Every finding on record at Palolo Chinese Home

Based on observations, interviews, and record review, the facility failed to ensure that residents were free from abuse by failing to adequately protect one of three residents reviewed for abuse allegations (R) 12). Specifically, a staff member willfully pushed R12's head without a care related purpose. This failure placed residents at risk of abuse and harm.Findings Include: Cross reference to F609, Reporting of Alleged Violations. The facility failed to ensure that a staff member who witnessed an incident involving another staff member willfully hitting a resident in the head immediately reported the incident to the administrator. On 05/04/26, the facility submitted a completed event report to the State Agency (SA), Intake #2999087. The report documented that on 04/21/26, between approximately 7:00 PM and 8:00 PM, Certified Nurse Aide (CNA) 30 reportedly witnessed CNA19 strike R12 twice on the head, once on the back of the head and once on the side of the head. According to the report, CNA30 was in the room assisting R12's roommate and .reported hearing the resident and .[CNA19] .engaging in a back-and-forth conversation; however, was unable to determine the content or subject of the discussion. Following this, .[CNA30] .witnessed the incident, which subsequently ceased [CNA30] .assisted .[CNA19] .in transferring resident [R12] back to bed [CNA30] .checked on him later, and the resident stated he was okay. The report also documented that CNA30 demonstrated what she witnessed and that R12 stated CNA19 had slapped him the previous week. The facility interviewed CNA19, who stated she used one finger to push the back of R12's head one time. CNA19 reported that the resident had been assisted to the toilet at his request and remained there for approximately 35 minutes without urinating or having a bowel movement. CNA19 stated that the resident's lack of output, combined with the difficulty of transferring him back to bed, led to her frustration and the incident.Review of the facility's completed investigation file showed that the facility interviewed R12 after becoming aware of the allegation on 04/29/26. Documentation indicated, Resident stated the staff member .[CNA19] .hit him on the back and side of his head. On 05/21/26 at 10:51 AM, a telephone interview was conducted with CNA30. CNA30 confirmed she witnessed CNA19 hit R12 on the back and side of the head with an open hand. CNA30 stated the force was enough to cause R12's head to jerk forward slightly and produce an audible sound, but not enough to cause him to fall. CNA30 reported she directly witnessed the incident and stated CNA19 stopped and looked at her immediately afterward. CNA30 stated that after the incident she offered to assist CNA19 with transferring R12. Although she did not discuss with CNA19 what had occurred, CNA30 reported she later asked R12 if he was okay after CNA19 left the room. On 05/21/26 at 11:46 AM, a telephone interview was conducted with CNA19. CNA19 stated she pushed R12's head with her pointer finger and did not slap him. CNA19 reported that she was joking with R12 because they had a good relationship. CNA19 stated that after assisting R12 to the bathroom, where he did not urinate or have a bowel movement, she told him not to ask to be taken to the bathroom if he did not need to use it.On 05/21/26 at 12:40 PM, an interview was conducted with R12. R12 stated that CNA19 slapped him. R12 reported he was shocked by the incident because he had a good relationship with CNA19. Although R12 stated he had difficulty recalling all the details of the incident, he recognized that CNA19's actions had made him sad and confused. On 05/21/26 at 11:23 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that after receiving CNA30's report of the incident, she immediately interviewed R12 regarding what had occurred. The IP stated R12 was able to describe being slapped on the back and side of the head by CNA19 without prompting, consistent with CNA30's report. On 05/22/26 at 8:53 AM, an interview was conducted with the Director of Nursing (DON). When asked whether it was appropriate for CNA19 to push R12's head with her pointer finger, the DON stated CNA19 should not have placed her hands on the resident because the action was not related to providing care. The DON confirmed the incident was considered physical abuse. On 05/22/26 at 9:27 AM, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator confirmed that, following completion of the facility's investigation, the facility concluded physical abuse had occurred. They stated this determination was based on CNA19's admission that she pushed the resident's head with her finger and the consistent accounts provided by CNA30 and R12 regarding the incident.Review of the facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed on 02/26/24, stated: Physical Abuse includes but is not limited to, hitting, slapping, punching, kicking or controlling behavior through corporal punishments. Corporal punishment, which is physical abuse includes, but not limited to, punching spanking, slapping hands, flicking, or hitting with an object. The policy further stated, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to ensure that a staff member who witnessed an incident involving another staff member willfully hitting a resident in the head immediately reported the incident to the administrator for one of three residents (Resident (R) 12) reviewed for allegations of abuse. This failure had the potential to delay the facility's response to allegations of abuse and place residents at risk for harm.Findings Include: Cross reference to F600, Free from Abuse and Neglect. The facility failed to ensure that R12 remained free from abuse when a staff member was witnessed willfully pushing/hitting the resident's head without a care-related purpose. On 04/29/26, the facility submitted an initial event report to the State Agency (SA), Intake #2999087. The report documented that on 04/21/26, between approximately 7:00 PM and 8:00 PM, Certified Nurse Aide (CNA) 30 reportedly witnessed CNA19 strike R12 twice on the head, once on the back of the head and once on the side of the head. The facility's report revealed that the incident occurred on 04/21/26 but was not reported to the SA until 04/29/26, eight days after the alleged incident.Review of the facility's completed investigation file showed that the facility interviewed CNA30, the witness, and the Infection Preventionist (IP). Documentation indicated that CNA30 did not report the incident immediately because she feared retaliation from CNA19.On 05/21/26 at 10:51 AM, a telephone interview was conducted with CNA30. CNA30 confirmed she witnessed CNA19 hit R12 in the back and side of the head. CNA30 stated that she did not report the incident immediately because CNA19 had assisted her with housing and was a contract staff member. She expressed concern that reporting the incident could negatively affect her living situation if retaliation occurred. CNA30 stated that she ultimately reported the allegation to the IP on 04/29/26.On 05/21/26 at 11:23 AM, an interview was conducted with the IP. The IP stated that another staff member informed her on 04/29/26 that CNA30 had disclosed witnessing the incident. The IP reported that she instructed CNA30 to formally report the allegation and provide a written statement because the allegation involved potential resident abuse.On 05/22/26 at 8:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff are required to immediately report any suspicion of abuse and confirmed that CNA30 should have reported the incident as soon as it occurred. The DON acknowledged that CNA30 delayed reporting because she feared retaliation. The DON further confirmed CNA19 continued to work with R12 after the incident due to the delay in reporting. Review of the facility's nursing staff schedule from 04/21/26 through 04/29/26 revealed that CNA19 was assigned to provide care to R12 on 04/21/26, 04/22/26, 04/24/26, 04/25/26, 04/26/26, and 04/28/26.Review of the facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed on 02/26/24, stated: Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report it to the Nursing Home Administrator. If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or withing 24 hours) reported to the State Agency.

Based on interview and record review, the facility failed to ensure an agency staff (AS) 10 who was a full-time employee completed the required training and competency evaluation program, or a competency evaluation program approved by the State for certification within four months of hire for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). This failure had the potential to place residents at risk for inadequate care and abuse. Findings Include:On [DATE] at 10:36 AM, record review was done. Review of facility document titled, Agency Staff Checklist for Credentials with staff credentials and hire dates revealed no specific Start Date for NA10. C.N.A. Certification did not also include any License Number and Expiration Date for NA10 indicating not certified. On [DATE] at 11:12 AM, an interview was conducted with Administrator. Administrator confirmed that AS10, did not meet competency evaluation requirements or a certification for nurse aide. Administrator also stated that AS10 received on the job training for caregiver but would not be appropriate for the Long-Term Care program of the facility. Administrator explained that facility usually checks and requires certified nurse aide (CNA). Administrator agreed that AS10 should not have worked in the Long-Term Care facility. Review of facility document titled, Certified Nurse Aide (C.N.A. Job Description with an updated date of [DATE] stated, .Education and Training.Must have current CPR.and Hawaii CNA certification.

Based on interview and record review, the facility failed to ensure that an agency staff (AS) 10 providing nurse aide services was listed on the state nurse aide registry prior to working in the facility for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). This deficient practice placed residents at risk for care being provided by unqualified staff and had the potential to affect resident safety and well-being. Findings Include:Cross reference to F0728 - Facility Hiring and Use of Nurse On 05/21/26 at 11:12 AM, an interview was conducted with Administrator. Administrator confirmed that AS10 did not meet competency evaluation requirements or a certification for nurse aide. Administrator also stated that AS10 received on-the-job training as caregiver but would not be appropriate for the Long-Term Care program. Administrator explained that the facility usually checks and requires complete education and training to include certified nurse aide (CNA) certification. Administrator agreed that SA10 should not have worked in Long-Term Care. On 05/21/26 at 09:19 AM, an interview with the Director of Nursing (DON) was done. When DON was queried if facility should verify nurse aide registry prior to hiring staff, DON confirmed and agreed.

Based on interviews and record review, the facility failed to identify and intervene for an acute change in a resident's condition related to a stroke for one (Resident (R) 4) of three residents sampled, resulting in the family telling the facility to transport the resident to the hospital.Care plan did not address the resident's stroke or include interventions for the prevention of aspirationStaff did not identify R4's occasional moist cough when eating as an early symptom of aspirationStaff did not communicate to the physician that the resident's cough had occurred while eating Staff did not follow the physician's orders for treatment of symptoms of R4's coughConflicting information in the documentation, which did not relay the resident's distress when positioned on his backAs a result of these deficient practices, the resident was admitted to the hospital in respiratory distress due to aspiration and is currently receiving hospice services (less than 6 months life expectancy). Findings Include: On 09/04/25 at 12:07 PM, conducted a telephone interview with R4's Family Member (FM). During the telephone interview FM reported visiting R4 from approximately 03:30 PM to 06:00 PM on 08/13/25. During that time, R4 was breathing on his own, not coughing, and no respiratory distress symptoms (i.e. supplemental oxygen, coughing up mucous, or audible wheezing). At 10:18 PM, FM received a call from the facility informing her that R4's oxygen (O2) levels had decreased to 78%, which was a significant change from his earlier presentation. Facility staff discussed life saving measures and FM's care preferences. FM informed the facility it was okay to send the resident to the hospital and wanted to be updated on the resident's condition. FM stated she did not hear anything more from the facility and was under the impression R4 was okay. However, when FM visited R4 at approximately 07:30 AM the next morning, FM stated R4's state of condition had dramatically declined overnight. R4 appeared run down. R4 was coughing, on oxygen, and it looked as if R4 had not slept all night. FM reported hearing audible wheezing from the resident. FM sought out facility staff and requested for R4 be transported to the hospital immediately. FM stated he/she was upset and disappointed the facility did not do more for R4 and had not sent the resident to the hospital or been informed of R4's condition change. According to FM, any reasonable person could hear and see that R4 was in distress. On 09/04/25 at 12:08 PM, conducted a review of R4's Electronic Health Record (EHR). R4 was admitted to the facility on the afternoon of 08/13/25 with diagnosis of, but not limited to, acute multifocal strokes, symptomatic bradycardia (low heart rate), atrial fibrillation, hypertension, hearing loss, and Dementia. R4 did not have a cough and was breathing normally on room air with oxygen saturations at 94% and was at the facility for physical and occupational therapy rehabilitation. R4 was transferred to the hospital and subsequently discharged from the facility in the morning of 08/14/25. Reviewed R4's care plan. The care plan addressed altered fluid balance, falls, and safety, but did not address the resident's recent stroke (08/02/25) or include interventions as a standard of practice for stroke residents. For example, ensuring the head of the resident's bed (HOB) be elevated for aspiration (the inhalation of substances, i.e. food, thickened saliva, or drinks, into the lungs) prevention during and after meals and/or medications. For residents who have experienced a stroke, it is common practice to ensure the HOB is elevated at all times and the resident does not lay flat on the back to prevent aspiration. Review of the progress notes documented on:Written on 08/13/25 at 10:02 PM, .occasional moist cough noted when eating .Resident noted with increased moist cough and audible congestion around 2100 (09:00 PM). Suctioning performed producing large amounts of white sputum. O2 sat (saturation) to 78% on RA (room air).On 08/13/25 at 11:28 PM, documented new physician orders for 1) Duoneb (breathing treatment) inhaled every 4 hours as needed for cough/shortness of breath/wheeze 2) Robitussin 10 milliliters (ml) every 4 hours as needed for cough. A late entry progress note was written on 08/15/25 at 02:13 AM, for 08/14/25 at 05:58 AM, which documented .No noted congestion or cough .Endorsed to CNAs (certified nurse aide) and will endorse to morning shift that HOB needs to stay up . This progress note was written after the resident was discharged to the hospital. (Cross reference to F842: Resident-Identifiable Information)Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented staff did not administer Duoneb or Robitussin as ordered by the physician to alleviate R4's cough/wheezing. Conducted a concurrent interview and record review with Registered Nurse (RN)3 on 09/04/25 at 01:35 PM. RN3 stated he was given report from the night shift nurse (RN12) and was informed that R4's oxygen levels desaturated to 78% SpO2 on their shift. RN12 also informed RN3 of R4 coughing throughout the night and white sputum upon suctioning (which was later included into R4's progress notes as a late entry, after the resident had already been discharged to the hospital). Inquired with RN3 as to what prompted him to send R4 to the hospital. RN3 recounted that he was assisting another resident when he was alerted by staff that FM was concerned about R4's condition and wanted the resident to be assessed by the nurse. RN3 stated R4 appeared weak and lethargic, the resident's eyes were closed and answered questions by nodding his head yes (up and down) or no (side to side) and was not verbalizing any answers. According to FM, R4 did not present to the facility in this condition. R4's wheezing (while on oxygen) was audible and visually noticeable, it looked like the resident was struggling to breath. RN3 reported administering a Duoneb treatment with no improvement. RN3 stated FM told him to send the resident to the hospital. RN3 called and spoke to the physician, then transferred R4 to the hospital. Inquired with RN3, after assessing R4's physical condition what was your professional assessment. RN3 replied that it looked like the resident was struggling for some time and was tired, RN3 described attempts to suction the audible mucous to clear his airway, but the mucous was too deep. RN3 confirmed the resident should have been transferred to the hospital sooner due to an extremely low oxygen saturation of 78% and the sustained intermittent coughing; deep, wet white sputum; and lethargic presentation. Inquired with RN3 regarding the hand-off communication received from RN12 (night shift nurse on 08/13/25). RN3 reported RN12 informed him of an incident where R4's oxygen saturation decreased into the 70's and the resident's O2 saturation was increased by elevating the resident's HOB (which was not included in R4's progress notes or addressed in the care plan). On 09/04/25 at 02:56 PM, conducted a concurrent interview and record review with RN13 (evening shift nurse on 08/13/25). RN13 reported at approximately 09:00 PM, the resident started to cough and had audible congestion of the chest. The resident was suctioned and produced white sputum, and the lowest oxygen saturation reading was 78%. The resident was put on 5 Liters (L) of oxygen, then notified the physician and FM of the resident's condition. RN13 reported last suctioning the resident at 10:30 PM with positive results and that the resident's oxygen saturation was fluctuating, the resident was awake the entire shift. RN13 informed this surveyor that a note was written that R4's condition had improved. Reviewed R4's progress notes with RN13 which documented a late progress note entry on 09/04/25 at 02:46 PM (right before this interview) for 08/13/25 at 10:40 PM documenting the physician was notified of R4's decreased coughing and congestion with respirations 24-26 breaths per minute (BPM), normal range 16-20 BPM, remains on 3 liters (L) of oxygen via nasal cannula with oxygen saturations of 96-97%. On 09/05/25 at 11:41 AM, conducted a telephone interview with Physician (P)1 regarding R4. P1 recalled receiving a phone call from RN13who reported R4 was wheezing and coughing and ordered Duoneb and Robitussin as a plan of care. Inquired if P1 was informed that R4 had coughing while eating or oral intake. Reviewed a progress note written by RN13 which documented R4 with an occasional moist cough noted when eating. and P1 confirmed he was not verbally informed of this by RN13 during their telephone call and it may have warranted a different course of care. Also reviewed RN13's late progress note entry on 09/04/25 at 02:46 PM (written immediately prior to this interview) if P1 recalled receiving a telephone call form RN13 reporting that the resident's condition had improved. P1 confirmed a follow-up telephone call was not received from RN13, reporting R4's improved physical status, then stated it would be unusual to receive a call of a resident doing better that time of night, protocol dictates that staff would call back if the resident was not improving and required additional interventions or needed to be transferred out to the hospital. On 09/05/25 at 06:23 AM, conducted a concurrent telephone interview and record review with RN12 (08/13/25 night shift nurse). RN12 recalled R4 being awake throughout the night and could not recall any significant incidents for the resident. RN12 stated it was a while ago. On 09/05/25 at approximately 10:00 AM, conducted an interview and review of R4's care plan with the Director of Nursing (DON)1. DON1 confirmed that R4's diagnosis of a stroke should have been addressed upon admission to prevent the potential for aspiration.

Based on interviews and record review, the facility failed to maintain accurate documentation in a medical record for one (Resident (R) 4) of three residents sampled. Late entries affected the care the resident was provided and did not reflect an accurate presentation of the resident. Finding Include: (Cross Reference to F684- Quality of Care)1) Review of R4's Electronic Health Record (EHR) documented Registered Nurse (RN) 12 wrote a late entry progress note on 08/15/25 at 02:13 AM for 08/14/25 at 05:58 AM, after the resident was discharged to the hospital. The progress note written documented, endorsed to CNAs (Certified Nurse Aide) and will endorse to morning shift that R4's Head of Bed (HOB) needs to stay elevated. However, this progress note was entered into the resident's Electronic Health Record (EHR) late. As a result of a late entry this information the resident's record was incomplete. This incident could be pertinent to other facility disciplines in assisting the resident to reach his/her highest attainable physical well-being. As a result of the late entry, instructions to elevate R4's head of bed was not communicated to staff. 2) During an interview with RN13 on 09/04/25 at 02:56 PM, discovered a late progress note RN13 wrote on 09/04/25 at 02:46 PM (prior to the interview) for 08/13/25 at 10:40 PM. The progress note documented that RN13 notified Physician (P) 1 that R4's coughing and wheezing had decreased. However, during a telephone interview with P1 on 09/05/25 at 11:41 AM, P1 confirmed he did not receive a second phone call from RN13 reporting R4's decreased coughing and wheezing.

