Every finding on record at Samuel Mahelona Memorial Hospital

Based on record review and interview the facility failed to provide adequate supervision to prevent an accident for one of three residents (R) 13 sampled for accidents related to falls resulting in major injury and pain. The deficient practice puts all residents, who are at a high risk for falls, who are informally monitored on one to one for falls prevention, at great risk for a fall with injury and pain.Findings Include:On 08/06/25 at 4:49 PM the Office of Health Care Assurance received an initial report via fax from the facility reporting R13 had an unattended fall on 07/04/25 at 1:00 PM resulting in an Acute comminuted right femoral neck fracture. R13 was transferred to the hospital on [DATE] and underwent surgical repair on 07/05/25. R13 returned to the facility on [DATE] at 1015. Facility reported on 07/14/25 at 3:30 PM R13 had an unwitnessed fall from her wheelchair when she attempted to stand. X-rays were done showing Right proximal femoral endoprosthesis in place; No acute fractures identified. On 7/15/25, she visited the orthopedic office where repeat X-Rays showed Stable R Hip Hemi - L Hip no Fx Seen. Facility reported today 08/01/25 at 12:24 PM, x-rays were repeated because R13 complained of pain while up ambulating and had no demonstrated improvement. X-ray today showed Fracture of the right greater trochanter appears new since 07/14/25; Right proximal femoral endoprosthesis in place. Follow up visit at hospital x-ray done prior to visit shows no fracture. On 05/14/26 at 9:19 AM an interview was conducted with Certified Nurse Aide (CNA) 62 in the conference room. Inquired of CNA62 if she was assigned to do one to one with R13 on 07/14/25. CNA62 denied being assigned one to one with resident on 07/14/25, stated she was taking care of the residents in this section that R13 resides in, she was assigned residents that day, a case load which is about 8 residents. CNA62 confirmed that she told Registered Nurse (RN)29 that she wanted to go home and CNA62 stated she tagged (endorsed/handed over duties of one to one) RN29 who said yes and CNA62 stated so I can go home. Inquired of CNA62 what tagged meant and she stated, I can tag you which means they can stay with the resident. Inquired if R13 was on a one-to-one monitoring and CNA62 stated she was not sure if R13 was on one-to-one monitoring. CNA62 denies R13 stood up and fell while she was monitoring R13. On 05/14/26 at 9:38 AM an interview was conducted with the Director of Nursing (DON) in the conference room. Inquired of DON when R13 was placed on one-to-one monitoring and she stated on 07/09/25, when she returned to the facility after having had right hip surgery due to a previous fall on 07/04/25. DON stated on 07/04/25 R13 was positive for COVID, and she was in isolation and stood up to go to the bathroom and fell right outside of the bathroom. R13 required stand by assistance because of her advanced dementia that she would forget what needs to be done in the bathroom. At this time, on 07/04/25, DON stated R13 was a medium risk for falls. Resident had a floor alarm but because the door needed to be closed (due to COVID) the staff did not hear the alarm. Since this occurred the facility has changed its practice to leave the door open. Inquired of the DON who was assigned to do one to one monitoring with R13 and she stated CNA62 and CNA47. DON stated she believes the resident stood up from her wheelchair and tripped over the footrest and had the fall. DON stated the unit had an outbreak of COVID at this time, and the other CNAs were helping on the floor. Inquired why the CNAs assigned were helping on the floor instead of staying with the resident and she stated to help the staff. Inquired why the one-to-one staff did not stay with the R13 and DON said they would tag another staff to watch the resident, and it was nearing the end of the shift. On 05/14/26 at 9:53 AM an interview was conducted with CNA19 in the conference room. Inquired about what a one-to-one staff does with the resident, and she stated that as a one-to-one you would stay with the resident. CNA19 confirmed she worked with R13 as a one-to-one when R13 returned to the facility after having her surgery. CNA19 stated the staff stay with the resident unless they endorse to another staff. Surveyor asked CNA19 to give an example of when she would endorse to another staff member and she stated she endorsed to another staff when she took a break but cannot remember who she endorsed to. Inquired of CNA19 if she was working with R13 when she had the fall on 07/14/25 and CNA19 denied being with the resident when she had the fall. Inquired who told her what needed to be done as a one-to-one with R13 and CNA19 stated the charge nurse and sometimes the DON tell the CNAs, staff meet before the shift and are told to stay with the resident if you are assigned one-to-one and to tag or endorse off to another staff member. On 05/14/26 at 9:59 AM an interview was conducted with CNA47 in the conference room. Inquired if she worked with R13 as a one to one in July 2025 and CNA47 was able to confirm she was one of the 1:1's. Inquired where staff position themselves to monitor the one-to-one and CNA47 stated if the resident is in her room, we sit at the door facing into the room to see the resident who is in the bed and their bed is low. If the resident is outside, we sit with her, next to her. CNA47 stated she worked with R13 in the morning on 07/14/25. Inquired who relieved her and CNA47 stated she did not remember who relieved her to leave the resident. CNA47 stated she worked with only those residents who were positive for COVID during this time, approximately 4 residents, but does not remember the accurate number. Inquired of CNA47 if she was with R13 when she fell and CNA47 denied being with the resident when she fell.On 05/14/26 at10:30 AM interviewed the DON again in the conference room. Inquired about the x-ray that was taken on 08/01/25 which showed R13 had a trochanter fracture. DON stated the fracture might be due to the hardware placed in the resident's hip and osteoporosis. Inquired if R13 had a diagnosis of osteoporosis and DON could not recall. Inquired if the impact of the fall could have caused the pain and fracture R13 sustained and DON stated she was not sure. Inquired why CNAs assigned to work with R13 also worked with the other residents in the section of rooms and one was not designated as the one-to-one staff with R13 and DON stated we have to be clearer about the staff assignment, that they know they are the one-to-one with the resident. DON also stated the nurse maybe should not have taken the resident. DON confirmed that the CNA should have waited for the next shift CNA to hand off care to. DON stated Resident returned to the facility as a high risk for falls after she had her first fall and had surgery. DON was able to confirm that the CNAs had left and RN29 was the staff who was with the resident when she fell on [DATE]. Inquired for a copy of the facility's policy for one-to-one monitoring and DON stated they do not have a policy for one-to-one monitoring for residents who are being monitored for falls. Requested printed documentation of the fall the nurse wrote which the DON was able to provide. On 05/14/25 record review of R13's printed copy of progress note written on 07/14/25 and signed by RN29 at 23:21 (11:21 PM) states .Resident was comfortably sitting on wheelchair with footrests on, outside of room [ROOM NUMBER] while this writer at the med cart parked by room [ROOM NUMBER]. This writer head [sic.] loud thud sound and noted resident on the floor, L side passed the middle side of the hallway. Tramadol given at 1625 (4:25 PM) due to grimacing with ambulation, .Continued record review of printed documents provided by DON found a Physical Therapy note dated 07/17/25 verified by Physical Therapist (PT) 4 at 16:08 (4:08 PM) stated PT Clinical Assessment Summary: Resident was found in her wheelchair in the long-term care (LTC) facility, accompanied by a nurse. She (R13) ambulated 10 feet with wheelchair follow, CGA, and support from her left upper extremity on the railing. Due to a recent increase in pain, the resident was unable to tolerate longer distances during ambulation. Her previous ambulation of 300 feet may have contributed to the exacerbation of symptoms observed today.Continued record revied of R13's progress notes provided by DON found a progress note written by DON on 08/01/25 and electronically signed at 15:58 (3:58 PM) which stated Resident continues to complain of pain when staff attempted to walk her. Resident will stand with minimal assist however complains of pain with mobility stating that it hurts. Decision was made by doctor and nurse practitioner to re-x-ray rt hip. Results Rt Greater Trochanter fracture.Continued record review of R13's progress notes found a note written by the Nurse Practitioner (NP) dated 08/01/25 and electronically signed at 16:07 (4:07 PM) which states . Since, 07/14/25, patient moves from sitting to standing with contact guard but when attempting to ambulate with PT, she can plant R (right) leg but has great difficulty then moving L (left) leg forward. As a result of this presentation, in spite of previous x-ray results, x-ray of R (right) hip and pelvis done 8/1/25. See results from 8/1/25 x-ray showing slightly displaced fracture of the right great trochanter which appears new since 7/14/2025.Continued record review of R13's printed progress notes found on 08/01/25 electronically signed at 18:36 (6:36 PM) RN13 wrote Xray of right hip was done results fracture of the right great trochanter. APRN name and doctor's name aware of the results New order from APRN's name: Tramadol 50 mg po q (every) 6 hrs for 7 days prn (as needed) pain breakthrough stop date 08/08/25.

