Aloha Nursing & Rehab Centre

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. After exiting a Transmission Based Precaution (TPB) room (a COVID positive resident), Certified Nurse Aide (CNA) 57 was not wearing applicable Personal Protective Equipment (PPE), Registered Nurse (RN) 127 did not perform glove change and any hand hygiene while performing wound care for resident (Resident (R) R104). The facility also failed to assure Resident (R) 67's urinary catheter bag was hanging and not on the ground while he was in bed. These deficient practices placed the resident at risk for developing preventable infections and other adverse health complications. Findings Include:
1) Record review of R67's Electronic Health Record (EHR) on 07/29/25 revealed he is a [AGE] year-old who was admitted to the facility on [DATE]. Review of R67's Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 07/22/25 revealed his Brief Interview for Mental Status (BIMS) summary score was 13 identifying him as cognitively intact. R67 was also coded as having an Indwelling catheter (suprapubic catheter) under Section H: Bladder and Bowel. Review of the facility provided matrix also coded resident as having a suprapubic catheter.
On 07/30/25 at 10:19 AM observed R67's urinary bag on the ground near his bed. At this time requested Registered Nurse (RN) 21 come to R67's room. Inquired of RN21 if R67's urinary bag should be left on the ground and RN21 stated it is supposed to be hanging, that it might have got knocked off the bed frame when or if the resident moved his bedside table. Inquired with R67 if he moved his bedside table and he said no.
2) On 07/29/25 at 09:15 AM, observed CNA57 exiting the room of a Covid positive resident, wearing a regular mask and not a N95 mask. Interviewed CNA57 and she confirmed, she should have been using a N95 mask instead of a regular mask to prevent spread of Covid.
On 07/29/25 at 09:30 AM interview with Registered Nurse (RN) 66, noted that for TBP and prevention of the spread of COVID, all staff should be wearing, gloves, gown, face shield, and N95 masks.
On 08/01/25 at 08:45 AM interview with Director of Nursing (DON) confirmed that for the prevention of COVID, staff should be wearing N95 masks.
On 08/01/25 at 01:15 PM, review of the “Precautions” postage in front of the TBP room noted, “before entering room, everyone must: including visitors, doctors, staff…must use a NIOSH-approved N95 or equivalent.”
On 08/01/25 at 01:30 PM, review of the facility's “Infection Control-Transmission Based Precautions” policy, with revised date of 04/17/25, in the “Explanation and Compliance Guidelines” section, it notes for “Airborne Precautions, d. If unable to transfer resident to an AIIR room, as in the case of COVID-19 infection, the facility will follow Center for Disease Center (CDC) guidance…staff will wear N95 or equivalent respirator and other PPE while delivering care to the resident.”
On 08/01/25 at 01:30 PM, review of the facility's “COVID-19 Risk Mitigation Plan,” with revised date of 04/17/25, in the “Isolation Strategies and Resident Placement Considerations” section, it notes, “n. Wear appropriate PPE: gown, N95 mask, eye protection and gloves.”
3) On 08/01/2025 at 10:15 AM, observed RN127 performing wound care to R104's sacral ulcer. RN127 cleaned R104's feces with wipes, did not change gloves, and complete any hand hygiene before proceeding with applying wet gauze and foam dressing to R104's sacrum.
On 08/01/25 10:30 AM, interview with RN127 noted that they are not supposed to change gloves in between dressing changes (RN127 was to complete sacral and right foot ulcer dressing), but acknowledged she should have changed her gloves and performed hand hygiene after wiping R104's feces prior to applying wet gauze and foam dressing to sacrum. RN127 agreed that changing gloves and completing hand hygiene prevents worsening of R127's sacral infection.
On 08/01/25 at 10:46 AM, interview with Unit Manager (UM) 2 confirmed that hand hygiene should be completed before and after each task and going from dirty to clean tasks to prevent infection.
On 08/01/25 at 01:00 PM, record review of R104's Electronic Health Record (EHR) noted R104 has stage IV pressure ulcer (PU) to sacrum and right lateral foot. R104's care plan noted he is currently on Intravenous (IV) antibiotic therapy for sacral wound infection.
On 08/01/2025 at 11:50 AM, interview with Infection Preventionist (IP) nurse noted that staff are supposed to be changing gloves and doing hand hygiene in between dressing changes. IP also stated that RN127 should have changed PPEs after cleaning feces to ensure that there was no contamination.
On 08/07/25 at 12:00 PM, review of the facility's “Wound Care” policies, dated 04/17/25, in the “Explanation and Compliance Guidelines” section, it notes “7. Dressing changes will be completed utilizing proper technique…” Review of the facility's “Hand Hygiene” policy dated 04/17/25, it notes, “Appropriate hand hygiene must be performed under the following conditions: 4. After having prolonged contact with a resident, 5. After handling used dressings…contaminated tissues, 6. After contact with…broken skin, 7. After handing items or work surfaces potentially contaminated with a resident's…excretion and secretions…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that medications and equipment in two of three medication carts and wound care supplies for one resident (Resident (R) 9) were stored and labeled in accordance with professional standards. Proper storage and labeling of medications and equipment are necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications and utilize equipment stored in the medication and treatment carts. Findings Include:
1) On [DATE] at 09:44 AM, a medication cup containing a white cream and tongue depressor was observed at the bedside of Resident (R) 9. At 09:47 AM, interviewed Registered Nurse (RN) 75 inside R9's room. RN75 stated that the white cream was Flagyl powder that was mixed with the cream and applied to R9's coccyx wound by the evening shift nurse. RN75 confirmed that it should not have been left by the bedside unattended and should have been discarded.
2) On [DATE] at 09:47 AM, an unlabeled bottle of Dakin's solution and unlabeled tube of Hydrogel was observed in a box placed in R9's nightstand. On [DATE] at 09:00 AM, interviewed RN75 regarding the bottle of Dakin's solution and tube of Hydrogel which was now located on R9's bedside table. RN75 stated the Dakin's solution and Hydrogel tube were provided by Hospice and were currently being used for R9's wound care. RN75 stated both items should have been labeled with R9's name, room number, and stored in the locked treatment cart. On [DATE] at 09:15 AM, interviewed the Director of Nursing (DON) in R9's room. The bottle of Dakin's solution and tube of Hydrogel remained on R9's bedside table. DON confirmed no matter who supplies the wound care treatments and medications (e.g. hospice, family, pharmacy), all should be labeled with at least the resident's names and locked in the unit's treatment cart when not in use.
3) On [DATE] at 07:57 AM, observed RN75 preparing medications. When RN75 left the medication cart and went into a resident's room, observed a medication cup with crushed medications was left on the medication cart under a stack of drinking cups. The medication cup was labeled with R108's name. At 08:04 AM, interviewed R75 upon returning to the medication cart. RN75 confirmed that the medication cup with the crushed medications should have been placed in the medication drawer and locked up before leaving the cart. RN75 stated the medicine cup contained Tylenol 500mg 2 tablets and Senna Plus 8.6-50mg 2 tablets.
A facility policy titled, “MEDICATIONS: STORAGE”, with a revision date of [DATE], noted “1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments…d. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards…”
4) On [DATE] at 08:51 AM during a medication cart observation with Registered Nurse (RN) 15 observed three residents (R) 97, R113, and R117 eye drops did not have the open on and discard by date. Inquired of RN15 if the eye drops should have had the opened on and discard by dates written on them and RN15 confirmed these dates were missing and should have been written on the label when the eye drops were opened.
5) On [DATE] at 08:58 AM an observation of a medication cart with RN15 was made of the glucometer control solutions that were expired, labeled as opened on [DATE] with a discard date written on the box of [DATE]. This was the only control solution observed in the medication cart near the blood glucose testing machine. Inquired of RN15 if the control solution should have been discarded and RN15 confirmed the control solution should have been thrown away when it expired on [DATE].

Based observation, interviews and review of the facility's Food Management System policies, the facility failed to monitor and check the dishwasher sanitizing temperature logs on a consistent basis, properly label open food items in the freezer, and discard food items in the refrigerator by its use-by date. This deficient practice places residents in the facility who are provided with meals, at risk for foodborne illness.Findings Include:1) On 07/29/25 at 08:00 AM, initial walkthrough of the kitchen with Kitchen Staff (KS) 1, noted dishwasher heat sanitizing log with missing temperature checks for the following dates and mealtimes for the month of July:07/08-07/29, missing dinner check07/11-07/20, missing breakfast check07/25-07/27, missing breakfast check07/27, miss lunch checkConcurrent interview with KS2 noted the missed documentation and she forgot to check temperature on some of those days. Both KS1 and KS2 confirmed that the dishwasher sanitizing temperature should be checked three times a day, every day when washing dirty dishes after each meal to ensure dishes and utensils are being sanitized appropriately before being reused. 2) Observed in refrigerator, a storage container bin with tomato pastes with use-by date of 07/27/25, a container of ham with use-by date of 07/23/25, and a container of green leaf lettuce with use-by date of 07/26/25 still in the refrigerator. Concurrent interview with K2 noted that staff forgot to check the refrigerator and throw out food that were past the use-by date. K2 noted that foods should be discarded by the use-by date to ensure that foods being served to residents are not spoiled and to prevent foodborne illness.3) Observed in freezer, an open bag of carrots and open bag of boiled eggs without any labels of when it was first used. K2 noted that staff forgot to label the items with an open and use-by date. K2 confirmed that properly labeling food items helps to identify the use-by date and to keep old food from being served to residents. On 07/30/25 at 01:30 PM, interview with Dietary Manager (DM) confirmed that the dishwashing sanitization logs should be checked three times a day to ensure that dishes and utensils are being thoroughly cleaned, and that no transmission of bacteria occurs. DM stated he has not been able to review the logs for missing entries as they have been short. DM stated there are days where he and his cooks are being pulled to complete other duties. DM also noted that opened items in both the refrigerator and freezer should be labeled appropriately with open and discard date, and food items to be discarded by the use-by date to prevent foodborne illness.On 08/01/25 at 01:30 PM, review of the facility's Low Temperature Mechanical Warewashing Process, with revised date of 06/01/25, indicates that Manager must review the log within seven days. Employees responsible for taking and recording concentrations must be trained on these procedures.Date: 3. Document the date the temperature are taken, 4. Meal Period: Circle the meal period where temperatures and sanitizer concentration are taken, 5. Wash Temperature: Document the temperature of the wash cycle.8. Initial: Employee responsible for taking temperature initials. Review of the facility's Food Product Shelf-Life Guidelines policy, with revised date of 01/28/22, it notes in the Safety of food after expiration dates section, Products with a Sell by, best buy or before, or Use-By: Adhere to that date for quality reasons. In the facility's Food Safety Product Labeling and Dating Guidelines policy, with a revised date of 12/06/22, it notes in the Date Marking Non-Time Control for food safety section, Once a product does have a documented use by date, the FDA Food Code and Sodexo Policy requires the product to be consumed or discarded by that date. Review of the facility's Food Storage and Use guidelines, Eggs should be used within 10 days.carrots to be used within one to two weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to assure one of one Resident ((R) 69) sampled for Hospice had a current certification of terminal illness and current Interdisciplinary Group (IDG) Comprehensive Assessment in her hospice binder or electronic health record (EHR). R69's EHR and hospice folder were not updated with current care information putting the resident at risk for not being provided continuity of care at the end of life. Findings Include:On 07/30/25 record review of R69's Electronic Health Record (EHR) and facility provided matrix revealed resident is receiving hospice services. Review of R69's hospice binder revealed it did not have a current hospice certification of terminal illness and the last IDG Comprehensive Assessment Details form from July 2025. On 07/30/25 at 03:45 PM inquired of Director of Nursing (DON) for current hospice certification of terminal illness and IDG Comprehensive Assessment Details form. DON reviewed R69's hospice binder and confirmed it was not in the hospice binder. DON stated she had them on her desk. At this time DON looked for these documents and reported to surveyor they were not on her desk that she would contact the hospice provider. On 07/31/25 at 07:40 AM the DON provided a copy of R69's hospice certification of terminal illness that was dated from 06/18/25 - 08/16/25 and the IDG Comprehensive Assessment Details form dated from 07/28/25 which were faxed to the facility on [DATE] at 16:06 PM. On 07/31/25 at 12:59 PM interviewed DON. Inquired if the facility should have had the current hospice certification of terminal illness and IDG Comprehensive Assessment Details form and the DON confirmed the facility did not have them yesterday and should have had them for this resident.

