Every finding on record at The NM Behavioral Health Institute at Las Vegas

Based on record review and interview, the facility failed to provide documentation confirming 2 (NA #1 and NA #3) of 5 (NA #1, NA #3, NA #4, and NA #5) Nurse Aides had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 102 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: NA #1:A. Record review of NA #1's personnel record revealed the following:1. NA #1's is a current employee with a hire date of [DATE]. NA #1's date of Certified Nurse Aide Training was completed on [DATE].3. NA #1 is not certified and has not taken her certification test as of [DATE].NA #3:B. Record review of NA #3's personnel record revealed the following:1. NA #3's is a current employee with an original hire date of [DATE], rehire on [DATE]. 2. NA #3's date of original Certified Nurse Aide Training was completed on [DATE].3. NA #3's certification had expired on [DATE].4. NA #3 had not registered to attend a NATCEP or CEP training as of [DATE].C. On [DATE] at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed NA #1 received her certified nurse aide training late and continued to work shifts during that time. The DON also confirmed that NA #3 has been working shifts at this facility even though NA #3's certification has been expired since 2017. The DON stated her expectation is for all nurse aides to attend the certified nurse aide training and become certified within four months of hire date.

Based on record review and interview, the facility's Administrator (ADM) and Director of Nursing (DON) failed to administer the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring staff were trained and/or competent before providing care to residents. 2. Allowing untrained and uncertified nurse aides to train other nurse aides. These deficient practices are likely to affect all 102 residents residing in the facility according to the daily census provided by the Admissions Coordinator (AC) on [DATE] and could lead to residents not maintaining their highest practicable physical, mental, and social well-being. The findings are: A. Record review of the facility's progress notes for R #12 revealed on [DATE] R #12 had fallen out of mechanical lift sling while being transferred by Nurse Aide (NA) #1 and NA #2. R #12 landed on the floor and was lying on his back, left leg was under bed, right leg propped on bed, and laceration (a wound produced by tearing) to back of head was noted. Physician notified at 7:43 pm, instructed to send the resident out to hospital via ambulance. R #12 was transported to hospital via ambulance at 8:15 pm. B. On [DATE] at 3:53 pm, during an interview with Director of Nursing (DON), she confirmed R #12 fell during a mechanical lift transfer. The DON confirmed that Nurse Aide (NA) #1 was training NA #2 and were the staff with R #12 during that transfer. The DON stated that NA #1 is not a certified nurse aide but is trained to operate a mechanical lift; and NA #2 is also not a certified nurse aide and has not completed training to become a certified nurse aide. C. On [DATE] at 11:37 am, during an interview with the administrator, he stated that one of two mechanical lift operators must be a certified nurse aide. The administrator confirmed that during the transfer of R #12, both NA's #1 and #2 are not certified and they must not operate the mechanical lift together.D. Record review of the facility's personnel records revealed the following:1. NA #1's is a current employee with a hire date of [DATE]. NA #1's date of Certified Nurse Aide Training was completed on [DATE].3. NA #1 is not certified and has not taken her certification test as of [DATE].4. NA #3's is a current employee with a hire date was [DATE].5. NA #3's date of original Certified Nurse Aide Training was completed on [DATE].6. NA #3's certification expired on [DATE].7. NA #3 had not registered to attend a NATCEP or CEP training as of [DATE].E. On [DATE] at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed NA #1 received her certified nurse aide training late and continued to work shifts during that time. The DON also confirmed that NA #3 has been working shifts at this facility even though NA #3's certification has been expired since 2017. The DON stated her expectation is for all nurse aides to attend the certified nurse aide training and become certified within four months of hire date.F. On [DATE] at 11:18 am during an interview with the DON, she stated that she assigns nurse aides and certified nurse aides to the unit they are to work in, but it is the floor nurses that make the assignments of which staff work together and with which residents. The DON stated that she does not notify the floor nurses of which staff are trained and certified and which staff are not. The DON stated that she feels that allowing uncertified nurse aides to train untrained nurse aides is acceptable. G. On [DATE] at 11:37 am during an interview with the ADM, he stated that untrained and uncertified nurse aides should only work with and receive training from certified nurse aides. The ADM was unable to answer how the facility ensures that residents receive care and support from trained, competent, and certified nurse aides, instead he stated, I know it needs to be corrected.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #29) of 3 (R #1, R #29, and R #32) residents reviewed when staff failed to update a care plan after a resident was diagnosed with dementia. This deficient practice could result in residents' care and needs not being addressed. The findings are:A. Record review of R #29's admission Record revealed she was admitted to the facility on [DATE].B. Record review of R #29's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/09/25, revealed the following:1. R #29's most recent admission or reentry to this facility was on 05/13/22.2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not conducted because the resident is rarely or never understood.3. R #29's active diagnoses include a diagnosis of Non-Alzheimer's Dementia (a variety of dementia types that are not caused by Alzheimer's disease which is a type mental deterioration). C. Record review of R #29's care plan, last updated on 08/14/25 revealed the care plan did not contain any goals or interventions in place for R #29 dementia or the care and support she needs.D. On 12/11/25 at 11:43 am, during an interview with the Director of Nursing (DON), she confirmed that R #29's care plan does not meet her expectations because it does not include her having dementia or the care and support she needs.

Based on record review and staff interview, the facility failed to ensure the annual performance review for the certified nursing assistants (CNAs) was completed for 1 (CNA #2) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed. This could lead to residents not receiving the care and services as described on the care plan. The findings are:A. Record review of the facility's Personnel Records revealed CNA #2's hire date of 05/18/13. The most recent annual performance evaluation for CNA #2 was dated 10/29/24. B. On 12/12/25 at 11:43 am during an interview, the Director of Nursing (DON) could not confirm if CNA #2 had an annual performance evaluation completed since 10/29/24 and stated, [Name of city where this facility's Human Resources office is located] keeps up with the evaluations, they are sent to me when it is time for the employees to sign the yearly evaluation. She stated that she does expect the evaluations to be completed every 12 months.

Based on observation, and interviews, the facility failed to properly store medications in the facility by making sure:-Medications in bubble wraps are not compromised (not opened or punctured and secured in the original packaging from the pharmacy). -All medical supplies are not expired.These deficient practices are likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication.The findings are:A. On 12/10/25 at 9:07 am during an observation of the medication cart, in the locked unit, revealed the following:-A medication bubble card labeled with the name of R #70 and containing Clonazepam (a prescribed medication used to manage anxiety) 1 mg (milligrams). The bubble pack labeled number 1 had a small green pill in the bubble. The bubble had been opened.- A 25g (gauge refers to the size of the hole in a needle) needle with an expiration date of 09/10/25.B. On 12/10/25 at 9:07 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the bubble card is compromised. LPN #1 also confirmed that the needle is expired.C. On 12/11/25 at 1:36 pm, during an interview with Director of Nursing (DON), she confirmed that the compromised medication inside the bubble card and the expired needle should have been discarded properly and did not happen.

Based on observation, record review, and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (R #8) of 1 (R #8) resident observed for food preferences. This deficient practice is likely to result in food intolerance and/or an allergic reaction to the food being served to the residents. The findings are:A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].B. Record review of R #8's meal card (card that identifies what to serve or not serve each resident) revealed R #8 is not to have chocolate and is allergic to peas. C. On 12/09/25 at 11:31 am, during an observation of dining, R #8 was served his lunch meal, on his plate was pasta that contained peas. Also noted on his tray was a bowl of chocolate pudding. R #8 stated to staff that he could not eat that because he is allergic to peas and chocolate.D. On 12/09/25 at 11:33 am during an interview with Certified Nurse Aide (CNA #1), she stated R #8's meal ticket stated R#8 has an allergy to peas and cannot have chocolate. She confirmed that these two foods were served to R #8 and should not have been.

Based on record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 2 (R #19 and R #32) of 4 (R #8, R #15, R #19, and R #32) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:R #19 A. Record review of R #19's admission Record revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease (a progressive mental deterioration), unspecified, 2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 3. Essential (primary) hypertension (HTN; high blood pressure). B. Record review of R #19's progress notes revealed the following: 1. On 09/05/25 at 7:45 am, facility staff found R #19 asleep in a chair in the activity room. When staff woke R #19 up and assisted her to get in her wheelchair, she complained of pain in her left hip. R #19 was assessed by Registered Nurse (RN) #1 where swelling to the left hip and outward rotation (movement of a limb away from the midline of the body) of the left foot as well as R #19's inability to bear weight (not able to support or hold weight) was discovered. R #19 was sent to the hospital for further evaluation. 2. On 09/05/25 at 12:33 pm, the facility was notified that R #19 had a comminuted fracture (type of bone fracture where the bone is broken into three or more separate pieces) of her left femur (the thigh bone). C. Record review of R #19's Discharge MDS dated [DATE] revealed R #19 was discharged from the facility and her return is anticipated. D. Record review of R #19's readmission admission MDS dated [DATE], section J1700 revealed the following: 1. R #19 did not have any falls in the last two to six months prior to admission or reentry as indicated by a zero (the answer for no) being placed in the Enter Code column, meaning the facility staff that answered the questions in this section indicated that R #19 had not fallen. 2. R #19 did not have any fractures related to a fall in the six months prior to admission or reentry. E. On 12/11/25 at 11:43 am, during an interview with the Director of Nursing (DON), she confirmed that R #19's MDS should indicate that she suffered a fracture related to a fall and it does not. The DON stated she expects all MDS assessments to be accurate and confirmed this one is not accurate. R #32 F. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE]. G. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23. H. Record review of R #32's care plan dated 11/29/25 revealed no care plan for hearing aid use. I. Record review of R #32's annual MDS assessment dated [DATE] revealed the following: -Section B0200: Moderate difficulty (hearing), speaker has to increase volume and speak distinctly. -Section B0300: No hearing aid or other hearing appliance used. J. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair of hearing aids were on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility. K. On 12/11/25 at 3:48 am, during an interview, the Social Services Supervisor (SSS) stated I do not recall if R #32 needs hearing aids, but I know he is hard of hearing. The nursing staff has to let me know if any residents in the facility need services like hearing aids, otherwise I won't know. L. On 12/12/25 at 8:10 am, during an interview with MDS (Minimum Data Set) Coordinator, she stated that she is not aware that R #32 has hearing aids. MDS coordinator confirmed that it should have been in the MDS assessments and did not happen.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #1 and R #19) of 3 (R #1, R #19, and R #29) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #1 A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Chronic viral hepatitis C (inflammation of the liver), 2. Chronic obstructive pulmonary disease (COPD; lung disease), 3. Dependence on supplemental oxygen, 4. Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), 5. Blindness (loss of eyesight), one eye, low vision in the other eye, 6. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). B. Record review of R #1's electronic health record revealed R #1's baseline care plan is dated 04/29/25 and revealed the following 1. R #1 has impaired gas exchange related to hypoxia; requiring the use of oxygen as needed. 2. R #1 has a potential for behavioral expressions related to impaired cognitive function secondary to Dementia. 3. R #1 has a risk for falls related to unsteady gate. 4. R #1 has self-care deficits Actual/Potential related to mobility/Blind. 5. Dietary was not addressed on this baseline care plan. C. On 12/12/25 at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed R #1's baseline care plan was dated 04/29/25 and should have been completed within 48 hours. The DON also confirmed that the baseline care plan omitted required information, such as dietary requirements. R #19 D. Record review of R #19's admission Record revealed she was readmitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease (a progressive mental deterioration), unspecified, 2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), E. Essential (primary) hypertension (HTN; high blood pressure). F. Record review of R #19's progress notes dated 10/21/25 revealed R #19 was readmitted to the facility on [DATE] with a surgical incision (a deliberate cut made through the skin and underlying tissues during surgery) noted on her left hip that measured two centimeters in length. G. Record review of R #19's EHR revealed no evidence of a baseline care plan. H. Record review of R #19's comprehensive care plan revealed it was initiated on 10/30/25. I. On 12/12/25 at 9:11 am, during an interview with the DON, she confirmed the facility failed to create and implement a baseline care plan for R #19 when she was readmitted to the facility. The DON stated that she expects a baseline care plan to be created within 48 hours of a resident being admitted to the facility.

Based on record review and interview, the facility failed to notify a resident's representative of a transfer or discharge and the reasons for the move in writing prior to the transfer or discharge for 1 (R #104) of 3 (R #29, R #104, and R #106) residents reviewed for transfers and discharges. This deficient practice could lead to residents' representatives being unaware of the residents' health status. The findings are:A. Record review of R #104's admission Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) dated 09/04/25, revealed the following: 1. R #104 was admitted to the facility on [DATE] with the following diagnoses:- Epilepsy (a seizure disorder),- Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), - Human Immunodeficiency Virus (HIV; a virus that attacks the body's immune system),- Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head).2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. B. Record review of R #104's progress notes dated 09/23/25 revealed the following:1. The facility's social worker attempted to contact R #104's guardian via phone to inform them of R #104's discharge from the facility and was unsuccessful, this documentation was completed at 11:25 am. 2. R #104 was discharged from the facility at 12:00 pm and sent to a local psychiatric hospital. C. On 12/12/25 at 9:36 am, during an interview with the Director of Nursing (DON), she confirmed that R #104's guardian was not notified prior to the discharge taking place.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #11) of 1 (R #11) resident when the staff failed to follow physician order for derma saver palm pillow (a pillow to keep fingernails from digging into palms) to R #11's right hand. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: A. Record review of R #11's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to:-Cerebrovascular accident (or CVA, is a medical term that refers to types of strokes), TIA (A transient ischemic attack is a short period of symptoms similar to those of a stroke), or stroke (can occur when blood flow to the brain is blocked or there is sudden bleeding in the brain).-Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down).B. Record review of the care plan dated 10/22/25 revealed impaired physical mobility related to right hand contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing deformity).C. Record review of R #11's current medical orders revealed an order dated 12/04/25 for R #11 to wear a derma saver palm pillow (a skin protection and pressure reducing product) on the right hand anytime R #11 is awake.D. On 12/10/25 at 2:27 pm during an observation of R #11's room, revealed R #11 was awake in his room, and not using the derma saver palm pillow because it was observed to be on the bedside table.E. On 12/10/25 at 2:27 pm, during an interview, Licensed Practical Nurse (LPN) #2 confirmed that R #11 is awake in his room and is not wearing the derma saver palm pillow. LPN #2 confirmed the derma saver palm pillow was located on the bedside table. F. On 12/11/25 at 2:40 pm during observation of R #11 room, revealed R #11 awake in his room and the derma saver palm pillow on the bedside table.G. On 12/11/25 at 2:40 pm, during an interview, the Patient Care Associate (PCA) #1, confirmed R #11's derma saver palm pillow is on the bedside table. PCA #1 stated that R #11 should have the derma saver pillow on his right hand when awake and did not happen.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (R #32) of 1 (R #32) resident reviewed who was identified as having a hearing impairment and utilizing a hearing aid. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. Record review of R #32's care plan dated 11/29/25 revealed the care plan did not contain any information on R #32's hearing aid use.D. Record review of R #32's annual MDS (minimum data set) assessment dated [DATE] revealed the following:-Section B0200: Moderate difficulty (hearing), speaker has to increase volume and speak distinctly.-Section B0300: No hearing aid or other hearing appliance used.E. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair hearing aids were observed to be on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility. F. On 12/11/25 at 3:48 am, during an interview with Social Services Supervisor (SSS), she stated I do not recall if R #32 needs hearing aids, but I know he has hard of hearing. The nursing staff has to let me know if any residents in the facility is needing services like hearing aids, otherwise I won't know.G. On 12/12/25 at 8:10 am, during an interview with MDS Coordinator, she stated she is not aware that R #32 has hearing aids. MDS coordinator confirmed that it should have been in the MDS assessments and did not happen.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for 1 (R #32) of 1 (R #32) resident reviewed. This deficient practice had the potential to result in unmet hearing needs, miscommunication, and decreased participation in daily activities. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair hearing aids were on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility. D. On 12/10/25 at 1:36 pm, during an interview, Patient Care Associate (PCA) #2, confirmed R #32's hearing aids are on top of his bedside table. PCA #2 confirmed that R #32 has hard of hearing and would benefit from a proper fitting hearing aid.E. On 12/11/25 at 3:48 pm, during an interview, Social Services Supervisor (SSS) stated I do not recall if R #32 needs hearing aids, but I know he has hard of hearing. The nursing staff has to let me know if any residents in the facility is needing services like hearing aids, otherwise I won't know.

