Every finding on record at Morton Bakar Center

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication was available for use for Resident 23 in the medication cart, which put residents 23 at risk of receiving expired medication, 1b. One open and expired medication was available for use for Resident 45 in the medication cart, which put residents 45 at risk of receiving expired medication, 1c. Two open and expired medications were available for use for Resident 59 in the medication cart, which put residents 59 at risk of receiving expired medication, 1d. One expired medication was available in the medication cart, which put all residents at risk for receiving expired medications. These deficient practices had the potential for residents to receive medications with reduced potency, had the potential to result in medication errors, or drug diversion. Findings: 1. During an inspection of the Treatment medication Cart number 1 on 7/24/23, at 11:50 a.m., with Licensed Vocational Nurse (LVN 1), four expired, one expired and unlabeled with open date medications were identified in the locked compartment of the treatment medication cart, as follows: a. A Betaxolol (used to relax blood vessels and for slowing heart rate to improve blood flow and decrease blood pressure) eye drop for Resident 23 with an open date of 6/19/23. b. A Brimonidine (is used to lower pressure in the eyes) eye drop for Resident 45 with an open date of 6/25/23. c. A Brimonidine eye drop for Resident 59 with an open date of 6/25/23. d. A Dorzolamide (is used to treat increased pressure in the eye) eye drop for Resident 59 with an open date of 6/25/23. e. An opened multiuse Calmoseptine (multipurpose moisture barrier that protects and helps heal skin irritations) ointment tube without an open date. During an interview on 7/24/23, at 12:17 p.m., with LVN 1, LVN1 stated, The Betaxolol, the Brimonidine, and the Dorzolamide are expired, The eye drops expire 28 days after opening and that and that all three eye drops bottles were now expired. LVN 1 stated, the Calmoseptine tube is used on more than one resident and could not see an open date or a discard date on the tube. LVN 1 stated, did not know who was responsible for removing of the expired medication from the carts. During an interview with the Director of Nursing (DON) on 7/24/23 at 1:30 p.m., DON stated, the staff nurse was supposed to give expired and discontinued medications to her. The DON verified the expired medications should have been removed from the medication carts to prevent medication errors. The DON stated, All licensed nurses working on the cart are to check for the discard date and remove expired and discontinued drugs from the medication and treatment carts. During a review of the facility's policy and procedure titled Disposal of Medications, dated 2007, the policy and procedure indicated, 8. Outdated medications, contaminated, or deteriorated medications and the contents of containers with no label shall be destroyed . During a review of the facility's policy and procedure titled Medication Administration, dated 2007, indicated, 8. No expired medication will be administered to a resident .b. The nurse shall place a 'date opened' sticker on the medication .and enter the date opened .c.multi-use eye drops and ointments should be disposed of 28 days after initial use .

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who had a diagnosis of dysphagia (difficulty swallowing) was provided adequate supervision during meals. This failure had the potential to result in avoidable accidents such as choking. Findings: Review of Resident 1's Admission Record indicated, Resident 1 had been known to the facility since September 2008. Resident 1 was recently readmitted to the facility on [DATE] with diagnoses that included dysphagia, glaucoma (eye condition that can cause blindness) and schizoaffective disorder (mental illness). Review of Resident 1's Post-Event Assessment Form 1 dated 12/24/21 indicated, Resident 1 had appeared pale, was unable to talk and had difficulty breathing. Resident 1's oxygen saturation was 60 percent (%) and code blue was activated. When Resident 1 finally started talking, Resident 1 stated I ate cupcake, it got stuck in my throat but now went down. Review of Resident 1's Hospitalist Discharge Summary & Transfer Instruction dated 12/27/21 indicated, on 12/24/21, Resident 1 was brought into emergency room for [shortness of breath] after choking on a piece of cake .[Resident 1] was coughing while eating cake and felt cake stuck in her throat. Heimlich maneuver was performed at the facility. (Heimlich maneuver, otherwise known as abdominal thrust, a first aid procedure used when a person is choking). The form also indicated for facility staff to provide 1:1 (allocating one staff member to provide continuous visual observation of a resident or staying within arm's length) supervision with meals. Review of Resident 1's Order Summary Report /Physician's Order for February 2022 indicated, an order dated 12/28/21 for staff to observe aspiration precautions. The report did not indicate the transfer instruction from the hospital for Resident 1 to receive 1:1 supervision with meals. Further review of Resident 1's care plan, dated 2/15/22, indicated, Resident 1 was at Risk for aspiration r/t (related to) depressed gag/cough reflex, eats too fast and impulsive. Review of Resident 1's dehydration risk care plan (identifies the patient's specific care needs and current treatments/interventions) undated, did not indicate 1:1 supervision with meals. During an interview and concurrent review of Resident 1's clinical record with Speech Therapist (ST) on 4/13/22 at 12:45 p.m., ST stated, Resident 1 was referred for speech therapy upon return from the hospital and was evaluated on 12/31/21. ST stated Resident 1 was initially on pureed diet (blenderized food for people with swallowing or chewing difficulty) with nectar thick liquids (thicker than water consistency, like heavy syrup found in canned fruits) but was discharged from speech therapy on 2/15/22 with mechanical soft (soft foods that don't take a lot of effort to chew or swallow) with thin liquids. Review of Resident 1's ST-Therapist Progress & Discharge Summary dated and signed by ST on 2/15/22 indicated, under Discharge Plans & Instructions, recommendations discussed with Resident 1 and/or caregivers to include safe swallow strategies including chin tuck (person drops the chin towards the chest, maneuver that facilitates swallowing), small bites, and slow rate (eat slowly). ST stated, Resident 1 needed stand-by assist (staff has to be physically present, within arm's reach for safety) when eating. Review of Resident 1's Nutrition/Dietary Notes dated and signed by Registered Dietician (RD) on 2/15/22 indicated, RD did not address Resident 1's aspiration precaution or Resident 1's level of assistance during meals. Review of the facility's staffing schedule for 2/18/22, afternoon shift, indicated Licensed Vocational Nurse (LVN) 1, Certified Nursing Assistant (CNA) 1, CNA 2, CNA 3 and CNA 4 were assigned to the big dining room where Resident 1 ate dinner. During a telephone interview with LVN 1 on 4/18/22 at 1:30 p.m., LVN 1 assigned in the big dining room to supervise all the residents stated, she did not know what standby assist entailed. During a follow-up interview with LVN 1 on 4/18/22 at 1:47 p.m., LVN 1 stated, she did not sit with Resident 1 during meals and only watched Resident 1 on and off as there were other residents in the dining room needing assist with feeding. LVN 1 also stated, she did not know Resident 1 had finished eating and had already left the room. During a telephone interview with Certified Nursing Assistant (CNA) 1 on 4/14/22 at 12:49 p.m., CNA 1 stated, on 2/18/22, CNA 1 saw Resident 1 enter the big dining room but did not see Resident 1 during and after meals. During a telephone interview with CNA 2 on 2/22/23 at 9:53 a.m., CNA 2 stated, on 2/18/22, CNA 2 assisted another resident and did not supervise Resident 1 during meals. CNA 2 added Resident 1 was on puree diet and ate meals without staff supervision. During a telephone interview with CNA 3 on 2/22/23 at 1:20 p.m., CNA 3 stated, on 2/18/22, CNA 3 stated, saw Resident 1 left the dining room. and CNA 3 was helping another resident into the dining room. CNA 3 stated, as she left the dining room to get another resident, CNA 3 was told that Resident 1 was on the floor. Review of Resident 1's Post-Event Assessment Form 2 dated 2/22/22 indicated, code blue was initiated and 911 was activated. Review of the facility's policy and procedure titled Meal Observation (undated) indicated, persons served are supervised during meals to promote safety and too observe and/or manage behaviors. The policy indicated, staff were to remain with residents served throughout meal time, interact with residents during meals and appropriate level of assistance is provided as indicated.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from physical abuse. During an unprovoked incident, Resident 2 pushed Resident 1 by the shoulder causing Resident 1 to fall backwards. This failure resulted in Resident 1's emotional distress and had the potential to cause physical harm related to the fall. Findings:had been known to the facility since 11/20/17 with Review of Resident 1's Admission Record indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Certified Nursing Assistant (CNA) 1 on 11/10/21 at 3:20 p.m., CNA 1 stated, Resident 1 and Resident 3 were both at the nurse's station talking to each other. Resident 3 was sitting in a wheelchair while Resident 1 was standing with the walker. Resident 2 was coming out of the room and walking down the hallway to the nurse's station. CNA 1 stated when Resident 2 got to the nurse's station, Resident 2 yelled at both Resident 1 and Resident 3 to, Get out of here! CNA 1 stated she saw Resident 2 walk towards Resident 1 and pushed Resident 1 on the shoulder, causing Resident 1 to fall backwards. Review of Resident 1's Post-Event Assessment Form dated 9/19/21 indicated Resident 2 called Resident 1 [OBSCENITY] , [OBSCENITY] then pushed Resident 1 by the shoulder. Resident 1 fell backward to the floor and had initially complained of pain that went away after a few minutes. No injury sustained. During an interview on 9/29/21 at 10:46 a.m., with the Director of Nursing (DON), DON stated Resident 2 told her it was Resident 1 that attacked him, however, that was not observed by staff. During an interview with Resident 2 on 9/29/21 at 12:01 p.m., Resident 2 denied pushing Resident 1. During an interview with Resident 1 on 9/29/21 at 12:15 p.m., Resident 1 stated Resident 2 was very rude, talked loudly and was also verbally abusive to staff when agitated. Resident 1 stated she knows not to say anythng back and try to avoid Resident 2. Review of Resident 2's Post-Assessment Form Interdisciplinary (IDT, a group of individuals representing different departments of the facility) notes dated 9/22/21 indicated Resident 2 had an extensive history of verbally aggressive behavior.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who had aggressive behavior, was free from physical abuse when Resident 2 punched Resident 1 in the face and back of the head during a verbal confrontation. This failure had resulted in Resident 1 being punched by Resident 2 causing redness on the face. Findings: Review of Resident 1's Admission Record dated 10/6/21 indicated Resident 1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/22/21 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment of a resident's orientation to time and capacity to remember) score of 14. The BIMS score range is from 0-15 (15 meaning no impairment). Review of Resident 1's undated Mental Health Recovery Plan indicated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility with [CONDITION(S)] disorder (symptoms include delusions, hallucinations, manic episodes of high energy and depressed episodes). Review of Resident 2's MDS dated [DATE] indicated a BIMS score of 13. Resident 2 was oriented to year, month and day. Review of Resident 2's undated Living In Control Recovery Plan indicated Resident 2 could become verbally aggressive, yelling, banging on the walls and slamming doors when frustrated. Resident 2 had Put many holes on the wall and bathroom door from hitting the walls so hard .chased staff in the hall with a fork angrily. Review of Resident 1's Post-Event Assessment Form dated 10/1/21 indicated Resident 1 was in the hallway, yelling, and calling staff names. Resident 2 heard the yelling and came out of the room and punched Resident 1 on the left side of the face and back of the head, while Resident 1 covered his face with both hands. During an interview with Resident 1 on 11/10/21 at 2:50 p.m., Resident 1 stated at the time he was in the hallway when Resident 2 approached and hit him in the back of the head with a closed fist. During an interview with Resident 2 on 11/10/21 at 2:58 p.m., Resident 2 stated Resident 1 was in the hallway yelling and calling people names. Resident 2 came out of the room and was called the n word by Resident 1. Resident 2 stated being upset with the name calling, and hit Resident 1 in the head two times. During an interview with the Registered Nurse (RN) on 11/10/21 at 3:10 p.m., RN stated Resident 1 appeared anxious after the incident and had redness on the side of the face where Resident 1 was punched.

