiated on 08/01/25 by LPN3 documented the following in nursing notes:08/01/25: Noticed bruise on the left hip and left thigh.8/02/25: Still with visible bruise on left hip and left thigh.08/03/25: Resident with fading bruise on the left hip and left thigh. and Left hip/thigh still bruised.08/04/25: With fading bruise to L [left] him and thigh, yellow and purple in color.08/07/25: Resident with fading bruise on the left hip and left thigh.08/09/25: Left hip and left thigh bruise is fading. and Left hip and left thigh bruised is fading.08/10/25: Left hip and left thigh bruise is fading.08/11/25: With fading bruise to L hip and L thigh. Bruise yellow in color.08/14/25: Bruise to L hip and L thigh fading. Bruise is currently yellow in color.08/15/25: Bruise to L hip and L thigh fading. Bruise is currently yellow in color.These notes did not include a complete skin assessment or documentation of the bruise's progression, including color, size, and shape, the initial appearance, or date of resolution. On 02/26/26 at 11:59 AM, interviews were conducted with Infection Preventionist (IP) and Administrator. Both confirmed RN10 did complete proper weekly skin assessments, which should have included the bruise. The IP stated that if a new skin issue is identified, staff should immediately perform a full skin assessment and initiate a RMC Injury/Integumentary Alteration event, requiring documentation of description and type of injury, location and size, pain, activity during discovery, who was notified, and nursing notes/monitoring. The IP and Administrator confirmed RN10 should not have assumed an assessment had been completed and should have reviewed R70's chart to ensure the injury was assessed and reported. They also confirmed the event report initiated by LPN3 was not the correct form and did not include a complete assessment of the bruise.

Based on observation, interview, and record review, the facility failed to ensure medication carts were locked and under direct observation of authorized staff in an area where residents could access it for one of four medication carts observed. This practice does not ensure the protection and control of medications. Findings Include: On 02/26/26 at 10:12 AM, after exiting a resident's room, an unlocked medication cart was observed in the Ewa Unit hallway and left unattended. Facility staff were observed walking by the cart, and residents in wheelchairs were present in the hallway at the time.At 10:13 AM, Registered Nurse (RN)5 was observed walking from the Diamond Unit while carrying a pitcher of water. RN5 briefly spoke with another staff member while walking past the nurse's station to the Ewa Unit, not at direct observation of the medication cart. RN5 then introduced herself and confirmed that the medication cart was assigned to her. She stated that she had stepped away from the cart and acknowledged that it should have been locked.Review of the facility's policy and procedure Medication Storage dated 12/2025, documented under general guidelines, All drugs and biologicals will be stored in locked compartments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation and interview the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. The deficient practice puts all residents at risk for possible entrapment if they have bed rails and they are not inspected and maintained according to manufacturer's recommendations and requirements.Findings Include:1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed. 2) On 02/25/2026 at 9:05 AM R38 was observed lying in her bed with bilateral upper quarter bed rails which were up in use. Inquired of R38 about the bed rails and she said she uses it if she needs to hold onto it and the staff use it.On 02/27/2026 at 10:55 AM interviewed Maintenance Supervisor in the conference room. Inquired if he or his staff do routine maintenance for the residents' bed rails and have logs of this and he stated they, tighten the bolt if it is loose but do not have logs of this work. Inquired if he does anything else and he said no.

Based on interviews and record review, the facility failed to ensure a safe discharge for one Resident (R)2 of a sample size of three. Specifically, prior to an inpatient hospitalization, R2 was moderately independent with some assistance, but his functional level changed. At discharge, he required maximum assistance for most activities of daily living. There was lack of evidence that R2's discharge home met his identified needs of 24/7 supervision. Caregiver availability, capacity and capability were not determined. As a result of this deficiency, R2 was at high risk of readmission and harm. This deficient practice has the potential to affect any resident discharged home. Findings include: 1) On 02/07/2025 the Office of Healthcare Assurance (OHCA) received a report from an external agency regarding concern of R2, self neglect and possible inappropriate discharge. The report included R2 lived with his girlfriend, but that she was disabled and not able to care for him. It also documented he does not have any other support system and .girlfriend is only able to assist with grocery shopping. 2) R2 was a [AGE] year-old admitted to the facility on [DATE] for short term physical and occupational therapy to improve functional status due to weakness and immobility after being hospitalized for sepsis. His medical history included poorly controlled Diabetes, muscle weakness, thoracic and cervical spinal stenosis, stroke with left sided weakness. and incontinence of bowel and bladder. R2 is capable of making his own decisions. Prior to admission he lived at home with his significant other, who assisted him. He was discharged home on [DATE], with a referral to Home Health. 3) Reviewed R2's hospital Rehab Consult Notes dated 12/27/2024, which included the following: - Lives with: .lady friend. - Assistance at discharge: Family, Home Alone During the Day. - Home equipment: shower chair. wheelchair, transport, walker, rolling. - Living Environment Comments: Pt reported that when his lady friend stays over she helps but when she does not he performs tasks on his own. - Toileting prior to admit 12/24/2024 level of function: pt. (patient/R2) reported that he takes his transport w/c (wheelchair) to the bathroom door then uses his RW (rolling walker) to get to the toilet. - Prior fall history: Pt has fallen a lot and reports that when he falls on his face he can not even breathe or turn his head to help him. Pt reports he can lay there half an hour before being found by significant other. Reviewed R2's facility Occupational Therapy (OT) Discharge Summary, for services ending on 01/26/2025. The summary included the following: Eating: Sup (supervision)/SBA (standby assist)- Cueing, coaxing, standby for safety; Hygiene: Oral hygiene = Mod A (Moderate Assist, 26-50% care giver support); Toileting hygiene = Dependent (100% assist), or two or more helpers; Transfers: Toilet transfer = Total A (79-99% assist), substantial Maximal Assist; Bathing: Shower/bathe self = Dependent; Dressing: Upper body dressing = Mod A; Lower body dressing = Total A; Putting on/taking off footwear: Total A; Self-Care Performance Skills: Self Care Function Score (score 0-12; 12 being highest function) = 5; Discharge Recommendations: Air mattress, 24 hour care, Home exercise program, Home health services and in-home aide. 4) Reviewed R2's Physical Therapy (PT) Discharge Summary for services ended on 01/27/2025. The summary included: Bed mobility: PLOF (Prior level of functioning): MODI; discharge: Mod-Max assist, MOD to roll to sides, able to pull self with .but requires MAX A (maximal assist-caregiver provides 51-75% of effort) to complete supine to sitting and back. Transfers (bed to chair/chair to bed, sit to stand, toilet transfers): PLOF: MOD I; discharge: MAX A/TA (Maximum Assist/Total Assist-caregiver does 100%). Standing Balance: PLOF: Fair; discharge: Poor. Ambulate with FWW (front wheel walker) to 10 ft: PLOF: MOD I-20 ft.; discharge: Attempted, but not able to demonstrate any steps. Mobility Score: Functional Mobility Score (ranges from 0-12; 12 being highest function) = 2. Discharge Location = Patient discharged to home w/support/(A) from others. Assistance/Support to be provided = Community Assistance. AM assistance/caregiver available, PM assistance/caregiver available. D/C Recommendations: Assistive device for safe functional mobility, ., Elevated toilet seat/3 in 1 commode, Environmental modifications, Functional Maintenance Program, Home health services, Shower chair back, Grab bars and Reacher. 5) Reviewed R2's discharge MDS (Minimal Data Set) dated 01/28/2025 revealed Section GG-Functional Abilities documented the following: Eating: 5 (Setup or clean-up assistance) Oral Hygiene: 5 (Set up or clean-up assistance) Toileting hygiene: 1 (Dependent) Shower/bathe self: 2 (Substantial/maximal assistance) Upper body dressing: 3 (Partial/moderate assistance) Lower body dressing: 2 (Substantial/maximal assist) Putting on/taking off footwear: 1 (Dependent) Person hygiene: 2 (Substantial/maximal assist) 6) On 03/27/2025 at 01:39 PM, interviewed the facility's Assistant Director of Rehab (PTA), in the conference room. The PTA said the Physical Therapist comes to the facility and does the admission evaluations and develops the plan, and then the PTA provides the therapy. When asked PTA about R2, he said Across the board he was max assist. He went on to say, R2's baseline was that he needed some assistance at home, and his girlfriend helped him, but his condition and needs changed. The PTA said at discharge, R2 could not ambulate and could not transfer self from bed to wheelchair. When inquired if his department does caregiver training, he said in this case, he thought there had been attempts to get the girlfriend in, to provide her training, but she never came. At that time reviewed the discharge evaluation note, and PTA confirmed he wrote the content, and the Therapist electronically signed it offsite. He went on to say they recommended home care therapy and Social Services would make the arrangements. The PTA recalled they discussed options for R2 post discharge at a care planning meeting, but that He was adamant about going home. On 03/27/2025 at 02:00 PM, interviewed Social Services (SS) in the conference room. He said his supervisor was assigned R2, but she was unavailable. SS said he did have some knowledge of the resident and was sure R2 had been offered other options such as care home, but He (R2) had one adamant request, which was to go home, and was not interested in any other option. At that time, reviewed all discharge planning notes and SS confirmed there was no documentation that other options other than home were discussed to ensure his safety. He said a referral was made for PT/OT home health services. On 03/28/2025 at 11:16 AM, interviewed the Physical Therapist (PT) in the conference room. PT did R2's admission evaluation and electronically signed his discharge summary. He confirmed his involvement with R2's care. At that time, PT reviewed R2's therapy documentation, and noted there had been a decline in R2's functional level while he had been at the facility. He confirmed at the time of the discharge evaluation on 01/27/2025 R2 needed maximum assistance. On 03/28/20025 at 12:40 PM, PT returned to he conference room after he reviewed P2's records again, and said he noted in the Occupational Therapy notes, there was a recommendation for 24 hour supervision. 7) On 03/28/2025 at 10:34 AM, conducted a phone interview with the Home Health Agency (HHA), who confirmed a referral was uploaded into their system on 01/28/2025, for PT, OT and Aide services. The home evaluation was conducted on 01/31/2025 and due to unsafe home environment, R2 was not admitted for services. The HHA notified R2's insurance coordinator to assist with further care coordination. 8) Reviewed the facility policy titled Discharge/Transfer, which included The post-discharge plan will be developed by the interdisciplinary team with the assistance of the resident and resident representative. As [sic] a minimum, the post-discharge plan will include a current assessment of resident's ADL (Activity of Daily Living) functioning .social services, and physical therapy as appropriate. In addition, the post-discharge care plan will address follow up with PCP as well as provisions for medical equipment, housekeeping needs, meals .A telephone follow-up call will be performed one week after discharge by the Social Worker or designee to inquire as to status and adjustment of the resident, as appropriate. There was no evidence a follow-up phone call had been made to R2.

