Every finding on record at The Care Center of Honolulu

Based on interviews and record reviews, the facility failed to provide care in accordance with professional standards by not performing an accurate assessment of Resident (R)6 returning to the facility, and not taking actions to ensure family-supplied prescription medication was available for R7. As a result of this deficient practice, R6 received delayed medical attention after a fall, and R7 was placed at risk for adverse health effects for not taking prescribed medications. Findings include:Cross Reference to F641 - Accuracy of Assessments 1) Resident (R) 6 did not receive necessary treatment and intervention in a timely manner when R6 had a fall incident causing multiple skin abrasions and fractured ribs on 04/20/26 while R6 was out on pass. Registered Nurse (RN) 10 conducted head to toe and pain assessment on 04/20/26 but failed to observe multiple injuries, including a scratch to the right inner forearm measuring 0.9 cm by 0.5 cm, a skin tear with total flap loss to the left elbow measuring 1.7 cm by 1.9 cm with scant serosanguineous drainage, abrasions and intact blood blisters to the left dorsal first digit, and a skin tear to the right dorsal first digit measuring 0.6 cm by 1.5 cm. R6 was transferred to Kuakini Medical Center on 04/22/26 for further evaluation.Cross reference to F842 - Resident Records - Identifiable Information 2) Review of Intake # 2719441 stated R7 missed multiple doses of Eltrombopag Olamine (medication that boosts the production of a blood component to stop bleeding) in December 2025 after returning from the hospital and in January 2026 prior to discharge. The medication was not available from the facility-contracted pharmacy and was being provided by the family. The facility was provided with enough medication to last until January 19, 2026, which was his planned discharge date . Review of Electronic Health Record (EHR) revealed that R7 was a [AGE] year-old resident admitted to the facility for short-term rehabilitation services. Diagnoses included but not limited to immune thrombocytopenic purpura (disorder that can lead to bruising and bleeding), encephalopathy (a condition that causes brain dysfunction) and atrial fibrillation (irregular and fast heart rhythm). R7 was prescribed Eltrombopag Olamine 50 milligrams daily to be administered every Monday to Friday. On 12/16/25, R7 was transferred to an acute care hospital for gastrointestinal bleeding and evaluation after an unwitnessed fall and returned to the facility on [DATE]. Review of Medication Administration Record (MAR) for December 2026 done, Eltrombopag Olamine was not administered 12/18/25. Reason stated in the progress notes stated, . waiting on delivery from family. Review of MAR for January 2026 revealed that the medication was not administered from 01/05/26 to 01/14/26. Reason noted in the progress notes was that the facility was waiting for the family to provide the medication. On 04/23/26 at 08:58 AM, concurrent interview and record review was conducted with Registered Nurse (RN)12 at the nurses' station. Queried RN12 about the medication being provided by the family for R7 and the reason for the missed doses. RN12 stated that the reason for the missed dose on 12/18/25 was because the medication was placed in the discard box after he was transferred to the hospital. RN12 added that another RN later found the medication and administered the dose on 12/19/25. Queried RN12 about the eight missed doses in January. RN12 said the medication was not available and was not administered. Queried RN12 if this information was communicated to the family and documented in the progress notes. RN12 searched the progress notes and was not able to find documentation that the family was notified to provide more of the medication.

Based on record review and interview, the facility failed to accurately assess one of three residents (Resident (R) 6) selected for review to reflect resident's health status upon returning from out on pass.Findings Include: Resident (R)6 is a [AGE] year-old male admitted to the facility on [DATE] and is currently receiving Intermediate Care Facility level of Care. Diagnoses included but not limited to congestive heart failure, nicotine dependence, osteoarthritis and diabetic neuropathy. On 04/22/26 at 11:00 AM, Office of Health Care Assurance (OHCA) received Facility Reported Incident (FRI) initial report with Intake #2991932. FRI noted that, .R6 self-reported a fall on 04/21/26 that occurred on 04/20/26 while out on pass from 11:18 AM and returned at 04:18 PM.On 04/21/26, head-to-toe skin assessment was conducted.skin and pain re-assessment identified multiple minor injuries, including a scratch to the right inner forearm measuring 0.9 cm by 0.5 cm, a skin tear with total flap loss to the left elbow measuring 1.7 cm by 1.9 cm with scant serosanguineous drainage, abrasions and intact blood blisters to the left dorsal first digit, and a skin tear to the right dorsal first digit measuring 0.6 cm by 1.5 cm.X-ray obtained in facility resulted on 4/22/26 indicating acute minimally displaced fractures involving the left 6th, 7th, 8th, 9th, and 10th ribs. On 04/23/26 at 09:34 AM, record review of electronic R6's electronic health record (EHR) was done. EHR reflected that, Registered Nurse (RN) 10 conducted head to toe and pain assessment on 04/20/26 at 04:18 PM. RN10 documented on form titled, Nursing Assessment before/after Resident Transport/Leave of Absence, Section C. Description of consult/Appointment stated, .Resident returned to facility via taxi at approximately 04:18 PM in stable condition following a personal errand with wife. A&Ox3, denies pain or discomfort upon arrival. No acute distress noted, No new skin issues noted. On 04/23/26 at 11:45 AM, an interview and record review were done with Administrator in the conference room. After reviewing R6 Electronic Health Record, asked Administrator if RN10 did an accurate assessment with R6, Administrator confirmed that RN10 did not accurately assess R6 on 04/20/26 upon coming back from Kuakini Emergency Room. Review of facility policy titled Resident Assessments with a revision date of 03/22 stated, . 1. Interdisciplinary team conducts timely and appropriate resident assessments.

Based on record review and interviews, the facility failed to maintain accurate medical records for Resident (R)7) in accordance with accepted professional standards and practices. The documented reason for R7's missed medication dose was not accurate. This deficient practice has the potential to affect medical care provided to all the residents in the facility. Findings include:Cross-reference to F684 - Quality of Care Review of intake #2719563 stated R7's family filed a grievance regarding multiple missed doses of a prescribed medication. The medication in question was being provided by the family. The facility stated in the report that the medication was put on hold by the attending physician on 01/05/26. Review of R7's Electronic Health Record (EHR) was conducted. The Medication Administration Record (MAR) for January showed that Eltrombopag Olamine (medication that boosts the production of a blood component to stop bleeding) was not administered from 01/05/26 to 01/14/26, a total of eight doses. Documented reason for the missed dose on 01/05/26 was coded as Hold/See Progress Notes. Review of physician's orders conducted and no order to hold the medication was found. Review of the progress note dated 01/05/26 stated, . Awaiting arrival of meds (medication) from family member. On 04/23/26 at 08:58 AM, an interview and concurrent record review was conducted with Registered Nurse (RN)12 at the nurses' station. Queried RN12 if there was an order to hold the medication for R7 on 01/05/26 as stated in the MAR and in the grievance investigation notes. RN12 reviewed the physician's orders in the EHR and confirmed that there was no order to hold the medication. Review of attending physician's notes that were scanned into the EHR was also reviewed and no documentation to hold the medication was found. On 04/23/25 at 11:53 AM, review of the physician orders and January MAR was conducted with the Administrator in the conference room. Administrator acknowledged that there was no order found in the EHR to hold the administration of Eltrombopag Olamine.

Based on interviews, and document review, the facility failed to provide evidence of a comprehensive Water Management Program (WMP) that is essential to prevent the spread of Legionella bacteria and other opportunistic waterborne pathogens (i.e. Pseudomonas, Acinetobacter) in the building water systems. The facility was not able to provide evidence that a facility risk assessment was conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. In addition, the plan did not include any text or comprehensive description of the building water system, or specify the testing protocols and acceptable ranges for control measures. As a result of this deficiency, the vulnerable residents were at increased risk of exposure to waterborne pathogens, which can cause serious health issues, or death. Findings include: The Care Center of Honolulu is a skilled nursing facility, that provides rehabilitation therapies and has a specialized respiratory unit that provides care to ventilator-dependent individuals. The Office of Health Care Assurance (OHCA) received notification on 12/17/25 regarding a possible case of Legionnaires' outbreak. On 12/22/25 at approximately 12:30 PM, during an interview with the Infection preventionist (IP), she confirmed the facility received notification on December 8, 2025, that R1 had tested positive for LD while hospitalized . She said R1 returned to the facility on [DATE], when discharged from the hospital. Review of R1's medical records revealed she was [AGE] years old and her past pertinent medical history included a hospitalization from 10/10/25 to 10/24/25 for septic shock (life-threatening condition) secondary to peritonitis (inflammation of the lining of the inner wall of the abdomen). R1's diagnoses included, but not limited to chronic anemia, urinary retention (bladder does not empty completely), hypertension, hyponatremia (low sodium level in the blood), chronic kidney disease, atrial fibrillation, and asthma. R1 was discharged from the hospital, and admitted to the facility for rehabilitation on 10/24/25. At that time she had a foley catheter in place for the urinary retention. On 11/30/25, R1 was sent to the hospital for altered mental status and admitted with a diagnoses of septic shock secondary to acute cystitis (bladder infection) and pneumonia. On 11/30/25, R1 had a positive urine test for Legionella antigen that indicated a current or past infection associated with Legionnaires' Disease. She returned to the facility when discharged from the hospital on [DATE]. On 12/22/25, the IP provided a document titled Water Management Program (Including Legionella), revised date December 2025. She said after the Legionella case, the WMP team revised this plan, and it was currently in place. The IP went on to say the plan had been sent to a consultant for review, and they were waiting for feedback for any additional revisions. The IP also provided a document titled Legionella-Specific Risk Assessment, Testing Interpretation, and Response Framework (To be included with the Water Management Program), revised date of December 2025. A request was made for the previous WMP and all policies related to the plan. Reviewed the second document provided by the IP titled Legionella Water Management Program, last revised date of July 1017 and two policies that were active when the case was identified. The WMP included the following: 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE (American Society of Heating, Refrigeration and Air Conditioning Engineers) recommendations for developing Legionella water management program. 5. A description of water system in the facility, including the following: i. Receiving; ii. Cold water distribution; iii. Heating; . 7.b. [sic/outline format incorrect] The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: i. storage tanks; ii. water heaters; iii Filters; iv. Aerators; v. Showerheads, and hoses; vi. Misters, atomizers, air washers and humidifiers, vii. Hot tubs; vii. Fountains; and ix. Medical devices such as CPAP (provides steady uninterrupted breathing during sleep), hydrotherapy equipment, etc. 7.c. The identification of situations that can lead to Legionella growth, such as: . iv. The presence of biofilm (film of bacteria that adheres to a surface), scale or sediment; .vii. water stagnation; and viii. inadequate disinfection. 7.d. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); 7.e. The control limits or parameters that are acceptable and that are monitored; 7.f. A diagram of where control measures are applied; . 7.i. Documentation of the program. This WMP was a basic outline of what is recommended to be included in a facility WMP, but lacked detail and did not include the required elements of a WMP. The plan did not: - Include a risk assessment of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. It listed potential areas, but did not include or describe specifically what the facility had i.e.two water heaters located on the roof, identified areas that could develop biofilm or potential stagnation. - The current water system diagram was very basic and does not include or have supporting text where control measures are applied, what the specific control measures are, or the acceptable parameters. - Include a building description. Reviewed the policy titled Water Supply, copyright 2001 (Revised November 2009) MED-PASS, Inc (recognized provider of policy and procedure manuals). The policy statement was Our facility handles and maintains its water supply in accordance with recommendations of the CDC, the Healthcare Infection Control Practices Advisory Committee and the FDA (Food and Drug Administration). The purpose was To maintain a sanitary water supply and control the spread of waterborne microorganisms. The policy included .2. Do not place decorative fountains and fish tanks within easy access of cognitively impaired residents. 3. Hot water distribution systems serving resident care will be continuously recirculated. At the bottom of the policy was Related Documents: Water Supply- Disruption Due to Repairs or Emergencies, Legionella Surveillances and Detection, Water Management Program. No additional policies were provided while on site.These documents did not reflect a coordinated WMP consistent with CDC and ASHRAE standards. In addition, there was a lack of documentation of the programs activities. A request was made to document the actions taken after notification of the positive Legionella case. On 12/23/25 at 10:00 AM, during an interview with the IP, asked if a risk assessment for the WMP had been conducted. The IP said she started to complete a LEAF (Legionella Environmental Assessment Form, a CDC tool to evaluate water systems to minimize the risk of Legionnaires' disease), after notification of the positive case, but had not finished it. She went on to say the WMP team completed the tool with the DOH, but had not yet received the final document. The IP said the building was very old and she felt the highest risk in the water system was, the dead legs in the old pipes, and not knowing exactly where they were located. At this time the IP left the conference room and returned with architectural plans and blueprints. The documents were illegible due to age. She acknowledged they did not have a documented risk assessment and said that the facility had contracted with a consultant (C)1, who would be conducting a comprehensive assessment of the building in the near future. On 12/24/25 at 10:30 AM, interviewed the Facility Manager (FM) in the conference room. He said he did not know when the current water system diagram was developed and that it had been in place when he was hired in 2021. At the time of the interview, the white board in the conference room had a water system diagram on it, that the DOH developed with the facility during their visit. When asked the FM what the water systems highest risk for water borne pathogens was, he pointed to the diagram on the board and said it was the Resident rooms located at the farthest point from the distribution of water supply (room [ROOM NUMBER] and 238). The FM said the second highest risk would be the ice machines. He confirmed the facility had not previously done a risk assessment as part of the WMP.The FM said there were measures in place to minimize the risk of waterborne disease and provided the following documentation: - Water Heater Temperature: The facility logged temperature reading once a week on the two water heaters located on the roof. The Water Heater Temperature Monitoring Log used to document did not include the acceptable range, and there is no supporting policy or document that defined it. The log reads Within Range' with a Yes, or No. - Ice Machines: There is scheduled maintenance on the two ice machines on a quarterly basis. The work is scheduled through the internal electronic system, Direct Supply. The Preventive Maintenance steps are preprinted on the LogBook [sic] Documentation form, which is signed by the staff when the tasks were completed (One form is used for both machines). The sanitizing interior step on the form read per manufacturer's instructions, but does not say what specifically that means. - Housekeeping (HK)/Resident rooms; The FM said the HK staff are in the resident rooms every day and run the water, which helps to maintain water quality and part of the WMP. For documentation of completion, he provided a checklist titled CDC Environmental Checklist for Monitoring Occupied Cleaning, that HK staff check off after cleaning a room. This tool was specifically developed by the CDC to provide a framework for environmental cleaning to optimize the thoroughness of high touch cleaning, rather than the purpose of contribution to a WMP. - Water Quality; To monitor the water quality, the FM said they use the Water Quality Report from the Board of Water Supply, City and County of Honolulu, once a year. This measure is not included in the current plan, and the revised plan stated The facility must document: .Chlorine residual levels (via municipal reports or handheld testing) biannually. : On 12/24/25 at approximately 11:00 AM, during an interview with the ADM, she confirmed the facility recently obtained C1 to do a full risk assessment of the building and assist to develop the WMP. At that time, she acknowledged the current plan was missing essential elements and that the revised WMP was scheduled to go to Quality Assessment Performance Improvement Committee for approval.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment and properly labeled. Medication was left on a resident beside table; One of nine medication carts was observed unlocked and unattended in the hallway; and insulin syringes were not labeled according to industry standards. The deficient practice compromised the safe storage and administration of medication to the residents and the potential diversion of medications on the unit. Findings Include: On [DATE] at 02:11 PM, concurrent observation and interviews were done inside Resident (R) 57's room. Observed two white tablets inside a medication cup on R57's bedside table, while Registered Nurse (RN)25 was outside resident's room talking on the phone. When R57 was asked if the medications on her bedside table were given to her by the staff, she stated that she was not aware of the medication, name and dose. An interview was done with RN25 after he returned to check with the resident. When asked if those medications were intended for R57, he acknowledged that he left medications on top of resident's bedside table. RN25 explained that he should remain with the resident until all medications have been taken. On [DATE] at 08:35 AM, an interview with the Assistant Director of Nursing (ADON) was conducted in the conference room. The ADON confirmed that staff nurse should not leave medications at resident's bedside and should always remain with resident until all medications have been taken. The ADON also explained that no resident is allowed to self-administer medications in the facility. Review of the facility policy titled Administering Oral Medications revised on 10/2010, stated, . 32. Remain with the resident until all medications have been taken. 2) On [DATE] at 08:44 AM, observed a medication cart against the wall in the hallway outside room [ROOM NUMBER] unlocked while Registered Nurse (RN)20 was in room [ROOM NUMBER] administering medications. Housekeeping staff, Certified Nurse Aides, Respiratory Therapists and two facility visitors were also observed walking through the area. RN20 returned to the medication cart at 08:54 AM and acknowledged the medication cart was not locked. RN20 confirmed that the medication carts are to be locked whenever it is unattended. Review of the facility policy titled Storage of Medications stated, . Compartments (including, but not limited to, drawers cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended . 3) On [DATE] at 09:34 AM, inspection of medication cart three was conducted with RN20. Observed two of three insulin pens in one of the drawers in the cart without a label that noted the open and discard dates. One of the two insulin pens did not identify which resident the medication was for, and the other insulin pen only had the name and room number of the resident written with a green marker. RN20 acknowledged the two insulin pens were not labeled properly and should include the resident's name, medication dosage, frequency, and open and discard dates. On [DATE] at 08:29 AM, an interview with the ADON was conducted in the conference room. The ADON confirmed that insulin pens are to be labeled with the residents' information and should include the open and discard dates since they are only good for 28 days after opening. 4) On [DATE] at 09:30 AM an observation was made of one medication cart with RN18. A new insulin pen labeled with R182's name was found in the medication cart. The same insulin pen was not labeled with the opened on and discard by date. Inquired of RN18 if he had put the insulin pen in the medication cart and he said no. Inquired of RN18 when the insulin pen was put in the medication cart and he said he did not know and that he would check with his supervisor. RN18 brought Nursing Supervisor (NS)3 to the medication cart. At this time inquired with NS3 if she knew when the insulin pen had been put into the medication cart. NS3 was unable to state when the insulin pen was put in the medication cart but would investigate this and let surveyor know. On [DATE] at 08:12 AM interviewed the ADON in the conference room and inquired if he knew when R182's new insulin pen, that was found in the medication cart on [DATE], was put in the medication cart. ADON stated RN27, nurse on day shift, took out the insulin pen from the refrigerator on [DATE] and put it in the medication cart. ADON shared the nurse stated she was helping the other nurses and had taken the insulin pen out of the refrigerator and put it in the medication cart for the other nurse to use. The ADON confirmed the nurses did not label the insulin pen when it was opened and when it must be discarded by and confirmed this should have been done. 5) On [DATE] at 11:15 AM an observation was made of the medication storage room with the ADON. At this time three bottles of Dakin's solution were found with an expiration date of 05/2025. Inquired of the ADON about the expiration date and he confirmed the three bottles of Dakin's solution were expired and stated he would throw them away.