Based on observation, interviews, and review of the facility's Feeding Impaired Resident's policy, the facility failed to promote care that maintains the dignity for one out of seven residents (Resident (R) 57) observed during dining observation. This deficient practice has the potential to affect all residents who require assistance with their meals.Findings Include:On 07/29/25 at 12:30 PM, observed R57 in bed waiting for assistance with lunch. At 12:35 PM, Certified Nurse Aide (CNA) 41 came into R57's room to assist R57 with lunch. Observed CNA41 assisting R57 with four to five spoonful of food and sips of juice while standing up. At 12:40 PM, observed CNA41 taking the lunch tray away. CNA41 did not take time to encourage resident to eat more and only spent five minutes assisting R57 with lunch.On 07/29/25 at 12:45 PM, interview with CNA41 stated the facility's policy for assisting impaired residents with their meals is to be sitting down. CNA41 stated sitting down while assisting the residents with their meals would make them feel more comfortable. CNA41 also verbalized that R57 does not eat that much and requires a lot of encouraging. On 07/29/25 at 12:50 PM, interview with Registered Nurse (RN) 66 confirmed CNAs should be sitting down when assisting resident with meals so that residents do not feel intimidated and residents should be allowed enough time to eat as much as possible and agreed that five minutes was not enough time.On 08/01/25 at 01:30 PM, review of the facility's Feeding Impaired Residents policy, with revised date of 04/17/25, in the Procedure section, it notes, 7. Allow the resident plenty time to eat and chew his/her food. Do not rush the resident. Talk with the resident as he/she eats. Be pleasant. Do not give the resident the impression that you are in a hurry.18. Continue assisting until the resident has had enough food or until the meal is finished. In the Steps in the Procedure section, it notes, 8. If you are going to be seated during the meal, position a chair where it will be convenient for you and the resident.20. Assist the resident slowly. Allow plenty of time between mouthfuls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to discuss and complete the baseline care plan (BCP) within 48 hours for one out of one residents (Resident (R) 28) sampled for BCPs. This deficient practice places residents at risk for not receiving appropriate and timely care, delays the development of care to address resident's immediate health and safety needs, hinders continuity of care, and impedes communication amongst nursing staff. Findings Include:On 07/30/25 at 09:29 AM, interview with R28 noted that the facility did not include him in care plan decision making when he first was admitted . On 07/31/25 at 3:00 PM, record review of R28's Electronic Health Record (EHR) noted he was admitted to the facility on [DATE]. No BCP found in the EHR and no documentation that BCP was discussed with R28 or Family Member (FM) within 48 hours of admission. On 8/01/25 at 08:45 AM, interview with Director of Nursing (DON) noted the facility will discuss the care plan conference summary and med orders with resident and family upon admission and will give them a copy of it. DON confirmed that the discussion took place on 07/22/25 and it was delayed (delayed by 13 days). DON also confirmed that there was no other documentation that a BCP was given sooner than 07/22/25. DON confirmed that BCPs are important to be reviewed and completed timely for both resident and family as it provides additional input to know and what to expect in a new environment. On 08/01/25 at 01:30 PM, review of the facility's Baseline Care Plans policy, with a revised date of 04/17/25, in the Policy Explanation and Compliance Guidelines section, it notes, 1. The baseline care plan will be developed within 48 hours of a resident's admission.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one of two residents (Resident (R) 2), sampled for limited range of motion (ROM), received the appropriate treatment to prevent or delay a further decrease to the contracted lower extremities. This hindered R2's ability to maintain the highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility who have limited ROM.Findings Include:Resident (R) 2 is a [AGE] year-old male admitted to the facility on [DATE] for long term care with a primary diagnosis of anoxic brain damage (brain loses oxygen supply causing permanent brain damage). A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/25 noted R2 requires dependent care (resident does none of the effort to complete the activity) for his Activities of Daily Living (ADL) and for rolling left and right in bed. On 08/01/25 at 08:07 AM, a review of R2's care plan was conducted. The Focus section of R2's ADL care plan documented, He is noted with contractures to BLE (Bilateral lower extremities) with a revision date of 07/10/25. The Intervention section of this care plan listed, Apply black LE (lower extremity) positioning device in bed and Geri chair.Apply Left knee comfy splint daily. Both interventions listed 07/11/25 as the initiation date. R2's Wound Management care plan stated, Heel boots in place with an initiation date of 07/14/25. On 08/01/25 at 09:05 AM, interviewed Certified Nurse Aide (CNA) 80 in R2's room. CNA80 stated R2 should have a left knee splint and a positioning cushion between his legs to help with his contractures. CNA80 was unable to locate both items and stated she was then going to check with the laundry department if the cushion for his legs was being washed.On 08/01/25 at 09:18 AM, CNA80 brought up the positioning cushion from the laundry department but stated the left knee splint was missing. CNA80 stated she checked with Physical Therapist (PT) 1, and a new one was going to be ordered. On 08/01/25 at 09:43 AM, interviewed PT1 in the therapy department. PT1 confirmed R2's left knee splint was missing, last recalled seeing it on 07/11/25, and will be ordering a new one. On 08/01/25 at 09:21 AM, observed CNA14, CNA18, and CNA80 assisting R2 with incontinence care and positioning. CNA80 first applied one blue and then one black cover over the positioning cushion and confirmed this was R2's black LE positioning device. CNA80 was able to locate only one heel boot. All three CNAs stated they were unsure if R2 is supposed to have two heel boots. On 08/01/25 at 09:25 AM, CNA18, who was assigned to care for R2 for the shift, stated she was not sure how to apply the positioning cushion because she had not worked with R2 for a long time. CNA14 stated that they are informed about R2's left knee splint, positioning cushion, and heel boots through the shift report sheet. However, upon review of the shift report sheet, the heel boots were not listed. On 08/01/25 at 09:55 AM, Unit Manager (UM) 2 confirmed that the heel boots should have been listed on the shift report.On 08/01/25 at 10:20 AM, interviewed the Resident Care Coordinator (RCC) 2. RCC2 confirmed that R2's left knee splint was missing since 07/11/25. A concurrent review of the Point of Care (POC) screen where CNAs document their tasks and located in the Electronic Health Record (EHR) was marked as done. A sample audit of dates (07/11/25, 07/12/25, 07/14/25, 07/18/25, 07/28/25, and 07/31/25) for the application of the left knee splint were reviewed, and all were signed off as being applied. However, the splint was missing during those dates. RCC2 confirmed that the CNAs should not have signed off for the left knee splint application since it was missing. RCC2 also stated that the CNAs were responsible for applying R2's left knee splint, LE positioning device, and heel boots. RCC2 confirmed R2 should have two heel boots applied and confirmed that both the LE positioning device and heel boots were not listed on the POC for the CNAs to sign off the application of that equipment.

Based on observations, interviews and record reviews, the facility failed to implement interventions to prevent avoidable falls for one of one (Resident (R)19) sampled. R19 had fall five fall incidents from 05/11, 06/01, 06/10, 06/17, and 07/17/25. One of the five fall incidents resulted with R19 sustaining an arm injury (abrasion or skin tear).Findings Include: On 07/29/25 at 09:16 AM, during a tour of the facility, observed R19's room was located farthest from the nurses' station and with door completely closed. After knocking and requesting permission to enter R19's room, seen him alone, sitting at the right side of the bed eating breakfast.Reviewed the facility matrix on 07/29/25 at 10:30 AM. Noted R19 with Alzheimer's/Dementia or a syndrome characterized by progressive decline in cognitive functions, such as memory, thinking, reasoning, language, and judgment, that interferes with daily life and independence, and a fall with injury. On 07/30/25 at 11:17 AM, Electronic Medical Record (EMR) review was done. Noted nursing staff implemented neuro-checks with R19 after a fall incident on 07/17/25. Minimum Data Set (MDS) quarterly review dated 07/22/25, Brief Interview for Mental Status (BIMS) summary score of 99, indicating unable to complete the interview. Under functional abilities and goals under section GG-Mobility noted devices included walker and wheelchair. Under self-care section, with R19's toileting, indicated set-up or clean-up assistance. Under mobility, noted R19 requiring supervision. Comprehensive care plan noted the resident is at risk for injury and/or falls. R19 is noted with incontinence, impaired gait, and poor safety awareness. Revision on 06/10/25 noted with interventions to .continue with all interventions in place to reduce risk of injury. Revision on 06/17/25 was done with interventions instructing staff to .encourage resident to leave the door open for increased supervision. On 07/30/25 at 10:15 AM, concurrent observation and interview was done with Registered Nurse (RN) 20. When asked if staff always closes resident's door, RN20 confirmed that they always made sure that R19's door was closed. RN20 also added that staff honor the resident's choice. On 07/31/25 at 02:21 PM, an interview was done with the Director of Nursing (DON) in the training room. When asked if R19's care plan was updated to include a goal for fall prevention, DON confirmed that following R19's fall incidents, the facility did not assess factors contributing falls and did not update care plan accordingly to include routine visual checks to reduce potential for further falls and/or injury. On 07/31/25, reviewed facility policy titled Falls: Post Fall Guidelines directs the facility, . that timely and appropriate assessment, monitoring.Licensed nurse will monitor the resident.more frequently if indicated .will be completed following a resident's fall.to provide care, to reduce the potential for further falls and/or minimize resident's injury.