Based on observation and staff interviews, the facility failed to have maintain a sanitary and clean shower room for two of the four shower rooms observed. This deficient practice could affect all residents at the facility if appropriate cleaning of the showers are not done. Findings include: On 02/03/25 at 09:00 AM, a walkthrough of the 2nd floor [NAME] Wing shower room noted black substance on the left bottom corner caulking through the bottom middle caulking, extending to the right corner side caulking of the shower stall. The Ewa Wing shower room also noted black substance on the bottom right corner caulking of the shower stall. On 02/05/25 at 09:20 AM, interviewed Certified Nurses Aid (CNA) 15 and identified that the black substance was mold and wasn't sure how housekeeping cleaned it. At 09:30 am, during an interview with Housekeeper (H)1 and H2, they housekeepers acknowledged the black substance and noted that they didn't know what it was and have tried to remove it by scrubbing it. On 02/05/25 at 12:40 PM, met with Maintenance Director (MD), MD accompanied surveyors to observe the Ewa Wing shower room and noted that he already removed the black substance after surveyors brought it up to housekeeping staffs' attention. He initially stated the black substance was black caulking that was applied by previous maintenance worker, but when asked why would the maintenance worker mix black and white caulking between the tiles, MD then stated the black substance was dirt. MD confirmed he used tools to scrape the caulking earlier today and applied grout. He acknowledged the black subtance should've been taken cared of sooner.

Based on record review and interview, the facility failed to provide documentation that written notice of transfer or discharge was provided to the resident and resident's representative(s), and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of five resident samples. This deficient practice has the potential to affect resident or resident's representative(s) right to appeal the discharge. Findings include: Resident (R) 69 was sent to the Emergency Department and admitted to the hospital on 01/02/25. Record review was done on 02/05/25 at 12:26 PM for two forms titled, Discharge/Transfer Notice and [Provider] Notice of Discharge. Information for R69 was noted on both forms, but no documentation was found that it was sent to the resident's representative or Long-Term Care Ombudsman. The Social Services Director (SSD) was interviewed, in her office, on 02/25/25 at 12:33 PM, and stated that there is nothing documented that the written discharge/transfer notification was sent to the resident's representative. In addition, the SSD was not able to provide a copy of any fax confirmation notice.

Based on observation, interview, and record review, the facility failed to develop and implement a resident-centered Comprehensive Care Plan (CP) for 8 of 18 residents (R) sampled (R20, R21, R55, R37, R32, R24, R27, and R56). As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) Cross-reference to F641 Accuracy of Assessments for R20. The facility failed to include R20's active diagnosis Contracture of muscle, left upper arm, in his Minimum Data Set (MDS) Quarterly Assessment. The facility failed to develop and implement a care plan to address R20's limited ROM needs of his left arm. 2) Cross-reference to F641 Accuracy of Assessments for R21. The facility failed to identify pressure ulcers (PUs) to bilateral heels on R21's Minimum Data Set (MDS) Quarterly Assessment after R21 returned to the facility from being hospitalized . The facility failed to develop and implement a care plan to provide treatment and monitoring of R21's PUs on his heels. 3) Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities Despite identifying upon admission R55's primary language is Cantonese and that he needs or wants an interpreter to communicate with a doctor or health care staff the facility failed to develop and implement a Communication/Language Barrier care plan for R55. 43245 4) Cross-reference to F684 Quality of Care for R37. Despite identifying that he was at risk for dehydration, the facility failed to develop and implement a dehydration care plan. Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities Despite identifying upon admission that his primary language was not English, the facility failed to develop and implement a Communication/Language Barrier care plan for R37. 5) Cross-reference to F684 Quality of Care for R32 despite identifying and documenting an ongoing pruritic skin condition since September 2024, the facility failed to develop and implement a care plan that effectively monitored and addressed R32's itching. 6) Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities. Despite identifying upon admission that her primary language was not English, the facility failed to develop and implement a Communication/Language Barrier care plan for R24. 7) Cross-reference to F688 Maintain/Prevent Decline in Range of Motion for R27. Despite identifying a left-hand contracture, the facility failed to develop and implement a care plan to address R27's limited ROM needs. 43414 8) Cross Reference to F688. The facility failed to ensure R56 with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion, and ensure treatment provided was evaluated by therapy, physician ordered, and/or care planned. R56 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, history of occlusion and stenosis of unspecified cerebral artery, muscle weakness, and contracture of muscle right upper arm and right lower leg. Review of R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG. Functional Abilities and Goals, R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion. Review of R56's CP reviewed/revised on 01/25/25 documented R56 .has impaired range of motion to right arm and right leg r/t [related to] previous stroke and contractures .will have no unaddressed complications related to limited range of motion through the review, .Monitor for presence of pain, intolerance, or muscle spasm during range of motion .OT/PT [Occupational Therapy/Physical Therapy] to eval [evaluation] and treat as indicated. Encourage to follow guidelines set from therapy. Multiple observations of R56 in bed were done on 02/03/25 at 08:41 AM and 11:35 AM, 02/04/25 at 08:05 AM, and 02/05/25 at 08:41 AM and 12:59 PM. R56's arms were observed to be bent to chest with closed fists holding rolled hand towels in both hands. Right leg was bent, knee toward stomach and left leg was positioned straight. Review of R56's Electronic Health Record (EHR) found no documentation that range of motion was done including monitoring for pain, intolerance, or muscle spam during range of motion as indicated in the CP. Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found. On 02/05/25 at 02:11 PM, an interview with Director of Nursing (DON) was done. DON reported the facility does not have a Rehabilitation Nursing Aide (RNA) program so the Certified Nurse Aids (CNA) are encouraged to do passive range of motion (PROM) for residents. DON confirmed there was no documentation in R56's EHR because there is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services. Inquired if R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in R56's EHR.

Based on observations, record reviews, and interviews, the facility failed to ensure the comprehensive person-centered care plan (CP) was reviewed and/or revised by the interdisciplinary team for four of 18 residents (Resident (R) 29, R55, R38, and R54) sampled for care plans. As a result of this deficit practice, R29's need for assistance with meals was not care planned for which was something new with the resident, R55's range of motion (ROM) was not addressed as recommended by physical therapy to prevent further contractures, R38's respiratory care was not person-centered and/or revised to appropriately reflect her status, and R54's pressure ulcer status was not updated to a Stage 4 with person-centered interventions. Findings include: 1) During record review of R29's Electronic Health Record (EHR) found she was hospitalized on ce in December 2024 and she returned to the facility on [DATE]. On 12/15/2024 at 14:37 the Minimum Data Set Coordinator (MDSC)1 documented R29 had a significant change for The assessment was originally scheduled due to new indwelling Foley catheter. However, Foley catheter was discontinued and resident successfully completed voiding trial. On the other hand, IDT (Interdiisciplinary Team) reported that resident has declined in her ability to feed herself from setup help to dependent. For this reason, will continue to complete significant change assessment. On 02/06/25 at 09:59 AM interviewed Unit Manager (UM)1. Inquired if R29 requires assistance with meals and UM1 confirmed this. Inquired about significant change R29 had and UM1 confirmed R29's significant change was for the decline with her Activities of Daily Living (ADLS) with requiring assistance with her meals. At this time reviewed R29's Care Plan (CP) with UM1 and found there were no interventions to address resident's decline and the need for assisitance with her meals. Inquired of UM1 if R29's CP should have been updated to reflect this significant change and UM1 confirmed it should have been updated with R29's significant change for requiring assistance with her meals. 2) On 02/03/25 at 02:29 PM a family interview was conducted with R55's family member. Inquired if R55 had full range of motion (ROM) of his arms and family member stated he is able to lift up his cup to his mouth and they were unsure if he has higher ROM with his arms. During record review of R55's Electronic Health Record (EHR) found resident has a CP that states [Name of R55] is quadriplegic and contractures to bilateral legs related to this. His L (left) hand fingers, and R (right) index finger are contracted. Elbows and shoulders ROM are still WNL (within normal limits). R hand ROM slightly weak. with a Long Term Goal Target Date: 04/27/2025 Name of R55 will participate in self care activities at highest level of independence. with an Approach Start Date: 02/15/2024 OT/PT to eval and treat per MD orders as needed for ROM. On 02/06/25 at 10:28 AM interviewed Physical Therapy Assistant (PTA)1. Inquired if R55 had Physical Therapy (PT) and PTA1 stated resident has finished with PT. PTA provided documentation that resident refused PT each time they asked. PTA1 provided a copy of the directions for ROM for R55 and his preferences. Inquired if this was shared with nursing and PTA1 confirmed it was. PT's recommendation for facility staff was to perform passive range of motion (PROM) exercises in bed 2-3 times a week. On 02/06/25 at 10:42 AM inquired of Director of Nursing (DON) if resident has recommendation listed on his CP from PT Continue PROM exercises in bed 2-3 times a week. DON confirmed it did not include the information provided by the PT department for R55's PROM exercises. DON confirmed this should have been included on resident's CP. 43414 3) R38 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hyperlipidemia, hypertension, and hypoxemia. Review of R38's physician orders for oxygen (O2) included, continuous O2 at two liters per minute (LPM) via face mask, may titrate flow to keep saturation (SATS) greater than (>) 90 percent (%) and O2 at 0-5 LPM via nasal cannula or face mask (per resident preference) as needed, may titrate flow to keep SATS > 90%. Observations of R38 in her room on 02/03/25 at 09:47 AM, 12:40 PM, and 02:26 PM, 02/04/25 at 08:25 AM, 02/05/25 at 08:01 AM and 11:06 AM and on 02/06/25 at 08:01 AM and 10:13 AM, found R38's O2 face mask not covering her mouth or nose to provide continuous oxygen, but located on the side of her face. The O2 concentrator was running at two LPM. On 02/03/25 at 09:47 AM, interview with R38 was done. R38 reported her O2 is on the whole day but she puts on her face mask herself when needed. R38 stated she does not need to inform nursing staff when she used or needs O2. A second interview with R38 was done on 02/05/25 at 08:01 AM, R38 reported when she needs O2 she will put the mask on herself and if she doesn't, she takes it off. When inquired how often does she need to utilize O2 she stated all day and all night. R38 was not using her O2 mask at this time, and although the O2 concentrator was running, the tubing connecting the face mask to the concentrator was not connected. On 02/06/25 at 10:14 AM, an interview with Registered Nurse (RN) 5 was done. RN5 reported R38 puts on and off her own face mask for O2 because R38 wanted the O2 on all the time. RN5 clarified and stated R38 does not necessarily need the O2 concentrator to be on continuously but more so wants it on continuously. On 02/06/25 at 10:37 AM, an interview and concurrent record review with Unit Manager (UM) 1 was done. UM1 reported R38 does not use O2 all the time but likes to have it on continuously for comfort. R38 takes on and off her face mask on her own. Inquired if R38's CP reflected R38's preference to have the O2 run continuously for comfort and was educated and assessed to independently remove and put on her mask on her own, UM1 confirmed it did not. Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found by UM1. Review of the facility's policy and procedure Oxygen Administration reviewed/revised on 06/2023 documented, The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. 