Every finding on record at Oahu Care Facility

Based on interviews and record review, the facility failed to ensure an effective discharge planning process was developed and implemented which considered the care giver's availability, capacity, and capability to perform needed care, to meet the needs of the resident following discharge for one out of three residents sampled. This deficient practice resulted in an unsafe discharge. Findings include: On 05/19/26 at 09:10 AM, conducted a review of Resident (R) 2's Electronic Health Records (EHR). R2 was admitted on [DATE] to the facility with diagnosis which include, but not limited to, congestive heart failure, dysphagia, end-stage renal disease, and cognitive communication deficit. The resident was discharged on 03/04/26. The discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/26, documented in Section C. Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the resident Care Conference Summary conducted on 02/16/26 at 05:48 AM (Locked on 02/27/26 at 11:06 PM) which documented, .Plan is to return home with brother who is cognitively and physically impaired as well, daughter expressing concern, SS (Social Services) present and aware . and Care conference held with IDT (Interdisciplinary Team), resident, and niece. Niece's concerns were more related to resident being discharged with brother who cannot care for him (R2) while facing his (brother) own health challenges . On 05/19/26 at 10:09 AM, conducted a telephone interview with R2's Family Member (FM) 1 regarding R2's discharge. FM1's understanding of the discharge was that R2's insurance could only cover 20 days of the stay, R2 was not ready to go home. He had a G-tube, dialysis, he was being unsafe, attempting to removing the G-tube, and FM4 has the mentality of a toddler and cannot manage R2 at home. The discharge plan was for R2 to go home with FM4. FM1 reported it was not the family's preference to have R2 live with the FM4. FM1 reported working with an agency to have the resident approved for another payment form and the facility was aware of this. FM1 confirmed feeling pressured by the facility to follow through with the unsafe discharge to FM4's home, despite informing the Social Worker (SW) multiple times that FM4 could not safely care for R2. FM1 stated, I verbally told SW it is not safe for R2. I did not agree or confirm the discharge plan the facility implemented. Inquired if FM4 was a part of the discharge planning process, FM1 confirmed FM4 did not participate in the discharge planning process due to lack of mental capacity to participate in the process. FM1 reported having text messages with SW, which confirmed that the facility was aware of FM4's inability to safely care for R2 upon discharge. On 05/19/27 at 11:45 PM, reviewed text messages between FM1 and SW. According to the text messages, leading up to the discharge, FM1 applied R2 for Medicaid long term coverage (LTM) as an alternative to discharging R2. FM1 why Adult Protective services have not been called because FM1 emphasized many times he/she cannot support R2. SW continued attempting to coordinate pick-up times and appointment times despite FM1 reporting there is no support for R2. FM1 informed SW that she cannot assist coordination of the discharge at this time, questions why R2 is being discharged to a situation where the level of care R2 requires cannot be met, there is no support at the discharge residence, he may choke or cause harm to himself, needs more time at the facility so that SW can complete the job and ensure R2 has the right level of care R2 requires when discharged . SW responded that R2 is only at the facility short-term with a discharge plan as home with brother. The facility is aware that R2 couldn't afford copay and wasn't agreeable to copay that is why we planned to discharge R2 today and this was the discussion during the care conference. On 05/20/26 at 09:47 AM, conducted a concurrent interview and record review (through a cellular phone) with SW. Inquired how the facility assessed the physical environment and the caregiver's ability to provide needed services for R2. SW replied that they ask about the physical environment. Inquired who did the facility speak with, SW reported that the facility attempted to call FM4 and confirmed the facility did not have any form of communication with FM4. When asked if FM1 informed the facility that it was not a safe place for R2 to be discharge due to FM4's inability to care for R2. SW responded that she would get back to the surveyor on that and did not provide an answer. During this interview, SW confirmed the cellular phone number used to communicate with FM1 as the same phone number FM1 exchanged text messages with. A second interview was conducted with SW on 05/20/26 at 01:15 PM. During this interview SW was informed that the text messages with FM1 were provided to this surveyor. SW then stated SW stated that FM1 may have verbalized something to the effect that FM4 could not safely care for R2 upon discharge. Asked SW if FM1 was informing the facility that it was not a safe discharge and the facility had no conversations with FM4, and FM1 was working on LTM, in hindsight was it a safe discharge and what could have been done instead of discharging R2. SW confirmed it was not a safe discharge and looking back R2 should have stayed in the facility, R2's LTM was approved.On 05/20/26 at 01:27 AM, conducted an interview with the Director of Nursing (DON). Inquired if the facility had a conversation with FM4 regarding R2's discharge to his residence. DON stated the facility did not speak to FM4, only to FM1. DON also confirmed knowledge that FM1 did not live in the same residence as FM4. Inquired how the facility evaluates the capacity, capability, and availability of the caregiver the resident is being discharged to. DON replied, it is not necessarily the practice of the facility to evaluate the ability and capability of the caregiver. Family would be the one to ensure safety. Inquired with DON, if the family is reporting that the planned discharge caregiver is not capable and does not have the capacity to provide needed care, and the facility has not had contact with the discharge caregiver, is it a safe discharge. DON replied, the resident wanted to go home.

Based on interview and record review, the facility failed to ensure a discharge summary included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and and/or consultation results for one of three residents sampled. As a result of this deficient practice, relevant information was not relayed to the appropriate care provider. Findings include: Definition: Recapitulation of Stay- A concise summary of the resident's stay and course of treatment in the facility. On [DATE] at 09:10 AM, conducted a review of Resident (R) 2's Electronic Health Records (EHR). R2 was admitted on [DATE] to the facility with diagnosis which includes, but not limited to, congestive heart failure, dysphagia, end-stage renal disease, and cognitive communication deficit. The resident was discharged on [DATE]. Review of progress notes documented R2:Was dependent on dialysis services and would not always complete the entire dialysis treatment as prescribed.Would present as confused and reported looking for deceased mother (multiple occasions), attempted to enter into a co-female resident's room and needed reorientation.Difficulty sleeping and administered medication.Became agitated, combative hitting and swearing at staff, saying mom.Complaints of lower back pain 9/10.Went to the emergency department (ED) for not responding to tactile or verbal stimuli, with eyes closed. Had medication adjustments for Hypotension. Physician notified for hypertension and prescribed medicationReceived medication for agitation and restlessnessPeriodic medication refusalNon-complaint, he gets up and walks in hallway with his walker without helpWanderguard alarm placed of right ankle due to episode of elopement, exit seeking behaviorsChronic disorganized thinking, confusion, requires cues, oriented to personPEG-tube (feeding tube) removed, no reason or assessment found Review of the facility's Discharge Summary included only:Resident NameDischarge Statusadmit date discharge date Medical record NumberPrognosis: GoodSummary: Did well in rehab. GT (PEG tube) was removed. On [DATE] at 10:05 AM conducted a concurrent interview and record review of R2's EHR with the Medical Director (MD) via telephone. Requested for the MD to review the Discharge Summary and inquired if it provides a recapitulation of R2's stay at the facility. MD confirmed the discharge summary was not sufficient and would have liked to see more information, especially information on the removal of R2's PEG tube. During an interview with the Director of Nursing (DON) on [DATE] at 01:27 PM, requested for the DON to read the prognosis and summary of the Discharge Summary due to not being legible. DON read prognosis: good and Summary: Did well in rehab. GT was removed. Inquired if this was a recapitulation of R2's stay at the facility. DON responded that it captured the removal of the PEG tube and agreed with the discharge summary.

Based on observation, interview, and record review, the facility failed to protect and promote quality of life for 1 of 1 resident (Resident (R)68) sampled for dignity by ensuring that he was treated with the respect and consideration any reasonable person would expect. Specifically, the facility failed to ensure staff provided feeding assistance in a manner that considered proper pacing and dignity. As a result of this deficient practice, R68's dignity was compromised, and he was placed at risk of a decreased quality of life. Findings include: Resident (R)68 is a [AGE] year-old male admitted to the facility on [DATE]. R68's current diagnoses include, but are not limited to, dysphagia (difficulty swallowing), and functional quadriplegia (the complete immobility of all four limbs due to a severe disability or frailty from a medical condition. It means the person cannot move their limbs, requiring total assistance with daily activities). A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/11/2025 confirmed that R68 was found to be fully dependent on facility staff for all activities of daily living (ADLs) including eating, hygiene, toileting, showering/bathing, dressing, transfers, and mobility. On 09/24/2025 at 8:10 AM, observed Restorative Nurse Aide (RNA)3 as she was feeding R68 his breakfast of pureed food. RNA3 fed R68 with a metal spoon at a moderate to quick pace, spoonful after spoonful, getting pureed food all over his mouth, chin, and nose despite the fact that R68 was not moving his head excessively. Observed RNA3 use the metal spoon to wipe up the excess of pureed food she had given, including what was on and under his nose, put it in his mouth, then continue to use the same spoon to feed him the remaining food. RNA3 stood over R68 while feeding him. Once done with feeding him, and after RNA3 had left the room with his meal tray, an interview was attempted with R68, however he would neither make eye contact nor respond to questions. On 09/25/2025 at 1:44 PM, an interview was done with the Director of Nursing (DON) regarding dignity while assisting a resident to eat. When asked about R68, DON acknowledged that he does not move a whole lot when eating. DON also agreed that care should be taken when feeding him, and staff should try to ensure pureed food does not get on his nose. When observations were shared with DON, she agreed that any reasonable person would not feel it was dignified to use a spoon to wipe excess food off their face, chin, and nose, then continue using it to spoon more food into their mouth. DON explained that she would expect staff to use a napkin to wipe/clean the excess. Review of the facility's policy and procedure, Assistance with Meals, last revised 03/2022, revealed the following: Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals.

Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record the type of discharge in the RAI, Minimum Data Set (MDS) for one Resident (R)92 of three residents sampled. As a result of this deficiency, the facility put R92 at risk for further RAI, MDS inaccuracy.Findings include:Review of Electronic Health Record (EHR) showed R92 was admitted on [DATE] with diagnoses including Metabolic Encephalopathy, Intestinal Obstruction, Anemia, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Hypertension, Depression.Review of the most recent MDS, Assessment Reference Date 09/06/25, Section A310G, type of Discharge was inaccurately marked as Unplanned Discharge which meant that the discharge was not expected and did not follow the discharge plan. Review of Electronic Health Record (EHR), progress notes showed that R92 was discharged home on [DATE], as expected and followed the discharge plan.During staff interview on 09/26/25 at 12:20 PM, MDS Coordinator acknowledged that R92 was inaccurately marked for Unplanned Discharge. MDS Coordinator said that they would immediately make the necessary correction.Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on interview and record review, the facility failed to ensure that 2 of 3 residents (Residents (R)8 and R84) sampled for pressure ulcers received the necessary monitoring, treatment, and services, consistent with professional standards of practice and their comprehensive care plans, to promote healing and prevent worsening. Specifically, the facility did not monitor/document the wound status of the pressure ulcers. As a result of this deficient practice, there was no way to measure if the treatment being provided was effective or needed to be modified. Findings include: 1) Resident (R)8 is an [AGE] year-old female admitted to the facility on [DATE] for hospice/end-of-life care. A review of her Minimum Data Set (MDS) admission Comprehensive Assessment, with an Assessment Reference Date (ARD) of 08/28/2024 revealed that she was admitted with a Stage 4 pressure ulcer (bed sore classification meaning there was full-thickness tissue loss extending into muscle, bone, or tendons) on her coccyx (tailbone). Review of R8's provider orders noted an order since 12/20/2024 for daily and as needed dressing changes to the wound on her coccyx. The order was changed to increase the dressing changes to every day and every evening shift (twice daily) on 06/11/2025. Further review of provider orders noted an order to conduct a Weekly Skin Assessment every Wednesday night. Review of R8's Comprehensive Care Plan revealed the following interventions for the goal of The resident's Pressure ulcer will show signs of healing and remain free from infection: Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [doctor]. Revision on: 08/22/2024 Monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size (length X width X depth), stage. Date Initiated: 08/22/2024On 09/25/2025 a review of R8's electronic health record (EHR) revealed no documentation of wound status found either on the Treatment Administration Record (documenting twice daily dressing changes), in the nurse progress notes, or on the Weekly Skin Assessment(s). Closer review of the Weekly Skin Assessments requested from the facility for the last four weeks revealed no Weekly Skin Assessment done for the week of 09/08/2024, and of the Weekly Skin Assessments that were done, the following was consistently documented: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Issue type: Pressure ulcer/ injury. Pressure ulcer staging: Stage 4 Pressure ulcer/ injury. On 09/25/2025 at 1:38 PM, an interview was done with the Director of Nursing (DON). Regarding documentation expectations, DON disclosed that if facility staff are doing a dressing change, she expects there to be a nurse progress note that includes a wound assessment. In addition, DON agreed that the Weekly Skin Assessment should include a wound assessment documenting wound status and appearance. On 09/26/2025 at 7:40 AM, an interview was done with Registered Nurse (RN)2, who reported that she had been the facility Wound Nurse for 6-7 years. When asked who was responsible to document wound status. RN2 answered that if a resident was not on wound rounds [weekly wound assessment/treatment done by wound care consultants], as R8 was not, the wound assessment should be documented by the nurse who does the Weekly Skin Assessment. During a concurrent review of R8's Weekly Skin Assessments for the last month, RN2 confirmed that they should be documenting wound status assessments for every identified skin issue but did not. RN2 agreed that it is important to know what the wound status is and what the wound looks like to ensure that R8 is comfortable and that her pain is managed appropriately. 2) R84 is an [AGE] year-old female admitted to the facility on [DATE]. R84 was discharged home on [DATE] and re-admitted to the facility on [DATE]. Review of her MDS admission Comprehensive Assessment, with an ARD of 09/10/2025 revealed that she was re-admitted with a Stage 4 pressure ulcer to her right hip and an unstageable (bedsore classification for a wound covered by dead tissue or scab-like tissue that prevents the depth of the wound from being determined) pressure ulcer to her right ankle. Review of R84's provider orders noted orders for daily dressing changes to her wounds. Further review of provider orders noted an order to conduct a Weekly Skin Assessment every Monday on day shift. Review of R84's Comprehensive Care Plan revealed the following interventions: Provide wound care per treatment order . Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. On 09/25/2025 a review of R84's EHR revealed no documentation of wound status found either on the Treatment Administration Record (documenting daily dressing changes), in the nurse progress notes, or on the Weekly Skin Assessment(s). Closer review of the Weekly Skin Assessments revealed the following was consistently documented: Skin Issue: #001: Skin issue has not been evaluated. Location: Rear right trochanter (Hip) . Pressure ulcer staging: Stage 4 Pressure ulcer . #002: Skin issue has not been evaluated. Location: Rear right malleolus [ankle] . Pressure ulcer staging: Unstageable pressure ulcer .On 09/26/2025 at 7:54 AM, an interview was done with RN2 regarding R84's wound care. As the Wound Nurse, RN2 reported that because R84 was not on wound rounds, the expectation is that wound assessments should be documented on the Weekly Skin Assessments and are done by the assigned unit/floor nurse. During a concurrent review of R84's Weekly Skin Assessments since readmission, RN2 confirmed that they should be documenting wound status assessments for every identified skin issue but did not. RN2 agreed it could not be determined what the status of R84's wounds were because there had been no documentation that they had been assessed in 3 weeks.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident (R)68) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services, to increase mobility or prevent further decrease in ROM. As a result of this deficient practice, R68 was placed at risk of decreased mobility and comfort and hindered from reaching his highest practicable well-being. Findings include: Resident (R)68 is a [AGE] year-old male admitted to the facility on [DATE]. R68's current diagnoses include, but are not limited to, contracture (tightening and shortening of muscles, tendons, skin, and other soft tissues, causing joints to become stiff and limiting their normal movement), and functional quadriplegia (the complete immobility of all four limbs due to a severe disability or frailty from a medical condition. It means the person cannot move their limbs, requiring total assistance with daily activities). A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/11/2025 confirmed that R68 was found to be fully dependent on facility staff for all activities of daily living (ADLs) including eating, hygiene, toileting, showering/bathing, dressing, transfers, and mobility. The same assessment also documented that R68 had not received Restorative Nursing Programs services, including, but not limited to, active or passive range of motion, splint or brace assistance, and/or training and skill practice in bed mobility or transfer in the last 7 calendar days . On 09/23/2025 at 1:40 PM, observed R68 sitting in his wheelchair in the dining room. R68 had his left wrist drawn up to his chest with a contracture (flexing/bending) visible of less than 20 degrees (space between the palm pad and the inner aspect of his wrist).On 09/24/2025 at 8:12 AM, an interview was done with Restorative Nurse Aide (RNA)3, who said she had been working with R68 since his admission. When asked about a wrist splint, RNA3 reported that R68 had one before, but it had not been applied for a long time. RNA3 explained that there were no current orders for a wrist splint. Concurrent observation of R68 noted his left wrist was drawn up to his chest with a contracture of less than 20 degrees.A review of R68's provider orders noted the following 07/16/2025 order: D/C [discontinue] OT [occupational therapy] after treatment on 7/15/25. Will pick back up after splints arrive. Further review confirmed there were no active splint orders. Review of R68's Comprehensive Care Plan revealed the following interventions under the Focus of Resident is on RNA program, last revised on 07/07/2025: Perform RNA program as scheduled. Document refusal and reason for refusal. RNA Program: Range of Motion (Passive) Date Initiated: 07/07/2025 Revision on: 07/07/2025 RNA Program: Range of Motion (Active) Date Initiated: 07/07/2025 Revision on: 07/07/2025 RNA Program: Splint or Brace Date Initiated: 07/07/2025 Revision on: 07/07/2025Review of Occupational Therapist (OT)1's 07/15/2025 Treatment Encounter Note revealed documentation of increased LUE [left upper extremity] flexor [bending that decreases the angle between bones on two sides of a joint] tone . tolerated PROM [passive range of motion] with BUEs [both upper extremities]. No significant change in ROM, d/t [due to] splints being delayed . specialized splint to arrive in 2-3 weeks . D/C'd [discontinued] patient from therapy until splints arrive.On 09/26/2025 at 8:10 AM, an interview was done with the Director of Rehabilitation (DOR) and OT1. OT1 confirmed that she had ordered a special splint to address R68's left wrist contracture around 07/07/2025, then discontinued OT services on 07/15/2025 pending arrival of the splint, however RNA services should have continued. DOR confirmed that no follow-up on the splint order had been done since July, but when she called this morning, she discovered that there would be an additional delay. Both DOR and OT1 agreed that follow-up should have been done earlier than this morning. OT1 explained that had she known about the continued difficulty in receiving the splint, she would have assessed whether she needed to modify the treatment plan or not. When asked about what type of RNA Program should be currently implemented, OT1 explained that she filled out a Restorative Hand-Off Form in July and gave it to the RNAs. OT1 reported that the Rehabilitation (Rehab) office did not keep copies of those forms but that it should be on the unit in the RNA binder. On 09/26/2025 at 8:30 AM, an interview was done with Unit Clerk (UC)1 who reported that there were no RNAs scheduled on the unit for the day, and she did not know where the RNA binder was. Current RNA Hand-off Form was requested from the facility, however by survey exit, the most recent RNA Hand-off Form located was dated 06/01/2023, and applied to R68's lower extremities only.