Based on record review, observation, and interview, the facility failed to ensure resident records were accurate for 1 (R #15) of 3 (R #12, R #15, and R #77) residents reviewed for catheter care (proper cleaning and maintenance of a catheter). This deficient practice could likely cause staff confusion and residents to get care and services that are not needed. The findings are: A. Record review of R #15's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified bilateral hearing loss (reduction of hearing ability in both ears),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety),4. Calculus in bladder (bladder stones; hard mineral deposits that form in the bladder),5. Benign prostatic hyperplasia with lower urinary tract symptoms (a condition in older men where the prostate gland enlarges leading to urinary issues),6. Personal history of urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).B. Record review of R #15's current physician orders revealed an order dated 04/28/25 to change R #15's catheter monthly and prn (as needed). C. Record review of R #15's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment dated [DATE] revealed R #15 does not utilize a catheter of any kind.D. On 12/08/25 at 12:00 pm, during an observation and interview with R #15, revealed R #15 did not have a catheter and stated that he hasn't had one of those in a long time.E. Record review of R #15's progress notes revealed a health status note dated 07/25/25 where R #15's physician wanted the catheter removed and physically removed the catheter.F. On 12/11/25 at 9:37 am, during an interview with the Director of Nursing (DON), she confirmed that R #15's order was never discontinued and should have been.

Based on record review and interview, the facility failed to prevent abuse for 1 (R #79) of 1 (R #79) resident reviewed when the facility staff failed to recognize the difference between horseplay and unwanted touching and harassment between a staff and resident. This deficient practice likely resulted in R #79 increase of isolation and fear of further abuse. The findings are: A. On 08/19/24 at 2:47 pm, during an interview with R #79, she stated. One of the activities persons kicked me in the ass (buttocks). They (staff) thought she was messing around. I did not think she was messing around, she kicked me. That's not funny. They sent her home for a couple of days. I felt bad because she [Activities Assistant (AA) #1] might have a ton of bills to pay or whatever. This happened on August first. I told (name of Registered Nurse #1). After that I kind of just stayed in my room because I didn't want to see her [AA #1] or do activities when she is there. She might do it again. I don't want to cause trouble and they will make me leave here (facility). R #79 further stated that she has participated less in the activity program and feels that AA #1 is upset with her and does not talk to her anymore. B. Record review of camera footage dated 08/01/24 revealed the following: - At 11:36:04 am, R #79 walked down the hallway, headed to the dining room. - At 11:36:09 am, R #79 turned to her right side, Agency Tech (T) #1 talked to R #79. Licensed Practical Nurse (LPN) #1 was at the medication cart, AA #1 stood next to the medication cart and Tech (T) #1 sat on a short bench in the hallway where R #79 walked. - At 11:36:12 am, R #79 stopped in the hallway in front of LPN #1, T #1 AT #1 and AA #1 when AA #1 approached R #79 and kicked R #79 in the backside. -At 11:36:14 am, R #79 turned around and looked at AA #1 and R #79 rubbed her left buttock with her left hand. - At 11:36:18 am, AA #1 kicked towards R #79 a second time, R #79 reached down to try and catch AA #1's leg. -At 11:36:20 am, R #79 pointed to AA #1 as AA #1 approached R #79 and hugged her. R #79 held her left arm between herself and AA #1. AA #1 continued to hug her and R #79 pats her on the back with her right arm and appeared to push AA #1 away. AA #1 and R #79 proceed to walk down the hallway towards the dining room. -At 11:36:31 am, AA #1 patted R #79 on the left buttock, R #79 steps back and grabbed AA #1 by the arm, picked up her right foot and kicked towards AA #1 on her right leg. AA #1 kicked towards R #79. R #79 moved back against the wall and proceeds to put her walker between herself and AA #1. AA #1 shook R #79's walker while R #79 was holding onto the walker. LPN #1, T #1 and AT #1 all appeared to watch the incident down the hallway. -At 11:37:18 am, R #79 put her walker in the entryway of the dining room, AA #1 took the walker, shuffled a short distance with the walker and then returned the walker and proceeded to walk down the hallway away from the dining room. R #79 remained in the dining room. C. On 08/21/24 at 4:19 pm, during an interview with AA #1, she stated, she was familiar with R #79, and they liked to joke and horseplay. Regarding the incident on 08/01/24, she stated that R #79 was on her way to the dining room and she was playing around with R #79 and did not believe that she had kicked R #79. AA #1 stated she was just playing around with R #79 and did not feel that she had hurt her in any way. Since the incident she has been told that she is not to interact with R #79 alone and if she needs to go to R #79's room she is to take another staff with her and she is not to approach her other then to invite her to an activity. AA #1 also stated that Registered Nurse (RN) #1 was told by R #79 about the incident. AA #1 was heading out for the day and did not return for several days. An investigation was conducted and then she was told she could return to work. D. On 08/22/24 at 10:19 am during an interview with AT #1, she stated that she was present during the incident between AA #1 and R #79. She did witness AA #1 tap the side of R #79's thigh. R #79 stated to AA #1 that she was too old to box. AT #1 also stated that they (AA#1) do horseplay. She further stated, I do not believe staff should kick residents in anyway. I did see the whole thing along with [Name of LPN #1] and [Name of T #1]. I did think it was wrong for her to play around like that. I think she [AA #1] took things a little too far. I know now [Name of R #79] stays in her room more. I did notice a change in [name of R #79] when she hears [name of AA #1]'s voice, and she will go into her room and does not come out. AT #1 stated that R #79 will go to activities when AA #1 is not here. AT #1 stated that she did not say anything [report the incident] because the nurse was there and she [nurse] had not done anything about it. E. On 08/22/24 at 10:59 am, during an interview with RN #1, she stated, the incident had been reported to her by R #79 on 08/03/24 and she thought it could be considered mistreatment/abuse and she reported it to the Standards and Compliance department at the facility, to Adult Protective Services, and the Health Care Authority on 08/03/24. RN #1 further stated, she had to prioritize R #79's safety by removing the staff from the facility. RN #1 also stated she had interviewed AA #1 and she told her that they [AA #1 and R #79] were playing. R #79 revealed to RN #1 that AA #1 had kicked her on the buttocks. RN #1 stated there is a boundary and it is not a good idea to play with a resident in that manner. RN #1 had noticed that she (R #79) is a little more paranoid and she will make comments about it (kicking incident between R #79 and AA #1). RN #1 stated. I do not think it is acceptable behavior to kick a resident. If I saw something like that happen, I would intervene and I would let the staff know it is not appropriate. Residents are to be treated with respect and dignity. F. On 08/22/24 at 11:29 am, during an interview with T #1, she stated that during the time of the incident on 08/01/24, she was waiting for lunch to start, and R #79 was headed to lunch. AA #1 was teasing R #79 and then AA #1 kicked R #79 on the buttocks. There were other staff there that saw AA #1 kick R #79 and they [staff witnesses] all thought they were just playing, no one intervened. I do not think that kicking a resident is ok. It was not a hard kick. I think it is inappropriate, but not abusive. T #1 further stated that she has noticed changes in R #79 and she is more anxious, and she is quieter since the incident. T #1 further stated that she did not report it because she thought they were just playing around. G. On 08/22/24 at 11:45 am, during an interview with the Director of Nursing (DON), she stated she was aware of the incident between AA #1, and R #79 and her understanding was that the investigation confirmed that they were horseplaying however kicking a resident is not acceptable. DON was not part of the investigation. DON further stated that after reviewing the video footage she would consider the actions of AA #1 to be abuse. DON felt that these actions should have been reported as abuse. H. On 08/22/24 at 12:02 pm, during an interview with Activity Director (AD). He stated, he was aware of the incident between AA #1 and R #79. He had spoken with AA #1 and it was determined that it was horseplay. AA #1 was trained on boundaries following the incident. He stated that a kick is overboard and could border on abuse and a playful kick is excessive and should not happen. AD stated he did not review the video but standards and compliance had determined it was horseplay. I. On 08/22/24 at 3:31 pm, during an interview with Interim Administrator, he stated, that after viewing the video footage he did believe that it was abuse and the investigation was inappropriate and that kicking a resident is never acceptable. Administrator stated he was not involved in the investigation because standards and compliance are the ones that do the investigations. He was aware of the incident but was dependent on the outcome from standards and compliance. J. On 08/23/24 at 9:35 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated, she was passing medications at the time of the incident. R #79 was on her way to the dining room and the staff were joking around with R #79. LPN #1 does not recall seeing AA #1 kick R #79. She stated that kicking a resident is not acceptable and if she would have seen it [AA #1 kick R #79], she would have intervened.