Based on record review and interview, the facility failed to develop and implement individualized dementia care plans for three of four residents (Resident (R) 4, R6, and R7) reviewed for dementia care. This deficient practice placed residents with dementia at risk for unmet needs and failure to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Include:1) R6 is [AGE] year-old female admitted to the facility on [DATE] for long term care. Diagnoses included the following, but not limited, to high blood pressure, vascular dementia, type 2 diabetes, and motor speech disorder. Review of R6's Electronic Health Record (EHR) revealed R6 is prescribed psychotropic medications, has a diagnosis of dementia, and found no care plan related to dementia care. On 05/13/26 at 02:47 PM, an interview was conducted with Director of Nursing (DON). DON confirmed R6 did not have a care plan for dementia care. 2) R4 was admitted to the facility on [DATE] with diagnoses, but not limited to, dementia with mood disturbance, major depressive disorder, borderline personality disorder, and obtrusive sleep apnea. Review of R4's EHR revealed R4 is prescribed psychotropic medications, has a diagnosis of dementia, and found no care plan related to dementia care. On 05/13/26 at 01:47 PM, an interview was conducted with DON. DON confirmed R4 did not have a care plan for dementia care. 3) On 05/12/26 at 03:45 PM, record review of R7's EHR found his diagnoses include, but are not limited to, peripheral neuropathy, atrial fibrillation and chronic constant pain due to injury. Review of R7's Center of Medicare and Medicaid Services Minimum Data Set (MDS) with an Assessment Reference Date (ARD) observation end date of 04/28/2026 found resident was coded as having an active diagnosis of non-Alzheimer's dementia. On 05/13/26 at 08:00 AM, requested a printed copy of R7's dementia care plan from the DON. On 05/13/26 at 11:13 AM, an interview was conducted with the DON in the conference room. DON was able to provide copies of some of R7's care plans. DON stated R7 did not have a CP for resident's dementia care. Inquired if this should have been included in R7's CP and DON confirmed this should have been included. Requested a copy of the facility's policy on care planning which she was able to provide. On 05/13/26, review of facility policy titled Behavior Management Program with an effective date of November 14, 2025, states, I. Purpose: To define and set expectations for the provision of mood, behavioral health, and dementia care services to ensure each resident attains and maintains their highest practicable physical, mental, and psychological well-being. This includes residents with dementia, severe mental illness, intellectual disability, or related conditions.IV. Procedure: D. Person-Centered Care Plan 1. The IDT will develop a comprehensive care plan including: a. Mood and behavior interventions b. Dementia-specific approaches c. Environmental modifications d. Non-pharmacological interventions.

Based on observation and interview, the facility failed to store and label food, and failed to ensure the ice machine in the kitchen was kept in clean and sanitary condition, in accordance with professional standards for food service safety. This deficient practice puts residents at risk for serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents at the facility. Findings Include: On 05/11/26 at 08:29 AM, during initial tour of the facility's kitchen, concurrent observation and interview were done with the Hospital Executive Chef (HEC). Observed large plastic container with expired uncooked rice with a use-by label date of 04/07/26. Multiple food items stored in the walk-in freezer observed as expired and without proper labels. HEC was queried if containers should be labeled correctly after food was transferred from the original containers and expired foods should be discarded, HEC confirmed and agreed that all food containers should be properly labeled and all expired food discarded. On 05/11/26 at 08:37 AM, continued concurrent observation and interview of facility's kitchen with HEC. Observed a buildup of hardened brown sediment/material around the bottom edge and side panel of ice machine in the kitchen. HEC explained that an outside vendor, [NAME] Refrigeration Kauai (RRK), is responsible for doing preventive maintenance (PM) and cleaning of the ice machine. RRK was scheduled to perform PM and cleaning of the ice machine in February 2026 but had to reschedule for 05/11/26 due to staffing issues. EC also agreed that the ice machine should be cleaned regularly to maintain and prevent buildup of brown sediment/material on any part of the ice machine. The kitchen ice machine quarterly PM log indicated that PM was only done on 08/12/25 and 11/17/25, but no PM was done for 2026. Reviewed facility's policy and procedure titled, Food Preparation and Storage with an effective date of 03/02/26. The policy instructs staff to make sure that .Items will be labeled with the date and food service employee number.3. All chilled food items.will be disposed within expiration.all frozen food items.will be disposed within expiration. Policy and procedure titled, Storage and Handling of Ice with an effective date of 06/14/25 stated, .D. Preventive Maintenance (PM) Ice Machine.1. PM will be done quarterly and as needed.

Based on observations and interviews, the facility failed to ensure one of three treatment carts and one of three medication carts were locked when unattended by nursing staff. This deficient practice allowed unauthorized access to medications and treatment supplies, placing medications at risk for diversion and placing residents at risk for not receiving medications and dressing changes as prescribed.Findings Include:1) On 05/13/26 at 08:34 AM, during medication administration observation, observed the treatment cart with prescribed topical medications and other supplies for the residents in the hallway unlocked and unsecured. Registered Nurse (RN) 24 was asked if medication cart should be locked when not in use, or before leaving treatment cart to administer medication to residents, RN24 confirmed that it should be locked and secured. RN24 stated that she forgot to lock the cart after grabbing band aid to apply to a resident's wound. On 05/13/26 at 09:20 AM, an interview was conducted with the Director of Nursing (DON). Shared observation of the unlocked treatment cart with DON and DON confirmed that treatment carts should always be locked and secured when not in use. 2) On 05/13/26 at 11:28 AM, observed a medication cart in the hallway near a resident's room unlocked and no nurses nearby. Licensed Practical Nurse (LPN) 4 came out of the resident's room. LPN4 noticed the medication cart was unlocked and stated she got distracted by the resident who had yelled out for help and she went to help him. Inquired if the medication cart is to be locked before the nurse leaves the cart and LPN4 confirmed she is to lock the medication cart before leaving it. On 05/14/26 requested, received and reviewed facility policy on Medication Storage with an effective date of March 15, 2026, stated, I. Purpose: To ensure all medications and biologicals are stored, secured, handled, and maintained in accordance with Centers for Medicare and Medicaid Services (CMS) Requirements of Participation, state regulations, Drug Enforcement Agency (DEA) requirements, and accepted professional standards of practice. To provide guidelines that support resident safety, prevent medication diversion, and preserve medication integrity. III Policy: . B. Medications will be stored in a manner that prevents contamination, deterioration, and unauthorized access. D. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on record review and interview the facility failed to provide education for one of five residents (Resident (R) 1) or their representative, reviewed for COVID-19 vaccine, regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine before offering the vaccine and obtaining consent or declination from the resident or their representative. This deficient practice puts all residents at risk of not being fully informed about the benefits and risks and potential side effects associated with the COVID-19 vaccine administered at the facility.Findings Include:On 05/12/26 at 02:53 PM, record review was conducted for R1 to assure the resident received or declined their COVID-19 vaccine. The facility was able to provide a copy of R1's consent/declination form.Review of R1's consent/declination form found it was dated 09/28/25 and consent was given for the COVID-19 vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. On 05/14/26 at 11:17 AM, an interview was conducted with the Infection Preventionist (IP) in the conference room. Inquired of IP why facility staff were putting N (no) for no education given to the resident/representative prior to getting consent or declination for the COVID-19 vaccine. IP stated she tracks the dates of the vaccines but was not aware the nurses were doing this. IP nurse confirmed the resident, or their representative is to be given the education/CDC sheet and confirmed this is in their facility policy.

Based on record review and interview, the facility failed to provide education for five of five residents (Resident (R) 1, R3, R4, R7 and R13) or their representative, reviewed for influenza immunizations, regarding the risks and benefits and potential side effects of influenza immunization before offering the influenza immunization and obtaining consent or declination from the resident or their representative. This deficient practice puts all residents at risk of not being fully informed about their risks and benefits and potential side effects of receiving or declining the influenza immunization.Findings Include:On 05/12/26 at 02:53 PM, record review was conducted for R1, R3, R4, R7 and R13 to assure each resident received or declined their annual influenza vaccination for 2025. The facility was able to provide copies of these residents' consent/declination forms.Review of R1's form found it was dated 09/28/25 and consent was given for the influenza vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. Review of R3's consent/declination form which was dated 10/27/25 and consent given to be vaccinated for influenza vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. Review of R4's consent/declination form which was dated 10/04/25 and consent given to be vaccinated for influenza vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. Review of R7's consent/declination form which was dated 10/27/25 and consent given to be vaccinated for influenza vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. Review of R13's consent/declination form which was dated 09/25/25 and declination signed not to be vaccinated for influenza vaccination. Review of this form found the facility staff had circled N (No) for I was provided with education and the CDC Vaccination Information Statement (VIS) (if available) about the benefits, risks and potential side effects associated with the vaccine. On 05/14/26 at 11:17 AM, an interview was conducted with the Infection Preventionist (IP) in the conference room. Inquired of IP why facility staff were putting N (no) for no education given to the resident/representative prior to getting consent or declination for the influenza vaccination. IP stated she tracks the dates of the vaccines for all residents but was not aware the nurses were doing this. IP nurse confirmed the resident, or their representative, is to be given the education/CDC Vaccination Information Statement (VIS) prior to acquiring consent or declination for the influenza vaccination and confirmed this information is in the facility policy.

Based on record review and interview, the facility failed to ensure a resident or resident representative was informed of treatment and provided consent for the use of psychotropic medication for one of five residents (Resident (R) 40) reviewed for unnecessary medications. This failure placed R40 at risk for receiving treatment without informed consent and compromised the resident's rights to participate in care planning and treatment decisions. Findings Include: Review of R40's physician orders revealed the resident was prescribed trazodone, an antidepressant medication, 50 milligrams (mg) every morning beginning on 11/10/25.Review of R40's Electronic Health Record (EHR) revealed no documented informed consent for trazodone 50mg prior to administration of the medication.On 05/13/26 at 02:01 PM, an interview was conducted with the Director of Nursing (DON), who confirmed the facility did not obtain consent for the administration of trazodone 50mg.

