Does LILIHA HEALTHCARE CENTER have any serious inspection findings?

Yes, LILIHA HEALTHCARE CENTER has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 66 total deficiencies from recent inspections.

What are the staffing levels at LILIHA HEALTHCARE CENTER?

LILIHA HEALTHCARE CENTER has a three-star staffing rating from CMS with 1.18 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is LILIHA HEALTHCARE CENTER located?

LILIHA HEALTHCARE CENTER is located in HONOLULU, HI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LILIHA HEALTHCARE CENTER have?

LILIHA HEALTHCARE CENTER has 92 certified beds.

Who owns LILIHA HEALTHCARE CENTER?

LILIHA HEALTHCARE CENTER is a for profit - corporation facility and operates independently (not part of a chain).

What questions should families ask when visiting LILIHA HEALTHCARE CENTER?

Families visiting LILIHA HEALTHCARE CENTER should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does LILIHA HEALTHCARE CENTER compare to other nursing homes?

LILIHA HEALTHCARE CENTER has a 1-star overall rating, which is below average compared to other nursing homes in HI. Families should carefully review inspection findings and consider alternatives.

LILIHA HEALTHCARE CENTER

Name: LILIHA HEALTHCARE CENTER
Address: 1814 LILIHA STREET, HONOLULU, HI, 96817, US
Telephone: (808) 537-9557
Rating: 1.0

1814 LILIHA STREET, HONOLULU, HI 96817 · (808) 537-9557

For profit - Corporation 92 Beds Independent Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#39 of 41 in HI

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Liliha Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided, which is poor. Ranking #39 out of 41 facilities in Hawaii places it in the bottom half, and #24 out of 26 in Honolulu County shows that there are only two better options locally. The facility's condition is worsening, with the number of reported issues increasing from 8 in 2024 to 16 in 2025. While staffing is a relative strength with a 3/5 star rating and only 0% turnover, indicating staff stability, the facility has several serious problems. For example, it failed to properly manage COVID-19 protocols, leading to outbreaks among residents and staff, and did not provide adequate supervision for a resident who subsequently suffered a serious fall resulting in hospitalization. Overall, while there are some strengths in staffing, the critical issues raise significant concerns for potential residents and their families.

Trust Score: F
In Hawaii: #39/41
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: Turnover data not reported for this facility.
Penalties: $11,170 in fines. Higher than 50% of Hawaii facilities. Some compliance issues.
Skilled Nurses: Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of Hawaii nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 66 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 8 issues

2025: 16 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Hawaii average (3.4)

Significant quality concerns identified by CMS

Federal Fines: $11,170

Below median ($33,413)

Minor penalties assessed

The Ugly 66 deficiencies on record

2 life-threatening 4 actual harm

Jun 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one Resident (R)3 of a sample size of three reviewed for abuse. This deficient practice potentially compromised the protection and safety of all residents on the unit where R3 resided. Findings include: On 02/24/2025 at 07:05 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11520, documenting an allegation of staff-to-resident abuse by Certified Nurse Aide (CNA)12 to R3. On 06/05/2025, the SA entered the facility to investigate the allegation. On 06/05/2025, the facility provided a copy of the 02/24/2025 Nurse staff schedule for the second-floor unit which revealed four CNAs (including CNA12) and two Registered Nurses (RN) working at the time the incident allegedly occurred (day shift). On 06/05/2025 at 11:30 AM, a review of the facility's investigation packet revealed that the facility obtained information from CNA12. There was no evidence provided to indicate the facility interviewed or obtained statements from the other staff members working at the time of the incident. There was also no evidence of interviews with R3's roommates and other residents residing on the second-floor unit, and no evidence that residents who were not interviewable were assessed for signs and symptoms of abuse. On 06/05/25 at 02:00 PM, an interview was done with the Administrator (ADM) in his office and confirmed that the facility did not conduct interviews with other staff members working at the time of the incident, R3's roommates, and other residents residing on the unit. The ADM stated, The focus was just on that resident. A review of the facility's policy titled, Abuse, Neglect, and Exploitation, last revised 06/2023, under V. Investigation of Alleged Abuse, Neglect, and Exploitation, the following was noted: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect .has occurred, the extent . 6. Providing complete and thorough documentation of the investigation.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to make timely revisions to two resident's (R)1 and R2's Comprehensive Care Plans (CP) of a sample size of six. As a result of this deficient practice, staff did not have all the information necessary to effectively address the resident's status, condition, and/or needs adequately so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) R1 was a [AGE] year old female admitted to the facility on [DATE]. Her medical history included but not limited to chronic obstructive pulmonary disease, stroke affecting the left side, dysphasia (difficulty swallowing), dementia, Type 2 diabetes, and anemia. R1 was incontinent of bowel and bladder and had a feeding tube (tube placed in stomach) for long term nutritional support. She required one person assist with bed mobility. On 06/09/2025 at 12:00 PM, observed R1 lying in bed and noted she had protective arm sleeves on both arms. Reviewed R1's provider orders, which included an order dated 04/29/2025, for GERI (skin protector) sleeves to bilateral arms for protection. Reviewed R1's nursing progress note, dated 06/03/2025 at 04:37 PM. The note read Resident noted with several small open wounds on BUE (bilateral upper extremities) due to resident's scratching. Reviewed R1's CP, which indicated that she was at risk for skin issues due to fragile skin, but the CP was not updated to include the GERI sleeves to protect her skin. 2 ) R2 was a [AGE] year old female admitted to the facility on [DATE]. Her medical history included Parkinson's. Reviewed R2's provider orders, which included an order dated 05/08/2025 for Prevalon Boot to R (right) ankle/foot for protection. Monitor for skin breakdown. On 06/09/2025 at 11:55 PM, interviewed RN1 in the first floor nursing station. Inquired why R2 had a boot ordered for her ankle. RN1 demonstrated how R2's Right (Rt ) foot rotated out, causing pressure on the ankle bone. At that time, reviewed R2's CP with RN1, who confirmed the boot was not included as an intervention for skin integrity. She said the boot should be in the care plan. On 06/09/2025 at 12:10 PM, accompanied RN1 to R2's room and observed her lying in bed. It was noted that she was not wearing the Prevalon Boot on her Rt foot. At that time, RN1 obtained the boot from the cabinet, and placed it on her foot. Observed a small area of redness to the outside of R2's ankle area, which is the reason the boot was ordered.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record and document review, the facility failed to provide the standard of nursing care to one Resident (R)6 of a sample size of three. Specifically, when R6 was diagnosed with COVID infection, the nursing staff failed to consistently monitor all vitals signs, which would include temperature (T), blood pressure (BP), pulse rate (P), respiration rate (R), and pulse oximetry (O2% - measures oxygen in blood). As a result of this deficient practice, there was a higher risk that changes in condition may be missed. Findings include: 1) R6 was an [AGE] year old female long term resident at the facility. Her medical history included advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder and hypertension. R6 had dysphasia, which affected her ability to communicate and at baseline, she was not alert or oriented. On 03/30/2025 she was diagnosed with COVID infection, and placed in isolation until 04/08/2025. On 04/10/2025, R6 was transferred to the hospital for a higher level of care due to altered mental status and high blood sugar, where she was admitted with diagnosis that included sepsis (life threatening reaction to infection), metabolic encephalopathy (brain dysfunction), respiratory failure, hypernatremia (high sodium levels) and hyperglycemia (high blood sugar levels). 2) After R6 was diagnosed with COVID, the nursing staff were to monitor and record her vital signs each shift (twice a day). Monitoring vitals signs to include T, R, Pulse Oximetry on room air and/or oxygen, P and BP are important to identify early decline of Residents with COVID. Review of the vital signs record from 03/30/2025 to 04/10/2025, revealed the following vital signs were not taken. 03/30/2025: Day shift, No P, No R, No PO2 04/01/2025: No P, No R all day 04/02/2025: No P, No R all day 04/03/2025: No P, No R all day 04/04/2025: No P, No R all day 04/05/2025: No P, No R all day 04/06/2025: No P, No R all day 04/07/2025: No P, No R all day 04/07/2025: Noc shift, No P, No R 04/08/2025: Day shift, No T, No P, No R, No PO2 04/08/2025-04/09/2025: Noc shift, No P, No R, No PO2 04/09/2025: Day shift, No T, No P, No R, No PO2 04/10/2025 Only BP was taken during the day. Just prior to end of shift, at 06:34 PM, a full set of vitals were taken, which were recorded as BP 135/88, P 121, Temp 98.4 (Temporal), R21, PO2 92% on room air. Oxygen was then provided at 2 liters per minute, and her PO2 was recorded to improve at 06:34 PM to be 95%. Review of Nursing Progress notes revealed the following: - 04/10/2025 at 02:05 PM: Daughter visited today shortly before lunch. c/o (complain of) resident appears so sleepy, unable to wake her up, worried and concerned about resident's status especially since she just came out of COVID, she is coughing, looking tired and sleepy. Family met with administrator to discuss concern.chest xray, . CBC (lab test, complete blood count) with diff (differential), bmp (basis metabolic profile), IPRAT q shift (Ipratropium and albuterol/bronchodilater every shift) and PRN (as needed) x 3 days for cough. Endorsed to floor nurse. - 04/10/2025 entered at 04:00 PM: In bed, resident appears sleepy, able to consume 50% breakfast, and CNA (Certified Nurse Assistant) staff was able to feed her lunch with 75% consumed at 02:00 PM. Order of CXR (chest xray) was facilitated, STAT (immediate) cbc with diff and BMP done, awaiting result. Started ipratropium-albuteral at 14:30 (02:30) pm. PRN Tussin administered for coughing, low pitch wheezing assessed before nebulization improved. - 04/10/2025 entered at 10:40 PM: Received resident lying in bed, appears comfortable, however sleepy though responding to tactile stimulation and open her eyes. Around 4:10 (PM), 2 staff assist in bedside care/changed her adult brief . Vital signs .BS (blood sugar) 313 mg/dl (high) at 4:46 (PM). After the daughter expressed concern about R6's condition to the Unit Manager (UM)1 at 02:05 PM, nursing provided a nebulizer treatment. Although lung sounds were documented in the progress notes as above, there was no pre-nebulizer baseline assessment that included pulse, respiratory rate, and oxygen saturation, which is the standard of care (Nursing Fundamentals and Skills, Nebulizer Therapy, November 24,2024). At 03:50 PM, a T and PO2 was taken, but no P, R or BP. In addition, a thorough nursing assessment including level of consciousness should be done in a timely manner after someone expresses concern of resident's level of consciousness. 3) On 06/09/2025 at approximately 02:30 PM, during an interview with UM1, reviewed the documentation of R6's vital signs. At that time UM1 confirmed it was the expectation that vitals were taken twice a day and that they should include T, P, R, PO2, and BP. She agreed the vitals signs were incomplete and did not meet the standard of care.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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Based on interview and document review, the facility did not have a process in place to maintain documentation of grievances. Six out of the six grievances sampled, did not meet the documentation requirements for the grievance decision. In addition the facility did not follow their own policy. As a result of this deficient practice, it is unknown what action had been taken, and if Residents/Representatives were satisfied with the outcome. Findings include: 1) Reviewed the facility policy titled Resident and Family Grievance, revised date 01/2025. The policy included: 1. The Administrator has been designated as the Grievance Official . 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances though the conclusion .; Issuing written grievance decisions to the resident; . 3. The Social Services Director, in coordination with the Grievance Official, is responsible for conducting any necessary investigations by the facility, ensuring the facility's grievance form is completed for any grievance filed; conducting correspondence with the individual who filed the grievance .; and informing the resident(s) and/or resident representative of their right to a written summary of the grievance, including the outcome of the grievance, and resolution; providing a written summary to the individuals, if requested; completing the Grievance Log, and maintaining grievances for 3 years. 11b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated form, or assist the resident . 11c. The Social Services Director, in coordination with the Grievance Official, will take steps to resolve the grievance, and record information about the grievance, and those actions taken, on the grievance form. 11g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Social Services Director will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. 2) Reviewed the designated form referenced in the policy which is titled Concern Form. The form includes the following: First part of the form: Date of Report, Time of Report, Date of incident, Name of Affected Residents(s), Person reporting the incident with Phone number, Location of incident /Circumstances surrounding incident, Resident account of Incident, Immediate Action Taken and who initiated them. The last question was if the Resident/Family were Satisfied. Second part of the form included: Follow-up needed? (Check box for Yes or No) Reported to: Check box for Administrator, DON (Director of Nursing)/Unit Mgr (manager) Social Services, Maintenance, Housekeeping, Dietary, Laundry, Transportation, other, or NA (not applicable). Departments(s) action taken to prevent recurrence. Complainant Notified? Check box, Yes or No. Department head signature and date, Social Services signature and date, and Administrator signature and date reviewed. 3) On survey entry, a request was made for the grievance log from February 2025 to current. The Administrator provided six individual Concern Forms, which included the following: Resident (R)4 had three concern forms initiated on 04/24/2025, which included the following: - Saw mold and water damage on ceiling in the first floor day room. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding investigation and follow up. - Need for more CNA's (Certified Nurse Assistants) during night shift. There were only 2 CNA's [sic] working and had to wait long periods for call light to be answered. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding - investigation and follow up. - Notified 3 weeks ago he was missing 1 blue blanket, 1 plaid blanket and one sweater. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding investigation and follow up. It is unknown how this was resolved and if R4 was satisfied with the outcome. R5's family member (FM) had one concern initiated on 04/14/2025 and two on 04/16/2025, which included the following: - 04/14/2025: .called her (FM) to ask if okay for resident to come out to day room for day time stimulation p (after) Covid; Another nurse .talked to her and stated, resident (R5) is out @ the day room, looks tired & sleepy. I (FM) still want my mom to be out @ the same time (11:00-11:30 AM) allow her to sleep after medpass because her meds make her sleepy & if she's still tired, keep her inside the room until she's fully recovered because I don't want her to make other people/resident sick even if she's already covid negative. Actions documented by the Unit Manager (UM)1 were Informed Administrator-Both nurses were verbally educated, reminders added to shift report reminders. The form did not indicate if FM was satisfied, and there was no documentation on the second part of the form. -04/16/2025 at 03:50 PM, FM reported a concern. The form documented the following: Concern was: Nurse called her to get consent for OT (occupational therapy) - OT seen [sic] resident without family's idea. Still waiting for Rehab to provide updates on resident's status with physical therapy and OT evaluation. RNA's (restorative nurse aid) not supposed to walk her yet until PT (physical therapy) provides update with education. Actions taken by UM1: Immediate action taken: Emailed Rehab Director. Provided reminder to RNA as well-verbal reminder to floor nurses- Added to shift report reminders. The form did not indicate if FM was satisfied, and there was no documentation on the second part of the form to indicate the status of R5's PT and OT evaluations. - 04/16/2025 at 05:30 PM, the FM reported a concern: Rotten banana (served during dinner) CN1 documented: Immediate Action Taken: Notified Administrator - went down to kitchen and checked all supplies of bananas, met with kitchen staff. The form did not indicate if Family was satisfied, and there was no documentation on the second part of the form. 4) On 06/09/2025 at 11:50 AM, observed dark spots on the ceiling tile in the first floor day room located by the AC unit, which was reported as a concern by R4 on 04/24/2025. 5) On 06/06/2025, interviewed the Administrator (ADM), who confirmed he was the designated Grievance Official. He stated the facility currently does not have a Social Service Director, and said they followed up on the grievances, but acknowledged they had not been able to keep up with the required documentation. At that time, asked the status of R4's concern about ceiling tile mold, and he replied the issue was referred to maintenance. He went on to say it was not fixed yet, and there was no work order available to document the work request. Inquired if there had been follow up with R4 about the staffing concern, and the ADM said he had reviewed staffing schedules and did not find shortages of concern. He said he had discussed the situation with R4, but had not documented it. The ADM said they had not been able to keep the grievance log up to date with the open Social Services position.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to have a process in place to ensure resident repositioning to prevent pressure ulcers (damage to the skin with open wound as a result of prolonged pressure). The facility did not have evidence that three of three Residents(R)1, R2 and R6 that were at risk for pressure ulcers, and who required assistance for bed mobility, were repositioned to prevent pressure ulcers. There was not a schedule/regimen for staff to follow and process to document the task. As a result of this deficient practice there is a higher risk residents will develop a pressure ulcer (PU). Findings include: 1) R1 was a [AGE] year old female admitted to the facility on [DATE]. Her diagnosis list included functional quadriplegia, hemiplegia (weakness or paralysis) and hemiparesis (severe or complete loss) affecting left dominant side, following a stroke. She was incontinent of bowel and bladder and required assist of one staff for bed mobility. Reviewed R1's care plan (CP), which included the problem .at risk for alteration in skin integrity . An identified intervention to ensure skin integrity was turn and reposition per rounding schedule. Reviewed R1's nursing progress notes, dated 06/01/2025 at 09:57 PM to 06/08/2025 06:42 PM, which revealed the following entries related to positioning and turning: 06/02/2025, 04:19 PM: .Turned and repositioned for pressure relief and comfort. 06/02/2025, 11:06 PM: .Turned and repositioned for pressure relief and comfort. 06/03/2025, 11:05 PM: .Turned and repositioned for pressure relief and comfort. 06/05/2025, 05:36 PM: .Turned and repositioned for pressure relief and comfort. 06/06/2025, 12:40 PM: .Turned and repositioned q2h (every two hours) and prn (as needed) for pressure relief and comfort. 06/07/2025, 03:47 PM: .Turned and repositioned for pressure relief and comfort. On 06/09/2025 at 12:00 PM, observed R1 lying in bed, positioned on her back. On 06/09/2025 at 03:30 PM, observed R1 lying in bed, in the same position on her back. 2) R2 was a [AGE] year old female admitted to the facility on [DATE]. R2 had limited mobility related to Parkinson's and functional quadriplegia (complete inability to move). She is bedbound and requires assistance of one staff with bed mobility. Reviewed R2's CP, which included the problem .at risk for alteration in skin integrity due to secondary weakness and deconditioning, impaired bed mobility, bladder and bowel incontinence. An identified approach to ensure skin integrity included turn and reposition per rounding schedule. Reviewed R2's medical records that included the CNA task documentation and nursing progress notes. There was no documentation by the CNA's that R2 was turned and repositioned. Review of the Nursing Progress notes from 05/08/2025 (readmitted 04:47 PM) to 06/08/2025 day shift, revealed the following entries related to positioning, with no details: 05/09/2025, 04:24 PM: .Turned and repositioned for pressure relief . 05/12/2025, 04:36 PM: .Turned and repositioned for pressure relief . 05/13/2025, 04:20 PM: .Turned and repositioned for pressure relief . 05/14/2025, 04:41 PM: .Turned and repositioned for pressure relief . 05/19/2025, 05:03 PM: .Encouraged with turning and repositioning . 05/21/2025, 05:14 PM: .Turned and repositioned q 2 h (every two hours) and prn (as needed) for pressure relief 05/22/2025, 04:38 PM: .Turned and repositioned q2H and prn . 05/22/2025, 11:33 PM: .Turned and repositioned for comfort and pressure relief. 05/29/2025, 04:13 PM: .Turned and repositioned for pressure relief . There were no additional notes found 05/29/2025 to 06/08/2025 about positioning. On 06/09/2025 at 12:00 PM, observed R2 lying in bed, positioned on her back. On 06/09/2025 at 03:30 PM, observed R2 lying in bed in the same position. 3) R6 was an [AGE] year old female long term resident at the facility. Her medical history included advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder and hypertension. R6 was incontinent of bowel and bladder and required 1-2 person assist for bed mobility. Reviewed R6's Wound Care progress notes, which revealed on 02/19/2025 she had a wound on her buttocks that measured 1.5 cm (centimeters) length x .2 cm width. The note dated 03/15/2025 documented Wound on Lt (left) buttock is healed this week. Reviewed R6's CP, which included the problem .at risk for alteration in skin integrity R/T (related to) aging process, history of skin bruising. An identified approach to ensure skin integrity included Assist with turning, frequent repositioning, PRN. Reviewed R6's Nursing progress notes 04/01/2025 at 12:59 PM through 04/10/2025, which revealed the following entries r/t positioning: 04/02/2025, 11:50 PM: .Turning and repositioning for pressure relief and comfort. 04/04/2025, 11:34 PM: .Turning and repositioning done for pressure relief and comfort. 04/05/2025, 11:38 PM: .Turned and repositioned for pressure relief and comfort. 04/06/2025, 04:04 AM: .Turned and repositioned for pressure relief and comfort. 04/06/2025, 11:21 PM: .Turned and repositioned for pressure relief and comfort. 04/07/2025, 09:09 AM: .Turned and repositioned for pressure relief and comfort. 04/07/2025, 03:40 PM: .Turned and repositioned every 2 hours for pressure relief and comfort. 04/09/2025, 11:34 PM: .Turned and repositioned for pressure relief and comfort. 4) On 06/09/2025 at 12:00 PM. interviewed Certified Nurse Assistant (CNA)2 .She stated she was hired at the facility about two months ago. Inquired what the CNA role was to help prevent pressure ulcers, and she said they are to rotate Residents who are at risk every two hours and make sure they are comfortable. Informed CNA had seen per rounding schedule in Residents' CPs, and asked what that meant. She said she was not sure, but that she thought the second floor still had clocks in the rooms, which indicated when and how to reposition a Resident, and it might have something to do with that. She went on to say the first floor did not have the clocks anymore. On 06/10/2025 at approximately 02:00 PM, during an interview with Unit Manager (UM)1, she confirmed the CNAs currently do not have a process in place to document when a resident is turned or what position they are placed. UM1 said the nurses have been documenting turning and positioning in the progress notes.

