Every finding on record at Yukio Okutsu State Veterans Home

Based on record review and interview, the facility failed to ensure the Binding Arbitration Agreements (BAA) followed all the requirements as specified in the regulations. Specifically, the agreements residents were asked to enter into, did not explicitly grant the residents or their representatives the right to rescind the agreement within 30 calendar days of them signing it. Findings include: On 11/14/24 at 10:00 AM, review of resident (R)25's Electronic Health Record (EHR) was conducted. Review of the document titled Patient and Facility Arbitration Agreement revealed that it did not include language that the resident or their representative have the right to rescind the agreement within 30 calendar days of signing it. Review of the list of residents that have entered into a BAA showed 42 of the 60 residents have agreed to it. On 11/15/24 at 10:32 AM, a concurrent interview and record review was conducted with the Administrator in her office. Administrator reviewed the BAA and acknowledged the agreement did not explicitly grant the residents or their representatives the right to rescind the agreement withing 30 days of signing.

Based on observations and interviews, the facility failed to ensure the resident's right to a dignified existence and is treated with respect and dignity for one resident (Resident (R)36) sampled. Registered Nurse (RN)6 referred to resident's who require assistance with meals as feeders in front of R36, who requires assistance with meals. As a result of this deficient practice, residents are at a potential risk of psychosocial harm. Findings include: On 11/12/24 at 12:09 PM, while conducting an interview with R36 in the resident's room, RN6 entered the room, stood next to the resident, and informed this surveyor, The unit has two other feeders, and the aide will be over to assist the resident (R36 with lunch) when they (aides) are done. After RN6 left the room, R36 stated, I guess I'm a feeder. and reported it did not feel good to hear staff refer to him as a feeder. RN6 returned to R36's room a short time later to assist the resident with lunch and R36 refused the meal. Review of R36's Electronic Health Record (EHR) documented the resident's most recent annual Minimum Data Set (MDS), Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 15, indicating R36's cognition is intact. A significant change in status MDS with an Assessment Reference Date (ARD) of 07/23/24, documented R36's BIMS score was 14, and his cognition was intact. On 11/13/24 at 03:15 PM, while conducting an interview with the Director of Nursing (DON) in her office, DON confirmed staff should not call or refer to residents as feeder.

Based on observation and interview, the facility failed to facilitate a resident's self-determination through support of the resident's choice of food preferences for one resident (Resident (R)58) sampled. R58's reported he informed the facility of his food preferences and still receives foods that he informed the facility he does not like, for example milk and fish. During lunch observation on 11/12/24, the resident was served salmon for lunch and the resident's meal ticket documented R58 dislikes fish. As a result of this deficient practice, residents are at risk for more than minimal physical and/or psychosocial harm. Findings include: On 11/12/24 at 10:55 AM, conducted an interview with R58. During the interview, R58 reported the food is not so good and he receives foods that he has told staff he dislikes or has stopped eating/drinking. Asked R58 for an example of an event he experienced. R58 reported since last week, he has had diarrhea and, in an attempt, to minimize the incident of having diarrhea, he told staff that he does not want any milk or dairy products, with the thought that the lactose in the milk is potentially a cause or is contributing to the diarrhea. However, for breakfast, he is brought cereal and milk. The resident has his own refrigerator, with R58's permission, the refrigerator was inspected and noted there were 6 containers of milk stored. R58 stated that those are the milks he received with his meals after informing the facility staff that he did not want milk with his meals. On 11/12/25 at 12:15 PM, conducted a lunch dining observation for R58. R58 stated, Look they gave me fish and I don't eat fish. It's on my paper, dislikes fish. Reviewed R58's lunch meal ticket which documented, Dislikes: Fish. R58 reported, this is not the first time I have received something I told them I do not want. On 11/15/24 at 09:05 AM, conducted an interview with the Dietitian (D)1. D1 confirmed R58 received fish for lunch on 11/12/24 despite his meal ticket documenting that he dislikes fish and confirmed kitchen staff made a mistake. On 11/15/24 at 09:10 AM, the Director of Nursing (DON) was informed of R58's food preferences were not being honored. DON confirmed R58 should not have been served fish for lunch.

Based on interview and record review, the facility failed to ensure the resident or their representative was given written notice of transfer or discharge from the facility and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for two residents (Resident (R)7 and R43) sampled. This deficient practice has the potential to affect all the residents who are transferred or discharged from the facility. Findings include: 1) Review of R7's Electronic Health Record (EHR) documented R7 was sent to an acute hospital on 07/09/24 due to difficulty breathing. On 11/15/24 at 09:18 AM, conducted an interview and concurrent review of R7's Transfer/Discharge Notice (which was provided by the facility) with Social Service staff (SS)2. Inquired if a copy of R7's Transfer/Discharge Notice for 07/09/24 was sent to a representative of the Office of the State Long-Term Care Ombudsman and requested for SS2 to provide a confirmation of the date and time the notice was sent. SS2 confirmed R7's Notice of Transfer/Discharge for 07/09/24 was not sent to a representative of the Office of the State Long-Term Care Ombudsman but should have been. 48351 2) R43 is a [AGE] year-old male admitted to the facility on [DATE]. On 10/17/24, R43 fell out of his wheelchair and was transferred to the hospital. A review of the R43's EHR was conducted on 11/13/24. R43's EHR did not contain any documentation that the facility had provided R43 and his representative a written notification for his transfer to the hospital. Interview was conducted with the facility Administrator on 11/13/24 at 04:49 PM. Administrator confirmed that no written notification was given to R43 or R43's family member. A review of the facility policy titled, Discharge/Transfer Notice, with a last revised date of 03/2024 was conducted. The policy noted, . Before the facility transfers or discharges a resident, the facility must make the following notifications-notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan (CP) for pain which included non-pharmacological interventions for one of five residents (Resident (R)16) sampled for unnecessary medication. Review of R16's CP for pain did not include non-pharmacological interventions as a standard of practice of multimodal approaches for pain relief according to the American Nurses Association (ANA). As a result of this deficient practice, resident is at risk for potential harm by potentially receiving unnecessary medications, which could include opioids, prior to implementing other effective modalities of pain relief (cold, heat, repositioning, exercise, stretching etc.). Findings include: Review of R16's Electronic Health Record (EHR) documented R16 was admitted to the facility on [DATE] with diagnosis which included low back pain and has a current diagnosis of cellulitis to both lower limbs, and gangrene. R16 was admitted to hospice on 10/31/24. R16's physician's orders which included Oxycodone HCl 5 mg as needed for pain give 5 mg (milligrams) by mouth every 4 hours as needed for pain level 4-7/10 and give 10 mg by mouth every 4 hours as needed for pain level of 8-10/10 ; Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML, give 0.25 ml by mouth every 1 hours as needed for pain 1-3/10 not to exceed 20 mg per hour. May give sublingual (under the tongue) if unable to swallow and give 0.5 ml by mouth every 1 hours as needed for pain 4-6/10 not to exceed 20 mg per hour. May give sublingual if unable to swallow and give 1 ml by mouth every 1 hours as needed for Pain 7-10/10 not to exceed 20 mg per hour. May give SL if unable to swallow and give 0.25 ml by mouth every 1 hours as needed for SOB (shortness of breath) not to exceed 20 mg per hour. May give sublingual if unable to swallow; Methadone HCl Oral Tablet 5 mg, give 0.5 tablet by mouth one time a day for pain and give 1 tablet by mouth at bedtime for pain. Review of R16's November 2024 Medication Administration Record (MAR) documented the resident received Oxycodone 5 mg on 11/01/24 at 12:05 AM and 09:30 PM, 11/02/24 at 05:25 AM, 11/03/24 at 04:37 PM, 11/05/24 at 12:40 AM, 11/06/24 at 07:46 AM, 11/07/24 at 05:06 AM, and 11/10/24 at 09:10 PM. R16 also received Morphine on 11/07/24 at 05:45 AM. On 11/13/24 at 03:45 PM, conducted a concurrent interview and record review of R16's EHR with the Director of Nursing (DON) in her office. After reviewing R16's physician orders and CP, DON confirmed non-pharmacological interventions should be implemented prior to administering medications as a standard of practice for implementing least invasive interventions first and R16's CP does not include non-pharmacological interventions but should have included any effective non-pharmacological interventions. DON reviewed R16's chart and could not provide documentation confirming the facility is currently implementing other modalities of treating R16's pain besides medication.

Based on observation, interviews, and record review, the facility failed to provide appropriate medical care for one resident (R)58. The facility failed to manage R58's bowel regimen and manage the resident's diarrhea. This deficient practice has the potential to result in more than minimal psychosocial and physical harm. Findings include: On 11/12/24 at 10:52 AM, entered R58's room and conducted an interview with R58 and R58's Family Member (FM)1. R58 reported having diarrhea since last week Thursday (11/07/24). R58 expressed concerns about having diarrhea for the past six (6) days and felt that the facility has not been managing his condition according to professional standards of medical care. R58 reported to date, the facility has not taken a stool sample to ensure he does not have C. difficile (a germ bacterium that causes diarrhea and inflammation of the colon and can be life threatening) or a similar condition; administered medication that is an osmotic laxative (MiraLAX, which draws water into the colon) while having soft/loose stools which worsened his condition; R58 reported having to ask the nurses for medication to treat the symptoms of diarrhea and stop attempting to give him a laxative; experiencing pain to an area where the skin was starting to breakdown on his bottom area; no nursing interventions were implemented to mediate R58's condition so he started to elevate his legs to alleviate the pain and pressure on the area where his skin was hurting; reduced the amount he ate and drank to reduce the incidence of having diarrhea and started to feel weak as a result. R58 informed staff that he was no longer eating/drinking dairy products to see if that was the cause of his condition but still received milk and cereal for breakfast. Inquired if Attending Physician (AP)1 had been in to assess or address his condition. R58 confirmed AP1 has not assessed him and added that he only sees AP1 approximately once a month when he must certify that his condition qualifies him to be in the facility and the visits with AP1 are minimal lasting less than several minutes. R58 shared that he does not feel he is receiving person-centered care from AP1, and the facility is not doing all they can to immediately address the issue before it affects him to the point that he must go to the hospital. Asked R58 how he was currently feeling. R58 reported feeling weak due to dehydration and minimizing his intake to avoid having diarrhea. Also, R58 shared that he was feeling emotionally down due to lack of attention to his concerns and lack of confidence in the facility's ability to provide quality care. While in the resident's room, inspected his personal refrigerator and observed approximately six (6) containers of milk. R58 confirmed those were the milk which came on his meal trays after he told staff that he did not want milk or dairy due to this condition. While conducting the interview with R58, AP1 entered the resident's room, walked pass this surveyor and up to R58's bedside. AP1 asked R58 about his breathing and if he had any pain. R58 confirmed he did not have any difficulty breathing or pain. AP1 put on his stethoscope placed it over R58's heart, then removed his stethoscope. R58 was telling AP1 about having diarrhea and AP1 did not ask any clarifying questions. After the third time, R58 reported he had pain in his stomach. AP1 moved to R58's abdomen area and made contact with this surveyor. I identified myself as a nurse surveyor with the Department of Health (DOH), held up my identification badge, and was wearing a shirt with the Department of Health logo. AP1 smiled and nodded, then turned to R58 and quickly palpated his stomach. R58 informed AP1 that he's been having diarrhea for several days and he was surprised that AP1 did not order a stool sample or some sort of diagnostic test to figure out what is going on. AP1 responded and told R58 that they could get a stool sample, then left the room shortly after. AP1 interaction and assessment of R58 took approximately five (5) minutes or less. AP1 did not auscultate R58's stomach area and did not give any orders to this surveyor. Reviewed of R58's Electronic Health Record (EHR) documented R58 was admitted to the facility on [DATE] and diagnosis included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus, hypertension, and atrial fibrillation. Review of R58's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/24, Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 14, indicating the resident's cognition is intact. Review of R58's Bowel Elimination Task monitoring form documented R58 was consistently incontinent of bowels, had not had an event of loose stools or diarrhea from 10/15/24 to 11/06/24 (timeframe of monitoring form is 30 days). Documentation of the size and consistency of R58's bowel movements were: Day 1: 11/07/24 at 11:15 AM- Large Putty- like 11/07/24 at 12:23 PM- Medium Putty- like 11/07/24 at 01:23 PM- Large Putty- like 11/07/24 at 06:51 PM- Medium Loose/Diarrhea 11/07/24 at 09:21 PM- Medium Loose/Diarrhea Day 2: 11/08/24 at 01:27 AM- Medium Loose/Diarrhea 11/08/24 at 12:38 PM- Small Loose/Diarrhea 11/08/24 at 06:39 PM- Medium Formed 11/08/24 at 08:18 PM- Small Loose/Diarrhea 11/08/24 at 09:38 PM- Small Loose/Diarrhea Day 3: 11/09/24 at 01:46 AM- Medium Formed 11/09/24 at 05:10 AM- Medium Formed 11/09/24 at 07:14 AM- Medium Putty- like 11/09/24 at 09:14 AM- Medium Putty- like Day 4: 11/10/24 at 01:30 AM- Large Loose/Diarrhea 11/10/24 at 05:40 AM- Large Loose/Diarrhea 11/10/24 at 09:25 AM- Small Loose/Diarrhea Day 5: 11/11/24 at 04:02 AM- Large (consistency not documented) 11/11/24 at 11:50 PM- Large Putty- like 11/11/24 at 11:50 PM- Medium Putty- like Day 6: 11/12/24 at 01:52 PM- Medium Putty-like 11/12/24 at 06:16 PM- Small Putty-like Review of R58's physician orders documented an order of MiraLAX 1 scoop by mouth in the afternoon for constipation. Hold for loose BM (bowel movement) at 04:00 PM daily and Loperamide HCl Capsule 2 mg (milligram), Give 1 capsule by mouth every 6 hours as needed (PRN) for loose stool after each loose stool (ordered on 11/08/24). Loperamide is administered to control and relieve symptoms of acute diarrhea by slowing down intestinal movement. AP1 ordered the stool sample on 11/13/24, a day after AP1 informed R58 a stool sample would be done. Also, contact precautions for R58's loose stool was not implemented until 11/13/24, six days after the onset of symptoms. Review of R58's Medication Administration Record (MAR) for MiraLAX documented nursing staff attempted to administer the laxative when R58 was actively having stool with the consistency of putty-like and loose/diarrhea of two occasions: 11/07/24- R58 refused 11/08/24- R58 refused 11/09/24- R58 was administered MiraLAX 11/10/24- MiraLAX was held (not administered) 11/11/24- MiraLAX was placed on hold Review of R58's MAR for Loperamide HCl 2 mg documented: 11/08/24- ordered and administered twice 11/09/24- administered once 11/10/24- administered three times 11/11/24- administered once 11/12/24- administered twice. R58 continued to have putty-like and loose/diarrhea after the implementation of Loperamide HCl 2 mg and the consistency of the resident's BM continued be mostly putty-like and loose/diarrhea. Review of R58's comprehensive person-centered care plan confirmed a care plan was not developed to address R58's bowel management and infection prevention goals and interventions, until 11/13/24. Review of R58's progress notes documented: 11/08/24 at 12:37 PM, . Resident requested if he could have an order of Loperamide 2 mg every 6 hours as needed for loose stool . Confirmed the resident was actively advocating for himself. 11/09/24- No progress notes documented in R58's EHR 11/10/24 at 10:46 PM, Resident had x1 episode of mucous in stool with a scant amount of blood . 11/12/24 at 11:20 AM, a progress not written by AP1 documented, . Stool studies ordered and pending . Abd (abdomen): flat, non tender, no mass, bowel sounds present . However, this surveyor did not observe AP1 listen to R58's abdomen/stomach area during his assessment of R58. In a follow-up with R58, the resident confirmed AP1 did not conduct any additional assessments on 11/12/24 and this surveyor was present during the only assessment AP1 conducted on him at the time of the recertification survey. On 11/13/24 at 03:24 PM, conducted a concurrent interview and record review of R58's EHR with the Director of Nursing (DON). DON navigated R58's EHR and confirmed according to professional standard of practice, R58 should not have been offered or administered MiraLAX due to having multiple episodes of loose stools; as a result of on-going loose stool, a stool sample should have been taken sooner and the resident should have been placed on contact precautions sooner and until the facility could rule out the cause of his condition was not due to a potentially contagious bacterial or viral infection; and the care plan was not developed for bowel management. Also, DON confirmed the collection of R58's stool was delayed because the collection and test was not ordered until the following day. DON stated on follow-up with AP1 regarding the day delay in the order, AP1 stated he gave a verbal order to the new nurse in the room. Informed DON the only people in the room when AP1 was conducting his assessment was R58, FM1, and this surveyor. AP1 did not address me or verbalize any orders and the only mention of a stool sample was AP1 telling R58 that they (the facility) could get a stool sample. AP1 did not give any orders to this surveyor and this surveyor did not accept any orders from AP1 according to professional standards of practice which would include directly addressing staff with the resident's information and parameters of the order with a verbal read back to the physician. Also, as professional standards of practice, if the physician is onsite, verbal order should not be given to licensed staff and the physician should directly input orders into the ordering system. On 11/15/214 at 10:11 AM, conducted a telephone interview with AP1. Inquired about the nature and reason of AP1 visit with R58 on 11/12/24. AP1 stated the visit was a regular recertification visit and during the visit R58 reported having diarrhea. AP1 confirmed there was a delay in ordering the stool culture and testing.AP1 said he gave the order to the nurse in the room. Informed AP1 there was a total of four (4) people in the room: AP1, R58, FM1, and this surveyor. Inquired if AP1 recalls this surveyor introducing and identifying herself as a nurse surveyor with the DOH. AP1 replied that he must have missed that and did not recall this surveyor identifying herself, did not notice the DOH logo on my shirt and did not notice that I was not wearing scrubs.