Based on interviews and record review, the facility failed to ensure the discharge/transfer form used by the facility was provided to the resident, resident's representative, and Ombudsman for one of three sampled residents (Resident (R)49). Findings include: On 05/12/26 at 01:36 PM, review of R49's Electronic Health Record (EHR) documented the resident was transferred and discharged to the hospital on [DATE] at 11:39 AM. Unable to locate a written discharge/transfer notification to the resident/resident representative or Ombudsman. Request a copy of the written transfer/discharge notification from the Director of Nursing (DON). On 05/13/26 at 02:28 PM, conducted an interview with the DON. DON confirmed a written notification was not provided to the resident, resident representative, and Ombudsman. Review of the facility's policy and procedure titled, Resident Transfer and Discharge with an effective date of 07/22/25, states that, .D. 1. Notice of discharge shall be provided to the resident and the resident's representative. 2. A copy of the notice shall also be provided to the Hawaii LTC Ombudsman at least 30 days prior to the discharge.

Based on observations, interviews and record review, the facility failed to dispose of food items that have passed the use by date and store food in accordance with professional standards. This deficient practice puts all the residents and staff who consume food or drink prepared at the facility at risk for foodborne illnesses. Findings include: 1) On 11/19/24 at 11:16 AM, initial tour of the kitchen was done with Hospital Executive Chef (HEC). Inspection of the dry goods storage was done. Observed three jars of mustard with an expiration date of 05/08/24 on the storage shelf. HEC acknowledged that they were past the manufacturer's stated expiration date and removed them from the shelf. An opened jar of mustard was also found in the refrigerator by the food preparation area with an expiration date of 05/08/24 and confirmed by Kitchen Helper (KH)3. During the inspection of the walk-in refrigerator, observed 10 one-quart jugs of milk with an expiration date of 10/29/24. HEC asked another kitchen worker to remove them from the refrigerator and discard them. 2) On 11/19/24 at 01:28 PM, inspected walk-in freezer with HEC. Observed a box of peas and cut carrots on the floor under a storage shelf. In an interview, asked HEC if the box was supposed to be on the floor. HEC said the staff are supposed to stack them on the shelf or plastic pallets and proceeded to removed it off the floor. Review of the facility policy Nutritional Services - Infection Control Guidelines stated, . Food will be stored sufficiently above floor level . to protect against contamination .

Based on interview and record review, the facility failed to ensure a resident's preferences documented on the Advance Health Care Directive (AHCD) was accurately documented on the resident's Physician Order for Life-Sustaining Treatment (POLST) for one of three residents sampled. Review of Resident (R)40's AHCD via Electronic Health Records (EHR) documented the resident's preferences to receive medical treatment to prolong the resident's life. However, review of R40's POLST documented contradicted the resident's AHCD and documented the resident should not have Cardiopulmonary Resuscitation (CPR) and do not attempt to resuscitate. Also, the resident's active diagnosis documented R40 as Do Not Resuscitate (DNR). As a result of this deficient practice, residents are at risk for more than minimal physical harm. Findings include: Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On [DATE] at 10:41 AM, conducted a review of R40's EHR. Review of the resident's AHCD documented, I want medical treatment that would prolong my life as the resident's preference for life saving measures. Review of R40's POLST documented, NO CPR, Do Not Attempt Resuscitation (DNR). The POLST contradicted R40's preferences for live saving measures documented on the resident's AHCD. Also, R40's list of active diagnosis documented the resident as DNR, which also contradicted the resident's preferences documented on his AHCD. Requested a copy of R40's most recent AHCD and POLST. On [DATE] at 02:29 PM, reviewed R40's AHCD and POLST provided by the Director of Nursing and the Administrator, and confirmed it was the same forms this surveyor reviewed earlier in R40's EHR. On [DATE] at 03:44 PM, conducted a concurrent record review and interview with R40's physician (P)1. P1 reviewed R40's AHCD and POLST and confirmed both forms were completed by the facility and were the most current forms. After a closer review of the AHCD and POLST, P1 confirmed the POLST did not match the resident's preferences documented on the AHCD and it should have. Requested for P1 to further review R40's EHR to ensure there was no other documentation related to why the POLST lifesaving treatments were not the same as documented on the resident's AHCD. P1 reviewed R40's EHR and confirmed there was no additional documentation related to the discrepancy between the AHCD and POLST.

Based on observation, interview and record review, the facility failed to discard expired medication stored in the medication cart for one Resident. The deficient practice potentially places residents at risk for more than minimal harm. Findings include: On [DATE] at 08:35 AM, conducted an inspection of a medication cart with Registered Nurse (RN)45. Observed an expired bottle of Melatonin, 5 milligrams (mg) (a medication used for sleep), expiration date of ,d+[DATE], was stored in the medication cart. The bottle was labeled with Resident (R) 37's name. RN45 reviewed the bottle of Melatonin and confirmed the expired medication should have been removed from the cart. RN45 confirmed the resident currently resides in the facility and takes the medication every night. Electronic Health Record (EHR) reviewed. R37's Medication Administration Record (MAR) documented R37 was administered two expired tablets of Melatonin 5 mg every evening and had last received the medication on [DATE] at 06:00 PM, last night. Review of Nursing Care Center Pharmacy Policy & Procedure Manual 2007 PharMerica Corp. Medication Storage Section 4.1 was received and reviewed. It documented, 14. Outdated, contaminated, discontinued, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from the pharmacy .

Based on observation and interviews, the facility failed to ensure a comfortable temperature level for one Resident (R12) sampled. Observed R12 was lying in bed with a blanket covering his entire body, including his face and R12's Family Member (FM)3 seated under the air conditioner (AC). The room was noticeably colder in R12's portion of the room and the AC was blowing directly onto R12. R12 and FM3 reported the room is too cold, the air conditioner constantly blows cold air directly onto him, and must cover his entire body, head included, to avoid the cold air even when he has visitors. Director of Nursing (DON) confirmed the temperature in R12's room was colder than the temperature displayed on the AC controller and the cold air from the AC is not a comfortable temperature for R12. As a result of this deficient practice, residents are at risk for more that minimal physical and psychosocial harm. Findings include: On 11/19/24 at 01:15 PM, Surveyor (S)1 entered room [ROOM NUMBER] walked the room and observed FM3 seated in a chair under a split air conditioner (AC) and R12 lying on the bed with the blanket over his head. Inquired as to why R12's head was covered with the blanket while FM3 is visiting and if R12 was sleeping. FM3 stated, It's too cold in here. The AC is blowing directly onto his face and the air blowing onto him too cold for him, so he has to cover up with the blanket. This surveyor placed my hand in front of R12's face and over the general area of R12's bed and confirmed the air coming from the AC was noticeably colder than the seven other rooms this surveyor had just inspected, and the AC was blowing directly onto the resident's face and general area of his bed. FM3 called out R12 and the resident pulled the blanket down, exposing his face and said, Its cold, it's right on me and put his hand up in front of his face. FM3 stated, It's not good for him to be too cold, so he goes under the blanket then gets hot, then comes out and gets cold again. Plus, I'm here to visit him and see him, but he has to hide himself from the cold. On 11/21/24 at 02:57 PM, S1 and S2 entered R12's room and both surveyors observed R12 completely under a blanket and confirmed room [ROOM NUMBER] felt noticeably colder than other rooms on the unit. The AC was blowing out air at a rate high enough to visibly blow around R12's privacy curtains. At 03:00 PM, S1 and DON entered R12's room. Inquired with the DON as to the desired temperature of resident rooms. DON confirmed the temperature should be between 71 to 81 degrees Fahrenheit (F). DON confirmed the rate of air blowing from the AC was strong enough to visibly blow around R12's privacy curtain, the AC was faced directly onto R12's bed and R12 was lying in bed completed covered with a blanket. DON retrieved the AC controller for room [ROOM NUMBER] which displayed the AC was set to 72 degrees F. Asked the DON if the AC felt like the air coming from the AC felt like 72 degrees F. DON confirmed the air coming from the AC felt colder than 72 degrees F which was displayed as the set temperature on the AC controller. DON and S1 walked to R12's bedside and the resident pulled the blanket off his head and R12 stated, It's so cold in here, it's giving me a headache. DON confirmed the temperature of the AC and the AC blowing directly onto R12 was not a comfortable environment for the resident.