4) Cross Reference to F686. The facility failed to provide R54 necessary treatment, consistent with professional standards of practice to promote healing of a stage 4 pressure injury. R54 was admitted to the facility on [DATE]. R54's diagnoses include, not limited to, stage 4 pressure ulcer of sacral region, posterior reversible encephalopathy syndrome, local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus with other skin complications peripheral vascular disease, acquired absence of right leg above knee, type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right lower leg with necrosis of bone, pain, and infection of amputation stump of right and left lower extremity. Review of R54's quarterly Minimum Data Set (MDS) with assessment reference date of 12/17/24 found R54's Brief Interview for Mental Status (BIMS) scored a 15 (cognitively intact). In Section GG. Functional Abilities and Goals, under Mobility, R54 needs substantial/maximal assistance to roll left and right, is dependent sit to lying and lying to sitting on the side of bed. On 02/03/25 at 08:59 AM, observation and interview with R54 was done. R54 reported she has a pressure injury on her coccyx and had it for a while. The wound team reportedly informed her on their last visit that the wound was getting bigger. R54 expressed that she was frustrated because she tries to do the turning and positioning herself by using the bed rails to hold on to and offload but cannot do it for long because it is sore and becomes more painful. R54 stated she must ask staff to be repositioned but if she doesn't ask, they do not help or reposition her. Observed resident attempt to reposition herself by using her arm strength and holding on to the bed rail lifting herself up, for less than thirty seconds, before going back to a flat on her back position. No pillows or wedges were observed to be used to help reposition her. During a second observation and interview with R54, on 02/04/25 at 08:36 AM, R54 was observed lying flat on her back and stated her arm was sore when turning herself. Inquired if the facility offered a wedge to help reposition so she does not have to hold on to the bed rail and lift herself up, R54 reported she has a wedge, but it is a hard foam and every time they put it behind her back it is uncomfortable, so she takes it off. R54 reportedly requested for pillows instead to reposition, and staff tell her they will look but never come back with pillows. On 02/06/25 at 03:28 PM, concurrent record review and interview with UM1 and Infection Preventionist (IP) was done. Concurrent review of R54's EHR documented R54 has a stage 4 pressure injury. UM1 stated residents with pressure injuries or are at risk and are not able to turn themselves should be turned every two hours and may use a wedge to assist residents in repositioning. IP reported R54 uses her arm to turn herself and has a wedge and pressure mattress but R54 refuses the wedge because it is too hard. Staff had offered covering the wedge with a blanket. UM1 stated if a resident refuses treatment, nursing staff should educate and reapproach or offer different interventions as well as education of risk and benefits. Refusals should be documented in the progress notes. UM1 confirmed refusals were not documented. Review of R54's CP, UM1 confirmed the resident's CP was not updated to reflect R54's pressure injury status, did not include person-centered intervention, to aid with turning and positioning every two hours and to use pillows/wedges or other devices to assist with turning and positioning and should have been care planned. Review of the facility's policy and procedure (P&P) Pressure Injury Prevention and Management reviewed/revised on 06/2023 documented under intervention for prevention and to promote healing of a pressure injury, The goals and preferences of the resident .will be included in the plan of care .Interventions will be documented in the care plan and communicated to all relevant staff .Compliance with interventions will be documented in the weekly summary charting. The P&P included when modifications of interventions are needed, Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include .Changes in resident's degree of risk for developing a pressure injury .Resident non-compliance. Review of the facility's P&P Comprehensive Care Plans reviewed/revised 06/2023 documented the CP will describe, at a minimum, The services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being .Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .Resident specific interventions that reflect the resident's needs and preferences that align with the resident's cultural identity, as indicated. The P&P further documented The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed and the resident will be informed of .risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal or treatment and services document such attempts in the clinical record, including discussions with the resident .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to ensure a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1) ensure a pill cutter, used for multiple residents, was cleaned between patient use, observed from one of three medication carts; 2) ensure staff perform hand hygiene after discarding dirty gloves before assisting resident (R) 123 with her meal, one unsampled resident; 3) ensure clean medical supplies to be used are kept on clean surfaces and follow standard precautions by performing hand hygiene between glove change for one of five residents (Resident (R) 54) sampled for wound care; 4) ensure a nursing staff member providing care used appropriate Personal Protective Equipment and performed hand hygiene between gloves for one of six residents (R68) sampled with Enhanced Barrier Precautions (EBP); 5) ensure a lancet, a needle used to puncture the fingertip, was properly discarded for one of two residents (R54) sampled with Transmission Based Precautions (TBP); and 6) ensure a urinary catheter bag was not left on the floor for one of one resident (R68) sampled for urinary catheters. These deficient practices could put residents at risk of contamination that receive medication(s) being cut by the pill cutter, puts R123, R54 and R68 at risk of infection, and puts residents, visitors, and staff members at risk for infection and blood-borne pathogen transmission. Findings include: 1) During inspection of the facility's second floor Ewa medication cart on 02/05/25 at 08:17 AM, a pill cutter, located in the top drawer of the medication cart, was observed to have large amounts of white/brown sediments in the interior portion of the cutter. The Registered Nurse (RN) 12 administering medications from this cart was concurrently interviewed. RN12 confirmed seeing the white and brown sediments in the pill cutter and stated it could be from not cleaning it. RN12 also stated that the cutter should be cleaned after each use. 37954 2) On 02/03/25 at 11:30 AM observed Certified Nurse Assistant (CNA)11 deliver a lunch tray to R123 in her room. CNA11 had performed hand hygiene by applying hand sanitizer to her hands before picking up the lunch tray from the cart. CNA11 delivered the lunch tray and then put on clean gloves to re-position R123 in her bed. CNA11 used the draw sheet to raise R123 up in her bed. CNA11 disposed of the dirty gloves and then used the bed control to raise resident's head of bed so R123 was sitting up for her meal. CNA11 then proceeded to assist R123 with her lunch by sitting at the bedside and fed R123. CNA11 did not do hand hygiene after disposing of the dirty gloves or before feeding R123. On 02/03/25 at 11:45 AM interviewed CNA12 and asked what staff are expected to do after wearing gloves to position a resident and disposing of gloves, he stated sanitize hands. On 02/05/25 at 10:39 AM interviewed Director of Nursing (DON). Inquired what staff are expected to do when they take off dirty gloves and she stated staff are supposed to perform hand hygiene. Explained observation that occurred with CNA11 to DON who confirmed best practice is to wash hands if they are soiled and hand sanitize if not. 3) On 02/04/25 at 01:40 PM observed Registered Nurse (RN)12 do dressing change for resident (R)54. RN12 brought in supplies to the resident's room, used proper personal protective equipment (PPE) as resident is on contact precautions. RN12 was observed placing clean gauze on resident's bed side table. Bed side table was not wiped down prior to nurse placing dressing change supplies directly onto the table, such as the clean gauze. RN12 cleaned R54's pressure ulcer (PU) as ordered by the physician. Afterwards RN12 took off her dirty gloves and put on clean gloves. No hand hygiene was observed prior to RN12 putting on clean gloves. After dressing change interviewed RN12 and asked if it was ok to put clean gauze on resident's dirty bed side table. RN12 confirmed it was dirty and asked if surveyor had any recommendations. RN12 was also told she was seen putting on clean gloves after taking off dirty gloves. Asked her if she is supposed to do anything before putting on clean gloves and she stated wash hands. Inquired with RN12 if she had training on hand hygiene and she said not in a while. Surveyor asked RN12 when she started working at facility and she said about six months ago. Asked if she had training at that time and she confirmed that she had. On 02/04/25 at 02:03 PM interviewed DON who confirmed staff have had training on hand hygiene during orientation, as needed and annually and she reported they do audits. DON explained audits consist of watching to see if staff sanitize their hands before they go into the room or if hands are soiled. DON explained wound nurse or Infection Preventionist nurse does audits as well of wound dressing changes. DON stated she will look into getting small chux that nurses can use for barriers. DON also stated they have trays, I don't know why she didn't use it. On 02/04/25 at 02:10 PM interviewed education nurse who confirmed they do training with staff on hand hygiene and dressing change during orientation and annually. She confirmed nurse should have sanitized hands after taking off dirty gloves before putting on clean gloves. 43414 4) On 02/04/25 at 08:10 AM, observed RN12 respond to R68 when yelling for help because she made a bowel movement (BM). Prior to entering R68's room, a sign outside the door indicated she was under EBP, gloves and gown are needed when providing contact care. RN12 observed at bedside wearing gloves and wiping R68's hands. RN12 was not wearing a gown. R68 complained to RN12 that her stomach was sore and RN12 was observed to assess and touch R68's stomach. RN12 then took off her gloves and grabbed a new pair without hand washing in between glove use and adjusted R68 oxygen tubing. RN12 informed R68 someone will be coming to change and clean her BM. RN12 reported she was wiping R68's hands because she was touching the BM stains on her incontinence under pads. RN12 confirmed R68 is under EBP and should have worn a gown when providing direct care and hand sanitize between gloves. On 02/06/25 at 11:35 AM, an interview with Infection Preventionist (IP) was done. IP stated nursing staff are to wear gown and gloves while providing high contact care to residents with EBP to prevent infections or multidrug-resistant organism (MDRO). Residents with certain medical devices are prone to more infections. IP confirmed nursing staff should hand wash or sanitize between glove use. 5) On 02/04/25 at 08:36 AM, during an interview with R54 observed an opened lancet on the foot of R54's bed and the cover on R54's bedside table. On 02/04/25 at 08:41 AM, an interview with RN12 was done. RN12 confirmed the item on R54's bed was an opened lancet and was used to puncture a finger to test blood sugar levels. RN12 reported used lancets are discarded in a sharps container (a container used to prevent injuries and spread of infections from sharp objects.) On 02/06/25 at 11:35 AM, an interview with IP was done. IP confirmed lancets are to be discarded in a sharps container because it could potentially prick someone else and puts others at risk of blood-borne pathogen contamination. 51870 6) R68 is a [AGE] year-old resident who was admitted to the facility on [DATE] for hospice services. Review of the electronic health record (EHR) , R68 has an indwelling catheter. On 02/05/25 at 08:05 AM, observed R68's catheter bag on the floor. Noted a basin adjacent to the catheter bag. On 02/05/25 at 08:45 AM, Certified Nurses Aid (CNA) 5 verified that catheter bag should be off the floor and in the basin. CNA5 noted that they use the basin as a barrier. Observed CNA5 place catheter bag in basin. Staff interview on 02/05/25 at 11:50 AM, Director of Nursing stated that CNAs are supposed to clean catheters from top to bottom, reporting any signs/symptoms of foul-smelling odor, color of the urine, bag secured to their leg and that there should be a barrier between the catheter bag and the floor. Staff interview on 02/06/25 at 12:40 PM, IP stated that catheters should be hung on the bed, should be off the floor, and basin used as a barrier. She stated that this was to prevent contamination. Review of the facility's catheter policy dated 07/2021 and revised on 01/11/24, Catheter care will be performed every shift and as needed by nursing personnel and catheter drainage bags will be positioned below bladder level, clear from the floor and will not be level with resident in while resident is in bed.