Based on observations, interviews and record review, the facility failed to provide care consistent with professional standards of practice for the resident (Resident (R)25) who received hemodialysis (treatment to remove waste and excess fluids from the blood) treatments. Specifically, the facility did not ensure fluid restrictions were followed as ordered by the attending physician. This deficient practice could result in preventable adverse health conditions like fluid overload and congestive heart failure for residents with end stage renal disease. Findings include: R25 was admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to End Stage Renal Disease (ESRD) and dependence on renal dialysis. During an interview with R25 on 11/13/24 at 09:25 AM, R25 said he has been on hemodialysis for over [AGE] years. Asked R25 if he has had any complications during his treatments. R25 said his blood pressure drops during treatments when the weight gains between treatments are high. Asked R25 if the staff limit his fluid intake. R25 nodded Yes and said I don't drink much. Review of R25's Electronic Health Records (EHR) revealed that the fluid restriction ordered by the physician was 1,200 milliliters (ml) per day. On the following dates for November, R25's recorded fluid intake was above 1,200 ml: 11/03/24 was 1,680 ml; 11/07/24 was 1,680 ml, 11/08/24 was 3,360 ml, 11/10/24 was 1,338 ml and 11/11/24 was 1,318 ml. On 11/14/24 at 11:12 AM, a concurrent interview and record review was conducted with Registered Nurse (RN)6 at the second-floor nurse's station. Asked RN6 how they monitor and ensure R25's fluid restriction is followed. RN6 said they coordinate with the CNAs (Certified Nurse Aide) on the amount of fluid given to R25 every shift. RN6 added that the night shift nurse will add up all the documented fluids given to R25 at the end of the day and enter that amount in the monitoring log. Reviewed fluid intake log with RN6, acknowledged that ordered fluid restrictions were not followed for the five days listed above. Asked RN6 if the resident was able to get his own water or other fluids to drink. RN6 said, No, fluids are provided by the staff. The family also come to visit and we would not know if they also give him anything to drink. Asked RN6 why it is important to follow the fluid restrictions for R25. RN6 said, it was because the resident is on hemodialysis, he is not able to remove excess fluid from his body and added they have to follow the restrictions as ordered.

Based on interviews and record review, the facility failed to provide competent nursing services for one resident (Resident (R)166) sampled. Specifically, nursing staff did not take immediate action and seek a higher level of care for R166's respiratory distress. As a result of this deficient practice, R166 was placed at risk of more than minimal physical harm. Findings include: Review of R166's Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with diagnosis which included hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, and hypertension. R166 was at the facility for physical, speech, and occupational therapy services after experiencing a cerebral infarction (condition that occurs when brain tissue dies as a result of a lack of blood flow). Review of R166's oxygen saturations documented R166's oxygen saturation as: 10/06/24 at 11:15 PM- 91.0 % on room air 10/07/24 at 06:07 AM- 92.0% oxygen via nasal cannula 10/07/24 at 08:09 AM- 83.0% oxygen via nasal cannula 10/07/24 at 08:53 AM- 84.0% oxygen via nasal cannula Oxygen saturation levels under 90% are considered low and levels below 88% require immediate medical attention. R166 was also COVID positive with documented oxygen saturation level of 83% on 2 liters (L) of oxygen. Approximately an hour later R166's oxygen saturation was 84% on 4 L of oxygen. Review of R166's a nursing progress note on 10/07/24 at 09:15 AM documented, At 0840 resident desated (desaturated) to 83-84% with 4 liters of oxygen via nasal cannula. Family is into visit and requested to have resident to be send out to ER for further evaluation and treatments. Called and spoke with . (Attending Physician (AP)1) . of resident's status and family wishes and received an order for the resident to be sent to the emergency room for further evaluation and treatments. Emergency medical services was contacted at 08:47 AM and called the emergency room (ER) which reported to charge nurse . During the survey, a telephone interview was conducted with Family Member (FM)2. Inquired about R166's physical presentation prior to the family requesting for the resident to be sent out to the ER. FM2 stated that R166 did not look good. He was struggling to breath, he looked pale, and was coughing a lot. FM2 recalled R166's oxygen level was low and nursing staff was attempting to administer oral medication to him. R166 was unable to swallow the medication, choked on a pill and did not attempt to administer medications or treatment to increase the resident's oxygen level other than increasing the amount of oxygen to 4 L. FM2 reported it was clear that he needed a higher level of care and they did not take action to transfer him to the ER and the family felt R166 needed to go to the ER because he was not doing good. On 11/15/24 at 11:26 AM, conducted a concurrent review of R166's EHR and interview with Registered Nurse (RN)3 in the Director of Nursing's (DON) office, with the DON present regarding the delay in providing a higher level of care for R166 on 10/07/24. RN3 reported R166 was not symptomatic and not using auxiliary muscles to assist the resident in breathing or struggling to breath despite the resident coughing a lot. RN3 reportedly provided treatment by increasing the resident's oxygen from 2 L to 4 L. RN3 confirmed she did not stay in R166's room after becoming aware of the resident's desaturation and attempted to administer medications to the resident and he was having difficulty swallowing the medication. RN3 stated R166 did not appear to be in distress or need to be transferred to the ER. However, members of R166's family who were present at the time wanted him to be sent out to the ER. DON confirmed the normal range for oxygen saturation is 90% to 100% and action should have been taken sooner than when R166's oxygen was increased to 4L with a 1% increase in oxygen saturation.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two medication errors observed out of 30 opportunities, for an error rate of 6.67%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, two residents (Resident (R)56 and 52) were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications. Findings include: 1) On 11/14/24 at 08:14 AM, observed Licensed Practical Nurse (LPN)2 administer medications on the second floor. One of the medications administered to R56 was Mucinex Extended Release, 600 mg (milligrams). LPN2 cut the tablet into two pieces prior to giving it to R56. 2) On 11/14/24 at 08:31 AM, LPN2 administered Flonase nasal spray to R52. LPN2 inserted the applicator into R52's nostril and administered two sprays into each nostril as ordered. LPN2 then replaced the applicator cover and did not give any instructions to R52 while administering the nasal spray. On 11/14/24 at 01:31 PM, a concurrent interview and record review was conducted with LPN2 by the nurses' station. Asked LPN2 if there was an order to cut the Mucinex Extended Release tablet into two for R56. LPN2 reviewed the orders in the Electronic Heath Records (EHR) and said she could not find an order. Reviewed package instructions for the medication with LPN2 that stated, . Do not crush, chew or break tablet . LPN2 confirmed that she should not have cut the tablet into two pieces unless it was ordered by the physician. Surveyor then asked LPN2 if there was a package insert for the Flonase nasal spray in the box. LPN2 checked the box and pulled out the package insert. Reviewed administration directions with LPN2 that stated, . Blow your nose to clear your nostrils . Close 1 nostril. Tilt your head forward slightly . insert the nasal applicator into the other nostril . Start to breathe in through your nose . press firmly . Breathe out through your mouth . wipe the nasal applicator with a clean tissue and replace the dust cap . LPN2 confirmed that she did not follow the manufacturer's directions for administering the nasal spray and thanked the surveyor for sharing the information in the package insert.

Based on observations and interviews, the facility failed to clean and maintain food serving equipment, dishes, and utensils in a sanitary condition. This deficient practice places the residents at risk for food borne illness and has the potential to affect all the residents who have meals served by the facility. Findings Include: 1) Concurrent observation and interview were conducted on [DATE] at 09:31 AM. Observation was made of a food warmer that contained an uncovered container of soup. The top of the food warmer had a worn down rubber seal and a buildup of dust and lint. The dust and lint were directly above the uncovered soup. Both the cook and the Dietitian (D)1 were shown the dirty warmer and the uncovered soup. D1 confirmed that the container of soup should have been covered and the food warmer should be cleaned. 2) Concurrent observation and interview were conducted on [DATE] at 09:43 AM. Dietary Assistant (DA)1 was observed testing the dishwasher solution. After the solution was tested , observation of the test strip bottle showed that the container had an expiration date of [DATE]. Both DA1 and D1 were shown the bottle of strips. DA1 and D1 confirmed that the bottle of strips were expired and should not have been used to test the dishwasher sanitizing solution. A review of the facility policy titled, Cleaning and Sanitation of Dining and Food Service Area, with a revised date of ,d+[DATE], was conducted. The policy noted, The food service staff will maintain the cleanliness and sanitation of the dining and food service areas .

Based on interviews and record review, the facility failed to ensure a resident's medical record included documentation that indicated the resident did not receive the influenza immunizations for one of five residents (Resident (R)46) sampled for immunizations. R46 signed a consent form to receive the influenza immunization. However, R46 did not receive the influenza immunization and the resident's refusal and education regarding the benefits of the vaccination was not documented in his medical record. As a result of this deficient practice, R46 was placed at risk for more than minimal harm. Findings include: On 11/14/24 at 03:04 PM, conducted an interview and concurrent record review with the Director of Nursing (DON), in her office regarding the facility's infection control program. Reviewed the immunization status of five (5) preselected residents. R46 did not receive the influenza immunization but had signed a consent form to receive it. Provided an opportunity for DON to provide an attestation or other documentation of R46's refusal and education the facility provided to the resident on the risks and benefits of receiving the influenza immunization. DON reviewed R46's Electronic Health Record (EHR) and could not find the requested documentation in his chart. DON inquired with Registered Nurse (RN)99 who was responsible for obtaining consents and refusal forms. RN99 recalled R46 initially signed the consent to receive the influenza immunization, but when staff was administering the immunization, R46 changed his mind and refused it. Provided an opportunity for NS99 and DON to provide any form of documentation of R46's refusal and of the education provided to the resident upon his refusal. On 11/15/24 at 09:52 AM, checked back in with DON regarding the requested documentation. DON confirmed the facility did not document the R46's refusal and education provided at the time of refusal in the medical chart or EHR. Review of R46's EHR documented a progress note (11/14/2024 at 06:32 PM) Fluzone administered to L (left) deltoid. Placed on alert to monitor for adverse effects x 72. R46 received the immunization.

Based on interviews and record reviews, the facility failed to ensure one of the residents (Resident (R) 161) in the sample was free from accident hazards from the use of a mechanical lift. A facility staff independently operated the mechanical lift without assistance form another staff member. As a result of this deficient practice, R161 sustained multiple fractures to his vertebra and ribs. This deficient practice has the potential to affect all residents that require the use of a mechanical lift for transfers. Findings include: Review conducted for the Facility Reported Incident (FRI) document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10397. Initial report was submitted to the Office of Healthcare Assurance on 06/29/23 and the completed report on 07/07/23. Type of incident was listed as Other, Serious Bodily Injury. Details of incident stated that on 06/29/23, R161 was being transferred from the wheelchair to the bed using a mechanical lift by a Certified Nurse Assistant (CNA) when the lift malfunctioned and R161 fell to the floor from an approximated height of three feet. R161 was transferred to a local acute care hospital and subsequently admitted for multiple acute fractures of his spine and ribs. The CNA was immediately placed on administrative leave until the investigation was completed. The mechanical lift was removed from service and inspected by maintenance team on 06/29/23. A facility-wide inspection of all mechanical lifts was completed on the same day. It was identified that the lifting strap failed and all other were confirmed to be functioning properly. Maintenance inspections were being completed monthly with the last one done on 06/14/23. On 07/06/23, maintenance and inspections were transitioned to a different team and completed per manufacturer guidelines. The CNA that transferred the resident confirmed that she was operating the mechanical lift without the assistance of another staff member. On 06/30/23, all staff were required to watch a training video on the proper use of the mechanical lift. Education was also provided on the facility policy where two staff members must always be present for all resident transfers using the mechanical lift. Skills validation training was also conducted and documented. The training and skills validation was made mandatory for all employees and was completed on 07/27/23. All new employees hired after the incident were also required to complete the mechanical lift training and skills validation. After completion of the mandatory training, the facility developed focused rounds to monitor compliance of the staff when using the mechanical lifts. Findings were reported in the Quality Assurance and Performance Improvement (QAPI) meetings monthly for 90 days. On 10/27/23 at 09:44 AM, interview conducted with Restorative Aide (RA) 2 in the hallway of [NAME] Lane unit. RA2 verbalized that two staff members are required when using the mechanical lift and safety checks need to be completed prior to its use.

Based on record review (RR) and interview, the facility did not provide a written notice to specify a bed-hold at the time of transfer. In addition, the facility failed to provide written information to the resident and/or resident representative at the time of transfer. Findings include: RR of resident (R)37 reveals multiple hospitalization s to an acute facility. R37 was initially admitted to the facility on [DATE]. Most recent admission was 10/27/23 at 11:46 AM. Unable to locate via record review documentation regarding bed-hold policy except on admission and notice of transfer to resident or resident representative. Interview with Nursing Home Administrator (NHA) and Direction of Nursing (DON) regarding admission to the hospital for R(37). He was admitted on [DATE] for aspiration and then most recently on 10/27/23. NHA stated that they have a weekly communication every week and the facility still has a bed for him. NHA stated that they have no written communication that goes out to patient representative before transfer. On further questioning, it was revealed that the facility provides a notice of bed-hold transfer by admission agreement on admission; however, not at the time of transfer for hospitalization .

Based on observation, record review and interview, the facility failed to ensure dishes used to serve food were appropriately sanitized in accordance with professional standards for food service safety. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses. Findings include: An observation and concurrent interview was done on 10/24/23 at 09:47 AM. The initial tour of the kitchen area was conducted with Dining Services Director (DSD). Observed a log on the wall by the dishwashing machine that DSD identified as the temperature log. DSD added that the staff use the log to record the temperatures for the dishwasher to make sure that the dishes are disinfected properly after use. Review of the log titled Dishwashing/Warewashing Machine Temperature Log and noted an entry for 10/23/23 was missing. Asked DSD how often the staff record the temperatures on the log. DSD said the staff record it three times a day since they use the dishwashing machine after each meal service. Asked DSD if the dishwasher was used after dinner on 10/23/23. DSD looked at the log and said Yes, but they forgot to record the temperature in the log. DSD apologized and said he will remind the staff the importance of recording the temperatures on the log since it can affect all the residents if the dishes were not disinfected properly.