Based on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one (Resident (R) 21) of one resident in the sample, despite identifying them as at risk for compromised nutrition and hydration. This deficient practice could affect residents who rely on staff to provide fluids to them throughout the day to maintain proper hydration and health.Findings Include:On 07/29/25 at 09:15 AM, concurrent observation and interview was done. Observed no water pitcher found in R115's bedside. Subsequent observation was done at 10:35 AM and found no water pitcher was provided at resident's bedside. An interview was done at 11:00 AM with Certified Nurse Aide (CNA135) inside resident's room if R115 requires a water pitcher inside her room and she confirmed that resident is able to pour water from a pitcher and should have water pitcher at bedside.On 07/30/25, review of R115's Electronic Health Record (EHR) found her diagnoses included, but are not limited to, Cerebral infarction or death of brain tissue due to a lack of blood supply, Hemiplegia and Hemiparesis or medical conditions that cause weakness or paralysis on one side of the body. During this review, found R115's care plan with date of initiation on 07/18/25, stated that resident is at risk for fluid and nutritional imbalance. Hydration/Nutrition note with initiation date of 07/29/25, instructed staff to monitor R115's estimated daily nutrition and hydration needs between 1615 ml - 1940 ml fluids per day. Bladder/Incontinence included interventions for staff to encourage fluids during the day to promote prompting voiding responses. On 07/31/25 at 02:25 PM, an interview was done with the Director of Nursing (DON) in the training room. When asked if R115 should have water pitcher at her bedside. The DON confirmed that R115 should have been provided with water picture at bedside. The facility's policy and procedure titled, Fluid Intake: Hydration Program, with a revision date of 04/17/25, stated that, . Additional fluids are routinely available via pitchers of water at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a protocol to identify past trauma experienced for two of two residents (Resident (R) 3 and R40) sampled for mood/behavior. As a result of this deficient practice, both residents did not have their trauma triggers identified, placing them at increased risk of re-traumatization, and was hindered from attaining their highest practicable mental and psychosocial well-being.Findings Include:1) R3 is a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses that include vascular dementia, with other behavioral disturbance and post-traumatic stress disorder (PTSD). A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 noted that R3's Brief Interview for Mental Status (BIMS) score of 03, which indicated that R3 has severe cognitive impairment. On 07/30/25 at 08:45 AM, interviewed R3's Family Member (FM10). When asked about past trauma in R3's life, FM10 stated that R3 was in the Vietnam War and has a diagnosis of PTSD. FM10 stated there was one incident in the past when R3 and his wife went to a war movie that caused a negative reaction and caused him to try and hide under the seat.On 08/01/25 at 06:45 AM, a review of the records was conducted for R3. No TIC assessments were able to be found. 2) R40 is a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses that include unspecified dementia and post-traumatic stress disorder. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/25 noted that R40 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated that R40 has severe cognitive impairment.On 07/30/25 at 06:31 AM, a review of the records was conducted for R40. No TIC assessments were able to be found. A review of the facility's policy titled, Quality of Care -Trauma Informed Care stated, Organizational strategies.6. Implement screening of residents for trauma .Resident-Care Strategies 1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence.may involve record review or the use of screening tools.On 08/01/25 at 10:00 AM, interviewed Social Services (SS) 2 in the conference room. SS2 was asked how the facility attempts to identify past trauma and triggers that may be stressors for a resident diagnosed with PTSD and if a trauma screening was done on admission for R3 and R40. SS2 stated there was no process in place to conduct a TIC assessment if a resident is admitted with a diagnosis of PTSD, but it should be done. SS2 stated there is no trauma screen or assessment form that is utilized. SS2 stated that she was unable to look if a TIC assessment was completed on initial admission for R3 and R40 because the current Electronic Health Record (EHR) did not contain information for both residents' initial admission dates (07/10/18 for R3 and 02/25/21 for R40). No TIC assessment documents from the current EHR system were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and document review, the facility failed to make timely revisions to the comprehensive person-centered care plan of four residents (R)1, R2, R3 and R4, of six residents sampled.
Findings include:
1) R1 was a male admitted to the facility on [DATE] for pneumonia, due to Coronavirus. He required one person assist for all activities of daily living. On 09/09/2024, a family member (FM)1 made a complaint regarding nursing care, and specifically requested that R1's clothes be changed daily, and that he would be up for all meals.
Review of the complaint/grievance form included the follow up .(Director of Nursing/DON) to f/u w/CNA's (follow up with Certified Nurse Assistants) about standard of care-specifically changing Res' (R1's) clothes daily. Res will be up for all meals. The document indicated the issue was resolved.
Review of Nursing Progress notes dated 09/25/2024 at 10:57 AM revealed the following entry: .Requires 1x person mod (moderate) assist with ADL's and transfers.Requires 1:1 Feeding Assistance.
Review of R1's care plan (CP), revealed it was initiated on 08/08/2024, but there were no revisions to the CP to reflect the preferences of care agreed on in the grievance. In addition, the CP did not include R1's need for 1:1 feeding and one person assist for ADL's and transfers.
On 05/30/2025 at 03:15 PM during an interview with the DON in the conference room, she said although there was verbal follow through with the staff, the CP should have been revised.
2) R2 was a [AGE] year old male admitted to the facility on [DATE] for services related to Metabolic Encephalopathy (condition characterized by systemic metabolic disturbances). R2 uses oxygen due to hypoxic respiratory failure (insufficient oxygen in the blood) and aspiration pneumonia, congestive heart failure and chronic obstructive pulmonary disease.
Reviewed R2's orders, which included EMERGENCY O2 (oxygen) ORDER: In the event of an emergency where the resident's oxygen decreases below 90% and requires supplemental oxygen, may initiate O2 via nasal cannula at 0-3L (liters), .
Reviewed R2's active CP, which revealed the following intervention:
EMERGENCY O2 ORDER: In the event of an emergency where the resident's oxygen level decreases below 90% and requires supplemental oxygen, may initiate O2 via nasal cannula at 0-3L or simple mask, then attempt to wean. The CP did not reflect the actual order.
3) R3 was a [AGE] year old male was admitted to the facility on [DATE] after being hospitalized for respiratory failure. He had a history that included heart failure, hypertension, diabetes type 2, and carcinoma of the tongue. R3 needed assistance with activities of daily living and transfers.
On 02/28/2025 at 04:45 PM, R3 was found on the floor in his room after attempting to get out of bed. Reviewed the Fall Report #1160, which revealed after the fall, floor mats were ordered for safety.
On 02/28/2025 at 07:20 PM, R3 was found sitting on the floor. The immediate action included: .Ordered floor mats for safety. R3 was transferred to the hospital for further evaluation and admitted .
On 03/03/2025, R3 was readmitted to the facility after hospitalization with a terminal prognosis and hospice services, related to his metabolic encephalopathy and failure to thrive. On 03/06/2025, R3 had an additional unwitnessed fall on 03/06/2025. The fall report included Resident .was found on the floor mat .
Reviewed R3's CP, which revealed the initial CP developed on 02/21/2025, included the following fall interventions:
- Be sure call light is within reach and encourage the resident to use it for assistance as needed. the resident needs prompt response to all requests for assistance.
- Encourage resident to OOB (out of bed) and engage in meals. activities.
- Ensure that the resident is wearing appropriate footwear non-skid when ambulating or mobilizing in w/c.
- Follow facility Fall Prevention protocol.
- Frequent rounding to assess needs, offering toilet and reposition.
The CP was not revised after the three falls to include the mats, or other interventions to help prevent more.
4) R4 was a [AGE] year old long term resident at the facility. He had a medical history that included Parkinsons Disease, aspiration pneumonia, dementia, severe dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, asthma, hypertension, and congestive heart failure. R4 requires supplemental oxygen at times for shortness of breath.
Reviewed R4's medical records which revealed the following:
Physician order dated 03/22/2025: May administer supplemental oxygen via nasal cannula at 0-3 Liter/minute, in order to keep oxygen saturation >92%, wean when tolerated.
Review R4's CP, intervention initiated on 02/12/2025 for respiratory issue included: EMERGENCY O2 ORDER: In the event of an emergency where the resident's oxygen level decreases below 90% and requires supplemental oxygen, may initiate O2 via nasal cannula at 0-3L or simple mask at 0-3L, then attempt to wean. The CP does not accurately reflect the order.
Nursing Progress note dated 04/05/2025 01:22 PM: Resident is being monitored for Stage 3 pressure injury to left lateral floor. Heel boots on when in bed.
R4's CP identified R4 had a Deep Tissue Injury to the left lateral foot, but the CP had not been revised to include the current condition of the now Stage 3 wound, or the preventive heel boots.
Due to R4's severe dysphasia and high risk of aspiration, he required 1:1 monitoring for meals and had hired caregivers to feed him. The CP related to nutrition was last revised 03/13/2025 to reflect he was NPO (nothing by mouth), which was not accurate. On 04/03/2025 there was a dietary order Pureed texture, Pudding Thick consistency, Pleasure feeding .
5) On 05/30/2025 at 03:15 PM. during an interview with the DON in the conference room, reviewed the care plans of R1, R2, and R3. She agreed the CP's had not been revised to reflect current orders and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify and plan in advance for the situation where one Resident (R)4, of one sampled, would have a predictable condition decline, in which health care decision-making would be needed to provide guidance to the direct care staff. Specifically, when R4 had a significant change of condition, clinical interventions where implemented, the Power of Attorney (POA) was notified in a timely manner for direction, but staff failed to immediately consult with the physician about the condition change. As a result of the lack of planning, there may have been a delay in transfer to a higher level of care.
Findings include:
1) R4 was a [AGE] year old male, who was a long term resident at the facility with a history of Parkinson's Disease, dementia, severe dysphagia (difficulty swallowing), coronary artery disease, chronic obstructive pulmonary disease, asthma, hypertension, and congestive heart failure. On 03/03/2025, R4 was sent to the hospital due to shortness of breath, and poor oral intake, where he was diagnosed with aspiration pneumonia (lung infection that occurs when food, or vomit is inhaled into the lung instead of being swallowed). R4 was transferred back to the facility on [DATE]. On return, R4 remained a high risk for aspiration. On 04/06/2025, R4 was found to have unstable vital signs and transferred to the hospital again for a higher level of care. He was admitted to the intensive care unit with acute hypoxic respiratory distress, aspiration pnuemonitis and sepsis, where he deteriorated and passed on 04/07/2025.
2) Review of R4's medical records revealed the following:
R4 had an Advanced Health Care Directive (AHCD) he signed on 09/08/2017. His wishes were documented to be as follows:
- 1 A. Choice not to prolong life if: I have an incurable and irreversible condition that will result in my death within a relatively short period of time, OR I become unconscious and, to a reasonable degree of medical certainly, I will not regain consciousness, OR The likely risks and burdens of treatment would outweigh the expected benefits.
- I do want artificial Nutrition and Hydration regardless of my condition and regardless of the choice I have made in question 1A/B.
R4 designated his daughter to be his agent to make health care decisions for him (POA/power of attorney) at that time, which became effective when he was no longer to make his own decisions.
R4 did not have a Hawaii Provider Order for Life-Sustaining Treatment (POLST). The POLST is a medical order, that Emergency Medical Services follow when called to transfer a resident. It is not an Advanced Directive and is not intended to replace one.
R4's Care Plan for Advanced Directives last revised 07/30/2024 included Resident's Advanced Directives Wishes Will Be Known With DNAR (do not attempt resuscitation/DNR) status.Licensed staff will honor resident's wishes regarding resuscitation, instituting only comfort/dignity measures in the event resident has no pulse and no breathing.
Reviewed the facility policy titled Advance Directives, revision date 04/17/2025. The policy included:
Policy: It is the policy of this facility to recognize the right of an adult to make decisions regarding his/her medical care, including the right to accept or refuse treatment. The facility supports a resident's right to execute Advance Directives, including a Living will, a Durable Power of Attorney for Health Care and a Legal Surrogate for Health Care.
Reviewed the last two letters the facility provided to R4's POA on a quarterly basis, to document if there are any changes they would like to make to the existing Advanced Heath Care Directive. Both letters were checked by the POA that she did not want to make any changes. There was no discussion of AHCD, POLST or situations that might occur in the Interdisciplinary Team notes.
3) Reviewed R4's Speech evaluations, which included the following:
03/11/2025 Assessment summary: .Patient requires extensive assistance and cueing to safely tolerate a small amount of PO (oral) for adequate nutrition/hydration. Patient exhibits increased difficulty managing honey thickened liquids, therefore if pleasure feeding is initiated, this ST (speech therapist) recommends the patient consume nectar liquids.In limited amounts, patient may tolerate puree solids and nectar liquids for pleasure, however, it is imperative for caregiver to utilize strategies consistently and or the entirety of PO intake, otherwise potential for aspiration is high.patient is not safe to consume PO by mouth to maintain adequate hydration /nutrition .
03/24/2025: Pt severe risk for asp PNA (aspiration pneumonia), MPOA (medical power of attorney) wishes pt. (R4) to remain PO despite NPO (nothing by mouth) recommendations .
03/26/2025: Precautions/Contraindications: Diet: puree/pudding for oral gratification/comfort feeding ONLY. Pt must be fed by trained caregiver. High aspiration risk. Strategies do not eliminate risk for aspiration. PO is for comfort only at the request of daughter.with dedicated feeder.
The POA hired caregivers to feed R4, who were trained strategies to feed him.
4) Reviewed Provider (MD1) visit notes dated 04/02/2025. The notes revealed the following entries:
- Pneumonia: continues to be high risk for aspiration.
- Dysphasia: failed swallow evaluation, continued discussion with daughter regarding high risk for patient to aspirate with any consistency, still does want not PEG (feeding tube inserted through abdominal wall used for nutrition) and also encouraged her that it does not line up with his wishes.
- Severe protein-caloric malnutrition: intake is poor, continue one on one support during meals
5) Nursing Progress Note 04/06/2025, entered at 05:16 PM: Resident was fed by caregiver (private paid caregiver) pudding think [sic] liquids starting at 09:30 (AM) until 1300 (01:00 PM) including breakfast, snack and lunch. Daughter called caregiver and spoke to her while she was with the resident. Resident's lungs and heart were checked after feeding per orders. The [sic] was no coughing noted, lung sounds were diminished in both lower lobes. Resident's private care giver left at 13:30 (01:30 PM). He (P4) stayed in his chair in the hallway in view of nurse until he was put in bed around 14:00 (02:00 PM). At 15:20 (03:20 PM) vitals: BP 58/33, pulse 90, SaO2 (oxygen saturation) 83% on 3 liters nasal cannula. A nebulizer treatment (device used for respiratory conditions that turns liquid medication into fine mist inhaled into the lungs) was given at 15:30 (03:30 PM). At 15:34 (03:34 PM) family was called to inform of change in condition. A message was left. Supervisor informed at 15:45 (03:45 PM) and MD1 was called around 16:00 (04:00 PM) and message left on his phone. Nasal cannula was switched to mask on 10 liters per min (minute) at 1550 (03:50 PM). 911 was called and arrived at 04:45 PM and left for hospital at 1700 (05:00 PM).
6) On 05/30/2025 at 12:30 PM, interviewed the House Supervisor (HS) about her involvement on 04/06/2025. She said the Nurse (RN1) called and informed her R4 was not stable. She said she went to assess him, and asked RN1 if she reached out to daughter, which she had already done. The HS said R4's Code Status was DNR and they wanted to make sure the POA wanted to transfer him to the ER. She said when she arrived to the room, RN1 was in the process of giving a nebulizer treatment. The HS said vitals were rechecked and he had 74 systolic with 83% on cannula. He seemed comfortable, was looking at me and tracking, but nonverbal. She said she spoke with the POA on the phone and wanted to get a decision to send R4 to ER, or not. The HS told the POA that there were no other interventions that could be done at the facility, and needed to know if she wanted him to go to the hospital. At that time, the POA said to send him out. The HS called EMS immediately, who had an arrival time of about 20 minutes. She said R4 was still alert when he left the facility.
On 05/30/2025 at approximately 02:00 PM, conducted a telephone interview with RN1. She said R4 had several trips to the hospital and had shown significant decline. She said the POA was actively involved in his care and they would call her with any condition change. She went on to say that day, he stayed up about 30 minutes after lunch and around 02:00-03:00 PM, R4 was lying in bed when one of the CNA's came out of room, and said his vitals weren't good. RN1 said she went in, assessed him and immediately gave a nebulizer treatment around 03:00-03:20 PM. She said that she can increase the oxygen to 5L. RN1 said she called the POA and a left message about R4's vital signs. She said when she did call back, the POA was very upset and difficult to get her to understand she was trying to get clarification to send him to the hospital or not. The POA told her to call MD1, so she left a message. RN1 said at some point, the HS called 911. RN1 explained she was confident calling 911 without an MD order, but in this case, she wanted to have the conversation with the POA and I wanted to fulfill everyone's wishes.
On 05/30/2025 at 03:15 PM, interviewed the Director of Nursing (DON) in the conference room. She said the facility reviewed what happened that day, and she felt confident in the decisions the staff made. The DON said the CNA called for help, they found his O2 dropped, and staff intervened by elevating the head of bed, gave nebulizer treatment and additional oxygen. The House Supervisor was notified and they reached out to POA and MD, to plan for what to do next, discuss whether to send him to the hospital or not. They were waiting to get directive from her.
On 06/06/2025 at 09:15 AM conducted a phone interview with MD1. He said he had multiple discussions with R4's POA about what to do should her father have a condition change. It was his suggestion to keep him at the facility and care for him there, rather than transfer to the hospital. He went on to say the Resident was a DNR and she did not want any nutritional support or CPR. MD1 said the POA said that the last time R4 went to the ER, he had to wait in the ER for 9 hours and she did not want to happen again. She wanted to be called with any update regarding her father's condition and wanted to keep her right to make the decision then to transfer him or not. MD1 said the POA wanted to arrange for a direct admission rather than go to the ER if something happened, and that he had explained should there be a condition change, the decision to transfer would need to be timely and would likely not allow for arrangements such as that to be made. He also explained her father's condition may need interventions on arrival to the ER and direct admission would not be best in that situation. He said she wanted to avoid the ER, but didn't want to give up the right to make the decision to go to the hospital, or not. Inquired if the nursing staff were aware of the POA's feelings, and he said yes.
7) Reviewed the facility policy titled Emergency Care of Residents, revision date 04/17/2025. The policy included:
Policy: It is the policy of this facility to provide or arrange for appropriate medical care and other professional services for each resident when emergency care is needed.
1. Complete an initial assessment, i.e., head to toe assessment, checking for obvious injuries and taking vital signs. Note: Nursing Services staff are trained to do appropriate resident assessment prior to contacting the physician.
3. Notify the Charge Nurse as soon as possible. Nurses are expected to use clinical judgement skills (or consult with Charge Nurse) in deciding if an event is a medical emergency.
4. Seek a physician's assistance as indicated by the type and severity of the emergency.
5. If required, arrange for transport to the Emergency Room. If an ambulance is called, refer to the policy and procedure entitled, Emergency Procedure for 911 Calls.
6. Contact the resident's responsible party .as needed.
7. Document pertinent information in the Nurses' Notes.
Reviewed the facility policy titled Emergency Procedure for 911 Calls, revision date 04/17/2025. The policy included:
Policy: It is the policy of this facility to activate the Emergency Medical Services (EMS) ambulance system by calling 911 when indicated.
1. Staff personnel will call 911 with a directive from a physician, or conditions warranting assistance from emergency personnel and transport to an acute facility. Such conditions include discovery of a resident who is unconscious and has a physicians order for Cardiopulmonary Resuscitation (CPR).
Reviewed the facility policy titled Oxygen Therapy, revision date 04/17/2025. The policy included:
Purpose: The purpose of this policy is to establish responsibilities for the care and use of oxygen therapy.
Policy Explanation and Compliance Guidelines:
1. Oxygen is administered under orders of a MD/APRN, except in case of an emergency. In such case, an emergency oxygen order can be initiated that states: In an event where the resident's oxygen level decreases below 90% and requires supplemental oxygen, may initiate O2 via nasal cannula at 0-3 L (liters per minutes), then attempt to wean. If a resident is unstable, requires additional oxygen above 3L, MD/APRN will be notified immediately.
8. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.
8) R4 had a AHCD and a designated agent/POA, who was clear that she did not want tube feedings and understood he was at high risk of aspiration. R4 was DNR for the clinical situation of no pulse or respirations. MD1 had discussions with the POA, who felt strongly she wanted to be notified of any condition change and keep the right to determine to transfer to the ER or not. It was explained to her timeliness could be an issue. These interactions and discussions did not occur in the IDT and there was no further planning to provide guidance to the staff how to respond to a predictable situation. In addition, there was no discussion about the importance of a POLST in this situation, to ensure the POA understood if R4 had respiratory or cardiac arrest during transport, CPR would occur which she did not want.