Based on observation, record review, and interviews, the facility failed to ensure that residents received food in accordance with their documented preferences for two [Residents (R) 111 and R104] of three sampled residents reviewed for food preferences, and for two non-sampled residents (R83 and R50) observed during the tray line. Specifically, R111, R104, R83, and R50 were served food items that were documented as dislikes in their dietary records. This failure resulted in residents receiving meals inconsistent with their stated preferences, potentially affecting their nutritional intake and satisfaction with food services.Findings Include: On 09/02/25 at 09:44 AM, an interview was conducted with R111. R111 stated he has concerns with the food at the facility and not following his preferences. R111 reported the facility sometimes doesn't follow his preferences or substitutions. On 09/02/25 at 12:43 PM, an observation and follow-up interview were conducted with Resident R111 during the lunch meal service. R111 stated he disliked rice and gravy but was served rice and gravy on his pork chop. He reported that he only ate the pork chop and the fruit that were served. Observation confirmed rice on the resident's plate. A review of R111's tray card revealed documentation under Notes indicating No rice, and listed rice and gravy under the resident's documented dislikes. On 09/03/25 at 11:24 AM, an interview was conducted with Director of Dietary Services (DDS) 2. DDS2 confirmed R111 dislikes rice and gravy, and it should be honored. His tray card should be followed. 2) On 09/03/25 at 11:24 AM, an observation was done in the kitchen during tray line. At 11:38 AM, observed Dining Services Manager (DSM) preparing R83's tray during tray line. DSM called out double chopped meat to the tray line staff, who then placed double chopped meat onto R83's plate. DSM placed a plate cover over the dish and placed R83's completed tray into the tray rack for service. When asked what was being served for lunch, DSM stated the entrée was barbeque pork ribs. A concurrent review of R83's tray card showed pork listed under the resident's documented dislikes. DSM confirmed pork was served on R83's plate and should not be on there At 11:49 AM, observed Dietary Aide (DA) 5 review R50's tray and tray card in the tray rack. DA5 called out House Chopped to tray line staff. Tray line staff were observed placing chopped food items onto R50's plate, including a vegetable mix containing broccoli. DA5 then placed a plate cover over the dish and positioned the plate on R50's tray in the tray rack before proceeding to prepare the next resident's tray. Upon request, DA5 removed R50's tray for review. Concurrent inspection of R50's tray card confirmed that broccoli was listed under the resident's documented dislikes. DA5 confirmed broccoli was present on the plate and should not be on there. 3) On 09/02/25 at 12:20 PM, concurrent observation and interview was done with R104 during lunch meal in her room. Observation of the tray card revealed documentation of Pork (HAM, SPAM) under the resident's list of dislikes. R104 stated she disliked pork in general but was served a pork chop for lunch. R104 reported the facility sometimes doesn't follow her preferences or substitutions. R104 always asks her family to bring her food from home to the facility. Observation confirmed pork on the resident's plate. On 09/02/25 at 12:35 PM, interview was done with the Certified Nurse Aide (CNA) 87 inside resident's room. The CNA 87 confirmed that R104 dislikes pork but was served a Pork chop for lunch. On 09/03/25 at 11:36 AM, an interview was conducted with Director of Dietary Services (DDS) 2. DDS2 confirmed R104 dislikes pork, and it should be honored. Review of the facility's policy and procedure Resident Food Preferences revised on 07/2017 documented .preferences will communicate them to Dietary Staff for implementation.The Dietary team will make reasonable efforts to fulfill individual resident needs for food and/or beverage requests.

Based on interviews and record review, the facility failed to ensure the personal belongings were inventoried upon admission for one [Resident (R) 29] of three sampled for missing property. R29's hearing aids were not identified as missing until greater than one month, resulting in R29's inability to effectively communicate with others. The deficient practice affected the resident's quality of life. Findings include:During an interview on 09/02/2025 at 12:12 PM in R29's room with R29's Family Member (FM), the FM stated that she was concerned because R29 lost her dentures and hearing aids three weeks ago. The FM said, it's very concerning now because they have had her on a pureed diet, but she can eat regular foods when she has her dentures. I'm worried that she has lost or will lose weight because she doesn't like the pureed food. When she has her dentures, she can eat regular foods. Also, her hearing aids are missing. R29 is very alert, but now people think she's confused but it is because she can't hear. Asked if she or other family members had reported the missing items to the Administrator, the FM said yes but they haven't heard any updates. Reviewed the Inventory of Belongings form for R29. The form is used to document the personal belongings when a resident is admitted to the facility. R29 was admitted on [DATE] however, the form was dated and signed as completed on 08/14/25, five weeks after R29 was admitted to the facility and included two dresses, one jacket, two scarves, and one chaleko. The dentures and hearing aids were not checked. Received and reviewed the grievance complaint log for the last year on 09/04/2025. R29 filed a grievance for missing items on 07/12/25. The missing items did not include R29's missing hearing aids.Interview with the Assistant Director of Nursing (ADON) on 09/05/2025 at 08:29 AM. Asked the ADON what the process is for missing items that are reported. The ADON stated when a resident has missing items, they can report it to the unit manager on the floor, and they can file a grievance. The manager will investigate the missing items and give the resident a follow up report.Interview with the AA on 09/05/25 at 09:00 AM in the Administrators office. Asked the AA if there was a report about R29's missing hearing aids. The AA said not to her knowledge and that she wasn't aware of missing hearing aids and that she will look into it. Confirmed with the AA there was not an inventory form completed at the time of R29's admission to the facility on [DATE].Telephone interview with R29's Power of Attorney (POA) on 09/05/2025 at 09:38 AM. Asked the POA if she was aware that R29's hearing aides were missing. The POA stated that another family member told her that they were missing and that she had spoked to a nursing staff on the telephone and asked her to check R29's belongings for the hearing aids. The POA said she would follow up with the administration about it. Lost and Found Policy Statement (not date) reviewed. Policy Statement. Our facility shall assist all personnel and residents in safeguarding their personal property.

Based on observations, interviews and record review, the facility failed to accommodate the needs of one of one resident [Resident (R)78] sampled by not ensuring that the call light was always placed within reach or positioned so that it could be activated. As a result of this deficient practice, R78 was placed at risk of not having his emergent needs met in a timely manner. This deficient practice has the potential to affect all the residents at the facility who can activate a call light.Findings include:R78 was a [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. Diagnoses included, but not limited to, quadriplegia (paralysis in all four limbs and torso) and has a tracheostomy (surgical opening in the front of the neck where a tube is inserted into the windpipe to maintain an airway). Recent Minimum Data Set (MDS) quarterly assessment on 08/02/2025 revealed R78 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he is cognitively intact.On 09/02/25 at 10:21 AM, observed R78 lying in bed watching television. Call light was placed on the mattress, left side of R78's pillow and out of his reach. Asked R78 if he was capable of using the call light if he needed assistance from the staff. R78 said, Yes, if I can reach it with my head. R78 asked the surveyor to activate the call light so staff can pin it to the pillow and closer to his head. One minute after activating the call light, Certified Nurse Aide (CNA)122 knocked at the door and asked if R78 needed assistance. R78 asked CNA122 to position the call light closer to his head so he can reach it. CNA122 acknowledged the call light was out of R78's reach and proceeded to pin it on the left side of the pillow.On 09/03/25 at 09:19 AM, observed R78 lying in bed with his eyes closed. Call light was placed on the mattress near the pillow and out of R78's reach.On 09/05/25 at 10:11 AM, an interview was conducted with the Nurse Supervisor (NS) 3 in front of the nurse's station. Shared with the NS3 observations of R78's call light being out of his reach. NS3 said staff are to make sure R78 is able to reach his call light at all times since he is able to activate it in case he needed assistance.

Based on interview and record review, the facility failed to ensure that an allegation of abuse was reported to the State Agency (SA) and Adult Protective Services (APS) for one of two residents (Resident (R) 49) sampled for abuse. R49 alleged that two staff members had held her down in bed, at an undetermined time in the past.Findings Include: On 09/03/25 at 09:30 AM, an interview was conducted with R49. R49 reported that, some time ago, two staff members grabbed her, pushed her down, and held her in bed. R49 could not recall the names of the staff members, when the incident occurred, or the reasons for the interaction. However, she identified the staff members as Certified Nurse Aides (CNAs), noting that one of them was blonde and always wore her hair in a ponytail. R49 described feeling violated and attacked, stating that the staff members treated her as though she were crazy. She explained she experiences significant nerve pain, and that their actions were causing her extreme discomfort. R49 mentioned that she had reported the incident to the facility, though she could not recall when it occurred. She further stated that the staff members involved were sent downstairs after the incident and told they would not provide care for her again, but R49 expressed that she wanted them dismissed from the facility. She also mentioned seeing one of the staff members yesterday in her room and hearing that the individual had received a promotion rather than being dismissed as she had expected.Review of R49's progress notes documented on 08/15/25 that social services notified the interdisciplinary team (IDT) that R49 is .possibly experiencing delusions. Met with resident after IDT meeting to assess. Resident stated that she had previously spoken to the president regarding an incident with staff in which two staff members were removed from providing care to unit 4 d/t [due to] an incident with her wherein those staff members were rough with her and threw her on the bed and pinned her down. States that those staff members were instead given a promotion and that the president broke his promise to her. Resident unable to name the president or the staff members. Stated that this incident occurred possibly 7 months ago. A follow-up note was documented on 08/16/25, During psychosocial visit, resident verbalized delusional thought content, stating that a couple years ago the president came to see me in my room, and it was not. [the current president of the United States]. Resident also expressed upset regarding a reported CNA promotion and questioned, how does a CNA get promoted, though later acknowledged hearing from roommate that this may not be true. Resident further reported hearing multiple conversations and three TVs being on, which she feels may distort what is actually heard.On 09/04/25 at 02:59 PM, an interview was conducted with Social Services Director (SSD). When asked about the process for reporting allegations of abuse made by residents, the SSD explained that while administration typically initiates the report to APS, the social services department may also submit a report if necessary. SSD confirmed that social services did not submit an APS report regarding the alleged incident involving R49. SSD reported she did not know the outcome of the investigation of R49's alleged abuse but was aware the facility had concerns with her cognition and history of delusions. SSD acknowledged regardless of a resident's cognitive status or mental health history, any allegation of abuse, such as R49's claim of being held down by two staff members, should be reported to the appropriate authorities, such as APS.On 09/04/25 at 03:11 PM, an interview was conducted with Assistant Administrator (AA). AA reported that an investigation into the allegation was initiated, and the facility was unable to determine when the alleged incident occurred or identify any staff members matching the description provided by R49. AA noted that R49's account of the incident was inconsistent. During the investigation, AA reported it was identified that R49 had a documented history of delusions and Post-Traumatic Stress Disorder (PTSD), and AA believed R49 may have had a Urinary Tract Infection (UTI) at the time the allegation was reported. The facility concluded that the allegation was likely a result of R49's delusional behavior rather than an actual event and decided not to report the allegation to the SA or APS.Review of Resident R49's Electronic Health Record (EHR), including psychiatry consult notes, prior to 08/15/25, revealed no documentation of R49 reporting that two staff members pushed and held her down in bed. Additionally, there was no indication in the EHR that such an allegation had previously been made or investigated, nor was there any record linking this specific incident to her documented history of a delusional disorder prior to 08/15/25.On 09/05/25 at 09:43 AM, an interview was conducted with Nurse Supervisor (NS) 2. NS2 stated that the alleged incident was new information to her and expressed shock upon hearing about it. She confirmed that, prior to 08/15/25, there was no known history or documentation of such an allegation, nor had any other staff members reported it to her. NS2 acknowledged that, although R49 has a history of delusional behavior, there could still be some truth to the allegation, and therefore, it should have been treated and reported as an abuse allegation. On 09/05/25 at 11:18 AM, an interview was conducted with the Administrator. The Administrator stated R49 has been in the facility since 2018. During the investigation, they were unable to determine whether the alleged incident occurred at the facility or prior to R49's admission. Administrator confirmed that there was no record indicating the incident was reported to APS or SA prior to becoming Administrator to the facility and did not report the incident to APS or SA after they became aware of the allegation. On 09/05/25 at 02:35 PM, Administrator and Director of Nursing (DON) reported they showed R49 a picture of a previous administrator and R49 identified him as the president. Review of the facility's policy and procedure Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised in April 2021 documented All reports of resident abuse.are reported to local, state, and federal agencies (as required by current regulations) .Findings of all investigations are documented and reported. The policy further documented The administer or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services.; e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director.within two hours of an allegation involving abuse.or within 24 hours of an allegation that does not involve abuse.

Based on observation, record review, and interview the facility failed to accurately assess three of four resident's status sampled for Resident Assessment, [Resident (R) 5, R140, and R33]. The facility failed to identify R5's use of a mitten restraint on her right hand, instead identified it as not being used. The facility incorrectly coded R140 as receiving insulin one day a week instead of receiving a GLP-1 receptor antagonist, Trulicity. The facility coded R33 as a low risk for developing a pressure ulcer when in fact she is a high risk for developing a pressure ulcer. The deficient practice could affect all residents in the facility if the facility fails to accurately assess resident's medications, risk for pressure ulcer and use of restraints, incorrectly coding resident's status. Findings include: On 09/02/25 at 10:28 AM, observed R5 lying in bed with her head elevated and a mitten restraint applied to her right hand. Review of R5's Electronic Health Record (EHR) conducted. R5 was a [AGE] year-old resident admitted on [DATE] for long-term placement. Diagnoses included, but not limited to quadriplegia, epilepsy (seizure disorder), encephalopathy (disturbance in brain function that causes changes in mental state, behavior and cognitive abilities), and had a tracheostomy and gastrostomy tube (medical device inserted through the abdomen into the stomach to provide nutrition, fluids and medications). Minimum Data Set (MDS) quarterly assessment on 06/17/25 under Section P – Restraints and Alarms coded R5 as not using any restraints. On 09/04/25 at 02:06 PM, concurrent interview and record review conducted with MDS Coordinator (MDSC) 3 in the conference room. Reviewed most recent MDS for R5 and asked MDSC3 if Section P was accurate. MDSC3 confirmed that the assessment was not accurate since R5 used a mitten restraint on her right hand for safety to prevent her from inadvertently pulling out her tracheostomy or gastrostomy tube. 2) On 09/03/25 during a Record Review of R140's EMR a review of R140's MDS with an Assessment Reference Date (ARD) of 08/10/25 revealed under Section N: Medications Injections Record the number of days that injections of any type were received during the last 7 days . and R140 was coded as 1. Right below the Injections section the Insulin section states, Record the number of days that insulin injections were received during the last 7 days . and R140 was coded as 1. On 09/04/25 at 01:30 PM interviewed the MDSC1. Reviewed R140's MDS with an ARD of 08/10/25 with MDSC1 who confirmed she coded R140 as getting insulin on his MDS. A review of R140's medication orders revealed he was not ordered insulin. Further review of medication orders found R140 has Trulicity ordered, which is a GLP-1 receptor antagonist that is given weekly by injection. MDSC1 confirmed this should not have been coded as insulin and stated this was an error. 3) On 09/03/25 at 12:58 PM during a review of R33's MDS with an ARD of 07/24/25 revealed under Section M Skin Conditions R33 was coded as No for Is this resident at risk of developing pressure ulcers/injuries? Continued record review of R33's EHR revealed she is a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy, difficulty in walking, unspecified dementia, moderate protein- calorie malnutrition and need for assistance with personal care. R33's care plan has a Focus that states The resident has potential/actual impairment to skin integrity r/t fragile skin with multiple interventions for staff to follow to prevent injury to R33's skin. On 09/05/25 at 03:23 PM interviewed MDS Lead in the conference room. Inquired if she was familiar with R33 and she confirmed she was. Concurrent review of R33's MDS with an ARD of 07/24/25 was done during this interview. Inquired about R33's MDS coding as not being at risk of developing a pressure ulcers/injuries and she confirmed the coding was an error and they will have to do a modification.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for one [Resident (R) 6] of one resident sampled for restraints, The deficient practice could affect all residents at the facility who are using bedrails. Findings Include: On 09/03/25 at 12:13 PM observed R6 in bed with bilateral 1/2 upper bedrails up on her bed. R6 was observed holding onto the rails as she lay in her bed. On 09/04/25 at 02:30 PM requested the Director of Nursing (DON) provide a copy of R6's consent for bedrail use and she stated it is in the resident's restraint physical assessment that was filled out on 07/27/25. The DON also stated the nurse wrote a progress note regarding the conversation with the Resident's daughter giving verbal consent for bedrail use. On 09/04/25 record review of R6's Electronic Health Record (EHR) revealed an assessment to use the 1/2 upper bedrails was completed on 07/27/25. Reviewed R6's Care Plan (CP) and found the use of bedrails was not included in the care plan. On 09/05/25 at 03:52 PM, interviewed the DON in the conference room, who stated they resolved the issue with the physical restraint because the bedrail is not being used as a physical restraint but is being used for bed mobility. The DON stated that they had made the change to the CP yesterday and it was taken out. Reviewed the CP with the DON and did not find anything related to the bedrail use for bed mobility. DON confirmed the CP did not have any mention of the bedrails and use for bed mobility and it should have been included.

Based on observation, interview and record review, the facility failed to ensure the care plan for one of two residents investigated for care planning, [Resident (R) 1] was revised by the interdisciplinary team to include interventions to prevent recurring hospitalizations. The resident has had multiple re-hospitalizations within the recent months and was not reflected in his care plan. The deficient practice may impact the resident's quality of life and the right to a dignified existence. Findings Include:Observation on 09/03/2025 at 02:08 PM in R1s room. R1 was lying in his bed and didn't answer make eye contact or speak when asked questions. R1 had a trachea collar that was connected to the mechanical ventilator. Noted a Gastric (G-tube) feeding pump at the bedside and an intravenous (IV) infusion pump on the other side of the bed. R1 was resting with his eyes open. Review of the Electronic Medical Record (EMR) on 09/04/25. R1 is an [AGE] year-old male resident admitted to the facility on [DATE] (most recent re-admission). Diagnosis includes tracheostomy and ventilator dependent, and malignant neoplasm of nasopharynx. Reviewed six discharge letters to R1's representative. R1 was transferred to acute care on the following dates: 05/16/25; 06/13/25; 07/07/25; 07/14/25; 07/23/25; 08/02/25; and 08/21/25. R1 had seven re-hospitalizations since May 16, 2025. Minimum Data Set (MDS) discharge return anticipated 08/22/25 reviewed. Resident dependent on staff for his activities of daily living (ADL's). Care Plan revision dated 10/22/24 reviewed. R1 will remain at the facility for Long Term Care (LTC) services. IDT will discuss recommendation for discharge. Interview with the Infection Preventionist (IP) on 09/05/2025 at 01:17 PM in her office. Asked her why R1 has had so many hospitalizations. The IP said, R1 has a very high frailty score, of the last five rehospitalizations, three have been related to displacement or blockage in his feeding tube. R1 is currently being treated with an intravenous antibiotic for Pneumonia., a lung infection. The IP said, Asked the IP if there have been any discussions among the intradisciplinary team (IDT) about his frequent rehospitalizations? The IP reviewed the IDT conference notes saying, no, they updated his Physician Ordered Life Sustaining Treatment (POLST) and Advanced Healthcare Directives. Interview with the Social Services Director (SSD) on 09/05/2025 at 01:29 PM. Asked if the IDT has addressed concerns related to R1s frequent rehospitalizations, code status, or palliative care with each other or with the family. The SSD stated, no, at the last quarterly meeting the focus was mostly on wound care, mood & behaviors with updates to the care plan. We rely on nursing to address changing services such as hospices. We have not had any discussions with the family for hospice services. R1 is full code, he is supposed to have a welcome meeting on September 2, 2025, after his last hospitalization, but his power of attorney (POA) postponed it. Interview with the Director of Nursing (DON) on 09/05/2025 at 01:54 PM. Asked the DON if there has been any discussion with the family about palliative or hospice care. Have the frequent rehospitalizations been addressed by the team and have they looked at the root cause for the hospitalizations? The DON stated the goal is for R1 to go to California to be with his family. R1s frailty score is high. Asked why couldn't the hospitalization have been avoided by either addressing the issue to prevent it from becoming acute, or treating the resident in-house? The DON stated the family education would be during our quarterly IDT meetings with any discussion about the hospitalizations and readmissions. Asked what has been implemented for R1 to prevent additional hospitalizations? The DON stated that when his JG tube (feeding tube) gets displaced or blocked, we he needs to have an Xray for it to be reinserted and has to go to the hospital. Plan of care note dated 08/08/25 reviewed. Social Services Assistant SSA 3 at 13:10. Welcome Meeting Attendance . Meeting was held in resident's room with IDT; SSA3 and Director of Dietary Services (DDS) 3. SSA3 reviewed the POLST; no changes at this time.Per staff assessment, residents have short- and long-term memory deficits. Resident is severely cognitively impaired and require assistance of others for decision making.Discharge plans remain the same for resident to remain at the facility for long term care s family not able to provide level of care at home. No further needs at this time.