Based on observation, interviews and record review (RR), two residents of the three sampled resident (R)38 and R43, failed to receive accurate assessments, reflective of their status at the time, to identify relevant care areas. As a result of this deficiency, their care plans (CP) did not identify focus areas needed to ensure they maintain or attain their highest medical, functional, and psychosocial potential. All residents are at risk of not receiving an accurate assessment. Findings include: 1) On 10/27/2023 at 08:00 AM, observed R38 in his room, lying in bed. During the interview, he said he had a cracked tooth, for some time. R38 said he wanted to have the tooth taken out. The MDS (Minimum Data Set), used for standardized assessments (comprehensive, quarterly, significant change in status) includes a Dental Section L. which assesses for any Obvious or likely cavity or broken natural teeth. On R38's annual assessment completed on 02/07/2023, this was checked off, indicating he did have a current issue with his natural teeth. On 08/12/2023, R38 was transferred to the hospital for altered mental status and respiratory failure. When he was discharged , R38 returned back to the facility. An Entry tracking record was created on 08/19/2023, which indicated add new record. This assessment did not identify or document R38 had the ongoing dental issue, and therefore did not trigger or activate a care plan for a dental focus, goal, or interventions. On 10/27/23 at 09:13 AM, interviewed MDS Coordinator (MDS)1, who completed R38's assessments. At that time, she reviewed the documentation, and acknowledged the assessment completed on his return to the facility was not accurate, and should have documented the dental issue. 47783 2) R43 is a [AGE] year-old resident admitted on [DATE] for long-term care. Diagnoses include end stage renal disease and dependence on renal dialysis. Review of R43's Electronic Health Record (EHR) revealed two quarterly MDS (Minimum Data Set) assessments were done with an assessment reference date of 08/04/23. Under Section O, Special Treatments, Procedures, and Programs, there was no check mark if dialysis was performed in the last 14 days for one of the MDS assessments. On 10/24/23 at 01:30 PM, an interview with R43 was conducted in his room. R43 said he has been on dialysis for the past [AGE] year and has treatments three times a week. On 10/26/23 at 01:43 PM, concurrent interview and record review conducted with MDS Coordinator (MDS) 2. Review of the MDS tab of the EHR showed two quarterly assessments dated 08/04/23. Under the Status, one had Modified and the other had Export Ready. MDS2 confirmed that the first quarterly MDS completed on 08/04/23 that had Modified under the status was not accurate because there was no check mark for Dialysis in Section O. MDS2 said the information was updated on 10/24/23 when they realized the MDS Resident Matrix that they ran after the entrance conference was incorrect.

Based on observations, interviews and record reviews, the facility failed to implement person-centered comprehensive care plan for one of two sampled residents (Resident (R) 39). An intervention to prevent falls for R39 was not implemented. As a result of this deficient practice, the R39 was placed at risk for potential harm from avoidable falls and has the potential to affect all resident at the facility on close monitoring. Findings include: On 10/24/23 at 11:37 AM, observed R39 lying in bed, awake, with Certified Nurse Assistant (CNA) 11 sitting at bedside. CNA11 said R39 is on one-on-one close observation during the day due to a history of frequent falls. Review of R39's care plan documented that he is at risk for falls and interventions included but not limited to, 1:1 (one-on-one) observation and supervision, Q-15 (every 15) minute check QHS (every night at bedtime). Further review of progress notes for the past six months revealed R39 has had falls on the following dates: 04/03/23, 04/15/23, 04/25/23, 05/19/23, 05/30/23, 05/31/23, 06/06/23, 06/13/23, and 06/14/23. One-on-one observation was implemented on 06/15/23 after the interdisciplinary team meeting. On 10/27/23 at 08:03 AM, interview with Registered Nurse (RN) 5 was conducted at the nurses' station. RN5 said that a CNA is always assigned to stay with R39 while he is awake and at night whenR39 is sleeping, the staff check on him every 15 minutes. RN5 added that the staff document the 15-minute checks on a log but was not able to locate them when asked. Monitoring logs for October were later provided by the Administrator at 11:30 AM. Review of the logs revealed that there were multiple instances where there were no entries every 15 minutes when R39 was sleeping as specified in the care plan intervention. On 10/30/23 at 12:40 PM, interview conducted with Administrator in her office. Administrator confirmed that since the intervention in the care plan stated to check on the R39 every 15 minutes, the expectation is for the staff to record an entry into the log every 15 mins when one-on-one observation is not being provided. No entries were being recorded.

Based on observation, interview and record review, the facility failed to meet the standards of good clinical practice and ensure timeliness of revisions to the Care Plan (CP) of two Residents (R) of a sample size of 3, R9 and R43. Specifically, R9's dental issue, was not addressed in his CP and R43's hearing aid was not being used. As a result of these deficiencies there was the potential they would not meet their highest level of medical, physical and psychological well-being. This deficient has the potential to affect all residents. Findings include: 1) R9 was admitted to the facility on [DATE], and is a long term resident. His medical history includes, type 2 diabetes, hypertension, Parkinson's disease, dementia without disturbance, major depressive disorder, and acute kidney failure. On 10/27/2023 at approximately 08:30 AM, during an interview with R9 in his room, he said he had been having tooth pain, and pointed to the upper tooth. He went on to say, he wanted it removed because he had a bad experience with another tooth and didn' t want to get an infection. Review of R9's nursing progress included, but not limited to the following entries: 10/27/2023 at 01:47 AM: No c/o (complaint of) any discomfort to left upper tooth . 10/26/2023 at 06:30 PM: Resident w/out (without) c/o tooth pain. 10/26/2023 at 03:19 PM: No c/o left upper tooth pain throughout this shift. 10/26/2023 at 06:23 AM: Denies tooth pain. 10/25/2023 at 11:07 PM: Denies tooth pain. 10/25/2023 at 03:51 PM: No c/o left upper tooth pain. 10/25/2023 at 03:45 AM: No c/o tooth pain. 10/24/2023 at 09:50 PM: .Denies tooth pain. 10/24/2023 at 03:11 PM: Continues on alert for left upper tooth pain. 10/24/2023 at 05:40 AM: resident is on alert for left upper tooth pain. 10/23/2023 at 09:14 PM: On alert for upper tooth pain. Review of IDT (interdisciplinary team) note by Dietician revealed the following entry: 10/23/2023 at 04:16 PM: Met with resident regarding teeth pain. Review of R9's active CP revealed Dental, was not included as a focused problem with a goal and interventions. On 10/272023 at approximately 01:30 PM, the facility provided a revised CP to include Dental. 47783 2) R43 was admitted to the facility on [DATE] for long-term care. Interview conducted with R43 in his room on 10/24/23 at 01:39 PM. Prior to the interview, observed R43 watching television with the volume on high. R43 stated that he is hard of hearing and that he has a hearing aid but was not using it. When asked why he was not using the hearing aid, R43 said he is not able to place it in his ears by himself because the device was small, and he has poor dexterity. R43 also added that he did not know where it is now since he has not used it for some time. Review of Electronic Health Record (EHR) conducted. R43's active care plan dated 06/15/23 stated he has a communication problem related to his impaired hearing. The only intervention documented in the care plan was to ensure hearing aid to both ears are in place. On 10/30/23 at 10:21 AM, concurrent interview and record review conducted with Licensed Practical Nurse (LPN) 2 at the nurses' station. Asked LPN2 why R43's hearing aid was not being used. LPN2 replied she was not aware that he had a hearing aid. LPN2 reviewed active care plan in the EHR and confirmed intervention to ensure R43 used hearing aid for both ears. LPN2 said she will follow up with R43's family representative. At 11:34 AM, LPN2 said she called R42's family representative and was told they were waiting for a replacement device since the old one was too small. LPN2 confirmed that the active care plan intervention was not updated with she will correct it before the end of her shift.

Based on interviews, observation and record review, the facility failed to provide consistent repositioning for one of the one sampled residents (R) 45 in the sample. R45 had an existing Stage 4 (Full-thickness skin and tissue loss) Pressure Ulcer (PU) on the sacrum. As a result of this deficiency, R45 was at increased risk for new PU's and the potential of healing the current PU was decreased. This deficient practice could affect any resident identified at risk for the development of PU, and those with current PU's, resulting in preventing them from reaching their highest physical and psychosocial well-being. as ordered, and consistent with professional standards of practice. Findings include: R45 is a [AGE] year old male admitted to the facility on [DATE]. He has a pertinent medical history that includes a history of paraplegia (paralysis, loss of function in the lower part of body) due to astrocytoma (tumor of the spinal cord) with a neurogenic bladder (lack of control of bladder). He has a chronic indwelling Foley catheter, and being treated for wound management of a Stage 4 PU of the sacrum. R45 is not mobile and stays in bed. He requires assistance to reposition. R45 was hospitalized from 08/01/2023-08/22/2023 due to Urinary Tract Infection and diagnosed with sepsis. When discharged , he returned to the facility for ongoing long term care. 1) On 10/27/2023 at 08:38 AM, observed R45 lying on his back, During an interview at that time, asked him how often the staff repositioned him to promote healing of the sacrum PU. R45 said, About every couple of hours. R45 went on to say the Physical Therapist (PT) wanted him to be at 45 degrees on his side, but he did not like that. On 10/27/2023, at 10:25 AM, during an Interview with Certified Nurse Assistant (CNA)10, asked her about R45's mobility and positioning. She said he was totally dependent on staff to reposition, and He is suppose to be turned every hour. On 10/27/23 at 10:30 AM, accompanied the RN to observe a dressing change of R45's sacrum wound. At that time, noted him to be in the same position on his back. When the RN prepared R45 for the dressing change, observed there was a wedge on his right side located by his waist, providing some offloading to the wound. When the RN completed the dressing change, R45 was very specific and told the RN where to place the wedge. Inquired if he ever rotated more on his side to look out the window, and the RN said he refuses. On 10/27/2023, at 01:00 PM, Physical Therapy (PT)1 accompanied surveyor to assess R45's positioning. At this time he was in the same position on his back, the same position when the dressing change occurred at 10:30 AM. PT1 said she would like R45 be more at 45 degree angle, but due to his neuropathic pain in his back, thorax and shoulders, he is unable to do so. She said he does not like to face toward the window. PT demonstrated the wedge was offloading pressure on his wound, by placing her hand under him. Reviewed R45's care plan history, which revealed the following entries: On 03/04/2023, the CP included: The resident needs assistance to turn/reposition at least every 2 hours and more often as needed or requested. On 09/08/2023, the CP was revised to include Ensure frequent small turns with repositioning of sacrum to prevent further pressure. On 10/11/2023, the CP was revised to include Ensure frequent small turns with repositioning off of sacrum to prevent further pressure. Offer every hour and with rounding. The current, active CP included, but not limited to the following: Focus: The resident has a stage 4 pressure injury to sacrum and history of non-compliance with turning and positioning (10/10/2023). Interventions/Tasks included: .4. Place one wedge at buttocks, 2 wedges at shoulder blades. Reviewed the Follow up Question Report for October 2023, which summarized the Certified Nurse Assistants documentation of task completion for the question Did you turn and reposition every hour. Ensure resident is not [sic] positioned off of his sacrum to prevent further pressure to wound. The report included, but not limited to the following gaps of time when R45 was not repositioned, or documented a refusal to do so: 10/16/2023: Repositioned at 03:07 PM, next documented at 06:22 PM. 10/17/2023: Repositioned at 01:30 AM, next documented at 05:53 AM. 10/18/2023: Repositioned at 02:36 AM, next documented at 05:51 AM. 10/19/2023: Repositioned at 05:16 AM, next documented at 11:25 AM. 10/19/2023: Repositioned at 01:00 PM, next documented at 06:58 PM. 10/20/2023: Repositioned at 04:00 AM, next documented at 08:12 AM. 10/20/2023: Repositioned at 02:50 PM, next documented at 07:57 PM. 10/21/2023: Repositioned at 01:57 PM, next documented at 06:56 PM. 10/24/2023: Repositioned at 01:11 AM, next documented at 05:17 PM. 10/24/2023: Repositioned at 01:00 PM, next documented at 08:28 PM. Reviewed the facility policy titled Quality of Care Skin Integrity, dated 05/2023. The policy guidelines included: 6. A resident identified as at risk of developing PU/PI's (pressure injuries) will have individualized interventions implemented to attempt to prevent PU/PI from developing. 15. Prevention and treatment plans will be individualized and consistently provided. 18. If a resident is refusing care and treatment, the facility will attempt to identify the basis for the refusal and identify potential alternatives, as indicated. 22. Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5 percent for one of five sample residents Resident (R)46. This deficient practice has the potential to harm other residents and failure for R46 to reach their highest practicable level of health and well-being. Findings include: Observation and concurrent record review (RR) on 10/26/23 at 08:36 PM was done during medication pass with Registered Nurse (RN)4. Doctor's orders for Metoprolol 100 mg extended release (ER) to give one tab twice a day for hypertension. RN4 reported blood pressure was 96/64 mmHg and stated that she was going to hold the medication from the resident. Surveyor asked if there were parameters to hold the medications and RN4 stated there were no parameters. Surveyor asked if this was a common practice of other nurses for this blood pressure reading. RN4 stated I am not responsible for what others do. RN4 stated that she was going to hold blood pressure medication Lisinopril/hydrochlorathiazide 50 mg which is given one tablet by mouth every day. This medication also did not have parameters written by the physician to follow. RN4 further stated that all of R46's medications are crushed. R46 receives Metoprolol 100 mg extended release (ER) which is against advisement of manufacturer recommendations to crush time-released medications and in this case Metoprolol is an extended release.

Based on observation, record review, and interview, the facility failed to ensure appropriate temperatures for one of its two medication refrigerators that are monitored and maintained. This deficient practice has the potential to negatively affect the efficacy and integrity of medications that require storage at proper temperatures. Findings include: On 10/26/23 at 03:27 PM, observation and concurrent interview of the medication refrigerator was done with Registered Nurse (RN) 6 on the first-floor unit. The refrigerator contained insulin, suppositories and vaccines. Further review of the instructions on the temperature log stated, Refrigerator temperature to be monitored and documented on day shift and NOC [night] shift to maintain a desired refrigerator temperature of 36-46 degrees Fahrenheit (F). Temperature log for the month of October was on the door of the refrigerator. Review of the log showed that the temperature readings for 10/18/23 was missing. RN6 confirmed that the nurses assigned to work on that day should have checked and documented the temperatures on the log.