Based on interviews and record review, the facility failed to ensure a resident's right to be informed in advance of the risks and benefits of proposed care for two of three residents (R) (R4 and R11) sampled. The facility did not have documentation that the resident or resident representative was informed, in advance, of the risk and benefits of psychotropic medication therapy. As a result of this deficient practice, resident's receiving psychotropic medication are at risk for more than minimal harm.
Findings include:
1) On 01/03/25 at 02:13 PM, conducted a review of R4's Electronic Health Record (EHR). Review of physician orders documented an order for scheduled Lexapro (ordered on 12/03/24) and Ativan as needed (PRN) (ordered 11/29/24). R4's EHR did not contain documentation for the use of Lexapro and Ativan and documentation of education regarding the risk versus benefit for both medications.
On 01/03/25 at 03:40 PM, conducted a concurrent interview and record review of R4's EHR with the Director of Nursing (DON). DON navigated R4's EHR and confirmed the facility did not inform of the risk versus benefit for both medications.
2) On 01/03/25 at 01:50 PM, conducted a review of R11's EHR. Review of the physician orders documented an order for scheduled Citalopram (ordered on 12/21/24) and Ativan PRN (ordered on 12/20/24). Further review of R11's EHR did not contain documentation in advance of the care to be provided which included medications and risk versus benefit for R11's of Citalopram or Ativan.
On 01/03/25 at 03:50 PM, conducted a concurrent interview and record review of R4's EHR with the Director of Nursing (DON). DON navigated R11's EHR and confirmed the facility did not inform the resident or resident representative in advance of the risk versus benefit or education for both medications.

Based on observations, interviews, and records review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled. This deficient practice increases the risk for diversion of residents' medications.
Findings include:
Concurrent observation, record review, and interview was conducted during a medication cart check on 08/08/24 at 08:20 AM. The facility document titled, Verification of Controlled Substance Count, dated August 2024, contained a blank spot for the oncoming day shift nurse signature for 08/08/24. Registered Nurse (RN)7 was informed of the missing signature. RN7 was observed placing his signature in the blank space. RN7 stated that he had forgotten to sign his name after he counted the medications with the outgoing night shift nurse. RN7 confirmed that signing the form together with the outgoing shift is the correct process.
Interview was conducted with the Director of Nursing (DON) on 08/08/24 at 10:22 AM. DON stated that outgoing and incoming nurses will both go to the medication cart and go through the count, verifying each controlled medication with one another. After completing the count and verifying that it is correct, both nurses sign off on the cart and handoff is complete. DON confirmed that RN should have signed off the same time the outgoing nurse had signed off.
Facility policy titled, Medications: Narcotic Record, with a revision date of 01/23/24 was conducted. The facility policy documented, Narcotics are verified at the beginning and end of shift with licensed staff signature indicated on the Verification of Controlled Substance Count Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident's right to formulate an Advanced Health Care Directive (AHCD) for three of six Residents [(R)151, R87, and R97] sampled.
Findings include:
R151 is an [AGE] year-old male, admitted to the facility on [DATE], after a hospitalization for metabolic encephalopathy (brain dysfunction caused by an underlying illness), and has full code status per his medical record face sheet.
R151's Electronic Health Record (EHR) reviewed. No AHCD found. No supporting documentation about formulating or obtaining an AHCD was found in the progress notes or Care Plan (CP) dated 07/24/24.
Copy of the AHCD and/or supporting documentation for R151 requested from the Administrator on 08/07/24 at 11:40 AM.
Social services progress note dated 08/07/24 at 12:35 PM reviewed that documented the following: Previously inquired about AHCD? POLST and spouse said that they have a will which she believes includes that, requested she bring in a copy. Reminded spouse today if she was able to find the will. She hasn't had the time to look for it.
Social Services Manager (SSM)8 interviewed on 08/09/24 at 09:34 AM. SSM8 stated that when R151 was admitted to the facility on [DATE], the spouse was asked at the time of admission for a copy of the AHCD, but there was no follow up in obtaining a copy of R151's AHCD.
Cross reference to F657: Timing/Revision of Care Plan
2) A review of R87's EHR on 08/07/24 at 10:08 AM did not contain documentation of the resident's AHCD on file. Review of R87's admission Agreement documented R87 did not have an AHCD formulated and R87 returned from the hospital on [DATE].
On 08/07/24 at 11:40 AM, requested a copy of R87's AHCD with the Administrator. At approximately 02:00 PM, the Administrator provided a progress note written by Social Services Manager (SSM)8 on 08/07/24 at 01:11 AM (after surveyor requested a copy of R87's AHCD with the Administrator) which documented, TCT (telephone call to) Res' (resident's) dtr (daughter) and inquired about the AHCD. She (daughter) stated that someone is helping her mom w/ it (with it) but they haven't completed it yet.
On 08/07/24 at 02:38 PM, conducted a concurrent interview and review of R87's EHR with SSM8 regarding R87's AHCD after returning from the hospital on the facility's processes for formulating and/or reviewing AHCD with the resident and/or the Resident's Representative (RR) after returning from the hospital. SSM8 reported in the admission packet the family is asked if they have an existing AHCD, then it is discussed at the initial care plan meetings if they would like to formulate one and if they do have an AHCD, if there are still okay with the interventions previously selected by the resident. Inquired if there is any documentation of an AHCD directive for R87 and if the resident did not have an AHCD, if the resident would like to formula one. SSM8 confirmed R87 did not have an AHCD and has not had a care plan meeting since returning from the hospital on [DATE] and was not on the calendar to have a care plan meeting since returning to the facility.
On 08/07/24 at 03:25 PM, conducted a concurrent interview and record review with the DON and Administrator regarding R87's AHCD. DON navigated R87's EHR and confirmed R87 did not have an AHCD on file and there is no documentation (prior to this surveyor request) that the facility discussed R87's right to formulate an AHCD.
3) R97 is an [AGE] year-old male, who was admitted to the facility on [DATE]. A review of R97's EHR noted that a Brief Interview for Mental Status (BIMS) assessment was conducted by SSM8 on 07/31/24. SSM8 documented R97's score a 15, indicating the resident's cognition is intact.
Reviewed R97's EHR on 08/07/24 at 08:39 AM. At the time of the review there were no documentation that R79 had an AHCD or if facility staff had provided information on creating one.
On 08/07/24 at 11:40 AM, a list containing residents whose AHCD were not found in the EHR was given to the Administrator. R97's name was on that list.
On 08/07/24 at 02:00 PM, the Administrator provided a copy of an EHR documentation created by SSM8 and a review of it was conducted. The progress note was created on 08/07/24 at 01:34 PM by SSM8. SSM8 noted, TCT [telephone call to], [NAME], to inquire if Res [resident] has an AHCD or POLST [Physician Orders for Life Sustaining Treatment]-left msg [message]. Res doesn't think he has anything like that.
Interview with SSM8 was conducted on 08/09/24 at 10:02 AM. SSM8 confirmed that the phone call to R97's Public Guardian (PG) was made after the Administrator was given the list. SSM8 stated that she assumed R97's PG handled everything, so she had not discussed AHCD with R97 or R97's PG.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to electronically transmit and complete the Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within 14 days for one Resident [(R)87] sampled.
Findings include:
On 08/07/24 at 02:49 PM, conducted an interview and concurrent record review of R87's Electronic Health Record with the Minimum Data Set Coordinator (MDSC)1. Reviewing R87's Minimum Data Set (MDS) documented there was a late warning for the submission of the admissions MDS, R87 returned from the hospital on [DATE]. The MDS had not yet been submitted. MDSC1 confirmed R87's MDS was late and should have been submitted to the CMS system but was not.
During an interview with the Director of Nursing (DON) and the Administrator on 08/07/24 at 03:25 PM, requested the MDS 3.0 Final Validation Report. DON provided the MDS 3.0 Final Validation Report on 08/09/24 at 09:58 AM which documented R87's target date was 07/23/24 Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (Assessment Reference Date). The DON confirmed the resident should have had an admissions MDS completed and transmitted by 08/06/24 but it was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and/or implemented for three residents (Resident (R)300, R250 and R52) in the sample. Specifically, a care plan was not developed to monitor for adverse effects of taking a blood thinner for R300. No care plan was developed for the care of R250's Peripherally Inserted Central Catheter (PICC) line (tube inserted into a vein in the upper arm and threaded into a large vein above the heart to provide intravenous treatments), The facility did not develop a care plan to address R52's skin condition. As a result of these deficient practices, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. These deficient practices have the potential to affect all the residents at the facility.
Findings include:
1) R250 is a [AGE] year-old resident, admitted to the facility on [DATE] for short-term rehabilitation and long-term intravenous (IV) antibiotics administration with diagnoses included but not limited to infection and inflammatory reaction due to cardiac valve prosthesis, bacteremia (bacteria in the blood) and endocarditis (inflammation of the inner lining of the heart).
On 08/06/24 at 09:21 AM, observed R250 sitting upright in a wheelchair in his room. On the side of his bed was an IV pole with an IV pump (device used to administer IV medications). R250 observed to have a PICC line on his right upper arm.
Review of R250's Electronic Health Record (EHR) conducted on 08/08/24. There was no mention of R250 having a PICC line for the administration of IV antibiotics in the resident's current care plan.
During an interview with the Director of Nursing (DON) on 08/09/24 at 10:00 PM in the conference room, DON confirmed that there was no care plan developed for the care of R250's PICC line. DON also said that R250 was admitted to the facility with the PICC line, and the interdisciplinary team should have developed a care plan for it.
Review of the facility policy Baseline Care plans stated, . Interventions shall be initiated that address the resident's current needs . Any special needs such as for IV therapy . goals and interventions shall be documented in the designated format.
2) R52 is a [AGE] year-old resident admitted to the facility on [DATE] for long-term care. During an interview with him on 08/07/24 at 09:29 AM in the dining area, R52 said there was something on his left arm and he needs to see a doctor about it. R52 was wearing a long sleeve shirt and did not want this surveyor to roll up his sleeve because he said, It hurts when it is touched.
On 08/07/24 at 01:05 PM, an interview was conducted with Registered Nurse (RN) 14 outside R52's room. RN14 said that here was a raised growth on his left forearm but the skin is intact. RN14 said it was found a couple of weeks ago when he bumped his arm on the wall and complained of pain to the area. RN14 added she took a picture of it and uploaded it into the EHR.
Review of R52's EHR conducted, unable to find a picture of the left arm that RN14 took. Documentation found in the progress note dated 07/21/24 at 12:30 AM stated, Resident with raised growth to left forearm. Photo taken and uploaded into PCC (Point Click Care - EHR the facility uses). Has h/o (history of) squamous cell carcinoma (skin cancer) and has had [NAME] procedure (surgery for treating skin cancer lesions) in the past . There was no mention of the left forearm skin condition in the current care plan.
During an interview with the DON on 08/09/24 at 10:00 AM in the conference room, DON confirmed that there should have been a specific care plan developed by the interdisciplinary team to address the left forearm skin condition of R52.
3) R300 is a [AGE] year-old male, admitted to the facility on [DATE]. R300 has a medical history which includes, but not limited to, congestive heart failure, left lower extremity thrombosis (blood clot) and embolism (blockage of blood flow), and long-term use of anticoagulants (blood thinner).
A review of R300's current care plan was conducted in the EHR. R300's care plan did not contain a care plan for the use of a blood thinner.
Concurrent interview and record review were conducted with the DON on 08/08/24 at 10:26 AM. DON confirmed that R300 was on a blood thinner. DON stated that R300 should have a care plan in place for monitoring side effects of the blood thinner. DON reviewed R300's EHR and confirmed that he did not have a care plan in place for the use of blood thinner. DON added, side effects monitoring and a care plan should have been in place for the length of time R300 has been residing in the facility.
The facility policy titled, Anticoagulants, dated 04/10/24, was conducted. The facility policy documented, The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: Bleeding and hemorrhage (bleeding gums, nose bleed, unusual bruising, blood in urine, or stool), fall in hematocrit or blood pressure, thromboembolism.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident's comprehensive person-centered care plan was revised for one Resident (R)87 of 22 residents in the sample.
Findings include:
Review of R87's Electronic Health Record (EHR) documented R87 was discharged to a hospital on [DATE] and returned to the facility on [DATE].
On 08/07/24 at 02:38 PM, inquired with Social Services Manager (SSM)8 if R87 had a care plan meeting since the resident returned from the hospital. SSM8 confirmed R87 has not had a care plan meeting since the resident returned from the hospital (07/17/24) and was not currently on the facility's calendar to have a care plan meeting. SSM8 reported when the Minimum Data Set (MDS) is submitted, it triggers facility to schedule a care plan meeting on their calendar.
(Cross reference with F640: Encoding/transmitting/Resident Assessment) During a concurrent record review and interview with MSDC1, it was confirmed the facility had not yet submitted R87's MDS to the Centers for Medicare & Medicaid Services system since R87 returned from the hospital. MDSC1 also confirmed R87 was not scheduled for a care plan meeting on the facility's calendar.
During a concurrent interview and record review with the Director of Nursing and Administrator on 08/07/24 at 03:25 PM, confirmed R87 had not had a care plan meeting since returning from the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one resident (R)150 of 22 in the sample, was free of accidents during her stay in the facility and failed to develop a discharge plan that would ensure the resident was safely discharged . R150 had multiple falls during her stay in the facility. The deficient practice increased the resident's risk for injury and has the potential to affect residents who are discharged home.
Findings include:
Aspen Complaint Tracking System (ACTS) intake #10993 dated 05/30/24 documented, R150 had several falls while in the facility and was discharged home from the facility on 05/25/24, without home supervision, and without family support due to an unsafe environment.
Telephone call to R150's Family Member (FM) and Power of Attorney on 08/08/24 at 5:06 PM. FM stated the day before she was going to be discharged , R150 had a fall, and that she had at least four while in the facility. I worked with the Social Services Assistant (SSA)2 and told her that R150 isn't safe by herself, because me and my husband are at work during the day and my kids go to school, there is no one to supervise my mom during the day. The SSA2 told me my mom needed to go home and wouldn't be able to stay at the facility and it was our problem to find help for her. Then she gave me some papers to fill out to see if she could qualify for Medicaid, and some numbers to call for help, but she didn't help me or tell me how to fill out the paperwork. The original date they were going to release her was on May 11, 2024. An hour and a half before the discharge, my mom fell and hit her head and was taken to the hospital. After she went back to the facility the SSA2 told me I needed to take my mom to the primary care provider (PCP) before her next discharge. She told me my mom only needed supervision with her mobility, but when I took her to the appointment on May 17, I realized that she needed a lot more help than just supervision. It was very difficult to get in and out of the car, she shuffled her feet when she walks, she was very unsteady. The PCP voiced his concern to my mom and to me that she can't go home and be alone, it was too unsafe. I told the social worker this and they said there was nothing they could do. We had a conference on the 05/23/24 with the SSA2, the PT, OT, and Dietary. There was no one from nursing at the conference. We discussed her discharge. I didn't get a written notice when her services ended, or that I could appeal the discharge, I learned this from the long-term care ombudsman who told me I could file an appeal. They withheld information from us about the appeal process. I went to the administrator and told her about the appeal and that I wouldn't take my mom home because she was not safe and would be alone. The Administrator threatened to call the adult protective services because I wouldn't take her home. My mom did not receive services in the home after her discharge.
Electronic Medical Record (EMR) was reviewed and documented, R150 is a [AGE] year-old female, admitted to the facility on [DATE] for surgical aftercare following surgery for a malignant neoplasm of the brain.
R150's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 04/09/2024 documented, Section C. Cognitive Function, the resident scored an 11 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition is moderately impaired. Section GG- Functional Abilities and Goals documented the resident has impairment of one of the upper extremities, used a wheelchair for mobility, requires partial/moderate assistance for sitting to lying (ability to move from sitting on the side of the bed to lying flat on the bed), Lying to sitting on the side of the bed, sit to standing (ability to safely come to a standing position form sitting in a chair or on the side of the bed); Chair/bed-to-chair (ability to safely come to a standing position from sitting in a chair or on the side of the bed; Toilet transfer (ability to safely get on and off a toilet or commode).
Review of R150's Morse Fall Scale (a method of assessing a patient's likelihood of falling) conducted on 04/24/21 documented a score of 80, indicating the resident is a High Risk for Falling.
Progress notes reviewed from 04/11/24 to 05/25/24 documented several falls while R150 resided in the facility. The resident's last fall occurred on 05/24/24, the day before the facility discharged the resident.
- 04/23/24. R150 is moderate to maximum assist with ADL's and transfers.
- 04/24/24. Resident found sitting on floor in room . resident unable to remember to use call light for assistance. Continues with poor safety awareness.
- 04/28/24. Resident went to bathroom without calling for assistance and states she fell against the wall by the toilet and scraped her back. Fall was unwitnessed. 1 inch scrape noted to left scapula, no other injuries .
- 05/01/24. Resident attempted to get up and ambulate without assistance several times on this shift, res seen walking in the hallway without her mobility device, resident also wanted to take the stairs to the first floor, needs redirection and needs reminder to call before getting up for safety, residents' gait can be unsteady.
- 05/07/24. Resident wanders during the night. With episode of confusion noted .
- 05/24/24 .resident's left elbow was bleeding . resident told them that she went to the bathroom and lost her balance on the way back to her bed.
Review of R150's Care Plan (CP) documented, a falls care plan was initiated on admission and despite having multiple falls, only one revision was made (05/25/2024) for staff to assist the resident with routine toileting, despite the resident having multiple falls. Also, no discharge plan was initiated for R150 in the care plan. A care plan conference summary on 04/08/2024 documented Discharge plan to home. Steps, needs DME, (PT)/(OT). Goal is independent as possible. However, the facility did not take into consideration the steps the resident needs to be able to walk-up and down when assessing R150's readiness and safety upon being discharged .
PT Discharge Summary reviewed 05/27/24. Discharge Recommendations: Assistance with ADLs, Assistive device for safe functional mobility, home exercise program, home health services and 24 hour care. Patient has been educated on use of FWW and recommendation of having supervision for safety. Pt. verbalized understanding, however, displays questionable carryover.
Conducted a concurrent interview and record review with Physical Therapist (PT)15 on 08/09/24 at 10:35 AM, in the rehab services office on the second floor. Inquired with PT15 what was R150's level of function at the time of discharge. PT15 stated that she was a standby assist level with poor safety awareness and balance deficits. We informed the family that R150 would need supervision 24/7 upon discharge to home. The family said that no one would be home because of work and school, and they were concerned about her falling at home.
On 08/09/24 at 11:02 AM, conducted a concurrent interview and record review with Director of Nursing (DON). Inquired as to how many falls R150 had during her stay in the facility? After reviewing the HER and the care plan, DON stated, I only see one. Inquired about R150's risk factors for having falls. DON replied, the resident was alert but forgetful. DON confirmed R150's care plan was not timely updated after each fall.
Social Services Manager (SSM)8 interview on 08/09/24 at 09:34 AM in the first-floor training room. The surveyor asked her what the discharge process was for R150 and when did it begin for the resident. The SSM said, we discuss the discharge plan at the CP meeting. The SSA2 who worked with R150 is no longer here. R150 had several falls, and she went to the hospital on [DATE] which was the day after her last covered day. R150 returned to facility and her last covered date was 5/25/24. A meeting was held on 5/23/24 and the recommendations from the primary care provider were discussed. The recommendation was for a private duty hire and adult day care program. R150 needed more assistance with ambulating and toileting and would need supervision at home. The surveyor asked the SSM is it was safe to discharge R150 home since she had so many falls and she was moderately cognitively impaired. She responded that it was the residents wishes to go home.
Reviewed the progress note from SSA2 dated 05/28/24 with the SSM8 on 08/09/24 at 10:09 AM that stated Resident has Medicare but was here under an employer plan. The surveyor asked the SSM8 for clarification on whether or not the resident had Medicare, if so would R150 have been eligible to receive services under Medicare after the employer provider benefit ended? The SSM8 said she would check and get back to the surveyor. The SSM8 returned and stated that the resident was covered under an employer health plan and didn't have Medicare. She was working under an employer plan and that's why she didn't receive the Notice of Medicare Non-Coverage (NOMNC) or information about the appeal process. Asked the SSM8 again, if the resident didn't have Medicare, wouldn't the facility help sign the resident up for Medicare so she may qualify for additional services under Medicare?