Based on observation, interviews and record review, the facility failed to provide the following for one [Resident (R) 15] of one resident sampled for quality of care: A homelike environment with a comfortable room temperature; provision of adequate personal care of hair, skin and nails; and provision of a water pitcher for hydration between meals. The deficient practice impacted the resident's quality of end-of-life care with a comfortable and dignified existence in the facility. Findings include:Observation and interview with R15 on 09/03/2025 at 10:34 AM in his room. R15 was in an isolation room on transmission-based precautions for a respiratory infection. R15's skin on his arms, hands, legs and feet were dry, scaly and flaky. R15's hair was tousled, and his mustache was over his lip which made him appear disheveled. The nails on his hands were 3/4 inch long, yellow, and thick. Asked if the staff ever trim his hair, shave him or offered to trim his nails. He said he can't shave himself and the nurse said she would trim his nails. Resident said he is hot, during the daytime it gets hot. He said he would sometimes use the menus to fan his self. Standing next to R15's bed near the windows the room felt very hot. Light yellow curtains were hanging over the long windows allowing bright light to shine into the room. The sun shines bright, and he said he can't see the T.V. because of the glare. The surveyor could feel the heat radiating directly next to the curtains. No water pitcher or cup observed on R15's bedside table or nightstand. Interview with the Nurse Supervisor 2 (NS2) who was immediately outside of R15's room. Asked the NS2 if she has been in R15's room and if she was familiar with him. The NS2 responded that she didn't know R15. Discussed with the NS2 that R15 complained that the room is too warm and asked her if she has been inside the room. Shared observations of R15's personal hygiene. The NS2 said she would put on the personal protective equipment (PPE) and go inside to see R15. Asked the NS2 if she would know why R15 doesn't have a water pitcher or cup? She said she wasn't sure if R15 is on fluid restrictions or precautions, but she would investigate it. Asked the NS2 if she knew if R15s personal care was coordinated between the Hospice staff and the facility staff. The NS2 said she wasn't sure but would investigate it. Observed a certified Nurse Aide (CNA) go into the room with her PPE on and commented that it is hot inside the room.Electronic Medical Record (EMR) reviewed on 09/04/25. R15 is an [AGE] year-old male admitted to the facility on [DATE]. Diagnosis includes positive for Respiratory Syncytial Virus (RSV); stage four pressure ulcer of the sacrum; venous insufficiency; history of stroke and heart attack; and protein calorie malnutrition. Receiving hospice services with skilled nursing care one time per week and hospice aide care one time per week. Activities of Daily Living (ADL) self-care performance deficit r/t weakness and terminal prognosis. Shave resident as he requests or as needed. Resident is dependent with shaving-shave per resident/family wishes, if not every day .Check nail length and trim and clean on bath day and as necessary.have Licensed Nurse (LN) trim nails.Coordination of skin treatments will be discussed and decided on between Hospice service and the facility to ensure proper care for resident through the next review date.Resident's choice for comfort will be honored, and physical and psychosocial needs will be met daily. Interviewed the NS2 on the next day on 09/04/25 at 09:50 AM. Asked her if the resident can have a water pitcher or cup at the bedside for hydration. The NS2 stated that R15 is on thickened liquids so wouldn't have a bedside pitcher. The NS2 stated that she visited the resident in his room on the previous day and observed staff providing care to R15 were hot and sweating. Asked if she knew how the personal care was being coordinated between the facility and Hospice staff. The NS2 said she wasn't sure. The surveyor asked NS2 if she thought if R15 needed personal care, (a hair and nail trim). The NS2 said yes, if I were taking care of him, I would make sure it was done.Interview with the Director of Dietary Services (DDS) 2 on 09/04/2025 at 3:20 PM in the surveyor conference room. Asked the DDS2 what type of diet and texture R15 is on. The DDS2 said he is on pureed and nectar fluids. Asked him if R15 would be allowed to have a water cup on his table if he is on nectar fluids. The DDS2 said it would have to be in his care plan to have it, and he would require assistance. Review of the care plan dated 10/23/24 did not include water pitcher at the bedside for assistance with hydration. Did not observe staff assisting with hydration outside of the mealtimes. Activities of Daily living (ADLs), Supporting Policy Statement revised March 2018 reviewed. 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.Resident Hydration and Prevention of Dehydration Policy statement revised October 2017 reviewed. 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids in accordance with diet order, on a daily and routine basis as part of daily care. Intake will be documented in the medical records.

Based on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one of one resident's sampled for nutrition/hydration, [Resident (R) 74]. This deficient practice affects residents who rely on staff to provide fluids to maintain proper hydration and health.Findings Include: On 09/02/25 at 10:29 AM, concurrent observation and interview was done. Observed no water pitcher at R74's bedside. Subsequent observation was done at 11:35 AM, and no water pitcher was observed at resident's bedside. An interview was done at 11:37 AM with R74, when asked if she needed water pitcher at her bedside, R74 stated, Yes, I would like to have my own water pitcher. R74 also explained that she feels thirsty at times and has dry lips but was not provided a water pitcher. An interview was done at 11:40 AM with Certified Nurse Aide (CNA)103 inside resident's room. Asked if R74 requires a water pitcher in her room and confirmed that the resident is able to pour water from a pitcher without assistance and should have a water pitcher at her bedside.On 09/05/2025 at 09:36 AM, an interview was done with the Unit Manager (UM) 3 in the Nurse's Station. She stated that R74 is not on fluid restriction. She also confirmed that R74 can pour water from the pitcher without assistance from staff, or sometimes with minimal assistance. Record review was done with UM3, and no documentation was found that staff encouraged resident to drink extra fluids between meals. When UM3 was asked if R74 should have a water pitcher at her bedside UM3 said yes and confirmed that she should be encouraged to drink extra fluid between meals. On 07/30/25, review of R74's Electronic Health Record (EHR). Reviewed R74's care plan with date of initiation on 01/24/25, stated that resident is at risk for fluid and nutritional imbalance. Hydration/Nutrition note with initiation date of 01/24/25, instructed staff to encourage good nutrition and hydration in order to promote healthier skin. Also, for staff to encourage fluids between meals, and CNA to record food/fluid intake every shift.The facility's policy and procedure titled, Resident Hydration and Prevention of Dehydration, with a revision date of October 2017, stated that, . 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids.8. extra fluids to be encouraged between meals.

Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and improper hand hygiene and glove changes between a dirty and clean task. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.Findings include:1) On 09/04/25 at 08:14 AM, observed Registered Nurse (RN)27 administer medications to Resident (R)5 through her gastrostomy tube. RN27 was wearing a mask and gloves as she administered the medications to R5 but did not wear a gown. On 09/05/25 at 12:53 PM, an interview with the Infection Preventionist (IP) was conducted in her office. The IP confirmed that staff are to wear a gown, gloves and mask when administering medications through a gastrostomy tube for a Resident who is on enhanced barrier precautions.Review of facility policy titled Standard Precautions with Enhanced Barrier Precautions stated, . Implementation of EBP requires the proper use of personal protective equipment (PPE), gown and gloves are to be worn during activities of high-contact care . high-contact care activities requiring gown and glove use for Enhanced Barrier Precautions include . Device care or use . feeding tube .2) On 09/04/25 at 09:20 AM, observed Respiratory Therapist (RT)5 perform tracheostomy care for Resident (R)10. RT5 performed hand hygiene and donned gown, mask and gloves prior to entering R10's room. RT5 then assessed R5's lung sounds with a stethoscope and said suctioning is needed before performing tracheostomy care. RT5 proceeded to suction R5's tracheostomy tube. RT5 then removed the gauze dressing under the tracheostomy tube and tracheostomy ties (device that wraps around the neck to keep the tracheostomy tube in place), and with the same gloves, cleaned the stoma (area around the tracheostomy insertion site) and applied new gauze dressing. RT5 then opened a package containing the inner cannula for the tracheostomy tube and replace the old one while still wearing the same gloves used when entered room.On 09/05/25 at 07:22 AM, an interview was conducted with Respiratory Therapist Manager (RTM) by the first-floor elevators. RTM confirmed that staff are supposed to change their gloves and perform hand hygiene after removing old dressing and before applying new dressing and before handling clean or non-contaminated items like gauze and new inner cannula for the tracheostomy tube.Review of facility policy titled Disposable Inner Cannula stated, . [NAME] Clean gloves . if suctioning is needed, suction the resident . [NAME] clean gloves, unlock the inner cannula and remove it gently . Discard inner cannula . Remove and discard gloves. Perform hand hygiene and don a new set of gloves. Insert the new cannula .

Based on observation, interview, and record review, the facility failed to promptly, within three days, refer a resident with lost dentures for dental services for one [Resident (R) 150] of two residents sampled for dental services. As a result, R150 did not obtain the option or consult of denture replacement, and her dietary order was downgraded.Findings Include: On 09/02/25 at 09:22 AM, an observation and interview were conducted with R150. R150 reported that her dentures were stolen and needs a new pair. She could not recall how long her dentures have been missing, only that it has been a while. She stated she had informed the facility about the loss and was told the dentist comes to the facility. She has been waiting for a dentist to come for a replacement. R150 explained the missing denture has been affecting her ability to chew while eating. An observation of her room and R150 confirmed the absence of her upper denture.Review of R150 inventory list confirmed R150 had upper dentures upon admission to the facility on [DATE].Review of R150's nutrition/dietary note on 04/22/25 documented Per resident, difficulty chewing foods d/t [due to] dentition. Resident is agreeable to downgrading diet texture to chopped per preference.On 09/05/25 at 08:09 AM, a concurrent record review and interview were conducted with Director of Dietary Services (DDS) 2. When asked about the nutrition/dietary note dated 04/22/25, DDS2 stated the note was entered by DDS1. DDS2 recalled R150 dentures were missing, and resident was agreeable to the downgraded diet texture as a result. DDS2 reviewed R150's admission nutrition assessment, which indicated the resident had top dentures, good dentition, and was receiving a regular diet with no issues chewing. DDS2 was unable to locate any documentation in the Electronic Health Record (EHR) regarding the status of R150's dentures or whether a dental appointment had been scheduled. At 08:24 AM, DDS2 contacted DDS1 by phone. DDS1 reported the Unit Manager, Nurse Supervisor (NS) 2, had informed him in person that R150 was missing her dentures and requested an evaluation of the resident's current diet texture.On 09/09/25 at 09:24 AM, an interview was conducted with NS2. NS2 stated R150 informed her that her dentures were missing. During clinical stand-up, NS2 relayed this information to DDS1 and requested an evaluation of the resident's current diet texture. NS2 reported that prior to learning the dentures were missing, she was not aware that R150 had dentures, and no other staff had previously informed her that her dentures were missing. NS2 also confirmed that no dental referral or appointment was made after she became aware of the missing dentures and there was no further documentation of the status of R150's dentures in the EHR.Review of an email sent on 05/19/25 documented NS2 requesting assistance from the Director of Nursing (DON) and Assistant Administrator (AA) in obtaining dentures for R150. The email documented R150 .arrived to facility with upper dentures which are now missing .[R150] .stated she wanted to take care of fixing her dentures. I'm unsure of process to fixing a replacing . Review of the facility's policy and procedure Dental Services revised on 08/2017 documented If dentures are damaged or lost, residents will be referred for dental services as soon as possible within 30 days. Documentation will be provided regarding what is being done to ensure that the residents is able to eat and drink adequately while awaiting the dental services.

Based on interview and record review, the facility failed to support the resident's right to voice a complaint without the fear of reprisal or retaliation for one resident (Resident (R) 31) sampled. R31 reported an allegation of mistreatment by the Alleged Perpetrator (AP) to the Assistant Administrator (AADM). Initially, R31 reported he did not want to file a formal grievance due to being fearful what AP's reaction would be, and that R31 would not receive assistance from staff, or care would be withheld. During the facility's investigation, the facility informed R31 and AP that there should not be any form of contact between the two individuals. R31 informed AADM that despite this instruction, AP went into the resident's room and confronted him in a manner which made him feel fearful, intimidated, and unsafe. During an interview, R31 stated he did not feel that the facility could keep him safe from retaliation by the AP. As a result, R31 felt anxious, fearful, unsafe, hypervigilant causing loss of sleep, and experienced a new onset of nightmares in which he was violently defending himself from AP. R31 confirmed he does not usually have nightmares. AADM did not identify R31's allegations as potential abuse and did not investigate R31's allegations or report the incident to the appropriate state and federal agencies. As a result of this deficient practice, R31 experienced psychosocial harm as evidenced by new onset of nightmares, hypervigilance, anxiousness, and being fearful of retaliation by AP which interrupted the resident's sleep patterns. All residents receiving care by AP have the potential for harm. Findings include: (Cross Reference to F600, F609, and F610) Review of the facility's policy and procedure, Grievance/Complaints: Recording and Investigating documented 9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegation. All alleged violations of neglect, abuse, and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect, and misappropriation of property, as per state law. R31 is a [AGE] year-old resident, who was admitted to the facility on [DATE] for physical and occupational therapy to improve the resident's level of functioning. R31's diagnoses include sepsis, cellulitis (skin infection that appears red and swollen) of upper limb, hypertension, a history of falling, and a need for assistance with personal care, weakness, and unsteadiness on feet. Review of R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C. Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information. Section GG- Functional Abilities and Goals documented the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands). During an interview with R31 on 08/12/24 at 10:06 AM, the resident stated he did not feel safe in the facility. Asked R31 why he did not feel safe, R31 explained he reported an incident to AADM of AP's treatment of the resident when the resident requested assistance with the air conditioner on one occasion, and pain medication on another. R31 reported, I didn't want to cause a problem with staff (AP), I just wanted him to treat me better. I felt like staff [AP] was already kind of aggressive towards me. R31 stated AP told the resident, What the fuck do you want now, when he answered my call light. Then he [AP] told me if I kept pressing the call light, he was going to take it away from me. He [AP] was irritable and snappy with me, but I was new to the facility, and I thought that's what the call light was for. If I needed something, I call for staff, instead of getting out of bed by myself. I'm not sure how long I have to be here, and if he [AP] treated me bad before I complained, I could only imagine how he would treat me if I filed a grievance. The resident explained after he complained to AADM about how AP treated him, AADM assured him that AP would not be taking care of him any longer and should not have any contact with him. Despite instructions not to have contact with the resident, R31 reported AP went into his and confronted him about reporting AP to management, stating, You got a problem with me? in an intimidating tone while the resident was alone in the room, laying on the bed. R31 informed AADM that AP came into his room and confronted him about complaining to management. R31 reported to AADM that he did not feel safe and elaborated that he cannot defend himself against AP should the staff member decide to do something to him. R31 stated that he was scared of AP and requested to move rooms to get away from him. Surveyor inquired if R31 knew, or if AADM updated him on the outcome of an investigation into AP confronting him after he complained to the facility. R31 confirmed he did not know of, and was not informed of an investigation into AP confronting him. R31 stated, After I moved [rooms], I started having nightmares and I feel anxious that AP could just come into my room when I'm sleeping or by myself and do something to me. Asked R31 about the nightmares he was having. R31 reported the nightmares were violent dreams about the resident having to defend himself or fighting AP, and that he would wake up because he was yelling and upset in his dream. R31 reported it is unusual for him to have nightmares or violent dreams, but he started having them after AP entered his room and confronted him about complaining. While speaking with this surveyor, R31 was visibly upset. His eyes welled-up with tears, and he required pauses in the interview to regain his composure. The tone and rate of his voice was shaky, and he cried at one point of the interview. R31 expressed he was spontaneously waking up throughout the night with a feeling of AP's presence in his room. Inquired if he informed the facility about how he was feeling and about the nightmares he was having. R31 responded he did not tell the facility because they (facility management) could not keep him safe the first time he reported AP's behaviors, and he feared AP could retaliate again and/or harm him. On 08/14/24 at 11:10 AM, conducted an interview with AADM and the Administrator regarding R31's incident(s) with AP. Informed AADM and Administrator of R31's interview with this surveyor, and asked for the facility's account of the incident(s) between AP and R31. AADM confirmed that during a meeting which included AP and the Director of Nursing (DON), AP was informed of the initial complaint, and told that he was not allowed to have any contact with R31. The Administrator stated she was not aware that AP had confronted R31 after being instructed to not have contact with him. AADM reported he followed up on the initial complaint with R31, and that R31 did inform him that AP confronted him in his room after being instructed not to have contact with him. Inquired if the facility investigated R31's report of AP confronting and intimidating him for the potential of abuse. AADM confirmed no other investigation was initiated following R31's report of AP confronting him. AADM also confirmed he had not identified the incident as potential verbal abuse, retaliation, and/or intimidation. AADM stated it was not identified as potential verbal abuse, retaliation, and/or intimidation because R31 did not file an official grievance when the resident first reported AP. Inquired if AADM asked R31 why he did not want to file an official grievance. AADM responded he did not ask R31 why he did not want to file an official grievance, but he [AADM] filled out the grievance form as a complaint on the resident's behalf. On 08/14/24 at 01:48 PM, conducted an interview with Social Service Director (SSD) regarding R31's allegations. SSD stated she normally handles the resident's complaints and grievances; however, she was on leave during this time and had not been informed of R31's allegations. SSD confirmed no investigation was conducted into the resident's report of AP confronting the resident after complaining about staff's treatment of the resident and it was not reported to the state agencies. SSD stated at the time of the incident, AADM was acting as the Grievance Officer. After SSD was informed of R31's allegations, she confirmed AP should have been placed on leave after R31 reported he confronted the resident, while a formal investigation was completed to ensure the resident's safety. At 03:00 PM, SSD reported R31 was interviewed regarding the incident, and her interview with the resident was consistent with this surveyor's resident interview. SSD stated she would be conducting a formal investigation of R31's allegation of verbal abuse and intimidation by AP. On 08/14/24 at 01:49 PM, conducted an interview with the DON regarding AP confronting R31 regarding the his complaint of AP's treatment of him. During the interview, DON stated an investigation was conducted into R31's allegations. Requested to review the DON's full investigation complete with witness statements. DON initially stated the investigation was in the Human Resource office and did not provide any documentation on 08/14/24. On 08/15/24, the DON submitted typed, Timeline of Events 7/31/24 which documented Resident had a care concern for the attitude of a night shift CNA [Certified Nurse Aide (AP)] and gave him [R31] attitude about turning up the temperature . Union Meeting held . on 08/02, and included an unidentified staff member (no ledger on form) reporting that CNA48, CNA2, and Registered Nurse (RN)11 did not report anything related to the incident on 07/31/24. The investigation notes did not address AP confronting R31, and intimidating him after finding out the resident had filed a complaint.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment. The facility did not remove any of the resident meal trays (an institutional characteristic) after serving residents in the dining room. This deficient practice affects all residents dining in the dining areas. Findings include: On 08/12/24 at 11:55 AM, conducted a dining observation of twelve (12) residents eating lunch in the main dining room on the 1st floor. All 12 residents' meals remained on the meal trays. Inquired with Resident (R)138 and the resident's Family Member (FM)1 if it was their preference for the resident's meal to remain directly on the tray for the entirety of the meal. FM1 reported that they were not given the option to have the food taken off the cafeteria style trays, staff just always leave it on the trays. Inquired with Dining Staff (DS)3 regarding residents' meals being served and remaining on the cafeteria style tray throughout the meal service. DS3 confirmed all the residents dining in the 1st floor dining room have their meals on the tray. Asked if the residents' preference is to have the meal remain on the cafeteria style tray. DS3 confirmed he/she is unaware of the residents' preference if they want their food to remain on the trays or not and stated, This is just how we always do it. Review of R138's care plan (last reviewed 05/01/24) did not contain documentation that the resident preferred to have his meal plate remain on the cafeteria like trays while eating in the 1st floor dining room. 43414 2) On 08/12/24 at 12:19 PM, observed five residents in a common dining room area eating lunch with their meals on top of a meal tray that was not removed when the meal was served. A second observation was done on 08/14/24 at 08:10 AM, observed three residents in a common dining room area eating breakfast with meals on top of a meal tray that was not removed when the meal was served. On 08/15/24 at 11:27 AM, an interview with Registered Nurse (RN) 40 was done. Inquired if RN40 eats on meal trays when at home, he stated he does not but uses a place mat. Further inquired if he does not use meal trays when eating at home, would it be a homelike environment for residents in the dining room to eat with meal trays, RN40 stated, .it would seem it would not. On 08/15/24 at 11:29 AM, an interview with Assistant Administrator (AADM) was done. AADM reported he does not eat his meals with meal trays at home. Inquired if it would be homelike for residents to use meal trays when eating their meals in the dining room at the facility, AADM stated it depends on the resident and if they prefer to eat with meal trays. Further inquired if this would be in resident care plans, AADM reported it should be in their care plan.