Based on observations, record review and interview with staff members, the facility failed to ensure residents received care to prevent development of new pressure inuries and provide care to promote healing and prevention of infections from developing for two (Residents 11 and 54) of four residents included in the sample. The facility failed to develop a person-centered care plan for the prevention of development and infection of pressure injuries; implement the resident's care plan to facilitate healing of the pressure injuries (application of foam boots and elevating feet); and provide resident with informed choices regarding the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's pressure injury also became infected requiring antibiotic treatment. R54 was admitted to the facility with deep tissue injury (DTI) to the left heel. The facility failed to develop a person-centered care plan to prevent the development of pressure injuries and infection of pressure injuries. As a result of this deficient practice, R54 had pressure injury related infections, including [CONDITION(S)] (infection to the bone) requiring four rounds of antibiotic treatment (orally and intravenously) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1) Cross Reference F656 (Comprehensive Care Plan). Resident (R)11 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation during the initial tour of the facility on 10/10/22 found R11 seated in a recliner with a urinal hanging on his rubbish can. R11's head was hanging down to the right and appeared asleep. R11 has an air mattress and on oxygen. On 10/11/22 at 07:41 AM observed R11 sleeping in his recliner. He was upright and slouched over to the right side. R11 was wearing socks and feet were not elevated. His lower legs were wrapped. Second observation at 10:49 AM, R11 was lying on his left side in bed, uncovered with his personal brief open. Two staff members entered and R11 was asked whether he wanted to be covered up and get out of bed. R11 was agreeable. Observation at 12:40 PM, R11 was seated in his recliner, leaning to his right side and feet were not elevated. R11 had earphones on and did not respond to greeting by surveyor. On 10/11/22 at 10:58 AM, Registered Nurse (RN)7 was observed leaving R11's room. RN7 reported the wound team saw R11 and the pressure injury on the buttock has worsened, it's not getting better. RN7 reported they will be changing treatment and awaiting physician orders. On 10/12/22 at 01:15 PM and 02:15 PM, R11 was seated in the recliner, his feet were not elevated. At 02:15 PM, R11 was asleep, leaning on the right of the armrest. At 03:15 PM, R11 had a shower and was assisted back to bed. On 10/13/22 at 08:32 AM, R11 observed seated in his recliner, wearing socks and his feet were not elevated. Second observation at 09:30 AM, the privacy curtain was drawn, staff stated pericare was being provided. At 09:45 AM, staff asked whether he wanted to go back to his recliner. R11 was agreeable to transfer back to his recliner. Restorative Nurse Aide (RNA) waited for assistance to transfer R11 via mechanical lift. Certified Nurse Aide (CNA)2 assisted with the transfer. R11 was placed in the recliner, no foam boots and legs were not elevated. CNA2 was asked whether R11's foam boots should be applied. CNA2 responded the RNA will apply and thinks it is applied only when in bed. CNA2 further reported she needs to read the Kardex as she is new to the facility. RNA reported R11 does not like to wear foam boots, he will get mad if it is applied and will kick it off. RNA also reported R11 does not like to elevate his feet, he just wants to sit in his recliner. RNA placed a pillow to R11's right side and proceeded to tidy the resident's bed. Observed R11's air mattress was not covered with a sheet; a sheet was laid across the bed under the resident's lower half of his torso. Review of R11's admission Minimum Data Set (MDS) with an assessment reference date of 07/12/22 noted he yielded a score of 14 (cognitively intact) when the Brief Interview for Mental Status was administered. R11 was also noted to require extensive assistance with two+ (plus) person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and toilet use. R11 was coded as occasionally incontinent (less than 7 episodes of incontinence) for bladder and always incontinent of bowel. In Section M - Skin Conditions, R11 noted to be at risk of developing pressure ulcers and no unhealed pressure ulcer(s) at Stage 1 or higher. Review of R11's Braden Scale (standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) for 07/14/22, 07/21/22 and 07/28/22 documents a score of 15 (moderate risk). A review of the PCC Skin & Wound: Total Body Skin Assessment for 07/14/22 and 07/21/22 documents no wounds. The assessment for 07/28/22 and 08/04/22 documents one new wound. The assessment includes skin turgor (elasticity), color (ashen, pale, cyanotic, flushed, jaundiced, mottled), temperature, moisture (normal, moist, diaphoretic, clammy), condition (extremely dry, dry, normal, oily, friable), and number of new wounds. A review of the progress note dated 07/28/22 documents R11 developed a pressure injury - DTI (deep tissue injury) to the left heel. Also noted, the outer layer of skin has ruptured and about 40% of wound filled with eschar (a dry, dark scab or falling away of dead skin). The plan was to apply bordered foam every evening shift, foam boats to both feet, and consult wound specialist. Review of the wound note of 08/02/22 notes R11 is a [AGE] year-old with wound on left heel, wound occurred by pressure mechanism, started as deep tissue injury (DTI) prior to admission. R11 was admitted from an acute hospital due to femoral neck fracture and post-surgery. Subsequent wound consult note dated 08/16/22 documents R11 with a pressure ulcer to the left heel, unstageable. Subsequent note of 08/23/22 notes an unstageable pressure ulcer of the left heel and a non-pressure chronic ulcer of other part of left lower leg. R11 noted with severe peripheral artery disease, limited elevation, and worsening [CONDITION(S)]. Culture of the wound found bacteria, enterococcus, MSSA, and mixed GNR indicative of an infection. R11 was prescribed antibiotic ([MEDICATION(S)] from 08/30/22 to 09/09/22 and [MEDICATION(S)] from 10/04/22 to 10/11/22). Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . right toe, and right lower leg). R11 also noted with a sacral wound. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 has a care plan for pressure injury (Stage 4 pressure injury to the left heel and Stage 3 pressure injury to the right buttock). Interventions included: -Administer treatments as ordered and monitor for effectiveness; -Foam boots to bilateral feet in bed and in wheelchair; -Pressure injury to left heel (report to nurse if dressing is soiled or displaced); -Remind resident to keep pressure off left heel when transferring and ambulating; and -Roho cushion and dycem for offloading. There was no care plan including interventions for the prevention of pressure injuries and prevention of infection. Review of the Task bar which provides direction to CNAs regarding care did not include offloading or ensuring position change. On 10/13/22 at 10:00 AM an interview was conducted with the Assistant Director of Nursing (ADON). ADON confirmed R11's pressure ulcer was facility acquired. ADON reported the pressure ulcer to the heel started as a deep tissue injury, a blister. ADON further reported R11 spent a lot of time sitting up in bed and has poor circulation, so they brought a recliner for him to keep his feet slightly elevated off the ground. ADON explained R11's pressure ulcer became infected as he was very swollen and with the use of diuretics his legs were really weeping providing opportunity for bacterial growth. ADON also reported R11 is not compliant with wearing the foam boots and elevating his legs. Inquired whether R11 was provided with informed choices about his treatment (i.e., treatment options, consequences of refusing treatment) and offering of alternative treatment. ADON referred to Wound Care Consult report where it is documented education was provided. The ADON stated the facility was concerned about R11's comfort. ADON was agreeable to follow up on providing care plan for the prevention of pressure ulcers and documentation of the facility's discussion with R11 regarding informed choices and offering of alternative treatment. On 10/13/22 at 12:20 PM, ADON provided a copy of the care plan for skin integrity. The date of initiation was 07/20/22 (14 days after admission) and documents resident has moisture associated skin damage (MASD) and pressure ulcers due to weakness and impaired mobility. This care plan was initiated/developed after R11 presented with skin breakdown. The interventions include: -Administer treatments as ordered and monitor for effectiveness -Educate the resident/family/caregivers as to cause of skin breakdown; including transfer/positioning requirement; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The ADON did not provide documentation of the facility's discussion with R11 regarding informed choices and offering of alternative treatment. 2) R54 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 07:45 AM, R54 was interviewed in his room. R54 was observed lying in bed with his blanket suspended off his feet by a wired apparatus and an IV pole next to his bed. R54 reported that he currently has an infection in the bone and has sores to the left heel and on the right side. He reported the sores were very painful and the wired apparatus helps to keep the weight of his blanket off his feet. R54 reported he also had a sore on his backside. On 10/11/22 at 12:53 PM, R54 reported the wound team came to see him and he requires two more weeks of antibiotics and wounds have healed up. R54 stated he will be discharged to his home after he completes the antibiotics. On 10/12/22 at 01:15 PM, R54 was observed in bed. Inquired whether staff reposition him while in bed. He replied, staff do not assist to reposition him. Observed R54 has an air mattress and no sheet covering the mattress. Queried whether a sheet is used on his mattress, he replied a sheet is not used. He commented the mattress is slippery and he slides down, so he needs to be pulled up every four hours. R54 reported he wears the foam boots in bed and the doctor has told him he can remove the boots when out of bed. R54 further reported he received education about his wounds and has been cooperative. He stated that he was not aware the wound was present upon admission to the facility. Subsequent observation at 02:15 PM, R54 was seated in a wheelchair with prevalon boots on. On 10/13/22 at 08:32 AM, R54 was lying in bed, he was observed wearing his prevalon boots. Review of the admission MDS with an ARD of 11/22/21 notes upon administration of the BIMS, R54 yielded a score of 15 (cognitively intact) required extensive assist with one-person physical assist for bed mobility, toilet use, and personal hygiene. Section M. Skin Conditions, documents R54 was at risk for development of pressure ulcer and had one unhealed pressure ulcer at Stage 1 or higher. The pressure ulcer was documented as unstageable. The treatment included pressure reducing device for chair, pressure reducing device for bed and pressure ulcer care. A review of the resident's care plan provided by the facility found a focus area for infection (resident has IV antibiotic treatment due to [CONDITION(S)] of the right lateral foot), there were no interventions for prevention of infections. The care plan for pressure injury with the goal to remain free from infection does not include interventions to ensure prevention of wound infections. Interventions include administer treatment as ordered and monitor for effectiveness, air mattress, apply foam boots to both feet while in bed, elevate resident's both legs with heel suspension/leg elevation cushion while in bed, monitor nutritional status, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue and exudate. The first documentation of wound care note (11/23/21) documents R54 with a DTI on left heel which reportedly occurred after falling asleep sitting down with foot down about 1.5 months prior to admission. R54 was admitted from home. Summary of subsequent wound care notes include: -12/21/21: DTI on the left heel measuring larger with a new DTI to right lateral foot which may be related to use of new footrests. The impression was pressure injury of deep tissue of left heel and pressure injury of deep tissue of right foot. -01/11/22: coccyx appears healed with dimple deformity. -02/08/22: addition of pressure injury of deep tissue of toe on right foot. Also noted, resident reporting he slips down his bed and fee are up against the footboard. On 03/02/22 R54 assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . -03/01/22: culture of the wound found mixed skin-type flora -03/22/22: new opening to spine/back and R54 on IV antibiotic for bacteremia -05/03/22: pressure injury of right foot (Stage 4) and pressure injury to left heel (unstageable), there is exposure of bone on right lateral foot, and poor compliance with prevalon boots. -05/24/22: bone culture of left heel grew staph lugdunensis (bacteria) and recommendation was for treatment -06/14/22: R54 completed course for oral doxycline (antibiotic) for right foot infection -06/28/22: missed appointment with wound team due to COVID-19 infection and poor compliance to boots and pillow offloading (elevating feet) -08/02/22: culture of left heel and right foot grew [CONDITION(S)], poor compliance with prevalon boots and pillow offloading -08/16/22: R54 on oral doxycline for right and left wound infection -09/13/22: wound not visualized as R54 in hurry for PICC line insertion, recommendation for IV antibiotics for six weeks ([MEDICATION(S)] and [MEDICATION(S)]) -10/04/22: R54 continues IV antibiotics, left heel intact, and right foot (stage 4 pressure injury). Also noted under Miscellaneous the resident received [MEDICATION(S)] for bacteremia (03/17/22 to 03/24/22), [MEDICATION(S)] for right foot wound infection (05/24/22 to 06/07/22), and [MEDICATION(S)] for left heel infection (08/02/22 to 08/16/22). Review of the weekly wound care notes from 07/05/22 through 10/04/22 documents R54 had poor compliance with the application of prevalon boots since 11/18/21. However, a review of R54's treatment record provided by the facility found from December 2021 through October 2022 there was no documentation of refusal for the application of bilateral foam boots. On 10/13/22 an interview was conducted with the ADON, the identified Infection Preventionist. ADON reported [CONDITION(S)] (infection of the bone) was in the left lateral foot and R54 developed the pressure injury on his right foot due to poor circulation. Inquired how did R54 develop [CONDITION(S)]. ADON reported organisms causing infections are introduced to the wound. ADON further reported she tracks infections and has observed facility staff performing dressing change and there has not been infection control breeches. The ADON suggested the surveyor contact the wound consultants. A review of the facility's policy and procedure, titled Quality of Care Skin Integrity. The guidelines include the following: -3. The facility will implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. -6. A resident identified as at risk of developing PU/PIs (pressure ulcer/pressure injury) will have individualized interventions implemented to attempt to prevent PU/PI from developing. Interventions will be monitored for effectiveness. The resident's care plan will reflect the interventions. -15. Prevention and treatment plans will be individualized and consistently provided. -41. The first sign of infection in a PU/PI may delay in healing and an increase in exudate. In a chronic wound, signs of infection may include: a. Increase in amount or change in characteristics of exudate; b. decolonization and friability of granulation tissue; c. Undermining; d. Abnormal odor; 3. Epithelial bridging at base of the wound; and f. Sudden pain.

Based on observation, interview, and record review, the facility failed to ensure that adequate pain management was provided to one resident (R34) in the sample. As a result of this deficient practice, R34 experienced pain that interfered with his movement, affected his mood, and diminished his appetite, thereby preventing him from attaining his highest practicable level of well-being. Findings include: Resident (R)34 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 01:29 PM, an interview was done with R34 at his bedside. R34 reported constant pain everywhere, but worse in his neck and hands. When asked, R34 stated that the pain medications he was on did little to relieve his pain. Concurrent observations noted several signs indicating severe pain. R34 was observed grimacing, biting his lower lip, holding his breath and or taking very shallow breaths, speaking in few words at a time, frequently stopping to catch his breath. His posture was stiff, and he moved slowly, making small, careful movements. R34 rated his pain at the time as a 10 out of 10 and stated that he was waiting for the Licensed Practical Nurse (LPN) to bring him his pain medication. R34 shared feelings of hopelessness, acute depression, and feeling overwhelmed. I'm miserable, I hate it here, I hate being here, but I feel like there is no way I will ever get out of here now [due to constant pain affecting his mobility]. Expressed many fatalistic thoughts, feels he will die here. When asked if he gets out of bed, R34 stated I just can't . it hurts . just everywhere. At 01:58 PM when LPN2 brought in his pain medication, he asked her to put the tablet in his mouth and hold the water cup and straw for him because his hands hurt too much. On 10/12/22 at 03:52 PM, a review of R34's medication orders noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R34's comprehensive care plan noted no non-pharmacological interventions for pain management. A review of R34's progress notes noted a dietary note on 10/11/22 documenting, The resident is having decreased appetite . pain in his hands/arms, affecting his appetite . A nursing note from 10/08/22 documented Resident has poor intake and requires increased assistance with eating. OT (occupational therapy) eval (evaluation) requested. On 10/13/22 at 08:40 AM, observed R34 lying in bed with his breakfast tray on his bedside table. Some of his oatmeal was eaten, but nothing else on the tray had been touched. R34 reported severe pain and that he was waiting for pain medication. R34 stated he takes [MEDICATION(S)] for pain but that it does not help much. R34 was observed with facial grimacing and shallow breathing, speaking in short, slow sentences, and seemed short of breath. When asked if he wanted the Surveyor to get his nurse, R34 stated no, I'm tired of arguing with them, f*ck, I don't want to get you involved. R34 reported that the pain in his hands was so bad, it made it hard to eat or do much of anything.