Based on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one resident (Resident (R) 52) sampled. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.
Findings include:
On 08/06/24 at 11:58 AM, observed R52 in a wheelchair being assisted out of the elevator on the second floor. R52 had a urinary catheter tubing connected to a collection bag placed in a privacy cover hung under the wheelchair seat. While R52 was being pushed from the elevator to the dining area table, the catheter tubing was dragging on the floor.
Review of the Electronic Health Record (EHR) for R52 revealed that he has a suprapubic catheter (tube inserted into the bladder through a cut in the abdomen to drain urine) and went out on 08/06/24 to see his doctor to have it changed.
On 08/08/24 at 01:33 PM, an interview with the Infection Preventionist (IP) was conducted, IP confirmed that the urinary catheter tubing and collection bag are not supposed to be coming in contact with the floor to prevent possible exposure to contaminants that could cause infections.
Review of facility policy Urinary Catheter stated, . 13. Make sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interviews, and record review, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm.
Findings include:
1) Review of Resident (R)34's Electronic Health Record (EHR) documented on the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/24, Section C. Cognitive Patterns, R34 scored a seven (7) on the Brief Interview for Mental Status (BIMS), indicating R34's cognition is severely impaired.
On 08/06/24 at 10:29 AM, conducted an observation of R34 is the resident's room, seated in a wheelchair, with a bedside table in front of the wheelchair, with ten (10) medications tablets on the table, and no staff present in the room or in the line of sight of the resident. Inquired with R34 about the pills on the bedside table and if he took any, he reported those were his medications and could not remember if he took any of the medications.
On 08/06/24 at 11:05 AM, conducted a concurrent interview and record review with Registered Nurse (RN)39 regarding observation of R34, unattended with medication on the bedside table. RN39 pulled out a cup of medications and confirmed this was the medications on R34's bedside table. RN39 confirmed the resident was left unattended and should not have been. Inquired with RN39 if R34 took any medication(s). RN39 was unsure and proceeded to reconcile the medication in the cup with the 08:00 AM scheduled medications. When reviewing the Medication Administration Record (MAR), RN39 confirmed marking the medication as administered, prior to actually administering the medication to R34 and confirmed she should have marked the medication as given after observing R34 take the medication but did not.
Review of R34's EHR, documented the resident scheduled 08:00 AM medications included:
- Sennosides Oral Tablet 8.6 MG (Sennosides); Give 1 tablet by mouth two times a day for Constipation *Hold for loose stools
- Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl); Give 25 mg by mouth three times a day for HTN (hypertension) Hold for SBP (Systolic Blood Pressure) <110
- Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) (2 tabs); Give 10 mg (milligrams) by mouth one time a day for Depression
- Prazosin HCl Oral Capsule 2 mg (Prazosin HCl); Give 1 capsule by mouth two times a day for HTN *Hold for SBP <110. Hold for sedation
- Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG (Metoprolol Succinate); Give 1 tablet by mouth in the morning for HTN *Hold for SBP <110, HR <55
- Apixaban Oral Tablet 2.5 mg (Apixaban); Give 1 tablet by mouth two times a day for Atrial Fibrillation
- Vitamin B12 Oral Tablet 500 Mcg (microgram) (Cyanocobalamin); Give 1 tablet by mouth one time a day for Supplement
- Magnesium Oxide 400 Oral Tablet; Give 1 tablet by mouth in the morning for Supplement
- Levetiracetam Oral Tablet 500 mg (Levetiracetam); Give 2 tablet by mouth two times a day for Seizure
- Felodipine ER Oral Tablet Extended Release 24 Hour 10 mg (Felodipine); Give 10 mg by mouth one time a day for HTN hold SBP less than 120
After reconciling the medication left in the cup with the scheduled medications, R34 took:
- Levetiracetam Oral Tablet 500 mg (Levetiracetam); Give 2 tablet by mouth two times a day for Seizure
- Felodipine ER Oral Tablet Extended Release 24 Hour 10 mg (Felodipine); Give 10 mg by mouth one time a day for HTN hold SBP less than 120
On 08/09/24 at 11:35 PM, during an interview with the Director of Nursing, it was confirmed RN39 should not have marked the MAR prior to administering the medications to R34 and should have not left the resident unattended with the medications.

Based on interview and record review, the facility failed to review and act upon a pharmacist's recommendation on a monthly Medication Regimen Review (MRR) for one of five sampled residents (Resident (R) 79). This deficient practice has the potential to negatively affect R79's overall health and well-being.
Findings Include:
A review of R79's Electronic Health Record (EHR) was conducted. R79's EHR documented a MRR dated 05/31/24. The MRR noted a recommendation by the pharmacist, This resident continues to receive an atypical antipsychotic. Please consider, lipid panel [measurement of cholesterol and triglyceride in the blood], LFT [Liver Function Test], A1C [measurement of the average amount of sugar in the blood in the past few months].
Further review of R79's EHR, did not contain lab results for lipid panel, LFTs, and A1c.
An interview with the Director of Nursing (DON) was conducted on 08/08/24 at 01:55 PM, near the conference room. DON confirmed that R79's MRR, dated 05/31/24, was not reviewed by the physician. Therefore, the recommendations for the lab work were not completed. DON added that it should have been reviewed by the physician.
A review of the facility policy titled, Medication Regimen Review, with a revision date 04/01/24, was conducted. The facility policy documented, Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to accommodate a diet preference for one of 25 sampled residents (Resident (R)300). This deficient practice has the potential to affect R300's overall well-being.
Findings include:
R300 is a [AGE] year-old male admitted to the facility on [DATE].
Interview was conducted with R300 on 08/06/24 at 09:25 AM in R300's room. R300 stated that a dietician and cook had taken notes on his diet/food preference, and he often does not receive what he had requested. When asked what was listed on his preference, R300 stated he was a vegetarian. R300 continued to add that on multiple occasions he was served food that contained meat. R300 stated that he was served spaghetti with meat sauce at one point. He also mentioned two occasions when the kitchen had served him potato chips, when he specifically asked for fries.
Interview was conducted with R300 on 08/07/24 at 12:35 PM. R300 was observed eating spaghetti with tomato sauce. R300 stated that the kitchen had originally given him beef stew for lunch. R300 added, beef stew is not very vegetarian.
An interview was conducted with Physical Therapist (PT)5 on 08/07/24 at 12:57 PM. PT5 confirmed that he saw beef stew served on R300's lunch tray.
Interview was conducted with the Executive Director (ED) for the kitchen on 08/07/24 at 01:38 PM. ED stated that he is aware of R300's vegetarian food preference, but one of the kitchen staff had mistakenly placed beef stew on R300's lunch tray, instead of spaghetti with tomato sauce.
A review of R300's Electronic Health Record (EHR) was conducted. R300's current care plan, noted, Nutrition: (R300) is at risk for fluid and nutritional imbalance/deficit r/t: inadequate intake, increased needs for healing, vegetarian/limited preferences, and CHF.
A review of the facility policy titled, Resident Rights, with a revision date of 03/04/24, was conducted. The policy noted, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the policy, the facility failed to store food in a safe manner and maintain a sanitary cooking area. Two nourishment refrigerators on the first and second floors internal temperatures were not kept at or below 41 degrees. Perishable foods in the refrigerators were found to be at temperatures that were at 49.5 and 51 degrees. One pantry refrigerator in the main kitchen was found with an internal temperature at 43 degrees. Opened foods were not labeled with an indication of when staff should dispose of the food in the pantry, dry storage, and cooking areas. The deficient practice places residents in the facility at risk for foodborne illness.
Findings include:
Observation in the Kitchen on 08/06/24 at 08:40 AM in the pantry refrigerator, observed an open package of shredded [NAME] mozzarella cheese with no label or date. There was no internal thermometer found inside the unit. The external digital temperature reading was 48 degrees. The surveyor asked the kitchen manager to check the internal temperature of the unit. The thermometer read 43, and stated the temp is running a little on the warm side. In the dry storage room, observed an open box of biscuit mix with an unsealed plastic bag. In the kitchen near the cook station on the left side, a container of cattleman's barbecue sauce was 25 percent (%) full and sitting on the shelf with other dry spices. When asked by this surveyor, the Kitchen Supervisor said, it really shouldn't be up here and removed it. He asked the cook who was preparing food in the area if he opened this today, the cook shook his head and said no. In the same cooking area near the shelf was a fan with heavy dust on the back screen. The fan was facing toward the cook station and stove where the food is being prepared.
Observation of the nourishment refrigerator on the second floor on 08/08/24 at 12:30 pm, observed the thermometer inside the refrigerator read 58 degrees. The temperature log found on the shelf had temperatures documented from 11/2024 and 12/2024. The surveyor checked the internal temperature for a turkey sandwich inside the refrigerator that read 50 degrees. Notified Registered Nurse (RN) 12 of the unsafe temperatures and advised they remove all the perishable food items from the refrigerator.
Observation of the nourishment refrigerator on the first floor on 08/08/24 at 12:45 PM. The thermometer inside the refrigerator read 51 degrees. The surveyor checked the internal temperature for a tuna sandwich inside the refrigerator that read 49.5 degrees. Notified RN7 of the unsafe temperatures and advised all the perishable food items from the refrigerator be removed.
Interview with the Maintenance (M)5 at 12:55 PM on the second floor in the dining area, stated that they just filled it this morning, and they open it a lot, that's why it's warm. When asked where the temperature logs are kept since there wasn't a log found with the current date. M5 stated that the temperature is logged in the computer where we can check it. M5 pointed to a metal box located on top of the refrigerator with a metal cord coming out of the box. He added that these ice boxes are new, they are only a year old. Noted thick frost in the back of the refrigerator. The electronic temperature logs by the maintenance department weren't available for review.
Sodexo. Sanitation & Infection Control food safety policy #11.12 Date revised: 05/2023 reviewed. 7. Refrigerators must maintain Temperature Controlled for Safety (TCS) foods at 41degrees F or below . 9. All foods prepared in operation must be covered and labeled as to the contents and date of preparation prior to storage in refrigerators and freezers.