Jan 2025 11 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on resident interview and policy review, the facility failed to treat one Residents (R) 10 of eight residents sampled, with respect and dignity. As a result of this deficiency, R10 felt the right to a dignified existence was violated. Findings include: Resident interview on 01/29/25 at 12:30 PM, R10 said there were many times where staff were speaking in their native language (not English) and R10 felt staff were talking about him/her. Review of policy on Resident Rights read Policy; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights; The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, family interview, staff interview and review of policy, the facility failed to maintain a clean environment as evidenced by noted stains, spots on the cloth napkins. As a result of this deficiency, the facility increased the risk for spread of disease-causing organisms. Findings include: During family interview on 01/27/25 at 10:05 AM, said they saw numerous stains, spots on the cloth napkins that came with the meal trays. Observation of the breakfast trays on 01/28/25 at 07:30 AM, revealed several cloth napkins with spot stains and smudge stains. Staff interview on 01/28/25 at 01:50 PM, Dietary Manager looked at all the stored cloth napkins and acknowledged several with spots, stains as previously described. Review of facility policy on Safe and Homelike Environment read; Policy, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . Sanitary, includes but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, for one of one sampled residents (Resident (R) 5) for restraints. This deficient practice placed R5 at risk for physical harm and has the potential to affect all the residents in the facility. Findings Include: During a Facilty Reported Incident (FRI) investigation, interview was conducted on 01/30/25 with Unit Manager (UM) 2. UM2 stated that Certified Nurse Aide (CNA) 10 approached her on 12/31/24. CNA10 had informed her that while providing personal care, R5 was resisting care by pushing down with her hands. CNA10 decided to wrap R5's hands with the lower portion of her gown so that CNA10 can finish changing her incontinence brief. Interview was conducted on 01/31/25 at 09:35 AM with the Administrator. The Administrator stated that during an investigation interview, CNA10 had mentioned wrapping up R5's hands with the lower portion of her gown. CNA10 confirmed that R5 continued to push her hands down while it was wrapped and that CNA10 did it so that she can perform personal care on her. The Administrator stated that CNA10 had demonstrated what she had done with hand gestures and described the hand wrapping as being tight. A review of the facility policy titled, Restraint Free Environment, with a revised date of 06/01/23 was conducted. The policy documented, The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)76 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication. Findings include: Review of the Electronic Health Record (EHR) indicated that R76 was discharged to the hospital on [DATE]. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 10/31/25 at 11:00 AM, Social Services Director acknowledged that the facility did not provide written notification of discharge on [DATE]. Review of facility policy on Transfer and Discharge (including AMA) read; Policy, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Emergency Transfers/Discharges, initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0678 (Tag F0678)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and staff interviews, three of ten staff sampled for cardiopulmonary resuscitation (CPR) competency were not properly trained to provide basic life support subject to accepted professional guidelines. This deficient practice could result in the facility not providing the necessary care, placing residents at risk for decline in health status and/or death. Findings Include: A review of Cardiopulmonary Resuscitation (CPR) documentation for three staff was done on [DATE] at 11:15 AM. Documentation for Registered Nurse (RN) 11, Certified Nurse Aide (CNA) 12 and CNA13 reflects training from an online training course that does not provide hands-on practice and in-person skills assessment. Interviewed the Administrator on [DATE] at 11:49 AM, in his office, regarding CPR requirements for the facility. Administrator stated there is nothing in writing for CPR training requirements. Administrator stated on [DATE] at 11:59 AM that he spoke to the Infection Preventionist (IP), who provided clarification that Basic Life Support (BLS) is required for the Licensed Nurse. A Review of the American Heart Association (AHA) website stated that the AHA BLS course Trains participants to promptly recognize several life-threatening emergencies, give high-quality chest compressions, deliver appropriate ventilations and provide early use of an AED. Reflects science and education from the American Heart Association Guidelines Update for CPR and Emergency Cardiovascular Care (ECC). This is accomplished thorough a full classroom course or blended learning course (HeartCode BLS + a hands-on skills session training). Website link: https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/basic-life-support-bls-training, Interviewed RN11 on [DATE] at 12:03 PM. RN11 confirmed that the current CPR training course she completed did not have any hands-on practice and in-person skills assessment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one resident sampled (Resident (R) 22) for elopement, received adequate supervision to prevent accidents when he was an elopement risk. As a result of this deficient practice, R22 left the facility without authorization. This put R22 at risk of injury or getting hit by a car at a busy street. Findings include: R22 was admitted to the facility on [DATE] with diagnoses, but not limited to, pyogenic arthritis, muscle weakness, difficulty in walking, other abnormalities of gait and mobility, anxiety, depression, cognitive communication deficit, and attention-deficit hyperactivity disorder. Review of R22's admission Minimum Data Set (MDS) with assessment reference date of 12/16/24 found R22's Brief Interview for Mental Status (BIMS) score a 15 (cognitively intact). In Section GG. Functional Abilities and Goals, mobility devices used were cane/crutch and wheelchair. Further documented R22 needed supervision or touching assistance when walking 10 feet and 50 feet. Walking 150 feet, 10 feet on uneven surf and one step (curb) was not attempted due to medical condition or safety concerns. Review of an Event Report completed by the facility on 12/26/24, the facility reported R22 attempted .to exit the facility, through the main entrance, following a visitor out the door on 12/17/24 at approximately 11:30 AM. Social Services Director (SSD), was supervising and observing the resident from his office, which has a window and clear view of the lobby, Resident was seated in a chair, in the lobby. Social Services Director, observed resident stand from chair and head towards the front door. SSD immediately stood from his desk and headed to the found door. At the time the SSD reached the resident, resident made his way through the front door to the outside of the facility The visitor, who the resident followed out of the facility, put his arm out in attempts to redirect resident back in the facility. SSD attempted redirection, not able to redirect resident back into the building. Per SSD, resident stated he wanted to go home Resident is ambulatory and began walking down the facility's entrance ramp and up the street. SSD escorted and supervised resident, walking with resident Facility's transporter witnessed resident and SSD walking on the sidewalk. Assisted SSD by walking behind resident with a wheelchair. Prior to the incident the event report documented R22 attempted to elope and expressed he wanted to return home that morning. On 01/29/25 at 09:01 AM, an interview with Licensed Practical Nurse (LPN) 2 was done. LPN2 confirmed she worked the night before R22 eloped from the facility. LPN2 reported R22 was restless that night and walking in the hallway. Since admission, R22 wanders in the hallway but is redirectable. On 01/30/25 at 08:06 AM, an interview with Certified Nurse Aide (CNA) 6 was done. CNA6 reported on admission and when R22 first arrived at the facility, R22 expressed he wanted to go home and was easily redirectable during the night shift. Review of R22's nursing note on 12/11/24 at 11:39 PM documented Received resident up in wheelchair at dining area. Noted to be agitated during beginning part of shift, unable to redirect, want to go home to get some clothes and come back to facility. Called wife, will drop off clothes tomorrow morning. PRN [as needed] Lorazepam 0.5mg [milligrams] give at 6:10pm for behavior issues with relief . On 01/29/25 at 09:22 AM, an interview with Receptionist was done. Receptionist reported a nursing staff asked her to monitor R22 in the lobby on 12/17/24. Receptionist reportedly observed R22 to be sitting in the lobby but had also been observed to get up and walk back and forth. Receptionist was located behind her desk and was not able to continuously monitor him when busy answering the phone or when a visitor enters the facility. Receptionist stated she did not see the resident leave the facility on 12/17/24. On 01/29/25 at 09:38 AM, an interview with Licensed Practical Nurse (LPN) 3 was done. LPN3 was not assigned to R22 but confirmed she worked the day R22 eloped from the facility on 12/17/24. At approximately 09:00 AM the day of the incident, LPN3 reported she was on the phone at the nurse's station when a staff member yelled R22 is outside. LPN3 hung up the phone and located R22 outside of the facility's main entrance door at the end of the walkway ramp to the public sidewalk. LPN3 showed this surveyor exactly where she found R22 outside, a busy main street is located right outside the facility. LPN3 asked R22 where he was going and R22 responded he wanted to go home. LPN3 was able to convince R22 to return the facility. LPN3 confirmed that was the first elopement that day and a second elopement occurred when SSD had followed R22 out of the door. A second interview was done with LPN3 on 01/30/25 at 10:11 AM, LPN2 stated one to one supervision was not provided after the first elopement but close supervision was provided. Inquired who was providing the close supervision, LPN3 was not sure but saw Central Supply Coordinator (CSC) with R22. On 01/30/25 at 10:13 AM, an interview with CSC was done. CSC stated no one asked her to provide supervision or monitor R22. CSC heard he attempted to elope and expressed he wanted to go home so decided to try and talk to him to provide comfort but was unsuccessful at approximately 10:00 AM on 12/17/24. CSC spoke to him for about five to 10 minutes but noticed resident was getting more agitated. On 01/30/25 at 08:45 AM, an interview with Unit Manager (UM) 1 was done. UM1 was on vacation when the incident occurred. UM1 stated if a resident was actively attempting to elope, one on one supervision should be provided. UM1 was not able to confirm if R22 received one on one on 12/17/24 after the first elopement which may have prevented or decreased the risk of R22 eloping the second time that day. On 01/30/25 at 09:28 AM, an interview with SSD was done. SSD reported he sat with R22 in the morning at the lobby on 12/17/24, prior to the second elopement, and the resident had expressed he wanted to go home and reportedly observed him trying to push the front doors open that morning. No one asked him to monitor or provide close supervision to the resident but does keep an eye on residents when they are in the lobby from his window. SSD reportedly observed R22 go outside the facility main doors after a vendor entered the facility and followed him out the door. SSD continued to encourage R22 back into the facility but was unsuccessful. R22 began walking up the street and SSD continued to follow and attempt to encourage resident back to the facility with casual conversation. R22 reportedly expressed he was going to walk home. The facility's transport driver was on his way back to the facility when he saw R22 and SSD walking up the street and brought a wheelchair and walked behind the resident. While walking up the street, R22 would cross the street with no cross walk or safety awareness. R22 stopped in the middle of the road. SSD reported he positioned himself toward oncoming traffic because of the dangerous situation. SSD was able to convince R22 to sit in the wheelchair and attempted to take R22 back to the facility but R22 stopped the wheelchair and began walking up the street again. R22 crossed the street without looking both way or demonstrate safety awareness. R22 walked toward a residence and sat in front of an unknown residence's home. During this time, the transport driver went back to the facility to inform the administrator. SSD stated that it was not until further into walking that he realized R22 was not coherent to place and referred to the area as Boston. SSD stated he was with the resident for about an hour until the administrator arrived and the administrator was able to redirect R22 back to the facility. On 01/30/25 at 11:02 AM, an interview with Administrator was done. Administrator believed nursing staff knew R22 was missing but was not notified. Only after the transport driver notified him, he became aware that R22 was missing. Administrator did not know R22 left the doors of the facility and made it to the end of the ramp earlier in the morning prior to the incident. Inquired if R22 would have benefited from one on one after demonstrating exit seeking behavior throughout the morning on 12/11/24, Administrator stated it may have prevented or decreased the risk of him actually leaving the facility. Review of the facility's policy and procedure (P&P) Elopements and Wandering Residents reviewed/reviewed 06/2023 documented elopement .occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Under monitoring and managing residents at risk for elopement in the P&P, Adequate supervision will be provided to help prevent accidents or elopements. The procedure for locating missing resident documented Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment for one out of four medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings Include: Concurrent observation and interview with Registered Nurse (RN) 10 were conducted on 01/28/25 at 01:46 PM on the second-floor hallway. One of the medication carts was left unlocked and two staff members were observed passing the unlocked cart. A few minutes later RN10 returned to the medication cart and locked it. RN10 then confirmed that the medication cart should have been locked and secured when left unattended. Interview was conducted with Unit Manager (UM) 2 on the second floor. UM2 confirmed that unattended carts should be locked and secured. A review of the facility policy titled, Medication Storage, with a revised date of 06/01/23 was conducted. The policy documented, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation and staff interviews, the facility failed to ensure a clean working area before initiating wound care for one of one sampled resident (Resident (R) 35) for wounds. This failed practice has the potential to place a resident at risk for the development of infection and has the potential to affect all the residents that require dressing changes. Findings Include: Observation was conducted on 01/29/25 at 10:13 AM in R35's room during wound care rounds. R35 was turned to her side in bed and noted to have bowel movement on her buttocks, extending to the bottom edge of the resident's dressing located over her sacral area. Physician Assistant (PA) 1 proceeded to remove the dressing to the sacral area, and assessed the wound area before the bowel movement of R35 was cleaned, and before a clean brief was placed under the resident. Certified Nurse Aide (CNA) 11 proceeded to clean the bowel movement after PA1 was done with the wound assessment. Interviewed the Infection Preventionist (IP) on 01/29/25 at 12:50 PM at the second-floor nurse's station. IP confirmed that the CNA should clean a resident's incontinence before a wound is looked at. Interviewed Unit Manager (UM) 2 on 01/30/25 at 08:26 AM near the second-floor nurse's station. UM2 stated that for infection control, incontinence should be cleaned first before starting wound care. Interviewed CNA11 on 01/31/25 at 07:31 AM at the second-floor resident unit hallway. CNA11 verbalized that the resident needs to be cleaned first before nursing does the wound dressing to prevent infection.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure cooked and stored food were properly labeled in accordance with professional standards for food service safety and failed to ensure bottles of sauce were labeled with the manufacturer's expiration date for one of one kitchen observed. Failure to appropriately label cooked and stored food has the potential to affect residents that receive food from the kitchen, and visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness. Findings include: On 01/28/25 at 08:05 AM, during interview and observation of the kitchen with Dietary [NAME] (DC) 1, observed a container of cooked white rice, confirmed by DC1, in a small refrigerator without a label identifying the food item or preparation and discard date. DC1 reported the rice was prepared this morning and a label should have been created with today's date and a discard date. Further observed in the dry food storage room, multiple unopened bottles of Browning and Seasoning Sauce with a yellow cap that included the best-by-date. Two of the bottles did not have a yellow cap to determine the best-by-date, but were unopened and sealed. DC1 was not sure why the bottles did not have a cap and removed the two bottles from the storage room. Review of the facility's policy and procedure Food Safety Requirements reviewed/revised 06/2023 documented Follow contract/vendor procedures when food arrives damaged or concerns are noted. Remove these foods from use .Labeling dating, and monitoring refrigerated food, including, but not limited to leftovers, so it used by its use-by-date, or frozen (where applicable)/discarded .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on staff interview and review of facility assessment, the facility did not fulfill the requirement to designate a registered nurse as the Director of Nursing (DON). As a result of this deficiency, there was risk of negative impact on quality of care and outcomes. Findings include: Cross-reference to F868 Quality Assessment and Assurance. During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that the facility was currently looking for one. During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position. Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

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Based on staff interview and review Quality Assurance Performance Improvement (QAPI) program, the facility did not fulfill the requirement to have Director of Nursing (DON) participation on the Quality Assessment and Assurance Committee. As a result of this deficiency, there was risk of negative impact on coordination and evaluation activities under the QAPI program. Findings include: Cross-reference to F727 Registered Nurse, DON. During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that the facility was currently looking for one. During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position. Review of the QAPI meeting minutes for the past two months did not show a DON present. Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

Jan 2024 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on resident interviews and policy review, the facility failed to treat two Residents (R) 9 and R139, 68 of eight residents sampled, with respect and dignity. Findings include: Resident interview on 01/23/24 at 01:30 PM, R68 said that Staff would respond to the call bell and say they would be back but not return until several hours later. R68 said that this made him/her feel ignored. Resident interview on 01/24/24 at 08:45 AM, R9 revealed the following: Staff would respond to the call bell and say they would be back but it would take several hours for them to return, Staff would ignore and not pass on a request to speak to the doctor or other person, Staff would speak to each other in a language other than English and it felt as if they were talking about him/her. Review of policy on Resident Rights read Policy; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights; The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . R139 stated during an interview on 01/23/2024 that often he would press call bell, staff would acknowledge the call bell and state to R139 they would be back soon. R139 went onto to say staff would return after a long time, one time 40 minutes. Minimum Data Set (MDS) for R139 displayed under Section GG, that R139 required substantial assistance for movement. R139 due to extensive edema of both lower and upper extremities was unable to move by themselves without staff assistance. R139 stated during interview on 01/29/2023, that they would call for assistance to move when in pain, and waiting lengthy time periods increased the pain. R139 was tearful during the interview while relying this information. R139's reliance on staff assistance, and their lack of timely assistance did not provide care for these residents in a dignified manner.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure 2 of 6 residents sampled (Residents 33 and 55) were informed of their right to develop an advance health care directive, aided in doing so, and/or was periodically reassessed in his/her decision-making capacity to do such. As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 01/24/24 at 11:23 AM, during a review of Resident (R)33's electronic health record (EHR), an advance health care directive (AHCD) was not found. A review of the social services progress notes revealed no mention of an AHCD. The documentation was requested from the facility. On 01/25/24 at 02:22 PM, an interview with the Social Services Director (SSD) was done in his office. The SSD confirmed that R33 was admitted to the facility in August of 2023, and that there was no documentation available indicating that R33 had an AHCD, or was offered assistance in creating one. 2) An AHCD was not found during a review of R55's EHR on 01/24/2024. A request to the SSD was made on 01/24/2024 for the AHCD for a list of residents including R55. No AHCD was found by the SSD for R55. A request to the SSD was made on the afternoon of 01/25/2024 for any documentation to show that R55 had been offered information on the option of formulating an AHCD on admission and was further offered on other occasions during the resident's admission. No documentation was provided. The same request was made to the administrator on the morning of 01/26/2024. No documentation was received.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident (R)33 received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in range of motion (ROM) of her neck/head. As a result of this deficient practice, R33 was hindered from reaching her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits. Findings include: Resident (R)33 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. R33's diagnoses include but are not limited to left-sided hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) following a stroke, anarthria (complete loss of speech), and gastrostomy status (a surgical opening into the stomach made for a feeding tube). A review of R33's most recent Occupational Therapy (OT) Discharge Summary on 04/19/23 notes a discharge impairment of 100% . This score indicates that she [R33] requires 27 hours of 1:1 (one to one) care to complete her basic ADLs [activities of daily living] per week. In addition, R33's Functional Skills Assessment indicated she was completely Dependent (100% assist, or 2 or more helpers) . in all categories [eating, hygiene, transfers, bathing, and dressing] with a Self Care Function Score (score 0-12; 12 being the highest function) = 0. The discharge summary also included documentation of caregiver training of . Positioning maneuvers, Proper body mechanics . PROM [passive range of motion] . with 100% return demonstration provided during session. A review of R33's Comprehensive Care Plan noted the following intervention under the Category: Med [medication] Management . Maintain body in functional alignment when at rest. Despite being completely dependent on staff for positioning, there were neither interventions addressing positioning/proper body mechanics under the category of ADLs Functional Status, nor was there a separate category/care plan addressing positioning. Multiple observations were made of R33 in bed on 01/23/24 at 09:21 AM, 09:30 AM, 11:11 AM, and 02:24 PM, on 01/24/24 at 11:14 AM, 11:59 AM, and 02:14 PM, and on 01/25/24 at 08:45 AM, with her head bent heavily and uncomfortably to the right, with her right ear less than two inches from her right shoulder. No pillows, neck rolls, or braces were observed to assist in positioning her head in functional alignment with her shoulders or body. On 01/25/24 at 08:45 AM in particular, R33 was observed with a wedge pillow under her right shoulder, propping her right shoulder up, causing her head to be positioned back and heavily bent to the right. R33 was noted to be moaning in her sleep, which was not observed on previous days. On 01/25/24 at 11:36 AM, an interview was done with Unit Manager (UM)3 at R33's bedside. UM3 agreed that R33 appeared uncomfortable with her head in misalignment with her shoulders and body, bent heavily towards her right shoulder. When asked if R33 was able to straighten her neck anymore, as all observations up until then had her with her head in the same position, UM3 stated she did not know. UM3 also reported that she was unaware of any neck braces, or orthotic devices ordered to assist in positioning R33's head.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 4 residents in the sample (Resident 52) was free from accidents hazards. Resident (R)52 was observed ambulating with slippers oversized for her feet, placing her at increased risk for an avoidable fall. Despite previously being identified as a high risk for falls, the facility failed to recognize R52's oversized footwear as a potential hazard until pointed out by the State Agency (SA). This deficient practice has the potential to affect all ambulating residents at the facility. Findings include: Resident (R)52 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her current diagnoses include but are not limited to dementia, difficulty in walking, history of syncope (fainting) and collapse, and restlessness and agitation. On 01/23/24 at 10:53 AM, observed R52 sitting in the second-floor dining room at activities. Noted a bright yellow Falls Risk identification bracelet around her right ankle, an oversized pair of slippers on her feet, no socks, and a front-wheeled walker next to her. A review of R52's electronic health record (EHR) noted no documentation that a risks versus benefits discussion had taken place regarding R52's use of oversized slippers for ambulation. On 01/23/24 at 01:51 PM, an interview was done with Unit Manager (UM)3 in the second-floor dining room. During a concurrent observation of R52 ambulating back to her room with stand-by assistance, UM3 confirmed that the slippers were too large for her feet, and combined with her high falls risk status, were safety hazards. UM3 reported that the oversized slippers were provided by R52's family and were the only footwear R52 had. UM3 noted that R52 loved her slippers, refused to wear non-slip socks, and always put her slippers on when she wanted to walk anywhere. On 01/24/24 at 08:35 AM, an interview was done with UM3 in her office. UM3 confirmed that the oversized slippers were not previously identified as a safety hazard contributing to an increased risk of falls, and so had not been care planned for. Concurrent review of R52's Comprehensive Care Plan (CP) noted an intervention for proper well-maintained footwear under the category of Falls, but it did not define what proper footwear would be. UM3 agreed that proper footwear is too vague, and that for R52, proper footwear should include proper fit, which no one had assessed before.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review (RR), the facility failed to ensure nurse competency in pain assessment for 1 of 1 resident (Resident 64) sampled for pain management. As a result of this deficient practice, Resident (R)64 remained on a narcotic with a high risk of addiction and dependence for pain that could potentially have been managed with non-narcotic medication. This deficient practice placed R64 at risk for avoidable addiction and dependence in addition to other adverse effects of taking Fentanyl, and has the potential to affect all the residents at the facility receiving narcotic pain medication. Findings include: Resident (R)64 is a [AGE] year-old female admitted to the facility on [DATE]. Her current diagnoses include but are not limited to Alzheimer's disease, muscle weakness, an almost healed sacral pressure ulcer (pressure sore on the lower back), and severe protein-calorie malnutrition. A review of her electronic health record (EHR) noted that R64's primary language is Cantonese, and that she was discharged off of Hospice care in November 2023. On 01/24/24 at 08:20 AM while doing morning rounds, asked R64 how she was doing. R64 did not respond. Asked R64 are you OK? R64 answered no. Due to the language barrier, asked R64 how come no? To which it sounded as if R64 responded, sore feet. Repeated sore feet back to her, and R64 answered yes, and pointed towards her right foot. Asked to see her feet, to which she nodded yes, but while trying to unwrap her feet which were tightly tucked into her blanket, R64 repeated sore, sore. Refrained from attempting to unwrap feet any further so as not to cause additional pain. Grabbed the Cantonese picture cards at the bedside and pointed to the pictures/writing for pain and medicine. R64 nodded yes. Informed Registered Nurse (RN)9 that R64 was complaining of pain. RN9 responded quickly, stating she would give R64 some acetaminophen. At 11:50 AM, checked back with R64, who reported that her pain was a little bit better. A review of R64's medication administration record (MAR) noted that RN9 had given R64 her routine acetaminophen 650 milligrams (mg), due at 09:00 AM, earlier that morning when she had complained of pain, and had not given any as needed analgesics. Further review of R64's MAR revealed routine orders for acetaminophen 650mg three times a day for pain, and fentanyl patch 25 micrograms (mcg)/hour, one patch applied every three days for pain management, with the last patch documented as applied on 01/21/24 at 08:00 PM. Also noted were the following as needed orders for pain: acetaminophen 650mg every four hours, and tramadol 50mg three times a day for severe pain if routine . [acetaminophen] is ineffective. Neither as needed medication had been documented as given at any time during the month of January. On 01/24/24 at 12:00 PM, an interview was done with RN9 in the hallway outside of R64's room. When asked where R64 usually had pain, RN9 reported that she was uncertain, stating that it could be R64's feet or that there might be contractures (a tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the associated body part) in her lower legs that were causing pain. RN9 did a concurrent review of R64's EHR to confirm where her pain usually was. After a brief review, RN9 reported that she was unsure what was the location, source, or character of R64's pain. When asked if she had assessed R64's feet or legs earlier that morning when she had complained of pain, RN9 stated that she did not assess the source of pain this morning, but stated that she had before. After further review of R64's EHR, RN9 could find no documentation in the progress notes, physician orders, or MAR to indicate the location or characteristics of R64's pain, or why she continued to have a routine fentanyl order, a medication known to be a powerful narcotic. At 12:08 PM, as Unit Manager (UM)3 walked by, RN9 stopped her to ask if she knew why R64 had the routine fentanyl order. UM3 stated her belief that it was a carryover order from when R64 was on Hospice for pain associated with her pressure ulcer, however RN9 reported that the pressure ulcer was almost healed with no openings remaining to the surface of the skin. On 01/25/24 at 11:15 AM, an interview was done with UM3 in her office. UM3 reported that following her own review of R64's EHR, she could find no clear documentation of the location and character of R64's pain. UM3 agreed that a more thorough pain assessment should be done to identify where R64 was feeling pain, what her level of pain was, and if the routine pain medications could be reduced. On 01/26/24 at 09:56 AM, an interview was done with the Director of Nursing (DON) in the conference room. The DON confirmed that his expectation is for nurses to conduct a thorough pain assessment when administering any pain medication, whether routine or as needed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient practice has the potential to affect all residents currently residing in the facility. Findings include: Resident (R)27 is an [AGE] year-old female admitted to the facility on [DATE]. During an interview with her family representative (FR)5 on 01/23/24 at 01:34 PM at her bedside, FR5 reported that R27 had not received any routine dental visits since her admission. On 01/25/24 at 10:20 AM, a review of R27's electronic health record (EHR) found no documentation of any dental visits or exams since admission. On 01/25/24 at 11:15 AM, an interview was done with Unit Manager (UM)3 in her office. When asked, UM3 reported that the facility dentist had not been in for routine or emergency dental services since COVID began in 2020. UM3 confirmed that for dental emergencies, residents were sent out to his office, but that routine dental services had not been done since he (the facility dentist) stopped coming in. A review of the facility's Dental Services policy, last revised 06/2023 revealed the following: It is the policy of this facility to assist residents in obtaining routine . and emergency dental care . and; Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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Based on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for 3 of 25 residents (Residents 33, 60 and 139) in the sample. As a result of this deficient practice, 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. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F688 Increase/Prevent Decrease in ROM/Mobility. Despite identifying positioning/mobility needs for Resident (R)33, the facility failed to develop a care plan to effectively address those needs. 2) During interview with R60 on 01/23/2024, R60 expressed a desire to mobilize more with the Hemi-Walker available to R60. R60 feels confident this could be achieved if staff walked him daily. R60 had a care plan in place for altered ADL function, with an approach/intervention stating uses Hemi-walker and Wheelchair for mobility stating CNAs and nursing are the responisble disciplines to carry out this approach/intervention. Record review conducted on 01/24/2024, showed that R60 particpated in a restorative nursing program, which provided R60 assistance and guidance in using the Hemi-Walker. The care plan was missing the frequency of occurance for this intervention for R60. Interview with MDS staff, confirmed there was no frequency included in the care plan, as the care plans are generalized and not indivalized. 3) Minimum Data Set (MDS) for R139, displayed under Section GG, that R139 required substantial assistance for movement, including moving from lying to sitting, sitting to lying and moving from left to right sides and vice versa. Progress notes have documented on several occasions that R139 requires 3-4 person assist. Due to extensive edema to both lower and upper extremities, R139 is dependent on staff for all movement. Care plans are in place for R139 for altered self care and decrease in Activities of Daily Living (ADL) performance. These careplans have interventions in place to encourage resident to use enablers and to be independent. There are no interventions that state the required amount of assistance that R139 requires to move in bed, sit from lying and lie down from sitting. Interview with MDS staff member verified there are no specific interventions on the amount of assistance that is required by R139, stating their careplans are generalized an individualized.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations the facility failed to provide a comfortable environment for residents, staff and the public by not maintaining the environment in good repair. Findings include: Observations on 01/23/2024 - 01/26/2024, showed wallpaper on upper half of walls in the hallway of 1st floor, is lifting off in several areas and curling over. Outside of room [ROOM NUMBER] there is patch of wallpaper missing, approximately 12 x 18. It appears this patch has been torn off. On the opposite wall a picture has been removed with the area underneath significantly lighter in color than the rest of the wallpaper, providing an appearance of unkept cleaning of walls. The disrepair of the state of the wallpaper, is unkept and not conducive to a homelike environment. Watermarks are apparent on several areas of the wallpapered area of the hallway on the 1st floor unit.