Based on interview, record review, and policy review, the facility failed to conduct and provide evidence of QAPI meeting in order to mitigate and pull all resources together to stop the spread of COVID 19, and implement process changes to improve outcomes. Currently the facility has 10 residents which are negative (-) for COVID 19 and since the facility was identified to have a failure in the screening process, not having a QAPI meeting to mitigate the risk further place the residents and staff at risk for contracting the COVID-19 virus. There were 77 residents and 37 staff members infected with the COVID-19 virus. Twenty-seven (27) resident deaths were related to the COVID-19 outbreak. Findings include: 1. A prior SA visit revealed IJ #1 at F880 Infection Control. The SA notified the facility of IJ #1 on 10/16/20 by teleconference. During that visit the: a. Facility failed to adequately screen employees for exposure to COVID-19; b. Facility failed to respond timely to an outbreak when they failed to implement precautions for 2 days after becoming aware of the outbreak for seven residents; and c. Facility failed to adequately contact trace residents and staff who were exposed to COVID-19 cases. 2. On October 20, 2020 at 4:00 PM, the SA identified continued noncompliance IJ #2 at F880 Infection Control for: a. Failure to properly screen staff and visitors entering the facility; and b. Failure to completely separate residents identified as persons under investigation (PUI) for COVID-19 in a designated PUI unit. On 10/21/20, at 3:13 PM, surveyor conducted an interview and RR with the Administrator and RNC. The Administrator provided a blank template of a QAPI agenda dated August 19, 2020. The surveyor asked for evidence of program systemic analysis, policies and procedures, systemic actions, and performance improvement and activities. The facility provided a blank template and failed to provide evidence of a QAPI program. Surveyor asked the Administrator the following questions: 1. Were there any concerns identified during QAPI? The administrator stated, You need to refer to the QAPI agenda. The agenda provided by the facility was blank. 2. Identify top three concerns in the facility in the last six months. Administrator stated, I'll have you refer to the agenda. The agenda provided by the facility was blank. 3. Was COVID-19 one of the top three concerns you identified? The administrator stated, Once again, you will have to refer to the agenda. The agenda provided by the facility was blank. On 10/23/20 at 10:30 AM, the survey team interviewed the Administrator, DON, RVP and the two RNCs. The team asked the following questions, As a result of the outbreak or before the outbreak, what processes were in place? The administrator indicated since the outbreak they have not had a QAPI meeting to reevaluate the processes that caused the outbreak on 08/20/20-there was no QAPI meeting since the outbreak. Can the facility provide any evidential documents of improvements that were generated to help mitigate any identified vulnerabilities? The lead surveyor asked the facility to provide copies of action plans, reviews, screening logs, corrections or re-evaluations of their quality assurance program. The facility failed to make the QAPI plan available for surveyors to evaluate for regulatory compliance during the survey. The Administrator said that the facility can supply dates that the QAPI meetings were held and that other answers were under QAPI, but it would not be shared with the survey team because it was confidential. The meeting dates and evidence of a QAPI program were not provided. IJ #3 was identified on 10/27/20 at 2:36 PM, (refer F865). Surveyor interviewed the Medical Director by phone on 10/26/20 at 08:14 AM. He was asked if there were any QAPI meetings during the COVID-19 outbreak which begun on 8/20/20 to determine if their strategies were working to mitigate the spread of [MEDICAL CONDITION]. He stated that he talked with the DON mostly and both the DON and the Administrator occasionally, but no meeting minutes were documented, and he stated, It was all verbal. There were also no new facility policies identified from the outbreak. He stated, We set up all our COVID-19 policies ahead of time. The Medical Director was asked if there was a retrospective review of the outbreak and if opportunities for improvement were identified and he stated, No, because somebody was there (at the facility), but we were going to have our meeting on Wednesday (10/28/20). On 10/27/20, surveyor conducted a RR of the facility's policy Quality Assurance and Performance Improvement revised on 08/20/2018, which states The facility will develop, implement and maintain and effective, comprehensive, data driven QAPI program that focuses outcomes of care and quality of life. The program should address the full range of care and services provided by the facility. The program identifies and prioritizes opportunities that reflect organizational process, functions and services to residents based on performance indicators, resident and staff input, and other informational data. The facility makes good faith attempts to identify and correct quality deficiencies. It is expected that these attempts will not be used as the basis for actions.

Based on observation, interview and record review, the facility failed to ensure the protection of its 10 COVID-19 negative residents as evidenced by the following: 1. The facility allowed screened staff and visitors to enter the facility with questions that were answered correctly; but the facility failed to follow up as the form/P&P required. One surveyor and facility staff screening forms indicated a Yes answer to the screening question Did any facility/ location you visited have recognized COVID-19 cases, that should prompt the screener to contact the director of nursing (DON) and acting infection preventionist (IP) for further evaluation of the visitor/ staff entering the facility. The screener failed to call the DON to evaluate the staff/ visitor in question. 2. The facility placed two residents who were persons under investigation (PUI) for COVID-19 and placed on droplet precautions on the same wing with 10 COVID-19 negative residents. Additionally, the same direct care staff were caring for both PUI/negative residents. No education was provided to the resident or their family for the risk versus benefit of moving or staying on the unit with the negative residents. 3. The facility did not establish/implement an effective surveillance plan based on a facility assessment for identifying, tracking, and monitoring staff and residents with COVID-19. The deficient practices placed the COVID-19 negative residents at risk for contracting the COVID-19 infection. There were 77 residents and 37 staff members infected with the COVID-19 virus. Twenty-seven (27) resident deaths were related to the COVID-19 outbreak which begun on August 20, 2020. Findings include: 1. Surveyor entered the screening station at the facility entrance on 10/20/20 at approximately 08:25 AM and proceeded to be screened. The screener began to ask the screening questions. When asked the question Did any facility/ location you visited have recognized COVID-19 cases yes or no? Surveyor answered Yes. The screener looked up at the surveyor and continued to ask the remaining questions. Screener checked the surveyor's temperature, gave a sticker that indicates the person passed the screening and allowed the surveyor to pass the station into the facility. At no time was the surveyor asked to wait to enter the facility until the director of nursing (DON) was called. Survey team interviewed the screener on 10/20/20 at 11:45 AM. She was asked about the screening process, hand hygiene, the Yes answer to one of the questions on the screening document, and what to do when this occurs. She responded, For a yes answer, the director of nursing is notified. Survey team mentioned that one of the surveyors had a Yes answer, was not seen by the DON, but allowed to come into the building. On 10/20/20, the survey team received and reviewed 43 forms and out of 43, there were seven (Yes) responses to the question that were not referred to the DON for follow up. Survey team met with the DON (and acting as Infection Preventionist) on 10/20/20 at 09:14 AM to discuss the abatement plan for the IJ #1. The DON was discussing the screening tool and stated that she is to be notified if any of the screening questions are answered with a yes and that she is on call 24/7. In the event the DON is not available, the managers are the back up and will be called in the event there is a yes during the screening of staff and visitors to the facility. The DON stated that she was not contacted by the screener regarding any questionable answers that day. Surveyor reviewed the facility's IJ #1 removal plan update 10/20/20 Screening tool will be updated to reflect any y answers are reported to DON/designee. Surveyor reviewed the Healthcare management Clinical systems COVID-19 policy dated 09/09/20. Everyone entering the facility will be screened according to centers for disease control and prevention (CDC) guidelines. Entry into the facility will be in accordance with CDC Guidelines. Page 2. Screen and Triage Everyone entering a healthcare facility for signs and symptoms of COVID-19 .although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with [DIAGNOSES REDACTED]-Cov-2 infection, symptom screening remains an important strategy to identify those who could have COVID - 19 so appropriate precautions can be implemented. 2. Surveyor toured the second-floor resident rooms which housed the COVID-19 recovered residents and 10 COVID-19 negative residents. During the tour, surveyor observed room [ROOM NUMBER], and noted a droplet precautions sign on the outside of the room with a personal protective equipment (PPE) cart next to the door. Observed occupational therapist (OT)1 donning a PPE gown preparing to enter the room. When surveyor asked why the resident in room [ROOM NUMBER] was on droplet precautions, OT1 replied, This resident went out of the facility for a chest X-ray and returned to the facility and the resident is now on isolation precautions for 14 days. Surveyor observed a second room, 238 with droplet precautions sign on the door and a PPE cart next to the room. Queried RN5 if the resident in that room is on droplet precautions and replied yes, the resident went out of the facility for a procedure and when he came back was placed in isolation precautions for 14 days. Queried RN5 if the other residents on this wing were COVID-19 recovered or COVID negative? RN5 stated that there are 10 COVID-19 negative residents on this wing with the two residents who are on droplet precautions. On 10/26/20, surveyor reviewed the facility Health Care Management Clinical systems COVID-19 policy dated 09/09/20. The facility will isolate symptomatic patients . Place patients with suspected or confirmed COVID-19 symptoms. The policy did not state how residents who go out of the facility for appointments and return to the facility will be isolated or cohorted. On 10/26/20, surveyor reviewed the COVID-19 Long-Term Care Facility Guidance dated April 2, 2020. Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not or have an unknown status. To this end, long-term care facilities should work with State and local community leaders to identify and designate facilities dedicated to patients and residents with known COVID-19-positive and those with suspected COVID-19, ensuring they are separate from patients and residents who are COVID-19-negative. On 10/26/20, surveyor reviewed the American Healthcare Association (AHA) Cohorting guidance on residents to limit the spread of COVID-19, dated April 4, 2020. To ensure transparency and comfort, it is absolutely necessary to have clear communication with residents and families explaining the rationale for cohorting (minimizing exposure risk) and need for transfer or a move to another location in the building. Surveyor interviewed the facility Social Worker (SW)1 on 10/23/29 at 09:50 AM. SW1 stated part of her role includes calling families to report the positive test result and or when a need to change rooms occurs. SW1 explained that when she made the calls to R11 and R12's families on 10/20/20, she explained that the state is asking them to move to different rooms. R12's wife adamantly refused, although I was able to talk her into it. SW1 stated when she talked to R11's son, He was hot, he adamantly refused to move him. SW1 let him know that she would do her best to advocate to not having R11 move. When asked if at any time there was education for the resident or family that they were possibly affecting others by staying in their room, SW1 stated No, I defer any education that needs to be provided to the residents to the nursing staff. SW1 did not provide encouragement for the move to the resident to move to another room. Surveyor interviewed the Nurse Manager (NM) on 2nd floor on 10/23/20 at 11:00 AM to question the process for providing rationale to a resident who may need to change rooms due to an unknown or positive COVID-19 test result, specifically, does the nurse provide the risk versus benefit of moving to the resident and their family? the NM stated it is always the SW who calls the family when a resident needs to change rooms. The facility informed the residents of the need to change rooms because the state said they needed to move, which angered the residents families instead of offering a rationale for moving them to another room to prevent the risk of infecting other COVID-19 negative residents who resided on the same unit. 3. An interview was conducted with the DON on 10/22/20 at 2:15 PM about infection control. Surveyor asked why the Monthly Infection Surveillance Report (MISR) did not include all the infections known in the facility during August 2020 and September 2020. The DON responded, That would be our normal monthly surveillance we do every month for antibiotic stewardship, we were keeping track of our COVIDs with the line listing. Surveyor reviewed the MISR on 10/22/20. The report showed an incomplete recording of the infections in the facility. The 46 positive COVID-19 cases in August 2020 and the 25 positive cases in September were not included in the monthly report. Since the positive cases of COVID-19 were not included in the monthly surveillance report the positivity rate was not reflected correctly. The surveillance record reflected a 2.96 positivity rate in August 2020 and for September 2020 it was 5.23. When the DON combined all the infections in the facility, the positivity rate for August 2020 was 19.95 and September was 18.32.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help identify and prevent the transmission of COVID-19. Additionally, the facility failed to follow the Centers for Medicare and Medicaid Services (CMS) and the Center for Disease Control and Prevention (CDC) recommendations and guidelines for COVID-19. These deficient practices are evidenced by the following: 1.The facility failed to adequately screen employees for exposure to COVID-19. 2.The facility failed to respond timely to an outbreak when they failed to implement precautions for 2 days after becoming aware of the outbreak for Residents (R)2, 3, 4, 5, 6, 7, and 8. Additionally, they failed to adequately contact trace residents and staff exposed to suspected and COVID-19 positive cases, and failed to implement work restrictions for Maintenance Staff (MS)3. 3.Medical Doctor (MD)2 and Licensed Practical Nurse (LPN)2 failed to adhere to national standards for Personal Protective Equipment (PPE) usage and hand hygiene. These failed practices contributed to the outbreak in the facility. As of [DATE], this included 51 residents and 17 employees testing positive for COVID-19. As of [DATE] there were 19 deaths in the facility, seven (7) resident deaths in the hospital, for a total of 26 deaths, and the outbreak was on-going. Findings include: 1) Upon initial arrival at the facility on [DATE] at 08:45 AM and on subsequent onsite visits on [DATE], [DATE], [DATE] and [DATE], surveyor was screened for the COVID-19 virus before entering the facility. The screener asked the surveyor if she washed her hands, then proceeded to ask questions listed on the facility's COVID-19 Screening Tool. The tool is used to consistently screen all visitors entering the facility and each employee prior to the start of their shift. Surveyor was not asked if she had contact with someone positive or under investigation for COVID-19. During the entrance conference with the facility's management team on [DATE] at 09:15 AM, Regional Vice President (RVP) speculated there were possibly two index individuals for the COVID-19 outbreak that ensued on [DATE], which included a maintenance staff and a resident. In an interview with MS1 on [DATE] at 10:08 AM, he stated that he was screened with the COVID-19 Screening Tool with the screener prior to his shift on [DATE] and was allowed to work. The COVID-19 Screening Tool was used to screen the Maintenance Staff (MS)1, 2, and 3 prior to their shift on [DATE]. On [DATE] MS3 was screened before he started his shift. The facility's COVID 19 Screening Tool, did not include an inquiry about possible exposure with someone positive or under investigation for COVID-19. MS1 worked with MS2 and MS3 on [DATE]. MS3 ate lunch with MS1 on [DATE]. Both MS1 and MS2 were sent home on [DATE] due to possible exposure and having symptom for the COVID-19 virus. On [DATE] at 09:00 AM, surveyor interviewed the DON/IP regarding the facility's COVID-19 Screening Tool. She mentioned that it was revised as guidelines changed. The facility's COVID-19 Screening Tool has gone through several updates - [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. A follow up interview with the DON/IP and RVP was done on [DATE] at 11:46 AM. Surveyor inquired about the COVID-19 Screening Tool and its numerous changes not including the prompt for the visitor or employee to be screened for possible exposure to the COVID-19 virus. The DON/IP and RVP stated, It should have been there and don't know why it's not there. The facility's COVID-19 Screening Tool, version date [DATE] was reviewed on [DATE] at 09:30 AM. The tool does not include screening for possible contact with persons who are positive or under investigation for COVID-19. A review of the facility's policy Infection Prevention & Control Process for Screening Employees During the COVID-19 Pandemic dated ,[DATE] was done. It did not specify the screening criteria. The Centers for Medicare and Medicaid Services (CMS) guidance memo QSO-,[DATE]-NH, dated [DATE], stated that screening of visitors and health care staff should include contact with someone with or under investigation for COVID-19. CMS memo QSO-,[DATE]-ALL dated [DATE], stated that screening should include contact with someone with known or suspected COVID-19. 2) Upon arrival at the facility on [DATE] at 08:30 AM, observed a screening station for visitors and employees posted at the entrance of the facility. After being greeted by the Regional Nurse Consultant (RNC) at 08:45 AM, she stated a private company was at the facility conducting COVID-19 testing for employees due to the COVID-19 outbreak. She also stated that the dedicated COVID-19 resident care unit was located on the first floor of the facility. In a tour of the facility at 1:09 PM, the RNC stated that residents negative for and residents recovered from COVID-19 were housed on two hallways of the second floor. The third hallway of the second floor housed the persons under investigation (PUI; residents who have not yet been confirmed with having the COVID-19 virus) unit. Four residents from here, tested positive for the COVID-19 virus and was transferred to the first floor in the middle of the night last night. On [DATE] surveyor requested the facility's line listing of the COVID-19 positive residents and staff. A review of the facility's staff COVID19 Positive Cases date of onset [DATE] revealed that the first staff who tested positive for the COVID-19 virus was from the maintenance department. A tour to the maintenance department was conducted on [DATE] at 09:30 AM. During the tour, an interview with MS1 was conducted in the hallway outside of the maintenance office and the maintenance staff break room. An inquiry was made with MS1 regarding social distancing inside their break room. MS1 stated there were four (4) people in the breakroom at a time starting in the beginning of [DATE] and it was changed to two (2) people in late [DATE] when facility staff and residents started to become infected with the COVID-19 virus. MS1 stated that he tested positive for COVID-19 on [DATE]. An interview was conducted with the Maintenance Staff Supervisor (MSS) on [DATE] at 10:10 AM. He informed the surveyor that on [DATE] a random testing was scheduled on some of his staff. Later that day, MS1 and MS3 were in the break room for lunch. The MSS claimed he was informed by MS1 that he had just received a call from his daughter that her friend tested positive and that they may have been exposed to the COVID-19 virus. The MSS called the Administrator and informed him about MS1. MS1 was sent home on [DATE] at 11:42 AM. His time sheet revealed that he worked for 5.75 hours on that day. The MSS further revealed that as he was walking back to his office, he came across MS2. He heard MS2's hoarse voice and suspected that he was sick. MSS sent MS2 home at 11:38 AM on [DATE]. Review of MS2's time sheet shows that he worked for 5.75 hours on that day. On [DATE] at 11:00 AM, a phone interview was conducted with MS2. He explained that on [DATE], MS1, MS3 and himself (MS2) ate together in the break room. On [DATE], the three of them worked together to demolish a wall in room [ROOM NUMBER], the facility's designated as the COVID unit. MS2 stated that during lunch, he ate his lunch outside while MS1 and MS3 ate in the breakroom. MS2 tested positive for COVID-19 on [DATE]. On [DATE] at 11:37 AM, a concurrent interview and record review was conducted with MS3. MS3 stated, After working together on the first floor on [DATE], I had lunch with MS1 for about 15 minutes and then MS1was sent home. The maintenance work order log was reviewed with MS3. The log showed a request to fix a broken staff bathroom handle on the first floor, and someone attempted to fix the handle. MS3 confirmed that he attempted to fix the handle on [DATE]. Surveyor asked why he was not sent home on [DATE] and why he came to work the next day, [DATE]. MS3 said, No one talked to me and I was scheduled to work. He mentioned that his supervisor knew that he was working on [DATE] and he was told to stay in the office. MS3 informed surveyor that he came to the facility on [DATE] for another testing. He was screened and tested and as he began to leave the facility, Human Resources Staff (HR) informed him that his test on [DATE] was positive for COVID-19. MS3 informed surveyor that on [DATE] he was in the emergency room for ,[DATE] hours due to shortness of breath. On [DATE] at 10:15 AM, review of the maintenance work order log was done with the assistance of MSS. He stated, My staff are constantly everywhere. Some of their work/job are not always documented because I communicate with them using walkie talkie. Surveyor asked why MS3 was not sent home since all his staff worked together and had lunch together on [DATE]. The MSS responded, It's not my call but if I have to do it all over again, I would have sent them home. The MSS informed surveyor that he instructed MS3 on [DATE] to stay in the office and not go outside unless the building is on fire. On [DATE] at 3:12 PM, the DON was interviewed. Surveyor asked the DON the reason why MS1 and MS2 were sent home on [DATE], but MS3 continued to work despite exposure to MS1 and MS2. MS1, MS2, and MS3 worked on demolishing a wall in room [ROOM NUMBER] located in the nursing facility. In addition, MS1 and MS3 ate lunch together on [DATE] for about fifteen minutes without their mask on. Surveyor further inquired about MS3's continuation to work on [DATE] and she responded, He was asymptomatic, so he can come to work. The DON also stated that MS3 had no symptoms per the COVID-19 Screening Tool. On [DATE] at 09:00 AM, a copy of the facility's contact tracing of the maintenance staff was requested from the DON/IP. The DON claimed, They have it and it will take only few minutes to pull from the system. In addition, the DON said, It's in my head, it should be fast for me to write. There was no document received by the end of the workday. The contact tracing sent by the RNC was received via email as an attachment on [DATE] at 12:11 PM. The attachment revealed an undated and untitled summary of what was discussed when surveyor requested the contact tracing. The summary failed to identify that MS3 was exposed to MS1 and MS2 who were possibly exposed to the COVID-19 virus on [DATE]. On [DATE] 10:30 AM, a record review of the resident COVID19 Positive Cases with the onset date of [DATE] was done. This document identified the facility's COVID-19 positive residents with their COVID-19 test date and results, date the resident was placed on droplet/contact precautions (an infection control measure of isolation and PPE use to prevent transmission of germs that cause illness), symptoms and their expiration date, if applicable, and it revealed: a) Resident (R)2 experienced symptoms of fever and cough and tested positive on [DATE] but was not placed on droplet/contact precautions until [DATE]. b) R3 experienced symptoms of fever and cough and tested positive on [DATE] but was not placed on droplet/contact precautions until [DATE]. c) R4 experienced symptoms of fever and cough and tested positive on [DATE] but not placed on droplet/contact precautions until [DATE]. He expired on [DATE]. d) R5 experienced symptoms of fever and tested positive on [DATE] but was not placed on droplet/contact precautions until [DATE]. He expired on [DATE]. e) R6 experienced symptoms of cough, shortness of breath and body aches and tested positive on [DATE] but was not placed on droplet/contact precautions until [DATE]. f) R7 tested positive on [DATE] but was not placed on droplet/contact precautions until [DATE]. g) R8 tested positive for COVID-19 on [DATE] but was not placed on droplet/contact precautions until [DATE]. He expired on [DATE]. The facility's COVID-19 policy, undated, was received on [DATE] at 09:15 AM. A request for an updated policy was made on [DATE], but not received. The policy revealed Contact/droplet precautions are implemented as soon as able, once a resident is suspected to have COVID 19. The CDC guidance, Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 Potential Exposure at Work, dated [DATE] stated, exposures can also occur from a suspected case of COVID-19 or a person under investigation (PUI) if testing has not yet occurred or if results are pending. Work restrictions might be applied to healthcare personnel exposed to a PUI if test results for the PUI are not expected to return within ,[DATE] hours. In the CDC's guidance, Responding to Coronavirus (COVID-19) in Nursing Homes updated Apr. 30, 2020, it stated If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. 3) On [DATE] at 1:15 PM, upon entry into the COVID-19 resident care unit, the ward clerk supplied a gown to the surveyor and instructed the surveyor to use the same N95 mask, face shield and gown throughout the unit. Gloves would need to be changed in between residents and there is to be no glove use at the nursing station and in the hallways. On [DATE] at 2:00 PM, surveyor observed MD2 entering the designated COVID-19 resident care unit wearing a face shield and N95 respirator mask. LPN1 noticed MD2 enter the unit without a gown and immediately retrieved a gown by the screening table and gave a gown to MD2. MD2 donned the gown and tied the straps behind his neck and proceeded to walk past the central nursing station. LPN1 helped MD2 to tie the straps at the back of his gown. At 3:20 PM, MD2 was seen walking out wearing all his PPE. He proceeded to take off his gown and placed it into the trash receptacle. MD2 did not remove his contaminated face shield and N95 respirator mask. MD2 did not wash his hands at the sink stationed next to the trash receptacle nor use alcohol-based hand rub (ABHR). MD2 walked out of the facility into his private vehicle while wearing his contaminated face shield and N95 respirator mask. On [DATE] at 08:00 AM, LPN2 was exiting the main entrance of the facility where the screening area is located. There is a sink, soap dispenser and paper towel dispenser in this area. LPN2 was observed to remove her N95 mask and discard it in an open trash receptacle. Then proceeded towards the parking lot without hand hygiene. On [DATE] at 3:30 PM interviewed RN1 in the COVID-19 positive resident care unit and verified MD2 was attending to his residents in the unit. The surveyor informed RN1 that MD2 was observed wearing his contaminated face shield, N95 mask, and did not perform hand hygiene prior to going to his personal vehicle. RN1 confirmed that upon exiting the COVID-19 positive resident care unit, MD2 was supposed to remove all contaminated PPE and perform hand hygiene. On [DATE] at 1:10 PM, during a conference with the facility's management team, the team was informed of MD2 leaving the COVID-19 resident care unit without removing his PPE and failed to perform hand hygiene before leaving the facility. The facility management acknowledged the failed practice and conducted an in-service with MD2 in the evening of [DATE]. On [DATE] at 08:10 AM, an interview was conducted with the DON. She acknowledged that LPN2 should have washed her hands. In addition, the RVP, employed by the facility's managing agency, mentioned that if staff are on the facility's premises, they are required to follow the facility's protocol which included hand hygiene after removing their mask. Surveyor interviewed MD2 via phone call on [DATE] at 2:28 PM. MD2 confirmed that he used the same face shield and N95 respirator mask in the COVID-19 resident care unit and did not remove them upon exiting the unit because no one told me that the process was changed. He further said that after he had received education from the facility in the evening of [DATE], he now discards all his personal protective equipment (PPE) after use and does hand hygiene afterwards. On [DATE] reviewed the PPE + Transmission-based Precautions in-service log and it showed LPN2 attended the PPE in-service on [DATE]. On [DATE] reviewed the facility's policy titled Clinical Services Policy and Guidelines for Implementation. Infection Prevention and Control Program (IPCP) revised on ,[DATE], it revealed: Standard Precautions #2. Staff will perform hand hygiene, even if gloves are used: d. After removing PPE. On [DATE] reviewed the CDC guidelines in the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on [DATE] it revealed: Eye protection and respirators be removed after leaving the care area. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. When the survey team questioned the facility's Administrator on [DATE] and [DATE] about the outbreak, he deferred their inquiries to the facility's clinical management.