Based on observations, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (R)8 sampled. The facility implemented interventions to allow the resident to self-transfer from the bed to the floor mattress, but did not evaluate, analyze, identify, or address any environmental hazards which existed once R8 self-transferred to the floor mattress prior to implementing this intervention. Also, after implementing the did not monitor the effectiveness or safety for the floor mattress. As a result of this deficient practice, R8 sustained multiple skin tears, bruising, and wounds on both lower legs. Findings include: According to Definitions 483.25 (d) an Avoidable Accident means that an accident occurred because the facility failed to: - Identify environmental hazards and/or access individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or - Evaluate and analyze the hazard and risks and eliminate them, if possible, or if not possible, identify and implement measures to reduce the hazards/risk as much as possible; and/or - Implement interventions, which include adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan, and current professional standard of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident; and/or - Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Cross reference to F550- Resident Rights. During a telephone interview with RN21, it was reported that facility staff would leave R8 on the floor with no clothes or brief, in puddles of urine on the night shift (11 PM to 7 AM). On 03/07/24 at 01:45 AM, conducted a review of R8's EHR. R8 was admitted to the facility on [DATE] with diagnosis which included a myocardial infarction (heart attack), Dementia with behavioral disturbances, spinal stenosis (narrowing of spaces in the spinal canal), dry eye syndrome, ocular laceration, and rupture with prolapse/loss of intraocular tissue (ruptured eye which causes permanent blindness), high blood pressure, sleep apnea, and anxiety disorder. Review of R8's quarterly MDS with an ARD of 02/12/24, Section C. Cognitive Patterns documented R8's BIMS score was 13, indicating R8's cognition is intact. Section GG. Functional Abilities and Goals documented R8 has impairment to upper and lower extremities and is dependent on staff for toileting and transfer (requires 2 or more staff and use of a Hoyer lift for transfers). Reviewed R8's care plan which documented an approach (intervention) (started on 08/11/22): 08/11/22: Bed against wall and standard mattress to left side of bed at all times. Bed in lowest position due to POA's, request to allow R8 to self-transfer to mattress. POA prefers to keep bed rails between resident bed and floor mattress to assist in bed mobility and independence with self-transfer to floor mattress. POA aware of risk and benefits, verbal consent obtained by DON and UM. Bed rail does not prevent resident from self-transferring to floor mattress. Nursing staff will reposition R8 when he self-transfers to standard mattress as indicated and tolerated by resident. On 08/07/22 an approach for staff to do frequent visual check while R8 is in bed and encourage the resident to call for assistance with repositioning and to ensure the call light is in reach at all times. On 03/08/24 at 04:55 AM, while conducting observations on the Ewa unit, heard a resident calling out for Help multiple times and identified a resident in room [ROOM NUMBER] was calling out for staff. The closest staff to room [ROOM NUMBER] was Certified nurse aide (CNA)3, who actively providing care to a resident in room [ROOM NUMBER] and was unable to hear the calls for help. Upon entering room [ROOM NUMBER], observed R8 lying on the floor naked, on his stomach, two pillows under the resident's upper torso, in-between two floor mattresses, and the resident's genitalia was in direct contact with the ground. The oxygen concentrator humidifying solution bottle was under R8's shins and calves were tangled in the nasal tubing which bottle. R8's feet were tangled in the call light cord which was wrapped around the bed rail and connected to the wall and the cord of the oxygen concentrator machine which was also plugged into the wall. After applying the blanket, R8 while attempting to roll onto his back and began kicking his feet to try and untangle his feet from the cords, despite his attempt, R8 was unable to free his feet from the cords. Surveyor assisted the resident with detangling from the cords, then R8 grabbed onto the bed sheet (on the framed bed mattress) for help with turning back onto his stomach during and the resident's feet were forcefully hitting the oxygen concentrator machine. Surveyor encouraged R8 to not turn and wait for staff assistance. Asked R8 how he alerts staff when he needs help/assistance. R8 responded he calls out for help until staff come. Inquired if he can use the call light. R8 stated, I'm blind, I cannot see where the call light is and even if I did use the call light, my light is broken because they said I need too much help and they have to take care of other residents. Informed R8 that the call light was wrapped around the bed rail and was going to activate it. R8 reported, They [staff] put it far away from me so I can't use it. The call light was activated and certified nurse aide (CNA)3 responded within five minutes. CNA3 assessed the resident then stated she was going to get supplies and another staff to help with R8's care. Observed two large bandages on R8's shins (both dated 03/07), redness on both knees and feet, multiple skin tears/small wounds both feet and legs, a scabbed cut (approximately 2-3 inches long) on the resident's right upper back, and two straight line cuts on the left calf. On 03/08/24 at 08:58 AM, conducted a concurrent review of R8's EHR and interview with the director of nursing (DON) regarding the observations of R8 at 04:55 AM. DON reported R8 received a new bariatric bed during the recent recertification survey (January 22-26, 2024), it is the preference of R8 to self-transfer from the bed to a mattress on the floor, R8's power of attorney (POA) is aware of this and signed a consent for to implement bedrails to assist R8 with self-transfers. DON revealed it is R8's preference to rest on the floor mattress, it helps him feel safe because he is blind. Reviewed R8's care plan. Although the facility obtained a signed consent for the use of bedrails and verbal consent from R8's POA allowing the resident to transfer from the bed to the floor, the consent do not eliminate the facility's responsibility to protect the resident from avoidable accidents, nor does it relieve the provider of its responsibility to assure the safety health, safety, and welfare of its residents. DON confirmed the only relevant approaches does not address R8's safety while on the floor mattress and the DON was unaware that two mattresses were being used on the floor. Inquired if the facility completed any assessment(s) of R8's room/floor space to ensure the resident was free of potential accident hazards and how the facility monitors R8 while on the floor. DON confirmed assessments of R8's room/floor space was not assessed for potential/actual accident hazards, the facility did not evaluate R8's floor mattress for accident/hazards, direct care staff did not report any concerns so there was no follow-up for appropriateness of the intervention. DON reported the facility did have a logbook for checking on resident every 2 hours and used a logbook to document the checks. Requested to review the logbook, DON stated staff used the logbook for one month then discontinued it. DON reviewed R'8 entire care plan and confirmed there were no care plan area or approach which address R8's safety while on the floor. Inquired about the bandages on R8's shins. DON reviewed progress notes and reported on 03/05/24 the resident got two skin tears while self-transferring from the bed to the floor. The DON and surveyor conducted a concurrent observation of R8 during which the resident was in the bed. While in R8's room, DON confirmed because of not assessing for potential environmental hazards and risk of area R8's mattress is on the ground, the facility did not identify, evaluate, or analyze the safety of the interventions (approaches) implemented for R8 and after implementing the intervention, the facility did not monitor intervention even after the resident sustained skin tears on both shins while self-transferring.