Based on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, - Store open food protected and with labels and dates to prevent cross contamination and outdated usage, - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen, - Use the sanitizing solution according to manufacturer's instructions, - Protect clean disposable wares (includes dishware, drinkware, and flatware such as spoons, forks, and knives) to prevent contamination, These failures had the potential to result in cross contamination and foodborne which could affect all residents who ate food from the kitchens. The findings are: Handwashing and Glove Use A. Record review of the facility's Sanitation and Infection Control, Hand Hygiene policy, dated January 2014, revealed staff directed to wash hands with soap and water at the following times: - Before handling food or clean utensils, dishes, equipment, - Before putting on gloves, - After touching hair, skin, beard, or clothing, - After handling soiled silverware, - After handling garbage, - After removing gloves, - After any other activity that may contaminate the hands. B. Observation on 08/20/24 at 12:15 pm, of the kitchen located on Unit #1 revealed Server 1 wore gloves and entered the kitchen. The Server touched the door, the trash can, and dirty dishes. The Server took clean dishes out of the dishwasher and put them away. The Server did not remove his gloves and did not perform hand hygiene when he moved from dirty tasks (touching dirty dishes, cleaning the kitchen, taking out trash, and similar) to clean task (touching clean dishes, preparing food, and similar). At 12:26 pm, Server 1 touched dietary cards and dirty dishes. He took the dirty dishes to the three-compartment sink (a sink with three sections to wash, rinse, and sanitize) and touched the hose with dish detergent to fill a tub of dishes with soapy water. He took the tubs to the dirty side of the dishwashing area, removed a clean pitcher from the dishwasher, and placed it on the storage shelf. Server 1 did not remove his gloves and did not perform hand hygiene when moving from dirty dishes to clean dishes. The Server placed the same gloved hand on a trash can, with part of his fingers inside the can, to move it across the floor. He removed the trash bag of waste from the can, and he placed a new trash bag in the can. The Server removed clean dishes from the dishwasher and put them away. The Server did not remove his gloves and did not perform hand washing after touching the trash can. C. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy for glove use and handwashing, and staff have been trained on the policy. She stated staff should hand wash before putting on gloves and after removing the gloves. She stated staff should also hand wash every time they entered the kitchen, when they moved from a dirty task to a clean task, and after they used the restroom, took a break, or touched their face or body. She stated staff should change their gloves when soiled, between processes, and after touching something that was not food related. The Supervisor stated staff should not treat their gloved hands like their bare hands. D. Observation on 08/21/24 at 11:25 am of the kitchen located on Unit #2 revealed Server 2 wore gloves and prepared for the resident's lunch service. The Server threw a piece of paper into the trash can and touched the lid. The Server continued to touch the steam table, the door to the dining room, a piece of paper, the refrigerator door handle, serving containers of butter and supplement drinks, and drink pitchers. The Server did not change her gloves or wash her hands after touching the trash can and before touching the steam table and food related items. At 11:34 am, the Server removed her gloves and performed hand washing. Server 1 pressed the buttons to open the partition between the kitchen and the dining room. She put on new gloves. The Server touched the resident food trays, dietary cards, the thermometer, food containers. The Server touched the resident plates, serving utensils, refrigerator doors, and bread slices with her gloved hands. She pulled up the sleeve on her right arm using her gloved left hand. The Server touched resident bowls with her gloved thumb on the food surface area. The Server did not wash her hands after touching the divider buttons and before putting on gloves. The Server did not change her gloves and perform hand washing after she touched the refrigerator doors and her sleeve and before she touched food and food related items. E. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated it was expected staff would perform handwashing when they moved from a dirty task to a clean task. She stated staff should wear gloves when handling ready to eat food, like bread. She stated staff should wash their hands before they put on and after they removed their gloves. The Director stated staff should not treat their gloved hands like their bare hands. Unprotected, Unlabeled, and Undated Open Food Items F. Record review of the facility's Production, Purchasing, Storage: Food and Supply Storage Procedures policy, dated January 2014, revealed staff directed to cover, label, and date unused portions and open packages. G. Observation on 08/19/24 at 12:20 pm, of the dry storage area, revealed two, 25 pound (lb) bags of pinto beans open to air. H. Observation on 08/20/24 at 8:52 am, of the walk-in refrigerator Morning Box, revealed the following: - One package of sliced ham open to air, - One, 16 ounces (oz) container of beef base opened and undated, - One, 16 oz container of vegetable base opened and undated. I. On 08/20/24 at 8:53 am, during an interview, the Director of General Services stated opened food should be labeled, dated, and sealed. She said it was expected staff would have wrapped the opened ham slices with saran wrap to protect it from the air. She stated she and the Supervisors walked through the walk-ins every day and looked for items that were not in compliance. The Director of General Services stated she was not aware the unlabeled, undated, and unprotected food items were in the walk-in. J. Observation on 08/20/24 at 8:28 pm of the dry storage area, revealed one 5 lb bag of powdered cocoa loosely rolled, opened, and exposed to air. K. On 08/20/24 at 8:30 am, during an interview, the Stocker stated, she was responsible to ensure the dry storage area was maintained in an orderly and sanitary manner. She stated she checked the dry pantry every day to ensure items were stored correctly, labeled, dated, and protected. The Stocker stated staff used the cocoa for breakfast. She stated they forgot to secure the cocoa bag with the plastic tabs when they rolled the top closed. The Stocker stated staff should have ensured the bag remained rolled closed to prevent exposure to air. L. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy on food storage, and staff have been trained on the policy. She stated it was expected for staff to label and date open food with the date the food was opened. She stated food should be securely protected from air to prevent cross contamination. Hairnets and [NAME] Guards M. On 08/20/24 at 10:50 am during an interview with the Director of General Services, the Director of Food Services, and the Dieticians, Dietician 1 and Dietician 2 stated they were responsible to perform audits of kitchen staff, and they performed the audits twice a week. The Dieticians stated they completed a form for each audit and gave the form to the Director of General Services to address any issues with the dietary staff. N. Observation on 08/21/24 at 11:07 am revealed Server 1 in the kitchen Unit #1 took the food temperatures in preparation for the resident's lunch service. The Server wore a beard guard, but the beard guard did not cover the Server's mustache. The Server's mustache measured approximately 1/4 inch () to 1 in length. O. Observation on 08/21/24 at 11:25 am revealed Server 2 in the kitchen Unit #2 prepared food items for the resident's lunch service. The Server wore a hairnet, but the hairnet did not cover all the Server's hair. The Server's hair hung loosely around her face and measured approximately 2 1/2 in length. Further observation revealed two Dieticians stood in the kitchen and observed Server 2, but the Dieticians did not coach the Server to cover all her hair with the hairnet while working with the residents' food. P. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated the facility had a policy on hair nets, and staff are trained on the policy. She stated all staff must wear hairnets at all times when they enter the kitchen, and they are to wear beard guards, as needed, at all times in the kitchen. She stated they must wear hairnets and beard guards regardless of the length of their hair. The Director stated the hairnets and beard guards should cover all the hair. Dishes Not Sanitized According to Manufacturer's Instructions Q. Review of the facility's Sanitation and Infection Control, Sanitizing Food Contact Surfaces policy, dated January 2014, revealed staff directed to immerse items in the sanitizing solution for a minimum of 60 seconds when washing dishes in the pot sink (three-compartment sink). R. Review of the manufacturer's instructions for the sanitizing solution used by the facility in the three-compartment sink revealed the product could be used to clean and sanitize hard, non-porous surfaces of equipment. To sanitize, allow surfaces to remain wet for at least 60 seconds. S. Observation on 08/21/24 at 8:05 am revealed the Dishwasher washed pots and pans in the three-compartment sink. The Dishwasher washed a pan in the soapy water, placed the pan in the clean rinse water, dipped the pan in the sanitizing solution, and placed the pan on the rack to air dry. The Dishwasher washed a plastic container in the soapy water, rinsed it in the clean water, dipped it the sanitizing solution, and placed it on the rack to air dry. The Dishwasher did not submerge the pan or the plastic container in the sanitizing solution for one minute, per the manufacturer's instructions. At 8:15 am, the Supervisor watched the Dishwasher dip the pots and pans into the sanitizing solution instead of submerging the items for one minute. The Supervisor coached the Dishwasher and told her to submerge the items in the sanitizing solution for one minute. At 8:22 am, the Dishwasher washed a baking sheet in the soapy water, rinsed it in the clean water, dipped it into the sanitizing solution, and placed it on the rack to air dry. The Dishwasher did not submerge the baking sheet in the sanitizing solution for one minute, per the manufacturer's instructions. T. On 08/21/24 at 8:25 am during an interview, the Dishwasher stated items should be submerged into the sanitizing solution and not just dipped. The Dishwasher stated she was not exactly sure how long the items should be in the sanitizing solution, but she thought it should be around one minute. U. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated staff should completely submerge the dishes in the sanitizing solution for one minute when they washed dishes in the three-compartment sink. The Supervisor stated she observed the Dishwasher failed to sanitize the dishes correctly, so she told the Dishwasher to leave the items in the sink for one minute. The Supervisor stated it was expected the Dishwasher would have followed the directions for sanitizing the equipment. She stated dipping the dishes into the sanitizing solution was not sufficient. V. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated staff should ensure dishes are completely submerged in the sanitizer solution for one minute to ensure the items were properly sanitized. Protection of Disposable Ware W. Observation on 08/20/24 at 8:31 am of the dry storage area revealed the following: - One box of plastic spoons opened and unprotected. - One box of plastic forks opened and unprotected. - One box of plastic knives opened and unprotected. - One box of disposable aluminum serving pans opened with food surface exposed and unprotected. X. Record review of the facility's Production, Purchasing, Storage: Food and Supply Storage Procedures policy, dated January 2014, revealed staff directed as follows: - Store all single-service items with food contact surfaces facing down. - After single-serve items, such as disposable plates or containers, have been opened, they must be stored inverted on clean surfaces to prevent contamination. - The policy did not address the storage of plastic wares, such as forks, spoons, and knives. Y. On 08/20/24 at 8:33 am, the Stocker stated she was responsible to ensure items in the dry storage area were stored in a sanitary manner. She stated staff got plastic ware for the residents' breakfast service. She stated it was expected the staff would cover the plastic ware after they got what they needed. The Stocker stated the disposable aluminum pans should also be protected. She stated when the items are unprotected and open to air then they are at risk of contamination by dust, flies, or other contaminants. Z. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy on ware storage, and the staff have been trained on the policy. She stated it was expected wares were stored in their original packaging. She stated staff should take what they needed out of the box and use the plastic to recover the items. The Supervisor stated disposable wares should not be exposed to air to prevent cross contamination. AA. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated it was expected disposable wares were covered and not exposed to the air and potential contaminates. She stated staff should take what they needed and cover the items. She stated the Stocker checked the storage areas daily to ensure all items were covered, but other staff were also responsible to ensure the items were covered after they got what they needed.

Based on record review and interview, the facility failed to meet professional standards of care for 3 (R #8, #42, and #52) of 3 (R #'s #8, #42, and #52) residents reviewed by not providing restorative nursing services (a type of rehabilitation that helps residents regain or maintain their independence and physical abilities) as ordered by a physician. This deficient practice is likely to result in the resident experiencing psychosocial harm (harm to someone's mental health) and despair. The findings are: R #8: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. B. Record review of R #8's physician order/referral dated 07/10/24 revealed R #8 was to receive restorative nursing services weekly that focused on Upper extremity [arms] exercises that focus on range of motion (ROM). C. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #8 was offered/provided six (6) restorative nursing sessions out eight (8) opportunities. D. On 08/19/24 at 4:21 pm during an interview with R #8, she stated that she was not offered restorative nursing services as often as she would like. E. On 08/23/24 at 12:14 pm during an interview with the Physical Therapy Assistant (PTA) #1, she stated that they try to offer R #8 restorative nursing services at least two times a week, but that doesn't always happen because PTA #1 and the other restorative staff are needed on the units instead. PTA #1 confirmed R #8 should be seen by restorative nursing services at least two times a week and that does not consistently happen. R #42: F. Record review of R #42's face sheet revealed R #42 was admitted into the facility on [DATE]. G. Record review of R #42's physician order/referral dated 08/01/24 revealed R #42 was to receive restorative nursing services weekly that focused on ambulation (the ability to walk or move about without assistance) and ROM. H. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #42 was offered/provided one restorative nursing sessions out eight (8) opportunities. I. On 08/23/24 at 2:42 pm during an interview with PTA #1, she stated that they are supposed to help ambulate R #42, but they cannot because they do not have the staff available to do that while also taking residents to appointments and working on the units. PTA #1 confirmed R #8 had only been offered one restorative nursing service session since 08/01/24, and he should have been offered more. R #52: J. Record review of R #52's face sheet revealed R #52 was admitted into the facility on [DATE]. K. Record review of R #52's physician order/referral dated 02/27/24 revealed R #52 was to receive restorative nursing services weekly that focused on ROM. L. Record review of the facility restorative nursing program schedule dated 07/01/24 through 07/19/24 revealed R #52 was offered/provided one restorative nursing sessions out six (6) opportunities. M. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #52 was offered/provided two (2) restorative nursing sessions out eight (8) opportunities. N. On 08/23/24 at 2:49 pm during an interview with PTA #1, she confirmed R #52 was not offered consistent restorative nursing sessions due to staffing issues and R #52 should be offered more restorative nursing sessions. O. On 08/23/24 at 3:04 pm during an interview with the Director of Nursing (DON), she stated she was not aware of restorative nursing staff not completing their treatments with the residents. DON confirmed residents that are receiving restorative nursing services should be offered/provided those multiple times per week as expected.

Based on record review, and interview, the facility failed to provide food that accommodated resident preferences for 2 (R #9 and R #69) of 2 (R #9 and R #69) residents reviewed for food preferences. This deficient practice is likely to result in weight loss due to the residents not eating or an allergic reaction to the food being served to the residents. The findings are: A. Record review of R #69's face sheet revealed, R #69 was admitted into the facility on [DATE]. B. Record review of R #69's care plan dated 7/10/2024, revealed the following: -Focus: Diet is Therapeutic Diet.(diet modified to fit the nutrition need of a resident) -Interventions: Provide diet as ordered and honor all food preferences. C. Record review of facility incident report form dated 03/20/24, R #69 requested a chicken sandwich (choice #2 ) for dinner. R #69 did not receive chicken sandwich as ordered because the dietary had only sent three chicken sandwiches for the unit. D. Record review of facility incident report form dated 03/20/24, revealed there were only three chicken sandwiches sent to the unit for 14 residents as an alternate meal and regular menu items were sent for all residents. E. Record review of R #9's facesheet revealed R #9 was admitted to the facility on [DATE]. F. Record review of R #9's nutritional assessment review dated 06/30/2024 revealed Regular LCS (Low Concentrated Sweets), bland diet, no Chile, Glucerna (nutritional supplement) with lunch and milk with all meals. HS (evening) snack. Honor all food preferences. G. Record review of facility incident report form dated 03/20/24 stated there were only three chicken sandwiches sent to the unit for 14 residents as an alternate meal and R #9 was not able to get one. H. On 08/22/2024, during an interview with Dietary Manager, she stated only a set amount of alternate food is sent to the units. If a resident request an alternate food, and there were not enough food then the can call and request a alternate meal. The resident will have to wait until service of meals are done and then they would accommodate the residnets' alternative request which could take a considerable amount of time to wait.

Based on observation, interviews, and record review, the facility failed to have recipes for all menu items and to ensure staff followed nutritionally calculated recipes for pureed diets. This failure had the potential for food not to meet the nutritional requirements of all residents who ate pureed foods. The findings are: A. On 08/20/24 at 8:55 am, during an interview, the Supervisor stated the menu for the resident's lunch was pork enchiladas, mixed vegetables, beans, and fruit. She stated the alternative was egg salad sandwich, and residents with a pureed diet were having pureed carrots instead of pureed mixed vegetables. B. Observation on 08/20/24 at 8:56 am revealed the Supervisor prepared pureed enchiladas for the residents' lunch service. She placed six corn tortillas (six inch), six servings of enchilada mixture, and scooped an unmeasured amount of thickening powder into a food processor. The Supervisor pureed the mixture to a pudding consistency. C. On 08/20/24 at 8:58 am during an interview, the Supervisor stated the scoop for the thickening powder was equal to one cup. She stated she put 1/2 cup (c) of thickening powder into the enchilada puree. D. Record review of the facility's recipes revealed a recipe for green chicken or pork enchiladas for regular diets. Further review revealed the records did not contain a recipe for green chicken or pork enchiladas for pureed diets. E. Observation on 08/20/24 at 9:00 am, revealed pureed carrots in bowls in the warmer for the residents' lunch service. Taste test of the pureed carrots revealed the mixture tasted flavorless. F. On 08/20/24 at 9:02 am during an interview, the Supervisor stated the puree carrots was made of carrots and thickening powder. G. Record review of the facility's recipes revealed a recipe for pureed carrots with the following instructions: - Recipe for 240 servings. - Ingredients: fresh steamed carrots, thickener, hot water, vegetable base, salted and melted butter. - Process carrots to a fine consistency. - Add thickener, vegetable base mixed with hot water, and butter. - Process until smooth. H. Observation on 08/20/24 at 9:22 am revealed the [NAME] prepared pureed carrot cake for the residents' meal. She placed 12 slices of carrot cake, 12 cups of water, and two cups of a thickening powder into a food processor. She pureed the mixture to a smooth consistency. Taste test showed the mixture tasted watery. The [NAME] placed the mixture into styrofoam bowls and topped with an icing mixture. I. On 08/20/24 at 9:32 am, the [NAME] stated she had recipes in her phone and in a binder. She stated she made the pureed carrot cake in the past, so she did not refer to the recipe. J. Record review of the facility's recipes revealed the facility did not have a recipe for pureed carrot cake. K. Observation on 08/20/24 at 9:45 am revealed the Supervisor prepared pureed beans for the residents' lunch service. She placed 24 ounces (oz) of beans and broth mixture and scooped an unmeasured amount of thickening powder into a food processor. She pureed the mixture to a smooth consistency. The Supervisor added an unmeasured amount of tap water to the mixture and continued to puree to a smooth consistency. L. On 08/20/24 at 9:50 am during an interview, the Supervisor stated she added 3/4 c of thickening powder to the beans and 1/2 c of water. The Supervisor stated she knew how to prepare the pureed food because she worked at the facility for a long time. She stated, she measured all the ingredients, and there was a sheet posted in the kitchen regarding the consistency of each diet type. The Supervisor stated there were recipes for the menu items, and there was a recipe for everything. M. Record review of the facility's recipes revealed a recipe for pureed beans with the following instructions: - Recipe for 240 servings. - Ingredients: pinto beans cooked with onions, chopped garlic cloves, bay leaf, salt, oregano. - Place the cooked beans in food processor and process fine and until the texture is very smooth. - Scrape down the sides of the bowl and repeat the process. N. On 08/20/24 at 10:25 during an interview, the Director of Food Services stated, she was responsible for the residents' meals, the menus, and the recipes. She stated the Dieticians created the menus and approved the recipes based on an analysis of the residents' needs. The Director stated the residents asked for more authentic New Mexican food, and the menu did not have those items. She stated she created the recipe for the green chicken or pork enchiladas to meet the residents' requests. O. On 08/20/24 at 10:50 am during an interview with the Director of General Services, the Director of Food Services, and the Dieticians, and the Supervisor, Dietician 1 and Dietician 2 stated they were responsible to develop and analyze the menus. They stated, they made the menus from scratch in order to take into account what the residents wanted to eat. They stated they also approved the recipes, but there was not a recipe for all food items. The Dieticians stated staff cooked the way they were used to, because the most important part of the recipe was the meat. They stated the meat was pre-portioned, so all cooks used the same amount of meat in their recipe. The Dieticians stated cooks should use the recipe closest to what they were preparing, even if it was not for the exact food item on the menu. The Dieticians reviewed the green chicken or pork enchilada recipe. They stated they had not seen and did not approve the enchilada recipe. The Dietician stated it was expected all food items on the menu had a recipe for staff to follow and that they review and approve all recipes served to the residents. They stated this was important for consistency across all cooks and preparation, for nutritional values, and for flavor. The Dieticians stated there was not a recipe for the carrot cake puree, but it was expected staff would use milk instead of water. They stated the milk had more nutritional value and flavor. The Dieticians stated it was expected staff would use thickening powder sparingly, because it did not have any nutritional value. They stated staff should not use thickening powder by the cup. They stated the Supervisor did not need to add thickening powder to the beans. The Dieticians stated they performed competency audits of the dietary staff, but the audits did not include an observation of the preparation of pureed foods.