Based on record review and interview, the facility failed to include in the facility assessment the staffing resources required to meet the needs of their resident population. This deficient practice has the potential to affect all the facility's resident's ability to maintain or attain their highest practicable physical, functional mental and psychosocial well-being.
Findings include:
The facility assessment stated the facility is licensed for 141 beds with an average daily census of 95 residents based on the resident population profile from 06/05/23 to 06/04/24.
Review of the facility assessment found documentation that describes the facility's resident population and acuity levels, however, there was no documentation of the staffing levels required to meet the residents' needs.
On 08/09/24 at 10:04 AM, a concurrent interview and record review was conducted with the Administrator and the Director of Nursing (DON) in the education room. Asked Administrator and DON how staffing levels are determined. DON said it is based on the census and acuity. Asked if the required staffing levels were documented in the facility assessment. After reviewing the facility assessment, the Administrator and DON confirmed that staffing levels were not documented in the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. While providing care for Resident (R)250, the facility staff was not wearing applicable Personal Protective Equipment (PPE), did not perform hand hygiene between glove change, and did not follow guidelines to prevent possible cross-contamination of clean supplies. These deficient practices placed the resident at risk for developing preventable infections and other adverse health complications.
Findings include:
Review of R250's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] for short-term rehabilitation and long-term intravenous (IV) antibiotics administration. R250 has a Peripherally Inserted Central Catheter (PICC) line (tube inserted into a vein in the upper arm and threaded into a large vein above the heart to provide intravenous treatments) for the administration of prescribed IV antibiotics.
On 08/08/24 at 08:11 AM, observed Registered Nurse (RN)17 administer prescribed IV antibiotic. Sign outside R250's room stated that he was on Enhanced Barrier Precaution (EBP) and the use of a gown, gloves and mask are required when providing high contact care. RN17 entered room without donning a gown and place the IV antibiotic bag, prefilled normal saline syringes (used to flush the PICC line after use), PICC line caps, and alcohol wipes on the resident's bedside table right next to his urinal. RN17 did not use a barrier to place the clean supplies on. RN17 performed hand hygiene, donned a pair of gloves, and proceeded to flush and change the cap of the PICC line arterial port. RN17 then prepared the IV antibiotic bag, connected the lines, and set up the IV pump. After removing the air from the lines, RN17 changed her gloves without performing hand hygiene, cleaned and flushed the venous port, connected the IV line, and started the IV infusion.
On 08/08/24 at 01:34 PM, an interview was conducted with the Infection Preventionist (IP) by the first-floor conference room. Asked IP if administering an IV medication to a resident with a PICC line considered high contact care. IP said it is and staff should be using a gown when performing this task. Asked IP if it was acceptable to place clean supplies used when administering IV medications next to a urinal that the resident uses. IP said the expectation is for the staff to use a barrier on a clean surface prior to setting the supplies down. When asked if staff are supposed to perform hand hygiene between glove changes, IP said, Yes.
Review of facility policy Infection Control - Enhanced Barrier Precaution stated, . gowns and gloves available immediately near or outside of the resident's room. High-contact resident care activities include: . Device care or use: central lines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record/document review, out of a sample of three residents (R), the nursing staff failed to immediately consult one Resident's (R)1 physician when there was a change in condition. In addition, the resident's family was not notified of the change of condition and subsequent transfer to a hospital. As a result of this deficiency, the MD was not aware of the condition change from baseline and was not able to implement interventions which may have prevented further decline. This deficient practice has the potential to affect any resident with a change of condition and may result in harm or death.
Findings include:
1) R1 was a [AGE] year old female that was at the facility for short term rehabilitation. Diagnosis included, but not limited to exacerbation of bronchiectasis (chronic lung condition from inflammation and infection), COPD (chronic obstructive pulmonary disease, progressive respiratory disorder) with Pseudomonas (bacteria), MAC (uncommon lung disease caused by a specific group of bacteria) infection, Hyperammonemia (high levels of ammonia in the body), chronic migraines and anorexia.
2) Review of R1's nursing progress notes revealed the following documentation entered on 08/18/2023 at 06:50 AM by RN1:
At 19:40 (08/17/2023, 07:40 PM) resident's (R1) oxygen saturation (O2 sat) was at 69% (normal 88-92% for someone with lung disease). Respirations (RR) were 11 per minute. Resident was placed on 2 liters (L/l) via nasal cannula. Resident was AO (alert and oriented) x3-4 to person, time, and situation, stated she was at .hospital then corrected herself .
At 1958 (07:58 PM), writer heard a thud while in the hallway preparing medications and ran to residents room. Resident was found by writer on the floor on her left side .Resident was assessed. PERRLA (pupils equal, round, and react to light), AOx3-4 to person, time, unable to recall how she fell but she recalled she was trying to get to the restroom to urinate.Vital sign checks were conducted every 30 minutes.
Neuro checks remained within baseline, resident seemed lethargic (drowsy, unusually tired, or not alert), stated she was tired, but was cooperative with care. Weak but present response to stimuli to both hands, arms, legs and feet.Vital signs were as follows:
2009: BP (blood pressure) 109/67, HR (heart rate) 84, RR (respiratory rate) 16, T (temperature) 98.6
2030: BP 102/65, HR 84, RR 15, T 98.1
2100: BP 97/61, HR 85, RR 15, T 98.1
Intervention: Patient was offered sips of water and ensure plus. Patient tolerated 1-2 sips with each re-eval thereafter.
2130: BP 97/62, HR 85, RR 15, T 98
2200: BP 85/53, HR 81, RR 15, T 97.6
Intervention: Patient placed in semi-Trendelenburg (bed position) with feet elevated about heart, but head remained at 30 degrees due to risk of desaturation (low O2 sat).
2230: BP 99/61, HR 84, RR 15, T 97.8
2300: BP 102/61, HR 82, RR 15, T 97.8
0000: BP 104/62, HR 80, RR 14, T 97.8
-Patient refused neuro checks stating she was tired and wanted to sleep.
Around 04:00 (AM, 08/18/2023): Resident communicated that she was tired but able to take medication.
About 04:15 (AM): Writer heard a thud while passing medication in room across from resident's room. Resident had a pulse and breathing, but not responsive.Writer called 911. EMS arrived on scene around 0430 (AM).
Writer alerted MD and on-call managers around 2245 (10:45 PM) on 08/17 regarding first fall and decreasing blood pressure. Writer called MD1 at 04:48 (AM), but was unable to contact. Writer left a text note notifying MD and on-call managers that resident was sent out to .hospital. Resident's daughter .called and stated that she was trying to get a hold of her mom since last night and called the facility a few times, but her call was not received. Writer apologized for missing her calls and updated daughter.
3) R1's baseline O2 sat since admission ranged from 90%-99% with only one reading of 87% . Her RR ranged from 16-21, with one reading of RR12. R1 did not have any previous mental confusion. On 08/17/2023 at 07:40 PM, when R1's O2 sat decreased to 69% and her RR was 11 with some confusion, the MD should have been consulted immediately. The first attempt to contact MD was around 10:45 PM, after R1's BP dropped to 85/53. RN1 did not make any other attempts to contact MD, or alternate provider for consultation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for two Residents (R)1 and R2, out of a sample size of three. The physician order for R1's oxygen therapy did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates, and R2's oxygen administration was outside the parameters of the physician order. In addition, the facility Oxygen Therapy Protocol does not meet the requirements of a complete order/standing order. These deficient practices could potentially cause harm to any residents who is administered oxygen.
Findings Include:
1) R1 was a [AGE] year old female that was transferred to the facility from acute care on 07/19/23 for short term rehabilitation. She had been hospitalized for respiratory failure, and weight loss. Diagnosis included, but not limited to, hypercapnic respiratory failure (usually caused by COPD (chronic obstructive pulmonary disease), exacerbation of bronchiectasis (chronic condition where the walls of the bronchi are thickened from inflammation and infection), COPD (progressive respiratory disorder) with Pseudomonas (bacteria), MAC (uncommon lung disease caused by a specific group of bacteria) infection, Hyperammonemia (high levels of ammonia in the body), chronic migraines and anorexia.
Reviewed R1's medical record, which revealed an order initiated on admission [DATE], O2 PRN (as needed). There was no other oxygen order. Review of R1's Care Plan (CP) revealed it was identified she was at Risk for altered respiratory status. The interventions included Document, observe & report PRN for s/sx (signs/symptoms) of acute respiratory insufficiency: anxiety, confusion, The CP also included oxygen as ordered.
On 10/05/2023 at 01:50 PM, concurrent record review and interview conducted with RN2. She said at the time of admission, all residents get a PRN order for oxygen. RN2 went on to say, if their oxygen level falls below their norm, the RN would put oxygen on, then call the MD. A new order would be obtained from the MD and should be entered into the system. RN2 confirmed R1 received oxygen several times during her stay at the facility, and that the only oxygen therapy order in the chart was a PRN order.
On 10/06/2023 at 12:45 PM, concurrent review and interview conducted with the Director of Nursing (DON). She said the facility received a citation related to oxygen therapy on their recertification survey (09/09/2023), and they had been working on the oxygen therapy protocol and made some changes. The DON provided a copy of the new protocol, which read:
Upon admission ., all residents have a standard O2 PRN order.
MD/NP to be updated regarding resident's change of condition.
If nursing assessment of vitals indicated a resident's oxygen saturation level is below 88 %, supplemental O2 will be initiated.
Once MD is updated, initiate house oxygen protocol: 1-10L of O2 use Nasal cannula, Simple Mask or Non-Rebreather Mask. Nurse to assess and monitor to maintain O2 level WNL (within normal limits).
If resident requires specific parameter, an MD order will be obtained.
The DON said the Medical Director had been involved in development of the oxygen therapy protocol and had approved it. Requested documentation the Medical Director had approved the protocol, which was not provided by the the time of survey exit, 10/06/2023 at 03:00 PM.
On 10/06/2023 at 12:00 PM, during an interview with the Medical Director (MD1), he said he was asked about the oxygen therapy protocol. MD1 said he would like to see it more specific. Inquired if he would ever write the order 1-10L of O2 use Nasal cannula, Simple Mask or Non-Rebreather Mask, to which he replied No.
2) R2's had a history of COPD. His oxygen order written on the day of this admission was to titrate off the oxygen if O2 sat > 88%. Documentation revealed 11 entries of R2's O2 sat. 11 of 11 readings were >88%, yet he continued with oxygen therapy. Of the 11 entries, there was only one progress note on 09/16/2023 at 03:11 PM, that indicated there was an attempt to wean him off the oxygen. There was no documentation that the Provider was notified of R2's refusal.
3) Review of facility policy Oxygen Therapy with a revision date of 07/24/23 included:
4. The resident's physician orders shall identify the interventions for oxygen therapy, based upon the resident's assessment such as: a. The type of oxygen delivery system, b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.
8. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentration, or evidence of complications associated with the use of oxygen.
4) Cross Reference F726, Competent Nusing Staff
The nursing staff failed to demonstrate competency when caring for two residents (R1 and R2). Evidence included: 1. R1 had a change of condition that the Registered Nurse (RN)1 failed to immediately notify the physician (MD)1. 2. When MD1 failed to respond, there were no other attempt to contact him or another provider. 3. RN1 failed to monitor R1's condition according to nursing standards. 4. The nursing staff failed to attempt to wean R2 off oxygen as directed by MD order, and. 5. MD was not notified R2 refused to wean off oxygen.