Based on interviews, observation and record review (RR) the facility failed to prevent one Resident (R1) fall of a sample of seven. On 10/27/19, R1 fell off the bed while a Certified Nurse Assistant (CNA)1 was providing care. As a result of this deficient practice, R1 fractured his left hip, and required [MEDICATION NAME], an opioid medication for pain control. The [MEDICAL CONDITION] and pain could potentially effect R1's quality of life. Findings include: R1, a [AGE] year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 had a communication deficit and communicates with single words. He required assistance for ADL's (Activities of daily living, and was non ambulatory. Review of the facility's Office of Healthcare Assurance (OHCA) Event Report stated the following, On 10/27/19 at 02:05 PM, .CNA1 was attempting to change R1's brief and draw sheet and requested the resident to help turn himself to right side. In doing so, he rolled over bed onto the floor . R1 was transported to Hilo Medical Center (HMC) for x-rays and returned to the facility with a knee immobilizer in place and a new order for PRN (as needed) [MEDICATION NAME] for pain. The care plan was modified to two person total assist with ADL's. The x-ray report revealed, . resident had sustained a Left Femoral Neck fracture (break in the bone of the leg, just below the ball-shaped head that fits into the hip socket) .Director of Nursing (DON) and Staff Development Coordinator (SDC) held reenactment of scene with CNA that was providing care to resident when fall took place. Education provided on: safely repositioning resident prior to brief change by using draw sheet to pull resident closer to person prior to turning; obtain second staff member to assist with check and change and repositioning for safety if at all in doubt of resident's ability to assist . Review of an internal report number 4340 witnessed fall itnessed fall report dated 10/27/29 at 03:15 PM prepared by RN Supervisor dcumented: R1 received one person assist prior to fall. Day shift Licensed Nurse (LN) was notified at time of fall from day shift CN[NAME] Evening shift nurse coming on shift for report from day shift LN. Bed approximately three feet from floor and flat. Found resident lying on his left side on the right side of the bed closest to the window in a fetal position. Resident unable to verbalize description of fall. Review of the facility Fall Scene Investigation Tool included the following statement from CNA1 dated 10/27/19, While I was changing patient (R1), he was turned toward his window while I was putting his brief and new draw sheet. When it was time to turn back, he went more forward instead and he fell off his bed . Review of the Actions, Progress, and Resolution section of the facility's VHA issue brief (system report of fall incident) dated 11/04/19, also revealed the following statements: DON and SDC held reenactment scene with CNA that was providing care to resident when fall took place. Education provided on: Safely repositioning resident prior to brief change by using draw sheet to pull resident closer to person prior to turning . Review of 10/27/19 R1's Hilo Medical Center Emergency Physician (MD1) notes documented: This is a [AGE] year-old male with history of dementia who has one word nonverbal status . He has an impacted left femoral neck fracture. Due to his nonambulatory status he will not be a candidate for operative management. We will place him in a knee immobilizer so he does not flex his knee and thus flex his hip. I have given him a dose of [MEDICATION NAME] as he has had Tylenol for pain at the outside facility. I am going to recommend Tylenol first and [MEDICATION NAME] second for pain management for him. The patient was discharged back to the nursing home. Review of Progress Notes revealed R1 had ongoing pain after the fall. Entries included: 10/28/19 01:28 During perineal care (peri-care) at approximately 06:30 PM, CNA attempted to turn resident to his right side to change his brief when she observed resident with facial grimacing and moaning. CNA asked if he was in pain and resident nodded his head . 10/28/19 23:36 Denies any pain or discomfort however, during rounding and re-positioning, resident was observed with facial grimacing and soft moaning. 10/29/19 02:39 Denies pain. Reported some facial grimacing during incontinence care. 10/29/19 14:59 Resident noted to be in pain upon movement in bed by two-person assistance with ADL care. 10/29/19 23:32 Denies any pain or discomfort however, resident is observed groaning and guarding Left Lower Extremity (LLE) during peri-care and re-positioning. 10/30/19 01:22 .facial grimacing and other nonverbal cues of pain during bed mobility . 10/30/19 14:37 .Resident noted with facial grimacing and saying ow during rounds. Review of Medication Administration Records (MAR) revealed prior to the fall, R1 had an order in place dated 02/25/18 for [MEDICATION NAME] (Tylenol) tablet 325 mg (milligrams) every six hours as needed for mild pain not to exceed over three grams in 24 hours. The MAR from 10/01/19 through 10/26/19 revealed R1 did not need or receive any Tylenol for pain during that period of time. After the fall (10/27/19), a new order for pain medication was entered for [MEDICATION NAME] Capsule 5 mg. via pe[DEVICE] (tube in patient's stomach through the abdominal wall because of difficulty swallowing) every four hours needed for moderate to severe pain. The MAR further documents medication was administered for pain as below: 10/27/19 Tylenol 325 mg prior to transport to the hospital. 10/28/19 Tylenol 325 mg at 08:36 and 18:47. 10/29/19 Tylenol 325 mg at 01:01 and 18:30, and [MEDICATION NAME] at 11:46, 18:30, and 23:26. 10/30/19 Tylenol 325 mg at 10:00 and 19:42, and [MEDICATION NAME] at 06:48, 17:20, and 23:04. 10/31/19 Tylenol 325 mg at 06:45 and 18:10, and [MEDICATION NAME] at 03:39, and 13:34. 11/01/19 at 20:00, a new pain medication order was entered for [MEDICATION NAME] twice a day with the PRN as needed ([MEDICATION NAME] HCL tab 5 mg give 5 mg via [DEVICE] two times a day for PAIN.) R1 received the scheduled [MEDICATION NAME] twice a day 11/01/19 through 11/13/19. On 11/11/19 and 11/12/19 he required one additional PRN dose of [MEDICATION NAME], and on 11/13/19 R1 required two additional PRN doses of [MEDICATION NAME]. On 11/14/19 at 01:05 PM during an interview with the SDC and DON, the SDC said she reviewed the incident with the employee on her first day back to work. She said she provided education to CNA1 in the room with the resident in bed, after doing a reenactment of the fall. CNA1 roll played and described where she stood, where R1 was positioned in bed, and how he moved. When the SDC was asked what they determined the cause of the fall was, she said, positioning, he rolled over a little more than usual. He was more positioned on that side of the bed than when she usually works with him. SDC said the CNA1 was giving him (R1) cues so they would be coordinated with the turning procedure. The DON stated, We also identified during the reenactment that CNA1 should bring him closer to her first before moving. On 11/14/19 at 03:30 PM, observed that R1's bed had upper assist rails attached to help him with bed mobility/repositioning. At 03:35 PM observed CNA2 in R1's room preparing to provide care. CNA3 came to assist, and they provided peri-care and changed his brief. When R1 was rolled, he would grimace and groan loudly. He did this both times he was rolled to change his brief. When the two CNA's were asked if R1 groaned like that when they moved him prior to the fall, CNA2 said, No, he only does that after the fall. On 11/15/19 at 07:38 during an interview with R1's Physician (MD2), he said R1 had progressive dementia. When he came in, he had a significant mental health [DIAGNOSES REDACTED]. MD2 confirmed R1 had not been taking anything for pain prior to the fall .Surgery is not worth the risk, and treatment course is clear with comfort measures. The fracture, I expect will take three months to heal. There was sufficient evidence that the facility corrected noncompliance and is in substantial compliance at the time of the current survey for F-tag 689. Interventions and Findings include: 1. DON and SDC held reenactment of scene with CNA1. Education provided on: safely repositioning resident prior to brief change by using the draw sheet to pull resident closer to person prior to turning; obtain second staff member to assist with check and change and repositioning for safety if at all in doubt of resident's ability to assist . 2. RR revealed on 11/01/19 CNA1 completed the Competency Checklist titled, Moving a Resident in Bed. This competency included specific technique to move a resident safely with draw sheet utilizing one or two persons. 3. During interview with DON, discussed post event staff training. DON said she determined to retrain only the CNA involved in the event, as there were no other incidents or falls related to positioning. This was validated by RR of incident log. DON stated her decision was also because all CNA's are required to complete the mandatory Moving a Resident in Bed competency in orientation. RR confirmed all CNA's currently on staff had documentation of completing the competency. 4. On 10/28/19 R1's care plan was updated to reflect two persons assist with ADL's and incontinence care. 5. On 10/28/19, the CNA Kardex (task instructions) was updated to communicate to all CNA's the change of two persons assist for ADL's and incontinence care. 6. A new intervention included adding transfer bars to assist P1 with bed mobility and promote participation with care. RR revealed on 11/01/19 R1's POA (Power of Attorney) signed consent for the use of transfer bars. On 11/14/10, observation confirmed the bars were installed on R1's bed. 7. Ongoing staff huddles were held with all staff with a focus on safety, fall prevention and reporting any resident changes that might affect need for additional assistance. 8. On 11/14/19 observed brief change and peri-care provided by two CNA's according to R1's updated care plan. 9. All residents who were one-person assist were reevaluated for appropriate assessment, and emphasis in huddles to report resident changes that might require a change in assistance.

