Every finding on record at Pearl City Post Acute

Based on observations, interviews and record reviews, the facility failed to follow proper food handling and storage practices in accordance with professional standards for food service safety. Specifically, the facility failed to keep bulk food items off the floor in the storage room and did not label two containers of food brought in by family/visitors in one of three unit refrigerators sampled. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness as a result of their compromised health status. Findings include: 1) On 04/06/26 at 08:17 AM, an initial tour of the facility's kitchen and interview with the Dietary Manager, were done. Observed seven boxes of instant food thickeners on the floor of the dry storage area. The Dietary Manager confirmed the boxes of food items should not be on the floor. On 04/08/2026 at 9:36 AM, review of the facility's policy and procedure titled Food Receiving and Storage with a revision date of November 2022, stated, . 5. Food in designated dry storage are kept at least six (6) inches off the floor . 2) On 04/06/26 at 12:00 PM, the resident refrigerator, located in the third-floor dining room (P3), was checked. Two containers of cut fruits were observed labeled with Resident (R)47's name but no expiration or use-by date was found. The containers were checked by Registered Nurse (RN)20 who confirmed that it was brought in by visitors of R47 and was not labeled by the facility with an expiration date. On 04/06/26 at 12:05 PM, interviewed Activity Assistant (AA)10 in P3 dining room, who stated that food items brought in from the outside should be dated and is kept for three days. On 04/09/26 at 08:37 AM, interviewed the Dietary Manager (DM) right outside of the kitchen. DM stated that family/visitors are allowed to bring in food for the residents and Nursing or Activity staff should label the food item with the resident's name, room number and expiration date. DM stated that no matter what type of food item is brought in, it should only be kept for three days and then discarded. A facility policy titled, Foods brought by Family/Visitors, dated 2021, stated, . 5. Food brought in by family/visitors that is left with the resident to consume later is labeled and stored . a. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the time and the use by date . 6. The nursing staff will discard perishable foods on or before the use by date.

Based on record review and staff interview, the facility failed to ensure that the resident's court-appointed guardian was informed, in advance, of the risks, benefits, and available treatment alternatives related to psychotropic medications prescribed by the physician for one of five residents (Resident (R) 74) reviewed for unnecessary medications. This puts R74 at risk of receiving unnecessary psychotropic medications without informed consent.Findings Include:R74 was admitted to the facility on [DATE] with diagnoses of unspecified mood (affective) disorder, insomnia, and history of falling. On 10/04/24, R74 was deemed incapacitated and a court-appointed guardian with unlimited authority was established. Review of R74's physician orders document R74 was receiving the following psychotropic medications; olanzapine 5 milligrams (mg) once a day for major neurocognitive disorder effective 03/04/26, paroxetine HCI 10mg once a day for major neurocognitive disorder effective 08/22/24 and trazodone HCI 25 mg at bedtime for depression effective 03/03/26. Review of R74's Electronic Health Record (EHR), indicated that consent forms for use of psychotropic medications, paroxetine and olanzapine, including risk and benefits, were signed by a family member dated 08/22/24, not the court-appointed guardian. Documentation further revealed the court-appointed guardian was notified of the psychotropic medication, olanzapine until 04/06/26. Review of R74's Medication Administration Record (MAR) for March 2026 and April 2026 showed R74 received these psychotropic medications daily. Review of the pharmacist's Medication Regime Review (MRR) dated 03/21/26 documented a recommendation for the facility to update the signed consent forms to reflect the current medication regimen, noting recent dose decreases for trazodone and olanzapine. On 04/08/26 at 01:30 PM, an interview with Registered Nurse (RN)12 was conducted. RN12 confirmed there was no documentation that the court-appointed guardian had been informed of the risks and benefits of the prescribed psychotropic medications when the facility became aware of the guardian status. RN12 further confirmed the guardian was not informed in advance of medication changes. RN12 stated there were changes to olanzapine and trazodone, and a note was later observed instructing staff to contact the guardian on 04/06/26, at which time verbal consent was obtained. Review of the facility's policy and procedure Psychotropic Medication Use revised on 02/25, documented . Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with resident/representative prior to obtaining documented or refusal: . non-pharmacological alternatives; . the indications and rationale for the recommendation; the potential risks and benefits . and the resident's/representative's right to accept or decline the treatment.

Based on observation, interview, and record review, the facility failed to identify, support, and honor the preferences for one of one resident (Resident (R)47) sampled for Choices. The facility failed to honor R47's preference to be assisted outside the facility for fresh air wearing the hospital gown. As a result of this deficient practice, R47 did not have his needs met and was placed at risk of not attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include:On 04/06/2026 at 12:15 PM, an interview was done with R47 and family member (FM) at bedside. When asked about the right to make choices in his daily life that were important to him, R47 stated that he wishes he could go outside for some fresh air and sunlight. R47 also explained that he wanted to go down to the ground level with family member but was told that the facility will not allow residents to go outside unless they are wearing regular street clothes. On 04/08/26 at 08:36 AM, an interview was conducted with the Nursing Supervisor (NS)11 in her office. When asked about the right to make choices for R47's preferred clothing when going outside the facility, NS11 confirmed that facility should honor the resident's choice for clothing they prefer to wear. On 04/09/2026 at 09:32 AM, review of facility policy titled Dignity with a revision date of October 2025 stated, . 2. Resident goals, preferences, values.are respected and honored to the extent possible . 5 . residents are supported in exercising their rights . c. dress in clothing they prefer .

Based on observations and interview, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by a heavy buildup of dust on the fans for Resident (R)83 and R109. This deficient practice could affect all residents in the facility if their environment is not kept clean, putting them at risk for increased adverse health conditions. Findings include:1) On 04/06/26 at 09:41 AM, observed R109 lying in bed with head elevated and eyes closed. R109 had a tracheostomy tube (surgically created opening in the neck to establish an airway) and was on supplemental oxygen via tracheostomy collar (plastic mask worn around neck to deliver humidified oxygen). Observed a fan turned on and was directed at R109. The front and back screens of the fan had a buildup of a light grayish substance. 2) On 04/08/26 at 08:34 AM, observed Registered Nurse (RN)12 administer medications to R83. Observed a heavy buildup of a light grayish substance on the front and back screens of the fan that was being used and directed at R83. R83 had a tracheostomy tube and was connected to a ventilator (machine used to provide mechanical breathing to patients unable to breathe on their own). On 04/09/26 at 08:49 AM, concurrent interview and observations were done with Nurse Supervisor (NS)9 at R109's bedside. Queried NS9 how often are the fans used by the residents inspected and cleaned. NS9 said the fans are checked every week and cleaned as needed. NS9 acknowledged that the fan being used for R109 was dusty and said she will have housekeeping clean it. At 09:50 AM, checked the fan being used for R83 with NS9. NS9 acknowledged that the fan had a heavy buildup of dust and turned it off.

Based on observations, interviews, and record reviews, the facility failed to ensure that two of four sampled residents (Resident (R)3, and R8) were free from physical restraints. Specifically, the facility failed to document when the restraints were applied and released. As a result of this deficient practice, R3 and R8's rights were violated, and were placed at risk of avoidable injury and/or a decline in their psychosocial well-being. Findings include:1) R3 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. On 04/06/26 at 10:06 AM, and 02:05 PM, observations were done with R3 at bedside. R3 observed wearing mitten restraint on right hand. The placement of the mitten restraint was ordered to prevent R3 from pulling out tube connected to his tracheostomy (surgically created opening in the neck) and gastrostomy tube (medical device inserted through the abdomen and into the stomach used to deliver food, fluids and medications). Review of R3's Treatment Administration Record (TAR) dated 04/07/26 instructing the staff to release mitten restraint to right hand every two hours and as needed revealed that it was marked YES at 09:50 PM. No other form of documentation was found in R3's Electronic Health Record (EHR). On 04/08/26 at 02:6 PM, conducted concurrent interview and record review with Nursing Supervisor (NS)9 in her office. When asked if staff document observations of the resident and when the restraint is applied or removed, NS9 concurred. NS9 said, The staff were releasing the mitten but was only documented on 04/07/26. On 04/08/2026 at 02:44 PM, review of facility policy titled Use of Restraints with a revision date of 04/17 stated, .12. The following safety guidelines shall be implemented and documented . c. A resident placed in a restraint will be observed at least every thirty (30) minutes.resident's condition shall be recorded in the resident's medical record 2) R8 was an [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. Diagnoses included but not limited to mild cognitive impairment, chronic respiratory failure with a tracheostomy and ventilator (machine used to provide mechanical breathing to patients unable to breathe on their own) dependence. On 04/06/2026 at 11:53 AM, observed R8 lying in bed with head elevated. R8 had mitten restraints applied to both hands. On 04/07/2026 08:34 AM, 12:39 AM and 03:07 PM, observed R8 with mitten restraints applied to both hands while lying in bed. Review of EHR revealed mitten restraints were ordered on 10/16/25 to prevent R8 from pulling on tracheostomy tube and ventilator lines. Review of Care Plan with a revision date of 03/16/26 stated, . Document restraint use and release as per facility protocol. Further review of the EHR conducted and documentation of use and release of the restraint was not found. 04/09/2026 at 08:52 AM, concurrent interview and record review was done with NS9 in her office. Queried NS9 where staff document when they use and release the mitten restraint for R8. NS9 said the staff document in the EHR under Task. NS9 navigated to the log and only found documentation for 04/07/26 and 04/08/26, no other documentation was found in the EHR. NS9 acknowledged that the staff were not documenting when the restraint was applied and when it was released.

Based on interview and record review, the facility failed to ensure a psychotropic medication was necessary to treat a specific, diagnosed, and documented condition and an as needed (PRN) antipsychotic medication order was limited to 14 days without exception for two of five residents (Resident (R)74 and R13) reviewed for unnecessary medications. This puts residents at risk for unnecessary use of psychotropic medications, including use as chemical restraints, which may lead to over-sedation, confusion, falls, and decreased quality of life, and violates their right to receive medications only when clinically indicated. Findings Include:1) R74 was admitted to the facility on [DATE] with diagnoses of unspecified mood (affective) disorder, insomnia, and history of falling. Review of R74's physician orders revealed the resident was prescribed the antidepressant trazodone 25 milligrams (mg), one tablet at bedtime for depression. Review of R74's Electronic Health Record (EHR) revealed no documented diagnosis of depression. Review of discharge documentation from the acute care hospital and admission records to the facility also did not include a diagnosis of depression. Review of the facility's quarterly geriatric depression assessment dated [DATE] indicated R74 scaled at a 4, reflecting low risk for depression, with no follow-up assessment indicated. On 04/08/26 at 01:22 PM, an interview was conducted with Registered Nurse (RN)10. RN10 confirmed R74 does not have a diagnosis of depression and stated trazodone was prescribed upon admission due to nighttime restlessness. Review of the facility's policy and procedure Psychotropic Medication Use revised on February 2025, stated, . Psychotropic medication management is an interdisciplinary a process that involves the resident, family, and/or the representative and includes . determining adequate indications for use . Residents who have not used psychotropic medications are no prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnoses and documented in the medical record . 2) Review of R13's physician orders revealed an order for the antipsychotic medication quetiapine fumarate 25mg, 0.5 tablet, PRN for agitation, initiated on 03/05/26 with a duration of three months. On 04/08/26 at 01:48 PM, an interview was conducted with Registered Nurse (RN)12. RN12 confirmed that PRN antipsychotic medications should not be prescribed longer than 14 days, and is considered a chemical restraint. Review of the facility's policy and procedure Psychotropic Medication Use revised on February 2025, stated, . PRN orders for psychotropic medications are limited to 14 days . For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication .

Based on record review and interviews, the facility failed to report an injury of unknown origin that resulted in serious bodily injury for one of one resident (Resident (R)63) reviewed for abuse. The facility did not ensure that the injury was reported immediately, but no later than two hours after identification, to the State Survey Agency (SA) and Adult Protective Services (APS). Specifically, while providing care, a staff member observed that R63's contracted right shoulder and elbow unusually loose. Subsequent X-rays confirmed a fracture of the right humerus (upper arm bone). Despite this finding, the facility did not report the injury within the required timeframe. Findings Include: Review of R63's Electronic Health Record (EHR) revealed that on 08/05/26, a Restorative Nursing Aide (RNA) reported to the primary nurse that the contractures in R63's right shoulder and elbow appeared more loose while assisting the resident with dressing. Nursing documentation indicated an assessment was completed, noting right arm swollen and that the resident cried during turning. An X-ray was ordered the same day. Review of the X-ray results dated 08/05/26 revealed an acute mildly displaced fracture of the mid humerus, with a recommendation for an orthopedic consultation. On 08/06/26, R63 was transferred to the emergency room for further evaluation and treatment. On 04/07/26 at 12:52 PM, a telephone interview was conducted with R63 representative (RR2). RR2 reported that the facility was unable to determine how the resident sustained the fracture to the right arm. On 04/08/26 at 11:55 AM, an interview was conducted with Director of Nursing (DON). DON confirmed that the facility did not report the injury of unknown origin to the SA. The DON acknowledged that, in consideration of reporting requirements and timeframes, the injury should have been reported, even though the physician later assessed the fracture as pathological. Review of the facility's policy and procedure Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating indicated that injuries of unknown source are to be reported to the administrator immediately. The policy further stated that allegations involving abuse or injuries resulting in serious bodily injury must be reported within two hours to the State Survey Agency (SA), ombudsman, resident representative, Adult Protective Services (APS), law enforcement, the attending physician, and the medical director.

Based on observation, interview and record review, the facility failed to recognize and put preventive measures in place to prevent the potential development of pressure injury for one of one resident (Resident (R)2) utilizing a nasal cannula to receive oxygen. This deficient practice put all residents that utilize a nasal cannula at risk for potential development of medical device related pressure injury. Findings include:On 04/07/2026 at 08:51 AM, R2 had an oxygen nasal cannula with the cannula prongs in her nostrils and tubing under her chin, along her cheek bones and looped around her ears. The cannula tubing was observed pressing into her right facial cheek bone area. When the oxygen cannula was lifted from that area an indentation mark and redness was noted to the cheekbone area that the cannula was pressing into. On 04/07/2026 at 10:30 AM, R2's right cheekbone skin area remained with the indentation mark and redness. On 04/08/2026 at 09:10 AM, observed the oxygen cannula tubing pressing against the same right cheekbone area for R2 with an indentation mark and redness to the skin area under the cannula and immediately surrounding the cannula area. On 04/08/2026 at 09:22 AM, a review of R2's care plan listed care plans for Risk of Skin breakdown, Pressure ulcer risk, Respiratory, and Oxygen therapy. All did not include any specific interventions to check a resident's pressure points (e.g. nares, cheeks, chin, ears) while oxygen cannula was in use and to protect tubing contact points. On 04/08/26 at 11:20 AM, interviewed the Wound Nurse (WN)2 in R2's room with concurrent observation of the placement of R2's oxygen nasal cannula on her face. WN2 identified that R2's nasal cannula was pressing into her right cheek. She lifted the cannula and confirmed there was an indentation mark and blanchable redness caused by the cannula pressing into the R2's skin. WN2 stated that what she observed was a risk for development of pressure ulcers. WN2 stated that she was unsure if there was a specific protocol to check skin integrity when a resident was wearing an oxygen nasal cannula, but checks should have been done and the skin integrity change reported. On 04/09/26 at 09:55 AM, interviewed Director of Nursing (DON) in his office. DON stated that the facility does not have any specific protocol to check the oxygen nasal cannula placement when a resident is wearing it. DON stated that the ears and cheekbones are high risk areas for development of pressure injuries and should be checked and identified when a resident is using an oxygen cannula.

Based on observations, interviews, and record review, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff wear applicable personal protective equipment (PPE) when providing care to two of 11 residents on Transmission Based Precautions (TBP). This deficient practice placed the residents at risk for the potential spread of preventable infections and communicable diseases. Findings include:1) On 04/07/26 at 08:26 AM, observed signage by the door of Resident (R)14's room with a heading that stated, Contact Precautions. Resident (R)14 was lying in bed with a tablet computer on the table in front of her. At 08:28 AM, observed Activity Assistant (AA)5 at R14's bedside without a gown or gloves. AA5 was helping R14 with the power cord for a tablet computer that was on the table. At 08:29 AM, AA5 was also observed leaning close to R14 when communicating since R14 was talking in a very soft voice. On 04/07/26 at 08:35 AM, queried Nurse Supervisor (NS)9 at the nurses' station regarding the sign posted outside R14's door. NS9 said R14 was on contact precaution and the sign outside her door is to make staff aware of using the proper PPEs when entering the room. 2) On 04/08/26 at 08:26 AM, observed Certified Nurse Aide (CNA)22 assisting R89 with breakfast in his room. CNA22 was seated next to R89's bed and was not wearing a gown or gloves. At 08:27 AM, Registered Nurse (RN)12 confirmed that R89 was one of the residents on contact precautions as indicated by the poster at the entrance of the room. On 04/08/26 at 03:07 PM, an interview was conducted with the Infection Preventionist (IP) in her office. IP confirmed that staff are to a wear gown and gloves when providing care to residents on contact precautions. 3) On 04/09/26 at 08:51 AM, observed CNA29 assisting R89 with his meal in his room. CNA29 was not wearing a gown or gloves and was sitting next to R89. At 08:51 AM, NS9 confirmed that R89 was still on contact precautions and staff are to wear gown and gloves when providing care. Review of facility policy titled Isolation - Categories of Transmission-Based Precautions dated September 2022, stated, . Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact . Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room .

Based on observations, interviews and record review, the facility failed to ensure shared medical devices were properly disinfected after use. Specifically, the facility did not use the appropriate disinfectant to wipe the shared blood glucose meter (device used to measure blood sugar levels). The facility also failed to ensure proper aseptic technique was used to prevent the transmission of communicable diseases and infections when initiating Intravenous (IV) medication for Resident (R)82. The deficient practices have the potential to expose the residents requiring blood glucose testing and IV medications to diseases-causing pathogens. Findings include: 1) On 05/22/25 at 09:14 AM, inspection of the of the medication cart was conducted with Registered Nurse (RN)10. Observed a blood glucose meter in the top drawer of the cart that RN10 said the staff use to check blood sugar levels of multiple residents on the unit. Asked RN10 how often is the device disinfected and what do they use. RN10 replied the staff disinfect it immediately after each use with the alcohol wipes or the PDI Super Sani-Cloth germicidal disposable wipes. On 05/23/25 at 07:39 AM, an interview was conducted with the Director of Nursing (DON) in the conference room. DON confirmed that alcohol wipes are not approved for use on the blood glucose meter since it is not on the list of disinfectants specified by the manufacturer. Review of the users' manual for the blood glucose meter (Arkray Assure Platinum) used by the facility revealed that alcohol wipes or pads was not on the list of products the manufacturer validated for disinfecting the meter. CMS (Centers for Medicare and Medicaid Services) Memo, S&C: 10-28-NH dated 08/27/10 stated, . Point of care devices, such as blood glucose meters, . if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer's instructions. 51868 2) On 05/22/25 at 07:56 AM, observed medication administration with Licensed Practical Nurse (LPN)45. After LPN45 prepared intra-venous (IV) antibiotic medication for R82, he proceeded to hang the medication on an IV pole with the end of the IV tube (the port end) uncovered and unprotected. LPN45 then connected the IV antibiotic but failed to keep the port end of the IV line clean and sterile when it touched the resident's gown, prior to connecting with R82's Peripherally Inserted Central Catheter (PICC) line (tube inserted into a large vein near the heart to deliver medication). On 05/23/25 at 10:30 AM, an interview was done with the DON and the Infection Preventionist (IP) inside DON's office. When asked if staff should keep IV line sterile and always protected to prevent contamination, both DON and IP confirmed that the end part of the IV line should always be covered with a sterile green cap when it is not connected to the PICC line. This is to ensure the tip is not exposed to contaminants that could cause preventable infections or other adverse complications associated with having a PICC line.