Based on observation, record review, and interview, the facility failed to ensure that 1 (R #16) of 1 (R #16) residents reviewed was free from accidents and hazards. Facility was using a call light attached to R #16's clothing to alert staff when resident attempts to transfer on her own. Call light would detach from the wall and ring and staff would be alerted that resident was attempting to transfer self. This deficient practice is likely to put residents at risk of unsafe situations. The findings are: A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE]. B. Record review of R #16's nursing progress notes dated 06/09/24 through 06/10/24 revealed the following: 1. 06/09/24: R #16 was found on the floor next to her bed by staff. R #16 was attempting to use the restroom on her own prior to fall and told staff her left hip hurt badly. R #16 was transported to the emergency room (ER). 2. 06/10/24: R #16 was diagnosed with two fractures in the ER and returned to the facility. C. On 08/20/24 at 10:13 am during an observation of R #16's room, R #16 sat in a wheelchair with the room call light attached to her left shoulder shirt. D. Record review of R #16's care plan dated 07/09/24 revealed R #16 was at risk for falls. R #16's care plan interventions stated, I am able to use the call bell. It will be kept within my reach. Staff will educate me on using the call bell with transfers. E. On 08/23/24 at 9:42 am during an interview with Certified Nursing Assistant (CNA) #6, she stated R #16 has become less independent and is prone to falls. CNA #6 also stated the staff attaches R #16's call light onto her clothing because when R #16 attempts to self transfer, the call light will disconnect from the wall (since it's attached to her body), which will alert staff. F. On 08/23/24 at 10:47 am during an interview with Licensed Practical Nurse (LPN) #2, she stated R #16 sustained a left hip fracture after her most recent fall on 06/09/24. LPN #2 also stated the nursing staff will attach R #16's call light to her clothing, so staff will be alerted if R #16 attempts to self transfer. G. On 08/23/24 at 11:04 am during an observation of R #16's room, R #16 laid in bed with the call light attached to right shoulder. H. On 08/23/24 at 12:59 pm during an interview with the Director of Nursing (DON), she stated the expectation is staff can clip R #16's call light to blanket or something like that, but not to R #16's clothing. DON confirmed the way the staff is currently using the call light for R #16 is considered a form of a restraint and should not be happening.

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 1 (R #16) of 1 (R #16) residents reviewed when staff failed to update wound care treatment orders according to R #16's care plan and in relation to R #16's pressure ulcer becoming worse. This deficient practice is also likely to lead to residents developing more/other pressure ulcers and wounds worsening. The findings are: A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE]. B. Record review of R #16's care plan dated 07/09/24 revealed, Focus: Impaired skin integrity related to Stage II [2] pressure injury (level of skin damage which results from unrelieved pressure on the body) to coccyx (tailbone). Interventions: If pressure injury is not improving within 2 weeks of using current treatment, reassess and notify medical provider for a change of treatment. C. Record review of R #16's coccyx pressure ulcer assessment dated [DATE] through 08/23/24 revealed the following: 1. 07/05/24: Length: 3 cm (centimeters), Width: 1 cm. 2. 07/08/24: Length: 3 cm, Width: 1 cm. 3. 07/10/24: Length: 3 cm, Width: 1 cm. 4. 07/12/24: Length: 3 cm, Width: 1 cm. 5. 07/15/24: Length: 3 cm, Width: 1 cm. 6. 07/17/24: Length: 3 cm, Width: 1 cm. 7. 07/19/24: Length: 3 cm, Width: 1 cm. 8. 07/22/24: Length: 3 cm, Width: 1 cm. 9. 07/24/24: Length: 3 cm, Width: 1 cm. 10. 07/26/24: Length: 3 cm, Width: 1 cm. 11. 07/29/24: Length: 3 cm, Width: 1 cm. Wounds showing no signs of improvement. 12. 07/31/24: Length: 4 cm, Width: 1 cm. 13. 08/02/24: Length: 4 cm, Width: 1 cm. 14. 08/05/24: Length: 4 cm, Width: 1 cm. 15. 08/07/24: Length: 4 cm, Width: 1 cm. 16. 08/09/24: Length: 4 cm, Width: 1 cm. 17. 08/12/24: Length: 4 cm, Width: 1 cm. 18. 08/14/24: Length: 4 cm, Width: 1 cm. 19. 08/16/24: Length: 4 cm, Width: 1 cm. 20. 08/19/24: Length: 4 cm, Width: 1 cm. 21. 08/21/24: Length: 2.5 cm, Width: 0.5 cm. D. Record review of R #16's Medication Administration Record (MAR) dated 07/01/24 through 07/31/24 revealed the following medications/treatments used for R #16's coccyx pressure ulcer: 1. Apply skin protectant, cover with 2x2 (2 by 2) gauze and transparent tape twice a day and as needed- completed twice a day, every day from 07/01/24 through 07/10/24. 2. Apply skin protectant, cover with 2x2 gauze and transparent tape daily- completed once a day, every day from 07/11/24 through 07/31/24. E. On 08/23/24 at 10:44 am, during an interview with Licensed Practical Nurse (LPN) #2, she stated R #16's coccyx pressure ulcer was a stage 2 and was not getting better until recently. LPN #2 confirmed R #16's pressure ulcer treatment and care had not changed since R #16 developed on 06/28/24 the pressure ulcer (Apply skin protectant, cove with 2x2 gauze and transparent tape daily) . F. On 08/23/24 at 1:03 pm during an interview with the Director of Nursing (DON), she stated she would expect R #16's pressure ulcer treatment to change according to her care plan which stated if R #16's pressure ulcer did not improve within two weeks treatment would change. DON confirmed R #16's pressure ulcer treatments changed, but not within the two week timeframe as expected. Treatment was changed from BID (twice a day) to daily.