Based on observation, interview, and record review, the facility failed to provide one resident sampled for smoking (Resident (R) 12) with an ashtray made of non-combustible material while he was smoking, and the facility's designated smoking area did not contain a metal container with a self-closing cover device to dispose of cigarette butts and ashes. This deficient practice did not ensure the safety for R12 and other residents in the facility that smoke.Findings include:On 09/23/25 at 12:23 PM, observed R12 being assisted by Activity Aide (AA) 10 via wheelchair to the designated smoking area located outside of the facility near the Administration building. On the way, AA10 stopped with R12 at the ground floor station near the kitchen and asked Administration Assistant (NAA) 5 for an ashtray. NAA5 responded that the ashtrays were missing. AA10 proceeded with R12 to the designated smoking area without an ashtray. The designated smoking area did not contain a metal container with a self-closing cover device to safely dispose of cigarette butt and ashes. When R12 was done with smoking a cigarette, he ran the cigarette butt on the concrete ground and gave it to AA12 who then put it in his pocket. Prior to R12 leaving the designated smoking area, NAA5 arrived with a small metal container without a self-closing cover and asked AA10 for the cigarette butt to place in that container.On 09/26/25 at 7:20 AM, interviewed NAA5 regarding the ashtrays used for smoking. NAA5 voiced that staff who escort residents who smoke, will come and get the ashtray from her station on the ground floor before proceeding to the designated smoking area. NAA5 then showed a round, black colored container with holders on the rim and a black colored cylindrical container. Both did not contain a self-closing cover device.On 09/26/25 at 07:23 AM, AA10 confirmed that after he received the used cigarette butt by R12 he placed it in his pants pocket since there was no ashtray available. A policy titled, Smoking Policy - Residents with a revised date of October 2023 stated, 5. Metal containers, with self-closing cover devices, are available in smoking areas.

Based on observation, interview, and record review the facility had no defined policy and procedure on how to manage the disposition for discontinued non-controlled medications located in the medication administration cart. This deficient practice creates a potential unsafe situation where discontinued medications could inadvertently be administered to residents in the facility.Findings include:On 09/25/25 at 08:22 AM, medication cart A on the second floor of the facility was checked. While checking the medications in the drawers, Registered Nurse (RN) 8 identified medication for three residents were discontinued but remained stored in the medication cart (NovoLog (Aspart) insulin pen for Resident (R) 19 and R29 and Nicotine Patches for R12). A concurrent review of the Electronic Health Record (EHR) showed 09/24/25 discharge orders for R19 and R29's Novolog insulin pen. RN8 stated she was the one that received the discontinuation order. The Nicotine patch had a discontinuation date of 08/29/25 noted in the EHR. RN8 stated the three medications should have been removed from the cart, however, was unable to describe the specific procedure for removal and destruction.A review of three facility medication policies titled, Medication Administration, Medication Labeling and Storage, and Discarding and Destroying Medications received on 09/25/25 at 11:35 AM was done. All three policies were dated 2001 MED-PASS at the bottom of each the pages. None of the three polices contained specific procedures on the disposition process for discontinued non-controlled medications.On 09/26/25 at 10:40 AM, Interviewed the DON in her office. DON explained that when a non-controlled medication is ordered to be discontinued, it is removed from the cart, with no defined time frame to do so, and placed in the Nursing Supervisor's office which is a secured room. A nurse will then eventually destroy the stored medications. DON stated that for safety reasons, she would like discontinued medications to be removed from the medication cart by the end of the shift. The night shift nurse could do a double check regarding the order for the discontinuation of the medication and removal from the medication cart. If okay, it would be destroyed at that point. DON was made aware that none of the three medication policies (Medication Administration, Medication Labeling and Storage, and Discarding and Destroying Medications contained specific facility procedures and time frames for the removal and destruction of non-controlled medications that are discontinued.

Based on observation, interview, and record review, the facility failed to monitor the medication regimen for 1 of 6 residents (Resident (R)45) sampled for unnecessary medications. Specifically, the facility failed to monitor for and appropriately document episodes of excessive sleepiness despite identifying it as a problem. As a result of this deficient practice, R45 was placed at risk of avoidable accidents related to adverse effects of potentially unnecessary medication(s). Findings include:Resident (R)45 is an [AGE] year-old female admitted to the facility on [DATE]. R45's current diagnoses include, but are not limited to, dementia and insomnia. A review of her provider orders noted the following:11/26/2021: monitor hours of sleep every shift.07/01/2022: melatonin (a sleep aid supplement) 3 milligrams (mg) at every bedtime for sleep aid. Scheduled for 7:00 PM. 06/20/2023: l-tryptophan (a sleep aid supplement) give 2 capsules at bedtime for sleep aid. Scheduled for 9:00 PM.04/02/2025: mirtazapine (a medication with sleepiness and tiredness listed as very common side effects) 7.5 mg at every bedtime for anorexia. Scheduled for 9:00 PM. Review of R45's Progress Notes revealed a Nutrition/Dietary Note documented on 09/09/2025 at 8:47 AM with the following: Chewing/Swallowing: OOB [out of bed] and on a seating position during mealtime with meals for Aspiration [when foreign material, such as food, liquid, or stomach contents, accidentally enters the airway and potentially the lungs] precautions 1:1 [one to one] supervision to assistance as needed too sleepy.On 09/23/2025 at 9:08 AM, an initial observation was made of R45 sleeping in bed with her breakfast tray sitting on the bedside table untouched. At 9:57 AM, second observation made of R45 still sound asleep in bed. Nurse Aide (NA)4 at the bedside trying to wake her (unsuccessfully); breakfast still sitting on the bedside table untouched. NA4 explained that she had heard that R45 was awake all night and did not sleep until 5:00 AM. Licensed Practical Nurse (LPN)1 entered the room and shared that besides not waking for breakfast, she had not given R45 her morning medications yet because she was too sleepy, and LPN1 was worried about her aspirating. LPN1 explained that R45 will cycle through staying up for days then sleeping for a couple days straight. Confirmed with both NA4 and LPN1 that this was not the first time R45 had been noted to be extra sleepy during normal waking hours. Review of LPN1's Health Status Note written on 09/23/2025 at 10:17 AM about the incident revealed the following documented: Resident refused morning medication. Resident awake all night.Notably absent from the progress note was any mention of excessive sleepiness. Review of R45's Treatment Administration Record (TAR) for 09/22/2025 revealed she was documented as sleeping a full 8 hours on the overnight shift (the previous shift).Review of R45's Medication Administration Record (MAR) for the month of September revealed the mirtazapine, melatonin, and l-tryptophan had been administered every night without fail. Review of R45's Comprehensive Care Plan (CP), MAR, TAR, and provider orders, noted no monitoring specifically for excessive sleepiness. The monitor hours of sleep every shift order had been implemented on the TAR with a numerical entry required each 8-hour shift, with no consideration or way to document the quality of those hours of sleep or when in the shift those hours took place. For example, if documented for 5 hours of sleep on the day shift, were the night shift hours running into those day shift hours to make consecutive hours of sleep, or did R45 take a nap in the middle of the day shift? On 09/25/2025 at 1:29 PM, an interview was done with the Director of Nursing (DON). Upon hearing of the observation of R45's excessive sleepiness, and reviewing the provider orders, DON agreed that if staff are aware of excessive sleepiness, she would expect to see it documented in a progress note. DON confirmed that at a minimum, she would expect monitoring for excessive sleepiness to be a part of the CP. DON also agreed that it was important to document incidents of excessive sleepiness to help the provider determine if any of the sleep aids (or medications such as mirtazapine) could potentially be decreased or discontinued.

Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections as evidenced by: 1) Failing to ensure staff followed transmission-based precautions (additional measures used to help stop infection transmission when a patient/resident has been found to be infected or colonized with certain infectious agents), wearing and cleaning proper personal protective equipment (PPE), keeping dedicated equipment in the room, and 2) Failing to label and properly store a nasal cannula. As a result of the deficiencies, the facility put the residents at increased risk to communicable disease and infections. Findings include: 1) On 09/23/2025 at 8:37 AM, while doing an initial tour of the third floor, observed Special Droplet/Contact Precautions signage outside of room [ROOM NUMBER] with instructions for anyone entering to put on the following PPE: mask or respirator, face shield or goggles, gown, and gloves. The signage also indicated: Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. In addition, the signage indicated that the residents in beds B, C, and D were affected. Concurrent interview with Registered Nurse (RN)3 confirmed that the room contained residents who had been found positive for COVID-19 (COVID). Review of the facility's Transmission Based Precaution: Droplet/Contact precaution training material used to in-service staff on 09/18/2025 regarding the topic COVID outbreak in service [sic], Follow right proper PPE and COVID (+) TBP instruction revealed the following: Staff should continue to wear recommended PPE for COVID, N95 mask, Gown, Gloves and face shield. On 09/23/2025 at 12:08 PM, observed Nurse Aide (NA)5 in the doorway of room [ROOM NUMBER] carrying the lunch trays in to the residents. NA5 was not wearing an N95 respirator. Concurrent interview with Licensed Practical Nurse (LPN)1, who also observed NA5 in the doorway, confirmed that she should have donned an N95 before entering the room. At 12:21 PM, NA5 had still not exited the room, nor had she put on an N95. Interview with LPN1 confirmed that NA5 had stayed in the room to assist feeding one of the residents. On 09/23/2025 at 12:24 PM, observed NA5 exit room [ROOM NUMBER], take off her face shield, and hang it on a hook outside the door without cleaning it. Concurrent interview with NA5 confirmed she had not put on an N95 to enter the room. When asked if she should have worn one, NA5 answered, yes but I cannot breathe in that one [N95]. When asked if face shields should be cleaned after exiting the room, NA5 answered, no. When asked a second time if the face shields are cleaned between uses, NA5 again answered no. On 09/23/2025 at 2:25 PM, observed Certified Nurse Aide (CNA)6 enter room [ROOM NUMBER] with no gown, gloves, N95, or face shield, grab the basket of dedicated vital sign equipment from a shelf in the closet and bring it out of the room. Concurrent interview with CNA6 confirmed that she should have put on the appropriate PPE before entering the room. When asked why she removed the equipment from the COVID room, CNA6 answered that she had removed it so that she could clean the equipment. CNA6 agreed that best practice would be to clean the equipment in the room and not bring it out. On 09/24/2025 at 2:17 PM, an interview was done with covering Infection Preventionist (IP)2 and the Director of Nursing (DON). IP2 shared that the residents in beds 312B and 312C had been cleared from COVID TBP on 09/22/25 but confirmed that the signage outside the door did not reflect that. Both IP2 and DON agreed that staff are trained and expected to follow the signage that is posted. On 09/25/2025 at 2:05 PM, an interview was done with IP1, who confirmed that for COVID-positive rooms, staff are expected to put on a gown, gloves, face shield, and N95 prior to entering the room, and regardless of which resident they are going in to see. For example, even if a resident in the room has been cleared of COVID, if the room is still on droplet/contact precautions, then the TBP applies to the entire room. When asked about when the face shields are cleaned, IP1 answered that they should be cleaned upon exit of the room but also between residents within the room. When asked about cleaning dedicated equipment, IP1 confirmed that to minimize the risk of carrying infectious agents out of the room, dedicated equipment should be cleaned in the room. 2) On 09/24/25 at 09:33 AM, observed Resident (R) 97's undated and uncovered nasal cannula wrapped around the handle of the oxygen concentrator positioned on the left side of R97's bed. On 09/25/25 at 07:52 AM, observed R97's oxygen concentrator running and the prongs of the nasal cannula on the ground while resident was not in the room. On 09/25/25 at 07:52 AM, observed Resident (R) 1's undated and uncovered nasal cannula wrapped around the right enabler located at the head of the R1's bed. R1 was in bed asleep. On 09/25/25 at 08:34 AM, interviewed Registered Nurse (RN) 9 in R1's room. RN9 responded that proper storage of the nasal cannula when not in use is a brown bag labeled with the resident name and date. On 09/25/25 at 02:44 PM, a facility policy titled, Departmental (Respiratory Therapy) – Prevention of Infection with a revised date of November 2011 stated, Steps in the Procedure. Infection Control Considerations Related to Oxygen Administration.7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannulae and tubing.in a plastic bag when not in use. Marking the date on the cannula or plastic storage bag was not noted in the policy.