Based on observations and interviews, the facility failed to ensure posted nurse staffing information was in clear and in an identifiable and prominent place. As a result of this deficient practice, residents and resident representatives are not informed of the number of staff available for resident care. Findings include: 1) On 08/13/24 at 10:55 AM, conducted observations of daily staff posting at the entrance of the building and on all four (4) units. Near the entrance of the building, after the screener's station, Daily Staff Posting is posted on a bulletin board along with the employee clock in/out system, a Stay up to Date with your Covid Vaccine poster, Cover your Cough poster, August 2024 Employee Calendar, Mandatory CNA (Certified Nurse Aide) Meeting, and a list of employees who need to see the Director of Nursing (DON) prior to starting the shift. The 24-hour-Daily Staff Posting form was printed on what appeared to be an 11-inch (in) x 13 in paper. The print was small, and this surveyor was unable to clearly read the form until standing approximately two (2) feet away from the form. There was no larger sign clearly indicating the form was the 24-Hour-Daily Staff Posting. A visitor approached the main exit doors and this surveyor inquired if she knew where the daily staff posting was located. The visitor confirmed she did not know where it was despite standing approximately 3-4 feet away from the posted form. On each of the four units, the names of the staff working are written on a dry erase board which is set in the back of the nurses' station, over 10 feet from the entrance to the nurses' station. The entrance of the nurses' station is noted by a high counter/desktop, which is where any resident or visitor would be stopped prior to entering the nurses' station. The dry erase board was difficult to identify the location the units were listing, or the individual staffing census. On 08/14/24 at approximately 02:10 PM, inquired with the Director of nursing where the daily staffing information was posted. DON confirmed daily staffing is written on the whiteboards on each unit and at the entrance of the building. Informed DON on initial observation, the listing was not identifiable or highly visible when entering into the building due to the form being posted on the employee notification board, it appears like information for staff. On 08/15/24 at 11:37 AM, observed Resident (R)315 and multiple family members (FM), walk past the nursing station at a slow rate, then into the resident's room. Inquired with FM99, who was a young adult male (25-[AGE] years old), confirmed he does not need or use glasses and has great eyesight, if he was aware where the daily staffing was posted for the unit and for the facility. FM99 confirmed he has never seen any daily staffing form or information, and stated, Nope, I don't know where it is, and staff never told me where it was at. At 11:40 AM, inquired with R138's FM if she knew where the facility's daily staffing information for R138's unit and for the entire facility was located. FM confirmed she did not know where that information was and has never seen the form. 43414 2) On 08/12/24 at 08:24 AM, during an initial observation of Unit 3, the daily nursing staffing posting with total number and actual hours worked per shift for nursing staff responsible for resident care was not found.

Based on observations, interview, and record review, the facility failed to store and serve food in accordance with professional standard for food service safety. This deficient practice has the potential to place facility residents at risk for food-borne illness. Findings include: 1) A concurrent observation and interview were conducted on 08/12/24 at 08:27 AM in the facility kitchen. One of the refrigerators contained a container of rice porridge with a discard date of 08/11/24. Dietary Director (DD) stated that it should have been discarded since the kitchen staff performs audits twice a day. Review of the facility policy titled, Food Receiving and Storage, with a revised date of 10/2017, was conducted. The facility policy documented, Food shall be received and stored in a manner that complies with safe food handling practices. 2) Concurrent observation and interview were conducted with the Dietary Aide (DA) 1 on 08/12/24 at 08:53 AM. DA1 was observed checking the dishwasher sanitizer with a quality assurance strip. When asked if she logs the results, DA1 stated that kitchen staff only logs the temperature for the dishwasher and there was no log for checking the dishwasher sanitizer. Interview was conducted on 08/12/24 at 01:28 PM with DD. DD confirmed that the facility did not have a log for the dishwasher sanitizer quality assurance checks. A review of the facility policy titled, Dishwashing Machine Use, with a revised date of 03/2010, was conducted. The facility policy documented, A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log.

Based on interviews and record review, the facility failed to protect Resident (R)52 from physical harm. Facility Staff (FS)7 confirmed pulling R52's right arm to repositioned in bed, no other staff were present at the time. Immediately after pulling R52's arm the resident reported pain and swelling to his/her right shoulder as a result of the incident. R52 was assessed by nursing staff which also noted redness to the resident's right shoulder. X-ray results confirmed R52 sustained a subluxation (partial dislocation) of the right (R) shoulder. R52 experienced pain and a decline in the resident's mobility ability which affected the resident's ability to achieve and maintain her highest level of physical well-being and had a decline in functional status. All residents requiring staff assistance for repositioning are at risk of this type of unintentional abuse if residents are not handled in a safe manner to prevent injury. Findings include: (Cross Reference to F609 Reporting an Allegation on Abuse/Neglect/Misappropriation; F610 Conducting a Thorough Investigation; and F676 Maintain Abilities) The definition of Willful as defined at 485.5 in the definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The definition of Abuse as defined at 483.5 as the willful infliction of injury with resulting physical harm, pain, or mental anguish Review of a Facility Reported Incident (FRI) in the Aspen Complaints/Incidents Tracking System (ACTS) #10193 initial report was reported to the State Agency (SA) on 03/30/23 at 01:35 PM via email, Resident was being repositioned in bed by staff CNA (FS)4. Staff pulled on resident's arm to straighten her position in the bed and resident reported pain in the rt (right) shoulder. X-ray ordered, report received 3/29/23 and x-ray shows subluxation of Rt shoulder with chronic rotator cuff tear, advanced osteopenia, and mild osteoarthritis of the AC joint. Ortho consult ordered, ortho unable to accommodate in person timely appointment, resident sent to ER for treatment on 3/30/23. Investigation was initiated. The facility's completed report for ACT#10193 was reported to the SA via email on 04/04/23 documented, On 3/28/23 Resident was being repositioned in bed by staff CNA. Staff pulled on the resident's arm to straighten her position in the bed and resident reported pain in the rt shoulder. A portable X-ray was obtained, and the facility received the report on 3/29/23 which shows a subluxation of resident's Rt shoulder and Abuse or neglect was ruled out. Facility provided re-education of staff member regarding using a draw sheet and 2 person assist for repositioning resident. 1:1 education provided. Staff has verbalized understanding of need to use draw sheet and 2-person assist. Upon follow up she has returned demonstration of appropriate method of transfer. On 08/08/23 at 11:05 AM, conducted an interview with R52's Family Member (FM)2 via telephone regarding the incident. FM2 reported he/she was aware of the incident and prior to FS7 pulling on the resident's arm to reposition the resident, R52 was walking and there was a possibility that the resident would be able to leave the facility. But since the incident, R52's ability to walk has been affected and stated that R52 has reported pain to him/her. R52 had used a walker for assistance but due to pain, loss of strength, loss of the ability to raise his/her arm above the head, or bear weight with the right (R) shoulder R52 has not been able to walk and is not receiving services to help the resident regain mobility. FM2 reported R52 has not walked since the incident and is concerned that R52's issues is not being properly addressed. Observations of R52 conducted throughout the survey (08/07/23 at 09:28 am, 10:45 AM, 12:07 PM, 01:45 PM; 08/08/23 at 08:35 AM, 09:20 AM, 10:15 AM, 12:45 PM, and 02:15 PM; 08/09/23 at 08:00 AM, 08:53 AM, 12:12 PM, and 01:17 PM; and 08/10/23 at 09:00 AM and 10:35 AM) observed R52 lying in bed on his/her back. Resident was alert and orientated to person, place, time, and situation. During the observation on 08/10/23 at 09:00 AM, R52 reported that FS7 pulled on her arm to reposition the resident and immediately felt pain and was unable to move his/her arm. R52 then called FM2, who in turn called the unit nursing station and reported the incident to nursing staff. R52 stated the facility did an x-ray that day then 2 days later he/she went to the hospital because the doctor appointment was too far away. R52 confirmed that since the incident the resident has not been able to lift his/her right arm and has not walked because he/she cannot use a walker. R52 then attempted to lift the right arm and stopped immediately due to pain, observed R52 tightly squeezed both eyes shut and wince in pain and observed that the resident was not able to lift his/her right arm off the bed. Inquired with R52 if the resident had received rehab therapy since the incident to help regain functioning. R52 confirmed that although he/she would like to have therapy the resident has not received services for the partial dislocation. Inquired if the resident has pain related to the injury. R52 confirmed having pain. On 08/10/23 at 12:40 PM, conducted a concurrent interview and record review of R52's Electronic Health Record (EHR) with the Director of Rehab Services. DRS reviewed R52's EHR and stated R52 is currently not receiving services, the facility had requested for approval for rehab services with the resident's insurance, but the request was denied. Inquired if R52 was referred for restorative services. Review of records documented on 01/03/23, R52 sustained an acute distal fracture of the right wrist and an x-ray report of the right shoulder documented There is no radiographic evidence of acute fracture or dislocation. The humeral head and neck as well as the clavicle and scapula are intact. Visualized lung and parenchyma is clear. The bony mineralization is mildly decreased. Mild narrowing of Gleno-hemeral joint space and AC joint. DRS was unaware that R52 has sustained a right wrist fracture and further confirmed that staff should not have been pulling on the resident's arm to reposition the resident. DRS reviewed a physical therapy progress note, on 02/01/23, which documented R52 had been walking up to 100 feet with minimal to no assistance prior to the partial dislocation of the resident's right shoulder. Reviewed all x-ray results (from 01/03/23, 02/28/23, and 02/30/23) DRS confirmed the impression of the presence of a chronic rotator cuff tear was not documented on the 01/03/23 and the impression of injury or chronic injury to R52's right shoulder was only documented after FS7 pulled on R52's arm resulting a partial right shoulder dislocation which can go back into place without interventions. On 08/10/23 at 01:29 PM, conducted an interview with the Administrator, Assistant Administrator (AA), and the Director of Nursing (DON) regarding FRI #10193. The DON confirmed she had conducted the investigation for the incident and abuse was not substantiated because when FS7 pulled R52's arm he/she did not intend to hurt the resident. This surveyor reviewed the definition of willful and abuse the Administrator, AA, and DON further explaining that although FS7 stated he/she did not pull R52's arm to hurt the resident, but FS7 did know that by pulling on R52's arm the resident could be injured and knowing this and not by not adhering to the professional standard of practice, still chose to pull the resident's arm to reposition. After further clarifying the definition of willful the Administrator and DON confirmed understanding that the intent of the action does not negate knowing the potential outcome could result in harm and still affect other residents. The DON stated that the facility did not identify the incident as abuse because the staff involved in the incident was apologetic about the incident and did not intentionally hurt the resident. As a result of not identifying the incident as abuse, the facility did not remove the staff from the floor to ensure knowledge and teaching of the professional standard of practice for repositioning residents would be implemented and did not meet the timeframe of reporting or completing a thorough investigation within two hours.

Based on record reviews and interviews, the facility failed to provide the required care and needed treatment for one resident, whose family prefers to be anonymous, (RA), out of a sample of 36 residents. This deficient practice resulted in the potentially avoidable death of RA and could pose harm to other residents who have complex medical conditions. Finding includes: Record review of the Intake Information document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10464. RA was admitted to the facility in August 2022 for rehabilitation, did not improve with rehabilitation, and was transferred to long term care. RA's health status significantly declined and needed to be emergently transferred to the emergency room (ER) on 12/06/22. RA was admitted to an acute care provider with a diagnosis of pneumonia (an infection in the lungs) and passed away two days later. Record review of RA's electronic health record (EHR). Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/05/22 revealed that RA was admitted to the facility on [DATE] from a hospital. RA had the following medical diagnoses: irregular heart rate, heart failure (a weakened heart that cannot supply the body with enough oxygen), an active cancer (multiple myeloma) of a type of white blood cells (WBCs) that produce antibodies to help the body fight off infections, an anemia (low blood cell count) where the bone marrow cannot produce new WBCs, red blood cells (RBCs, provides oxygen to all cells in the body), and platelets (helps to clot and stop bleeding). RA received chemotherapy and transfusions while hospitalized . Read the discharge summary from the hospital filed on 08/31/22 at 08:44 AM. R378's physician agreed to hold RA's chemotherapy regimen while RA received short-term rehabilitation (STR) at the long term care facility. Record review of progress notes revealed a Incident Note documented on 10/14/22 at 02:39 PM by a nurse that described a fall that RA sustained. RA was found on the floor by a nurse's aide with the wheelchair located close to his head. RA stated that he fell out of his wheelchair because he fell asleep from feeling tired after receiving physical therapy. A General note documented by a nurse on 10/17/22 at 02:59 PM stated that RA required a blood transfusion on 10/17/22 and was transferred to an acute care provide to receive the blood transfusion. Nutrition/Dietary Note documented on 10/19/22 at 01:44 PM by the Registered Dietitian (RD) revealed that RA progressively lost weight. On 09/21/22, RA weighed 144 pounds and on 10/17/22, RA weighed approximately 126 pounds. Health Status Note documented on 10/30/22 at 01:31 PM by a nurse, stated that while RA sat up in a wheelchair visiting with his family, RA complained to his family that he did not feel well and was assessed by the nurse to be pale and complained of dizziness (symptoms of low blood pressure). A General note documented on 10/31/22 at 03:31 PM stated that RA had blood pressure (BP) changes while changing his position. RA's BP while lying down was 132/86 mmHg (milimeters of mercury) (normal BP is 120/80 mmHg) and sitting BP was 76/49 mmHg (normal is 120/80 mmHg). RA's medical doctor (MD)1 was notified but no directive was given. Nutrition/Dietary Note documented on 11/21/22 by the RD revealed that RA weighed 122 pounds on 11/05/22. Nutrition/Dietary Note documented by the RD on 12/05/22 at 11:30 AM stated that RA refused to eat and had continued nausea with vomiting despite the use of an antiemetic (medication used to treat nausea and vomiting). There was no documentation by a nurse between the dates of 11/29/22 through 12/05/22 leading up to the following situation. Read SBAR [situation, background, action, and response] progress note documented on 12/06/22 at 11:45 AM. It stated that RA was to be transferred to the hospital for RA's complaints of weakness and needed further evaluation and treatment of low blood pressure. Record review of the physician's progress notes. On 10/14/22, MD1 documented that RA had a fall and that his fluid status was stable. On 10/18/22, MD1 documented again that RA's fluid status was stable, in addition to Monitor weights. Anemia [low blood count] monitor Plan of care. On 11/01/22, MD1 documented that RA was doing well with a stable fluid status, . Monitor weights. Hypertension [high blood pressure]. Blood pressure levels have been within normal limits . MD1 documented on 11/22/22 and 11/30/22, . Continue present therapy to maintain current health status . On 08/10/23 at 10:39 AM, conducted a phone interview with MD1. MD1 stated that RA's diagnosis of multiple myeloma had associated conditions of low blood count, malnutrition, and a compromised immune system that could render RA susceptible to infections. Laboratory blood counts should be done frequently. Intravenous fluid (IVF) would have been given if RA's blood pressure was below 80, but was cautious to do so because of RA's diagnosis of heart failure. On 08/10/23 at 11:31 AM, interviewed Unit Manager (UM)1 in her office. UM1 stated that if a resident had low blood pressure, laboratory and medication checks should be done, in addition to conferring with the physician. A resident's problem with malnutrition and/or low blood pressure would be assessed for the possible cause as the resident could have an infection. A problem with orthostatic hypotension would require the interventions of checking blood pressures in different positions (lying, sitting, and standing), to closely monitor the resident if he/she is sitting up, and other safety measures. The resident's care plan should be revised for any new problem identified as it drives the care and treatment the resident should receive. Record review of RA's care plan with last care plan review date of 09/28/22. There was no personalized problem with associated care interventions identified for RA's active cancer (multiple myeloma) that wasn't currently treated with RA's chemotherapy regimen and associated conditions of anemia, malnutrition, and high potential for infection. There was no problem for RA's orthostatic hypotension identified, in addition to the needed interventions for personalized treatment and care. RA's problem of ongoing malnutrition was not addressed and therefore, there were no personalized care interventions to treat this condition.

Based on observation, record review (RR), and interview, the facility failed to ensure one resident (R)41 in the sample received the appropriate treatment and services to prevent pressure-related skin conditions from occurring. This was evidenced by a stage II (a shallow, open sore) pressure ulcer (PU) on R41's ischium (lower back portion of his hip bone), and a deep tissue injury (DTI), or a closed pressure sore with signs of underlying tissue damage, on his left ear. Despite the resident being identified as at-risk for pressure ulcer development upon admission, and multiple interventions being incorporated to prevent them, the facility failed to ensure those interventions were consistently implemented. This deficient practice has the potential to affect all the residents at the facility. Findings Include: R41 was a [AGE] year-old admitted to the facility on [DATE] for long-term care services following a traumatic motor vehicle accident where he suffered a subdural hemorrhage (bleeding that occurs between the brain and its outermost covering, that is usually caused by a severe head injury), and numerous fractures (broken bones), resulting in complete paralysis from the neck down. R41 was hospitalized for a week on 03/10/21 and was readmitted to the facility where he has remained since 03/17/21. On 04/07/21 at 02:00 PM, an observation was done of R41 in his room on the Ventilator Care Unit (VCU). R41 was observed lying on his back in bed with his head all the way left, bent at the neck in an almost 90-degree angle. R41 had a gray u-shaped cervical pillow around his neck, however it was not providing any support for the left side of his head. An intact, purple, scabby ulcer was visible, approximately one inch in length, to the left antihelix and antihelical fold (outer edge of ear flap) of his left ear. There was a small purple egg crate pillow with a hole in the center noted above R41's head. On 04/08/21 at 09:51 AM, an observation was done of R41 in his room on the VCU. R41 was observed lying on his back in bed with his head positioned all the way left, bent at the neck in an almost 90-degree angle. The gray cervical pillow was loosely placed around his neck, providing no support, and the purple egg crate pillow was sitting on his chest. Certified Nurse Aide (CNA)10 and CNA11 entered and re-positioned R41 to his left side, taking the purple egg crate pillow and positioning it under R41's left hand. On 04/08/21 at 10:15 AM, an interview was done with Facility Staff Member (FS)24 at R41's bedside. FS24 confirmed that R41 had a newly acquired PU to his left hip and a DTI to his left ear. FS24 stated that the CNAs, who had all started in the facility less than two weeks earlier, had not been turning, re-positioning, or changing any of the residents as they should. FS24 then took the purple egg crate pillow from under R41's left hand and positioned it under his left ear, stating that the pillow had been ordered by the physician a couple days ago when the DTI was first noticed, and that she frequently had to re-position it to its correct spot. On 04/09/21 at 11:30 AM, an interview was done with FS27 at R41's bedside. FS27 demonstrated that R41's head cannot physically be lifted from the extreme left-hanging position more than thirty degrees due to contractures in his neck. FS27 explained this was why it was so important to position him properly with his support devices appropriately placed. RR of R41's Weekly Wound Assessment, dated 04/07/21, noted a DTI to R41's left ear, documented as acquired on 04/06/21, and a stage II PU on his right ischium, documented as acquired on 04/05/21. RR of R41's Comprehensive Care Plan, last updated on 03/17/21, noted identification of potential for pressure ulcers, self-care performance deficits, limited physical mobility, and actual skin impairments, with corresponding goals and interventions. Specifically, the intervention of turn and reposition every 2 hours was noted repeatedly. A review of R41's POC (Point-of-care) documentation for turning and repositioning notes that for 04/07/21, R41 is documented as being positioned to his left side seven out of the nine times a turn is documented, and twice out of those nine times he was positioned to his right. On 04/08/21, turns are documented a total of six times in twenty-four hours, three to his left side, one to his right side, and twice to his back. Further review of R41's Comprehensive Care Plan revealed that the new stage II PU and DTI, along with the order for the purple egg crate pillow were not added to the care plan.