Jun 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure one of four residents (Resident (R) 48) sampled for accidents received adequate supervision to prevent a fall that resulted in a laceration of the head, fracture to neck of right femur, hospitalization, and surgery after R48 displayed atypical behavior and has history of falls. The facility failed to ensure a second resident R15 was identified as a high risk of leaving the facility to obtain cigarettes and alcohol. R15 did not receive the admission agreement, (cross reference (CR) to F572 notice of rights and rules) which included the rules about consumming alcohol in the facility and that it was prohibited without a physicians order. In addition, The facility did not include interventions on the baseline care plan to address the risk for elopement based on R15 alcoholic cirrhosis of the liver and history of substance abuse (cross reference to F655 baseline care plan). The resident left the facility unsupervised on two occasions to purchase cigarettes (06/19/23) and alcohol (06/25/23). The deficient practice left R15 and other residents in the facility at an increased risk for harm. Findings include: 1) R48 is a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses of but not limited to vascular dementia, repeated falls, post-traumatic stress disorder, muscle weakness, and difficulty in walking. R48's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 06/05/23 in Section G Functional Status, under G.0110.Activities of Daily Living (ADL) Assistance, R48 required supervision and one person physical assistance in transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and locomotion on unit (how resident moves between locations in his room and adjacent corridor on same floor). Under G0300.Balance During Transitions and Walking, R48 was documented to be not steady, only able to stabilize with staff assistance in moving from seated to standing position and was documented the activity did not occur for turning around and for walking. R48 used a wheelchair. Review of R48's care plan documented R48 at risk for fall and injury due to .impaired mobility/balance, impaired cognition with poor safety awareness secondary to Vascular Dementia, possible effect of antidepressant, HTN [hypertension], and DM [diabetic] meds; h/o [history of] falling . and further documented to notify staff that R48 is a high fall risk resident. Review of R48's Event Report regarding an incident 06/16/23, R48 had a witnessed fall and sustained fracture to neck of right femur. The report documents R48 in the dining area, self-propelling himself with wheelchair and attempting to get a closer look out the window. R48 attempted to stand, went forward, fell on his right side and hit his head, right temple with laceration. R48 complained of pain to right temple and right leg and hip. After assessment by nurse, R48 consumed an Ensure supplement and vomited shortly after. R48 was transferred to acute care with pending results for electrocardiogram (EKG), X-ray and lab results. On 06/30/23 at 09:29 AM interview with Certified Nurse Aide (CNA) 20 was done. CNA20 confirmed she worked on 06/16/23, the day of the incident. CNA20 reported prior to the incident R48 displayed signs of confusion and was attempting to get to the window side of his room. CNA20 reported she brought R48 out to the dining area for breakfast and left to help other residents. After breakfast, CNA20 was alerted by another resident that R48 was in another resident's room at the window side. CNA20 brought R48 back to the dining room area to participate in activities, the activity volunteer was in the dining room and the charge nurse was at the medication cart when she left R48 in the dining room area. CNA20 further reported she informed the nurse that she thought R48 was confused and had been trying to go to the window. CNA20 stated that this was not R48's .normal behavior that is why I reported it to the charge nurse. Inquired if further instructions were given after reporting the behavior to the charge nurse, CNA20 stated there was none and she went back to assist other residents. Inquired if R48 needed close supervision, CNA20 did not answer the inquiry, stated she needed to help other residents and reiterated the activity volunteer was in the dining room and further stated the facility does not provide one on one (1:1) supervision but after the incident 1:1 supervision was provided to R48. CNA20 confirmed R48 was a fall risk. On 06/29/23 at 02:48 PM interview with Registered Nurse (RN) 3 was done. RN3 confirmed she worked on 06/16/23, the day of the incident. RN3 reported that R48 was restless in the morning and was wandering in resident rooms to peak out the window. RN3 confirmed R48 attempting to look out the window was not atypical behavior and was the first time she heard of this behavior from him, usually he would want to go to the bathroom frequently. RN3 reported she later found out from R48's family member that R48 thought someone was watching over him due to Post-Traumatic Stress Disorder and social history. RN3 reported prior to the incident she was at the medication cart at the nurse station when the incident happened but did not witness the incident. RN3 stated she heard the activity volunteer yell for help and found R48 on the ground near the window in the dining room, on the other side of the room from the nurse's station. RN3 reported after her assessment, providing 1:1 supervision for R48, informing the physician and following the physician's order, R48 vomited after drinking Ensure and was transferred to acute care. RN3 stated R48 needs close supervision and needs to have staff a proximity to him and stated at times R48 would benefit from 1:1 supervision, particularly on the day of the incident, because although he is unsteady, he is quick and was displaying a new behavior. RN3 confirmed R48 is a risk for falls and has had multiple falls in the facility. On 06/30/23 at 09:02 AM interview with Activity Volunteer (AV) 1 and Activity Director (AD) was done. AV1 started volunteering at the facility from November 2022 through a partnership with a senior vocational program. During the interview AV1's hearing aid was not working properly and was hard of hearing. AV1 confirmed she was at the facility and witnessed the incident on 06/16/23. AV1 demonstrated and explained she was at the activities table with other residents when R48 began propelling himself toward the window. AV1 reported when R48 got closer to the window he stood up and began dragging his wheelchair from behind him and attempted to reach the curtain but could not open it. AV1 further reported while standing R48 began pivoting toward another window when he fell. AV1 stated I was not near him. I was just watching him. What I know he can walk. I am alone . in the dining room. AV1 reported two nurses came and helped after she yelled for help. AD inputted that the activity aide who usually works with the AV1 was on leave and that although activity aides may help with transfers, sitting, or standing, the volunteers are to just assist the activity aide by passing out items, or check bingo cards, not care type duties. AD stated she was at a meeting when the incident happened, and it was not communicated with her that the activity staff should provide close supervision to R48 due to a new behavior that morning. AD stated AV1 would not have known R48 was a fall risk or what his level of function was and R48 does not usually participate in activities but may come to the common area to watch television. On 06/30/23 at 10:47 AM interview with Nurse Manager (NM) 2 was done. NM2 confirmed she worked on 06/16/23 and was at a meeting when the incident happened. NM2 confirmed R48 had frequent falls at the facility and can be impulsive when he gets up. NM2 confirmed R48 does not normally wander to resident rooms but may go to the closest bathroom. NM2 further confirmed that R48 going toward the window in his room and other resident's rooms was not normal behavior for R48. Inquired with NM2 what type of supervision would have been appropriate for R48 prior to the incident, NM2 reported the facility does not really provide 1:1 supervision but at least close supervision should have been provided due to displaying confusion and at risk for falls. NM2 stated a staff member should have been at proximity and at line of sight to assist if he stands or gets up. NM2 further explained the activity volunteers are not to provide close supervision because they are not going to support or assist the patient to get up and is not sure what training the activity volunteers receive. NM2 reported after the incident R48 was sent to the emergency room and was hospitalized due to a fracture to right femur and needing surgery. NM2 reported R48 needed surgery based on the hospital's report because he would suffer more if he did not. Review of the hospital's admission report dated 06/16/23 documents right femoral neck fracture due to fall. Overall, patient has acceptable risk for surgery, since without surgery the patient's risk for significant morbidity and mortality is much higher. Review of the facility's policy and procedure for volunteers last reviewed on 02/2023, documents Volunteers are not allowed to provide care for residents in place of care that normally provided by staff members. 2) Reviewed the facility reported incident intake on 06/28/23, that OHCA received from the facility via email on 06/19/23. Per the report on 06/19/23 at 09:30 AM, the unit manager (UM) was notified that R15 could not be found on the campus. At 09:45 AM R15 returned to the campus with a pack of cigarettes. Resident who is mentally and physically capable of living independently left facility without realizing it was against facility policy. He returned safely and apologized for actions. Signed by the Administrator. Reviewed the following notes from the electronic medical record (EMR).: R15's history and physical from the acute care facility dated 06/14/23. [AGE] year-old male with history of alcohol use disorder, alcoholic cirrhosis .social history includes smoking 1 pack for two weeks. Alcohol, drinks beer 12 cans every 3 days, patient drank 200 ml vodka on 06/09/23 for his pain . R15's care plan on 06/29/23 at 10:13 AM. Start Date: 06/20/2023 .risk for elopement due to history of substance abuse. Resident is alert and oriented. Noted the start date was not implemented for R15's alcohol use disorder and risk for elopement prior to the first elopement on 06/19/23. Nursing note dated 06/25/23 at 19:05. At around 18:30 resident was nowhere to be found. Resident was last seen by the front door getting fresh air with another male resident. This writer and other staff looked inside all facility rooms, bathrooms, activity area, rehab gym, basement/facility parking area, bus stop, Korean church parking area and immediate vicinity areas but still resident nowhere to be found. Roommate that was with him at the front door informed staff that R15 went to the convenient store. This writer went to nearby stores and saw resident walking back from a grocery store. After resident returned, he went to his room to rest. Went to observe and check on the residents to make sure everything was alright. When I spoke to the residents in the room, they both smelled like alcohol, especially when they spoke you could smell alcohol on both residents breath. Resident had a bottle of alcohol in the room hidden and a drink made at bed side that contains alcohol in his gray water pitcher container. Spoke to both residents and diffused the arguing and both residents got into their bed and went to sleep. Notified MD, UM and Administrator. SS note dated 06/26/2023 at 11:09 AM The resident left the facility around 10:30 AM. a bottle of vodka and cigarettes were found inside the bedside cabinet. Interview with S27 on 06/30/2023 at 11:10 AM regarding the incident with R15. S27 stated the first time, on 6/19 at 9:30 AM he left the facility and returned at 9:45 AM, resident said he went to the store for cigarettes. The second time he left the facility was on 6/25/23 at 6:30 PM, R15 went to the store for cigarettes and alcohol. 06/30/23 Interview with S23, who stated that she told the CNA's to make sure they watched him because he was outside on the front porch. At around 6:30 PM I went to check on him and he was not there. I went outside and didn't see anybody. I walked down the street to look for him and saw him coming out of the store. I asked him where he went, and he said he ran out of cigarettes and bought some more, we walked back to the facility (cr F572 notice or rights and rules). Telephone interview with S25 on 06/30/23 at 12:10 PM to ask her to recall the incident when R15 left on 06/25/23. Around 8:30 or 9 PM I found the bottle of alcohol that was hidden in the drawer. Facility Elopement and Wandering Residents policy dated 02/23 reviewed on 06/30/2023 at 12:45 PM . Page one, paragraph two: The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement .including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks . 06/30/23 at approximately 2:00 PM, interviewed the SSD and asked for a copy of R15's signed admission agreement. There was none found, indicating that the resident didn't ever receive the admission agreement at the time of admission. SSD stated R15 was admitted late on a Friday afternoon. Reviewed the facility admission agreement on 06/30/23 at 3:00 PM. Page five, paragraph four states: Smoking Regulations: Facility is a smoke-free environment .failure to comply with the facility regulations will result in the voluntary or involuntary discharge of the resident. Paragraph Five states: The resident understands .that consumption of alcohol could result in the voluntary or involuntary discharge of the resident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews, the facility failed to ensure Resident (R) 72 was treated with respect and dignity. The facility did not supervise or monitor a contracted worker that performed the ultrasound in a manner that caused physical and emotional pain to R72. Findings Include: On 06/29/23, review of Electronic Health Record (EHR) for R72 was conducted. Documented in the Progress Notes on 05/27/23 at 02:51 PM was the following: . Resident was scheduled for ultrasound this am [morning] due to edema from L [left] arm. XRAY tech [contracted worker] came into facility to perform test. Voiced his annoyance in front of nursing staff and patient stating that we should've been ready to have him perform test because he has another appointment scheduled shortly after. Continued to make us aware that he was agitated by huffing and grunting as we got . (R72) . into bed. Tech left immediately after test was finished without leaving yellow copy of paperwork. Nurse went into room to find . (R72) . hysterically crying saying he was rude and rough while performing test. Scolded her that she should've been ready for him. Was non-compliant when she asked him to be gentle with her arm. She stated that he was pushing the table aggressively away out of annoyance and banging his leg off of the bed. Stating she's never been treated that badly by medical staff before. Incident was reported to Administrator, State Survey Agency and Adult Protective Services. A complaint was also filed with the contracted worker's imaging company. On 06/29/23 at 08:46 AM, interview with R72 was conducted. R72 said that she noticed the contracted worker was angry and snapping at the nurse as they entered the room. The nurse and the Certified Nursing Assistant (CNA) assisted R72 into the bed and then exited the room. Asked R72 if she felt uncomfortable or scared when she was left alone with the contracted worker, she replied, No, not until he started hitting the bed with his knee as he was doing the procedure. On 06/30/23 at 10:14 AM, interview with Licensed Practical Nurse (LPN) 1 conducted. LPN1 confirmed that she was working on the day of the incident. Asked LPN1 if she would have left R72 alone in the room with the contracted worker if he was agitated as described by nurse working that day. LPN1 said she would have stayed in the room or ask the CNA to observe to make sure the resident is safe. On 06/30/23 at 10:52 AM, interview with the Administrator was conducted. Asked Administrator if she would have left the room leaving R72 alone with the contracted worker knowing he was already upset when he arrived and was being rude to the staff. The Administrator said, I would have stayed and observed. Review of facility policy, Promoting/Maintaining Resident Dignity stated: . 11. The facility will ensure all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of the resident and the responsibility of the facility to properly care for its residents.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify Resident (R)15 of his rights and the rules of conduct during his stay in the facility between June 16, 2023, and June 26, 2023. At the time of the residents admission, the facility did not provide and have him sign the admission agreement that states the rules and agreements between the facility and the resident. The facility did not include interventions on the baseline care plan to address the risk for elopement based on his alcoholic abuse and nicotine dependence (cross reference to F655 baseline care plan). The resident left the facility unsupervised on two occasions to purchase cigarettes on 06/19/23 and alcohol and cigarettes on (06/25/23). The deficient practice resulted in the resident conducting high risk behavior which placed himself and other residents at risk for harm. The resident signed out against medical advice (AMA) on June 26, 2023. Findings Include: Reviewed the facility reported incident intake on 06/28/23, that the office of healthcare assurance (OHCA) received from the facility via email on 06/19/23. On 06/19/23 at 09:30 AM, the unit manager (UM) was notified that R15 could not be found on the campus. At 09:45 AM, R15 returned to the campus with a pack of cigarettes. Resident left the facility without realizing it was against the facility policy. Reviewed the following notes from the electronic medical record (EMR): Social services (SS) progress note dated 06/19/2023 at 11:04 AM. [AGE] year-old male resident admitted from an acute care hospital. Admitting and other diagnosis includes: Alcoholic cirrhosis (liver disease caused by alcohol abuse); history of esophageal varices (bleeding of the airway pipe), and chronic hepatitis C virus, (a liver disease caused by a virus. Nursing note dated 06/25/23 at 19:05. At around 18:30 resident was nowhere to be found. Resident was last seen by the front door getting fresh air with another male resident. This writer and other staff looked inside all facility rooms, bathrooms, activity area, rehab gym, basement/facility parking area, bus stop, Korean church parking area and immediate vicinity areas but still resident nowhere to be found. Roommate that was with him at the front door informed staff that R15 went to the convenient store. This writer went to nearby stores and saw resident walking back from a grocery store. When asked resident where he'd been, he replied, I went to buy a cigarette from the store. I'm running out of cigarette. Resident arrived safely at the facility, no injury noted, denies any pain or discomfort. Educated resident that he cannot leave the facility by himself, that he needs to inform staff and/or call family if he needs to get/buy something. After resident returned, he went to his room to rest. About one hour after that occurred the resident and roommate were arguing with one another. Went to observe and check on the residents to make sure everything was alright. When I spoke to the residents in the room, they both smelled like alcohol, especially when they spoke you could smell alcohol on both residents breath. Resident had a bottle of alcohol in the room hidden and a drink made at bed side that contains alcohol in his gray water pitcher container. Spoke to both residents and diffused the arguing and both residents got into their bed and went to sleep. Notified physician (MD), UM and Administrator. Nursing note dated 06/26/2023 08:40 AM. UM, S27 and SSD approached the resident in his room and discussed yesterday's elopement and bought alcohol and cigarette. SSD insisted these behaviors violate the facility rules and put the resident himself and the facility at risk. Also, this time is his second elopement (he has been warned 1st time). R15 agreed and signed to discharge himself or AMA. Interview with S27 on 06/30/2023 at 11:10 AM regarding the incident with R15. S27 stated the first time, on 6/19 at 9:30 AM he left the facility and returned at 9:45 AM, resident said he went to the store. The second time he left the facility was on 6/25/23 at 6:30 PM, R15 went to the store for cigarettes and alcohol. 06/30/23 Interview with S23, stated that she stayed back to help with the evening shift. R15 was outside on the front entrance. I told the CNA's to make sure they watched him. At around 6:30 PM after I gave med's, I went to check on him and he was not there. I went outside and didn't see anybody. He had a roommate, so we asked him where R15 went. He said he went to the convenience store. I walked down the street to look for him and saw him coming out of the store. I asked him where he went, and he said he ran out of cigarettes and bought some more, we walked back to the facility. At the time I didn't suspect he bought alcohol. He had only had a shirt and shorts on, and he was walking alright. Telephone interview with S25 on 06/30/23 at 12:10 PM to ask her to recall the incident when R15 left on 06/25/23. Around 8:30 or 9 PM he and his roommate started arguing. They always got a long before and laughed together so when I went into the room, I knew something was up, they never fight. After they calmed down and went to sleep, I found the alcohol that was hidden in the drawer. I took it without him knowing about it, left the room and called the doctor and the supervisor. 0n 06/30/23 at approximately 2:00 PM, surveyor interviewed the SSD and asked for a copy of R15's signed admission agreement. There was none found, indicating that the resident didn't ever receive the admission agreement at the time of admission. SSD stated R15 was admitted late on a Friday afternoon on June 16, 2023. Reviewed the facility admission agreement on 06/30/23 at 3:00 PM. Page five, paragraph four states: Smoking Regulations: Facility is a smoke-free environment .failure to comply with the facility regulations will result in the voluntary or involuntary discharge of the resident. Paragraph Five states: The resident understands .that consumption of alcohol without a physician's order and in an inappropriate manner, such as in resident rooms is prohibited .alcohol consumption could result in the voluntary or involuntary discharge of the resident.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include interventions on one Resident's (R)15 care plan to address a medical history of alcoholic cirrhosis of the liver and history of alcoholic abuse placing the resident at a risk for elopement. The resident left the facility unsupervised on two occasions without the facility's knowledge to purchase cigarettes on 06/19/23 and alcohol and cigarettes on 06/25/23. The deficient practice resulted in the resident conducting high risk behavior and a danger to himself and other residents residing in the facility. R15 signed out against medical advice (AMA) on 06/25/23. (Cross reference to F542 resident notice of rights and rules, and F689 Free of Accidents/supervision/devices ). Findings include: Reviewed the facility reported incident intake on 06/28/23, the office of healthcare assurance (OHCA) received from the facility via email on 06/19/23. On 06/19/23 at 09:30 AM, R15 could not be found on the campus. At 09:45 AM R15 returned to the campus with a pack of cigarettes. Resident who is mentally and physically capable of living independently left facility without realizing it was against facility policy. He returned safely and apologized for actions. Reviewed the following notes from the electronic medical record (EMR): Social services (SS) progress note dated 06/19/2023 at 11:04 AM. [AGE] year-old male resident admitted from an acute care hospital. Admitting and other diagnosis includes alcoholic cirrhosis (liver disease caused by alcohol abuse) and alcohol abuse. Cognition: alert, long term memory intact, oriented, short-term memory intact, person, place, situation, time. Communication: verbal. Nursing note dated 06/25/23 at 19:05. At around 18:30 resident was nowhere to be found. Resident was last seen by the front door getting fresh air with another male resident. Upon the residents return I went to observe and check on the resident to make sure everything was alright. When I spoke to the residents in the room, they both smelled like alcohol, especially when they spoke you could smell alcohol on both residents breath. Resident had a bottle of alcohol in the room hidden and a drink made at bed side that contains alcohol in his gray water pitcher container. Spoke to both residents and diffused the arguing and both residents got into their bed and went to sleep. Notified MD, UM and Administrator (NHA). Reviewed an email provided by the SSD with R15's history and physical from the acute care facility dated 06/14/23. [AGE] year-old male with history of alcohol use disorder, alcoholic cirrhosis .social history includes smoking one pack of cigarettes for two weeks. Alcohol, drinks beer 12 cans every 3 days, patient drank 200ml vodka on 06/09/23 for his pain . Reviewed R15's care plan on 06/29/23 at 10:13 AM. Start Date: 06/20/2023 Risk for elopement due to history of substance abuse. Resident is alert and oriented. No problems were implemented for R15's substance abuse disorder and risk for elopement prior to the first elopement on 06/19/23. Interview with Staff (S)27 on 06/30/2023 at 11:10 AM regarding the incident with R15. Asked if the facility was aware that the resident had an alcohol use disorder. S27 explained that the admissions coordinator screens the resident at the hospital for substance abuse, smoking etc. I am not sure it was written on the care plan. The minimum data set (MDS) coordinator implements the care plan. The floor nurse would do the admission assessment. Interview with SSD on 06/30/2023 at 11:45 AM regarding the assessment of R15's history of substance use disorder. When asked if the facility was aware of R15's history of alcohol dependence with the chronic illnesses of cirrhosis and esophageal varices. SSD stated that the acute care facility stated in its history and physical the resident was in alcoholic remission.

Feb 2023 24 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect one resident (R)33 from physical harm. R33 was totally dependent on staff for all activities of daily living (ADL's), including repositioning every two hours. R33 suffered an unwitnessed and unexplainable injury due to the manner in which her care was provided. As a result, R33 suffered a dislocated left (L) shoulder and pain, which affected her ability to achieve and maintain her highest level of physical well being. All residents dependent on staff are at risk of this type of unintentional abuse if they are not handled in a safe, secure manner to prevent injury. Findings include: 1) The Office of Healthcare Assurance received an initial facility incident report (FRI) regarding the injury on 12/13/2022 and the completed report on 12/20/2022 (date recorded as 2020 in error). The type of incident was marked injuries of unknown source. The FRI included It was noted during breakfast that her L shoulder was swollen and warm to touch. X-ray results in PM revealed subluxation (partial dislocation) of her humerous [sic]. Resident sent to ER for further treatment.Resident return from hospital but could not relocate injury due to swelling.Could not identify incident that would have been the source of the injury. As the resident is completely dependent upon staff we can only assess that it may have occurred during transfer or repositioning of the resident, or if while laying on her left side.'' 2) Review of the Hospital medical records revealed the following: 12/14/2022 Hospitalist Discharge Summary: Principal Diagnosis: Anterior dislocation of left shoulder, initial encounter. Brief history of presentation included: . Hx of CVA dysarthria/hemiplegia/bedbound and other medical problems presenting to the ER post fall resulting in a shoulder displacement. Apparently, the patient was found with a contracted left upper extremity during rounds . X-ray -Humerus: .Reason for Exam: Trauma . Findings: Anterior shoulder dislocation. CT-Shoulder: Reason for Exam: Shoulder Trauma, instability or dislocation suspected, xray done; Shoulder dislocation comparison Impression: 1. Anterior Glenohumeral Subluxation (Partial dislocation) 2. Small Cortical irregularity of the posterior humeral head, likely related to impaction. 3) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body), dysphasia (swallowing disorder) and dsyarthria (speech disorder caused by muscle weakness) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, stage 3 pressure ulcer sacral area, hypertension, diabetes type 2 and age related osteoporosis without pathological fractures. R33 was incontinent of bowel and bladder and wore diapers. She had difficulty making herself understood due to her dysarthria, had impaired vision and cognitive loss. 4) Review of R33' records included: Minimum Data Set (MDS) dated [DATE] Section G, Functional Status coded R33 to be totally dependent (Full staff performance every time during entire 7-day period) for bed mobility, transfers (occurred once or twice) and required the support of one staff for assist for all ADL's including dressing, bathing and eating. Nursing Progress notes: 12/13/2022 09:05 AM: Resident (R33) noted by CNA (certified nurse assistant) when feeding her this AM at about 07:50 AM that her contracted hand (L)=elbow was swollen and warm to touch and with facial grimacing when touched. RN aware and will call MD as appropriate. 12/13/2022 05:00 PM: R33 sent to Emergency Department (ER) by private ambulance. Resident crying during transfer . 12/13/2022 0836 PM: ER called and spoke with emergency room Physician (MD)1.questions with resident's ADLs and assessment when it (injury) was noted. 12/14/2022 08:35 PM: re-admitted resident at 15:32 with principal diagnosis of Anterior dislocation of the left shoulder.Resident looking calm and comfortable however with pressure or movement to L arm, observed with moaning and crying and attempts to guard L arm using R arm. L arm with swelling lower arm. 12/15/2022 11:16 PM: .Left elbow/arm remains swollen and left arm still with bruise and discoloration. Continue nursing care with comfort. Noted with facial grimace during nursing care only. 12/18/2022 10:24 PM: Left elbow/arm remains swollen and left arm still bruise/dislocation. Treatment to coccyx wound done this evening as ordered with 2 person assist. Continue nursing care with comfort and gently handling.Noted with facial grimace during nursing care only. 12/21/2022 03:39 PM: . Advised caregiver assigned to maintain 2 staff assistance during nursing care, especially during turning and repositioning to ensure proper positioning while keeping L arm free of any pressure . Care Plan: 03/24/2022, the problem self care/ADL deficit included the interventions of bilateral mobility bars and 1 staff assistance for bed mobility, and use of Hoyer lift for transfers. 5) Reviewed the policy titled Safe Resident Handling/Transfers last reviewed/revised 05/20/2022, which included: Policy statement read It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. The facility provided a policy titled Resident Rights-Freedom from abuse, neglect and exploitation last revised 04/11/2018. Review of the policy included: - Policy header had a different (sister) facility (F2) name on it. - Section Procedure for preventing resident abuse . 2. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. - Section Procedure for preventing resident abuse .Does not tolerate any of the following actions, regardless of a resident's age, ability to comprehend, or degree of disability: .10. Any hitting, slapping punching, pushing, pulling . or other means of physical control of a resident. (Physical Abuse) - An attachment of a flow chart (no date or resource reference) titled Incident Reporting for Alleged Abuse. The first step of the process was to answer Was there willful infliction of injury to a resident? Note: Instances of unintended or ignorant harm does not meet facility policy or definition. 6) On 02/10/2023 at 11:30 AM, observed R33 lying in bed on her back sleeping with both arms across her chest under the sheet. On 02/10/2023 at 01:30 PM, observed R33 lying in bed positioned on her right side sleeping with both arms across her chest under the sheet. 7) On 02/10/2023 at 01:35 PM, during an interview with Charge Nurse (CN)1, inquired the last time R33 was out of bed. She said R33 doesn't really get out of bed anymore because of the pressure ulcer on her buttock. CN1 said the last time she recalled the Hoyer lift (mechanical equipment used for transfers) being used or R33 getting out of bed was when she went to the hospital for x-rays (12/13/2022). On 02/10/2023 at 04:00 PM, interviewed the two CNA's working day shift, who both said since R33's injury, when they provide care for her, they now use two staff. 8) Cross Reference F641-Accuracy of Assessments. Although R33 was to have two person assist starting 12/18/2022, the required staff support documented on the MDS (Minimal Data Sheet) dated 12/20/2022 was one person assist. In addition two of four weekly (from 01/14/2023 to 02/02/2023) assessments after the injury did not accurately reflect R33's need for two staff support for activities of daily living (ADL's). It is unknown if one person assist was the actual support being provided, or if it inappropriately documented by the RN. 9) Cross Reference 657- Care Plan (CP) Revision R33's CP was not revised timely to reflect she needed two person staff support for all ADL's. 10) Due to R33's immobility, she would not have been able to injury herself by striking anything and could not turn herself to roll off the bed. Staff validated she had not been out of bed or transferred using the Hoyer lift and that she had been bedbound. The shoulder can dislocate forward, backward, or downward, and completely or partially. Contact sports injuries, trauma from motor vehicle accidents and falls are the most common source of dislocation. Mechanism of injury is usually a blow to an abducted (movement of a limb away from the midline of the body), externally rotated and extended (fully stretched out) extremity. (Shoulder Dislocations Overview; StatPearls Publishing LLC. 2022)