Based on interviews and record review, the facility failed to provide protections for the health, welfare and rights of each resident residing in the facility by developing and fully implementing policy/procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not (1) include how the facility would ensure contract/agency caregivers who provide care on behalf of the facility would receive the required training elements, and (2) four of a sample size of six contracted Nursing Assistants did not have evidence of the required training. As a result of this deficiency, the facility can not ensure contracted staff have the required knowledge to recognize and prevent abuse, which may result in negative outcomes. Findings include: 1) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024. The policy included: a. Employee screening and training .v. All new employees/volunteers will receive training on the abuse policy prior to direct or indirect resident contact. vi. All new employees/volunteers will be oriented to the Abuse Policy and made aware of their responsibility to report any suspected maltreatment as defined and described in this policy. vii. Attendance at a yearly in-service on the Abuse Policy and on Resident Rights is mandatory for all employees/volunteers. B) Training Components: It is the policy of this facility to train employees, through orientation and on-going sessions on issues related to abuse and prohibition practices. Staff and volunteers receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that, incorporating the following elements: - orientation and ongoing programs - Training on the abuse policies and procedures - How to deal with aggressive and catastrophic reaction of residents - How to report abuse without fear of reprisal - Recognizing the signs of burnout, frustration, and stress - Training about challenging behaviors and how to intervene - Communication of reports of resident mistreatment, neglect, and/or abuse. including injuries of unknown source, and misappropriation of property. - How to identify residents at risk of neglect or abuse. - Resident [NAME] of Rights - Review of facility abuse policies and procedures - Annual notification of covered individuals of their obligation to comply with reporting requirements. - Immediate Action to an Abuse or Suspected Abuse: Any employee who witnesses potential abusive behavior is required to intervene to end such behavior and protect the health and welfare of the resident. - (S) Stop the abuse from happening. (P) Protect the resident. (O) Oust /Remove the alleged abuser from the residents out of all resident areas (T) Tell the Charge Nurse/On Call Manager immediately. Procedure: A. Staff and contracted individuals will be taught the signs and symptoms of staff burnout. The facility policy does not address the training requirements for contract/agency staff, with the exception of training to identify staff burnout. 2) The Human Resource Director (HRD) reported that the facility supplements staffing with contract/agency staff, and as of 05/23/2025, 22% of the licensed nurses are contract, and 28% of the Nurse Assistant staff are contract. 3) Reviewed a sample of contract profiles for education on abuse. The review revealed the following: CNA1, employed by Agency (A)6, had documentation of completing Relias training through the agency on 08/21/2024. Further investigation revealed there were five abuse questions, which CNA1 scored only 40%. Two questions were related to Child abuse, and one on Intimate Partner Violence. This would not be an acceptable content/score to validate competency and would not meet the required training elements. CNA4, employed by A1, agency documents included a Quiz completed by CNA4 on 12/19/2022. The quiz consisted of six true or false questions, which was not corrected/graded. False was circled as the correct answer for the first question; Patients have the right to be free from mental, physical, sexual, and verbal abuse. At the bottom of the quiz, there was a signed statement, that read I have completed the in-service training for Patient Abuse and/or Neglect and understand my responsibility to report any knowledge of abuse, neglect, or exploitation of any patient to the Agency Administrator or Designee. This would not be acceptable validation that training requirements are met. CNA5, employed by A4 had documentation of an exam titled Core Concepts in Healthcare-Nursing, completed 01/08/2025, which included one question on Elderly Abuse, that CNA5 got correct. There is no other documentation of training on abuse. This would not meet the required training elements. CNA6, employed by A2 had document of training titled Abuse and Neglect, which included signs of physical abuse, signs of neglect, signs of sexual abuse, and signs of psychological abuse. This training did not cover all the required training elements. 4) On 05/23/2025 at 12:45 PM, interviewed the ADON in the conference room. She discussed the CNA orientation checklist and said all contract CNA's should have a completed checklist in their file. She explained each contract CNA will have a preceptor assigned that is to go over the checklist with them. ADON went on to say the staff will either verbally test the contract CNA or they we will ask them to demonstrate a skill for competency. She said sometimes the preceptor does not have time to sign the checklist, so she will sign it instead of the preceptor. ADON acknowledged she signs for demonstrations which she did not actually observe. Inquired what training they were provided on abuse, and she said they go over STOP, but do not do any other specific training on abuse. The ADON stated the Agency would provide the rest of abuse training. When asked if the Agency included types of abuse, sand signs and symptoms, she stated I don't go over it, maybe its in their agency training. On 05/22/2025 at 12:00 PM, interviewed the Administrator in Training (ADM) and the Chief Executive Officer (CEO) in the conference room to discuss contract training. The ADM said when they contract with then, they will send over a credential packet that includes training they have completed with the Agency, prior to coming to the facility. He said some of them use the same online educational modules, Relias, that would have similar content. He said they use a lot of agency staff at the facility, so when someone starts, they use an onboarding checklist, as well as they would attend any monthly in-services. The ADM said one of the Agencies (A)1 have new, inexperienced CNA's, so the facility provides them the same orientation as their own staff. At that time, informed the ADM and CEO that some of the contract CNA packets reviewed did not have evidence the Agency provided abuse training that included all the required elements. On 05/22/2025 at 01:20 PM, interviewed Human Resource Director (HRD), who assists with arranging contract staff. She said when the contract staff packet arrives, they review the packet to ensure the background checks, registry checks and all required documents are there. The HRD said she does not get involved with the details of the Facility agreements with Agencies, and did not know specifics of what each agency included in their abuse education. She said that would be up to Nursing to review. 5) Reviewed seven contracts the facility used for supplemental staffing. The contracts were reviewed for content for any details related to abuse training. The document review revealed the following: A1 Service Agreement (signed 12/19/2024) This agreement does not address client (facility) orientation or required training by agency prior to placement. A2 Staffing Agreement (signed 04/30/2021): A2 responsibilities: .b. Upon request provide .skills assessments . Client responsibilities: c. Orient personnel to CLIENT facilities and its rules and regulations, .Allow personnel, on their own time, to attend appropriate facility staff development programs. A3 Service agreement (signed 04/04/2025): Customer (facility): Number 8 addresses training to comply with OSHA (Occupational Safety Health Administration), to protect workers from hazards and injuries, and requires the facility to train to their specific policies for compliance. There was nothing in the agreement regarding training for abuse. A4 Client Services Agreement (signed 06/06/2022) A4's Responsibilities: 1.shall conduct and supply .skills checklist, application, education, . Facility responsibilities: 7. Client (Facility) shall orient Personnel to its facility, including its rules, regulations, policies procedures . The length and extent of orientation shall be determined by Client. A5 Client Staffing Agreement (signed 08/22/2019): 6. Client orientation. Client will provide AGENCY personnel with an orientation to CLIENT specific policies and procedures and processes necessary to equip AGENCY personnel with the knowledge necessary to meet CLIENT expectations for personnel. A6 Staffing Agreement (signed 12/29/2022): Client Duties and Responsibilities: (e) .provide Assigned Employees with appropriate orientation, education, training regarding Client's facility, rules, regulation, policies and procedures; This agreement included a Credentialing Verification and Screening Requirements that included skills checklist. A7 Professional Contract Agreement (signed 06/25/2020): The agreement provided does not address any orientation or abuse training.

Based on observation, interview, and record review, the facility failed to provide Resident's/representatives with the name and contact information of the facility grievance official and did not inform them of the right to receive the findings of the investigation and conclusion in writing. In addition, three out of four Resident (R) grievances reviewed, did not include findings, conclusions or if any corrective action was, or would be taken. This deficient practice could affect all Residents because the facility does not provide them the required information for them to file a grievance, and obtain an acceptable resolution. Findings include: 1) On 05/22/2025 at 02:58 PM, interviewed the Administrator-in-Training (ADM) in the conference room. The ADM confirmed that the grievance official is the Administrator. A concurrent review of the policy, with a revised date of 02/15/2021 stated, 5. The resident or person filing/addressing the grievance .will be informed of the findings .Such report will be made orally by the Administrator or his designee . The ADM stated this was accurate. The policy did not state that the resident or person filing the grievance had the right to obtain a written decision regarding his or her grievance and did not include the name of a grievance official with his/her contact information. 2) On 05/22/2025 at 03:30 PM, the facility's admission Handbook was received and the Grievance Policy in the handbook, with a revised date of 02/2022, was reviewed. The policy stated, 5. The resident or person filing/addressing the grievance .will be informed of the findings .Such report will be made orally by the Administrator or his designee . The policy did not state that the resident or person filing the grievance had the right to obtain a written decision regarding his or her grievance. 3) On 05/22/2025 at 03:45 PM, a walkthrough was done at the facility's Ilima Wing in the [NAME] Building. No posting of the grievance official's name and contact information was located. 4) Reviewed R1's Grievance and Complaint report dated 04/03/2025 at 09:20 AM. The report included: Incident Description heading that .someone in the middle of the night had gotten into the bed with the patient . A review of the report demonstrated that an investigation was conducted by the facility. However, a summary of the internal investigation was not found. On 05/22/2025 at 12:05 PM, the ADM stated that the investigation was still open because the facility was waiting for the police investigator's conclusion. However, the police investigation is an external investigation and not part of the internal facility investigation. The report also did not include a statement whether the grievance was confirmed or not confirmed, any corrective action to be taken or to be taken by the facility because of the grievance/complaint, and no follow-up provided to the complainant. On 04/03/2025 at 02:41 PM, the Social Services Coordinator (SSC) noted in the progress notes, Daughter .expecting a call back with update. 5) Reviewed R2's Grievance and Complaint report dated 02/10/2025 at 04:34 PM, which included: Incident Description heading that R2 complained Registered Nurse (RN)4, .didn't respond to the [NAME] (alarm) alert on his [NAME] vest (wearable cardioverter defibrillator) timely and that the LN's (Licensed Nurse's/RN4) behavior is strange like she is on drugs. On 02/10/2025, the Assistant Director of Nursing (ADON) documented in the report that R2 mentioned Certified Nurse Aide (CNA)7 was lazy and while he was in the dining room, he saw CNA7 walking around the unit 11 times. On 02/11/2025, the ADON reported R2's concerns to the contracted Nursing Agency that employed RN4 and CNA7. However, a summary of the facility's internal investigation and monitoring of RN4 and CNA7 was not documented. On 05/03/2025 at 09:15 AM, the ADON stated that if a performance issue is received for an agency staff, the facility will email the Agency regarding the issue. ADON then stated the Director of Nursing (DON), ADON, Infection Preventionist (IP), and Nurse Managers do discuss the issues, but it is not documented. The report also did not include a statement whether the grievance/complaint was confirmed or not confirmed and any corrective action taken or to be taken by the facility because of the grievance/complaint. 6) Reviewed R4's Grievance and Complaint report dated 03/10/2025 at 04:49 PM, which included: Incident Description heading, Received email from resident's Family Member (FM)1 .newly assigned CNA (CNA8) being too rough and being scared to be alone with her. On 05/22/2025 at 02:48 PM, the ADM was interviewed. The ADM stated that it was determined it was a transferring issue and the outcome was to not have CNA8 work any further shifts, which was communicated via email to FM1. The report did not include a summary of the investigation, the corrective action taken by the facility, or the communication to FM1 as stated by the ADM.

Based on interviews, observation, record and document review, the facility failed to thoroughly investigate one alleged abuse of a sample of one, reported by Resident (R)1. Specifically, the facility did not; 1) interview R1's roommate, and all staff working, 2) summarize the findings of review of the video surveillance, and 3) document the results of their independent, internal investigation and report them to the Office of Healthcare Assurance. As a result of this deficient practice, there is the potential important information is missing from the investigation, necessary to determine the outcome. Findings include: 1) Cross Reference F609 Reporting of Alleged violations: R1 reported to the facility she woke up with someone lying next to her in bed. The facility did not identify this incident as potential abuse, and failed to report the allegation and results of their internal investigation to the Office of Healthcare Assurance (OHCA). 2) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024. The policy included: a. Investigation of abuse : .The investigation will include: .iii Resident's roommate statements (if applicable). 3) Reviewed the documentation of the investigation provided by the Administrator in Training (ADM). The individual assigned to lead the investigation was the Assistant Director of Nursing (ADON), who was on duty and notified when R1 made the allegation that someone laid in bed with her. The notes of the investigation were documented electronically in Grievance and Compliant, with entry dates, but no times. The notes were not in sequential order. The document included, but not limited to the following: 04/03/2025 Part 1: Writer (ADON) interviewed resident in her room. She stated the lady jumped in bed. She was sleeping and this lady lied down next to her and pulled down her brief without saying one word. Brief down to her upper thigh and she was exposed. Resident stated that she pulled the brief right back up. Resident denied anything else happened. 04/03/2025 Part 2: .Resident (R1) said she was afraid and did not report it to anyone.Resident was very confident that she could identify the staff. Daughter requested to check the cameras to see who entered the room. 04/03/2025 Part 3: .checked the video clips. 04/03/2025 Part 4: The ADON showed R1 pictures of six staff members, who she did not identify as the person who got in bed with her. 04/03/2025 Part 5: The ADON showed R1 another picture, who she did not identify as the person. 04/04/2025. Reviewed findings with Medical Director. Met with Detective. 04/23/2025: HPD (Honolulu Police Department) Detective coming in today for further investigation . 05/19/2025: Emailed Detective .if there are any further follow up .or if case is closed. 05/20/2025: APS investigation. This document also included statements from several staff, but did not have a time documented and did not specify if the statement was written or statement made during an interview. Some of the dates on the statement entries were 04/09/2025, which is six days after the allegation was made. The facility provided on request seven separate handwritten/typed staff statements. Review of the statements revealed two were dated, three did not have dates the statement was written, and two were dated 04/09/2025. 4) On 05/22/2025 at 09:45 AM, interviewed the ADON, who was lead for this investigation, in the conference room. She said she was the nursing leader that was notified that day. The ADON said the nurse had already assessed R1, so when she arrived to the room, she interviewed R1, and stayed with her until her daughter arrived. The ADON said usually they do interviews of staff who worked at the time of the incident, pinpoint the shift or person, but do a wider investigation if needed. The ADON said sometimes they would ask for written statements. She said they would interview other Residents if they witnessed the incident. When inquired if they would interview other residents that an alleged perpetrator had provided care to, she said no. She said that the person who does the interview or gets other pertinent information, documents it in the IR (incident report), which is the running document of the investigation. The ADON said the electronic IR does not automatically time stamp entries and for some reason, it does not show the entries in consecutive order. On 05/22/2025 at 10:15 AM, interviewed RN1 in the conference room. She said she was assigned to R1 on day shift 04/03/2025. RN1 said when she interviewed R1, she was unable to clarify the timeframe of the alleged incident. RN1 said R1 denied being touched, other than someone laid next to her in bed. She said at that time, she checked R1 and looked for redness, and bruising to her legs, upper arms, and chest. She said she did not see anything. RN1 said she did not look at or assess R1's lower abdomen or pelvic area. On 05/22/2025 at 12:00 PM, conducted an interview with the ADM and the Chief Executive Officer (CEO) in the conference room. The CEO said they were contacted by a detective the next day. She went on to say what had been described to her was that R1 was confused and someone went into the room and probably changed her brief. The CEO said the conclusion of the investigation was that it was nursing care that was provided. She said she knew the RN tried to do an head to toe assessment after it was reported, but was unable to complete one. 5) The document of the investigation did not include the following: - An interview with R1's Roommate. - A written statement or interview with three CNA's (CNA1, CNA2, and CNA9) and RN6, who had been assigned to the unit during that period of time. - A summary of the findings of the surveillance camera review to include possible correlation with staff statements and interviews. - The facility's summary and conclusion of the investigation.