Based on observations, record review, and interviews, the facility failed to ensure the resident's environment remained free from accident hazards and residents received adequate supervision and assistance to prevent accidents. As a result of this deficiency, as evidenced by for R75, who's wheelchair was placed in a position that restricted the resident from freely moving, adequate supervision was not provided and hot water temperatures were not checked after repair work was completed and were found to be unsafe for the residents, staff and visitors. Findings Include: 1) Cross Reference to F604 Observations on 03/09/21 at 09:50 AM, 03/10/21 at 09:00 AM, 03/11/21 at 09:18 AM and 4:35 PM, and on 03/15/21 at 08:00 AM) were made of R76 in the unit's common dining area seated in a wheelchair at a table which was not near the nurse's station. R76's wheelchair was positioned between a table and a wall on the unit's main dining are. The positioning of R76's wheelchair prevented R76 from moving the wheelchair in any direction or freely standing. The handlebars on the back of the wheelchair were approximately one inch away from the wall making impeding the wheelchair from backward movement and the front of the wheelchair was approximately two-three inches away from the table impeding R76 from standing for moving the wheelchair forward. Observed R76 grabbing the side of the table and attempting to stand, however, the table was too close to R76 and stopped her from fully standing, R76 was not engaged in any activities and there were no staff was in the immediate area. Conducted a record review (RR) of R76's electronic medical record. R76's care plan, last reviewed on 02/12/21, documented R76 is a high risk for falls and serious injury related to severe cognitive impairment which presents with confusion, forgetfulness, and impaired safety awareness due to Dementia, [CONDITION(S)] and adverse effects of multiple [CONDITION(S)] medications. R76 had two (2) unwitnessed falls, on 04/21/20, R76 fell in the shower which resulted in an admission to an acute hospital for a left femur fracture and underwent an Arthroplasty (surgical replacement of the joint) and on 11/28/20 which the resident had redness to the left side of her head. Interventions documented in the care plan includes for staff to ensure R76 is by nurse station while in wheelchair and frequent check while at nurse station due to frequently stand up and sitting. Both of those interventions were not implemented for R76. On 03/15/21 at 12:36 PM, conducted an interview with the Unit Manager (UM)3 regarding observations of R76' wheelchair wedged between the wall and the table. UM3 confirmed the placement of R75's wheelchair (wedged between a table and wall), medical diagnoses of dementia with Lewy bodies, and severe cognition impairment with [CONDITION(S)] placed R75 at a higher risk of experiencing an avoidable accident. 2) A modified resident council meeting was conducted on 03/10/21 at 09:58 AM. R4, R14, R27, R72, R94, and R118 were in attendance. R118 stated that the hot water was hot on the second floor where he resided. Few of the other residents who resided on either the first or second floors concurred with him. On 03/12/21 at 08:11 AM, surveyor called LM and requested the facility's water temperature logs. He stated that he would look for their logs. Surveyor queried as to who was the maintenance director and he stated that the Administrator was their department leader. On 03/12/21 at 08:22 AM, surveyor spoke to the Administrator and he stated that LM will meet with the surveyor after he sets up for resident's visitations. While waiting for LM on Unit Two, surveyor queried RT3 at 09:17 AM regarding the facility's hot water. She stated that she turns on both the hot and cold water for a tolerable hot water temperature. At 03/12/21 at 09:41 AM, surveyor met with LM in room 129 of Unit Two. He stated that he could not find the facility's water temperature logs. He then proceeded to turn on the hot water. Steam could be seen coming from the sink. LM placed his temperature probe into the hot water stream and the digital reading displayed 71.9 C (71.9 degrees Celsius or 161.4 degrees F). Surveyor and LM went to room 136 of the same nursing unit to check the hot water. LM's temperature probe displayed 129.5 degrees F. LM stated that the circulating pump for the water had been broken and was fixed three weeks ago. He had been doing water temperature checks but was not logging them. He stated that the boiler for the water is on the roof so the hottest water would be on the second floor and water going down the center of the nursing units. The hot water would become cooler as it flowed away from the center. On 03/12/21 at 09:51 AM, the hot water was checked in room 115 of Unit One. The temperature probe read 128.3 degrees F. On 03/12/21 at 11:10 AM, the State Agency (SA), Administrator and LM checked room 206's hot water temperature. It was verified to be 129.5 degrees F. The resident shower located on Unit Three registered at 116 degrees F. The Administrator stated that the mixing valve was adjusted approximately two minutes prior to checking the water temperature in room 206. He also stated that the initial setting temperature of the facility's boiler was set at 115 degrees F. On 03/12/21 at 11:56 AM, surveyor asked the Administrator for the facility's policy on Water Temperatures. On 03/12/21 at 12:15 PM, SA informed the Administrator and DON of an Immediate Jeopardy (IJ) situation regarding the facility's hot water temperatures. The Administrator was informed by SA that an abatement plan for this situation needed to be presented to SA by the end of the working day. On 03/12/21 at 4:40 PM a meeting with SA and the Administrator was held. The Administrator stated that on 03/02/21, a contracted service worked on the facility's water heating system and the cold-water supply was not turned back on after repairs were completed. Timeline/plan to remedy the facility's hot water temperatures on 03/12/21 was as follows: - At 3:00 PM, a plumber was called to assess and fix the situation. - At 4:00 PM, the plumber assessed the incident and found that the cold water connected to the mixing valve was turned off. He turned on the cold-water supply and adjusted the mixing valve and boiler settings. - The hot water heaters were purged to allow the hot water to escape from the system. - Temperature readings at 4:30 PM, taken in room 115 - 88 degrees F, room 129 - 88 degrees F, and room 136 - 88 degrees F. - The maintenance team is slowly adjusting the hot water temperatures until an ideal temperature of 110 degrees F is achieved. - A nursing assessment of residents in rooms 115, 129 and 136 were done and documented to verify that none of them sustained harm from the unsafe hot water temperatures. - A letter was given to the residents of the facility notifying them that repairs were being made to the facility's water system. - A meeting was conducted with the facility staff notifying them of the situation. SA accepted the facility's abatement plan and determined that it was operationalized on 03/12/21 at 5:00 PM. A final record of hot water temperatures taken in every resident room and resident shower rooms on 03/15/21 was reviewed on 03/15/21 at 2:30 PM. The hot water temperatures were verified to be less than 112 degrees. The facility's policy on Water Temperatures, Safety of revised in December 2009 was reviewed on 03/15/21 at 2:40 PM. It stated, 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F, or the maximum allowable temperature per state regulation.

Based on observations, interviews, and staff interviews, the facility failed to ensure the resident's right to be free from any physical restraint imposed for the purpose of convenience, and not required to treat the resident's medical symptoms as evidenced by Resident (R)76's wheelchair placed tightly between a table and wall, restricting the resident from standing up and staff applying a right-handed mitten on R16, restricting the use of the resident's hands without a doctors order or care plan. As a result of this deficiency, the residents are at risk of the potential for more than minimal harm and psychosocial harm to residents. Findings Include: 1) Cross Reference to F689 and F838 On 03/09/21 at 09:50 AM, observed R76 in a common dining area seated in a wheelchair at a table which was not near the nurse's station. R76's wheelchair was positioned between a table and a wall on the unit's main dining are. The positioning of R76's wheelchair prevented R76 from moving the wheelchair in any direction or freely standing. The handlebars on the back of the wheelchair were approximately one inch away from the wall making impeding the wheelchair from backward movement and the front of the wheelchair was approximately two-three inches away from the table impeding R76 from standing for moving the wheelchair forward. Observed R76 grabbing the side of the table and attempting to stand, however, the table was too close to R76 and stopped her from fully standing, R76 was not engaged in any activities and there were no staff was in the immediate area. On 03/09/21 at 10:00 AM, inquired with Registered Nurse (RN)6 regarding R76's wheelchair being tightly placed between the table and wall, and continuous attempts to stand. RN6 stated R76 does that. RN6 was asked to further clarify the statement and RN6 replied, R76 is always trying to stand, but the resident is confused and will fall. R76 observed seated in the wheelchair in the dining area until approximately 1:00 PM. This surveyor made a total of five observations (03/09/21 at 09:50 AM, 03/10/21 at 09:00 AM, 03/11/21 at 09:18 AM and 4:35 PM, and on 03/15/21 at 08:00 AM) R76 same position, seated in the wheelchair which was placed between a wall and a table, attempting to stand but was physically unable to due to her positioning, and not engaged in activities On 03/10/21 at 1:16 PM, two surveyors observed R76 positioned the same as described above, but this time R76 was frantically grabbing at the sides of the table, pulling at the tablecloth on the table while grabbing at the side of the table, and attempting to stand up. R76 appeared extremely distressed and frightened to both surveyors making the observation. Unit staff were assisting other residents and would occasionally go to the medication cart, which was in the line of sight or R76, prepare medications, then leave the area. Staff passing the main dining area did not stop to assess or help R76. Conducted a record review (RR) of R76's electronic medical record (EMR). R76's care plan, last reviewed on 02/12/21, documented interventions which includes that staff ensures R76 is by nurse station while in wheelchair, provide table in front with snacks or activity to utilized in keeping busy to divert attention, involve in activities that promote independence, frequent check while at nurse station due to frequently stand up and sitting, and ensure the table and chair are aligned due to poor balance when standing which were not implemented. Review of the physician orders did not document restraint orders. On 03/15/21 at 12:35 PM, conducted an interview with the Unit Manager (UM)3 regarding observations of R76' wheelchair positioned between the wall and the table which stopped R76 from freely standing. UM3 confirmed the placement of R76's wheelchair did prevent R76 from freely standing and restricted the resident's movement. Inquired if R76's wheelchair was positioned in that manner due to any medical condition. UM3 stated R76 did not have a medical condition which would require the resident's wheelchair to be placed in a manner which would restrict R76 from moving. UM3 stated R76 requires constant supervision which the staff are unable to accommodate and staff have a difficult time finding activities to keep R76 engaged due to R76's level of cognition. Inquired if R76 would benefit from the implementation of dementia care. R76 confirmed specific dementia care would benefit the resident, however, the resident does not have a detailed dementia program or interventions. On 03/15/21 at 2:51 PM, conducted an interview with the Director of Nursing (DON). Shared observations of position of R76's wheelchair and restricted ability to stand freely. The DON confirmed the positioning of the wheelchair did work as a physical restraint and the facility did not implement effective interventions related to R76's dementia care. 2) On 03/09/21 at 09:28 AM, an initial observation made of R16 in her room revealed that she had on a right-hand mitten restraint. R16 also presented with a [CONDITION(S)] (a surgically formed opening into the windpipe to allow breathing) through which she was receiving oxygen. R16 was alert and made eye contact with the surveyor. R16 began rubbing her back side to side on the bed. R16 made no discernable indication of yes or no when asked if she was okay. R16 stopped rubbing her back side to side. An observation of R16 was made again at 11:38 AM, the resident was resting in bed calmly with a right-hand mitten restraint applied. At 2:07 PM, R16 was observed to be sleeping in bed with the right-hand mitten restraint applied. Further observations done of R16 on 03/10/21 09:19 AM and on 03/11/21 08:16 AM revealed R16 was calmly resting in bed with the right-hand mitten restraint applied. A record review of R16's EMR was done on 03/11/21 at 10:19 AM. According to the Respiratory Service Note, R16 was able to decannulate the [CONDITION(S)] (remove the plastic insert maintaining the surgically formed opening to her windpipe) on 01/04/21, 02/12/21, 02/27/21 and 03/02/21. In the 01/04/21 note, the respiratory therapist (RT) recommended to the RN (registered nurse) and CNA (certified nurse assistant) the use of a right-hand mitten restraint to prevent R16 from decannulating her [CONDITION(S)] further. A continued record review revealed no care plan was documented outlining the safe use of the right-hand mitten restraint and needed resident monitoring. No limb circulation, movement, and sensation (CMS) nursing assessments of R16 and assessments of the right-hand mitten restraint were found in the EMR or medical record on Unit 2. No alternative methods prior to the use of the right-hand mitten restraint to prevent R16 from decannulating her [CONDITION(S)] was documented. No nursing pre-assessment of R16 was found to be documented before the continued application of her right-hand wrist restraint. The record review further documented R16 did not have a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/10/21, RN28 addressed the use of the right-handed mitten as a restraint and a consent from R16's resident representative/family member for the use of restraints was not obtained by RN28 until 03/11/21. An interview was done with RN3 on 03/11/21 at 10:50 AM at the nursing station of Unit 2. RN3 stated that there was no flowsheet done for monitoring R16 of right-hand wrist restraint and that the restraint is required to be released every two hours. A review of the facility's policy Use of Restraints was reviewed on 03/11/21 at 2:30 PM. Several violations of their policy were found: 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention . 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: .c. A resident placed in a restraint will be observed at least every (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s) 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. 19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of the physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets.

Based on observation, record review (RR), and interview, the facility failed to ensure one resident (Resident (R)25) in the sample received the appropriate treatment, equipment and services to prevent further decrease in range of motion (ROM) in his left hand, and in both feet. As a result of these deficient practices, R25 had lost the ability and strength to move the fingers and wrist of his left hand, resulting in loss of function, and both of his ankles can no longer bend, resulting in an inability for R25 to reach his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: Cross-reference to F825, F656, F657 R25 was a [AGE] year-old admitted to the facility on [DATE] for long-term care services following a C6-C7 (sixth and seventh cervical vertebrae near the lower part of the neck) spinal cord injury. On 03/09/21 at 02:51 PM, an observation was done of R25 in his room on Unit 1. Noted R25's fingers on both hands were contracted (a shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) and barely usable, with contractures to both wrist as well. Observed R25 repeatedly trying to flop his left hand onto the left side of his face, near his left eye. R25 eyes were red, brows drawn together, face scrunched together in a grimace, and was repeatedly calling out help and help me, while continuing to move left hand, in almost a hitting motion at his face. Licensed Practical Nurse (LPN) 3 entered the room at this time, approaching R25 as he called for help. R25 expressed frustration that his eyes were itchy, .especially my left ., and that he could not scratch them or rub them because of his contractures. On 03/10/21 at 10:12 AM, an observation and interview were done with R25 in his room, following wound care to his hips and sacrum (lower back). R25 observed with both feet in a resting position of extreme plantar flexion (toes pointing towards the foot of the bed). R25 stated he used to wear boots for his feet, a long time ago. Regarding his upper extremities, in addition to not being able to rub his eyes, R25 also complained of an untreated itch to the back of his neck that drives me crazy. R25 stated that he remembers being able to do more with his hands before he got here. Said now he cannot even grab or hold anything with his hands. When asked if he could press the flat, round, call light on his chest to call for help, R25 demonstrated that even that is difficult. R25 observed repeatedly trying to hit the call light with the medial surface of his left thumb. Out of five attempts to hit the call light, R25 was successful once. R25 stated that the call light must be in exactly the right spot on his chest for him to press it, but he is unable to move or place it there himself. On 03/11/21 at 09:21 AM, an interview was done with the Restorative Nurse Aide (RNA) 2 in front of the Unit 1 Nurses Station. RNA2 stated that he does passive ROM with R25's arms and legs daily. Said that there are no orders for hand splints, hand towels, or any support for contractures in hands or feet. Reported that R25's feet cannot dorsiflex (point toes straight up and move them back towards shin) any longer, too long they've [the feet] been like that, the joints, muscles and tendons in both lower legs have hardened. Although RNA2 can recall a time a while ago when R25 used to wear boots provided by physical therapy (PT) for his foot contractures, he stated that R25 has had so many readmissions and room changes, that the boots got lost. Even if a new pair were issued today, R25 would not be able to use them due to the advanced state of his bilateral (both sides) foot contractures. On 03/15/21 at 11:03 AM, an interview was done with the Director of Nursing (DON) in the second floor Conference Room. DON stated that R25 received occupational therapy (OT) services that addressed his upper and lower extremity contractures in July 2018 and [DATE]. He had not received further OT services since signing a refusal for bilateral hand splints on 01/30/19. DON unable to find documentation of hand splints being offered or encouraged since then, also unable to produce documentation of hand supports, foot supports or refusal to wear splints ever being added to the Comprehensive Care Plan (CP) in the electronic medical records (EMR). DON stated that there should be continual offerings of refused interventions and acknowledged that the orthotic supports should have been added to R25's care plans. On 03/15/21 at 04:15 PM another interview with DON was done in her office. DON said that despite not having OT services since 01/30/19, R25 continued to receive RNA Services three times a week. The RNA Team, consisting of the Director of Rehabilitative (Rehab) Services (DOR), the MDS (minimum data set) Supervisor (MDSS), and three RNAs, meet and review all residents receiving RNA services once a week. The MDSS is then responsible to document a Restorative Note at least weekly. DON unable to produce any of these notes documented in the EMR. DON acknowledged that the MDSS, who oversees the RNA Program, is too stretched, and that may be the reason the weekly documentation is lacking. RR of the 07/20/18 (one month after admission) RNA Long Term Care Referral notes the Occupational Therapist (OT) 2 documented under Current Functional Status, that R25 was able to wipe his face [with a washcloth] with his left hand with minimal assistance at that time. Review of the RNA Long Term Care Referral six months later, dated 01/30/19, notes OT1 documented that R25 had become completely dependent for all activities of daily living (ADLs), including face washing.