Based on observations, interview and record review, the facility failed to ensure one Resident (R) 68 of five residents in the sample, was free from unnecessary medication by providing R68 with an anti-anxiety medication as needed for greater than 14 days, and the physician did not provide the rationale for continuing the medication as ordered. The deficient practice may affect the residents who are receiving psychotropic medications. Findings include: Observation and interview at the bedside in R68s room on 05/21/25 at 09:00 AM. R68 was lying in bed, with the head of the bed at 45 degrees. He was dependent on a ventilator, and able to speak with the surveyor. He said that he takes pain medication for back pain that is always present, and the medication helps most of the time. Observation on 05/21/25 03:20PM R68 was in bed with his eyes open, watching the television. R68 looked comfortable without any distressful gestures or facial expression. Record Review of the Minimum Data Set (MDS) unplanned discharge/ return anticipated assessment date 03/18/25 on 05/22/25. [AGE] year-old male with a primary diagnosis that includes: Quadriplegia (paralysis of both upper and lower extremities) with multiple medical conditions; anxiety disorder; Post-Traumatic Stress Disorder (PTSD); chronic respiratory failure with hypoxia; one stage four pressure ulcer to the sacrum; and dependance on respirator (ventilator) status. Received as needed pain medication and scheduled pain medication regimen. Is taking an antidepressant, antianxiety, and an opioid. Care Plan reviewed on 05/22/25. Mood/Behaviors. R68 has anxiety and can become combative and verbally aggressive. Date revised on 03/26/25. Administer medications (antianxiety and antidepressant med as ordered), date revised 10/21/2024. Medication Administration Record (MAR) reviewed on 05/22/25. Ativan (medication for anxiety); oral tab 0.5 milligrams (mg) give 0.5 mg via gastric (G) tube every (Q) three hours, as needed (prn) anxiety for three months. Start 04/30/25. Telephone call to R68s family member (FM) 1 on 05/22/25 at 12:54 PM. During the call FM1 stated to the surveyor that R68 has a lot of anxiety and sometimes he takes it out on the staff with yelling. He has gotten a lot better lately; I keep reminding him that he needs to try to be patient and that the staff are taking good care of him. Requested documentation from the Director of Nursing (DON) on 05/22/25 at 02:30 PM. Specifically a note written from the Physician that states the rationale for giving Ativan to R68 on an as needed order longer than 14 days. The DON explained to the surveyor that there wasn't any documentation from the physician that he was aware of and would speak with the pharmacist.

Based on observation, interview, and record review, the facility failed to protect and promote the rights for two of 25 residents sampled (Resident (R) 28 and R82) by ensuring that she was treated with respect and dignity. This deficient practice has the potential to affect all residents in the facility. Findings Include: R28 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of the following but not limited to Hemiplegia and Hemiparesis (weakness) following non-traumatic Intracerebral Hemorrhage (stroke) affecting the left side. A review of her Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 02/20/25 noted R28 had severe cognitive impairment, and the Brief Interview for Mental Status (BIMS) couldn't be conducted. On 05/20/25 at 10:19 AM, concurrent observation and interview was done with R28's Family Member (FM) 1 at her bedside. FM1 described an incident where he observed staff repeatedly going in and out of the resident's room without knocking and requesting permission before entering R28's room. At 10:26 AM, an interview was done with the Administrator at the nurse's station and confirmed that all staff should always knock and request permission first before entering a resident's room. 2) On 05/20/25 at 10:30 AM, observed Licensed Practical Nurse (LPN) 45 repeatedly going in and out from R82's room but failed to knock and introduce himself prior to entering the room. When the surveyor asked LPN45 if he should knock first and introduce himself before entering the room, he confirmed he should always knock and introduce himself before going inside the resident's room. Review of the facility's policy and procedure on 05/22/25 titled Dignity revised February 2021, directed the staff, . 7. Staff are expected to knock and request permission before entering resident's room .

Based on observations, interviews, and record review, the facility failed to ensure a resident's care plan was revised to include and implement interventions to prevent and minimize conflicts between residents for one of two residents (Resident (R) 69) sampled for mood and behavior. R69 displayed aggressive behavior toward selective residents when eye contact is made. This puts residents at risk of untoward behavior. Findings Include: On 05/20/25 at 09:52 AM, observed a resident, R83, from a distance in the activity room upset and yelling toward another resident, later identified as R69. R69 was observed to be sitting in the activity room not responding and far away from R83. Staff was able to redirect R83 and did not appear upset anymore. Inquired with R83 who she was yelling at and what happened, R83 stated she was not upset, and nothing happened but did not like R69 because she was mean to everyone. R83 was not able to elaborate. While talking to R83, suddenly heard R69 and an unidentified resident yelling at each other as the unidentified resident attempted to leave the activity room and pass R69. R83 also began yelling as well. R83, R69, and the unidentified resident were quickly redirected by staff and when the unidentified resident was removed from the room the yelling quickly subsided. On 05/22/25 at 03:26 PM, R69 was observed in her wheelchair, wheeling herself to the activity room. R69 grabbed a basket from a table she is assigned to in the activity room and attempted to place it on another table between two other residents, R13 and R18. A chair was in between the two residents preventing R69 from sitting in between them. R18's sitting position had her back toward R69. A staff member approached R69 to redirect her and R18 looked to her side toward R69. R69 started yelling at R18 What are you looking at me for? You look at somebody else! The staff member redirected R69 immediately and assisted R69 out of the activity room into the hallway. R69 was observed to wheel herself toward nurse's station and her room. R18 did not respond to R69's yelling. At 03:29 PM, R18 was observed to ask a staff member to help her get back to her room to use the restroom. The staff member wheeled her in the hallway, past her room, the nurse's station and R69, then turned around asking R18 where her room was. R18 directed her elsewhere, toward her room, and the staff member turned R18 around to pass R69 again. R69 attempted to hit R18 but the staff member quickly anticipated the action and moved R18 out of reach of R69. R18 did not respond to R69's action. Review of progress notes documented multiple incidents of R69 displaying behaviors of yelling and attempting to strike residents. It was documented in the progress notes that R18 used to be R69's roommate but changed rooms due to R69's behaviors toward R18. In a progress note documenting communication with the physician on 04/10/25, R69 had been displaying untoward behavior like yelling at other residents or anyone who makes noises at the nurse's station. The note described R69 to dislike certain residents, screaming, isolating herself, staying away from activities, roaming, hiding near the elevator, declining to eat her meals, and stating she is going to sleep outside. On 05/23/25 at 11:03 AM, an interview with Activity Assistant (AA) 1 was done. AA1 reported there are two residents she knows R69 does not like, R83 and R18. R69 gets upset when the residents look at her, even unintentionally. In activities, R83 sits far away from R69, with a pillar that sometimes blocks each other's view, and R18 was strategically placed at the group activity table to have her back toward R69 to prevent accidental eye contact. R18 used to sit away but facing the front of the activity room but they noticed once R18 looked to her side, accidently toward the direction of R69, R69 would get upset. AA1 confirmed R18 and R69 used to share a room but R18 was moved to another room due to R69's behavior toward her. R69 can wheel herself in the wheelchair and has a specific spot, close to the door, she likes to occupy in the activity room. When R69 is feeling upset she usually leaves the activity room and spends time outside of her bedroom in the hallway. Staff members try to ensure R69 and R18 avoid each other in the hallways to prevent any untoward behaviors. On 05/23/25 at 11:12 AM, a concurrent record review and interview with Licensed Practical Nurse (LPN) 43 was done. LPN43 reported R69 has a behavior of screaming and there are specific residents that trigger her behaviors. Staff try to separate the residents that R69 is known to yell at, such as separating them in the activity room, changing bedrooms, and ensuring residents that trigger R69 avoid her in the hallways by taking a different pathway. Inquired if R69's care plan, included the interventions mentioned regarding R69's behaviors and conflicts with other residents, LPN43 confirmed it was not included in the care plan. On 05/23/25 at 11:23 AM, a concurrent record review and interview with Social Services (SS) 5 was done. SS5 further confirmed there is a section for mood and behavior in R69's care plan but there were no interventions for behaviors toward other residents and reported it should be care planned. Review of the facility's policy and procedure, Behavioral Assessment, Intervention, Monitoring revised March 2022, documented The care plan includes, as a minimum: a. a description of the behavioral symptoms, including: (1) frequency; (2) intensity; (3) duration; (4) outcomes; (5) location; (6) environment; and precipitating factors or situations. b. targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. rationale for the interventions and approaches; d. specific and measurable goals for targets behaviors; and e. how the staff will monitor the effectiveness of the interventions.

Based on observation, interview and record review, the facility failed to assist two dependent resident's (R) 66 and R75 of three residents in the sample, in the care necessary to achieve basic hygiene. The deficient practice may affect all the residents who are dependent on the staff on the unit. Findings include: Observation on the 4th floor at R66s bedside on 05/21/25 at 10:03 AM. R66 was lying in bed, with respiratory tubing connected to the ventilator. He didn't respond to the surveyor. The toenails on both lower extremities were thick, long, and with crust. The dry flakes on his feet were sloughing onto the bed sheet. The fingernails on his hands were long and untrimmed. R66 moved his left hand to scratch his right arm. Additional observations of R66s hands and feet were made on 05/21/25 at 10:04 AM; 01:00 PM; and 02:45 PM. Observation on 05/22/25 at 02:23 PM of R66 at the bedside. Skin tear approximately three centimeters (cm) long on the right forearm. R66 was positioned facing the left side toward the door. He had flaky skin on his hands and fingers. His feet had dry flaky skin with skin flakes present on the top sheet. R66s face had hair growth present. A musty odor was detected while standing next to R66. Record review of the face sheet on 05/23/25. R66 is a [AGE] year-old male with chronic respiratory failure, dependent on a ventilator (a mechanical machine that breathes for the resident) and dependent on staff for his personal care and hygiene. Minimum Data Set (MDS) quarterly assessment dated [DATE] reviewed on 05/23/25. R66 is severely cognitively impaired, is on a Gastric tube for nutrition and is dependent on staff for all his activities of daily living (ADLs). His primary diagnosis is debility, cardiorespiratory conditions including seizure disorder, depression, asthma, chronic obstructive pulmonary disease (long term respiratory disease) and respiratory failure. Care plan reviewed on 05/23/25. ADL self-care. R66 has an ADL self-care performance deficit related to (r/t) contracture, activity intolerance, impaired balance due to history of a traumatic brain injury. The resident is bedfast all or most of the time. The resident is totally dependent on two staff to provide the following: Bath/shower every Wednesday and Saturday and as necessary; repositioning and turning in bed every 2-3 hours and as necessary; dressing; personal hygiene and oral care; toilet use; and requires mechanical lift with two staff assistance for transfers. R66 is on tube feeding. Revised date 03/04/25. SKIN. R66 has history of recurrent rash of the upper back. Apply Betamethasone Valerate External Lotion as ordered by the Medical Doctor (MD). For dry and flaky skin use high quality moisturizers to rehydrate skin. Monitor skin rashes for increased spread or signs of infection. Reviewed skin check, skin warm and dry. Normal turgor. Revised 03/04/25. Interview with the Charge Nurse (CN) 20 on 05/23/25 at 10:33 AM at the 4th floor nurses station. The surveyor asked CN20 what is the process for residents to obtain nail trimming. CN20 explained that we have a list of residents to be seen by the Podiatrist, who comes once per month to trim the resident's nails. The nursing staff recommend residents who need to have their nails trimmed and the unit clerk makes the list of residents to be seen. The surveyor asked about R66 to see if he was seen by the Podiatrist. CN20 asked the unit clerk to check to see if the resident has a consultation. CN20 got back to the surveyor at 10:45 AM and said R66 wasn't on the list to be seen by the Podiatrist. The surveyor discussed the concerns about R66 thick long nails and that a scratch was present on his right forearm with CN20. The surveyor also shared the observations of the flaking skin on his feet and his hands and the hygiene concerns. CN20 said the assessments are done by the nurses and the Certified Nurse Aide's (CNAs) are good at informing the nurses that a resident's nails need to be trimmed or if there are any issues with the skin. CN20 said he will follow up with the nursing staff about the concerns with the dry skin and he will follow up with ensuring the nails are looked at and a referral made to the Podiatrist. 2) Observation of R75 at the bedside in her room on 05/21/25 at 09:19 AM. R75 had a rash to her right upper middle arm with several small red dots. Observed many healed spots to her left lower extremity, on top of her foot and ankle. Observed both feet with long untrimmed toenails. Record review of the face sheet on 05/22/25 at 1:00 PM. R75 is a [AGE] year-old female with a diagnosis of hemiplegia and hemiparesis (weakness) following a stroke that affected her left side. She is dependent on a ventilator and is dependent on staff for her personal care and hygiene. Skin check dated 05/04/25 reviewed. Skin normal, rash to face resolved. Interview with Registered Nurse (RN) 40 who was preparing medications on 05/23/25 at 09:45 AM outside of R75's room. The surveyor asked RN40 what the rash was on her upper extremities? RN 40 responded that R75 used to have a rash on her face, but it has healed. RN40 looked in the Electronic Health Record (EHR) and said, there weren't any notes about the rash to her upper extremities. During an interview with the CN20 on 05/23/25 at 10:33 AM at the 4th floor nurses station. The surveyor asked CN20 if R75 is one of the residents on the list to have their nails trimmed by the Podiatrist. CN20 checked the list and with the unit clerk and said, R75 was not on the list. The surveyor discussed R75s rash on the upper extremities and the conversation with RN40 that there weren't any notes documented in the EHR with CN20. CN20 said he would follow up with an assessment of R75s nails and the rash and ensure the MD is made aware. At 11:00 AM, CN20 said he checked R66 and R75s skin and nails and confirmed the concerns that were discussed with the surveyor. ADL, Supporting Policy 2001 MED-PASS, Inc. Revised March 2018 reviewed on 05/23/25. Policy Statement. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .5. e. Total dependence. Full staff performance of an activity with no participation by a resident for any aspect of the ADL activity .

Based on observation, interview, and record review, the facility failed to provide the appropriate treatment and services to prevent potential complications of enteral tube-feeding (TF) for one of one resident (Resident (R) 19) sampled for TF. The TF formula and TF flush bag was not labeled with a date which would indicate that the formula and flush bag were changed every 48 hours. As a result of this deficient practice, the facility placed residents who are on enteral nutrition at risk for avoidable infections and complications. Findings Include: On 05/20/25 at 09:33 AM, observed R19's TF formula with approximately 100 milliliters (mL) left and TF flush bag with a label indicating it belonged to R19, but the date was left blank. On 05/22/25 at 02:18 PM, an interview with Director of Nursing (DON) was done. The DON explained the TF formula bags and flush bags should be labeled with the resident's name and the date. The DON reported the facility uses a closed system and changes the TF formula based on the manufacturers recommendation of expiration within 48 hours of use. Review of a procedure document provided by the facility labeled Enteral Feeding Supplies Labeling, Cleaning and Disposal updated on 05/12/23 documented The TF formula and TF flush bag should be labeled with the following information: -Patient's name or identification number -Type of formula/water flush -Administration rate -Date and time of Administration It is important to note the TF formula and flush bad should be changed when the TF is consumed or 48 hours have passed since the administration, whichever comes first.

Based on observation and interviews, the facility failed to dispose of an intravenous (IV) medication vial labeled for single use. As a result of this deficient practice, residents who require IV fluids and medications were placed at risk of receiving expired fluids. This deficient practice has the potential to affect any patient taking IV medications. Findings include: On [DATE] at 09:14 AM, an inspection of the medication room was conducted with Registered Nurse (RN)10. A bag containing five vials of sterile water was found in one of the cabinets. One of the vials was open and had the following written, [DATE], 0200. Asked RN10 what the numbers meant. RN10 said it meant the vial was opened on [DATE] at 02:00 AM. RN10 also added that the vial should have been discarded after it was opened since it was single use. Asked RN10 if any of the current residents in the unit are on IV medications. RN10 confirmed there were currently two residents receiving IV medications. On [DATE] at 07:39 AM, an interview was conducted with the Director of Nursing (DON) in the conference room. Asked the DON what is the facility practice for single use medication vials. The DON said single use vials are to be discarded immediately after use to ensure if is only used once.

Based on observation, interview and record review, the facility failed to follow food handling and storage practices in accordance with professional standards for food service safety. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for foodborne illness. Findings include: On 05/20/25 at 08:17 AM, an initial tour of the facility's kitchen and interview with the Lead [NAME] (LC) were done. Observed one box of syrup on the floor of the dry storage area. LC confirmed the boxes of food items should not be on the floor. Review of the facility's policy and procedure on 05/21/25 titled Food Receiving and Storage revised November 2022, directed the staff, . 5. Food in designated dry storage are kept at least six (6) inches off the floor .