Based on interviews, document and record review (RR) the facility failed to report to authorities an allegation of potential abuse of one Resident (R)1 of a sample of one. R1 reported she woke up with someone lying next to her in bed. The facility did not identify this incident as potential abuse, and failed to report the allegation to the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the Police. As a result of this deficiency external agencies investigations were delayed and the facility failed to meet their mandated reporting requirements. Findings include: 1) On 05/19/2025, OHCA received a report from an external agency of an allegation of sexual abuse of an [AGE] year-old female that occurred at the facility by an unknown perpetrator The report included on 04/02/2025 (time not provided), AV (alleged victim) was sleeping and she awoke after she felt AP (alleged perpetrator) laying next to her. When AP found out that AV was awake, AP slid off AV's bed and left AV's room quietly.AV felt her undergarment and stated it was pulled down. 2) Record review revealed R1 was an [AGE] year-old female, who was hospitalized at hospital (H)1 from 03/23/2025 to 04/02/2025 for acute kidney injury, superimposed on chronic kidney disease. Her medical history includes chronic urinary retention requiring a suprapubic catheter, recurrent urinary tract infections, bladder cancer and chronic pain. On 04/02/2025 she was discharged to the facility for short-term rehabilitation. 3) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024. The policy included: The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. (See State Agencies to be notified for State Specific requirements). Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. The follow up investigation notes will be submitted .to OHCA within five working days of initial report. The Director of Nursing, or designee, will promptly report (orally or in writing) the matter to : 1. Department of Health, State Office of Health Care Assurance (OHCA) 2. Adult Protective Services or Child Protective Services 3. Med-[NAME]. State Agencies to be Notified: a) Adult Protective Services (APS) .APS will be called promptly, . 4) On 05/21/2025 at 01:30 PM, interviewed the Social Services Coordinator (SSC) in the conference room. She said when there is an abuse allegation, nursing is responsible to report to the State (OHCA) and Social Service reports to APS. The SCC said if there is concern for the safety of the resident, the police would also be notified. She said she was notified by the ADON (Assistant Director of Nursing) of the incident, and was told R1 said a female staff got in bed with her, pulled down her brief and spooned her for 10 minutes or so and left. SSC said she did not report the incident to APS. On 05/22/2025 at 09:45 AM, interviewed the ADON in the conference room. At that time asked her what authorities are required to be notified if there is an allegation of sexual abuse. She said if they were aware that a crime was committed, they would notify the police, but that she was not aware of any crime in this incident. The ADON went on to say OHCA would be notified if there was a confirmed allegation. The ADON stated I had no idea that there was an alleged abuse. When asked what R1 told her, she said, In the middle of the night, a female laid next to her. Pulled her brief down and pulled it back up. The ADON said she thought maybe this occurred during patient care, and that R1 didn't say she was touched in anyway. The ADON said the daughter was very concerned, and requested the facility review camera surveillance. Asked the ADON if she offered to call the police, and she said No, I don't think so. When asked why the incident was not reported to external authorities, she said there was no indication there was anything sexual or that she was touched. She went on to say that those words (sexual) were used only after they R1 left the facility. The ADON said she thought the allegation was strange, but it did not make her think it sexual abuse. On 05/22/2025 at 10:15 AM, interviewed Registered Nurse (RN)1 in the conference room. RN1 said she was a travel nurse and assigned to R1 day shift 04/03/2025. She said that morning R1 used the unit cell phone to call her family, and told her daughter someone got into bed with her. She said the conversation was confusing and she was unable to clarify the timeframe when this occurred. RN1 said R1 denied any other touching. When inquired what her thoughts were regarding the incident based on her training, she said R1 was not oriented to her surroundings, so would not be able to immediately determine how accurate her allegation was, but given the circumstances, and how serious the situation was, it would require a full investigation and reporting to the authorities. On 05/22/25 at 12:00 PM, conducted an interview with the Administrator in training (ADM) and the Chief Executive Officer (CEO) in the conference room. The ADM said the allegation was being handled as a grievance. He said the next day, he was notified by a detective, requesting the video for evidence, because the daughter reported sexual assault. The ADM said they were aware R1 had been taken to the Emergency Department of two hospitals for examination on 04/03/2025. When inquired why the facility did not notify APS and OHCA, he said because the initial investigation didn't find anything. The CEO said she felt it was the hospitals responsibility to notify APS because the sexual allegation came forward after R1 was discharged from the facility. The CEO said she did not feel this incident was a sexual allegation or potential assault, because what R1 described was nursing care.

Based on interviews, record review and observation, the facility admission staff accessed one Resident's (R)1 external medical records from an acute care Hospital (H)1 through a portal/link used to facilitate referrals and admissions without R1's consent, after she left the facility against medical advice (AMA). As a result of this deficient practice, R1's rights were violated. Findings include: 1) R1 was an [AGE] year-old female, who was hospitalized at H1 from 03/23/2025 to 04/02/2025 for acute kidney injury, superimposed on chronic kidney disease. Her medical history includes chronic urinary retention requiring a suprapubic catheter (tube that drains urine from the bladder through the abdomen), recurrent urinary tract infections, bladder cancer and chronic pain. On 04/02/2025 she was discharged to the facility for short-term rehabilitation. On 04/03/2025, R1 left the facility without completing her care. Her daughter signed a Release of Responsibility Against Medical Advice (AMA), and took R1 home. 2) On 05/23/2025 at approximately 02:30 PM, interviewed Registered Nurse (RN5) in the conference room. RN5 worked in the admission office on a temporary basis. She explained that the facility had an Internet portal (H1 Link) with H1, to review medical records of patients that want to come to the facility for care after discharged from the hospital. RN5 explained that once a Resident has chosen the facility for post discharge care, the facility has access to part of their confidential medical records. She explained the admission staff also use the H1 Link to monitor Residents that were transferred to the hospital for a higher level of care and are expected to return to the facility after discharge. RN5 said she was aware that R1 left the facility AMA on 04/03/2025, and would not be returning. She went on to say on 04/04/2025, she accessed part of R1's Emergency Department medical records in H1 Link after she left the facility AMA. 3) On 05/23/2025 at approximately 03:00 PM, accompanied RN5 to admissions office, where she demonstrated the use of H1 Link. 4) Hospital (H)1 had a signed agreement with the facility titled H1's Link Access Agreement. This agreement included: A. The parties seek to facilitate the use of health information technology in an effort to improve continuity and quality of care through effective communication, ., while also maintaining patient data security and privacy. 6. HIPAA(Health Insurance Portability and Accountability Act (standards protecting health information from disclosure without patients' consents)) and HITECH (Health Information Technology for Economic and Clinical Health) Act. Entity (Facility) agrees to comply with the Health Insurance Portability and Accountability Act of 1996 .Entity assures that his employees and Authorized users are compliant with HITECH and HIPAA, and will monitor all use of H1's Link. Each authorized user of H1 Link executes a Confidentially and Use Agreement. Reviewed the user agreement titled .Link Confidentiality and Use Agreement Exhibit B, which included: 5. I acknowledge that by accessing the H1 Link, I may obtain confidential patient and clinical information including but not limited to electronic medical records in whole or in part (Confidential Information) and that such Confidential Information constitutes Protected Health Information under Health Insurance Portability and Accountability Act (HIPAA).I agree to access Confidential Information only for those individuals with whom I or the physician(s) for whom I work have an authorized treatment relationship. 5) Reviewed the facility policy titled Confidentiality of Personal and Medical Records Policy, last revised May 2024. The policy included: 2. Keep confidential is defined as safeguarding the content of information including .other computer stored information from unauthorized disclosure without the consent of the individual and/or the individuals' surrogate or representative. 10. Unauthorized persons are permitted to review records only with the signed permission of the resident or legal document allowing such access. Reviewed the facility policy titled Resident Rights, last revised 04/18/2024. The policy included: i. Be entitled to have their personal and medical records kept confidential and subject to release only as directed by HIPAA regulations. Reviewed the Admissions Coordinator Job Description last updated 09/22/2021. The essential duties/functions included Treats with confidentiality all information obtained; knowledgeable of all practices and policies concerning confidentiality of information with HIPAA. 6) When R1 left the facility AMA, there was no intent to return back to the facility, so there was no longer a treatment relationship. Any access to R1's medical records through the H1 Link after she left AMA, was a breach of confidentiality.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to a dignified existence for two (Residents (R) 395 and R18) of three residents sampled for dignity. As a result of this deficient practice, residents dependent on staff are at risk for more than minimal physical and/or psychosocial harm. Findings include: 1) On 04/28/25 at 08:47 AM, conducted an interview with R394. Inquired if staff provide timely care and respond to call lights in a reasonable time frame. R394 responded, not all the time. R394 explained it depends on who is working, some staff are better than others. R394 reported activating the call light because his/her roommate (R395) needed assistance, and staff took about 25 minutes to respond. R394 stated he/she was worried that his/her call light may not have been working because it took staff a long time to acknowledge the activated call light. R394 activated the call light because R395's legs were dangling off the bed and he/she was concerned the resident was going to fall off the bed. On 04/28/25 at 01:19 PM, conducted a telephone interview with R395's Resident Representative (RR) 7. RR7 reported two incidents when R395's family members activated the call light for staff assistance with the resident's care needs. RR7 stated the first incident, family waited approximately an hour for staff to respond to the call light and another incident where the family waited approximately 30 minutes for staff to answer the call light. Inquired why the family had activated the call light and RR7 responded the resident's incontinent brief needed to be changed on both occasions. RR7 stated it is difficult to leave R395 knowing that the resident may not be receiving care when needed. On 04/30/25 at 12:31 PM, conducted an interview with the Director of Nursing (DON) in his office. Informed the DON of reports regarding long waiting timeframes for staff to respond to call lights and helping the residents. DON confirmed 30 minutes is too long for call lights to go unanswered and if staff are unable to immediately answer a call light, staff is trained to, at minimum, verbally check in with the resident and inform them that staff will assist the resident as soon as staff is able to. 2) Resident (R)18 is a [AGE] year-old male re-admitted to the facility on [DATE] for long-term care. R18's admitting diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) left non-dominant side. A review of R18's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/12/25. The assessment indicated R18 had been assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating a determination that he was cognitively intact. On 04/28/25 at 09:05 AM, observation and concurrent interview was done with R18 at his bedside. R18 stated facility failed to protect and value his private space by not knocking and asking permission before entering, and staff does not close his bathroom door as requested. Observed signage with instruction of, Please . close door all the time. posted on R18's bathroom door. R18 stated that Certified Nurse Aide (CNA)45 let him wait for 30 minutes before assisting him with toileting. On 04/30/25 at 01:25 PM, interviewed Director of Nursing (DON) in his office. When asked if DON was notified for all R18's complaints and if formal investigation should have been completed, DON confirmed he met with R18 to discuss all his complaints, and formal investigation(s) should have been completed for all of them but had not. DON also stated R18 should be treated with respect and in a dignified manner. Review of facility's policy and procedure titled, Resident Rights with a revision date of 04/18/24 stated, .[the facility] will treat each resident with respect and dignity . staff will knock, announce themselves, and provide reason for entry before entering . staff will await resident approval prior to entry .

Based on observation, interviews, and record review, the facility failed to ensure the resident's right to choose aspects of the resident's life that are significant to the resident for two (Resident (R) 394 and R395) of two residents sampled. R394 prefers to brush her teeth in the morning, but staff regularly assist the resident in the afternoon. R395 receives hospice service and family reported not wanting the resident up in the wheelchair for more than 15-20 minutes (for meals) to allow the resident to rest in bed. As a result of this deficient practice, residents are at risk for more than minimal negative psychosocial and/or physical outcomes. Findings include: 1) On 04/28/25 at 08:42 AM, conducted an interview with R394 in the resident's room. R394 reported her preference of brushing her teeth three times a day, when she wakes up and after each meal. However, at the facility, the resident waits long after she wakes up for staff to assist her with brushing her teeth. R394 stated at times she has brushed her teeth around lunch time, well after having breakfast and waking up, which makes the resident feel, Yucky. R394 confirmed brushing her teeth in the morning is important to her. Review of the facility task, activities of daily living, personal hygiene which included oral hygiene, revealed starting from 04/14/25 (date of admission) to 04/30/25, staff documented the resident brushing her teeth at 10:21 AM, 12:32 PM, 12:40 PM, 12:27 PM, 08:23 AM, 12:25 PM, 12:09 PM, 10:07 AM, 12:46 PM, 12:33 PM, 12:19 PM, 01:42 PM, 08:23 AM, 12:18 PM, 10:21 AM, and 12:31 PM. On 04/30/25 at 11:53 PM, conducted an interview with the Director of Nursing (DON) regarding the time R394 is assisted with oral hygiene. DON reviewed the oral hygiene task and confirmed staff is assisting the resident in the afternoon most of the time and that is not aligned with R394's preferences. 2) On 04/28/25 at 08:24 AM, entered the [NAME] unit and observed R395 seated in a wheelchair at a table in the unit dining room until 10:40 AM. During this time the resident was observed sleeping periodically in the wheelchair at the table. During lunch observations at 11:15 AM to 11:50 AM, R395 was observed to still be in the wheelchair in the unit's dining room. Mentioned to Unit Clerk (UC)1 that R395 is still out in the wheelchair and UC1 confirmed it. At 01:19 PM, entered the unit and observed R395 in bed with two Family Members, (FM) 10 and FM 54, visiting. FM54 reported R395 had returned to bed about 10 minutes prior. FM54 reported R395 is unable to tolerate sitting in the wheelchair for long periods of time and the family thinks it's important for the resident to be resting in bed and not sleeping in the wheelchair. FM54 stated they told staff to not keep her (R395) in the wheelchair after breakfast, instead take the resident back to bed to rest. Conducted a telephone interview with R395's Resident Representative (RR) 7 on 04/28/25 at 01:18 PM. RR7 reported R395 is on hospice and has a weakened physical state, and is unable to tolerate sitting in the wheelchair for 20 minutes or longer. RR7 stated that family members have come into the facility and found the resident slumped forward while seated in the wheelchair. As a result of this, RR7 requested that R395 not be left seated in the wheelchair in the common area for more than 15-20 minutes. On 04/30/25 at 12:05 PM, conducted an interview with DON. Informed DON of the observation of R395 up in the wheelchair for more than 20 minutes and sleeping in the wheelchair, which was not what RR7 and family members wanted for the resident. DON confirmed R395 should have been assisted back to bed when staff was done assisting the resident with her meal and prior to the resident being observed sleeping in the wheelchair.

Based on observation, interview, and record review, the facility failed to provide necessary assistance to help maintain functional mobility and independence on one of two sampled residents (Resident (R)18), for accommodation of needs. This deficient practice has the potential to affect all the residents at the facility. Findings include: Resident (R)18 is a [AGE] year-old male re-admitted to the facility on [DATE] for long-term care. R18's admitting diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) left non-dominant side. A review of R18's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/12/25. The assessment indicated R18 had been assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating a determination that he was cognitively intact. On 04/28/25 at 09:05 AM, observation and concurrent interview was done with R18 at his bedside. When asked about how often he gets out of his room to participate with any activities, R18 reported that he does not get to participate with activities as often as he wanted to due to his limited mobility. R18 stated staying in his room is not his preference and that on 12/07/24, he had requested the facility provide him with a one-arm-drive wheelchair so that he could safely and independently complete all his Activities of Daily Living (ADLs) including but not limited to grooming, dressing, and toileting throughout the day. Record review of R18's Electronic Health Record (EHR) revealed a Physical Therapy evaluation dated 03/17/25 documented, .Pt [patient/resident] requires wheelchair for functional mobility due to bilateral amputation .Pt would have maximum independence with functional mobility with a one arm drive wheelchair. On 04/30/25 at 01:15 PM, concurrent interview and record review was done with the Social Services Coordinator (SS)1 at the dining area. When asked if the resident's request for a one-arm-drive wheelchair for functional mobility had been addressed, SS1 confirmed that the facility was still waiting for an update from the supplier since 12/07/24. Review of the EHR revealed a Social Services note that documented, . resident asked for a manual wheelchair to propel himself. This worker will f/u [follow-up]. On 04/30/25 at 01:25 PM, interviewed Director of Nursing (DON) in his office. DON confirmed that there was no documentation that a timely follow-up had been done. Review of facility's policy and procedure titled, Resident Rights with a revision date of 04/18/24 stated, . [residents] Have the right to meet with and participate in activities of social . at their own discretion.

Based on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD) and did not inform the resident of his/her right to develop one, provide assist in doing so, and/or periodically assess the residents' preference for formulating an AHCD for 2 of 2 residents (Residents (R) 46 and R12) sampled. This deficient practice does not allow residents, when incapacitated, the right to have their health care choices identified and honored. Findings include: 1) On 04/29/25 at 02:50 PM, review of R46's electronic health record (EHR) revealed a Social Services note dated 09/16/24 at 04:28 PM stating that Social Services to follow-up with hospice provider regarding R46's AHCD. Upon further review of R46's progress notes, no follow-up attempts to obtain the AHCD were documented. On 04/30/25 at 01:42 PM, interviewed the Social Services Coordinator (SS) 1 in the Social Services office. SS1 confirmed there was no documented follow-up regarding obtaining the AHCD from the hospice provider. SS1 voiced that the Social Worker at the hospice provider is difficult to reach to inquire about the AHCD, but also stated that she could have contacted the visiting Nurse from the hospice provider. 2) On 04/29/25 at 07:51 AM, record review of the R12's Electronic Health Record (EHR) was completed. Advance Health Care Directive (AHCD) could not be found in the EHR. On 04/30/25 at 01:00 PM, requested AHCD documentation from Director of Nursing (DON). No AHCD documentation was given this day. On 05/01/25 at 08:16 AM, the facility provided Social Worker (SW)1's progress notes of the AHCD discussion with R12 on 03/05/25. The note details that resident continues to refuse AHCD and is not interested in further discussion. The note was a late entry and created by SW1 on 04/30/25. On 05/01/25 at 08:31 AM, interview with SW1 completed. SW1 stated she forgot to document her discussion with R12 on 03/05/25 because she went on vacation. SW1 confirmed she was reminded this week from leadership to complete documentation. SW1 agreed that she should have documented after the discussion, or sooner than 04/30/25, but noted that they have been doing their best to keep up. On 05/01/25 at 09:30 AM, interview with R12 completed. R12 stated that AHCD was discussed with him when he first came to the facility, but did not remember any discussion recently. On 05/01/25 at 09:45 AM, a follow up interview with SW1, and Social Services Coordinator (SS)1 completed. When SW1 was asked to provide handwritten notes from the discussion with R12 on 03/5/25, SW1 responded, I already shredded it today. SW1 noted she shredded her notes as it was her last day with facility, and she was in the process of cleaning up her work. When both SW1 and SSI were asked how often AHCD documentation should be completed, both stated that it should be done quarterly, and documented timely in the EHR. SW1 and SS1 also agreed that timely documentation in the EHR is extremely important because things can change over time, it is a running record of the resident's care, and it reflects the most updated status of the resident. Review of the facility's Advance Directive policy, dated 01/30/19, in the On-going Review section, it notes, 1. Quarterly, Social Service Coordinator will review with resident/resident representative regarding Advance Directive as preferences may change over time. For those that don't have an Advance Directive, Social Service Coordinator will discuss again the option for establishing and Advance Directive.