Based on interviews, medical record review and document review, the facility failed to provide adequate supervision of one Resident (R)3 of three residents sampled that were high risk of elopement. R3 eloped on 02/09/2025 and suffered harm. When she was found, she was taken to the hospital where she was treated for abrasions from a fall and discharged back to the facility. The facility met the following three criteria for past non-compliance 1) Not in compliance with the regulatory requirement at the time the situation occurred; 2) The noncompliance occurred after the exit date of the last recertification and 3) There is evidence that the facility corrected the noncompliance and is in substantial compliant at the time of this survey. Findings include: 1) The Office of Healthcare Assurance received an initial facility reported incident (ACTS # 11488) on 02/10/2025 regarding an elopement. The report included the following information: -R3 initially admitted to facility on 01/10/2025 for skilled nursing facility services after a hospital admission following an unwitnessed fall with acute traumatic injury of CSpine (C3-C4), Unsteady gait, Multilevel degenerative changes of C-spine, Stage 5 Chronic Kidney Disease and dementia. R3 is pleasant, alert, oriented to self, forgetful of place/situation, able to verbalize needs and understands others, and able to walk with a front wheel walker with supervision. R3 had nondirectable exit seeking behavior on 1/12/2025 and a wanderguard bracelet was determined to be the least restrictive device. -On 2/9/2025 at 4pm [sic] R3 was unable to be found on the facility property and staff initiated the missing resident procedure. The resident was found by a good Samaritan on [NAME] Avenue (several blocks away in high traffic area) and had taken R3 to .ER for evaluation. R3 sustained a minor skin injury on bilateral knees, right elbow, and palm. She returned to the facility accompanied by facility Administrator on 2/9/2025 at 9:22Pm . -R3's wanderguard bracelet was noted in good working condition by day shift RN. On evening shift, RN noted R3's wanderguard triggered by elevator, staff escorted her away, and RN administered medications at 3:26pm. CNA (Certified Nurse Assistant) then escorted her to the dining room to participate in activities. Activity staff were aware resident was in the dining room, but did not observe R3 walking out of the dining room. At 4:00pm, RN started looking for resident to give her next scheduled medication. He looked in the dining room and her room, and resident was not found. Staff began missing resident procedure at approximately 4:10pm. Staff contacted the administrator soon after and called 911. -Upon R3's return to the facility, the facility Administrator and Nursing Supervisor tested the wanderguard bracelet on R3's right ankle and found that the wanderguard bracelet is faulty. The wander guard bracelet did not trigger the elevator door until the Administrator was right in front of the elevator door and called for the elevator. A new wanderguard bracelet was immediately tested and .placed on resident. The completed report was received on 02/14/2025 and included the following: -Upon incident on 02/09/2025, RF Technologies (RFT) Senior Service Technician was dispatched (urgent request was submitted immediately) and arrived on 2/12/2025. Technician assessed resident's transmitter bracelet (the one on at the time of elopement) and verified that the equipment was faulty. The hardware (elevator and exit door system) for the WanderGuard transmitter bracelet was tested multiple times, and all devices were found to be working in good condition-please see attached report. 15 minute checks were done immediately upon incident on 2/9/2025, on resident and all other residents wearing the WanderGuard transmitter bracelets until the technician confirmed the system was in good condition. -Additional education was done on 2/10/2025 regarding Wandering and Elopements and Missing Resident policies and procedures. -In conclusion, resident's transmitter bracelet was effective and noted to be working by licensed staff an hour prior to the incident. The transmission bracelet resident had on was later identified to be faulty and malfunctioned .and tested by RFT technician; and thus the technical glitch was determined to have caused the incident. Facility did not identify any problem with the WanderGuard system, and noted to be working properly, also verified and confirmed by technician. -R3 .was discharged as planned on 2/13/2025 .after successful rehabilitation and was transferred to a lower-level of care. 2) Reviewed R3's Hospital Emergency Department Provider record dated 02/09/2025, time seen 06:14 PM. The record included: Chief Complaint: Fall. Location of injuries-right elbow, right wrist and right knee and left knee. The injury occurred just prior to arrival. Occurred on a street. (Apparently a patient at .rehab and eloped undetected. Found on [NAME] Ave with wounds to extremities. Unwitnessed fall. Patient does not recall what happened.She complains of pain in right elbow and wrist). Skin: (Multiple large skin tears involving right elbow and bilateral knees). Neuro: Altered mental status: disoriented to place and time. Course of Care:Wounds were thoroughly irrigated and dressed . R3 was discharged back to the facility with the nursing home manager. 3) Reviewed the facility policy titled WanderGuard Device, which included but not limited to the following: 1. Residents will be assessed for the need of WanderGuard bracelet at the time of admission and as needed. 3. The Director of Nursing or designee will be notified of any residents assessed for the need of the WanderGuard bracelet. 4. The Director of Nursing or designee will ensure that an order has been received from the attending physician and immediately facilitate the placement of the WanderGuard bracelet on the resident. Resident family will be notified in a timely manner. 5. Nurses will obtain an order on TAR (treatment administration record) for WanderGuard check every shift. 6. Environmental Services will be notified of resident receiving WanderGuard service and will issue the WanderGuard bracelet to the Nursing department. 7. An interdisciplinary team will develop a care plan for all residents wearing a WanderGuard bracelet 4) The facility is a three story building located on a busy street. There is one entrance/exit to the street and another to the parking garage. The first floor has a very small lobby with one elevator. All Residents live on the second and third floor. The only exits from the Resident floors are the elevator and the fire exit doors/stairs. On 03/25/2025 at approximately 10:30 AM, conducted a facility tour with maintenance staff (MS) and the Administrator (ADM). At that time, interviewed MS, who described their audit process for ensuring the equipment is working. Observed that all exits had the WanderGuard System in place, which was tested by maintenance with surveyor present. At the time of survey, there were eight residents that had been assessed to be at risk of elopement, who had the WanderGuard bracelets on. A random sample of three Residents were selected and maintenance staff accompanied surveyor and demonstrated and checked the bracelets with a handheld device. All three bracelets were functioning. Reviewed the Maintenance Audit tools completed once/week from February to current and confirmed R4 had been on the list and the new Resident had been added the day the WanderGuard was put on. The tool included: Resident Room, date of expiration, did the elevator alarm activate, did the elevator door lock, did the exit door alarm activate, did the exit door lock, keypad working and alarm cleared, and any alarm delay less than 2-4 ft of the elevator or door noted. Reviewed all Resident's with WanderGuard to confirm there was a Provider order. Some orders were specific to monitor the bracelet six times a day. This is a shared task between the Nurses and CNA's. Record Review revealed compliance with monitoring on all Resident's. The monitoring includes Wanderguard Monitor placement and quality of device. Monitor skin integrity of resident. Confirmed education on Wandering and Elopement, Resident Safety, and Policy had been completed for all staff In summary, there was sufficient evidence of compliance at the time of survey.