Based on interview, record review and document review, the facility failed to ensure that one resident (R) 25 of three in the sample received care and services to prevent a urinary tract infection (UTI). The resident's indwelling foley catheter was not removed as ordered upon admission to the facility until [DATE] and the resident developed a UTI. The Resident declined and was hospitalized on [DATE] for a serious illness. Findings include: Cross reference to F692 Reviewed intake ID11269. Resident's family member (F)1 filed a complaint to the state agency regarding care at the facility from [DATE] to [DATE]. F1 interviewed by telephone on [DATE] at 3:00 PM. F1 confirmed the concerns noted in the intake and emphasized that she was aware of the discharge instructions to remove R25s indwelling catheter, and that she asked the nursing staff repeatedly when the foley catheter was going to be removed. F1 was very worried that R25 would develop a UTI and did test positive on [DATE]. F1 stated that her mother also lost 20 pounds (lbs.) during the time she resided in the facility. F1 stated that R25 was in the hospital until [DATE], and was discharged home on hospice. On [DATE], R25 died . Onsite survey conducted on [DATE]. Electronic Medical Record (EMR) reviewed. R25 is a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of rhabdomyolysis, a breakdown of skeletal muscle due to muscle injury, and generalized muscle weakness. (Per review of the admission record), [DATE]. Discharge instructions dated [DATE] from Acute care hospital reviewed. Cardiac diet . Rehab .Voiding trial at skilled nursing facility (SNF) for foley removal . Minimum data set (MDS) admission five-day assessment dated [DATE] reviewed. Resident has an indwelling foley catheter at the time of assessment. No trial of a toileting program attempted on admission/entry or reentry. Care plan reviewed. Focus: The resident has indwelling catheter due to urinary retension (sic). Monitor to the Medical Doctor (MD) for signs and symptoms (s/sx) UTI: pain, burning .altered mental status, change in behavior, change in eating patterns. Progress notes reviewed. Removed indwelling foley catheter at 3:00 PM. [DATE]. 3:12 PM resident is confused, F1 came and also notice that R25 is confused, called MD to made aware and ordered Urinalysis (UA). Straight Cath done and noted cloudy urine 350 cubic centimeters (cc) out. [DATE] 02:05 AM. 2:35 PM. F1 called about R25's UA. Informed her that report status pending. MD is aware but will wait for the final result. [DATE] 3:40 PM MD ordered Cipro (antibiotic) 250 milligrams (mg) by mouth (PO) x five days. [DATE] 11:45 Final UA culture & sensitivity (C&S) result showing Extended Spectrum Beta Lactamases (ESBL), a type of enzyme or chemical produced by some bacteria that are resistant to common antibiotics. Relayed to MD. Received order to complete 14 days treatment of Cipro. [DATE] 11:42 AM. Mental Status: Resident is confused. [DATE] 3:54 PM. F1 requested transfer to Emergency Department (ED). MD made aware of patient's decline. Ambulance arrived at facility at 1:30 PM to take R25 to ED. [DATE] at 09:01 AM. Confirmed patient arrived at ED at 2:34 PM. Resident admitted at 9:53 PM with an admitting diagnosis of Metabolic encephalopathy, a brain dysfunction caused by systemic illness. Interview with Director of Nursing (DON), Nursing Supervisor (NS)1, and Registered dietician, (RD)1. On [DATE] at 12:24 PM in the Administrators office. The surveyor asked the DON and NS1 when did the hospitalization for R25 occur and what was the cause. They looked in the EMR and said she was sent to ED for weakness, poor po intake and weight loss of 20 pounds. The DON added that the resident's dehydration status would have affected the UTI and confirmed that the indwelling catheter had not been removed as ordered in the admission orders. Urinary Tract Infections (Catheter-Associated), Guidelines for preventing Level III 2001 MED-PASS, Inc. reviewed. The purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs) .Be able to identify and report the clinical signs and symptoms of a urinary tract infection (with or without catheter), including: .Confusion and/or functional decline .General Guidelines .It is the responsibility of the interdisciplinary team to maintain vigilant practices to prevent CAUTIs and to recognize and report early indications that a CAUTI may be developing .Leave catheters in place only as long as needed. Conduct ongoing assessment and monitoring of residents with indwelling catheters to establish continued need .Initiate steps to discontinue order and remove catheter if criteria is no longer met . Hospital medical record dated [DATE] to [DATE] reviewed. Principal diagnosis: UTI .Secondary diagnoses include .Acute-subacute metabolic encephalopathy, multifactorial, resolving. Chief issue on admission, significantly worsening confusion at her SNF .On this admission initial UA was from Old foley, but on repeat urine culture still grew ESBL E coli resistant to multiple agents .Treated 7-day course of Ertapenem .discharged home on hospice.

Based on interview, record review and document review, the facility failed to Recognize, evaluate, and address the needs of one resident of three in the sample who was at risk for adequate hydration and nutrition status. This deficient practice may have resulted in decline, weight loss, and an unplanned hospitalization with severe illness. Findings include: Cross reference to F690. Resident (R)25 is a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of rhabdomyolysis a breakdown of skeletal muscle due to muscle injury, and generalized muscle weakness. (Per review of the admission record), 06/24/24. Hospital (H) discharge summary dated 06/24/24 reviewed. Principal diagnosis: rhabdomyolysis, (when muscles are severely injured or inflamed) and multiple medical diagnoses. Admission orders reviewed. Take resident weight everyday x three days of admission, weekly for four weeks then monthly thereafter unless otherwise notified by Registered Dietician (RD)/Medical Doctor (MD) 06/25/24. Weights reviewed from 06/25/24 to 07/16/24: 06/25/24 1:07 PM, 181.6 Lbs. in wheelchair; 06/28/24 10:04 AM 177.0 lbs. in wheelchair; 07/01/24 2:08 PM 176.8 lbs. in wheelchair. Next weight documented on 07/16/24 2:02 PM 160.8 lbs. in wheelchair. Noted 11.5 percent (%) decrease in weight since admission on 06/25/24. No weights documented between 07/01/24 to 07/16/24. Fluid and nutrition intake from 07/05/24 to 07/19/24 reviewed. Average fluid intake was 274 cubic centimeters (cc) per day. Average nutrition intake documented was 0-25%. Skilled nursing notes reviewed from 06/25/24 to 07/18/24. Skilled nursing evaluation notes state Taking nutrition and hydration orally, no complaints of thirst . No documentation of the resident with poor oral intake noted. Interview with the Director of Nursing (DON), Nursing Manager (NM)1 and Registered Dietician (RD) on 11/07/2024 at 12:24 PM in the Administrators office. The Surveyor asked the RD when was the weight loss identified and what interventions were put in place? Who was notified and when? The RD looked into the EMR and stated, R25's oral (PO) intake was documented between 0-50% during the week of 07/07 to 07/13. The diet was liberalized from Cardiac to regular. Snacks and supplements were offered with our alternative menu. The resident was offered assistance with her meals, and she would say that she didn't need help, but she really did need help to eat and drink. The surveyor asked why there weren't any orders for supplements? The DON and NM1 looked in the medical record and stated, R25 declined the supplements and snacks. The MD was updated on R25's weight loss on 07/17/24. The surveyor asked the RD if weights were taken between 07/01 and 07/16. The RD looked into the record and confirmed there were no weights documented during that time and on 07/16/24 the resident was identified with an 11percent % weight loss. Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol 2001 MED-PASS, Inc. reviewed. 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time .4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake .For individuals with recent or rapid weight gain or loss .the staff and will review for possible fluid and electrolyte imbalance as a cause .The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting) . Hospital medical record dated 07/19/2024 to 08/04/2024 reviewed. Principal diagnosis: UTI .Secondary diagnoses include .unintentional/ rapid weight loss .Robust appetite was noted (both in chart and by F1 when she discharged from Hospital eating plateful meals three times/day; standing weight on 06/24/24 was 180 lbs. Developed poor PO intake/appetite at SNF. Admission weight on 07/19/24 bed scale was 159 lb. F1 and R25 report intermittent discomfort with swallowing, while overall swallow mechanics appear intact, he struggles with even simple foods - her dentures no longer fit due to the rapid weight loss .

Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Minimum Data Set (MDS), the facility in-accurately coded Restraint use for Resident (R)33 of three residents sampled. As a result of this deficiency, the facility put R33 at risk for further RAI, MDS inaccuracy. Findings include: During review of R33's most recent MDS, Assessment Reference Date 03/15/24, Section P0100 Physical Restraints was coded as Used daily. Review of R33's care plan revealed the use of bed rail for bed mobility and not as a restraint. During staff interview on 04/24/24 at 09:20 AM, MDS Coordinator (MDS1) acknowledged that R33 was in-accurately coded for Restraint use. MDS1 stated that they would do the necessary correction. Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on record review, observations, and interviews, the facility failed to provide treatment and care of Moisture-Associated Skin Damage (MASD) for Resident (R) 12 in accordance with professional standards of practice and comprehensive care plan, resulting in the progressive worsening of R12's sacrum wound. Findings Include: Cross reference to F656. A record review on 06/15/22 of R12's Discharge Summary dated 05/10/22, documented that R12 was discharged from the hospital and readmitted to the facility on [DATE]. R12 was readmitted to the facility after being hospitalized for a [CONDITION(S)] sustained during an offsite hemodialysis session on 04/26/22. R12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set Discharge Assessment with assessment reference date 04/27/22, indicated that R12 requires extensive assistance for bed mobility and is completely dependent on staff for transfers and incontinence care. Health Status Note on 06/15/22 at 06:05 AM stated that R12 is Alert and oriented to self. Review of R12's care plan stated that R12 is unable to verbalize her needs. On 06/14/22, surveyor observed R12 in her room at 09:03 AM, 11:45 AM and 02:11 PM. At each observation, R12 was laying in her bed on her back with the head of the bed elevated at 30 degrees. R12 had a pillow underneath her head. R12 had a wedge underneath her left shoulder and a wedge underneath her left waist. Her legs were elevated with a pillow. At each observation, R12's eyes were either opened or closed, and R12 did not attempt to move her position or respond to surveyor's greetings. On 06/15/22 at 04:00 PM, a record review of R12's Monitor-Turn and reposition task sheet for 06/14/22 documented that R12 was turned at 09:05 AM, 11:19 AM, and 01:00 PM. Surveyor did not observe a change in R12's position after these documented times. On 06/15/22, surveyor observed R12 in her room at 08:10 AM, 10:34 AM, 12:49 PM, and 03:21 PM. At each observation, R12 was laying in her bed on her back with the head of the bed elevated 30 degrees. R12 had a wedge underneath her right shoulder and a wedge underneath her right waist. R12 had a pillow underneath her head and a pillow underneath her left shoulder. Her legs were elevated on a pillow. On 06/16/22 at 04:10 PM, a record review of R12's Monitor-Turn and reposition task sheet for 06/15/22 documented that R12 was turned and repositioned at 09:00 AM, 11: 00 AM, 12:38 PM, and 03:00 PM. Surveyor did not see a change in R12's position after 09:00 AM, 12:38 PM, and 03:00 PM. On 06/16/22 at 08:02 AM, surveyor observed R12 lying in bed on her back with the head of the bed elevated at 30 degrees. R12 had a pillow underneath her head and a pillow underneath her right shoulder. R12 had a wedge underneath her left shoulder and a wedge underneath her left waist. Her legs were elevated on a pillow. On 06/16/22 at 09:21 AM, surveyor observed Physician Assistant (PA) 1 perform R12's weekly wound assessment with Training Coordinator (TC) and Registered Nurse (RN) 5. Surveyor observed R12 in the same position that was observed at 08:02 AM that morning. RN5 and staff turned R1 to her left side without any assistance from R12. PA1 observed R12's sacrum area. PA1 stated that R12's wound was a result of MASD (moisture-associated skin damage or skin erosion cause by prolonged exposure to moisture) and was not a pressure ulcer. PA1 stated that R12's wound looked bigger this week but was not infected. The wound appeared beefy red with no drainage. PA1 measured the wound to be 3.5 cm in length, 3.5 cm width, and 0.1 cm depth. PA1 recommended that R12's brief be changed more frequently and that she be turned and offloaded more frequently. When PA1 asked whether R12's air mattress overlay had come in yet, TC replied that the mattress hadn't come yet due to supply shortages. TC stated that the air mattress overlay would help with offloading of R12's wound. PA1 also recommended a ROHO (pressure relief) seat cushion to replace R12's current foam wheelchair cushion and to be used on R12's wheelchair during [CONDITION(S)] sessions to help with offloading. A wedge was then placed under R12's right shoulder and both legs were elevated on a pillow. A pillow was placed underneath her left shoulder. R12 was laying on her back with the head of the bed elevated 30 degrees. On 06/16/22 at 10:54 AM, a concurrent observation and interview was done with Certified Nursing Assistant (CNA) 9. Surveyor observed R12 in the same position that she was in after her wound assessment at 09:21 AM (wedge under right shoulder). CNA9 stated that she would check R12 every 2 hours and reposition and turn her. When surveyor asked what turning meant, CNA9 stated that if R12 was facing right then they would turn her left and that they would also change the position of the wedges to the opposite side. CNA9 stated that she would chart when she turned R12 but there was no option to chart what direction R12 was turned to. At 06/16/22 at 11:12 AM, RN5 came into R12's room and performed R12's wound dressing change and peri care with CNA9's assistance. R12 needed total assistance from staff to perform peri care and repositioning in bed. After the dressing change, surveyor observed RN5 ask CNA9 what position to place R12 in but CNA9 stated that she couldn't remember R12's previous position. CNA9 and RN5 positioned R12 with a wedge under her right shoulder and a wedge underneath her right waist. A pillow was placed underneath her left shoulder. R12's legs were elevated on a pillow. A pillow was placed underneath her head and the head of her bed was elevated at 30 degrees. R12 was lying on her back. Surveyor observed that R12 was placed in the same position prior to this dressing change (wedges under right shoulder and right waist). At 06/16/22 at 01:15 PM, surveyor observed R12 in her room. The wedge remained under her right shoulder and a wedge underneath her right waist. A pillow was underneath her left shoulder. Her legs were elevated on a pillow. A pillow was placed underneath her head and the head of her bed was elevated at 30 degrees. R12 was lying on her back with her eyes closed. On 06/17/22 at 08:00 AM, a record review of R12's Monitor-Turn and reposition task sheet for 06/16/22 documented that R12 was turned at 08:12 AM, 12:41 PM, and 01:00 PM. Except for R12 being turned to a different position after her wound assessment at 09:21 AM, surveyor did not observe R12 in a different position after these documented times. On 6/17/22 at 09:45 AM, a record review of Weekly Skin Observation Tool dated 05/22/22 documented Right buttock w/ dry open area, 4 x 1 cm, left buttock w/ dry open area, 0.5 cm x 0.5 cm. A record review on 06/17/22 of R12's Wound Care SNF Consult Service Progress Note dated 05/26/22, PA1 stated History of Present Illness: Wound located on Sacrum. Wound occurred by MASD mechanism over the past 1-2 months .Wound assessment: Yellow (fibrinous slough), length 2.5 cm, width 6 cm, and depth 0.2 cm .Air mattress overlay requested on 05/26/22 counseled staff in regards to nutrition, offloading, and elevation .Follow-Up in one week for re-evaluation and wound assessment. A record review on 06/17/22 of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with NS (normal saline), pat dry, and apply paste. A record review on 06/17/22 of R12's Wound care SNF Consult Service Progress Note dated 06/02/22, PA1 stated Wound assessment: Red, Wound length 0.5 cm, width 0.3 cm, and depth 0.15 cm .Air mattress overlay requested 05/26/22, pending as of 06/02/22. A record review on 06/17/22 of R12's Wound care SNF Consult Progress Note dated 06/09/22, PA1 stated Wound located on sacrum is larger with small bruising noted. Air mattress pending .Wound Assessment: yellow (fibrinous slough), 2.5 cm length, 2.2 cm width, 0.2 cm depth .air mattress overlay requested 05/26/22, pending as of 06/09/22 .Counseled staff in regard to nutrition, offloading, elevation. A record review on 06/18/22 of R12's Wound care SNF Consult Service Progress Note dated 06/16/22, PA1 stated Wound located on sacrum is again larger this week, no bruising noted. Air Mattress pending .Wound assessment: Yellow (fibrinous slough), length 3.5 cm, width 3.5 cm, and depth 0.1 cm . Air mattress overlay requested 05/26/22, pending as of 06/16/22 .Wheelchair foam cushion in use. 06/16/22 ROHO cushion ordered to use in wheelchair and while at HD (hemodialysis). Limited ability to offloading buttocks/sacrum due to HD status .Counseled staff in regard to nutrition, offloading, elevation. On 06/17/22 at 11:13 AM, a concurrent interview and record review was done with the Director of Nursing (DON) and TC. DON stated that the facility staff had met on 04/05/22 and noted that R12 had a wound to the left buttock that was being treated with [MEDICATION(S)] Ointment. DON stated that the same wound continued to be treated until R12 was hospitalized on [DATE]. DON reviewed R12's Discharge Summary dated 05/10/22 and confirmed that she had her sacrum wound upon readmission to the facility on [DATE] and that wound consultations with PA1 started on 05/26/22. DON and TC confirmed that R12's sacrum ulcer had increased in size since 05/26/22. DON confirmed that the air mattress overlay had been ordered by the PA1 on 05/26/22, but there was a delay in the facility ordering the mattress because the employee who is responsible for ordering supplies was on maternity leave. DON stated that the facility is now working with a third company party to obtain wound supplies and that the DON contacted the company two days ago regarding R12's overlay mattress. When surveyor asked if an alternative could have been found for the overlay air mattress due to the delay, DON stated that they could look in-house for an inflatable mattress until R12's air overlay mattress arrived. On 06/17/22 at 11:20 AM, DON and TC reviewed R12's care plan and confirmed that there was no care plan to address R12's sacrum wound. DON stated that a care plan for R12's wound should be included and that an intervention for turning R12 every 2 hours should also be included in the care plan. DON and TC reviewed Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] and confirmed that R12 was at very high risk for pressure ulcers and that clinical suggestions listed on the assessment to turn and reposition at least every 2 hours while in bed should be followed and included in R12's care plan. When surveyor asked what the definition of turning every 2 hours for R12 was, DON stated that R12's body would be turned to the opposite side every 2 hours and any wedges would also be repositioned to the opposite side. DON and TC then reviewed R12's Monitor-Turn and Reposition task sheet and confirmed that there was no documentation showing what side R12 was turned to whenever she was documented as turned by staff. When surveyor explained how CNA9 and RN5 put R12 in the same position (wedges under the right side of R12's body) after her dressing change on 06/16/22 at 11:12 AM, DON stated that CNA9 and RN5 should have positioned R12 and her wedges on her opposite side (left side) instead.