Based on record review and interview, the following was discovered: Facility failed to notify the physician of high blood sugars in [DATE] and beginning of [DATE] for one resident which prevented the Physician from being able to modify the treatment plan. By mid October, resident continued to have high blood sugar levels which were not controlled by sliding scale insulin. After 14 hours of elevated blood sugars (between ,d+[DATE]) facility received order to send resident to ER (emergency room ). Resident expired in facility parking lot prior to transfer. This resulted in Immediate Jeopardy being called on [DATE] at 5:01 pm. The Hospital Administrator and Director of Nursing (DON) were notified in person at this time. A first plan of removal was received on [DATE] at 9:48 pm and accepted on [DATE] at 1:19 pm. The facility Administrator and DON were notified. The plan of removal included: 1. Nursing staff to review the health records of all diabetic residents to ensure all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Nurses to place glucose monitoring flow sheets in Physician box to be reviewed weekly. 3. Facility Chief of Medicine reviewed all diabetic resident charts and glucose levels for the last 3 months to identify any residents at imminent risk. 4. Facility Chief of Medicine sent a memo to all medical providers instructing them to include parameters for notification to the medical provider on blood glucose monitoring orders and to ensure all results are reviewed weekly. Based on the plan of removal, the scope and severity was reduced from Level 4, J to Level 3, G. Based on observation, record review, and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 ( R #1) of 1 (R #1) residents reviewed for change in condition and unexpected death. This deficient practice is likely to result in residents not receiving the appropriate medical care and leading to an exacerbation (to make worse) of current medical conditions. The findings are: A. Record review of R #1's face sheet revealed an original admitted [DATE]. B. Record review of R #1's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], UNSPECIFIED TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS [CONDITION(S)], UNSPECIFIED [a condition where there are high levels of fat particles in the blood] PRESSURE ULCER OF UNSPECIFIED SITE, STAGE 2 PAIN, UNSPECIFIED PNEUMONIA [lung inflammation caused by bacterial or [CONDITION(S)] infection], UNSPECIFIED ORGANISM UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE PERSON INJURED IN UNSPECIFIED MOTOR-VEHICLE ACCIDENT, TRAFFIC, INITIAL ENCOUNTER OTHER CYSTOSTOMY [urinary catheter] STATUS URINARY TRACT INFECTION [[CONDITION(S)]], SITE NOT SPECIFIED OTHER SPECIFIED POSTPROCEDURAL STATES DYSPHASIA [a language disorder that affects one's ability to communicate] FULL INCONTINENCE OF FECES CALCULUS OF KIDNEY [kidney stones] DO NOT RESUSCITATE GASTROSTOMY STATUS PERSONAL HISTORY OF OTHER DISEASES OF THE DIGESTIVE SYSTEM PERSONAL HISTORY OF OTHER VENOUS [CONDITION(S)] AND EMBOLISM [blood clot] PERSONAL HISTORY OF OTHER SPECIFIED CONDITIONS PERSISTENT VEGETATIVE STATE OTHER SEASONAL ALLERGIC RHINITIS [seasonal allergies] CONTRACTURE OF MUSCLE, MULTIPLE SITES OTHER ARTIFICIAL OPENINGS OF GASTROINTESTINAL TRACT STATUS [CONDITION(S)], UNSPECIFIED PERSONAL HISTORY OF [CONDITION(S)] DYSPHAGIA [difficulty or discomfort in swallowing], UNSPECIFIED OTHER MUSCLE SPASM UNSPECIFIED INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION, SEQUELA NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED GASTRO-[CONDITION(S)] REFLUX DISEASE WITHOUT ESOPHAGITIS [acid reflux] CONSTIPATION, UNSPECIFIED ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] [CONDITION(S)] [[CONDITION(S)] disorder], UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS [seizures follow one another without recovery of consciousness between them]. C. Record review of Facility Emergency and Crisis Care Policy dated [DATE] revealed, PROTOCOL- RECOGNITION AND RESPONSE TO CHANGES IN PATIENT'S/CLIENT'S/RESIDENT'S CONDITION: When staff recognize changes in patients/clients/residents' condition, or condition appears to be worsening, staff will contact the supervisor immediately and document on the progress notes before the end of their shift. Staff must contact house nurse if unit nurse does not respond appropriately. Unit nurse will call medical doctor and inform him/her of the changes in medical condition. If nurse feels strongly that medical doctor did not respond appropriately, they must contact the House Nurse immediately. House nurse will contact Administrator and may call for additional assistance when needed. Nursing must document all changes and contacts made in progress notes before the end of their shift. An incident report must be completed any time a patient/client/resident is transported to an outside hospital for further evaluation of medical condition. -Changes in conditions may include the following emergencies but are not limited to:Critical Blood Sugar > [greater than] 450 mg [milligrams]/ dL [deciliter] or < [less than] 45 mg/ dL -(Contact medical doctor if patient is not covered by an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The effectiveness of the rapid response to deteriorating medical condition will be evaluated on a quarterly basis. All patients who are hospitalized or taken to the emergency room in response to a deteriorating medical condition will be tracked through the incident management system. Each case is reviewed by the Mortality and Morbidity Committee to determine whether there was an appropriate response to medical condition. D. Record review of R #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for sliding scale insulin. E. Record review of R #1's Sliding Scale Blood Sugar Flow Chart dated [DATE] revealed the following blood sugar levels: There were no other records of blood sugar levels. 1. [DATE]- 127 2. [DATE]- 199 3. [DATE]- 94 4. [DATE]- 215 5. [DATE]- 193 6. [DATE]- 248 F. Record review of R #1's Sliding Scale Blood Sugar Flow Chart dated [DATE] revealed the following blood sugar levels: There were no other records of blood sugar levels. 1. [DATE] at 6:00 am- 329 2. [DATE] at 5:30 am- 289 [MEDICATION(S)] Feeding (Nutritional supplement through tube feeding) 3. [DATE] at 9:00 pm- 237 4. [DATE] at 6:23 pm- 439 Recheck at 18:27 [6:27 pm]- 450 and feeding 5. [DATE] at 9:30 pm- 434 6. [DATE] at 2:15 am- 534- 7 units insulin given- Recheck at 5:30 am, notified MD (Medical Doctor) 7. [DATE] at 4:20 am- 490- 10 units insulin given- Notified MD 8. [DATE] at 8:20 am- 384- 6 units insulin given 9. [DATE] at 4:48 pm- High- Recheck 10. [DATE] at 4:51 pm- High- Recheck 11. [DATE] at 4:53 pm- High- Gave 10 units of insulin at 17:00 [5 pm] per NP (Nurse Practitioner) 12. [DATE] at 6:09 pm- 569- Rechecked 13. [DATE] at 6:12 pm- 590- 10 units per NP at 18:25 [6:25 pm]. 14. [DATE] at 8:00 pm- 563- Rechecked 15. [DATE] at 8:02 pm- 542- Called medical order to send to ER [emergency room ]. G. Record review of R #1's Labs of a metabolic panel collected on [DATE] revealed blood sugar level of 313. Facility was notified of results on [DATE]. H. Record review of R #1's progress notes dated [DATE] to [DATE] did not identify that the Physician was notified of any elevated blood sugar levels. I. Record review of R #1's progress notes dated [DATE] revealed, Note Text: Res [resident] continues with leakage from GT [gastrostomy tube] stoma ( opening on the abdomen that can be connected to either the digestive or urinary system to allow waste (urine or feces) to be diverted out of the body) Dsg [dressing] was changed x1 [one time], res [resident] slept quietly this am. No moaning. [MEDICATION(S)] [tube feeding formula] was tolerated well. Res [resident] Foley catheter was patent [open and unobstructed] with yellow urine. VS [vital signs] stable. J. Record review of R #1's progress notes dated [DATE] at 6:46 pm revealed, Note Text: [Name of R #1] accu check was done at 1823 [6:23 pm] 439 [blood glucose level], re checked it was 450 [blood glucose level]. [Name of on-call Medical Doctor (MD) #1] was notified and gave orders to administer 5 Units Novolog [insulin] stat (now) X1 [one time], recheck accu check at 2100 [9:00 pm] and call results. House Nurse RN [Registered Nurse] notified and faxed order to him. K. Record review of R #1's progress notes dated [DATE] at 5:34 am revealed, Note Text: Res [resident] accu ck [BGL check] at 0200 [2:00 am] was 534 [blood glucose level], immediately rechecked at 530 [blood glucose level]. Notified MD, [Name of on-call MD #1] Ordered to administer 7 units Novolog Sub-Q [subcutaneous- medication administration under the skin] x1 [one time] now then recheck in 2 hours. Accu ck at 0415 [4:15 am] was 490 [blood glucose level]. Notified [Name of on-call MD #1], ordered Novolog 10 units Sub-Q x1 [one time] now. [Name of on-call MD #1] requested writer to call him at 5 am for new orders. Res [resident] tolerated injections well. Res [resident] had 20 cc [cubic centimeter/ milliliter] residual x1 [one time] , none second time. Dressing changed x2 [two times] to stoma, continues to leak but less amounts. GT [gastrostomy tube] patent [open], flushed without difficulty. Moaned during dressing change. New orders from [Name of on-call MD #1] as follows: Accu ck [blood glucose level check] every 8hrs [hours] x [for]72 hrs [hours] then BID [two times a day] (to start at 8 am). -Novolog Insulin per sliding scale: -,d+[DATE]= 0 insulin -,d+[DATE]=2 units -,d+[DATE]=4 units -,d+[DATE]=6 units -,d+[DATE]=8 units -[greater than] >451= [equals] 10 units and notify MD. [MEDICATION(S)] Insulin 20 units Sub-Q BID [twice a day]. L. Record review of R #1's progress notes dated [DATE] revealed, Note Text: At 1648 [4:48 pm] residents FS [finger stick- blood sugar level] was high rechecked at 1651 [4:51 pm] and again monitor read high rechecked at 1653 [4:53 pm] and monitor read high. [Name of on-call Certified Nurse Practioner (CNP) #1] notified and ordered to give 10 units of Novolog [insulin] per sliding scale and recheck FS [finger stick] in 1 hour. FS [finger stick] 596 [blood sugar level] at 1809 [6:09 pm] and 590 [blood sugar level] at 1812 [6:12 pm], [Name of on-call CNP (Certified Nurse Practioner) #1] notified and ordered 10 units Novolog per sliding scale and to recheck FS [finger stick] at 2000 [8:00 pm]. FS [finger stick] at 2000 [8:00 pm] was 563 [blood sugar level] and 542 [blood sugar level] at 2002 [8:02 pm]. [Name of on-call CNP #1] notified at ordered for resident to be transferred via ambulance to [Name of local hospital] for evaluation of uncontrolled diabetes and R/O [rule out] [CONDITION(S)] [Urinary Tract Infection]. Resident was transferred to ambulance by EMT [Emergency Medical Technician] at 2045 [8:45 pm]. At approx [approximately]. 2130 [9:30 pm] PBX [post box exchange] operator [telecommunication console used in hospitals] notified me that EMTs were still in the parking lot and needed to ask me a question. Resident coded [[CONDITION(S)]] in ambulance before they took him, I was informed by DON to bring resident back to the unit and call [Name of Medical Investigator]. EMTs reported to me that residents time of death was 2121 [9:21 pm] and that he was pronounced by [Name of local hospital MD] over the phone from [Name of local hospital]. M. Record review of R #1's Medical Prescriber Notes dated [DATE] at 12:00 pm revealed the following: S: Resident noted to have blood glucoses in excess of 500 for at least 24 hours. Until this episode, his diabetes has been treated successfully with [MEDICATION(S)] [diabetic medication], 250 mg, BID [twice a day]. O: Blood sugars as noted above. Vital signs within normal limits. Heart sounds normal. Lungs clear to auscultation. A: Acute [CONDITION(S)] [high blood sugar]. P: Insulin dosage adjusted. Continue to monitor blood glucose regularly. Administer insulin per sliding scale. Follow up pm. N. On [DATE] at 12:42 pm during an interview with Registered Nurse (RN) #1, she stated, They said he [R #1] had a blood sugar check at 4 am [[DATE]] and he didn't look good. I went to check his [R #1] sugar and it just said high. I just checked it again and it said high, so I called the doctor and they sent in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It kept reading high and I kept calling the doctor. I got report from the nurse, and they were thinking about sending him [R #1 to the hospital] because he wasn't doing good, and he might have a [CONDITION(S)]. About the second or third time I talked to her [CNP #1], she said yeah, we should send him [R #1] out. We have insulin for him there and I believe it was a NovoLog for a sliding scale. The first time I checked it [R #1's blood sugar], it was high, and I checked it again. It was high again and she [CNP #1] said to give him [R #1] insulin and check it again in an hour, which is what I did. O. On [DATE] at 12:38 pm during an interview with RN #2 regarding when Physician's are notified of blood sugar levels, she stated, Depending if it's [residents glucose level] above 450 or below 40, we notify the physician. It depends if they are on insulin or have sliding scale. If they are on sliding scale, we give insulin depending on sugar levels. RN #2 confirmed she checked R #1's BGL several times when R #1 was experiencing [CONDITION(S)] prior to [DATE], but RN #2 did not notify a physician because R #1's BGL was not at a critical level. P. On [DATE] at 2:24 pm during an interview with RN #3, she stated, I wasn't here that day [R #1's incident on [DATE]], but it started on that Friday [[DATE]]. He [R #1] was on [MEDICATION(S)] [diabetic medication]. We checked his [R #1] sugar that day and it was 439 and so I checked it again and it was 450. I called [Name of on-call MD #1] and he said to give him [R #1] 10 units of insulin. I put in the paperwork and had that faxed and they gave him [R #1] the insulin as soon as I left. At 18:23 [6:23 pm] is when I checked his [R #1] sugar. I think maybe 6:30 pm [called on-call MD #1]. I know he [R #1] gets that high calorie tube feeding and that will raise his sugar, but he's been on that for years. Q. On [DATE] at 3:00 pm during an interview with Medical Doctor (MD) #1, he stated, I do know that his [R #1] medication was insufficient for the blood sugar he was having according to the nurse. They told me his [R #1] blood sugar was high the weeks preceding the 15th [[DATE]]. I gave him [R #1] additional medication that he was taking. I noticed his [R #1] oral medications weren't working, and I put him on a schedule to have it [blood sugar levels] monitored. We have to do it slowly and carefully. [Name of CNP #1] took over and was aware of the case. She [CNP #1] took over on the 16th [[DATE]] after 8:00 am. She's [CNP #1] more familiar with him [R #1]. Normally, it's not necessary to initiate 911 when monitoring someone with the blood sugar with the range he had when it can be monitored in a careful way. The purpose was to initiate more blood sugar control over the oral medication. With the oral medication, he [R #1] went over 500 units and that was with his medication he was routinely on. The medication I gave him didn't make any influence on him. This is common and it needs to be done carefully when you convert someone from oral to injectable form [of diabetic medications]. It [blood sugar management] has to be done carefully and slowly. I think she [CNP #1] made that decision [to transport R #1 to the ER] sometime in the afternoon on that day [[DATE]]. I think it was a good decision because she [CNP #1] believed he [R #1] was probably having a [CONDITION(S)] that was affecting him [R #1] and she felt it would be better treated in the ER [emergency room ]. Compared to other cases that we treated with ,d+[DATE] glucose levels, we always treat in the same manner and there was no expectation that the individual [R #1] required more than careful monitoring. That [monitoring and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . His [R #1] treatment was for someone who didn't know the patient, but who was treating the elevated blood sugar. My hope was that he [R #1], like patients on several units we have treated, would have gone quite well, but he had other conditions. My wish is the blood sugars that were so high in the preceding weeks would have been handled better, but he [R #1] had other issues for him. Yes, it [elevated blood sugar levels] could have been treated sooner. R. On [DATE] at 3:29 pm during an interview with the Director of Nursing (DON), she stated, I don't feel like it was a delay in treatment, the doctors were on board, and they felt like that was the appropriate treatment. Our policy on blood sugars is we call the doctor for sugars below 45 [mg/dL] and above 450 [mg/dL] and these numbers [R #1's BGL prior to [DATE]] wouldn't have prompted them [nursing staff] to call the doctor. Those are the [BGL] critical ranges and that [consult Doctor for insulin] is only applied. The normal range is just there to let everyone know. The nurses check the glucometers every day and input the critical ranges. I don't know what the doctor would order, and the docs [doctors] write progress notes. He [R #1] had kidney stones and ordered nephrology (kidney study) consult. When reviewing R #1's physician orders, DON also stated MD #2 wrote the latest Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1's increased blood sugars or input an order to be notified of changes. She stated I would have thought it was the medical doc [doctor] ordering it [BGL checks and [MEDICATION(S)] for R #1] to follow up with it [R #1's elevated BGL], but I don't see that. On [DATE], [Name of R #1's facility physician (MD #2)] signed off on the weekly blood sugar. S. [DATE] at 1:28 pm during an interview with the CNP #1, she stated, During that time [[DATE]], I probably wouldn't have sent him [R #1 to the ER] any sooner, but knowing what I do now [R #1 blood sugar levels had been rising and R #1 ended up passing], I probably would [have sent R #1 to the ER sooner]. The nurse notified me that his [R #1] sugars had been rising for a while and I would have sent him [R #1] out [to the ER] sooner if I would have known this. [Name of on-call MD #1] said something about his sugars being high. I think he [R #1] had some sort of chronic [CONDITION(S)]. If it didn't stage an immediate response, I don't know when he [R #1] was started on insulin. I don't know if there's a policy on that [contacting providers when blood sugars are elevated, but not to the point of critical lab values]. T. On [DATE] at 2:03 pm during an interview with Medical Doctor (MD) #2, he confirmed that he was R #1's primary care physician and writes R #1's medication orders and stated that he only works on Wednesday and Thursdays and was not notified of what had happened on [DATE] [Friday] and [DATE] [Saturday]. He stated, I can't honestly say they [nursing staff] did or didn't [inform him of R #1's elevated BGL in September and the beginning of October]. I wasn't made aware of the other increases. That's a strange policy [nursing staff only informing providers of critical BGL ranges] and I'm not aware of that [policy]. If he's [R #1] not on insulin and it [R #1's BGL] rises that high, I don't know why they [nursing staff] wouldn't call somebody. I don't know if I was ever informed of the sugar or not. As far as I know I wasn't made aware. U. On [DATE] at 12:38 pm during an interview with MD #2, he stated, I looked over the chart, he [R #1] was in a chronic vegetative state (no cognitive function) . We were more lenient on treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . I looked over the sugars [R #1's BGL for September and beginning of October] and I was never contacted [by the facility] about them [blood sugar levels]. He [R #1] was on [MEDICATION(S)], and I don't think that had anything to do with any deterioration. MD #2 stated, I think it would have been reasonable to notify me when it [R #1's BGL] was in the 300's, but I don't think it was a big mistake. I would want to be notified if there was a change, which there was on the 15th [[DATE]], but the rest [R #1's BGL] were lower. MD #2 confirmed that he would have caught (if any) high A1C levels during the quarterly lab orders [last lab order on [DATE], in range]. MD #2 also stated, If the nurses were concerned, they would have told me or they would have put that in the book. There weren't striking changes, even the 329 [blood sugar level]. Then it [R #1's BGL] went back to the 200's and that might be why they weren't concerned. We could have done treatment [if been made aware of increased blood sugar levels], but I would not have wanted to treat it where he [R #1] became hypoglycemic. He [R #1] was in a vegetative state. He [R #1] was on a low dose of [MEDICATION(S)] and my first step [had he been aware of the increased blood sugar levels] would have increased [MEDICATION(S)] and then I might have gone with insulin. In a clinical setting, I would have probably tried another oral medication, but we're limited here, so I most likely would have started him on insulin [if he had been aware of increased sugar levels]. MD #2 confirmed he was not notified of R #1 BGL increase, but he does not believe that ultimately led to the R #1's death. MD #2 also confirmed when he renews patient orders, he would expect the nursing staff to contact him with any changes to blood sugar levels.