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

ADL Care (Tag F0677)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) CMS defines oral care in the State Operating Manual (SOM) Appendix PP revised on 10/21/22 as .the maintenance of a healthy mouth, which includes not only teeth, but the lips . R3 was admitted to the facility on [DATE] with diagnoses not limited to hemiplegia and hemiparesis, dysphagia following cerebral infarction, hyperlipidemia, contractures to left hand, left elbow, and ankles, gastro-esophageal reflux disease without esophagitis, and chronic gingivitis non-plaque induced. R3 has tube feeding and has a dietary order of nothing by mouth (NPO). R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/22 under Section G. Function Status for F0110. ADL Assistance R3 needs extensive assistance with one person physical assistance for personal hygiene. Under Section GG. Functional Abilities and Goals for GG0130. Self-Care R3 is dependent in oral hygiene. During an initial observation of R3 on 02/07/23 at 08:52 AM, observed R3 lips to be dry with thick patches of peeling skin on R3's bottom lip, as well as, cracks on her top and bottom lips. Subsequent observations of R3's lips to be dry with thick patches of peeling skin and cracks on her lips were done on 02/07/23 at 12:32 PM and 03:25 PM, on 02/08/23 at 07:59 AM and 12:07 PM. On 12/09/23 at 08:26 AM observed R3's lips without thick patches of peeling skin but observed to be dry and cracked. Review of R3's Electronic Health Record (EHR) noted R3's family member visited her in the evening on 12/08/23. Review of R3's physician order documents a reminder for nursing staff to apply Vaseline to lip every shift to moisturize and sooth dry, cracked lips. Special instructions indicated Reprocessed due to concerns received from Daughter. Review of R3's comprehensive care plan under skin integrity R3 is to use lip balm or emollient on lips. On 02/10/23 at 08:15 AM and at 11:23 AM observed R3's lips to be dry but smooth, no peeling skin or cracks. On 02/10/23 at 11:26 AM interview with Unit Manager (UM) 1 was done. UM1 stated the Nurse puts Vaseline on R3's lips after oral care, for the day shift they put Vaseline before 10:00 AM because she has tube feeding. Concurrent review of the Administration History documents nursing staff had put Vaseline on R3's lips everyday for day, evening, and night shift. Inquired if it would be obvious if R3 did not receive Vaseline on her lips and if it makes a difference, UM1 stated the Vaseline does make a difference because her lips would become so dry that her lips would be bleeding. UM1 reported if R3 did not receive Vaseline, her lips would have white dry skin on top of her lips. Based on observations, interviews, and record review, the facility failed to ensure a resident who is unable to carry out acitvities of daily living receives the necessary services to maintain grooming, and personal and oral hygiene for two of four residents (Resident (R)37 and R3) sampled. R37 unable to perform ADLs due to diagnosis of hemoplegia, hemiparesis, progressing Dementia and is dependent on staff for all ADLs needs. Observations on 02/07/23 through 02/10/23 documented R37's ADLs were not completed, appeared increasingly unkept, lips progressed to crack, and body odor was pungent. R3 is dependent on staff for oral hygiene did not receive lip care for dry lips. As a result of severity in the neglect of R37's ADLs, any reasonable person would experience psychosocial harm. Findings include: Cross reference to F656 Develop/Implement Comprehensive Care Plan 1) Centers for Medicare & Medicaid Services (CMS), Appendix P, Seiction IV, E, Psychosocial Outcome Severity Guide, October 2022, defines the resonable person concept as a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident's position. It also defines psychosocial as the combined influence of psychological facotrs and the surrounding social envirno,ent on physical, emotional, and/or mental wellness. R37 is a [AGE] year-old female that was admitted to the facility on [DATE] with diagnosis that include hemiplegia, hemiparesis following a cerebral infarction (stroke) affecting the left non-dominant side and dementia. Multiple observations (02/07/23 at 10:31 AM, 12:30PM, 03:35 PM; 02/08/23 at 08:51 AM, 09:34 AM, 11:21 AM; 02/09/23 at 09:15 AM, 11:15 AM, 02:45 PM; 02/10/23 at 08:30 AM, 10:15 AM, 1:13 PM) were made of R37. During the first observsation, this surveyor asked R37 questions and asked the her to grab her call light. R37 was unable to speak and could not move her arms to grab the call light. Observed on 02/07/23 at 10:31 AM, R37 appeared unkept, her lips were cracked and peeling, and was malodorous. R37's had yellow-nonslip socks (toe of the sock was cut to allow the resident's hand through) applied to both arms that was visibly dirty with brown markings and appeared worn. The fabric strip from the socks dug into the skin between the pointer finger and thumb. On 02/09/23 at 01:54 PM, conducted a review of R37's EHR. Review of R64's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/22 Section C., Cognitive Pattern documented the Brief Interview for Mental Status (BIMS) attempt to conduct interview with resident was not conducted (0. No (resident is rarely/never understood). Section G., Functional Status, R37 is totally dependent (full staff performance every time during entire 7-day period) and requires the support of two or more staff for bed mobility and one or more staff for dressing, eating, toilet use, and personal hygiene. Review of the quarterly MDS with an ARD of 11/21/22 R64's BIMS was not completed and Section G., Functional Status, remained the same and during the 7-day look back period, R37 was not transferred out of bed. Review of R37's CP documented the resident has self-care deficits due to dementia, hemiplegia gastritis, anarthria, and decreased mobility, the goal for R37 to remain clean and comfortable, odor free, and will be treated with dignity in daily basis with an approach to assist in completing ADL task each day (started 03/24/22), encourage the use of call lights when ADL assistance is needed (started 03/24/22). On 02/10/23 at 04:15 PM, conducted an interview with Certified Nurse Aide (CNA)87 regarding R37's ADLs. CNA87 showed this surveyor R37's shower schedule and stated R37's receives baths on Monday, Thursdays, and as needed. CNA87 reported that R37 does not receive bed baths and is transferred from the bed to the shower room. Inquired with CNA87 for documentation supporting R37's received showers as scheduled. CNA87 logged on the EHR and could not provide documentation that R37 was showered. CNA87 confirmed R37 had not received a shower that week and knew this because he/she had been working with the resident that week. On 02/10/23 at 04:20 PM, conducted a concurrent observation of R37 and interview with RN33. RN33 confirmed R37's lips were cracked and appeared unkept. This surveyor pulled R37's blanket down to inspect R37's arms and RN33 confirmed that R37's malodor was noticeable through the surgical mask he/she wore and stated he/she thought this surveyor was going to reveal an untreated/unknown wound due to how bad the odor was. RN33 confirmed R37's ADL needs were not being met. RN33 also confirmed that due to R37's cognitive impairment, any resonable person with the same state of ADLs as R37 would experience negative psychosocial outcomes such as depressed mood and personal embarssment to the level that would change a person's social interactions resulting in isolation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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3) On 02/08/23 at 08:26 AM, observed Certified Nurse Aide (CNA) 36 set up R21's breakfast on bedside table. After performing hand hygiene, CNA36 then assisted R21 with breakfast while standing at his bedside. 4) On 02/09/23 at 08:26 AM, observed CNA6 set up R53's breakfast on bedside table. After performing hand hygiene, CNA6 then assisted R53 with breakfast while standing at her bedside. Interview with Administrator on 2/13/23 at 02:33 PM, confirmed that staff should be sitting on the same level as the resident when they are assisting them with their meal so they do not feel intimidated and that the residents would feel like the CNA's are their companion. 2) On 02/07/23 at 08:19 AM observed with a second surveyor (S2) outside of R45's room in the hallway, Nurse (N) 12 provide assistance putting a patch on R45's back. R45 was observed to be standing slightly bent over, using her walker for support, with her shirt lifted. R45's curtain was not drawn closed for privacy and R45's midriff could be seen from outside R45's room in the hallway. S2 reported she could see R45's chest, including her nipple, from S2's view in the hallway, and observed Assistant Administrator walk by as R45's shirt was lifted. On 02/10/23 at 11:14 AM interview with N6 was done. N6 stated when providing care in a resident's room, such as putting a patch on that requires a resident's shirt to be lifted, the privacy curtain should be drawn closed for privacy and dignity to not expose the resident. Based on observations, record review, and interview with staff members the facility failed to ensure three of 21 residents sampled exercised their right to a dignified existence. Resident (R) 60 and R45 were not provided privacy when receiving care requiring them to lift their shirt and a staff member was standing over R21 and R53 while providing assistance during breakfast. Findings include: Review of the facility's policy and procedure Promoting/Maintaining Resident Dignity reviewed/revised 05/20/22 documents It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as are for each resident in a manner and in an enviroment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy's compliance guidelines include 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .5. When interacting with a resident, pay attention to the resident as an individual .12. Maintain resident privacy . 1) On 02/07/23 at 09:20 AM, observed R60 sitting up in a wheelchair at a table in the common area. R60's shirt was lifted, exposing his abdomen, and Nurse (N)12 administered an injectable medication into his abdomen. The common room is a large open area that housed the nursing station and is used as a dining room and activity area. R60 sat at a table approximately 15 feet from the main entrance, another resident sat at a table adjacent to the table where R60 was sitting approximately 8 feet away, and several residents were doing activities with staff approximately 40 feet away. On 02/13/23 at 10:10 AM, interviewed Nurse(N)11. N11 stated that medications, especially injectable medications, are not to be given out in the common area. R60 was supposed to be brought into his room and curtain closed for dignity before his injectable medication was given.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R7 is an [AGE] year-old resident admitted on [DATE] with a diagnosis of dementia, major depressive disorder and anxiety disorder. Review of R7's EHR revealed that she is on escitalopram oxalate (antidepressant medication) 2.5 mg (milligrams) once a day and quetiapine (antipsychotic medication) 50 mg three times a day for depression. Consent for the use of psychotropic medications (medications that alter mood, perceptions and behavior) including education on risks and benefits were not found. 3) R74 is a [AGE] year-old resident admitted on [DATE] with a diagnosis on left hemiplegia (paralysis of one side of the body), anxiety disorder and depression. Psychiatry consult was done on 12/17/22 and was ordered to take escitalopram oxalate 5 mg daily in the morning for depression and trazadone (antidepressant medication) 50 mg daily at night for anxiety. Review of R74's EHR was done, consent for the use of psychotropic medications including education on risks and benefits were not found. On 2/10/23 at 12:01 PM, asked Administrator where the consents for the psychotropic medications for R7 and R74 are filed in the EHR, she said she will ask the nurses. After 30 minutes, she brought printed progress notes where the Registered Nurse is communicating to the attending physician drug to drug interactions. On 2/13/23 at 01:30 PM, Administrator confirmed that there is no documentation of consent for the use psychotropic medications for both R7 and R74. Based on record review and interview with staff members, the facility failed to inform three of five residents (Resident (R) 58, R7, and R74) reviewed for unnecessary medications, the risks and benefits of the use of psychotropic drugs and obtain consent. As a result of this deficiency, residents are at risk for more than minimal harm. Findings include: 1) R58 was admitted to the facility on [DATE] with diagnoses of depression and anxiety disorder. Review of R58's physician orders document R58 was receiving the following psychotropic medications; diazepam 5 milligrams (mg) twice a day as needed for anxiety and mirtazapine 15 mg once a day for depression. Review of R58's Electronic Health Record (EHR), consent for use of psychotropic medications including the risk and benefits were not found. On 02/09/23 at 12:29 PM, interview with Regional Nurse and Infection Preventionist (IP) was done. Regional Nurse confirmed the facility did not obtain consent for the psychotropic medications and was not able to find any further documentation in the EHR.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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5) On 02/06/23 at 3:00 PM, reviewed the document Office of Health Care Assurance (OHCA) Event Report for Aspen Complaints/Incidents Tracking System (ACTS) 9889. On 10/26/22 at 5:30 PM, Resident (R)7 allegedly hit R10. The initial report filed on 10/28/22 by the facility indicated the Type of Incident as a Mistreatment, and not as a resident to resident abuse. The Concern Form document revealed handwritten under Concern Investigation, . 5) Report abuse to Administrator and State. The Social Services Director (SSD) signed it. No document from the Adult Protective Services (APS) was found. On 02/13/23 at 2:06 PM, interviewed SSD. SSD stated that he conducts investigations for abuse and files reports to APS. SSD further stated that he did not report R10's alleged abuse by R7 to APS. Reviewed the policy and procedure, Resident Rights - Freedom from Abuse, Neglect & Exploitation. Under Procedure for Investigation of allegation of abuse, neglect, exploitation or mistreatment read, . 1. Allegations that involve abuse or result in serious bodily injury shall be reported immediately, but not later than 2 hours after the allegation is made, and .3. immediately initiate the reporting to the Office of Health Care Assurance, Adult Protective Services and/or the Department of Human Services via the required reporting forms for each respective agency and as per above time frames . Based on interviews and document review, the facility failed to report two reportable events of suspected resident (R) abuse events to the State Agency (SA) Adult Protective Services (APS) as mandated by law. On 12/13/23 the facility identified R33 had an unobserved/unexplained dislocation of the left shoulder. On 10/28/22, R10 was allegedly abused by R7. As a result of this deficient practice the SA did not have information to determine if an investigation by their agency was needed, and there is the potential incidents are not thoroughly investigated, putting all residents of potential abuse at risk. Findings include: 1) The facility provided a policy titled Resident Rights-Freedom from abuse, neglect and exploitation last revised 04/11/2018. Review of the policy included: - Policy header had a different (sister) facility (F2) name on it. - Section Procedure for Investigation of allegations of abuse, neglect, exploitation or mistreatment: An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation, or mistreatment, including injuries . shall be immediately reported.3. The Administrator (ADM) or designee shall be notified immediately, who will immediately initiate the reporting to the Office of Healthcare Assurance, Adult Protective Services and/or the Department of Human Services via the required reporting forms for each respective agency. - Section Procedure for preventing resident abuse . 2. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. - Section When abuse is believed to be possible, is suspected or is observed . 7. The Director of Nursing (DON)and/or Administrator conducts an immediate investigation of the circumstances of the incident. Notification of the appropriate agencies of all substantial abuse, mistreatment or neglect or exploitation occurs immediately. A written report of the investigation is submitted within 2 hours of serious bodily injury occurs, and 24 hours if no serious bodily injury occurs, with a final report sent within five days of completion, to required agencies, including the State Survey Agency (OHCA), Adult Protective Services . - Attachment of a flow chart titled Incident Reporting for Alleged Abuse. The first step of the process was to answer Was there willful infliction of injury to a resident? Note: Instances of unintended or ignorant harm does not meet facility policy or definition. Attachment directs staff to Report to State agencies if the injury was of unknown source and resident injuries resulted from an unwitnessed event, resident could not explain how injuries were received, and resident was not found on the floor and injuries consistent with a fall. Final step titled Reportable to State Agencies identifies the Risk Manager or designee responsible for review of the Incident Report and immediately notifies ADM, DON and Social Worker, coordinates and completes investigation and sends report to OHCA and APS (except resident to resident cases). The facility does not have an identified Risk Manager. 2) During an interview with the Social Services Director (SSD), he said the facility process was all information regarding a possible abuse incident, including investigation results are sent to the ADM, who makes the determination if it would be reported to APS. The ADM at the time of the incidents was no longer at the facility, but SSD said the process is the same with the change of Administration. 3) During an interview with the Regional Director of Nursing, she confirmed the facility practice was the ADM makes the decision if the incident should be reported to external agencies, and sometimes would delegated to another individual such as the Social Worker to report it. 4) OCHA received an initial facility incident report (FRI) regarding R33's injury on 12/13/2022. The FRI reported R33 had an unwitnessed, unexplained injury of her Left (L) shoulder which was swollen and warm to touch. She was sent to the Emergency Department and diagnosed with a Subluxation of her humerus (dislocation). This incident met criteria for mandated reporting to APS, but was not done.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and document review, the facility failed to thoroughly investigate the unobserved/unexplained injury of R33, diagnosed as a dislocated shoulder. In addition there was lack of evidence administration was involved as necessary in the investigation. If thorough investigations are not completed and appropriate action taken, it increases the risk of reoccurrence of a similar event to residents who are totally dependant on staff for Activities of Daily Living (ADL's). Findings include: 1) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body) and dysphasia (swallowing disorder) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, mood disturbance, sacral stage 3 pressure ulcer and age related osteoporosis without pathological fractures. R33 was totally dependent on staff for all ADL's including bed mobility, and transfers. On 12/13/2023 R33 was noted to have an unwitnessed, unexplained injury of her Left (L) shoulder which was swollen and warm to touch. She was sent to the Emergency Department and diagnosed with a Subluxation of her humerus (partial dislocation). Her Care Plan at the time of injury included she was a one person assist for bed mobility and transfers and that she used a Hoyer lift (mobility equipment). 2) The Office of Healthcare Assurance received the initial facility incident reports (FRI) regarding the injury on 12/13/2022. The initial report marked injuries of unknown source, and the section Perpetrator (Non-staff) was marked Another Resident, with a residents name. The completed report was received on 12/20/2022. The section Perpetrator (Non-staff) was still marked Another Resident, but the name of that resident had been removed. The FRI included Interviewed several staff who worked with the patient and 5+ residents who live on that floor for abuse. Could not identify incident that would have been the source of the injury. As the resident is completely dependent upon staff we can only assess that it may have occurred during transfer or repositioning of the resident, or if while laying on her left side. Facility initiated transfer/positioning training from a licensed Physical therapist for all direct care staff. Facility also initiated abuse identification and reporting requirement training to remind direct line staff to report any incident that could have occurred at any hour of the day or night that may impact the health and wellbeing of the resident. 3) Request was made for all investigation documents. The only documents provided were written statements from six Certified Nursing Assistants (CNA's) and one Registered Nurse (RN) dated 12/15/2022. All statements referenced the date 12/12/2022 (injury found on 12/13/2022). Statements included: RN16 03:00 PM-11:00 PM shift: Assigned LN17 (licensed nurse) requested this RN to insert peripheral IV line/saline lock for IV (intravenous) ABX (antibiotics) order . for R33. Saline lock inserted aseptically to Right hand . The resident's left hand is positioned across her chest during the entire time of IV insertion. No noticeable swelling, bruise or discoloration noted. No indication of pain nor discomfort. The assigned LN/LPN didn't report any injuries or unusual changes the rest of the shift. CNA18: On December 12, 2022 Monday i [sic] worked and assigned to room [ROOM NUMBER], 210, 211, 212. (R33 was in 208-2). CNA10: .I was on duty on that day and I was assigned to room [ROOM NUMBER], 202, 203, +204 last December 12, 2022 and I didn't enter in that room on that night. CNA21: NA (CNA) 3 to 11 shift and I worked that date 12/12/22 Monday in first floor. CNA38 I'm CNA38 working at .evening shift 3-11 PM on the 12th of December on the 2nd floor, I was not the CNA who assigned to R33 at that night/evening. CNA 7: .CNA working 3-11 shift. I was on duty on the day Monday the 12 of December. I'm not the assign CNA on that group. I don't know exactly happened. CNA11: I'm the assigned of R33 for 11-7 shift since [DATE]. On 12/12/22 I did my first round. I changed her diaper. I did not see any swelling on the left arm. But I noticed an old discoloration on Right arm. I know this was reported on the charge nurse few days [sic]. After that I reposition her every two hours using the drawsheet (used to facilitate turning side to side). When i move her she's using the same tone of voice that I hear everytime. I did my 2nd rounds on her, there was no swelling on the left arm during my shift. 4) On 02/10/2023 at 11:40 AM, during an interview with the Social Services Director (SSD), he said the investigation of alleged abuse is a team effort and depends on the situation, but the Unit Manager (UM) or Director of Nursing will usually investigate the clinical side and Social Services would interview residents, family members and assist as needed. SSD said he had not been involved with R33's investigation. On 02/10/2023 at 12:00 PM. during an interview with the Unit Manager (UM)3, she stated she received an email from Regional Nurse Director (RND) to get statements from CNA's if they had cared for R33. She said she did not have specific instructions or direction how to proceed, so requested the CNAs on the unit to complete a written statement and return it to her. UM3 said she gave the statements to RND and did not have any further discussion about the allegation. She went on to say she had not been involved with an alleged abuse investigation before, and to her knowledge no one interviewed the staff. 5) Reviewed the facility policy titled Resident Rights-Freedom from abuse, neglect and exploitation last revised 04/11/2018. The policy header had a different facility's (F2/sister facility) name on it. The policy section Procedure for Investigation of allegations of abuse, neglect,exploitation or mistreatment included: An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation or mistreatment, including injures of unknown source . The content in that section all refers to reporting the event, with the exception of 4. An initial report will be initiated with a final report submitted within 5 days. If investigation is not able to completed, an interim report shall be submitted providing agencies with a revised time frame for submittal of final investigative report. There were no guidelines or directions how the investigation is completed. 6) Although there is no specific investigation process, the facility must thoroughly collect evidence to allow Administrator to determine what actions are necessary for the protection of the residents. It would be expected that the investigation would include, but not limited to conducting observations of staff interactions with R33 (i.e. how repositioned/transferred), conducting interviews with the practitioner, appropriate emergency room personnel, as well as conduct record review for pertinent information (i.e care plan for level of mobility and staff assist). It was assumed the injury occurred on 12/12/2022, as those were the only staff asked for statements. 7) The facility provided copies of the content of the referenced inservice which was completed on 12/13/2022 and 12/14/2022. The inservice included, but not limited to information on the importance of thorough abuse investigation and reporting. At that time, Physical Therapy also gave a presentation on appropriate repositioning techniques. Individual staff quizs were provided, so requested to provide percent of staff that completed the education. On 02/13/2023, facility provided attendance sheet with staff listed indicating if they completed, or did not complete. The total percentage (%) of completion for all job categories was documented to be 78%. On further review it was noted that the staff listed on the education sheet did not match the staff list provided on survey entry. Seven CNA's (CNA1, CNA21, CNA25, CNA26, CNA28, CNA30 and CNA34) were not listed on the education staff list. If all CNA's had been listed, the CNA completion would have been 41%. Further investigation of the report for accuracy of other job categories was not done.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, the facility failed to notify the family or resident representative of one resident's (R), R39's, transfer to the hospital. The facility failed to provide a written notification to the resident's close contacts about R39's transfer out of the facility for emergent care. This deficient practice does not protect the resident from an inappropriate discharge and has the potential to affect all residents transferred out of the facility. Finding includes: On 02/07/23 at 08:47 AM, R39 was observed to be lying in bed in his room. R39 did not respond to verbal stimulation. On 02/08/23 at 11:30 AM, R39 was observed to be assessed by an Emergency Medical Technician (EMT). Record review revealed that R39 was transferred to a local area hospital for acute care. Nurse (N)12 tried notifying R39's close contacts but was unable to reach them via phone and was unable to leave a voicemail. On 02/13/23 at 2:22 PM, queried the Area admission Director (AAD). AAD stated that the Social Services Director (SSD) is responsible for notifying the family and Long Term Care Ombudsman (LTCO) of any resident transfers and discharges. On 02/13/23 at 3:07 PM, interviewed SSD. SSD stated that a written notification was not sent to R39's close contacts informing them of his transfer to the local area hospital because he did not know he was supposed to. Reviewed the policy and procedure, Transfer to Emergency Care. Under Procedures, it stated, .5. The licensed nurse will contact the resident's physician or alternate and resident representative to inform them of situation, and if resident is to be transferred from the facility. The policy and procedure did not have direction for a written notification to be sent to close contacts of the resident if the resident is transferred to the hospital.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure one residents (R)33 functional ability and required staff support was accurately documented on the MDS (Minimal Data Sheet) dated 12/20/2022. In addition two of four weekly (from 01/14/2023 to 02/02/2023) assessments did not accurately reflect R33's need for two staff support for activities of daily living (ADL's). As a result of this deficiency, R33 may not have received the necessary support to meet her goals. This deficient practice has the potential to affect all residents. Findings include: 1) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body), dysphasia (swallowing disorder) and dsyarthria (speech disorder caused by muscle weakness) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, stage 3 pressure ulcer sacral area, hypertension, diabetes type 2 and age related osteoporosis without pathological fractures. R33 is incontinent of bowel and bladder and wore diapers. She had difficulty making herself understood due to her dysarthria, had impaired vision and cognitive loss. On 12/13/2022 R33 was noted to have an unexplained, unwitnessed injury which was diagnosed as a subluxation (partial dislocation) of her humerus. Prior to her injury, she required one person assist for ADL's. Staff said they could not remember the last time she had not been out of bed because of her sacral pressure ulcer. After R33's injury, it was determined she needed the support of two staff for ADL's to prevent further injury. 2) On 12/18/2022, nursing progress note documented Left elbow/arm remains swollen and left arm still bruise/dislocation. Treatment to coccyx wound done this evening as ordered with 2 person assist. 3) Review of R33' Minimum Data Set (MDS) dated [DATE] Section G, Functional Status coded her to be totally dependent (Full staff performance every time during entire 7-day period) for bed mobility, transfers (occurred once or twice), dressing, eating, toilet use and personal hygiene, and required the support of one staff for assist for all ADL's including dressing, bathing and eating. Section G0300 Balance During Transitions and Walking documented R33 was Not steady, Only able to stabilize with staff assistance for Moving from seated to standing position. R33 had very limited mobility, and had been bedbound for some time. If she was transferred, staff were to be using the Hoyer lift. This entry did not reflect her current status. 3) Reviewed the Observation Detail List Reports dated 01/14/2023, 01/20/2023, 01/27/2023 and 02/07/2023. The purpose of the report is to capture the residents accurate and current status by staff who work with the resident. Review of the reports revealed R1 was assessed as totally dependent for bed mobility and transfers, but there were discrepancies on the required support provided by staff. The reports included the following: 01/14/2023 completed by RN12: Bed mobility-Total Dependent (Resident not involved in activity, staff provided full support) with Two + person physical assist. Transfer-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position; Total Dependent with support provided by staff. Two + persons physical assist. 01/20/2023 completed by RN12: Bed mobility-Total Dependent. Bed mobility-One Person Physical assist. Transfer-Total Dependent. Transfer-One person Physical assist. 01/27/2023 completed by RN14: Bed mobility-Total Dependent. Bed mobility-One Person Physical assist. Transfer-Total Dependent. Transfer-One person Physical assist. 02/02/2023 completed by RN15: Bed mobility-Total Dependent. Bed mobility-Two + person physical assist. Transfer-Total Dependent. Transfer-Two + persons physical assist. 4) On 02/10/2023 at 01:00 PM, during an interview with the MDS Coordinator, he said uses the weekly assessments to complete the required MDS assessments. On 02/10/2023 at 01:30 PM, during an interview with RN12, inquired how she gets the information to complete the assessment on the weekly observation detail list report. RN12 said she knows the residents and works with them. When asked about what type of support R33 currently needed, she replied to my knowledge, she is a one person assist. She's on the smaller side and I can do her wound care (sacral pressure ulcer) by myself .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) R38 is a [AGE] year-old resident admitted on [DATE]. Diagnoses that include traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) and dementia with agitation. Observation on 02/07/23 at 09:10 AM, R38 was awake lying on specialty mattress, face appeared oily and started yelling in Korean and waving his arms when we knocked on door to ask permission to enter room. According to another surveyor that understands Korean, R38 was using curse words. On 02/08/23 at 12:48 PM, this surveyor knocked on door to ask permission to enter room, no response from R38. As soon as he saw us approach his bed, he started yelling in Korean so we exited the room. Interview with Certified Nurse Aide (CNA) 6 and Nurse (N) 11 on 02/09/23 at 12:52 PM. CNA6 said R38 yells a lot when the staff care for him, he sometimes refuses care. He only speaks Korean, and the staff sometimes use Google Translate on their phones to communicate with him. The staff understand some common words like change and turn. N11 also said that she knows some simple Korean words like pain and no pain. The staff also uses gestures to communicate with him. Review of records done. Progress Notes revealed that R38 had episodes of yelling at staff since he was admitted . He also refuses care and medications and can be combative. R38 was started on buspirone (anti-anxiety medication) 5 (milligrams) mg three times a day for dementia on 10/17/22. Further review of records revealed that care plan meeting notes for R38 were not kept in the electronic health records (EHR) and that there were no plans to address his behavioral issues (yelling at staff, refusing care and medications and being combative). Interview and review of EHR with Social Services Director (SSD) done on 2/13/23 at 03:20 PM. SSD confirmed that there was no plan to address R38's behavioral issues and that there should be one since it happens often. Based on observations, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs were developed and/or implemented for 2 of 21 residents (Resident (R)37 and R38) sampled. R37's comprehensive person-centered care plan (CP) was not implemented to ensure the resident's Activity of Daily Living (ADLs) needs were met and the appropriate Geri sleeves were not applied to prevent bruising. A comprehensive person-centered care plan was not developed to address R38's behavioral and verbal aggression/agitation. As a result of these deficient practices, residents are at risk for the potential of harm and/or neglect. Findings include: (Cross reference to F677 ADL Care Provided for Dependent Residents) 1) R37 is a [AGE] year-old female that was admitted to the facility on [DATE] with diagnosis that include hemiplegia, hemiparesis following a cerebral infarction affecting the left non-dominant side, dysphagia, gastrostomy, dementia, diabetes mellitius type 2. Multiple observations (02/07/23 at 10:31 AM, 12:30PM, 03:35 PM; 02/08/23 at 08:51 AM, 09:34 AM, 11:21 AM; 02/09/23 at 09:15 AM, 11:15 AM, 02:45 PM; 02/10/23 at 08:30 AM, 10:15 AM, 1:13 PM) were made of R37 during which the resident had yellow non-slip socks applied to both arms. The toes of the socks were cut in a way that allowed R37's arms to past through with a strip of fabric between her thumb and pointer finger. The edges of the fabric strip had rolled together and was tightly wedged in the web of her thumb. Throughout the observation period (07/07/23 to 02/10/23) the same yellow non-slip socks were applied to R37 and had visible brown marks and appeared dirty. During these observations, R37 appeared unkept, her lips were cracked and continued to progressively crack throughout the observation period and was notably malodorous (pungent) on 02/10/23. On 02/09/23 at 01:54 PM, conducted a review of R37's Electronic Health Record (EHR). Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/22 documented in Section G. Functional Status, R37 is totally dependent (full staff performance every time during entire 7-day period) and requires the support of two or more staff for bed mobility and one or more staff for dressing, eating, toilet use, and personal hygiene. During the 7-day look back period, R37 was not transferred out of bed. Review of the CP documented, R37 is at risk for complications secondary to Anti-Coagulant use. Category Anti-Coagulant Start Date 02/26/2022 Last Reviewed/Revised 11/08/2022 10:13 with intervention to protect R37 from injury/trauma (started 02/26/22). Review of the physician's orders documented an order for Geri sleeves to bilateral arms for protection, monitor placement Q (every) shift Special Instructions: monitor placement q (every) shift. Regularly monitor for skin integrity and perfusion status at least every 2 hours (signs of poor blood supply or discoloration) Every Shift Day, Evening, NOC (night) that started on 02/06/2023. r37's CP ALSO documented the resident has self-care deficits due to dementia, hemiplegia gastritis, anarthria, and decreased mobility, the goal for R37 to remain clean and comfortable, odor free, and will be treated with dignity in daily basis with an approach to assist in completing ADL task each day. On 02/10/23 at 04:20 PM, conducted a concurrent observation of R37 and interview with the Regional Nurse (RN)33. R37 had the same yellow-non-slip socks applied to her arms that were first observed on 02/07/23 at 10:31 AM. RN33 confirmed the yellow non-slip socks were dirty and the use of the socks in place of Geri sleeves was not appropriate due observation of the fabric strip rolled and wedged into the webbing of R37's thumb. RN33 confirmed because of not using the appropriate Geri sleeves it was just a matter of time before the sock would cut into the resident's skin. On 02/09/23 at 01:54 PM, conducted a review of R37's EHR, a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/22 documented in Section G. Functional Status, R37 is totally dependent (full staff performance every time during entire 7-day period) and requires the support of two or more staff for bed mobility and one or more staff for dressing, eating, toilet use, and personal hygiene. During the 7-day look back period, R37 was not transferred out of bed. On 02/10/23 at 04:15 PM, conducted an interview with Certified Nurse Aide (CNA)87 regarding R37's ADLs. CNA87 showed this surveyor R37's shower schedule and stated R37's receives baths on Monday, Thursdays, and as needed. CNA87 reported that R37 does not receive bed baths and is transferred from the bed to the shower room. Inquired with CNA87 for documentation supporting R37's received showers as scheduled. CNA87 logged on the EHR and could not provide documentation that R37 was showered. CNA87 confirmed R37 had not received a shower that week and knew this because she had been working with the resident that week. On 02/10/23 at 04:20 PM, conducted a concurrent observation of R37 and interview with RN33. RN33 confirmed R37's lips were cracked and appeared unkept. This surveyor pulled R37's blanket down to inspect R37's arms and RN33 confirmed that R37's malodor was noticeable through the surgical mask he/she wore and stated she/he thought this surveyor was going to reveal an untreated/unknown wound due to the odor coming from the resident. RN33 confirmed R37's ADL needs were not being met and was not dignified.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to revise two Resident (R)33 and R58's care plans (CP) in a timely manner. Specifically the facility failed to ensure Resident (R) 58's comprehensive CP plan was person-centered and does not include safe approaches for smoking, expressing the facility's current designated smoking area is unsafe and prefers to smoke at a non-designated smoking area. R33's CP was not revised in a timely manner after it was determined she needed more staff assist for activities of daily living (ADL's). Findings include: 1) Cross reference to F689. The facility failed to identify and assess hazards and risks for Resident (R) 58's smoking environment, designated by the facility and non-designated by the facility, and implement interventions to reduce hazards and risks. On 02/07/23 at 01:46 PM interview with R58 was done. R58 stated the facility's designated smoking area is at the back of the facility and is difficult to access. R58 stated she smokes on the side walk once or twice a day at the front of the facility. R58 further stated they don't like us going in the front but in the back there are two doors and at one door you have to go down, staff have a hard time getting me back up. R58 reported there is no trash can for her to throw away her cigarette at her preference location to smoke so she throws her used cigarette in the trash can located inside the facility. Review of R58's Electronic Health Record (EHR) included a scanned document of a note R58 handwritten. The document's content included I .[R58] .take full responsibility to be taken off property to smoke, if anything should happen to me while off the property the facility is not liable signed by R58. The document had another resident's handwritten note below R58's note with the same statement and was dated 12/02/21. Review of R58's most recent care plan on smoking with a start date of 12/29/22 documents the following approaches for R58 to be safe; Staff to provide quarterly safe smoking observation as needed .Praise resident for being safe and responsible .Resident will not share or borrow tobacco products or paraphernalia from other .involve support person or Ombudsman as needed .Resident will follow SNF [Skilled Nursing Facility] smoking policy .Offer cessation information as desired. R58's care plan does not include how resident will be safe when smoking outside of the non-designated smoking locations, interventions to be put in place, education on risks, and/or include R58's concern with the facility's designated smoking area. 2) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body), dysphasia (swallowing disorder) and dsyarthria (speech disorder caused by muscle weakness) following a cerebral infarction (stroke) affecting her left non-dominant side. On 12/13/2022 she was found to have an unwitnessed, unexplainable injury to her Left shoulder/arm, and was sent to the emergency room where she was diagnosed to have an anterior dislocation left shoulder. R33 was readmitted to the facility on [DATE]. Review of R33's progress notes included: On 12/18/2022 at 10:24 PM: Left elbow/arm remains swollen and left arm still bruise/dislocation. Treatment to coccyx wound done this evening as ordered with 2 person assist. Continue nursing care with comfort and gently handling.Noted with facial grimace during nursing care only. On 12/21/2022 at 03:39 PM: . Advised caregiver assigned to maintain 2 staff assistance during nursing care, especially during turning and repositioning to ensure proper positioning while keeping L arm free of any pressure . Review of R33's Care Plan (CP) included but not limited to: 03/24/2022, the problem self care/ADL (activities of daily living) deficit included the interventions of bilateral mobility bars and 1 staff assistance for bed mobility, and use of Hoyer lift for transfers. 12/14/2022, the problem pain was initiated with the comment Resident has pain R/T (related to) anterior dislocation of left shoulder. The change to two staff assist for ADL's was first noted in the EMR on 12/18/2022. On 12/21/2022, the intervention/approach Provide 2 staff assistance during nursing care, turning and positioning was added to the CP.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to identify and assess hazards and risks for Resident (R) 58's smoking enviroment, designated by the facility and non-designated by the facility, and implement interventions to reduce hazards and risks. This deficient practice effects R58's individual safety, as well as the safety of others in the facility. Findings include: (Cross reference to F657- Care Plan Timing and Revision) The facility failed to revise and ensure Resident (R) 58's comprehensive care plan was person-centered. R58's care plan for smoking does not include approaches when expressing the facility's current designated smoking area is unsafe and prefers to smoke at a non-designated smoking area. R58 was readmitted to the facility on [DATE] with diagnoses of embolism and thrombosis of arteries of the lower extremities, acquired absence of right leg above knee, history of falls, difficulty in walking, depression, and anxiety disorder. Review of R58's Electronic Health Record (EHR) found only one smoking assessment completed on 02/07/23. R58's assessment documents Smokes in Unauthorized Areas as a minimal problem. No smoking assessment was found upon admission or prior to readmittance. On 02/07/23 at 01:46 PM interview with R58 was done. R58 stated the facility's designated smoking area is at the back of the facility and is difficult to access. R58 stated she smokes on the sidewalk once or twice a day at the front of the facility. R58 further stated they don't like us going in the front but in the back, there are two doors and at one door you have to go down, staff have a hard time getting me back up. R58 reported there is no trash can for her to throw away her cigarette at her preference location to smoke so she throws her used cigarette in the trash can located inside the facility. During an interview with resident council members on 02/09/23 at 10:09 AM, R58 reported she heard the facility is going to redo the designated smoking area to make it more assessable. R58 reported there is another way to enter the designated smoking area where you go out in the front and go down the ramp to a garden area but it is difficult for her to go down the ramp, and it is uneven and unsteady. R58 reported she tries to go as far back as possible. R58 also reported other solutions that were brought up such as going down the parking ramp but that seemed dangerous. R58 stated she usually smokes late at night. Inquired if staff supervise her while she smokes in the front at a non-designated smoking area, R58 reported sometimes they do and sometimes they don't. R58 further reported sometimes she meets nice people walking their dogs outside. On 02/10/23 at 10:01 AM observation was made to the entrance of the designated smoking area from the back of Unit 1. The first door was locked and needs access from a staff member. The first door led to a staircase and the size of the door was standard and heavy. It had a small transition strip (bump) at doorway. The second door, standard size and heavy, led to outside the back of the facility, the doorway had an approximately once inch step that led to a zig-zag ramp to the designated smoking area. The step at the doorway of the second door did not have a threshold ramp. Further observed the front of the facility, a ramp is located at the front main entrance/exit door of the facility that leads to the public side walk and the main street. On one side of the front of the facility is a driveway ramp to the parking structure and on the other side is a public bus stop. The sidewalk was busy with the public utilizing the walkway and bus stop. Review of R58's EHR included a scanned document of a note R58 handwritten. The document's content included I .[R58] .take full responsibility to be taken off property to smoke, if anything should happen to me while off the property the facility is not liable signed by R58. The document had another resident's handwritten note below R58's note with the same statement and was dated 12/02/21. Review of R58's most recent care plan on smoking with a start date of 12/29/22 did not include how R58 will be safe when smoking outside of the non-designated smoking locations, interventions to be put in place, education on risks, and/or include R58's concern with the facility's designated smoking area. On 02/13/23 at 09:55 AM interview and concurrent record review with Director of Nursing (DON) was done. DON reported she started working for the facility a couple of weeks ago, 02/01/23. DON stated one of the projects she recently worked on was updating the smoking policy, created a smoking assessment, and enforce using the designated smoking area with scheduled staff to provide supervision which was implemented last week (during the survey period). DON further reported maintenance is working installing a little ramp to one of the doors .because there is a little of a bit of a limp there. DON confirmed documentation of a smoking assessment done for R58 prior to the recent one created last week on 02/07/23 was not in the EHR. Inquired if R58's current assessment and care plan included the risk and hazards associated with the smoking enviroment, designated and non-designated, DON confirmed it did not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation and record review, the facility failed to adhere to professional standards of practice and infection prevention and control measures for one resident with an indwelling urinary catheter. This deficient practice has the potential to affect all residents that have an indwelling urinary catheter putting them at risk to develop complications including urinary tract infections. Finding Includes: On 02/07/23 at 09:10 AM, observed Resident (R)53 lying in bed with indwelling urinary catheter tubing and collection bag touching the floor. Then at 12:35 PM when the resident was being brought to the dining area via wheelchair, observed the urinary catheter tubing being dragged on the floor during transport. On 02/08/23 at 11:29 AM, observed R53 lying in bed and no longer has the indwelling urinary catheter. Review of records revealed that on 02/07/23 at 13:19 PM, Progress Notes documented: received report from floor nurse that resident is not at her baseline, with noted confusion, foul smelling dark colored urine with sediment. MD (attending physician) made aware received orders for UA (urine test) and C&S (culture and sensitivity, test to identify bacteria and its sensitivity to antibiotics). Further review of records revealed that on 02/07/23 at 11:03 PM, Progress Notes documented: MD made aware of resident with positive results for ESBL (extended-spectrum beta-lactamases, which is an enzyme found on some strains of bacteria) to urine. Resident was also started on ciprofloxacin (antibiotic) 250 milligrams twice a day for 7 days for ESBL to urine on the same day.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to identify and verify a significant weight loss/gain and ensure a resident maintained acceptable parameters of body weight for 1 of 4 residents (Resident (R)64) sampled. R64 had a significant weight loss of 19.30% from 10/27/22 to 11/10/22 and a significant weight gain of 20.62% from 11/10/22 to 01/29/23 that was not verified and/or addressed. As a result of this deficiency, residents are at risk for the potential of negative outcomes due to unidentified changes. Findings include: R64 was admitted to the facility on [DATE] with diagnosis that include dementia, with behavioral disturbances, diabetes mellitus type 2 without complications, anxiety disorder, major depressive disorder, and insomnia. On 02/10/22 at 10:10 AM, conducted a review of R64's Electronic Health Record (EHR). Review of the resident's weights documented: 10/27/22- 120.2 lbs (pounds); 11/10/22- 97.0 lbs; 12/22- Refused weights; and 01/29/23- 117 lbs. Indicating R64 had a significant weight loss of 19.30% from 10/27/22 to 11/10/22 and a significant weight gain of 20.62% from 11/10/22 to 01/29/23. Reviewed R64's progress notes, physician notes, and Registered Dietician for documentation that the facility was aware of the changes and addressed the resident's significant weight loss/gain and could not find documentation. On 02/10/23 at 9:24 AM, conducted a concurrent record review and interview of R63's EHR with unit Charge Nurse (CN)2. Inquired with CN2 about R64's significant weight loss/gain. CN2 confirmed that there was no documentation that weight was rechecked to confirm the changes, notification of physician, or the notification of the dietician. CN92 stated R64's weight should have been rechecked to confirm it was an accurate weight and if the weight was accurate, the physician and the registered dietician should have been notified and the weight loss would be addressed. On 02/10/23 at 12:15 PM, conducted a telephone interview and concurrent record review of R64's EHR with Registered Dietician (RD)2. RD reviewed R64's EHR and confirmed per dietician notes that the facility did not notify the registered dietician of R64's significant weight loss on 10/27/22. RD2 stated the process is if there is a weight change then the resident should be re-weighed and if the weight change is correct then the facility should notify the physician and the RD.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an account (route and time) of a controlled medication for one resident (Resident (R)23) sampled. As a result of this deficiency, the resident is at risk for more than minimal harm and provides an opportunity for diversion of a controlled medication. Findings include: R23 is a [AGE] year-old resident admitted with type 2 diabetes mellitus, end stage renal disease and dependence on renal dialysis, non-pressure chronic ulcers to both heels, cellulitis (bacterial skin infection causing redness, swelling and pain) to both lower limbs, chronic osteomyelitis (bone inflammation or infection) to both left and right ankles. Resident is transported to an incenter dialysis clinic three times a week and is on oxycodone (narcotic pain medication) 10 milligrams (mg) every 3 hours routinely for pain. Review of R23's electronic health record (EHR) included scanned communications between the facility and the incenter dialysis clinic in Resident Documents. Physician's order for oxycodone 10 mg every 3 hours routinely for pain included instruction that the facility may send the medication with the resident when going out for her scheduled dialysis treatments. Review of the last 10 dialysis communication records from 01/18/23 to 02/11/23 done. Dialysis treatments start times vary from 11:09 AM to 11:48 AM and end times are from 03:45 pm to 04:14 PM. Documentation for the time oxycodone was administered was only written in four out of the ten dialysis communication records reviewed. Medication administration record (MAR) also revealed that there are scheduled administration times on 01/17/23, 01/18/23, 01/19/23, 02/07/23 and 02/08/23 for oxycodone that are left blank with no explanation noted. Interview with Nurse (N)8 on 02/13/23 at 10:15 AM revealed that the 12:00 PM and 03:00 PM doses of oxycodone are secured in a plastic pouch and given to the resident to hand carry when she goes out for her dialysis treatments. N8 also said that the dialysis nurse gives the oxycodone at the incenter dialysis clinic. When asked if the dialysis nurse communicates what time the oxycodone is administered, N8 said: sometimes they write it in the dialysis communication records or we just ask the resident since she is alert. Review of the dialysis communication records and interview with the Administrator done on 02/13/23 at 01:30 PM. Asked if she can tell what time the oxycodone was given to the resident when she goes out for her dialysis treatments. Administrator confirmed that she is not able to, and that administration times should be noted in the dialysis communication records. She also said that if the administration time is not written, the nurse should call the incenter dialysis clinic and confirm what time the dialysis nurse administered the medication. Review of facility's policy and procedure Medication Pass Protocol documented: 13. Should a drug be withheld, refused, or given other than the scheduled time, the nurse must provide this information on the Medication Administration Record including an explanatory note.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to ensure medication error rates are not 5 percent (%) or greater. The survey team observed a total of 28 medications, the total number of errors were 2, and the medication error rate was 7.14%. As a result of this deficient practice, there is potential for more than minimal harm. Findings include: On 02/09/23 at 08:24 AM, conducted observation of medication administration on the second-floor unit with Registered Nurse (RN)71 for R33. RN71 prepared the residents medication and crushed all medications (Acetaminophen 325 mg (2 tablets, total dose 650 mg); Laxatives (2 tablets); and Vitamin C 500 mg (1 tab, not factored into percent rate)) and mixed the crushed medications with applesauce in a medication cup. RN71 administered the crushed medications to R33 then proceeded to walk towards the trash in the resident's room. This surveyor inquired if RN71 completed administering the medication to R33. RN71 confirmed he/she had administered the medication and was going to throw the medication cup away. Asked RN71 if there were any administrable medication in the cup. RN71 replied, No, I gave her all the medication. Requested for RN71 to attempt to scoop the medication cup to ensure all the crushed medications were given. RN71 complied and was able to scoop more crushed medications (approximately half of a regular spoon) and confirmed all medications were not administered and would not have been administered if this surveyor did not intervene.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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2) During observation of the second floor medication storage room on 02/09/23 at 03:40 PM with Licensed Practical Nurse (LPN) 4, observed on the bottom of a shelf a box of facility stock IV fluid. Observed the facility stock IV fluids sealed individually with a thick plastic bag and one IV fluid, sodium chloride injection 1000 milliliters (ml), without the thick plastic bag on top of the facility's stock. Inquired with LPN4 why one of the IV fluids was not sealed in a thick plastic bag, LPN4 looked at it and stated it was specifically for a resident, R27. Inquired if R27 was still receiving IV fluid treatment, LPN4 stated R27 was not. LPN4 reported discontinued medications are put into a large container and are discarded every Wednesday and R27's IV fluid should have been discarded. Review of R27's physician order documents R27's sodium chloride IV therapy for dehydration and decreased PO [Per Oral] intake was discontinued on 01/14/23. On 02/13/23 at 09:53 AM interview with Director of Nursing (DON) stated if the IV fluid was designated to a specific individual and was discontinued it should be piled with the discontinued medications to be disposed of. Review of the facility's policy and procedures Disposal of Medications documents for non-controlled prescribed medications that is discontinued .containing only dextrose, saline, sterile water, or electrolytes, or a combination thereof, may be discharged , disposed of, flushed, poured, or emptied into a public waste water collection system or s septic system. Based on observations, interviews, and record review, the facility failed to ensure all drugs are stored in locked compartments and intravenous (IV) fluid was discarded when IV therapy was discontinued. A treatment cart with topical medications was not kept locked or under the direct observation of authorized staffing in an area where residents could access it. No medications were taken by the resident but the potential for more than minimal harm exist. Findings include: 1) On 02/08/23 at 08:15 AM, observed the treatment cart on 1 of 2 units was unlocked in the main dining/activity room. The treatment cart was unsupervised, there were two residents in the area, unsupervised, and no staff in the immediate area. This surveyor opened the treatment cart and documented the cart had topical creams that included Clotrimazole cream, Ketoconazole cream, and Triamcinolone Acetonide ointment. On 02/08/23 at 2:35 PM, conducted a review of R48's Electronic Health Record (EHR). Review of R48's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 Section G. Functional Status, documented R48 requires limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility, transfers, and walking in room and requires supervision (oversight, encouragement or cueing) for locomotion on the unit. On 02/08/23 at 2:37 PM, conducted a review of R38's EHR documented the most recent quarterly MDS with an ARD of 01/30/23, Section G. Functional Status, locomotion on the unit occurred only once or twice. The most recent annual MDS with an ARD of 11/17/22 documented R38 required limited assistance for locomotion on the unit. On 02/08/23 at 08:16 AM, conducted an interview with Registered Nurse (RN)33 regarding observation of the unlocked treatment cart with unsupervised residents in the area. RN83 confirmed the treatment cart should be locked and if it is unlocked then the cart should not be unsupervised.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observations, interview, and record reviews, the facility failed to ensure Resident (R) 58's menu was followed to meet her choices and preferences. Findings include: On 02/09/23 at 08:08 AM, observed R58 receive her breakfast tray and inform nursing staff she did not get milk on her tray. At 08:20 AM, inquired with R58 how breakfast was, R58 reported her milk was not on her tray. On 02/09/23 at 10:09 AM, interview with R58 with resident council members was done. R58 reported sometimes their meal tickets (menu) are not followed. R58 stated For instance, my meal ticket said milk and on the meal tray, I did not get milk this morning. R58 stated she had to let nursing staff know so she could get her milk but is worried about those who cannot speak for themselves. On 02/10/23 at 09:28 AM, observed R58 eating breakfast. R58 stated she received papaya and hot cereal although her meal ticket says no papaya and no hot cereal. R58 reported she gave her papaya to the resident next to her. Observed papaya on a plate with the resident next to R58 and hot cereal on R58's tray. Review of R58's meal ticket documents NO HOT CEREAL .NO PAPAYA .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record review, the facility failed to provide a clean environment for residents and staff, by not instituting the process of checking the facility's water for Legionella, not providing resident (R)38 a clean area to have his meal, 2 of 2 thickener scoopers were stored in the containers on one unit, and reusable medical equipment was not sanitized between residents. This deficient practice encourages the development and transmission of communicable diseases and infections and has the potential to affect all residents, staff, and visitors in the facility. Findings include: 1) On 02/13/23 at 2:34 PM, interviewed the Infection Preventionist (IP). The IP stated that the process for checking the facility's water for Legionella contamination has not started and that she will have to check if the facility has a policy and procedure. On 02/13/23 at 3:51 PM, interviewed the Maintenance Manager (MM) via phone. MM stated that the facility's water has not been checked for Legionella and the facility did not have a policy and procedure for Legionella surveillance. On 02/13/23 at 3:53 PM, in a query with the Administrator, the Administrator confirmed that the facility has not checked the water for Legionella and did not have a policy and procedure to surveil the facility's water for Legionella contamination. On 02/13/23 at 4:30 PM, the Administrator gave the state agency (SA) the policy and procedure for LEGIONELLA SURVEILLANCE, date implemented 06/22 and date reviewed/revised 06/22. 2) On 02/07/23 at 12:05 PM, observed R38. R38 laid in his bed with his urinal filled with urine sat on his bedside table located adjacent to his bed. On 02/08/23 at 08:00 AM, observed R38's empty urinal on his bedside table. On 02/08/23 at 12:00 PM, observed R38's urinal filled with urine on his bedside table. Certified Nursing Assistant (CNA)9 put on gloves, emptied the urinal, and placed it back on his bedside table. CNA9 removed her gloves, did hand hygiene, and left the room. CNA9 returned with R38's lunch tray and placed it next to the empty urinal. On 02/13/23 at 10:30, a concurrent observation of R38 in his room and interview of nurse (N)11 was done. N11 saw the urinal on R38's bedside table and she was queried if R38 should receive his meal trays on the same bedside table where his urinal resides. N11 stated to prevent contamination and infection, R38's meal tray should not be placed on the same bedside table where R38 keeps his urinal. N11 then directed a CNA to place another bedside table to be used for meals next to R38's bed. 3) On 02/09/23 at 08:15 AM, observed RN71 using a wrist blood pressure cuff on R33. RN71 did not disinfect the wrist blood pressure cuff before or after use. Inquired with RN71 how the wrist blood pressure cuffs should be disinfected due to the porous material that is in direct contact with the resident's skin and if it should have been disinfected before and/or after use. RN71 stated the wrist blood pressure cuff should have been cleaned before it was used on R33 but was not and purple wipes are used to clean the reusable equipment and had not thought about the band of the cuff is fabric and the purple wipes may not be an appropriate way to disinfect it. Conducted an interview with the facility's IP and shared my observation of staff not disinfecting the reusable wrist blood pressure cuff. The IP confirmed reusable medical equipment should be disinfected before and after use, at a minimum, before it is used. IP also confirmed that due to the fabric on the wrist blood pressure cuff, the purple wipes is not an appropriate disinfectant and staff should use blood pressure cuffs that can be adequately cleaned to prevent the spread of communicable disease and infections. 4) On 02/09/23 at 08:35 AM, during observation of medication administration, both medication carts had a can of liquid thickener with the scooper stored in the container. An observation was made of Registered Nurse (RN71) opening the thickener can, using the scooper with bare hands, then placing the scooper back in the container. Inquired with RN71 if the scooper should be stored in the container. RN71 confirmed the scooper should not be stored in the can. Conducted an interview with the facility IP and shared the observation of staff storing the thickener scoopers in the can. IP confirmed the scoopers should not be stored in the can with the thickening product.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide a safe, clean equipment for a resident (Resident(R14) sampled. R14 is dependent on supplemental oxygen and the filter of the oxygen concentrator machine had a layer of dust on it. As a result of this deficient practice, the resident is at risk for more than minimal harm. Finding includes: R14 is a [AGE] year-old resident admitted on [DATE] with diagnosis that include chronic obstructive pulmonary disease (disease that blocks air from entering the lungs making it harder to breath), chronic respiratory failure, and dependence on supplemental oxygen. On 02/07/23 at 09:47 AM, Observed R14 lying in bed, receiving oxygen 2 liters (L) of oxygen via nasal cannula. The external filter located on the right side of the machine, was covered with a layer of whitish/grayish dust. On 02/08/23 at 08:42 AM, conducted a concurrent observation and interview with Unit Manager (UM) 4 of R14 and the oxygen concentrator filter. It was observed to be the same filter from the observation made on 02/07/23 at 09:47 AM and the layer of dust remained. Inquired with UM4 how often they clean the filter of the oxygen concentrator. UM4 stated housekeeping cleans the oxygen concentrator filters weekly. UM4 was shown R14's filter and confirmed it had not been cleaned. UM4 stated R14 is at risk of breathing in the dust form the filter and will notify housekeeping to clean it. she replied that the residents could be breathing in the dust. On 02/09/23 at 08:26 AM, conducted a concurrent observation and interview with Nurse (N)11 regarding the dust on R14's oxygen concentrator filter. The oxygen concentrator filter had not been replaced or cleaned and still had a layer of dust on it. N11 was unaware if housekeeping was notified to clean the filter, removed the filter and took it to the nursing station. At 08:33 AM, N11 returned to R14's room and installed the cleaned filter on the oxygen concentrator. Inquired with N11 when are the filters cleaned. N11 stated housekeeping cleans the filters weekly.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observations and interview with staff member, the facility failed to provide a homelike environment for residents receiving meal service in the first and second floor dining room. The facility failed to remove trays when passing meals to residents. As a result of this deficiency, resident is at risk of a negative psychosocial outcome. Findings include: 1) On 02/07/20 at 12:18 PM, observed 12 residents in the first-floor dining room. 11 of the 12 residents had their meals and beverages remain on the meal trays until they were done eating lunch. On 02/13/23 at 02:33 PM, interviewed Administrator. She confirmed that for a more homelike environment, the staff should be removing the meals and beverages off the trays and serving them on a placemat. 2) During lunch dining observation on 02/08/23 at 12:43 PM, observed 11 of 15 residents on the second-floor dining room with meal trays underneath residents plates, bowls, and cups while eating and not removed. During the meal pass, observed one Certified Nursing Aide (CNA) remove the trays as he was passing meals to four residents. During dining observation on the second floor on 02/08/23 at 12:44 PM observed nine residents eat lunch with their meal trays not removed.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R14 is a [AGE] year-old resident admitted on [DATE] with diagnoses that include chronic obstructive pulmonary disease (disease that blocks air from entering the lungs making it harder to breath), diabetes (high levels of sugar in the blood), anxiety, and depression. Review of R14's Electronic Health Records (EHR) under Orders dated 10/07/2022, documented the resident's food texture as chopped. On 02/07/23 at 12:47 PM, observed R14 in her room, sitting up in bed with a tray of food on her bedside table. Meal ticked that was taped to the tray indicated diet was chopped. Broccoli and green beans, greater than one inch in size, were observed on R14's plate. Asked Certified Nurse Aide (CNA)17 if the mixed vegetables looked chopped. CNA17 replied No and said she will call the kitchen to send up the correct consistency. 3) R53 is a [AGE] year-old resident admitted on [DATE] with diagnoses that include hemiplegia (loss of strength leading to paralysis on one side of the body) affecting right side, aphasia (disorder affecting how a person communicates), and dysphagia (difficulty swallowing). Review of R53's EHR under Orders dated 12/28/22 indicated diet consistency as chopped and liquids as nectar thick. On 02/07/23 at 12:57 PM, observed family member (FM) 2 assisting R53 for lunch at bedside. The meal ticket documented the resident's diet texture as chopped and liquids as nectar thick. Broccoli and green beans on R53's plate were greater than one inch in size. FM2 was cutting the vegetables into smaller pieces before giving it to R53. On 02/08/23 at 08:29 AM, CNA6 was assisting R53 with breakfast at bedside. Meal ticket taped to the tray indicated diet as chopped and liquids to be nectar thick. Observed cranberry juice not coating spoon when dipped indicating it was regular consistency. Asked CNA6 if cranberry juice was thickened, she replied: No, I'll ask the nurse to thicken it. On 02/09/23 at 12:28 PM, observed FM2 assisting R53 with lunch (4 pieces of tuna sushi roll, miso soup, and cranberry juice). R53's repeatedly coughed and Unit Manager (UM) 4 came to the resident to investigate. Conducted an interview with UM4 regarding texture and consistency of R53's lunch. R53's lunch ticket documented the diet texture should be chopped and liquids should be nectar thick. Reviewed the texture of the miso soup and cranberry juice with UM4. UM4 confirmed both items were not nectar thick. UM4 stated there has been issues with receiving the correct consistency of food and liquids from the kitchen. Inquired wit UM4 as to how the facility ensures the residents receive the correct diet and consistency of food and liquids. UM4 stated the kitchen should do a check when preparing the food and the CNAs or staff delivering the meals should also check the food and liquids before giving it to the resident. On 02/10/23 at 12:17 PM, conducted a telephone interview with Registered Dietician (RD) 1. Shared my observations of the texture of solid food and consistency of liquids received by R53 during meals. RD1 confirmed the broccoli and green beans should be cut into half inch pieces for chopped order. Also, the miso soup and cranberry juice should have been nectar thick consistency before it was served to R53. Based on observation, interviews, and record review, the facility failed to ensure residents receive foods in the appropriate form as prescribed by a physician for 2 of 2 residents (Resident (R)28 and R14). As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: Review of the facility's policy and procedure Dietary Services documents All diets shall be meet the nutrient, texture, and fluid needs of each resident. 1) R28 was admitted to the facility with hospice on 12/05/22 with diagnoses that include Alzheimer's disease, dementia, and Parkinson's disease. Review of R28's comprehensive person-centered care plan documented .Provide diet as ordered: Regular diet, chopped texture and thin liquids . Review of R26's dietary order documented Chopped texture was prescribed. On 02/07/23 at 12:34 PM, observed R28 in the dining room, eating lunch, with her personal caregiver (PCG). The mixed vegetables on R28's lunch plate included pieces of whole broccoli and green beans (approximately one inch long). R28's lunch meal ticket documented the texture of the resident's food is chopped. On 02/09/23 at 08:26 AM, conducted an interview with PCG. PCG reported R28 needs more assistance when eating breakfast, but for lunch and dinner the resident is encouraged to eat on her own. PCG reported she needed to cut the vegetables (whole broccoli and one inch long green beans) in half for R28 on 02/07/23 during lunch. On 02/10/23 at 12:17 PM, interview with Registered Dietician (RD)1 via telephone was done. RD1 reported vegetables with more texture should be chopped into half an inch cubes.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected most or all residents