Based on record reviews and interviews, the facility failed to provide Resident (R)234 more interventions to ensure a safe environment to prevent her from falling. This deficient practice caused R234 to sustain a right [CONDITION(S)] and needing care in an acute facility. This can potentially affect residents who are at a high risk for falls placed into quarantine. Findings include: A record review was done on 05/05/21 at 2:25 PM of R234's completed facility reported incident (FRI). R234 sustained a fall on 11/30/20 at 1:35 PM and was admitted to a local hospital on 12/02/20 for a right [CONDITION(S)]. R234 was an [AGE] year-old female admitted to the facility on [DATE] for rehabilitation services. Her diagnoses included stroke with right sided weakness, dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities) and she sustained a fall at home prior to her admission to the facility. At the facility, R234 was in contact isolation and under quarantine for 14 days to rule out COVID-19. The FRI further stated .She is unable to express needs and wants with poor safety awareness . Review of R234's EMR revealed that her medical diagnosis for her admission into the facility was [CONDITION(S)] following unspecified [CONDITION(S)] disease (difficulty communicating after a stroke). A physician encounter note for 11/17/20 described R234 as .Unsteady, muscle weakness, high risk for falls Poor memory and safety awareness . Health status progress notes in R234's EMR revealed that she was alert and oriented to self only and needed one-to-two-person assistance with her activities of daily living (ADL; tasks performed routinely i.e., eating, dressing, eating), moving from bed to wheelchair and vice versa and walking. Health status progress note of 11/20/20 stated, .resident is confused and tends to get out of bed & always moving around on her bed . A Social Services note documented on 11/20/20 stated that with the help of an Ilocano interpreter .she usually gets up at least 5 times throughout the night, to use the restroom when she was at home. When at home resident was ambulatory with a walker, and independent with her ADLs . A Health Status note documented on 11/21/20 revealed that R234 was .forgetful & confused at times. Keep moving in bed, tossing & turning, high risk for fall . An Incident Note on 11/23/20 documented that R234 fell from her wheelchair when she was left unattended in her room after therapy, despite having an accessible call light and a personal alarm. A review of R234's At Risk for Falls care plan revealed that interventions dated for her admission of 11/17/20 revealed no plan for increased rounding by staff despite R234 experiencing a fall at home prior to admission. There was also no plan for increased staff monitoring after her first fall in the facility on 11/23/20. An intervention to not leave the resident unattended in her room was also not documented. This was an intervention identified to be included in R234's care plan after her 11/23/20 fall as stated in the Resident Incident Report of 11/23/20. In an interview with the DON on 05/06/21 at 3:10 PM, she was queried as to why R234 was not placed closer to the nursing station after her first fall and she stated that there was no vacant room, so they did not relocate the resident. An interview with the speech language pathologist (SLP) on 05/07/21 at 11:17 AM was done. The SLP was asked about the second fall R234 had on 11/30/20. She stated that she saw R234 by the door to the room. R234 told her that she was getting up to go and wash the dishes. SLP stated, I must have heard the alarm and that's why she went towards the room. She further stated that R234 was alone in the room and was nowhere near the bed. In another interview with the DON on 05/07/21 at 2:24 PM, she stated that R234 was not relocated to a different room because she was under quarantine for COVID-19. She did her rounds on the units and did not receive a report of R234 getting out of bed and that R234 remained calm and stayed in bed. She also stated that she did not update R234's care plan with the intervention of not leaving the resident unattended in her room. Surveyor asked the DON for documentation indicating that frequent rounding was done by staff, but none was received.

Based on observations, staff interviews, and record reviews, the facility failed to ensure staff applied Resident (R)41's right-hand resting splint according to the resident's person-centered care plan. As a result of this deficiency, R41 experienced contracture progression as evidence by R41's continued inability to wear current right-hand resting splint. Cross reference with F[AGE]2 Findings include: R41 is a [AGE] years old and was admitted to the facility on [DATE]. A review of R41's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2019 documents R41's active [DIAGNOSES REDACTED]. R41 is totally dependent on staff for bed mobility, transferring, personal hygiene, always incontinent of bowel, and has an indwelling catheter. Additionally, R41 receives nutritional intake via tube feeding and has a tracheotomy. R41 is unable (rarely/never) to make needs/self understood and is unable (rarely/never) to understand others. Review of R41's Care Plan: Restorative Care Plan documented, Resident has actual contractures/impaired functional range of motion of: Bilateral Hands related to [CONDITION]I ([MEDICAL CONDITION]). The Care plan goals were: Resident will not experience contracture progression as evidenced by continued ability to wear current splints comfortably and without complication; Resident will not experience any complications related to wearing splint with a target date of 03/19/20. Interventions implemented for R41's Restorative Splinting Program includes applying resting hand splints to both hands: on for 6 hours; off 18 hours; apply at 09:00; remove at 15:00; and refer to therapy as needed. Reviewed R41's medical chart. Occupational Therapy Upper Extremity Splint Schedule includes directions of application/removal times (09:00 AM/ 03:00 PM) regarding splint usage. Throughout the survey (02/18- 24/20) multiple observations (02/18/20 at 10:57 AM, 01:45 PM, and 02:30 PM; 0[DATE] at 09:14 AM, 10:35 AM, and 02:45 PM; 02/20/20 at 10:58 AM and 01:15 PM; 0[DATE] at 10:07 AM and 02:15 PM; 02/24/20 at 09:00 AM) were made of R41 with no right-hand splint applied as indicated by the care plan. On 02/24/20 at 09:00 AM, Restorative Staff (RS)2 confirmed resting hand splint was not applied to R41's right hand, due to worsening of (R41's) contracture of the right hand and the splint not longer fits the resident. On 02/24/20 at 08:40 AM, inquired with Occupational Therapy staff (OT)1 regarding R41's bilateral resting hand splints. OT1 produced and reviewed R41's OT- Therapist Progress & Discharge Summary dated 05/24/19 and signed by OT2, which documented on, [ENTITY]t of Goal Status as of 02/15/2019, Tolerates BUE(bilateral upper extremity) resting hand splints for 4 hours; Prior level as of 05/03/2019, Tolerates B (bilateral) resting hand splints for 6 hours; End of Goal Status as of 02/24/2019, Tolerates B (bilateral) resting hand splint for 6 hours. OT1 confirmed facility staff's inability to apply the resting hand splint to R41's hand would indicate a contracture progression and staff should document and evaluate the progression of the contracture to assess for the resident's need for therapy services. OT1 also confirmed there was no record R41 had been referred for therapy services by the facility after R41's discharge from physical therapy on 09/17/19. Reviewed of R41's February 2020 Treatment Administration Record (TAR), initialed by the licensed nursing staff, and February 24, 2020 ADL (activity of daily living) Flowsheet, initialed by the restorative staff, with RS2. Facility staff documented on both, TAR and ADL Flowsheet, resting hand splints were applied to both hands, which contradicted observations made by this surveyor. RS2's confirmed the discrepancy between observations made by this surveyor and staff documentation of the right hand splint being applied by staff. RS2 stated R41 has not been able to wear the right-hand resting splint for a month or so and could not confirm a specific date or time staff stopped applying the splint. On 02/24/20 at 09:44 AM, inquired with the Director of Nursing (DON) regarding observations made by this surveyor, contracture progression for R41, and the accuracy of staff documentation. DON explained, residents who are on the RNA Program are visually and verbally reviewed monthly by multiple disciplines (DON, RNA, RN, and PT) for progress, status and the need for physical/occupational/speech therapy referrals. Reviewed Monthly RNA Meeting with DON held on 02/07/20. The monthly meetings report, documented R41's current treatment program PROM (passive range of movement) BLE (bilateral lower extremity) 4 times a week; B (bilateral) resting hand 5 times per week was reviewed and continued with no changes. DON could not recall if R41 wore the right-hand resting splint at the time of the monthly meeting and confirmed R41's contracture progression was not identified. DON further explained, if a change is identified residents are referred for rehab services. Also, DON confirmed staff should not document application of the splint if it was not applied. Accurate documentation is essential in the identification of contracture progression and the need for rehab referral to prevent contracture progression for R41.

Based on interview, observation, and record review (RR), the facility failed to prevent two residents (R) 68 and R[AGE] from avoidable falls that resulted in injuries to these residents of three sampled. This deficient practice has the potential to put all residents at high risk for harm, serious injuries, and/or death. Findings Include: 1) On [DATE], review of facility reported incident (FRI) dated 12/24/19, the facility reported R68 fell by the nurse's station on [DATE] at approximately 01:15 AM. According to the FRI, R68 was restless and unable to sleep so the Certified Nurse Aide (CNA) [AGE] brought R68 out to the nurse's station but subsequently went to answer a call light while leaving R68 by the nurse's station. Upon returning, CNA[AGE] found R68 sitting on the floor in front of her wheelchair. Initial assessment found no injuries at that time. The FRI stated CNA on the next shift (day shift) attempted to toilet R68 but noted resident was unable to bear weight on the left foot. Director of Nursing (DON) and Nursing Supervisor assessed R68 and notified the physician who ordered bilateral hip x-ray and pain medication for the resident. On 0[DATE] RR of R68's hip x-ray dated [DATE] showed an acute comminuted fracture present in the intertrochanteric proximal left femur. Impression: Acute comminuted fracture in the left intertrochanteric femur. On 02/20/20 RR showed R68 was admitted to facility on 03/14/19. R68 had sustained a fall at home resulting in a right [MEDICAL CONDITION] requiring hospitalization for surgery and subsequently transferred to this facility for rehabilitation services. Medical History for R68: 1) Closed fracture of right hip, surgically repaired 2) [MEDICAL CONDITION] 3) Vitamin D deficiency 4) Calorie malnutrition 5) Dementia with behavioral disturbances. R68's medications: [REDACTED]. Review of R68's care plan showed resident was already assessed and care planned for falls from time of admission. On 0[DATE] at 09:23 AM, interview with CNA[AGE] who stated on the night in question ([DATE]) R68 was restless and and unable to sleep. CNA[AGE] said she got R68 up in the wheelchair and took resident to the bathroom. CNA[AGE] stated after bathroom, she wheeled R68 to the nurse's station and gave resident a sandwich and coffee because resident likes coffee a lot. CNA[AGE] said she sat with R68 for awhile and noted R68 was falling asleep. CNA[AGE] stated she needed to do her rounds which was approximately 12-12:30 AM from rooms 201 to 204. CNA[AGE] said each time she came out of a room, she would check on R68 and noted resident to be asleep. CNA[AGE] stated when she came out of room [ROOM NUMBER] the last room she needed to finish, she saw her nurse with R68 by the nurse's station telling her that R68 had fallen. CNA[AGE] said she ran there to assists her nurse in assessing R68 and found no injuries at the time. CNA[AGE] said she knows that day shift had found R68 complaining of pain to the left hip area and later found [MEDICAL CONDITION] hip. CNA[AGE] said she has been working at this facility for almost [AGE] years but admitted she made an error in judgement for leaving R68 unattended that night by the nurse's station resulting in R68 fracturing her left hip. On 02/24/20 at 07:45 AM, interview with DON who stated the fall for R68 was definitely avoidable. DON stated she already started in-servicing all staff yesterday informing them they are to focus on what they are doing at all times and not to leave any residents especially high risk fall residents unattended. 2) On 02/18/20 at 08:50 AM, observed R[AGE] in the dining room sitting in wheelchair with gauze bandage noted to forehead above right eye. R[AGE] also had some bruising to her face around the eye area. Staff stated R[AGE]'s injuries were from a recent fall over the weekend. On 0[DATE] at 09:48 AM, interview with Registered Nurse (RN) 26 who stated R[AGE] fell over the weekend, Saturday (02/15/20) at approximately 02:30 PM. RN26 stated R[AGE] was in the activity/dining room for activities at the time of the fall. RN26 continued to say she was having problems that day with CNA25 in room [ROOM NUMBER]. RN26 stated CNA25 informed her she had back pain and needed help with the resident in room [ROOM NUMBER]. RN26 stated she wanted CNA25 to go home but CNA25 didn't want to. RN26 said she was unable to resolve the issue with CNA25 so she went to get another CNA to help the resident in room [ROOM NUMBER]. RN26 said she found CNA62 near the activity/dining room to help CNA25 in room [ROOM NUMBER]. When queried, RN26 denied knowing CNA62 was supposed to be watching the residents in the activity/dining room at the time. RN26 said she did not know CNA62 who was also training someone was asked by the Activity Aide (AA) 2 to watch the residents in the activity/dining room while AA2 left to take care of something. RN26 stated she did not think of asking CNA62 what she was doing at that time and denied she was informed by CNA62 that she was supposed to be watching residents in the activity/dining room because there were no staff there. RN26 admitted there should be staff watching the residents in the activity/dining room. On 02/20/20 RR reflected R[AGE] was admitted to facility on 08/11/16 with History of Dementia without Behavioral Disturbance, Hypertension, Chronic Systolic [MEDICAL CONDITIONS]. R[AGE] is on: [MEDICATION NAME] 7.5mg by mouth at bedtime, [MEDICATION NAME] 3mg by mouth at bedtime, [MED] 3.125mg by mouth twice a day hold for systolic blood pressure less than 120 or heart rate less than [AGE], [MEDICATION NAME] 20mg by mouth daily hold for systolic blood pressure less than 120. R[AGE]'s care plan showed appropriate goals and interventions for falls including a specific intervention dated 08/04/18 Do not leave resident in dining room unattended - Nursing. Documentation in Interdisciplinary Progress Notes dated 02/15/20 at 1520 noted R[AGE] found lying face down on floor with foot rest of wheelchair on back, blood on floor. Resident with laceration to right eyebrow with moderate amount of blood. Discoloration to right side of forehead and both knees. R[AGE]'s physician was called and orders given to cleanse laceration with normal saline, apply steri-strips, and monitor. On 0[DATE] at 08:23 AM, interview with CNA62 who confirmed she was training another CNA that day (Saturday 02/15/20). CNA62 stated she and the trainee were in the activity/dining room around 2:00 PM and she was showing the trainee how to document. CNA62 said she was asked by AA2 to watch the residents in the activity/dining room because AA2 had to leave the room to do something. CNA62 said she was fine with it because she was already in the room along with the trainee so no problem with watching the residents for AA2. CNA62 said RN26 came running up to her in a panic-look asking her to assists CNA25 in room [ROOM NUMBER]. CNA62 stated adamantly she told RN26 she was supposed to be watching the residents in the activity/dining room. CNA62 said she agreed to go to room [ROOM NUMBER] because she thought RN26 was staying behind to watch the residents in the activity/dining room. CNA62 said by the time she got to room [ROOM NUMBER], the resident in the room was already in the shower chair with help from other staff so she did not need to help. CNA62 said it was then she realized the trainee was following behind her and RN26 was also in room [ROOM NUMBER] with them. CNA62 said she did not know RN26 would leave the activity/dining room with no staff watching the residents. CNA62 said she then heard a staff calling out for help because someone had fallen in the activity/dining room. CNA62 said she headed back to the activity/dining room to find R[AGE] on the floor and staff trying to help. On 0[DATE] at 01:40 PM, interview with CNA25 who confirmed on day in question (02/15/20) she was in room [ROOM NUMBER] attempting to take the resident to shower. CNA25 said she had issues with her back, back pain and just deals with it. CNA25 stated adamantly she did not want to go home and wanted to finish what she was doing. CNA25 said RN26 kept insisting she fill out the blue paper (work injury form) and go home. Again CNA25 stated vehemently she did not want to go home and insisted she was able to finish what she was doing. CNA25 stated she and RN26 were in a heated discussion that should not have happened especially in front of residents. CNA25 admitted she feels badly R[AGE] fell and getting injured and is partly to blame. On 02/24/20 at 07:45 AM, interview with DON regarding R[AGE]'s fall on 02/15/20 and DON admitted the fall was avoidable. DON stated the staff are too comfortable at times and need to focus more on what they are doing. DON stated she already started meeting and in-servicing all staff telling them they are not to leave residents especially the ones with high risk for falls, unattended. On 02/24/20 at 10:15 AM, interview with CNA34 who stated R[AGE] fell on Saturday 02/15/20 at approximately 02:30 PM in the activity/dining room. CNA34 said he was assisting residents in room [ROOM NUMBER] when he heard a loud bang and a personal positioning alarm go off. CNA34 said he ran out of room [ROOM NUMBER] and across into the activity/dining room where he found R[AGE] face down on the floor with blood to forehead. CNA34 said R[AGE]'s wheelchair was partially tipped over with footrest on resident's back. CNA34 stated he called out to staff for help. CNA34 said he noted there were no staff in the activity/dining room at the time but they came shortly thereafter.

Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Cumulative findings included the development of facility acquired pressure ulcers for physical harm; resident reports of psychosocial distress due to delayed personal hygiene to change briefs; family report of need to come to facility during meal times because lack of staff to feed residents incapable of self-feeding; nurse comments of having to work double shifts; and the lack of development of resident-centered care plans. Findings Include: 1) On 01/11/2019 at 12:21 PM reviewed R77's pressure ulcer (PU) care plans (CP) with RN4 as he stated that PUs were avoidable because staff should turn resident q (every) two hours (hrs). RN4 stated that staff turned R77 q two hrs but resident tends to turn towards the left (L) side, and a pillow was used to position R77's head to off-load on ears. The RN4 couldn't find in R77's CP interventions that a pillow should be used to position R77's head to off-load on ears. On 01/11/2019 at 12:45 PM observed R77 with towel roll under the R shoulder area and inquired of CNA how towel roll, placed in shoulder area, kept R77's head from moving. The CNA did not have an answer and stated that when R77 was admitted she/he was unable to move head side to side but now able to and can now track with eyes. On 01/14/2019 at 11:11 AM interviewed UM121 and he stated that R77's PU on the ears were probably from the nasal cannula (NC) tubing for oxygen. UM121 further stated that at admission R77 was flaccid and couldn't move and head rested on a soft pillow, with the only hard surface being the NC tubing around the ears. Queried whether a CP was developed to prevent PU's from developing with NC use, and UM121 stated that a PU CP9 was implemented, and subsequently a separate PU CP13 was developed for the R ear. Inquired what was done differently from CP9 to CP13, and UM121 stated that the wound specialist educated staff and CP should have been updated by treatment nurse after education. On both CP9 and 13 there were no interventions to prevent PU on ear from NC. The facility failed to continually assess and develop comprehensive PU CPs for R77 and the resident acquired PUs to both ears after admission to the facility. Also, R77 had developed a skin wound on the L inner thigh close to where Foley tubing was secured, that was not yet diagnosed by the physician at time of survey. 2) Review of R159's, R111's and R109's baseline care plan status revealed licensed staff failed to develop and implement baseline care plans (comprehensive care plans were developed in lieu of them), yet not within 48 hours of admission, and failed to ensure written summaries were provided to the residents and/or their representatives (refer to F655). 3) Review of R33's and R35's comprehensive care plans revealed a failure to ensure each resident's highest practicable physical, mental, and psychosocial well-being was provided as resident-centered care plans were not developed for the R33's limited range of motion (ROM) and R35's bruise and limited ROM (refer to F656). A family (F) member 1 for R35 said the facility's staffing was different now with a lot of agency staff. F1 said if she did not come to feed R35, she was not assured the staff would be able to feed R35 timely because there were many residents who needed to be assisted with not enough staff. 4) During the Resident Council (RC) interview conducted on 01/09/2018 at 10:15 AM, two residents voiced concerns of the lack of staffing on their units. One resident confidentially shared on her fourth floor unit, they were often short of staff and staff did not come timely when she called for them. The resident stated it could take approximately 30 minutes for nursing staff to attend to her on the night shift, especially when she needed to be changed or cleaned. The resident said although she used her call light, one CNA often would not be able to attend to her because they were short of staff. Another resident also confidentially shared that on her third floor unit, during the day, there often was only one activity aide in the dining room. This resident said because the other CNAs are busy feeding and giving showers, so when you want to go, you have to wait and have no way of calling somebody. She said she has witnessed an old timer CNA tell a resident, You have to wait, and felt uncomfortable with how the resident was told this. This resident did not want to identify the old timer CNA, but stated she witnessed this upon her recent admission to the facility. 5) On 01/10/2019 at 06:30 AM, the resident on the fourth floor stated they had three CNAs for the night, and the response time was good. The resident verified it was when there were only two CNAs for the night shift that it took as long as 30 minutes for her needs to be met. The fourth floor nursing unit was identified as the more subacute unit with some residents who are ventilator dependent. 6) On 01/10/2019 at 06:59 AM, a confidential interview with three third floor night shift CNAs was done. They stated they are usually staffed with two CNAs at night with the exception to add an additional CNA if they have more restless residents to care for. The three CNAs said one resident likes to toilet herself and stands often and there were three other residents who were often restless at night. They said they were all in different rooms attending to them, and having an extra third CNA helped a lot. They said their fall rate was low because they took it upon themselves to literally run to get to a resident's bedside when they heard any slight noise, even like the rubbish can moving. Otherwise, they acknowledged it was harder to be staffed with only two CNAs at night with residents who were often restless. 7) On 01/10/2019 at 09:14 AM, per CNA40, she said for the third floor, the CNAs help one another. CNA40 confirmed this floor had a lot of residents requiring assistance with feeding, and said, I don't want to lie, hesitated, and continued on to say they help each other out and try their best to serve the residents. 8) A closed record review for R111 revealed a late 11/24/2018 nursing entry for a 11/23/2018 entry. The licensed nurse wrote a family member of R111 was so upset regarding what happened, . made her very anxious, pressed the call light and been waiting for someone to come but no one attended her for 30 minutes per resident. 9) On 01/14/2019 at 09:00 AM, an interview with the DON was done. She acknowledged they have had staffing concerns and worked with adding an additional agency to fill the shifts. The DON acknowledged the fourth floor nursing unit, because of subacute, our staffing is done differently there, but could not elaborate on how it is done differently to ensure the residents' care needs were being met on all shifts. In addition, the DON was vague in her response to various questions, such as what her process was to ensure the residents were being assessed and care plans were being developed and implemented. The DON said she has lost old timers, I have 100% change in my nursing leadership. The DON then referenced a process using a reference book for her new unit managers to use. However, she confirmed she has not done any training with her nursing staff for, this guide, that relates specifically to long term. The DON further said for their baseline care plans, it was a product she pushed forward, but other administrative staff did not agree with it so they were deadlocked over it. Hence, the baseline care plans nor their care plan policy had not been updated to reflect the new regulatory requirements and the DON affirmed she did not provide the long term care guidance to her new managers/nursing staff. 10) An anonymous complaint investigation was also reviewed during the survey related to the lack of sufficient staffing. Although the resident was not identified, based on the information provided by the complainant and the survey findings, the SA substantiates the allegation of the lack of staff which affects nursing's core ability to identify, assess, develop, implement and revise necessary care plans for their residents. 11) Interview on 01/08/2019 at 9:55 AM with Resident (R)96 stated I talked with the supervisor and told him but nobody is taking us seriously that it takes 2-3 hours to get my diaper changed. R96 goes on to say that last night, I wanted to get something to make me warm and she doubled the sheets to make me warm. Staff said oh there are no blankets. A couple of weeks ago, there was no socks. I had to tell my wife to go buy me socks because my feet was so cold. It's the nurses who say, I'll be back and they don't get back. I wait 2-3 hours. During the relicensing survey, complaint 5669 was investigated. An observation along with interview was conducted with R91's family (F) member (F2) on 01/09/2019 at 8:28 AM. F2 Stated that sometimes, the temperature is at 68 degrees but lately it's gotten better. F2 further states that a lot of nurses are working double time and they are tired. I am worried that they are so tired and the patients are being neglected. Something bad could happen, like a wrong medication administered. Interview and concommitant observation with Unit manager (UM)115 who stated that the air is at 72 degrees to accomodate the comfort of the residents and showed this surveyor the temperature reading. Temperature was confirmed at 72 degrees. Interview and observation on 01/10/2019 at 6:39 AM R96 stated I asked for a blanket last night and they gave me two sheets. I'm cold but it's too late. They said they had no blankets. This surveyor validated that the resident had double sheets. At 6:45 AM, CNAs were doing change of shift and this surveyor asked CNA if they had any blankets. Observed delivery of a cart from laundry department. No blankets were noted on the cart that was delivered. Checked the supply room where the CNAs stated that they stock their portable carts with blankets. Carts are located throughout the floor. There were no blankets in the supply room. Confirmed with Clinical Nurses Aide (CNA)52 who stated that they don't have any blankets on the 4th floor. CNA 52 stated I had to go to the 3rd floor to get a blanket. Interview on 01/10/2019 at 9:06 AM with Recreational Coordinator (RC)127 stated On the fourth floor, there is only me. There is only one staff because this is the rehab floor and there is less attendance. It's 8 hours a day and 7 days a week. All residents can participate in activities on any floor. We have a part-time position for sub-acute level to designate the ones that have difficulty coming out of bed, like the trachs. The position has been in place shortly after we started about 3-4 years ago. This is to accomodate more bedside visits, one to one. We set their bedside tables up. However, it's been vacant or six months. I've had students and some CNAs but haven't been able to find anyone. Activity Aide (AA)128 will dedicate part of her day where she will go one to one on the floor. She spends roughly 1-1/2 hours seeing residents on the floor. Interview with AA128 at 01/10/2019 at 9:17 AM - I go on the floor almost every day, like in the morning, I greet them, talk story. I give the newspaper, let them know the lunch and dinner. I go to every room. Since I start at 8:00 AM, I spend about one hour and 15 minutes because I have to come here before 9:15 AM. 01/11/2019 at 5:33 AM - Interview with Registered Nurse (RN)30 who wanted to remain anonymous because of retaliation. Queried RN30 regarding how often she has to work overtime, how much agency staff is being used, how are current staffing needs determined? RN30 stated Staffing has been bad since the last survey. Our sister facility transferred their vents here and admin didn't increase the staffing to accommodate the level of acuity. They don't see what our needs are . It's not safe when we have two CNAs and a lot of times we are short CNAs. When we are short CNAs, it is difficult. We just had a batch of new nurses in (MONTH) that are in training. A lot of times, we will train them and they stay for a year and they leave because they see how it is. I work at times 16 hours a day for a week and come in on my day off because if their short, the residents will suffer and there are too many newbies who cannot function as house manager. It seems that administration does not see how short we are, either nurses or CNAs or both. We want change. A lot of nurses want change. We are not a union. They will mandate us to stay and I have worked five days in a row of 16 hours at a time. It is getting better but I hope the new batch of nurses will stay. We have two agency nurses tonight and one RN on orientation. Our census is 33, capacity is 41. We need three CNAs. Interview on 01/11/2019 at 545 AM with RN130. I am an agency nurse and I've been here for three days. When I first started coming here, you get oriented to one side, 2nd and 3rd floor. Orientation on the 4th floor is five days and for the sub-acute, I took a respiratory class. Interview on 01/11/2019 at 5:55 AM with RN9 states I've been training since December. I will train a total of ten shifts for 4th floor A and B side. Two days on my own and three days for sub-acute. I also had a respiratory class. Interview on 01/11/2019 at 6:06 AM with RN129 states I haven't been here since (MONTH) but it was unsafe then. We were short for CNAs. As a nurse, when it is short, it pulls me away from the duties of the RN because we can't ignore lights. It was short staffed when I came in November. Tonight it's not too bad. Interview on 01/11/2019 at 6:21 AM with CNA99 states sometimes they mandate us to stay for day shift, either four hours or eight hours to help with vital signs, get residents up. Usually, we should have 3 CNAs but a lot of times we have two and evening stays back to help with vitals. A lot of CNAs work 16 hours. It happens a lot. Interview on 01/11/2019 at 6:30 AM with RN30 stated we usually have a treatment nurse but today we only have four with one orientee. The treatment nurse helps although they don't consider it a permanent position. Today we are short for treatment nurse and all week. We are short for a CNA today. Evening shift functions on four and pretty much short all week. On Monday, two evening shifts stayed back to for nights because we only had one CNA, so CNA was mandated to stay over. Interview on 01/11/2019 at 8:33 AM with Nursing Supervisor (NS)131 stated the treatment nurse is not an actual position. CNA level 2 can fill that position but it has to be a CNA2. If we have extra nurses, we try to fill it. Interview on 01/11/2019 at 9:02 AM with Director of Nursing (DON) stated the staffing is done differently on 4th floor because of the subcute and there would be 5 CNAs for 41. I inherited this grid. I have 16 vents, 12 on A and 12 on B. We have been advertising. I had six openings for RNs and filled one. I have six licensed practical nurse positions to fill but we have not been able to fill those. DON shared the various advertising and recruitment scenarios but says filling positions has been a challenge.

Based on observations and interviews the facility failed to ensure that facility staff possess the competencies and skill sets necessary to provide nursing and related services to meet the resident's need safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings Included: 1) On 01/08/2019 at 12:28 PM interviewed the administrator (ADM) to investigate complaint (ACTS#6292), made to the state agency (SA) on 05/09/2018. The complainant reported that his mother (victim) was administered the wrong medications (meds) and sent to an acute hospital emergency department for treatment on 05/04/2018. According to the ADM, an agency nurse mistakenly administered meds that belonged to resident in bed (403C) to resident (victim) in bed (403B). On 05/04/2018 at 06:00 PM the resident (victim) was incorrectly administered: Atorvastatin 80 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 2 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 5 mg, Senna-S 8.6/50 mg, and [MEDICATION NAME] 5 mg. The resident was sent to an acute hospital emergency department (ED) by ambulance and arrived there at 08:39 PM. The ED progress notes documented that the resident (victim) was assessed, monitored and treated with 0.4 mg of [MEDICATION NAME]. The resident had no [MEDICAL CONDITION], no [MEDICAL CONDITION], no respiratory distress and vital signs remained stable. The resident (victim) was released from the ED on 05/05/2018 at 08:30 AM and brought back to the facility. The ADM stated that the resident was discharged on [DATE] to family with homecare services after completing her short-term rehab stay at the facility and had no other adverse events after the above incident. On 01/14/2019 at 02:49 PM interviewed the ADM and DON and inquired if the facility developed a new process for orienting agency nurses to the facility. The ADM stated that agency nurses follow seasoned nurses for one shift in general. The agency that the nurse (perpetrator) came from was more problematic with med errors. The facility still uses the agency but now use nurses that are known to them. The facility made med errors a quality assurance (QA) project and the med error rate decreased from a high of 65 in (YEAR) down to 5 in (YEAR). The med error went back up to 21 in (YEAR) on the fourth floor due to the resident status mix of subacute and short-term rehab. The resident (victim) was on the fourth floor. 2) On 01/10/2019 at 10:03 AM observed two CNAs transfer R77 from the shower gurney back to bed. The R77's Foley catheter container was lying flat on the shower gurney to the left side of R77. The Foley catheter container had urine in it and was was placed into the Hoyer-lift sling next to R77. As one CNA operated the Hoyer-lift to transfer R77 back to bed, the other CNA grabbed a towel to catch the urine that began to leak from the sling. Inquired of the CNA whether the Foley catheter container should be lower than R77 and the CNA stated, Yes, but we're transferring. Interviewed UM121 at the unit's nursing station and queried how Foley catheter system should be placed when transferring resident on shower gurney and Hoyer-lift. The UM121 stated that Foley catheter system should be hung to side of shower gurney and one CNA should be holding Foley catheter container when the resident is transferred in Hoyer -lift sling. Shared observations with UM121 and he stated that would talk to CNAs. 3) On 01/10/2019 at 12:50 PM observed RN4 administer insulin to R77. Observed that RN4 prepped the insulin 3 cc syringe for two units of insulin by pushing two units of air into the insulin bottle rubber stop and then pulling back two units of insulin. Followed RN4 to R77's bedside for insulin administration and RN4 removed the syringe cap and pushed out some insulin before administering to R77. Inquired of RN4 if that was the usual practice for insulin administration. RN4 stated that there was a small air bubble in the syringe and whether he injects subcutaneous (SQ) or intramuscularly need to ensure no air bubble in syringe. Inquired if R77 received the two units of insulin after RN4 pushed out some insulin with air bubble and he did not have an answer. The DON provided the policy and procedure for subcutaneous injections and there was no step in the procedures to remove air bubble from the syringe for SQ injections. 4) On 01/14/2019 at 09:00 AM, an interview with the DON was done. She acknowledged they have had staffing concerns and worked with adding an additional agency to fill the shifts. The DON acknowledged the fourth floor nursing unit, because of subacute, our staffing is done differently there, but could not elaborate on how it is done differently to ensure the residents' care needs were being met on all shifts. In addition, the DON was vague in her response to various questions, such as what her process was to ensure the residents were being assessed and care plans were being developed and implemented. The DON said she has lost old timers, I have 100% change in my nursing leadership. The DON then referenced a process using a reference book for her new unit managers to use. However, she confirmed she has not done any training with her nursing staff for, this guide, that relates specifically to long term. The DON further said for their baseline care plans, it was a product she pushed forward, but other administrative staff did not agree with it so they were deadlocked over it. Hence, the baseline care plans nor their care plan policy had not been updated to reflect the new regulatory requirements and the DON affirmed she did not provide the long term care guidance to her new managers/nursing staff. 5) The facility failed to provide no less than twelve hours of in-service education for every nurse aide employed by the facility. There were seven CNAs who did not meet this requirement. This included various topics, such as one for dementia care for the (MONTH) (YEAR). This topic was not completed by these seven CNAs (refer to F730). 6) Review of R159's, R111's and R109's baseline care plan status revealed licensed staff failed to develop and implement baseline care plans (comprehensive care plans were developed in lieu of them), yet not within 48 hours of admission, and failed to ensure written summaries were provided to the residents and/or their representatives (refer to F655). 7) Review of R33's and R35's comprehensive care plans revealed a failure to to ensure each resident's highest practicable physical, mental, and psychosocial well-being was provided as resident-centered care plans were not developed for the R33's limited range of motion (ROM) and R35's bruise and limited ROM (refer to F656). A family (F) member 1 for R35 said the facility's staffing was different now with a lot of agency staff. F1 said if she did not come to feed R35, she was not assured the staff would be able to feed R35 timely because there were many residents who needed to be assisted with not enough staff. F1 said with the change in staffing, this administration has been different, just different, about how concerns were addressed and with many different staff, F1 expressed uncertainty in whether the staff knew about the residents, including R35. 8) R20 was identified with recurrent urinary tract infections [MEDICAL CONDITION] and recently started on an antibiotics for eight weeks for a UTI. During an observation of perineal care for R20 done by CNA117 on 01/14/2019 at 10:43 AM, CNA117 stated this was the first time she was assigned to care for R20. CNA117 said she is an agency CNA and today was her first solo shift to care for residents on the third floor unit. CNA117 stated during the morning rounds and endorsement, she was told there was nothing to worry about for R20, including her skin condition. CNA117 was asked whether she knew that this resident was currently on antibiotics for a UTI and if she read R20's care plan. CNA117 said no, and said no other information or guidance was provided to her. CNA117 said she received two days of orientation, which was good enough for her, but nodded that it would be better to know more about the resident's condition in order to care for them. The facility failed to ensure agency staff were given adequate information to ensure for R20's highest practicable well- being, such as knowledge of R20's current underlying condition to assist CNA117 to provide for and track R20's hydration and intake/output status, report any potential side effects of antibiotic use, and/or provide timely perineal care for the resident.