During observation of the facility surveillane video recording on [DATE], R #1 was observed to approach a cart containing cookies and coffee with creamer that was left unattended in the activities room. R #1 proceeded to grab and eat handfuls of cookies. R #1 in the video appears to lean to the side and arm goes limp. Video recording shows staff approach R #1 and begin abdominal thrusts, breathes using ambu-bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately), suctioning and an AED (automated external defibrillator) was applied. R #1 expired. R #1 had a stroke in (MONTH) 2019 was recently place on a mechanical soft diet. R #1 had a history of [REDACTED]. R #1 also had multiple incidents of choking, most recent incident on [DATE] in which staff performed abdominal thrusts and suctioning to dislodge food in R #1's throat, breaking multiple ribs. Facility was aware of the incidents and failed to implement safeguards and interventions (besides re-directing) to keep R #1 safe. In addition, multiple other residents had been identified with similar behavior of grabbing and eating unattended food. This resulted in Immediate Jeopardy being called on [DATE] at 8:32 pm. The Administrator and Director of Nursing (DON) were notified at this time. A plan of Removal was received and rejected on [DATE] at 12:46 pm and [DATE] at 3:06 pm. A third Plan of Removal was approved and verified on [DATE] at 5:55 pm. Facility Administrator was notified. The scope and severity was reduced from Level 4, K to a Level 3, H. The Plan of Removal included: 1. A list was composed which identifies the residents receiving therapeutic/altered diets and who demonstrate high risk behaviors that place them at high risk for choking. 2. The DON met with all nurse managers and directed them to immediately audit and modify the care plans for all residents who have exhibited high risk behaviors increasingly (sic) their risk for choking episode. 3. Nursing will conduct unit rounds after each meal to ensure that no edible items are left unattended to safeguard our resident who are at risk for choking. 4. All care plans were audited for resident who are on altered diets and exhibit high risk behaviors to ensure that all proper interventions are in place. 5. After each choking episode, the treatment team will meet to discuss and add proper interventions by reviewing the care plan during the treatment team meeting. 6. New secure trash cans will be ordered to prevent residents from reaching into the garbage and will be placed in highly visible areas. 7. Training is being conducted with all LTC (Long Term Care) staff regarding proper disposal of food items to safeguard residents. Based on record review, observation and interview the facility failed to provide services for 2 (R#1 and 2) of 3 (R #1, 2 and 3) residents reviewed for diets, necessary to avoid physical harm. This deficient practice likely resulted in R #1 experiencing multiple choking incidents without appropriate intervention and his death. If the facility is not implementing appropriate safeguards to residents at risk of choking, then residents are at risk of serious harm. The findings are: Findings for R #1: [NAME] Record review of R #1's face sheet indicated that resident was admitted to the facility [DATE]. B. Record review of Medical History & Physical dated [DATE] reveals [DIAGNOSES REDACTED]. status is fair [MEDICAL CONDITION]([MEDICAL CONDITION], ie stroke- when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel.). He requires a wheelchair for mobility to maintain safety.[MEDICAL CONDITION] in (MONTH) 2019. C. Record review of the Physician orders [REDACTED].>1. Order on [DATE] for Speech/swallow evaluation. 2. Order on [DATE]: cancel swallow eval, unable to cooperate. D. Record review of Exam request dated [DATE] revealed order for swallow evaluation to be scheduled. E. Record review of local hospital appointment form revealed Fluoroscopy (a type of medical imaging that shows a continuous X-ray image on a monitor) Modified [MEDICATION NAME] Swallow (Liquid [MEDICATION NAME] is a white, chalky solution that helps healthcare providers see the pictures more clearly. [MEDICATION NAME] is mixed with liquids and foods to show how they are swallowed) for [DATE]. F. Record review of Medical Progress Note dated [DATE] revealed Patient with no improvement. Observed wheeling himself around the unit. He wheeled himself into the conference room where he attempted to grab one of two soft drinks. He became irritable when denied. His eating has been on the run. He was observed to eat his food without a fork or spoon and most missed his mouth. Staff are exhausted and burnt out. He was more vocal than usual; can I have a coke? cake? Mood is irritable .major neurocognitive disorder (general term that describes decreased mental function due to a medical disease other than a psychiatric illness) with behavioral disturbances, irritable, impulsive and aggressive. [NAME] Record review of Nursing Progress Notes revealed: 1. [DATE] at 14:24 (2:24 pm) reveals (Name of R #1) refused to allow staff to check his vital signs this evening resident was noted earlier during supper to be choking on a tortilla, resident was able to cough it out and clear his airway. 2. [DATE] at 13:49 (1:49 pm) reveals Resident was in the dining room and noted to be choking on his food at 17:45 (5:45 pm) staff gave him several back blows until resident coughed up a large piece of tortilla. Normal respirations resumed. This is the second time this week that (Name of R #1) was noted choking on a tortilla. He was noted on [DATE] to be choking on a tortilla during supper. I will leave a message on the Physician's calendar to request a swallowing evaluation to possibly down grade residents diet from Mechanical soft (avoiding foods that require a lot of chewing and are easy to swallow) to Puree (a smooth, creamy substance made of liquidized or crushed fruit or vegetables). 3. [DATE] at 6:45 am He (R #1) was redirected from getting in the trash can. 4. [DATE] reveals Was reported to me by (Name of staff #1) that resident (R #1) had fallen a Nursing assessment was preformed by Nurse (RN #2) who then preformed abdominal thrusts. Oxygen placed on resident via nasal Cannula. resident was then suctioned. A piece of bread was obtained from the residents mouth. Resident was then more alert. Resident sent to ER (emergency room ) for evaluation and treatment. Glasgow scale (common scoring system used to describe the level of consciousness in a person following a [MEDICAL CONDITION])done was abnormal. 5. [DATE] Resident back from ER after he choked during lunch back with DX (diagnosis) of fractured ribs, ABX (antibiotics), pain medication and changed diet to Mechanical Soft. H. Record review of Medical Progress Notes dated [DATE] reveals Choking episode with possible aspiration, Rib Fractures, Plan to downgrade diet to Mechanical Soft (from regular diet). I. Record review of Incident Report Form dated [DATE] at 12:00 pm reveals, Resident (R #1) had a choking episode on bread was suctioned by Nurse (Name of RN #2) was able to obtain bread out of residents mouth. Resident had fall and choking episode and was sent to (name of local hospital) ER (emergency room ). During choking episode resident was given abdominal thrusts may be cause of fractures. [NAME] Record review of progress notes dated [DATE] reveals: Residents noted to be out in the hallway between (name of facility units) where he was seen by Administrative Secretary (AS), digging the trash can just outside of these units. Resident reached into the trash can and pulled out a burrito. Resident preceded to eat the burrito as he headed towards the door leading into (name of unit) AS came into the nurses station and reported the above. AS said that she didn't try to take the burrito away because she was afraid that the resident would try to hit her. Note: Resident is on a mechanical soft diet, but the burrito was whole and not mechanical soft. Mechanical soft diet ordered on [DATE] because of previous choking episodes, Licensed Practical Nurse (LPN) #2 immediately went into the hallway where resident was, but resident had already stuffed the burrito into his mouth and was in the process of swallowing it. K. Record review of the Care Plan for R #1 did not identify behavior of grabbing and eating food and did not include any interventions related to this behavior or any choking incidents. L. Record review of Internal Review Department Report of Investigation Case #[DATE] reveals: On [DATE] at 9:25 hrs, R #1 was discovered nonresponsive in his wheelchair with food in his mouth (name of unit) Nursing staff attempted to clear the obstruction from (Name of R #1's) mouth via suction machine and multiple abdominal thrusts. At 09:43 hrs (hours), CNP #1 pronounced R #1's death. M. Record review of Security Surveillance Video dated [DATE] reveals: 1. 9:27:19 am: Recreational Therapist (Rec T) exited activities storage room with a cart. The cart had cookies and coffee machine on the top with coffee creamer/sugar. Rec T pushed the cart to the entrance of the activities room. 2. 9:28:16 am: Rec T removed a cellphone from his pocket and appeared to begin a conversation on his cellphone then exited the activities room to the outside courtyard. The cart remained unattended in the activities room. 3. 9:29:55 am: R #1 wheeled himself into the activities room to the cart. 4. 9:30:03 am to 9:33:58 am: R #1 is observed obtaining a bag of cookies and a eating them by the handful and shoving them in his mouth. 5. 9:34:14 am: R #1 placed the bag of cookies back on the cart and wheeled himself out of the activities room to the main hallway. R #1 stopped himself just outside the activities room in the main hallway. R #1 moved himself forward and backward. 6. 9:35:23 am: R #1 leaned forward and to his right in his wheelchair. R #1's right arm appeared flaccid over the right rear wheel of his wheelchair. 7. 9:35:56 am: RN #1 walked to R #1 and appeared to assess R #1. 8. 9:36:12 am: Rec T re-entered the activities room from courtyard. RN #2 pulled R #1's wheelchair backward and conversed at Rec T, Rec T ran to (name of unit #1) nurses station. 9. 9:36:23 am: DON walked back to R #1 obtained a pair of gloves and walked back to R #1. DON assessed R #1's mouth area. 10. 9:37:42 am: DON began to give R #1 abdominal thrusts as R #1 remained in his chair and was later moved to the floor. 11. 9:38:47 am: DON began suctioning and continued abdominal thrusts. 12. 9:42:29 am: Psychiatric Technician (PT) #2 performed chest compressions 13. 9:43:19 am: No chest compression or abdominal thrusts 14. 9:43:59 am: Chest compression re-initiated and DON continued to suction 15. 9:45:15 am: RN #1 took over performing chest compressions 16. 9:46:24 am: All work stopped by staff. 17. 9:46::39 am: RN #1 re-initiated chest compressions. 18. 9:48:23 am: CNP (Certified Nurse Practitioner) arrived at unit CNP #1 stood and watched. 19. 9:50:50 am: CNP leaned over R #1 and appeared to assess CNP had stethoscope in her ears. 20. 9:51:50 am: all work stopped equipment was collected. 21. 9:52:03 am: CNP leaned over and listened to R #1 via stethoscope 22. 9:54:05 am: Rec T arrived with a gurney 23. 9:57:51 am: R #1 was lifted and placed on the gurney and wheeled to his room. N. On [DATE] at 5:28 pm during an interview with Recreational Therapist #1 he stated, I was having a coffee cookie social. I took the cookies and coffee out in a cart from the activity closet. I was ready to go pass it out and I got a personal phone call and I stepped out to take the call and left the cart un-attended. I was out for about 7 minutes. I know I should not have taken the phone call. When I came back into the building RN #1 was with R #1 she told me to go get (Name of DON). They started to do CPR. I was in shock I realized at that time he had gotten into the cookies. I was asked to go get the crash cart from the other unit because the tube in the suction machine was not long enough. They were doing chest compressions and the AED was placed on him (R #1). I remember one of the girls was picking up a heart rate for a little bit, they were trying to suction him (R #1). They continued to do CPR. He (R #1) is always trying to grab things and put them in his mouth when he was in activities I know he would get in the trash, he tried to eat the game pieces, he would grab any food or drinks close by him. I know he was on a level 1 for awhile but we are so short staffed that is why I think they took him off the level because there is not enough staff to be with him. He should have been on some kind of level because he was always grabbing things. I know I should not have left the cart un-attended, but staff knew that he had a problem with grabbing all sorts of things. O. On [DATE] at 3:37 pm during interview with the Director of Nursing (DON), when asked why R #1 never had the swallow study, she stated I don't know why we didn't try again (to get appointment sooner) but it takes a long time to get an appointment. P. On [DATE] at 4:41 pm during an interview with RN #1, she stated when asked if there had been any other choking incidents with R #1, she stated. I know of one time he took food out of the trash can and stuffed it in his mouth another time he got a hold of bread and cheese and he was choking on that. He used to take food from other people's plates. He used to be on a level 1, (is when someone is a hands distance away). He was moved to a level 2 that is when someone checks on him every 15 minutes. He was not on any level at the time of the last choking incident. Q. Record review of Death Certificate dated [DATE] reveals Immediate cause Aspiration of foreign body. R. On [DATE] at 9:00 am record review of the Manager Investigation Follow-Up Form reveals: Conclusion; Upon review of this investigation there is evidence to substantiate neglect as the Activity Therapy staff, left food unattended. Video surveillance revealed that staff left food items unattended for approx. 7 (Seven) minutes and 56 seconds resident wheeled himself to the cart with cookies and coffee. R #1 was seen eating up to 6 handfuls of cookies, without any staff present. He then wheeled himself out of the Activities room to the (Name of Unit) Main Hallway and was slumped into the wheelchair. Findings for R #2 S. On [DATE] at 8:47 am and 9:15 am during observation (300 unit) a plate of scrambled eggs, sausage, orange slices and Raisin Bran cereal were observed on a counter top unattended. T. On [DATE] at 1:23 pm during interview with the Director of Nursing (DON), regarding R #2, she stated He (R #2) has taken food off other (residents) plates, so we moved him to another table where everyone is given a mechanically altered diet. U. Record review of the Care Plan for R #2 revealed Potential for significant weight changes related to history of overeating, dietary non-compliance and GI (Gastrointestinal tract definition is the part of the digestive system that consists of the stomach and intestines) discomfort related [MEDICAL CONDITIONS] reflux disease is a digestive disorder that affects the lower [MEDICAL CONDITION] sphincter (LES), the ring of muscle between the esophagus and stomach (define) symptoms. Interventions included remind me to take my time during meals. V. On [DATE] at 3:25 pm during interview with the registered Dietician regarding R #2, she stated He would shove 3 honey buns in his mouth and he would tell me, 'Look Dietician.' We explained to him that it (changing his diet consistency) is because he cannot slow down (eating). W. Record review of Physician order [REDACTED]. X. Record review of Incident Report revealed: 1. On [DATE], R #2 was provided a mechanical soft diet. Resident began eating lunch when nurse noticed error and took tray away from R #2. 2. [DATE], R #2 was served a mechanical soft meal and after eating 85% of the meal, staff noticed error and removed the tray. Y. On [DATE] at 3:37 pm during interview with the DON, she confirmed that they have multiple residents with the behavior of grabbing unattended food, including R #2