Based on observation, record review, interview and a review of the facility's documentation, the facility failed to ensure each residents' risk for elopement/wandering was thoroughly evaluated/assessed, and failed to ensure adequate supervision was provided to their residents to prevent the elopements from occurring for four of 32 residents (Resident (R) 40, R63, R50 and R5) selected for review. As a result of this deficient practice, R40's safety was endangered when he eloped and was found about three miles from the facility on 6/17/18. R63's safety was endangered as he eloped and was found walking on the driveway on 9/16/18; R2's safety was endangered as he was found outside the facility's first floor entrance on 1/21/18, and, similarly for R50, who was found unsupervised outside the front office door on 9/9/2018. In addition, the facility failed to ensure their upgraded door alarm system was being checked on the weekends. R4, R63, R2 and R50 eloped or found a way out of the facility on a Sunday. Staff also failed to follow the residents' care plan interventions for monitoring their residents, and the cumulative effect of the deficient practices led to an ongoing situation where the non-compliance is likely to cause serious injury or harm to the 26 residents deemed at risk for wandering/elopement out of the total census of 84. Findings Include: 1) Record review found that resident (Resident (R) 40) was admitted to the facility in (MONTH) of (YEAR) with several diagnoses, including high blood pressure, [MEDICAL CONDITION], anxiety disorder and impaired physical mobility related to a history of a left [MEDICAL CONDITION]. R40 also had a care plan for his elopement risk/wandering related to his [MEDICAL CONDITION], impaired safety awareness and exit seeking behaviors. The interventions included monitoring and documenting any wandering behavior. During the survey, R40 was observed sitting in his wheelchair in his room or the Ohana 1 TV lounge area. He was able to self-propel himself around the unit and had a wander guard alarm bracelet on. On 9/19/18 at 1:11 PM, RN3, the unit manager, stated the resident could also walk, but preferred his wheelchair. Random observations found R40 to be alert when up in his wheelchair and able to move around freely on his unit. R40 was identified on a facility reported incident (FRI) as having eloped from the facility on Sunday, 6/17/18. Per the FRI, R40 was found that morning approximately three miles from the facility in downtown Hilo, by an off-duty certified nurse aide (CNA) 1. The facility's investigation noted R40 was last toileted around 9:30 AM and he stayed by the main TV lounge area. The charge nurse, registered nurse (RN) 1, documented the resident was in the facility specifically in the TV lounge area from 9:00-11:00 AM. However, it was revealed from an interview with CNA1 who found R40, that RN1's documentation of R40's whereabouts that morning had been falsified. The facility had not known that R40 was missing from their facility. On 9/19/18 at 2:40 PM, an interview with CNA1 was done. CNA1 stated she spotted R40 on Sunday, 6/17/18 in the downtown Hilo area while on her way to church. She recalled it was between 10:00-10:30 AM, when she passed R40 sitting in a wheelchair, unattended, by a nearby store. CNA1 recognized R40 and said, When I passed him, just how he sits and has a plaid jacket, so when I turned around I called the facility and that's when I got to him. She said she spoke to RN2 (no longer at the facility), who asked her to stay with R40 until they could arrange to pick him up. CNA1 said when she found R40, he was pretty clear and asked how he got there along with the plate of food on his lap. R40 told her he used his wheelchair to come down the hill, using his brakes and there was grass on the wheels of his wheelchair. She said R40 was able to show her how he used the brakes on his wheelchair. CNA1 said R40 did not tell her about riding down the hill with a lady from the facility. But he did first say the lady with the red truck gave him the food. CNA1 stated she told the Assistant Administrator (AA) and the Director of Nursing (DON) that R40's version was not what RN2's 6/17/18 progress note stated. CNA1 told them R40 told her, I used my wheelchair, and showed how he used his brakes. RN2's progress note however, stated R40 indicated he had a ride in a truck and a woman bought him breakfast. But he also was confused upon his return to the facility around 11:30 AM, and could not state how he eloped from the building. CNA1 said she did not return to the facility with R40 since it was her day off. She verified although she was the first witness to see and speak with R40 that morning, her account of that day was not reflected in the progress notes nor in the facility's FRI or investigation. On 9/21/18 at 9:57 AM, CNA2 was interviewed. CNA2 said she was present when R40 returned to the facility around or after 11:00 AM on 6/17/18. She spoke to R40 while RN1 assessed him and recalled that R40 told her a lady gave him the plate of food on his lap. R40 also told her, went down the road. CNA2 said there was grass on his wheelchair tires and on his shoes. She recalled this because the administrator asked that it be cleaned up and she did it. CNA2 said R40 did not tell her that a lady gave him a ride down the hill. She said R40 is very fast in his wheelchair when he propels and, is always looking for a boat or his truck and will mention that. She said she is familar with R40 as she has cared for him. Record review revealed that RN1 was the day shift charge nurse on 6/17/18, which was Sunday, Father's Day. The facility had many visitors entering and exiting the facility using the Ohana 1 double door entrance. R40 resides on the Ohana 1 nursing floor. One of RN1's responsibility was to document/monitor R40 hourly as he was care planned to be at risk for wandering/elopement. Review of RN1's 6/17/18 clinical entries for the 0900, 1000 and 1100 hours showed R40 was in the facility. RN1 documented her entries on the Medication Administration Record [REDACTED]. On 9/21/18 at 8:35 AM, the Nursing Home Administrator (NHA) and DON verified that RN1 falsified her clinical documentation about where R40 was on the morning of his elopement on 6/17/18. The facility also failed to include CNA1's account in their investigation, and failed to ensure RN1's falsification of R40's clinical record was reported to the appropriate authorities, including the State Survey Agency (SA)'s (omitted in their FRI), Adult Protective Services (APS) and the Regulated Industries Complaint Office (RICO). 2) Even after the 6/17/18 elopement, the facility failed to thoroughly reassess residents deemed potentially at risk for elopement. On 9/19/18, the Assistant Administrator (AA) verified another elopement by R63 recently occurred on Sunday, 9/16/18. Record review revealed that on 9/16/18 at around 6:00 PM, R63 was found walking on the driveway outside of the facility. Prior to his elopement, R63 had been agitated and spoke about going home after being unable to contact a family member by phone. Then sometime after dinner, a CNA saw him through the second floor window and brought him into the facility. R63 was admitted in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. At the time, R63 did not have a wander guard placed. His care plan for elopement risk related to his [MEDICAL CONDITION] and history of wandering was developed after his 9/16/18 elopement. Yet, a resident with Alheimer's disease and a history of verbalizing wanting to go home had not been monitored for his whereabouts and safety on the day he eloped. 3) Further record review found a 9/9/18 1:41 PM nursing progress note whereby a licensed staff documented that R50 was found unsupervised and, out by the front door office. R50's record stated, Upon investigation, resident verbalized, 'I went there to get sunshine', asked how he opened it & stated 'I turn the door latch & the door open, I used to be maintenance worker before that's why I know all those'. Instructed resident to inform staff & the importance of being supervised because no office staff during weekends. Also offered alternatives to go outdoor garden. Resident verbalized understanding. Manager on duty aware. This event occurred on a Sunday. Record review found a 9/20/18 nursing progress note, which stated R50's physician authorized that R50 was allowed to go outside the premises of the facility unsupervised for relaxation and enjoyment, post incident. A 9/19/18 nursing entry found the resident was spoken to about safety concerns and staff were to periodically check him. Although the R50 verbalized his understanding, on 9/20/18, R50 had been left unsupervised, did open an alarmed door and exited to the front of the building. R50 resides on Ohana 1 and Ohana 2 (upstairs) is where the front office is. There also was a potential for other residents at risk for wandering/eloping to have gone out with R50, if they had been in the vicinity with him, with no staff present to prevent it. 4) In addition, review of an FRI for R2 revealed he had eloped on 1/21/18, Sunday morning at 3:25 AM. R2 was found outside of the facility standing at the first floor entrance, carrying his black bag. Staff redirected him back into the facility. R2 was also known to have a history of wandering and exit seeking behaviors. The facility did an audit of their elopement binders containing those residents identified to be high risk for elopement/exit seeking. Yet, there was no indication if the facility's alarm system had failed to alarm to notify staff that R2 had exited the facility when his elopement occurred, and similarly for R63, R50 and R40. 5) A review of the facility's door alarm system was done on 9/19/18 at 3:47 PM with the Environmental Services Director (ESD). As part of the facility's internal investigation as to how R40 had eloped, he said the staff knew R40 was in the TV room fronting the Ohana 1 double door entrance. He said he tested the doors at least 20 times, and found if someone walked in the middle of the doorway entrance, there was a brief moment of interrupting the signal such that the alarm would not trigger. The ESD stated 6/17/18 was a busy day per the visitor log with many people entering/exiting through the Ohana 1 doors. The ESD acknowledged that if R40 had exited through this, middle zone, R40 could have gone undetected as there was a potential his wander guard signal would not have triggered the alarm. The ESD stated, So if you test it every time with no one around, it works. So later I found out we had to change the frequency, but that's later. The ESD and his maintenance staff found that the frequencies from various signals emitted by other electronic devices affected their alarm system. The ESD said they, had to lower the frequency to pick up the wander guard transmitting signal. Yet, a review of the Daily Wander Guard Test from a 1/1/18 to 9/19/18 printout revealed there was no indication this was done. There also was missing information as to how his staff were testing/checking the alarms at specified door locations. Review of the printout also found that all of the weekend checks that were to be done, were all missing and not documented. Thus, on the day R40 eloped, Sunday, (MONTH) 17th, there was no documentation the Ohana 1 or Ohana 2 door alarms had been tested /checked. On 9/19/18 at 4:32 PM, the NHA was also interviewed with ESD. The NHA stated there was an upgrade to their system, but when they converted their data, they did not do a thorough review. The NHA said they also had no hard copies of their wander guard and/or door alarm checks. The ESD stated he relied on two maintenance staff to do the weekend door alarm checks, but he would input their results into their system on Monday mornings. The ESD said if his staff did not tell him that, it was broken, then he would enter, that everything is fine. On 9/19/18 at 5:52 PM, in response to how the facility could demonstate standardization of testing their alarm system, the NHA stated although the ESD inserviced his maintenance staff verbally, nothing was written. Further, on 9/20/18 at 8:50 AM, although the NHA produced another printout, Historical Meter Readings from 1/1/18 to 9/20/18, the documentation showed the Location of testing as either, pass, 2, pass/2, entry, and the Reading as 0, pass, 2. There was no notation of what the values/codes meant on the printout. In addition, it was found that Ohana 1's floor map showed approximately seven exit doors, which were not accounted for in the facility's overall alarm testing system. 6) On 9/20/18 at approximately 3:05 PM, the facility was notified of an immediate jeopardy (IJ) based on the investigations related to the residents' elopements. There also was an omission of pertinent information related to R40's elopement within the facility's FRI to the SA and their own investigation, which included the neglectful action by RN1 to monitor R40, and then falsifying the record about it. The NHA stated it was, inaccurate documentation by RN1 and that RN1 had been written up for it. This was reaffirmed on 9/21/18 at 10:28 AM which the NHA and DON verified RN1 falsified her documentation about R40 being in the TV lounge area at 10:00 AM on 6/17/18, when he was not. The IJ was abated on 9/21/18 at 12:12 PM with an acceptable Preformance Improvement Action Plan (PIAP). This included residents who were assessed to be at risk for wandering/elopement and whom had not been thoroughly evaluated. It also included the facility's door alarm system, for which the daily function checks of their wander monitoring system was not being documented. Substandard quality of care was identified with the IJ. As such, the SA returned to the facility from 10/10/18 through 10/12/18 to complete the extended survey. On 10/10/18 at 1:47 PM, the DON and NHA verified there had been no further elopements from their facility since the IJ abatement on 9/21/18. On 10/11/18 at 8:40 AM, the NHA presented an updated PIAP for the SA to review during the extended survey. The quality assurance performance improvement (QAPI) review was done with the NHA and DON on 10/12/18 at 9:10 AM. The NHA stated in review of their past elopements, there was a failure of their assessments and it was a systems error. The NHA explained after R2 eloped in (MONTH) (YEAR), although they had put in extra alarms at the doors, it was not loud enough so amplifiers were placed at the side door he got out from. The NHA presented further documentation showing all their residents were thoroughly re-assessed, that alarms were placed at every exit door, all staff were in-serviced on the implementation of their corrective measures, the falsification of documentation by RN1 was reported to the proper authorities, daily documentation to check the functionality of all exit doors alarms to be conducted each shift was to be implemented, a new out of pass procedure and education for residents/POAs was done and, a qualified technician was to conduct/document quarterly functionality checks of their alarm system. Further, the NHA stated an elopement is a never event and with the new corrective actions in place as of 9/24/18, the SA found it as a credible allegation of compliance (A[NAME]) and the scope and severity of the IJ was reduced to E, no actual harm with potential for more than minimal harm.