Based on observations, record reviews (RR) and interviews the facility failed to promote the prevention of pressure ulcer (PU) development; and prevent development of additional PU for one of 38 residents (R) 77 on the survey sample. As a result of this deficient practice, R77 developed a Stage 4 PU to the left (L) ear six days after admission; and, Stage 4 PU to the right (R) ear 13 days after admission. Findings Include: On 01/10/2019 at 08:05 AM observed R77 lying in bed with adhesive bandage covering top of L ear . RR on R77 included admission orders [REDACTED]. Review of R77's physicians orders (PO) included a telephone PO dated 12/17/2018, Cleanse L ear helix with normal saline (NS), pat dry, apply [MEDICATION NAME] to open areas, and cover with absorbent dressing daily (QD) and as needed (PRN) until healed (Diagnosis: [REDACTED]. Additionally, a Wound Assessment Details Report, with date of 12/29/2018 noted a facility acquired pressure ulcer on the R ear at Stage 4. Description of the R ear wound included: tissue bright pink to red 50%; slough loosely adherent 40%; necrotic soft, adherent 10%; light serosanguineous exudates; maceration; and, measured 1.80 x 1.50 x unknown (LxWxD); area 2.70 cm2; no tunneling. On 01/10/2019 at 08:44 AM interviewed RN4 and inquired how R77's PU's on both ears started, and RN4 stated that R77 had L side weakness and tends to lie on L side. Reviewed R77's medical records with RN4 and on the 12/16/2018 [MEDICAL CONDITION] assessment, Stage 2 (0.2 x 0.8 cm); serosanguineous scant drainage; open edge pink/red; L ear tip (Helix) superior; and on 12/19/2018 Stage 4; 0.8 cm x 0.5 cm, written by RN29 (facility wound nurse). According to RN4, the unit manager (UM)121, corrected the wound from Stage 2 to Stage 4. On 01/10/2019 at 11:25 AM observed RN29 do dressing change for PU on R77's bilateral ears. According to RN29 both ears were at Stage 4 due to ears have no muscle tissue or subcutaneous tissue just cartilage. The RN29 cleansed PUs with NS, applied [MEDICATION NAME] and absorbent bandage to both ears. The R77 was observed lying on back and had rolled towel at L side of head to position off of ear. Inquired of RN29 if PU to ears happened due to R77 not turning q (every) 2 hours (hrs), and RN29 stated that R77 is turned q 2 hrs but tends to turn head to the left. The care plan problem list dated 12/11/2018 included a care plan (CP)9 At Risk for Skin Breakdown, that included interventions for staff to: assess skin daily during activity of daily living (ADL) care and report changes to charge nurse; reinforce importance of mobility, turning or ambulating; turn and reposition q 1-2 hrs and PRN; maintain proper body alignment; and, provide pressure relief interventions as needed based on skin assessments. On 12/17/2018 a comprehensive CP was developed for, Pressure Ulcer; Site: L ear helix. The CP goal was for resident to receive stage appropriate wound care, experience pressure reduction, and controlled risk factors for prevention of additional ulcers within the next 14 days. On 12/29/2018 a comprehensive CP13 was developed for pressure ulcer on the R ear midsection; Pressure ulcer noted on the R ear mid section (St. IV). On 01/11/2019 at 10:18 AM observed wound care assessment done by contracted wound specialist (WS) and RN26. The WS assessed, measured, applied treatment of [REDACTED]. The WS commented that the PU on the R ear was improving but the PU on the L ear was taking longer because R77's head leaned towards the [MI] The WS stated that R77 lying on ears caused PUs and when staff off-loaded the head from the L side, PU on the R ear started. On 01/11/2019 at 01:21 PM interviewed RN4 and inquired if R77's PU to ears were avoidable or unavoidable and RN4 stated that PU's were avoidable because staff should turn resident q two hours. Inquired whether PU started because staff did not reposition R77 off of ears, and RN4 stated R77 tends to turn towards the L side (weak side) even if staff reposition. Staff were supposed to position R77's head by using pillow to off-load on ears. On 01/14/2019 at 07:23 AM observed R77 lying on back and L ear open to air with gauze dressing underneath with scant serosanguineous drainage and towel roll to R of pillow. Inquired of RN4 if R77's PU on L ear now left open to air. RN4 stated that should be covered with foam dressing, then went to R77's bedside to close dressing shut as adhesive bandage didn't close properly. On 01/14/2019 at 11:11 AM interviewed UM121 and inquired about R77's PU to both ears. The UM121 stated that PU's probably from nasal cannula (NC) tubing because at admission R77 was flaccid and couldn't move. Staff positioned R77 to off-load on L ear and that's when PU on R ear started. The UM121 stated that facility staff didn't want to switch R77 to oxygen mask because there would be more pressure points from a mask. The UM121 further stated that R77 was referred to the wound consultant, provided PO for PU treatment, and PU CP implemented, with a separate PU CP for the R ear when it occurred. Inquired of UM121 what was done differently after PU on R ear was noted, and he stated that WS educated staff and the treatment nurse should have updated the CP after received education. Queried UM121 on his role in regards to pressure ulcer development and response was that he monitored whether wound consultant followed treatment plan, and discussed in weekly wound meetings. On 01/14/2019 at 12:14 PM interviewed agency RN131, who stated that it was her 3rd time to work at the facility as treatment nurse. RN131 finished treatment dressing to R77's L thigh wound and PU on both ears. RN131 described the PU to the R ear as drying, and PU on L ear still open The RN131 stated that R77's treatment plan was followed and found in the unit's treatment book. The RN131 further stated that R77 was weaned from oxygen yesterday and no longer using NC. The facility did not promote the prevention of pressure ulcer development and prevent development of additional pressure ulcers for R77.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision in order to eliminate and/ or reduce the risk of an accident and monitor the effectiveness of the interventions and modify the care plan in accordance with current professional standards of practice for three of five sampled residents (R #89, R #34 and R #362). Findings include: 1) Cross reference to F 641 and F657. R #89 was admitted to the facility from an Acute care hospital in August 2017 after having a fall and serious head injury. The resident was living on the memory care unit of a community assisted living facility . On 12/19/17 at 10:00 AM R# 89 was observed to wheel himself into another female residents room (206). Staff #113 came into the room and told the resident this isn't your room, your room is in 201. Staff #113 removed the resident from the room. Staff #113 said R #89 often wheels himself into other residents room's and we have to keep an eye on him. On 12/20/17 at 08:36 AM Res #89 was observed to wheel himself into room [ROOM NUMBER], Staff #113 approached the resident saying wrong room, this is a ladies room and assisted R #89 to the dining/ activity room across the hall. During a review of the Medical Record on 12/20/17 at 10:19 AM the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 9/01/17 and Quarterly MDS with ARD of 11/27/17 Section E 0900 wandering-presence & frequency was coded 0 on both assessments indicating wandering behavior not exhibited. Review of the resident's care plan noted an intervention for wandering was implemented on 12/04/17 after a fall. A progress note dated 12/04/17 stated that R#89 was found on the floor in front of another resident's room. He suffered with mild bleeding and an abrasion on the forehead. The Physician ordered a Physical Therapy (PT) evaluation on 12/04/17 for fall risk due to increased wandering. Review of the Progress notes dated 12/03/17 they day before the fall revealed that R #89 was found in another residents room [ROOM NUMBER] asleep at 21:45. On 12/21/17 the Behavior/ Intervention monthly flow record was reviewed, R #89 was being monitored for wandering beginning on 11/01/17 through 12/20/17. From 11/01/17 - 11/30/17 R #89 had episodes of wandering on 22 of the 30 days reviewed. Episodes ranged from 1 to 15 times per shift. Interventions used were redirection and offering fluids. The outcome was unchanged or worsened on 14 of the 30 days reviewed. From 12/01/17 - 12/20/17 R #89 had episodes of wandering on 14 of the 20 days reviewed. Episodes ranged from 1 to 20 times per shift. Interventions used were redirection, 1:1, and Return to room. The outcome was unchanged or worsened on 13 of the 20 days reviewed. The majority of the episodes documented on both of the flow sheets occurred on the evening and night shift. During an interview on 12/21/17 at 1:33 PM with Staff #54, R #89 was moved from the 4th floor in October 2017 to the second floor. Staff #54 stated that when he came to the floor in October it was noticed that he would often wheel himself around the unit and wander into other resident's rooms. We got the wander guard to monitor him so that if he gets close to the elevator or stairway to leave the floor an alarm will sound. When asked if 4th floor nursing staff reported to the 2nd floor nursing staff that R #89 wanders staff #87 stated that the progress notes only mentioned the Resident has [MEDICAL CONDITION]. During an interview on 12/22/17, Staff #2 stated that R #89 pedals around in his wheel chair. The Resident's care plan was shared with Staff #2 and Staff #54 informing them that an intervention for wandering was put on care plan on 12/04/17 the day of the fall. Also discussed that R #89 was transferred from the 4th floor on 10/23/17 and there was no documentation that R#89 wandered. Discussed the facility's lack of assessment, evaluation, and documentation of the resident's wandering and the potential risk for accidents (falls) and potential conflict with other residents. Discussed that documentation in the progress notes stated resident was reminded not to go into other's rooms. and that a progress note dated 12/03/17 stated R #89 was found sleeping in room [ROOM NUMBER] at 21:45. Discussed that resident had a fall on 12/04/17 and was wandering at the time. Discussed that R #89 was being monitored for wandering from 11/01/17 to 12/21/17 and that the interventions were not developed until 12/04/17 and the interventions were not effective as evidenced by the resident's monitoring monthly flow record (increase in the episodes of wandering). Staff #2 responded by saying that we're providing the least restrictive environment as possible for this resident, he is not violent has not shown any aggressive behaviors. However, the progress notes dated 11/05/19 documented that R #89 hit a CNA during a shower. The facility failed to do the following in order to keep the residents safe: Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and evaluate/analyze the hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible; Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident; and monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. R #89 created a likelihood of potential serious harm and and potential harm can cause serious injury. R #89 was allowed to wander throughout the unit into other residents rooms where there was a potential for the resident to be injured through either conflict with another resident or during an accident such as a fall. In spite of the facility's efforts to monitor the resident, they failed to provide direct supervision for R #89 to ensure resident safety to all who are residing on the unit. On 12/22/17 at 09:17 AM The Administrator was informed of an Immediate Jeopardy (IJ) identified under accidents, wandering. The team identified the three components of the immediate Jeopardy. There is a likelihood of potential serious harm and the potential harm can cause serious injury. If not corrected one or more individuals at risk of immediate serious injury, harm, impairment or death. The facility was culpable in that they knew of the situation and did not ensure safeguards. They did not thoroughly investigate the circumstances. On 12/22/17 at 03:02 PM a written plan of Abatement was received from the Administrator, reviewed and accepted by the team. 2 ) Cross Reference to F657. Resident #34 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 9/21/17 the facility submitted an Event Report to the State Agency to report an injury for Resident #34. On 9/20/17 at 8:45 A.M. Resident #34 was receiving a shower and slid out of the shower chair and sat on the floor. The aide was unable to prevent the resident from sliding out of the chair. The resident complained of lower back pain on 9/21/17. Resident #34 was sent for imaging and found to have an age indeterminate L1, L4 and possibly L5 compression fractures. On 12/21/17 at 3:08 P.M. a record review was done for Resident #34. A review of the resident's care plan noted on 5/14/17 the resident slipped down to the floor while sitting in the shower chair. Subsequently on 9/20/17 there was further note documenting Resident #34 slid down to the floor while sitting down in chair inside of the shower room. A review of Resident #34's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/15/17 found in Section G0120. Bathing, the resident was totally dependent on staff with one person assistance for bathing. Subsequent quarterly assessment with an ARD of 10/10/17 (after the fall of 9/20/17) notes no change in the resident's bathing skills. Further review of the quarterly MDS with an ARD of 7/15/17 notes in Section G0300. Balance During Transitions and Walking, Resident #34 was coded 2 (not steady, only able to stabilize with staff assistance) for the following areas: moving from seated to standing position; moving on and off toilet; and surface-to-surface transfer (transfer between bed and chair or wheelchair). Subsequently, the quarterly MDS with an ARD of 10/10/17 documents the resident is now coded with 8 (activity did not occur) in the aforementioned areas. On 12/21/17 a request was made to Staff Member #51 to review the facility's incident report related to the fall on 5/14/17. Further record review with the assistance of Staff Member #5 found no documentation in the progress notes of the incident. A review of the Interdisciplinary Progress Notes (IPN) found an entry dated 9/20/17 at 1300 noting at approximately 0845 a loud noise was heard in the shower room. The writer went into the shower room and found the resident sitting on the floor with the aide behind the resident, holding up the resident's back. The resident was still wet and soapy. No injuries were noted, bruises were noted to the right upper buttock, redness to right buttock and upper left back. On 9/21/17 Resident #34 was seen by the physician for a follow up to a mechanical fall. The physician notes at baseline patient is able to assist with transfers and stand with assist .but today, patient was unable to transfer or stand with assist, as patient noted pain to lower back. A lower back x-ray was ordered which revealed an indeterminate L1-L4 compression fracture and possible L5. The physician also noted an MR of the spine without contrast done on 12/17/13 revealed mild spinal stenosis at L3-4 and L4-5. A review of the Plan of Care documents on 5/14/17 Resident #34 slipped down to the floor while sitting on shower chair. A care plan was developed which included the following interventions: assess level of care functioning; inform resident of actions or care to be done to be able to act upon cuing; remind CNA to call for assistance as needed when transferring, use arjo lift; organize shower needs prior to starting shower, place them within reach maintaining safety or resident; do not leave resident unattended in the bathroom; reassess risk for falls; and two person assist during transfer. Following the fall (slid down to the floor while sitting down in chair inside shower room) on 9/20/17, the resident's care plan was updated to include the following: make sure resident is well positioned while up on shower chair or shower gurney and use the shower chair with safety front lock. On 12/21/17 at 2:01 P.M. an interview was done with Staff Member #51. The staff member reported he/she was not at the facility in May 2017 and could not locate the incident report related to the fall on 5/14/17. However, the staff member reported in May the aide completed the shower, reached for a towel and the resident leaned forward, eventually landing on the floor. Queried the staff member whether the use of a front lock shower chair would have been indicated following the first fall in May to prevent future falls in the shower room. The staff member responded he/she could not speculate whether the inclusion of a front lock shower chair after the fall in May would have prevented the second fall. Upon further query, Staff Member #51 acknowledged that he/she would have updated the resident's care plan to add the use of the front lock shower chair for fall prevention. Interview was done with Staff Member #67 on 12/22/17 at 3:09 P.M. The staff member was queried regarding the use of bed and chair alarm as identified in the resident's care plan. The staff member reviewed the resident's care plan and reported these interventions were discontinued when the resident moved to their floor; however, the care plan was not revised to discontinue these devices. Staff Member #67 also confirmed the compression fracture was the result of the resident's fall on 9/20/17. On 12/22/17 at 10:20 A.M. the facility's policy for Fall Prevention Program and Resident Incident Report was provided for review. The review of the fall prevention policy notes the following: 4. When a fall occurs, the licensed nurse will thoroughly complete the Incident Report Form to collect data for process improvement. a. The report shall be completed on the shift on which the event occurred and b. The completed reports shall be submitted to the Unit Supervisor to provide information on the incident to the IDT team, as well as completing a root cause analysis. A review of the incident report policy notes reportable events must be reported to Administration within 24 hours, reportable events include witnessed and un-witnessed resident falls/slips. The facility failed to revise the resident's care plan based on a root cause analysis following the resident's fall in the shower on 5/14/17. The facility was unable to provide the incident report related to the fall which occurred on 5/14/17 and a review of the resident's record found no documentation of the fall in the progress notes. The failure to provide interventions (i.e. use of the front lock shower chair) to prevent further falls in the shower room resulted in actual harm (compression fractures and decline in activities of daily living). 3) Resident #362 had care plan for falls initiated on 12/7/17 and resident fell from bed on 12/8/17 at 2130 PM and sustained 0.5 cm abrasion to left great toe and care plan for falls was modified that same day. Resident fell a second time from wheelchair without injury on 12/9/17 at 1420 PM, no documentation that fall risks were re-evaluated, interventions were modified and no documentation that supervision needs were reassessed to prevent avoidable accidents after 2nd fall. Care plan for falls was modified on 12/13/17 after a 3rd assisted fall from wheelchair to bed. 4) On 12/26/17 at 12:35 PM while talking with staff #17, on 4th floor, checked the janitor room door to make sure that it was locked and noted that it was left unlocked and the door opened. Asked staff #17 why the door was left unlocked and she stated for maintenance. Staff #9 was present and when asked why the janitor room would be left unlocked he turned and asked staff #17 How come? and staff #17 stated that she left it unlocked so that maintenance could get into the room if they needed to. Staff #17 and #9 confirmed that the janitor room door was to remain closed and locked to prevent residents from getting inside and having access to the cleaning chemicals.

Based on observation, record review and interview with staff members, the facility failed to ensure one resident (R #164) of three sampled residents received the necessary treatment and services to promote the healing of a pressure ulcer. Findings include: Cross Reference to F657. Resident #164 was admitted to the facility on [DATE] with unspecified dementia without behavior; [MEDICAL CONDITION] stage 3 (moderate); anemic in [MEDICAL CONDITION]; muscle weakness; unspecified disorder of circulatory system; and vitamin D deficiency, unspecified. On 12/20/17 at 10:09 A.M. a brief record review was done. The review found Resident #164 with two Stage 2 pressure ulcers to the coccyx. Further review found one of the Stage 2 ulcers progressed to Stage 3. A record review on 12/21/17 at 1:00 P.M. found a [MEDICAL CONDITION] Assessment form documenting Resident #164 was found to have an in-house acquired Stage 2 pressure ulcer, dated 7/26/17. The cause of the wound was due to incontinence of bowel and bladder. The size was 0.5 cm (length) x 1.7 cm (width) with <0.1 cm in depth. There was no undermining or draining noted. The ulcer margins were open edged and the surrounding skin and wound bed were pink. The treatment include application of [MEDICATION NAME] foam to Stage 2 pressure injury after cleansing with normal saline once daily. On 8/1/17 the response to treatment deteriorated, the wound was 2.3 cm (length) x 1.6 cm (width) and <0.1 cm in depth. On 8/3/17 an overlay mattress was added and on 8/7/17 one scoop of protein powder was added for meals (breakfast, lunch and dinner) to aid in the healing of the ulcer. The weekly assessments from 8/8/17 through 8/21/17 documented improvement. On 8/29/17 the ulcer was noted to deteriorate (an increase in size). Documentation was found that Resident #164's plan of care was updated on 8/29/17; however, a review of the plan of care did not find documentation of updated interventions. The wound measurements were 1.6 cm (length) x 0.6 cm (width) and <0.1 cm in depth. On 9/11/17 the weekly assessment notes the ulcer deteriorated. The assessor noted that the care plan was update on 9/11/17; however, a review of the plan of care found there is no documentation of the updated intervention. The following week (9/19/17) there was noted improvement and no change on 9/26/17. On 10/6/17 the pressure ulcer was noted to be a Stage 3, measuring 1.5 cm (length) x 0.4 cm (width) with 0.1 cm in depth. Also noted there was slough (pinkish/yellow) in the wound bed. The assessment on 10/10/17 notes the ulcer deteriorated, the measurements include 1.5 cm (length) x 0.6 cm (width) with <0/1 cm in depth. There continued to be pink/pale yellow slough. The Interdisciplinary Progress Note dated 10/6/17 notes during treatment, the wound to the coccyx was noted with slough and there was no drainage. The care plan was revised on 10/6/17 to continue interventions with onset date of 7/26/17. On 10/11/17 the intervention added was to cleanse Stage 3 pressure injury to coccyx with saline, apply medi-honey and cover with foam dressing daily and prn when soiled. Based on the recommendation by the Dietitian on 10/16/17, a physician's orders [REDACTED]. On 10/17/17 the ulcer was noted to deteriorate. The order for juven was put on hold on 10/23/17 due to frequent soft bowel movements. The weekly assessments dated 10/24/17 and 10/31/17 noted improvement. The assessment for 11/7/17 noted deterioration. The treatment was changed on 11/10/17 to cleanse abrasion above coccyx between upper buttocks with normal saline, pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME] foam daily until healed. Due to continued deterioration of the ulcer, the treatment order was changed on 11/20/17. The physician's orders [REDACTED]. The documentation on 11/28/17 notes the Stage 3 ulcer deteriorated. The measurements were 2 cm (length) x 3 cm (width) and 0.1 cm in depth. The wound was noted to have a small amount of serous sanguineous drainage. On 12/4/17 the order for medi-honey was discontinued. The new order was to apply compound cream ([MEDICATION NAME] cream + zinc + [MEDICATION NAME]) to coccyx after cleaning with normal saline and cover with [MEDICATION NAME] foam twice a day. Subsequent note on 12/5/17 and 12/7/17 noted improvement with continued drainage. The last documented assessment is dated 12/19/17 which notes continued improvement in response to treatment. A review of the resident's quarterly Minimum Data Set (MDS) with assessment reference date of 9/20/17 noted in Section M. Skin Conditions, the resident had two Stage 2 pressure ulcers. The oldest ulcer was dated at 7/26/17. Further review found Resident #164 was coded as severely impaired for cognitive skills for daily decision making. In Section G. Functional Status, Resident #164 was noted coded as totally dependent on staff with one person physical assist for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) and toilet use. The resident was coded as always incontinent of bowel and bladder. A review of the care plan for Stage 3 pressure ulcer (onset date of 10/6/17) included the following interventions that were continued from 7/26/17 for the Stage 2 pressure ulcer: assess specific risk factors for pressure ulcers; assess and stage pressure ulcer/s; measure the size of the ulcer and note the presence of undermining; describe the condition of the wound; assess for wound exudates, condition of wound edges and surrounding tissues, and pain levels; change resident's position frequently - bed-bound resident every 2 hours and chair bound every hour; and provide thorough perineal hygiene after each episode of incontinence. Further updates to the care plan after 10/6/17 reflected the changes in treatment on 10/11/17, 11/20/17 and 12/4/17. Observation on the morning of 12/20/17 found the resident was receiving morning care and treatment for [REDACTED].M. Resident #164 was observed up in the wheelchair and was taken to participate in activities. Subsequent observation at 12:34 P.M. (approximately two hours later) found the resident still in the wheelchair having lunch. On 12/22/16 at 8:48 A.M. an interview was conducted with Staff Member #67. The staff member confirmed one of the Stage 2 ulcers (as noted in the MDS) healed. Inquired why Resident #164's pressure ulcer on the coccyx got worst and not healing. The staff member reported that the facility has changed the treatment orders and the resident is not meeting the fluid intake goals as well as decreased food intake; however, the staff member acknowledged that protein powder was added to the meals to promote healing. The staff member provided documentation of staff members repositioning the resident in bed. Further queried regarding the time the resident spends in the wheelchair. The staff member confirmed the care plan does not specify the amount of time the resident spends in the wheelchair. The staff member was unable to explain how the resident's position in the wheel chair would be changed every hour. The observation of the resident up in the wheelchair for approximately two hours was shared with Staff Member #67. The staff member acknowledged the care plan is not specific for the amount of time resident is up in the wheelchair to facilitate healing of the pressure ulcer and discussed the possibility that the resident may benefit from a gel cushion in the wheelchair. Concurrent observation with the staff member found the resident does not have a gel cushion in the wheelchair. On 12/26/17 at approximately 12:15 P.M. an interview was done with Staff Member #59. The staff member acknowledged that the resident's healing time is long and worsened, from a Stage 2 to a Stage 3. Inquired why did the pressure ulcer worsen. The staff member responded it is because the resident always has bowel movements so the order to stop taking senna was made by the physician. The staff member explained that the dressing does not ensure urine will not leak under the tape and when the resident has a bowel movement it is all over. Staff Member #59 confirmed that there was a change in the treatment for [REDACTED]. On 12/26/17 at 12:20 P.M. an interview was done with Staff Member #104. The staff member confirmed the resident is incontinent of bladder and bowel and confirmed the need to change the resident is important due to the pressure ulcer. The staff member reported the resident is checked in the morning and after breakfast for incontinence. Then the resident is checked before and after lunch too. Resident #164 had a facility acquired Stage 2 pressure ulcer to the coccyx which was identified on 7/26/17 which eventually progressed to a Stage 3 pressure ulcer on 10/6/17. There is documentation of changes in treatment and interventions on 8/3/17 (overlay mattress) and 8/7/17 (addition of protein powder). After the identification of the progression to the Stage 3 ulcer there was a change in the treatment order on 10/11/17 to cleanse with normal saline and apply medi-honey daily and prn. The treatment order was changed on 11/20/17 for the change of dressing every shift and prn. On 12/4/17 the treatment order was changed to discontinue the medi-honey and apply the compound cream ([MEDICATION NAME] cream + zinc + [MEDICATION NAME]). Although the treatments were changed, there was no care plan revision based on a root cause analysis (poor fluid and food intake) or lack of incontinence care or positioning/length of time spent in the wheelchair. Therefore, the development of the pressure ulcer and progression of the ulcer was avoidable if the facility had defined and implemented interventions that were consistent with the resident's need(s); monitored and evaluated the impact of the interventions; and revised the interventions as appropriate which resulted in actual harm, worsening of the Stage 2 pressure ulcer to a Stage 3 pressure ulcer and failure to progress towards healing.