Based on interviews and Record Review (RR) the facility staff failed to have the skill set to ensure that one Resident (R)1 was in stable condition prior to sending him in a handivan to a physician office visit. Staff did not recognize a change in R1's baseline condition. R1 could not speak and did not respond as usual prior to being put in the handivan. The staff failed to recognize a medical condition that required immediate intervention. On [DATE] at approximately 10:45 AM R1 was put in a handivan and sent to a routine office visit. MD1 directed the Family Member (F) to take R1 to an emergency room (ER) for evaluation. R1 was taken to an ER and was pronounced dead on arrival at 12:21 PM. There is potential that the staff may not identify symptoms in other residents that require immediate attention that could result in harm or death. Findings Include: 1. The Office of Healthcare Assurance received a complaint (ACTS intake 8184) [DATE] from a family member (F) who's relative had been a resident at the facility since [DATE]. F stated, R1 had a wound care appointment with MD1 last week. The facility scheduled the handivan for wheelchair pickup, and I drove my car to the facility to meet them. I go to the appointments with him. When I got there the CNA (Certified Nursing Assistant) said 'He's sleepy'. He wasn't sleepy, he was unresponsive. F went on to say, I should have called 911 and transported him to the ER. They (facility staff) put him in a wheelchair. They should have recognized something was wrong. They got him up, dressed him, and used the Hoyer (mechanical lift) to put him in the wheelchair. He passed away at the ER, and all they said to me was 'He's sleepy.' F said, I'm not trained but I could tell he wasn't just sleepy. When I saw him, I tried to talk to him and asked if he was OK. He just looked at me . the way he looked; they should have canceled the appointment. I hadn't seen him for about two to three weeks because of the COVID and no visitors. He wasn't in great condition but was doing OK and I talked to him on the phone two days ago and had a long conversation. We talked about a package my work was offering me for voluntary early out. I had a whole conversation with him. He also was still a trustee for someone, so this was defiantly not him. F said they went to the MD1's office, which was just across the street, and MD1 told her to take him to the ER. F said she called the handivan and we took him to the ER which took about 15 minutes. He always gets his care at that hospital and they have all his records. They took him in right away. He had no pulse, not breathing. It must have happened on the way. I followed in my car. My biggest regret was not calling an ambulance when I first saw him that day. 2. R1 is a [AGE] year-old male who was admitted to the facility on [DATE] for rehabilitation. R1 had deficits related to a cervical spine fracture with spinal cord injury. He had impaired balance, limited mobility and was dependent on staff for dressing, bathing, and required two persons assist for transfers to his wheelchair. On admission R1 had a [MEDICAL CONDITION] that was decannulated (tube removed) on [DATE]. He had difficulty swallowing and needed frequent suctioning. R1 was able to hold the suction catheter and suctioned himself. He was fed through a gastrostomy tube and had an indwelling Foley catheter because of incontinence. Relevant [DIAGNOSES REDACTED]. R1 had an open wound to his left foot and upper leg and necrotic (dead tissue) area to his right great toe and 3rd toe with chronic venous stasis ([MEDICAL CONDITION]) leg ulcers. He was receiving wound care at the facility and referred to a Vascular Surgeon, MD1 for examination. 3. RR of R1's Care Plan revealed Resident is a FULL CODE status (If a cardiac or respiratory arrest occurs, individual wants to have all interventions needed to get their heart started again). 4. RR of R1's Minimum Data Set (MDS) assessment dated [DATE] included the following documentation: Section B. Hearing, Speech, and Vision: .Ability to hear-Adequate-no difficulty in normal conversation, social interaction . and Speech Clarity-Clear speech-distinct intelligible words. Section D Mood: Documented that R1 did not have symptoms of feeling tired or having little energy. Section G: Functional Status: Documented R1 did not have any impairment in functional limitation in Range of Motion to Upper or Lower extremities. 5. A RR of R1's Resident Monitoring forms from [DATE] through [DATE] was conducted. The form starts at midnight (24:00) and is a 24-hour daily log staff record observations/monitoring every 15 minutes. RR revealed the following comments: On [DATE], There was no documentation of behavior/observation from 15:15 to 23:45. There was a total of 61 observations recorded. Nine entries documented an activity which included: 0030 awake watching TV. Refuse to turn 0045 watching TV 0300 call to suction mouth 0315 awake refuse to turn 0545 call to suction mouth 0700 awake refuse to turn 0745 mouth care 0800 given meds and GTF ([DEVICE] feeding) 1400 reposition All other 52 entries documented R1 sleeping. On [DATE], There was no documentation from 24:00 to 0730. There was a total of 66 observations recorded. Eight entries documented activity which included: 0830 mouth care 0900 turn, reposition 1300 reposition 1345 mouth care 1430 turn/reposition 1600 offer to turn/refused 1830 change/reposition All other 58 entries documented R1 sleeping On [DATE] the documentation revealed R1 sleeping with the following exceptions: 0800 mouth care 0945 AM care 1000 AM care 1015 put him in w/c (wheel chair) 1030 downstairs 1045 out on pass The behavioral monitoring forms revealed R1 was sleeping most of the time the past two days and awake only for mouth care, AM care, suctioning and repositioning except for watching TV for approximately 30 minutes. 6. On [DATE] at 10:30 AM, during an interview with the Unit Manager (UM), she said R1 had come to her unit from the respiratory unit. He required frequent suctioning and preferred to suction himself. Inquired if R1 drooled, and UM said, I have not seen him drool, he suctions his saliva. UM went on to say, He requires assistance in turning but can move himself in bed with limited assistance. UM said she had recently worked with R1 and his wife setting up an appointment. Conducted a review of nursing notes and the behavioral monitoring forms that revealed R1 was sleeping a lot. review of medication records [REDACTED]. Inquired how often MD2 came to see R1 and if he was aware of how much he was sleeping. UM said he is there twice a week and was not sure if he was aware. Staff write notes to relay information about resident's to MD2 in a communication book, which was reviewed and revealed no documentation regarding R1's sleeping pattern. 7. On [DATE] at 02:30 PM during an interview with the Restorative Aid (RA), she said she worked with R1 three times a week and did exercises and ROM (range of motion) of both arms and legs. Inquired about R1's mobility, and RA stated, He was able to move his arms by himself, especially the left side and can move the right. I help sometimes with stretches. He can move his right leg and left leg a little. R1 can use the call light and suction I saw him the day before and he wanted to do exercises. He was OK then . He is sleeping a lot, but I wake him up. We always talked a lot. 8. RR of Nursing Progress notes revealed the following entries: [DATE] 13:58 . resident able to do mouth suctioning using yankeur . [DATE] 22:50 . alert and oriented x2, verbally responsive to make needs known . [DATE] 23:07 Asleep, but easily arousable by tactile and verbal stimuli. Remains alert and oriented x2, verbally responsive to make needs known. [DATE] 23:45 . Asleep, but easily awaken by tactile and verbal stimuli. Remains alert and oriented, verbally responsive to make needs known.Good hand grip on both hands. [DATE] 20:50 . sleeping but easily arousable by verbal stimuli. Asleep most of the shift. [DATE] 17:15 received resident on bed awake and oriented to person & place . resident sleeps at intervals, easily arousable when name called . follows commands and directions. [DATE] 23:00 . sleeping but easily arousable by verbal stimuli.able to move BUE (Both upper extremities) independently and able to suction self orally using yankuer . [DATE] 14:41 entered by Registered Nurse (RN)1 received resident on bed asleep but arousable with eye opening with verbal stimuli, . noticed both hands swelling . tube feeding started by night shift around 07:00 as resident has appointment to MD1 (vascular) picked up at 10:45 am. @ 08:00 mouth care done by CNA resident verbalizes enough while doing the care. @ 0900 resident spontaneously open his eyes when being greeted good morning, asked how are you, answers back I'm fine . resident verbalizes wants suctioned and open his mouth .resident went back to sleep. @10:00 morning care done by CNA . during turning verbalizes ouch my leg . resident verbalizes pain in the leg during transfer but decreased movement BUE noted. resident stays on wheelchair for a while waiting for the pickup . @10:30 picked up by .transport, transported by wheelchair accompanied by staff to front door. Received and ac companied by wife resident remains sleepy but appears stable not on (sic)any distress. @1200 received a call from transport driver stating that he just picked up the resident from doctor's appointment and he is bringing the resident to ER as per instruction of the wife . @1310 called up ER .got an update regarding resident status, given information that resident expired. [DATE] 15:11 Follow up resident situation/condition of resident while treated at MD1 (Vascular MD). Per MD1 he was able to see him at the clinic alert and responsive and able to check wound and change dressing, and per him he noticed resident to be obtunded (a state similar to lethargy in which the patient has slowed responses to stimulation and tends to sleep more than normal with drowsiness in between sleep states). Per MD1 advised resident F to bring resident at downstairs ER (office is located on same campus as an ER). 9. On [DATE] at 02:45 PM during an interview with CNA1, she said I called for assist to get him ready to go to his appointment. He smiled at me. I could tell he was excited to see his wife. We put him in the wheelchair with the lift. CNA1 said, I didn't notice anything unusual that day. I do notice him sleeping a lot. We turn him every two hours to reposition him and he opens his eyes and would respond. 10. On [DATE] at 04:15 PM during a phone interview with CNA2, she said, CNA1 called me to help with AM care because everything with R1 is a two man assist. CNA2 said she hadn't worked with R1 much, but that he sometimes would talk with us in Hawaiian and could carry on a conversation. I remember asking him where he was going that day, and he said, 'the doctor.' I think he was holding his suction catheter. He knows if it's not there. The Ward Clerk (WC) and I took him down cause the F and transporter were already there. When we got downstairs F was calling 'R1, are you ok?' I don't think he heard her. He opened his eyes and smiled. When asked if R1 usually talked, CNA2 replied, Yes, he usually does . When I went upstairs, I told RN1 we brought him down and told her the F is asking R1 if he is OK, and he doesn't respond. He opened his eyes and smiled. I don't know what happened. 11. On [DATE] at 02:07 PM, during an interview with the WC, she said, I remember the F asking him (R1) if he was OK. He just looked at her, he didn't really talk words. WC said, When I got back upstairs, we told the nurse F's reaction and that she was asking if he was OK. 12. On [DATE] at 12:00 PM, during a phone interview with RN1, she said she was assigned to R1 [DATE] day shift. When asked to describe R1, she said, He would sometimes yell or shout for help, but easily directed. He was alert ., and he suctions himself. That morning I went to the room and said hi to him. He opened his eyes, and when I asked him how he was, he said he was fine. I remember I suctioned him. He usually does it himself, but that day, he just let me do it. The CNA did oral care and approximately 10:00 AM CNA's did AM care, sponge bath and prepared him to go out. He was yelling 'ouch'. They put him in a wheelchair with the lift. He appeared sleepy, but when you want to wake him up, he will. I noticed both arms swelling. Review of RN1's nursing notes R1 wrote that day was conducted. RN1 confirmed the notes were written on [DATE] at 02:41 PM and that the notation of decreased BUE was entered by her. Inquired if she checked R1's extremities for ROM or did a neurological assessment when it was noted he had decreased movement of bilateral upper extremities, and RN1 replied, No, because he was sleeping at the time and not in the mood. I noticed he wasn't using his hand and couldn't hold the yankeur (suction catheter). RN1 went on to say, I saw R1 sitting in the w/c by the dining area prior to leaving. Asked if R1 was sleeping, and RN1 responded, His eyes were closed. Inquired if the staff that took R1 to the front for pick up reported anything to her when they returned to the unit, and RN1 said, They told me the F was there with the driver and she kept saying, 'R1, R1 how are you? Are you ok?' and he didn't respond but opened eyes. 13. Review of the facility policy titled, Resident Examination and Assessment revised February 2014 states The purpose of the policy is to examine and assess the resident for any abnormalities in health status . It also describes a neurological physical exam includes; alertness and orientation; speech clarity, drooping eyelids, facial paralysis, asymmetry; strength and equality of hand grasps; and numbness or tingling in extremities. There is no documentation of R1 having any additional assessment after it was noted he had decreased BUE from his baseline. 14. On [DATE] at 12:45 PM during a phone interview with MD1, he said, R1 had an appointment with me to look at the wounds on his feet. This was the first time I saw him, so did not know what his baseline condition was. MD1 went on to say, I started to examine him and asked his F if this was the way he always was, and she said 'no'. That's when I told her she should take him to the ER. I brought it up to her because I thought maybe it was his normal state. I thought it looked like maybe he had a stroke, and this was his normal condition. I looked at his feet because he was there, and the F called the van to come back. I had to pick up his foot to put it back on the footrest. He was warm at that time . He was breathing and had a pulse but wasn't responding. He never talked. 15. On [DATE] at 11:30 AM during a phone interview with the handivan Transporter (TR), he said the pickup was about 10:45 AM. He said, I met R1 at the front door of the facility and pushed him to the van and loaded him up. His F was with him. Inquired what conversation he had with R1's F and he said, She expressed concern about him. She said she hadn't seen him since they stopped allowing visitors and that he didn't look good. She said maybe I should bring him to the ER. TR said the F decided to see what the doctor says since the office is right across the street. TR said he tried to converse with R1, but he would just look at me. Asked TR to describe how R1 looked, and he said, Pale, he was drooling and couldn't really talk. He would only nod his head. TR said that MD1's office was not even a minute, right down the street. I took him to the office and left. TR proceeded to say the F called him back shortly after and that MD1 wanted her to bring him to the ER downstairs or any place she's comfortable with. She wanted to go to the ER where they know him and had his records. Asked TR to describe how R1 looked when he picked him up at the MD1's office, and he replied, He looked the same as when I picked him up earlier. Pale, mouth open, speechless, drooling. I called the facility and told them I took R1 to the ER. 16. RR of Hospital emergency room (ER) records revealed the following: [DATE] 12:17 PM Arrival to ER [DATE] 12:18: RN triage note: Patient arrived from triage in a wheelchair, patient pulseless and ashen in color, placed patient on monitor to confirm no heartbeat. MD2 speaking to F on code status. Per F patient from Long Term Care Facility (LTC) and needing reevaluation so transport called to take patient to the Emergency Department. Upon arrival to triage patient apneic (no respirations) and pulseless but hands still warm. MD2 documentation: This is a [AGE] year old male history of central cord syndrome history of MI ([MEDICAL CONDITION] infarction), CABG [MEDICAL CONDITION]-patient had an appointment with his vascular surgeon today. F reports MD1's office is across the street from LTC facility. He went for his appointment while he was there the vascular surgeon recommended, he have additional evaluation in the emergency room since he did not appear well. The wife was with him at the appointment she reports that he was not responding. She is not sure if he had his vital signs taken in clinic. A transportation service was called for wheelchairs she went to get her vehicle to meet him here. When she arrived in the waiting room the patient was in a wheelchair, he was unresponsive pale with no respirations he was taken immediately to room and placed on a monitor. He was found to be in asystole .Patient presenting in asystole unclear of his down time since there was no CPR in progress-patient was unresponsive in cardiopulmonary arrest. [DATE] Nurse Comments: Patient Pronounced at 12:21 PM .