Based on interviews , medical record and document review, the facility failed to ensure a physician (MD)1 responded when staff attempted to contact him regarding a resident's (R)1 change of condition, on 08/17/2023. As a result of this deficiency, no provider was made aware of R1's status and there were no interventions implemented, that may have prevented further decline of R1's condition. In addition, the facility policy to provide/arrange for provision of physician services 24 hours a day in case of emergency directs staff to contact the medical director if unable to reach the provider, but does not provide arrangements if the medical director does not respond. This deficiency puts all residents at risk of decline which may result in harm or death, if there is not a system in place to reach a physician 24/7 for emergencies.
Findings include:
1) On 08/17/2023 at approximately 10:45 PM, Registered Nurse (RN)1 attempted to notify Resident (R)1's physician (MD)1, regarding a change of condition. RN1's progress note read, Writer alerted MD and on-call managers around 2245 (10:45 PM) on 08/17 regarding first fall and decreasing blood pressure. R1 fell a second time on 08//18/2023 approximately 04:00 AM. R1 was unresponsive and transferred to a hospital via EMS to an Emergency Department for further care. RN1's progress note read; .called MD1 at 04:48 (AM), but was unable to contact. Writer left a text note notifying MD that resident was sent out .
2) On 10/05/2023, at 03:45 PM, conducted a phone interview with RN1. Inquired if nursing contacts providers late evening and during the night for a change of condition. She said overnight we call them, if no answer, we text them. RN1 went on to say she alerted MD, when R1 became hypotensive after the first fall. When asked RN1 further clarified, she made a telephone call to MD1 around 10:20 PM, but got no answer, so sent a text. She did not hear back from MD1. RN1 said she attempted to contact MD1 again after R1's second fall, when she was transferred to the hospital, but did not get an answer, so sent a text.
3) Reviewed the facility policy titled Physician Contact revision date 08/07/2023. The policy statement was; It is the policy of this facility to ensure a means of timely response for medical attention needed by residents who are patients of the facility via Physician/APRN (Advanced Practice Registered Nurse) or Medical Director. The policy also stated If a resident who has a different physician needs to be assessed, and you are having difficulty reaching the resident's primary or alternate physician, you may call the Medical Director to see that patient.
4) On 10/06/2023 at approximately 12:00 PM, conducted an interview with MD1, who as R1's physician, as well as the facility Medical Director. Reviewed the nursing notes of attempts to contact him regarding R1's condition change. MD1 said if the nursing staff were unable to reach him for any reason, they should contact the Nurse Practioner who splits call with him. He went on to say if they were unable to reach the NP, nursing should call Physicians Exchange, who would call the medical group he was a part of, who would locate a physician. MD1 said he was not sure what type of education was provided to the nursing staff regarding notification, but they should be aware of how to reach a physician if he does not respond.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the nursing staff failed to demonstrate competency when caring for two residents (R1 and R2) out of a sample size of three. Evidence included: 1. R1 had a change of condition that the Registered Nurse (RN)1 failed to immediately notify the physician (MD1). 2. When MD1 failed to respond, there were no other attempts to contact him or another provider. 3. RN1 failed to monitor R1's condition according to nursing standards. 4. The nursing staff failed to attempt to wean R2 off oxygen as directed by MD order, and 5. MD was not notified R2 refused to wean off oxygen therapy. As a result of these deficiencies, R1 suffered harm when she fell a second time and became unresponsive requiring transfer to the hospital. In addition, R2 was at increased risk of complications due to the oxygen administration. If nursing staff do not have the skill set and competency to assess, evaluate and respond to resident's needs, the residents are at increased risk of harm or death.
Findings include:
1) R1 was a [AGE] year old female that was admitted to the facility for short term rehabilitation on [DATE]. Diagnosis included, but not limited to, hypercapnic respiratory failure (usually caused by COPD (chronic obstructive pulmonary disease), exacerbation of bronchiectasis (chronic condition where the walls of the bronchi are thickened from inflammation and infection), COPD (chronic obstructive pulmonary disease/progressive respiratory disorder) with Pseudomonas (bacteria), MAC (uncommon lung disease caused by a specific group of bacteria) infection, Hyperammonemia (high levels of ammonia in the body), chronic migraines and anorexia. R1 was progressing well at the facility until [DATE] when she had a change in condition. Her oxygen level dropped and her RR was 11. In addition, she had some confusion that was not her baseline. R1 fell two times, the second time she was unresponsive and transferred to a hospital emergency department. R1 subsequently expired from a subdural hematoma (life threatening condition with collection of blood that forms on the surface of the brain).
Review of R1's nursing progress notes documented at [DATE] at 06:50 AM read:
At 19:40 ([DATE], 07:40 PM) resident's (R1) oxygen saturation was at 69% on room air. Respirations were 11 per minute. Resident was placed on 2 liters (L) via nasal cannula (NC). Resident was AO (alert and oriented) x3-4 to person, time, and situation, stated she was at .hospital then corrected herself .
At 1958 (07:58 PM), writer heard a thud while in the hallway preparing medications and ran to resident's room. Resident was found by writer on the floor on her left side . Resident was assessed. PERRLA (pupils equal, round and react to light and accommodation), AOx3-4 ., unable to recall how she fell but she recalled she was trying to get to the restroom to urinate.Vital sign checks were conducted every 30 minutes.
Neuro checks remained within baseline, resident seemed lethargic (drowsy, unusually tired, or not alert), stated she was tired, but was cooperative with care. Weak but present response to stimuli to both hands, arms, legs and feet. Vital signs were as follows:
08:09 PM: BP (blood pressure) 109/67, HR (heart rate) 84, RR (respiratory rate) 16, T (temperature) 98.6
08:30 PM: BP 102/65, HR 84, RR 15, T 98.1
09:00 PM: BP 97/61, HR 85, RR 15, T 98.1
Intervention: Patient was offered sips of water and ensure plus. Patient tolerated 1-2 sips with each re-eval hereafter.
09:30 PM: BP 97/62, HR 85, RR 15, T 98
10:00 PM: BP 85/53, HR 81, RR 15, T 97.6
Intervention: Patient placed in semi-Trendelenburg (positioning bed) with feet elevated about heart, but head remained at 30 degrees due to risk of desaturation.
10:30 PM: BP 99/61, HR 84, RR 15, T 97.8
11:00 PM: BP 102/61, HR 82, RR 15, T 97.8
00:00 PM: BP 104/62, HR 80, RR 14, T 97.8
-Patient refused neuro checks stating she was tired and wanted to sleep.
Around 04:00 (AM, [DATE]): Resident communicated that she was tired but able to take medication.
About 04:15 (AM): Writer heard a thud while passing medication in room across from resident's room. Resident had a pulse and breathing, but not responsive.Writer called 911. EMS arrived on scene around 0430 (AM).
Writer alerted MD and on-call managers around 2245 (10:45 PM) on 08/17 regarding first fall and decreasing blood pressure. Writer called MD1 at 04:48, but was unable to contact. Writer left a text note notifying MD and on -call mangers that resident was sent out to .hospital. Resident's daughter .called and stated that she was trying to get a hold of her mom since last night and called the facility a few times, but her call was not received. Writer apologized for missing her calls and updated daughter.
On [DATE], at 03:45 PM, conducted a phone interview and concurrent record review with RN1. She said when R1 became hypotensive. so she pushed fluids. When asked to clarify, RN1 said she thought she gave R1 ensure and water. She confirmed she did not try to contact MD1 again, because R1's BP went back to baseline.
RN1 did not demonstrate competency as evidenced by:
- There was a significant change in R1's condition documented by RN1 at 07:40 PM on [DATE], when R1's oxygen saturation decreased to 69% and her RR was 11 with some confusion. The Provider (MD1) should have been notified immediately at that time. The first attempt to contact MD1 was around 10:45 PM, after R1's BP dropped to 85/53.
- After R1's O2 sat was 69% at 07:40 PM, it was not rechecked again until 08:57 PM. There were no additional O2 levels checked until EMS arrived to transport at around 04:30 AM.
- RN1 left R1 alone to pass medications after noting she had some confusion, very low O2 sat level and RR 11. This is when the first fall occurred.
- After R1 refused continued neuro checks, RN1 did not explain the risks of the refusal to R1. The next time RN1 checked R1 was when meds were being passed again around 04:00 AM.
2) Cross reference F580 Notify of Changes.
The nursing staff failed to immediately consult R1's physician when R1 had a significant change in condition. The RN attempted to contact the MD about three hours later when R1 was hypotensive, but he did not respond. There were no repeat attempts to contact the MD, or another provider.
3) Cross reference F 695 Respiratory Care
The nursing staff administered oxygen per nasal cannula to R1 several times, but failed to obtain a complete order from the physician. The only oxygen administration order R1 had was PRN (as needed), which was not a complete order.
4) R2 was a [AGE] year old male admitted to the facility on [DATE] for deconditioning post acute hospitalization for pneumonia. His diagnosis included, but not limited to End Stage Renal Disease, Diabetes mellitus, MI (heart attack), cardiac arrest, chronic pleural effusion and COPD. R2 had an order for Supplemental O2. Use 1-3 lpm (liters per minute) via NC (nasal cannula), Wean (titrate) off if >88%. Start date was [DATE].
Review of the Medication Administration Record revealed the following:
[DATE], 10:00 PM: O2 Sat 94 %
[DATE], 06:00 AM: O2 Sat 95%
[DATE], 02:00 PM: O2 Sat 96%
[DATE], 10:00 PM: O2 Sat 96%
[DATE], 06:00 AM: O2 Sat 96%
[DATE], 02:00 PM: O2 Sat 94%
[DATE], 10:00 PM: O2 Sat 91%
[DATE], 06:00 AM: O2 Sat 90%
[DATE], 02:00 PM: O2 Sat 90%
[DATE], 10:00 PM: O2 Sat 91%
[DATE], 06:00 AM: O2 Sat 94%
Review of R2's Nursing Progress Notes revealed the following pertinent entries:
[DATE], 04:48 PM: .O2 sat 96% @ 1.5 LPM via NC.
[DATE], 10:17 PM: .On continuous supplemental O2 via NC at 1 LPM sating 94% .
[DATE], 01:10 PM: .O2 sat 95% @ 1.5 LPM via NC.
[DATE], 03:22 AM: .O2 sat 96% 1.5 L.
[DATE], 03:55 PM: .oxygen saturation 96% via 1.5L/min NC .
[DATE], 03:11 PM: .oxygen saturation 96% via 1.5L/min NC, he refuses to titrate off of the oxygen use, he verbalized having comfort in oxygen use.
[DATE], 07:30 AM: .oxygen saturation 94% via 1.5 L/min NC .
[DATE] 02:43 PM: . oxygen saturation 92-93% via 2L/min NC .
R2 was transferred to acute care facility [DATE] when he had a change in mentation.
The nursing staff did not demonstrate competency as evidenced by the delivery of R2's oxygen. The order was to titrate off the oxygen if O2 sat > 88%. Documentation revealed he was >88% every day from [DATE] to [DATE], but there was only one progress note that documented the RN attempted to wean R2 off the oxygen. There was no documentation that the Provider was notified of R2's refusal. Due to R2's history of lung disease, continued oxygen administration outside the order parameters, and refusal to wean, should be discussed with the Provider and documented, which is the standard of nursing practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for three of 22 residents (R)26, R34,and R64 in the sample. Care plans and interventions were not personalized to the needs of the residents. As a result of this deficient practice, the residents are at risk of not reaching their highest practicable physical and psychosocial well-being.
Findings Include:
1) Cross Reference F692 Nutrition/Hydration Status Maintenance
On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture.
On 08/22/23 at 12:18 PM, observed R26 in her room with her lunch tray on her bedside table pushed to the left side of her bed. R26's entree of chicken and noodles were not eaten. The chicken piece was approximately 4.5 inches in length and 3 inches wide and not chopped. The meal ticket on R26's meal tray indicated a regular diet with chopped texture.
Record review of R26's electronic health record (EHR). Orders revealed a diet order for Regular diet, Chopped texture, regular/Thin consistency with a start date of 08/08/22. Review of R26's latest care plan for the Focus for Resident is at risk for fluid and nutritional deficit r/t [related to]: variable intake, underwt [underweight]/adult FTT [failure to thrive], malnutrition/severe PCM [protein calorie malnutrition], chewing deficit, CKD [chronic kidney disease, hx [history] wound. There was no indication for R26's need for a regular diet with chopped texture.
2) On 08/21/23 at 01:52 PM, observed R34 sitting up on wheelchair just outside her room. Noted right arm was bent and up against her torso, and the right hand was clenched in a fist. There was no splint for the arm and no rolled towel for the hand. On 08/23/23 at 03:43 PM, observed R34 lying in bed and slightly turned to her left side. A stuffed animal was placed between her right arm and torso. Right hand was clenched in a fist, no brace or rolled towel noted.
On 08/24/23 at 08:30 AM, review of R34's electronic health record (EHR) was done. R34 was admitted to the facility on [DATE]. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness or inability to move) following cerebral infarction (stroke) affecting right dominant side. Review of comprehensive care plan with a revision date of 08/18/23 revealed there was no specific problem identified to address the resident's contracted right arm and clenched right hand.
On 08/24/23 at 09:48 AM, concurrent interview and record review conducted with Unit Manager (UM) 1 in her office. Asked UM1 what the facility was doing for her contracted right arm and clenched hand. UM1 said R34's right arm was always contracted, and the staff use a pillow to keep it separated from her torso since it is also causing some skin irritations. UM1 also said R34's hand is mostly closed, and it is hard to open to put a rolled towel in it. Asked UM1 to check if there is a care plan in the EHR for the contractures and she was not able to find one.
3) On 08/21/23 at 09:59 AM, observed R64 sitting up in bed watching television. R64 said he was waiting for the staff to bring him outside so his transportation service can bring him to his dialysis (procedure to remove toxins and excess fluids from the body when the kidneys are not functioning) treatment. R64 had a central venous catheter (CVC, a surgically placed device providing access into a large central vein) on his right chest as his vascular access (a way to reach the blood for hemodialysis).
Record review of R64's comprehensive care plan dated 08/10/23. A problem identified for R64, was the need for dialysis. Interventions for identified problem included tasks to be done specifically for a fistula (vascular access surgically created by joining a native artery and vein) or a graft (vascular access surgically created by implanting a tube to join an artery and vein). These interventions were, Assess bruit and thrill QSHIFT (every shift) . Do not draw or take B/P (blood pressure) in left arm with graft . Notify MD (attending physician) if evidence of loos of shunt patency. Further review of R64's EHR under Misc (miscellaneous), where facility upload paper documents, revealed that R64 used to have a fistula on his left arm. A scanned document uploaded on 12/20/22 stated that R64's fistula was ligated (closed off) due to rupture and a CVC was inserted on 12/16/23.

Based on observations, record reviews, and interviews, the facility failed to maintain the nutrition status of one Resident (R)26 out of a sample of four residents. R26's diet texture was not provided to her according to the physician's order, which could potentially impact her dietary intake. This deficient practice rendered R26 under nourished and does not allow R26 to live at her highest practicable physical and psychosocial well-being.
Findings Include:
Cross Reference to F656 Develop/implement Comprehensive Care Plan
On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture.
Record review of R26's electronic health record (EHR). Orders revealed a diet order for Regular diet, Chopped texture, regular/Thin consistency with a start date of 08/08/22. Review of R26's latest care plan for the Focus for Resident is at risk for fluid and nutritional deficit r/t [related to]: variable intake, underwt [underweight]/adult FTT [failure to thrive], malnutrition/severe PCM [protein calorie malnutrition], chewing deficit, CKD [chronic kidney disease, hx [history] wound. There was no indication for R26's need for a regular diet with chopped texture. A task flowsheet for NUTRITION - Amount Eaten for R26's three daily meals from 08/11/23 to 08/23/23 revealed that R26 consumed 0 - 25% of the meal, 51% of the time.
On 08/24/23 at 08:31 AM, interviewed Unit Manager (UM)2 in UM2's office. UM2 stated that R26's broccoli served for lunch on 08/21/23 and the chicken served for lunch on 08/22/23, was supposed to be initially chopped by the kitchen staff. UM2 further stated that the direct patient care staff serving the tray to R26 was supposed to double check the consistency of the meal and chop the appropriate food items if they were not done so by the kitchen staff.
On 08/24/23 at 09:07 AM, interviewed the Registered Dietitian (RD) in the RD's temporary office. RD stated that a chopped consistency diet entails that harder textured foods are cut into ½ inch pieces. RD confirmed that not providing a chopped texture diet to R26 could render her with the inability to chew, causing her not to eat her meal, which then could cause her to become undernourished.
On 08/24/23 at 10:12 AM, interviewed Kitchen Manager (KM) in KM's office. KM confirmed that the broccoli and chicken served to R26 for lunch were supposed to be chopped by the cook.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to communicate two medication recommendations, between the pharmacist and the attending physician, for one resident(R), R51, out of five residents sampled. As a result of this deficiency, the facility put R51 at risk for complications related to medications.
Findings Include:
Review of the electronic health record (EHR) showed R51 was admitted to the facility on [DATE] with diagnosis including Dementia, Diabetes, Post-Traumatic Stress Disorder, Hypothyroidism, and Depression.
Review of the Medication Regimen Review (MRR) document completed by the Pharmacist dated 02/23/23 read . Will recommend clarification on diagnosis of Sertraline [antidepressant medication] . There was no documentation that this was communicated to the attending physician.
Another review of the MRR completed by the Pharmacist dated 05/31/23 read .Will recommend possibility of discontinuing evening supplements to reduce pill burdens at bedtime . There was no documentation that this was communicated to the attending physician.
During staff interview on 08/23/23 at 01:00 PM, Director of Nursing (DON) acknowledged there was no documentation to show that the two recommendations were communicated to the attending physician.