Based on observation and interview with staff member, the facility failed to ensure food products were stored under sanitary condition and discarded before the expiration or used by date. This failed practice could place all facility residents at risk for food-borne illness. Findings Include: On 11/28/23 at 09:25 AM, concurrent observation and interview was done during the initial kitchen tour with Kitchen Manager (KM). 1) Observed in the kitchen helper three-door fridge, a clear squeeze bottle labeled LV with the date of 11/04. Inquired with KM what was in the clear squeeze bottle, and she stated Lemon vinegar juice. KM further stated the date 11/04 indicated when the lemon vinegar juice was made and should have been discarded a week from when it was made. KM confirmed the lemon vinegar juice was made longer than one week ago. 2) In the walk-in produce refrigerator, observed a large metal bowl of cooked macaroni, uncovered. KM confirmed the macaroni should be covered and will be used for tomorrow's lunch. Further observation of one container of cottage cheese with the use by date of 11/16/23 and two low-fat cultured buttermilk with the use by date of 11/26/23. KM confirmed the items were past the use by date and should have been discarded. 3) In the two-door freezer, observed a bag of opened, exposed, French fries not sealed and not dated. KM confirmed the bag of fries should have been sealed and a date indicating when it was opened. 4) In the reach-in fridge, observed chopped spam, chopped green onion, and chopped fish cake with the date 11/19. KM stated the refrigerator is used to keep prepped dinner and the spam, green onion, and fish cake should have been thrown out a week from being made. The food items were made on 11/19. 5) In the dry goods pantry, observed 11 bottles of nutritional shakes with a use by date of 09/2023 and two large containers of cranberry sauce dated 11/18/21. KM confirmed the nutritional shakes and cranberry sauce should have been discarded. Review of the facility's policy and procedure Food Preparation and Storage effective 05/18/21 documented All items prepared and stored will be portioned out in individual containers and covered .items will be labeled with the date .all chilled food items not in original container will be disposed within 72 hours of labeled date .Leftovers will be placed in the main walk-in refrigerator and available for use within 72 hours of labeled date. All unused portions will be disposed.

Based on interviews and record review, the facility failed to ensure that all residents who were eligible for the Pneumococcal vaccine received it and/or their medical record indicated that the resident or resident's representative were provided education regarding the benefits and potential side effects of the Pneumococcal vaccine. This deficient practice places one of five residents (Resident (R) 11) sampled at risk for developing pneumonia related complications. This deficient practice has the potential to affect all the residents in the facility. Findings Include: Record review of R11's Electronic Health Record (EHR) was conducted on 11/30/23. R11's EHR indicated that her Pneumococcal vaccination status was unknown. Interview was conducted with the facility's Infection Preventionist (IP) on 11/30/23 at 02:29 PM in the conference room. IP indicated that she could not find any documentation in R11's EHR for offering or declining the Pneumococcal vaccine. Record review and Interview were conducted with the Regional Chief Quality Officer (RCQO) on 11/29/23 at 02:33 PM in the conference room. RCQO went through R11's EHR and could not find any documentation that the Pneumococcal vaccine was administered prior to R11's admission into the facility. RCQO also was not able to find documentation on the facility administering, offering, or providing education to R11 or R11's representative regarding Pneumococcal vaccination.

Based on record review and interviews, the facility failed to accurately document the code status of one of the residents sampled (Resident (R) 5). This deficient practice has the potential to adversely affect the level of care for all residents in the facility. Findings Include: A review of R5's Electronic Health Record (EHR) was conducted on [DATE]. R5's EHR contained a completed document titled, Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE]. The POLST document on section A titled, Cardiopulmonary Resuscitation (CPR), indicated that R5 had chosen, Do not attempt resuscitation/DNAR (Allow natural death). Further review of R5's EHR contained a completed document titled, Hawaii Advance Heath Care Directive, dated [DATE]. R5's completed advanced health care document indicated under, End of Life Decisions, section that R5 had chosen, I want medical treatment that would prolong my life as long as possible within the limits generally accepted health care standards. A review of R5's EHR indicated that her code status was currently Do Not Resuscitate (DNR). Concurrent record review and interview was conducted on [DATE] at 02:27 PM with facility Social Worker (SW). SW was presented with a copy of R5's POLST and Advanced Health Care Directive (AHCD) documents. SW conducted a review of R5's records in the hard chart at the nurse's station. R5's hard chart indicated that R5's code status was currently DNR. SW stated that it should have been updated and she would discuss it with the medical doctor. Concurrent record review and interview was conducted on [DATE] at 02:33 PM with the Director of Nursing (DON) at the nurse's station. DON was provided with a copy of R5's POLST and AHCD documents to review. After reviewing R5's documents, DON stated that R5 no longer want DNR status, and the facility should have updated R5's records.

Based on review of the facility's policy and procedures and staff interview, the facility failed to immediately report allegation of abuse to the adult protective services (APS) in accordance with State Law for a facility reported incident related to allegations of abuse. Findings include: The facility submitted an Event Report to the State Agency regarding an allegation of staff to resident abuse for an incident on 10/29/23. On 11/24/23, Resident (R) 48 reported Certified Nurse Aide (CNA) 12 was water boarding him, CNA12 put soap on her gloves, rubbed it on his face then stood at the end of the shower gurney and sprayed him. The facility completed an investigation and was unable to substantiate the allegation. On 11/30/23 at 01:24 PM interview with R48 was done. R48 confirmed he reported the incident to the Director of Nursing (DON) and continued to report to the State Agency (SA) that he felt like he was drowning when CNA12 sprayed the water on his face. A review of the facility's Incident Report submitted on 11/24/23 and Event Report submitted on 11/29/23 by the facility found this allegation was not reported to APS. A review of the facility's policy and procedure for abuse and neglect entitled Freedom From Abuse and Neglect with an effective date of 07/10/23 refers to an attached Outside Agency Reporting Information sheet to determine if report to APS is necessary. Review of the Outside Agency Reporting Information sheet attached documented Verbal report due within 24 hours of the event; to be followed by fax of written report to APS. Criteria for reporting to APS include Accusation or report of abuse by resident or family member of vulnerable adult . On 11/30/23 at 02:16 PM interviewed the DON was done. DON confirmed R48 reported the incident to her and the Social Worker (SW). DON further confirmed a report was not made to APS regarding the allegation. On 11/30/23 at 02:28 PM interview with Social Worker (SW) was done. SW confirmed R48 also reported the incident to her, and she did not report the allegation to APS. SW reported the facility usually does the event reporting and internal investigation prior to reporting to APS. On 12/01/23, the Regional Chief Quality Officer (RCQO) provided an internal email documenting APS not wanting to process reports that are already deemed unsubstantiated from the facility. The email did not include an official memo, official letter, or official exemption, that documents health care facilities are exempt from mandate reporting allegations of abuse according to state law. RCQO reported the facility does not report all allegations of abuse to APS unless the facility substantiates the abuse. This practice did not allow APS to make the determination to open an alleged abuse investigation outside of the facility's internal investigation.

Based on observations and staff interview, the facility failed to maintain a safe environment as evidenced by having four cracked, broken electrical outlet covers in the resident's room. Findings include: Observations on 11/28/23 at 01:00 PM in room [ROOM NUMBER] revealed four different electrical outlet covers were cracked and broken off. The broken sections were around two centimeters wide and created a risk for accident hazards. During staff interview on 11/29/23 at 02:00 PM, Maintenance Supervisor (Maint) acknowledged the cracked, broken electrical outlet covers. Maint further stated that they would have the covers replaced immediately.

Based on record review and interview with staff member, the facility failed to assure one of two residents (R)17 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes. Findings include: On 11/29/23 at 10:12 AM record review found R17's AHCD did not include two witness signatures or an official notary seal indicating the signed document was acknowledged before a notary public in the state. The AHCD signed by R17 on 06/01/05 documented (14) WITNESS: This power of attorney will not be valid for making health-care decisions unless it is either (a) signed by two qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (b) acknowledged before a notary public in the state. The document included a statement WITNESS my hand and official seal for the Notary Public, a signature and date under My commission expires, but no official seal. On 11/29/23 at 02:12 PM, Social Worker (SW) confirmed the notarized seal was missing from the form and will inquire with family for a better copy that may include the seal. On 11/30/23 at 02:47 PM, SW stated she was not able to get a copy with the notarized seal from family and was pending their return to the State.

Based on interview and record review (RR), the facility failed to ensure that all residents who were eligible for the influenza immunization received it and/or that their medical record(s) indicated that the resident (R) or resident's representative(s) were provided education regarding the benefits and potential side effects of influenza immunization. Coupled with advanced age and chronic conditions, this deficient practice made three of seven residents sampled vulnerable to the influenza virus and placed them at risk of developing flu-related complications such as pneumonia. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) On 09/29/22 at 08:44 AM, an influenza immunization review was done for Resident (R)30. The resident's electronic health record (EHR) was reviewed for documentation that the resident was offered, provided education regarding the benefits and potential side effects of influenza immunization, and either received or refused it. R30 is a [AGE] year-old female admitted to the facility on [DATE]. Review of R30's EHR revealed that although she was offered and refused the influenza immunization in the past year, there was no documentation found that R30, either directly or through her representative, had been provided education regarding the immunization. On 09/29/22 at 02:20 PM, the Director of Nursing (DON) provided an influenza declination signed by R30 on 10/10/20, and an Influenza Vaccine Information Summary (VIS), also signed by R30 on 10/10/20, that clearly documented the provision of education she received at that time. The DON confirmed that similar documentation could not be found for 2021. A review of the facility's Influenza and Pneumococcal Prevention Plan, last revised 04/11/22, revealed the following: III. Procedure: . B. Nursing Facility Residents: . 1. Influenza Vaccination . c. All residents offered vaccination will be given a copy of the applicable Vaccination [sic]Information Summary (VIS) (see Attachment B) for signing after a verbal explanation of the risks and benefits and a copy of the signed VIS shall be placed in the medical record. 2) On 09/29/22 at 03:04 PM, the sample was expanded to include two closed record influenza immunization reviews (for R52 and R104). R52 was a [AGE] year-old male admitted to the facility on [DATE]. On 09/29/22 at 03:04 PM, the facility was asked to produce documentation regarding R52's influenza immunization status for 2021. On 09/30/22 at 07:58 AM, the DON stated that after her review of R52's medical record, she found that although he was offered and refused the influenza immunization several times in the past year, there was no documentation that R52, either directly or through his representative, had been provided education regarding the immunization. The DON also confirmed that there was no signed Influenza VIS form for 2021 found. 3) R104 was a [AGE] year-old male admitted to the facility on [DATE]. On 09/29/22 at 03:04 PM, the facility was asked to produce documentation regarding R104's influenza immunization status for 2021. On 09/30/22 at 07:58 AM, the DON stated that after her review of R104's medical record, she could find no documentation that R104 had been offered the influenza vaccine or provided education, either directly or through his representative, regarding the immunization. The DON also confirmed that there was no signed Influenza VIS form for 2021 found.