Based on observations, residents and staff interviews, record review, and review of the facility policy and procedures, the facility failed to ensure the safety of their residents so that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of the 3 residents investigated for accidents (R #1 and R#174) in the Stage 2 sample of 38 residents; resulting in an Immediate Jeopardy (IJ) for one resident (R#1). Finding includes: 1)The R #1 was being investigated for a fall he endured in April 2014 which resulted in a left leg fracture. During the investigation of the R #1's fall on the afternoon of 2/12/15, a Licensed Nurse #5 (LN#5), reported to the Surveyor that the R #1 was "difficult and occasionally combative". The LN #5 further indicated the R #1 often left the facility without permission. She stated that he liked going to a store next to the facility. The LN #5 stated that the R #1 was sometimes found in the facility's parking lot and was sometimes found off the premises. A review of the resident's medical record found the following Diagnoses: [REDACTED]. The R #1's latest Resident Assessment Instrument, RAI, with assessment reference date of 11/29/14 found he had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points. The R #1's BIMS score revealed he was alert and oriented to person, place and time. He utilized a wheelchair which he was able to wheel around independently. The LN #5 provided a listing of when the resident eloped in the past. The R #1 resided on the 4th floor of the facility. A review of the incidents revealed the R #1 attempted to leave the facility on 9/7/13 when he was found wheeling himself out of the parking lot on the ground floor to a store next to the facility. Following this incident, the facility generated a care plan on 9/9/13 titled, "I want to go outside on my own." The care plan goal was that R #1 would be accompanied by someone to go outside and he would be reminded he couldn't go on his own over the next 6 months. The care plan interventions included, "Place Wanderguard on wheelchair at all times; Inform (R #1) he can go outdoors with someone accompanying him; Remind (R #1) to let staff know when he wishes to go outside; Offer to take (R #1) outdoors for fresh air/stroll at least 2 times per week ". The care plan was current during the 2/13/15 survey. The R #1 again eloped on 7/27/14 when a Certified Nurses Aide (CNA) was unable to find him on the unit. The Licenced Nurse #2 (LN#2) went down to the parking lot of the facility and found the resident there. The R #1 informed the LN #2, " I want to buy something at the store." The LN #2 accompanied the resident to the store where he bought 2 bottles of iced tea and the LN #2 brought him back to the facility. Another care plan was generated on 7/27/14 titled, "Elopement" which noted the problem, "Resident went down to the parking lot unaccompanied without notifying staff (elopement)". The interventions included, "Wanderguard to be placed on wheelchair to alert staff when resident tries to enter the elevator." The care plan was current during the 2/13/15 survey. The R #1 again eloped on 1/9/15 at 8:00 P.M. Another resident's family member saw the R #1 wheeling himself out of the elevator on the ground floor. The family member reported it to the Licensed Nurse #6 (LN # 6) who was the Charge Nurse. A staff member went down to get R #1 when he said, "I like go to the Korean store." The staff member accompanied R #1 to the store but it was already closed. The R #1 was returned to the facility in stable condition. During observations on the morning of 2/12/15, the R #1 did not have a Wanderguard alarm on his wheelchair. An interview with the Certified Nurse Aide #1 (CNA #1) on the morning of 2/12/15 revealed the R #1 no longer used the Wanderguard. An interview of the Licensed Nurse #2 (LN #2) on the morning of 2/12/15 revealed the R #1 did not have a Wanderguard alarm. A demonstration of the Wanderguard testing system was conducted by the Environmental Services Coordinator (ESC) on the morning of 2/12/15 at approximately 11:30 A.M. During the demonstration, the ESC asked the nursing staff for a resident who was using the Wanderguard alarm. The nursing staff informed the ESC that none of the residents on the 4th floor used the Wanderguard alarm system. The R #1 resided on the 4th floor. An interview with the Director of Nursing (DON), on the afternoon of 2/12/15 at approximately 2:15 P.M. revealed she attempted to keep the R #1 from eloping but he continued to do so. She stated, "As much as we remind him and encourage him to seek assistance, he continues to do so." The DON referenced the care plan, "Desire to go outside", and stated they maintain a Wanderguard alarm on his wheelchair at all times. The DON reported the Wanderguard was R #1's safety net to prevent him from leaving the facility unaccompanied. The Surveyor asked if R #1 was still utilizing the Wanderguard and she responded, "Yes, didn't you see it?" The Surveyor informed the DON that observations made on 2/9/15, 2/10/15, 2/11/15, and the morning of 2/12/15 revealed the R #1 did not have a Wanderguard in place. The DON stated, "To be honest, the Wanderguard system we have is antiquated. We aren't able to order new devices for the residents. We determine who absolutely needs it then reassign them as needed." The DON further stated, "He may be less of a risk than another resident. It was determined because he goes outside to the store around the corner and then he comes back. We teach him to not do that." She stated, "He had the Wanderguard on then another resident comes along with less cognition than him so we would swap it out to that resident." The DON was unsure of the number of Wanderguards the facility had. The DON reported R #1 was safe to go on his own to the store. Inquired whether the facility assessed the resident for safety, the DON replied he was not assessed. Further inquired whether there was the likelihood that R #1 would elope again, the DON replied," Yes." A Surveyor team meeting was conducted on 2/12/15 at approximately 3:00 P.M. to determine the level of harm. The Survey team determined an Immediate Jeopardy (IJ), was in progress. The team leader notified the Hawaii State Survey Agency's supervisor, the Medicare Certification Officer (MCO), who concurred with the IJ. The Survey team attempted to notify the Regional Office(RO), of the IJ but because of the time difference the RO staff had already left the office for the day. The Survey team met with the Administrator and DON on the afternoon of 2/12/15 at approximately 3:45 P.M. to inform them of the IJ. The Administrator and DON stated they would immediately write a Plan Of Correction, POC, for the IJ. The facility provided a written POC for the IJ which was accepted by the Survey team on 2/12/15 at approximately 4:30 P.M. The facility documented that they would provide one to one supervision of R #1 until their alarm system could be updated. The one to one supervision had already been implemented for the resident. The RO Long Term Care (LTC) Supervisor was notified of the IJ on the morning of 2/13/15 at approximately 10:00 A.M. Hawaii Standard Time. The RO LTC Supervisor supported the IJ. 2) An interview was conducted with R #1 on the afternoon of 2/9/15 when he stated that a CNA "broke my knee." He stated the CNA pushed him in his wheelchair into his room where he fell out of his wheelchair and broke his left leg. He stated, "It was so sore. It was the most painful thing I ever felt." He reported that the CNA has since resigned from the facility and therefore no longer worked there. He reported it was a male CNA. Investigation of the resident's complaint revealed the facility failed to prevent further injuries, as evidenced by their knowledge of the R #'s high risk for falls without revising interventions to promote his highest practicable potential physical well-being. An observation of R #1 in the afternoon of 2/9/15 found him in a wheelchair, wearing black gloves, a baseball cap with sunglasses on top, and a large knee brace on his left leg. The resident was able to wheel himself around the unit. A review of the facility's incident log on the morning of 2/12/15 found the The R #1 experienced falls on 10/19/13 (no injuries), 3/31/14 (no injuries), 4/20/14, and 6/9/14 (no injuries). The R #1 sustained injuries from the 4/20/14 fall when he was found on the floor lying on his left side partially under the corner of the foot of the bed with his left arm behind him. The physician was notified and ordered x-rays of his left hip and leg. The x-rays revealed the resident had a depressed tibial plateau fracture. He was transferred to the hospital for treatment and later returned to the nursing facility. On 6/9/14 at approximately 7:50 P.M., the R #1 was found on the floor lying on his left side and was holding his left leg up with both hands and his right leg was in a bent position on the floor with his head raised. When asked if he hit his head on the floor, he replied, "Not really." A medical record review on the afternoon of 2/11/15 found the facility routinely assessed the resident for his fall risk. The facility conducted their "Fall Risk Assessment (Attachment A)" on: 10/3/13 with a score of 8 (8-18=high risk, initiate Fall Prevention Protocol (Falling Coconut)"; 10/18/13 with a score of 10; 12/19/13 with a score of 10; 4/11/14 with a score of 12; 4/20/14 with a score of 13; 6/11/14 with a score of 13; 9/5/14 with a score of 13; and 12/2/14 with a score of 13. A review of the care plans revealed a care plan dated 3/15/14 (Updated) and titled, "Risk for Fall. (R #1) is at risk for fall related to history of falls and use of psychoactive drugs (Zoloft) and need for assistance with ADL's and impaired balance/gait." Interventions included, "Use the mechanical lift with 2 persons assisting him for transfers." Since his fall on 4/20/14 and 6/9/14, no intervention changes were made to the Falls care plan. The care plan was current during the 2/13/15 survey. An interview of R #1 on the afternoon of 2/11/15 found that when he fell on [DATE], the facility was providing 1 person transfer assistance. After the 4/20/14 incident, the facility changed to 2 person assistance during transfers. On the afternoon of 2/11/15, a review of the Resident Assessment Instrument, RAI, with Assessment Reference Date, ARD, of 3/13/14 revealed the R # 1 was able to independently move between locations in his wheelchair with setup assistance; and he was totally dependent with 2-person assistance for transfers. The RAI with ARD of 6/8/14 (after the 4/20/14 fall) indicated the R #1 was totally dependent and required one person assistance to move between locations in his wheelchair; and his transfer ability remained the same as the 3/13/14 RAI. The most current RAI with ARD of 11/29/14 indicated the R #1 did not move between locations; and he continued to be totally dependent with 1 person assistance for transfers (no longer 2 person assistance). An interview of the DON on the afternoon of 2/12/15 at approximately 2:15 P.M. revealed the Social Worker, SW, notified her of R #1's fall with the report that he fell out of his wheelchair. The DON stated, "I thought it was 'suspicious'." The DON explained that on 4/20/14, the CNA caring for R #1 wheeled him into his room. The CNA attempted to place the mechanical lift sling under the resident by pushing the R #1 forward in his wheelchair. The CNA realized he forgot the mechanical lift; and left the room to get the lift. The DON stated a staff member heard the resident had fallen. The staff member went in to help the CNA pick him up. She reported that she received varying reports from staff members and the Resident. The DON stated that she spoke with the then Administrator (who was no longer employed at the facility) about her concerns with the CNA. The DON stated her concern was possible abuse/neglect by the CNA based on the information she had collected up to that time. The CNA was off for the next few days when the DON attempted to contact him at home. The DON left several messages and never received a return call. The CNA was scheduled to work on a Saturday, when the DON was off, so she asked another LN to get a statement from the CNA. The statement from the CNA stated, "I left the room. He fell . Effective today, I resign." The DON stated, "It was hard for me to make a decision whether it was abuse. Statements from involved parties revealed the resident's story changed with different staff members." The DON stated that she didn't have concerns in care areas with the CNA. When asked if she had concerns about that CNA, she said she thought he was aloof and behaved like a teenager. The DON then stated that she never personally met the CNA. She stated the CNA worked night shift and somehow she never crossed paths with him. The DON was asked what types of safeguards she put in place to prevent further injury of R #1 since the 4/20/14 fall. She replied, "It was taken care of since the CNA resigned. If he hadn't resigned, he probably would've been terminated. As far as his previous falls, I wasn't here for those." When asked about changes in interventions, she stated they used episodic care plans for fall prevention. She indicated that the Ward Clerk might have thinned the chart. The DON was asked about reporting their policy for reporting significant injuries to the State Agency, SA. She stated they reported major injuries. She further indicated that the previous Administrator (who left 10/14) was responsible for reporting to the SA. She stated, "I wasn't brought into it at all." The R #1's accident on 6/9/14 was avoidable as evidenced by the facility's failure to implement the resident's care plan to use 2 persons for transferring this resident which resulted in injury (depressed tibial plateau fracture). 3) Cross Reference F280. Resident #174 was admitted to the facility on [DATE] with hospice services. The staff interview done on 2/9/15 at 1:23 P.M., the staff member reported Resident #174 fell on [DATE] resulting in a fracture of the right wrist. The staff member also reported the resident fell on [DATE] with no injury. On 2/10/15 at 12:40 P.M., Resident #174 (R#174) was observed in bed asleep, the bedside table was placed across her body, there was no pad on the floor. At 1:56 P.M. observed a staff member placing a second floor padding atop the pad that was already placed to the resident's left side. On 2/11/15 at 7:49 A.M. observed the resident seated in the dining room with an alarm clipped to her clothing. Observation on 2/12/15 at 8:22 A.M. found the resident feeding herself, using her right hand with the splint applied. On 2/12/15 at 9:52 A.M. observed Resident #174 ambulating with a forward wheel walker and the assistance of one staff member to the activity room. Review of the facility's "Occurrence Event Report" documents on 1/16/15 at 10:10 P.M. Resident #174 was found on the hallway floor stating she fell from bed. The witness notes that he/she was charting at the nursing station and heard "help me" and saw the resident crawling in the hallway, attempting to stand, pushing the plastic isolation cart outside of Room 408. The resident stated she wanted to use the bathroom. The initial finding in the even report documents the personal alarm was attached and the bed alarm was turned on. Review of the "Interdisciplinary Progress Notes" (IPN) documents on 1/16/15 (2215) at 2215 resident was found crawling on the hallway floor asking for help. The nurse also documents the personal alarm attached, bed alarm on, call light within reach and reminded resident to ask for help when needs assistance. Resident #174 had another fall on 2/2/15. Review of the "Occurrence Event Report" notes the resident's alarm was heard and before staff member stepped into the room, a loud "bang" sound was heard in the bathroom. The resident was found in "lying position under the sink". The resident was responsive and alert and sustained a bump on the head and skin tear. The initial investigative findings note the personal alarm was attached and the bed alarm turned on. The resident was in Room 413. Record review on the afternoon of 2/10/15 found an admission Minimum Data Set with assessment reference date of 12/30/14 which notes Resident #174 yielded a score of 14 (cognitively intact) on the Brief Interview for Mental Status. Review of Section G. Functional Status, notes the resident requires limited assistance with one person assistance for bed mobility, transfer, walking in room, and toilet use. The resident was also coded to be occasionally incontinent of urine and always continent of bowel. The Care Area Assessment notes the resident has poor safety awareness that puts her at risk for falls. A bed alarm is utilized and a personal alarm is utilized when she is out of bed; however, the resident can remove the personal alarm. A review of the care plan dated 12/26/14, risk for fall related to poor safety awareness, history of falls, cognitive impairment, assistance with activities of daily living and impaired balance/gait was done. The goal is for no fall incident within the next 90 days. Interventions include: assess level of cognition and function q shift and prn; orient resident to staff, roommates, and room; place call light within easy reach; anticipate resident's needs; personal alarm on at all times and attached to clothing; keep environment clutter free and adequate light; monitor often for safety; proper transfer technique; monitor for signs/symptoms of pain and administer pain meds prn; use of assistive device in transfers and ambulation; monitor for side effects of drugs, update MD/NP as needed; observe for signs/symptoms of delirium, update MD/NP as needed; and follow consultant pharmacist recommendation. Subsequent to a fall on 1/16/14, Resident #174's care plan was updated on 1/16/15. The goals identified was resident will be kept comfortable and pain-free every shift within the next 7 days; resident will maintain level of care within the next 7 days; and resident will be free from injury related to fall in the next 30 days. The interventions remained the same as the 12/26/14 care plan with the addition of answer call light and alarm promptly and offer toileting every two hours while awake offer to assist resident to use the bathroom before going out for meals, activities and going back to bed. This care plan was crossed diagonally with handwritten note, resolved 1/23/15. Following a second fall on 2/2/15, the resident's care plan was updated on 2/2/15. The goals identified were the same as the care plan dated 1/16/15. The care plan included the same interventions in the discontinued care plan with the addition of the following interventions: bathroom door alarm always on; bed alarm in place and on; floor mattress in place; follow neuro check protocol; notify MD/NP and family; assess for possible injury, change in LOC; and monitor for signs and symptoms of delirium and infection and update MD/NP. After the fall of 2/2/15, Resident #174 complained of pain. Review of the IPN documents resident complained of pain and swelling was noted to the right hand on the following dates: 2/2/15 at 1145 pain (head) and a headache; 2/2/15 at 2300 redness to back of right hand; 2/3/15 at 1020 complained of chest pain and pain to both upper arms; 2/3/15 at 1050 complained of pain which was relieved with morphine sulfate; 2/3/15 at 1300 the resident complained of pain to right wrist, 10/10, refusing medications; 2/5/15 at 0950 the resident right hand slightly swollen; 2/5/15 (late entry) complain of pain to right wrist; 2/6/15 at 0930 right hand red with order for x-ray; 2/6/15 at 1330 the resident confused for 2 days; 2/7/15 at 1110 complained of right wrist pain; and 2/7/15 at 1900 right hand still swollen. The physician documents on 2/2/15 the resident has a hematoma along the scale on the right side and bruising of the right wrist. The physician note of 2/9/15 documents resident has a radial fracture with the recommendation for use of splint. On 2/11/15 at 9:28 A.M. an interview was done with Resident #174. The resident was aware that she fell twice. Inquired what happened, she stated that she was calling for help and when she has to wait for 15 to 20 minutes she has to go to the toilet by herself. She reported her call light works. Inquired what happened to her wrist, she replied she has a fracture, she hurt herself when she tried to brace the fall and commented that she fell because she is "old". The resident reported the splint is "humbug" because she can't use her hand. The resident also shared that the first fall was her fault because she did not wait for staff to answer her call light and was rushing to go to the bathroom and was in the hallway looking for help. She also reported the second time she fell it was the same thing, she was rushing around to get to the bathroom. The resident added not to be too hard "on them, I really blame myself, if I listen to them and waited". The resident commented that it is embarrassing to make "shi-shi" (urinate) in your pants. Interview and concurrent record review was done with the Director of Nursing (DON) on 2/12/15 at 8:27 A.M. The first fall (1/16/15) was reviewed with the DON. Review of the facility's report with the DON, highlighted that the report documents the resident has a bed alarm, did that sound before the resident was found on the floor in the first fall. The DON's response was that she thinks a bed alarm was applied in response to the actual fall and was not implemented before the fall. Inquired whether an alarm was heard as care plan indicates resident has a personal alarm on at all times. The DON responded that her assumption is that the resident took it off and that's why staff members did not hear the alarm. Further queried whether a thorough root cause analysis was done and the care plan was revised based on the analysis. The DON responded affirmatively. The DON replied a bed alarm was added as well as checking on the resident more frequently and offering toileting every two hours while awake. Inquired how often is "frequently"? The DON confirmed the care plan does not specify how often staff members are to check on the resident and the care plan was not updated to include the use of a bed alarm. The DON stated the resident was trying to get to the restroom. Inquired whether the facility's analysis included the availability of staff, call light response time, if bed alarm was in use at that time and an assessment of the resident's abilities for toileting was done. The DON was asked whether the facility did a root cause analysis and implemented appropriate interventions based on their analysis. The DON replied "probably not". The resolved care plan dated 1/16/15 was reviewed with the DON. Inquired why this plan was resolved and the facility reverted back to the initial plan that was in place when the resident had her first fall and subsequently had another fall on 2/2/15. The DON surmised the plan dated 1/16/15 was for a seven day period and would need to reeducate the nurses on care plan. The second fall of 2/2/15 was reviewed with the DON. Queried DON regarding the alarm as the report documents an alarm was heard, asked which alarm sounded as the resident has a personal alarm, bed alarm and there is an alarm on the bathroom door. The DON replied probably the bathroom alarm. Inquired whether the use of medication (mirtazapine, prn lorazepam and prn morphine) contributed to the fall. The DON acknowledged a side effect of mirtazapine has side effect of dizziness, similar to side effects related to taking a sleeping pill. The DON confirmed the use of medication was not included in the analysis. On 2/11/15 at 9:16 A.M. observation was made with Certified Nurse Aide #6. The CNA confirmed the bed alarm was in place; however, there was a cord that was not plugged in. The CNA reported this was the cord for the call light and plugged in the cord. Observation on 2/11/15 at 1:58 P.M. found the resident lying in bed, no mats on the floor. The resident's front wheeled walker was closed and placed against the wall. At 2:42 P.M. Licensed Nurse #1 (LN #1) was asked if mats on the floor are used for Resident #174. The LN stated floor mats are used for this resident as she is at high risk for falls. The LN entered the resident's room and found the resident did not have floor mats. The LN proceeded to place a mat on both sides of the resident's bed. At 3:02 P.M. the LN was asked how are the floor mats used for this resident as there is an observation of the resident having two floor mats stacked atop one another and placed to the resident's left side of the bed. The LN responded a mat should be placed on both sides of the resident's bed. Further queried what does the care plan specify for the placement of the floor pads. LN #1 confirmed the care plan was not specific on placement of mats. The facility did not ensure a thorough analysis of the resident's falls. Resident #174's care plan interventions were updated to prevent future falls. Following the fall on 1/16/15 the care plan was updated with an addition of two interventions to the original plan and resolved on 1/23/15, reverting to the previous care plan interventions which were in place when the resident had her first fall. The resident experienced another fall on 2/2/15, which resulted in actual harm, radial fracture requiring splints. 4) On 02/13/2015 at 9:35 AM An interview with the DON, Administrator (ADM) and Quality Assurance Auditor (QA) when asked about reporting of R#1's fall to the state surveyors office the DON stated, "I assumed the Administration would submit a report (to the State agency) and he thought I would do the report." There was no follow up with ADM or DON if the fall was reported to the State Agency. The report of the fall was never filed to the state agency at the time of the survey.