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2) During a group interview with resident council members on 02/09/23 at 10:09 AM, four of four residents sampled (Resident (R) 47, R26, R58, R50) stated they did not know where the most recent survey results were. Based on observations and interviews, the facility failed ensure to post the most recent survey conducted by State surveyors in a place readily assessable to residents, family members and legal representatives of residents. Findings include: 1) On 02/08/23 at 03:17 PM, this surveyor inspected the second-floor nursing unit and was unable to locate the most recent survey results conducted by the State surveyors. Inquired with Unit Manager (UM)1 where the results were located. UM1 stated that if the survey results were available, it would be located in the designated box on the outside of the nursing station. UM2 walked to a medication cart, moved the medication cart and pointed out the survey result box. UM1 confirmed that there were no survey results located in the box and if the results were in the box, residents and resident representatives would not be able to see the results because the medication cart blocked the entire result's box. At 03:20 PM, this surveyor inspected the first-floor unit and was unable to locate the most recent State surveyor's results. Inquired with Nurse (N)8 where the results were located. N8 confirmed the results was not posted and was not readily available to residents or resident representatives. On 02/09/23 at 09:30 AM, this surveyor observed the most recent recertification survey results were posted now posted on both floors. The first-floor results were posted in a clear file holder on top of the nursing station along with the grievance forms and was posted on the second-floor results box that was still blocked by the medication cart. Eventually, the results on the second floor were placed on top of the nursing station.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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2) On 02/07/23 at 12:47 PM, observed broccoli and green beans served to R14 and R53 at bedside for lunch was not cut into half-inch pieces. Both meal tickets taped to meal trays stated that food consistency is chopped. On 02/08/23 at 08:29 AM, observed cranberry juice served to R53 at bedside for breakfast was not thickened. Meal ticket taped to R53's meal tray stated that liquids be nectar thick consistency. On 02/09/23, observed miso soup and cranberry juice served to R53 at the first-floor dining area for lunch was not thickened. On 02/09/23 at 10:19 AM, read memo with the subject Temporary Adjustment of Mealtime Service from Rocky Mountain Care and interim administrator dated 02/03/23 inside elevator. Memo stated that: Due to staffing shortage, mealtimes will be adjusted ., .snacks must be offered if mealtime goes over 14 hrs (hours). Concurrent interview and observation done with Dietary Manager (DM) on 02/13/21 at 11:40 AM while he was preparing meals for lunch in the kitchen. Asked DM what is the process the kitchen staff follow to make sure the food served to the residents are the same as what the diet order is. DM said that the Dietary Aide (DA) would call out diet order on the meal ticket. DM would then plate the meal as it was called out and place it in a tray. The DA would then tape the meal ticket on the tray and place it in the cart that holds all the finished trays that will be brought up to the resident's floor. DM also said that if they had enough staff, another DA would check the food on the trays against the meal ticket before placing it on the cart. This check is not being done since according to the DM, I'm already preparing the plates, I can't be in two places at the same time. Observed schedule posted in the kitchen area for January 29 to February 11, 2023. DM is scheduled to work from 04:30 AM to 01:00 PM for 12 of the 14 days and 04:30 AM to 07:00 PM for the other two days, a total of 14 days straight. DM said he does not get a day off. Based on observations, record review and interviews the facility failed to provide sufficient dietary staff to safely and effectively carry out the functions of food and nutrition services. As A result of this deficiency, there is the potential for more than minimal harm. Findings include: 1) On 02/13/23 at 01:54 PM, Resident (R)28's Family Member (FM)1 reported she was frustrated because breakfast and lunch has frequently arrived to the dining area late. FM1 reported dinner sometimes comes early and sometimes comes late. FM1 also reported the lunch today just came at 01:50 PM, and R28 is a diabetic and it is important for R28 to eat timely, so her blood sugar does not drop.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected most or all residents

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2) On 02/13/23 at 12:32 PM, conducted an interview with Dietary Aide (DA) 4 regarding snacks for residents. DA4 stated kitchen staff only prepare sandwiches for snacks, every other day. On the days kitchen staff are not scheduled to prepare sandwiches, residents receive soda crackers or graham crackers for snack. Based on observations and interviews, the facility failed to provide nourishing snacks at bedtime, for meals more than 14 hours between a substantial evening meal and breakfast the following day. Findings include: Review of the facility's policy and procedure Dietary Services documents Three meals plus a bedtime snack shall be serves at regular intervals with no more than 14 hours between dinner and breakfast. 1) During a group interview with resident council members (Resident (R) 47, R26, R58, R50) on 02/09/23 at 10:09 AM, R58 reported and R26, R47, and R50 concurred, the residents eat dinner at 05:30 PM and breakfast comes late at 08:30 AM and they have not received a snack in between for about a month. The facility will sometimes offer soda crackers or graham crackers, but it is not enough. R58 stated they used to serve sandwiches but that has stopped and reported starting Tuesday or Wednesday they were provided sandwiches again but believe it is because surveyors are here. On 02/13/23 at 10:20 AM, conducted an interview with Certified Nursing Aide (CNA) 6. CNA6 stated she occasionally works the evening shift and residents complain about the snacks because they always get soda cracker or graham cracker and juice.

Nov 2022 14 deficiencies 2 IJ (2 facility-wide)

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policies and procedures, the facility failed to have adequate knowledge of the facility's COVID-19 policies and procedures in order to effectively implement the facility's COVID-19 plan during an outbreak as evidenced by failing to established a facility-wide infection control plan including written infection control standards, policies, and procedures that are current and based on the facility assessment and national standards, failing to notify state authorities of COVID-19 cases in the facility, failing to provide education to staff on COVID-19, proper use of PPE, and hand hygiene and failing to have an infection surveillance plan in place to monitor and evaluate clusters or outbreaks of illness among staff and residents. The deficient practices placed the COVID-19 negative residents at risk for contracting the COVID-19 infection. There were four staff members and 25 residents that tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: Cross Reference to F882, Infection Preventionist. The facility failed to clearly identify an individual responsible for the Infection Preventionist position, failed to ensure that the IP was performing the duties of the position, including an understanding of the facility's COVID-19 policies and procedures. Cross Reference to F886, COVID-19 resident and staff testing. The facility failed to conduct testing in a manner that is consistent with current standards of practice for COVID-19 tests. On [DATE] at 08:30 AM, the Administrator was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. On [DATE], a review of the facility's COVID-19 staff line list (flowsheet that shows who tested positive and date of when they were tested, COVID-19 symptoms if any and onset date, location of place last worked, and whether vaccinated or not) indicated that the following staff had been tested for COVID-19 on the following dates: Certified Nursing Assistant (CNA) 1 on [DATE], CNA2 on [DATE], Licensed Professional Nurse (LPN) 1 on [DATE], and CNA3 on [DATE]. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive A review of resident line listing (flowsheet that shows who tested positive, location of room, COVID-19 symptoms if any with onset date, PCR test results and date collected, and vaccination status) indicated 25 residents were listed as tested positive for COVID-19 from [DATE] to [DATE]. Resident (R) 24 was the first resident that tested positive for COVID-19 on [DATE] for symptoms of sore throat, cough, and increased phlegm. On [DATE] at 12:19 PM, Director of Nursing (DON) and DON2 (DON of the facility's sister facility) were interviewed. DON stated that she is covering for the Infection Preventionist (IP) position and had completed the Centers For Disease Control and Prevention (CDC) modules on infection prevention. DON reported she was not at the facility during the first week of the outbreak due to attending a conference and was on medical leave afterwards. DON stated the outbreak started after the first resident tested positive for COVID-19 on [DATE], R24, who receives dialysis services offsite. DON did not mention any information about staff testing positive prior to R24 testing positive. DON further stated that the facility isolated R24 and tested his roommate who also tested positive. Due to DON not available during the outbreak, DON2 stated that she was asked to come to the facility to assist with the outbreak. DON2 recommended the facility to test all the residents and staff. DON2 stated that the outbreak had started with three staff testing positive for COVID-19. DON2 confirmed four staff members and 25 residents tested positive for COVID-19. DON2 further stated that Resident (R) 10, who was still positive for COVID-19, was found unresponsive and passed away last night ([DATE]). When inquired to see the facility's infection prevention manual, DON stated that Assistant Director of Nursing (ADON) was in the next room printing it and putting it together. On [DATE] at 1:00 PM a subsequent interview was done with DON2. DON2 stated that she had previously worked as the facility's IP, but then transferred to work as the DON at a sister facility in [DATE]. DON2 reported the facility has not had an IP since then. DON2 stated that the Administrator called her on [DATE] to assist with the outbreak at this facility. DON2 reported that when she came to the facility on [DATE], there was no COVID-19 line list for staff and residents, no contact tracing done, and not enough (Personal Protective Equipment) PPE carts on the floor. DON2 further reported it took her a week to gather information on the outbreak. She stated that only the roommates of positive residents had been tested for COVID-19 and staff that had been in contact with R24 had not been tested. A total of nine residents were positive for COVID-19 when she arrived. She stated she then had all staff and residents tested, with 11 other residents testing positive. DON2 stated that she had to create the resident line list for the facility and that the facility does not have their own policies and procedures for COVID-19. DON2 explained that the facility had a general COVID-19 plan from their corporate company, but that the facility should have taken that plan and catered it the needs of their own facility. On [DATE] at 1:50 PM, a concurrent record review and interview was done with ADON. ADON stated that she initially was hired as a shift supervisor on [DATE] and was promoted to ADON on [DATE]. On [DATE], the facility asked her to assume the role of infection preventionist and that she could work under the DON who was IP certified, until ADON was certified herself. During the COVID-19 outbreak, ADON stated that the facility told her that the DON would not be onsite, and that DON2 would be at the facility for two days to assist with the outbreak. Prior to DON2 assisting with the outbreak, ADON stated the facility tested on e resident on [DATE], one resident on [DATE], three residents on [DATE], two residents on [DATE], and two residents on [DATE] for COVID-19, a total of nine residents tested positive for COVID-19. ADON confirmed there was no COVID-19 line listing for staff and residents and that she was not sure if there was mass testing prior to being asked to take on the IP role. ADON stated that on [DATE], she assisted with mass testing. During concurrent review of the facility's policy and procedures, ADON confirmed that the facility's infection prevention policies dated 06/22, were directly from their corporate company. ADON stated that the facility does not have their own infection control policies and that she had received and printed out the policies from their regional director today. ADON confirmed that she was not familiar with these policies and today was the first time she seen them. When inquired about R10, the resident who tested positive for COVID-19 and deceased on [DATE], ADON reviewed R10's medical record and stated that R10 had tested positive for COVID-19 on [DATE]. ADON stated that R10 was supposed to be transferred to another facility for care, but the transfer was delayed due to her contracting COVID-19. ADON stated the other facility would not accept R10 until she was cleared from COVID-19, with a negative test result. ADON stated that on [DATE], R10 was found unresponsive in her room, 911 was called, and R10 was taken to the hospital. ADON stated that R10 could not be revived. Review of R10's Electronic Health Record (EHR) indicated that R10 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, hypertensive heart and chronic kidney disease requiring dialysis. COVID-19 resident line listing stated that R10 tested positive for COVID-19 on [DATE] and that she had symptoms of cough, fatigue, sleeping more, and eating less. Progress note dated [DATE] at 09:30 AM stated Covid antigen swab done [DATE] still positive. Re[s]ults relayed to son at bedside. Resident currently still has slight cough per son but no other symptoms. Progress note dated [DATE] at 04:30 PM stated that at 01:40 PM, R10 resident was on ongoing oxygen support at 2 liters per minute via nasal cannula and had unlabored breathing, sitting at the edge of the bed. When nurse went to room again about 10 minutes later, R10 was found still sitting at the edge of the bed but with her head down. R10 was unresponsive. 911 was called and R10 was taken to the hospital. Progress note dated [DATE] at 8:51 PM stated Follow up condition of resident at KMC-ER. Per ER nurse, resident had Cardiac Arrest, expired at 15:09. ADON informed. On [DATE] at 08:26 AM a second interview with DON was done. Inquired with DON the timeline of the recent COVID-19 outbreak at the facility, DON stated that she was at a conference offsite from [DATE] to [DATE] and while at the conference, she had received a phone text from staff reporting R24 was a presumptive positive and that there were more cases of COVID-19 in the facility. DON stated that she did not actively manage the outbreak while she was at the conference and that she was only in communication with the facility about what was happening. When inquired for documentation of the phone texts DON received from staff, none was provided. DON stated that she did not know the timeline of interventions taken for COVID-19 at the facility. When DON returned to the facility on [DATE], DON stated that she had received a call on [DATE] from the Department of Health (DOH) to follow-up on R24 whom had tested positive for COVID-19. When inquired if the facility informed the DOH of R24 being positive for COVID-19 beforehand, DON stated that she was not sure, and she did not report the positive cases to DOH. DON stated that she was on medical leave thereafter and returned to work on [DATE]. Inquired with DON what responsibilities or role she had as DON for infection control, DON stated that she was in the process of working with the ADON on the facility's infections tracker. DON stated that the DON would be responsible for reporting diseases to the DOH. When inquired what diseases she would report, DON pointed to facility's infection control binder and stated that the information was somewhere in the binder and did not specify what disease she would report. When inquired what she would do if a staff member showed signs and symptoms of COVID-19 today, DON stated that she would have the staff member sent home and tested for COVID-19. When further inquired if there would be any other steps that would be done after staff member was sent home, DON remained silent and stared at surveyor. Surveyor then asked if any contact tracing would be done. DON then stated that they would find who the positive employee worked in close contact with or had any significant exposure to. Inquired what would constitute a close contact or significant exposure, DON looked in the facility's infection control binder for a few minutes for the definition of a significant exposure. Inquired if the facility had done contact tracing for the staff who tested positive on the facility's staff line listing for COVID-19, DON reviewed the staff line listing for COVID-19 and stated that she did not know who created it. DON further stated that she was not sure if there was any documentation showing if there was any follow-up or contact tracing done regarding staff who had tested positive for COVID-19. DON confirmed that the policies and procedures for Infection Control dated 06/22 were received and printed from their corporate company yesterday, [DATE]. DON stated that they store their infection control policies and procedures on the computer and that she hasn't had time to review it. DON reported that these policies and procedures have not been reviewed by the facility's QAPI committee. When further inquired if any staff education or audits had been done regarding PPE use, hand hygiene, and COVID-19, DON was not able to confirm and said that she would look for any documentation. On [DATE] at 10:36 AM, a third interview and concurrent record review was done with DON. DON provided a schedule for [DATE], confirming that there was a conference from [DATE] to [DATE]. DON stated that the DOH called the facility to follow-up on R24 on [DATE] and another call from DOH to the facility was done on [DATE]. The calendar did not indicate that there were phone calls from DOH made on those dates. DON confirmed she did not report to DOH when staff and/or residents were positive for COVID-19 and the DOH was not initially notified by the facility of R24 when tested positive for COVID-19. On [DATE] at 10:48 AM and interview with the Administrator was done. Administrator stated on [DATE] he was notified that there was an outbreak of COVID-19 and that he was out of the facility two weeks prior. Administrator stated that he inquired if DON called the DOH and that the DON reported she had had already spoken to someone. Administrator understood DON was taking the lead on the recent COVID-19 outbreak. Administrator further stated that on [DATE], he received a call from the DOH reporting they received information that the facility had positive COVID-19 residents and they were trying to contact DON. Administrator stated from then he realized DON did not initially call DOH to report COVID-19 positives at the facility and DON was not following-up on the outbreak, but by then DON was out on medical leave. On [DATE] at 11:30 AM DON further confirmed that there was no documentation for audits for compliance with PPE use and hand hygiene, no staff education on PPE use and hand hygiene, and no documentation for staff training on COVID-19. DON also stated that there was no documentation on follow-up contact tracing for staff who had tested positive for COVID-19. On [DATE] at 01:12 PM, a fourth interview and concurrent record review was done with DON regarding R24's EHR, the first resident that test positive for COVID-19 at the facility. DON confirmed that R24 required dialysis services offsite every Monday, Wednesday, and Friday. DON confirmed that progress note dated [DATE] at 2:57 PM stated that resident was tested for COVID-19 due to sore throat and that resident was sent afterwards to his hemodialysis appointment. DON reviewed R24's lab results dated [DATE] at 05:48 AM which stated that R24 was tested for COVID-19 on [DATE] at 2:00 PM, with positive COVID-19 results on [DATE] at 05:48 AM. DON reviewed Dialysis Communication Record dated [DATE] and confirmed that there was no documentation on the record regarding R24 being tested for COVID-19 and that R24 left the facility for dialysis at 3:00 PM. DON stated that the dialysis facility should have been informed of R24 being tested for COVID-19 prior to R24 leaving the facility for dialysis since the dialysis facility does not accept residents who are currently COVID-19 positive. When inquired if there were any policies and procedures regarding residents who required offsite dialysis services but were being tested for COVID-19 or were positive for COVID-19, DON stated that she was not sure. Review of the facility's Infection Prevention and Control Assessment Tool for Long-Term Care Facilities (ICAR), which was conducted by Infection Control Consultant (ICC) from the Disease Outbreak Control Division at the Hawaii State Department of Health on [DATE] in response to an earlier COVID-19 outbreak at the facility. The ICAR included the following discrepancy in the facility's IP program, III. Surveillance and Disease Reporting and IV. Hand Hygiene. The ICAR documents the facility does not have .a written surveillance plan or policy outlining the activities for monitoring/tracking infections occurring in residents of the facility . and .all personnel receive training and competency validation on HH [Hand Hygiene] at the time of employment and within the past 12 months. It was recommended for the facility to Include Hand Hygiene in orientation.

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0882 (Tag F0882)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to properly prevent and contain COVID-19 as evidenced by failing to clearly identify an individual responsible for the Infection Preventionist (IP) position, failing to ensure that the IP was performing the duties of the position and demonstrated understanding of the facility's COVID-19 policies and procedures. The deficient practice puts all residents at risk of infection diseases, including COVID-19. Four staff and 25 residents tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: Cross Reference to F880, Infection Prevention and Control. The facility failed to have adequate knowledge of the facility's COVID-19 policies and procedures in order to effectively implement the facility's COVID-19 plan during an outbreak as evidenced by failing to establish a facility-wide infection control plan including written infection control standards, policies, and procedures that are current and based on the facility assessment and national standards, failing to notify state authorities of COVID-19 cases in the facility, failing to provide education to staff on COVID-19, proper use of PPE, and hand hygiene and failing to have an infection surveillance plan in place to monitor and evaluate clusters or outbreaks of illness among staff and residents. Cross Reference to F883, Influenza and Pneumococcal Immunization. The facility failed to offer updated influenza and pneumococcal immunizations to four residents. The facility's policy and procedures document the IP responsible for ensuring the pneumococcal vaccination was given or offered to residents and documented. On [DATE] at 08:30 AM, the Administrator was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. On [DATE], a review of the facility's COVID-19 staff line list (flowsheet that shows who tested positive and date of when they were tested, COVID-19 symptoms if any and onset date, location of place last worked, and whether vaccinated or not) indicated that the following staff had been tested for COVID-19 on the following dates: Certified Nursing Assistant (CNA) 1 on [DATE], CNA2 on [DATE], Licensed Professional Nurse (LPN) 1 on [DATE], and CNA3 on [DATE]. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive A review of resident line listing (flowsheet that shows who tested positive, location of room, COVID-19 symptoms if any with onset date, PCR test results and date collected, and vaccination status) indicated 25 residents were listed as tested positive for COVID-19 from [DATE] to [DATE]. Resident (R) 24 was the first resident that tested positive for COVID-19 on [DATE] for symptoms of sore throat, cough, and increased phlegm. On [DATE] at 12:19 PM, Director of Nursing (DON) and DON2 (DON of the facility's sister facility) were interviewed. During this interview, DON stated the facility does not have a dedicated Infection Preventionist (IP) position but has completed the Center for Disease Control and Prevention (CDC) modules on infection prevention and is covering for now. DON further stated the Assistant Director of Nursing (ADON) will eventually be taking on the role of IP and is in training to be a certified IP. DON reported she was not at the facility during the first week of the outbreak due to attending a conference and was on medical leave afterwards, returned to work on [DATE]. Due to DON not available during the outbreak, DON2 stated that she was asked to come to the facility to assist with the outbreak. DON2 confirmed 4 staff and 25 residents total tested positive for COVID-19 and a resident, R10, who was still positive for COVID-19, was found unresponsive and passed away last night ([DATE]). When inquired to see the facility's infection prevention manual, DON stated that ADON was in the next room printing it and putting it together. On [DATE] at 1:00 PM a subsequent interview with DON2 was done. DON2 stated that she had previously worked as the facility's IP, but then transferred to work as the DON at a sister facility in [DATE]. DON2 stated that the facility has not had an IP since then. DON2 reported that the current ADON was hired recently and was not IP certified and the DON was never supposed to be the IP. DON2 further reported during an assessment done by an Infection Control Consultant (ICC) from the Disease Outbreak and Control Division at the Hawaii State Department of Health in the summer, the DON informed the ICC she was not going to be the IP. DON2 stated that the Administrator called her on [DATE] to assist with the outbreak at this facility. DON2 reported that when she came to the facility on [DATE], the facility did not implement the facility's COVID-19 plan due to not developing a facility COVID-19 plan and/or policy and procedures to prevent and control the COVID-19 outbreak. On [DATE] at 1:50 PM, a concurrent record review and interview was done with ADON. ADON stated that on [DATE], the facility asked her to assume the role of infection preventionist and that she could work under the DON who was IP certified, until ADON was certified herself. ADON reviewed and confirmed that the facility's infection prevention policies dated 06/22, were directly from their corporate company. ADON stated that she was not familiar with the facility's infection prevention policies, and they were printed today. On [DATE] at 08:00 AM, a record review was done of the facility's Infection Prevention and Control Assessment Tool for Long-Term Care Facilities (ICAR), which was conducted by an ICC from the Disease Outbreak and Control Division at the Hawaii State Department of Health on [DATE] in response to an earlier COVID-19 outbreak at the facility. The ICAR stated the following discrepancy in the facility's IP program for I. Infection Control Program and Infrastructure .Elements to be assessed: A. The facility has specified person (e.g. staff, consultant) who is responsible for coordinating the IC program .Assessment: Yes .Notes/areas for improvement: Need an IP On [DATE] at 08:26 AM, a second interview and concurrent interview was done with the DON. Inquired about the facility's ICAR and DON stated that she had informed ICC and Administrator that it was not realistic for herself to be both the IP and DON at the facility. DON stated that she has worked at the facility as the DON since [DATE]. DON stated that the facility previously had an IP consultant, but the contract had ended. DON stated that she was qualified to be an IP and that the facility was currently in the process of having the ADON become IP certified and assume the role of IP. DON confirmed the facility does not currently have a staff member in the IP position and reiterated she was clear with Administrator she cannot take on the role. When inquired what responsibilities DON had for infection control, DON stated that she was in the process of working with the ADON on the facility's infections tracker and would be responsible for reporting diseases to the state department of health. When inquired what diseases she would report, DON pointed to facility's infection control binder and stated that the information was somewhere in the binder and did not provide surveyor diseases she would report. DON stated the facility did not have COVID-19 policies in place when she started working at the facility. DON confirmed that the facility's infection prevention policies dated 06/22, were directly from their corporate company and were printed yesterday, [DATE]. DON stated that she has not read and is not familiar with the facility's infection prevention policies because they are stored in the computer and has not had time to review it. Due to the facility not having a dedicated IP, DON reported no one can speak into the policies and the policies have not been reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) committee. On [DATE] at 10:48 AM, Administrator was interviewed. Administrator stated that the DON was hired in [DATE] and that the facility did not have an IP at that time. When inquired who the facility's IP was, Administrator stated the DON was certified to be an IP and the ADON is in training to be the facility's IP under DON. Clarified with Administrator if DON agreed to take on the role as IP, Administrator stated that DON was responsible for making sure that all the infection control policies were followed, and that DON was responsible for delegating the IP role as necessary. During the most recent COVID-19 outbreak, Administrator stated he initiated the placement of a new IP who was the ADON, although the ADON was not certified. Administrator stated that DON2 from their sister facility assisted ADON during the outbreak. On [DATE] at 12:00 PM, a review of an e-mail dated [DATE], Re: Liliha IP support and leadership during outbreak, Administrator responded to the ICC , Thank you for working with [name of DON2] while [name of DON] was out unexpectedly due to an acute health concern (return undetermined). As [name of DON2] is the DON at [sister facility's name], our sister facility, she cannot provide the required 20 hours of support for IP activities. She will be providing direct and remote support to our new ADON/IP [name of ADON], RN, going forward. [Name of ADON] is not IP certified. However, [name of DON2 and name of regional consultant], RN, our Regional Nurse Consultant, will also be supporting [name of ADON] in her transition and to bring this outbreak to a speedy conclusion. Review of the facility's job description for Infection Preventionist documented the position purpose, Develops, implements, and maintains a facility-wide infection prevention and control program. Duties and responsibilities in the job description include but is not limited to: Develops and implements an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable enviroment. Establish facility-wide systems for prevention, identification, reporting, investigation, and control of infections and communicable disease of residents, staff, and visitors. Develops and implements written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevent and control .Leads the facility's Infection and Prevention Control Committee. Develops actions plans to address opportunities for improvement .Reviews and/or revises the facility's infections prevention and control program, its standards, policies, and procedures annually and as needed for changes to the facility assessment to ensure they are effective and in accordance with current standards of practice for preventing and controlling infections. Provides educations related to infection preventions and control principles, policies, and procedures to staff, residents, and families .Ensure public health is notified of reportable diseases .maintains documentation of infection prevention and control program activities.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0726 (Tag F0726)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff members and record review the facility failed to demonstrate that all nursing staff possessed the competencies and skill set necessary to identify a change in condition and provide nursing and related services to meet the needs of one of three residents (Resident (R)5) sampled to maintain her highest practicable physical well-being. Nursing staff failed to document they report to the physician that R5 had a trend of hypotensive (low blood pressure) episodes. On [DATE], R5 fell and was diagnosed with a fractured right (R) hip, nursing staffs' initial and ongoing assessments while R5 remained in the facility (over eight hours) until non emergent transfer to the Emergency Department, failed to include assessment of the skin or pulse of the affected extremity. At the time of transfer, R5 was assessed to have diminished pulse of the extremity and it was cold to touch. R5 expired at the hospital prior to going to surgery. The lack of nursing skill set to properly assess and respond to R5's needs and delay in transfer resulted in harm and may have contributed to her death. Findings include: The Office of Healthcare Assurance received the initial Facility Incident Report (ACTS # 9868) that R5 fell on [DATE]. An updated report included the following: Resident assessed at the time of fall with resident complaint of Right side hip/low back pain. resident assisted [sic] back to bed with 1:1 supervision while awaiting Mobile imaging services. Images revealed R Hip fracture(fx). Orders given to send resident to ER for further evaluation and treatment. Update: Resident expired at acute hospital before going into operating room for hip surgery. R5 was a [AGE] year old female who had lived at the facility since [DATE]. Her pertinent medical history included Alzheimer's, hypertension, age related physical debility, Type 2 diabetes, insomnia, gastro-espohageal reflux, muscle weakness, dysphasia, and unsteadiness on feet. R5 used a front wheel walker (FWW) and frequently ambulated the halls. She was on losartan 25 milligrams (mg) and metoprolol 100 mg once a day for high blood pressure. The medication order for these two medications included criteria to hold the medication if R5s blood pressure was less than 100 systolic (top number) blood pressure. Review of R5's Records revealed the following: [DATE] Physician (MD)1's Progress note documented: ongoing significant weakness. Medication Administration Record (MAR) revealed R5 had her two blood pressure medications (losartan and metoprolol) held four out of nine days during the time period of [DATE] through [DATE] for low blood pressure. There was no documentation of repeat blood pressure, assessment if R5 was symptomatic, or notification of the trend to the physician. [DATE]: BP [blood pressure] 95/53, Not administered: On hold [DATE]: BP 99/55, Not administered: On hold [DATE]: BP 93/57, Not administered: On hold [DATE]: BP 96/60, Not administered: On hold Time frame of pertinent events related to R5's fall on [DATE]: [DATE], 02:55 PM Nursing notes: Witnessed fall from standing position while using FWW. Did not hit head.restless after fall .1:1 supervision. [DATE], 03:45 PM Nursing note: vomited 1x; lab and x-rays ordered. Medication given for nausea/vomiting. [DATE], 03: 26-03:45 PM Nursing note: ETA (estimated time of arrival) imaging 05:00 PM. [DATE], 07:30 PM Nursing note: x-rays done [DATE], 08:30 PM Radiology report signed with impression: acute right hip fracture. It is unknown what time the facility received the report. [DATE], 09:25 PM Nursing note: Notified MD1 of x-ray result. Ordered transfer to the Emergency Department. [DATE], 11:30 PM Nursing note: Scheduled transport with . ETA 11:30 PM [DATE], 11:50 PM Nursing note: Right LE (lower extremity) appears pale, cold, clammy to touch, diminished pedal pulses ., ambulance came in at 11:35 PM, Left facility at around 11:50 PM. [DATE] ([DATE] PM 07:29 PM Recorded as late entry) by MD1: D/C (discharge) --FELL R HIP PAINS= = R HIP FRACTURE/N/V LATER = = TO ER ASAP X-rays were not done in a timely manner, the results of the x-rays were not provided to the MD1 in a timely manner and the transfer to the hospital was not done in a timely manner. On [DATE] at 01:00 PM, during an interview with Registered Nurse (RN)1, inquired what the practice was if a blood pressure medication was held due to low blood pressure outside the physicians defined parameter. She said they are supposed to recheck the BP, document the second reading, and if way high or low, would notify the physician. RN1 went on to say that some residents are asymptomatic even if their blood pressure is low, but if it continues .to be low daily, at least two to three days, would usually call the physician, and document it in the progress notes. RN1 further stated they (RNs) just follow the parameters identified by the physician. RN1 was assigned R5 the day of the fall. She said R5 spoke Korean, and uses mostly gestures to communicate. Her baseline is oriented to self only. RN1 said she assessed R5 after the fall and did not see any signs of fx. She checked her vitals, called the physician, gave Tylenol for pain and got an order for X-rays. RN1 said about 20-30 minutes later, R5 vomited one time. She then got an order for an oral antiemetic (for nausea and vomiting) and abdominal x-rays. RN1 said when she called for the X-rays and was told they would come at 05:00 PM. RN1 stated R5 kept wanting to stand, so had a CNA (certified nurse assistant) watching her the whole time. RN1 said when she left R5 was still sitting on the edge of the bed. When RN1 was informed R5 did not leave the facility until 11:50 PM, she said that's too long. She said she had heard her coworker was only able to notice everything when R5 was on the gurney lying down. On [DATE] at 03:10 PM, during an interview with RN2, she said she notified MD1 of P5's x-ray results. Inquired with RN2 what kind of monitoring and assessments should be done after a similar fall, RN2 stated they would monitor level of consciousness, vitals signs, assess for pain, bruising and limitation of movement. RN2 said they usually have a vendor come to the facility to do x-rays for this type of injury, who provides ETA (Estimated Time of Arrival). RN2 stated it often takes four to five hours, sometimes even seven, and then it takes one to two hours to get the results. When inquired how it was determined to transfer a resident by 911, or nonemergent ambulance, RN2 said it depends on our assessment and vital signs. RN2 said the physician will sometimes say it is OK to transfer via non emergent ambulance, depending on residents condition. She said R5 was hard to assess because she wouldn't lay down. RN2 said after X-rays are taken, they have to keep checking to see if the report has been sent. She said when she got the results, she called MD1 with the report and asked to transfer R5 to the hospital. RN2 reported the doctor said she could call the nonemergency ambulance. RN2 stated R5 had been sitting at the time, vitals were OK, and she was moving a lot in bed. RN2 said they had the LPN (licensed practical nurse) stay with R5 the entire time. She went on to say when getting ready to transfer her, R5 was able to lay down. At that time, she said she was able to check her, and the leg looked pale, was cold and moist with a weak pulse. RN2 said she checked the color of her leg and touched it earlier, but didn't document it. Inquired if RN2 notified MD1 of R5's condition at the time she left the facility, and she replied I'm not sure. There was no documentation RN2 notified MD1 of this change in condition in the medical record. Inquired if RN2 would notify the physician if a medication was held when the BP was outside the parameters identified in the MD order, RN2 stated she would not. RN2 stated the MD can see the vitals in the MAR. RN2 further stated if it happened several days in a row, we would usually update the doctor, and ask if they wanted to reduce the medication. On [DATE] at 02:30 PM concurrent record review and interview with Assistant Director of Nursing (ADON) was done. Inquired what should be included in the initial and ongoing assessments when a resident falls and diagnosed with a hip fx. ADON stated she would expect to see documentation of a head to toe assessment, neurological status, skin issues, notable different leg lengths, and vitals. Asked if they should document pulses and temperature of skin of the extremity, and the ADON said, Of course. ADON stated the staff should use 911 for transport of hip fractures as it would be considered a medical emergency. Concurrent review of R5's MAR with ADON, ADON validated R5's blood pressure medication had been held several times and said she would expect the staff to notify the MD in this situation. Review of the facility policy titled Notification of Changes last reviewed on 07/2021 included the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician . when there is a change requiring notification. Circumstances requiring notification include: 2. significant change in the resident's physical, metal or psychosocial condition such as deterioration in health, .That may include: a. life-threatening conditions, or b. Clinical complications. 3. Circumstances that require or may need to alter treatment. This may include .b. Discontinuation of current treatment due to: i. Adverse consequences. ii Acute condition. iii. Exacerbation of a chronic condition.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members the facility failed to dispose four medications (three of the four medications were controlled drugs) from discharged residents and reconcile one controlled drug that was missing of the three controlled drugs. Findings Include: On 01/05/23 at 10:35 AM received a sealed yellow letter envelope addressed to State Agency (SA) containing an anonymous letter. The letter stated that there are unlocked narcotics in the Director of Nursing (DON) office. On 01/05/23 at 12:56 PM inquired with Registered Nurse (RN) 1 for a tour of the DON office. RN1 reported that the facility currently does not have a DON and nursing staff will sometimes use the office. Upon entering the DON office, RN19 was observed sitting behind the DON desk. Inquired with RN19 how the facility disposes narcotics and RN19 reported the incident of found medications in the DON office today, 01/05/23. RN19 reported she was looking for a charging cable in the DON office and looked in the closet. RN19 reported the closet was unlocked and cannot be locked. In the closet, RN19 found four Controlled Drug Record (CDR) forms with discharged residents names (Resident (R) 94, R63 and R32), the medication name, prescription information, and medication quantity. RN19 reported she only found three of the medications identified on the four CDR forms found and one medication is missing. RN19 confirmed the medication missing was a controlled drug, tramadol, a total of 56 pills ordered for R94. RN19 reported the three found medications, tramadol, morphine sulfate, and lorazepam in the closet were reconciled and disposed by her and RN8 after discovering the medications. On 01/05/23 at 02:04 PM interview with RN1 was done. RN1 stated it is concerning that R94's 56 ordered tramadol tablets were discovered missing. On 01/05/23 at 03:00 PM a second interview with RN19 was done. RN19 reported after she discovered the medications in the closet she informed RN1 and was directed to seek direction from a senior nurse. RN19 reported she sought RN8 and they crushed the medications, dissolved the crushed medications and liquid medication with water into depends and disposed them in the biohazard bin. RN19 reported RN8 and her signed off on the disposals. RN19 stated the medications should have been disposed of upon the residents' discharge if the physician discontinued the medication or should have went with the residents' if the medications continued to be ordered by the physician. RN19 stated the missing tramadol was discontinued so it did not go home with R94. RN19 reported she checked the medication disposal log with RN8 and there was no mention of R94's tramadol. During record review, the four CDR forms revealed the facility received medications for R94, R63, and R32. R94's CDR form documented the facility received 56 tablets of the controlled drug tramadol on 03/03/22. R94 was discharged home on [DATE] and tramadol was discontinued on 03/29/22 due to it not being used. R63's CDR forms documented the facility received 120 milligrams (mg) of the controlled drug morphine sulfate received on 09/03/21 and 30 tablets of controlled drug lorazepam (unable to read date received). R63 was discharged on 03/31/22 to hospice level of care. R32's CDR form documents the facility received 56 tablets of the controlled drug tramadol with no received date and four of 56 tablets were administered. R32 was transferred to the emergency room for pneumonia and pulmonary embolism on 03/27/22. Review of the facility's policy and procedure Destroying Medications last reviewed on 02/12/19 documents Medications not qualifying for return to the issuing pharmacy (i.e., [that is] non-unit dose medications, medications refused by resident, and/or medications left by residents upon discharge) shall be destroyed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to store all drugs in locked compartments and keep a Schedule II controlled drug in a separately locked, permanently affixed compartment. Findings Include: Cross to F755. The facility failed to dispose four controlled drugs from discharged residents and reconcile one drug that was missing of the four controlled drugs. On 01/05/23 at 12:56 PM inquired with Registered Nurse (RN) 1 for a tour of the DON office. RN1 reported that the facility currently does not have a DON and nursing staff will sometimes use the office. Upon entering the DON office, RN19 was observed sitting behind the DON desk. RN19 reported an incident of found medications in the DON office today, 01/05/23. RN19 reported she was looking for a charging cable in the DON office and looked in the closet. RN19 reported the closet was unlocked and cannot be locked. In the closet on a shelf, RN19 found four Controlled Drug Record (CDR) forms with discharged residents names (Resident (R) 94, R63 and R32), medication name, prescription information, and medication quantity. RN19 reported she only found three of the medications, tramadol for R32 and lorazepam and sulfate morphine (a Schedule II controlled drug) for R63, identified on the four CDR forms found. RN19 stated R94's 56 tablets of tramadol received by the facility was missing. On 01/05/23 at 02:04 PM interview with RN1 was done. RN1 reported the DON's office is not kept locked because the nursing staff use it during the day, evening, and night shift. On 01/05/23 at 03:00 PM a second interview with RN19 was done. RN19 confirmed the closet where the medications were found has a latch to close it but does not have a lock. RN19 further confirmed the office has been unlocked the last few weeks because no one knows where the office key went. Review of the facility's policy and procedure Medication Storage in the Facility last reviewed on 02/12/19 documents Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized are allowed to access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access .Except for those requiring refrigeration, medications are intended for internal use are stored in a medication cart or other designated area .Schedule II controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member the facility failed to ensure two of seven residents (Resident (R) 11 and R27) sampled for immunizations were offered and/or received the primary series of the COVID-19 vaccine. Findings Include: On 11/15/22, upon review of the facility's Electronic Health Record (EHR) for immunizations; 1) R11, a [AGE] year old male, was admitted to the facility on [DATE]. Review of R11 's record found no documentation R11 received the primary series of the COVID-19 vaccine but received the COVID-19 booster on 09/28/22. 2) R27, a [AGE] year old female, was admitted to the facility on [DATE]. Review of R27 's record found no documentation R27 received the primary series of the COVID-19 vaccine. R27's record did not include if the facility offered, if the resident or resident representative refused, or did not receive the the primary series of COVID-19 vaccine due to medical contradictions. On 11/15/22 at 03:12 PM Director of Nursing (DON) confirmed there is no documentation that residents R11 and R27 were offered the COVID-19 vaccine. Review of the facility's policy and procedure COVID-19 Resident Vaccination reviewed/revised on 06/22, defines primary series as 2-dose series of an mRNA [Messenger RNA] COVID-19 vaccine (Pfizer-BioNTech and Moderna) or a single does of [NAME] COVID-19 vaccine, for people who are moderately to severely immunocompromised, a 3-does serious of an mRNA COVID-19 vaccine or single does of [NAME] COVID-19 vaccine. The policy and procedure documents 10. COVID-19 vaccinations will be offered to resident when supplies are available, as per CDC [Centers for Disease Control and Prevention] and and/or FDA [Food and Drug Administration] guidelines unless such immunization is medically contradicted, the individual has already been immunized during this time period, or refuse to receive the vaccine .20. The resident's medical record will include documentation of the following: .b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccination due to medical contradiction or refusal.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R6 was [AGE] year old female with Type 2 diabetes, hypertension, and history of intracranial hemorrhage. She was transferred to a hospital on [DATE] after a change in condition by Emergency Medical Services (911), where she was admitted with a diagnosis of acute kidney injury (AKI, is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). On 01/05/2023 at 02:29 PM, during an interview with RN2 she said when she transfers a resident to the hospital, she gives a verbal report to the receiving facility which would include the latest vitals and reason for transfer. She said she not aware of the need to complete an event report or send any additional documentation/information to the receiving facility. RN2 confirmed she did not complete an SBAR form. Based on record review and interview with staff members, the facility did not assure documentation communicating a resident's status (i.e. contact information of the practitioner, resident representative information including contact information, advance healthcare directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals) to ensure a safe and effective transition of care was provided to the receiving health care institution for two Residents (R) 5 and R6 of four residents reviewed. Findings include: 1 ) Cross Reference to F726: Competent Nursing Staff. The facility did not ensure a resident's physician was notified of a change in health status to assure proper treatment and follow-up was done. Resident (R)5 was transferred to an acute hospital for medical evaluation on 12/13/22 due to oxygen desaturation and shortness of breath. Review of the medical record found no transfer summary. On 01/04/23 at 04:17 PM interviewed Registered Nurse (RN)1. RN1 reported the facility uses an SBAR (Situation Background Assessment Report) to communicate with physician and emergency responders to notify them of the resident's current status. RN1 confirmed there is no documentation in the electronic health record an SBAR was completed. On 01/05/23 at 02:35 PM an interview was conducted with RN2. RN2 prepared R5 for transfer to acute hospital. RN2 reported verbal information is provided to the emergency responders.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member the facility failed to offer updated influenza and pneumococcal immunizations to four of seven residents (Resident (R) 24, R11, R35, and R27) sampled for immunizations. Findings Include: On 11/15/22, upon review of the facility's Electronic Health Record (EHR) for immunizations; 1) R24, a [AGE] year old male, was admitted to the facility on [DATE]. Review of R24's record documented his last influenza immunization on 09/23/21 and no documentation for pneumococcal immunization. R24's record did not include if the facility offered, if the resident or resident representative refused, or did not receive the annual influenza or the pneumococcal immunizations due to medical contradictions. 2) R11, a [AGE] year old male, was admitted to the facility on [DATE]. Review of R11 's record found no documentation for influenza and pneumococcal immunizations. R11's record did not include if the facility offered, if the resident or resident representative refused, or did not receive the annual influenza or the pneumococcal immunizations due to medical contradictions. 3) R35, a [AGE] year old female, was admitted to the facility on [DATE]. Review of R35's record documented her last influenza immunization on 02/22/2018 and pneumococcal immunization (PCV13-Pneumococcal conjugate, unspecified formula) was given in 2015 outside of the facility. R35's record did not include if the facility offered, if the resident or resident representative refused, or did not receive the annual influenza or an additionl pneumococcal immunization due to medical contradictions. The Center of Disease Contol Pneumococcal Vaccine Timing for Adults, dated 04/01/2022 recommends one dose of PPSV23 at least one year after PCV13 was recieved. 4) R27, a [AGE] year old female, was admitted to the facility on [DATE]. Review of R27 's record found no documentation for influenza and pneumococcal immunization. R27's record did not include if the facility offered, if the resident or resident representative refused, or did not receive the annual influenza or the pneumococcal immunizations due to medical contradictions. On 11/15/22 at 03:12 PM Director of Nursing (DON) confirmed residents R24, R11, R35, and R27 were not offered influenza and pneumococcal immunizations. DON stated the facility follows current Centers of Disease Control and Prevention (CDC) guidelines for pneumococcal immunizations, but was unable to verbalize what they were. Review of the facility's policy and procedure Pneumococcal Vaccinations policy number 6050 documents All residents are provided the opportunity and encouraged to receive pneumococcal vaccinations. The procedure includes The Infection Control Nurse and admitting nurse are responsible to research the medical record and history to determine if the pneumococcal vaccination have ever been given and to maintain file and record the vaccination date. Review of the facility's policy and procedure Influenza Vaccinations policy number 6034 documents Residents are protected from influenza virus by receiving the vaccine annually.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct testing in a manner that is consistent with current standards of practice for COVID-19 tests. As a result of this deficiency, 4 staff and 25 residents tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: On [DATE] at 08:30 AM, Facility Administrator (FA) was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. On [DATE], a review of the facility's COVID-19 staff line list and resident line list indicated four staff members and 25 residents (from [DATE] to [DATE]) tested positive for COVID-19. The following staff tested positive for COVID-19, Certified Nursing Assistant (CNA) 1 on [DATE], CNA2 on [DATE], Licensed Professional Nurse (LPN) 1 on [DATE], and CNA3 on [DATE]. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive. Resident (R) 24 was tested for COVID-19 on [DATE] for symptoms of sore throat, cough, and increased phlegm and was the 1st resident that had tested positive for COVID-19 in the facility. A review of R24's lab results showed that R24 was tested for COVID-19 on [DATE] and had results positive for COVID-19 on [DATE] at 05:48 AM. On [DATE] at 12:19 PM, Director of Nursing (DON) and DON2 (DON of facility's sister facility) was interviewed. DON confirmed that R24 was the first resident that tested positive for COVID-19 on [DATE]. DON stated that the outbreak started with R24 who receives dialysis services offsite. DON did not mention any information about staff testing positive before R24 tested positive. DON stated that they isolated R24 and tested his roommate who was also positive. DON stated that she was not at the facility during the first week of the outbreak due to attending a conference and then was on medical leave afterwards. Due to DON not available during the outbreak, DON2 stated that she was asked to come to the facility to assist with the outbreak. DON2 recommended the facility to test all the residents and staff. DON2 stated that the outbreak had started with three staff testing positive for COVID-19. DON2 confirmed four staff members and 25 residents tested positive for COVID-19. And one resident (R10), continued to test positive for COVID-19, deceased on [DATE]. On [DATE] at 1:00 PM, DON2 was interviewed. DON2 stated that she had previously worked as the facility's IP, but then transferred to work as the DON at a sister facility in [DATE]. DON2 stated that she had been called by Administrator on [DATE] to assist with the outbreak at this facility. DON2 reported that when she came to the facility on [DATE], only positive COVID-19 residents' and their roommates had been tested for COVID-19 and staff that had been in contact with the residents had not been tested. A total of nine residents were positive for COVID-19. She stated she then had all staff and residents tested and found 11 other residents testing positive. DON2 stated that she had to create the resident line list for the facility because they were not keeping track of the COVID-19 positive cases. On [DATE] at 1:50 PM, a concurrent record review and interview was done with ADON. ADON reported that the facility tested on e resident on [DATE], one resident on [DATE], three residents on [DATE], two residents on [DATE], and two residents on [DATE] for COVID-19. ADON stated that on [DATE], she assisted with testing all staff and resident for COVID-19. ADON confirmed there was no COVID-19 line listing for staff and residents and that the facility wasn't sure if there was mass testing prior to [DATE]. When inquired about R10, ADON reviewed R10's medical record and stated that R10 had tested positive for COVID-19 on [DATE]. ADON stated that R10 was supposed to be transferred to another facility for care, but the transfer was delayed to her contracting COVID-19. ADON stated the facility would not accept R10 until she was cleared from COVID-19. ADON stated that on [DATE], R10 was found unresponsive in her room, 911 was called, and R10 was taken to the hospital. ADON stated that R10 could not be revived. Further record review of R10 indicated that R10 was admitted to the facility on [DATE]. R10's diagnoses included chronic respiratory failure, hypertensive heart and chronic kidney disease requiring dialysis. COVID-19 Resident line listing stated that R10 tested positive for COVID-19 on [DATE] and that she had symptoms of cough, fatigue, sleeping more, and eating less. Progress note dated [DATE] at 09:30 AM documented Covid antigen swab done [DATE] still positive. Re[s]ults relayed to son at bedside. Resident currently still has slight cough per son but no other symptoms. Progress note dated [DATE] at 04:30 PM documented that at 01:40 PM, R10 resident was on ongoing oxygen support at 2 liters per minute via nasal cannula and unlabored breathing, sitting at the edge of the bed. When nurse went to room again about 10 minutes later, R10 was found still sitting at the edge of the bed but with her head down. R10 was unresponsive. 911 was called and R10 was taken to the hospital. Progress note dated [DATE] at 8:51 PM documented Follow up condition of resident at KMC-ER. Per ER nurse, resident had Cardiac Arrest, expired at 15:09. ADON informed. On [DATE] at 08:26 AM, a second interview and concurrent record review was done with the DON. When inquired about what she would do if a staff member showed signs and symptoms of COVID-19 today, DON stated that she would have the staff member sent home and tested for COVID-19. When inquired if there would be any other steps that would be done after staff member was sent home, DON remained silent and stared at surveyor. Surveyor then asked if any contact tracing would be done. DON then stated that they would find who the positive employee worked in close contact with or had any significant exposure to. When asked what would constitute a close contact or significant exposure, DON had to look in the facility's infection control binder for a few minutes to find the definition of a significant exposure. DON reviewed the staff line listing for COVID-19 and stated that she did not know who created it. DON stated that she was not sure if there was any documentation showing if there was any follow-up or contact tracing done regarding staff who had tested positive for COVID-19. On [DATE] at 11:30 AM, DON stated there was no documentation on follow-up contact tracing for staff who had tested positive for COVID-19. On [DATE] at 3:00 PM, review of facility policy Coronavirus Testing #6074 revised 06/22 stated Testing of Staff and Residents with COVID-19 Symptoms or Signs: 4. Residents who have signs or symptoms of COVID-19, regardless of vaccinations status, will be tested immediately and will be placed on transmission-based precautions in accordance with CDC guidance pending test results. Once test results are obtained, the facility will take the appropriate actions based on the results .Testing of Staff and Residents in response to an outbreak: 2. Upon identification of a single new case of COIVD-19 infection in any staff or residents, testing will begin immediately.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on interviews and an email sent to the State Agency (SA) the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis. Findings Include: On 12/05/22 at 02:35 PM an email was sent to the SA stating effective 12/05/22, Registered Nurse (RN) 4 currently in the DON position has stepped down from the DON position. During the Entrance Conference on 01/04/23 at 08:49 AM with RN1 and Governing Body Board Member (GBM) 1, RN1 stated the facility currently does not have a full time DON and is interviewing for the position. On 01/05/23 at 10:06 AM interview with the facility's management company Chief People Officer (CPO) and Chief Business Development Officer (CBDO). CPO described her position as the head of human resources and CBDO described his position as marketing and acquisition for the management company which manages the facility. CPO stated she is directly involved in hiring the Administrator and DON and CBDO is involved in the hiring process to ensure the hired Administrator and/or DON is able to represent the management company in the community. CPO stated at the end of November the DON was terminated and RN4 was promoted to the DON position but stepped down from the position on 12/19/22. CPO confirmed since RN4 stepped down from the DON position the facility has not had a full time DON.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members the administration (administrator, governing body, and management company) failed to effectively and efficiently provide support to the facility and staff members to ensure residents attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility failed to ensure all areas of the facility's Plan of Correction (POC) was corrected and/or worked toward compliance by the corrective action date the facility chose, 12/27/22, and the Directed Plan of Correction (DPOC) was completed by 12/28/22. Findings Include: 1) On 11/30/22 the State Agency (SA) sent a letter to the facility Re: COVID-19 Survey on November 15, 2022 the letter included the purpose of the survey that was conducted on 11/15/22, remedies, and information on the required POC, Informal Dispute Resolution (IDR) and Appeal Rights. As part of the remedies documented, the facility was to complete the DPOC consisting of seven items to be completed by 12/28/22. The seven items included: (1) All staff must view the training videos and the facility shall submit attendance sheets on: * COVID-19 Prevention PPE [Personal Protective Equipment] Use . * Closely Monitor Reisndet [sic] for COVID-19 . * Keep COVID-19 Out! . (2) Utilize online infection prevention training courses such as hand hygiene and glove use found in QSO 19-10 NH dated 03/11/2019, specifically, Module 5 Outbreaks, Module 6B Principles of Transmission-Based Precautions, and Module 7 Hand Hygiene. Training shall be provided by the Director of Nursing, Infection Preventionist, Medical Director, or other facility training coordinator; (3) Immediately implement an appropriate infection prevention and intervention plan which includes the Root Cause Analysis (RCA) for the affected resident(s) identified in the deficiency and consistent with the requirements of 42 CFR §483.30. The RCA will be conducted with assistance from the Infection Preventionist, Quality Assurance and Performance Improvement (QAPI) committee and Governing Body. The RCA should be incorporated into the intervention plan. Information regarding RCA can be found at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceforRCA.pdf; (4) The facility shall submit the credentials of the Infection Preventionist to .[SA]; (5) Hire or contract with an infection control consultant or manager. If the consultant hired is an Infection Control Nurse (ICN)/Infection Preventionist, the ICN must have completed specialized training in infection prevention and control. The ICN will be at the facility for a minimum of six months. Further, the contract will be pre-approved in writing by OHCA within 15 days of receipt of your plan of correction; (6) The Infection Preventionist shall assist the Medical Director, Regional Nurse Consultant (RNC), and Regional [NAME] President (RVP) to complete the LTC infection control self-assessment. If this assessment was completed prior to the citation of harm and IJ [immediate jeopardy], the assessment should be reviewed to determine if it is a true and accurate reflection of the nursing home; (7) Submit all above training records to the .[SA] .by December 28, 2022. From 12/28/22 to 01/03/23 the facility did not submit training records or supporting documents for the DPOC or request an extension from the SA. On 01/03/23 at 09:00 AM a phone interview was made to the administrator regarding the training records and supporting documents for the DPOC that was due on 12/28/22. Administrator stated he went on emergency leave on 12/30/22 and is not in the State. Administrator further stated he instructed staff to send the supporting documents to SA and to expect it today. Inquired who is the point of contact at the facility since there is currently no Director of Nursing (DON), Administrator stated the facility's sister facility administrator (Governing Body Member (GBM) 1) and the facility's management company's [NAME] President of Skilled Nursing Facility Operations are interim the facility's point of contact. On 01/03/23 at 10:12 AM a phone interview with Registered Nurse (RN) 1 (DON for the sister facility) was done. RN1 stated she is attempting to gather supporting documents for the POC but is having difficulty locating everything. Clarified with RN1 that the facility was supposed to send the training records and supporting documents for the DPOC that was due on 12/28/22. RN1 stated she was not aware of the DPOC and has not seen the letter sent to the facility on [DATE] Re: COVID-19 Survey on November 15, 2022. RN1 stated she will attempt to retrieve training records and supporting documents for the DPOC. On 01/04/23 at 08:16 AM the SA entered the facility and requested to have an entrance conference for the onsite revisit to address the facility's non-compliance on 11/15/22. At 08:49 AM, 33 minutes later, RN1 and GBM1 arrived at the facility and an entrance conference was conducted. RN1 confirmed nothing has been submitted for the DPOC to the SA. On 01/04/23 at 11:33 AM RN1 confirmed the RCA was not included in the infection prevention plan and was not done as required from item three of the DPOC. On 01/04/23 at 03:23 PM RN 1 confirmed there is no documentation that staff members viewed the training video Closely Monitor Resident for COVID-19 required in item one of the DPOC. 2) Review of the facility's POC documented for the deficient practice in Infection Control PPE use audit will be completed on 3 random employees weekly x 4 weeks and until QAPI team deems necessary On 01/04/23 at 11:33 AM interview with RN1 was done. RN1 confirmed the facility did not do competencies for PPE use and was not able to find documentation that audits for PPE use was done. On 01/05/23 at 10:36 AM interview with Infection Preventionist (IP) was done. IP confirmed the facility did not audit staff members on PPE use. 3) Review of the Infection Control policy and procedures received by the facility had the management company's header, not the facility's header, and the revised/reviewed dates were dated prior to the focused infection control survey on 11/15/22. During the 11/15/22 survey, the facility submitted an IJ removal plan on 11/15/22 at 01:57 PM and included in the removal plan that the facility will review and update the Infection Control policy and procedures by 11/18/22. On 01/05/23 at 03:23 PM concurrent review of the Infection Control policy and procedures and interview with RN1 was done. RN1 stated the Infection Control policy and procedures are the same ones printed on 11/15/22. RN1 confirmed the facility did not update or revise the Infection Control policy and procedure. RN1 stated the management company provides the facility a copy of their policies and procedures for guidance but the facilities are responsible for changing the header to their facility name, and review/ revise the policies and procedures based on facility's State and tailor it to the facility. 4) Cross Reference to F865. The facility failed to provide evidence that the facility has a functional Quality Assurance and Performance Improvement (QAPI) program. The facility failed to provide documentation the QAPI committee reviewed the corrective actions described in the facility's POC. Review of the facility's POC documents the QAPI committee will review audits for blood pressure screening and medications, hand washing competency, Personal Protective Equipment (PPE) use, new admissions and monthly summary for vaccinations, COVID-19 testing, and COVID-19 vaccination status. The POC documented the QAPI committee reviewed and updated the facility's policies regarding COVID-19 and infection control practices on 11/28/22 and is to review infection surveillance data, and communication compliance for COVID-19. monthly. On 01/04/23 at 12:18 PM requested with Registered Nurse (RN) 1 to provide documentation and/or evidence that the QAPI committee discussed the POC items. The facility did not provide documentation and/or evidence.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interviews, the facility did not demonstrate there was an active (effective and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. Minutes of meetings did not show there was an effective method of communication between the administrator, governing body and the contracted management company (MC). In addition, there was lack of evidence that the Administrator (ADM) was held accountable and reported information about the facilities management and operations directly to the governing body. Findings include: Cross Reference 726: Competent Nurse Staff. The nursing staff failed to demonstrate competency to provide safe care and according to standards of nursing practice in four residents of a sample size of five. Cross Reference 727. The facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis. Cross Reference 835. The administration (administrator, governing body, and management company) failed to effectively and efficiently provide support to the facility and staff members to ensure residents attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility failed to ensure all areas of the facility's Plan of Correction (POC) was corrected and/or worked toward compliance by the corrective action date the facility chose, 12/27/22, and the Directed Plan of Correction (DPOC) was completed by 12/28/22. 1) The Board of Directors oversees two facilities, this facility (F)1, and F2. The facilities have a contract with a management company (MC) for both facilities. At time of this survey, the ADM was on emergency leave and unavailable. The facility also did not have a Director of Nursing (DON). Due to the fact that the documents for the were not sent to the State Agency (SA) as required, and findings of this revisit, a review of the governing board was completed. Registered Nurse (RN)1 from F2, was on site to provide support to F1 during the survey and the individual providing documents and support to the survey team. A request was made for any documents that would define roles and responsibilities of the board, management company, and ADM. The facility was unable to provide a board charter or policy document that clearly defined respective roles, responsibilities and authorities of the Board of Directors (both individually and collectively) in setting the direction, the management and the control of the facility. The facility also was unable to provide an organizational chart or any documents how the organization was structured. It was unknown what types of problems and information are reported or not reported directly to the board. The Governing board members (GBM)1 and GBM2 said the MC had direct oversight of the ADM, and that the (MC) communicates to the board. It was not clear how that communication occurs, how often and what specifically is reported, and how the board responds back 2) On 01/05/2023 at 11:25 AM, during an interview with Governing Board Member (GBM)1 (F2's ADM), she said the board meeting is held annually and as necessary, and there are weekly meetings schedule with the facility administration (ADM). Inquired what the the purpose of the weekly meetings was, and she said to update the board on how the facility is doing. When asked if there was an established agenda for the meeting, GBM1 said they go over census, staffing issues, survey results and any other issues going on in the facility survey. GBM1 went on to say because some of the board members are doctors, they want updates on residents concerns, grievances and financial's. She said they met after the initial survey (conducted on 11/15/2022) and at least two times, possibly more. GBM1 said they do take minutes. At that time, a request was made for the minutes. Inquired if the ADM discussed the results of survey, and she said he emailed out the letters (State Agency/SA) and the 2567 (survey report of findings, citations with scope and severity) for everybody to review. She said she recalled one of the Physician Board Members had questions and they had a discussion about it. GBM1 said the ADM reviewed the types of citations and overall how the survey went, and what the ADM's take on it was, as well as what we are going to be doing to correct those things. After further discussion GBM1 said she received the letter and 2567, but was not sure if the rest of the board did, and she may have gotten it due her position as F2's ADM. Asked if the F1 ADM discussed the need to revise the facility COVID-19 policies, and she said she did not think that was brought up. Further asked if the board reviewed or approved any COVID-19 policy/procedures, and she said generally they (board) do not do that, and the policies are handled at the facility level. The GBM1 said ADM did report there was an issue submitting the POC (SA requested amended POC), and they were told that he was working on it. She went on to say the board was GBM1 said they were aware for the need to have an Infection Preventionist (IP) at the facility and that someone had been appointed. She said the last meeting was canceled and that ADM had not reported any barriers to meeting the POC. When informed GBM1, the POC included obtaining an IP consultant, she said ADM didn't bring that up to the board. Inquired how the board ensure ADM is meeting expectations in the role, and she said it is based on what he reports back to the board. GBM1 said the MC VP, would be the one responsible to ensure the documents were submitted to SA. When inquired who has the responsible to establish and implement policies regarding the management and operations of the facility, she said she thought it was the administrator, governing board and MC [NAME] President (VP). She explained the board doesn't approve the day to day functions, but annually look at the budgets and monthly financial's. GBM1 said they board was aware there were two Immediate Jeopardy (IJ) and one harm citation. She said this past week when ADM left for mainland, they found out from RN1 nothing had been submitted to SA for the infection focused survey POC. The GBM1 said the VP at the MC would ensure it was submitted. He would look at the POC before submitting to us. On 01/05/2023 at 12:02 PM during an interview with GBM2, she was designated as the board secretary. She said they meet weekly, but if members cannot attend the meeting, the meeting is held until the majority is available. GBM2 said back in November, the ADM mentioned the results of the complaint survey, based on a family members complaint regarding a fall that occurred and the resident was transferred out, and that it was reported the facility had two IJ's and a harm. At that time she said the facility had not received the survey report (2567). GBM2 said they (the board) wanted know about the 2567, and there was to be follow-up. She said she didn't see the 2567, but knew the ADM had submitted a response (Plan of Correction/POC). GBM2 said the last time they met ADM said he said there are some part of POC that had to be fixed, and said the IJ was abated. She went on to say they knew after December 20th a revisit could occur. GBM2 said the board did not get copies of the SA letters, and did not know possible consequences. She said the last time (12/19) they the POC had been resubmitted. She said [NAME] asked specifically if the facility was ready, but that it was more of an assumption we were. GBM2 confirmed meetings were held on 12/19/2022, 12/12/2022, 11/28/2022 and 11/21/2022. Inquired if the board agenda includes Quality, and she said QAPI is addressed by having copies of the report, but that doesn't occur half the time. She said the weekly meetings are 30 minutes and although QAPI (Quality Assurance Performance Improvement) is one of seven items listed on the agenda, they prioritize and usually have only time to discuss any immediate problems. When inquired if the board asked if the facility was ready for the revisit, she said it was more of an assumption we were ready. 3) Reviewed the Board minutes dated 11/21/2022, 11/28/2022 12/12/2022 and 12/19/2022. The minutes included the following: 11/21/2022 minutes: Survey Management: Surveyors visited d/t Covid outbreak. Outcome-2 Immediate Jeopardy, 1 G (actual harm), . Survey report 2567 not received; financial penalties may be involved. Former DON (Director of Nursing) has been let go; .Newly hired unit manager RN2 has stepped into DON role; . Also, a new IP nurse has been hired who can work 24 hrs. per week. Both will handle survey issues. Clinical RN from MC, will be coming out to support F1 and F2. . Dr. requesting to see P&L (profit and loss) sheet, change in personnel balance sheet, payroll, and budget for 2023. There was no documented or attached QAPI report. 11/28/2022 minutes: Census/Trend: . Also for support, MC assigned F2 DON to oversee nursing operations at F1 and F2. Survey Management: Question: What is being done to fix the 2 IJ's at F1? There could be a significant monetary penalty and potential inherit danger to the resident population. Response: Citation received because there was no designated IP. Currently Manager (M)1 and LPN1 will receive CDC training for IP. In addition, a new IP was hired to work 24 hours a week, which the surveyors accepted. MC Clinical RN who is IP certified and DON F2 will assist with audits and training. Question: What were the specific virus? Response: It was the singular Covid outbreak. DON did not report some positive cases to DOH. She was out sick during outbreak and did not communicate with the DOH who will be covering her. Question: What happened to other F-tags? Response: Only 1 G (Harm) d/t fall. Upon review of MC, res. had syncope episodes and bp irregularities, but not reported to MD. Comment: 2 IJ and 1 G on an abbreviated survey. The concern is that the surveyors come back . in a month. Response: .They (surveyors) are aware and approved our abatement plan to hire IP and train all staff for infection control. By that time the 2567 is received, we should have POC actions in place already.Comment: The POC needs to have a strong, watertight and something that we are all comfortable with. Comment on POC: Let ADM2 and MC see the POC. Language of POC needs to be precise. There was no documented or attached QAPI report. The 2567 and SA letters were sent on 11/30/2022. 12/12/2022 minutes: Where do we stand on the 2567 and Civil Monetary Penalty? Response: The 2567 date of compliance is December 20th. Surveyors can come back for revisit after that date. This week, there is inservice training for all staff. MC is sending Sr. VP for clinical and HR (Human Resources) to help. HR will assist with nursing leadership as recently promoted DON decided to step down to unit manager role We have a Infection Preventionist who is seeking full time status. MC clinical support has been less than what's needed. Despite, weekly or biweekly calls, there are still problems Response- .Let me know what specific issues or areas you need help.Re: 2567 Let me know when completed. We will have our next meeting on 12/19/2022 one day before our deadline. There was no documented or attached QAPI report. 12/19/2022 minutes: Other matter: .POC has been submitted, but some areas need to be revised. IJ has been abated. IP position in place; DON temporarily covered in spirit by unit manager. There was no documented or attached QAPI report.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