Based on observation, interview, and record review, the facility failed to develop and implement a Comprehensive Care Plan (CP) for two residents (Residents 20 and 16) in the sample. Resident (R)20's CP did not include resident-specific behavior monitoring for impulse control, nor did it include monitoring for signs of tardive dyskinesia (a condition affecting the nervous system causing repetitive, involuntary movements, such as grimacing, tongue thrusting, and eye blinking), despite being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of these deficient practices, both R20 and R16 were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)20 is a [AGE] year-old admitted to the facility on [DATE] for long-term care. R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/27/22 at 11:31 AM, R20 was observed sitting up in bed feeding herself lunch. Repetitive and involuntary head and mouth movements observed, frequent grimacing, but R20 was able to effectively chew and swallow her food. On 09/28/22 at 01:26 PM, R20 was observed wandering in and out of her room and in and out of the Station 2 entrance. Staff seemed used to R20 walking around unmonitored and no redirection of R20 was observed. R20 was observed with repetitive and involuntary head movements, eye blinking, and tongue thrusting. On 09/30/22 at 09:53 AM, during a review of R20's electronic health record (EHR), a Neurological IPOC (individual plan of care) and a Behavioral Symptoms IPOC were noted. A review of the Neurological IPOC revealed the following: Outcomes . No Avoidable Complications from Neurological Disease . Interventions . Evaluate . Neurological Signs . Judgement .Med [medication]: [MEDICATION(S)] [used for impulse control] . [MEDICATION(S)] [used to prevent and control seizures] . There were no specific examples of complications, neurological signs, judgement, or side effects of medications to monitor for. A review of the Behavioral Symptoms IPOC revealed the following: Interventions . Evaluate Usual Time, Duration, and Frequency of Behaviors . Evaluate Medications for Desired and Adverse Outcomes .Administer [MEDICATION(S)] [an antipsychotic], [MEDICATION(S)] as order . There were no specific examples of behaviors, desired or adverse outcomes, or side effects of medications to monitor for. A review of a Psych [Psychiatric] Consult Note, dated 07/29/22, revealed the following: . had previously been treated with neuroleptics [antipsychotics] which cause severe TD [tardive dyskinesia] that has been mitigated with starting [MEDICATION(S)] . mild tardive tongue protruding movements . consider uptitration of [MEDICATION(S)] [sic] . to further improve tardive dyskinesia . On 09/30/22 at 10:59 AM, an interview was done with the Director of Nursing (DON) at Station 2. During a concurrent review of R20's CP, the DON agreed that the CP should include specific behaviors to monitor for as targeted behaviors are resident-specific. The DON then confirmed that there was no IPOC or task list to monitor for signs of worsening or improving TD. The DON agreed that without that there was no effective and consistent way to tell if the medication targeting TD should be increased. 2) Resident 16 (R)16 is an [AGE] year old male who has a history of depression, bipolarism and [CONDITION(S)]. Observation and concurrent interview with R16 on 09/27/22 at 12:30 PM was done. R16 resides in a contact isolation room. R16's Television (TV) is on but R16 is looking up to the ceiling. Interview with R16 who stated that he can't get up because it hurt him when they tried to get him up in the chair and used the sling. I am refusing to go into the sling. Observation of a special chair with pillows on chair in room. Light is turned off. Surveyor noted a heap of things lying on the table to the left of the head of the bed. Observation and concurrent interview with R16 done on 09/28/22 at 3:26 PM. R16 stated that he had not been up in a while. He was concerned about his teeth and getting dentures. TV was on. R16 is supine. R16 denied having any skin breakdown. R 16 stated he was depressed and wanted something from his things on the side table instead of watching TV. Resident stated that he has been in isolation for one month. Record review was done on 09/29/22 at 09:49 AM revealed that resident had no careplans on his current electronic record. Interview with Director of Nursing (DON) and Registered Nurse (RN)1 was done on 09/29/22 @ 11:20 AM . Queried if there were any care plans for R16. After searching DON and RN1 stated that their were no care plans that had carried on from his previous record.