Based on observation, record review, and interview with staff members, the facility failed to ensure 2 (Residents 11 and 16) of 5 residents sampled with pressure injuries received preventative care to avoid the development of pressure ulcers. The facility failed to ensure accurate weekly skin assessments were done for Resident (R)16, resulting in delayed treatment to prevent the development of a Stage 3 pressure injury. The facility also failed to develop interventions for R11 to prevent the recurrent development or pressure injuries related to contractures. Findings include: 1) Resident (R)16 was admitted to the facility on [DATE]. Multiple medical diagnoses include but not limited to pressure ulcer of sacral region, stage 2 (01/11/23). R16 noted with multiple self-inflicted wounds and a Stage 2 pressure ulcer to the left buttock. A review of the Long Term Weekly Charting from 12/05/22 through 01/30/23 was done. The charting for 12/05/22 documents open lesions, however, no documentation of location. Subsequent assessment of 12/12/22 documents new onset of skin impairment with pressure reducing device for bed. The entry for 12/19/22 notes open lesions (cut fissure, boil, cyst, cancer lesion, small wound under nose with scant on and off bleeding due to scratching. The weekly documentation for 12/26/22, 01/03/23, 01/09/23, 01/10/23, 01/16/23, and 01/30/23 notes no wound present. There was a missing assessment for 01/23/23. A review of the Minimum Data Set (MDS) with assessment reference date of 12/21/22. R16 assessed as being at risk for developing pressure ulcers. There was no documentation of pressure ulcers. A review of the care plan dated 08/31/21 for skin integrity has a goal for R16 to have no unaddressed alteration to skin integrity. Interventions include alternating pressure air mattress as prescribed (01/19/23); assist with turning/frequent repositioning, as needed (08/15/22); barrier cream to peri-area after toileting and as needed (08/15/22); provide skin and incontinence care assistance, as needed (08/15/22); and weekly skin check per facility schedule, notify MD of alterations for prompt/proper intervention (08/15/22). A review of the progress note dated 01/11/23 at 10:30 AM documented R16 with a Stage 2 pressure injury located on the bottom of her left buttock, measuring 2 cm x 1.5 cm with bloody drainage. The physician ordered application of topical Medi-Honey daily until healed as well as repositioning every two hours. Review of wound consultant reports were done. The consultation report of 01/17/23 noted skin ulcer of flank with fat layer exposed, skin ulcer of right side of neck with fat layer exposed, ulcer of abdomen wall with fat layer exposed, skin bulla, and decubitus ulcer of left buttock, stage 3. The consultant notes that wounds occurred by excoriation/skin picking mechanism for unknown duration, with noted worsening over the past week. The stage 3 pressure ulcer to the left buttock measured 4.3 cm in length x 4.5 cm in width with a depth of 0.2 cm. Also noted serosanguineous drainage (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). The most current consultant report dated 01/31/23 notes wounds from last week are variable. The measurement was 3 cm x 1 cm. x 0.2 cm. Also noted small amount of serosanguineous drainage. On 02/03/23 at 07:41 AM an interview was conducted with Unit Manager (UM)2. UM2 reported the identification of the pressure injury was 01/11/23 when it was brought to her attention. UM2 reported staging of pressure injuries are done by the facility's consultants. The consultants staged the pressure injury to the resident's right buttock as a Stage 3 on 01/17/23. UM2 reported if impairment to the resident's skin was brought to her attention earlier interventions would have been aggressively implemented and wound probably would not have progressed to a Stage 3 (at this stage, the sore has gone through all layers of skin into the fat tissue, exposing the patient to infection). UM2 confirmed there was a missing weekly assessment for 01/23/23. UM2 also confirmed the weekly assessments prior to the actual skin break down did not document R16's skin was compromised. UM2 reported the Stage 3 pressure injury was initially measured at 3 cm x 1 cm and most recently 3.8 cm x 1.5 cm. 47783 2) During initial observation on 01/31/23 at 09:52 AM, noted R11 in bed using a specialty mattress, head of bed elevated, arms and legs severely contracted with rolled paper towel in both hands, pillows between legs and foam boot in place. No pillow noted between arms and torso. On 01/31/23 at 01:04 PM, observed Infection Preventionist (IP) and physician assistant (PA) change the dressing on left wrist open area and right foot pressure ulcer. IP and PA had a difficult time placing the cushion between the resident's arms and torso. IP had to use both hands to separate resident's arms from his body as another staff positioned the cushion. Observed that R11 gets spasms when he is stimulated by sound and touch and cushion had to be adjusted a second time before IP and contracted staff exited the room. Record review of Wound Notes for R11 revealed that left wrist open area recurred 5 times in 2022 on the following dates: 03/29/22, 07/05/22, 08/02/22, 08/16/22, and 11/22/22 for the most recent one which started as a 0.2 X 0.5-centimeter (cm) open area. Measurement as of 01/31/23 is 2.0 X 6.0 cm. Wound culture and sensitivity test was done on 01/03/23 and was found to be infected, Levofloxacin for 14 days was started on 01/06/23 for 14 days. (Cross Reference to F657- Care Plan Timing and Revision). Treatments for the left wrist from Orders are as follows: 03/09/22: Wound care: Cleanse with NS (normal saline), apply silver alginate and bordered foam dressing to re-opened left wrist wound. 08/16/22: Wound care: Cleanse with NS, apply silver alginate and bordered foam dressing to re-opened wound to left wrist dorsal (back portion) area. 08/22/22: MediHoney (honey)gel; 80 %; amt: 1 application; topical. Special Instructions: Cleanse with NS, pat dry, apply honey gel to L (left) dorsal wrist and cover with foam dressing once daily until healed. 09/07/22: Wound care for left wrist wound: Cleanse with NS, pat dry, apply wet to dry dressing once daily until healed. 10/05/22: Wound prophylaxis for left wrist: Cleanse with NS, pat dry, apply border foam dressing for pressure injury prevention. 10/29/22: Use air filled cushion between chest and hands/forearms at all times, to decrease risk of skin breakdown. Skin check q shift to assess skin integrity. Remove for showers. Assess firmness each shift, if it is not firm, notify therapy. 11/23/22: MediHoney (hydrocolloid-honey) (honey-hydrocolloid dressing) bandage; 2X2 (inches) ; amt: 1 application; topical. Special Instructions: Cleanse L (left) wrist wound w/ (with) NS and pat dry. Apply MediHoney and cover w/ foam dressing daily. IP was interviewed on 02/03/23 at 02:23 PM. She stated that the cushion between the R11's wrist and chest area can come off if the resident gets spastic when stimulated and the staff have a hard time putting it back. She also said that she has asked staff to call her when they need help replacing it, but they don't. Review of facility's policy and procedure Pressure Injury Prevention and Staging states: . 4. Resident's Care Plan will reflect appropriate preventative interventions to be followed and the RN will document these in the resident's clinical record.

Based on observations, record review, and interviews with staff members, the facility failed to implement interventions, including adequate supervision, to reduce the risk of accidents for two of six sampled residents, Residents 23 and 36. As a result of this deficient practice, Resident (R)36 had multiple falls, with a fall resulting in the resident being taken to the emergency department for evaluation. Finding include: Resident (R)36 has an extensive history but not limited to hereditary musculoskeletal disease, blindness to the left eye secondary to a ruptured globe (repaired). Recurring depression/anxiety, cognitive decline with behavioral disturbances. Also hereditary spinocerebellar ataxia (type 3, [NAME]-Joseph with recurrent falls and dysarthria.) Facility reported incident summary dated 01/10/23 at 12:30 AM in Ewa Hallway revealed R36 was found lying belly down with hands out in front of him and forehead touching the floor. Wheelchair was on top of resident and his chest belt was still strapped on. R36 was taken to a hospital emergency room by emergency medical services (EMS). Record documented that the resident lost consciousness and had a weak and thready pulse. Record review (RR) reveals fall events on: 09/30/22 - slid out of chair - no injury. 01/07/23 - Fall with abrasion to left forehead. 01/10/23 - Fall with loss of consciousness. 02/02/23 - Fall with a minor scratch to his forehead Observation on 02/01/23 at 09:05 AM, R36 was waiting in que for a shower. This surveyor noted that his toe was bleeding. Noted that R36's toes were dangling on the floor and leaving a trail of blood. Unit manager (UM)1 was notified. Observation on 02/02/23 at 08:46 AM in the hall, R36 is in the hall in his wheelchair with his iPad. R36 is slouched down and tends to slide in his wheelchair. No wedge pillow was noted. No dedicated staff to supervise resident on a one-to-one basis. On 02/02/23 at 11:45 AM, interview with Registered Nurse (RN)6 stated that R36 had an unwitnessed fall this am before morning shift and sustained a minor scratch to his forehead. Interview with director of nursing (DON) about what the facility is doing about falls for R36. DON stated that the Physician (MD) is discontinuing his blood thinner. DON stated R36's mother is very involved and has ordered a special wheelchair that is custom fit to the resident, ordered in August but not available yet. Resident has refused a Geri-chair, vest restraint, changing rooms. Resident is brought to nursing station but will loosen lap belt and slide out of chair. Facility has had 1:1 sitting in the past. Mother comes in every afternoon and sits with him. Resident has been seen to propel himself onto the floor by staff. RR on 02/03/23 at 07:32 details R36 was seen on the floor on 02/02/03, surrounded by morning staff. CNA witnessed resident slide himself from the wheelchair onto the floor and falling forward face down, small laceration superior to left eyebrow, no bleeding, no change in LOC, called American Medical Response (AMR) for pick up. Interview on 02/03/23 at 07:56 AM with LPN 9, who is R36's nurse today. Queried LPN9 if she was aware of the fall. LPN9 stated that she was aware of the fall but had not had a chance to review it. LPN9 stated honestly, it's a matter of keeping him comfortable and entertained. Observation on 02/03/23 at 08:27 AM of nurse talking with R36. Immediately after nurse goes down the hall, R36, is calling out in hall to be pulled up. All staff in rooms, busy and unit clerk is the only person nearby. Observation on 02/03/23 at 09:22 AM of R36 who is loudly crying out I'm going to fall down. LPN9 responded to R36. 47783 2) R23 is a [AGE] year-old resident with Alzheimer's disease, dementia, history of falls and fractures, muscle weakness, orthostatic hypotension (sudden drop in blood pressure when standing from a seated or lying position), difficulty in walking and age-related osteoporosis (weakened bones). R23 also has a history of wandering. On 1/31/23 at 09:10 AM, observed R23 lying in bed with only her head and back directly on the bed, and both feet touching the floor. Registered Nurse (RN) 6 was in the room passing medications to another resident, asked if the resident needs to be positioned properly in the bed. RN6 replied that that's how R23 is and can get combative if they try and place her on the bed properly. On 02/02/23 at 10:45 AM, observed resident get out of bed unsupervised and unassisted, used front wheel walker (FWW) and walked to the toilet. After using the toilet, R23 proceeded to the elevator by herself using her FWW as the recreational therapy staff was bringing other residents down to the first-floor activities area. Record review revealed that R23 had an unwitnessed fall in her room on 10/08/22 at 09:39 PM, unwitnessed fall in the hallway on 11/21/22 at 01:23 PM, witnessed (by a resident) fall in the hallway on 12/19/22 at 02:21 PM, and was trapped in the elevator by herself on 11/26/22 for approximately 15 mins and on 01/26/230 for approximately 50 minutes. Most recent Rocky Mountain Fall Risk assessment dated [DATE] described the resident as a moderate fall risk with no mobility concerns and impulsive actions. However, assessments for the following dates: 10/08/22 described R23 as high fall risk, requires assistance or supervision for mobility, transfers, or ambulation and lack of understanding of physical and/or cognitive limitations; 11/21/22 as high fall risk with unsteady gait, altered awareness on immediate physical environment, impulsive actions and lack of understanding of physical and/or cognitive limitations; and on 12/19/22 as high fall risk, requires assistance or supervision for mobility, transfers, or ambulation, altered awareness on immediate physical environment, and lack of understanding of physical and/or cognitive limitations. Review of care plan (CP) documented the resident was at risk for falls (11/06/21), and wandering (09/18/21). (Cross reference to F657 Care Plan Timing and Revision). On 02/02/23 at 11:04 AM, conducted an interview with RN6 and unit clerk (UC)10. Asked RN6 if they have a device to prevent R23 from accessing the doors, she confirmed that R23 does not have a wander bracelet. According to the UC10, they used to have wander bracelets but not anymore since they upgraded their doors. A key card is needed to open the door. The residents are still able to access the elevator, but all the doors downstairs also require a key card to open. On 02/03/23 at 10:27 AM, conducted an interview with Unit Manager (UM)1. Asked how closely is R23 being supervised when wandering in the hallway, UM1 responded: we try to keep an eye on her as much as we can resident goes to activities and does not need constant assistance able to walk around and has a fascination with the elevator. We tried to have her sit by the nurse's station, but she would still try to get up and walk away. We are not able to provide her with one to one supervision.