Based on record review and interview, the facility failed to ensure that residents received the appropriate and safe transfer assistance for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice likely resulted in R #1 falling and sustaining a broken shoulder and hip. The findings are: [NAME] Record review of R #2's face sheet dated [DATE] reveals resident admitted to facility on [DATE]. Diagnosis: [REDACTED]. episode (Overwhelming feeling of depression and sadness). B. Record review of R #2's care plan dated [DATE] revealed: Focus: Self-care deficits in Activities of Daily Living (ADL)'s related to cognitive and physical limitations. Interventions: I require total assistance of 2 staff for safe transfers. The Sara lift (mechanical devise used to assist a person to move from a sitting to standing position) will be used for all transfers. Self care deficits in Activities of Daily Living related to cognitive and physical limitations. Interventions: I am alert and able to make my needs known verbally. C. On [DATE] at 8:08 am during an interview with Physical Therapist Assistant (PA) #1, she stated. I worked with him (Name of R #2). He never complained of any pain. His memory was amazing. (Name of R #2) was a Sara lift transfer, he was unable to stand on his own. He did not have enough mobility. He needed help with transition from one position to another. I believe he would have been able to remember a fall. D. Record review of nurses progress note dated [DATE] revealed, that R #2 was in the dining area yelling that he needed to see a doctor. R #2 stated that he had been dropped by Psychiatric Technician (PT) #1. R #2 was asked if he had fallen that morning and R #2 stated I didn't fall. I was dropped, man! E. On [DATE] at 9:15 am during interview, PT #2 stated he assisted R #2 to bed between 6:30 pm or 7:00 pm on [DATE] and that R #2 didn't not complain of having any pain. PT #2 confirmed that the care plan required a Sara Lift be used when moving R #2. PT #2 confirmed he did not follow the care plan and that he always transferred R # 2 without the use of a Sara lift. He stated, I picked him up. I put my hands under his arms. I picked him up and pivoted him on his legs. I use a Sara lift with (Name of R # 2) occasionally when I change him, sometimes there is not a lift available to use. F. On [DATE] at 10:44 am during interview with PT #1 he stated, (Name of PT #3) asked me to help her get (Name of R #2) out of bed on the morning of [DATE]. I came to help her and she was busy and she never came to assist in getting him up, so I started off by changing (Name of R #2) first by rolling him over, I got him dressed in bed then sat him up. I did not use a lift I used both arms. He (R #2) was complaining of pain, so I called the nurse to assess him. When I put his shirt on he complained of pain and I stopped and put on his shoes. I went to get (Name of Registered Nurse (RN) #1) and it took awhile for her to come in. I sat him up and she assessed him (she looked at him). I got him up and took him up to the TV room and (Name of R#2) started to complain that his shoulder hurt. G. On [DATE] at 10:56 am during interview with RN #1 she stated, I was passing meds (medications) ([DATE]) a little before 6:00 am and I heard him (R #2) saying oww (ouch) or yelling so I went in his room. (Name of PT #1) was getting ready to transfer him. I asked if he needed help transferring, he stated No. (Name of R #2) stated he fell . At the time I didn't assess his shoulder because he wasn't complaining of pain, he (R #2) just reported a fall. Later he continued to complain of pain and kept saying he fell . I asked him (PT #1) what happened, did he fall, which he (PT#1) said no. I kept asking 'are you sure because he was complaining of pain?' Later R #2 started complaining of pain and his shoulder did look different and out of place. Nurse Manager (NM) #1 went to look at him a little after 6:00 am and she said it does look like something is wrong and she called the doctor. I think PT #1 transferred him by pivot because sometimes he could bear weight. He should be a 2 person assist or sara lift for transfers. H. On [DATE] at 11:00 am during interview with NM #1 she stated, I walked into work that morning ([DATE]) around 6:15 am. (Name of RN #1) asked me to assess (Name of R #2) who told me, 'I need a doctor.' When asked if he fell . he stated, No I didn't fall, he pointed at (name of PT #1) and stated, 'I was dropped. I saw his shoulder and it looked displaced and was protruding forward. The doctor was called and ( Name of R #2} was sent to the emergency room shortly after. I assumed it was (name of PT #1) that had dropped him. (Name of R #2) was pretty well oriented, he would remember the situation. (Name of R #2) was a Sara lift transfer. When (Name of RN #1) told me it was (Name of PT #1), I (NM#1) pulled (Name of PT #1) off the unit. When I asked (Name of PT #1) if (Name of R #2) had fallen he picked up his arms and said, 'I swear to God boss, I didn't drop him.' (Name of PT #1) was reprimanded and never returned to the unit. (Name of R #2's) daughter called later on and stated, 'My dad has a dislocated shoulder and a broken hip'. Later his son called and he also told us his father would be having surgery later that day for a fractured shoulder and a broken hip. NM #1 stated that R #2 was sent to the hospital within 15 minutes of her assessing him. I. Record review of R #2's medical record did not reveal an assessment of R #2 after he complained of pain or any additional notes regarding R #1 on [DATE]. [NAME] On [DATE] at 1:14 pm during interview with R #2's Power of Attorney (POA) he stated, I received a call around 7:34 am from the facility that my father was being transported to (name of local hospital) because his shoulder looked dislocated. Just before surgery, my father told me he had been dropped. At 6:00 pm that evening he had surgery. He continued to say he was dropped. POA confirmed that following the surgery, his father was transferred to another hospital where he was placed in an Intensive Care Unit and later died .

On 02/21/18 at 2:52 pm during an interview with Psych (Psychological) Tech (Technician) #1 she stated The call light system in the (Name of Unit) south doesn't work, it hasn't for a few months. During observation of the south unit the call system was tested by surveyors. The Code Blue (resident requiring resuscitation or in need of immediate medical attention) alarm was pulled at 3:14 pm in room [ROOM NUMBER]. The alarm light outside the room door was visible indicating the need for assistance, but the alarm bell did not sound in the hall. Surveyor #1 present in the nursing station located at the top of the north hall way did not hear or see alerts on the call system monitor located in the Nurse station. The Surveyor #2 located in the north hall did not hear the call system sound in that hallway, and the Surveyor #3 located in the south hall could not hear the call system sound. The code blue alarm in room [ROOM NUMBER] was not answered until 3:21 pm when Licensed Practical Nurse (LPN) #1 and LPN #2 were walking down the hall to complete their medication count prior to shift change and saw the blue light on outside of room [ROOM NUMBER]. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at a scope and severity (S&S) level K. The facility Administrator was notified of the IJ on 02/22/18 at 10:51 am. On 02/22/18 at 3:48 pm the Plan of Removal (POR) was submitted and approved at 4:31 pm. The scope and severity was changed to level 2, E. Based on the POR the interventions included: 1. On (MONTH) 22, (YEAR) at 11:45 am one staff was placed on each of the unit hallways (north and south) of the (Names of the 2 affected units). No issues were identified on the (Names of two other facility units) The purpose of this assignment is to observe and alert nursing staff in the event of an emergency and assure that all residents needs are met. 2. The assigned staff will monitor the call lights by walking up and down the hallways and alerting staff to the situation at hand this will continue until the issue is resolved on 02/27/18. 3. Compliance with this step will be completed on the form typically used for Fire Safety Watch documentation. A schedule of employees to fill this role on a 24/7 (24 hours a day 7 days a week) basis until completed will be developed to ensure that there are employees available for this purpose. The functions of this position will not be allowed to assist in any resident care so as not to e removed from the primary function of observing for call bells or code blue alarms. Since this is not a resident care position, employees who are not CNA's (Certified Nurse Aides) will be brought in to fill this function. Basic training of what is expected will be provided at each employee's first assignment and as needed. 4. Effective Immediately all non-functioning alarm systems to include (call lights, door alarms, fire alarms) will be reported to the Nursing Home Administrator or designee for immediate attention and correction. whenever an issue is noted by staff. This will be communicated to all Nurse Managers via memorandum to be dated 02/22/18. 5. (Name of alarm system contractor) who is the contractor for the call bell system, will be onsite Tuesday (MONTH) 27, (YEAR) at which time, the issue will be corrected. In the remote chance that they cannot correct the issue on that day, action #1 will continue until it can be completed. 6. Ongoing Compliance Monitoring: Current call bell monitoring process will be enhanced by inclusion of the Administrator and/or Director of Nurses (or designees) to increase awareness of the status of call bell system. This will take place with the current monthly schedule of testing. Based on observation and interview, the facility failed to ensure that facility residents have an adequate call light system with visual and auditory notification and a monitoring system of call lights at the Nurse's station. This deficient practice affects all 34 residents residing on Unit #1, listed on the resident census list and provided by the Administrator on 02/21/18. If the facility is not ensuring that the call light system is functioning, then staff are likely to not be notified when a resident is in distress and in need of assistance. The findings are: A. On 12/21/18 at 12:56 pm during an interview with Psych (Psychological) Tech (Technician) #4, when asked what he would do if he found a resident unresponsive, he stated I would pull the code light (code blue) and yell for help. B. On 02/21/18 at 2:52 pm during an interview with Psych (Psychological) Tech (Technician) #1 she stated The call light system in the (Name of Unit #1) south doesn't work, it hasn't for a few months. Every time they try to fix it, it doesn't stay (fixed). When asked when would you press the blue light, she stated that she didn't know what that light was for. C. On 02/21/18 at 3:08 pm during observation of Unit #1 south and north hallways a constant beep sound is heard, no call lights are activated at this time. D. On 02/21/18 at 3:13 pm during observation the following was found: 1. The bathroom alarm was pulled in room [ROOM NUMBER] at 3:13 pm, the Code Blue alarm was pulled in room [ROOM NUMBER] at 3:14 pm and the bed alarm was pulled in room [ROOM NUMBER] at 3:15 pm. 2. The alarm lights outside the room doors were seen to be on indicating the need for assistance, but the alarm bells did not sound in the hall. The Surveyor #1 present in the nursing station located at the top of the north hall way did not hear or see alerts on the call system monitor located in the nurse station. Surveyor #2 located in the north hall did not hear the call system sound in that hallway, and Surveyor #3 located in the south hall could not hear the call system sound. 3. Psych Tech #2 responded to the bathroom call light in room [ROOM NUMBER] at 3:15 pm, and the bed alarm in room [ROOM NUMBER] at 3:17 pm. The code blue alarm in room [ROOM NUMBER] was not answered until 3:21 pm when Licensed Practical Nurse (LPN) #1 and LPN #2 were walking down the hall to complete their medication count at shift change when they saw the blue light on outside of room [ROOM NUMBER]. 4. No call bell sound was heard over the continuous beeping sound. E. On 2/21/18 at 3:18 pm during interview with LPN #2, she stated that the call lights have been messed up for a couple months. The Techs come running to the monitor all the time (to see where the call light is coming from) cause of the beeps. F. On 02/21/18 at 3:28 pm during interview with LPN #1 confirmed that the call light system had not been working for awhile. G. On 02/21/18 at 4:21 pm during an interview with the Administrator she stated No, I didn't know the call system in (Name of unit #1) was not working. It's not appropriate to take 5 minutes to respond to a Code Blue call light. They should have let me or (Name of Director of Nursing) know there was an issue. H. On 2/21/18 at 4:35 pm during an interview with the Director of Maintenance (DM), he stated the call lights should sound in the Nurse's station, the Supervisor's office and the unit. He stated I know that the call system doesn't work in the (Name of Unit #1)'s Supervisor's office, and at one at nurse's station. I submitted a purchase order for the parts and to have it serviced on 01/31/18 and I'm waiting for the central office to approve it so the company can come and fix it. There is a constant beep, that sounds the same as a regular call light, but it shows nothing on the monitor (indicating the room the call light was triggered). The staff is frustrated. The system (call light panel which indicates where the call light was pulled) is monitored at the nurse station. The beeping at the monitor is because it is connected to the supervisor computer which is not working. I reset it and it worked for a while then I had to reset it again. The last time I reset it was 2 months ago, I haven't been able to reset it again, it no longer lets me. I know for sure the Code Blue south side is not working for 2 months maybe longer. I. On 2/21/18 at 5:01 pm during an interview with the Director of Nursing (DON) she stated No, I didn't know the call system wasn't working in (Name of Unit #1), it should have been reported to me right away. I would expect the staff to respond immediately to a Code Blue, 5 minutes is too long. J. On 2/22/18 at 11:18 am during observation and interview, the Administrator pulled the code blue call light on Unit #1 south. During interview with Licensed Practical Nurse (LPN) #1 and #2 who were standing in the main hallway/entryway of Unit #1 by the dining room when asked if they could hear the code blue call light, LPN #1 stated I could not hear the call light from here. LPN #2 stated No, I didn't hear anything. K. On 2/22/18 at 11:30 am during an interview with Registered Nurse (RN) #1 who is also the Nurse Manager for Unit #2; when asked if the staff on Unit #2 could hear the code blue light from Unit #1's south hall she stated The system (call light panel which indicates where the call light was pulled) showed it was room [ROOM NUMBER] which is right down this hall, but there was no light going on at the room when we checked.