Based on observation, interview, and record review, the facility failed to keep one of three sampled residents (Resident 10) free from abuse. Resident 10 was verbally abused by the Certified Nursing Assistant (CNA 1) on 9/30/20 when CNA 1 was observed using command language and making disparaging comments to Resident 10 while providing incontinence (loss of bladder or bowel control) care. This failure resulted in Resident 10 being verbally abused and suffering psychosocial harm. Findings: During an interview with the facility's transport Driver (DVR) on 10/19/20, at 12:35 p.m., DVR stated he went to Resident 10's room to transport Resident 10 to a scheduled appointment. DVR stated CNA 1 appeared frustrated and upset because Resident 10 had an episode of incontinence and needed assistance with being changed. CNA 1 asked DVR why Resident 10 couldn't use his commode instead of being incontinent while Resident 10 was there laying in bed DVR stated CNA 1 was rough with the resident verbally saying to move your leg over while putting an incontinence brief and clean pants on Resident 10. After CNA 1 placed the incontinence brief on Resident 10, was quiet at first, then cried a few times. DVR stated, The impression I got was (Resident 10])was afraid to say anything during the process. During an observation and interview with Resident 10 on 10/19/20, at 12:55 p.m., Resident 10 described how CNA 1 talked rough which made Resident 10 feel less than human, like an object. Resident 10 made a facial grimace when talking about CNA 1 and had a sad facial expression when recalling this incident. Resident 10 further stated I feel better about myself since CNA 1 is not at the facility anymore. During an interview with the Administrator (ADM) on 10/19/20,at 1:55 p.m., ADM stated the facility had terminated CNA 1 for abuse of Resident 10 after conducting their investigation of this reported incident of abuse. During an interview with the Clinical Director (CD) on 10/19/20, at 2:10 p.m., CD stated Resident 10 had described feeling depressed around the time of the reported incident of abuse with CNA 1 on 9/30/20, and told CD, Why can't I be treated like a human? During an interview with the Director of Nursing (DON) on 10/19/20 at 4:15 p.m., DON stated Resident 10's mood has improved and he appears happier now that he does not have to interact with CNA 1 anymore. A telephone contact to interview CNA 1 on 10/19/20 at 4:30 p.m., received a recorded busy signal and no option to leave a voicemail. During a review of the facility's policy and procedure titled, Abuse Prevention and Reporting, last revised on 1/16/19 indicated, Purpose: To maintain each resident's right to be free from abuse, corporal punishment, involuntary seclusion and any crime .7. Verbal Abuse-may be considered to be a type of mental abuse. Verbal abuse included the use of oral, written, or gestured communication, or sounds (this includes saying derogatory terms) to residents within hearing distance, regardless of age, ability to comprehend or disability.

Based on interviews and record review, the facility failed to implement their abuse policy and procedure to prevent misappropriation of residents property when Licensed Vocational Nurse (LVN 1) could not account for one resident's (Resident 2) missing [MEDICATION(S)] tablets (controlled substance used to treat anxiety). This failure had the potential for diversion of controlled medications. Findings: During an interview on 4/15/21 at 10:31 a.m., the Director of Nursing (DON) stated on 1/4/21 LVN 1 could not account for two [MEDICATION(S)] tablets that belonged to Resident 2. During an interview on 4/27/21 at 11:09 a.m., LVN 1 stated she counted Resident 2's [MEDICATION(S)] tablets at the start of shift with Registered Nurse 1 (RN 1) and the count was correct. LVN 1 further stated she could not account for the discrepancy at the end of her shift for two missing tablets of [MEDICATION(S)]. During an interview on 5/3/21 at 2:27 p.m., RN 1 stated on 1/4/21 she counted the resident narcotic drugs with LVN 1 and discovered Resident 2 was missing two [MEDICATION(S)] tablets. During a review of the narcotic count records on 4/15/21 at 12:20 p.m., with DON, DON could not provide the shift-to-shift controlled drug inventory log dated 1/4/21 reflecting the count was completed and the records were accurate. The facility's policy and procedure titled, Abuse Reporting and Investigations dated 5/15/ 2018, indicated, Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews and record review, the facility failed to provide care and treatment services for one resident (Resident 1) to prevent skin breakdown when the Certified Nursing Assistant (CNA 1) did not use extensive assistance to transfer and reposition Resident 1 from bed to wheelchair according to the care plan. This failure had the potential to cause Resident 1 skin discoloration, bruises or other injuries. Findings: Review of the nursing progress notes dated 11/25/20 indicated a small bruise was noted on Resident 1's arm. Resident 1 believed the bruise was from a staff member being too rough with her at night during care. During an interview on 4/15/21 at 1:45 p.m., CNA 1 stated Resident 1 had pressed the call light about five times that night. CNA 1 stated Resident 1 wanted to use the restroom, and did most of the transfer from bed to the wheelchair herself. CNA 1 further stated she guided Resident 1 into her wheelchair, and was not aware Resident 1 needed extensive assistance using two-persons, physical assistance with transfers and positioning prior to Resident 1's allegation of rough handling. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 9/10/20, showed Resident 1 needed extensive - two person's physical assistance for transfer movement from and to bed, chair, wheelchair and standing position, toileting, dressing, personal hygiene, and locomotion on and off the unit. Review of the Self-Care deficit care plan dated 3/4/20, indicated Resident 1 needs extensive assistance for all Activities of Daily Living (ADLs). During an interview on 4/15/21 at 12:10 p.m., the Director of Nursing (DON) stated she expected CNAs to transfer and reposition Resident 1 according to the care plan.

Based on interviews and record review, the facility failed to maintain an accurate record count of the narcotic controlled drugs for reconciliation when Licensed Vocational Nurse (LVN 1) could not account for one resident's (Resident 2) missing [MEDICATION(S)] tablets (controlled drug to treat anxiety). This failure had the potential for the diversion of [MEDICATION(S)]. Findings: During an interview on 4/15/21 at 10:31 a.m., the Director of Nursing (DON) stated on 1/4/21 LVN 1 could not account for two [MEDICATION(S)] tablets that belong to Resident 2. During an interview on 4/27/21 at 11:09 a.m., LVN 1 stated she counted Resident 2's [MEDICATION(S)] tablets at the start of shift with Registered Nurse (RN 1) and the count was correct. LVN 1 stated she could not account for the discrepancy at the end of her shift for the two missing tablets of [MEDICATION(S)]. LVN 1 stated she did not remember if she recorded the count on the shift-to-shift controlled drug inventory log because the count was done in a hurry. During a review of the narcotic count records on 4/15/21 at 12:20 p.m., DON could not provide the [MEDICATION(S)] record dated 1/4/21 for the shift-to-shift narcotic count of the controlled drug inventory to indicate the count was completed. The facility's policy and procedure titled, Administration of Controlled Drugs (undated) indicated, Two licensed nurses, the outgoing and incoming shift will conduct a controlled drug inventory at each shift change. The oncoming nurse performs the count and the off-going nurse confirms and records the count. Both nurses must sign, time and date the record. Record thereby indicating that the count was made and that the records are accurate.