Based on observation, interview, review of facility event reports and resident records, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 3 residents in the sample. (Residents # 3, #19, Add-on Resident #1) Findings include: 1) The facility did not ensure protection from mistreatment for two female residents, Resident #3 and Add-on Resident #1 from Resident #1 touching them inappropriately. Cross reference to F225, F250, and F319. There were 3 documented incidents of mistreatment against female residents by Resident #1. The first incident was reported to the Department of Health, Office of Health Care Assurance (OHCA) on 11/14/09. The facility reported that an alleged sexual abuse incident occurred on 11/13/09 where Resident #1 "was found to have his hand under resident ..name... (victim) shorts on top of her thigh. Residents were immediately separated." The facility determined that "actual sexual abuse is ruled out, however, there was potential for this." The corrective actions include immediate separation of the two residents, "the perpetrator was placed on 30 minutes checks.", his care plan was updated. Record review found a care plan dated 11/14/09 titled "Altered Behavior Plan as evidenced by inappropriate touching of female residents/female staff." Interventions on the care plan included: 1) Discourage inappropriate sexual behavior by telling him "Its inappropriate"; 2) Social Services referral; 3) Divert resident to activities; 4) Keep resident away from vulnerable female residents. Know his whereabouts. 5) Place on watch and document inappropriate behavior; 6) Report behavior to important parties such as MD, Family, SS, etc.; 7) Huddle/inservice staff on res. Inappropriate behavior/approaches. The care plan was not specific as to what was meant as "place on watch". Interview with a licensed nurse on the afternoon of 2/23/10 found that the resident was placed on a 30 minute watch. When asked what was meant by 30 minute watch, the nurse stated that every 30 minutes they need to check on his whereabouts and document that he was checked. Interview on the afternoon of 2/23/10 with the DON confirmed that the resident was on a 30 minute watch. The nurse and DON did not answer how the resident was being watched between the 30 minute check, since he would be able to approach and touch a female within a time period of less than 30 minutes. The record contained Social Services Progress Notes dated 11/16/09 of his inappropriate touching of other female residents. It noted that he was alert and oriented to self and place. He had no recollection of touching other female residents. The social worker reiterated to him that staff doesn't tolerate inappropriate behavior, and that the focus is to keep all residents safe. No other intervention needed at this time was documented. The MDS dated [DATE] and 1/3/10 had the resident coded as "2" (moderately impaired) for cognitive skills for daily decision making. Although the resident had short term memory problem, it was not determined whether a verbal reminder that staff not tolerating inappropriate behavior and keeping residents safe would be remembered and understood by this resident. The facility did not initiate a comprehensive psychosocial evaluation of Resident #1 to assess the inappropriate behavior of touching female residents and what interventions would be appropriate based on that assessment. The second incident was reported to the Office of Health Care Assurance on 12/7/09. The report noted that on 12/4/09 at 6 P.M. Resident #1 was found with his hand on Resident #3's breast. The incident was observed and discovered by a housekeeper, who with a RNA separated the two residents. Facility ruled out abuse and neglect. The event report documented that the alleged abuse was reported to the administrator (administrative designee) on 12/7/09. As the event occurred on 12/4/09 the alleged abuse was not reported immediately to the administrator or to the OHCA. On 12/7/09, there was a revision to the care plan, with another problem was added titled "(name) displays concerns for residents and interacts with others easily with cognitive deficits and self awareness.... with an 8th intervention added to the care plan. "8) Provide gentle reminder of others feeling of privacy and space relations." He was also moved to the 1st floor of the facility as there were "less vulnerable female residents". The care plan after the first incident of 11/14/09 did not provide adequate protection for the female residents, as evidenced through a 2nd incident where he placed his hand on Resident #3's breast. After the second incident of mistreatment, the facility did not take aggressive action to protect female residents. There was no change in the timing of the 30 minute checks, although that proved to be unsuccessful. There was no thorough comprehensive assessment of the behaviors, including past history, any issues of change in the past few months, time of day of the occurrences, triggers, or any screening for his mental status. On 1/7/10 a care conference note was completed by social services. It documented that the resident denied any mood issues at this time. Also, "Activity noted resident has a hx of sexual behaviors towards female residents breasts. Upon further discussion staff reports resident is affectionate ... has impaired vision. So previous incidents of touching female residents was r/t being friendly ...not having an awareness of where he is touching. Staff agrees resident does not target other residents has no signs of being a sexual predator." The notes documented to follow up with vision exam. It did not address the protection of female residents from mistreatment, whether or not he had impaired vision. Also, the issue of the boundaries of his friendliness was not addressed. Record review on the afternoon of 2/22/10 located a 3rd incident involving Resident #1 mistreating a female resident. The nurses notes dated 1/7/10 at 2250 documented that Resident #1 was "following a female resident also in w/c, holding & kissing her hand before being quietly relocated by staff, x2." The licensed nurse noted that the "30 min monitoring" check by RN is actually continuous monitoring by staff". In an interview with the DON on the afternoon of 2/23/10, a copy of the incident report was requested, however, she stated no incident or event report for this mistreatment had been done. The DON reported she did not have knowledge of this and did not know who the female resident was. She reported that the incident should have been reported to her, and an incident report should have been generated. A copy of the incident report was not provided to the surveyor by the exit conference on 2/26/10. On the afternoon of 2/25/10 in an interview with the DON and the corporate senior nurse consultant it was learned that the facility had written an incident report for alleged victim. Upon surveyor request, the DON provided the alleged victim's name, and she is noted as Add-on Resident #1. Record review on the afternoon of 2/25/10 for Add-on Resident #1 found she resided on the same floor as Resident #1. There was no care plan related to the 1/7/10 incident. Social services documentation had 3 entries dated, 1/9, 1/26 and 2/11/10. The entries did not address any issues related to the alleged mistreatment/kissing incident. Social services did not provide any services related to the alleged mistreatment incident. The facility failed to implement facility policy and procedure to report immediately any alleged abuse, neglect, or mistreatment of residents. There was no corrective action for Add-on Resident #1. There was no effective and appropriate corrective action after the 2nd incident as the care plan failed to keep the resident away from inappropriately touching female residents. 2 ) The facility did not ensure Resident #19 was free of mistreatment resulting in actual harm and decline of mood/behavior patterns and psychosocial well-being. The facility reported to the Office of Health Care Assurance on 2/2/09 an event of alleged resident to resident abuse. On 2/2/09 Resident #19 reported an allegation of sexual abuse. Resident #19 reported that on 1/31/09 at approximately 8:00 P.M. while completing his shower, his roommate, Resident #18 entered the shower. Resident #18 reportedly was nude, holding his penis in his hand and attempted to "mount" him. Resident #19 reported he utilized a "half Nelson" to stop Resident #18. Resident #19 also reported at approximately 15 minutes following the altercation, Resident #18 opened the privacy curtain, opened his robe exposing himself with his penis in hand and pursed his lips. Record review was done on the afternoon of 2/24/10 and 2/25/10. Resident #19 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with assessment reference date (ARD) of 11/21/08 notes Resident #19 has short term and long-term memory problems and coded "2" (modified independence) for cognitive skills for daily decision-making. Following Resident #19's report, a skin assessment was done. The Nurse's Notes dated 2/2/09 noted the following results of the assessment: reddened discoloration to left elbow (2.5 cm. x 1.5 cm.), left forearm (2.5 cm. x 1.5 cm.), and right lateral forearm (3.5 cm. x 1.5 cm.). Also noted in the "Verification of Investigation" report, Resident #19 was sent for x-ray on 2/5/09. Results found Resident #19 has [MEDICAL CONDITION] disc disease on C-spine and there is a grade 1 anterior slip of C7 on C6 and [MEDICATION NAME]. Review of the care plan developed on 2/2/09 included the following approaches: Protect Resident #19, remove and relocate alleged perpetrator from room where incident occurred; Encourage Resident #19 to express feelings to staff regarding alleged resident-to-resident incident; Encourage and praise positive statements by Resident #19; Assess for physical pain associated with alleged physical altercation, provide medication PRN; and Monitor for s/s of behavior and mood changes. Review of the Social Services Progress Notes found a note dated 2/4/09 that Resident #19 divulged he has a history of sexual molestation by a Catholic priest while he was in the 5th and 6th grade. Also noted Resident #19 reported, Resident #18 was seen on the 2nd floor in activities. Resident #19 stated "I want him out of sight". The Social Worker informed Resident #19 that Resident #18 has a right to attend activities on the second floor and suggested Resident #19 remain in his room to read. Resident #19 responded "I don't want to feel like a prisoner in my own room. I don't want to have to look over my shoulder all the time. Can't he just play cards downstairs on the first floor? I don't have anywhere else to go. There are no other nursing homes that I could afford". The Social Worker then informed Resident #19 that there are other long term care facilities that he could consider if he wants to leave. A late entry by the Social Worker dated 2/20/09 documents Resident #19 attended his care plan meeting. At this time resident is noted to express to the interdisciplinary team that he "momentarily gets anxious when male nurses come into room to take vitals". The Social Worker further notes that resident "attributes reaction to previous childhood molestation by Catholic priest and recent alleged incident. He recognizes reaction to male nurses, yet is understanding that they are there to provide care to him". Review of the care plan found revision dated 2/19/09 identifying the concern that resident expressed reaction to male caregivers related to status [REDACTED]. The approach added to care plan was "Consults as ordered". A social work note dated 2/5/09 documents Resident #19 was scheduled for an appointment with a psychologist on 2/10/09. There was no documentation of notes from psychologist. Interview with the Director of Nursing (DON) on 2/25/10 at 9:15 A.M. confirmed Resident #19 was seen by the psychologist. DON reported that he was seen twice as evidenced by documentation by the resident's transporter. A request was made to the DON to review the psychologist's notes or documentation of the resident's progress in counseling or that counseling was no longer needed. Documentation was not provided prior to exit. Review of the admission Minimum Data Set (MDS) with assessment reference date of 11/21/08 noted in Section E. Mood and Behavior Patterns, Resident #19 coded "0" (indicator not exhibited in last 30 days) and was checked for "At ease interacting with others" under psychosocial well-being. Following the alleged incident a quarterly MDS with ARD of 2/15/09 was done. MDS noted in Section E1. Indicators of Depression, Anxiety, Sad Mood, Resident #19 coded "1" (Indicator of this type exhibited up to five days a week) for the following: persistent anger; repetitive health complaints; sad, pained worried facial expressions; withdrawal from activities of interest; and reduced social interaction that is not easily altered. Subsequent quarterly MDS with ARD of 7/12/09 noted Resident #19 continued to code "1" for persistent anger with self or others; repetitive health complaints; and sad, pained, worried facial expressions. Interview and concurrent review of the MDS and care plan with DON was done on 2/25/10 at 10:05 A.M. It was noted that Resident #19 exhibited a decline in mood and behavior following the alleged sexual abuse in February and continued to exhibit mood/behavior in the July assessment. Also, noted that resident had expressed his anxiety regarding male care givers. Concurrent review of the care plan, the DON confirmed that the care plan revision to address resident's anxiety of having male care givers to obtain consults as ordered did not address the resident's concern. The DON also confirmed there was no documentation of care plan to address resident's mood/behaviors and was agreeable to review the chart further. Care plan addressing resident's mood/behaviors was not provided for review prior to exit. A review of the facility's completed investigation, "Verification of Investigation" by the Social Worker dated 2/6/09 found that there was evidence of physical altercation that was confirmed by skin assessments of both the alleged perpetrator and victim as well as the results of Resident #19's x-ray. However, "sexual assault" was not confirmed. The facility failed to protect the resident during the investigation period. On the second day of investigation, Resident #19 (alleged victim) encountered Resident #18 (alleged perpetrator) during activities when Resident #18 was accompanied by staff to activities. Resident #19 was told that the alleged perpetrator has a right to attend activities and it was suggested to Resident #19 to remain in his room. The facility failed to provide appropriate interventions to Resident #19 who was displaying mental/psychosocial difficulties (persistent anger, repetitive health complaints, sad,withdrawn from activities of interest and reduced social interaction) following the incident of alleged sexual abuse. There is no documentation of care plan based on an assessment to address mental/psychosocial difficulties. Resident #19 also informed staff that he was anxious with having male caregivers related to alleged incident of sexual abuse and history of sexual molestation. The facility did not revise resident's care plan with appropriate interventions. The facility did not follow their policy and procedure for "Abuse - Allegation and Reporting", a behavioral evaluation and appropriate care plan was not done and corrective action was not taken resulting in resident experiencing mood and psychosocial decline related to alleged sexual abuse and the resurfacing of past trauma, history of sexual abuse. 3 ) The facility submitted an Event Report to the Office Of Health Care Assurance reporting on 12/4/09 at approximately 6:00 P.M. a Housekeeping staff witnessed Resident #1 fondling Resident #3's breast. The residents were seated in the TV room on the second floor. The housekeeping staff reported it and the Restorative Aide assisted in separating the residents. Record review done on the afternoon of 2/22/10 and morning of 2/23/10 notes Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with assessment reference date (ARD) of 10/8/09 notes resident coded "2" (moderately impaired) for cognitive skills for daily decision-making. Resident also noted to be easily distracted with periods of altered perception and restlessness. Resident also noted to have disorganized speech. Review of the social work progress note dated 12/8/09 documents resident is not displaying ill effects from the occurrence of 12/4/09. A review of the behavior monitoring flow sheets found there was no increase in agitation or aggression. Review of the care plan did not find documentation of a care plan to protect Resident #3 from reoccurrence or preventing resident from becoming a victim to other residents. Interview with Social Worker on 2/23/10 at 9:40 A.M. confirmed there was no care plan to address how Resident #3 will be protected.

Based on review of facility's incident report sent to the Department of Health (DOH), Office of Health Care Assurance (OHCA), closed record review, and staff interviews, the facility failed to monitor anticoagulant medications given to one (Resident #17) of 19 residents in the case sample. Findings include: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility submitted an incident report to the DOH/OHCA for Resident #17 on 1/14/10. The resident was sent to an emergency room during the night shift on 1/8/10 as he vomited pink emesis. Staff reported small amount bloody discharge on the resident's penis. The resident's blood pressure was inaudible and oxygen saturations would not register. The resident remained alert, responsive, and verbal, but respirations were noted to be labored even after a nebulizer treatment. The physician was notified of the resident's condition and ordered transfer to the emergency room for evaluation and treatment. On 11/18/09, PT/INR was done and MD aware of results; lab results in chart (PT 19.5 sec. (normal 11.5-14.5); INR 1.66 (Therapeutic range 2.0-3.0; 2.5-3.5 mechanical prosthetic valves, prevention of recurrent MI)). Physician notes on 11/25/09 indicate MD was considering ordering PT/INR every 2 weeks. Physician order [REDACTED]. The PT/INR lab was drawn on 11/26/09. There was no documentation regarding the lab results of 11/26/09 (PT 33.5 sec.; INR 3.20). The facility did not follow-up on the missing lab results and the physician was not notified. On 1/7/10 at 8:45 A.M., the lab called results of PT > 100 sec. (normal 11.5-14.5 sec); INR > 12; (Therapeutic range 2.0 - 3.0; 2.5 - 3.5 (Mechanical prosthetic valves, prevention of recurrent MI)). The physician was notified of the critical abnormal lab values and ordered to hold [MEDICATION NAME] and ASA on 1/7/10 and 1/8/10; repeat PT/INR in the evening of 1/8/10. The resident was transferred to the emergency roiagnom on the morning of 1/8/10 as the resident's condition declined. Review of the hospital's emergency room note indicated the resident was transferred on 1/8/10 at 0438 with primary [DIAGNOSES REDACTED]. Progress note dated 1/8/10 at 0616 stated "pt arrives with low BP, in [MEDICAL CONDITION] with rapid ventricular response and feeling gen weak. Pt has multiple bruises on forearms, known pt to be toxic on [MEDICATION NAME] and nursing home held evening dose, will start transfuse FFP, give vit K and obs for any further bleeding. NG tube, no BRB, guiac stools, neg, noted Hgb is stable at 10 ...." Closed record review on 2/23/10 found an Admission Minimum Data Set with assessment reference date of 11/24/09. The resident was coded as moderately impaired in cognitive skills for daily decision-making and required extensive assistance with activities of daily living. Further review of the record found Physician orders [REDACTED]. 11/17/09 [MEDICATION NAME] 2 tabs po qd; ASA 81 mg po qd. 11/23/09 [MEDICATION NAME] 20 mg po qd; depression. 11/30/09 [MEDICATION NAME] 50 mg po qd; [MEDICAL CONDITION]. Physician's progress note dated 11/25/09 noted "Pharmacy worried about his INR since starting [MEDICATION NAME] and [MEDICATION NAME] --- so will draw q2 weeks". Review of "Alert Charting" dated 12/19/09 at 1455 noted "bruise to right flank 24 x 12 cm". Resident could not explain how he received the bruise. Review of the Transfer/Discharge Summary with transfer date of 1/8/10 noted under Skin Assessment, "various bruises to chest and BUE". Interview with the consultant pharmacist on 2/25/10 at 10:15 A.M. revealed with the addition of [MEDICATION NAME] and [MEDICATION NAME] to the resident's anticoagulant therapies, closer monitoring of PT and INR levels should be done. Interview with the DON during survey confirmed the facility is responsible to follow-up with the physician and monitor the resident's PT and INR levels while on anticoagulant therapy.