Based on observations, interviews, and record review, the facility failed to ensure residents' environments were clean and homelike, as well as, protecting residents' personal property from loss, for two of four residents (Resident (R) 8 and R65) sampled for environment. A staff member did not dispose of soiled and dirty trash items properly, leaving it on top of R8's personal property in her room. This has the potential to cause unpleasant odors and an unsanitary environment. R65's personal lamp was removed from his room without explanation or follow-up. The facility did not exercise reasonable care for the protection of the resident's property from loss. Findings include: 1) Cross reference to F880, Infection Prevention & Control. The facility failed to ensure R8's soiled incontinence bed pads were properly disposed of to decrease the risk of spreading infectious disease. Review of R8's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/25 found R8 with a score of 15 (cognitively intact) when the Brief Interview for Mental Status (BIMS) was administered. On 04/29/25 at 08:33 AM, during observation and interview with R8, observed a used wrapped-up incontinence item and used gloves on top of an opened bag that stored incontinence briefs, this was on top of R8's personal belongings (a green bag filled with other bags, arts and craft supplies, and a reusable bowl to microwave food placed inside a plastic bag). A trash bin was observed to be right next to it. Inquired of R8 what the item was and if she put it there, R8 used her reach grabber tool to pick up the item and stated she did not put that there and described the item as her dirty bed pad. R8 proceeded to throw the dirty bed pad into the trash bin and reported she did not know how long it had been there. R8 stated she was last changed this morning but saw the staff member take it out. R8 proceeded to report that agency staff sometimes don't do their job correctly like leave dirty things in her room and wondered where they get their training from. On 04/30/25 at 11:38 AM, interview with Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were done. IP reported after a staff member provides incontinence care, the dirty supplies should be disposed in a trash bag and if disposing the item in a resident's trash bin in the room it should be taken out of the room to reduce unpleasant smells. Review of the facility's policy and procedure Safe and Homelike Environment dated 02/28/24 documented General Consideration to Minimize odors by disposing of soiled linens promptly . 2) Resident (R) 65 is a [AGE] year-old male, admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/28/25 noted that R65 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that R65 had intact cognitive function. On 04/29/25 at 08:31 AM, interviewed R65 who stated that approximately three months ago, he had a personal black floor lamp and the top broke off. Maintenance took it and never brought it back. No replacement was offered, and R65 felt he needed more lighting in the room. R65 also stated he received no explanation by staff if the lamp was going to be fixed or that he could not keep it in his room. On 04/30/25 at 11:31 AM, interviewed the Maintenance/Housekeeper Manager (MAINT) outside of the facility's Lehua Wing entrance. MAINT stated that he did not recall a floor lamp being removed from R65's room. MAINT stated if any resident's personal property is removed, it is put on the facility TELS work order program and the nursing staff will put a work order in. On 04/30/25 at 11:38 AM, interviewed Registered Nurse (RN) 6 who stated that she remembered a broken floor lamp and maintenance was told to look at it. On 04/30/25 at 03:31 PM, a follow-up interview with MAINT was done who confirmed that he could not locate a work order for R65's lamp and the maintenance staff could not recall R65's lamp being removed from his room. On 05/01/25 at 08:12 AM, interviewed the Assistant Director of Nursing (ADON) in the Activity room. ADON stated that she was made aware that the lamp maybe fell over when staff was providing care. The base and stand were flimsy and had broken. R65 was okay with the lamp being removed but was unsure if his consent for removal and explanation for removal was documented. On 05/01/25 at 08:29 AM, Interviewed SS1 in the Social Services office. SS1 stated that she was told by the ADON that R65's lamp was in the MDS office and was taken out of his room for safety purposes because it was a tripping hazard, it was shaky, and the facility did not want the electrical outlet to be overloaded. On 05/01/25 at 08:48 AM, a black lamp was observed in the MDS office, and a picture was taken. On 05/01/25 at 08:51 AM, R65 confirmed the picture of the black lamp was his personal lamp that was taken out his room. On 05/01/25 at 11:59 AM, ADON stated that no documentation could be found regarding R65 providing consent for the lamp to be removed from his room or explanation given to R65 for the reason it was being removed.

Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment accurately reflected the resident's status at the time the assessment was completed for one of seven residents (Resident (R) 293) reviewed for falls. Staff members were utilizing the bed/chair alarm as an intervention for falls and it was not reflected in the assessment under restraint. This deficient practice put R293 at risk of an inaccurate assessment of the bed/chair alarm and its appropriateness as an intervention. Findings include: Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to her left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to her discharge. Review of the completed facility report incident (FRI) received by the State Agency (SA) on 08/19/24, documented on 08/12/24 at 06:15 AM, prior to R293's fall with major injury that resulted in fracture to her left femur, the assigned night shift Certified Nurse Aide (CNA) documented, .performed a visual check on resident. Without any restlessness observed, and clip [bed/chair] alarm was in place. Review of R293's care plan found the intervention for bed/chair alarm was not included in the care plan as an intervention to prevent falls until 10/26/24, after R293's second fall. The care plan documented, The resident uses (SPECIFY: chair/bed) electronic alarm. Ensure the device in in place as needed, initiated on 10/26/24. Review of R293's progress notes documented the use of a clip or bed alarm after 08/12/24, 10/26/24, and 11/10/24 falls. Review of R293's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/22/24 under Section P. Restraints, bed alarm and chair alarms were noted to not be in use. On 05/01/25 at 09:19 AM, an interview and concurrent record review with Director of Nursing (DON) was done. DON reported that there was no task area for staff to document whether clip bed/chair alarms were in place when nursing rounds are done. DON reviewed the MDS Initial Review, by the MDS coordinator, dated 08/19/24 for the quarterly MDS with an ARD of 08/22/24, and during the assessment the bed alarm and chair alarm were not observed to be used. DON stated the MDS coordinator would need to review the progress notes to get an accurate reflection. Upon concurrent review of the progress notes, DON confirmed from 08/16/24 to 08/23/24, during the assessment seven-day look-back, the progress notes documented the clip bed/chair alarms were used. Based on the documentation provided by the progress notes, DON confirmed bed and chair alarm should have been included in the quarterly MDS assessment.

Based on observation, interview, and record review, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for two (Residents (R)30 and R56) of 22 sampled residents. As a result of this deficient practice, residents were placed at risk for decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. Findings include: 1) On 04/29/25 at 02:31 PM, conducted a record review of R30's Electronic Health Record (EHR). Review of physician orders documented an order for Insulin Glargine- Subcutaneous [under the skin] Solution Pen-injector 100 UNIT/ML [milliliter] Inject as per sliding scale [dose is titrated depending on blood glucose result]: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 600 = 10 units > [if greater than] 400 give 10 units and notify MD [physician] and NP [nurse practitioner], subcutaneously in the morning for DM [diabetes]. Review of R30's comprehensive care plan revealed a care plan was not developed for the use of insulin. On 04/30/25 at 11:40 PM, conducted a concurrent interview and record review of R30's EHR with the Director of Nursing (DON). DON reviewed R30's physician orders and confirmed R30 has an order to receive a sliding scale dose of Insulin Glargine. DON reviewed R30's comprehensive care plan and confirmed a care plan was not developed for R30's use of insulin. Review of the facility's policy for baseline, comprehensive, and discharge care plans revealed the following documented: a comprehensive care plan will reflect the resident's stated goals, objectives, and include interventions that address his/her current needs by the nurse observing the needs. The Interdisciplinary team will conduct a care plan meeting to review the comprehensive care plan with the resident/resident representative which should include: Measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. 2) On 04/28/25, 04/29/25, and 04/30/25 observed R56 comfortably lying in bed with Oxygen (O2) at 4 liters per minute via nasal cannula. On 04/30/25 at 01:11 PM, interviewed Licensed Practical Nurse (LPN)1 at the nurse's station. During a concurrent review of R56's comprehensive care plan, when asked if R56's Plan of Care included any respiratory care, LPN1 confirmed it did not include/address any respiratory care evaluation(s), including but not limited to, oxygen administration. On 04/30/25 at 01:28 PM, concurrent interview and record review with the Director of Nursing (DON) was done in his office. DON reviewed R56's physician orders and confirmed R56 had an order to receive oxygen. When asked if R56's comprehensive care plan was developed to include R56's respiratory care, DON confirmed it was not. On 04/30/25 at 01:46 PM, conducted a record review of R56's Electronic Health Record (EHR). R56 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, moderate, with other behavioral disturbance. An order was made on 03/04/25 at 01:44 PM, written by the Assistant Director of Nursing (ADON), . Oxygen at 2 Liters/Minute PRN [as needed] via nasal prong [cannula] or 02 mask. Titrate oxygen up to 5 Liters/Minute to keep 02 saturation >93%. Notify MD [physician] if resident is requiring more than 2 Liters/Minute of oxygen and/or is requiring routine oxygen. Review of R56's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/09/25, Section J. Health Conditions, noted, .Other Health Conditions. J1100. Shortness of Breath (dyspnea) documented R56 does not have any shortness of breath or trouble breathing. Review of the R56's comprehensive person-centered care plan with a revision date of 04/15/25, noted it did not include the resident's respiratory care including the administration of oxygen. The facility's policy titled, Oxygen Administration, with a revised date of 04/09/25, stated, . 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as. b. When to administer, such as continuous or intermittent. c. Equipment setting for the prescribed flow rates. e. Monitoring for complications associated with the use of oxygen.

Based on observation, interviews, and record review, the facility failed to revise the comprehensive person-centered care plan for one of seven residents (Resident (R) 293) reviewed for falls, and one of one resident (R12) sampled for urinary catheters. R293's care plan did not include new interventions for falls after sustaining a fall with major injury. As a result, R293 experienced additional falls that may have been avoided. By not revising R12's care plan to include urinary catheter care, R12 was placed at risk for adverse catheter-related issues. Findings include: 1) Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to discharge. Review of the completed facility reported incident (FRI) received by the State Agency (SA) on 08/19/24, documented R293's fall with major injury that resulted in fracture to left femur on 08/12/24. The facility documented under interventions implemented in the report, Upon readmission, resident will continue with current fall interventions: Bed in lowest position, fall mat, clip alarm, and bed sensor alarm in place. Consider positioning alarms out of reach i.e. [for example] head of bed behind headboard as not to be tampered with. Staff to continue frequent checks to anticipate and meet needs. Review of R293's care plan found bed in lowest position, fall mat, clip alarm, bed sensor alarm in place, and/or positioning alarm out of reach not included in the care plan after readmission on [DATE]. On 05/01/25 at 09:19 AM, an interview and concurrent record review with Director of Nursing (DON) was done. Concurrent review of R293's care plan, DON stated the typical interventions were in place, such as, .call light within reach, ensure wearing appropriate footwear, toilet before and after meals, at bedtime and in the morning . at were in place at admission prior to the incident on 08/12/24. Inquired after readmission, what new interventions were in place, DON confirmed there were no new interventions and the interventions in the care plan were already in place. DON further confirmed the interventions listed in the FRI were not documented in the care plan and new interventions should have been in place after the fall with major injury on 08/12/24. Review of the progress notes documented R293 had two subsequent falls after 08/12/24, on 10/26/24 and 11/10/24. Review of the facility's Fall Prevention Policy and Procedure included, if a resident falls, nursing to review and update care plan. 2) On 04/28/25 at 01:05 PM, observed R12 with an indwelling urinary catheter. Concurrent interview with R12 noted that he had the catheter for over a month. Record review noted that resident had the catheter reinserted on 03/16/25. Physician's orders showed catheter care to be done every shift. Review of R12's care plan revealed it was not revised to include goals and interventions for catheter care after it was reinserted on 03/16/25. On 04/30/25 at 09:00 AM, interview with Registered Nurse (RN)8 completed. RN8 confirmed that care plan was not revised to include catheter care. RN8 also agreed that keeping care plan current is important as it shows what type of care the resident needs. On 04/30/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that catheter care should have been included in R12's care plan. DON also agreed that the care plan is important as it reflects the current needs of the resident and to ensure that appropriate interventions are taken. Review of the facility's Baseline, Comprehensive, and Discharge Care Plan policy, revised on 12/06/24, in the Procedure section, it notes, 10.Changes will be made as necessary, resulting from significant changes in condition or needs .

2) On 10/03/24 at 12:47 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11247, documenting a fall with major injury (fracture of the right ankle) for Resident (R)29. On 04/28/25, the SA entered the facility to investigate the incident. R29 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of R29's most recent Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/18/25 noted a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reflecting a determination that she is cognitively intact. R29's diagnoses include, but are not limited to, quadriplegia C5-C7 incomplete (weakness or paralysis in both arms), generalized muscle weakness, contracture (a shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, and contracture of muscle of the left hand. On 04/28/25 at 10:30 AM, an interview was done with R29 at her bedside. When asked about her fall on 10/02/24, R29 stated that Certified Nurse Aide (CNA)33 was transferring her from the bed to a shower chair and she just crumbled. R29 also stated that staff had transferred her many times before with only one person. On 04/28/25 at 02:42 PM, an interview was done with CNA33 in the staff dining room. When asked about the incident, CNA33 stated, I was not given proper report on this resident [R29]. CNA33 explained that she had never been assigned to R29 before, when her assignment suddenly changed to R29 at the last minute. CNA33 further explained that usually she will receive a verbal report from the previously assigned CNA, but they were both so busy at the time that the only information she received from the off-going CNA was that R29 needed a shower. CNA33 acknowledged that since she was not familiar with R29, she should have checked the Kardex [CNA care plan]. At the time of the incident, CNA33 stated that she knew about the Kardex, but I didn't know how to access it. CNA33 stated R29 started to fall as soon as she got her up off the bed. When asked about the ankle fracture, CNA33 stated I heard a crack [as R29 fell], so she was not surprised to learn that R29 had a major injury. On 04/30/25 at 09:17 AM, an interview was done with the Director of Nursing (DON) in his office. During a concurrent review of her electronic health record (EHR), DON confirmed that R29 had been a 2-person mechanical lift transfer since 2020, and that this information was reflected in the Kardex. DON also confirmed that CNA33 should have checked the Kardex before transferring a resident she was not familiar with. Based on interview and record review, the facility failed to ensure two of seven residents (Resident (R) 293 and R29) reviewed for falls were free from accident hazards. R293, whom previously had a fall with major injury (a fracture to the left thigh bone that required surgery), had no new interventions care planned for falls, then had a subsequent fall putting R293 at risk for further injuries. R29 was inappropriately transferred via 1-person manual transfer instead of a 2-person mechanical lift, and as a result suffered a fall with a fracture to her right ankle. Findings include: 1) R293 was admitted to the facility on [DATE] for skilled nursing with admitting diagnoses of closed distal phalanx (toe) fracture to the right foot, first digit, dementia related to Alzheimer's disease, repeated falls, and osteoarthritis (when the flexible, protective tissue at the ends of bones, called cartilage, wears down) to bilateral knees. Review of R293's discharge summary from the hospital, prior to admittance to the facility, revealed that in the history and physical section, the resident had been documented with a history of falls and .admitted with a fall with resultant R [right] foot pain found to have fracture of R 1st distal phalanx. Recurrent falls-seem mechanical. She lost her balance - wasn't using her walker and walking on a windy day and fell .There does remain a concern for hypoglycemia [low blood sugar] or hypotension [low blood pressure] since she lives alone and with her memory impairment there is possibility of medications errors leading on to falls. Review of the completed facility reported incident (FRI) received by the State Agency (SA) on 08/19/24, documented R293's fall with major injury that resulted in fracture to left femur (thigh bone) on 08/12/24. On 08/12/24 at 6:20am [sic] at shift change between Night Shift and Day Shift, CNA [Certified Nurse Aide] .was standing in the hall when he heard a garbage can falling to the floor in resident's room. Upon going to check on resident, CNA observed resident in fetal position on her left side by foot of the bed, not on the fall mat .Resident was admitted .Surgery planned on 08/13/24. The facility documented under interventions implemented in the report, Upon readmission, resident will continue with current fall interventions: Bed in lowest position, fall mat, clip alarm, and bed sensor alarm in place. Consider positioning alarms out of reach i.e. [for example] head of bed behind headboard as not to be tampered with. Staff to continue frequent checks to anticipate and meet needs. Review of R293's care plan found bed in lowest position, fall mat, clip alarm, bed sensor alarm in place, and/or positioning alarms out of reach not included in the care plan after readmission on [DATE]. (Cross reference to F657, Revision of Care Plan) Review of the progress notes documented R293 had two subsequent falls after 08/12/24, on 10/26/24 and 11/20/24. On 10/26/24, During medication pass at 05:30AM [sic], CNA alerted this writer that resident was found on the floor next to her bed. This writer rushed to the resident's room and found resident on the floor with head at end of bed. Resident found with brief soiled with fecesand [sic] urine. When asked what happened resident repeated, shee shee, shee shee. Meaning she wanted to use the toilet. This writer performed nursing assessment and took resident's vitals. Resident noted with small bump to L [left] side of head. No other injuries noted. A follow-up entry on 10/26/24 was completed as a late entry, Call light was not on at time of writer entering room Call light was in reach when resident found. Fall mat found against wall - unsure when or who moves fall mat. House keeping moves fall mats - interventions added to care plan to ensure bed alarm and fall mat are in place. On 11/10/24, RN [Registered Nurse] notified by CNA that patient [R293] was found to be sitting on the floor at the End of the patients bed. RN went in to assess patient. Patient sitting on the floor. Bed alarm didn't sound off, patient alarm tested and working, patient clip alarm was off the patient. No head injury noted. Vitals taken, Patient denied pain .Patient stated she tried to go to the bathroom. On 05/01/25 at 09:19 AM, an interview with Director of Nursing (DON) was done. During a concurrent review of R293's care plan, DON stated the typical interventions were in place, such as, .call light within reach, ensure wearing appropriate footwear, toilet before and after meals, at bedtime and in the morning . that were in place at admission prior to the incident on 08/12/24. Inquired after readmission, what new interventions were added, DON confirmed there were no new interventions and that the interventions in the care plan were already in place. DON further confirmed the interventions listed in the FRI were not documented in the care plan. Although the facility planned to use fall mats, DON confirmed the fall mats were not implemented on 10/26/24 and were only documented in the care plan after the incident. For the incident on 11/10/24, DON confirmed the clip alarm was not on R293 and it was documented she could remove it, DON could not confirm if the intervention listed in the FRI to consider .positioning alarms out of reach . was implemented.