Based on observations, interview, and record review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications.
Findings Include:
Concurrent observation and interview were conducted on 08/24/23 at 08:11 AM in the first-floor hallway. A medication cart was observed unlocked in the hallway with staff members, residents, and visitors walking by. This surveyor and Director of Nursing (DON) were present when Licensed Practical Nurse (LPN) 1 was interviewed. LPN1 stated, I thought I locked it. He also added that medication carts should always be locked.
A review of the facility's policy titled, Medications: Storage, with a revision date of 01/11/23 was conducted. The document indicated, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

Based on observations and interview, the facility failed to label food items with the dates they were opened to ensure they were not served after the expiration date. As a result of this deficiency, residents, visitors, and staff were put at risk for contracting a foodborne illness.
Findings Include:
On 08/21/23 at 08:07 AM, conducted the initial brief tour of the kitchen. Observed two thickener containers by the food preparation area that were opened. Both containers did not have a label to indicate when they were initially opened, and both were nearly empty. Observed an open bottle of cranberry juice on another counter that was half full and without a label indicating when it was opened.
Interviewed Kitchen Manager (KM) in the kitchen at the end of the intial brief tour conducted on 08/21/23. Queried KM if the thickener and cranberry juice were supposed to be labeled and KM stated staff are supposed to put a sticker on the item with the open date and use-by date written on it. KM asked one of the kitchen staff to put a label with their respective dates on the containers.

Based on observations, interview, and record review, the facility failed to completely screen visitors, guest, vendors for signs and symptoms of COVID-19. As a result of this deficiency, residents, staff, and visitors were at increased risk for contracting the COVID-19 virus.
Findings Include:
Observation on 08/21/23 at 07:50 AM, there was a passive screening station for COVID-19 at the entrance to the facility. The station prompted visitors, guest, vendors to complete a screening questionnaire related to COVID-19. There was no staff in the immediate vicinity to monitor the station. Upon completion of the questionnaire, there was nothing provided to verify that the screening questionnaire was completed. The visitor, guest, vendor could enter the facility and there was no visual validation to show that the screening for COVID-19 was completed.
On 08/21/23 at 08:07 AM, conducted the initial brief tour of the kitchen. Observed outside contractor for pest control walk into the kitchen area from the dining room without a mask. Asked outside contractor if he was supposed to be wearing a mask while in the facility, he said he was trying to find out. Outside contractor then asked Kitchen Manager (KM) if he needs to wear a mask. KM said, Yes, and directed him to go to the screening area at the main entrance to get a mask.
On 08/23/23 at 03:25 PM, interview conducted with Infection Preventionist (IP) by the first-floor dining area. Asked IP if everyone that enters the facility must wear a mask while in the facility. IP said, Yes, we have postings in the front entrance and screening area. IP also pointed out a posting in the dining area titled, Guidelines for Visitation, with an effective date of 05/01/23. The posting stated, . Visitors will wear a facial covering/mask (nose and mouth covered) within the facility. Asked IP if it includes outside contractors like elevator maintenance workers, plumbers, electricians and exterminators. The IP responded, Yes.
Staff interview on 08/22/23 at 02:15 PM, the Chief Operations Officer (COO) acknowledged the observation previously mentioned that visitors, guest, vendors could enter the facility and there was no quick way to show that screening for COVID-19 was completed. COO revealed that there was supposed to be a sticker provided to everyone, after the completion of the screening questionnaire, but they ran out of the stickers and new stickers were currently on order.
Review of facility procedure on Guidelines for Visitation, effective 05/01/23, read the following: . Visitation is allowed at all times, however please take into consideration sleep/wake times of residents, Visitors will be screened and observed for signs and symptoms of COVID-19 prior to visitation. If you are sick, have had close contact or have tested positive for COVID-19 refrain in person visitation . Visitors will wear a facial covering/mask (nose and mouth covered) within the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for one Resident (R)64, out of one resident in the sample. The physician order for the use of oxygen did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates. This deficient practice could potentially cause harm to residents due to the lack of physician direction.
Findings Include:
On 08/21/23 at 09:59 AM, observed R64 sitting up in bed watching television. R64 had a nasal cannula (plastic tubing placed into the nares) connected to an oxygen concentrator set at 2.5 liter per minute. R64 said he was going out for his hemodialysis treatment and will not be back until later that afternoon.
Review of the electronic health records (EHR) revealed that R64 was admitted on [DATE]. Diagnoses includes but not limited to end stage renal disease (kidneys are not functioning) with dependence on renal dialysis (procedure to remove toxins and excess fluids from the body when the kidneys are not functioning) and chronic obstructive pulmonary disease (condition that causes airflow blockage and breathing problems). Comprehensive care plan reviewed, and a problem identified was Risk for altered resp [respiratory] status. Interventions for this problem included, Administer Oxygen as needed. Review of physician orders revealed an entry on 07/05/23 that stated. O2 (oxygen) PRN (as needed). No other parameters were included in the order.
On 08/24/23 at 10:39 AM, concurrent record review and interview conducted with the Unit Manager (UM) 1 in her office. Asked UM1 how the does the staff determine how much oxygen is administered to R64 and how to administer it. UM1 said the staff would refer to the order. UM1 then reviewed the oxygen order in the EHR and said, They are supposed to specify how much oxygen to give and how to deliver it. I will correct the order and update the care plan.
Review of facility policy Oxygen Therapy with a revision date of 07/24/23 stated, . 4. The resident's physician orders shall identify the interventions for oxygen therapy, based upon the resident's assessment such as: a. The type of oxygen delivery system. c. Equipment setting for the prescribed flow rates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to treat one resident (R), R46, out of two residents sampled, with dignity and respect. This deficient practice has a negative effect on maintaining and enhancing R46's self-esteem and self-worth. The deficient practice has the potential to cause psychosocial harm to R46.
Findings Include:
R46 is a [AGE] year-old male admitted to the facility on [DATE]. R46 has a diagnosis that include but is not limited to Parkinson's Disease. A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/23/23 revealed that R46 was determined to have a Brief Interview for Mental Status (BIMS) score of 14, meaning he was found to be cognitively intact.
Observation was conducted on 08/21/23 at 11:18 AM in R46's room. R46 was in the middle of eating a meal. A staff member was in the room handing him a drink. R46 was observed without pants or shorts on. R46 only had a shirt and his incontinence brief. He was not covered with a blanket.
Observation was conducted on 08/22/23 at 07:22 AM in R46's room. R46 was lying in bed with no shorts or pants on. R46 only had a shirt and incontinence brief on. He was not covered with a blanket.
Interview was conducted on 08/22/23 at 09:14 AM in R46's room. R46 verbalized that he would like to have shorts or pants on first thing in the morning but sometimes the staff do not put shorts or pants on him.
Observation was conducted on 08/23/23 at 07:10 AM in R46's room. R46 was seen lying in bed with his shorts pulled down below his hips, exposing his incontinence brief. R46 also had his shoes on. R46 remained in that position for 40 minutes until this surveyor called Certified Nurse's Aide (CNA) 44 into the room.
Interview with CNA44 was conducted on 08/23/23 at 07:50 AM in R46's room. CNA44 was queried on R46's shorts. CNA44 stated that R46's shorts were only placed halfway because R46 changed his mind on going into the wheelchair. CNA44 usually pulls it up once R46 was in a standing position. Since R46 changed his mind, CNA44 left him lying in his bed with his shorts down below his hips, exposing his incontinence briefs.
A review of the facility's policy titled, Promoting and Maintaining Resident Dignity, with a review date of 01/10/23 was conducted. The policy indicated, Groom and dress residents according to resident preferences.

Based on observation, record review, and interviews, the facility failed to document an interdisciplinary (IDT, includes but not limited to, the physician, social worker, dietitian, and nurse) assessment and care plan regarding a resident's self-administration of medication. The lack of this process failed to ensure that resident (R), R56, out of a sample of one, was assessed appropriately for having the capability to self-administer his medication safely and correctly. There also was no process to follow-up with R56 to ensure that he retained the capability to self-administer medication. This deficient practice could potentially harm residents who want to self-administer their medication(s).
Findings Include:
On 08/23/23 at 08:30 AM, conducted a concurrent observation and interview with Registered Nurse (RN)11 while administering R56's medications in R56's room. RN11 stated that R56 was able to administer his own medicated eye drops (Dorzolamide Hcl (Hydrochloride) - Timolol Mal Solution 22.8 - 6.8 mg (milligrams)/ml (milliliter) to treat his glaucoma). RN11 stated that there was no documented assessment by the interdisciplinary team (IDT) and no care plan for R56 to self-administer his eye drops.
Record review of R56's electronic health record (EHR). Order Summary Report revealed Dorzolamide HCl - Timolol Mal Solution 22.3 - 6.8 MG/ML Instill 1 drop in both eyes two times a day for Glaucoma *Space each drop by 5 minutes ordered on 08/09/22. There was an order dated on 08/08/22, May keep eye drops at bedside for self administration two times a day. No written documentation of an assessment by the IDT for the self-administration of medications was found nor was the self-administration of R56's eye drops was identified on R56's care plan.
On 08/23/23 at 11:52 AM, interviewed RN12 at the nursing station. RN12 stated that if a resident requests to self-administer medications, the resident is assessed by the nurse, but is not formally documented, to see if he/she is aware of and can identify him/herself, the place, time, and situation (alert and oriented four times). An order is then obtained from the resident's physician for the resident to be able to self-administer medications.
On 08/23/23 at 11:56 AM, interviewed Unit Manager (UM)2 in her office. UM2 stated that to self-administer medication(s), the resident needs to know the name of the medication and what it is used for, the dose, time, and correct procedure. UM2 confirmed that there was no formal and documented assessment done by the IDT for R56's capability to administer his own eye drops to treat his glaucoma. UM2 agreed that R56's self-administration of his eye drops should be in the resident's care plan for proper monitoring of his continued capability.
Reviewed the policy, MEDICATIONS: SELF - ADMINISTRATION, with revision date 01/23/23. It stated, . Procedure: 1. The resident is determined by the Interdisciplinary Care Plan Team to be physically and mentally competent to self-administer medications. Use of self-medication will be addressed in the resident's care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a safe and effective transition of care for three of five residents (R), (R64, R82 and R12) in the sample. The facility did not provide a copy of the comprehensive care plan goals to the receiving provider. This deficient practice does not provide an accurate picture of the resident and of his/her needs which will result in poor continuity of care.
Findings Include:
1) During an interview on 08/22/23 at 09:01 AM, R64 stated he was recently hospitalized for low blood pressure and pneumonia (lung infection).
Review of Electronic Health Record (EHR) revealed that R64 is a [AGE] year-old resident admitted on [DATE]. R64 was transferred to an acute care hospital on [DATE] for non-ST-elevation myocardial infarction (less severe form of heart attack), respiratory failure, and pneumonia. Documented in the Progress Notes on 07/01/23 at 04:06 PM, . Report including recent labs (laboratory results), AHCD (advanced health care directives), face sheet, med/tx (medication and treatment) list given to paramedics.
2) During an interview on 08/21/23 at 02:54 PM, R82 said she was recently hospitalized for an infection to the surgical site on her abdomen.
Review of the EHR revealed that R82 is a [AGE] year-old resident admitted to the facility on [DATE] for surgical aftercare. R82 was in the hospital for perforated bowels and colostomy (an opening for the intestines through the abdomen) creation. Review of progress notes revealed that R82 was sent to the emergency department for a blood transfusion on 07/22/23 but was admitted for an infected surgical site and returned to the facility on [DATE].
On 08/23/23 at 09:30 AM, Social Worker (SW) 1 provided documents titled Notice of Transfer / Discharge for both R64 and R82. SW1 said they also fax a copy of the form to the State Long Term Care Ombudsman and email a copy to the residents' family along with the bed hold policy. When asked about what documents go to the receiving facility, SW1 said the facility has a checklist and the nurses print out the documents from the EHR.
On 08/23/23 at 12:25 PM, interview conducted with the Director of Nursing (DON) in the training room. Asked DON what documents are sent to the receiving facility when a resident is transferred out for a higher level of care. DON said the facility sends out a packet with the resident that included the face sheet, physician's orders, advance health care directives, medication administration record, treatment administration record, consultation notes, and laboratory results. The DON added that the nurse would also call the receiving facility to give report. When asked if the comprehensive care plan is also sent to the receiving facility, the DON said, No, we do not send the care plan.
3) Record review of R12's EHR. R12 is an [AGE] year-old female admitted to the facility on [DATE] for cellulitis (inflammation of tissue) of left lower limb. On 07/25/23, R12 was transferred to the hospital for further assessment of left lower extremities. Further review of R12's EHR indicated no documentation of R12's care plans being sent over to the receiving hospital.
Interview with DON was conducted on 08/23/23 at 12:25 PM in the training room. DON verbalized that the facility does not send over care plan records to the receiving hospital when a facility resident is transferred or discharged .