Based on observation, interview, and record review, the facility failed to ensure a vulnerable Resident (R1) was free from alleged criminal sexual assault by a Certified Nurse Aide (CNA)1 while providing personal care early in the morning. CNA1 allegedly entered her room, placed an object in her mouth which left her unable to call for help, held her down on her bed and aggressively sexually assaulted her. The deficient practice left the resident traumatized and afraid which was demonstrated by the inability of the resident to sleep and feel safe in the facility. In addition to the emotional trauma suffered by the resident, R1 experienced pain and injury (lacerations) to her vagina and buttocks. The facility also failed to provide emotional support and trauma informed care after the assault, leaving the resident to feel helpless and afraid while residing in the facility. Findings include: On 12/10/19 at 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from the facility Administrator (FA) who stated that a Resident reported sexual assault by a staff member. The FA stated that the police had been called and an investigation was being conducted. Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, going forward. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Adult protective services (APS) report dated 12/11/19 at 03:00 PM received via fax and reviewed. Presenting problem states: Allegations of sexual abuse of an [AGE] year old female by a male certified nurse aide (CNA) at the Facility, name NOT provided by the facility to APS. R1 reported that on 12/10/19 at about 08:00 AM the alleged perpetrator (AP) came into alleged victim's (AV)'s room at the facility to check her diaper and returned at about 9:00 AM stating that AV had diarrhea/ peed herself, and that AP would return to change AV. AV stated she did not have a good feeling about AP at this point. At 9:15 AM. AP returned with supplies, entered AV's room, put a handkerchief in AV's mouth, thus AV could not speak and could barely breathe they were alone, no known witness. AP held AV down by the bend of AV's elbows, got on top of AV, and penetrated AV's vagina with AP's penis. AV stated she felt pain. AV repeatedly stated I didn't want that. At about 11:30 AM when AV's sister arrived at the facility, AV informed sister of the incident, who reported it to the social worker staff, who called the police. The Sex Abuse Treatment Center (SATC) Forensic exam showed findings of assault including lacerations from the vagina to the anus, and also in the anus. AV's Diagnosis: [REDACTED]. Alert/ oriented, has decisional capacity, but no known formal assessment. Currently has mobility issues due to recent hip surgery, but reportedly needed assistance with her care prior as AV indicated her sister has been AV's primary caregiver. Assessment/ Disposition: The AV meets the definition of a vulnerable adult as statutorily defined. Protective services are warranted for sexual abuse, per HRS 346-222 (3). Disposition: Accepted for investigation. Facility event report completed by the Administrator dated 12/13/19 received via email by the State Agency and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the ER. Administrator's summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. Please refer to the attached documents for further evidence of my conclusion. Attachments include the following: 1. Handwritten statement by two CNA's. 2. Handwritten timeline of shift activities by CNA1 and his partner (CNA2). CNA1 and his partner worked together in caring for R1 from 11:05 PM till 06:15 AM when the partner ended her shift. Noted CNA1 was working alone with R1 from 03:00 AM till 04:00 AM while partner was on her break and again from 06:15 AM till 08:00 AM till his shift ended. He stated R1 called to be changed at 6:55 AM when he changed her alone. 3. Time card report from CNA1. 5. Interview with CNA1. When asked do you have an idea why this resident would accuse you of this? he answered, no I don't have any idea why she would have this story, she is going to change her story anytime now. I think she is confused. Why would I do anything to her like that? I don't know her, I don't know how she knows my name since we are wearing gown's when we go in to clean her. When she have wet diaper my partner did by herself and I did one time at the end of the shift by myself. Like I put on the paper. I think it was just before I talked to you in the hall outside that room. FA stated we did talk about 06:45 AM I believe. I started my rounds about 06:35 AM and saw you charting about 10 minutes later. CNA1 stated I will do whatever I need to swab or blood or test, even lie detector test anytime you want. I never did this. Why would I do something like this? You know you can call me and I will come to do anything you want for tests or what I need to do. I never did this. I am innocent. Why would I do anything to her like that. Sex with her??? I never did. 6. Interview with CNA2 (CNA1's partner). Stated we changed R1 together only a couple of times. We worked together all night until I went home at 06:15 AM. We are in gown and masks because she is on isolation. How she knows his name then if we are covered in gowns every time we are in there? 7. Professional summary by the F[NAME] Several calls were made to the detective at the Criminal Investigation Division (CID). I was unable to speak with the Officer, therefore I am writing my professional summary of the investigation I conducted, as follows: Summary of the alleged events. R1 states that during the alleged assault, It hurt from him pounding into me During independent and separate interviews, both CNA staff state the resident was calm and unemotional, and talking normally with them during the personal care they provided to her approximately 08:00 AM. Neither of the CNA staff noted any type of abnormal findings or injury/ blood in the resident's perineal area, buttocks, or abdominal area during the personal care. Neither of the CNA staff identified any abnormal fluid in the brief when it was changed. I made a call to the ER and was informed I could not have any information because there is no account of the physician's assessment in the record. This information concludes what I have for my investigation. Neither R1 or FM1 have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Based on review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the SS interview with R1 and without obtaining further information from the ER assessment or HPD. During an interview with the FA during the entrance conference on 12/17/19 at 9:15 AM, stated that the employee (CNA1) is currently on administrative leave. The Administrator gave a verbal account of the events from the initial report by R1 until the investigation was completed. The Director of Nursing was out with illness so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to make contact with the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS). The FA added that CNA1 was employed here at the facility last (MONTH) 2019, and certified as a CNA in (MONTH) 2019. Requested and received CNA1's personal file that included the background investigation conducted at the time of hire. Discharge summary report dated 12/09/19 reviewed. R1 is an [AGE] year old female admitted to an acute care facility on 11/30/19 after a fall at home. Primary [DIAGNOSES REDACTED]. Secondary Diagnosis: [REDACTED]. She was diagnosed with [REDACTED]. Her hemoglobin was noted to be 8.5 (Low). discharged to long term care for rehabilitative services on 12/09/19. Progress notes reviewed. Admission note dated 12/09/19 11:17 PM. Able to speak but with some words unclear. Able to move in bed with extensive assistance one person assist. Incontinent to bowel and bladder on shift. Percare provided by staff. Skilled Progress Note dated 12/10/19 06:13 AM. On contact isolation for positive [MEDICAL CONDITION] resistant staff aureus(MRSA) to nares and positive ESBL to urine, a bacterial infection requiring the resident to be on isolation precautions,. Staff are required to wear personal protective equipment (PPE). Resident was able to communicate needs. Incontinent to bowel and bladder kept clean, dry and comfortable. 4. SS note dated 12/10/19 at 12:15 PM stated Pt. reported that at some point this morning, she was raped by someone name who she describes as Five feet three or four inches, with a broad face, broad around the middle, and has a chin with whiskers on it. She stated that this morning she had diarrhea, and he stated he needed to get some supplies to clean her up, came back in 20 minutes . note continues to state details of the assault. 12/10/19 11:44 General Note. At 04:30 PM EMS came to pick up resident going to ER for sexual abuse assessment. During a telephone interview with Social worker (SW) at the SATC where R1 completed the sexual assault assessment. R1 has a follow up appointment on 12/26/19. Requested a copy of the exam results for R1. During an interview with the SS Director on 12/17/19 at 10:26 AM stated on the 10th FM1 was seen in the hall and asked for help and to talk with the Social Worker. FM1 gave a brief account of the incident that R1 reported had happened earlier in the morning. My assistant and I went into the room to interview R1. R1 said she couldn't remember the time the incident occurred but said the sun was up. We told R1 that we were talking this very seriously and I wanted to be sure of our protocol here, only been here for three months. I found the ADON and asked her what is the protocol to follow in this facility. She responded saying she took it to the F[NAME] When asked if APS was notified, she stated I don't know if the Administrator reported the incident to APS. When asked if any psychosocial support had been provided to R1 she stated No. The following day the APS investigator called to ask for the medication list and for the identity of the AP, I told them I need to check with our Human resources offices. My associate SS2 did most of the interviewing, she said she saw R1 tear up during the interview. When asked if the care plan was updated after the incident the SS Director responded that we updated the care plan to state no male care giver alone with R1. If with male care giver, needs to have 1 female care giver at all times. During a telephone interview with the APS investigator on 12/17/19 at 11:00 AM, stated that she came to the facility the previous day on 12/16/19 and requested the name and contact information for the AP from the Human resources office. She conducted an interview with R1 and FM1. After speaking with R1 the investigator notified the SS Director that the results of the sexual assault assessment were conclusive. She also requested the facility begin to locate another facility for R1 to be transferred to considering the severity of the trauma that she suffered. The investigator provided the name and contact information for the detective at CID, who planned to conduct a formal interview with R1. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. She could only recall five letters in CNA1 name, although she stated that there were more letters in the name but she couldn't remember them all. He had come in to clean her up and said he had to go get supplies, then returned in about 20 minutes. When he came back he put a handkerchief like tissue in her mouth so she wouldn't scream. He took off her clothes and she tried to grab his thing .he said she was in a state of shock and didn't really remember what happened after that. She wanted to contact the police but she didn't know how so she told us. I just started here at the facility and the day of the incident was my first day here, I wasn't really sure about the state regulations. When asked if she knew if APS was notified by the facility stated that she didn't know and that the FA said he had calls to make. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During an interview with CNA1 on 12/17/19 at 12:40 PM in the facility conference room, who presented as a dark completed male, medium height, stocky stature with short groomed haircut and beard that appeared as thick gray short whiskers. He had a calm affect, was cooperative, smiling. He stated this is my first job as a CN[NAME] I have worked here at the facility for about eight months. When asked to describe what sexual abuse means stated touching a patient in a non appropriate way, touching a breast or fondling them, and can actually be intercourse. When asked to describe in his own words what happened that day stated. It was a regular day for me, R1 was alert, but she wasn't talking that much, that's kind a normal for a new patient. She seemed ok, I took her vitals, took other peoples vitals than we started patient care. Me and my partner did diaper changes. The one time I was alone with her was when my partner left. We changed her a lot since she had the urine infection maybe seven or eight times. My partner left at least an hour early, around 6:15 AM. R1 called around 6:50 AM to be changed. The whole time while we were cleaning her we wore, gown, gloves and mask. The last time I went in I only wore the gloves and mask, not a gown. I was by myself. She only requires one CN[NAME] She told me she needed to be changed, that time she had a bowel movement, the whole night it was just urine. I cleaned her and left the room. I stayed in the room less than 5 minutes. After that I washed my hands, fixed her sheets and then went out to the nurses station. It was light then, all of the people were starting to come in at that time. I reported off to the new CNA's coming in,, about her being on isolation for urine, about her legs. When asked how long he knew the resident stated I didn't know her for more than one day. They said that she just arrived on her shift. I was really surprised to learn about the incident that she claimed I had consensual sex with her. In training we learned about some patient's having mental issues. CNA1 stated he introduced his self to R1 and had his name tag on. When asked why he didn't wear a PPE gown only on that one visit with R1, stated we only wear the gowns for extra protection. The type of isolation she was on didn't require me to wear a gown. She had diarrhea at that point. She was on isolation for urine. During the interview with CNA1 noted that his description of the event conflicted with the interview he had with the FA which placed him in R1's room without a PPE gown on. In the interview with the FA he questioned how R1 could know his name when he was wearing a gown and mask. He also stated that he introduced his self to R1 and was wearing his badge. The description R1 gave about his identity was accurate, being wide and with whiskers. The letters stated in his name were also an accurate account of CNA's name (or part of his name). CNA1 employee personnel record reviewed. Received CNA certification on 03/18/19. Prior employment as Barber and security guard. Date of hire 04/09/19 by facility. Background investigation summary noted on 10/13/98 was charged with a misdemeanor for a violation of an order for [REDACTED]. Honolulu family court. All other information in the file was negative. Noted the file did not contain documentation from the facility about the allegation of assault. Reviewed in-service training record signed and dated 05/15/19. Resident rights; resident abuse/ dominant language, posttest includes misappropriation of resident property, physical abuse, sexual abuse. Problems and needs of the elderly: dementia, restraints, elopement, fall precautions. Sexual harassment. Staff meeting minutes dated (MONTH) 2019 with inservice training staff sign off roster reviewed. In service training provided: Dignity/ abuse/ dining. 89 staff signatures completed out of 180 staff. CNA1 did not sign the sign in roster that he completed the training. During an interview with the ADON on 12/17/19 at 1:06 PM. The DON was out with illness so I was covering for her. I collaborated with the FA to follow up with procedures we needed to follow. We went to interview R1. ADON recounted the report of the incident. R1 seems fairly cognitively intact, she takes time to respond to you. She is able to respond if you give her time. She has [MEDICAL CONDITION] and has a [DIAGNOSES REDACTED]. She has a flat affect. The Administrator made the phone calls to OHCA and HPD, I don't know if there was any report to APS. Not to my knowledge was there any complaints or incidents involving CNA1. When staff are onboarded here they receive abuse prevention training during orientation then annually. Last facility wide training that included abuse and neglect was given in (MONTH) 2019. Most but not all of the staff signed off on the attendance form. During a telephone interview with FM1 on 12/18/19 at 08:33 AM stated that when I went in to see her that morning, she told me about it. R1 doesn't have a great deal of confidence, she was very self contained and very clear when she was telling me about it, she held herself together very well although she was very upset and wanted to take care of this. She wants to press charges. FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the assessment. I thought she shouldn't go back there when we were at the ER. R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her another place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility. During an interview with the Registered Nurse (RN) unit manager on 12/18/19 at 10:30 AM stated that R1 is able to tell you what she needs she speaks softly. I made several rounds during the night and in the morning. We had a care plan meeting, the care plan was updated. The sister came to the meeting. She mentioned about being transferred. The SS responded that they made referral's to two other facilities to transfer R1, but no definite answer yet. During an interview with the DON on 12/18/19 at 11:11 AM stated she was out sick three days and returned to work on Thursday and feeling very overwhelmed. I talked to R1 to see if she was ok coming back to us. I didn't think they were coming back. I learned yesterday that the family want to transfer. The SS Director came into my office and said APS came in on Monday and said the sex assault ink test was positive. I asked her to contact the FA and let him know this information. When asked were there any updates to the care plan? Was psycho-social support being offered? stated the staff are only providing care for R1 with no male alone and two people at all times. I don't know if SS provided any psycho-social support to R1. She stated that she really doesn't know CNA1. During an interview with CNA3 on 12/18/19 at 11:40 AM stated she was working on the same unit as CNA1 although in the back of the unit so she didn't see him. During an interview with the RN Supervisor on 12/18/19 at 01:17 PM stated that she was working with CNA1 and CNA2 the night/ morning of the incident. I just saw the two CNAs charting and talking while doing rounds. I gave the medication at 12:00 AM and 6:00 AM. She was smiling at 06:00 AM. There was a period of time when I wanted to ask the CNA's about the new patient and they weren't around, maybe before 5. I can't remember the time exactly. At around 04:00 AM I noticed CNA1 was around me a lot, always standing right next to me, and he was just looking at me, it made me feel really uncomfortable. He asked if he needed to do the the six AM vital signs. His partner left at 06:15 AM. During an interview with CNA4 on 12/18/19 at 01:00 PM stated We saw each other when we were doing our rounds. I saw him in the hallway. We saw each other in the hall. During an interview with CNA 5 on 12/18/19 at 01:47 PM stated CNA1 reported off to my partner that he change a lot of the BM and changed her by himself. That was before 7:00 AM. I was putting my things in the back. CNA1 reported off to CNA3 at the end of the shift. I think they were done by the time I got back between 7:00 and 7:30 AM. During an interview with RN2 on on 12/18/19 at 02:25 PM I was working on the unit on the night of the incident but working on the back side. There are no other male CNAs working on the unit, only an RN but he wasn't working that night. I never worked with the resident before, she usually sleeps at night. Two nights now she has been complaining that she can't sleep. I think they referred her to a psychiatrist. Recently only. During an interview with CNA6 on 12/18/19 at 02:46 PM stated when asked if he knew CNA1 and how is his demeanor with the residents, stated he's ok. So far, he's here as a part time on call. He works as a hair dresser and a security guard. We only see him at night time, he stays by himself. Sometimes the residents say they don't want him to provide their care. He is a good worker. He floats. Some floors don't get used to him. They are hesitant to let him take care of them. Some residents have said they don't want him, I don't know why, he's quiet, maybe they don't like the way he looks.

Based on observation, interview, and record review, the facility failed to ensure a vulnerable Resident (R1) was free from criminal sexual assault by a Certified Nurse Aide (CNA)1 while providing personal care early in the morning. The deficient practice violated the residents right to be free from sexual abuse, the right to a dignified existence, and finally the right to an acceptable quality of life which failed when R1 was left traumatized, afraid, and unable to sleep or participate in her skilled services program. The facility also failed to provide R1 with emotional support and trauma informed care after the assault. The facility did not promote and protect R1's quality of life. (refer F600). Findings include: The facility reported that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with the facility Administrator (FA) at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, going forward. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Upon return of the resident to the facility at 05:00 AM on 12/10/19 to 12/17/19 there was no psycho-social support services put in place and the next follow up appointment to the Sex Abuse Treatment Center (SATC) was not until 12/26/19. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1, SS staff looked to see who was on duty and said there was a staff who had those letters in his name and matched the description that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid, and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated, I was mostly the one to talk to R1. According to R1, the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During an interview with the Assistant Director of Nursing (ADON) on 12/17/19 at 1:06 PM stated R1 seems fairly cognitively intact, she takes time to respond to you. She is able to respond if you give her time. She has [MEDICAL CONDITION], and has a [DIAGNOSES REDACTED]. She has a flat affect. During an interview with the Director of Nursing (DON) on 12/18/19 at 11:11 AM I talked to R1 to see if she was ok coming back to us. I didn't think they were coming back. I learned yesterday that the family want to transfer to another facility. The SS Director came into my office and said the Adult Protective Services (APS) investigator came in on Monday and said the sex assault ink test was positive. I asked her to contact the FA and let him know this information. She stated we updated R1's care plan which states which states that two staff were to provide R1's care at all times. If male staff were assigned they needed to work with a female staff. During an interview with Registered Nurse (RN)2 on 12/18/19 at 02:25 PM I was working on the unit on the night of the incident but working on the back side. There are no other male CNA's working on the unit, only an RN but he wasn't working that night. I never worked with the resident before, she usually sleeps at night. Two nights now she has been complaining that she can't sleep. I think they referred her to a psychiatrist. Electronic Medical Record (EMR) reviewed. Skilled nursing (SN) notes dated 12/11/19 04:05 PM reviewed, one person total assist; no transfer activity on this shift, no ambulation made. SN notes dated 12/12/19 02:41 PM reviewed. No transfer activity this shift. No ambulation made. One person total assist. SN notes dated 12/15/19 02:27 PM reviewed. Alert and oriented x 1-2, with episode of confusion. One person total assist no transfer activity on this shift. No ambulation made. SS notes dated 12/16/10 04:13 PM reviewed. SW met with APS worker regarding open APS case. Investigator reported that R1 is requesting for lateral transfer to another facility. SN notes dated 12/16/19 05:35 PM. R1 complained of inability to sleep well at night. Refused to take any as needed (PRN) sleeping pill and requested to increase her [MEDICATION NAME] (antipsychotic medication) from 15 milligram (mg) to 20 mg at bedtime. Resident assisted to wheelchair at lunch with two person extensive assist. SN notes dated 12/17/19 03:37 AM reviewed. Received resident in bed, watching television (TV).

Based on observation, interview and record review, the facility failed to conduct a thorough investigation of an allegation of sexual assault of a vulnerable Resident (R)1 by a facility certified nurse aide (CNA)1. The facility did not immediately assess the resident for psycho-social trauma and take steps to alleviate R1's fear by moving her to another room or transfer to another facility. The facility did not conduct interviews with other Residents who may have been assaulted by CNA1. The facility did not conduct interview's with personnel from outside agencies at Honolulu Police Department (HPD), Adult protective services (APS), or obtain medical records from the emergency department (ER) to include in its investigation. The deficient practice left Vulnerable resident's who reside in the facility at an increased risk for abuse, and left one Resident (R1) traumatized from the abuse and without immediate psycho-social support from the facility. (Ref F600). Findings include: On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from (TCF) the facility Administrator (FA) who stated that a Resident reported had been sexually assaulted by a staff member. The FA stated that the police had been called and an investigation was being conducted by the Facility. Completed facility event report from the FA dated 12/13/19 received via email and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the forensic evaluation at Sex abuse treatment center (SATC). FA Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. This information concludes what I have for my investigation. Neither R1 or her caregiver have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the Social services (SS) interview with R1 and without obtaining further information from the ER assessment or HPD. The FA or other facility staff who are mandated reporters to APS did not make a report. Therefore, there was no follow up collaboration done to include in the investigation findings. During an interview with the FA on 12/17/19 at 9:15 AM, stated that the employee (CNA1) is currently on administrative leave. The FA gave a verbal account of the events from the initial report by R1 until the investigation was completed. The Director of Nursing was out with illness, so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to contact the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS) or the State Long Term Care Ombudsmen. There were no interviews with other residents who were potentially abused by CNA1. There was nothing in CNA1's record to indicate he had any previous incidents of alleged abuse. There were no complaints made against CNA1. During an interview with CNA6 (who worked with CNA1) on 12/18/19 at 02:46 PM stated when asked if he knew CNA1 and how is his demeanor with the residents, stated he's here as a part time on call. He also works as a hair dresser and a security guard. We only see him at night time, he floats, and stays by himself. Sometimes the residents say they don't want him to provide their care and we change the assignment for them. Some floors don't get used to him because he is part time and floats to different units. They are hesitant to let him take care of them. Some residents have said they don't want him, I don't know why, he's quiet, maybe they don't like the way he looks. During an interview with the FA on 12/19/19 at 12:10 PM stated the investigation was completed, what OHCA already received in his completed report was the extent of the investigation and there has been no further investigation. During an interview with the SS Director on 12/17/19 at 10:26 AM stated my associate SS2 did most of the interviewing with R1, she said she saw R1 tear up during the interview. When asked if any psychosocial support had been provided to R1 she stated No. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. She could only recall five letters in CNA1 name, although she stated that there were more letters in the name but she couldn't remember them all. He had come in to clean her up and said he had to go get supplies, then returned in about 20 minutes. When he came back he put a handkerchief like tissue in her mouth so she wouldn't scream. He took off her clothes and she tried to grab his thing .he said she was in a state of shock and didn't really remember what happened after that. She wanted to contact the police but she didn't know how so she told us. I just started here at the facility and the day of the incident was my first day here, I wasn't really sure about the state regulations. When asked if she knew if APS was notified by the facility stated that she didn't know and that the FA said he had calls to make. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. When asked if R1 received a psycho-social assessment and were support services offered responded, not that I'm aware of, although the SSD has been out sick off and on since the incident occurred. I think we expected the SATC to follow up with the psycho-social support.

Based on observation, interview and record review the Facility failed to collaborate with its social services Department to coordinate the thorough reporting of an alleged sexual assault, thoroughly investigate the allegation, and file the allegation of abuse in the accused employee's (CNA)1 personnel record along with a statement by the employee disputing the allegation. The facility Administrator (FA) failed to ensure steps were completed to provide one Resident (R)1 with the highest practicable mental, physical and psycho-social well being. The Administration knew the proper steps which is described in in its abuse investigation and reporting policy which is referenced to Regulatory reference number483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment. (CR F600, F609, F610) Findings include: Completed facility event report from the FA dated 12/13/19 received via email and reviewed. On 12/11/19 at 0515 AM R1 returned to the facility from the Emergency Department (ER). FA Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. This information concludes what I have for my investigation. Review of the documentation in the FA completed report, noted the Facility Administrator (FA) made his conclusion based on interviews with four CNA staff, the SS interview with R1 and without obtaining further information from the ER assessment or HPD. During no time the FA or other facility staff who are mandated reporters, made a report to APS. The report to APS was made by the SATC after R1 forensic evaluation was completed. During an interview with the FA on 12/17/19 at 9:15 AM, stated the Director of Nursing was out with illness, so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to contact the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS). There were no interviews with other residents who were potentially abused by CNA1. There was nothing in CNA1's record to indicate he had any previous incidents of alleged abuse. There were no complaints made against CNA1. Facility Abuse Investigation and Reporting Policy revised (MONTH) (YEAR) reviewed. All reports of resident abuse, neglect, exploitation .shall be promptly reported . and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The individual conducting the investigation will, as a minimum. i. Interview other residents to whom the accused employee provides care or services . 3. The investigator will notify the ombudsman .Reporting. 1. All alleged violations involving abuse . will be reported by the facility Administrator, or his/ her designee . to the following persons or agencies: b. The local/ State Ombudsman. 4. Notices will include, as appropriate: e. The name (s) of all persons involved in the alleged incident; and .Any allegations of abuse will be filed in the accused employee's personnel record along with any statement by the employee . CNA1 employee file reviewed. No documentation of the allegation of abuse or the written statement of the allegation found in CNA1's file. During an interview with the Director of Nursing (DON) on 12/18/19 at 11:11 AM stated that documentation of the allegation of abuse is usually placed in the employees file. She wasn't aware that the accused employee's file did not have any documentation of the alleged abuse. During an interview with the Administrator on 12/19/19 at 12:10 PM, stated he wasn't aware that the employee's file did not contain documentation of the allegation of abuse.