Based on interviews and record review, the facility failed to ensure the accurate assessment, upon admission, for existing behavioral disorders that may indicate a psychiatric condition for one of three (Resident (R)3) residents sampled. R3 did not receive adequate treatment to address the resident's severe psychological needs. R3 was transferred to the Emergency Department (ED) after the resident's behavior escalated to physical and verbal aggression toward residents and staff. R3 was transferred between the facility and the Hospital (H)3 twice by ambulance, then waited in the ED for three days before receiving services. R3 did not receive skilled nursing services or a psychiatric evaluation while in the ED. Findings include: (Cross Reference to F623, Notice requirements before discharge/transfer, and F626, Permitting residents to return to the facility). On 12/20/22 at 10:00 AM, reviewed R3's Electronic Medical Record (EMR). R3's admission Minimum Data Set (MDS) documented R3's Brief Interview for Mental Status (BIMS) score was 0, indicating the resident's cognition was not measurable. R3's mood interview was 5, which indicates medium on the depression scale. R3 scored a 0 on the behavior interview, which indicates she didn't express any behavioral problems. Her active diagnoses included personal history of other mental and behavioral disorders and a history of falling, recent surgery requiring active skilled nursing facility (SNF) Care, and medication section indicated R3was taking antipsychotic's 5 times in the week. Baseline Care Plan dated 12/02/2022 reviewed. Cognitive: Alert and Oriented: x4. Behavior/ Mood: None. Pain: checked has pain or discomfort or potential location: Head, Hip (3). Preferences/ Strengths: Checked cognition/abilities to make own decisions, able to communicate needs. Comprehensive Care plan dated 12/05/22 reviewed; Behavioral symptoms, R3 exhibits verbally abusive behavioral symptoms. Target date 12/22/2022 (long term goal) Resident will not threaten, scream, or curse at other residents. Administer medications. Monitor and record effectiveness. Reviewed medication administration history dated 12/01/2022 to 12/06/2022. R3 takes the following routine antipsychotic medications. Risperidone 0.5 milligram (mg) tablet twice a day for a diagnosis (DX) of a personal history of other mental and behavioral disorders. Seroquel tablet; 50 mg; tab at bedtime. Crush and Administer 1 tab by mouth daily at bedtime for Bipolar. Reviewed orders: Monitor for angry outbursts for mood stabilizers drug use every shift day, evening, night (NOC) start 12/01/2022 to 12/06/2022. Psych Consult continuous as needed (PRN) start 12/01/2022 to 12/06/2022. Reviewed progress notes dated 12/01/22 to 12/06/22. No documentation found to indicate that R3's behavior was being monitored every shift of receiving as needed medication and no reference for a referral for psych consult was noted. No Pre-admission Screening and Resident Review (PASSR) level 1and 2 screening results found in the record. On 12/21/22 at 1:00 PM, telephone call to interview the registered nurse case manager (RNCM)5 at H3 and if R3 was there. RNCM5 confirmed R3 was in H3. Rehab services were started for R3 on 12/16/22 and that she is getting physical therapy (PT), and Occupational Therapy (OT). The facility said they wanted a psyche evaluation prior to receiving the resident back to their facility and we would have gotten one, but she wasn't appropriate since she already had one at the previous hospital (H1) where she had her surgery, and the facility should have consulted with H1 to ensure she received the psychological evaluation as this hospital does not have Psychiatric services. R3 was sitting in the ED from 12/06/22 to 12/09/22. On 12/22/22 at 11:00 AM, reviewed the Discharge summary from H1 dated 12/01/22 at 09:29 AM. Admitting diagnosis included Right hip fracture, Hypertension, Dementia Unspecified, Fall, History of Bipolar Disorder, (Personal history of other mental and behavioral disorders). R3 admitted for right Hip fracture, She did have some delirium and some issues with her history of bipolar. This was treated by Psychiatry. She will be on Risperdal and Seroquel (anti-psychotic medication used to treat behavior disorders). Reviewed the Baseline Care Plan dated 12/02/2022, PASSR box was not checked that it was reviewed and accurate. During an interview with the Administrator, Director of Nursing (DON) and Social Services Director (SSD) on 12/22/22 at 12:51 PM. Surveyor asked if the facility had called the H2 prior to sending R3 out for a psych eval to ensure services were available. The administrator replied that there was no communication between the facility and the hospital. The resident left by ambulance and was not taken to the intended location at H2, instead she went to H3. Surveyor asked if a screening was done prior to admission and if the facility had reviewed R3's medical history or had a conversation with staff at the transferring hospital as part of the assessment and to find out if any concerns were identified about R3's behavior prior to being admitted for skilled nursing at the facility. Both the DON and SSD replied that the Nurse Manager wasn't informed that there were any problems with her behavior. On 12/22/22 at 12:00 PM, reviewed the Admission Policy revised date 09/17/21 Pg. 2. 4. The following information is required at the time of admission. e. (PSSR) Level I/Level II evaluation. and procedure.

Based on observation, interview, and record review, after identifying a person under investigation (PUI), with a fever of 102.3 degrees at 03:38 PM on 08/11/21, the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were executed, as evidenced by the facility failing to revise, follow and implement their infection prevention and control policies and procedures, including the transmission-based precautions of their COVID-19 Plan to control and prevent the spread of infections. Due to the community increase of COVID-19 delta-variant infection in vaccinated individuals, failure to follow the facility policy related to COVID-19 had the potential to contribute to an outbreak in the facility's vulnerable population. As a result of this deficient practice, staff and patient safety was compromised and an immediate jeopardy (IJ) was identified. In addition, the facility failed to have a functional, sanitary shower/toilet area on the first floor, Diamond resident care area or ensure staff performed hand hygiene between residents and after doffing gloves and failed to physically distance residents lined up in the hallway. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. The State Agency (SA) identified Immediate Jeopardy (IJ) on 08/12/21 at 02:50 PM. On 08/12/21 at 03:26 PM, the Administrator was notified of the IJ at 483.80 (F880) and provided with the IJ template. The Administrator signed the template to attest receipt of the notice. The facility did not implement standard transmission-based precautions (TBP) to contain possible spread of COVID-19 upon identification of a resident suspected of COVID-19. The State's positivity rate for COVID-19, the Delta variant, has been exponentially increasing (> than 5% positivity). The facility failed to ensure the room door was closed, the resident's roommate (possibly infected) was seated amongst the other residents on the unit, the TBP supplies were not readily available for staff to sanitize their face mask or access the disposable liners, the resident's room did not have a container to dispose of gowns prior to exiting the resident's room, staff members did not follow the facility's COVID-19 guidelines (donning gowns properly and using an N-95 respirator), contractors did not don appropriate personal protective equipment (PPE), and there was no dedicated equipment for the PUI resident or provision of appropriate sanitizing solution for shared equipment. These deficient practices have the potential to result in adverse outcomes (spread of COVID-19) to residents and staff members in the facility. Due to the vulnerability of residents, contracting COVID-19 could result in death. On 08/12/21 at 06:00 PM, the facility provided a removal plan. The removal plan consisted of updating the facility's COVID-19 Plan and TBP signage, then re-training all staff on the updates, focusing on the procedure for responding to a suspected COVID-19 resident, and the implementation of TBP. The SA approved the removal plan. On 08/13/21, the facility provided a copy of their updated plan, and sign-in sheets verifying the staff that completed the in-service training. The SA requested return demonstration of the in-service training that was provided to the staff members. Three staff members were randomly selected by the SA to represent the direct care staff. The conference room and hall were set up to simulate a PUI resident's room. PPE cart and signage were posted in the hallway and the room was provided with a vessel to dispose of PPE before exiting the room. The facility used revised signage and ensured staff members had access to the solutions for sanitizing their face shields. The staff members successfully demonstrated competency for donning and doffing of PPE while providing care for resident suspected of COVID-19 infection. On 08/13/21 at 03:16 PM, the SA verified the IJ was removed, however a pattern of deficient practices at F880 remain. Findings include: 1) On 08/12/21 at 08:57 AM a Surveyor was notified that Resident (R)46 had a fever the previous night, tested negative for COVID, placed on droplet precautions, and was due for a chest x-ray (CXR) that morning. A quick record review (RR) of R46's electronic health record (EHR) revealed documentation of a fever of 102.3 degrees at 03:38 PM on 08/11/21, but no subsequent vital signs (temperature, pulse, blood pressure, respirations) documentation was found. There was also no documentation found of a COVID-19 test being done, or resulting as negative, as per the verbal report to the surveyor. On 08/12/21 at 09:00 AM, observations were done outside R46's room on the second floor. R46's room door was propped open, and his roommate was observed sitting in the hallway along with three other residents, with no mask on his face. A portable CXR was being done on R46, and from the doorway it was observed that the radiology technician was wearing a gown, goggles, a procedure mask, and gloves, as he positioned R46. There were contact and droplet signage placed outside the door, and directly left of the doorway was a small, semi-transparent, personal protective equipment (PPE) cart with a box of gloves, a box of procedure masks, and a box of N-95 respirators placed on top. The top drawer was secured with a closed combination lock and contained a roll of trash bags, and a spray bottle filled with clear liquid. The second and third drawers were not locked and contained cloth gowns. There were no EPA [environmental protection agency]-approved disinfectant wipes observed in or by the room/cart. On 08/12/21 at 10:15 AM, a Surveyor observed certified nurse aide (CNA)7 assist R46's roommate, who was still not masked, from the hallway into his room. CNA7 was observed taking note of the signage and PPE cart outside the doorway, turning to ask another staff member about it, then walking away from the room, leaving the door propped open. On 08/12/21 at 10:24 AM, CNA7 was observed returning to the area outside of R46's room. CNA7 performed hand hygiene with an alcohol-based hand rub (ABHR), donned a cloth gown, and a pair of gloves, then entered the room with the face shield and procedure mask that she was already wearing. At 10:27 AM, CNA7 was observed doffing her gown and gloves near the doorway, placing them inside of a regular trash bag, and leaving the bag on the floor by the doorway. She then used ABHR to complete hand hygiene and stepped out of the room. CNA7 did not stop to clean her face shield or change her procedure mask. At 10:30 AM, an interview was done with CNA7 as she stood outside of R46's room. CNA7 stated she had seen R46's roommate dozing in the chair and wanted to help him to his bed to lay down. CNA7 confirmed that she saw the precautions [signage] after she assisted R46's roommate into the room and stated that droplet precautions required those who entered the room to wear a face shield, a gown, gloves, and a duckbill. She clarified that the duckbill was an N-95 respirator. CNA7 stated that the top drawer of the PPE cart was locked, and she did not know the combination. When asked about the linen she left by the doorway she replied, I didn't see any bins to discard everything in. When asked if it was okay for R46's roommate to be out in the hallway without a mask, CNA7 stated she did not know. CNA7 then explained that she had not attended the morning huddle, so she did not know why the transmission-based precautions (TBP) were in place. CNA7 confirmed that she should have worn an N-95 respirator in the room and should have closed the door. On 08/12/21 at 10:40 AM, an observation and concurrent interview was done with R46 in his room on the second floor. R46 stated that he felt fine, was able to confirm that he had a CXR done but did not know if a COVID-19 test was conducted. There was no dedicated equipment for vital signs, no EPA-approved disinfectant wipes, and no receptacle to dispose of the used PPE in the room or shared bathroom. Not knowing where to place the doffed gown, this surveyor requested assistance from CNA9, while still standing in the open doorway of the room. CNA9 grabbed a regular trash bag to place the doffed gown in, picked up another trash bag that had been left inside the doorway, and walked them to the dirty linen room. On 08/12/21 at 10:55 AM, an observation was done of CNA10 donning PPE outside of R46's room. CNA10 wore a face shield and procedure mask, donned a pair of gloves, opened the box of N-95 respirators on the PPE cart, and then closed it without taking one. CNA10 then removed a cloth