Based on observation, interview and record review, three residents (R) 34, R59 and R77 had one or more falls in the facility. The three residents are diagnosed with severe cognitive impairment and dependent on staff to assist with mobility. two residents are taking [CONDITION(S)] medication which may cause unsteady gait and falls and have poor safety awareness and impulsiveness. The deficient practice places the residents at an increased risk for harm, requiring a higher level of staff supervision. Findings include: 1) An initial observation of R77 was made on 02/22/21 at 12:16 PM in her room. R77 was lying in bed with the radio on, bed in the lowest position, floor mats on both sides of the bed on the floor and side rails on both sides of the bed were lowered. Surveyor asked her if she was able to reach her call light and she made a vocalization that sounded like yes. Another observation of R77 on 02/23/21 at 07:54 AM in her room, revealed that R77 was sitting high up in bed with both side rails lowered being assisted with breakfast by the certified nurse assistant (CNA)73. The CNA73 stated that R77 liked to listen to Hawaiian music on the radio. R77's electronic health record (EHR) was reviewed on 02/22/21 at 1:17 PM. R77 is a [AGE] year old female resident with [CONDITION(S)] (a central nervous system disorder causing seizures) and functional [CONDITION(S)] (complete inability to move due to a severe disability). R77's Minimum Data Set (MDS) annual assessment of 05/01/20 revealed that R77 was total dependent on one staff member to provide toileting care. A review of R77's MDS quarterly assessment of 10/30/20 revealed that R77 had declined to total dependence on two staff members to provide her toileting care. R77's care plan problem was reviewed for Current Functional Performance - has impaired mobility due to [CONDITION(S)] (skin cancer), [CONDITION(S)] (paralysis of all four limbs) and contracture (shortening of muscles in the limbs) to right and left legs and Alzheimer's disease. Intervention initiated for 10/30/20 stated, Resident performance: Toilet use - Total assist/two-person physical assist. The facility's completed Office of Health Care Assurance (OHCA) Event Report of 11/02/20 was reviewed on 02/25/21 at 11:00 AM. It stated that R77 sustained a cut to her right forehead and her nose bridge was bruised and swollen after sustaining an unwitnessed fall on 10/31/20 at 07:30 AM. R77 was lying on her left side, centered on her bed, the bed was at CNA73's waist level and both side rails were down. CNA73 turned away from R77 to obtain supplies to provide toileting care. CNA73 then heard a noise and found R77 lying on the other side of the bed on her back. There was no other CNA assisting CNA73 with R77's toileting care. An interview was conducted with the Administrator on 02/26/21 at 1:33 PM in the outdoor patio of the facility. He stated that R77 has been a long time resident and that she had regular staff members care for her. No harm was meant for the resident and the fall was not anticipated. 2) Surveyor made observations on the Lehua unit in the activity/ dining room on 02/23/21 at 08:41 AM and noted R59 sitting up in a wheelchair with two clips on her shirt. CNA29 verified that they are fall alarms. She was noted to have a very dark purple colored lump on her right forehead and her eyes were closed. When asked why R59 had a bump on her forehead she verified with surveyor that R59 had a fall the previous day. At 09:51 AM R59's chair alarm sounded, and she appeared to be leaning over in her chair, restless putting her legs on the floor as if she were going to stand up. CNA29 went to R59 to help her lean back into her chair she said I want to go take a shower in a very low voice. At 10:03 AM a high pitched whining sound was heard from R59. CNA29 went to check on R59 stating why you cry? and adjusted her foot rest on her w/c, surveyor noted she had a facial grimace. The CNA moved her next to the desk at the nurses station. Surveyor reviewed the EMR for R59 on 02/23/21 at 01:33 PM. R59 is a [AGE] year old female admitted to facility on 10/20/20 for comfort care and Hospice, her primary diagnosis of [CONDITION(S)] disease and dementia. She is alert and oriented to her self only. Progress notes dated 02/22/21: Found on the floor at 1357 by CNA, 4 x 5 centimeter (cm) hematoma to right forehead and 1.3 cm skin tear to right forearm. Surveyor reviewed Incident report dated 02/22/21 on 02/24/21 at 3:45 PM: Unwitnessed fall. Oriented to person. predisposing physiological factors; confused, gait imbalance and impaired memory. Predisposing situation factors; does not use call light. Root cause: is resident attempting to toilet self without using call light or notifying staff. MDS quarterly review date 01/22/21: Brief interview for mental status (BIMS) summary score 99, (resident was unable to complete interview). Functional status: Bed mobility, transfer and toileting with extensive assistance, one person physical assist. Bladder/ Bowel: Incontinent/ continent. Fall history: one without injury and one with injury since admission. Medications: Antipsychotic, antianxiety, antidepressant and opioid use. Care plan dated 10/20/20: Risk for falls; revision on 02/11/21. History of fall prior to admission. Resident is not able to follow directions due to dementia, resident is not calling for assistance for toileting. Resident is at risk f fall due to possible side effects from anti-depressant. Risk for impaired communication. Has moderate difficulty of hearing. No hearing aids, moderate impaired vision, no eye glasses. The resident uses [CONDITION(S)] medications (Lorazepam, Risperidione, Depakote) r/t behavior management. Surveyor interviewed RN17 on 02/26/21 at 08:58 AM. When surveyor asked her about R59's fall she stated that she wasn't working on the day she fell . R59 had a telehealth appointment the next day with her primary care physician (PCP). The CNA found her sitting on the floor mattress in her room, we moved her to a room closer to the nurses station after the fall. RN17 explained the follow up investigation after a resident has a fall and the care plan is updated. The nursing staff should be rounding on the resident every 2 hours at the minimum; or more if they are a high risk. They should be toileting them every few hours. The resident should be on a toileting schedule. 3) Surveyor made observations on Pikake unit on 02/22/21 at 03:31 PM. R34 was sitting up in his wheelchair in activity/ dining room at a table. He was non-verbal and wearing a mask. R34 pushed his wheelchair back from the table, turned to the left and began to stand up in his chair. CNA83 went to assist R34 and asked if he wanted a snack, he said chocolate pudding. CNA83 stated I will get that for you in just a minute and quickly left the room. A few minutes later R34 was moving his chair and another staff approached him to ask what he needed, CNA83 proceeded to get a chocolate pudding out of the refrigerator for R34. Surveyor reviewed R34's hard chart on 02/23/21 at 2:42 PM and noted R34 had falls in the facility on the following dates: 10/23/20; 11/27/20; 02/01/21; 02/12/21. Surveyor reviewed the EMR on 02/24/21 at 11:44 AM. Res is an [AGE] year old male with diagnosis of urinary tract infection (UTI), chronic kidney disease (CKD), Stage 3/dementia with dysphagia (difficulty swallowing) and aspiration pneumonia (PNA). Res is incontinent to both bowel and bladder. Res is total assist with bathing, dressing, grooming and toileting. Surveyor reviewed progress notes on 02/24/21 at 03:05 PM. 11/12/2020 at 06:46 AM. Skin tear to left lateral calf. During rounds, staff noted resident to be incontinent of urine. Staff then attempted to transfer resident from bed to wheelchair via 1 person extensive assist. Resident has difficulty standing and maintaining balance during transfer. 2nd staff attempted to assist with transfer. After the transfer was completed, staff noted that resident sustained skin tear to left lateral calf. Resident sustained skin tear measuring 5.0 X 0.7 cm. 10/23/20 at 16:12. Status post (S/P) fall. At 08:15 am, staff found resident lying down on his side on the floor (end of the bed) , naked, and leaning his head on the bed' s foot board. Resident is incontinent to bladder and bowel. Resident' s brief and bedding are wet and resident did not sleep on their shift and that he remains with intermittent yelling. Surveyor reviewed the incident report on 02/24/21 at 3:50 PM. 10/23/20: Root cause. Resident was unsupervised during event. 11/16/20 at 22:39. Resident with unwitnessed fall at 2200. Resident was put back to bed with bed in lowest position around 2000. Resident was laying in bed with episodes of yelling. Resident was last toileted by CNA at 2130. CNA reports hearing bed sensor alarm going off, when CNA got to room resident was found laying parallel to bed with right side of body and head on floor matt. Resident unable to describe events before fall. Resident alert and oriented x 1 at baseline. Resident denies pain, nausea, headache. Resident denies trying to get out of bed or reach for any belongings. Surveyor reviewed the incident report on 02/24/21 at 2:50 PM. 11/16/20. Root cause. Staff to pay more attention to residents yelling as this may be the first indication with alarm as the second indication that resident is moving in bed or attempting to get out of bed. 02/01/21 at 2215 S/P witnessed fall. Surveyor reviewed the incident report on 02/24/21 at 3:50 PM. 02/01/21. Root cause. Resident has a history of pushing himself away from the table in effort to achieve independence of ADL's and ambulation which is his known behavior. 2/12/2021 00:55. Unwitnessed fall. Res bed alarm alerting at 0000. Res found on floor in front of cabinet laying on right side. Res with wet brief. Res with deep purple bruise to right trochanter. Deep purple bruise noted to right outer wrist, light red bruising/ discoloration noted to spine and skin tear (ST) noted to right elbow. Surveyor reviewed the incident report on 02/24/21 at 3:50 PM. 02/12/21. Root cause: Resident is known to have a behavior to not use his call light to make his needs known. Resident does have a cognitive deficit and lacks the awareness to make safe decisions such as getting out of bed with the assistance of staff as evidence by current BIMS score of 4/15. Resident unaware to call staff for assistance, found on floor with soiled brief. MDS quarterly assessment review date 12/24/20. Total BIMS score is 04. Functional assessment: Bed mobility, self performance is extensive assist, Staff support is two person physical assist. Toileting use: Extensive assist. Staff support is two person physical assist. Other behavioral symptoms not directed toward others, verbal/vocal symptoms like screaming, disruptive sounds. R34 is frequently incontinent and not participating in a toileting program. Primary medical condition non-traumatic [CONDITION(S)]. R34 coded with two or more falls with non-injury since admission. Medication administration record (MAR) dated 01/21; R34 is taking anti-depressant, [MEDICATION(S)] and anti-psychotic. (Celexa 10mg tab 1.5 in the morning for total 15 mg, [MEDICATION(S)] 3 mg give 2 tablet at bedtime for insomnia; [MEDICATION(S)] tablet give 0.25 mg two times per day for dementia). Care plan dated 08/26/20. Resident spends most of the day on his wheelchair. Several times throughout the day, he will attempt to stand up from his wheelchair on his own and legs come into contact with wheelchair parts causing bruising/skin tears. Problem: Risk for Falls: Impaired cognition and forgetful, unable to comprehend use of call light for staff assistance. Resident does not seek for staff's assistance and will attempt to get out of bed by self or push self away from the table without calling for assistance. Resident needs assistance with activities of daily living (ADL's). Has episodes of yelling. Repeated falls d/t progressive dementia. The resident uses [CONDITION(S)] medications ([MEDICATION(S)]) . Monitor/document/report as needed any adverse reactions of [CONDITION(S)] medications; unsteady gait .frequent falls . Surveyor did not find monitoring flowsheet for [CONDITION(S)] side effects on MAR dated 12/20 through 02/21. Surveyor interviewed RN54 on 02/26/21 at 09:41 AM. When asked what the nursing staff is doing for fall prevention on the unit, replied that the CNA's do their rounds every 2 hours, before and after meals and before and after activities, we are and keeping the bed low as possible, make sure the call light is in reach and making sure their personal items are within reach. There are bed alarms if they are assessed for safety and the call light system.

Based on closed record review (RR) and staff interview, the facility failed to prevent the development of pressure ulcers for one of three residents (Resident (R) 1) in the survey sample. As a result of this deficient practice, R1 developed five new facility acquired deep tissue injuries (DTIs) to her feet. These were pressure ulcers (also known as pressure injuries), which she did not have on admission. As a result, the potential for harm existed as the facility failed to ensure the resident received care and services to prevent pressure ulcers from developing and failed to develop resident-centered plans of care incorporating necessary treatment/services consistent with professional practice to prevent new ulcers from developing. This deficient practice has the potential to affect all current and newly admitted residents with skin impairments and wounds. Findings include: R1 was admitted to the facility for skilled nursing services on 08/19/20. Her primary admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Along with her spinal wound, R1 was also admitted with two pressure ulcers, which included a deep tissue injury (DTI) to her right (R) buttock and an unstageable pressure ulcer to her sacrum as per the Minimum Data Set Coordinator's (MDS-C1) 08/20/20 initial note. During this complaint investigation, the closed RR found there were no comprehensive care plans to address each of R1's existing skin/wound problems for five new facility or in-house acquired DTIs. This was verified by interviews done of the licensed staff on 01/12/21. Cross-reference to findings at F656. RR found R1's new DTIs were found on: a) her R heel, b) her L heel, c) the top of her R fifth toe, d) the top surface or dorsum of her L foot and e) the medial aspect of her L foot. The facility's 09/07/20 photographs of three new wounds which RN1 described as Stage 2 pressure ulcers, were all documented to be DTIs. The facility's in-house photographs documented, #21 - Pressure - Deep Tissue Injury Body Location: Dorsum Left Foot New - Age Unknown Acquired: In-House Acquired; #22 - Deep Tissue Injury Body Location: Medial Left Foot New - Age Unknown Acquired: In-House Acquired; #24 - Deep Tissue Injury Body Location: Right Foot, 5th Digit (Fifth Toe) - Age Unknown Acquired: In-House Acquired. Yet, RR found a Registered Nurse's (RN1) 09/07/20 progress note at 06:19 PM which stated, Pressure Ulcer stage 2: There are small pressure ulcer both side of feet which seemed to be caused by foot covers. No pain noted upon examination. No skin break noted. Apply a foam to each side of feet. Continue to cross monitor. Another, late entry by RN2 on 09/07/20 at 01:27 PM stated, New pressure injuries noted by PT/OT today to bilateral foot. Skin/Wound assessment done, IR (incident report) completed, notified (attending physician) via MD book per charge nurse, notified family member. Border Foam dressing applied, bilateral heel protectors continues. A 09/07/20 MD1 order stated, Apply a bordered foam to both side of feet, and change QD (daily) until healed, one time a day for Pressure Injury 2. However, another set of MD1's orders on 09/11/20 found treatment orders for DTIs to the left dorsum, left medial foot and right fifth toe. These new orders on 09/11/20 were new treatment orders for the three in-house acquired pressure ulcers, which became classified as DTIs within a four day span according to the clinical documentation. Further review found nursing progress notes that mentioned, Cont. to float heels on 09/30/20 and, DTI to bilateral heel persisting, kept pressure off bed and lifts at all times on 10/02/20. During an interview with the Nurse Manager (NM) on 01/11/21 at approximately 04:10 PM, she verified the DTIs to R1's bilateral heels developed in-house, and stated, I don't really know how it happened. She stated the facility's first and sole photographs of R1's bilateral DTIs to her heels were taken on 10/15/20, three days before her discharge to the hospital on 10/18/20. On 01/12/21 at 01:25 PM, the MDS-C1, MDS-C2 and NM acknowledged their current CPs did not address each specific problem area, and acknowledged the intervention, Heel lifts on at all times did not relate to the problem that was listed within an all-inclusive impaired skin CP which included R1's infected surgical wound to her back and the problem listed as DTIs to bilateral feet. R1 had five total DTIs to her feet by the time the facility recognized she had R and L heel DTIs. Yet, MD1's 09/11/20 order, Heel lifts on all time every shift, raised a query as to why licensed staff failed to identify the presence of new pressure injuries to R1's heels if the heel lifts were to be placed on her every shift starting from 09/11/20. In addition, with the development of multiple new DTIs to R1's feet, the attending physician's (MD1) progress notes Revealed he failed to mention anything about the development of her in-house acquired DTIs and/or the progress of her pressure injuries, except for separate physician treatment orders. In addition, the 09/29/20 care plan conference summary failed to address the clinical rationale for the development of five new multiple DTIs, and what clinical measures were being implemented to prevent further development of any new injuries. On the afternoon of 01/12/21, the Administrator was made aware of R1's new DTIs and lack of comprehensive care plans for R1 who was at risk for the development of future pressure ulcers/injuries as she was identified as a moderate risk for the development of pressure ulcers, but ended up developing five new DTIs.