Based on observation, interview and record review the facility failed to appropriately train direct care staff on dementia care prior to and after the residents were admitted to the facility and provide an environment free of accidents for three of 12 residents (Resident (R)44 and R36) investigated for facility reported incidents selected for review. The deficient practice resulted in harm for two residents having falls with serious injuries. Findings Include: 1. Review of R44's admission assessment revealed the following: diagnosed with [REDACTED]. Impulsive with balance difficulties due to left sided weakness and contractures, and no safety awareness. R44 can ambulate at the courtyard with one person assist and supervision. She can self-propel in the wheelchair which she uses for locomotion requiring constant close and/ or 1:1 supervision. She is difficult to redirect and on many occasions is un-directable she hits, slaps, kicks, and pinches nursing staff and has hit other residents. Review of R44's care plan revealed that R44 had 11 falls between 2/18/17 and 9/28/17 with four of the falls occurring on 7/27/17. Three of the falls resulted in the following injuries: Left shoulder fracture on 3/09/17; Left [MEDICAL CONDITION] on 7/27/17 and a 3 cm laceration to the left eye brow. Review of the facility incident reports completed for each fall revealed that at times R44 had a fall even while she had 1:1 supervision. R44 did not follow instructions given by staff such as put your shoes on, or wait there in your chair until I can help you get back to bed. R44 had impulsive behavior like jumping up out of her chair and losing her balance, or climbing up on a chair in the auditorium and losing her balance. She often became physically and verbally aggressive to staff when they attempted redirection. Review of the MDS Quarterly update dated 1/04/18: Section V: care area assessment (CAA) summary R44 triggered for Cognitive loss/ dementia, Communication, ADL functional/ rehabilitation potential, Urinary incontinence, psychosocial well being, Behavioral symptoms, activities, falls, nutritional status, Dehydration/ fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. Review of the Nurses notes dated 7/27/17 8:32 AM revealed that [MEDICATION NAME] 0.5 mg given @ 0040 for anxiety, restlessness, wandering to point of fatigue with leaning gait and unwilling to stop. Assisted to bed and fell asleep until 0240 when resident woke up due to incontinent of urine, lost balance, falling backward toward dresser and slid down dresser landing on her butt. Says she hit her head against the dresser. Slept rest of noc, easily awakened, responsive, behavior in am as usual. 7/27/17 at 9:39 revealed R44 had 2 falls at 8:55 AM then 9:05 AM. The second fall occurred while on 1:1 supervision with the CNA, the bed alarm on and education to R44 to please stay in bed and use bell for transfer assist. R44 stood up and fell into wardrobe dresser hitting back leaving 2 lines of redness and some skin abrasion. 7/27/17 at 14:57 revealed that R44 had multiple falls throughout the shift with bed alarm on. R44 was placed at Nurses station with 1:1 supervision. 07/27/17 at 20:23. R44 in bed resting. 07/27/17 at 21:49 R44 was showered by CNA and residents daughter when she complained of pain all over body and right hip pain. MD was notified and gave orders to do right hip X-ray in the AM and NP to examine R44 also in AM. 7/28/17 at 10:00 AM R44 transported to X-ray this am report reviewed/ fracture noted. R44 sent via AMR to ER for further exam and tx daughter to meet ambulance at hospital. 7/28/17 20:46 R44 was admitted to an acute care setting, after a total hip replacement for a right hip femoral neck fracture. Review of the care plan revealed that interventions updated on 1/18/18 with the following: Provide 1:1 supervision as able; provide clear instruction when reporting off, when providing tag team care & supervision. Maintain consistent physical environment or living space & daily routine; keep changes to a minimum. Provide any timed/ scheduled toileting; provide prompt incontinent care prn. Provide assistive devices; Enclosed rolling Walker. Observe & report promptly to nurse & MD if any change in ability to wt. bear or walk; increase in agitation, restlessness. When agitated, allow her to settle down before re-approaching. Review type of foot wear - if daughter unable to provide shoes without straps, assist to wear non-skid socks. Request MD evaluation to rule out s/s acute health condition, medication side effect, change in condition. Behavioral flow sheets were reviewed from 03/01/18 to 04/12/18. More than half of the behaviors monitored documented that R44 refused treatment, meds, food, hit, slapped, pinched, at staff. Interventions included redirect, 1:1, change position, provide PRN medications, try again later. The outcomes were improved at times although at times no change. Review of R44 MAR indicated [REDACTED]. R44 also received PRN [MEDICATION NAME] 0.5 mg PO prn anxiety on 7/27/18 at 0040 and at 1800. The same day of the multiple falls resulting in a right [MEDICAL CONDITION]. [MEDICATION NAME] (for mood stabilization) 250 mg tab po BID was increased to 500 mg tab po BID on 7/17/17. Root cause analysis (RCA) and action framework dated 08/04/17 was reviewed. After each fall, there was a plan to modify care to ensure that patient did not continue to fall including placing resident on 1:1 care. In spite of the action plan, R44 continued to fall and have injuries. There has been many discussions with the family about the long term care (LTC) setting the resident is currently in. The team feels it is the wrong setting for her. However, family is not able to care for her at home due to her behaviors. Inservice training records were reviewed. Common diseases affecting the elderly, Falls management and Geriatric Head to Toe Assessment were conducted from 8/29/17. The Falls management protocol training was conducted by direct care staff from 2/01/18 to 3/31/18. Review of the Training content revealed a review in the physical changes and conditions in the elderly and did not include dementia care. An interview was conducted with Clinical Nursing Director at 6:30 PM stating R44 is only on 1:1 supervision while in her enclosed rolling Walker. She used to be on 1:1 supervision 24/7 when she was having all of the falls. A root cause analysis (RCA) was done after R44 had four falls on 7/27/17 with a fracture. The DON was interviewed and stated that the CNA's direct care staff did not receive the dementia care but received other inservice training. Several observation's were made during the survey on 04/09/18, 04/10/18, 04/11/18 and 04/12/18. R44 was often seen strolling in the enclosed rolling walker supervised by Certified Nurses Aide (CNA). R44 had an unsteady gait, wobbling from side to side and dragging her left foot. R44 appeared to walk for a few steps then impulsively start to run ahead of the CNA who was attempting to provide 1:1 supervision having to run to catch up. When R44 was not in her enclosed rolling walker she was observed to be lying in bed without 1:1 supervision. At 6:30 PM the Director of clinical services was interviewed and stated that R 44 is only on 1:1 supervision while in her enclosed rolling walker. She used to be on 1:1 supervision 24/7. 2. Review of the Inter disciplinary team (IDT) meeting notes dated 7/26/17 revealed R36 had 27 falls in (YEAR); seven falls in (YEAR) with one Fall on 5/26/17 resulting in scrotal laceration. R36 has ongoing cyclic outbursts of intrusive behaviors threatening physical harm making verbally abusive & inappropriate sexual comments to caregivers associated with dx of dementia and [MEDICAL CONDITION]. Social services notes state he has forgetfulness combined with fixation that often fuels agitation, making problem behavior difficult to redirect. He has been reported to have been aggressively demanding and has been verbally inappropriate to staff as evidenced by swearing and insulting comments. History of recurrent falls confounded by dx extrapyramidal & movement disorder. Review of incident report dated 05/12/17 R36 found on floor lying on left side in room, no chair alarm on his wheelchair. Assisted back to wheelchair by four staff. No injury noted. R36 verbally abusive to staff and refused to have chair alarm put in place, threatening to throw alarm at staff. Follow up comments state staff will try to clip alarm on back of R36 clothing. The Post-fall quality improvement form completed with following recommendations: Complete falls risk assessment form, assess footwear used at time of fall and review medications & regimen changes in last 30 days. Educate/ re-educate precautions to staff as appropriate. Review of incident report dated 05/26/17 stated R36 was calling for help and was in the process of transferring himself from the toilet to his wheelchair and slid down the wall. Staff noted a superficial abrasion to right hip and small opening under scrotum area 2.2 cm length x 1.2 cm width. The post-fall Quality improvement form was completed. Action taken includes complete the falls risk assessment form. Update care plan, review medication regiments and changes in last 30 days. Update care plan. Reviewed care plan dated 03/02/18 for falls due to increased risk due to unwanted medication side effects and resident with history of recurrent falls, with injury. Initiation date 03/02/18: Approaches: In addition to standard falls risk, high fall risk. Communicate to all caregivers increased fall risk and need for increased surveillance of R36. Anticipate medication side effects. Follow up with MD, APRN & Pharmacy for poly-pharmacy concerns. Set bed alarm, chair alarm, and respond promptly. Anticipate toileting needs especially after prn bowel regimen given; remove wheelchair from bathroom when he is on toilet. Medication Administration Record [REDACTED]. [MEDICATION NAME] (for mood) 300 mg three times per day. [MEDICATION NAME] with [MEDICATION NAME] ordered as needed for pain although R36 takes two to three times per day. Noted R36 is also taking [MEDICATION NAME] (Diuretic) 25 mg tablet 1 tab daily .