Based on observation, interview and record review, the facility failed to provide psyco-social support to a Resident (R)1 after an alleged sexual assault by a certified Nurse Aide (CNA)1. The deficient practice left R1 who expressed symptoms of [MEDICAL CONDITIONS] evidenced by crying, the inability to sleep and verbal expressions of not feeling safe and feeling afraid without psycho-social support. The facility Social services failed to assess the residents mental and physical status, move the resident to a different location in the facility or transfer R1 out to another facility and failed to develop the comprehensive care plan which would ensure the provision of services. (CR F600). Findings include: During an Interview with the SS Director (SSD) on 12/17/19 at 10:26 AM stated after R1 returned to the facility from the sex abuse treatment center (SATC) early in the morning on 12/11/19, there was no follow up counseling services or psychosocial support provided for R1. My assistant went to check on her a couple of time. She was to have a follow up appointment at the SATC on 12/26/19. We thought they would provide the counseling services. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS staff looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During a phone conversation with the State Long Term Care Ombudsmen on 12/19/19 at 12:00 PM, who questioned if there was counseling offered by the facility or at the very minimum, if there was a room change. He offered to visit the resident if she is okay to speak to him. Requested if surveyor can give his contact information to the sister. During an interview with the Administrator on 12/19/19 at 12:10 PM who stated, usually the Social Workers are the drivers of care following an incident like this one. Our SSD has been out sick off and on since the incident occurred. Her assistant SS2 is new so she cant be expected to know all of the necessary steps. Care plan dated 12/11/19 reviewed. R1's base line care plan includes one intervention under the problem for Poly pharmacy and states: 2 staff assist. No male caregiver alone, should have 1 female caregiver at all times. No comprehensive care plan developed after the incident that included Psycho-social support for the resident. One updated intervention stated that two staff members will work and provide personal care when the CNA is a male.

Based on observation, interview and record review, the facility failed to provide one Resident (R)1 with care and services necessary to maintain a quality of life after she suffered an alleged sexual assault from a certified Nurse Aide (CNA)1, In addition, the facility did not consider moving the resident to a location in another room or in another facity to provide a feeling of safety and security. In addition, the facility did not develop the comprehensive care plan to ensure services were provided to R1 to meet her psycho-social needs. (CR F600). Findings include: On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from the facility Administrator stated that a Resident reported she had been sexually assaulted by a staff member. The Facility Administrator (FA) stated that the police had been called and an investigation was being conducted by the F[NAME] Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, no male caregiver alone, at least one female present going forward. R1 was transferred to the ER at 04:15 PM. During an Interview with the SS Director (SSD) on 12/17/19 at 10:26 AM stated after R1 returned to the facility from the Sex Abuse Treatment Center (SATC) early in the morning on 12/11/19, there was no follow up counseling services or psychosocial support provided for R1. My assistant went to check on her a couple of time. She was to have a follow up appointment at the SATC on 12/26/19. We thought they would provide the counseling services. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS staff looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. Care plan dated 12/11/19 reviewed. R1's base line care plan includes one intervention under the problem for Poly pharmacy and states: two staff assist. No male caregiver alone, should have 1 female caregiver at all times. No update to the care plan that included Psycho-social support for the resident. Only that 2 staff members will work and provide personal care when the CNA is a male. The intervention is inappropriate for the problem and the resident.

Based on interviews, record reviews and facility incident report the facility failed to provide adequate supervision and assistance in use of a Hoyer-lift to transfer a resident (R1) from the wheelchair back to bed. As a result of this deficient practice, R1 slipped out from the Hoyer- lift sling, fell on to the floor and sustained a skull laceration. Findings Include: On 01/03/2019 at 10:15 AM, an abbreviated survey was conducted to investigate an unrelated complaint allegation (#7219) on quality of care issues and observed facility staff on Unit 2. During observations noticed a visitor/care giver (CG) at R1's bedside and another resident in a wheelchair at R1's bedside with the CG tending to both residents. Interviewed the CG and she identified herself as R1's guardian and the resident in the wheelchair was from another room and visiting with R1. The CG explained that both residents roomed together in their previous facility for fifteen years and now resided in this facility in separate rooms. The CG was a retired special education teacher and taught both residents when they were younger, and so familiar with both. The CG stated that she acted as R1's guardian and visited daily from 9:00 AM to 6:00 PM and provided one-on-care to R1. The CG also brought the other resident (former roommate) to R1's bedside for stimulation as both had profound intellectual disabilities. Observed the CG talking to both residents, repositioning R1 in bed with pillows and wedges and called a certified nurses aide (CNA) when needed assistance. Reviewed the electronic medical record (EMR) on R1 to review care plan (CP) interventions. The resident had a CP focus for activities of daily living (ADL) self-care performance deficit due to, PVS, mental [MEDICAL CONDITION], spastic [MEDICAL CONDITION], and Hx of TBI during childhood. Being totally dependent in all ADLs, interventions for R1 included that required mechanical lift with 2 staff assistance for transfers. Under the CP focus high-risk for falls due to functional status, it was noted, 08/27/18 Accidental fall during transferring from wheelchair to bed when res slid off from sling using the Hoyer lift. The intervention section noted Do 2 staff assistance during all transfers using Hoyer-lift. Make sure sling secured prior to lifting Hoyer-lift. Created date: 08/28/18. On 01/03/2019 at 11:00 AM returned to Unit 2 and interviewed R1's CG regarding the fall from Hoyer-lift on 08/27/2018. According to the CG, R1 fell from the Hoyer-lift sling as the resident was lifted from the wheelchair to be placed back to bed. The CG demonstrated how she assisted the CNA by pulling the wheelchair away from R1 as the CNA operated the Hoyer-lift with R1 in the sling. Inquired of CG where the other CNA was standing and the CG stated that there was only one CNA and herself transferring R1. The CG further stated that the left clip of the sling became unhooked and R1 slipped out of the sling and fell approximately 3 feet to the floor. The CG was pulling R1's wheelchair backward away from the resident and was unable to break the fall. The resident was sent to a nearby acute hospital emergency department (ED), and a CT scan was done. According to the CG, R1 sustained a two inch gash to back of the head. In the ED, the wound was glued to hold the skin together because the cut was not deep, and the wound healed within a week. On 01/03/2019 at 11:45 AM interviewed the facility's director of nursing (DON) and requested falls with injury incident reports (IR) in the past 6 months that were not reported to the State agency (SA). The DON provided a batch of IRs but there was none for R1's fall, so honed down request for any accidents that occurred in (MONTH) (YEAR) not reported to the SA. The DON then recalled R1's fall from the Hoyer-lift and stated that the IR was not sent to the SA because it was a witnessed fall. The DON recalled that there were two CNAs at R1's bedside but the CG assisted one CNA with the Hoyer-lift and the other CNA was on the other side of R1's bed. The IR for R1's fall was provided by the DON and documentation of the facility's investigation noted that there was one CNA present with the CG assisting when R1 slipped out of the sling and hit head on floor. The IR also noted that R1 was transferred by ambulance to the ED and was treated for [REDACTED]. Verified IR documentation with the DON and she stated that the IR is accurate. The DON further stated that the CG is with R1 daily and was there with the CNA, so there were two people transferring R1 with the Hoyer-lift. On 01/03/2018 at 3:15 PM interviewed the CG to further verify if there were one or two staff present during R1's fall from Hoyer-lift sling on 08/27/2018. The CG stated that there was only one CNA and herself transferring R1 with the Hoyer-lift. The CG further elaborated that sometimes there are 2 CNAs to transfer R1 with the Hoyer-lift and sometimes just one CNA. Inquired of the CG if she was trained by the facility on use of the Hoyer-lift and she stated, No. The CG stated that after the accident on 08/27/2018, the facility's rehab nursing assistant (RNA) re-educated the two CNAs that were responsible for R1 on 08/27/2018. The CNAs were shown where they should stand when operating the Hoyer-lift. The CG also stated that different size slings were tried on R1, but back to the same size sling on date of fall. Inquired of the CG if she knew how to report to the SA when accidents/incidents occurred. The CG response was that she promised the facility administration that would work with them when issues arose instead of reporting to the SA. The CG further elaborated that R1 needed to be placed into a facility when the previous facility shut-down and R1 was the last resident to find another placement. The CG stated that when she comes to the facility daily, she spends time with three other residents in the facility besides R1, and acts as guardian to a female resident in the room next door to R1. The CG stated that previous reports to the SA were made on behalf of the other female resident she is guardian for, and made agreement with facility administration that would work with facility before reporting to SA so that R1 could also be placed at this facility. Observed the CG suctioning R1's secretions through the tracheotomy (trach) opening and queried if had training. The CG stated that the facility trained her how to properly suction R1 through [MEDICAL CONDITION] was taught proper technique by the respiratory therapist. On 01/04/2019 at 8:34 AM interviewed the RNA who reportedly trained the CNAs on proper Hoyer-lift use. According to the RNA, staff was shown how to properly transfer R1 in the Hoyer-lift per CG request when R1 was transferred from Unit 1 to Unit 2. The RNA stated that he had [AGE] years experience using the Hoyer-lift but the device company provided training to staff on proper use. The RNA stated that staff are corrected if observed using Hoyer-lift to transfer a resident by themselves; and, reminds staff to protect themselves as well as the resident. The RNA could not recall the last time the Hoyer-lift representative came to train staff. The RNA stated that staff should be following the Kardex on the computer and that if a resident is totally dependent that means a Hoyer-lift is needed, and always two staff to use Hoyer-lift. The RNA stated that R1 fell from the sling because one side of the sling became unhooked and the resident slid out. After the fall, different size slings were tried but R1 had the correct size sling on date of the fall. On 01/04/2019 at 9:15 AM interviewed the staff development coordinator (SDC), and he stated that the RNA, the two CNAs responsible for R1 on the day of the accident, besides himself were present when the Hoyer-lift representative came to train on proper usage of the Hoyer-lift. The SDC stated that the CG knew how to use the Hoyer-lift because with R1 for many years. Inquired if the facility allows family/guardians to operate Hoyer-lift, and the SDC stated that should be two trained staff to operate. Requested documentation of staff trained by Hoyer-lift representative and the SDC did not have information on the premises but could provide by the afternoon. On 01/04/2019 at 11:00 AM the DON provided a sign-in signature sheet for, TOPIC: Hoyer-Lift Transfer; DATE: 8/27/18 o 9/2/18, and attached Total Mechanical Lift Competency Checklist, with inservice only written in black ink above the title and the form was not completed for staff, date, etc. The facility did not provide documentation of staff trained by the mechanical lift device representative by the time of the exit conference at approximately 3:00 PM . An avoidable accident occurred because the facility failed to implement interventions, including adequate supervision in use of the mechanical lift device, consistent with R1's needs, care plan and current professional standards of practice.

Based on medical record review and interviews the facility failed to provide treatment and services to promote healing and prevent infections for 1 (Resident #27) 2 residents with pressure ulcers in the stage two sample. Findings include: Resident #27 was admitted to the facility initially on August 10, 2004 for dependence on respirator (ventilator) status with [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. During a staff interview conducted on November 6, with staff #45, it was stated that Resident #27 has a Stage 4 pressure injury to the right sacral/ischial area. A medical record review was conducted on the same day and the Stage 4 pressure injury to the right sacral/ischial area was also documented. Weekly wound care documentation by physician wound consultant on November 25, 2014, identified a new pressure ulcer on the right buttock of Resident # 27. The consultant documented this pressure ulcer as unstageable. The pressure ulcer was facility acquired. This is the same pressure injury stage 4, identified during a staff interview and medical record review on November 6, 2017. A thorough medical record review conducted during the survey onsite and afterwards, did not show any documented clinical justification for delayed healing of this pressure injury. The measurements of the pressure ulcer documented by consultant on November 25, 2014 was length 2 cm x width 1 cm with no depth documented. Below are measurements of the pressure injury that were documented on the weekly wound assessment over the three years. The measurements are in centimeters. DATE LENGTH WIDTH DEPTH 11/25/2014 2 1 0 3/4/2015 3 3 0 4/1/2015 1.5 0.5 0 7/8/2015 1.5 2.0 0.1 8/4/2015 4.3 2.2 0.2 9/2/2015 2.5 2 0.2 10/3/2015 6 3 1.5 11/3/2015 4 3 3 12/2/2015 2 2.5 3 1/13/2016 2 3 3 3/14/2016 1.5 1 2 4/13/2016 1 1 2.7 5/11/2016 1 0.8 3 6/15/2016 0.5 0.5 2.5 7/13/2016 0.5 0.5 2.7 8/10/2016 0.6 0.4 2.5 9/14/2016 1 0.8 2 10/12/2016 0.3 0.3 2.0 11/16/2016 0.4 0.5 2.5 12/14/2016 2.8 1.5 2.4 1/12/2017 2.5 2 2.8 2/2/2017 1.2 1 4 2/15/2017 1.2 1 3 2/22/2017 1.2 1.2 3 3/1/2017 1.2 1.2 3 3/8/2017 1.2 1.2 8 3/15/2017 1.2 1.2 8 3/29/2017 2 1.5 4 4/3/2017 1.7 1.2 4 4/12/2017 2 2 5.5 4/26/2017 1.5 1.5 5.5 5/3/2017 1.5 1.5 5.5 5/26/2017 2.2 1.8 6.4 5/31/2017 2.2 1.2 3 6/8/2017 2 1.5 7 6/15/2017 1.5 1.5 7 6/26/2017 1.5 1.5 7 7/12/2017 1.5 1.5 7 7/19/2017 1.5 1.5 7 7/26/2017 1.5 1.5 7.5 8/17/2017 2 1.5 7.5 8/31/2017 2 1.5 7.5 9/13/2017 2.5 1.5 7.5 9/20/2017 2.5 1.5 7.5 10/3/2017 2.5 1.5 7.5 10/18/2017 1.5 1.5 7.5 10/25/2017 1.5 1.5 7.5 11/1/2017 1.5 1.5 6.8 11/8/2017 1.5 1.5 6.8 Documentation on the weekly wound assessments, showed that treatments changed over the three year period. From November in 2014 until November 2016, although the treatments changed, there were alternating treatments and the introduction of a wound vac. The outside measurements of the pressure ulcer decreased with the use of the wound vac, but the ulcer depth remained to fluctuate between 2-3 centimeters in 2016. Resident #27 started to attend the wound clinic in November 2016. At the wound clinic, debridement of the wound took place on several occasions during 2017 where the depth of the wound increased to 8 centimeters after necrotic tissue was removed. Below are a list of the treatments used until attending the wound clinic in November, 2016. 12/ 4: Cleanse with normal saline. Pat dry and apply oreo thick [MEDICATION NAME] ointment liberally. Cover with foam dressing and tape, daily and PRN. Apply protective ointment to buttock every shift and PRN. 3/4/2015: Cleanse right ischium with normal saline. Apply [MEDICATION NAME] ointment and cover with boarded foam daily and PRN. 4/1/2015: [MEDICATION NAME] to wound daily and cover with foam. 7/8/2015: [MEDICATION NAME] to wound daily and cover with foam. 8/4/2015: Santyl with [MEDICATION NAME] ointment after cleansing with normal saline and cover with foam dressing. 9/25/2015: Cleanse with normal saline, continue collagen and boarded foam dressing. Change daily. 10/3/2015: Cleanse with normal saline, apply [MEDICATION NAME] then cover with non-boarded foam daily. New treatment: cleanse with normal saline, apply Santyl/Bactoban ointment and cover with non-boarded foam daily. 11/3/2015: Treatment wound vac initiated Friday 10/30/2015. May use wound vac dressing per physician consultant's recommendation, change every 72 hours per protocol. 12/2/2015: Wound vac, change every 72 hours. 1/13/2016: Wound vac, change every 72 hours. 2/17/2016: Wound vac, change three times a week. 3/14/2016: Wound vac, intermittently 10 minutes and 2 minutes off. 4/13/2016: Treatment change-4/11/2016- Cleanse right ischium pressure wound with normal saline, pat dry then place powdered collagen in wound bed and then cover with boarded foam daily and PRN when dislodged or soiled. 5/11/2016: New Treatment- Cleanse with normal saline, pat dry, pack with [MEDICATION NAME] packing strips with hydrogel ointment and cover with foam dressing. 6/15/2016; Cleanse right ischium with normal saline, pat dry, pack with [MEDICATION NAME] packing strips with hydrogel ointment and cover with foam dressing. 7/13/2016: Cleanse right ischium pressure with normal saline, pat dry, pack with [MEDICATION NAME] packing strips with hydrogel ointment and cover with foam dressing. 8/10/2016: Cleanse right ischium pressure with normal saline, pat dry, pack with [MEDICATION NAME] packing strip with hydrogel ointment and cover with foam dressing. 9/14/2016: Cleanse with normal saline and pack with [MEDICATION NAME] strip with hydrogel and cover with foam dressing. 11/16/2016: Cleanse with normal saline and pack with [MEDICATION NAME] strips and cover with foam dressing. 12/14/2016: Apply silver alginate and cover with foam dressing. Resident #27 attended consultation visit with Infection Disease Physician (IDP) on November 1, 2016 for consult regarding non-healing right ischium wound. The IDP recommended to attend a Wound Clinic with further follow up with him. Resident #27 initially attended the Wound Clinic on November 30, 2016 for evaluation and treatment. Pre-debridement measurements of the pressure ulcer at the Wound Clinic were 0.5 cm length, 0.4 cm width and 2.2 cm depth. Post debridement pressure ulcer measurements were 2.4 cm length, 1.2 cm width and 4.7 cm depth with tunneling at 9-12 o'clock of 3 cm and undermining of 1.4 cm at 360. Level of debridement was to bone. Description of procedure from the wound clinic stated the following: After usual preparation, sharp debridement into necrotic bone and viable, as well as non-viable, surrounding tissue to the point of bleeding was performed utilizing a curette, scalpel and electrical cautery with excision of necrotic bone, muscle, subcutaneous tissue, dermis, skin and surrounding viable, as well as non-viable, tissue resulting in clear demarcation of wound margins. The wound was debrided to an acute state with some bleeding from the capillary bed. Intra-Operative Findings: Necrotic Bone. Material Removed: Necrotic bone and viable, as well as non-viable adjacent tissue to the point of bleeding. Treatment ordered was silver alginate inner dressing with outer foam dressing to be changed every 3 days and PRN. Advised the importance of strict off loading and repositioning and use of air mattress. [DIAGNOSES REDACTED]. On May 11, 2017 treatment by the Wound Clinic was changed to Grafix being applied to wound with [MEDICATION NAME] dressing in place and to continue offloading to right buttock. May 25, 2017, silver alginate dressings every 3 days and PRN was ordered with turns every 1 and a half hours. This treatment has continued. A review of laboratory reports for Resident #27 showed the following results from cultures collected from right ischium wound: 10/21/2016 - [MEDICAL CONDITION] (MRSA) 2/2/2017 -[MEDICAL CONDITION] 2/24/2017 - Proteus mirabilis, Escherichia coli [MEDICAL CONDITION] 3/24/2017 - Escherichia coli, [DIAGNOSES REDACTED] pneumoniae, Proteus mirabilis and [MEDICATION NAME] faecalis 5/22/2017 - Bacteroides fragilis and Pseudomonas aeruginosa 6/1/2017 -[MEDICAL CONDITION] 8/8/2017 - Escherichia coli,[MEDICAL CONDITION] and Bacteroides fragilis 8/31/2017 -[MEDICAL CONDITION] and Escherichia Coli Results from a MRI of the Pelvis (Bone) performed on June 16, 2017 showed the following results: 1. New abnormal bone marrow signal and post contrast enhancement in the right issue tuberosity compared with 12/7/2016 suspicious for osteo[DIAGNOSES REDACTED]. 2. Complex deep soft tissue decubitus ulcer tracking from the skin and subcutaneous tissues to the margin of the right ischial tuberosity with enhancing granulation tissue and without subcutaneous abscess collection at this time. 3. Persistent nonspecific presacral [MEDICAL CONDITION]. 4. Diffuse marked [MEDICAL CONDITION] throughout the pelvis with nonspecific diffuse bilateral muscle [MEDICAL CONDITION] and enhancement. Based on this information the facility failed to provide a documented clinical justification for the delayed healing of this pressure ulcer/injury. The facility failed to identify in a timely manner buildup of necrotic tissue in the wound which hindered healing of the wound. The facility failed to prevent a facility acquired pressure ulcer/injury from becoming infected with various bacteria requiring antibiotic treatment over the last 12 months. The facility failed to prevent infection in the pressure ulcer/injury from causing bone injury suspicious of osteo[DIAGNOSES REDACTED].