gown from the PPE cart and donned it, securing it with a tie at the neck, and leaving the waist tie unsecured. CNA10 entered the room and turned to receive a lunch tray from another staff member in the hallway. CNA10 placed the lunch tray in front of R46's roommate, walked to R46's bed and was observed touching items in the environment, returned to R46's roommate after hearing him ask for something, and handled items on his food tray. CNA10 then walked back to R46's side of the room where she was again observed touching items in the environment. CNA10 then walked to the doorway and closed the door at 10:57 AM. CNA10 did not perform hand hygiene or change her gloves while providing care for R46 and his roommate. At the same time, the Assistant Director of Nursing (ADON) was observed trying different combinations to open the lock on the top drawer of the PPE cart without success. The ADON stated the top drawer contained alcohol spray for staff to clean their face shields with, and water-soluble plastic bags for the dirty linen. On 08/12/21 at 11:04 AM, an interview was done with the ADON outside of R46's room. CNA5 had just been observed entering the room wearing a gown, a face shield, a procedure mask, and gloves. The ADON confirmed that because R46 was still suspected [of potentially having COVID-19], anyone entering his room should be wearing an N-95 respirator and not a procedure mask. The ADON was also informed that the radiology technician had not been wearing an N-95 respirator when he was in the room, and she acknowledged that although he was outside staff, he should have known that the policy when entering a room with a PUI was to don an N-95 respirator. On 08/12/21 at 01:17 PM, a phone interview was done with the Infection Preventionist (IP). The IP stated that she is on-site three days a week and is full-time, splitting her time between the duties of both the IP and the MDS Coordinator positions. The IP reported that the facility uses the CDC guidelines for infection prevention. When asked about TBP and the Infection Prevention and Control Plan (IPCP), the IP stated that a couple weeks ago the facility changed its policy and was only admitting residents who were fully vaccinated. The facility also decided to remove its yellow zone at the same time. The IP reported that the DON and ADON helped to communicate the policy changes to staff. Asked to explain their COVID-19 Plan, the IP stated that when staff identifies a resident with COVID-19 symptoms, the plan is to isolate the resident (as much as possible), place a PPE cart and TBP signage outside the room, fill out a person under investigation (PUI) Form, which is kept on the unit, pull the privacy curtains around both the resident and roommate, and confine them both to the room until the PCR (polymerase chain reaction test for COVID-19) test is confirmed as negative. Also, the Charge Nurse notifies the IP, DON, and primary physician as soon as possible, and obtains orders for a PCR test, a rapid flu test, and a CXR. An [MEDICATION(S)] (screening test for COVID-19) test is usually done, and its result should be documented in the progress notes of the EHR. When asked about PPE for droplet precautions, the IP confirmed that primary staff (licensed nurses and CNAs) need to use gowns, N-95 respirators, face shields and gloves when entering the room. The IP then stated that although she was informed and on-site when R46's fever was identified, she did not participate in implementing the COVID-19 Plan. When asked if she did any assessment of the resident for surveillance purposes, the IP stated, I went up there [to R46's room], but I failed to go in. On 08/13/21 at 09:00 AM, an interview was done with Registered Nurse (RN)1 outside of room [ROOM NUMBER]. When asked about vital sign equipment and monitoring, RN1 stated that staff use the vital signs equipment on the medication cart of their unit to monitor all residents' vitals once every shift. The equipment (a portable blood pressure machine and a handheld digital thermometer) is wiped down between residents with the turquoise wipe [Sani-cloth HB], which are also kept in the medication carts on each unit. A review of List N: Disinfectants for Coronavirus (COVID-19) revealed that Sani-cloth HB has not been approved by the EPA as a disinfectant that kills COVID-19. When questioned which vital sign equipment was used to take R46's vitals that morning, RN1 answered the one on the cart. RN1 then confirmed that there was no dedicated equipment for R46 despite his TBP status. On 08/13/21 at 09:05 AM, an interview was done with RN3 in the hallway outside room [ROOM NUMBER]. RN3 stated the equipment on her medication cart was used to measure R46's vitals that morning. RN3 also confirmed that there was no dedicated equipment for R46 and stated that there should be. 2) On 08/10/21 at 11:50 AM, an observation was done of certified nurse aide (CNA)9 assisting resident (R)47 with her meal in the hallway of the second floor. Through the course of feeding her, R47 spit up a large amount of food. CNA9 was observed cleaning R47's mouth and chin with a cloth napkin, placing the napkin on R47's bedside table, grabbing a pair of gloves from inside the doorway of room [ROOM NUMBER], and donning those gloves without performing any hand hygiene. CNA9 then ran to the bathroom at the beginning of the hall for wet paper towels, returned to R47, and used the wet paper towels to wipe her face. CNA9 then walked back to the bathroom at the beginning of the hall, threw her gloves and paper towels away in the bathroom trash, then performed hand hygiene. CNA9 was interviewed at this time regarding hand hygiene, and she apologized for not doing it before donning her gloves, acknowledging that hand hygiene should be done before and after glove use. 3) On 08/11/21 from 11:53 AM to 12:00 PM, observations were done of the Social Services Designee (SSD) as he made his rounds on the second floor. The SSD was observed entering room [ROOM NUMBER], speaking supportively to the resident in bed 2, holding her hand, and touching her bedside table. The SSD then walked over to room [ROOM NUMBER], then room [ROOM NUMBER], and finally room [ROOM NUMBER]. In each room, the SSD was observed visiting with residents, touching both the residents and items in their immediate environment such as their privacy curtain or bedside table, and moving on to the next resident. At 12:00 PM, the SSD was observed entering the elevator and leaving the second floor. At no time was the SSD observed washing his hands or using the alcohol-based hand rub (ABHR) outside each room or the elevator, to perform hand hygiene. 4) On 08/10/21 at 10:46 AM observed five residents seated in the dining room waiting for lunch. The cart containing the lunch trays were brought out from the kitchen at 10:55 AM. Staff members distributed the lunch trays to residents. Residents were not observed to perform hand hygiene prior to consuming their meals. Second observation was done on 08/11/21. At 10:50 AM the food cart was delivered to the dining room. Seven residents were seated in the dining room following participation in activities. The tables which accommodated two residents were fitted with a plastic barrier between the residents. The lunch meal consisted of sandwich, soup, and beets. Residents were not observed to perform hand hygiene prior to consuming their meals. Observation on 08/11/21 of the Downstairs unit found staff members passing trays to residents' rooms. At 11:00 AM, Resident R4 was seated in the hall and requested to hand sanitize. Certified Nurse Aide (CNA)3 brought the dispenser of ABHR to R4. CNA3 was observed to provide ABHR to R80 with his lunch tray. Observed CNA13 deliver tray to R180, the resident was not provided with ABHR for hand hygiene before lunch. Interviewed CNA3 regarding provision of ABHR to residents, CNA3 reported she learned to do this while working at another facility. CNA3 was not aware other residents were not being provided with ABHR to perform hand hygiene before their meals. 5) Observation on 08/10/21 during the lunch meal found residents seated in the hall next to the nurses' station having lunch. R78 and R59 were seated in their wheelchairs with overbed trays in front of them, and placed next to one another, less than six feet apart. Three female residents were seated across the nurses' station, two on a built-in bench and one in her wheelchair. The residents were provided with overbed trays and were placed next to one another, less than six feet apart. Observation on 08/11/21 during lunch found R380 (R380 seated in his wheelchair facing the exit door with R4 seated in his wheelchair with his back to the wall). R380 goes out of the facility for hemodialysis three times a week. The residents were seated perpendicular to one another (R380 facing forward to the side of R4) and were placed less than six feet apart. The residents were observed to converse with one another. On 08/13/21 at 12:23 PM observed R380 sitting in the hall with no face mask, facing the exit door next to the wall. R78 was placed less than six feet away with her wheelchair placed against the wall, resulting in the residents being perpendicular to one another. On 08/13/21 at 12:25 PM concurrent observation was made with the Infection Preventionist (IP). The IP reported R380 is required to wear a mask at the [CONDITION(S)] facility and wears a mask as tolerated while in the facility. IP also reported residents should be placed six feet apart from one another, and moved R380 back away from R78. R380 was asked about his tolerance for wearing a mask, he responded he's allergic and it scratches his face. 6) On 08/12/21 at 12:22 PM during an interview with RN1, she said R46 was in isolation and considered a PUI for COVID-19. RN1 said she was notified R46 was in isolation by verbal endorsement at shift change and the [MEDICATION(S)] test done last night was negative. RN1 was unable to locate any documentation the [MEDICATION(S)] test was collected or the negative result. Inquired when the PCR result sent to the lab was expected, she said the lab had just picked up the specimen about 11:00-11:30 AM this morning and the test was not ordered STAT [rush] because the doctor didn't order it that way. When asked if the unit had any special cleaning by housekeeping, she said she did not know. 7) On 08/12/21, reviewed the facility COVID-19 Plan provided to surveyor. The plan had a revision date of 07/2021. The Administrator said the plan had not been revised to include the closure of the yellow zone on the first floor had been the designated COVID-19 unit. The written plan included the following directions for a highly suspicious COVID-19 resident: 2. Isolate resident in place with the door closed . 3. Primary Staff, the licensed nurse and CNA assigned to the resident - PUT ON FULL PPE (gown, N95, face shield, gloves) when entering the room.Since primary staff have been exposed to the resident with symptoms, they will wear FULL PPE for droplet precautions (Gown, N95 mask, face shield, grooves), when providing care to residents in other rooms. 6. Other staff to return residents to their rooms and close the doors, Clean and sanitize all common areas (hallways, railings, door handles, shared bathroom, etc, .). 7. Testing resident .Call Lab for stat pick up . The plan went on to direct staff if a resident was positive for COVID-19 to transport the resident to the designated COVID-19 unit. On 08/12/21 at 01:17 PM during a phone interview with the IP, when asked the current practice should be if a PUI had a roommate, she said We have to keep in the room because of all the changes we made recently. The IP was informed the CNA didn't know if the room mate could come out of the room. She said the staff had inservice's about a year ago and the changes to the plan were communicated to the staff by the ADON and DON. The IP went on to say, the DON, ADON and Administrator help me a lot with updates. Mostly our Administrator is getting the CMS [Centers for Medicare & Medicaid Services] and DOH [Department of Health] updates and monitors the positivity rate. On 08/13/21 at 02:00 PM during an interview with the IP, Administrator, ADON and two facility consultants, they confirmed the designated COVID-19 unit referred to in the facility plan had been closed approximately two weeks ago because the facility now admitted on ly vaccinated resident's. The facility did not have any documentation of education to the staff regarding the changes. 8) On 08/13/21 at 03:00 PM toured the first floor shower room located across from the nurses' station. The room had three distinct areas; a shower, and two additional areas divided by walls. The area adjacent to the shower had a toilet, the next area was equipped with a wheelchair-accessible sink and was utilized as a store room. There were no dispensers with ABHR or other ABHR available in the areas. During the tour, observed a full urinal labeled with R4's name hanging on the handrail by the toilet. R4 utilizes a wheelchair and independently mobilizes throughout the unit. Neither R4 or staff were observed in the hall or immediate area at the time. The sink in the next room was not accessible and blocked by an overbed table and a folded wheel chair which an ambulatory person would have had to move to get to the sink. The store room area at this time was not a functional, sanitary environment. The room contained a closed mobile cabinet with the clean linen for the unit that had a large trash receptacle with a lid sitting directly in front of it. There was a shower chair with a commode on top of it. There was another commode with plastic bags filled with unknown items on top of it. In addition, there were shower boots, a shower gown on a handrail hanging over a trash can and a tennis shoe under the sink. There were several other unlabeled clear plastic bags with unknown items in them piled on folded wheelchairs and other unidentifiable pieces of equipment.