Based on record review (RR) and interviews, the nursing staff failed to recognize that a change of condition was a medical emergency in one resident (R)2 of a sample size of two. When R2's pulse (P) increased and blood pressure (BP) dropped, the Registered Nurse (RN)4 did not notify the physician (MD) immediately to report the major change of vital signs so interventions could be done to prevent further deterioration. Low BP can be a life threatening condition and is consider a medical emergency. R2's BP and condition continued to decline and she was subsequently transferred to the hospital over two hours later where she was admitted to the Intensive Care Unit with the diagnosis (Dx) of septic shock. This deficient practice put R2 at greater risk of complications and mortality and resulted in harm. Early, aggressive treatment increases the likelihood of recovery ([CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During R2's hospitalization , R2 had an Acute Kidney Injury (AKI), metabolic [CONDITION(S)], and respiratory insufficiency complications documented to be secondary (caused by) to the septic shock. The nursing staff must have the skills and competency to identify residents at risk of [CONDITION(S)], monitor for infection, and respond timely to a condition change that needs urgent intervention. This has the potential to affect any resident in the facility at risk for [CONDITION(S)]. Findings include: 1. R2 was an [AGE] year old admitted on [DATE] for short term rehabilitation after a right below the knee amputation on [DATE] due to [CONDITION(S)] and gangrene. Her pertinent past medical history included diabetes, hypertension (high blood pressure) and peripheral artery disease. R2 was taking medication (Losartin 100 mg) for high blood pressure (BP), and completed a course of two intravenous antibiotics [DATE] prior to transfer to the facility. R2 was incontinent of bowel and bladder. The nursing progress notes dated [DATE] revealed R2 had discomfort to groin and buttocks; groin with significant redness, and buttocks w/ open MASD (Moisture Associated Skin [CONDITION(S)]-defined as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine and stool). R2 required one to two person assist for bed mobility and toileting and used disposable briefs. R2 had a POLST (provider orders for life-sustaining treatment) which included; Attempt Resuscitation/CPR, Full treatment, and transfer to hospital if indicated. Review of progress notes revealed the following entries: [DATE] at 19:42 RN4 entry; Received resident in bed sleeping but arousable. At 3:30 PM CNA (Certified Nursing Assistant) notified writer V/S (vital signs) ,d+[DATE](blood pressure) -104 (pulse) . Res (Resident [R2]) respond to verbal stimuli with slurring speech. Res is sleepy, open eyes to speech. Elevate legs, V/S rechecked at 4:00 PM ,d+[DATE]-100 . Continue to elevate legs. At 4:40 Pm [sic] rechecked res V/S ,d+[DATE]-103 . Unresponsive - Open eyes and withdraw to Pain. Unable to verbalized needs. Res baseline: AOx2 (alert and oriented to person and place) mainly Korean speaker able to understand and speak simple English and gesture. Able to make needs known. Notified MD, Manager and family at 5:01 PM, res [sic] requested to send res to ER. MD aware. Called 911. EMS arrived at 5:40 PM Transfer . at 5:43 PM. [DATE] at 06:18 AM; Called . ER at 06:18. Resident admitted . for diagnosis (Dx): septic shock. RR of vitals summary and progress notes revealed R2's V/S as follows: [DATE] ,d+[DATE] at 01:51 PM (date of admission) [DATE] ,d+[DATE] at 06:25 PM [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] at 07:10 AM [DATE] ,d+[DATE] at 08:44 AM [DATE] ,d+[DATE] at 07:44 AM [DATE] ,d+[DATE] P104 CNA notified RN at 03:30 PM. [DATE] ,d+[DATE] P100 at 04:00 PM [DATE] ,d+[DATE] P103 at 04:40 PM unresponsive MD called at 05:01 PM EMS arrived at 05:40 PM and transfer to ER. On [DATE] at 11:31 AM during an interview with the Nurse Manager (NM), inquired when staff should notify the MD if there was a change of condition or V/S. The NM said the facility had written guidelines what included if someone fell , had abnormal lab work, unusual occurrences, new skin care issue, new pressure ulcer, and there's V/S parameters when to notify the MD. Asked the NM how she would expect the nursing staff to respond if the BP was below the parameter, and she stated, I would expect them to recheck it right away and notify the MD if it is still low. Review of the facility document titled Uniform Call Guidelines (undated) stated; Urgent matters should be reported immediately to MD: Please check vital signs and nursing assessment before calling. Have Dx and Med list available, and use SBAR (organized communication tool; situation, background, assessment, recommendation) format when presenting your case. The document directed staff to contact the MD when there was; Major change in vital signs: confirm with repeat measurement . SBP (systolic blood pressure) < 90 ., Resting Pulse > 100 . and . mental status changes. On [DATE] at 03:30 PM R2's systolic BP was reported to be 82, P104 and documented slurring speech. A second blood pressure is not documented until 30 minutes later. At 03:30 PM, R2's condition met the facility criteria for an urgent matter that should have immediately been reported to the MD. The MD was not notified until 05:40 PM when the BP had dropped to ,d+[DATE] and R2 was unresponsive. On [DATE] at 02:30 PM, during an interview with RN4, she said she recalled the event and that R2 was sent to the hospital because of her blood pressure. RN4 said from what she could remember, R2's normal BP ranged from ,d+[DATE]. RN4 said when the CNA notified her the BP was low, she went inside the room right away and rechecked blood pressure but was still low, between ,d+[DATE]. I assessed for pain. She was still at baseline. Queried what interventions were done to address the [CONDITION(S)] and RN4 said; I elevated her legs, and described putting the bed in a position that lowered the head and elevated the lower extremities (Trendelenburg). RN4 recalled R2 was there for orthopedic aftercare following surgical amputation and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . , and then I reassessed again. I tried to reposition R2, but was in pain, so gave pain medication, she was in stable condition. RN4 validated she wrote the progress note that R4 had slurring speech, and said R2 was Kind of asleep at that time, looked sleepy. RN4 said R2 didn't really have difficulty speaking at that time but sleepy at that time. RN4 went on to say R2 was supposed to receive the COVID vaccine the next day, so she wanted to check her again to make sure if she was OK to still get the vaccine. RN4 said; When I checked the BP, it was 72, not responding to me. Tapped her shoulder and didn't talk. Opened eyes. Doesn't respond. I called the doctor right away. RN4 said she was familiar with the guidelines to call the MD. Reviewed with RN4 the documentation and R2's condition of the low BP, elevated P and slurring speech, and that it met the criteria of an urgent condition to contact the MD immediately. RN4 was asked if she recalled why she didn't notify the MD at that time, and she said; I was thinking I needed to do nursing interventions first before calling the doctor. The nursing intervention RN4 was referring to was elevating the legs/bed position. This practice is now controversial, and current literature has shown it does not improve BP and shock. Nursing Center, [DATE] stated; Trendelenburg should be avoided until larger studies are conducted as it may increase a patient's risk for hemodynamic compromise, elevated intracranial pressure, and impaired lung mechanics. Specific patient populations should not be placed in Trendelenburg. Review of the Licensed Nurse Competency Checklist, utilized for orientation included the skill area of Change of Condition. This skill area included; Assessment, Vital Signs, Neurological Assessment (level of consciousness, pupillary assessment, speech, motor function, extremity strength and pain). The checklist also included notification of MD, and IV therapy skills. RN2's orientation documents were reviewed and revealed she had a completed checklist. During an interview, the NM said the guidelines for contacting the MD is not part of the checklist, but was the expectation it was reviewed when orienting to the unit. RR revealed R2 was transferred to the hospital on [DATE] and remained hospitalized at the time of survey. Hospital documents revealed the following entries pertinent to her diagnosis, complications and treatment during the course of her hospitalization : Emergency Department Provider Notes by MD4 dated [DATE] at 06:41 PM: . Pt. lethargic . minimally responsive. Vital signs: Temp (!) 95.7 F. P 96 BP (!) ,d+[DATE] WBC (white blood cells) 24.4. (Normal 4.,d+[DATE].0 high WBC indicates potential infection) Severe pain with rectal exam. +mucous/purulent (containing or discharging pus) from rectum. Starting peripheral [MEDICATION(S)] (a potent medication that increases BP used for severe [CONDITION(S)] and shock). abx (antibiotic) started. Unsure of source (of infection) Sacral decub (decubitus) /rectal tenderness is concerning Diagnostic impression: Septic Shock Critical care admission history and physical by MD5 dated [DATE] at 09:24 PM: Purulent drainage from perirectal area Received just under 2 L (Liters) NS (Normal Saline) in the ED Infused an additional 1 L of LR (Lactated Ringers) in ICU Principle Problem: 1. Septic shock 2. Perirectal disease . suspect perirectal infection . 3. AKI (acute kidney injury) vs AKI on CKD (chronic kidney disease) . maintain renal perfusion . Disp (disposition): Admit to ICU. Patient with significant risk of complication/harm due to shock. Progress Notes by MD7 dated [DATE] at 07:21 AM: Septic shock . 2ary to possible proctocolitis & Skin/soft tissue infection w/Sacral Decubitus Ulcer. (+) evidence of hypo perfusion (reduced amount of blood flow to organs); (+) AKI (sudden episode of kidney damage) Renal Insufficiency: AKI improved . 2ary (secondary) to Septic Shock # Altered Mental Status: Toxic Metabolic [CONDITION(S)] (Toxic-metabolic [CONDITION(S)] is a result of infections, toxins, or organ failure that can impact the brain's function.) In setting of [CONDITION(S)]. Prognosis: uncertain at this point Progress note by RN7 dated [DATE] at 08:00 AM: Wound consult due to presence of skin breakdown. Moisture associated skin damage resulted in pressure injuries. [DATE] WBC increased to 41.6 [DATE] WBC 53.3 [DATE] Positive for C difficile (difficile or C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long-term care facilities and typically occurs after use of antibiotic medications) Progress note by MD6 [DATE] at 09:13 AM: # acute respiratory insufficiency: ,d+[DATE] (secondary to) [CONDITION(S)]. Progress note by Surgeon consult dated [DATE] at 12:48 PM. Large soft tissue necrotizing infection (necrotizing soft tissue infection develops when the bacteria enters the body. The bacteria begin to grow and release harmful substances that kill tissue and affect blood flow to the area.) Involving lower back and perineal region. This will require extensive debridement and likely a [CONDITION(S)]. Patient is very sick. Patient's daughter expressed desire to proceed with surgery even if she was told by me that the only sure thing is extended recovery (if patient survives) with a lot of pain and suffering during dressing changes and that the [CONDITION(S)] is likely to be permanent. [DATE] to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] (a type of stoma) is formed using the end of your small intestine. A stoma, an opening in your abdomen is surgically created. This diverts feces into a bag attached to the opening.) On exam in the OR, there was no evidence of full thickness injury or necrosis, and the wounds were debrided. RR of R2's progress note by MD6 dated [DATE] at 07:56 AM revealed the following entries: Dx: [CONDITION(S)] w/septic shock: likely source fulminant C difficile (C diff) [CONDITION(S)] (a serious complication of C Diff that usually requires surgical intervention.) Progress note of MD3 (Infectious Disease) dated [DATE] at 08:53 PM: Bilateral buttock [CONDITION(S)] Progress note by MD9 dated [DATE] at 07:22 AM; Patient developed skin breakdown of the buttocks while at . which worsened while at the Palolo Chinese home likely due to C difficile diarrhea. Due to the fact that R2 was diagnosed to have C diff infection, completed review of bowel elimination at the facility prior to transfer to the hospital. RR revealed the following: [DATE] 05:54 Consistency of BM (bowel movement): Formed/Normal [DATE]:59 Putty like [DATE] 17:08 Loose/Diarrhea [DATE] 05:53 Formed Normal [DATE] 13:42 Loose/Diarrhea [DATE] 21:38 Loose/Diarrhea [DATE] 05:14 Formed/Normal [DATE] 11:00 Loose/Diarrhea [DATE] 21:58 Formed/Normal [DATE] 05:04 Loose/Diarrhea [DATE] 13:59 Loose/Diarrhea [DATE] 18:06 Loose/Diarrhea [DATE] 13:59 Loose/Diarrhea [DATE] 17:30 Loose/Diarrhea R2 was at high risk for C-diff infection due to her long history of antibiotic usage, length of stay in healthcare settings, underlying illness and advanced age. The Center for Disease Prevention (CDC) [DATE] recommends; If a patient has had > 3 stools in 24 hours: Order a C. diff test if other etiologies of diarrhea are ruled out. 2. Cross-reference to findings at F656 and F686. The facility's licensed staff failed to develop comprehensive care plans (CPs) to address R1's identified needs upon her admission to the facility on [DATE] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plans which the facility had developed and reviewed concurrently with licensed staff, were also incorrectly started/initiated in February 2020. R1 was admitted in August, 2020 for primary treatment and services for post-surgical healing of her spinal wound with rehabilitation, and not in February 2020. In addition, it was found the licensed staff relied on physician treatment orders, but had CPs with measurable goals, resident involvement and other clinical interventions to heal, treat, evaluate and prevent further pressure ulcer development, or worsening of R1's existing pressure ulcers (the right ischial tuberosity). The MDS-C1, MDS-C2 and NM stated their CPs were all inclusive and acknowledged their understanding during their interview that all the wounds R1 came in with and the new ones she later developed, should have been individually assessed and care planned with a baseline to reflect the condition/characteristics of each wound with appropriate clinical interventions by nursing and/or other supportive care/treatment included. Each care plan should, drive the care for each identified problem, and be re-evaluated for treatment effectiveness to promote/heal each wound. This was not found, despite the facility's policy, Wound/Pressure Ulcer Management Policy & Procedure, revised [DATE], stating that measures specific to prevent pressure ulcer development should be included and was a part of standard clinical care and practice.