Based on observation, interview, and record review, the facility failed to supervise one of three sampled residents (Resident 1) during scheduled resident passes onto the patio of a locked mental health behavioral treatment facility. This failure resulted in the elopement of Resident 1, who was missing from the facility from 5 p.m. on 11/19/19 to 3 a.m. on 11/21/19. Findings: During an interview on 11/20/19, at 4:20 p.m., with the Administrator (ADM), ADM stated Resident 1 left the building through an unsupervised exit leading to the patio. ADM stated the building and the surrounding community was searched, but Resident 1 could not be found. ADM indicated Resident 1 remained absent without authorization from 5 p.m. on 11/19/19 until 3 p.m. on 11/21/19. During a concurrent observation and interview on 11/20/19, at 4:30 p.m., with Mental Health Recovery Specialist 1, (MHRS, a certified nursing assistant with specialized mental health training), in the break room, MHRS 1 demonstrated how he checked resident passes and obtained resident signature before exit from the building. MHRS 1 stated he was on duty on 11/19/19, from 4:30 to 5 p.m., and was assigned to check passes and direct residents out of the exit door for a supervised scheduled activity. MHRS 1 further stated, All passes are carefully checked, residents sign out when they leave the building, and sign in when they return. MHRS 1 said he did not see Resident 1 during his shift, and there was not an approved or signed pass for her. During a concurrent observation and interview on 11/20/19, at 4:55 p.m., with MHRS 2, outside of the exit door during Resident Scheduled Pass, MHRS 2 stated his assignment was to stand in front of the exit door in order to have a 180 degree view of residents when they were out of the building and in the courtyard during pass. MHRS 2 stated, Main thing is to pay attention .the door to the building is always open during pass time. During an interview on 11/20/19, at 5:15 p.m., MHRS 4 said that on 11/19/19, she was assigned to observe and supervise the exit door and the residents outside on the patio. MHRS 4 indicated Resident 1 did not have a pass but came into the break room and was redirected several times to move away from the door. MHRS 4 further stated she did not see Resident 1 leave the room through the patio door. MHRS 4 indicated that at 5:30 p.m., she was told Resident 1 was missing and helped search the building, patio, and outside area. During an interview on 11/20/19 at 5:35 p.m. MHRS 3 confirmed she was assigned to Resident Pass review and sign out from 4 p.m. to 4:30 p.m. MHRS 3 indicated MHRS 4 was assigned to observe the exit door and supervise residents outside the building. MHRS 3 stated Resident 1 entered the room at 4:15 p.m., and MHRS 3 informed MHRS 4 that Resident 1's pass was on hold. MHRS 3 saw Resident 1 talking to MHRS 4 and then noticed that Resident 1 next stood to the side of the other residents and did not leave the room. MHRS 3 stated that Resident 1 slowly moved to the exit door and stayed on the other side of the room, a few feet from the door. MHRS 3 indicated she did not actually see Resident 1 leave the room. MHRS 3 stated that at 4:30 p.m., she returned to her regular duties and performed a census count. MHRS 3 indicated she realized Resident 1 was not accounted for and that between 4:45 p.m. and 5:15 p.m., she made observation rounds of the resident rooms and the dining room. MHRS 3 indicated Resident 1 was not in any of the areas she observed, so she informed other staff and began searching the building. During a concurrent interview and record review on 11/20/19, at 5:50 p.m., Registered Nurse 1 (RN 1) stated that after an extensive search of the facility, grounds, and surrounding community, Resident 1 could not be found. A review of the nursing progress notes dated 11/19/19 at 5:30 p.m., signed by RN 1, indicated a search for Resident 1 was performed, followed by notification of local authorities and hospitals of the elopement. During a concurrent interview and video record review on 11/20/19, at 6:00 p.m., with ADM and the Clinical Director (CD), the facility's security video, dated 11/19/19, showed MHRS 4 seated on a chair inside the building with her back toward the door. The security video also showed Resident 1 walking slowly behind MHRS 4 to the open, unsupervised door, then walking quickly out of the door and running into the patio area. During a review of the facility's policy and procedure (P&P) titled, Independent Passes, dated 7/19/19, the P&P indicated, Prior to leaving the grounds, the resident or responsible party accompanying the resident is required to sign out in the Pass Book .Make sure that residents without pass order do not leave patio area .Do not let unauthorized residents leave the patio area and ensure that all residents return from pass.

Based on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents was free from abuse when Licensed Vocational Nurse (LVN 1) allegedly kicked Resident 1's foot while Resident 1 was seated on a couch. This deficient practice had the potential for Resident 1 to sustain injuries and the potential for Resident 1 to feel humiliated, vulnerable, and fearful while living in the facility. Findings: Review of the Admission Record for Resident 1 on 4/4/19, indicated he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation and concurrent interview with Resident 1 on 4/4/19 at 9:15 a.m., Resident 1 was in a Merry Walker (walker/chair combination, allowing a person who would normally be placed in a wheelchair the ability to ambulate independently and safely) in front of the Nursing Station, mimicking a violinist. When Resident 1 was asked if he remembered someone stepping on his foot, Resident 1 replied, So what? I'm fine. Resident 1 stated, I am playing the violin. Resident 1 did not answer anymore questions. During an interview on 4/4/19 at 10:15 a.m., Certified Nursing Assistant (CNA 1) stated Resident 1 and LVN 1 were in front of the nursing station and when she heard LVN 1 say, He hit me in the eye. Help me take him to the phone room. CNA 1 then stated they both brought Resident 1 to the phone room and transferred Resident 1 to the couch from his Merry Walker. CNA 1 further stated Resident 1 was slouched on the couch with his legs outstretched in front of him. CNA 1 stated Resident 1 was not fighting physically, but was very angry and saying a lot of bad words. CNA 1 stated she then observed LVN 1 kick Resident 1's foot with her foot, but not forcefully. CNA 1 then continued by stating she told LVN 1, The cameras are watching you. CNA 1 stated there were no other staff present in the phone room when the incident happened. During an interview on 4/4/19 at 11 a.m., Licensed Vocational Nurse (LVN 1) stated that at 3:20 a.m., Resident 1 was walking with his brief dragging on the floor in hallway. LVN 1 stated she stepped on Resident 1's brief hoping he would step out of it, however she then felt Resident 1 hit her left temple with his closed fist. LVN 1 continued by stating she decided to take Resident 1 to the phone room with CNA 1's assistance. LVN 1 stated they sat Resident 1 on the couch and Resident 1, started to come at me and CNA 1. LVN 1 stated she accidentally stepped on Resident 1's foot when they first sat him down on the couch. LVN 1 further stated, After about two minutes, Resident 1 jumped up off his seat and came at us again. LVN 1 stated the staff came out of the room, left the door of the phone room open, and then Resident 1 came out of the room on his own, still aggressive, agitated and verbally abusive. LVN 1 further stated they tried to hold Resident 1 until the paramedics and the police came. During an interview on 4/4/19 at 9 a.m., the Nursing Home Administrator (NHA) stated they saw LVN 1 stomp on Resident 1's foot while Resident 1 was seated on the couch according to the facility's videotape recording. NHA stated Resident 1 was not physically aggressive at the time as observed on the tape. Review of the facility policy and procedure titled, Abuse Prevention and Reporting, revised on 11/14/17, indicated that the facility would, maintain each resident's right to be free from abuse, corporal punishment, involuntary seclusion and any crime. Continued review also showed that, Residents must not be subjected to abuse by anyone, including but not limited to facility staff . or other individuals.

Based on interview and record review, for one of three (Resident 1) residents, the facility failed to implement its Abuse Prevention and Reporting policy and procedure when Certified Nursing Assistant (CNA 1) observed Licensed Vocational Nurse (LVN 1) kick Resident 1's foot and did not report it to the facility Administrator. This failure resulted in delayed intervention and had the potential to further place other residents in possible harms way of being abused. Findings: Review of the Admission Record for Resident 1 on 4/4/19 indicated he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation and concurrent interview with Resident 1 on 4/4/19 at 9:15 a.m., Resident 1 was in a Merry Walker (walker/chair combination, allowing a person who would normally be placed in a wheelchair the ability to ambulate independently and safely) in front of the Nursing Station, mimicking a violinist. When Resident 1 was asked if he remembered someone stepping on his foot, Resident 1 replied, So what? I'm fine. Resident 1 stated, I am playing the violin. Resident 1 did not answer anymore questions. During an interview on 4/4/19 at 10:15 a.m., Certified Nursing Assistant (CNA 1) stated Resident 1 and LVN 1 were in front of the nursing station and when she heard LVN 1 say, He hit me in the eye. Help me take him to the phone room. CNA 1 then stated they both brought Resident 1 to the phone room and transferred Resident 1 to the couch from his Merry Walker. CNA 1 further stated Resident 1 was slouched on the couch with his legs outstretched in front of him. CNA 1 stated Resident 1 was not fighting physically, but was very angry and saying a lot of bad words. CNA 1 stated she then observed LVN 1 kick Resident 1's foot with her foot, but not forcefully. CNA 1 then continued by stating she told LVN 1, The cameras are watching you. CNA 1 stated there were no other staff present in the phone room when the incident happened. In a continued interview on 4/4/19 at 10:15 a.m., CNA 1 stated she did not report the incident involving LVN 1 and that she did not think it was a big thing, and that she didn't want to be involved. CNA 1 further stated she did not report also because LVN 1 was the charge nurse. CNA 1 stated she realized she should have reported the incident when the Director of Nursing (DON) called her to investigate the abuse incident. During an interview on 4/4/19 at 9 a.m., the Nursing Home Administrator (NHA) stated they saw LVN 1 stomp on Resident 1's foot while Resident 1 was seated on the couch according to the facility's videotape recording. NHA stated Resident 1 was not physically aggressive at the time as observed on the tape. Review of the facility policy and procedure titled, Abuse Prevention and Reporting, revised on 11/14/17, indicated, Covered individuals are required to report known, suspected or alleged instances of physical abuse, abandonment, abduction, deprivation, mental suffering, isolation, to the administrator as soon as practically possible.

Based on observation, interview and record review, the facility failed to maintain personal hygienic care for two (Residents 25 and 80) of two sampled residents who had long facial hair. This failure had the potential to result in embarrassment and decreased self-esteem for both Residents 25 and 80. Findings: 1. Review of Resident 25's Admission Record on 5/19/19 indicated Resident 25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Continued review of Resident 25's Minimum Data Set (MDS - An assessment tool used to direct health care needs) dated 2/14/19 showed that Resident 25 was cognitively intact and could understand and be understood by others. The MDS also indicated Resident 25 needed extensive assistance with her Activities of Daily Living (ADL - everyday personal hygienic care) with the help of one person. During an observation and concurrent interview on 5/19/19 at 7:27 p.m., Resident 25 was sitting outside of her room. Resident 25 stated that her assigned Mental Health Worker (MHW) told her she would come back to shave her facial hair, however the MHW had not returned to assist her. During a separate observation and concurrent interview on 5/20/19 at 9:32 a.m., Resident 25's unshaven facial hair remained. Mental Health Worker (MHW 2) stated he would attend to Resident 25 personal hygienic needs. 2. Review of Resident 80's Admission Record on 5/19/19 showed Resident 80 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Continued review of Resident 80's Annual MDS dated on 4/10/19 showed that Resident 80 cognition was moderately impaired and that she had difficulties sometimes understanding or being understood by others. The MDS also indicated that Resident 80 needed supervision with her ADLs with the assistance of one person. During an observation and concurrent interview on 5/19/19 at 4:15 p.m., Resident 80 stated she wanted her facial hair shaved. During a separate observation and concurrent interview on 5/20/19 at 11:44 a.m., Resident 80 remained with unshaven facial hair. Mental Health Worker (MHW 1) stated, I will shave her today.

Based on interview and record review, the facility failed to maintain medical records that were accurate for three (Residents 25, 193 and 16) of three sampled residents when: 1. For Resident 25 the social services form titled, Danger to Self, Danger to Others Risk Assessment was incorrectly dated and Resident 25 was identified by a different name. 2. For Resident 193, the Admission Record did not reflect the correct location of the facility Resident 193 was admitted from. 3. For Resident 16, the Minimum Data Set (MDS- an assessment tool used to direct health care needs) was coded inaccurately. These failures resulted in inaccurate information being shared and had the potential for Residents 25, 193 and 16 to receive uncoordinated care. Findings: 1. Review of Resident 25's Admission Record on 5/19/19 indicated Resident 25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Continued review of Resident 25's Initial Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 2/14/19 indicated that Resident 25 was cognitively intact meaning that she had the ability to understand and be understood by others. Further review of a document titled, Social Services-Danger to Self/Others Risk Assessment, dated on 2/7/18 showed that Resident 25 was identified by another name. During an interview on 5/20/19 at 10:00 a.m., the Social Worker (SW 2) confirmed the date and name on the risk assessment were incorrect and that the assessment was done on 2/7/19. SW 2 stated however that she was describing Resident 25 and that the written notes on the assessment were accurate. SW 2 further stated she understood the importance of accuracy of medical records. 2. During a review of the clinical record 5/19/19 at 6 p.m., the admission record (face sheet), indicated that Resident 193 was admitted to the facility on [DATE] from a Regional Medical Center/Psychiatric Hospital with [DIAGNOSES REDACTED]. Review of discharge records from the transferring facility for Resident 193 dated on 4/29/19 showed that the coordination of transfer from the community hospital that Resident 193 came from was not indicated on the admission record. Review of the facility's social services progress notes dated on 4/30/19 at 4:41 p.m., showed that the admission history and physical for Resident 193 dated for 5/3/19 indicated Resident 193 was admitted from a hospital and location different than was indicated on the admission record. During an interview on 5/21/19 at 10:30 a.m., the Medical Records Director (MRD), stated the nurses enter information into the electronic admission record upon a resident's arrival to the facility. The MRD stated that documents received from a discharge location are used in order to audit the medical/clinical record within 72 hours of admission to the facility. The MRD confirmed the admitted from and admission location information on the admission record was incorrect for Resident 193. In an interview on 5/22/19 at 10 a.m., the Director of Nursing (DON) stated that the incorrect information in Resident 193's admission record, would make it difficult to contact the previous care team for information or coordination of care for Resident 193. Review of a document on 5/21/19 titled, PROT[NAME]OL on the electronic health record system showed that the Licensed Nurse will activate the resident's record and enter all other information such as completion of face sheet based on information gathered from discharging facility and that Medical Records will audit accuracy of information within 72 hours after admission. 3. Record review on 5/21/19 of the document titled, Admission Record, showed the facility admitted Resident 16 on 1/26/17 with [DIAGNOSES REDACTED]. Review of the document titled, MDS 3.0 Nursing Home Comprehensive Version, (Minimum Data Set - An assessment used to direct health care needs) dated for 2/4/19, showed Resident 16 was on an anticoagulant (blood thinner) medication. Review of Resident 16's Medication Administration Record [REDACTED]. In an interview on 5/21/19 at 8:30 a.m., the facility's Director of Nursing (DON) confirmed Resident 16 had not been receiving an anticoagulant medication and the MDS documentation that indicated he was, was a mistake. In an interview on 5/21/19 at 9:15 a.m., the facility's Minimum Data Set Coordinator (MDSC) confirmed the indication of Resident 16 being on an anticoagulant medication on Resident 16's MDS form, was an error.

Based on interview and record review, the skilled nursing facility did not coordinate hospice care for two of two sampled residents (Residents 24 and 31). Facility staff did not have a schedule for hospice nursing visits, maintain complete copies of the hospice nursing visit notes in the clinical record, or document communication/coordination with hospice services during their visits. These failures resulted in the potential for lack of continuity of care for Residents 24 and 31 who were receiving hospice services at the facility. Findings: 1. Review of the clinical record on 5/19/19 of the document titled Admission Record showed the facility admitted Resident 24 on 2/4/19 with [DIAGNOSES REDACTED]. In an interview on 5/20/19 at 2:20 p.m., the facility's Director of Nursing (DON) stated that licensed staff coordinated care with the hospice by checking to see if there were any new documented orders. The hospice nurse asks facility staff if they have any concerns. The DON stated however that this information should be documented in the clinical record. In an interview on 5/21/19 at 9:25 a.m., Licensed Vocational Nurse (LVN 3) stated there was no documented hospice nurse visit schedule at the facility. LVN 3 stated the hospice nurses, Just come, and they do not routinely leave a copy of their visit notes in the clinical record. LVN 3 then stated it would be better if they left copies so facility staff could ensure they were, On the same page, and that provision of coordinated and consistent care occurred. LVN 3 stated without a visit schedule or notes, the facility staff do not know when hospice visited or what type of care was provided. In an interview at on 5/21/19 at 10:12 a.m., the Social Worker (SW 1) stated the hospice agency re-evaluates Resident 24's hospice status at each visit. SW 1 stated hospice Manages the case, and she did not know when the hospice nurses made their visits to see Resident 24. In an interview at on 5/21/19 at 11:36 a.m., the facility's Associate Director of Nursing (ADON) stated once the hospice agreement and admission forms are signed, staff communicate with the hospice staff over the phone, and that this communication is not documented in the clinical record. In an interview at on 5/21/19 at 1:05 p.m., the hospice agency nurse (HPCC) stated hospice nursing staff do not send a schedule for visits to the facility and do not consistently leave copies of their visit notes. The HPCC stated the hospice agency focuses on the physical care of the resident while the facility focuses on the psychological care. In an interview on 5/22/19 at 11:16 a.m., the DON confirmed there was no documentation which showed staff communicated with the hospice agency. The DON stated, even if there wasn't a change in condition or new orders, the facility staff should document in their daily notes that hospice had made a visit on a particular day and staff discussed with them the continued effectiveness or ineffectiveness of the current plan of care. Record review on 5/24/19 of the documents titled HSPC Routine Visit, (hospice nursing visit notes) showed Resident 24 had been seen by hospice on 3/27/19, 3/29/19 and 4/2/19. There was no documentation in the clinical record which showed that the facility staff communicated or coordinated with the hospice nurse. Review of the document titled, Letter of Agreement for Routine and/or General Inpatient Levels of Care of a Hospice Patient in a Skilled Nursing Facility,(an agreement signed between the hospice and the facility) showed, The Medicare Conditions of Participation require that Hospice collaborate with Facility to develop a coordinated Plan of Care and that All services provided in accordance with this agreement must be documented. 2. Review of Resident 31's Admission Record on 5/19/19 indicated Resident 31 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Continued review of the clinical record showed that Resident 31 was admitted to the hospice care program (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than a cure) with the terminal [DIAGNOSES REDACTED]. Further review of Resident 31's medical record showed hospice nurse staff visits on 4/2/19, 5/9/19, 5/14/19, and 5/20/19. There was no documentation of hospice visits in Resident 31's medical record. During an interview on 5/21/19 at 10:10 a.m., Licensed Vocational Nurse (LVN 1) stated they have a hospice nurse visit schedule and it is usually hanging in the facility's chart room. LVN 1 was unable to show the hospice visit schedule and further stated that the licensed staff communicates with hospice service via phone. LVN 1 continued by stating she has called the hospice nurse due to Resident 31 running out of medication, but she did not document the conversation in Resident 31's medical record. LVN 1 stated that she, just wrote it on the 24-hour (nursing) report. During an interview on 5/21/19 at 10:35 a.m., Licensed Vocational Nurse (LVN 2) stated there is no schedule for hospice nurse visits, but that hospice services calls the facility on the day they visit Resident 31. LVN 2 admitted the hospice nurse did not call yesterday, but she knew hospice services was at the facility because LVN 2 saw the guy. LVN 2 also stated she did not document a discussion she had with the hospice Nurse Practitioner (NP) concerning another resident on hospice which was a very important concern but she did not document it, and that she should have charted it because it was important. In an interview with the Hospice Patient Care Coordinator (HPCC) on 5/21/19 at 1:00 p.m., HPCC stated there were no calendars for nurses' visits. HPCC further stated copies of visit notes are sometimes left in the chart, sometimes not. The HPCC also stated hospice deals with the physical/medical side of the resident and the facility deals with their mental side. Review of the facility policy and procedure titled, Hospice Care, dated 4/1/13 indicated, The hospice and the facility communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy .

Based on interview and record review, the facility failed to monitor one (Resident 3) of three sampled residents when Resident 3's belongings were not checked for contraband and Resident 3 subsequently used a pen to stab at Resident 2. This failure resulted in Resident 3 scratching Resident 2's finger with a pen and had the potential of placing both residents at risk for more extensive harm. Definitions: Contraband - An item that could potentially cause harm to a person or others. Paranoid [MEDICAL CONDITION] - A chronic mental health disorder in which a person loses touch with reality. 1:1 supervision - one assigned staff member throughout the shift monitoring the resident in close proximity usually within arms length distance Findings: Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. used to assess cognition/ability to make decisions and understand). During an interview on 1/15/19 at 9:47 a.m., the Clinical Director (CD) stated, Resident 3 was only allowed to have [MEDICATION NAME] and jumbo markers due to a similar incident with another resident. I do not know who gave a pen to her. CD further stated Resident 3 was on hourly monitoring checks on the date of the incident (1/9/19). CD then stated the facility does not do 1:1's and pens are not considered contraband. During a continued interview on 1/15/19 at 10:30 a.m., the CD stated after the last stabbing incident in (MONTH) (YEAR), Resident 3 was placed on monitoring checks every 15 minutes. Resident 3 did not have any incidents, so the facility then placed her on monitoring checks every hour and also allowed her to have roommates. During an interview on 1/15/19 at 11:00 a.m., the Director of Nursing (DON) stated, Resident 3 is agitated. She won't allow anyone near her or her belongings. Mental Health Workers (MHW) should check Resident 3's room and belongings every shift. During an interview on 1/15/19 at 11:46 a.m., Resident 2 stated at the time of the incident Resident 3 was screaming. I got tired of it and I told her to stop. Resident 3 then started telling me to shut up and was screaming at me for five minutes. No one checked on us. Staff ignored it. Resident 2 further stated, Resident 3 came up to me and I stood up. Resident 3 had a pen in her hand. I do not know where she got it from. I put my hand up and Resident 3 took the pen and hit my left ring finger. My finger was red. All the MHWs are scared of her. After the incident, I walked out of the room and reported it to the nurse at the nurses' station. During an interview on 1/16/19 at 9:37 a.m., Licensed Vocational Nurse (LVN 1) stated she was assigned to both Resident 2 and Resident 3 on 1/9/19. LVN 1 further stated she was in the dining room when LVN 2 told her Resident 3 scratched Resident 2's left ring finger with a pen. LVN 1 confiscated the pen from Resident 3 and assessed the left ring finger of Resident 2. LVN 1 stated it was a superficial wound (a scrape on the topmost layer of the skin). LVN 1 stated Resident 3 is not allowed to have pens in her room, however she never checks the room or belongings of Resident 3. During an interview on 1/18/19 at 8:36 a.m., LVN 2 stated, I was in the hallway near Resident 2's room. Resident 2 was screaming. Resident 2 said Resident 3 just stabbed her. Resident 3 cannot have pens. During an interview on 1/18/19 at 12:45 p.m., the Assistant Director of Nursing (ADON) stated MHWs are supposed to do room checks every shift for contraband and make sure Resident 3 has no pens. ADON further stated that MHWs do not document that rooms checks are done. During an interview on 1/18/19 at 3:05 p.m., MHW 1 stated she is assigned to Resident 3 occasionally, but does not check the belongings of Resident 3 or any other residents. During an interview on 1/23/19 at 9:14 a.m., MHW 2 stated she is the regular MHW assigned to Resident 3, but was not working at the time of the incident involving both Resident 3. MHW 2 further stated MHWs are responsible to check the belongings of Resident 3 every shift. MHW 2 stated, Resident 3 makes it hard for people to check her stuff, but we are supposed to. When I'm not working, I'm not sure if they check her stuff. Review of Resident 3's care plan titled, Living in Control Plan dated 3/30/18 showed under interventions, Staff to search room regularly to remove any sharp objects such as pointy pens and others items she may use as a weapon; provide resident only soft writing utensils such as wide markers or [MEDICATION NAME]. Review of the facility policy and procedure titled, Precautions (Close Observations), dated 4/14/08, showed, All (facility) programs strive to ensure the greatest degree of safety with the residents they serve. To that extent, residents who are demonstrating increased amount of harm and risk may be placed on close observation or precautions for a set amount of time to better monitor their behaviors and sure safety. Environmental Safety - Remove potentially dangerous articles from the resident's possession. these items will be kept in a designated area. Frequency of checks - It may be necessary to place a resident on constant observation, 1:1 observation. Documentation: Staff will document on each shift for any resident on precautions, reviewing any significant evidence of the current risk, behaviors exhibited related to the risk, and interventions.

Based on interview and record review, the facility failed to provide a safe environment, free from potential accident hazards, when one (Resident 3) of three sampled residents' belongings weren't checked for contraband when it was known Resident 3 had a history of [REDACTED]. This failure resulted in Resident 3 scratching Resident 2's finger with a pen and had the potential of placing both residents at risk for more extensive harm. Definitions: Contraband - An item that could potentially cause harm to a person or others. Paranoid [MEDICAL CONDITION] - A chronic mental health disorder in which a person loses touch with reality. 1:1 supervision - one assigned staff member throughout the shift monitoring the resident in close proximity usually within arms length distance Paranoia - An unrealistic distrust of others or a feeling of being persecuted. Delusion - A belief or altered reality that is held despite evidence of the contrary. Findings: Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. assess cognition) of 15 (cognitively intact). Review of the medical record showed Resident 2 was admitted to the facility on [DATE]. Further review of Resident 2's last comprehensive MDS dated [DATE] indicated Resident 2 had a BIMS score of 14 (cognitively intact). During an interview on 1/15/19 at 9:47 a.m., the Clinical Director (CD) stated, Resident 3 was only allowed to have [MEDICATION NAME] and jumbo markers due to a similar incident with another resident. I do not know who gave a pen to her. CD further stated Resident 3 was on hourly monitoring checks at the time of the incident. CD stated the facility does not do 1:1s and pens are not considered contraband. During an interview on 1/15/19 at 9:55 a.m., the Assistant Director of Nursing (ADON) stated Resident 2 is alert, and has never accused anyone of abusing her. Resident 3 gets agitated easily. She denies the incident ever happened. During an interview on 1/1519 at 10:30 a.m., CD stated after the last stabbing incident in (MONTH) (YEAR), Resident 3 was placed on monitoring checks every 15 minutes. Resident 3 did not have any incidents, so the facility placed Resident 3 on monitoring checks every hour and allowed her to have roommates. During an interview on 1/15/19 at 11:00 a.m., the Director of Nursing (DON) stated, Resident 3 is agitated. She won't allow anyone near her or her belongings. She will yell at you, but Mental Health Workers (MHW) should check Resident's 3 room and belongings every shift. During an observation on 1/15/19 at 11:39 a.m., Resident 3 was alone in her room and refused to interview. During an interview on 1/15/19 at 11:45 a.m., Resident 2 stated at the time of the incident, Resident 3 was screaming. I got tired of it, and I told her to stop. Resident 3 then started telling me to shut up and was screaming at me for five minutes. No one checked on us. Staff ignored it. Resident 2 further stated, Resident 3 came up to me, and I stood up. Resident 3 had a pen in her hand. I do not know where she got it from. I put my hand up and Resident 3 took the pen and hit my left ring finger. My finger was red. All MHWs are scared of her. After the incident, I walked out of the room, and reported it to the nurse at the nurses' station. During an interview on 1/16/19 at 9:37 a.m., Licensed Vocational Nurse (LVN 1) stated she was assigned to both Resident 2 and Resident 3 on 1/9/19 (date incident occurred). LVN 1 further stated she was in the dining room when LVN 2 told her Resident 3 scratched Resident 2 in her left ring finger with a pen. LVN 1 confiscated the pen from Resident 3, and assessed the left ring finger of Resident 2. LVN 1 stated it was a superficial wound (a scrape on the topmost layer of the skin). LVN 1 stated Resident 3 is not allowed to have pens. LVN 1 further stated she never checks the room or belongings of Resident 3. During an interview on 1/18/19 at 8:36 a.m., LVN 2 stated, I was in the hallway near Resident 2's room. Resident 2 was screaming. Resident 2 said Resident 3 just stabbed her. Resident 3 cannot have pens. During an interview on 1/18/19 at 12:32 p.m., MHW 3 stated, I am not sure if Resident 3 is allowed pens. MHW 3 further stated that Resident 3 is difficult to work with due to her hostile behavior. During an interview on 1/18/19 at 12:45 p.m., the ADON stated MHWs were supposed to do room checks every shift for contraband and make sure Resident 3 had no pens. ADON further stated that MHWs do not document that rooms checks were done. During an interview on 1/18/19 at 3:05 p.m., MHW 1 stated she was assigned to Resident 3 occasionally, but did not check the belongings of Resident 3 or any other residents. During an interview on 1/23/19 at 9:14 a.m., MHW 2 stated she is the regular MHW assigned to Resident 3, but was not working at the time of the incident. MHW 2 further stated MHWs were responsible to check the belongings of Resident 3 every shift. MHW 2 stated, Resident 3 makes it hard for people to check her stuff, but we are supposed to. When I'm not working, I'm not sure if they check her stuff. Review of Resident 3's care plan titled, Living in Control Plan dated 3/30/18, showed, Resident 3 also has a history of bizarre behaviors and struggles with roommates, cutting an oxygen line once due to the sound, and twice (3/2018 and 1/2019) attempting to stab others in the face. Resident 3 can occasionally become verbally aggressive and makes physically aggressive gestures. Resident 3 often makes false statements due to paranoia/delusion. The interventions further showed that, Due to history of aggression, redirect peers from close proximity to Resident 3. Staff to search room regularly to remove any sharp objects such as pointy pens and others items she may use as a weapon; provide Resident 3 with only soft writing utensils such as wide markers or [MEDICATION NAME]. Review of the facility policy and procedure titled, Contraband, dated 9/13/06, showed, To ensure resident and staff safety, it is sometimes necessary to search the resident, personal belongings, and room environment. Review of the facility policy and procedure titled, Precautions (Close Observations) dated 4/14/08, showed All (facility) programs strive to ensure the greatest degree of safety with the residents they serve. To that extent, residents who are demonstrating increased amount of harm and risk may be placed on close observation or precautions for a set amount of time to better monitor their behaviors and sure safety .Environmental Safety- Remove potentially dangerous articles from the resident's possession . These items will be kept in a designated area .Frequency of checks- It may be necessary to place a resident on constant observation, 1:1 observation . Documentation: Staff will document on each shift for any resident on precautions, reviewing any significant evidence of the current risk, behaviors exhibited related to the risk, and interventions.

Based on observation, interview, and record review, the facility failed to provide safe storage of laboratory test supplies when expired laboratory sample collection kits were found stored with currently used laboratory test kits. This failure had the potential to jeopardize the quality of the collected data and could result in inaccurate result for collected samples. Findings: During the Medication and Supply room inspection on [DATE] at 8:00 a.m., the following expired laboratory test kits were observed stored in the same drawer with the currently used test kits: 1. One Blood Culture Test Kit for aerobic and anaerobic bacteria (used to detect infections that are spreading through the bloodstream) with an expiration date of [DATE]. 2. 27 collection tubes labeled, BBL Culture Swab - for aerobic and anaerobic bacteria, influenza and [MEDICATION NAME] test with an expiration date of (MONTH) (YEAR). 3. 23 collection tubes labeled, E Culture Swab EZ Collection and Transport system - for aerobic and anaerobic and fastidious bacteria for wound with an expiration date of ,[DATE]. 4. 47 test tubes labeled, Universal [MEDICAL CONDITION] Transport (test-tube) for viruses with an expiration date of ,[DATE]. In an interview with the Registered Nurse (RN) on [DATE] at 8:15 a.m., RN stated that they are currently using the test kits to collect laboratory specimen for testing viruses and other infectious diseases. The RN confirmed the expired laboratory collection kits were mixed in with the currently used test kits. In a separate interview with the Director of Nurses (DON) on [DATE] at 1:13 p.m., the DON stated the expired test kits should have been discarded. Review of facility's policy on expired laboratory collection kits showed no policy to address expired laboratory test kits.

Based on interview and record review, the facility failed to ensure staff receive required abuse training for one of four employee when Licensed Vocational Nurse 1 (LVN 1) did not receive abuse training for 29 months. This failure has the potential to delay identification or protection of residents from possible abuse, neglect and exploitation. Findings: In a review of Personnel Records under Abuse training on 4/4/18 at 11:00 a.m., according to personnel records, Licensed Vocational Nurse 1 (LVN 1) was hired on 12/7/15 as a LVN Supervisor. Further review of the personnel record indicated LVN 1 did not have an abuse training recorded since 12/7/15 upon hire. In an interview with the Director of Staff Development (DSD) on 4/4/18 at 11:30 a.m., DSD stated LVN 1 currently works as one of the front-line supervisors whose tasks included supervising the staff in the care and safety of residents. The DSD confirmed that LVN 1 did not complete the required Abuse training since hired on 12/7/15. In another interview on 4/5/18 at 9:30 a.m., DSD stated that she has told LVN 1 several times to complete the Abuse training, and subsequently offered LVN 1 overtime pay to complete the abuse training but LVN 1 continued to not attend the abuse training. The DSD added that there were no procedures in the policy to address how to deal with staff that has not completed the mandatory Abuse training. In an interview with the Administrator (ADM) on 4/5/18 at 11:45 a.m., the ADM stated that he was not aware that LVN 1 has not completed the required Abuse training. The ADM confirmed that the policy will be reviewed to address staff who has not completed the abuse training. Review of the facility's policy titled, Abuse, Prevention and Reporting, dated 8/14/17 showed, Training - Upon hire and at least annually, all employees will be trained to identify potential and/or actual occurrences of abuse, neglect, misappropriation of property or suspected crimes against residents.

Based on interview and record review, the facility failed to assess residents for appropriateness of use of [MEDICAL CONDITION] (medication capable of affecting the mind, emotions, and behavior) medications in an as needed basis in a continuous basis for three (Residents 31, 50 and 72) of 20 sampled residents when the physician did not evaluate and document rationale for continued use of [MEDICATION NAME] (used to treat anxiety and certain types of [MEDICAL CONDITION]) in an as needed basis for Residents 31, 50 and 72. These failures had the potential to delay identification of serious or even life-threatening adverse effects of [MEDICAL CONDITION] medications. Findings: 1. Review of the Admission Record showed, Resident 31 was a [AGE] year old resident originally admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Inject 1 mg intramuscularly every 4 hours as needed for refusal of p.o. (by mouth) [MEDICATION NAME] NTE (Not to Exceed) 3/24 hours. Review of the clinical record showed no indication the medication was re-evaluated by the physician. In a telephone interview with the pharmacist (RP) on 4/5/18 at 10:15 a.m., the RP stated, that he joins the Quality Assurance meeting at the facility and reviews the anti-psychotic PRN orders. The RP added that the [MEDICATION NAME] injection was to be given only to Resident 31 when he refuses the to take [MEDICATION NAME] by mouth. In an interview with the Medical Director (MD) on 4/5/18 at 11:00 a.m., the MD confirms that the [MEDICATION NAME] was ordered in as needed basis for Resident 31 and should have been reevaluated and clarified. 2. Review of the Admission Record showed, Resident 50 was originally admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of another physician's orders [REDACTED]. Give 1 tablet by mouth every 4 hours as needed for Anxiety for 90 days NTE 3 doses in 24 hours. Review of the clinical record showed no indication the medication was re-evaluated by the physician. In an interview with the MD on 4/5/18 at 11:00 a.m., the MD confirms that the order was beyond 90 days and the medication use was not reviewed. 3. Review of the Admission Record showed, Resident 72, was a [AGE] year old resident originally admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Give 0.25 mg by mouth every 4 hours as needed for anxiety and increased irritability related to [MEDICAL CONDITION] Disorder, current episode mixed, severe, with psychotic features NTE 3/24 x 120 days. Review of the Gradual Dose Reduction report titled, Director of Nursing Report dated 1/31/18 and 3/27/18 showed, the [MEDICATION NAME] dose for Resident 72 was not discussed. Review of the clinical record showed no indication the medication was re-evaluated by the physician. Review of the facility's policy titled, Monitoring the Effectiveness of Routine and PRN [MEDICAL CONDITION] Medications, dated 2/15/04 showed, The psychiatrist will review antipsychotic PRN orders every 14 days and documents justification of use (benefits versus risk) if further order is required. According to the National Institute of Health publication titled, Daily Med, dated 12/1/16 showed, Benzodiazepines should be prescribed for short periods only (e.g. 2-4 weeks). Extension of the treatment period should not take place without reevaluation of the need for continued therapy. Continuous long-term use of product is not recommended. Ref: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid= c93-8155-4040-acec-64e877bd2b4c

Based on interview and record review, the facility failed to follow its abuse policy and procedure to report allegation of abuse in a timely manner and protect residents from potential abuser for one (Resident 1) of three sampled residents. This failure allowed two Certified Nursing Assistant (CNA 1 and CNA 2) accused of verbal abuse to continue caring for Resident 1 and potentially exposed Resident 1 from further abuse. Findings: Review of the Admission Record, showed the facility admitted Resident 1 on 5/30/17 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/19/17, showed Resident 1 was cognitively intact, had clear speech and was able to express her ideas. During an interview with Rehabilitation Therapist (RT) on 10/5/17 at 11:55 a.m., RT stated on 9/27/17, Resident 1 told RT before dinner time that she did not feel like eating because of how CNA 1 and CNA 2 said mean things to her after she had a bowel movement. RT further stated he did not notify anybody in the building of Resident 1's allegation and that the facility policy was to fill a Report of Suspected Dependent Adult/Elder Abuse form and report the allegation to the charge nurse immediately. In an interview on 10/5/17 at 3:40 p.m., CNA 1 stated she attended to Resident 1 the whole shift on 9/27/17 and was not aware of any allegation until the next day when facility suspended her. In an interview on 10/6/17 at 12:57 p.m., CNA 2 stated on 9/27/17 she worked in pair with CNA 1 when attending to Resident 1 the whole shift on 9/27/17 and was not aware of any allegation until the next day when she was told Resident 1 had a complaint. In an interview on 10/5/17 at 11:20 a.m., the Director of Nursing (DON) stated the two CNA's that was accused of verbal abuse were not immediately removed from contact with the resident. Review of facility's policy, Policy and Procedure on Abuse Prevention and Reporting, dated 7/10/16, indicated employees are responsible for reporting abuse or suspected crimes to the Administrator or designee and complying with requirements of mandated reporting .All reports whether from the residents, family or staff will be reported immediately .If an employee of facility has been accused of resident abuse, he/she will be immediately removed from contact with the resident. The Administrator/Designee will take all measures to protect the residents from further potential abuse.

Based on observation, interview, and record review, the facility failed to follow their own policy and procedure for prevention further abuse. The facility allowed Certified Nursing Assistant (CNA) 2 continued to provide resident care after CNA 2 witnessed Resident 1 was physical abused by CNA 1. A review of the facility video surveillance camera record with the Administrator and the Regional Director of Operations on 6/14/16 showed CNA 2 observed a physical abuse of Resident 1. CNA 2 did not report to the facility and denied she observed the incident. The facility allowed her to remain in the facility to continue providing care for residents during an investigation of abuse. This failure could potentially result in physical or psychological harm to all the residents of the facility. It was determined to constitute an Immediate Jeopardy situation (IJ). The Administrator and Director of Nursing were verbally notified of the IJ on 6/21/16 at 12:30 p.m. The facility failed to protect residents from further abuse by allowing Certified Nursing Assistant (CNA) 2 continued to provide resident care after CNA 2 witnessed Resident 1 was physical abused by CNA 1. By interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of correction through in-services regarding abuse and mandated reporting of employees on 6/21/16 and the remaining employees will received the training by 6/24/16. CNA 2 was placed on administrative leave on 6/21/16. With the presence of Regional Director of Operations (RDO), the Administrator and Director of Nursing, the IJ was abated on 6/21/16 at 3:01 p.m. Findings: During observations of facility's surveillance video with Administrator and the RDO, on 5/30/16 CNA 1 was assisting a resident with lunch. Resident 1 was seen approaching CNA 1. CNA 1 reached up with her left arm and in a swinging motion towards Resident 1's face. CNA 1's left hand pushed at Resident 1's cheek on the right side of the face. CNA 1 repeated the swinging motion towards Resident 1's face. At the second time, before touching Resident 1's face, CNA 1 lowered her arm and pulled on Resident 1's shirt. CNA 2 was present in the video directly in front of CNA 1 and Resident 1. In the video, CNA 2 was present during the incident. CNA 2 walked forward between Resident 1 and CNA 1 when CNA 1 had her left hand on Resident 1's sleeve. CNA 2 reached her hand between Resident 1 and CNA 1 to separate them. CNA 2 gestured with her hand to call Resident 1 to come with CNA 2. When CNA 2 walks away with Resident 1, she looked up directly and pointed at the camera. During an interview on 6/14/16 at 10:00 a.m., CNA 2 stated I didn't see anything but sensed an issue so I put my arm around Resident 1 and led her away. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/16/16 at 10:30 a.m., she stated she went to CNA 2 and asked her about physical abuse incident. LVN 1 further added that CNA 2 denied seeing the incident of abuse. LVN 2 confirmed that CNA 2 did not come to her to report the incident. During an interview with CNA 2 on 6/16/16 at 10:14 a.m., she stated she reported the incident to LVN 1 at, Same time it happened. During an interview with the Regional Director of Operations while in the presence of Administrator on 6/21/16 at 1:30 p.m., they acknowledged they did not remove CNA 2 from providing resident care until 6/21/16. During a record review on 6/14/16 of CNA 2's employee file, a document titled, Employee Acknowledgment of Elder and Dependent Adult Abuse Reporting Requirements was signed by CNA 2 on 3/26/15. The document stated: Failure to report physical abuse of an elder or dependent adult is a misdemeanor, punishable by no more than six months in the county jail or by a fine of not more than one thousand dollars, or by both fine and imprisonment. Review of facility's Policy and Procedure on Abuse Reporting with revision date of 4/10/13, shows: . The employee must comply with the mandated reporter requirements contained in the Elder Abuse and Dependent Adult Civil Protection Act as well as the Elder Justice Act under section 1150B. Welfare and Institutions Code . Prevention: All reports whether from the residents, family or staff will be reported immediately to the Administrator and DON/designee. Reporting: Mandated reporters are required to report known, suspected or alleged instances of physical abuse, abandonment, isolation, financial abuse, or neglect to the local ombudsman of local law enforcement agency.

Based on observation, interview, and record review, the facility failed to provide an environment free of physical abuse and protection from abuse when Resident 1 was physically assaulted by Certified Nursing Assistant (CNA 1). For Resident 1, these failures had the potential for physical and psychological harm. Findings: During an observation and concurrent interview of facility's surveillance video on 6/14/16 with the Administrator and the Regional Director of Operations (RDO), RDO stated the incident occurred on 5/30/16. The video showed CNA 1 was assisting Resident 2 with lunch. Resident 1 was seen approaching CNA 1. CNA 1 reached up with her left arm in a swinging motion towards Resident 1's face. CNA 1's left hand pushed at Resident 1's cheek on the right side of the face. CNA 1 repeated the swinging motion towards Resident 1's face. The second time, before touching Resident 1's face, CNA 1 lowered her arm and pulled on Resident 1's shirt. During an interview with Licensed Vocational Nurse (LVN 2) on 6/15/16 at 12:55 p.m., she stated CNA 1 came to her and she appeared very angry. LVN 2 added that CNA 1 stated Resident 1 was calling CNA 1 Black Lady, and spit on CNA 1's face. CNA 1 told LVN 2, I pushed her. LVN 2 instructed CNA 1 not go to or near Resident 1. LVN 2 stated she went to Resident 1 and found the resident lying in bed. Resident 1 told LVN 2, Go away. Resident 1 also told LVN 2 that CNA 1 was lying because she did not spit on CNA 1. During an interview with LVN 1 on 6/14/16 at 9:20 a.m., she stated CNA 1 reported the incident to her. LVN 1 stated I told CNA 1 not to go near Resident 1. I made up a new care plan. During a phone interview with Assistant Director of Nursing (ADON) on 6/14/16 at 11 a.m., she stated CNA 1 was reassigned and verbally warned to stay away from Resident 1. ADON confirmed CNA 1 worked in the same unit (where Resident 1's room was located) and up to the end of her shift on 5/30/16. ADON added CNAs had a Buddy system (working in pairs); ADON did not directly supervise CNA 1. During an interview with CNA 3 on 6/24/16 at 11:17 a.m., she stated she worked together with CNA 1 in Station 1. CNA 3 stated the ADON notified her that Resident 1 was transferred to her assignment during the end of shift 5/30/16 at 3:30 p.m. CNA 3 confirmed that CNA 1 stayed in Station 1 where Resident 1's room was located. CNA 3 further added that on 5/31/16, CNA 1 worked in Station 1 in the morning. During an interview with Director of Nurses (DON) on 6/14/16 at 12:00 p.m., she stated CNA 1 also came back to work the following day 5/31/16 and was sent home around lunch time. During a phone interview with CNA 1 on 6/15/16 at 10:07 a.m., she stated she worked until the end of shift on 5/30/16 and was instructed not to go near Resident 1. The following day, she worked until midday. Review of Resident 1's face sheet showed Resident 1 was admitted to the facility in August 2014 with multiple [DIAGNOSES REDACTED]. Minimum Data Set (comprehensive assessment tool) showed she had Brief Interview for Mental Status of 14 (score 00- 14) which indicate the person was cognitively intact. During an interview with Resident 1 on 6/14/16 at 9:30 a.m., she stated I don't want to talk about it anymore. It was a small minute in time. Review of the facility's policy and procedure titled, Abuse Reporting last revised on 4/10/13, showed, If an employee of facility has been accused of resident abuse, he/she will be immediately removed from contact with the resident.

Based on interviews and record review, the facility failed to protect one of one sampled resident, Resident R, from from verbal and physical abuse by a licensed nurse. This failure resulted in Licensed nurse I hitting Resident R's hat off his head and pulling his hair as witnessed by two staff members. Findings: The facility reported to the Department that two housekeepers witnessed licensed nurse 1 grabbing Resident R's hair. During an on-site investigation on 2/15/12 at 1:00 p.m. the assistant administrator stated that Licensed Nurse 1 was still on administrative leave. On 2/15/12, a review of Resident R's record showed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His admission comprehensive assessment dated [DATE], indicated that Resident R was oriented to year, month and day and was able to recall events. The assessment also documented that he ambulated independently and was continent of his bowels. Resident Rs' care plan dated 11/8/11 indicated that he was "Potential for victimization due to incites others due to verbally or physically assaultive behaviors." There was also a care plan for Resident R , "Assaultive, verbal aggression toward residents/staff, physical aggression toward residents/staff, history of pushing punching staff members." During an interview on 2/15/12 at 1:10 p.m., the Director of Nurses (DON) said the housekeeper manager informed her that two staff from the housekeeping Department saw Licensed Nurse 1 hit Resident R's hat off his head, pulled his hair, then took him in his room and closed the door. The DON stated, "We don't know what happen . But something inappropriate happen. When we first interviewed Licensed nurse 1, he said he couldn't remember anything remarkable that happened. He was sent home on administrative leave. He called me back and said he wanted to recant his statement. We are terminating him." An interview was attempted with Resident R on 2/15/12 at 1:30 p.m. while he was in his room on his bed. When he was asked about the incident he stated, "I don't remember." During a telephone interview with Licensed nurse 1 on 2/15/12 at 1:50 p.m. he said, "I heard Resident 1 had hit a staff member. I went over because it 's out of his character. He is used to yelling and he strikes at other residents but unusual to strike at staff. I asked him how he was. He was isolated by his room. I noticed some brown stuff on his hat. I just took his hat off to see if it was feces on his hair. Sometimes if he have feces on his hand he could rub it on his hair. He has had bowel movements on his self before. I took him in his room, and asked what caused him to hit the staff member. He said she was, " F... ing with me, and I gave her a left hook." I grabbed a paper tower wiped his hat off and brought him to the nursing station with me. He was not my assigned resident. He stayed around me the rest of the night. I did his blood sugar, because he didn't want anyone else to do it." On 2/15/11 at 5:00 p.m. Licensed nurse 2 who was assigned to take care of Resident R was interviewed. During the interview she said, "I saw licensed nurse 1, taking Resident R out of his room in a wheelchair. I went to Licensed nurse 1 station to get Resident R to check his blood glucose. Resident R refused. So I asked Licensed Nurse 1 to help. He did the fingerstick. After dinner I did his finger stick and gave him his medication. He was back in his room. I didn't have any problems with him." During an interview with housekeeper 1 on 2/15/12 at 2:40 p.m. he said, "I was dumping the trash. (Licensed nurse I) was the nurse take his hand and push Resident R's hat off his head. He grabbed his hair and pulled it. He pushed him in the room and closed the door. Resident R was yelling in Spanish, "What are you doing?" I see another laundry person, she was in front, closer to the room. She also saw what I saw. I was so afraid. I was in shock. She was also afraid and shocked." The facility's abuse policy and procedure dated 9/20/98 and revised 7/15/11 read, "Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff." The facility concluded their investigation on 2/14/12. Their investigator conclusion read, "We have concluded based on all the findings that .. behavior was abusive and would recommend termination."

The facility violated the aforementioned regulation by failing to provide the therapeutic diet ordered by the physician to ensure that Resident 1 was not given a food that was unsafe to eat. Resident 1 had no teeth, and a history of choking on foods. A facility staff person gave Resident 1 a cold cheese sandwich that was not suitable for the therapeutic diet. As a result, Resident 1 choked on the cheese sandwich, was unable to breathe and her heart stopped. Resident 1 did not recover from the incident, and she died .Review of the clinical record, on [DATE], showed that the facility readmitted Resident 1, a [AGE] year old, on [DATE]. Resident 1 had multiple medical [DIAGNOSES REDACTED]. A Licensed Nurse (LVN 1) recorded information about Resident 1's mouth condition on the "Nursing Oral/Dental Assessment," document, dated [DATE]. According to the record, Resident 1 had no teeth. Review of the physician's orders [REDACTED].The facility's plan of care for Resident 1, most recently updated on [DATE], contained instructions to care for Resident 1's nutritional needs. According to the care plan, Resident 1 had chewing difficulty and the facility was to provide a therapeutic, mechanical soft texture diet.According to the Minimum Data Set (an assessment of residents' health status), dated [DATE], Resident 1 needed supervision for decisions due to poor decision making. A review of the facility's kitchen snack plans, for 7 p.m. daily, showed that Resident 1 was to receive a mechanical soft consistency, "Fruit," snack. Nurses' notes, dated [DATE] at 7:40 p.m., reflected that Resident 1 was, "Eating snacks," at the nurses' station. A staff person, who was not a licensed nurse, called out to licensed staff that Resident 1 was, "Choking." Resident 1 was unable to talk and had food in her mouth. Resident 1 lost consciousness and facility staff began CPR (cardiopulmonary resuscitation) and called 911.Review of EMP (Emergency Medical Personnel) records, dated [DATE], showed that at the time of the arrival of the EMPs, 7:41 p.m., Resident 1 was not breathing and her heart was not beating. EMPs found Resident 1's airway obstruction was, "Complete." EMPs used a long, special tool to remove food from Resident 1's airway and used suction to clear her airway. The record reflected, "Patient has large amount of food in airway." Resident 1 was rushed to the nearest hospital for emergency care as EMPs provided CPR. According to the Admission History and Physical, dated [DATE], upon arrival at the hospital emergency department (ED), Resident 1's heart was beating but she did not breathe on her own. Resident 1 did not respond when spoken to and did not open her eyes. At the time of admission to the hospital from the ED, Physician 3 documented that Resident 1 was, "Comatose on ventilator" (Resident 1 did not breathe without a machine). Resident 1, "Had a very low probability of survival following her massive arrest." A summary of Resident 1's neurological status was dated [DATE]. According to Neurologist 1, Resident 1 was, "Deeply comatose." Her brain had been severely damaged due to a lack of oxygen. Resident 1 did not respond to verbal or painful stimulus. "(Resident 1's) outlook and survival expectancy is dismal."Resident 1 did not regain consciousness and did not regain the ability to breathe without a machine. The machine supported breathing was discontinued on [DATE] and Resident 1 died . In an interview, on [DATE] at 2:08 p.m., regarding the evening snacks that were provided to facility residents, Cook 1 stated that the evening snack cheese sandwiches were not grilled to soften the cheese. On [DATE] at 3:40 p.m., Certified Nurse Aide (CNA) 1 stated that EMP (Emergency Medical Personnel) took out a big piece of cheese sandwich from Resident 1's throat. CNA 1 stated that they showed the piece of sandwich to the facility staff, and that it was approximately a one inch by one inch square piece of cheese sandwich. During an interview, on [DATE] at 4:05 p.m., LVN 2 stated that, on [DATE] CNA 2 called to him saying Resident 1 was choking. LVN 2 stated that he saw a piece of sandwich bread in Resident 1's right hand. During an interview on [DATE] at 12:37 p.m., CNA 3 stated that the kitchen staff put extra cheese sandwiches (not assigned to a particular resident) on the snack cart along with the residents' prescribed snacks. CNA 3 stated that she gave half of a cheese sandwich to Resident 1, and did not stay with Resident 1 while she ate. CNA 3 also stated that she did not check with the Licensed Nurse before giving the sandwich to Resident 1. She stated that the Administrator told her she should have asked the Licensed Nurse, before giving any food to Resident 1. In an interview, on [DATE] at 9:36 a.m., FSW 1 (Food Service Worker) stated that the half cheese sandwiches sent out on the cart as extra snacks in the evening were prepared using bread, mayonnaise, and a cold slice of yellow American cheese. The half sandwiches were prepared and served cold with no grilling/cooking and with no texture alteration. In a telephone interview and concurrent record review of the facility's dietary manual's definition of what was allowable for someone on a Mechanical Soft Diet, on [DATE] at 10:10 a.m., the RD (Registered Dietician) stated that an American cheese sandwich, that was not grilled to soften the cheese, was not to be given to someone on a Mechanical Soft diet. The cheese slice would be too hard to chew. On [DATE] at 10:38 a.m., in an interview, the ADON (Assistant Director of Nurses) confirmed that Resident 1 had no teeth, no dentures, and had a history of [REDACTED].In a concurrent interview and record review, on [DATE] at 11 a.m., Physician 1 stated she had seen Resident 1 earlier that day, on [DATE], and she (Resident 1) had looked great, was interactive and talkative. In an interview, on [DATE] at 1:44 p.m., the Medical Director stated that the way the facility ensured that residents received the appropriate snack for their diet was by using labels that were pre-selected according to their diet cards and physician orders. If the resident wanted a substitute or extra food for their snack, the Medical Director stated that he depended on the Licensed Nurses to know what would be appropriate for that resident. In an interview, on [DATE] at 1:46 p.m., the ADON confirmed that the Certified Nurse Aides should check with the Licensed Nurses to see if the snack or extra food that the resident requested was appropriate for the resident's prescribed diet. In an interview, on [DATE] at 1:50 p.m., the DSS (Dietary Services Supervisor) stated that the snack labels printed from the computer were updated whenever there was a change in the physician's orders [REDACTED]. DSS explained that every day the kitchen prepared the prescribed snacks as well as extra snacks for any new admission or for residents who were hungry during the night. These extra snacks were made according to regular diet specifications (no alteration to the texture/consistency of the food). The prescribed snacks and extra snacks were placed on two carts (one cart per nursing station). In an interview, on [DATE] at 1:53 p.m., the ADON (Assistant Director of Nurses) stated that CNAs (Certified Nurse Aides) would then pick up the carts and distribute the prescribed snacks to the residents. The ADON explained that the facility's procedure was that if a resident would ask for extra food or a different snack than the one prescribed by their physician, the Certified Nurse Aide would check with the Licensed Nurse if the snack requested was appropriate for the diet prescribed for the resident . In an interview, on [DATE] at 2:01 p.m., the Medical Director stated that Resident 1 was not medically competent to make her own treatment decisions. Resident 1 had a history of [REDACTED]. In an interview on [DATE] at 2:06 p.m., the ADON stated that the Certified Nurse Aide should have gone to the Licensed Nurse to ask regarding Resident 1's extra food/snack request since Resident 1 had a history of [REDACTED]. Therefore, facility staff gave Resident 1 a cold cheese sandwich that was not appropriate for the therapeutic diet, a mechanical soft diet. Resident 1 could not safely eat the sandwich. Resident 1 died as a result of choking on the food that she should not have been given to eat.