Based on record reviews and interviews, the facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three of three Residents (R)1, R2, and R4. Specifically, R1 did not have a BCP developed within 48 hours of admission, R4's BCP did not include the Stage 2 Pressure Ulcer that was present on admission, and two residents were not provided summaries of the BCP. This deficient practice places residents at risk for not receiving appropriate and timely care, delays the development of care to address resident's immediate health and safety needs, hinders continuity of care, and impedes communication amongst nursing home staff. Findings include: 1) On 03/24/2025 at 10:30 AM, record review of R2s BCP was noted to be blank and not completed. R2 was admitted on [DATE], and comprehensive care plan (CCP) was initiated on 02/28/2025. Further review of R2's electronic medical record (EMR), did not note they were furnished with a copy of their BCP. On 03/24/2025 at 03:00 PM, interview with Director of Nursing (DON) confirmed that the BCP should be completed within 48 hours of resident's admission. Surveyor asked DON to show R2's BCP and noted that it was blank, and stated, I don't know what happened, I will check on it. On 03/25/2025 at 12:00 PM, DON provided a copy of a completed BCP for R2. It was completed by Nursing Supervisor (NS). There was no completion date noted on BCP. On 03/25/2025 at 12:20 PM, interview with NS, who confirmed that she was asked to complete the BCP that morning. When asked when the BCP should be completed, NS replied, It should be completed within 24 hours. On 03/25/2025 at 12:30 PM, interview with DON and Administrator confirmed that if the staff cannot complete the BCP, that the NS will be the one to complete it. At that time, they let surveyors know that the BCP for R2 and another resident were completed late. The Clinical Specialist (CS) said no matter how late the BCP is, it still needed to be completed to move forward in their next step of documentation. The BCP for R2 was completed 03/25/25. 2) On 03/24/2025 at 10:35 AM, record review of R1's EMR did not note they was furished a copy of their BCP. Concurrent record review and interview with DON on 03/24/2025 at 03:00 PM, DON confirmed that summary of BCP was not provided to the resident/guardian. 39853 3) R4 was a [AGE] year old female admitted to the facility for skilled nursing services on 03/19/2025 for short term rehabilitation after being hospitalized for two unwitnessed falls at home. Her medical diagnosis included but not limited to repeated falls, anorexia, severe malnutrition, hypertension, unsteadiness on feet, dysphagia (swallowing disorder), and pressure ulcer of sacral region Stage 2. Reviewed R4's medical records, which included the following: Hospital Discharge Summary dated 03/19/2025 revealed the following entries: - Related to unwitnessed fall; patient lives with special needs son and does not have anyone to take care of her. She is primary caretaker of son. Niece checks on her twice a week and found her down prior to admission.Has frequent falls and states that she uses walker/cane in her home to ambulate due to instability. The hospital discharge instructions included care for Pressure Injury (PU). - [NAME]-Baseline Care Plan was completed on 03/19/2029, and included skin risk. This section documented R4 to have current skin integrity issues, but did not identify the Stage 2 sacral PU present on admission. The signature of Resident and Representative was left blank and no evidence a copy of the BCP was provided to R4 or Representative. 3) Reviewed the facility's care plan policy titled, Care Plans - Baseline with revised date March 2022. The policy documented in the section titled Policy Statement noted, A BCP to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. Also noted in the same policy under section titled Policy Interpretation and Implementation, noted, 3. A comprehensive care plan (CCP) may be used in place of the BCP provided the CCP is developed within 48 hours of the resident's admission. 4. The resident and/or representative are provided a written summary of the BCP (in a language that the resident/representative can understand) .5. Provision of the summary to the resident/or resident representative is documented in the medical record. These policy statements were not followed by the facility.

Based on record reviews and interviews, the facility failed to provide repositioning, the standard of care for pressure ulcers (PU/ injury to the skin and tissue below the skin due to pressure on the skin for a long time), and as directed in care plans for three Residents (R)1, R2 and R4 out of a sample size of three. This deficient practice puts residents with PU's at risk of worsening the wound, and increases the potential of those at risk to develop one. Findings include: 1) Cross Reference F655 Baseline Care Plan R4 was a [AGE] year old female admitted to the facility for skilled nursing services on 03/19/2025 for short term rehabilitation after being hospitalized for two unwitnessed falls at home. She had a sacral Stage 2 PU present on admission that was not identified on her baseline care plan. Record review revealed no documentation the R4 had been turned or repositioned until after the treatment administration record (TAR) was initatiated on 03/25/2025. 2) Record review of R1's Minimum Data Set (MDS), noted R1 was admitted on [DATE] with an unstageable wound ulcer to his coccyx and required substantial/maximal assistance with rolling left to right in bed, sitting to lying position, and with transfers. Review of Wound Care Nurse (WCN) notes, dated 05/13/2024, indicated, wound on coccyx is necrotic and malodorous with large, purulent drainage. R1's care plan for unstageable ulcer, initiated on 05/16/2024, included tasks to assist R1 to turn/reposition at least every 2 hours. There was no documentation in R1's TAR that repositioning/turning every 2 hours was completed. 3) Record review of R2s MDS noted that R2 was admitted to the facility on [DATE] with multiple PUs. R2 had a Stage 3 PU on the right buttocks, unstageable wound left buttocks, Stage 2 coccyx, and left ankle ulcers. Review of WCN notes dated 03/21/2025, indicated wounds located on bilateral buttocks and left posterior thigh are smaller in size while the right posterior thigh is healed. R2's care plan initiated on 02/28/2025, included tasks that R2 needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. There was no documentation in R2's TAR that repositioning/turning every 2 hours was completed. 4) On 03/25/2025 at 10:25 AM, interview with Certified Nurse Assistant (CNA)1 inquired how often they would check on the residents with PUs. CNA1 stated, We check up on them every time they have bowel movement, at least three times a day, in the morning after breakfast, again at lunch, and after dinner. When asked about peri care and repositioning, CNA1 replied, We clean them and would report any findings to the charge nurse. We change their position every two hours and document that in the I-pad, under Activities of Daily Living (ADLs), repositioning and sign our name. At 10:30 AM, CNA1 showed surveyor, where in the I-pad, they would document repositioning was completed. On 03/03/2025 at 10:40 AM, interviewed CNA2, who confirmed that they check residents with PUs every two hours for bowel and bladder elimination and reposition them every two hours. CNA2 verified that they document these tasks in the ADLs section in the I-pad. Surveyor asked CNA2, to open up R2's chart to see if documentation was noted for repositioning. Documentation showed repositioning on 03/25/2025. CNA2 was asked to show if documentation for repositioning was completed on 03/24/2025, and she confirmed that there was none as she wasn't assigned to R2 yesterday. CNA2 checked another date, 03/11/2025 to see if documentation on repositioning was done by another CNA, but record showed none were documented. It was confirmed that the documentation for positioning started on 03/24/2025. CNA2 went on to note that the CNAs should be documenting every day. On 03/25/2025 at 01:30 PM, interview with Director of Nursing (DON) confirmed the importance of every two hours repositioning for residents with PUs and agreed there should be documentation of the task being done. DON also confirmed that there were no tasks triggered for the repositioning for both R1 and R2 upon admission but will do so to improve the process moving forward. 5) On 03/25/2025 at 01:45 PM, record review of the facility's Repositioning policy, with a revised date of May 2013, documented under General guidelines, states, 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief.3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Also noted in the same policy under the Documentation section, notes, The following should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name of the individual who gave the care.7. The signature and title of the person recording the data. These policy statements were not followed by the facility.

Based on record review and interviews, the facility failed to develop a comprehensive care plan (CCP) for one Resident (R)1 of a sample size of three. Specifically, R1's CCP did not address his safety needs in a timely manner. As a result of this deficiency, R1 may have been at higher risk of falls. The deficient practice of not addressing resident's needs timely in the CCP could affect any resident and be a barrier to meeting their highest potential of physical and mental well-being. Findings include: Record review of R1's electronic medical record (EMR) noted that prior to admission on 05/06/2024, R1 was admitted to a hospital with a subdural hematoma (brain bleed caused by trauma) due to falling at home. R1's baseline care plan (BCP) completed on admission to the facility, noted R1 to be cognitively impaired, marked Yes, for fall(s) in the past three months, level of consciousness marked as disoriented x3 at all times, and functional ability and goals were not assessed. Admission progress notes detailed resident was lethargic, disoriented, and oriented to person with mild impairment. Late entry on Admission note specified R1 was a fall risk. Review of the Nurses Notes dated 05/13/2024, at 11:13 AM, documented, R1 was found sitting on the floor with his back leaning against his bed at 02:20 AM. Alert but very confused and hallucinating. He thought that he was at the Club . When asked him if he was only dreaming, he said no and he believed that he was there at the Club. Review of the Nurses Notes dated 05/20/2024 at 00:02 AM, documented, At 2345h (11:45 PM) CNA (certified nurse assistant) found resident sitting on the floor next to his bed. No noted pain, other than his unchanged pain to his coccyx. He was then assisted back to bed.DON (Director of Nursing) and Kaiser notified. On the same day there was a late entry at 03:30 AM: Found resident facing down on the floor, alert c/o pain from head to toe .assisted back in bed with 4 person assist. Abrasion to right elbow 2 cm X 1cm .MD and family notified. MD stated to send to ER for further evaluation d/t (due to) frequent falls and confusion. Record review of R1's care plan noted that The resident is High Risk for falls r/t confusion, deconditioning, gait/balance problems, incontinence, use of Oxycodone (pain medication). Actual fall on 05/13/24-minor injury (complaints of pain), was initiated on 05/16/2024, three days from the initial fall on 05/13/2024. On 03/24/2025 at 03:00 PM, interview with DON, who confirmed that High Risk for falls was not included in R1's CCP on admission, and should have been due to his history. On 03/25/2025 at 01:00 PM reviewed the facility's care plan policy titled, Falls and Fall Risk, Managing with a revised date of March 2018. In the section titled, Policy Statement noted, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Also noted in the same policy under section titled Resident-Centered Approaches to Managing Falls and Fall Risk, noted, 1. The staff, with input of the attending physician, will implement a resident-centered fall prevention to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation and interview the facility failed to ensure staff use non-expired test strips for their kitchen three compartment sink to test for levels of strength of sanitizer solutions, failed to store clean meal lids on a rack that did not have rusty colored debris and failed to label opened beverages with the opened-on date. Findings Include: 1) Observation on [DATE] at 10:40 AM had kitchen staff test the strength of sanitizer in their three compartments sink and found facility was using expired Hydrion test strips with an expiration date of [DATE]. Food Service Worker (FSW) 11 confirmed the test strips were expired and got new test strips and tested the water which was in range. 2) On [DATE] at 10:57 AM while observing tray line observed a rack in the kitchen near the stove, which held clean lids for resident meals, had rust colored debris. Inquired with Dietary Manager who confirmed there was rust colored debris and stated, need to change it out. 3) On [DATE] at 09:50 AM observed nourishment refrigerator on the second floor. While looking at food and juices in the refrigerator found orange juice, prune juice and cranberry juice were open but not dated with the opened-on date. Inquired with Nursing Supervisor who confirmed juices are to have the opened-on dates on them.

Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to residents on transmission-based precautions (TBP). This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: On 08/26/24 at 11:03 AM, observed postings on the door of room [ROOM NUMBER] that stated, Special Droplet/Contact Precautions. The posting also stated that eye protection, gown and gloves are required when entering the room. Registered Nurse (RN)9 confirmed that one of the residents in room [ROOM NUMBER] recently tested positive for COVID-19. On 08/26/24 at 11:39 AM, observed Physical Therapist Assistant (PTA)1 in room [ROOM NUMBER] talking to Resident (R)61. PTA1 was not wearing a gown and did not have a face shield or eye protection. PTA1 then exited the room to speak to another staff member, put on a gown and reentered room [ROOM NUMBER]. PTA1 did not have a face shield or eye protection when he went back in. On 08/28/24 at 08:47 AM, an interview was conducted with the Director of Nursing (DON) in the hallway just outside room [ROOM NUMBER]. DON confirmed that all staff are expected to wear a gown, gloves, mask and face shield or eye protection when entering rooms assigned to residents on TBP. Review of facility policy titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment stated, . b. Eye Protection: (1) Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area. d. Gowns: (1) A clean isolation gown is donned upon entry into the resident room or area. 37954 2) On 08/26/24 at 09:11 AM observed on the second floor a plastic container that held PPE such as gloves in various sizes, disposable gowns, N95 and surgical masks. This was kept outside of a resident's room who tested positive for COVID. PPEs were placed outside the room near the door for staff to put on before entering the room and the red biohazard trash can with lid was next to the PPE container. Across the hall there was another PPE container next to a regular trash can that did not have a lid, placed outside another resident's room who also tested positive for COVID. On 08/26/24 at 11:28 AM second observation done on the second floor found a red biohazard trash can left outside of a resident's room who tested positive for COVID. At this time inquired with the Nursing Supervisor why it was not in the room, and she stated there was no room and that it would create a fall risk for the residents in the room. On 08/27/24 at 08:20 AM Administrator shared with surveyor why facility had PPEs, biohazard and regular trash cans outside resident rooms who tested positive for COVID. Administrator stated facility had a meeting with an Infection Control Consultant and shared what the consultant wrote in an email to Administrator on 09/22/23 at 4:04 PM I understand you are in the window for survey. If they ask why they are bringing doffed PPE in the hallway bin, explain the lack of space in the room does not allow a large trash bin and if you put one it could pose a safety risk for the residents and cause falls or injury to them .Explain you are looking at over the door PPE caddy's and over the door trash bag holder for the used PPE. At no time during survey was over the door PPE caddy's and over the door trash bag holder for the used PPE observed in the resident's rooms who tested positive for COVID. Review of facility policy titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment stated under Policy Interpretation and Implementation . 2. When caring for a resident with suspected or confirmed SARS-CoV-2 infection, personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. c. Gloves (1) Non-sterile gloves are applied upon entry into the resident care room or care area. (3) Gloves are removed and discarded before leaving the resident room or care area, and hand hygiene performed immediately. d. Gowns (1) A clean isolation gown is donned upon entry into the resident room or area. (3) The gown is removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area.

Based on record review and interview, the facility failed to inform a resident of the risks and benefits of the use of psychotropic drugs and obtain consent for one of five residents (Resident (R)3) sampled for unnecessary medications. As a result of this deficiency, the resident was placed at risk for more than minimal harm. Findings include: R3 was an [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses included but not limited to anxiety disorder, dementia, and major depressive disorder. Ordered medications included mirtazapine and duloxetine (antidepressants). Review of R3's Electronic Health Records (EHR) documented the consents for the use of the psychotropic medications including education on the risks and benefits were not found. On 08/28/24 at 12:34 PM, requested from Director of Nursing (DON) a copy of the consents for the use of antidepressants for R3. DON said he will look in the paper files since R3 was already on the medications before the facility switched over to the EHR. On 08/29/24 at 07:58 AM, the DON confirmed he was not able to locate the consents for the use of the antidepressants for R3.

Based on observations, interviews, and record review, the facility failed to ensure a resident's right to be free from physical restraint for staff convenience and not required to treat the resident's medical symptoms for one resident (Resident (R)5) sampled. Positioning wedges were placed under R5's mattress and under the resident's fitted sheet in a manner which could not be removed by the resident, which hindered the resident from freely moving at will. An interview with staff confirmed the positioning wedges were not used to reposition R5 and the resident is capable of independently moving around in bed. As a result of this deficient practice, residents with the ability to move independently are at risk of the potential for more than harm. Findings include: On 08/26/24 at 11:50 AM, 12:30 PM, and 02:05 PM, observed a large black positioning wedge and pillow placed under the bed's mattress. The placement of the positioning wedge and pillow caused the mattress to be concaved and restricted the resident from freely moving around. Inquired with the resident if he was able to move side to side independently while lying on the mattress, the resident tried and was unable to do so and reported he needed help. The resident confirmed he can move side to side by himself. On 08/27/24 at 07:55 AM, 09:03 AM, 11:47 AM, and 01:40 PM observed a positioning wedge placed under the resident's fitted sheet on both sides of the bed, parallel to the resident's legs only. The wedges were not placed under the resident and did not function to reposition the resident. Resident confirmed the wedges did stop him from moving to his side and could not remove the wedge from under the fitted sheet. On 08/27/24 at 01:40 PM, conducted concurrent observation and interview with Registered Nurse (RN)4 of R5 in bed with the wedges placed under the sheet. RN4 confirmed the placement of the wedges under the resident's fitted bed sheet, made it impossible for this resident to remove the wedge, was not placed in a manner consistent with repositioning the resident, and was not being used to treat a medical condition. RN4 stated, The way the wedges are placed under the sheet, on both sides of the resident, the wedges are being used as a restraint. Wedges should have only been placed on one side if we want to reposition him, but he (R5) can move side to side on his own and doesn't need to be repositioned by staff to prevent a pressure ulcer. He (R5) is a high fall risk and has fallen out of bed recently, we try our best but cannot be with him all the time. Asked RN4 if a bed alarm was implemented for the resident. RN4 confirmed R5 does not have a bed alarm and it should have been implemented after the resident's last fall but was not. Review of R5's skin integrity care plan, did not include using a wedge to reposition the resident. A care plan for R5's high fall risk and an elopement was developed and did not include the use of wedges. Review of the facility's policy and procedure (provided by the facility), Use of Restraints documented 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint.

Based on record reviews and interviews, the facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two of the five residents (Resident (R)6, and 167) sampled for hospitalization . As a result of this deficient practice, there was a potential for miscommunication. This has the potential to affect all the residents that are transferred to an acute care hospital. Findings include: 1) R6 is a [AGE] year-old resident admitted to the facility on [DATE]. Review of R6's electronic health record (EHR) revealed that she was transferred to an acute care hospital on 03/13/24 for acute lower GI (gastrointestinal) bleeding. R6's EHR did not contain documentation that R6's representative was provided a written notification of the facility's bed hold policy. On 08/29/24, requested a copy of the written notification of the bed hold policy provided to R6's representative from the Director of Nursing (DON). DON said he will check. On 08/29/24 at 04:14 PM, the Social Worker Designee (SWD) provided a printout of the progress notes from R6's EHR that stated the bed hold policy was communicated via phone call with the family representative. Asked SWD if a written copy of the bed hold policy was also provided. SWD confirmed the facility did not provide the resident representative a written copy of the bed hod policy. Review of the facility policy titled Notice of Bed-Hold and Readmission Policy stated, . In order to bed-hold, the resident or the resident's responsible party or agent must complete, sign and submit the BED-HOLD AGREEMENT within twenty-four (24) hours of discharge and pay a deposit . 37954 2) Record review on 08/28/24 of R167's EHR found she was transferred to an acute hospital on 07/23/24 at 5:25 PM for pain r/t (related to) fractures of her Right Hip and Right shoulder that she incurred from a fall (unwitnessed) in her room at 1305 (1:05 PM) this afternoon. On 08/29/24 at 03:46 PM, interviewed SWD and inquired if R167 or her resident representative was notified of the facility's bed hold policy at time of transfer to the hospital. SWD confirmed resident or resident representative was not notified of bed hold policy.