Based on closed record review (RR) and staff interviews, the facility failed to develop a comprehensive care plan (CP) for one of three residents (Resident (R) 1) in the survey sample. As a result of this deficient practice, the facility also failed to ensure comprehensive, individualized CPs were developed for: 1) the spinal wound and two separate pressure ulcers R1 was admitted with, and 2) the five facility acquired pressure ulcers which developed during R1's stay at the facility. In addition, the CPs did not have appropriate goals and specific interventions to direct staff on how to improve or maintain R1's highest practicable functional level, by failing to routinely get her out of bed into the wheelchair which was not only an intervention to avoid pressure ulcers, but to improve and/or maintain her functional status. Care planning drives the type of care and services that a resident receives. If care planning is not complete, or is inadequate, the consequences may negatively impact the resident's quality of life, and the quality of care and services provided, which was found for R1. As a result, the potential for harm existed as the facility failed to develop comprehensive CPs in order for R1 to maintain her highest, practicable quality of life. This deficient practice has the potential to affect all current and newly admitted residents with skin impairments and wounds. Findings include: 1. R1 was admitted to the facility for skilled nursing services on 08/19/20. Her primary admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Along with her spinal wound, R1 was also admitted with two pressure ulcers (also known as pressure injuries), which included a deep tissue injury (DTI) to her right (R) buttock and an unstageable pressure ulcer to her sacrum as per the Minimum Data Set Coordinator's (MDS-C1) 08/20/20 initial note. RR found however, there were no comprehensive CPs developed to address each of R1's existing skin/wound problems when she was admitted . These CPs would have been for R1's surgical spinal wound (her primary admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During interviews with the MDS-C1 and MDS-C2 on 01/08/21 at 03:00 PM, the MDS-C1 verified there was no comprehensive CP to address R1's spinal wound at baseline nor when her back wound showed dehiscence (a wound that separates along a surgical incision). MDS-C2 showed photos of R1's spinal/back wound, which measured 24.25 cm (L) x 0.8 cm (W) at baseline on 8/19/20, her date of admission. By 08/26/20, the wound remained intact with steri-strips, but on 09/02/20, the steristrips were removed. The MDS coordinators said, sometime between August 26th and September 2nd, they thought the wound opened up. A 09/17/20 photo showed a part of the wound to her back noticeably dehisced (a wound dehiscence is a surgical complication). The 09/10/20 Wound Care SNF Consult Service Progress Note documented the back surgical site wound dehisced and urgent follow-up was scheduled with the surgeon. The wound was noted to be necrotic with yellow fibrinous slough. The MDS-C1 said he and MDS-C2 usually did not touch the baseline care plans, but, the nurses on the floor did. Thus on admission, the expectation was for the floor nurse to start a wound care plan for this problem and the other two pressure ulcers R1 came in with. This was not found. MDS-C1 said then he and MDS-C2 would update it after they completed the care conference with the MDS assessment. The MDS-C1 further said, so I believe we combine it all in one care plan under skin, so any bruises, skin tears, pressure ulcers, we have it all under one problem under skin. This was found for the existing CP for R1's surgical/back wound which was combined together with R1's various other skin problems. This CP stated, Impaired Skin Integrity r/t . 3) Resident was admitted with Unstageable pressure injury to sacrum/stage 4 pressure injury to right buttock, Stage 4 pressure injury to right ischial tuberosity, and an infected surgical wound to spinal area (T9-L4). 4) Dx: Pelvic [CONDITION(S)] on 9/17/2010. 5) DTIs to bilateral feet. In addition, this CP start date, or the date it was created, was from a previous admission in February of 2020. R1's admitted was 08/19/20. Thus, this CP itself, was not correctly created, and should have been created based on R1's August 2020 admission assessment(s). The MDS-C1 acknowledged since there was no individualized, comprehensive CP for the spinal wound, they also had no specific interventions for the care, treatment and services to monitor and ensure her primary wound would heal. Without a comprehensive CP to outline care, treatment and services to render, eventually R1's primary back wound dehisced, became necrotic and required further medical intervention. RR found it was on 09/24/20, when R1's attending physician started an order to treat her dehisced surgical incision with [MEDICATION(S)] packing. Yet, no care plan for the baseline or a comprehensive CP was done for this wound, which was well approximated, clean, dry and intact upon R1's admission to the facility. Even at the time the wound dehisced, no CP had been developed for it. One complaint allegation stated that R1's pressure ulcers she was admitted with had significantly worsened during her stay the facility. During this investigation, staff interviews and RR found one of the pressure ulcers was noted by MD3 as, Right ischium has a large cavernous Stage IV necrotic ulcer that tunnels 2 cm cephalad and extends to bone, and was diagnosed on /about 10/16/20 with [CONDITION(S)] (infection of the bone) after the initial wound culture was done on 09/03/20. This had worsened from the RRs and staff interviews done and confirmed during the interviews of the MDS-C1, MDS-C2 and NM. This wound too, had no individualized, comprehensive CP developed by nursing, except for the one created in February 2020 as part of the impaired skin integrity CP. Further RR found R1 developed new facility acquired, or in-house DTIs. The complaint investigation found that in addition to what she was admitted with, R1 developed five new DTIs during her stay at the facility. These new DTIs were found on: a) her R heel, b) her L heel, c) top of her R fifth toe, d) top surface or dorsum of her L foot and e) the medial aspect of her L foot. There were no individualized, comprehensive CPs found for these new pressure injuries she developed during her stay at the facility. In addition, RR and interview found R1 also developed a skin tear to her inner R labial area on or about 09/30/20. The Nurse Manager (NM) on 01/11/21 said this skin tear had been incorrectly identified as a moisture associated skin damage (MASD), but verified it was a skin tear to R1's labial region. The MASD was documented as, 7. MASD right ischial tuberosity in a 08/20/20 nutritional problem CP, but the skin tear was not located at the R ischial tuberosity. Also, the first observation of this labial skin tear was documented by RN2 on 09/30/20 in her alert charting note, and not on 08/20/20 as per the nutritional CP date. The physician's treatment order for Triad paste was started on 10/01/20 for this skin tear to the R labial fold, and was not for a MASD to her R ischial tuberosity. There was no comprehensive CP developed for this identified labial skin tear injury. During an interview of MDS-C1, MDS-C2 and the NM on 01/12/21 at 01:25 PM, the MDS-C1 confirmed many of R1's existing CPs had the wrong start dates. He acknowledged the existing CPs were copied from R1's previous visit in February of 2020 and thus, were not correctly developed for her 08/19/20 admission. The MDS-C1 stated, Moving forward we need to resolve care plans when people leave and come in instead of using old ones. He stated this would be found for most of the CPs for residents. The SA queried the reason for putting all of the different skin conditions together under one skin impairment CP. The MDS-C1 acknowledged he allowed for the creation of the CPs to be this way and group the skin problems all together. In doing so, their existing CPs failed to include measurable objectives from the time each wound/injury was identified, and failed to provide specific treatment goals/interventions by the interdisciplinary team (IDT) members to heal R1's spinal wound and pressure ulcers/DTIs. The MDS-C1, MDS-C2 and NM acknowledged their current CPs did not address each specific problem area, such as the spinal wound dehiscence and related infection, and further acknowledged the intervention such as, Heel lifts on at all times, did not relate to the problem for an infected surgical wound to the back. Overall, there was a lack of resident-centered, comprehensive CP for each of R1's skin integrity problems, from her pressure ulcers/DTIs, surgical wound to her spine, and the skin tear injury. As such, the facility could not show their CPs included services and treatments being rendered to prevent the wounds from worsening or becoming infected, and, if so, what new interventions or revisions were being made to the CP. For the five new DTIs R1 developed in-house and prior to her discharge to the hospital, the NM stated they did not even know when her bilateral heels became DTIs. However, if staff had been treating R1's other DTIs to her feet every other day per the September 2020 Treatment Administration Record (TAR), nursing had somehow failed to thoroughly check her feet, including her heels for skin breakdown before it became DTIs. Thus, coupled with the existing CPs, many of which had incorrect start dates, the failure to develop individualized CPs with relevant clinical interventions (care/services) with measurable objectives and timeframes to evaluate her progress for each identified wound, was the potential for harm as evidenced by the development of new, multiple pressure related and skin injuries, and worsening of the spinal wound and right ischial tuberosity pressure injury. 2. R1 was admitted [DATE] post spinal surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was able to feel light sensation, but was not able to ambulate. MD2's office visit note dated 09/02/20 documented [CONDITION(S)] has not improved. RR of the inpatient PT/OT evaluations dated 08/16/20, three days prior to transfer to the facility included the following entries: Ambulation level: Does not occur PT Treatment Recommendations: . Pt at dependent level of assist for mobility at this time. Poor sitting trunk control. Unable to stand without Total assist with/without FWW (front wheel walker). OT impairments or limitations: Balance deficits, Basic Activity of daily living deficits. Cognitive, Endurance deficits, Equipment training, Mobility deficits, Pain, Safety awareness deficits, Strength deficits. OT Anticipated Treatments/Needs: Balance training, Basic Activities of Daily Living, Energy conservation training, Mobility training, Pain management, Patient education, Safety education, Therapeutic exercise, Work simplification. RR revealed the one facilities Short-term PT goal was; Patient will safely ambulate on level surfaces 30 feet using a Rolling walker with moderate assistance . The target date was 09/02/20. The PT long range goal was; Patient will safely ambulate on level surfaces 150 feet using a Rolling Walker with supervision . The CP goal initiated on 08/27/20 and revised 09/11/20 was; Resident will be able to ambulate 150 ft. using FWW with Supervision. This was an unrealistic goal for R1's current functional status and medical status. RR of R1's orders related to functional status included: Start date 08/19/20 Activity as tolerated Start date 09/29/20 Out of bed (OOB) daily as tolerated every shift. Start date 08/21/20 Skilled OT (occupational therapy) services 5x/week for 30 days Start date 08/21/20 Physical Therapy (PT) services 6x/week for 30 days The CP directed staff to utilize a two-person physical assist via mechanical lift and to get R1 OOB daily as tolerated. The order written 09/29/20 OOB daily as tolerated every shift, would mean to get her OOB three times a day because there are three shifts. During an interview, asked RN1 how she would interpret that order and she said, she thought it meant to get her up in the chair for meals, which would be three times a day. RN1 went on to say R1 often refused to get OOB and didn't like the mechanical lift. RN1 then demonstrated how the mechanical lift straps may have caused pain to R1's labial wound. RR of R1's intervention/task form for documentation of transfers, revealed the form had only two rows for staff to document when R1 was transferred (OOB in WC). The report showed the following: August 18-31, 2020: OOB three times - none OOB two times - four of the 13 days OOB one time - four of the 13 days Did not get OOB - five of the 13 days Refusal to get OOB documented two times. There were 13 entries of N/A (key of N/A was not applicable). It is unknown why getting R1 OOB would not be applicable as the legend included resident refusals and not available. September 2020: OOB three times - none OOB two times - three of 30 days OOB one time - three of 30 days Did not get OOB 24 days No refusal to get OOB documented. There were 51 entries of N/A. October 1st-18th, 2020: OOB three times - none OOB two times - none OOB one time - two of 18 days Did not get OOB 16 days Refusal to get OOB documented one time. There were 33 entries of N/A. During an interview with the NM, asked where the staff were to document transfers and she said they should be on the intervention/task form. Informed NM progress notes had some entries of transfers, so asked the NM to review the progress notes to identify any additional entries about transfers. There were 11 progress note entries that stated R1 refused to get OOB in October. There were also entries that R1 got OOB on 10/20/20 two times and once on 10/01/20 that were not recorded on the intervention/task form for transfer. Even with the additional transfers, the staff were not getting R1 OOB as ordered. The transfers should be documented consistently and accurately to clearly provide a picture of the resident's status so issues can be addressed timely. The refusals to get OOB were not addressed by the IDT or added to the CP. Review of MDS dated [DATE] Section GG Functional Abilities and Goals on admission revealed R1 was being transferred from the bed to a wheelchair (WC). MDS Discharge assessment dated [DATE] revealed R1 did not transfer to the WC in the seven day period preceding the assessment. RR revealed: 09/09/20 Nursing progress note entry at 12:10 PM by RN1; PT/OT visited her (R1) in the morning, resident sat in the edge of bed wearing a trunk support about 30 minutes. Per PT/OT, resident is still having a hard time to sit up without supports due to lack of muscle around the trunk. Per PT/OT, to sit in wheelchair will be future goal, but not now. 09/10/20 PT encounter note; Patient up in WC when therapist arrived. Sitting balance training with reaching forward to touch therapist hand, but patient fearful of falling stating, I'm going to fall. Reassured patient that she is not going to fall. 09/11/20 Pt encounter note; Patient positioned sitting in WC and performed various . exercises. The following two days after RN1 documented PT verbalized the WC was not a current goal, R1 was OOB. It is unsure if PT's intent was to change the goal. The CP had a revision date of 09/11/20 on the functional performance goals, and a revision date of 09/28/20 on interventions. There was no documentation regarding a change of the goal to get R1 OOB as directed by MD1's order, and there were no additional measures added to assist R1 to meet functional goals. If there was a potential conflict or concern from PT/OT regarding the MD order to get OOB (in WC) every shift, or the comprehensive CP, the MD should have been contacted and the issue discussed at IDT care conference with revisions. RR of MD2's Transfer Summary from the hospital dated 08/19/29 revealed the entry; . Transferring can be done without brace. There are no restrictions to her mobility. Another entry was R1 could be up without the brace. On 01/08/21 at 05:15 PM, during an interview, asked RN2 about the back brace, and she replied; She (R1) would use the back brace when we would transfer her to the WC and I know she used it when she went out on appointments. I did not see her sitting in bed with the brace. There was no order for a back (thoracic) brace or abdominal binder, and it was not included in the CP. It was unclear when and if the brace was to be used for additional support. RR of PT initial evaluation dated 08/20/20 documented spinal precautions as a precaution. RR of OT initial assessment dated [DATE] documented back surgery precautions as a precaution. Spinal precautions post spinal surgery usually include log rolling to change positions, avoid twisting, as well as sleep position for alignment. There is no mention of spinal precautions in the CP for staff to follow. RR of PT notes included the following: Encounter Note, date of service (DOS) 08/30/20; spoke to rn, about pnt (patient/resident) wanting to get up in w/c. Advised RN pnt has to have mechanical lift for safety. Encounter Note, DOS 08/28/20; Bed mobility: rolling . to position back brace. Static sitting at EOB (edge of bed) at least Approximately 10 min required Max A (assist) to maintain upright position as patient is fearful of falling and feels that she is falling forward all the time. Encounter Note DOS 08/30/20; . happy to be sitting up. Encounter Note DOS 09/07/20; Patient able to sit EOB for approximately 15 min and approx. 10 sec unsupported. Encounter Note DOS 09/08/20; Demonstrated to son how much help patient will need to don/doff (put on/take off) lumber [sic] brace. PT progress report dated 09/08/20; Patient progress and response to treatment: Reason/s for limited progress include severe neurological weakness bilateral lower extremity, poor trunk control, impaired cognition, pressure injury, and deconditioning requiring max to dependent for functional mobility. Goals to shift to compensatory strategy and discharge planning. Compensatory strategies are environmental modifications or behavioral strategies designed to address physical and cognitive impairments. There were no strategies identified in the CP that reflected the PT note for the goals to shift. RR of OT notes included the following: Encounter Note DOS 08/27/20; . Pt seated EOB (edge of bed) when nursing staff updated therapist that son requesting Pt have abdominal brace when sitting up supine in bed, MAX A (max assist) to don abdominal brace. Encounter Note DOS 08/31/20; Rolling to R/L sides at MAX A to don back brace and place Hoyer net (mechanical lift) under pt. in supine increased time required . d/t fear of rolling off bed. OT discharge summary dated 09/15/20; The short term goal of; Patient will tolerate sitting support at EOB for 9-10 minutes to participate in ADL activity of choice facilitating increased dependence with self-care tasks was met on 09/02/20. The long term goal of Patient will tolerate unsupported at EOB for 10 minutes to complete . ADL activity facilitating return to higher skill level. The OT discharge note said; Able to tolerate sitting EOB for approx. 10 min however completed at CGA (care giver assist) level (pt. fear of falling when sitting). There were no changes to the CP or specific goals with targets to reinforce or address R1 sitting at EOB. RR of nursing notes as well as OT encounter notes revealed R1 refused/declined to sit up and get OOB into the WC several times and that she had a fear of falling. Getting OOB was important to assist R1 to reach her highest practicable physical, mental and psychological well-being. The comprehensive care plan did not identify the care or service being declined, the risk the declination posed, or attempts to find alternative means to address the identified risk/need. Review of the facility policy titled Rehabilitation Services dated 06/15/04 said the facility will provide rehabilitation services to residents who need them as determined by a comprehensive assessment and care plan to prevent avoidable physical and mental deterioration. The procedure included; The Consultant (rehab staff) will be a member of the Interdisciplinary Team (IDT) and be involved with the resident's overall plan of care. A written rehabilitation plan of care shall be provided which is based on the attending physician's orders and assessment of resident needs in regard to specialize rehabilitative procedures. It shall be incorporated in and regularly reviewed with the overall resident care plan. Review of the Interdisciplinary Team Care Plan Conference Summaries revealed the following: 08/27/20 The ADL (activities of daily living) section had a place for PT and OT notes, but there were none documented. 09/20/20 The ADL section read; Requires total assist for dressing, bed mobility, transfers, and toileting. Resident able to feed self with some assistance including cueing. PT/OT did not attend the Care Conferences and there was no discussion regarding R1's functional progress or barriers.