Based on observation, interview and record review the facility failed to assess and supervise three residents (R) 30, R36 and R44 with dementia and at risk for falls, train direct care staff on dementia care prior to and after residents were admitted , and provide an environment free of accidents for three residents with facility reported incidents. The deficient practice resulted in harm for three residents (R)30, R36 and R44 who had multiple falls with serious injuries. Findings Include: 1. Review of R44's admission assessment revealed the following: diagnosed with [REDACTED]. Impulsive with balance difficulties due to left sided weakness and contractures, and no safety awareness. R44 can ambulate at the courtyard with one person assist and supervision. She can self-propel in the wheelchair which she uses for locomotion requiring constant close and/ or 1:1 supervision. She is difficult to redirect and on many occasions is un-directable she hits, slaps, kicks, and pinches nursing staff and has hit other residents. Review of R44's care plan revealed that R44 had 11 falls between 2/18/17 and 9/28/17 with four of the falls occurring on 7/27/17. Three of the falls resulted in the following injuries: Left shoulder fracture on 3/09/17; Left [MEDICAL CONDITION] on 7/27/17 and a 3 cm laceration to the left eye brow. Review of the facility incident reports completed for each fall revealed that at times R44 had a fall even while she had 1:1 supervision. R44 did not follow instructions given by staff such as put your shoes on, or wait there in your chair until I can help you get back to bed. R44 had impulsive behavior like jumping up out of her chair and losing her balance, or climbing up on a chair in the auditorium and losing her balance. She often became physically and verbally aggressive to staff when they attempted redirection. Review of the MDS Quarterly update dated 1/04/18: Section V: care area assessment (CAA) summary R44 triggered for Cognitive loss/ dementia, Communication, ADL functional/ rehabilitation potential, Urinary incontinence, psychosocial well being, Behavioral symptoms, activities, falls, nutritional status, Dehydration/ fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. Review of the Nurses notes dated 7/27/17 8:32 AM revealed that [MEDICATION NAME] 0.5 mg given @ 0040 for anxiety, restlessness, wandering to point of fatigue with leaning gait and unwilling to stop. Assisted to bed and fell asleep until 0240 when resident woke up due to incontinent of urine, lost balance, falling backward toward dresser and slid down dresser landing on her butt. Says she hit her head against the dresser. Slept rest of noc, easily awakened, responsive, behavior in am as usual. 7/27/17 at 9:39 revealed R44 had 2 falls at 8:55 AM then 9:05 AM. The second fall occurred while on 1:1 supervision with the CNA, the bed alarm on and education to R44 to please stay in bed and use bell for transfer assist. R44 stood up and fell into wardrobe dresser hitting back leaving 2 lines of redness and some skin abrasion. 7/27/17 at 14:57 revealed that R44 had multiple falls throughout the shift with bed alarm on. R44 was placed at Nurses station with 1:1 supervision. 07/27/17 at 20:23. R44 in bed resting. 07/27/17 at 21:49 R44 was showered by CNA and resident's daughter when she complained of pain all over body and right hip pain. MD was notified and gave orders to do right hip X-ray in the AM and NP to examine R44 also in AM. 7/28/17 at 10:00 AM R44 transported to X-ray this am report reviewed/ fracture noted. R44 sent via AMR to ER for further exam and tx daughter to meet ambulance at hospital. 7/28/17 20:46 R44 was admitted to an acute care setting, after a total hip replacement for a right hip femoral neck fracture. Review of the care plan revealed that interventions updated on 1/18/18 with the following: Provide 1:1 supervision as able; provide clear instruction when reporting off, when providing tag team care & supervision. Maintain consistent physical environment or living space & daily routine; keep changes to a minimum. Provide any timed/ scheduled toileting; provide prompt incontinent care prn. Provide assistive devices; Enclosed rolling Walker. Observe & report promptly to nurse & MD if any change in ability to wt. bear or walk; increase in agitation, restlessness. When agitated, allow her to settle down before re-approaching. Review type of foot wear- if daughter unable to provide shoes without straps, assist to wear non-skid socks. Request MD evaluation to rule out s/s acute health condition, medication side effect, change in condition. Behavioral flow sheets were reviewed from 03/01/18 to 04/12/18. More than half of the behaviors monitored documented that R44 refused treatment, meds, food, hit, slapped, pinched, at staff. Interventions included redirect, 1:1, change position, provide PRN medications, try again later. The outcomes were improved at times although at times no change. Review of R44 MAR indicated [REDACTED]. R44 also received PRN [MEDICATION NAME] 0.5 mg PO prn anxiety on 7/27/18 at 0040 and at 1800. The same day of the multiple falls resulting in a right [MEDICAL CONDITION]. [MEDICATION NAME] (for mood stabilization) 250 mg tab po BID was increased to 500 mg tab po BID on 7/17/17. Root cause analysis (RCA) and action framework dated 08/04/17 was reviewed. After each fall, there was a plan to modify care to ensure that patient did not continue to fall including placing resident on 1:1 care. In spite of the action plan, R44 continued to fall and have injuries. There has been many discussions with the family about the long term care (LTC) setting the resident is currently in. The team feels it is the wrong setting for her. However, family is not able to care for her at home due to her behaviors. Inservice training records were reviewed. Common diseases affecting the elderly, Falls management and Geriatric Head to Toe Assessment were conducted from 8/29/17. The Falls management protocol training was conducted by direct care staff from 2/01/18 to 3/31/18. Review of the Training content revealed a review in the physical changes and conditions in the elderly and did not include dementia care. An interview was conducted with Clinical Nursing Director at 6:30 PM stating R44 is only on 1:1 supervision while in her enclosed rolling Walker. She used to be on 1:1 supervision 24/7 when she was having all of the falls. A root cause analysis (RCA) was done after R44 had four falls on 7/27/17 with a fracture. The DON was interviewed and stated that the CNA's direct care staff did not receive the dementia care but received other inservice training. Several observation's were made during the survey on 04/09/18, 04/10/18, 04/11/18 and 04/12/18. R44 was often seen strolling in the enclosed rolling walker supervised by a Certified Nurses Aide (CNA). R44 had an unsteady gait, wobbling from side to side and dragging her left foot. R44 appeared to walk for a few steps then impulsively and start to run ahead of the CNA who was attempting to provide 1:1 supervision having to run to catch up. When R44 was not in her enclosed rolling walker she was observed to be lying in bed without 1:1 supervision. At 6:30 PM the Director of clinical services was interviewed and stated that R 44 is only on 1:1 supervision while in her enclosed rolling walker. She used to be on 1:1 supervision 24/7. 2. Review of the Inter disciplinary team (IDT) meeting notes dated 7/26/17 revealed R36 had 27 falls in (YEAR); seven falls in (YEAR) with one Fall on 5/26/17 resulting in scrotal laceration. R36 has ongoing cyclic outbursts of intrusive behaviors threatening physical harm making verbally abusive & inappropriate sexual comments to caregivers associated with dx of dementia and [MEDICAL CONDITIONS]. Social services notes state he has forgetfulness combined with fixation that often fuels agitation, making problem behavior difficult to redirect. He has been reported to have been aggressively demanding and has been verbally inappropriate to staff as evidenced by swearing and insulting comments. History of recurrent falls confounded by dx extrapyramidal & movement disorder. Review of incident report dated 05/12/17 R36 found on floor lying on left side in room, no chair alarm on his wheelchair. Assisted back to wheelchair by four staff. No injury noted. R36 verbally abusive to staff and refused to have chair alarm put in place, threatening to throw alarm at staff. Follow up comments state staff will try to clip alarm on back of R36 clothing. The Post-fall quality improvement form completed with following recommendations: Complete falls risk assessment form, assess footwear used at time of fall and review medications & regimen changes in last 30 days. Educate/ re-educate precautions to staff as appropriate. Review of incident report dated 05/26/17 stated R36 was calling for help and was in the process of transferring himself from the toilet to his wheelchair and slid down the wall. Staff noted a superficial abrasion to right hip and small opening under scrotum area 2.2 cm length x 1.2 cm width. The post-fall Quality improvement form was completed. Action taken includes complete the falls risk assessment form. Update care plan, review medication regiments and changes in last 30 days. Update care plan. Reviewed care plan dated 03/02/18 for falls due to increased risk due to unwanted medication side effects and resident with history of recurrent falls, with injury. Initiation date 03/02/18: Approaches: In addition to standard falls risk, high fall risk. Communicate to all caregivers increased fall risk and need for increased surveillance of R36. Anticipate medication side effects. Follow up with MD, APRN & Pharmacy for poly-pharmacy concerns. Set bed alarm, chair alarm, and respond promptly. Anticipate toileting needs especially after prn bowel regimen given; remove wheelchair from bathroom when he is on toilet. Medication Administration Record [REDACTED]. [MEDICATION NAME] (for mood) 300 mg three times per day. [MEDICATION NAME] with [MEDICATION NAME] ordered as needed for pain although R36 takes two to three times per day. Noted R36 is also taking [MEDICATION NAME] (Diuretic) 25 mg tablet 1 tab daily . 3. R30's record reflected that resident had a witnessed fall on 03/01/18. The progress note written on 03/01/18 at 0224 p.m. reflected that the resident fell after his recliner flipped over when he attempted to get up and the foot rest was still up. On 04/01/18 R30 had a second witnessed fall from his recliner. R30's care plan reflects the intervention initiated on 04/01/19 was, If resident is willing, offer to put him on his recliner after a.m. care. There was no investigation that ruled out the recliner as being contributory to resident's fall risk. On 04/12/18 at 1015 a.m. Staff (S) 127 was interviewed and asked why the resident fell so often. S127 answered that R30 is more independent, and combative. The care plan interventions were effective since the resident falls less often. When asked how the behaviors are being monitored for this resident S127 stated that the activities of daily living and behavior flow sheets is where the facility documents that the interventions in the care plan were being performed. S127 was unable to show the documentation for R30 which interventions were being performed. There is no proof that resident is being adequately supervised to prevent resident from continuing to fall.

Based on staff interviews and record review the facility failed to ensure that resident #15's environment remained as free of accident hazards as is possible; and the resident received adequate supervision and assistance devices to prevent accidents. Findings include: In a staff interview on 10/04/2016 at 2:40 P.M., regarding Resident (R)#15, she stated that he had experienced 2 falls without injuries within the past 30 days. In a record review of R#15 on 10/06/2016, falls documentation showed that he had experienced 44 falls from January 01, 2016 to present, with the last 3 falls occurring on 10/05/2016. Resident fractured the 3rd metatarsal on the left hand during one of the falls on 10/05/2016. In an interview on 10/05/2016 with charge nurse, she stated that R#15 was a difficult resident to monitor for falls as he is reminded to use the call light but he just gets up without any warning. She stated that they had tried various things such as chair and bed alarms, close monitoring, reminders to use the call button when wanting to toilet, and reminding him to wait until staff arrived before trying to get up. She further stated that he has been here for a long time and won't listen to any redirection, has a history of schizophrenia, and can be combative and strike out at times. When asked what new interventions they have implemented after the falls, she stated, we try to monitor him closely and he was moved closer to the nursing station. In an interview with the Chief Nursing Officer regarding root cause analysis after resident falls, she stated that she wasn't sure if they were consistently being done for this resident but they should be, and we are going to be implementing new software to track Event Report Forms (ERF). The Director of Nursing (DON) confirmed there are incidents within the facility which continue to recur and she shares it with nursing staff to correct the problem. For falls, such as what was identified for R#15, the DON stated they are above the State average for falls. Although the 6/01/16 IDT performance improvement review for falls and unnecessary drugs was provided, she stated, And yes, we did not make one step beyond what we're doing to continue to look for other measures to prevent falls. One thing I asked Occupational Therapy (OT) was to look at residents to identify a person trying to get up. Re-educating the staff. In a review of R#15's Care Plan updates, the following interventions were written: on 9/01/2016 : Apply bed/tab alarm. Be sure WC alarm in on; respond promptly to WC alarm; anticipate need for help w/toileting/attempt to return to bed after dinner meal. 9/07/2016 : Environmental Safety Management Bed Wheels in Locked Position, with crash mat on floor next to bed; check lighting, minimize clutter in room; limit furniture to simple desk. Call Light within reach, if mattress placed on floor, replace on bed frame when resident has calmed down. 9/18/2016: Assist Resident with transfers, offer transfer training at bedside with PT 1-2 x weekly. close monitoring when out of bed. Provide 1:1 supervision on P.M. shift as able. 9/19/2016 reads: alarm on, respond promptly when alarms. Anticipate resident needs and pay attention to nonverbal cues, call bell within reach, reminders to use call bell to request assistance out of bed. 9/22/2016 reads: Safety device on wheelchair, report promptly for repair/service PRN: anti-rolling WC brakes. Proper fitting footwear, none-skid soles. In an interview with LN #4 on 10/06/2016, she stated R#15 falls all of the time, it doesn't matter what we do, yesterday he was at the nursing station and he fell right in front of us before we could catch him. Physical Therapy (PT) evaluation was performed on 10/07/2016 after resident had fallen 3 times on 10/05/2016, the last resulting in a fracture of the left 3rd metacarpal. Recommendations from the evaluation included: WC brakes lock and release properly; nonskid footwear on for out of bed (OOB); Occupational Therapy (OT) Assessment and recommendations; physical therapy (PT) treatments to focus on strength, and safe transfers, and wheel chair (WC) propulsion, x 3 weeks, Monday - Friday; transfers with gait belt and max assist from staff; 1:1 sitter ongoing; PT inservices or caregiver trainings with interdisciplinary staff. In a review of the facility Fall Reduction Program Policy lists steps and interventions to implement for fall risk residents and high fall risk residents. 1. The IDT will review circumstances surrounding the fall and the completed Event Reporting Form (ERF) and provide additional recommendations and/or revisions to the resident's care plan as necessary at the next IDT meeting. 2. The IDT will review resident's falls monthly to identify patterns, assess the effectiveness of interventions, and modify care plans as necessary. Based on record reviews, staff interviews, and continuation of R#15 falls the program is not reducing falls. A review of the Interdisciplinary Resident Care Planning Policy reads under: 4. C. 1. identifies resident care outcomes and whether or not resident specific care plan goals were achieved and/or what modifications need to be made so that adjustments are made to address changes in the resident's status, goals, or improvement or decline. An immediate jeopardy (IJ) was identified based on the findings and the facility provided a final IJ abatement plan to the SA on 10/07/2016.

Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that each resident must receive and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. For Resident #42, this was not provided, and as a result, this resident suffered undue pain and harm. Finding includes: On [DATE], an IR was filed with the SA regarding Resident (R) #42's injury of unknown origin. The IR documented this resident was identified with pain to her right hip region on [DATE]. The resident was not able to verbally express her discomfort. An x-ray was ordered for her on [DATE], and it confirmed a dislocation of the resident's right hip. On [DATE], R#42 was then transferred to an offsite hospital's emergency department for an orthopedic consult. R#42's closed clinical record review on [DATE] revealed she was a [AGE] year old female with a history of a right [MEDICAL CONDITION] and prosthesis in 2014. R#42 also has a [DIAGNOSES REDACTED]. On [DATE], R#42 started exhibiting/ demonstrating pain symptoms manifested by her facial grimacing, grabbing of the staff's arms, and guarding with any turning or repositioning involving her right hip and/or leg. A pain management review revealed in the resident's Medication Administration Record (MAR), that there were inconsistencies in the documentation in comparison to the nursing notes. Additionally, the clinical documentation revealed R#42 continued with on-going pain without adequate pain relief as evidenced by the nursing entries. The documentation revealed the following: 1. There was no documentation on the MAR that R#42 received Tylenol on [DATE]. Yet, there was documentation in the nursing notes that she received Tylenol 325 mg by mouth at 1:20 P.M. for moaning with turns (MD notified); Tylenol 325 mg at 4:45 P.M. for facial grimacing of ,[DATE] (pain level) with some effect. In addition, the notes also stated Tylenol 325 mg was also given by mouth at 10:00 P.M. for grimacing and moaning (MD notified). On [DATE] at 11:28 P.M., the resident was grabbing rails and staff arms with attempt to move right leg. MD ordered physical therapy with evaluation and treatment. 2. On [DATE], documentation on the MAR noted that R#42 received Tylenol 325 mg by mouth at 4:30 A.M. and 9:00 A.M. Documentation in the nursing notes at 7:53 A.M. noted the resident was grimacing ,[DATE] with turning of her right leg with minimal effect. Documentation in the nurse's notes at 3:30 P.M. states, moaning and grimacing when being turned. Tylenol given at 9:30 A.M. with minimal effect. There was no documentation the attending physician (or any other physician or nurse practitioner) was notified. 3. On [DATE], documentation on the MAR showed [MEDICATION NAME] 200 mg by mouth was given to the resident at 7:45 A.M. and Tylenol 325 mg was given at 11:45 P.M. A nursing entry at 2:07 P.M. stated [MEDICATION NAME] was given at 7:45 A.M. for grimacing with turns. Again, no documentation that a physician or other practitioner was notified. 4. On [DATE], documentation on the MAR noted [MEDICATION NAME] 200 mg given by mouth at 8:15 A.M. A nursing entry at 4:19 A.M. on [DATE] stated Tylenol 325 mg by mouth was given at 11:45 P.M. for facial grimacing during care and noted a slightly swollen right ankle, and, per MD to put pillow in between legs to decrease contractions to the hip. A nursing entry on [DATE] at 4:42 P.M. stated, Resident has been with facial grimacing when right leg being repositioned. Guarding right leg area when care provided. Notified MD. Ordered x-ray of right hip and right knee. There was no documentation by the attending physician that he saw the resident and physically assessed the condition of her right hip and leg and/or the effectiveness of the pain medications given to her prior to ordering the x-ray. 5. On [DATE], the MAR and nursing notes for pain medication administration were consistent. However, R#42 continued to exhibit facial grimacing, grabbing of staff's arms, and guarding with movement. Yet, there was no other nursing or medical interventions being provided to R#42, which was already day 5 since her pain had been identified. Interview on [DATE] at 9:00 A.M. with the Educational Coordinator (EC) and concurrent record review was done. The EC verified the dates the medications were administered on the MAR and she also confirmed on [DATE], the MAR's entry by licensed staff was left blank for medication administration. The EC also verified the resident's Pain Score Post Intervention (PSPI) was missing clinical documentation as well. The PSPI tool was to be used to reassess the resident's pain before and after each intervention (medication administration), using a scale of 0 to 10, with 0 being pain free and 10 being most intolerable. The record showed on [DATE], the resident's PSPI pain score post medication administration was not charted at 5:00 P.M. Again, on [DATE] the PSPI was not charted at 9:34 P.M. For medications given on [DATE] on three separate occasions, there only was one entry of the PSPI charted on the assessment flowsheet at 9:31 P.M. Then again, on [DATE] the PSPI was not documented at 11:16 P.M Finally on [DATE], the PSPI was not charted at 4:48 A.M. and 2:24 P.M The EC stated, If it's not documented, it was not done. Further, on [DATE] at 10:50 A.M., an interview of the physical therapist (PT) was done. He remembered R#42 and said, Yes, she kind of declined and went downhill. When I got the order for PT evaluation and assessment, I went to assess the resident. She was in bed and she was in a lot of pain. We barely got her to sitting, she was in a lot of pain and we could not get her up. We stopped the evaluation. The PT stated it was a protocol to notify the charge nurse regarding the results of the assessment. In addition, he stated he charted his assessment in the nursing notes. However, both nursing and rehabilitation staff could not find the PT's clinical documentation in the resident's record. Nor did the PT attempt to contact the physician himself as a licensed professional, despite his knowledge that this resident was in a lot of pain. Interview on [DATE] at 11:38 A.M. with the CN#1 and Educational Coordinator (EC) was done regarding R#42. CN#1 was asked about her encounter with R#42 on [DATE]th, 6th and 7th. She stated, I was the charge nurse for (R#42) on the 6th. Her recollection of the resident's pain during the shift report was, I went to assess her. The CNA stated that she was in too much pain, so I told her to leave her in bed. During my assessment, I noted that it was unusual for her to be in pain with her turns. She was grabbing the side rails. She always goes into a fetal position but this was unusual with her grimacing with her turns and grabbing of the side rails. She was asked if she tried calling the attending physician and replied, No, I thought because they had called him already, it was not necessary for me to call him because they had already done so. CN#1 felt she met the standard for nursing care. She was then asked if she was aware of the order for physical therapy, and replied, No, I do not recall. CN#1 was asked if she was aware that on the 9th, the resident had an x-ray and the x-ray showed that she had a dislocation of her hip. She replied, Yes. She was then asked if there were any antecedents that would warrant her pain, and CN#1 stated, There was no report filed for falls or anything, so we weren't aware. On [DATE], the record showed R#42 was sent to the adjoining Critical Access Hospital (CAH) emergency department (ED). She was identified to have a dislocation of her right hip with a referral to orthopedics. It was also mentioned in the ED report, there is a concern she had an unwitnessed fall as she had pain after a night of sleeping and has bruises and leg pain now. A review of the P & P for pain management states: I. PURPOSE: To provide guidelines when indicated to collaboratively provide aggressive and appropriate pain management for comfort and well-being for the patients and residents receiving care. II. POLICY: A. Pain shall be assessed on admission and shall include pain history, its related disabilities and ratings of pain intensity and relief. B. Ongoing assessments shall be done to evaluate the changing nature of pain a well as the effectiveness of treatments . E. Provide the patient with optimal pain relief with prescribed [MEDICATION NAME]. It was evident the licensed staff were aware R#42 was in pain, but she suffered harm as the facility failed to effectively recognize and manage her on-going pain. Licensed staff noted it was not her usual presentation by their clinical documentation. In addition, the facility failed to follow their policy on pain management as they did not aggressively seek to find out the underlying cause of her pain, although the resident was verbally moaning, guarding, reaching out to grab staff's arms, etc. The licensed staff's charting was also inconsistent and incomplete, and thus, the facility failed to accurately track and monitor her pain intensity to determine if any pain relief was being achieved, which is a basic nursing standard. As a result, this R#42 suffered harm. She did not receive additional, needed pain relief in a timely manner, nor was any initiative taken by the staff to escalate her care needs such as notifying the physician if pain relief was minimally effective despite continued presentation of on-going pain. There also were no additional interventions such as a consideration for stronger [MEDICATION NAME] or expediting her care to involve an x-ray to rule out a traumatic event or an underlying emergency medical condition with her unrelieved pain. The x-ray was ordered five days later, upon which time she had to be transferred to the CAH ED and then to a larger hospital for admission and treatment. The resident did not return to the facility but later expired at the hospital. Thus, the facility neglected to provide the necessary nursing and medical care and services to maintain the resident's highest practicable physical, mental and psychosocial well-being for R#42. An immediate jeopardy (IJ) was identified based on the findings and the facility provided a final IJ abatement plan to the SA on [DATE].