Based on observations, record reviews, and staff interviews, the facility failed to ensure that 1 of 1 residents on the stage 2 sample list remained free of accident hazards and provided adequate supervision to prevent recurring falls. Findings include: During a staff interview on 03/01/2016 12:51 P.M. the resident had 2 falls (2/14/16 & 2/27/16) during the past 30 days and she was found to have fractured ribs two days after her fall on 2/14/16. A record review was conducted on 03/02/2016 at 10:08 A.M. The resident was admitted to the facility twice. R#39 was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The chart review revealed that R#39 had several falls prior to 2/2016. The previous falls happened on the following date and time: 10/10/15 at 10:45 AM, 11/17/15 at 2:45 PM, 12/9/15 at 06:00 AM, 12/13/15 at 8:00 PM, 12/20/15 at 08:30 AM, 1/5/16 at 2:10 PM, 2/14/16 at 8:45 PM, and 2/27/16 at 4:35 PM. There were 8 falls in 5 months. Per progress notes review, the resident had started complaining of pain and having grimaces two days after her fall. A x-ray was done on 2/16/16 at 1:26 PM and the result revealed: Findings: Acute fracture lateral left ninth rib. Acute fracture posterior left 10th rib. Impression: Fracture left and ninth rib. An interview was conducted with the Administrator and DON on 3/2/16 at 12:37 PM. The Administrator mentioned that the facility had been doing a root cause analysis after each fall and have been talking to staff, family, and Medical Director. The family was informed that the facility wanted to move the resident closer to the nurses' station but apparently the family did not agree. R#39 apparently wants to continue to be independent and DON and Administrator acknowledged that she has dementia and forgetful. The DON stated, the facility could have done more for the resident during the interview. The MDS was reviewed with the ARD dates of 10/21/15 & 1/13/16 under G0300: Balance during transitions and walking, the resident was coded as 1 (not steady, but able to stabilize without human assistance). An observation was conducted on 03/03/2016 at 1:00 PM. R#39 was walking in her room without her walker and was observed to be hanging onto the foot of the bed while walking towards the left hand side of her bed. An interview was done with the resident and R#39 responded, She does not want to bother/take up time from the nurses, they have a lot to do. The LPN reminded the resident to call before getting out of bed. An interview was conducted with the attending physician on 3/4/16 at 10:00 A.M. Yes, she is very compulsive, He looked at the chart, read it and said, the only thing I could do is to see what type of medicine I could use to help her, perhaps Exelon. An interview was conducted with the LPN and RN on 3/3/16 at 1:45 PM. They both acknowledged that she is prone to falls, she lacks safety awareness, she thinks she can do things on her own, and gets up without her walker. The resident's bed alarm was intermittently works on 3/4/16 at 8:18 AM. MDS coordinator and surveyor tested whether the bed alarm was functioning well. It was found that the alarm only works at a certain angle and pressure amount. He acknowledged that the facility do not have a preventative maintenance (PM) for the alarm unit at this time. Although the resident had fallen 8 times in five months (October to February 2016), the resident remained in the same room, further away from the nurses' station. Also, with the numerous falls, there was no PM log sheet to monitor if the bed alarm is in a good working condition. The facility continues to do root cause analysis after each fall and yet, the resident continues to fall. The staff who were interviewed acknowledged that facility needs to do more for the resident.

Based on record review and interview with staff, the facility failed to allow resident to remain in the facility and not be discharged unless discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for Resident #1. Finding includes: The facility did not allow Resident #1 to remain in the facility unless the transfer or discharge was necessary. As a result the resident was abandoned at the hospital emergency room , she had no place to live or knowledge of what would happen to her. Also, resident did not have her personal belongings when she was left at the hospital's emergency room . Record review on the morning of 4/2/09 found Resident #1 was discharged on [DATE]. The "Physician's Discharge Summary" signed on 12/24/08 notes "arrangements were made for discharge to hospital" when patient developed acute mental status change. On 12/17/08 resident was sent to a hospital emergency room (ER) due to acute anxiety and mental changes related to pending discharge from the facility to her son's home. There was no documentation by the facility staff or physician that resident's discharge/transfer was appropriate as the resident's needs could no longer be met in the facility; transfer is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or the health of individuals in the facility would otherwise be endangered. Review of summary provided by the Administrator entitled "Events Leading Up and Following Discharge of (Resident's Name)" prepared by the Administrator notes in an entry dated 12/17/08 Administrator informed resident that she was being sent to emergency room for evaluation. Subsequent entry states "Belongings were packed for safekeeping..." and the next entry states resident's son was notified of the transfer to emergency room . The last entry for 12/17/08 notes the Administrator spoke to the hospital social worker and "found out that resident would be placed in a care home." Entry for 12/18/08 notes resident's "medications and HMSA card were sent to caregiver's sister for resident". Review of the social worker's notes found an entry dated 12/10/08 that resident was found ineligible for Medicaid services. Also noted in social worker's entry dated 12/10/08 contact was made with resident's child's attorney. The social worker documented that the attorney stated the resident's child no longer feels he/she is financially responsible for his/her parent. At this time the social worker agreed that the facility would seek placement for resident with resident's other child. A review of the financial statement dated 2/5/09 provided by the facility on 4/2/09 noted facility was receiving resident's social security checks ($1,400.00) monthly; however, the payments to cover the remaining cost stopped in May 2008. The resident's balance as of 2/5/09 is $33,498.00. The Administrator reported in an interview on 4/2/09 at 2:00 P.M. that the resident's inability to pay was a contributing factor to the discharge. The Administrator reported that upon resident's admission the facility assumed that the resident would become Medicaid eligible and when resident was found ineligible and during the appeals process the facility continued to believe that the resident would be found eligible for Medicaid. The Administrator commented that discharge planning should've started long ago. The Administrator reported it was his/her impression was that when the resident was taken to the emergency room , she would be admitted to the hospital. The Administrator reported that the hospital offered to place this resident. The Administrator confirmed the resident left the facility for the hospital at 10:20 A.M. and the bed was filled at 1:45 P.M. Although the facility does not have a bedhold, the Administrator confirmed the facility released resident's bed without knowledge of whether the resident would be returning or admitted to the hospital. Interview with the Administrator and Director of Nursing (DON) on 4/2/09 at 2:00 P.M. the DON reported when the facility's residents are taken to the emergency room , the charge nurse will call the hospital to confirm whether the resident is being admitted to the hospital or released to the facility. And if the resident is not being admitted the bed is held for the resident's return. The Administrator and DON could not provide documentation that this practice was followed for this resident. The Administrator confirmed that this is the only resident where the facility did not follow their practice. Interview with the hospital RN Case Manager on the morning of 4/3/09 found resident was not admitted to the hospital, there was no medical reason to admit her. RN Case Manager also reported when the Emergency Department (ED) staff contacted the facility they were told the resident's bed had been filled already. RN Case Manager reported the hospital did not offer to find placement for this resident which is in conflict with the facility's Administrator's report that the hospital offered to find a placement. There was no documentation to support that this agreement was made between the facilities. The ED then made a referral to hospital social worker to assist in placement. A review of the ED Record notes on 12/17/08 at 12:50 P.M. a referral was made to hospital social worker to assist in locating housing. Documentation provided by the hospital noted the facility's Administrator was contacted by the hospital social worker on 12/17/08 at 14:15. At this time the Administrator informed the social worker that the facility "is not able to receive pt back - stated that her bed has already been filled". Interview with the resident via telephone contact was attempted on 4/27/09 at 12:40 P.M.. Resident refused the interview and hung up on the surveyor. Resident stated that this happened quite a long time ago and would like to put it behind her. Resident reported she is doing fine now. Telephone messages were left for resident's family on 4/27/09 and 4/27/09. There was no respond from the family. Interview with the respite care home operator was done on 4/29/09 at 2:00 P.M. Care home operator (CHO) reported resident arrived at the home dressed in a hospital gown and soaked personal briefs. Resident did not have a wheelchair. CHO reported resident expressed concern about what was going to happen to her and where her personal belongings were.