Based on interviews and record review (RR), the facility failed to protect the rights of one Resident (R)1. R1 was not treated with dignity and respect when a Certified Nurse Assistant (CNA) applied a physical restraint without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was abused when CNA1 willfully tied the sleeves of R1's jacket together to limit freedom of movement so care could be completed. As a result of this deficient practice there was the potential that R1 experienced mental anguish and increased agitation that may not allow her to maintain the highest psychosocial wellbeing possible. Findings Include: 1. The Office of Healthcare Assurance ([NAME]) received a facility incident report (ACTS # 8313) regarding staff to resident abuse. The event description stated, On 06/16/20 at approximately 04:45 AM, CNA1 was providing routine morning care to the resident (R1). When CNA1 was providing incontinent care, resident reacted by hitting, scratching, kicking and spitting at CNA1. Resident was wearing a zipped-up jacket at the time and CNA1 tied the end of the jacket arm sleeves together. CNA1 proceeded with providing incontinent care, dressed the resident, then transferred the resident onto the WC (wheelchair). Registered Nurse (RN)1 was in the hallway outside of resident's room when he/she heard the resident yelling. When he/she responded to the residents yelling, he/she noted resident sitting on the WC with the jacket arm sleeves tied together . 2. RR and event report revealed R1 was a [AGE] year-old female who was initially admitted to the facility on [DATE] with a diagnosis (Dx) of [CONDITION(S)] with behavioral disturbance. She was alert and oriented to person, had cognitive impairment, and does not initiate communication to verbalize needs. R1 can communicate verbally, however, her communication is limited to understanding simple phases, and responses may not be appropriate to reality. R1 has short, self-oriented outbursts. R1 has a known response when approached by other individuals, to shout out for others to go away, and gesture with her arms and legs for those approaching to stop and move away, almost interpreted as defending self or does not want others to bother her, or wants to be left alone. Resident does not understand her cognitive and physical deficits and does not understand the day to day care needs . R1 has a history of punching staff, pulling hair and yelling. R1's Care Plan (CP) identified these behaviors as an active problem and included several recommended interventions/actions to limit and control the behaviors. R1's medications included, [MEDICATION(S)] (stabilizes mood), [MEDICATION(S)] (for dementia with psychomotor agitation), and Trazadone (for sleep). 3. Review of the facility Resident Rights, included the right Not to be humiliated, harassed, injured or threatened and shall be free from chemical and physical restraints .Physical restraints may be used in an emergency, when necessary, to protect the resident from injury to the resident's self or others. This restraint did not meet the definition of an emergency and was not in accordance with R1's CP. Alternative measures were not implemented. Resident's preferences and needs were in the CP and should have been accommodated. In addition, R1 has the right to have a schedule for waking that meets her needs. 4. Review of R1's CP at the time of the event, revealed the following: Problem: Current Functional Performance-Resident has Impaired Functional Mobility due to dementia with psychomotor agitation .Resident requires assist for her ADL's (activities of daily living) but resident not cooperative frequently due to her dementia. Interventions included: .Resident often times has behavior (yelling, kicking, and telling staff to go away). Explain the procedure to the resident before touching her. If resident continues to refuse, leave the resident and come back in 30 minutes. Ensure that the resident is safe before leaving the room .Resident requires assistance with transferring from bed to wheelchair (W/C) .sometimes gets combative to staff. May ask the staff from [NAME] Booth (other unit) to assist with transferring because she is familiar with the staff there. If resident continues to refuse, explain to the resident that you will come back in 30 minutes. Problem: Risk for impaired communication due to 1) Resident has behavior of combativeness and screaming, 2) Impaired visual function-uses eyeglasses, 3) Hard of hearing-Uses bilateral hearing aids, 4) Dx: dementia with psychomotor agitation. Interventions included: If resident is combative try to return again at a later time. Approach the resident in the front and face the resident when talking . Problem: The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's, dementia. Resident is able to answer yes/no questions, but not all the time. Resident is able to tell staff her needs with simple words but not all the time. Resident has behavior such as yells, punching staff, and refusing care. Interventions included: Resident often has behavior (yelling, kicking, and telling staff to go away). Explain the procedure to the resident before touching her. If resident continues to refuse, leave the resident and come back in 30 minutes . Ensure the resident is safe before leaving the room. Problem: The resident displays target behavior(s) (Physical: punching, pulling hair, and screaming at staff when staff get close to resident to provide care). Res (R1) Behaviors increase in the mornings and towards male staff. Interventions: Identify potential triggers and patterns to the resident's behaviors, anticipate and prevent the trigger, meet the resident's needs: .Res triggers: when staff are not communicating what they do before they do it, unknown staff working with the resident, working with male staff, no stimulation. Resident also becomes combative and yells during showers and changing .Keep res routines consistent and allow for flexibility if res needs it (getting up later in the morning, doing care tasks later instead of right when she wakes up) .Resident preference is familiarity. If able, schedule consistent staff to care for resident. Resident does not want male staff to care for her .Resident does not do well with change. Problem: The resident is/has potential to be verbally aggressive r/t (related to) poor impulse control. Interventions included: Provide physical and verbal cues to alleviate anxiety .encourage seeking out staff members when agitated .If resident is combative, try to return again at a later time .Observe/monitor/report any episodes of physically aggressive behavior. Identify potential triggers to the behavior. Try to provide regular caregivers as much as possible. Minimize over stimulation and ensure resident has his/her glasses. Resident does not like being woken up . CNA1 was aware that R1 did not want to be cared for by males, but did not change assignments with the female CNA available that night. CNA1 woke R1 up at 04:45 AM, which was identified as a trigger for behaviors in the CP. CNA1 immediately began to perform tasks, and when R1 began to resist, he did not leave as directed in the CP, but restrained R1 and continued with routine care. 5. Review of the Daily Assignment staffing sheet for Monday 06/15/20 (incident on night shift approximately 04:45 AM) revealed there were two CNA's assigned to the [NAME] Hall (WH) where R1 resided in Room (Rm) 114B. CNA1 was assigned Rms 110 AB-117 AB, and the female (CNA2) was assigned Rms 118 AB-124 AB. 6. On 06/22/20 at 02:00 PM during an interview with the Clinical Clerk (CC), the CC said the main responsibility of the CC is staffing, which includes making the room assignments for the CNA's. The CC stated, That night the unit was fully staffed. One of the regular CNA's was on vacation so CNA1 was floated over. They had two CNA's, CNA1 and a female (CNA2). CC had been made aware of the need to assign female CNA's to R1 by the previous DON (Director of Nursing) when R1's CP was created. CC stated, There has always been a female CNA on. CC confirmed CNA1 had been assigned to care for R1 that night and stated, When I was doing the schedule it didn't dawn on me that the resident specifically needed a female care giver. 7. Review of RN1's interview provided by the facility revealed the following: RN1 Suddenly heard someone yelling like someone is upset. Wondered who it was, and followed the sound and found R1 on the WC yelling but couldn't understand what she was saying. CNA1 was combing her hair. Went to the front of them and noticed that the sleeves were tied together. Nurse (RN1) explained to CNA1 that he can't do that. RN1 untied her and brought her outside.Resident was upset banging on the table and throwing the tissue box. RN1 tried to calm her down but resident was upset. Later on, resident calmed down . RN1 informed RN2 of the incident because she thought RN2 was a Charge Nurse before, and asked if he/she should call the on-call manager about this matter. RN2 said, No need, just tell him not to do it next time.RN1 feels like other staff blame the resident (R1). RN1 spoke with the Charge Nurse (RN3) who said, you have to report it. 8. The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revised date 12/06/20 stated, It is the policy of the facility to encourage and support all residents, staff, families, visitors .in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms . The policy further states, Any owner, licensee, Administrator, Licensed Nurse, employee or volunteer of the nursing home shall not physically, mentally or emotionally abuse, mistreat, or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect .shall immediately report it to the Nursing Home Administrator. The policy states abuse is, . the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as used in the definition of abuse, means the individual must have acted deliberatively, not that the individual must have intended to inflict injury or harm. 9. Review of a typed document the facility provided of an interview conducted by leadership on 06/18/20 with CNA1 included the following: Q. (facility leadership) Were you aware the resident responds better to female staff? A. (CNA1's answer) Day staff are scared of her and told NOC (night) shift to get resident (R1) up. Combative during first round. Sleeping and got mad when woken up.Long time I never work that side, I forgot already. At some point he did know that resident doesn't like male CNA's. Q. Why didn't you look at the care plan if you haven't been there about 2-3 months ago to see if there were any changes made to care. A. The RN never told me. Q. Have you ever looked at R1's care plan? A. No Q. Why does resident need to get up so early at 04:45 AM? A. they get her up at that time because the day shift want NOC (night) shift to get her up. Q. Why can't we let her sleep if she is sleeping? A. How can I finish my job, last rounds, if I don't do that? Q. Isn't it about the resident's sleep pattern? A. I forgot that one. Q. Why didn't you wait for help? A. Because I like to get her up. Didn't think to go and ask the nurse for help .Didn't think about waiting or asking for help from others . Q. What made you think of tying her sleeves together? A. To protect self and resident. Q. How did you come up with that idea? Did you think about it being a restraint when you did it? Didn't really answer the question. Q. Is it about doing the care or doing it properly and safely? A. I need to get my job done.I know it's a restraint, but I did it for my safety. Review of the Timecard Report for CNA1 revealed he worked on WH1 three times in May 2020, and five times in April 2020. 10. Review of MD1's communication book staff utilize to write pertinent information for MD1's review, revealed the following entry regarding R1, dated 06/21/20: (What is the issue/concern?) Lost 3.8 lbs. in 1 week . (Pertinent hx to the issue) Resident has been having poor po (oral) intake. Increase agitation episodes. Also refusing meds. 11. Cross reference F600 Free From abuse and neglect R1 exhibited behaviors (hitting, kicking and spitting) of resisting care during morning incontinent care. CNA1 proceeded to physically restrain R1 by tying the sleeves of her jacket together to prohibit movement so care could be completed. The direct evaluation of R1's psychological outcome is limited due to cognitive impairments, however if a reasonable person was put in a similar situation, there would potentially be fear, a nxiety and the potential of psychological harm. Review of behavioral monitoring forms documented an increase in behaviors after the restraint event. 12. Cross reference F604 Right to free from physical restraint On 06/16/20 at approximately 04:46 AM CNA1 physically restrained R1 by tying the sleeves of her jacket together that restricted freedom of movement without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews, observations and record review (RR), the facility failed to ensure that one resident (R)1 was free of physical restraint. On 06/16/20 at approximately 04:45 AM a Certified Nurse Aide (CNA)1 was providing morning incontinent care and completing other tasks when R1 exhibited behaviors (hitting, kicking and spitting) of resisting. CNA1 proceeded to physically restrain R1 by tying the sleeves of her jacket together to prohibit movement so care could be completed. The fact that CNA1 used physical restraint intentionally would indicate an action of convenience. There was documentation that R1's behaviors increased after the restraint. The direct evaluation of R1's psychological outcome is limited due to cognitive impairments, however if a reasonable person was put in a similar situation, there would be the potential of harm due to a negative psychological outcome, and the potential the individual would not maintain the highest practicable mental well-being. Findings Include: 1. The Office of Healthcare Assurance ([NAME]) received a facility incident report (ACTS # 8313) regarding staff to resident abuse. The event description stated, On 06/16/20 at approximately 04:45 AM, CNA1 was providing routine morning care to the resident (R1). When CNA1 was providing incontinent care, resident reacted by hitting, scratching, kicking and spitting at CNA1. Resident was wearing a zipped-up jacket at the time and CNA1 tied the end of the jacket arm sleeves together. CNA1 proceeded with providing incontinent care, dressed the resident, then transferred the resident onto the WC (wheelchair). RN (Registered Nurse)1 was in the hallway outside of resident's room when he/she heard the resident yelling. When he/she responded to the residents yelling, he/she noted resident sitting on the WC with the jacket arm sleeves tied together . 2. RR and event report revealed R1 was a [AGE] year-old female who was initially admitted to the facility on [DATE] with a diagnosis (Dx) of [CONDITION(S)] with behavioral disturbance. She is alert and oriented to person, has cognitive impairment, and does not initiate communication to verbalize needs. R1 can communicate verbally, however, her communication is limited to understanding simple phases, but responses may not be appropriate to reality. R1 has short, self-oriented outbursts. R1 has a known response when approached by other individuals, to shout out for others to go away, and gesture with her arms and legs for those approaching to stop and move away, almost interpreted as defending self or does not want others to bother her, or wants to be left alone. Resident does not understand her cognitive and physical deficits and does not understand the day to day care needs . R1 has a history of punching staff, pulling hair and yelling. R1's Care Plan (CP) identified these behaviors as an active problem and included several recommended interventions/actions to limit and control the behaviors. R1's medications included, [MEDICATION(S)] (stabilizes mood), [MEDICATION(S)] (for dementia with psychomotor agitation), and Trazadone (for sleep). 3. The facility provided a typed document of interviews conducted by ADON (Assistant Director Of Nursing) with CNA1 and RN1 the morning of the incident at approximately 05:00 AM on 06/16/20, as well as an additional interview with CNA1 with other leadership. The document revealed the following: He (CNA1) stated that he did tie the resident's jacket arm sleeves together because he was trying to protect himself from the resident who was hitting, scratching, kicking and spitting at him during routine morning care which included incontinent care, dressing, and personal hygiene care. Writer (ADON), also spoke with assigned RN1, who reported that he/she heard resident (R1) yelling . When he/she went to the room, he/she noted resident sitting on the WC with the jacket arm sleeves tied together. He/She stated that he/she immediately untied the jacket . Writer (ADON), DON (Director of Nursing), and Manager spoke with CNA1 via phone for further investigation. CNA1 stated at around 01:00 AM, he provided incontinent care to resident with assistance from female CNA2. CNA2 assisted holding resident's hands d/t (due to) resident striking out at him. For the last rounds (of care), .CNA1 went into this resident's room at around 04:45 AM. When he entered the room, resident was sleeping, He woke up the resident (R1) and explained that he is going to change her and get her up. Before CNA1 touched the resident, resident was already mad and telling him to get out. Per CNA1 resident is always like this. He proceeded to provide incontinent care and resident reacted by hitting, scratching, kicking, and spitting .CNA1 stated that he tied the ends of the jacket arm sleeves together. Per CNA1, R1 was already wearing a zipped jacket prior to him tying the ends of the jacket arm sleeves together. CNA1 stated that he did this to protect himself and the resident from any bruise/skin tear when resident strikes out. He (CNA1) felt like he needed to continue with care because day shift is telling him to get her up. He left the jacket arm sleeves tied, finished up incontinent care, dressed the resident, transferred the resident to the WC then proceeded to finish morning care . RN1 entered the room. Per CNA1, the nurse told him he can't do that, RN1 untied the sleeves . CNA1 stated he understands that he should not have done this, as it is a restraint. He verbalized understanding on other alternatives such as not waking up the resident when sleeping, talking nicely to the resident, don't get R1 up if she is resistant, and wait until another staff is available to help him . 4 Review of the facility policy titled Restraint Use, revision date 03/10/11, revealed the following policy statements: The facility upholds the right of the resident to be free from any physical or chemical restraints for the purpose of discipline or convenience . Restraint use is limited to situations in which the resident exhibits medical symptoms that warrant its use . The decision to apply restraints is based on clinical assessment and the care plan process as completed by the Interdisciplinary Team (IDT) . If restraints are used, they must be used in accordance with the residents plan of care. The restraint is used only when other least restrictive measures or alternatives have been found ineffective. A restraint is ordered by the attending MD or designee and the order must clearly indicate the type of restraint . Assessment and supportive documentation must be completed to ensure that the least restrictive measures have been attempted prior to the order or application of a restraint. The policy also states, Healthcare staff will be trained to assess and manage residents with challenging medical symptoms or behaviors, to provide alternatives or interventions that minimize the use of restraints and in the proper application uses of restraint as indicated. The policy defines physical restraint: Any manual method, physical or mechanical device, material, or equipment that is attached or adjacent to the resident's body that the resident cannot remove easily and restricts freedom of movement or normal access to one's body. To be a physical restraint, a device must the following two criteria: 1) The device actually restricts the resident's freedom of movement .; and 2.) The intended use is to restrict movement of the resident movement of the resident in some way. The policy defines convenience, as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the residents best interest. Convenience may include when a resident is confused and become combative when care is provided, and staff hold the resident's arms and leg down to complete the care. This is not an emergency where staff briefly hold a resident for the sole purpose to providing necessary immediate medical care ordered by a physician. Tying the sleeves of R1's jacket meets the definition of a restraint, and was not in R1's best interest. 5. RR revealed R1 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Identify potential triggers and patterns, anticipate and prevent the trigger, meet the resident's needs .Resident does not want male staff to care for her .Resident does not like to be woken up .If resident is combative, try to return again at a later time. In addition, there was no documentation of alternatives measures attempted, and no documentation that an RN was notified to assess R1 prior to the application of restraint. 6. Review of the Monitoring Behavior logs for the medication [MEDICATION(S)] revealed an increase of behaviors after the restraint incident. The behavior monitoring logs for June were reviewed with ADON for clarification of entries and key. The behavior form documented the following number of incidents and type of behavior that occurred: 06/01/20-06/07/20 (seven days) Yelling: Four Combative: Four Refusal of care: None 06/08/20-06/14/20 (seven days) Yelling: Four Combative: Two Refusal of Care: Four Restraint occurred on 06/16/20 approximately 04:45 AM 06/16/20- 06/21/20 (six days) Yelling: Nine Combative: 18 Refusal of Care: 15 7. Review of the communication book staff utilize to communicate issues to MD1, revealed the following entry regarding R1, dated 06/21/20: (What is the issue/concern?) Lost 3.8 lbs. in 1 week . (Pertinent hx to the issue) Resident has been having poor po (oral) intake. Increase agitation episodes. Also refusing meds. 8. review of medication records [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had not refused this medication on the day shift during the period of 06/01/20 - 06/15/20 and refused the 05:00 PM dose once during that period. 9. Review of Nursing Progress notes revealed the following entries: 06/14/20 19:04: Wt. loss 3.6 lb. Meal intake averages 0-25%. She has supplemental Ensure PRN (as needed) which she refuses occasionally .MD was informed of significant weight change . 06/16/20 06:10: Res was currently in W/C drinking coffee. Res is noted of banging on the table before her occasionally. There was no documentation that shift regarding the restraint incident or R1's behavior reported by CNA1 that proceeded the application of the restraint. 06/17/20 06:23: Resident was combative during positioning and incontinent care .attempting to console and educate resident, unable to be reoriented. 06/17/20 18:31 .Res slept in bed throughout the shift this far, woke up briefly during vital sign check .refusal to drink ensure and eat dinner .held medication this evening due to resident lethargy and refusal. 06/18/20 12:08: Nutrition wt review: 6/14: 116#, decrease 3.6#/week. Res has a hx: wt fluctuations, with gradual wt loss from 5/17: 123.4# to 116.4#. PO intake is poor, 0-25% with refusals . 06/18/20 12:30: RD (Registered Dietician) documented called res daughter to inform her of res po intake, wt. loss, etc . Daughter states it is part of the aging process. Daughter reports that res would always eat all her food and did not like to waste food, per daughter, res has changed . 06/19/20 18:35: Unable to check O2 sat (oxygen saturation) resident suddenly became combative. Resident attempted to hit/scratch staff, which is resident's on and off behavior. Resident threw away pulse oximeter (small clip on device that attaches to a body part, most commonly on a finger that measures oxygen level in the blood). 06/21/20 19:04: Resident refused meal and medications. Resident pushed supplements away when offered. 06/21/20 22:31: RN documented, Resident lost 3.8 lbs. in 1 week Current weight is 112.6# .This week PO intake has been poor. She has been refusing meals and medication. She refused meals 7 times. She has also been refusing to take her ensure supplement. MD notified and will assess resident on next visit. 06/22/20 12:34: Resident stayed in bed this shift. Refused to get OOB (out of bed) and to eat meals .refused to take medications .sleepy most the shift. 06/22/20 06:46: .Needs 2-3 staff extensive assist .Combative with care & even with routine repositioning. Kicking, punching, scratching & spitting at staff, unable to reorient & calm down. 10. RR revealed documented R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the period of 6/01/20-06/16/20 R1 refused meals 11 times, and showed an increase in refusing meals. R1 refused meals seven times during the period of 06/16/20-06/21/20, and continued with significant weight loss. 11. Cross Reference Tag 550 The facility failed to protect the rights of one Resident (R)1, who was not treated with dignity and respect when CNA1 applied a physical restraint without a physician's order on 06/16/20. In addition, R1's care plan (CP) provided a clear picture of individualized needs and preferences to decrease behaviors, but CNA1 did not follow the CP.

Based on interviews, observations and record review (RR), the facility failed to ensure that one resident (R)1 was free of physical restraint. On 06/16/20 at approximately 04:45 AM, a Certified Nurse Aide (CNA)1 was providing morning incontinent care and completing other tasks when R1 exhibited behaviors (hitting, kicking and spitting) of resisting. CNA1 proceeded to physically restrain R1 by tying the sleeves of her jacket together to prohibit movement so care could be completed. This action met the definition of a physical restraint as the application was meant to limit R1's movement and actually restricted freedom of movement. As a result of this deficient practice there was the potential of psychological harm. Findings Include: 1. The Office of Healthcare Assurance ([NAME]) received a facility incident report (ACTS # 8313) regarding staff to resident abuse. The event description stated, On 06/16/20 at approximately 04:45 am, CNA1 was providing routine morning care to the resident (R1). When CNA1 was providing incontinent care, resident reacted by hitting, scratching, kicking and spitting at CNA1. Resident was wearing a zipped-up jacket at the time and CNA1 tied the end of the jacket arm sleeves together. CNA1 proceeded with providing incontinent care, dressed the resident, then transferred the resident onto the WC (wheelchair). Registered Nurse (RN)1 was in the hallway outside of resident's room when he/she heard the resident yelling. When he/she responded to the residents yelling, he/she noted resident sitting on the WC with the jacket arm sleeves tied together . 2. RR and review of the incident report revealed R1 was a [AGE] year-old female who was initially admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She is alert and oriented to person, has cognitive impairment, and does not initiate communication to verbalize her needs. R1 can communicate verbally, however, communication is limited to understanding simple phases, and responses may not be appropriate to reality. R1 has short, self-oriented outbursts. R1 has a known response when approached by other individuals, to shout out for others to go away, and gesture with her arms and legs for those approaching to stop and move away, almost interpreted as defending self or does not want others to bother her, or wants to be left alone. Resident does not understand her cognitive and physical deficits and does not understand the day to day care needs . R1 has a history of punching staff, pulling hair and yelling. R1's Care Plan (CP) identified the behaviors as an active problem and directed staff to implement several actions/interventions to limit behaviors. 3. The facility provided a typed document of interviews conducted by ADON (Assistant Director Of Nursing) with CNA1 and RN1 the morning of the incident at approximately 05:00 AM on 06/16/20, as well as an additional interview with CNA1 and other leadership. The document revealed the following: He (CNA1) stated that he did tie the resident's jacket arm sleeves together because he was trying to protect himself from the resident who was hitting, scratching, kicking and spitting at him during routine morning care which included incontinent care, dressing, and personal hygiene care. He understood that it was a restraint and shouldn't have done it. 4. Review of the facility policy titled Restraint Use, revision date 03/10/11, revealed the following policy statements: The facility upholds the right of the resident to be free from any physical or chemical restraints for the purpose of discipline or convenience . The policy defines Physical restraint: Any manual method, physical or mechanical device, material, or equipment that is attached or adjacent to the resident's body that the resident cannot remove easily and restricts freedom of movement or normal access to one's body. To be a physical restraint, a device must the following two criteria: 1) the device actually restricts the resident's freedom of movement .; and 2.) The intended use is to restrict movement of the resident in some way. 5. RR revealed R1 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .