Every finding on record at Nightingale at Glenwood

Based on record review and interview, the facility failed to ensure an Annual Minimum Data (MDS) Assessment was coded correctly to document a resident had a serious mental illness and or intellectual disability or related condition requiring level II Preadmission Screening and Resident Review (PASARR) to ensure continuity of care for 1 (Resident #22) sampled resident with a diagnosis of serious mental illness. The findings are: 1.The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2024 documented the resident had diagnoses of depression, anxiety, and bipolar disorder, and scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The Annual MDS also indicated on 1500 Preadmission Screening and Resident Review the following: .Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? 0. No . a. The Care Plan with a revision date of 2/22/2023 indicated Resident #22 had a mood problem related to depression, and anxiety and staff should observe the resident for any signs or symptoms of depression, anxiety, or sadness and report to the medical doctor as needed. b. On 08/06/2024 at 10:50 AM, the Surveyor requested a copy of the Resident #22's complete PASARR (Preadmission Assessment Screening and Resident Review) packet from the Registered Nurse Consultant. c. On 08/06/2024 at 10:54 AM, review of the complete PASSAR packet dated April 8th, 2021, received from the Registered Nurse Consultant, contained a letter dated April 8, 2021, from [State Designated Professional Associates] indicated Resident #22 did not require specialized services for their mental illness beyond the capabilities of a nursing facility. d. On 08/06/2024 at 11:20 AM, during an interview the MDS Coordinator stated Resident #22 did require a PASARR Level 2 and that the Annual MDS assessment dated [DATE] had been coded incorrectly. e. On 08/07/2024 at 1:45 PM, the Administrator was asked if the facility had a policy on accuracy of MDS assessments. f. On 08/07/2024 at 1:58 PM, the Administrator stated the facility did not have a policy on accuracy of MDS assessments but followed the federal RAI (Resident Assessment Instrument) manual.

Based on observation, interview, and record reviews, the facility failed to ensure a transfer with a gait belt was done properly for 1 (Resident #8) sampled resident. This failed practice had the potential to cause injury to the resident. The findings are: A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/17/2024 revealed Resident #8 scored 5 on the Brief Interview of Mental Status which indicated severe cognitive impairment. Resident #8 required supervision or touching assistance chair/bed-to-chair transfer. A review of Resident #8's Care Plan (date initiated 08/05/2024) revealed the resident required extensive assistance by staff to move between surfaces. On 08/05/24 at 11:10 AM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #3 place a gait belt around Resident #8's waistline. CNA #1 placed her left forearm under the resident's left arm pit and grabbed the back of the resident's pants with the right hand. On 08/05/24 at 11:15 AM, Certified Nursing Assistant (CNA) #1 confirmed she did not grab the gait belt to transfer despite being trained to do so. CNA #1 confirmed that she placed her forearm under the resident's armpit and grabbed the resident's pants to transfer from one surface to another. On 08/08/24 at 9:27 AM, the Director of Nursing (DON) voiced that staff should place hands on the gait when transferring, and staff should not put lower forearm under the resident's armpit or grab pants. The DON confirmed if staff placed their forearm under the resident's armpit and/or grabbed the resident's pants it was not a proper transfer it and could hurt the resident.

Based on interviews, record reviews, and facility policy reviews, the facility failed to ensure their protocol for antibiotic stewardship to constitute the criteria for infection was utilized prior to the use of an antibiotic for 1 (Resident #2) sampled resident, as evidenced by not obtaining a urine specimen for a culture to determine the right medication for the resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 06/18/2024 revealed Resident #2 was severely impaired and unable to verbalize pain. Resident #2 could make facial expressions and non-verbal sounds to indicate pain, and Resident #2 complained or showed evidence of pain daily. A review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/19/2024 indicated Resident #2 had a medical diagnosis of neurogenic bladder, non-Alzheimer's dementia, cognitive communication deficit, and person history of traumatic brain injury. A review of Physician's Order Summary Report indicated Resident #2 had an order for Levaquin 500 milligram for the treatment of Urinary Tract Infection (UTI) for the duration of seven days, initiated on 08/03/2024. A review of the Care Plan with a revision date of 08/05/2024,) indicated Resident #2 required Enhanced Barrier Precautions (EBP) due to colonization of extended-spectrum beta-lactamases in the urine and percutaneous endoscopic gastrostomy. Resident #2 exhibited pain related to contractures in upper and lower extremities. A review of the completed on 08/03/24 by Registered Nurse #4 indicated Resident #2 met the criteria for a Urinary Tract Infection (UTI) despite the resident not having a urine specimen with culture performed and not meeting the criteria according to the Criteria for Infection Surveillance Checklist. A review of the Medical Visit with an effective date of 08/06/2024 indicated Resident #2 had a follow up for Urinary Tract Infection (UTI) that noted staff reported on 8/3/2024 that Resident #2 had a foul odor to the urine and increased sediment with moaning out to suprapubic palpation and were unable to obtain urine analysis (UA) and Resident #2 was started on an antibiotic due to history of UTI's. No further problems reported. During an interview on 08/06/24 at 2:50 PM, Registered Nurse (RN) #2 stated Resident #2 was not able to verbalize or communicate that pain was present and the pain scale was used to determine if the resident was in pain which does not indicate were pain is located. During an interview on 08/07/24 at 10:20 AM, Registered Nurse (RN) #4 stated Resident #4 had foul smelling urine, was unhappy, the medications were not working to relive pain, and the Nurse Practitioner was notified. RN #4 voiced that pain was assessed, but no other assessment was completed. RN #4 voiced it was hard to see the resident's urine on the incontinence pads underneath the resident to see if it was cloudy or not, therefore, she was unable to see the resident's urine and she had forgotten to document. During an interview on 08/08/24 at 10:30 AM, the Infection Control Nurse stated the facility used the [named] Criteria for infection Surveillance Checklist to determine if an infection was present and will add symptoms if they are not listed. The Infection Control nurse voiced the facility did collect a urine sample to diagnose a UTI but if unable to obtain the sample the doctor will treat based on symptoms. The Infection Control nurse confirmed Resident #2 was non-verbal and was incontinent. During an interview on 08/08/24 at 9:27 AM, the Director of Nursing (DON) confirmed Resident #2 was in pain daily and moans throughout the day. A review of a policy titled, Antibiotic Stewardship, indicated under Responsibilities, .1. Facility shall support and promote antibiotic use protocols which include: a. Assessment of residents for infection using standardized tools and criteria. b. Therapeutic decisions regarding antibiotic prescriptions based on evidence that is appropriate for the care of Residents .

Based on observation, interview and record review, the facility failed to ensure food items received and stored in the refrigerator, freezer and dry storage were dated with received date and use by date and expired food items were promptly removed/discarded by the expiration date to prevent potential food borne illnesses for residents who receive meals from the facility kitchen. These failed practices had the potential to affect all 40 residents who received meals from the facility kitchen according to a list provide by the Dietary Manager on [DATE] at 8:40 AM. The findings are: 1. On [DATE] at 10:00 AM the following observations were made in the upright freezer in the kitchen: a. Five bags of frozen broccoli with no received or expiration date. b. One bag of frozen greens with no received or expiration date. c. One single serving of chocolate ice-cream in a covered dessert cup without an opened or expiration date. d. A quart tub of rainbow sherbet with no received date or expiration date. 2. On [DATE] at 10:05 AM the following observations were made in the upright large refrigerator in the kitchen: a. Four green salads covered with clear wrap with no prepared or use by date. b. A quart container of applesauce with no open or expiration date. c. A quart container of sour cream with no open or expiration date. d. Six covered individual servings of mandarin oranges with no prepared or expiration date. e. Three covered individual servings of pineapple chunks with no prepared or expiration date. f. Two 36 oz containers of cranberry cocktail that had expired. g. A gallon container of Italian dressing that had expired. h. A gallon container of ranch dressing that had expired. i. A ,d+[DATE] gallon container of imitation vanilla flavoring that had expired. j. Dietary worker #1 was gathering expired items as they were found by the surveyor and throwing them in the trash. 3. On [DATE] at 10:15 AM Observed, on metal shelf, located next to the disinfection sink: a. An undated open box containing five individually wrapped fudge round snack cakes. 4. On [DATE] at 10:17 AM the following observations were made in the refrigerator located in the dry storage area: a. A head of cabbage not bagged sitting in a bowl on the bottom shelf with no received or use by date. b. A cardboard box containing 7 loose cucumbers with no received or use by date. c. A cardboard box containing five bell peppers with no received or use by date. d. A plastic bag of salad with no received or use by date. 5. On [DATE] at 10:20 AM observed the following on a shelf behind the door in the dry storage area: a. Three open containers of decorative cake sanding sugar without an open or expiration date. 6. On [DATE] at 10:15 AM the Dietary Manager was asked, Can you tell me the procedure you use when you receive food from the supplier? They Dietary Manager stated, We date the packages of when it is received, rotate items so the older items are used first. We put the refrigerated and frozen items up first then work on the dry items. 7. The food storage policy obtained from the Dietary Manager on [DATE] documented, .All food not labeled with an expiration date will be discarded according the guidelines .All food will be labeled with a use by date when opened and stored in the appropriate manner.

Based on observation, interview and record review the facility failed to follow physician's orders for oxygen therapy and failed to change the oxygen tubing as ordered for 1 (resident #13) of three (Resident #8, #12 and #13) sampled residents who received supplemental oxygen. The failure had the potential to affect all 10 residents in the facility who received supplemental oxygen. The findings are: Resident #13 had a diagnosis of congestive heart failure (CHF) and obstructive sleep apnea. The Quarterly Minimum Data Set (MDS) with as assessment reference date (ARD) of 4/11/23 documented a brief interview of mental status (BIMS) of 13 (13-15 indicates cognitively intact), the Resident had shortness of breath upon exertion and when lying flat at rest and uses oxygen. On 07/03/23 at 11:06 AM Resident #13 was lying in bed with (named) ventilator on via face mask which was connected to oxygen. The oxygen tubing connecting the oxygen concentrator to the (named) ventilator was not dated. The oxygen was set to deliver 0.5 liter per minute. Resident #13 stated the oxygen should be set on 2 liters. Review of the Physician Order dated 04/26/22 noted oxygen tubing to be changed weekly on Thursday. Staff to date, initial and bag the tubing. The concentrator filter and (named) ventilator to be cleaned weekly. Review of the Physician Order dated 5/29/23, noted oxygen at 2 liters per minute by nasal cannula as needed for shortness of breath. Review of the care plan with a revision date of 1/21/20 noted: change oxygen tubing weekly on Thursday. Date, initial and bag. d. On 7/03/2023 the Surveyor asked Licensed Practical Nurse (LPN) #1 if she knew what Resident #13's oxygen should be set on. LPN #1 responded that she wasn't sure, but she could check. After checking the order LPN #1 stated it should be set on 2 liters. LPN #1 then accompanied the surveyor to Resident #13's room looked at the setting and said that's not right, and adjusted oxygen to correct setting. The Procedure Guidelines 12-12 for administering oxygen did not document the timing for changing and dating oxygen supplies. The document noted to set the flow rate at the prescribed liters per minute.

Based on observation, interview and record review, the facility failed to ensure the kitchen was free of pests to prevent potential cross contamination or bacteria growth. The failed practice had the potential to affect all 40 residents who received food from the facility kitchen, according to the list provided by the Dietary Manager on 7/07/2023 at 08:30 AM. The findings are: 1. On 7/03/2023 at 10:05 AM during the initial kitchen tour, observed two lifeless houseflies on a tray in the refrigerator which contained six individual servings of mandarin oranges and three individual servings of pineapple. 2. On 07/03/2023 at 10:28 AM three houseflies were observed flying in the air in the kitchen and four houseflies were sitting on the outside of a pan which was on a pan- rack by the stove. 3. On 7/05/2023 at 11:23 AM two houseflies were observed flying in the kitchen. 4. On 07/06/2023 at 3:00 PM the Business Office Manager was asked for invoices for pest control treatment. Pest control had treated the facility on June 2, 2023, and July 5, 2023. 5. The Pest Control Program policy obtained from the Administrator on 07/07/2023 at 8:57 AM documented, .Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated . 6. On 07/07/2023 at 10:10 AM the Surveyor asked Dietary worker #1 was asked, Have you seen flies in the kitchen? Dietary worker #1 replied, Yes, just a few here and there, we have sprayed but they are still around. The Surveyor asked, What do you do when you see flies in the kitchen? Dietary worker #1 responded, I try to keep everything covered until they can get someone else in here to spray. 7. On 07/07/2023 at 10:15 AM the Surveyor asked the Dietary Manager, Have you noticed flies in the kitchen? The Dietary Manager responded, Yes, I Have seen a few. The Surveyor asked, What do you do when you see a fly? The Dietary Manager stated, I keep everything covered and use a fly swatter if they are not in an area where food it being prepared, then disinfect the area.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the refrigerators and freezer were dated & labeled of when received, opened and/or prepared; foods stored in refrigerators and shelves were sealed/closed completely; and internal temperature of refrigerators were 41 degrees or lower to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen in facility. These failed practices had the potential to affect 45 residents who received meals from the kitchen, as documented by list of 1 resident NPO (nothing by mouth) 4/28/22 received from Director of Nursing (DON). The findings are: 1. On 04/25/22, during initial tour of kitchen with Dietary Manager (DM), the following observations were made: a. At 12:08 PM, the refrigerator near the dishware storage area contained a plastic bag of carrots that was not dated when received. b. At 12:15 PM, the freezer in the main kitchen contained a bag of frozen chocolate chip cookies not dated when received. DM stated, They were from this weekend so it's ok, I'll date them. c. At 12:23 PM, on the wall perpendicular to the back of the stove, there was an unsealed and undated bag of cereal. At 12:24 PM, there were pepper and onion powder tops open on spice canisters on a shelf. e. At 12:29 PM, the temperature of the refrigerator located near the stove and steam table registered at 50 degrees F. DM stated, It has been opened often during serving of lunch. The refrigerator contained 5 chicken salad sandwiches not labeled/dated. DM stated, They are for alternate for lunch today. f. At 12:33 PM., in the dry storage room, there was a white round container of Milk powder with a lid dated received 3/1/21 had no use by or expiration date able to be read. g. At 12:36 PM, the refrigerator in dry storage room contained 1 bag of salad with lettuce that had brown spots, and 2-3 tablespoons of brown liquid in bottom of an unopened bag that was not dated. The chest freezer in the dry storage room contained 2 bags of tater tots and 1 bag of carrots that were not dated. In the dry storage room, 5 loaves of sliced wheat bread dated received 3/15/22 with no use by date. DM was asked how long bread is good for once thawed. DM stated, the wheat bread lasts 3-4 weeks. 2. On 04/28/22 at 1:01 PM, a temperature check in the refrigerator near stove and steam table after lunch meal was completed. The temperature gauge on 2nd shelf read 55 degrees, gauge hanging from rack in middle read 54 degrees and the gauge attached to roof of refrigerator in middle read 58 degrees. DM was asked about the temperature readings. DM stated that old fridge has fluctuated and is the reason the facility received the new fridge (pointing to the one near hand washing station). a. At 1:23 PM, The DM provided a copy of the temperature log for the refrigerator that was located near the stove and steam table. The log showed 33 out of 55 (60%) temperatures taken twice daily, for the month of April 2022 were over 41 degrees internal temperature. 3. On 4/25/22 at 2:30 PM, a Food Receiving and Storage Policy stated, .6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date) ., 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .and 8. Refrigerated foods must be stored below 41 degrees F unless otherwise specified by law .

Based on observations, record review, and interview, the facility failed to ensure oxygen was administered at the prescribed flow rate for 2 (Resident #15 and #42) of 5 (Resident #8, 13, 15, 21 and 42) sampled residents who were receiving oxygen. This failed practice had the potential to affect 10 residents who were receiving oxygen according to a list provided by the Administrator on 4/27/22 at 1:53 pm. The findings are: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/22 documented on a Brief Interview of Mental Status (BIMS) the resident scored a 15 (13-15 indicates cognitively intact); was short of breath [SOB] with exertion, at rest and while lying flat and received oxygen therapy while a resident. a. The Revised Plan of Care dated 10/10/18 documented, .The resident has oxygen therapy r/t [related to] SOB [shortness of breath] .Interventions .OXYGEN SETTINGS: O2 [oxygen] per [according to] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 04/25/22 at 12:45 PM, the resident was lying in bed with his Head of Bed [HOB] up at approximately 30 degrees and receiving O2 at 1 1/2 Liters Per Minute (LPM). The resident was asked, Do you know what your O2 setting should be at? He stated, It should be set at 2 Liters. d. On 04/26/22 at 10:27 AM, the resident was lying in bed with his HOB (head of bed) up approximately 30 degrees and receiving O2 at 1 1/2 LPM. e. On 04/27/22 at 11:03 AM, the resident was lying in bed and his O2 was at 1 1/2 L; no s/sx of sob; Resident asked, Is my oxygen not at 2 liters? He was informed, No. I will notify your nurse. f. On 04/27/22 at 11:07 AM, the Registered Nurse RN #1 was asked what was his O2 set on? She stated, When I get at eye level, it is at 1 1/2, it should be at 2 and increased it to 2L 2. Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 4/13/22 documented the resident had a score of 13 (13 - 15 indicates cognitively intact) on a Brief Interview of Mental Status, had shortness of breath with exertion, at rest and while lying flat; and received oxygen therapy while a resident. a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2 LPM [liters per minute] PER [by] N/C [nasal canula] as needed for S.O.B. [shortness of breath] . Start Date: 05/29/2018 . b. The Resident Plan of Care [POC} last revised on 1/21/20 documented, .The resident has oxygen therapy r/t [related to] Dx [Diagnoses] Respiratory Disorder, CHF [[CONDITION(S)]] .Interventions: OXYGEN SETTINGS: O2 per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c. On 04/25/22 at 12:15 PM, Resident #42 was lying in bed receiving oxygen at 1 liter. The resident was asked, Do you wear your oxygen all the time? She stated, Yes, most all the time, it helps with my anxiety or panic attacks. She was asked, Do you know what your oxygen should be set on? She stated, I believe it should be set at 2. d. On 04/26/22 at 09:40 AM, the resident was lying in bed receiving O2 at 1 liter. e. On 04/26/22 at 10:58 AM, the resident was lying in bed on back; head of bed [hob] at approximately 15 degrees; receiving o2 at 1Lpm. f. On 04/26/22 at 1:22 PM, during Med Pass the resident was lying in bed receiving o2 at 1 1/2 L. Registered Nurse (RN) #1 was asked what the oxygen setting was at. She stated, 1 1/2 should be at 2 and raised it to 2. 3. On 4/27/22 at 1:53 PM, The Oxygen Management Policy and Procedure was received by the Administrator documented, Policy: It is the policy of this facility to require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews, the facility failed to ensure a referral was made to the appropriate state designated authority for a level II Pre-Admission Screening and Resident Review (PASARR) evaluation after a resident was identified after admission with newly evident or possibly serious Mental Diagnosis, Intellectual Disability, or related disorder for 1 (Resident #37) of 5 (Resident #15, 28, 37, and 43) sampled residents who had mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/22/22 documented that the resident scored 14 (a score of 13 - 15 indicates cognitively intact) on the Brief Interview of Mental Status (BIMS), scored a 3 on the Resident Mood Interview, had no documented behaviors and received an Antianxiety, and Antidepressant medication for 7 days out of the 7 days look back period. a. The Care Plan last reviewed on 4/11/22 did not address her Mental diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 04/27/22 at 9:15 AM, there was no PASARR II in Resident #37's Electronic Health Record (EHR) or in the binder containing other resident PASARR's. c. On 04/27/22 at 9:30 AM, the Director of Nursing (DON), was asked, Do you have a PASARR on [Resident #37]? The DON stated, I will look and see. d. On 04/27/22 at 10:30 AM, the DON stated, Resident #37 does not have a PASARR. The resident was admitted to the facility in 2019 and wasn't given those mental diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . e. On 4/28/22 at 9:15 AM, the DON was asked if Resident #37 was diagnosed with those Mental Disorders after she was admitted . She stated, Yes, Major Depressive and [CONDITION(S)] Disorders The DON was asked, Why is it important that a resident with mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, To make sure the resident is safe in the facility and to see if the resident might require other services that may need to be provided by the facility or outside of the facility.

Based on record review and interviews the facility failed to ensure the care plan was revised to reflect new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/22/22 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the Brief Interview of Mental Status (BIMS), scored a 3 on the Resident Mood Interview, had no documented behaviors and received an Antianxiety, and Antidepressant medication for 7 days out of the 7 days look back period. a. The Care Plan last reviewed on 4/11/22 did not address the resident's Mental diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She received the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 4/27/22 at 10:02 AM, the Director of Nursing (DON) was asked, Who is responsible for updating the Plan of Care [POC] She stated, The Minimum Data Set [MDS] Coordinator. c. On 4/27/22 at 10:05 AM, the MDS Coordinator was asked, Did you update Resident #37's POC when she was diagnosed with [CONDITION(S)] and Major Depressive Disorder on 1/19/21? She stated, I'll look. At 10:11 AM, she returned and stated, I did not update her POC with those newly diagnosed mental disorders, I'll do it today.

Based on observation, interview, and record review the facility failed to ensure the placement of the Percutaneous Endoscopy Gastrostomy (PEG) tube by auscultation of the resident's peg tube before administering medication for 1 (Resident #36) of 1 sampled resident who received medications through a tube feeding. This failed practice had the potential to affect 2 Residents receiving medications per PEG according to a list provided by the Director of Nursing (DON) on 4/27/22 at 2:45 PM. The sample mix of residents that receive medication, Feedings, and water for hydration per peg tube in the facility according to a list provided by the Director of Nursing (DON) on 04/20/22 with the potential to affect 4 residents that had a PEG. The findings are: Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/22 documented the resident was severely impaired in cognitive skills for daily decision making on the Staff Assessment for Mental Status (SAMS), was totally dependent on the assistance of 1 person for eating and received 51% or more calories and 501cc/day or more fluid intake via the PEG tube. a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Start Date: 5/25/21 .Check Peg Placement Via [By] Aspiration and Auscultation .Start Date: 8/31/18 . b. The Plan of Care last revised on 4/10/19 documented, .The resident requires tube feeding . Interventions: Check placement via auscultation and aspiration per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c. On 4/26/22 at 1:57PM during the 2 PM med pass, Registered Nurse (RN #1) prepared medications for administration via the feeding tube. Prior to administering medications per PEG she turned off the pump, disconnected the tube, placed a 60 cubic centimeter [cc] syringe into the gastric port of the feeding tube, pulled the plunger back to approximately 20 cc without any gastric contents. She did not check tube feeding placement by auscultating prior to administering medications. She poured approximately 30 cc water into the port and the contents would not flow via gravity. Using the plunger, she pushed slightly to aid the flow of the contents. After the water was almost infused, she poured the contents of the medications mixed with water and poured into the syringe. Again, she had to use the plunger and pushed slightly to aid the flow of the medications followed by 30 cc of additional water. After the water and medications completely infused, she reconnected the tubing and turned back on the pump. d. The Medication Administration/Feeding Tube Policy and Procedure provided by the DON on 4/27/22 at 9:38 AM documented, .Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice when administering medications, to safely administer ordered medications via feeding tube, and to prevent occlusion of feeding tube to the extent possible. Procedure: .9. Verify tube placement: * Instill 10 - 20 cc of air into the tube while simultaneously auscultating over the left upper quadrant of the abdomen with a stethoscope to validate air movement in the stomach. * Aspirate 2 - 10 cc of gastric contents and re-install . e. On 04/27/22 at 10:00 PM, the DON was asked about the Medication Administration per PEG after it was reviewed, What is the procedure for checking placement of the PEG prior to administering medications? She said, Verify tube placement by instilling 10 - 20 cc of air into the tube while auscultating over the abdomen with a stethoscope to ensure the feeding tube is in the stomach. f. On 4/28/22 at 9:00 AM, the DON was asked, Is the RN working today so I may interview her about not auscultating to check for tube feeding placement. She stated, No, she is camping and does not have phone service, but I called her yesterday at 5:36 PM and questioned her about what you had observed and she told me she did not check placement by auscultating. Said, she forgot due to a hectic morning with the fire drill and another resident falling during her med pass that afternoon.

Based on interview, observation, and record review, the facility failed to ensure residents and resident representatives/family had the right to examine the results of the most recent survey of the facility and past 3 years conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility without asking for 5 of 5 (Resident 1, R2, R6, R42, & R247) sample selected residents. The findings are: 1. Resident #1 with a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/22 documented the resident had a score of 8 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS). a. On 04/27/22 at 12:45 PM, Resident #1 was asked if he wished to be able to see survey results without asking, and if he knew where to find them. R#1 replied, Yes, I would like to know. That would be interesting. I know where they are, but I cannot remember right now. 2. Resident #2 with a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/22 documented the resident had a score of 15 (13-15 indicates intact cognitive response) on the Brief Interview for Mental Status (BIMS). a. On 04/27/22 at 11:05 AM, she was asked if she wished to be able to see survey results without asking and if she knew where to find the results. R#2 replied, If it affects me, then yes, I would. and Not sure, but could ask. 3. Resident #6 with a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/22 documented the resident had a score of 6 (0-7 indicates severely cognitively impaired) on the Brief Interview for Mental Status (BIMS). a. On 04/27/22 at 11:00 AM, R#6 was asked if he wished to be able to see survey results without asking and if he knew where to find the results. R#6 replied Yeah, I would. It could be important. and No, I do not know where. 4. Resident #42 with a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/22 documented the resident had a score of 13 (13-15 indicates intact cognitive response) on the Brief Interview for Mental Status (BIMS). a. On 04/27/22 at 11:10 AM, R #42 was asked if she wished to be able to see survey results without asking and if she knew where to find the results. R#42 replied, Yes, please. That is important and I will need it read to me because I cannot read. I do not know where and would need help finding it. She was asked if she would like that the Social Service Director (SSD) to be informed and for staff to read her the survey results. b. On 04/27/22 at 1:21 PM, the SSD was informed, that R#42 would like to have survey results read to her. SSD stated she would note that. 5. Resident #247 with a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/20/22 documented the resident had a score of 3 indicating severely impaired in cognitive skills for daily decision-making per the Staff Assessment for Mental Status (SAMS). a. On 04/27/22 at 12:41 PM, R#247's husband was asked if he wished to be able to see survey results without asking and if he knew where to find the results. R#247's husband replied Yes, that would be good to know. and I don't remember being told where to see that. 6. On 04/25/22 at 11:52 AM, it was a survey binder next to staffing log on front entry table. It consisted of surveys from 10/10/19 through 4/27/17 per pink tabs between copies of CMS 2567s with coordinating dates on letters regarding 2567 results. 7. On 04/27/22 at 10:45 AM, the Business Office Manager (BOM) was asked who updates the survey binder. The BOM stated she wasn't sure and texted the Administrator to meet surveyors. During the meeting, the Administrator was asked who was responsible for keeping survey binder up to date. Administrator stated, It's me. The Administrator was asked, What should be in binder? Administrator stated, the 2567s. the Administrator was asked, What period should be in binder? Administrator stated, I'm not sure, but I think 18 months of them.

Based on observation, record review, and interview the facility failed to ensure anti-rollback devices were properly working to prevent wheelchairs from rolling backwards which could result in falls for 2 (Residents #2 and #3) of 3 (Residents #1, #2 and #3) case mix residents who were at risk for falls. This failed practice had the potential to affect these 2 residents according to a list provided by the Administrator on 6/16/2021. The findings are: 1. Resident #2 had diagnoses of History of Falling, [CONDITION(S)] Disease, and Cardiac Arrhythmia. The Significant Change in Condition Minimum Data Set with an Assessment Reference Date of 05/18/2021 documented the resident scored 1 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status and required 1 person assist with transfers and toileting needs. a. The Plan of Care documented, .The resident is at risk for falls r/t [related to] Gait/balance problems, Vision problems .Resident re-educated to ask for assistance with transfers to prevent falls Date Initiated: 06/21/2019 .Non skid socks; Resident re-educated on use of c/l [call light] system and safety of transfers .Anti rollbacks to w/c Resident re-educated for w/c safety, therapy assessed w/c [wheelchair] Anti-tippers applied to w/c r/t fall Date Initiated: 02/16/2021 . b. The Safe*t mate SM2-2 Advanced Wheelchair Anti-Rollback Device Installation Instructions documented, .Recommended Use .Anti-rollback Device is intended as a supplemental attachment and not a replacement for factory installed hand brakes. It is recommended for wheelchair users with poor safety awareness who forget to set the manual hand brakes before exiting or entering the wheelchair . Once engaged, the brake arms prevent the wheels from rotating backward. The chair is still able to move forward in the engaged position .The Safe*t mate wheelchair Anti-rollback Device is designed to prevent a wheelchair from rolling back and away from the user as he/she attempts to sit down in or stand up from the chair. c. On 6/15/2021 at 4:38 p.m., Resident #2 was lying in her bed. The Infection Control Preventionist (ICP) accompanied the surveyor during initial rounds. Resident #2 had a wheelchair in her room that had an anti-rollback device on the back of her wheelchair. The wheels were unlocked and the wheelchair was pushed backwards. The left and right brake arms did not grab or secure the wheelchair wheels and the wheelchair rolled backwards approximately three to four feet. d. On 6/15/2021 at 4:40 p.m., the ICP was asked, Is [Resident #2] anti-rollback device working correctly? The ICP stated, Yes, you have to sit in the wheelchair for it to work right. The ICP sat in the wheelchair and disengaged the factory brakes. The ICP then rolled backwards in the wheelchair approximately four to five feet. The ICP was asked, Is the anti-rollback device working correclty on [Resident #2] wheelchair? The ICP stated, I don't guess it is. I will have maintenance look at it. 2. Resident #3 had diagnoses of [CONDITION(S)], Diabetes Mellitus, and [CONDITION(S)]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/18/2021 documented the resident scored 1 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status and required extensive assist with transfers and toileting needs. a. The Plan of Care revised on 09/02/2020 documented, .The resident is Moderate risk for falls r/t [related to] Confusion, Psychoactive drug use, Unaware of safety needs . Apply dycem in w/c r/t fall .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Ensure that the resident is wearing appropriate footwear when mobilizing . b. On 6/15/2021 at 5:18 p.m., Resident #4 was lying in bed. The ICP was also present during initial rounds. Resident #3 had a wheelchair in his room that had an anti-rollback device on the back of his wheelchair. The wheels were unlocked and the wheelchair was pushed backwards. The left and right brake arms did not grab or secure the wheelchair wheels and the wheelchair rolled backwards approximately three to four feet. c. On 6/16/2021 at 1:10 p.m., the Director of Nursing (DON) was asked, Why is (Resident #3) not care planned for an anti-rollback device that he has on the back of his wheelchair? The DON stated, It was more for behaviors. He would try to throw him self back in the wheelchair as it was rolling backwards. The DON was asked, Are the anti-rollback devices working correclty for [Resident #2] and [Resident #3]? The DON stated, They are now. The Maintenance Manager got them readjusted yesterday.

Based on observation and interview, the facility failed to ensure food items stored in the freezer were dated and labeled, and food items stored in the dry storage area were tightly sealed to maintain freshness and prevent potential cross-contamination and food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 36 residents who received meals from the kitchen (Total census: 37), according to the Diet list provided by the Administrator on 2/10/2021. The findings are: 1. On 2/8/2021 at 11:00 a.m., the following observations were made in the kitchen with the Dietary Manager: a. On 2/8/2021 at 11:01 a.m., two black bags were stored on a shelf in the reach-in freezer located in the storage room. The two black bags contained no label or date. The Dietary Manager was asked, What is in the two black bags? She stated, It's our chicken. I got them in on Thursday (2/4/2021). It comes in a huge bag. We divide it up and double bag it. It's a whole 40-pound box. She was asked, Is there a date or label? She stated, No. She was asked, Should it have been dated and labeled? She stated, Yes. b. On 2/8/2021 at 11:05 a.m., one opened bag of colored bow tie pasta was stored on a rack in the dry storage room. The bag of pasta was not sealed. The Dietary Manager was asked, Should the pasta have been sealed tightly? The Dietary Manager stated, Yes.

Based on record review and interview, the facility failed to ensure [MEDICAL CONDITION] medications utilized on an as needed (PRN) basis beyond a 14-day timeframe were re-evaluated by the physician and re-ordered, with the justification for continued use documented, to minimize the potential for adverse consequences for 2 (Residents #22 and #31) of 2 sampled residents who had physician's orders [REDACTED]. This failed practice had the potential to affect 7 residents who had physician's orders [REDACTED]. 1. Resident #22 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/2021 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); exhibited no behavioral symptoms; did not reject care; exhibited no wandering behavior; required extensive 2 person assistance with bed mobility and toilet use; was totally dependent on 2 person assistance with transfer; had limitation in functional range of motion on one side of upper extremities and both sides of lower extremities; did not receive antianxiety medications in the last 7 out of 7 days; received no antipsychotic medications; was examined by a physician 3 days out of the last 14 days; and resident orders were changed 5 times in the last 14 days. a. A Care Plan with a revised date of 7/17/2020 documented, .The resident uses anti-anxiety medications r/t (related to) Anxiety . Administer Antianxiety medications as ordered by physician . Observe for side effects and effectiveness . b. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 0.5 mg (milligrams) ([MEDICATION NAME]) Give 1 tablet by mouth as needed for anxiety PRN (as needed) . q (every) HS (bedtime) . c. The Medication Administration Record [REDACTED]. d. The MAR indicated [REDACTED]. e. The MAR indicated [REDACTED]. f. The MAR indicated [REDACTED]. g. The MAR indicated [REDACTED]. h. The MAR indicated [REDACTED]. i. The Medication Administration Record [REDACTED]. j. On 2/10/2021 at 12:35 p.m., the Director of Nursing (DON) was asked, Does (Resident #22) have a physician's orders [REDACTED].? She looked in the Electronic Medical Record and stated, Yes. She was asked, What is the date the physician's orders [REDACTED]. She was asked to provide documentation from the physician with the rationale for the extension of the order and the duration of the order. She looked in the Electronic Medical Record and stated, I don't see anything. She was asked, Is [MEDICATION NAME] considered a [MEDICAL CONDITION] drug? She stated, Yes. She was asked, Should it have been discontinued after 14 days or the physician document a rationale for the extension of the order and the duration of the order? She stated,Yes. 2. Resident #31 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/2021 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); exhibited no behavioral symptoms; did not reject care; exhibited no wandering behaviors; required extensive one-person assistance for bed mobility, transfer, dressing, and toilet use; had functional limitation in range of motion on one side of the lower extremities; had 2 falls with no injury since admission; received an antianxiety medication 1 day out of the last 7 days; received an antidepressant medication 5 days out of the last 7 days; was examined by a physician 1 time in the last 14 days; and resident orders were changed 1 time in the last 14 days. a. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 0.5 mg . Give 1 tablet by mouth every 4 hours as needed for Anxiety . b. The Medication Administration Record [REDACTED]. Give 1 tablet by mouth every 4 hours as needed (PRN) for Anxiety . Start date 1/18/2021 1530 (3:30 p.m.) . The Medication Administration Record [REDACTED]. c. The Medication Administration Record [REDACTED]. Give 1 tablet by mouth every 4 hours as needed (PRN) for Anxiety . Start date 1/18/2021 1530 (3:30 p.m.) . The Medication Administration Record [REDACTED]. d. On 2/10/2021 at 12:42 p.m., the Director of Nursing (DON) was asked, How long should a resident receive PRN (as needed) [MEDICATION NAME] before it needs to be reviewed? The DON stated, 14 days. She was asked, If the resident is receiving PRN (as needed) [MEDICAL CONDITION] or antipsychotic medication(s), how is this medication monitored and how does the Interdisciplinary Team (IDT) determine if the PRN medication is clinically indicated and ensure the PRN orders are consistent with PRN requirements for [MEDICAL CONDITION] and antipsychotic medications? She stated, Review how often they have been taking it (the PRN medication) and talk to the prescriber to see if they need to continue it. She was asked, Does (Resident #31) have a rationale documented in her medical records to extend the use of her PRN (as needed) [MEDICATION NAME] past 14 days? The DON looked in the Electronic Medical Record, and stated, No, she does not have one. 3. A facility policy titled Medication Regimen Review provided by the Director of Nursing on 2/10/2021 at 11:49 a.m. documented, .11. Based on a comprehensive assessment of a resident the facility will ensure . Residents do not receive [MEDICAL CONDITION] drugs pursuant to a PRN (as needed) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record . d. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . PRN orders for PRN Antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication .

Based on observation, record review, and interview, the facility failed to ensure appropriate COVID-19 screening procedures were consistently followed, by failure to ensure staff and visitors were properly screened prior to entering the healthcare facility to prevent the potential exposure and spread of COVID-19 to residents and staff. This failed practice had the potential to affect 37 residents who resided in the facility, according to the Residents Census and Conditions of Residents form provided by the Administrator on 2/8/2021. The findings are: 1. On 2/10/2021 at 8:10 a.m., Certified Nursing Assistant (CNA) #1 entered the facility through the front door of the facility. CNA #1 performed her own COVID-19 screening. She checked her own temperature and answered the screening questions. There was no staff member sitting at the door to perform the screening of staff and visitors prior to CNA #1 entering the facility. 2. On 2/10/2021 at 9:38 a.m., CNA #1 was asked, Why did you screen yourself in this morning? She stated, I was running late. I was just in a rush. She was asked, Do you usually screen yourself in when you come to work? She stated, There's usually a nurse at the door. 3. On 2/10/2021 at 9:47 a.m., the Director of Nursing (DON) was asked, Did you screen (CNA #1) in this morning? She stated, No. I can already tell you, she screened herself in which is a no-no . 4. On 2/10/2021 at 12:36 p.m., the Infection Preventionist was asked, What is the process when a staff member enters the building? She stated, I go to the door, open it, see if they have any symptoms, fill out the papers, and start a log. She was asked, Are the staff members allowed to screen themselves in? She stated, No, ma'am. 5. A facility policy titled Nursing Home Infection Prevention Assessment Tool for COVID-19 provided by the Infection Preventionist documented, .The assessment focuses on the following priorities, which should be implemented by all nursing homes . Keep COVID-19 from entering your facility . Actively screen all HCP (Healthcare Professionals) for fever and respiratory symptoms before starting each shift; send them home if they are ill .

Based on observation, record review, and interview, the facility failed to ensure infection control measures were consistently implemented to minimize the potential for the spread of disease/ (and or) Covid-19 and cross-contamination as evidenced by staff removal of isolation precautions while resident had Contact Isolation ordered for 1 (Resident #1) of 3 (Residents #1, #3, and #4) case mix residents who had isolation precautions ordered. This failed practice had the potential to affect 29 residents who resided on the South and West Halls as documented on a list provided by the Administrator on 06/12/2020. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/02/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and had isolation or quarantine for active infectious disease. a. The resident's Care Plan dated 03/16/2020 documented, Focus Isolation Precautions: contact isolation r/t (related to) [MEDICAL CONDITION] ([MEDICAL CONDITION] bacteria) Goal Isolation Precautions will be maintained when caring for resident Interventions Maintain Contact Isolation Precautions when caring for resident .Focus The resident is on antibiotic therapy r/t[DIAGNOSES REDACTED] .Date Initiated: 05/22/2020 . Focus The resident has [DIAGNOSES REDACTED]icile .Interventions .Educate .staff regarding preventive measures to contain the infection.Maintain Isolation Precautions as ordered . b. A Physician's Telephone Order dated 05/22/2020 documented, .Contact Isolation for[DIAGNOSES REDACTED] . c. On 06/11/2020 at 11:30 a.m., the Administrator was asked how many residents were on quarantine and/or isolation. The Administrator stated, South Hall quarantine 2, 2 isolation, 1 [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS] urine. d. On 06/11/2020 during initial rounds from 11:45 a.m. to 12:30 p.m., there were 2 residents on the quarantine hall for new admissions/readmissions. Only one of the two residents had a sign posted on the door that documented, Stop and see nurse before entering . A holder on the shelf contained PPE (Personal Protective Equipment) supplies. Registered Nurse (RN) #1 was asked, What type of isolation does the resident have ordered? the RN stated, Resident is in Contact Isolation for [MEDICAL CONDITION]. There was no other isolation resident identified in the facility from the rounds. e. On 06/11/2020 at 12:39 p.m., the Director of Nursing (DON) was asked who the isolation residents were. The DON stated, (Resident #1) and (Resident #4). f. On 06/11/2020 at 12:40 p.m., the DON accompanied the surveyor to Resident #1's room. The DON was asked if there was a sign on the door that indicated isolation. The DON stated, She may be off isolation. I'll have to check. g. On 06/11/2020 at 1:00 p.m., the DON stated, She is not off isolation. The DON was asked when the isolation precaution signs were removed. The DON stated, This morning. Can't give you the exact time but it was right before you got here. The DON was asked when the PPE had been removed. The DON stated, I would assume the same time. One of our other residents was taken off isolation and there was confusion. The DON was asked what the confusion was in discontinuing the isolation. The DON stated, We told them to take (Resident #2) off and they thought we said (Resident #1) . The DON was asked if the resident was to be on contact isolation and the DON stated, Yes. The DON was then asked if there should have been any interruption to the resident being on isolation. The DON stated, No. h. On 06/11/2020 at 2:04 p.m., CNA #1 was asked if the resident was to be on isolation. The CNA stated, Yes that was my fault. I thought she (DON) said take (Resident #1) off and it was (Resident #2). CNA #1 was asked what type of isolation the resident was on. The CNA stated, Contact, I want to say. I know we have to gown, glove, mask already. The CNA was asked if she had provided any care for the resident when off isolation. The CNA stated, I asked her what she wanted for lunch and she was being assisted by therapy. CNA #1 was asked if therapy staff had worn gown and if the resident was still on isolation. The CNA stated, They weren't because it was already broke down. i. On 06/12/2020 at 1:52 p.m., the Occupational Therapy Assistant (OTA) was asked if he had worked with the resident on 06/11/2020 and the OTA stated, I saw her early in morning, she is usually the first one. The OTA was asked if the resident had been on isolation when seen on 06/11/2020. The OTA stated, Not that I recall. The OTA was asked if the resident had therapy in the room. The OTA stated, Yes, usually start walking from her room down the hall and when she gets tired, I push her down to the gym (therapy department). The OTA was asked if there were any other residents in the department when the resident was present. The OTA stated, No. 2. The Procedure and Protocol received on 06/11/2020 from the Administrator documented, Surveillance will be monitored by designated infection control nurse under the guidance of the Infection Control Committee.Procedure/Protocol: .3. Standard and transmission-based precautions to be followed to prevent spread of infections. 4. When and how isolation/quarantine should be used for a resident; including but not limited to: .The type and duration of the isolation/quarantine, depending upon the infectious agent or organism involved . Signage to the door of resident indicating isolation/quarantine and to report to nurse prior to entering .Modes (means) of transmission are: Contact (direct and/or indirect) .Contact transmission is the most common form of transmitting diseases [MEDICAL CONDITION]. Direct contact transmission occurs when there is physical contact between an infected person and a susceptible person. In this situation full PPE (Personal Protective Equipment) should be worn when in proximity of a resident in contact isolation . 3. On 06/11/2020 at 12:38 p.m., the Isolation Precautions Policy and Procedure provided by the Administrator documented, Protocol/Procedure: 1. The charge nurse notifies the .resident's attending physician for appropriate isolation instructions . 2. The charge nurse obtains a physician's orders [REDACTED]. Post an isolation notice sign on the room entrance door instructing staff and visitors to report to the nursing station before entering the room. Explain to the . staff the reason(s) for the isolation precautions. Maintain isolation precautions until no longer indicated. 4. On 6/11/2020 at 4:20 p.m., an Isolation Precaution form provided by the DON documented, Precaution .Contact Transmission Direct or indirect contact with patient or environment Disease [MEDICAL CONDITION] .PPE .Gowns and gloves +/- Eye protection .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the refrigerator and freezer were sealed, the kitchen area was free of flies and or gnats, dishes and utensils were allowed to air dry prior to use or being stored, kitchen equipment was clean and free of dried on residue in between use, pot holders used when handling food items were clean and unstained to reduce the potential of cross contamination, dietary staff washed their hands and / or changed gloves between dirty and clean tasks, and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect all 47 residents who received meals from the kitchen (total census: 47), as documented on the Diet Roster dated 8/27/19. The findings are: 1. On 8/26/19, the following observations were made in the kitchen: a. On 8/26/19 at 11:17 a.m., in the freezer, there was a bag of turkey cubes that was not completely sealed. There were ice crystals inside of the bag. Dietary Employee (DE) #1 was asked, Does that look freezer burns? She said, Possibly, I'll throw it away. b. There was box of beef patties with the plastic bag not completely sealed. c. There was a commercial grade can opener attached to the clean prep table in the kitchen, that had black substance on the blade approximately 1/4 inch thick. Without cleaning the debris from the blades of the opener, DE #2 used the can opener to open a can of carrots. The surveyor took photographs of the can opener at this time. d. At 11:56 a.m., DE #2 washed her hands then placed her hands on her hips. She then pushed the brew coffee button and started stacking clean plates with her fingers touching the inside of the plates. 2. On 8/26/19 at 11:53 a.m., a fly was crawling on a pot handle that was hanging above the prep table. The fly then flew and landed onto a pair of tongs hanging from the pot rack over the prep table. DE #1 was asked, What do you see on the tongs? She stated, A fly. She removed the tongs and placed them on the dirty side. 3. On 8/26/19 at 11:53 a.m., a fly was crawling on the counter of the service line. The fly then flew over to the fruit cups and sat on the tray next to the bowls. A fly was crawling on a pot handle that was hanging above the prep table. The fly then flew and landed onto a pair of tongs hanging from the pot rack over the prep table. DE #1 was asked, What do you see on the tongs? 4. On 8/27/19 at 8:50 a.m., there was a black vent grate cover, above the top of refrigerator #2, that had approximately 1/4 inch thick covering of dust and lint on it. The wire apparatus that opens the dirty dish window also has a covering of dust and lint measuring approximately 1/4 inch thick. 5. On 8/27/19 at 8:50 a.m., during observation of meal prep, 2 flies were on the vent hood over the stove. 6. On 8/27/19 at 9:22 a.m., DE #3 washed her hands and removed a container with chicken from the refrigerator. She washed her hands again and donned gloves. She sat a plate on the scale and used a pair of tongs to pick up one piece of chicken at a time. She weighed the chicken and placed it in another container. She continued to do this until all the chicken was weighed. She removed the gloves and washed her hands. DE #4 removed the containers, cutting board and knife that DE # 3 had used when measuring the chicken in and washed them. DE #3 wiped down the counter with sanitizer. She then picked up a pan and placed it on the counter. She picked up another pan and placed it on the counter. She then lined the pans with foil pressing the inside of the foil down in the pan. She then used tongs to place the chicken in each of the pans until full. She washed her hands then left the kitchen and went to the dry storage area. When DE #3 returned, she was carrying a jar of barbeque sauce. She washed her hands and donned clean gloves. She attempted to open the barbeque sauce lid. She could not peel back the sealed on the lid. She opened a drawer and retrieved a knife. She inserted the knife into the seal and cut the seal. She picked up a box of salt and poultry seasoning from a shelf on the wall and poured an unmeasured amount of seasoning onto the chicken. She replaced the seasonings back on the shelf and poured an unmeasured amount of barbeque sauce onto the chicken. She opened a drawer and removed a basting brush to spread the sauce around on the chicken. DE #4 carried a 5 gallon bucket from the dishwasher area to the food prep area to be used to clean the tables. The bucket was dripping water onto the floor. When she put the bucket back in it's place, it dripped water onto other dishes. 7. On 8/27/19 at 9:22 a.m., 2 flies were crawling on the vent hood. One of the fly's flew down and landed on the food prep table. 8. On 8/27/19 at 9:30 a.m., DE #1 picked up a scale that was dripping water from the rinse table and sat it on top of the prep table. DE #3 washed her hands and donned gloves and continued to prepare more chicken pieces in another pan lined with the foil that was applied earlier. She removed her gloves and washed her hands. She picked up two pot holders that were hanging by the stove. The pot holders were stained with a black and brown substance on them. She pulled out a pan of rolls from the oven and turned the pan around with the pot holders touching the sides of the rolls. She pushed the pan back in the oven and hung the pot holders back up. 9. On 8/27/19 at 9:30 a.m., DE #3 remove containers of carrots and gravy from the refrigerator. She picked up a pan and placed a liner in the pan with her hands touching the inside of the liner. She left the kitchen and went into the dry storage room and returned carrying a bag of macaroni, holding the bag next to her shirt. She sat the bag on the clean prep table and placed the containers of carrots and white gravy back into the refrigerator. She walked to the freezer and came back with a bag of fish patties and an onion. She removed a container of green peas from the refrigerator and sat it on the counter. She retrieved a colander and poured the peas into the colander to drain the water in the sink. She washed her hands and poured the peas into the pan that had been lined. She cut the ends off the onion on the cutting board then rinsed the onion and placed it in the robot coupe. After chopping the onion in the robo coupe, she placed them in the pan with the peas. She covered the container with foil and placed it in the oven. She then retrieved 4 eggs from the refrigerator and placed them a pan of water on the stove. She opened a drawer and retrieved a lighter and lit the burner on the stove underneath the pan of eggs. She then picked up the two stained pot holders from the wall and used them to open the oven and remove the pan of rolls from the oven touching the sides of the rolls with the stained potholders. 10. On 8/27/19 at 9:30 a.m., two flies were on the vent a hood in the kitchen. 11. On 8/27/19 at 9:34 a.m., a fly was crawling on the clean food trays in the kitchen. 12. On 8/27/19 at 9:42 a.m., 2 flies were on the vent hood in the kitchen. 13. On 8/27/19 at 9:51 a.m., using the two stained potholders, DE #3 removed a pan covered with foil from the oven and sat the pan on the prep table. She removed the foil from the top of the pan and placed a thermometer into the vegetables using her right hand while her left hand was positioned on her left hip. The temperature read 130 degrees. She used the two stained pot holders and placed the pan onto the steam table and covered the pan with a lid. 14. On 8/27/19 at 11:14 a.m., DE #3 removed a pan of chicken from the oven with the two stained pot holders. She checked the temperature of the chicken and it was 196.6 degrees. She said, This is for my mechanical soft. She used tongs and placed the chicken into the blender. She turned the blender on and chopped the meat. She poured an unmeasured amount of barbeque sauce into the blender. She picked up a pan and sat it on the counter and picked up a pan liner and placed her right hand in the liner to spread it in the pan. She used a spatula and scraped the meat out of the blender into the pan with the liner with water dripping from the blender into a pan on the prep table. She handed the dirty blender to DE #4. She sat another clean blender on the base of the robot coupe. She used the two stained pot holders and removed a container from the oven. She removed the foil and there was macaroni and cheese in the container. Using her right hand to remove the foil with her left hand touching the inside of the container with the stained pot holder. She used a 1 cup scoop and scooped the macaroni into the blender. She poured in an unmeasured amount of milk into the blender. She turned the blender on. She removed the lid of the blender and stirred the contents using a spatula. She scraped the macaroni and cheese into a pan with a liner. The macaroni and cheese was visibly lumpy. The Surveyor asked the Dietary Manager, does that look smooth to you? She stated, No and told DE #3, You need to do it again it's not smooth. She added more milk to the macaroni into the blender until it was smooth. 15. On 8/27/19 at 11:15 a.m., 2 flies were on the vent hood in the kitchen. 16. On 8/27/19 at 11:21 a.m., a gnat landed on a hamburger bun that DE # 1 was using to make a hamburger to be served to a resident during the noon meal. 17. On 8/27/19 at 11:40 a.m., DE #3 used the 2 stained pot holders and removed the foil from the vegetable medley on the steam table. She picked up a pan and retrieved 2 scoops of vegetable medley placing it in the pan. She picked up the blender from the prep table where DE #2 had placed it earlier. There was a lined pan sitting there and as she placed the blender onto the robot coupe base, water dripped from the blender into the pan. She placed the vegetable medley into the blender and added an unmeasured amount of juice. She turned the blender on and blended until smooth. She scraped the pureed vegetables into the pan with the liner and placed the dirty blender on the prep table. DE #4 picked up the dirty blender and washed it. DE #3 washed her hands and used the 2 stained pot holders and removed a pan of chicken from the oven. She picked up a pan and sat it on the prep table and placed a liner in the pan with her right hand touching the inside of the liner. She removed the foil from the pan and used tongs to place 4 pieces of chicken into the blender. She used 3 teaspoons of powdered chicken broth and placed into a coffee cup. She added an unmeasured amount of hot water. She mixed the ingredients and added an unmeasured amount of the broth mixture to the chicken. She turned the blender on and added more of the chicken broth mixture to the blender. She used a spatula and scarped the puree chicken and poured into the pan with the liner. 18. On 8/27/19 at 1:16 p.m., the Dietary Manager was asked, Should items in the freezer be sealed, labeled and dated? She stated, Yes ma'am. The Dietary Manager was asked, Should you wash your hands between clean and dirty task? She stated, Yes. The Dietary Manager was asked, Should the vent grates above the refrigerators in the kitchen have lint and dirt in them? She stated, No. The Administrator was asked, Who is responsible for cleaning them? The Administrator stated, It would be maintenance. He has been here about a month and he probably don't know he is supposed to clean them. The Dietary Manager was asked, Should you use dirty, stained pot hot holders? She stated, They are pretty stained. The Dietary Manager was asked. When dishes are washed should they be air dried prior to being used and or stored for use later? She stated, Yes. 19. On 08/27/19 at 01:16 p.m., the Dietary Manager was asked, Should insects be in the kitchen? She stated, No. 20. A Pest Control Invoice, provided by the Administrator on 8/27/19 at 2:09 p.m. documented a date of service of 8/23/19 documented, . Basic service for crawling insects . Inspected/serviced exterior rodent bait stations .Interior fly service . 21. The Hand Washing Policy provided by the Dietary Manager on 8/27/19 at 2:17 p.m. documented, .The facility will practice safe food handling and avoid cross contamination through proper and adequate hand washing techniques . Employees are required to wash hands: Upon entering the food service area at the beginning of each shift . Before and after handling raw meat, poultry . touching the hair, face or body . 22. The facility's Policy, titled Pest Control Program, provided by the Administrator on 8/27/19 at 2:09 p.m., documented, .Facility will maintain an effective pest control program that eradicates and contains common household pests . 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. (such as) flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations .

Based on observation, record review and interview, the facility failed to ensure the blinds were free of a dust build-up on 2 (200 and 300 hall) of 3 halls, exterior door on the 200 hall, did not have a space/gap underneath the emergency door to prevent exposure to any elements from outside to provide for a clean and sanitary environment. This failed practice had the potential to affect 20 who resided on 2 (200 and 300 Halls) of 3 halls according to a list provided by the Administrator on 8/28/19 at 3:21 pm. The findings are: 1. On 8/26/19 at 2:22 p.m., the emergency exit door, on the 200 hall had a space measuring approximately 31 inches long approximately 3/4 inches wide creating a gap with the sunlight beaming underneath the door. 2. On 8/27/19 at 1:40 p.m., the blinds in the window of Resident room [ROOM NUMBER] had a 1/4 inch layer of dust on them. 3. On 8/27/19 at 1:42 p.m., Certified Nursing Assistant (CNA) #2 was asked, when are residents room cleaned? CNA #2 stated, They usually clean them when the residents go to lunch. 4. On 8/27/19 at 1:43 p.m., the blinds in the window of room [ROOM NUMBER] had a 1/4 inch layer of dust on them. 5. On 8/27/19 at 1:45 p.m., the blinds in the window of room [ROOM NUMBER] had a 1/4 inch layer of dust and spider webs on them. 6. On 8/27/19 at 1:48 p.m., Housekeeper #1 was asked, When do you clean the blinds in the resident's rooms? Housekeeper #1 stated, About once a week. Housekeeper #1 was asked, Can you tell me what is on the blinds in Resident room [ROOM NUMBER]? Housekeeper #1 stated, spider webs and dust. 7. On 8/28/19 at 3:14 p.m., the Administrator was asked, Could a rolling walker get caught in the crack on the floor and cause a resident to fall? The Administrator stated, Yes. The Administrator was asked, Should there be a crack/gap where the floor and door should meet? The Administrator stated, No. The Administrator was asked, what could happen with the crack under the door. The Administrator stated, Air, rain, it could make it slick and a snake could get in. The Administrator was asked, Could the missing cap on each end of the railing on the 200 Hall have the potential to cause a skin tear? The Administrator stated, Yes.

Based on observation and interview, the facility failed to ensure the environment was free of potential accident and hazards as possible, as evidenced by the failure to ensure molding was in good repair and free of sharp, jagged edges and floors were level and without cracked/indented and damaged tiles to reduce the potential of injury on 1 (200 hall), surge protectors were free of a build-up of a ¼ or greater layer of dust to prevent the potential for fire hazard for residents who resided on 3 (100, 200 and 300 hall), exterior door did not have a gap to prevent the potential of entry of outside hazards. This failed practice had the potential to affect 20 who resided on 2 (100 and 200 Halls) according to a list provided by the Administrator on 8/28/19 at 3:21 pm. The findings are: 1. On 8/26/19 at 2:17 p.m., approximately 16 feet of hard plastic molding was attached to the wall on the 200 hall. An approximate 12 inch area of the molding was open on each end of exposing sharp edges and screws. 2. On 8/26/19 at 2:20 p.m., an area of flooring on the 200 hall, measuring approximately 8 feet, had a 1 inch deep indention. 3. On 8/27/19 at 10:19 a.m., a multiple outlet surge protector extension cord was on the floor plugged into the wall between the bed and the bedside table with a thick layer of dust covering the area of the outlets on the 200 hall. The surveyor took a photo. 4. On 8/27/19 at 1:58 p.m., the Administrator was asked to look at the extension cord, He stated, It is a surge protector. The Administrator was asked what is on it. He stated, It is dirty, I will have that cleaned. I will replace it. He was asked what is the potential with all the dust on it. He stated, Potential for fire . 5. On 8/28/19 at 3:35 p.m., a non-sampled resident was walking down the 100 Hall by the Social services office. The resident was using a rolling walker. The resident stumbled into the right hand rail. The floor tile where the incident happened sloped downward approximately 5 degrees The floor beneath the tile was uneven. 6. At 3:37 p.m., the Administrator was asked to measure the area. The Surveyor showed the Administrator the slope in the floor and explained a resident almost fell while pointing out the resident who used a rolling walker. After measuring the area he stated, It has 1/2 inch wide and 48 1/2 inches length. He then stated, We are working a remodel but we will have to do something temporary until the other flooring goes down.

Based on observation, record review and interview, the facility failed to ensure the nutritional interventions that were developed to maintain nutritional parameters were consistently implemented and reviewed for effectiveness to prevent further weight loss for 1 of 1 (Resident #4) case mix resident with weight loss and for 1 of 1 (Resident #3) case mix resident who had a severe weight loss and failed to ensure weight loss was promptly identified and communicated to the interdisciplinary team, the Registered Dietitian (RD) was provided with accurate weights to conduct nutritional assessments, screening for swallowing problems was conducted and documented and the RD's recommended interventions were communicated to the interdisciplinary team to prevent further weight loss for 1 of 1 (Resident #3) case mix resident who had a severe weight loss. This failed practice resulted in a pattern of actual harm for Resident #3 who experienced a severe weight loss of 9.47 % in one month and had the potential to cause more than minimal harm for 18 residents who had weight loss, according to a list provided by the Assistant Director of Nursing (ADON) on 12/10/15 at 9:55 a.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/15 documented the resident reentered from an acute care hospital 10/26/15, was independent in cognitive skills for daily decision making per staff assessment for mental status, required extensive physical assistance of one person for eating, had an active [DIAGNOSES REDACTED]. a. The resident's Weight Change History provided by the Assistant Director of Nursing (ADON) on 12/10/15 documented the resident's weight for 5/1/15, 6/1/15 and 7/1/15 as 221 pounds. b. The Monthly Weights form for August 2015 documented, 8-1-15 . (weight) R (refused) . (Resident #3) . The Departmental Notes Nurse entry dated 8/12/15 at 2:37 p.m. documented, .Resident states to staff CNA (Certified Nursing Assistant) that she has trouble swallowing some of the food and coughing when she eats. Resident refused lunch. Request form for ST (Speech Therapy) to screen complete. Will continue to observe and provide care as needed. As of 12/9/15 at 4:39 p.m., there was no documentation the physician was notified or that a Speech Therapy consult was requested at this time. c. The resident's Weight Change History provided by the ADON on 12/10/15 documented the resident's weight on 9/1/15 as 217 pounds (loss of 4 pounds since last recorded weight in July). 1) The Departmental Notes Nurse entry dated 9/1/15 at 4:22 a.m. documented, resident complains of stomach feeling (gassy) and just not right bowel movements not normal gets sick at stomach a lot needs to find out (what's) going on. is willing to have egd (esophagogastroduodenoscopy) or (colonoscopy). told her would report to oncoming nurse. The Department Notes Nurse entry dated 9/1/15 at 11:34 p.m. documented, alert (times) 3 still having trouble with stomach pain more in left lower (quadrant). did have bowel movement feels some better but still feel like something not right. called (physician) orders given for cbc (complete blood count), bmp (basic metabolic panel), and to start [MEDICATION NAME] 500 mg (milligram) for 7 days . low grade fever down now . 2) The Departmental Notes Nurse entry dated 9/4/15 at 7:45 p.m. documented, cont (continues) to take [MEDICATION NAME] for abd (abdominal) pain. Resident is going to take the weekend to think about doing a colonoscopy. Understands the procedure just afraid she (would not) be able to drink 'that nasty stuff that clean you out'. 3) The Departmental Notes Nurse entry dated 9/22/15 at 6:54 a.m. documented, Resident pulled emergency light in restroom, upon entering resident was on the commode, appeared (diaphoretic), clammy skin and altered LOC (level of consciousness) . Voiced complaint of pain radiating up neck, Resident sated, 'I want to go to the hospital' .transported resident to (hospital) . Resident has been admitted and is being monitored . The Departmental Notes Nurse entry dated 9/22/15 at 6:31 p.m. documented, Resident arrived per ambulance at 1730 (5:30 p.m.) . readmitted to facility . Generalized weakness. Gait weak . Regular diet, thin liquids . The Consultant Dietitian Report dated 9/22/15 was provided by the Dietary Manager on 12/9/15 and contained no documentation of a dietary progress note or recommendations for Resident #3. 4) The Departmental Notes Nurse entry dated 9/25/15 at 2:03 p.m. documented, Resident did not eat lunch this shift. Resident noted to eat own personal snacks in room. 5) The laboratory report collected on 10/1/15 at 5:49 a.m. and reported on 10/2/15 at 12:50 p.m. documented, Total protein 5.1 (low) . (reference range) 6.8 - 8.5 . [MEDICATION NAME] 3.1 (low) . (reference range) 3.5-5.2 . 6) The Departmental Notes Nurse entry dated 10/4/15 at 12:01 a.m. documented, Res (Resident) received (lying) in bed with eyes closed. took a moment to awaken her. Decrease in mobility noted. Used to do own ADL's (activities of daily living) with minimal assist. decline noted. is using c/l (call light) for help to BR (bathroom). Weak. Nurses reviewed her meds with her. Reported to have decrease in appetite and staying in room to eat now . d. The Monthly Weights form for October 2015 documented, 10-5-15 . (weight) R (refused) . (Resident #3) . 1) The Departmental Notes Nurse entry dated 10/19/15 at 11:44 p.m. documented, continues to be confused but not as confused as last 2 nights. still complaining of not feeling well says stomach feels sick but not throwing up sick just feels bad . received ua (urinalysis) will have lab draw in (a.m.). 2) The Departmental Notes Nurse entry dated 10/20/15 at 1:08 p.m. documented, .Resident has refused to eat breakfast . and lunch times three . Staff educated resident about the importance of eating regular meals. Offered to get her something else to eat from kitchen. She refused. Refused [MEDICATION NAME]. Resident appears weak. Fluids offered and accepted . The Departmental Notes Therapy entry dated 10/20/15 at 4:57 p.m. documented, .completed eating with SBA (stand by assist) . reported feeling weak . had difficulty sitting up right to eat lunch . 3) The Departmental Notes Nurse entry dated 10/25/15 at 12:36 a.m. documented, AT 0010 (12:10 a.m.) CNA notified this nurse that resident was requesting a tylenol stating she had a 'terrible headache.' . (blood pressure) 220/120 . (physician) notified, sent to (hospital) . The Department Notes Nurse entry dated 10/25/15 at 2:50 a.m. documented, .resident has had a stroke and is being transferred to (metropolitan city) for neurology coverage . e. The resident's Weight Change History provided by the ADON on 12/10/15 documented the resident's weight on 10/26/15 was 197 pounds (loss of 24 pounds since July's recorded weight). 1) The Departmental Notes Nurse entry dated 10/27/15 at 1:52 a.m. documented, resident readmitted at 1930 (7:30 p.m.) (10/26/15) . Offered sandwich but refused . The Department Notes Nurse entry dated 10/27/15 at 11:21 p.m. documented, when this nurse entered residents room observed two trays sitting on bedside table untouched. When asked resident why she hadn't eaten her roommate spoke up and stated 'because this food ain't no good here'. Educated resident on importance of diet and in taking medications . 2) The Consultant Dietitian Report dated 10/29/15 documented, (Resident #3) . Significant Change Assessment . (Summary Nutritional Care) readmitted to facility from hospital. 81 yof (year old female). Current wt (weight) is 217 (pounds). BMI (Body Mass Index) (equals) 34. Diet: regular. Per nursing staff resident prefers soft foods that are easier to eat / chew. PO (by mouth) intake is 25 - 50%. Skin intact. Dx. (Diagnoses) affecting nutritional status: T2DM (Type II Diabetes Mellitus), gout, [MEDICAL CONDITION], [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease), constipation. Supplements: cranberry 425 mg 1 po bid (twice a day), vitamin B12 500 mcg (micrograms) 1 po qd (every day). Recommend: monitor po intake and weight . (Action) (blank) The RD based her assessment on an inaccurate weight, the resident's actual weight was 197 as of 10/26/15 (24 pounds less than the RD documented as a current weight). f. The Monthly Weights form for November 2015 documented, 11-2-15 . R (refused) . (Resident #3) . 1) The Department Notes Nurse entry dated 11/2/15 at 9:26 a.m. documented, Resident refused breakfast this shift. Attempted (times) 3. No intake noted. The Department Notes Nurse entry dated 11/2/15 at 11:04 p.m. documented, Called and spoke to daughter . Also voiced concerns to her about residents lack of appetite. She is not eating. is diabetic. Informed (daughter) that I was going to ask for a (medication) that will increase her appetite . 2) The Departmental Notes Nurse entry dated 11/3/15 at 8:55 a.m. documented, (physician) called this (a.m.) with New Order for [MEDICATION NAME] 15 mg 1 PO QD, order faxed to pharmacy . The Departmental Notes Nurse entry dated 11/3/15 at 9:26 a.m. documented, .breakfast served, resident eat a few small bites of (biscuit) and gravy and three bites oatmeal. Was drinking coffee when this Nurse left the room . 3) The Departmental Notes Nurse entry dated 11/4/15 at 7:46 p.m. documented, .is encouraged to eat due to loss in (appetite) . 4) The Departmental Notes Nurse entry dated 11/5/15 at 11:24 p.m. documented, still not her self weak. not as active still not eating good refused snack . 5) The Departmental Notes Nurse entry dated 11/6/15 at 1:17 p.m. documented, Attempted to call daughter . to discuss residents weight loss . The Care Plan dated 11/6/15 documented, .Problem onset: 11/06/2015 . I have lost weight recently, family is aware due to change in physical decline . Goal: I will eat at least 50% of all meals . I will maintain my healthy weight . (Approaches) Dietician to evaluate my current nutritional status . Maintain my current listing of food likes and dislikes . Offer me food alternatives when appropriate for any meal served . Provide me with verbal encouragement / cueing . I am a slower eater. Allow me sufficient time to feed myself . Provide attractive setting with socialization opportunities for meals . Weigh me weekly . Weigh me monthly . Invite my family / friends to visit at mealtime to assist with encouraging intake . (Assist) me with between meal snacks that I keep in my room my daughter brings . OT (occupational therapy) to evaluate me for my adaptive equipment needs for self feeding per orders . Observe for changes in my condition that may warrant increased supervision / assistance with nutritional intake and notify the physician. 6) The Departmental Notes Nurse entry dated 11/8/15 at 11:12 a.m. documented, .Resident refused breakfast despite encouragement from staff. She did not want a different tray . Staff continually encourages resident to eat . 7) The Departmental Notes Nurse entry dated 11/9/15 at 5:53 a.m. documented, FSBS (finger stick blood sugar) 77 discussed with resident importance of eating breakfast, ask resident if (she) was eating good and she said oh yes . 8) The Departmental Notes Nurse entry dated 11/10/15 at 10:41 a.m. documented, Resident noted to sit up and eat oatmeal this morning at breakfast . 9) The Departmental Notes Nurse entry dated 11/12/15 at 9:45 a.m. documented, Resident refused Breakfast this morning, Resident stated, 'I feel worthless', closed her eyes and rolled over . 10) The Standards of Care dated 11/13/15 documented, Wt. (weight) unstable. has had a 31 lb. (pound) wt. loss in 6 mo. (months) current weight is 190 lbs. starting house supplement bid (twice a day). She was on [MEDICATION NAME] for appetite stimulation but it was discontinued. The Departmental Notes Nurse entry dated 11/13/15 at 9:55 a.m. documented, Resident refused breakfast this shift. Stated 'I just can't eat anything this morning'. Attempted (times) 3. No intake noted. The Departmental Notes Nurse entry dated 11/13/15 at 9:20 p.m. documented, resident did not eat any of her evening meal and refused any snacks. (held) [MEDICATION NAME] per resident request of not eating . fsbs 117 . 11) The Departmental Notes Nurse entry dated 11/14/15 at 9:38 a.m. documented, Resident refused breakfast this shift. Attempted (times) 3. No intake noted. The Departmental Notes Nurse entry dated 11/14/15 at 1:12 p.m. documented, Resident did not eat any lunch. Only drank half of her 2% milk. Encouraged resident to eat. No further intake noted . 12) The Consultant Dietician Report dated 11/17/15 documented, (Resident #3) . Progress Note Weight . (Summary Nutritional Care) Current wt is 197 (pounds). BMI (equals) 30.9. Wt loss of 10.86% in 6 months. Regular diet. PO intake is 25%. Skin intact. Dx affecting nutritional status: GERD, T2DM, [MEDICAL CONDITIONS](hypertension). Meds affecting nutritional status: [MEDICATION NAME] 55 units sq (subcutaneous) q (every) hs (hour of sleep), [MEDICATION NAME] s/s (sliding scale). Per nursing staff resident does not eat a lot of her food but said that she would eat chicken noodle soup. Recommend: add chicken noodle soup to lunch and dinner tray, continue to monitor po intake and weight . (Action) Diet Order Change To: add 1 bowl of chicken noodle soup to lunch and dinner . Tray Card . Care Plan . The RD based her assessment on an inaccurate weight, the resident's actual weight was 190 as of 11/13/15 (7 pounds less than the RD documented as a current weight). The Departmental Notes Nurse entry dated 11/17/15 at 1:53 p.m. documented, Resident refusing lunch. CNA (Certified Nursing Assistant) reports that resident states 'It is hard for me to swallow'. Denies pain or irritation to throat or any other area. Will continue to observe for changes . Resident offered alternate meal and refused . As of 12/9/15 at 4:39 p.m., there was no documentation the physician was notified or that a Speech Therapy consult was requested at this time. g. The resident's Weight Change History provided by the ADON on 12/10/15 documented the resident's weight on 11/18/15 was 190 pounds. 1) The Departmental Notes Nurse entry dated 11/18/15 at 4:02 p.m. documented, Staff failed to complete lunch kiosk. Resident stated, 'I ate half of my jello'. The Departmental Notes Nurse entry dated 11/18/15 at 4:06 p.m. documented, Resident refused breakfast times three. Resident was offered an alternative, refused. The Departmental Notes Nurse entry dated 11/18/15 at 11:59 p.m. documented, At 2015 (8:15 p.m.) I was called into residents room by staff . pooling red discharge on the bathroom floor along with the residents brief soaked with the same red discharge. Further observation determined it was coming from the rectum . called . EMS (emergency medical services) for transport . Resident left facility at 2030 (8:30 p.m.) . 2) The Departmental Notes Nurse entry dated 11/22/15 at 3:39 a.m. documented, .BS (bowel sounds) present (times) 4, encouraged resident to consume more fluids to aide in bowel elimination . The Departmental Notes Nurse entry dated 11/23/15 at 10:15 p.m. documented, Late Entry - Resident arrived at facility via ambulance at 1830 (6:30 p.m.) . h. The Month at a Glance Weekly Weights form documented, (Resident #3) . 11-23-15 . (weight) R (Refused) . 1) The Departmental Notes Nurse entry dated 11/24/15 at 1:59 a.m. documented, Resident continues to improved, however refused to eat dinner. Roommate ate resident's tray. Resident did however eat some sliced peaches and a banana . The Departmental Notes Nurse entry dated 11/24/15 at 1:20 p.m. documented, Written order from (physician) to DC (discontinue) [MEDICATION NAME] and [MEDICATION NAME] . The December 2015 Physician order [REDACTED]. House supplement 4 oz (ounce) po BID with Med Pass . Document consumption . 2) The Departmental Notes Nurse entry dated 11/26/15 at 2:43 p.m. documented, Resident refused to eat breakfast this shift. Also refused most of lunch ate a slice of cherry pie and drank half a glass of tea. Spoke with resident about the need to eat, resident stated she 'just couldn't eat she felt like she'd get sick and throw it back up'. 3) The Departmental Notes Nurse entry dated 11/27/15 at 1:22 p.m. documented, Resident was (visited) by her daughter who brought food both the resident and (roommate). Upon entering the room after the daughter had left, staff observed the roommate eating residents food as well as his own. Resident stated 'I was just not hungry' however, when offered sliced peaches resident happily took them and ate them. It is beginning to be an issue with roommate eating the residents meals. Will observe further note any changes. i. The Month at a Glance Weekly Weights form documented, (Resident #3) . 11-28-15 . (weight) (blank) . 1) The Departmental Notes Nurse entry dated 11/29/15 at 12:24 p.m. documented, (At) 0800 (8:00 a.m.) resident refused House supplement stating 'it taste so yuck and makes my stomach hurt (I'm) not going to drink that you might as well pour it out'. LPN (Licensed Practical Nurse) encouraged resident to try and drink it due to decrease in appetite and weight loss. After several attempts Resident continue to refuse supplement. Resident agreed to eat some fruit instead and consumed half a cup of peaches . 2) The Departmental Notes Nurse entry dated 11/30/15 at 9:12 a.m. documented, Resident refused breakfast and house supplements after several attempts to get resident to eat. Alternate food offered and declined. The Departmental Notes Nurse entry dated 11/30/15 at 4:53 p.m. documented, Resident refused lunch today at 1200 (12:00 p.m.). Alternate meals offered and refused. At 1400 (2:00 p.m.) resident ate (approximately) half a cup of peaches and drank a glass of milk . j. The resident's Weight Change History provided by the ADON on 12/10/15 documented the resident's weight on 12/1/15 was 186 pounds. 1) The Departmental Notes Nurse entry dated 12/2/15 at 12:18 p.m. documented, Resident refused breakfast this shift. Noted to eat a few bites of mixed fruit cup . 2) The Departmental Notes Nurse entry dated 12/3/15 at 9:47 a.m. documented, Resident refused breakfast. consumed approximately half a cup of mixed fruit . House supplement offered and refused at this time. Resident states she does not like them and will not drink them . The Departmental Notes Nurse entry dated 12/3/15 at 1:03 p.m. documented, Resident refused lunch. Resident ate a few bites of mixed fruit and drank a glass of milk after several attempts of encouragement per (Licensed Practical Nurse) for resident to try and eat something . 3) The December 2015 Physician order [REDACTED]. Fortified Foods TID (three times a day) with meals. 4) The Departmental Notes Nurse entry dated 12/5/15 at 2:47 p.m. documented, Resident continues to have poor appetite. Alternate foods offered but refused. Resident states she is not hungry. this nurse encouraged resident to eat a snack but resident refused . will continue to observe. 5) The Departmental Notes Nurse entry dated 12/6/15 at 10:33 a.m. documented, Resident refused breakfast this shift. This nurse tried to encourage resident to eat something off of tray and get an alternate tray but resident refused . staff will continue to encourage and observe . The Departmental Notes Nurse entry dated 12/6/15 at 2:16 p.m. documented, Resident refused lunch, due to increase of resident refusing meals, new order obtained for stat CBC, BMP . The Departmental Notes Nurse entry dated 12/6/15 at 5:30 p.m. documented, Resident refused medications at 1600 (4:00 p.m.) (times) 3 attempts. Resident stated she did not feel like she could hold them down. Fluids encouraged and tolerated. On coming staff made aware of residents status. k. The Month at a Glance Weekly Weights form for December 2015 documented, (Resident #3) . 12-7-15 . (weight) R (refused) . 1) The Departmental Notes Nurse entry dated 12/7/15 at 5:44 p.m. documented, Resident continues to have poor appetite at meals. Alternate meal choices offered. Poor intake noted . Will continue to observe. 2) The Departmental Notes Nurse entry dated 12/8/15 at 10:13 a.m. documented, Resident refused breakfast at 0700 (7:00 a.m.) Spoke with (physician). New orders to start [MEDICATION NAME] 15 mg one po every HS (hour of sleep). Multivitamin one po QD and one time dose of Potassium 40 meq (milliequivalent) today only and to recheck potassium level next lab day (12-10-15) were received . The Departmental Notes Nurse entry dated 12/8/15 at 12:49 p.m. documented, Resident reluctant to take noon meds. Agreed to take after several attempts by the nurse. Resident refused lunch and alternate food offered . The December Physician order [REDACTED]. [MEDICATION NAME] 15 mg tablet 1 tab PO Q HS (Anorexia / Depression) . 12/08/15 . Multivitamins Tablet 1 tab PO QD . On 12/8/15 at 12:49 p.m., the resident's lunch tray was delivered to her room. She was served a bowl of pinto beans, 3 pieces of cornbread, a bowl of ice cream and a bowl of chocolate pudding. There was no fortified food or chicken noodle soup served to the resident. The resident refused to eat the meal. The lunch and supper tray cards provided by the Food Service Supervisor on 12/10/15 documented, Food Dislikes . All Beans . On 12/8/15 at 5:59 p.m., the resident's supper tray was delivered to her room. The resident was served a barbecue rib patty on a bun, Macaroni and Cheese, Green Beans, Chocolate cake with icing and a bowl of ice cream. There was no fortified foods or chicken noodle soup served. The lunch and supper tray cards provided by the Food Service Supervisor on 12/10/15 documented, Food Dislikes . Green Beans . 3) The Departmental Notes Nurse entry dated 12/9/15 at 12:37 a.m. documented, Resident did refuse supper this shift. Staff asked if there was anything resident would want to eat. She stated, 'fruit like peaches' CNA brought available fruit to bedside and resident said she would not be able to eat. Encouraged resident to eat snacks at bedside and to ask for assistance with anything. States to this nurse 'I did eat a couple of saltine crackers a bit ago'. On 12/9/15 at 3:20 p.m., the resident was asked if she thought she could eat some soup. She stated, I like soup, but I don't think they have any. Chicken Noodle is the only kind I can eat. At this time, CNA #1 stated, She loves soup. I try and make lists of things the residents like to eat and when they go shopping they can pick them up for them. The surveyor stated, The facility should be providing the soup. CNA #1 stated, They don't though. We have people all the time at night wanting something to eat but the kitchen is locked and we can't get anything. She did say the facility did have snacks but it was sweet foods. At 4:30 p.m., the resident was served a bowl of chicken noodle soup by the Dietary Manager. When asked if she was going to eat soup she stated, Oh yea, I'm going to try it. May take me a while but I'm going to try. I like the broth mostly. At 5:35 p.m., when asked how she liked the soup, she stated, I didn't; it's not (brand name). I like plain old chicken noodle soup. The resident did eat 1/2 of a serving of peaches. On 12/9/15 at 4:50 p.m., the Assistant Director of Nursing (ADON) was asked, When the dietician comes, does she give you a list of her recommendations? She stated, No, I read the Nurse's notes and get the information. She was asked, How do you know who she saw? She stated, I don't unless she makes a note. The ADON was asked, How do you know what notes to read? She stated, I pull up everybody's notes and hers are in there. This is done daily as part of our stand up. She was asked, You do not get a list of who she sees? She stated, No, (food service supervisor) may get a print out. The ADON was asked, Does she share this with you? She stated, No. The ADON was asked, How do you monitor the weights? She stated, I fill out a form for monthly or weekly weights. I put the weights in the computer. On 12/9/15 at 4:50 p.m., the DON stated, We also have IDT (interdisciplinary team) meetings to discuss the weight loss. The DON, Administrator, Treatment Nurse, Dietary Manager and Director of Clinical Education are on the team. She was asked, If you notice a weight loss what do you do? She stated, We fill out a weight loss form, we print the physician orders, make copies of recent labs and call the doctor, then send him the information. If he gives a new order we write it. She was asked, If you see that an intervention is not working what do you do? She stated, Usually the nurses will let us know and we will try something different. If there is any success at all, we don't discontinue the intervention because calories are calories, someone might drink a few sips or eat some of one. She was asked, How often do you review the weights when you notice a loss? She stated, We do weekly weights, once we notice the loss but she (Resident #3) often refuses. Restorative gets the weight she will try multiple times to get her to weigh. The ADON stated, I filled out a clinically unavoidable weight loss form on her this week. We just got it back today. The facility provided a copy of an Identifying Clinically Unavoidable Weight Loss form dated and signed by the physician on 12/8/15. She was asked, Why do you think her weight loss is clinically unavoidable? She did not answer the question. She was asked, What other methods of nourishment have you offered her? She stated, Like the house supplements. She refuses these. The staff is always trying to get her to eat a multitude of different things. The Administrator stated, Someone went to the store the other day and got her a can of chicken noodle soup. She was asked, Did she eat that? She stated, She ate some of it. The DON was asked, When was the last time (physician) saw the resident? She stated, He usually comes in and does monthly rounds on Sundays, every once in a while he will come during the week, but mostly Sundays. He wrote orders on 11/24/15. She was asked, Was he aware of the weight loss? She stated, Yes. She was asked, Did you do a weight loss form for the 20 pound loss from September to October (2015)? She stated, When trigger monthly, it goes for 30 days so it doesn't always show, like if she was weighed on 11/20 the dates go from 11/1-12/1 so it wouldn't pick up a loss. It is not the best system. 4) On 12/10/15 at 9:00 a.m., the resident's physician was asked, Are you aware of the 35 pound weight loss on (Resident #3)? He stated, Yes, they communicated that to me. There are orders in place, the Registered Dietician has consulted, she has supplements ordered. I think part of the problem is that she has no appetite, doesn't like food, she has diabetes and it is a desirable weight loss. He was asked, Have they told you about her swallowing concerns? He stated, Yes, she had a colonoscopy last month and I told them to refer her to the GI (gastrointestinal) doctor that did the colonoscopy. He was asked, When did you do this? He stated, I think we talked about it in the last day or so. The Physician order [REDACTED]. On 12/10/15 at 9:10 a.m., Therapy Worker #1 was asked, Did you ever do an ST (speech therapy) screen on (Resident #3 )?She stated, I did not find that form or the screen in our files. She was asked, Should the form be in your files if it was done? She stated, If they completed it. The Speech Therapist is due here today and I will get with her to see if she can find it. On 12/10/15 at 9:15 a.m., the ADON stated, We did not detect the weight loss until 11/3/15. She was asked, If a resident refuses to be weighed do you document anywhere that you attempted again to weigh the resident? She stated, No. On 12/10/15 at 9:25 a.m. the resident was asked, How many times have you told them you had trouble swallowing? She stated, Every day. It is just a big wad of spit I guess, or a lump that won't go away. She was asked, Who did you tell? She stated, All the CNAs and LPNs. She was asked, Did they do anything for you about the swallowing? She stated, No. She was asked, Do you know how long you've noticed this problem with swallowing or lump in your throat? She stated, About 3 months. She was asked, Do you have any pain in this area? She stated, I used to have quite a bit with my tonsils. She was asked, Have they ever offered to get you an EGD or other tests and you refused? She stated, They've never done anything, that I know of . Everything tastes so bitter I can't stand it. On 12/10/15 at 10:15 a.m., Therapy Worker # 2 was asked, Did you do a screen for ST on (Resident #3)? She stated, No ma'am, not in August. There was one done right before she went to the hospital on 11/19(15). It was verbal. She was asked, Did you do the screen? She stated, I spoke to the nurse, yes she explained everything that was going on, she told me that she had not been eating very much. I think she had had a weight loss, but not coughing or choking. She wanted me to know about it. I made sure no choking or signs of aspiration and told her to document it all for me, as long as no choking to talk to the doctor about an appetite stimulant. She was asked, Did she ever mention to you that she complained of a lump in her throat? She stated, Not that I recall. She was asked, Has anybody ever told you about a lump? She stated, Not that I remember. On 12/10/15 at 10:55 a.m., the Food Service Supervisor was asked, Have you assessed the resident for her weight loss? She stated, My RD did. She was asked, Were you aware of her weight loss? She stated, Just recently in the last couple of weeks. She was asked, What did you recommend to do after you were made aware of the loss? She stated, We talked to resident about her likes and dislikes. She was asked, When you get the dietary recommendations what do you do with them? She stated, I go over them with the Administrator and we follow up with that. She was asked, How do you let nursing know of any recommendations? She stated, We go over them in QA (Quality Assurance) meetings? She was asked, Have you been sending the chicken noodle soup for lunch and dinner as recommended on 11/17/15? She stated, I was just made aware of that when we pulled the RD reports on 12/9/15. She was asked, Why haven't you been sending it? She stated, Did not know the recommendation was there. She was asked, How come you did not know the recommendation was there? She stated, I don't know if we just overlooked it or what. l. On 12/10/15 at 11:30 a.m., the Restorative Nursing Assistant (RNA) weighed the resident at the surveyor's request. The weight was 172 pounds; a 14 pound loss since 12/1/15. On 12/10/15 at 12:10 p.m., the DON was asked, Was this a planned or desirable weight loss? She stated, I don't perceive it as (a planned weight loss). No. She was asked, What type of assessment do you have for a planned weight loss? She stated, The RD will come in and set up a diet plan with them, go over the amount of calories they need, monitor weights. The DON was asked, What type of limitation do you set, or do you, for desirable weight loss? She stated, Yea, don't want them to go below their normal BMI. <b

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure residents were free from verbal and mental abuse for 1 (Resident #1) of 1 case mix resident who was the victim of a founded issue of staff-to-resident verbal and mental abuse. The facility failed to ensure resident protection from abusive behaviors of staff, as evidenced by the facility's failure, after identifying staff-to-resident abuse for Resident #1, to develop and implement an action plan to monitor staff/resident interactions and allow management to quickly identify abusive situations and to promptly protect residents. This failed practice resulted in actual harm for Resident #1, who was verbally and mentally abused and threatened with theft of personal belongings, and had the potential to affect all 60 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 7/1/15. The findings are: Resident #1 was admitted [DATE] and discharged to the hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/15 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); had behaviors directed towards others; required extensive assistance of 3 person for bed mobility, transfers and personal hygiene; and was mobile per electric or manual wheelchair. a. An Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities documented, .Resident :(Resident #1). Date and time of incident: 4/26/15 at 11:00 p.m.date of discovery: 4/26/15 at 11:00 p.m. Reported to the Office of Long Term Care: 4/27/15 at 3:00 p.m. Reported to Law Enforcement: 4/27/15 at 11:00 a.m . Section II - Complete Description of Incident . The next day after (Resident#1) was gone to the hospital, (Licensed Practical Nurse (LPN) #4) her nurse, received a call from her daughter stating that a staff member had 'abused' her mom. I have called all (Resident #1's) children and they don't know what is going on or why (daughter) would say things like this. I have called (daughter) several times about details or her allegation and she has not returned calls. Section III - Findings and Action Taken .Police and family notified of the concern. We removed her roommate, provided one on one care and removed all male staff. Then in the morning, the daughter added her allegation of abuse we removed the NA (Nursing Assistant) in question during the investigation. During the investigation, I could not find anything that led me to believe that anything happened to (Resident #1). She had a confirmed UTI (Urinary Tract Infection) from the hospital and was admitted to the behavior health. All staff will return to work on their next scheduled day. A Staff Inservice Education sign-in sheet dated 4/30/15 documented an inservice titled, Abuse Policy and Procedure was included in the facility's documented investigation and follow-up. b. An Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities documented, .Resident: (Resident #1), Date of Incident: 4/16/15, Date of Discovery: 4/30/15 and Report to the Office of Long Term Care: 5/1/15 at (not timed) . Law Enforcement notified: 4/30/15 at 12:00 p.m. The resident's daughter came to the facility alleging that she has video footage of staff members (Certified Nursing Assistants (CNA) #1 and CNA #2) mentally abusing the resident on or about 4/16/15 and 4/17/15. The daughter stated that the video she watched included both of the above CNAs laughing at her mother openly and made derogatory remarks regarding resident's weight during personal care. The daughter also alleged that (CNA #1) had cursed her mother during care and has threatened to steal her belongings when her mother refused to let her have them which were also witnessed by (CNA #2) according to (daughter). At this time the daughter had allowed myself; DON (Director of Nursing) to view the footage which verified the allegations made by the (daughter). The resident is currently hospitalized in the behavioral health. We called the accused parties into the facility and interviewed them. The accused parties were immediately placed on suspension and escorted from the facility. We notified the Police Department, Administrator, Family and the Physician. We interviewed all cognitive residents regarding whether they had ever witnessed a staff member being mentally abusive to a resident. There were no further negative findings. We began in-servicing all staff on policy and procedures for abuse and abuse reporting. We began obtaining witness statements from all facility staff. A copy of a letter dated 6/8/15 from the Arkansas Department of Human Services / Division of Medical Services documented, .(CNA #1) . Based on reviews of investigations made and information received, the Nursing Assistant Review Committee validated the above allegation and accordingly, is issuing a Founded Report against you. This Founded Report will be entered on the registries if you do not appeal within 30 days, and will prevent your continued or future employment in Arkansas nursing facilities . A copy of a second letter dated 6/8/15 documented the same findings and consequences for CNA #2. c. On 7/2/15 6:00 p.m., the Director of Nursing (DON) stated the facility administration was not aware that the resident's daughter had placed the camera in the resident's room. The DON stated the daughter said the camera was in the room for approximately 2 years. The DON stated she only viewed a small portion of the film. The film was dated incorrectly as, .2045 or some weird date. The DON stated the film did show that the daughter's allegations of abuse were true, that the CNAs were making fun of the resident, laughing at the resident and making fun of her weight. The DON stated on one occasion, the resident needed to be pulled up in bed and the CNAs stated they didn't know if they could pull her up because she was a big lady and one CNA stated she (the CNA) only weighed 105 pounds and they laughed as they attempted to pull her up in bed. The DON stated the CNA did make remarks to the resident about the resident's scarf and that she would come back and steal it. The DON stated the CNAs were immediately suspended and then terminated, the reports were filed with the Office of Long Term Care (OLTC), interviews were conducted and in-services regarding abuse were conducted. The DON stated she was the only one who watched the video and only the portions that involved abuse. The DON stated, (CNA #1) appeared to the aggressor and (CNA #2) was a follower, but did laugh at the resident and failed to report the abuse, therefore she was guilty for not reporting the abuse. c. On 7/17/15 at 1:22 p.m., the DON was asked, .on the video tape from the Nanny Cam when you were viewing the video during the incidents with (CNA #1 and CNA #2), could you see the resident's response during the incident? The DON stated when CNA #1 was talking to the resident about the scarf, asking the resident for the scarf, asking to trade the scarf and then stating to the resident, .that's okay, I'll come back and steal it, that she could not see the resident ' s face or hear a verbal response from the resident on the video. The DON stated when the resident asked to be pulled up in the bed and CNA #1 made the remark that she didn't know if she could because of the resident's weight, she couldn't see the resident ' s face but her (the resident's) verbal response was, Just pull me up in a frustrated tone. The DON stated, When the CNAs were making jarring gestures and silently laughing at the resident behind (Licensed Practical Nurse #3's) back, I could not see the resident's face and did not hear the resident make any verbal remarks. d. On 7/17/15 at 3:30 p.m., the Administrator was asked how the facility prevented abuse with regard to monitoring the care the staff provided for the residents. The Administrator stated they did not know the abuse had occurred. The Administrator was asked how the facility had monitored their staff since this incident. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the staff had been talked to regarding monitoring of the staff-resident interactions. The Administrator stated, No, e. On 7/17/15 at 3:40 p.m., the DON was asked how the facility monitored care to ensure abuse did not occur. The DON stated, We have made visits on the other shifts. The DON was asked if, after becoming aware of the above abusive incidents, the facility had developed any plans to increase monitoring of staff-resident interactions or if she had instructed the Nurses regarding monitoring the staff-resident interactions. The DON stated, No.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the prevention section of their Abuse Prohibition Policy and Procedures was fully implemented. The facility failed to ensure resident protection from abusive behaviors of staff, as evidenced by the facility's failure, after identifying staff-to-resident abuse for 1 (Resident #1) of 1 case mix resident who was a victim of staff-to-resident abuse, to develop and implement an action plan to monitor staff/resident interactions and allow management to quickly identify abusive situations and to promptly protect residents. This failed practice resulted in actual harm for Resident #1, who was verbally and mentally abused and threatened with theft of personal belongings, and had the potential to affect all 60 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 7/1/15. The findings are: Resident #1 was admitted [DATE] and discharged to the hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/15 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); had behaviors directed towards others; required extensive assistance of 3 person for bed mobility, transfers and personal hygiene; and was mobile per electric or manual wheelchair. a. An Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities documented, .Resident :(Resident #1). Date and time of incident: 4/26/15 at 11:00 p.m.date of discovery: 4/26/15 at 11:00 p.m. Reported to the Office of Long Term Care: 4/27/15 at 3:00 p.m. Reported to Law Enforcement: 4/27/15 at 11:00 a.m . Section II - Complete Description of Incident . The next day after (Resident#1) was gone to the hospital, (Licensed Practical Nurse (LPN) #4) her nurse, received a call from her daughter stating that a staff member had 'abused' her mom. I have called all (Resident #1's) children and they don't know what is going on or why (daughter) would say things like this. I have called (daughter) several times about details or her allegation and she has not returned calls. Section III - Findings and Action Taken .Police and family notified of the concern. We removed her roommate, provided one on one care and removed all male staff. Then in the morning, the daughter added her allegation of abuse we removed the NA (Nursing Assistant) in question during the investigation. During the investigation, I could not find anything that led me to believe that anything happened to (Resident #1). She had a confirmed UTI (Urinary Tract Infection) from the hospital and was admitted to the behavior health. All staff will return to work on their next scheduled day. A Staff Inservice Education sign-in sheet dated 4/30/15 documented an inservice titled, Abuse Policy and Procedure was included in the facility's documented investigation and follow-up. b. An Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities documented, .Resident: (Resident #1), Date of Incident: 4/16/15, Date of Discovery: 4/30/15 and Report to the Office of Long Term Care: 5/1/15 at (not timed) . Law Enforcement notified: 4/30/15 at 12:00 p.m. The resident's daughter came to the facility alleging that she has video footage of staff members (Certified Nursing Assistants (CNA) #1 and CNA #2) mentally abusing the resident on or about 4/16/15 and 4/17/15. The daughter stated that the video she watched included both of the above CNAs laughing at her mother openly and made derogatory remarks regarding resident's weight during personal care. The daughter also alleged that (CNA #1) had cursed her mother during care and has threatened to steal her belongings when her mother refused to let her have them which were also witnessed by (CNA #2) according to (daughter). At this time the daughter had allowed myself; DON (Director of Nursing) to view the footage which verified the allegations made by the (daughter). The resident is currently hospitalized in the behavioral health. We called the accused parties into the facility and interviewed them. The accused parties were immediately placed on suspension and escorted from the facility. We notified the Police Department, Administrator, Family and the Physician. We interviewed all cognitive residents regarding whether they had ever witnessed a staff member being mentally abusive to a resident. There were no further negative findings. We began in-servicing all staff on policy and procedures for abuse and abuse reporting. We began obtaining witness statements from all facility staff. A copy of a letter dated 6/8/15 from the Arkansas Department of Human Services / Division of Medical Services documented, .(CNA #1) . Based on reviews of investigations made and information received, the Nursing Assistant Review Committee validated the above allegation and accordingly, is issuing a Founded Report against you. This Founded Report will be entered on the registries if you do not appeal within 30 days, and will prevent your continued or future employment in Arkansas nursing facilities . A copy of a second letter dated 6/8/15 documented the same findings and consequences for CNA #2. c. On 7/2/15 6:00 p.m., the Director of Nursing (DON) stated the facility administration was not aware that the resident's daughter had placed the camera in the resident's room. The DON stated the daughter said the camera was in the room for approximately 2 years. The DON stated she only viewed a small portion of the film. The film was dated incorrectly as, .2045 or some weird date. The DON stated the film did show that the daughter's allegations of abuse were true, that the CNAs were making fun of the resident, laughing at the resident and making fun of her weight. The DON stated on one occasion, the resident needed to be pulled up in bed and the CNAs stated they didn't know if they could pull her up because she was a big lady and one CNA stated she (the CNA) only weighed 105 pounds and they laughed as they attempted to pull her up in bed. The DON stated the CNA did make remarks to the resident about the resident's scarf and that she would come back and steal it. The DON stated the CNAs were immediately suspended and then terminated, the reports were filed with the Office of Long Term Care (OLTC), interviews were conducted and in-services regarding abuse were conducted. The DON stated she was the only one who watched the video and only the portions that involved abuse. The DON stated, (CNA #1) appeared to the aggressor and (CNA #2) was a follower, but did laugh at the resident and failed to report the abuse, therefore she was guilty for not reporting the abuse. d. On 7/17/15 at 1:22 p.m., the DON was asked, .on the video tape from the Nanny Cam when you were viewing the video during the incidents with (CNA #1 and CNA #2), could you see the resident's response during the incident? The DON stated when CNA #1 was talking to the resident about the scarf, asking the resident for the scarf, asking to trade the scarf and then stating to the resident, .that's okay, I'll come back and steal it, that she could not see the resident ' s face or hear a verbal response from the resident on the video. The DON stated when the resident asked to be pulled up in the bed and CNA #1 made the remark that she didn't know if she could because of the resident's weight, she couldn't see the resident ' s face but her (the resident's) verbal response was, Just pull me up in a frustrated tone. The DON stated, When the CNAs were making jarring gestures and silently laughing at the resident behind (Licensed Practical Nurse #3's) back, I could not see the resident's face and did not hear the resident make any verbal remarks. e. On 7/17/15 at 3:30 p.m., the Administrator was asked how the facility prevented abuse with regard to monitoring the care the staff provided for the residents. The Administrator stated they did not know the abuse had occurred. The Administrator was asked how the facility had monitored their staff since this incident. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the facility had developed any plans to prevent abuse. There was no answer from the Administrator. The Administrator was asked if the staff had been talked to regarding monitoring of the staff-resident interactions. The Administrator stated, No, f. On 7/17/15 at 3:40 p.m., the DON was asked how the facility monitored care to ensure abuse did not occur. The DON stated, We have made visits on the other shifts. The DON was asked if, after becoming aware of the above abusive incidents, the facility had developed any plans to increase monitoring of staff-resident interactions or if she had instructed the Nurses regarding monitoring the staff-resident interactions. The DON stated, No.

Complaint # was substantiated, (all or in part) with these findings: Based on observation, record review, and interview, the facility failed to implement the Abuse and Neglect Policy and Procedures to ensure Resident #2 was not subjected to sexually aggressive behaviors from a cognitively impaired resident. The facility failed to ensure allegations of resident to resident sexual aggression were immediately reported, investigated, and effective interventions were developed and implemented to ensure protection was provided to prevent further sexual abuse for 1 (Resident #2) of 4 (Residents #2 - 5) female case mix residents, who were cognitively impaired. This failure resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #2 and was likely to cause more than minimal harm for 16 female residents who were cognitively impaired, as documented on a list provided by the Director of Nursing (DON) dated 11/2/11 at 9:30 a.m. The facility was informed of the Immediate Jeopardy on 11/1/11 at 6:45 p.m. The findings are: 1. The facility's abuse and neglect policy and procedure (no effective date given) documented, "...Protection: ...If the suspected perpetrator is another resident, the DON or his/her designee shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined..." 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/8/11 documented the resident scored 6 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), had no behavioral symptoms and required extensive assistance of 1 person for activities of daily living (ADLs). 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/12/11 documented the resident had short and long term memory problems, was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, and exhibited behavioral symptoms such as "other behavioral symptoms not directed toward others (e.g. (for example) physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, disruptive sounds.)" a. Nurses Notes dated 2/2/11 at 1:32 a.m. documented, "Looking at CNAs (Certified Nursing Assistant) times (x) 2. States, 'You want what I got.' making movements up and down with hand over penis. Informed resident that type of behavior was not allowed. States, 'Ok'." b. Nurses Notes dated 2/18/11 at 7:30 a.m. documented, "...sometimes inappropriately places his hands where they don't belong and has to be redirected..." Nurses Notes dated 2/18/11 at 10:53 a.m. documented, "...Has some sexual behaviors and needs to be redirected Resident continues with his [MEDICATION NAME] He has a lady friend that we have to redirect him and her. She thinks he is her husband and he tries to take her to his room and staff redirects them. Resident is under the adult protective service and they come quarterly to see upon him. No plans for discharge." c. Nurses Notes dated 3/15/11 at 10:58 p.m. documented, "Resident was hugging up on other residents in dining room stating he loved them and blowing kisses at them. Resident was being very handsy and inappropriate..." d. Nurses Notes dated 4/8/11 at 8:33 p.m. documented, "Resident was asked where he was going and he stated, 'I'm going to piss.' The CNA did not hear him and ask him to repeat what he said and the resident yelled, 'I'm going to take my dick out and piss!' Redirected resident on his inappropriate language and behavior." e. Nurses Notes dated 5/17/11 at 9:27 p.m. documented, "...Female resident said that (Resident #1) touch her breasts. Resident moved to a private office. ADON (Assistant Director of Nursing) notified and counseled with resident. (Physician) notified via fax. APS (Adult Protective Services) notified of incident. Resident placed on 1 on 1 and was monitored throughout this shift..." On 11/2/11 at 10:30 p.m., the ADON was asked if she could remember this incident. The ADON indicated she could not recall. The ADON stated, "The reason why the staff have been told to separate the two residents is because (Resident #2) was married and they are both cognitively impaired." f. Nurses Notes dated 5/19/11 at 9:53 p.m. documented, "...(Resident #1) is usually a happy person, always throwing staff kisses wants hugs. At times staff has to redirect him when he gets inappropriate behavior, he pouts and goes on..." g. Nurses Notes dated 6/16/11 at 5:36 p.m. documented, "Resident was in dining room (DR) for dinner when CNA noticed resident had his hands down his pants. CNA approached resident and redirected him. Resident got mad and started cursing (at) CNA. Nurse and CNA brought resident to me (at) nurse's station. I talked to resident and got him to calm down and redirected him on his behavior. Resident back in dining room at this time..." h. Nurses Notes dated 8/15/11 at 12:30 p.m. documented, "...Staff has to redirect him away from a female resident, (Resident #1) has to be reminded that we don't do inappropriate things such as touching women..." i. A letter written to the physician dated 8/19/11 and signed by the Director of Nursing (DON) documented, "(Physician), Can you please evaluate (Resident #1)'s [MEDICATION NAME]? He is having more sexual ideations lately. Would he benefit from 20mg?" On 11/1/11 at 5:00 p.m., the DON was asked what sexual ideations was she referring to when she requested Resident #1's [MEDICATION NAME] be increased? The DON stated, "Because he would tell everyone he loved them." She was asked, "But was that an inappropriate sexual behavior?" The DON indicated she was still learning and with the past experiences she had with "State" the DON stated, "I thought I would do something before he got worse." j. The Speech Therapy follow-up Recommendations for Nursing dated 9/6/11 documented, "...Be cautious of leaving (Resident #1's) wheelchair next to another female resident, as he can be inappropriate with females at times." k. On 11/1/11 at 9:30 a.m., a care plan (no effective date given) was copied from the facility's computer. The care plan did not address Resident #1's sexually inappropriate behaviors. On 11/2/11 at 1:40 p.m., the MDS Coordinator (MDSC) was asked why Resident #1's sexually inappropriate behaviors were not addressed on his care plan. The MDS Coordinator reviewed the care plan and made no comments. l. On 11/1/11 at 12:00 noon, Resident #1 was in the dining room at an assisted feeding table. Resident #2 was located approximately 5 feet behind Resident #1. At 12:12 p.m., Resident #2 began to wheel herself, passing Resident #1 out of the dining room toward South hall. There was no staff member in the dining room at this time. Resident #1 unlocked his wheelchair (w/c) and rolled himself beside Resident #2 only inches apart from her. At 12:15 p.m., CNA #2 was bending over, assisting another resident nearby when Resident #1 reached with his left hand and patted CNA #2 on her left buttocks. A staff member assisted Resident #1 back to the assisted table between two female residents. Resident #2 was placed at the same assisted table, but was placed directly across from Resident #1. At 12:20 p.m., Resident #1 began to wheel himself back from the table. At 12:35 p.m., an aide pushed the resident back to the table and locked his wheelchair in place. At 12:37 p.m., Resident #1 unlocked his w/c and moved away from the table. At 12:45 p.m., Resident #1 received his lunch tray and a CNA began to feed him. At 1:00 p.m., the UFM (Unrelated Family Member) #2 stated as she passed by, "There is never this many people in this dining room." m. Interviews were conducted regarding the resident's sexually aggressive behaviors: 1) On 11/1/11 at 9:00 a.m. during a telephone interview, Unrelated Family Member #1 (UFM #1) stated, "I go to the nursing home every day and feed my husband at lunch and supper. I've seen (Resident #1) put his hands on about every female down there. I've seen him put his hands on (Resident #2), around her back, on her privates. ...It makes me sick, he's so sneaky about it. Her daughter didn't know about it until we told her. We got onto him about it. We tell him, Get your hands off her. She (Resident #2) doesn't really know what's going on. Her mind is bad. You get on to him about it and he raises his fist at you. I've held both of my fists up at him and said, Well, I've got 2 of these too. He gets mad when you correct him. We've told the nurses, they just tell him to keep his hands to himself ..." On 11/2/11 at 8:47 a.m., UFM #1 stated she attended a family council meeting last month or the month before. She stated, "We mentioned about (Resident #1) fondling Resident #2 and that we didn't like it. (Administrator) stated they're residents too, they have rights. We told her but she's married to...The UFM #1 also commented that they (staff) caught him (Resident #1) taking her (Resident #2) down the hall to try to get in the bed with him." 2) On 11/1/11 at 9:14 a.m., Unrelated Family Member #2 (UFM #2) was asked if she had ever seen (Resident #1) touch female residents in a sexual inappropriate manner? UFM #2 stated, "I haven't seen him touch anyone but that one woman, (Resident #2) ... They (staff) will bring that lady (Resident #2) out to the dining room and park her out there in one area ... (Resident #1) will wheel right up to her... He takes his hand straight to her crotch and plays with it. I thought... that can't be happening. When he thinks we're not looking, he will do it again. I started telling him to stop, get away from her. He'd roll away but then he'd just come back. We had a meeting about 2 months ago with the Administrator. The meeting was with family members who have loved ones out there. She (Administrator) wanted to ask those at the meeting if there were any complaints. Me and a few others told her we had a problem with (Resident #1) touching (Resident #2). (Administrator) told us they have their rights... But she (Administrator) said, they have rights and that we couldn't say anything about it." UFM #2 was asked, "When was the last time you saw (Resident #1) do this to (Resident #2)?" UFM #2 stated, "About a week ago." UFM #2 was asked if (Resident #1) has gone inside (Resident #2's) pants. UFM #2 stated, "No, nothing inside, just the hand massaging it just before we yell at him. I watch him like a hawk, while I'm there. About a month ago, I said (Resident #1) if you don't stop doing that to her I'm going to call the police. He just got mad and took off down the hall. One day I got on to him and told him, you need to leave her alone, get your hands away from her. He goes around and tells everyone he loves everyone. I know he's retarded ..." 3) On 11/1/11 at 9:43 a.m., Non-case mix Resident #1 (NCR #1) was asked, "How long have you lived here?" She stated, "About a month." NCR #1 was asked, "Do you eat in the dining room?" NCR #1 stated, "Yes." She was asked, "Have you observed anything in the dining or elsewhere that you feel is inappropriate, such as male or female residents touching each other?" NCR #1 stated, "(Resident #1). (Resident #1) touches women." NCR #1 was asked who does he touch? NCR #1 stated, "(Resident #2)." She was asked, "How does he touch her?" NCR #1 stated, "He puts his hand on her leg." NCR #1 was asked how does he do that. NCR #1 stated, "He rolls over to her." NCR #1 was asked, "Does staff know he does that?" NCR #1 stated, "I don't know." NCR #1 was asked, "When was the last time you saw him do this?" NCR #1 stated, "Probably 3 days ago." 4) On 11/1/11 at 9:50 a.m., Resident #5 was asked, "How long have you lived here?" She stated, "Since May." Resident #5 was asked if she ate in the dining room. Resident #5 stated, "Yes." Resident #5 was asked if she had seen anything in the dining room that she felt was inappropriate between male and female residents. Resident #5 stated, "(Resident #1)." She was asked what about (Resident #1). Resident #5 stated, "He rubs on (Resident #2)." She was asked how he does that. Resident #5 stated, "On her legs." She was asked what does the resident do when he does that. Resident #5 stated, "Last time she took his hand and moved it away." She was asked when that was. Resident #5 stated, "Last week. He used to not be that way." 5) On 11/1/11 at 11:50 a.m., Unrelated Family Member #3 (UFM #3) was sitting in the dining room and she was asked if she'd ever observed anything in the DR that she felt was inappropriate between male and female residents. UFM #3 stated, "I've seen a male resident, (Resident #1), touching a female resident (Resident #2)." She was asked how he touches her. UFM #3 stated, "He puts his hand between her legs." She was asked what does the resident do when he does this. UFM #3 stated, "She just sits there." She was asked what the staff does. UFM #3 stated, "I'm not sure they always see it." She was asked when was the last time she could remember seeing this. UFM #3 stated, "Maybe a week ago." 6) On 11/1/11 at 1:25 p.m., CNA#1 stated, " ...He's (Resident #1) touchy feely, grabs people everywhere. He likes to sit by (Resident #2). The daughter has asked to keep them apart. She's (Resident #2) always following him around. He doesn't realize what he's doing. I was helping one day and he hugged me and tried to pull me into his bed...I don't think he means harm. A family member told me the daughter wants (Resident #2) to be kept away from him. A couple of months ago, (Resident #2) made a statement that she didn't want to get up for meals because (Resident #1) bothers her. He's a friendly type of guy. I've never witnessed anything at all." 7) On 11/1/11 at 1:47 p.m., Resident #2's daughter stated she had attended a care plan meeting on 10/27/11 about her mother (Resident #2). She stated, "When the care plan meeting was over, my aunt who visits my mother weekly told me she wanted to introduce me to this person. Both of these ladies started telling me (Resident #1) was putting his hands down her (Resident #2) pants and this had been going on for a long time, anywhere from 6 months to a year. Since 10/27/11, I told (Ex-Social Director) who is gone now." She was asked if she had reported this to the DON or the Administrator. The daughter stated, " No." 8) On 11/1/11 at 2:15 p.m., CNA#2 was asked when was the last time she observed (Resident #1) being inappropriate. CNA stated, "Today. He touched my butt. I redirected him and told the charge nurse." 9) On 11/1/11 at 2:33 p.m., CNA #3 if she had ever observed Resident #1 have inappropriate behaviors with Resident #2. The CNA stated, "Not that I've seen. He just touches her leg. I've not seen him touch her groin at all. We go and separate them and tell the nurse." She was asked when she saw him touching Resident #2 ' s leg, did it make her feel uncomfortable. She stated, "Yes, we just tell him that is inappropriate." She was asked why it made her uncomfortable. CNA stated, "Well because he always tries to touch us too. When we put him to bed, he will wrap his arms around us, like he puts his body up against you and it makes you feel a little uncomfortable." 10) On 11/1/11 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 was asked if it had been reported to her that Resident #1 had ever touched Resident #2 inappropriately. She stated, "That's been a long time, 6 months or more." She was asked if she remembered what was reported back then. She stated, "That he was touching her breasts." She was asked what was done. She stated, "He was taken to his room." 11) On 11/1/11 at 2:45 p.m., CNA #4 was asked if she had ever observed Resident #1 have inappropriate behaviors with Resident #2. The CNA stated, "(Resident #1) is mentally... not normal. He's real handsy. We say (Resident #1) you're not supposed to do that. With (Resident #2), I see him put his arm around her. I know her family doesn't want that so I move one of them. I've never seen him put his hand in a bad place. He touches her legs." 12) On 11/1/11 at 3:00 p.m., CNA #5 was asked have you observed any inappropriate behavior between male and female residents. She stated, "I haven't seen it, but one of the wives here saw, and asked me to please move (Resident #1) because he was putting his hands down (Resident #2)'s pants. I went and asked (Resident #2) if she was ok and she nodded her head yes." She was asked when it happened. She stated, "This was a couple of weeks ago. An employee went up to him and said, '(Resident #1) you know better than that' and told him if he kept it up they were going to send him off ...It seems like it always happens when we're not in there, because I've seen him touch (Resident #2). He will pat us on the shoulder or the back, but he gets redirected. To be honest, I'm scared to be alone in the same room with him." The CNA was asked who was the person who asked her to move Resident #1. She stated, "(UFM #1)." She was asked, since (Resident #1) has a history of inappropriately touching a female resident, did she feel that it was okay to allow him to sit between 2 female residents during meals at the assist table, without staff being right there? The CNA stated, "No, it bothers me." On 11/1/11 at 7:30 p.m., CNA #5 (employed a approximately a month ago) stated that a family member in the dining room asked her to please move Resident #1 away from Resident #2 because Resident #1 was messing with her down there. The CNA stated, "I said, 'I sure will.' At that time when I moved him away from Resident #2, his hand was not there, it was on the arm of the chair. I don't know if he moved his hand when he seen me coming down the hall, but it wasn't there when I got to him. I then saw (Ex-Social Director) coming down the hall. I told her what was going on, that the family member asked me to move (Resident #1) because he put his hand down her pants. She went to the resident and got at eye level with Resident #1 and told him, 'You know better than this, if you keep on, they're going to send you out.' ... Apparently, it happened before but no one has told me ..." 13) On 11/1/11 at 3:10 p.m., LPN #3 was asked if she observed any inappropriate behavior between (Resident #1) and (Resident #2)? The LPN stated, "I had to separate them one time because he was touching her leg, but that was a while back. We've had to do 1 on 1 with him before, that was probably 6 or 7 months ago." The LPN was asked why 1 on 1. She stated, "For touching a female resident's breasts, I believe." She was asked had anything been reported to her lately about (Resident #1) behaviors. LPN stated, "Not lately." She was asked if she had ever been told that he put his hand down (Resident #2's) pants. The LPN stated, "No, but I have heard that he touched her breasts." The LPN was asked what the facility done to keep that from happening again. She stated, "I know they're changing his medications and reported to the doctor. We've been told to keep a close eye on him." She was asked since he has a history of touching this resident inappropriately, is it ok to let him sit right next to her, without staff being close to them. She stated, "I'd say that was wrong. Somebody should've been watching." She was asked how that happens if staff have been told to keep a close eye on them. She stated, "Well apparently he's not being monitored." 14) On 11/1/11 at 6:55 p.m., CNA #7 was asked if she had ever observed any inappropriate behavior between (Resident #1) and (Resident #2)? CNA stated, "When he's in the dining room, I just make sure he stays away from her. He likes to touch a lot." She was asked what she meant. The CNA stated, "He touches her on her knees and I tell him that's inappropriate, then move him." She was asked how Resident #2 reacts when he does that. The CNA stated, "I don't think she likes it because she shakes her head no. I've not heard that he's done more than that." 15) On 11/1/11 at 7:02 p.m., LPN #4 was asked had she observed any inappropriate behavior between (Resident #1) and (Resident #2). She stated, "(Resident #1) is a very touchy person. They always sit beside each other to eat." She was asked if she had seen him touch her. The LPN Stated, "He'll put his hand on her leg, but I move him if he does that because he's such a touchy person. I've never seen him do anything vulgar, but it seems like a long time ago I heard he touched someone's breasts. He'll pat staff members on the butt, but we redirect him." 16) On 11/2/11 at 9:10 a.m., LPN #5 stated, "(Resident #1) was friendly, touchy with everybody, more with staff. He will tell you, 'I love you.' I work the night shift.. I know they have rights, but he had pushed his call light and we would answer it and he would be masturbating. You would think he would stop when you walked in but he doesn't stop. I know he has his rights." n. Staff interviews regarding inservices or staff instructions in how to intervene regarding Resident #1's sexually aggressive behaviors: 1) On 11/1/11 at 1:25 p.m., CNA#1 stated she had never had an inservice regarding Resident #1's behaviors. 2) On 11/1/11 at 2:15 p.m., CNA#2 was asked if she had been inserviced or instructed on how to handle (Resident #1). CNA stated, "They've told us to redirect and remove with all residents, not (Resident #1) specifically." 3) On 11/1/11 at 2:33 p.m., CNA # 3 stated there had been no inservices about how to handle Resident #1's behaviors. She stated, "Usually we just tell him it's not appropriate, then we tell the charge nurse. They just tell us to keep them separated." 4) On 11/1/11 at 2:35 p.m., LPN#1 was asked had she been inserviced or instructed on how to monitor (Resident #1). She stated, "No." 5) On 11/1/11 at 2:45 p.m., CNA #4 was asked had she been told by anyone how to handle (Resident #1) and (Resident #2)'s relationship. CNA stated, "No." She was asked have you been inserviced on how to handle (Resident #1). CNA stated, "No." 6) On 11/1/11 at 3:00 p.m., CNA #5 was asked had she been inserviced or told specifically how to handle (Resident #1) and (Resident #2). CNA stated, "No." 7) On 11/1/11 at 7:02 p.m., LPN #4 was asked had she been inserviced or instructed on how to handle (Resident #1). LPN stated, "No." o. The Administrator and the Director of Nursing were interviewed regarding Resident #1's aggressive behaviors and any interventions: 1) On 11/1/11 at 4:23 p.m., the Administrator was asked if anybody expressed concerns about (Resident #1) and his behaviors to (Resident #2) during the meeting with family members a month or two ago. She stated, "I don't remember specifically. I was new, I hadn't been here very long." She was asked if anyone had reported anything inappropriate. She stated, "I would've done something with it, like reported it." The Administrator was informed the surveyor had received information that indicated in this meeting family members reported their concerns about (Resident #1) fondling (Resident #2) to her and they did not like it. It was also reported that her response to the family members was, 'they have their rights, they're boyfriend and girlfriend.' The Administrator stated, "I would not have said that. (Resident #2) was married. If they did say something to me, it was not specific like that." She was asked if there had been an inservice on how to handle Resident #1 and his behaviors. She stated, "There's not been one since I've been here." She was asked if Resident #2's family ever expressed their thoughts about wanting to keep (Resident #1) and (Resident #2) apart? She stated, "Not that I know of." 2) On 11/1/11 at 5:00 p.m., the DON was asked if anyone had reported to her that (Resident #1) put his hand between (Resident #2)'s legs. The DON stated, "I've only seen him say 'hi' to people, ask 'how are you doing.' He's very friendly, he will pat you on the hand, to shake hands with you." The DON stated nothing had ever been reported to her about Resident #1 touching Resident #2's crotch. 4. The Immediate Jeopardy was removed and the Scope and Severity was lowered to an "E", when the facility initiated the following plan of removal: Plan of Removal of Immediate Jeopardy 11/1/11 a. (Resident #1), resident, was alleged to have put his hand on a staff member's buttocks on 11/1/2011 at approximately 12 pm. Upon notification of facility staff, (Resident #1) was observed one - on - one (constant supervision) from 2 p.m. until the investigation was completed by the OLTC surveyors and other allegations were relayed to facility CEO. At 7:30 p.m. (Resident #1) was transferred to (Medical Center) for admission to the Geri psych unit after medical clearance through ER (emergency room ) under the care of (Psychiatrist) due to surveyors reporting allegations of sexual inappropriate behaviors to another resident. b. 100% of staff will be educated by the DON, CEO, or designee related to abuse (sexual or other) identification, reporting, and protecting residents from harm beginning 11/1/2011 2-10 shift and will be completed by 11/2/2011 and any staff who are not present will be educated before they provide any care to residents. c. 100% of all residents who are deemed credible by BIMS scores will be interviewed to determine if they have witnessed any sexual advances being made by any resident. Any positive responses will be investigated and reported as appropriate according to policy and Federal regulations, beginning 11/2/2011. Interviews will be done by ADON/MDSC or designee. These residents will be educated related to abuse reporting OLTC (Office of Long Term Care) guidelines by the Social Services Director or designee. d. If any delay in reporting sexually inappropriate behavior has taken place by any staff member disciplinary steps as per facility policy and procedure will be taken. e. All family members who regularly visit their loved ones will be interviewed by QA nurse on 11/2/2011 to determine if they have ever witnessed sexually inappropriate behaviors. Any positive responses will be investigated and reported as appropriate according to policy and Federal regulations. These family members will be educated related to abuse reporting OLTC guidelines by mailers sent to each responsible party. f. On 11/2/2011 the DON or designee will audit past 72 hours of nurse's notes to ensure no one has documented any sexual inappropriate behavior. g. The DON, CEO or designee will continue to interview 3 staff members daily, on different shifts to ensure there have been no instances of sexually inappropriate behavior occurring and not reported.

Complaint # was substantiated, (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #2. The facility failed to ensure the prompt development and implementation of effective interventions to ensure protection from Resident #1's sexually aggressive behaviors for 1 (Resident #2) of 4 female case mix residents (Resident #2 - 5) female case mix residents who were cognitively impaired. This failed practice resulted in Immediate Jeopardy, which had the likelihood of resulting in serious harm, injury or death for Resident #2 and was likely to cause more than minimal harm for 16 female residents who were cognitively impaired, as documented on a list provided by the Director of Nursing (DON) dated 11/2/11 at 9:30 a.m. The facility was informed of the Immediate Jeopardy on 11/1/11 at 6:45 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/8/11 documented the resident scored 6 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), had no behavioral symptoms and required extensive assistance of 1 person for activities of daily living (ADLs). 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/12/11 documented the resident had short and long term memory problems, was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, and exhibited behavioral symptoms such as "other behavioral symptoms not directed toward others (e.g. (for example) physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, disruptive sounds.)" a. Nurses Notes dated 2/2/11 at 1:32 a.m. documented, "Looking at CNAs (Certified Nursing Assistant) times (x) 2. States, 'You want what I got' making movements up and down with hand over penis. Informed resident that type of behavior was not allowed. States, 'Ok'." b. Nurses Notes dated 2/18/11 at 7:30 a.m. documented, "...sometimes inappropriately places his hands where they don't belong and has to be redirected..." Nurses Notes dated 2/18/11 at 10:53 a.m. documented, "...Has some sexual behaviors and needs to be redirected Resident continues with his [MEDICATION NAME] He has a lady friend that we have to redirect him and her. She thinks he is her husband and he tries to take her to his room and staff redirects them. Resident is under the adult protective service and they come quarterly to see upon him. No plans for discharge." c. Nurses Notes dated 3/15/11 at 10:58 p.m. documented, "Resident was hugging up on other residents in dining room stating he loved them and blowing kisses at them. Resident was being very handsy and inappropriate..." d. Nurses Notes dated 4/8/11 at 8:33 p.m. documented, "Resident was asked where he was going and he stated, 'I'm going to piss.' The CNA did not hear him and ask him to repeat what he said and the resident yelled, 'I'm going to take my dick out and piss!' Redirected resident on his inappropriate language and behavior." e. Nurses Notes dated 5/17/11 at 9:27 p.m. documented, "...Female resident said that (Resident #1) touch her breasts. Resident moved to a private office. ADON (Assistant Director of Nursing) notified and counseled with resident. (Physician) notified via fax. APS (Adult Protective Services) notified of incident. Resident placed on 1 on 1 and was monitored throughout this shift..." On 11/2/11 at 10:30 p.m., the ADON was asked if she could remember this incident. The ADON indicated she could not recall. The ADON stated, "The reason why the staff have been told to separate the two residents is because (Resident #2) was married and they are both cognitively impaired." f. Nurses Notes dated 5/19/11 at 9:53 p.m. documented, "...(Resident #1) is usually a happy person, always throwing staff kisses wants hugs. At times staff has to redirect him when he gets inappropriate behavior, he pouts and goes on..." g. Nurses Notes dated 6/16/11 at 5:36 p.m. documented, "Resident was in dining room (DR) for dinner when CNA noticed resident had his hands down his pants. CNA approached resident and redirected him. Resident got mad and started cursing (at) CNA. Nurse and CNA brought resident to me (at) nurse's station. I talked to resident and got him to calm down and redirected him on his behavior. Resident back in dining room at this time..." h. Nurses Notes dated 8/15/11 at 12:30 p.m. documented, "...Staff has to redirect him away from a female resident, (Resident #1) has to be reminded that we don't do inappropriate things such as touching women..." i. A letter written to the physician dated 8/19/11 and signed by the Director of Nursing (DON) documented, "(Physician), Can you please evaluate (Resident #1)'s [MEDICATION NAME]? He is having more sexual ideations lately. Would he benefit from 20mg.?" On 11/1/11 at 5:00 p.m., the DON was asked what sexual ideations was she referring to when she requested Resident #1's [MEDICATION NAME] be increased? The DON stated, "Because he would tell everyone he loved them." She was asked, "But was that an inappropriate sexual behavior?" The DON indicated she was still learning and with the past experiences she had with "State" the DON stated, "I thought I would do something before he got worse." j. The Speech Therapy follow-up Recommendations for Nursing dated 9/6/11 documented, "...Be cautious of leaving (Resident #1's) wheelchair next to another female resident, as he can be inappropriate with females at times." k. On 11/1/11 at 9:30 a.m., a care plan (no effective date given) was copied from the facility's computer. The care plan did not address Resident #1's sexually inappropriate behaviors. On 11/2/11 at 1:40 p.m., the MDS Coordinator (MDSC) was asked why Resident #1's sexually inappropriate behaviors were not addressed on his care plan. The MDS Coordinator reviewed the care plan and made no comments. l. On 11/1/11 at 12:00 noon, Resident #1 was in the dining room at an assisted feeding table. Resident #2 was located approximately 5 feet behind Resident #1. At 12:12 p.m., Resident #2 began to wheel herself, passing Resident #1 out of the dining room toward South hall. There was no staff member in the dining room at this time. Resident #1 unlocked his wheelchair (w/c) and rolled himself beside Resident #2 only inches apart from her. At 12:15 p.m., CNA #2 was bending over, assisting another resident nearby when Resident #1 reached with his left hand and patted CNA #2 on her left buttocks. A staff member assisted Resident #1 back to the assisted table between two female residents. Resident #2 was placed at the same assisted table, but was placed directly across from Resident #1. At 12:20 p.m., Resident #1 began to wheel himself back from the table. At 12:35 p.m., an aide pushed the resident back to the table and locked his wheelchair in place. At 12:37 p.m., Resident #1 unlocked his w/c and moved away from the table. At 12:45 p.m., Resident #1 received his lunch tray and a CNA began to feed him. At 1:00 p.m., the UFM (Unrelated Family Member) #2 stated as she passed by, "There is never this many people in this dining room." m. Interviews were conducted regarding the resident ' s sexually aggressive behaviors: 1) On 11/1/11 at 9:00 a.m. during a telephone interview, Unrelated Family Member #1 (UFM #1) stated, "I go to the nursing home every day and feed my husband at lunch and supper. I've seen (Resident #1) put his hands on about every female down there. I've seen him put his hands on (Resident #2), around her back, on her privates. ...It makes me sick, he's so sneaky about it. Her daughter didn't know about it until we told her. We got onto him about it. We tell him, Get your hands off her. She (Resident #2) doesn't really know what's going on. Her mind is bad. You get on to him about it and he raises his fist at you. I've held both of my fists up at him and said, Well, I've got 2 of these too. He gets mad when you correct him. We've told the nurses, they just tell him to keep his hands to himself ..." On 11/2/11 at 8:47 a.m., UFM #1 stated she attended a family council meeting last month or the month before. She stated, "We mentioned about (Resident #1) fondling Resident #2 and that we didn't like it. (Administrator) stated they're residents too, they have rights. We told her but she's married to...The UFM #1 also commented that they (staff) caught him (Resident #1) taking her (Resident #2) down the hall to try to get in the bed with him." 2) On 11/1/11 at 9:14 a.m., Unrelated Family Member #2 (UFM #2) was asked if she had ever seen (Resident #1) touch female residents in a sexual inappropriate manner? UFM #2 stated, "I haven't seen him touch anyone but that one woman, (Resident #2) ...They (staff) will bring that lady (Resident #2) out to the dining room and park her out there in one area ...(Resident #1) will wheel right up to her... He takes his hand straight to her crotch and plays with it. I thought... that can't be happening. When he thinks we're not looking, he will do it again. I started telling him to stop, get away from her. He'd roll away but then he'd just come back. We had a meeting about 2 months ago with the Administrator. The meeting was with family members who have loved ones out there. She (Administrator) wanted to ask those at the meeting if there were any complaints. Me and a few others told her we had a problem with (Resident #1) touching (Resident #2). (Administrator) told us they have their rights... But she (Administrator) said, they have rights and that we couldn't say anything about it." UFM #2 was asked, "When was the last time you saw (Resident #1) do this to (Resident #2)?" UFM #2 stated, "About a week ago." UFM #2 was asked if (Resident #1) has gone inside (Resident #2's) pants. UFM #2 stated, "No, nothing inside, just the hand massaging it just before we yell at him. I watch him like a hawk, while I'm there. About a month ago, I said (Resident #1) if you don't stop doing that to her I'm going to call the police. He just got mad and took off down the hall. One day I got on to him and told him, 'you need to leave her alone, get your hands away from her.' He goes around and tells everyone he loves everyone. I know he's retarded ..." 3) On 11/1/11 at 9:43 a.m., Non-case mix Resident #1 (NCR #1) was asked, "How long have you lived here?" She stated, "About a month." NCR #1 was asked, "Do you eat in the dining room?" NCR #1 stated, "Yes." She was asked, "Have you observed anything in the dining room or elsewhere that you feel is inappropriate, such as male or female residents touching each other?" NCR #1 stated, "(Resident #1). (Resident #1) touches women." NCR #1 was asked who does he touch? NCR #1 stated, "(Resident #2)." She was asked, "How does he touch her?" NCR #1 stated, "He puts his hand on her leg." NCR #1 was asked how does he do that. NCR #1 stated, "He rolls over to her." NCR #1 was asked, "Does staff know he does that?" NCR #1 stated, "I don't know." NCR #1 was asked, "When was the last time you saw him do this?" NCR #1 stated, "Probably 3 days ago." 4) On 11/1/11 at 9:50 a.m., Resident #5 was asked, "How long have you lived here?" She stated, "Since May." Resident #5 was asked if she ate in the dining room. Resident #5 stated, "Yes." Resident #5 was asked if she had seen anything in the dining room that she felt was inappropriate between male and female residents. Resident #5 stated, "(Resident #1)." She was asked what about (Resident #1). Resident #5 stated, "He rubs on (Resident #2)." She was asked how he does that. Resident #5 stated, "On her legs." She was asked what does the resident do when he does that. Resident #5 stated, "Last time she took his hand and moved it away." She was asked when that was. Resident #5 stated, "Last week. He used to not be that way." 5) On 11/1/11 at 11:50 a.m., Unrelated Family Member #3 (UFM #3) was sitting in the dining room and she was asked if she'd ever observed anything in the DR that she felt was inappropriate between male and female residents. UFM #3 stated, "I've seen a male resident, (Resident #1), touching a female resident (Resident #2)." She was asked how he touches her. UFM #3 stated, "He puts his hand between her legs." She was asked what does the resident do when he does this. UFM #3 stated, "She just sits there." She was asked what the staff does. UFM #3 stated, "I'm not sure they always see it." She was asked when was the last time she could remember seeing this. UFM #3 stated, "Maybe a week ago." 6) On 11/1/11 at 1:25 p.m., CNA#1 stated, " ...He's (Resident #1) touchy feely, grabs people everywhere. He likes to sit by (Resident #2). The daughter has asked to keep them apart. She's (Resident #2) always following him around. He doesn't realize what he's doing. I was helping one day and he hugged me and tried to pull me into his bed...I don't think he means harm. A family member told me the daughter wants (Resident #2) to be kept away from him. A couple of months ago, (Resident #2) made a statement that she didn't want to get up for meals because (Resident #1) bothers her. He's a friendly type of guy. I've never witnessed anything at all." 7) On 11/1/11 at 1:47 p.m., Resident #2's daughter stated she had attended a care plan meeting on 10/27/11 about her mother (Resident #2). She stated, "When the care plan meeting was over, my aunt who visits my mother weekly told me she wanted to introduce me to this person. Both of these ladies started telling me (Resident #1) was putting his hands down her (Resident #2) pants and this had been going on for a long time, anywhere from 6 months to a year. Since 10/27/11, I told (Ex-Social Director) who is gone now." She was asked if she had reported this to the DON or the Administrator. The daughter stated, "No." 8) On 11/1/11 at 2:15 p.m., CNA #2 was asked when was the last time she observed (Resident #1) being inappropriate. CNA stated, "Today. He touched my butt. I redirected him and told the charge nurse." 9) On 11/1/11 at 2:33 p.m., CNA #3 if she had ever observed Resident #1 have inappropriate behaviors with Resident #2. The CNA stated, "Not that I've seen. He just touches her leg. I've not seen him touch her groin at all. We go and separate them and tell the nurse." She was asked when she saw him touching Resident #2 ' s leg, did it make her feel uncomfortable. She stated, "Yes, we just tell him that is inappropriate." She was asked why it made her uncomfortable. CNA stated, "Well because he always tries to touch us too. When we put him to bed, he will wrap his arms around us, like he puts his body up against you and it makes you feel a little uncomfortable." 10) On 11/1/11 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 was asked if it had been reported to her that Resident #1 had ever touched Resident #2 inappropriately. She stated, "That's been a long time, 6 months or more." She was asked if she remembered what was reported back then. She stated, "That he was touching her breasts." She was asked what was done. She stated, "He was taken to his room." 11) On 11/1/11 at 2:45 p.m., CNA #4 was asked if she had ever observed Resident #1 have inappropriate behaviors with Resident #2. The CNA stated, "(Resident #1) is mentally... not normal. He's real handsey. We say (Resident #1) you're not supposed to do that. With (Resident #2), I see him put his arm around her. I know her family doesn't want that so I move one of them. I've never seen him put his hand in a bad place. He touches her legs." 12) On 11/1/11 at 3:00 p.m., CNA #5 was asked have you observed any inappropriate behavior between male and female residents. She stated, "I haven't seen it, but one of the wives here saw, and asked me to please move (Resident #1) because he was putting his hands down (Resident #2)'s pants. I went and asked (Resident #2) if she was ok and she nodded her head yes." She was asked when it happened. She stated, "This was a couple of weeks ago. An employee went up to him and said, '(Resident #1) you know better than that' and told him if he kept it up they were going to send him off ...It seems like it always happens when we're not in there, because I've seen him touch (Resident #2). He will pat us on the shoulder or the back, but he gets redirected. To be honest, I'm scared to be alone in the same room with him." The CNA was asked who was the person who asked her to move Resident #1. She stated, "(UFM #1)." She was asked, since (Resident #1) has a history of inappropriately touching a female resident, did she feel that it was okay to allow him to sit between 2 female residents during meals at the assist table, without staff being right there? The CNA stated, "No, it bothers me." On 11/1/11 at 7:30 p.m., CNA #5 (employed a approximately a month ago) stated that a family member in the dining room asked her to please move Resident #1 away from Resident #2 because Resident #1 was messing with her down there. The CNA stated, "I said I sure will. At that time when I moved him away from Resident #2, his hand was not there, it was on the arm of the chair. I don't know if he moved his hand when he seen me coming down the hall, but it wasn't there when I got to him. I then saw (Ex-Social Director) coming down the hall. I told her what was going on, that the family member asked me to move (Resident #1) because he put his hand down her pants. She went to the resident and got at eye level with Resident #1 and told him, 'You know better than this, if you keep on, they're going to send you out.' ... Apparently, it happened before but no one has told me ..." 13) On 11/1/11 at 3:10 p.m., LPN #3 was asked if she observed any inappropriate behavior between (Resident #1) and (Resident #2)? The LPN stated, "I had to separate them one time because he was touching her leg, but that was a while back. We've had to do 1 on 1 with him before, that was probably 6 or 7 months ago." The LPN was asked why 1 on 1. She stated, "For touching a female resident's breasts, I believe." She was asked had anything been reported to her lately about (Resident #1) behaviors. LPN stated, "Not lately." She was asked if she had ever been told that he put his hand down (Resident #2's) pants. The LPN stated, "No, but I have heard that he touched her breasts." The LPN was asked what the facility done to keep that from happening again. She stated, "I know they're changing his medications and reported to the doctor. We've been told to keep a close eye on him." She was asked since he has a history of touching this resident inappropriately, is it ok to let him sit right next to her without staff being close to them. She stated, "I'd say that was wrong. Somebody should've been watching." She was asked how that happens if staff have been told to keep a close eye on them. She stated, "Well apparently he's not being monitored." 14) On 11/1/11 at 6:55 p.m., CNA #7 was asked if she had ever observed any inappropriate behavior between (Resident #1) and (Resident #2)? CNA stated, "When he's in the dining room, I just make sure he stays away from her. He likes to touch a lot." She was asked what she meant. The CNA stated, "He touches her on her knees and I tell him that's inappropriate, then move him." She was asked how Resident #2 reacts when he does that. The CNA stated, "I don't think she likes it because she shakes her head no. I've not heard that he's done more than that." 15) On 11/1/11 at 7:02 p.m., LPN #4 was asked had she observed any inappropriate behavior between (Resident #1) and (Resident #2). She stated, "(Resident #1) is a very touchy person. They always sit beside each other to eat." She was asked if she had seen him touch her. The LPN Stated, "He'll put his hand on her leg, but I move him if he does that because he's such a touchy person. I've never seen him do anything vulgar, but it seems like a long time ago I heard he touched someone's breasts. He'll pat staff members on the butt, but we redirect him." 16) On 11/2/11 at 9:10 a.m., LPN #5 stated that Resident #1 was friendly, touchy with everybody, more with staff. He will tell you, 'I love you.' I work the night shift.. I know they have rights, but he had pushed his call light and we would answer it and he would be masturbating. You would think he would stop when you walked in but he doesn't stop. I know he has his rights." n. Staff interviews regarding inservices or staff instructions in how to intervene regarding Resident #1's sexually aggressive behaviors: 1) On 11/1/11 at 1:25 p.m., CNA#1 stated she had never had an inservice regarding Resident #1's behaviors. 2) On 11/1/11 at 2:15 p.m., CNA#2 was asked if she had been inserviced or instructed on how to handle (Resident #1). CNA stated, "They've told us to redirect and remove with all residents, not (Resident #1) specifically." 3) On 11/1/11 at 2:33 p.m., CNA # 3 stated there had been no inservices about how to handle Resident #1's behaviors. She stated, "Usually we just tell him it's not appropriate, then we tell the charge nurse. They just tell us to keep them separated." 4) On 11/1/11 at 2:35 p.m., LPN#1 was asked had she been inserviced or instructed on how to monitor (Resident #1). She stated, "No." 5) On 11/1/11 at 2:45 p.m., CNA #4 was asked had she been told by anyone how to handle (Resident #1) and (Resident #2)'s relationship. CNA stated, "No." She was asked have you been inserviced on how to handle (Resident #1)? CNA stated, "No." 6) On 11/1/11 at 3:00 p.m., CNA #5 was asked had she been inserviced or told specifically how to handle (Resident #1) and (Resident #2). CNA stated, "No." 7) On 11/1/11 at 7:02 p.m., LPN #4 was asked had she been inserviced or instructed on how to handle (Resident #1). LPN stated, "No." o. The Administrator and the Director of Nursing were interviewed regarding Resident #1's aggressive behaviors and any interventions: 1) On 11/1/11 at 4:23 p.m., the Administrator was asked if anybody expressed concerns about (Resident #1) and his behaviors to (Resident #2) during the meeting with family members a month or two ago. She stated, "I don't remember specifically. I was new, I hadn't been here very long." She was asked if anyone had reported anything inappropriate. She stated, "I would've done something with it, like reported it." The Administrator was informed the surveyor had received information that indicated in this meeting family members reported their concerns about (Resident #1) fondling (Resident #2) to her and they did not like it. It was also reported that her response to the family members was, 'they have their rights, they're boyfriend and girlfriend.' The Administrator stated, "I would not have said that. (Resident #2) was married. If they did say something to me, it was not specific like that." She was asked if there been an inservice on how to handle Resident #1 and his behaviors. She stated, "There's not been one since I've been here." She was asked if Resident #2's family ever expressed their thoughts about wanting to keep (Resident #1) and (Resident #2) apart? She stated, "Not that I know of." 2) On 11/1/11 at 5:00 p.m., the DON was asked if anyone had reported to her that (Resident #1) put his hand between (Resident #2)'s legs. The DON stated, "I've only seen him say 'hi' to people, ask 'how are you doing.' He's very friendly, he will pat you on the hand, to shake hands with you." The DON stated nothing had ever been reported to her about Resident #1 touching Resident #2's crotch. 3. The Immediate Jeopardy was removed and the Scope and Severity was lowered to an "E", when the facility initiated the following plan of removal: Plan of Removal of Immediate Jeopardy 11/1/11 a. (Resident #1), resident, was alleged to have put his hand on a staff member's buttocks on 11/1/2011 at approximately 12 pm. Upon notification of facility staff, (Resident #1) was observed one-on-one (constant supervision) from 2 pm until the investigation was completed by the OLTC surveyors and other allegations were relayed to facility CEO. At 7:30 pm (Resident #1) was transferred to (Medical Center) for admission to the Geri psych unit after medical clearance through ER (emergency room ) under the care of (Psychiatrist) due to surveyors reporting allegations of sexual inappropriate behaviors to another resident. b. 100% of staff will be educated by the DON, CEO, or designee related to abuse (sexual or other) identification, reporting, and protecting residents from harm beginning 11/1/2011 2-10 shift and will be completed by 11/2/2011 and any staff who are not present will be educated before they provide any care to residents. c. 100% of all residents who are deemed credible by BIMS scores will be interviewed to determine if they have witnessed any sexual advances being made by any resident. Any positive responses will be investigated and reported as appropriate according to policy and Federal regulations, beginning 11/2/2011. Interviews will be done by ADON/MDSC or designee. These residents will be educated related to abuse reporting OLTC (Office of Long Term Care) guidelines by the Social Services Director or designee. d. If any delay in reporting sexually inappropriate behavior has taken place by any staff member disciplinary steps as per facility policy and procedure will be taken. e. All family members who regularly visit their loved ones will be interviewed by QA nurse on 11/2/2011 to determine if they have ever witnessed sexually inappropriate behaviors. Any positive responses will be investigated and reported as appropriate according to policy and Federal regulations. These family members will be educated related to abuse reporting OLTC guidelines by mailers sent to each responsible party. f. On 11/2/2011 the DON or designee will audit past 72 hours of nurse's notes to ensure no one has documented any sexual inappropriate behavior. g. The DON, CEO or designee will continue to interview 3 staff members daily, on different shifts to ensure there have been no instances of sexually inappropriate behavior occurring and not reported.

Based on record review and interview, the facility failed to provide necessary care and services to ensure that Resident #6 attained or maintained the highest practicable physical well being. The facility failed to ensure the licensed nurses thoroughly and promptly assessed a resident when significant changes in condition were reported to them, the physician was immediately consulted regarding treatment, and the resident monitored for 1 of 1 case mix resident (Resident #6) who exhibited a change in condition. These failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #6 who was subsequently hospitalized and died [MEDICAL CONDITION] and a bowel obstruction. These failed practices had the potential to affect 3 residents who had a change in condition according to a list provided by the Director of Nursing on [DATE] at 1:40 p.m. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 10:25 a.m. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Medicare 30 day Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making according to the Staff Assessment of Mental Status, required total assistance with all activities of daily living except for limited assistance with transfers, and was always incontinent of bowel. a. The hospital's History and Physical dated [DATE] documented, "History of Present Illness: This is an [AGE] year old while female admitted via the emergency room from (nursing home). The patient has advanced Alzheimer's dementia and is unable to give any history. She was hospitalized recently from ,[DATE] to ,[DATE] (11) for coagulation negative staphylococcus aureus. She was sent back to the nursing home on [MEDICATION NAME]. The patient was sent back to the emergency room because of nausea, vomiting and diarrhea as well as decreased oxygen saturation ranging from 70 to 92 and erratic pulse ranging from 44 to 214. In the emergency room urinalysis revealed greater then 50 urine WBC (white blood cell)... Assessment: 1. Urinary tract infection secondary to coagulase negative staph with nausea, vomiting and fever. ...Procedures this hospitalization : 1. Blood transfusion 2. Placement of PICC (peripherally inserted central catheter) line..." b. The resident's care plan was reviewed on [DATE]. The care plan was updated [DATE] and did not address a history of vomiting. c. The vital sign sheets dated from [DATE] through [DATE] documented the resident's respiration rate ranged from 15 to 23 breaths per minute and the heart rate ranged from 52 to 93 beats per minute and nurses notes dated from [DATE] through [DATE] documented the resident's respirations ranged from 18 - 20 and pulse ranged from 64 to 69. There was no documentation of any other vitals signs on the vital sign sheet or nurses notes. d. There was no nurses notes in the clinical record dated [DATE]. 1) On [DATE] at 2:20 p.m., during an interview with CNA #4 who worked [DATE] (,[DATE] shift), she stated, "We changed her (Resident #6) several times that night because she was puking, 4 to 5 times. We reported it every time to (LPN #2)." CNA #4 was asked if she saw LPN #2 give Resident #6 a shot? CNA #4 stated, "Yes, I watched him give the shot, me and (CNA #5) were both in the room when he gave her a shot." As CNA #4 pointed to her own right hip and stated, (LPN #2) gave the shot in (Resident #6's) right hip about 9:30 p.m." CNA #4 stated, "She (Resident #6) didn't get really sick until after supper, then started really vomiting." CNA #4 stated the resident's emesis, "was like a creamy brown and a lot of it, darker than a tan color." CNA #4 was asked what her thoughts were regarding the vomiting problems, "I thought she wasn't going to make it. The way her skin color was she was really pale." She was asked if she checked the resident's vital signs? She stated, "I didn't do vital signs. Someone did vital signs, I'm sure." 2) A witness statement dated [DATE] at 4:30 p.m. and signed by CNA #3, "She (Resident #6) was throwing up a lot, it was yellow and didn't look good. Earlier that day [DATE] she was trying to have a BM when I was changing her and couldn't. A few hours later she did and it was very large and hard. She was pouring with sweat and very discolored, she was shaking when we put her in bed, her left leg was shaking and twitching. She had a high temp. I told the nurse. We cleaned her up every time she threw up. She did at least 5 times within my shift." On [DATE] at 2:30 p.m., during an interview with CNA #3 who worked [DATE] (,[DATE] shift), she stated, "Earlier that day, we were changing her (Resident #6's) brief, she acted like she was having a BM. But she didn't. Two hours later, she had a BM, a large hard BM. She usually has diarrhea type BM. Then about 7:30 p.m., we were doing our rounds, she had a little bit of throw up on her. We reported it to the nurse (LPN #2). After 7:30 p.m., (LPN #2) gave her a [MEDICATION NAME]. I saw him get it and go in the resident's room, I didn't see him give it though. (Resident #6) threw up all of it." She (Resident #6) threw up at least 2 more times, she was sweating. I told the nurse... I took her temp. He (LPN #2) told me get a wash cloth. I think it was elevated a little. I don't remember exactly what it was. I'm almost positive he gave her Tylenol." CNA #3 was asked how much did Resident #6 throw up? CNA #3 stated, "I saw it was enough to wonder about..." 3) On [DATE] at 3:15 p.m., LPN #2 indicated that on [DATE] on ,[DATE] shift, he worked and LPN #1 relieved him at 10:00 p.m. on [DATE]. Resident #6 started to vomit about 9:00 p.m. (,[DATE] shift) at bedtime. LPN #2 was informed it was not documented in the nurse's notes and was asked why wasn't it documented? LPN #2 stated, "I don't know, I don't have a good answer. It was at shift change, I was busy." LPN #2 stated, "(Resident #6) vomited approximately 9:00 p.m. I gave her a [MEDICATION NAME] tablet about 9:00 p.m. She (Resident #6) vomited that up about 10:00 p.m. I gave her an IM (intramuscular) injection of [MEDICATION NAME] in the (R) (right) hip. I didn't document it. I didn't go back to chart it. It's on the 24 hour report that I gave the resident something and I told (LPN #1)." LPN #2 was asked, "On [DATE] when you worked ,[DATE] shift and Resident #6 was vomiting, did you check for abdominal distention or bowel sounds?" LPN #2 stated, "No, ma'am. I knew she had a bowel movement that shift." e. The nurse's notes dated [DATE] at 5:46 p.m. and signed by Licensed Practical Nurse (LPN) #1, " LE (late entry for 10p [DATE] to 6 a.m. [DATE]) @ (at) shift report notified by off going nurse that R (resident) was having vomiting and med (medication) had been given already, and R had a large BM (bowel movement) that was very hard. R was assessed during first part of shift no vomiting @ this time CNAs were asked if R had been having regular BM, CNAs reported that they did not know. Reported that R had vomited x (times) 2 during shift and a medium BM and a small BM during the shift. called down from other hall @ approximately 0400 d/t (due to) emesis being brown this time, went in to R room to see emesis small amt. (amount) on bed pad on the floor, went to check MAR (Medication Administration Record), [MEDICATION NAME] noted, helped CNA pull R up in bed @ 0500 went to recheck R, R lying in bed, asked R if feeling better R opened eyes and gave a grin with an mmmhmm sound, offered R a drink of H2O (water) and R took a couple of sips. checked on R before shift report to next shift no changes noted." There was no documentation in the nurses notes that the staff obtained vital signs for [DATE] on the 10:00 p.m. to 6:00 a.m. (,[DATE]) shift. 1) On [DATE] at 5:15 p.m., LPN #1 (worked [DATE] ,[DATE] shift with Resident #6) was asked what did LPN #2 report to you regarding Resident #6's condition at (10:00 p.m. during shift change) on [DATE]? LPN #1 stated, "At shift change (10:00 p.m.), (LPN #2) said (Resident #6) was vomiting again (vomited one time), he had given her something, he also stated she had a very large BM." In reference to the late entry dated [DATE] documented in the nurse's notes on [DATE] LPN #1 was asked when did she assess the resident? LPN #1 stated she felt the resident's skin, it was cool and dry. Resident #6's eyes were open and the resident looked at her. LPN #1 stated she felt the resident's pulse, "it was not thready, not weak, normal type pulse." LPN #1 stated she felt Resident #6's stomach. She stated, "it was soft but when she touched her stomach the resident made a face when I pushed, grinned." LPN #1 was asked did you get a blood pressure? LPN #1 stated, "No, I didn't get her blood pressure, but (CNA #1) took her (Resident #6's) temp. (temperature) 99.6 Ax. (axillary)." LPN #1 was asked according to the witness statement she had documented it says you were called from another hall at approximately 4:00 a.m. due to resident having emesis being brown. She was asked what she did about the emesis? LPN #1 stated, "I looked at the medication administration record. (LPN #2) never told me when he gave the medication. I assume it was [MEDICATION NAME] I went down to resident's room. (CNA #1) was in room. There was no smell, light brown in color. LPN stated she gave [MEDICATION NAME] and [MEDICATION NAME] suppository between 4:00 and 4:30 a.m. LPN #1 stated at this same she helped the CNA pull the resident up in bed. LPN #1 stated, "at 5:00 a.m. she went to recheck on (Resident #6) and asked her if she was feeling better. (Resident #6) opened her eyes and gave a grin and made an ummhum sound, I offered her a drink of water and she took a couple of sips." LPN #1 was asked when she checked for abdominal distention and the resident grimaced when she palpated her stomach, did she think that was an issue? She stated, "No, she's done this before, nothing different. She does this, we try to get her to have a few BMs when she does that, she'd stop throwing up." LPN #1 was asked how many times did she take the resident's vital signs (VS) that shift? LPN #1 stated, "there were no vital signs taken that shift, just a temperature 99.6. They (CNAs) told me she had vomited twice, I don't recall anything else about that." LPN #1 was asked did the CNAs tell her that shift on more than one occasion the resident kept vomiting and they were worried about the resident? LPN #1 stated, "They said they were worried about her (Resident #6) because she was vomiting. But it wasn't something that I felt I needed to do anything about. I had given her a [MEDICATION NAME] and [MEDICATION NAME]. There was nothing else I could give her because I had just given her something." LPN #1 was informed, "CNA #1 indicated she spoke with you outside at lunch break regarding being worried about the resident's condition, do you remember talking about the resident?" LPN #1 stated, "I don't recall talking about the resident outside, not specifically." LPN #1 was asked how many times did the resident vomit that shift (,[DATE]) that she was aware of? LPN #1 stated, "Initially at the beginning of the shift, I assumed only one time..." She was asked if she obtained complete vital signs. LPN #1 stated, "I didn't really feel the need to. We just got her temp. (temperature). She had done this in the past. I wasn't that concerned, it wasn't something new, nothing out of the blue." LPN #1 was asked if the CNAs told her the resident had vomited fecal matter? She stated "I don't remember." LPN #1 was asked did the CNAs say anything such as Resident #6's vomit smelled like poop? LPN #1 stated, "I don't remember. I'm not saying they didn't. I don't remember. Those 3 days (Thursday, Friday and Saturday) they all kinda mix together. I can't even remember what day it was, it can be hectic for nurses. Those days intermingle. I can't remember right now. I can't remember anything." LPN #1 was asked looking back at the situation would she have done anything differently? She stated, "Yes, I'd have the resident sent to the hospital..." 2) CNA #1's witness statement dated [DATE] documented, "When I first came on my shift (,[DATE] [DATE]) , the ,[DATE] shift reported to me (Resident #6) was throwing up and running a temp. (temperature). When I first did my round, I went to her room and she had thrown up which looked like normal throw up. I told (LPN #1), at that time. She told me she couldn't give her anything at that time because (LPN #2) had already given her [MEDICATION NAME]. At that time she didn't go look at her. I cleaned her up. (Resident #6) was not on vital list so I put her name on the list to get temp. the temp was 99.8 Fahrenheit (F)) at the time. After I finished my vitals, about an hour later I went to check on her again and she had thrown up again around 11 p.m. It wasn't very much but I went and let (LPN #1) know again. Passed ice, made round at 12 am, at that time I noticed her throw up was black and smelled like BM and it was coming out her rump also. I went to call light and told (LPN #1) that I felt this was not normal and I felt like she needed to be sent out. She did not come and look at her, she told me through the call light that she had history of being sent out to hospital for this and the hospital would send her back. Being concerned I went back around 1 am (1:00 a.m.) to room. (Resident #6) had thrown up again it was black what appeared to be "run around" from mouth and bottom. I called (LPN #1) again on call light and told she needed to come look at her and send her out. She repeated the same thing as before that her and (LPN #2) have sent her out before and they would just send her back. Then it was time for round at 2am. She had thrown up black stuff that smelled like bm. Then threw up again before I could get her cleaned up. I called (LPN #1) on call light. (LPN #1) said, "(CNA #1) I've told you and I will tell you again, we have sent her out and they would do nothing and send her back." When I went outside for my lunch break (LPN #1) was outside talking to (CNA #8) and I told her again I was concerned and thought she needed to get her some help. (LPN #1) said, "(CNA #1) there is no sense to send her out." After lunch, I went back into her room, she had vomited again, cleaned her up. I was beginning to get upset and frustrated with (LPN #1). I got on call light and told her (Resident #6) was throwing up was looked like poop. (CNA #2) came in from lunch, it was around 4am, and asked what is that smell? It smelled like pure poop. (CNA #2) went in the room with me got on intercom told (LPN #1) again. This time she said she had already heard it she would check on her later. (CNA #2) said, "(CNA #1), she has to be sent out" and I told her I had tried several times telling (LPN #1), but (LPN #1) wouldn't send her out. I asked (CNA #2) if she would talk to (LPN #1) to see if that would do any good. (LPN #1) finally went in room about 4am to check on her, I was doing bed change at that time. Pad with vomit laying on floor (LPN #1) looked at it and wanted to know if I knew how to pull up the BM list on computer. Then she gave her [MEDICATION NAME] suppository and suppository to make her go to bathroom. I asked her to look at her I thought she needed to be sent out. After finishing round I went back around 5 am and had not thrown up. When next shift came in I told the CNAs and (LPN #2). And to please watch her. (LPN #2) said (LPN #1) had told him (Resident #6) had thrown up a couple times and had given her something." On [DATE] at 9:00 a.m., during an interview with CNA #1 she was asked if she was standing by what she had documented in her written statement? CNA #1 stated, "Yes." CNA #1 was asked if they checked the resident's vital signs. She stated, "She (LPN #1) didn't ask me to do vital signs. She didn't touch the resident at all." CNA #1 indicated she asked the other (CNA #2) to ask LPN #1 because "I thought it was me. I thought it would help if I got CNA #2 to try to get her (LPN #2) attention. CNA #1 stated when CNA #2 asked LPN #1 to check the resident, CNA #2 stated LPN #1 said, 'I'll be down in a few minutes', then she finally came down." CNA #1 was asked about the resident's emesis? CNA #1 stated, "At first it appeared to smell like poop or maybe a GI bleed. I don't know. It alarmed me. It wasn't normal. When you work as a CNA, you pick up on those things. She (Resident #6) had a glassy stare..." CNA #1 added, "I don't have a problem with anyone telling me I'm wrong, as long as they check on the resident..." 3) CNA #2's witness statement dated [DATE] documented, "I, (CNA #2), ...As we came on the hall ,[DATE] shift ([DATE]) told us, (Resident #6) in 11B West had been real sick & (and) vomiting all evening & for us to keep a close eye on her. We started out first round at 10 o'clock. Each on our own hall. Before I finished my hall on West, I heard (CNA #1) tell (LPN #1), our night nurse, that she had to do complete bed change on (Resident #6), she had been real sick. At that time, I didn't understand what the nurse said. All through the night (Resident #6) was sick & vomiting. Around 12 o'clock I did hear (CNA #1) tell her the vomit was black and smelled like BM. Every time she threw up (CNA #1) reported it to the nurse & was asking her to please help. (LPN #1) would state, she does this all the time & (LPN #2) ,[DATE] nurse always sends her out & they send her right back. I know (CNA #1) did have 4 full bed changes & cleaned her up several times with towels she threw up on. Each time was reported to nurse. I took my lunch break outside & when I opened the back door. It smelled of BM. (CNA #1) said (Resident #6) had just thrown up again. (CNA #1) took lunch break & (Resident #6) roommate got on call light. I went first over to (Resident #6) & I could see she hadn't thrown up. I ask her how she was feeling & she just stared into space. Her roommate said I'm the one who needs help. I pulled curtain & when I was cleaning roommate, (CNA #1) walked in & said, my goodness she has upchucked again, as soon as I finished with roommate & I walked over to help her & couldn't believe my eyes. I told (CNA #1) she has got to go to the hospital & (CNA #1) said (LPN #1) won't help. Please you ask her. (CNA #1) got on intercom & ask (LPN #1) to come to West hall. When she did come, I said (LPN #1) she has pure poop coming out of her mouth. (LPN #1) said I know but she has done this several times & hospital sends her back. I said maybe when I wasn't working this did happen, but on the nights I worked & she was sent out it did not look like it does now. She said I will check in a little while. This was around 3:30 a.m. When we were doing our 4 o'clock round (LPN #1) came up to me & said I gave her [MEDICATION NAME] suppository and something for fever. When day shift got here (CNA #1) went straight to (LPN #2) & was whispering to him. I saw but couldn't hear. She later said she told him how sick (Resident #6) was & please keep a close eye on her. I take (CNA #1) home & we are both upset & in tears..." On [DATE] at 10:33 a.m., during an interview with CNA #2, she was asked if she remembered CNA #1 report to the nurse the resident was vomiting? CNA #2 stated, "Yes, I did hear that." CNA #2 was asked if she remembered what Resident #6's emesis look like? She stated, "It looked and smelled just like poop. I did see that." CNA #2 stated, "I've tried and tried to get his nurse to send resident to hospital. I told her, "(LPN #1) it's coming out of her mouth, it smells like poop. I heard her (CNA #1) tell her (LPN #1) more than once." CNA #2 stated, "(LPN #1) wrote down a list of residents who she wanted us to get vital signs on. (CNA #1) put (Resident #6) on the list, just her temperature. (LPN #1) asked why (Resident #6) was on the list. I told her (LPN #1) I didn't write it on the list. I guess (CNA #1) put (Resident #6) on the list because she had been vomiting." f. The CNA's "Completed Care Task" sheet dated [DATE] documented the resident had one BM for the 2:00 p.m. to 10:00 p.m. (,[DATE]) shift at approximately 11:11 p.m. The sheet documented the resident had one small BM on [DATE], ,[DATE] shift that was reported to the nurse at approximately 3:13 a.m. and one small soft formed BM at 5:06 a.m. There was no further documentation on this sheet or in the nurses notes to indicate Resident #6 had any other bowel movements that shift. g. The nurse's notes dated [DATE] at 1:37 p.m. and signed by LPN #2, "staff getting resident up for breakfast and notified nurse that resident very hard to awaken, and breathing was erratic. upon initial assessment, decreased LOC (level of consciousness) noticed, would awaken to verbal stimulation but immediately close eyes, O2 (oxygen) sat (saturation) was varying 88% - 92% and respirations were 44, pulse was varying 44 - 52 bpm (beats per minute) (using pulse ox), advised staff to keep resident in bed with head elevated. During breakfast staff advised nurse that resident appeared worse. resident would not awaken to stimuli and BLE (bilateral lower extremity) were blotchy, skin was clammy. took VS (vital signs) again, not able to determine BP (blood pressure), O2 was steady at 88%, p (pulse) was 45, r (respiratory) 44. call to (doctor), got answering service, l/m (left message). call to family, family agreed that resident needed to go to hospital... call to ambulance and arranged transfer. call to family to advise that ambulance on way." On [DATE] at 3:15 p.m., LPN #2 stated, "(LPN #1) told me (Resident #6) did not sleep well all night ([DATE]) and was throwing up and had a BM. She said the BM was more runny." LPN #2 was asked did he think this sign was abnormal for her? LPN #2 stated, "She (Resident #6) had a practice of throwing up. It happened so frequently, it didn't alarm anybody because it happened all the time." LPN #2 was asked what did Resident #6's emesis look like? LPN #2 stated, it looked a little tan with food in it." LPN #2 stated it did not look like coffee ground color, looked a lot like Med Pass (supplement) tan." LPN #2 was asked why did it take almost an hour later to call the doctor. LPN #2 stated, "Because that was the next time the CNA came and told me she (Resident #6) was worse." LPN #2 was asked so (Resident #6) was vomiting... you didn't feel that was something to further assess or call the physician about? LPN #2 stated, "No, that was just (Resident #6), she'd be fine for awhile, she gets sick a lot. I just thought she was tired." LPN #2 was asked, "That morning on [DATE] when (Resident #6)'s respirations were elevated, pulse was low, her O2 Sat was down, did you assess the resident's abdomen, check bowel sounds or give oxygen?" LPN #2 stated, "No, I didn't do anything with her that morning." LPN #2 was asked, "Had Resident #6 ever exhibited signs like that (refer to nurse's notes dated [DATE] at 1:57 p.m.) before?" LPN #2 stated, "I guess, but I don't know how to prove it. She has been sick one day, then the next day alert and ok, then the next hadn't been out of bed all day." h. The Emergency Medical Transport dated [DATE] at 8:21 a.m. documented, "...Received call from (Nursing Home) stating a resident was unresponsive, breathing, with poor vital signs, U/A (upon arrival), 87 yo/f (year old/female) found supine in bed, unresponsive, with positive gag reflex, respirations approximately 26. Pupils left sluggish and constricted and right constricted. Lung sounds revealed rales spices, diminished bases. Staff relates that patient is normally although not very verbal and has history of alzheimer's. Staff also relates that patient was within her normal limits last night when they went off shift and was found this morning unresponsive. Patient was administered 100% oxygen via NRB (non-rebreather). Patient was moved to cot and unit. IV was established... Cardiac monitor revealed BBB (bundle branch block) with occasional PAC's (premature [MEDICAL CONDITION] complexes) and PJC's (premature junctional contractions). Unable to obtain accurate blood pressure. Lung sounds revealed rales apices and bases. Patient was transported to (hospital) per family request and was diverted enroute to (another hospital)..." i. The hospital Emergency Department Report dated [DATE] documented, "...History of Present Illness: This [AGE] year old female was transferred from (nursing home) after found unresponsive earlier this morning. In route when paramedics called they state that she was unresponsive, she was on 100% non-rebreather, and they were unable to hear or palpate a blood pressure. On arrival, as noted, she was unresponsive. She did have a rhythm per monitor, bradycardic, which appeared to be a junctional type rhythm. She did not have a pulse associated with this. CPR (cardiopulmonary resuscitation) initiated. She was administered [MEDICATION NAME] and [MEDICATION NAME]. She was subsequently intubated on the first attempt without difficulty... Breath sounds were equal bilaterally. CPR continued. ...However, her rhythm deteriorated to asystole. After approximately 20 minutes of CPR this I think discontinued. The patient was pronounced deceased at 0934 hours on [DATE]. I should note that in the process of CPR the patient did have emesis of frank fecal material which was suctioned. The abdomen was distended. Impression: Death, I suspect is secondary to [MEDICAL CONDITION], I suspect secondary to a bowel obstruction. Should note that the patient did have a mottled appearance on arrival..." j. The DMS-7734, Incident and Accident next Day reporting Form, dated [DATE] at 11:00 a.m. documented, "CNA questioned timeliness of care given by LPN on [DATE]." The DMS-7734 dated [DATE] at 11:00 a.m. documented, "Investigation initiated. Nurse suspended pending investigation. Staff witness statements initiated [DATE] Resident statements gathered by social worker on [DATE]. In-service on reporting changes in residents initiated on [DATE]. MD (Medical Doctor) notified. Family notified. Police notified. Resident's under the care of LPN assessed for any change of condition and no negative findings were found. Statements obtained from CNA and Nurse in question. Continuing to get witness statements from alert and oriented resident and staff. Inservice on abuse and neglect initiated." k. On [DATE], the facility provided a list of interventions to prevent further reoccurrences dated [DATE] which documented and included, "1. New systems to put in place: CNA communication book, monitor BM's (last 3 days) as part of start-up (ensure it is place). Schedule for for Physical Assessment Competency Workshop..." 1) On [DATE] at 8:20 a.m., CNA #6 was asked if she had been inserviced recently and if so what did the inservice consist of? CNA #6 stated, "Yes."' During the interview, the CNA did not mention the CNA communication book. CNA #6 had to be prompted. She was asked if she knew the purpose of the CNA communication book. CNA #6 stated, "I don't know the purpose, I've not used it yet." 2) On [DATE] at 8:27 a.m., CNA #7 was asked if she had been inserviced recently and if so what was the inservice about? CNA #7 stated, "Yes."' During the interview, the CNA did not mention the CNA communication book. CNA #7 had to be prompted. CNA #7 stated, "I've not asked about that book yet." 2. On [DATE] at 2:23 p.m., the Immediate Jeopardy was removed and the Scope and Severity was reduced to a "G"when the facility initiated the following plan of removal: a. 100% of all staff will be in-serviced by the DON, designee on abuse, neglect, reporting to include notifying Chief Executive Officer (CEO), DON if there is any question on standards of practice or care provided to residents, assessment, change of condition, documentation with evaluation of their understanding by verbal response and written testing beginning [DATE] before each employee is allowed to provide care or work their assigned shift. b. LPN in question related to delay in providing care continues to be suspended pending investigation in addition to the 2 aides making the allegation related to failure to report timely. c. The DON assessed all residents in direct care of LPN in question for any changes of condition [DATE] and there were no negative findings. d. The physician for the affected resident was contacted by the DON on [DATE] without further suggestions or interventions. e. Social Services Director (SSD) interviewed all cognitively aware residents on [DATE] regarding abuse and neglect with no negative findings and will be interviewed again on [DATE] regarding any knowledge of abuse and neglect of anyone. f. On [DATE], the QR nurse and facility treatment nurse reviewed logs (bowel movements) for the last 72 hours to ensure that there were no residents without a bowel movement in the last 3 days and any negative findings were reported to the charge nurse. g. The DON, designee will review Incident and Accident (I&A) logs and 24 hour reports daily 5 times a week and ongoing for any changes of condition and to ensure that the MD has been notified. Any negative findings will be corrected immediately by the DON calling the MD and taken to the monthly Quality Assurance and Assessment (QAA) for recommendations. h. The DON, designee will interview 5 staff members daily per one week and then weekly x 3 weeks to determine and evaluate the nurses response to change of condition, timely treatment and care that has been delivered that week. Any negative response will be immediately addressed by removing the employee from the floor and conduct a one-on-one retraining with that staff member to include a written test to demonstrate their understanding. The staff member will be placed back on the floor to work only after their competency has been demonstrated and their actions did not result in abuse or neglect. Any negative findings will be reported to the monthly QAA.

Based on observation, record review and interview, the facility failed to ensure that Resident #4 maintained acceptable parameters of nutritional status. The facility failed to ensure identified weight loss/continued weight loss was promptly assessed; the physician promptly consulted; and interventions were promptly developed, consistently implemented, and re-evaluated to prevent further weight loss and promote weight gain for 1 (Resident #4) of 4 (Residents #3, 4, 6 and 17) case mix residents who experienced severe, unplanned weight losses. The failed practices likely resulted in a pattern of actual harm for Resident #4 who experienced a severe weight loss and was likely to cause more than minimal harm for 27 residents who were at risk for weight loss as identified by the Administrator on 2/22/11 at 12:09 p.m. The findings are: 1. The facility ' s Weight Protocol received from the Director Of Nursing (DON) on 2/18/11 at 10:40 a.m. documented, "Policy: It is the intention of this facility to ensure the accurate assessment of the residents in order to provide adequate nutrition to maintain good health...All residents identified at risk for nutritional problems due to physical, emotional, etc. complications will have interventions put in place by the Dietary Service Manager, DON/Designee in a timely manner. Any weight concerns...will be addressed by the Dietary Manager and the DON/Designee which includes, but not limited to: Placing the resident on weekly weights list x 4 weeks, at a minimum; Contacting the physician...Coordinating a plan of care change; Contacting the Registered Dietitian as needed for further guidance; Updating the care plan, and Having a weekly note completed by the Dietary Service Manager or DON/Designee to reflect the resident's weight change, interventions in place and resident's response to the interventions." 2. Administrative Policies and Procedures titled Persons At Risk (PAR) Process received from the Registered Dietician (RD) on 2/18/11 at 1:00 p.m. documented: "Persons AT Risk It is the policy of this facility to aggressively address the status of residents who are considered to be at risk...Residents who have lost or gained 7.5% or more of their body weight over a 3 month period (undesired/unplanned) ...Residents who have decreased oral intake...Residents exhibiting pain in which pain medication is being adjusted...It is the responsibility of the PAR committee to screen residents to be added to the PAR program. The PAR Committee will review the screened residents' conditions on a weekly basis. The Care Plan will be individualized for each resident with appropriate interventions...The PAR Committee will consist of, but not be limited to, the D.O.N. (Director of Nursing), Food Service Supervisor (FSS), Licensed Nurse from appropriate resident unit, MDS (Minimum Data Set) Coordinator, Treatment Nurse (if appropriate), Social Services, Therapies (if appropriate)...Weight Loss ... Review weight-current and trend...Review RD and FSS documentation...Develop Interventions. Update care plan..." 3. Resident #4 had [DIAGNOSES REDACTED]. a. Physician order [REDACTED]." b. On 11/15/10 the Registered Dietitian documented under weight concern: "Nov. (November) wt. (weight) 127.6 # (pounds)...9.7% decrease x 30 (days), 13.6 % decrease x 90 (days) and 19.9 % in 180 (days). R (Resident) Signt (Significant) loss x 30/90/180 (days)...Rec: (Recommend) Fortify foods at meals to promote wt. maint. (maintenance)." On 2/17/11 at 3:10 p.m., the Dietary Manager was asked if she was the person who notifies the RD if there is a resident with weight loss. She stated, "Yes, she comes and sees me once a month. It is hard to get her since she is out of state. I call here and leave a message. The last time she saw (Resident #4) was in November when she wrote her note" c. The Annual Minimum Data Set with an assessment reference date of 12/8/10 documented the resident had a cognitive summary score of 15 (a score of 13 to 15 is cognitively intact), was independent in eating, had been on a scheduled pain medication regimen, received as needed (PRN) pain medications for pain rated as a 10 (with zero being no pain and ten as the worst pain you can imagine), no swallowing problems, weight was 127, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and not on a physician-prescribed weight-loss regimen. d. The Care Plan dated 12/8/10 documented Problem: "Nutrition: Risk of weight loss related to leaving 50% + of meals uneaten ...Approaches ...Diet as ordered per MD (Medical Doctor)...Report any adverse effects from weight loss to MD..." The care plan did not address the severe weight loss identified by the RD in her notes dated 11/15/10 nor did the care plan document the RD ' s recommended intervention to serve fortified foods at meals to promote weight maintenance. e. Physician order [REDACTED]." f. A Physician order [REDACTED]. g. The Dietary Departmental notes dated 12/31/10 and signed by the Food Service Manager documented weight in October 140 pounds, November 127 pounds and December 126 pounds, loss of 13 % in 90 days. The notes documented, "She is receiving health shakes three times a day with meals with a regular diet and average intake 50%...Does not want to eat breakfast, all she asked to have is 2 cups of coffee, voices likes and dislikes. No other changes at this time." There were no food likes documented in the Dietary Departmental notes. h. The Monthly Weights received from the Dietary Manager on 2/17/11 at 2:03 p.m., documented the following weights from October 2010 thru January 2011: October 2011: 140 pounds November 2010: 127 pounds December 2010: 126 pounds January 2011: 120 pounds The resident experienced a severe weight loss of 14.28 % over a 3 month period from October 1010 (Weight 140) through January 2011 (Weight 120). On 2/18/11 at 7:52 a.m., CNA/RA #1 (Certified Nursing Assistant/Restorative Aide) stated, "I do the weights." She was asked if she was aware of the resident's weight loss. She stated, "Yes, her weight loss is very significant. I tell the nurses, the Dietary Manager. We do not have her on weekly weights, just monthly weights. The Dietary Manager told me to start keeping track of her weekly weights. She told me yesterday...I give a monthly copy every month to the Dietary Manager, DON (Director of Nursing), and the ADON (Assistant Director of Nursing). I also keep track of residents on weekly weights." i. The Nursing Notes dated 12/7/10 to 2/14/11 were reviewed. The Notes did not document the resident's lack of appetite, weight loss or any need for encouragement for eating. 1). The January 2011 and the February 2011 Meal Intake Records for the resident were reviewed on 2/17/10 at 2:12 p.m. thru noon day meal. The January record documented the resident at 100% of her meal 1 time, 75% of her meal 14 times, 50% of her meals 11 times, 25% of her meals 3 times, less than 25% 1 time and liquids only one time. The February record documented the resident ate 75% of her meal 3 times, less than 25% 1 time and liquids only 13 times. 2). On 2/18/11 at 11:50 a.m., CNA #4 was asked about (Resident #4) and her weight loss. She stated, "She doesn't ever eat breakfast, only drinks coffee and Health Shake. I only heard about the weight loss today..." j. The Physician's Progress Notes dated 12/14/10, 12/20/10, 1/13/11, 1/24/11. 1/25/11, 1/31/11 and 2/14/11 did not document the resident's weight loss or awareness of the resident's continued weight loss. 1) On 2/17/11 at 12:40 p.m., the Administrator was asked if she found where the physician had been notified of the resident's continued weight loss since December. She stated, "No, just yesterday." 2) On 2/18/11 at 12:30 p.m., the physician was asked if the facility made him aware of the resident's continued weight loss since the [MEDICATION NAME] was ordered. He stated, "No they did not inform me the interventions were not working and the resident was continuing to lose weight. I just follow the RD's (Registered Dietitian) recommendations." k. On 2/15/11 at 12:27 p.m., the resident's tray card documented resident dislikes hushpuppies but no likes were noted. Also the tray card documented a regular diet, water, coffee and health shake. The tray card did not document fortified foods and there was no [MEDICATION NAME] documented on the tray card. On 2/17/11 at 3:42 p.m., the Dietary Manager was asked if the resident was getting scheduled snacks. She stated, "No, she (resident) would come up and get ice cream and coffee, sometimes chips, but no she is not getting scheduled snacks. But she does get them when she asks." l. On 2/15/11 at 12:27 p.m., 5:47 p.m. and on 2/17/11 at 5:35 p.m. and 2/18/11 at 7:35 a.m., observations were made of meals served to the resident. The resident did not have a protein powder on the tray, or on any other food items served to her. 1) On 2/17/11 at 11:50 a.m., the Dietary Manager was asked how the RD ' s recommendation of fortified foods was implemented. She stated, "We used [MEDICATION NAME] in the meats." She was asked if the resident received [MEDICATION NAME] and she stated, "She's been getting it since last week." 2) On 2/18/11 at 7:35 a.m., Certified Nursing Assistant (CNA) #3 served the breakfast meal to the resident in her room. The CNA was asked if there was any powder on the omelet. She stated, "No." The CNA was asked if there was any food on the tray that contained a fortified food. She stated, "What's that?" The CNA was told it was any food with extra protein or calories. She stated, "No ma'am. She usually just eats her shake and coffee." 3) On 2/18/11 at 8:54 a.m., Dietary Aide #2 was asked if anyone was getting a protein packet. She stated, "(Resident #8) gets a protein pack twice a day. She is the only one that gets a protein pack..." 4) On 2/18/11 at 8:59 a.m., the Dietary Manager was asked if she had monitored (Resident #4) to see if she was getting the [MEDICATION NAME]. She stated, "She got it for lunch yesterday and supper. But, she is getting extra sugar in sweet foods and extra butter...I've got a list of people we are going to see today (with RD). She (resident) is at the top of the list. I haven't tried ice cream in Health Shakes or her Ensure. She loves ice cream..." Note: Surveyor was in kitchen on 2/17/11 for the supper meal and the resident's tray did not have [MEDICATION NAME] or extra margarine. 5) On 2/18/11 at 12:07 p.m., Dietary Aid #1 was asked if she knew of any resident that is supposed to receive supplements with meals. She stated, "No." She was then asked if she knew of any resident getting protein powder with meals ([MEDICATION NAME]). She stated, "Yes, (Resident #8). " She was asked how would she finds out about a resident losing weight. She stated, "The only way we know is if a nurse writes out an order to give them supplements. I think (Resident #4) is who we are working on now. I heard about it yesterday, that she is losing weight." m. On 2/18/11 at 8:44 a.m., the resident was weighed for the surveyor. The resident ' s weight was 116.2 pound, a loss of 3.8 pounds since the January 2011 weight of 120 pounds. n. On 2/18/11 at 10:23 a.m., the Administrator was asked, "What is the protocol for weight loss? She stated, "We have monthly weights presented when they do their monthly weights. The Dietary Manager presents them during stand up meetings. Also the RD makes recommendations for any weight losses. It is also discussed in the monthly QA (Quality Assurance) meetings and action plans to prevent weight losses." She was asked if any of that was done for (Resident #4). She stated, "I saw on the RDs last consult note (11/15/10) she recommended fortified foods." She was asked if anyone monitored to make sure the resident received fortified foods. The Administrator stated, "I don't know." She was asked when was she aware (Resident #4) was losing weight. She stated, "I don't know, I guess it was the last weight report I received. " She was asked when the RD comes and gives recommendations how do you monitor for resident's losing weight. She stated, "I don't personally monitor, I leave it up to the Dietary Manager..." On 2/18/11 at 10:38 a.m., the DON was asked what is the protocol for weight loss. She stated, "I've been here one week. We are told that the weight losses or gains are given to the DON and Dietary Manager. They are reviewed and appropriate measures are taken to address the issue. We notify the doctor and the families that there is a weight loss. The (residents) are put on a weekly weight to monitor for anymore weight loss. The RD is asked for any further recommendations if it's in-between her visit." The DON was asked if she was aware of the resident's weight loss. She stated, "During my orientation last week it was mentioned," She was asked if they had shared with her anything they had tried for the resident. She stated, "No." On 2/18/11 at 11:07 a.m., the Dietary Manager was asked what is the protocol for weight loss. She stated, "I go to the DON and we go to the nurse." She was asked if she did that for (Resident #4). She stated, "Yes, I can't honestly tell you when. I'm thinking it was before December (2010). December 9th Health Shakes were started." She was asked if residents continue to lose weight, how do you follow up with that. She stated, "Get in touch with the doctor and monitor the resident. It should have been done already." She was asked if the intervention in place is not working, what is done. She stated, "We try something else." She was asked if that was done for the resident. She stated, "I had them make her a milkshake this morning for her 10:00 a.m. snack and I asked them to do it again at 2:30 p.m. (today)...I am going to have the RD go with me to (Resident #4) to find out what other foods she likes." She was asked if this had been done before. She stated, "We have done it with other residents but not with her until now."

Based on observation, record review and interview, the facility's Dietary Administration, Nursing Administration and Executive Administration failed to ensure that Resident #4 maintained acceptable parameters of nutritional status. The Dietary, Nursing, and Executive Administration failed to ensure identified weight loss/continued weight loss was promptly assessed; the physician promptly consulted; and interventions were promptly developed, consistently implemented, and re-evaluated to prevent further weight loss and promote weight gain for 1 (Resident #4) of 4 (Residents #3, 4, 6 and 17) case mix residents who experienced severe, unplanned weight losses. The failed practices likely resulted in a pattern of actual harm for Resident #4 who experienced a severe weight loss and was likely to cause more than minimal harm for 27 residents who were at risk for weight loss as identified by the Administrator on 2/22/11 at 12:09 p.m. The findings are: 1. Administrative Job Descriptions received from the Administrator on 2/18/11 10:45 a.m., documented: a. Job Title: Dietary Services Supervisor...Reports to: Chief Executive Officer. General Purpose: Manage the operation of the Dietary Department to include...food delivery...physician orders, resident care plans and appropriate regulations...Duties:...Be actively involved with the Facility Weight Program and ensure weights are being completed, accurate and follow up is completed as necessary to remain in the state and federal guidelines...Ensure appropriate meals and snacks are served to residents with special Dietary needs..." b. Job Title: Director of Nursing Services...Reports To: Chief Executive Officer. General Purpose: To lead and direct, and manage the overall operations of the nursing department in accordance with standards of practice, customer needs, government regulations and facility policies, with focus on maintaining excellent care for the residents/patients.... Duties:...Develops and maintains nursing care practices for the facility. Plan, organize and direct effective administration of nursing units and patient care based on the established goals and objectives, standards, policies and procedures...Provide mentoring, education and discipline in a consistent manner...Oversees regular rounds to monitor delivery of nursing care...and ensures needs are being addressed...Ensures consultants and other support resources are appropriately utilized and a high level of interdepartmental teamwork is maintained...Attend daily stand up meetings, manage daily start up for the nursing department...Maintain a working knowledge of and ensure compliance with all governmental regulations...Observe, monitor and participate as needed in the day-to-day functions of the nursing department. Conduct daily rounds to assess resident care..." c. Job Title: Chief Executive Officer...General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and facility policies, with focus on maintaining excellent care for the residents/patients...Duties:...Monitors each department's activities, communicates policies, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed...Oversees regular rounds to monitor delivery of nursing care, operation of support departments...and ensures needs are being addressed...Ensures consultants and other support resources are appropriately utilized and a high level of interdepartmental teamwork is maintained...Must adhere to and set the expectations for Compliance with Federal and State regulations, which include documentation..." 2. The facility ' s Weight Protocol received from the Director Of Nursing (DON) on 2/18/11 at 10:40 a.m. documented, "Policy: It is the intention of this facility to ensure the accurate assessment of the residents in order to provide adequate nutrition to maintain good health...All residents identified at risk for nutritional problems due to physical, emotional, etc. complications will have interventions put in place by the Dietary Service Manager, DON/Designee in a timely manner. Any weight concerns...will be addressed by the Dietary Manager and the DON/Designee which includes, but not limited to: Placing the resident on weekly weights list x 4 weeks, at a minimum; Contacting the physician...Coordinating a plan of care change; Contacting the Registered Dietitian as needed for further guidance; Updating the care plan, and Having a weekly note completed by the Dietary Service Manager or DON/Designee to reflect the resident's weight change, interventions in place and resident's response to the interventions." 3. Administrative Policies and Procedures titled Persons At Risk (PAR) Process received from the Registered Dietician (RD) on 2/18/11 at 1:00 p.m. documented: "Persons AT Risk It is the policy of this facility to aggressively address the status of residents who are considered to be at risk...Residents who have lost or gained 7.5% or more of their body weight over a 3 month period (undesired/unplanned) ...Residents who have decreased oral intake...Residents exhibiting pain in which pain medication is being adjusted...It is the responsibility of the PAR committee to screen residents to be added to the PAR program. The PAR Committee will review the screened residents' conditions on a weekly basis. The Care Plan will be individualized for each resident with appropriate interventions...The PAR Committee will consist of, but not be limited to, the D.O.N. (Director of Nursing), Food Service Supervisor (FSS), Licensed Nurse from appropriate resident unit, MDS (Minimum Data Set) Coordinator, Treatment Nurse (if appropriate), Social Services, Therapies (if appropriate)...Weight Loss ... Review weight-current and trend...Review RD and FSS documentation...Develop Interventions. Update care plan..." 4. Resident #4 had [DIAGNOSES REDACTED]. a. Physician order [REDACTED]." b. On 11/15/10 the Registered Dietitian documented under weight concern: "Nov. (November) wt. (weight) 127.6 # (pounds)...9.7% decrease x 30 (days), 13.6 % decrease x 90 (days) and 19.9 % in 180 (days). R (Resident) Signt (Significant) loss x 30/90/180 (days)...Rec: (Recommend) Fortify foods at meals to promote wt. maint. (maintenance)." On 2/17/11 at 3:10 p.m., the Dietary Manager was asked if she was the person who notifies the RD if there is a resident with weight loss. She stated, "Yes, she comes and sees me once a month. It is hard to get her since she is out of state. I call here and leave a message. The last time she saw (Resident #4) was in November when she wrote her note" c. The Annual Minimum Data Set with an assessment reference date of 12/8/10 documented the resident had a cognitive summary score of 15 (a score of 13 to 15 is cognitively intact), was independent in eating, had been on a scheduled pain medication regimen, received as needed (PRN) pain medications for pain rated as a 10 (with zero being no pain and ten as the worst pain you can imagine), no swallowing problems, weight was 127, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and not on a physician-prescribed weight-loss regimen. d. The Care Plan dated 12/8/10 documented Problem: "Nutrition: Risk of weight loss related to leaving 50% + of meals uneaten ...Approaches ...Diet as ordered per MD (Medical Doctor)...Report any adverse effects from weight loss to MD..." The care plan did not address the severe weight loss identified by the RD in her notes dated 11/15/10 nor did the care plan document the RD ' s recommended intervention to serve fortified foods at meals to promote weight maintenance. e. Physician order [REDACTED]." f. A Physician order [REDACTED]. g. The Dietary Departmental notes dated 12/31/10 and signed by the Food Service Manager documented weight in October 140 pounds, November 127 pounds and December 126 pounds, loss of 13 % in 90 days. The notes documented, "She is receiving health shakes three times a day with meals with a regular diet and average intake 50%...Does not want to eat breakfast, all she asked to have is 2 cups of coffee, voices likes and dislikes. No other changes at this time." There were no food likes documented in the Dietary Departmental notes. h. The Monthly Weights received from the Dietary Manager on 2/17/11 at 2:03 p.m., documented the following weights from October 2010 thru January 2011: October 2011: 140 pounds November 2010: 127 pounds December 2010: 126 pounds January 2011: 120 pounds The resident experienced a severe weight loss of 14.28 % over a 3 month period from October 1010 (Weight 140) through January 2011 (Weight 120). On 2/18/11 at 7:52 a.m., CNA/RA #1 (Certified Nursing Assistant/Restorative Aide) stated, "I do the weights." She was asked if she was aware of the resident's weight loss. She stated, "Yes, her weight loss is very significant. I tell the nurses, the Dietary Manager. We do not have her on weekly weights, just monthly weights. The Dietary Manager told me to start keeping track of her weekly weights. She told me yesterday...I give a monthly copy every month to the Dietary Manager, DON (Director of Nursing), and the ADON (Assistant Director of Nursing). I also keep track of residents on weekly weights." i. The Nursing Notes dated 12/7/10 to 2/14/11 were reviewed. The Notes did not document the resident's lack of appetite, weight loss or any need for encouragement for eating. 1). The January 2011 and the February 2011 Meal Intake Records for the resident were reviewed on 2/17/10 at 2:12 p.m. thru noon day meal. The January record documented the resident at 100% of her meal 1 time, 75% of her meal 14 times, 50% of her meals 11 times, 25% of her meals 3 times, less than 25% 1 time and liquids only one time. The February record documented the resident ate 75% of her meal 3 times, less than 25% 1 time and liquids only 13 times. 2). On 2/18/11 at 11:50 a.m., CNA #4 was asked about (Resident #4) and her weight loss. She stated, "She doesn't ever eat breakfast, only drinks coffee and Health Shake. I only heard about the weight loss today..." j. The Physician's Progress Notes dated 12/14/10, 12/20/10, 1/13/11, 1/24/11. 1/25/11, 1/31/11 and 2/14/11 did not document the resident's weight loss or awareness of the resident's continued weight loss. 1) On 2/17/11 at 12:40 p.m., the Administrator was asked if she found where the physician had been notified of the resident's continued weight loss since December. She stated, "No, just yesterday." 2) On 2/18/11 at 12:30 p.m., the physician was asked if the facility made him aware of the resident's continued weight loss since the [MEDICATION NAME] was ordered. He stated, "No they did not inform me the interventions were not working and the resident was continuing to lose weight. I just follow the RD's (Registered Dietitian) recommendations." k. On 2/15/11 at 12:27 p.m., the resident's tray card documented resident dislikes hushpuppies but no likes were noted. Also the tray card documented a regular diet, water, coffee and health shake. The tray card did not document fortified foods and there was no [MEDICATION NAME] documented on the tray card. On 2/17/11 at 3:42 p.m., the Dietary Manager was asked if the resident was getting scheduled snacks. She stated, "No, she (resident) would come up and get ice cream and coffee, sometimes chips, but no she is not getting scheduled snacks. But she does get them when she asks." l. On 2/15/11 at 12:27 p.m., 5:47 p.m. and on 2/17/11 at 5:35 p.m. and 2/18/11 at 7:35 a.m., observations were made of meals served to the resident. The resident did not have a protein powder on the tray, or on any other food items served to her. 1) On 2/17/11 at 11:50 a.m., the Dietary Manager was asked how the RD ' s recommendation of fortified foods was implemented. She stated, "We used [MEDICATION NAME] in the meats." She was asked if the resident received [MEDICATION NAME] and she stated, "She's been getting it since last week." 2) On 2/18/11 at 7:35 a.m., Certified Nursing Assistant (CNA) #3 served the breakfast meal to the resident in her room. The CNA was asked if there was any powder on the omelet. She stated, "No." The CNA was asked if there was any food on the tray that contained a fortified food. She stated, "What's that?" The CNA was told it was any food with extra protein or calories. She stated, "No ma'am. She usually just eats her shake and coffee." 3) On 2/18/11 at 8:54 a.m., Dietary Aide #2 was asked if anyone was getting a protein packet. She stated, "(Resident #8) gets a protein pack twice a day. She is the only one that gets a protein pack..." 4) On 2/18/11 at 8:59 a.m., the Dietary Manager was asked if she had monitored (Resident #4) to see if she was getting the [MEDICATION NAME]. She stated, "She got it for lunch yesterday and supper. But, she is getting extra sugar in sweet foods and extra butter...I've got a list of people we are going to see today (with RD). She (resident) is at the top of the list. I haven't tried ice cream in Health Shakes or her Ensure. She loves ice cream..." Note: Surveyor was in kitchen on 2/17/11 for the supper meal and the resident's tray did not have [MEDICATION NAME] or extra margarine. 5) On 2/18/11 at 12:07 p.m., Dietary Aid #1 was asked if she knew of any resident that is supposed to receive supplements with meals. She stated, "No." She was then asked if she knew of any resident getting protein powder with meals ([MEDICATION NAME]). She stated, "Yes, (Resident #8). " She was asked how would she finds out about a resident losing weight. She stated, "The only way we know is if a nurse writes out an order to give them supplements. I think (Resident #4) is who we are working on now. I heard about it yesterday, that she is losing weight." m. On 2/18/11 at 8:44 a.m., the resident was weighed for the surveyor. The resident ' s weight was 116.2 pound, a loss of 3.8 pounds since the January 2011 weight of 120 pounds. n. On 2/18/11 at 10:23 a.m., the Administrator was asked, "What is the protocol for weight loss? She stated, "We have monthly weights presented when they do their monthly weights. The Dietary Manager presents them during stand up meetings. Also the RD makes recommendations for any weight losses. It is also discussed in the monthly QA (Quality Assurance) meetings and action plans to prevent weight losses." She was asked if any of that was done for (Resident #4). She stated, "I saw on the RDs last consult note (11/15/10) she recommended fortified foods." She was asked if anyone monitored to make sure the resident received fortified foods. The Administrator stated, "I don't know." She was asked when was she aware (Resident #4) was losing weight. She stated, "I don't know, I guess it was the last weight report I received. " She was asked when the RD comes and gives recommendations how do you monitor for resident's losing weight. She stated, "I don't personally monitor, I leave it up to the Dietary Manager..." On 2/18/11 at 10:38 a.m., the DON was asked what is the protocol for weight loss. She stated, "I've been here one week. We are told that the weight losses or gains are given to the DON and Dietary Manager. They are reviewed and appropriate measures are taken to address the issue. We notify the doctor and the families that there is a weight loss. The (residents) are put on a weekly weight to monitor for anymore weight loss. The RD is asked for any further recommendations if it's in-between her visit." The DON was asked if she was aware of the resident's weight loss. She stated, "During my orientation last week it was mentioned," She was asked if they had shared with her anything they had tried for the resident. She stated, "No." On 2/18/11 at 11:07 a.m., the Dietary Manager was asked what is the protocol for weight loss. She stated, "I go to the DON and we go to the nurse." She was asked if she did that for (Resident #4). She stated, "Yes, I can't honestly tell you when. I'm thinking it was before December (2010). December 9th Health Shakes were started." She was asked if residents continue to lose weight, how do you follow up with that. She stated, "Get in touch with the doctor and monitor the resident. It should have been done already." She was asked if the intervention in place is not working, what is done. She stated, "We try something else." She was asked if that was done for the resident. She stated, "I had them make her a milkshake this morning for her 10:00 a.m. snack and I asked them to do it again at 2:30 p.m. (today)...I am going to have the RD go with me to (Resident #4) to find out what other foods she likes." She was asked if this had been done before. She stated, "We have done it with other residents but not with her until now."