Based on interviews and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident (R)56) sampled. R56's person-centered care plan included an intervention to use alternative communication tools (i.e. interpreter services, available for staff use) for this Korean speaking resident. Staff did not implement the use of interpreter services intervention when conducting the Brief Interview for Mental Status (a tool used to assess the resident's cognition). As a result of this deficient practice, all non-English speaking residents are at risk of the potential for more than minimal harm. Findings include: On 08/27/24 at 12:28 PM, conducted an observation of R56 in the unit's main dining room during lunch. The resident was seated next to another Korean speaking resident and conversed with each other throughout lunch. When R56 was done with her meal, facility staff approached R56 and attempted to have a conversation with the resident in English. R56 waived her hand at the staff then said No, English, then said something to the other resident in Korean and both residents proceeded to laugh and continue their conversation. Staff kept attempting to speak and interact with R56 about the meal but was unable to effectively communicate with the resident. Reviewed R56's Electronic Health Record (EHR). The resident's baseline care plan Section 1.B. Communication documented: 1. Can the resident communicate easily with staff? No 2. Does the resident understand the staff? No 3. Does the resident need or want an interpreter to communicate with a doctor or health care staff? Yes 4. Primary Language: Korean Review of R56's admission Minimum Data Set (MDS) with an Assessment Reference Date of 06/14/24 documented in Section C. Cognitive Patterns, R56 scored 99 on Brief Interview for Mental Status (BIMS) score, which assesses the resident's cognition, indicating the test could not be completed. R56's comprehensive person-centered care plan for communication documented an intervention which included .Use alternative communication tools as needed. On 08/29/24 at 12:13 PM, conducted an interview with the MDS Coordinator (MDSC). MDSC confirmed she conducts the BIMS testing with the residents. MDSC stated the facility's interpreter service has never been used to communicate with non-English speaking residents to conduct a BIMS test. MDSC confirmed R56 scored a 99 on the admissions BIMS score due to the resident's inability to understand English and is not an accurate BIMS score for the resident. On 08/29/24 at 01:57 PM, conducted a concurrent record review of R56's Electronic Health Record (EHR) and interview with Registered Nurse (RN)5. RN5 confirmed R56 is Korean speak and is minimally (i.e. tired, sleepy, hungry) able to communicate with staff, but is not able to understand complex statements. RN5 reported R56 is cognitively aware, she is observant of staff, and was able to incrementally find a way to elope from the facility. RN5 explained R56 eloped from the facility, she was cognitive enough to figure out that the Wander guard would prevent her from being able to get off the elevator, but she was determined to leave. R56 noticed staff inputting a code to disarm the Wander guard system and even attempted to input a code. Eventually, she was able to find a scissor in a manicure set, cut off the Wander guard bracelet which activates the system and prevented the resident from leaving the facility, and was able to exit the building and cross the street. RN5 stated most of the behaviors and the elopement attempt could have been mitigated if interpreter services were implemented to discover what was the real issues and to explain the circumstances of why the resident was in the facility in the first place. RN5 confirmed R56 is minimally interactive with staff who are only English speaking, but she will sit a have conversations with another Korean speaking resident.

Based on observation, staff interviews, and record review the facility failed to ensure resident (R)70 receives the correct physician's order for fluid consistency. As a result, R70 was observed coughing/choking during mealtime while consuming non-nectar thickened liquids. Findings Include: R70 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A speech therapist consultation on 07/31/18, identified R70 at risk for aspiration. However, the facility's kitchen staff, unit staff, dietary staff and NS1 were not aware R70 was not receiving a nectar thick fluid consistency as ordered since 07/18/19. On 10/22/19 at 11:47 AM, observed R70 in the 3rd floor dining area during lunch, drinking independently. R70 was seated at a table with one other resident which was being assisted with lunch by certified nurse's aide (CNA)2. The surveyor was positioned approximately 2 feet away from R70, with a clear view of the contents of R70's tray. R70 received a lunch tray that contained 3 separate cups of liquid. The cups contained different types of fluid. The fluid consistency appeared to be: a pre-filled thickened water; a cup of non-thickened water; and a brown mug filled with non-thickened coffee. Later confirmed in an interview with Registered Dietician (RD)1, the fluid on R70's tray consisted of 4 ounces(oz) of nectar thick fluid, 4 oz of regular (non-thickened) consistency that is to be mixed together for the appropriate consistency for R70 and confirmed R70 has not been receiving the ordered fluid consistency since 07/18/19. Observed R70 coughing/choking after drinking the clear fluid from the regular cup continuously throughout lunch. CNA2 was seated at the same table, did not inspect R70's food, drink or diet card and continued to assist another resident with lunch. While the surveyor observed R70 coughing/choking, the Nursing Supervisor (NS)1 entered the dining area and observed the surveyor monitoring R70. R70 started to cough/choke after drinking the non-thickened water. Later, observed NS1 removing the coffee and the diet card from R70. NS1 confirmed the consistency of the coffee was not thickened and should be thickened. Reviewed the diet card with NS1, the diet card stated, Fruit juice: 3 each Nectar thick water and 1/2C (cup) thin liquids by Nursing. However, a review of the (MONTH) 2019 Physician's Order sheet documented the fluid order as Nectar Thick Only. Further record review for R70 noted a nutrition assessment by RD2 which documented, .downgrade liquids to nectar thick liquids .Family also states kitchen is mincing meats, resident prefers meat mech (mechanical) soft as it states in diet order. Sent reminder to kitchen. On 07/18/19, RD2 completed a physician telephone order. The physician verified the telephone order as Nectar Thick Only fluid consistency. Additionally, R70's comprehensive care plan reflected the change to nectar thick consistency on 07/18/19. The Director of Nursing (DON) and NS1 both confirmed there was a discrepancy with the fluid consistency delivered to R70, the diet card (Fruit juice: 3 each Nectar thick water and 1/2C thin liquids) and the physician's order (nectar thick only). DON1, RD1, NS1, Unit Clerk (UC)1, Registered Nurse (RN)1 and Dietary Cook Supervisor (DCS)1 were unable to provide documentation of the change from nectar thick water and 1/2C thin liquids to nectar thick only fluid consistency for R70 on 07/18/19. DON1 and NS1 confirmed R70 has not received the changed fluid consistency since the order date of 07/18/19. The facility's failure to provide the correct fluid consistency and lack of staff awareness of what the resident should be receiving have contributed to R70's coughing/choking continuously during lunch on 10/22/19.