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Based on record review and interview with staff members the facility failed to provide evidence that the facility has a functional Quality Assurance and Performance Improvement (QAPI) program. The facility failed to provide documentation that the QAPI committee reviewed the corrective actions described in the facility's Plan of Correction (POC) for the survey date 11/15/22. Findings Include: Review of the facility's POC with a completion date of 12/27/22 documents the QAPI committee will review audits for blood pressure screening and medications, hand washing competency, Personal Protective Equipment (PPE) use, new admissions and monthly summary for vaccinations, COVID-19 testing, and COVID-19 vaccination status. The POC documented the QAPI committee reviewed and updated the facility's policies regarding COVID-19 and infection control practices on 11/28/22 and is to review infection surveillance data, and communication compliance for COVID-19. monthly. On 01/04/23 at 12:18 PM requested with Registered Nurse (RN) 1 to provide documentation and/or evidence that the QAPI committee discussed the POC items. The facility did not provide documentation and/or evidence. On 01/05/23 at 12:45 PM interview with Social Worker (SW) was done. SW stated the facility usually has QAPI minutes and it is assessable on the computer but the QAPI minutes for November and December were not posted. SW stated he does not know who created the QAPI minutes.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected most or all residents

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Based on interviews and record reviews, the facility failed to inform all residents, their representatives, and families by 5:00 PM the next calendar day following the single occurrence of a single confirmed COVID-19 infection. As a result of this deficiency, residents and their representatives were not able to make informed choices about whether to continue visiting their loved ones or be able to seek more information immediately regarding COVID-19 in the facility. Findings Include: On 11/14/22 at 08:30 AM, Administrator was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. FA stated that a letter of notification about the outbreak was emailed to the residents' families. On 11/14/22, a review of the facility's COVID-19 staff line listing indicated that the following staff had been tested for COVID-19 on the following dates: Certified Nursing Assistant (CNA) 1 on 10/17/22, CNA2 on 10/20/22, Licensed Professional Nurse (LPN) 1 on 10/23/22, and CNA3 on 11/04/22. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive A review of resident line listing log documented 25 residents listed as tested positive for COVID-19 from 10/21/22 to 11/04/22. Resident (R) 24 was tested for COVID-19 on 10/21/22 for symptoms of sore throat, cough, and increased phlegm and was the first resident that had tested positive for COVID-19 in the facility. A review of R24's lab results showed that R24 was tested for COVID-19 on 10/21/22 and had results positive for COVID-19 on 10/22/22 at 05:48 AM. On 11/14/22 at 10:08 AM, an interview and concurrent record review was done with Social Worker (SW). SW stated that the Outbreak Containment letter dated 10/25/22 was emailed by SW to families and resident representatives on 10/25/22. In a subsequent interview on 11/15/22 at 3:14 PM, SW stated that the nurses only called the family if their family member tested positive, otherwise the family received the Outbreak Containment letter. When asked if a letter was sent out when CNA1 tested positive on 10/17/22, SW stated that only the Outbreak Containment letter dated 10/25/22 was emailed to families. On 11/14/22 at 12:19 PM, Director of Nursing (DON) was interviewed. DON confirmed that R24 was the first resident that tested positive for COVID-19 on 10/21/22. DON stated that the outbreak started with R24 who receives dialysis services offsite. DON did not mention any staff testing positive for COVID-19 prior to R24 testing positive. DON confirmed that a letter was emailed to the families regarding the outbreak on 10/25/22. DON stated that she thought the facility was only required to send out a letter to families if the facility had three or more COVID-19 cases in the facility. DON stated that the facility did not call all the residents' family members or representatives by 5:00 PM the next calendar day when R24 tested positive on 10/21/22. On 11/14/22 at 1:50 PM, ADON was interviewed. ADON stated that she received two calls from family members stating that they were upset that no one had notified them regarding COVID-19 in the facility. A review of facility policy COVID-19 Reporting #6702, dated 09/01/20, stated 7. Residents, their representatives, and families are notified of the conditions inside the facility related to COVID-19: a. By 5:00 PM the next calendar day following the occurrence of either: i. A single confirmed infection of COVID-19. ii. 3 or more residents or staff with new- onset respiratory symptoms that occur within 72 hours of each other (i.e. outbreak) .b. Cumulative updates will be provided weekly by 5:00 PM the next calendar day following the subsequent occurrence of either: i. Each time a confirmed infection of COVID-19 is identified.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 2 life-threatening violation(s), Special Focus Facility, 4 harm violation(s). Review inspection reports carefully.
• 66 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $11,170 in fines. Above average for Hawaii. Some compliance problems on record.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.

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About This Facility

What is Liliha Healthcare Center's CMS Rating?

CMS assigns LILIHA HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Hawaii, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Liliha Healthcare Center Staffed?

CMS rates LILIHA HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.

What Have Inspectors Found at Liliha Healthcare Center?

State health inspectors documented 66 deficiencies at LILIHA HEALTHCARE CENTER during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 60 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Liliha Healthcare Center?

LILIHA HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 92 certified beds and approximately 81 residents (about 88% occupancy), it is a smaller facility located in HONOLULU, Hawaii.

How Does Liliha Healthcare Center Compare to Other Hawaii Nursing Homes?

Compared to the 100 nursing homes in Hawaii, LILIHA HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.4 and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Liliha Healthcare Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Liliha Healthcare Center Safe?

Based on CMS inspection data, LILIHA HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Hawaii. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Liliha Healthcare Center Stick Around?

LILIHA HEALTHCARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Liliha Healthcare Center Ever Fined?

LILIHA HEALTHCARE CENTER has been fined $11,170 across 1 penalty action. This is below the Hawaii average of $33,191. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Liliha Healthcare Center on Any Federal Watch List?

LILIHA HEALTHCARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 92
Avg. Residents: 81
Occupancy: 88.7%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Immediate Jeopardy citations: -24
4 Actual Harm citations: -20
66 Deficiencies: -10
Fines ($11,170): -2
Special Focus Facility: -20
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 125041