Based on observation, resident interviews, staff interviews, and faciltiy policy review, the facilty failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator and Director of Nursing failed to communicate and recommend trending, analysis to determine systemic improvements to the Quality Assessment and Quality Assurance committee. Findings include: Cross reference to F323 and F225 The survey team determined the facility was providing substandard quality of care and actual harm. An extended survey was initiated. 1) R#1 Occurrence Event Report for elopement occurring 1/9/15, 7/27/14 and 9/7/13 was completed by the charge nurse; reviewed and signed by the Adminitrator and Director of Nursing ; and not marked for assessment of trends and determination of systemic improvements. The Administrator and/or DON did not make a recommendation to the Quality Assessment and Qualtiy Assurance committee for review and analysis of the repeated events. R#1 Occurence Event Report for a fall occurring 6/9/14 that resulted in injury was signed by the former facilities Administrator and current DON and not marked for assessment of trends and determination of systemic improvements. In the facilities policy on Occurrence Event Report for Residents & Visitors revised 4/15/08 f. Event reports will be analyzed and monitored for trending and further action/recommendations as presented during the quarter Quality Improvement. 2 )R#1 elopements and fall are reportable events to the State Agency. In the facility's policy on Occurrence Event Report for Residents & Visitors revised 4/15/08 for unwitnessed falls and elopements the facility's policy titled, " Occurrence Event Report for Residents & Visitors", revised 4/15/08, unwitnessed falls and elopements will be subject to further investigation and reporting, as appropriate, to the Department of Health, Office of Healthcare Assurance, by the Administrator within the required reportable time as regulated. For the elopement and falls the facility failed to send the required report to the State Agency. The DON stated "I assumed the Administrator would submit a report to the State agency and he thought I would do the report." Both the Administror and Director of Nursing failed to check with each other to see if the report of the events were sent to the state agency. An investigation at the Office of Health Care Assurance for events reports sent in by the facility verified that there was no report sent into the state agency for elopements and fall for R#1. 3) On 2/12/15 at approximately 2:15pm the DON stated in an interview that she spoke to the Administrator (now retired) of possible abuse/neglect by the CNA caring for R#1. Both the DON and Administrator failed to follow the facility's policy to ensure the prevention, and safety of all residents from incidences of abuse, neglect or misappropriation of property. In the facility's policy "Investigation of Alleged Violations Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, Unusual Occurences and Misappropriation of Resident Property", it states all alleged violations involving neglect, abuse, injuries of uknown source and misappropriation of resident property, are reported immediately to the Administrator of the facility. Such violations shall also be reported to State agencies in accordance with State law. The faciltiy Administrator and Director of Nursing hold positions of leadership within the facility their oversight of the occurrence event reports and communication of recommendations to the Quality Assessment and Assurance committee is an important safeguard for the quality of life and quality of care to the residents.

Based on obervations, resident and staff interviews, and policy review, the facility's Quality Assessment and Assurance committee failed to identify quality deficiencies and failed to develop and implement appropriate plans of action to correct quality deficiencies identified in the facilities Occurence Investigation Form for 3 of the Stage 2 resident sample of 38. Findings include: Cross reference to F225, 323 for evaluation of falls and elopment; and F420 for administration 1) Part 2 of the Quality Assessment and Assurance (QAA) review was conducted on 02/13/2015 at 9:35 AM in attendance were the Administrator (ADM), Quality Assurance Auditor (QA) and the Director of Nursing (DON). The ADM and QA stated the Quality Assurance committee has a falls report in place to document fall occurrences and causes, diagnosis, and patterns. The facility uses an Occurrence Investigation Form to identify concerns. Quarterly reports are reviewed to see what has happened on the floors, from there the committee start the assessment process. The meetings are not resident specific - a single incident may not be a red flag. A review of the facility's policy titled, " Occurrence Event Report for Residents & Visitors", revised 4/15/08, indicated reportable events included: a. Witnessed and unwitnessed falls/slips; k. Elopements: The policy noted, " II. Documentation: e. Events alleged as possible abuse/neglect will be subject to further investigation and reporting, as appropriate, to the Department of Health, Office of Healthcare Assurance, by the Administrator within the required reportable time as regulated; f. Event reports will be analyzed and monitored for trending and further action/recommendations as presented during the quarterly Quality Improvement Committee meetings. R #1 had a history of [REDACTED]. A review of the facility's "Occurrence Investigation Form " indicated that the QAA failed to identify, analyze, and update interventions for the risks/hazards associated with the elopements. R#1 had a history of [REDACTED]. The fall on 4/20/14 resulted in injury . A review of the facility's "Occurrence Investigation Form" indicated the QAA failed to identify, analyze, and update interventions for fall risk. R#174 fell on [DATE] and 2/2/15. On 2/12/14 at 8:27AM the DON was asked whether the facility did a root cause analysis and implemented approriate inteventions based on their analysis. The DON replied "probably not". Cross reference to 279, 323, 329 Regarding care plan 2) On 02/13/2015 at 9:35 AM during an interview to discuss Quality Assessment and Quality Assurance (QAA) with the Administrator, Quality Assurance Auditor (QA) and the Director of Nursing (DON), the Administrator stated the Quality Assurance committee determines that an action plan is needed brought up by feedback from staff; observations; other facility concerns. For care plan updates the staff uses a blue marker and hand writes a discontinued date. Because the care plans are hand written they can get difficult to read. They are templating the care plans trying to make them easier to read and individualized. Staff are providing care according to the directives of these action plans. Implementation of plans are through seeing a trend (such as falls) and constantly adjusting plans as part of the whole process. When informed of the obervation that the residents care plans for falls (R#1 and R#174), elopement (R#1) and vision (R#1 and R #162) were not being followed by staff, or updated to address their current needs. That there was inadequate assessment of the root causes for each of these incidents event, the QA stated this may be something the QAA could study. 3) Cross reference to F441. There was general lack of knowledge on contact time and use of santizers by staff workers throughout the faciltiy. On 02/11/2015 at 3:07 PM the Administrator (ADM), Director of Nursing (DON), and Infection Control Coordinator (LCC) who was present by phone conference met. The LCC was informed that Morning Mist is used at the facility and when random staff was queried there were many different responses on contact time, when to use the different sanitizers, and the ESC was not following the recommended Morning Mist policy on contact time. The LCC stated, "no, they do not use Morning Mist, the facility uses the Purple top sani wipes". The ADM and DON informed the LCC that the facility does use Morning Mist. The LCC stated "this is a weak point in the program (Infection Control) I am disappointed." The QAA's failure to identify quality deficiencies and develop and implement plans of action to correct these deficiences, including monoitoring the effect implemented changes and making needed revisions to the action plan affects the overall quality of care to all residents at the facility.

Based on observation, resident and staff interviews, and medical record review, the facility failed to revise the care plans and use the results of assessments to develop a care plan to include measurable objectives to meet a resident's medical and nursing needs to maintain their highest practicable physical and psychosocial well-being for 3 residents (R #1, R #174, and R #162) of the 15 care plans reviewed in the Stage 2 sample of 38 residents. Findings include: Cross reference to F 323. 1) A review of the care plans for R #1 on the afternoon of 2/11/15 found the interventions for Elopement were not being implemented. The R #1 had a history of [REDACTED]. The R #1 continued to elope after the care plan was implemented on 7/27/14. The care plan indicated the R #1 had a Wanderguard alarm in place. Observations on the afternoon of 2/12/15 found the R #1 did not have a Wanderguard alarm on his wheelchair as was indicated on the care plan. The R # 1 eloped after the 7/27/14 care plan was created on 1/9/15. A review of the care plans for R #1, on the afternoon of 2/11/15 found the interventions for Falls were not being implemented. The R #1 continued to have falls after the update of the Falls care plan on 3/15/14. The interventions remained the same and had not been updated despite additional falls on 4/20/14 and 6/9/14. One of the interventions in place since 3/15/14 was, "Use the mechanical lift with 2 persons assisting him for transfers. "The intervention was contrary to the RAI dated 6/8/14 (after the 4/20/14 fall with fracture) which indicated the R #1 was to be transferred with 1 person assistance. The R #1 fell again on 6/9/14. The R #1 is a large man with a big frame and a [DIAGNOSES REDACTED]. Interview of the DON on the afternoon of 2/12/15 revealed her understanding that the R #1 was to have a Wanderguard alarm on his wheelchair. She reported that the facility did not have enough Wanderguard alarms for all the residents who needed them. The facility's approach was to assess who needed the Wanderguard most based on their cognizance. Interview of Certified Nurses Aide, CNA # 1 on the morning of 2/12/15 revealed R #1, "No longer used the Wanderguard alarm." She stated the resident previously used the Wanderguard alarm but no longer had one. Interview of Licensed Nurse, LN # 2 on the morning of 2/12/15 revealed R #1 no longer used the Wanderguard alarm. On the morning of 2/12/15, the Environmental Services Coordinator (ESC) was looking for a resident on the 4th floor (where R #1 resided) to test the Wanderguard alarm system. The staff on the 4th floor informed the ESC that no one on the 4th floor used a Wanderguard alarm. Interview of the CNA # 1 on the morning of 2/12/15 revealed the R #1 had always required 2-person assistance for transfers. Interview of LN # on the morning of 2/12/15 revealed the R #1 had always required 2-person assistance for transfers. The fall that occurred on 4/20/14 was the result of the CNA trying to transfer the R #1 without another person. 2) Cross Reference to F323. Resident #174 is prescribed [MEDICATION NAME] and prn [MEDICATION NAME]. The care plan was not specific to include the side effects for the use of [MEDICATION NAME] and [MEDICATION NAME]. Interview with the licensed nurse (LN) confirmed that staff members are not aware of side effects to monitor for the use of these medications. The LN was unable to identify side effects related to the use of [MEDICATION NAME] and [MEDICATION NAME]. The care plan did not include non-pharmacological interventions and parameters for the use of prn medication, [MEDICATION NAME]. 3) Cross Reference to F281 and F313. Resident #162 was selected for Stage 2 sample for vision review. Record review was done on 2/11/15 at 7:51 A.M. A review of the comprehensive Minimum Data Set (MDS) with assessment reference date of 11/11/14 notes Resident #162 has impaired vision (sees large print, but not regular print in newspapers/books) and does not have corrective lenses (contacts, glasses or magnifying glass). Review of the Care Area Assessment notes visual impairment was triggered due to having impaired vision and is at risk for further decline in visual function due to [DIAGNOSES REDACTED]. The decision was to care plan. Review of the resident's care plan found there is no care plan to address the resident's impaired vision. Interview with Floor Supervisor #1 (FS #1) was done on 2/11/15 at 8:00 A.M. The FS reported the resident has glasses and found glasses was found on the inventory list. Concurrent review of the care plan was done. The FS confirmed the resident does not have a care plan with goals and interventions to address his visual impairment. 4) On 02/13/2015 9:51 AM at a meeting with the DON, Administrator, Quality Assurance Auditor (QA) to discuss the quality assessement and assurance activities of the facility. The Administrator and QA verified that the Quality Assessment and Assurance committee does not look at resident specific concerns. The DON and QA stated care plan issues may be a quality assurance project.

Based on observation, record review, interview with resident and staff members, the facility failed to ensure 1 (Resident #174) of 15 residents' care plan in the Stage 2 sample of 38 was revised based on an assessment following a fall. Finding includes: Cross Reference to F323. Resident #174 was identified to be at high risk for falls upon admission. A care plan was developed on 12/26/14. The resident had a fall on 1/16/15 with a care plan update to include two additional interventions to the original care plan. The revision was not based on a thorough causal analysis. This care plan was "resolved" on 1/23/15 and the 12/26/14 care plan was not revised, reverting to the original care plan that was being implemented when the resident had her first fall. Subsequently, the resident had another fall resulting in a radial fracture to the right wrist.