Based on observations, interviews, record review and review of the facility's policy and procedure, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress for 2 of 45 residents included in the Stage 2 sample. Findings include: 1. On 1/26/12 during the Stage 2 review for Abuse Prohibition, a review of the facility's self-reported incident report related to an injury sustained by Resident #42 on 9/27/11 found the facility submitted their completed incident report (IR) to the Hawaii State Survey Agency (SA) on 9/28/11. The facility's investigation revealed Resident #42 had sustained a displaced humeral shaft fracture (upper arm fracture) and displacement of the humeral head (shoulder region). The facility determined the fracture was due to the resident's arm being in the side rail while the staff turned and repositioned her and that the resident frequently held onto the bed side rail tightly. The completed report stated the staff did not realize the resident was holding onto the side rail when she was repositioned. There were no other causal factors listed in the report and the facility also determined there was no abuse, neglect or mistreatment suspected from their investigation. The IR stated that on 9/27/11 at 8:00 P.M., a Certified Nurse Aide (CNA 1) noted the resident's right arm looked swollen and deformed. She summoned a licensed staff (RN 1) to examine the resident and that it appeared to RN 1 the resident had a fracture. RN 1 verified this with another licensed staff who concurred with the possibility of a fracture. The resident was unable to state what happened. RN 1 notified the covering physician who ordered the resident to be sent to an emergency room . The IR also stated that prior to the 9/27/11 incident, Resident #42 had care plans developed with interventions such as 1) At risk for injury related to [MEDICAL CONDITION] and history of fractures, with interventions that included gentle handling when transferring, repositioning and maintaining the resident's body alignment; 2) At risk for injury related to dementia, with interventions such as using simple words or instructions and allowing extra time for process and responses; 3) At risk for injury related to poor safety awareness, with interventions to use half rails during turning and repositioning; and 4) Assistance required in performing all ADL's, with interventions to use half rails during turning and repositioning. On 1/26/12, observation of Resident #42 at 1:05 P.M. found the resident in bed on the second floor nursing unit. Her mouth and eyes were both slightly open. The resident moved her upper torso slightly when spoken to and blinked her eyes, but had no verbal response. The bed side rails were not in use. On 1/26/12, a review of Resident #42's clinical record revealed a 1/20/12 attending physician progress notes [REDACTED]. The progress notes revealed the resident sustained [REDACTED]. On 1/26/12 at 3:04 P.M., RN 1 was interviewed. She worked as an on-call staff and recently obtained a full-time position from November 2011. She floats between the second and third floor nursing units and covered both day and night shifts. She was able to recall the 9/27/11 incident involving Resident #42. RN 1 said she was the charge nurse that evening and was completing her rounds at 8:00 P.M. She said CNA 1 suddenly called her check Resident #42 and was changing the resident's clothes. RN 1 said she noticed the resident's right upper arm "flexed in an unusual position and I already suspected a fracture." She saw it bulging out. She said the resident was non-verbal but saw facial grimacing. RN 1 said she then called the third floor nurse to confirm it. She then called the covering physician who ordered the resident to be transferred to an acute hospital. RN 1 said Tylenol was given to the resident before she was transferred out. RN 1 explained she asked CNA 1 if she turned the resident during the first round of the evening shift. CNA 1 told her the resident was, "not wet, she kept her in the position to eat, which was either flat or supine." RN 1 said she asked CNA 1 if she changed the resident's clothes, but recalled CNA 1 telling her no, and that she would change her after the feeding time. RN 1 thereafter prepared the incident report. RN 1 said another CNA (CNA 2) was going to help CNA 1 turn the resident, "but they called me before they even touched her or started the PM care for her." RN 1 clarified that CNA 1 checked Resident #42 on the first round, opened her brief and said because she was still dry, CNA 1 did not change her. At that time RN 1 said CNA 1 did not tell her there was something wrong with the resident's arm. RN 1 said she then completed the incident report, charted her findings and thought she also called the second floor Nursing Supervisor (NS 2). RN 1 said CNA 1 stayed on the evening shift for the rest of that night. Upon query, RN 1 said she did not think nor suspect it may have been abuse or neglect by the staff. RN 1 then paused and said, "did not think that." She verified CNA 1 and CNA 2 were helping each other out that evening, especially those residents who were hard to turn. CNA 2 had empty beds on her side and recalled that was the reason she went to help CNA 1. On 1/26/12 at 3:25 PM., CNA 2 was interviewed. She worked at the facility for almost [AGE] years and primarily worked the evening shift on the second floor. She recalled the events on 9/27/11 and said she called RN 1 to come and check whether Resident #42's arm was normal. CNA 2 explained she was caring for another resident, but when she went to see the resident, she saw the right arm, lifted it up and noted that, "the bone was wobbly and moved and so (CNA 1) called the two nurses to have them come look." CNA 2 said they checked the left arm and it was normal, but because the right arm was wobbly, "it was fractured." She said she had no prior contact with the resident until CNA 1 called her. CNA 2 stayed there until the nurses came and said it was a group of them looking at the resident's arm. CNA 2 said afterward, "two of us had to assist in changing her, think it was a gown she was wearing and we changed her diaper because it was past 8:00 o'clock." She said they did last rounds around 8:00 or 8:30 P.M. CNA 2 said she was not asked to provide a witness statement about the incident and said, "Only (CNA 1)." CNA 2 recalled returning to her group of residents for the remainder of the shift and CNA 1 did the same but that they were all worried. She said, "We didn't know if it happened during our shift or during the day." She thought the resident was taken to the hospital, found she had a fracture and had a cast placed. She said after this incident, the protocol for the resident became a two person assist for turning. On 1/26/12 at 3:36 P.M., CNA 1 was interviewed. She recalled the events of 9/27/11 and said she was the primary aide caring for Resident #42 on the evening shift. She said during the first round at the 4 PM check, the resident was "dry" and it was also her "early dinner time" and was intending to turn her, but that the resident was already supine so she left her that way. CNA 1 said the resident ate at 4:00 P.M., "but tried to close mouth when I tried to feed her. So after she ate and 30 mins. later I put her head of bed down." Then at 8:00 P.M., she did her last rounds and when she tried to undress the resident, she noticed a "deformity" to the right upper arm. She called CNA 2 to check it, and was told it might be a fracture. RN 1 also came, "and said it looks watery and then checked with (3rd floor nurse) who said it's a fracture and (another CNA) and said it's a fracture." She confirmed there were five staff present including herself. CNA 1 said the nursing supervisor was called, vital signs taken and she had to tell the nurse what happened and wrote it in an incident report. CNA 1 said she tried to undress the resident by her left arm first and then the right arm. "The left side was okay, but the right--I'm not really sure" and reiterated it was "a watery kind of thing, like fluid 'cuz it was loose and got worried." She said the resident was laying flat on her back. She said the resident was not holding onto anything and demonstrated how the resident's hands were positioned across her belly. CNA 1 reiterated she was going to change her from regular clothes to a nightgown, "because last rounds. I just put her head up and pulled the clothes up from the bottom up." CNA 1 was asked if the resident held onto the side rails during the time she was going to change her clothes. She stated the resident did not grab onto the side rails. CNA 1 also said she did not turn nor reposition the resident. She said the resident also did not display any signs of pain, "she can't talk" and was not grimacing or otherwise showing pain. CNA 1 said after everything happened the nursing supervisor just told her how to care for the resident when the resident came back. She said she had no inservice and recalled "things like try to be careful, if notice any changes to report it right away, how to position." CNA 1 said the resident moved around in bed and if she was changed, she would hold tightly to the padding on the side rails. She said the side rails were used then, but not anymore. On 1/26/12 at 3:55 P.M., the second floor Nursing Supervisor (NS 2) was interviewed. She has been the NS for a year and 9 months. She stated she ensures for the safety of the residents by making rounds, speaking to residents, family, observing staff and discussing issues with the administrative team. Regarding the 9/27/11 incident involving Resident #42's injuries, her role was to collect information and conduct the investigation. The nurse called her that night and told her the resident's arm appeared to have had a fracture. The nurse also called the doctor who sent the resident to the ER. She said the next morning, the Administrator, the Director of Nursing (DON) and she came in to do the investigation. They spoke with the staff, read over the notes and reviewed, "how the resident already was. We went over what were her normal behaviors, habits, and one of them was how she always grips on and holds onto the side rail." NS 2 said from that they came to the conclusion that was how the fracture occurred, from the resident holding onto the side rail when the aide was turning her and had not noticed the resident still holding onto the side rail. NS 2 however stated it was not what the aide told them. She acknowledged they did not interview the CNA allegedly involved in causing the injury during care. NS 2 stated the charge nurse did the initial investigation and wrote the resident's right arm may possibly have gotten caught while turning. NS 2 said based upon what had been written by RN 1 after she spoke to CNA 1, and based on what RN 1 said and spoke to the day shift staff about the resident's behaviors, and, "what we noticed with her behaviors that she held onto the side rails," was how they came to their conclusion. Interview with the Administrator, DON and NS 2 (Admin Team) on 1/26/12 at approximately 4:30 P.M. revealed the only interviews of staff were only what was contained in the completed investigation report. They acknowledged this was the completed investigation report produced on site, which included the same IR forwarded to the SA. However, the resident's follow-up x-ray report of 10/3/11 had not been sent to the SA and this report documented an added new finding, "There appears to be fractures of the right ribcage, the exact rib level is difficult to ascertain." Surveyor asked whether the Admin Team thought to query the day shift staff, to further determine whether any other causal factors, such as whether the resident had any scheduled or unscheduled activities, visitors, etc., were reviewed when they conducted their investigation. The DON said she essentially relied on the nurse who wrote the IR and that no one interviewed CNA 1 nor other staff who may have been involved with the resident on 9/27/11. Surveyor queried whether their knowledge that this resident sustained [REDACTED]. The DON said she thought it was the best determination they could come up with as to what happened (i.e., that CNA 1 turned the resident while the resident still held onto the side rails) as the cause of the injuries. She said if they believed this was what actually happened, then it was not abuse. The Administrator also stated they did not at any point think of it to be abuse. Surveyor queried how the Admin Team was able to rule out abuse and neglect as the surveyor found, based on the staff interviews conducted on 1/26/12, that CNA 1's story did not corroborate or validate the conclusion or determination made by the Admin Team. CNA 1 said she did not turn the resident and her employee statement also noted she found the right hand deformity when she was changing the resident's clothing. She did not state she was turning the resident while the resident had been holding onto the side rail. Review of the facility's policy and procedure, "Resident Abuse, Neglect and Misappropriation of Property (Rev. 9/20/11), stated the purpose of the policy was, "To ensure the prevention, protection and safety of all residents from incidences of abuse, neglect or misappropriation of property. To conduct a thorough investigation and reporting of all incidences and provide the appropriate corrective actions and preventive measures...Definitions: D. Investigative Steps: 5a. The DON/Supervisor and Social Worker will interview staff, visitor or residents who have knowledge of the alleged incident, using the attached Interview Record Form...to document information obtained from them..." The facility was unable to produce documentation which evidenced that a thorough, complete investigation had been conducted. Furthermore, the Admin Team, once aware of the rib fractures also sustained by Resident #42 along with the humeral fracture and shoulder dislocation, failed to report that finding to the SA and also did not provide evidence related to their investigation on how they ruled out abuse and neglect for this resident's significant injuries of unknown origin. 2. During the Stage 2 review for Abuse Prohibition, another IR was reviewed related to the facility's self-reporting of an allegation of staff to resident abuse. The IR stated a unit clerk (UC) observed Resident #50 and a CNA laughing and having fun in front of the nurse's station. The CNA was allegedly tickling the resident's ear and the UC heard Resident #50 say, "Ouch...(called out UC's name), (CNA's name) is hurting me." The UC later heard the resident say, "Ouch, ouch," and saw the CNA "konk/tap" the back of the resident's head with her fist teasing the resident about having an "uku" (head lice.). The facility completed their investigation and forwarded the IR to the SA on 6/27/11. It was noted however, the date of the witnessed event was 6/21/11 around 1:45 - 2:00 P.M., and the UC who witnessed it reported it the next day on 6/22/11, when the intial report was sent to the SA. On 1/27/12 at 11:30 A.M., the UC who witnessed the event was interviewed. The UC was able to recall the events of 6/21/11. The UC stated the CNA's actions were abusive even if it was playing around because Resident #50 said, "ouch," twice when she saw the CNA tap the resident's head with her fist. The UC said two charge nurses were present and available on 6/21/11 at the time she witnessed it. It was approximately between 1:45 to 2:00 P.M., but the nurses were busy charting and preparing for the incoming evening shift. The UC said she felt bothered by the incident, but left work before reporting the incident. The UC stated she did not feel comfortable reporting to the charge nurses because she did not know if they were friends with the CNA. The UC was able to state what she would do if she witnessed a allegation of abuse and verbalized the acronym SPOT (stop, protect, oust, and tell the supervisor). She confirmed she did not report the incident until 6/22/11 at 8:30 A.M. when she reported it to the second floor Nursing Supervisor (NS 2). Thereafter, the UC said the incident was immediately and appropriately investigated by NS 2 on 6/22/11, but the UC also stated she did not receive any disciplinary action for not following the facility's policy when an abusive situation, actual or potential, was witnessed. On 1/27/12 at 11:45 AM., Resident #50 was interviewed, but she could not recall or remember the incident. Surveyor inquired whether Resident #50 felt afraid of anyone in the facility, and she responded that there was "no one to be afraid of because everyone nice" to her. The resident's annual 11/5/11 MDS revealed a brief interview mental status (BIMS) score of 9 out of 15. Review of the facility's policy and procedure, "Resident Abuse, Neglect and Misappropriation of Property (Rev. 9/20/11), stated the purpose of the policy was, "To ensure the prevention, protection and safety of all residents from incidences of abuse, neglect or misappropriation of property...Procedure: Where incidents involving the health, welfare or safety of residents, including suspected abuse, are reported, the facility management staff shall take the following steps: A. Remove the resident to an environment necessary to protect the resident's safety, where appropriate...2. If the alleged perpetrator is a staff member: a. Place staff member on immediate administrative leave (or suspension) or place member in a non-resident care area while completing the investigation... Although the facility submitted their completed investigation within the five day reporting requirement, the facility however, failed to include the UC's failure to report the witnessed staff to resident abuse and thus, did not ensure for the protection of Resident #50 as a result.