1. R (resident) #1's name was printed on a white paper outside his room door which indicates residents who have DNR (Do Not Resuscitate) status. Early morning on [DATE], resident (R) #1 was found to be unresponsive. Licensed Practical Nurse (LPN) #3 who discovered him saw that his name was printed on a white paper outside his room door, so he did not initiate CPR or any life saving measures. 15 minutes later, after reviewing R #1's medical record, LPN #3 discovered that R #1 was a full code (wanting to receive lifesaving intervention in the event of a life threatening event), and then began life saving measures. The resident was not able to be revived. 2. During the investigation, it was also discovered that LPN #3 did not call code blue (emergency alert notifying facility personnel that respiratory arrest and/or [MEDICAL CONDITION] has occurred and the patient is requiring resuscitation or in need of immediate medical attention) as identified in the facility policy, which would have assisted him in confirming R #1's code status. 3. Further interviews with different staff identified that when finding a resident unresponsive, they would initiate CPR (cardiopulmonary resuscitation) even if the resident has a DNR status, contrary to facility policy. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at a scope and severity (S&S) level J. The facility Administrator was notified of the IJ on [DATE] at 10:51 am. On [DATE] at 3:48 pm the Plan of Removal (POR) was submitted and approved at 4:31 pm. The scope and severity was dropped to a level 2, D. Based on the POR the interventions included: 1. Kardex (medical information systemized by nursing staff to communicate important information) posters identifying residents with Full Code status made and implemented immediately. Review at each change of shift. 2. Hand-off report sheet modified to reflect Full Code status review. Nurse will check off when complete. 3. All staff trained on Full Code Identification, policy and procedures specifically what to do when resident found unresponsive. 4. Mock Code Blues will occur one time monthly on all units for 6 months 5. Educational review monthly for all LTC (long term care) staff 6. Audit of Full Code status done weekly to ensure accuracy. 7. Director of Nursing or designee will audit compliance and submit report to QAPI (Quality Assurance Performance Improvement) committee monthly for 6 months. Based on record review and interview, the facility failed to ensure that the facility staff provide emergency basic life support immediately when needed to any resident requiring such care in accordance with the resident's Advanced Directives (written statement of a person's wishes regarding medical treatment) for 1 (R #1) of 1 (R #1) resident reviewed by: 1. Not immediately providing basic life support including CPR (cardiopulmonary resuscitation), calling Code Blue (emergency alert notifying facility personnel that respiratory arrest and/or [MEDICAL CONDITION] has occurred and the patient is requiring resuscitation or in need of immediate medical attention), obtaining the crash cart and AED (Automated External Defibrillator) when R #1 was found unresponsive. 2. Not ensuring that the residents' door tags accurately reflect the residents' code status or that there are processes in place for staff to accurately identify a resident's code status in case of an emergency. 3. Not ensuring that staff know and follow policy regarding what to do if a resident is found unresponsive. If the facility staff do not know with certainty a residents code status and what to do when a resident is having cardiac [MEDICAL CONDITION] arrest (sudden stop in effective normal blood circulation due to the failure of the heart to pump blood and/or when a person stops breathing preventing the delivery of oxygen which can cause a resident to lose consciousness) then residents are likely to not receive life saving interventions or receive life saving interventions that are not within their preference. This deficient practice could likely result in harm or death to a resident. The findings are: A. Record review of the facility Emergency and Crisis Care Policy Statement revised [DATE] revealed B. Cardiac [MEDICAL CONDITION] Arrest 2 Call code blue and request AED if patient/client/resident is not breathing 3. In the event there is a DNR order on file, staff must follow protocol and not initiate CPR always keeping a staff member with patient/client/resident Findings related to R #1: B. Record review of R #1's face sheet dated [DATE] revealed that R #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 was a full code (wanting to receive lifesaving intervention in the event of a life threatening event). C. Record review of the Care Plan for R #1 dated [DATE] revealed (Name of R #1) has a tendency to yell and exhibit violent behaviors to himself .(Name of R #1) is unable to use a call bell. Call bell will be within reach for staff use however he is able to make some of his need known using signs and gestures. He is able to speak ,[DATE] words most of the time .(Name of R #1) is independent for transfers D. Record review of the Manager Investigation Follow-up Form (MIFF) reveals a written statement dated [DATE] by LPN #3 which states in brief that he entered R # 1's room on [DATE] about 4:55 am and noticed that he (R #1) had not moved which led him to believe that R #1 was deceased . He tapped R #1 on the shoulder and noted no response. He turned R #1 on his back and noted R #1 was stiff, his face was bluish purple, he was non-responsive, not breathing and had no pulse (beating of the heart noted in an extremity of the body). LPN #3 left the room glanced at the name on the door then went and got a stethoscope (device to amplify and listen to the heart). LPN #3 returned to R #1's room and checked again for a pulse. LPN #3 again left R #1's room and noted R #1's name was printed and posted in a holder next to his door on a white paper. LPN #3 believed this was an indicator that R #1 was a Do Not Resuscitate (DNR: refuses lifesaving intervention in the event of a life threatening event). LPN #3 then left the unit and walked to the nurses station where he checked R #1's medical chart and discovered that R #1 was actually a full code. Included with the MIFF was a transcription of a video monitoring tape which indicates that LPN #3 first entered R #1's room at 5:03 am. LPN #3 exits the room and gets a stethoscope from a desk at 5:05 am. At 5:07 am LPN #3 is seen walking down a hallway to the nurse's station. At 5:16 am, LPN #3 is seen returning to R #1's room with a defibrillator (a mechanical/electrical device used during lifesaving procedures which monitors heart rhythms and indicates to begin chest compressions or deliver an electrical shock). At 5:18 am LPN #3 leaves R #1's room and returns with a crash cart (a cart which contains supplies used during lifesaving procedures). The transcription notes that at no time did LPN #3 appear to be in any rush or moving in an urgent manner. The transcription indicates a total of 15 minutes from the time LPN #3 first entered R #1's room until the time he obtained a defibrillator and crash cart and re-entered the room with LPN #4. E. Record review of Performance Checklist: Initial Assessment for LPN #3 dated [DATE] revealed For an unresponsive victim: Call for help: a. Shout for someone to call [DATE] and get an AED .Check for normal breathing. If no breathing, begins CPR and use the AED as soon as available. Hand written was a note that read Push code blue button. F. On [DATE] at 5:01 pm during an interview with the DON, regarding R #1, she confirmed that he was found unresponsive and there was a delay in starting CPR. G. On [DATE] at 11:55 am during phone interview with LPN #3 he stated On the morning of the incident, I entered (Name of R #1's) room and noted he was unresponsive and appeared to be deceased . I looked at the resident name tag at the door to his room and saw that it was on a white paper. I believed this mean the (Name of R #1) was a DNR. I didn't think there was a reason to hurry and call the doctor or check his chart. I left the area and went to check on another resident and then I went and looked at his (R #1) chart just to be sure and that's when I saw he was a full code. LPN #3 further stated he told another nurse (LPN #4) of the situation and they went together to R #1's room where they began lifesaving measures and after a few moments he determined that R #1 was not responding and so he stopped CPR and told the other nurse to do the same and Wait for (Name of Medical Doctor (MD)) to come pronounce him. When asked what the facility procedure was he stated The procedure is to start CPR, pull the code blue switch thing (emergency alert alarm: code blue call light located in the resident restroom), and yell for help. H. Record review of the MIFF dated [DATE] revealed an interview with Psych Tech #7 who worked on Unit #1 on [DATE], shift started at 3:00 am. She stated that when she arrived to work (3:00 am), she was informed that R #1 had been yelling throughout the night by Psych Tech #3 and Psych Tech #6. She stated that she checked on R #1 at about 4:,[DATE]:45 am and R #1 appeared to be sleeping. Psych Tech #7 stated that she went into R #1's room [ROOM NUMBER]:,[DATE]:30 am when she heard the defibrillator. She stated that she touched R #1's body to move his arm and close his eyes and R #1 was warm to the touch. Later when LPN #3 stated to Psych tech #7 that R #1 had been dead for a long time when he found him, Psych Tech #7 stated that wasn't true because he was still warm. I. On [DATE] at 9:39 am during an interview with LPN #4 he stated I was on the north (Name of unit #1) side that night (shift [DATE] night to [DATE] morning) checking on a resident on the north; the room is right next to the nurses station. (Name of LPN #3) told me that a resident was dead, and then he told me the problem was he (R #1) was a full code. I told him we had to attempt to resuscitate him, so we pulled out the crash cart and tried to resuscitate the corpse. No, I did not see code blue light or hear a sound. LPN #4 confirmed that he did not pull the code blue call light cord. He (LPN #3) went to get a defibrillator from another unit but I had one on the crash cart in (Name of Unit #1). We put it on his chest and checked his vitals and the machine indicated No Response so we began CPR. Yes, we continued with CPR and (Name of LPN #3) said he had contacted the on call doc (doctor). After a while we stopped chest compressions and then the doctor arrived. There were 2 aides (Psych Techs) in the hallway. I was focused on the resident, but no, no one came in and helped. When I saw him he was not of this earth, rigor (rigor mortis: stiffening of the joints and muscles of a body a few hours after death) was setting in and he was gray in color laying on his back. Policy is you run to a code. The door tag colors should mean something but they don't always, they indicate who is DNR and who is a full code. I know who my residents are so I don't rely on those (name signs). J. Record review of R #1's record labeled Manager Investigation Follow-up Form (MIFF) dated [DATE] reveals a death certificate dated [DATE] stating R #1 died at 0530 (5:30 am) on [DATE] due to Coronary Event-Suspected MI ([MEDICAL CONDITION] Infarction-[MEDICAL CONDITION]) and signed by (Name of Medical Doctor (MD)). Findings related to identifying code status and responding to an unresponsive resident: K. On [DATE] at 9:53 am during observation and interview, the Ward Clerk was adding a name tag for R #2 outside room [ROOM NUMBER]B, Unit #1 South that was printed on white paper. The Ward Clerk reported that R #2's code status had changed from full code to DNR on [DATE] and she was replacing the old name tag to reflect the new code status. L. On [DATE] at 10:20 am during interview with Registered Nurse/Nurse Manager RNNM #1 she stated When finding an unresponsive resident, staff should begin CPR immediately and continue until the code status can be verified by checking the resident's chart or until a doctor determines to end interventions. M. On [DATE] at 11:09 am during observation and interview with Psych (Psychology) Tech's (Technician) #5 and 6, they both stated that a resident's code status is in the resident's chart and that they also know a resident is full code if the color of the resident's name tag beside the door is blue, and that the resident is DNR status if the sign behind the resident's name is white. When asked what they would do if they found a resident unresponsive, they both stated that they would immediately initiate CPR and continue until they were told to stop regardless of the name tag color. During observation it was noted that the nurse's station on Unit #1 was at the bottom of the South hallway and approximately 40 yards from the beginning of Unit #1's north hallway. Each hallway was approximately 30 yards long. The medical charts for each resident in Unit #1 are only located in the nurse's station. N. On [DATE] at 11:36 am during interview with Psych (Psychology) Tech (Technician) #4 when asked what he would do if he came across an unresponsive resident, he stated that he would start CPR, yell for help, have someone get the crash cart, AED and emergency kit. Psych Tech #4 stated that even if he knew a resident was DNR, he would start CPR, It (code status) could have changed. Psych Tech #4 also stated that the door sign could be wrong and that staff has been instructed to start CPR until they find out (code status) for sure. O. On [DATE] at 11:54 am during interview with Registered Nurse (RN) #2 when asked what would she do if she found a resident unresponsive, she stated that she would use the call light (code blue) first and then start CPR. P. On [DATE] at 12:36 pm during interview with LPN #1, she stated that the code status of a resident is on the facesheet in the chart. When asked what she would do if she found a resident unresponsive, she stated I would call code (Code Blue), start CPR and verify the code status. We only have a few full codes (on Unit #1). Q. On [DATE] at 3:49 pm during interview with Psych Tech #3, when asked what she would do if she found a resident unresponsive, she stated that she would call out, pull the code blue call light and then go call 911 before she would return to the resident and initiate CPR. R. On [DATE] at 9:30 am during interview with Director of Nursing (DON) she stated Training requires that when a resident is found unresponsive staff should pull the emergency alert alarm (Code Blue call light), take note of the color of the name tag at the resident's door and if the tag is written on a blue tag then they should initiate lifesaving procedures. If the tag is white then they should not begin lifesaving procedures. She further stated Staff is trained to respond according to the color of the name tag. S. On [DATE] at 9: 04 during interview with the Tech Supervisor #1 when asked what she would do if she found a resident unresponsive who had a white name tag on the door, she stated I would pull the call light (code blue), yell and begin CPR. T. On [DATE] at 10:33 am during interview with Tech Supervisor #2 when asked what he would do if he found a resident unresponsive who had a white name tag on the door, he stated I would start compressions. Continue till you are told otherwise by the nurse. U. On [DATE] at 10:34 pm during interview with Psych Tech #4 when asked how would he know a resident's code status, he responded We know our residents. When asked what he would do if he found a resident unresponsive, he stated that he would start chest compressions until a nurse or more experienced Tech told him to stop.

Based on observation, record review and interview, the facility failed to ensure that 1 (R #1) of 4 (R #,[DATE]) residents reviewed, received monitoring including neurological (neuro) checks (assessing sensory and motor responses, especially reflexes to determine whether the nervous system is impaired) according to the facility protocol after a fall with head trauma and change in condition. These deficient practices likely resulted in R #1 experiencing unidentified neurological changes or distress, which could likely have contributed to his death. The findings are: A. Record review of R #1's face sheet dated [DATE] revealed that R #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 was a full code (wanting to receive lifesaving intervention in the event of a life threatening event). B. Record review of the Care Plan for R #1 dated [DATE] revealed (Name of R #1) has a tendency to yell and exhibit violent behaviors to himself .(Name of R #1) is unable to use a call bell. Call bell will be within reach for staff use however he is able to make some of his need known using signs and gestures. He is able to speak ,[DATE] words most of the time .(Name of R #1) is independent for transfers C. Record review of progress notes for R #1 revealed: 1. On [DATE] at 9:40 am Resident had a fall in the front lobby. Nursing assessment done and resident reports he fell , 2.5 x 5 centimeters laceration (cut) to right eye. Resident usually ambulates independently and resident then got up and walked out and fell a 2nd time hitting the door jam with his face. 2. On [DATE] at 7:14 pm Resident returned (from hospital) with staff via w/c (wheel chair) at 1835 (6:35 pm) Resident is paranoid and states he fell and they gave him a shot. Per (First name of staff in ER (emergency room )) at the ER, 4 point restraints (tied down both arms and legs) used, got [MEDICATION NAME] (name of anti-anxiety) and [MEDICATION NAME] (name of [MEDICAL CONDITION]). Resident is unsteady and uncooperative. Resident was taken to his room and nursing assessment done. Resident has bruising to right side of nose, laceration to bridge of nose and right eye with steri strips (adhesive tape). (Name of Doctor) notified and also (Unknown name) of nasal fracture. 3. On [DATE] at 2:17 am He is currently in his room asleep on his bed. Note written by Licensed Practical Nurse (LPN) #3. 4. On [DATE] at 7:11 am On [DATE] at 0455 (4:55 am) walked into resident's room and noticed that he was not moving. I got a closer look and did not see any respirations. was not able to get a pulse. I went to get stethoscope. Resident had no apical pulse (wrist pulse). I then notified (name of doctor) around 0510 (5:10 am), then went back and started CPR (cardiopulmonary resuscitation). DR (doctor) came in at 0525 (5:25 am), she ordered to stop CPR at 0530 (5:30 am). Note written by Licensed Practical Nurse (LPN) #3. D. Record review of the local Hospital's Discharge Instructions dated [DATE] revealed (Name of R #1 presented with bruises, abrasions and a nasal laceration with multiple falls .spent the day in the ED (Emergency Department), he had labs and eventually CT (Computer topography: high grade X-ray) after some sedating medication his head ct was unremarkable but he did have a sinus infection. E. Record review of the Manager Investigation Follow-up Form (MIFF) dated [DATE] reveals a death certificate dated [DATE] stating R #1 died at 0530 (5:30 am) on [DATE] due to Coronary Event-Suspected MI ([MEDICAL CONDITION] Infarction-[MEDICAL CONDITION]) and signed by (Name of Medical Doctor (MD)). F. Record review of Glasgow scale documents (neurological checks) dated [DATE] and [DATE] for R #1 revealed neurological checks including, Eye Opening Response, Verbal Response, Motor Response, Strength of Arms, Strength of Legs, the precise measurement of a pupil and Vital Signs (blood pressure, temperature, pulse and respirations) documented: 1. On [DATE] at 8:20 am; normal results, (prior to transfer to the emergence room at 9:17 am) 2. On [DATE] at 8:45 am; normal results, (prior to transfer to the emergency room at 9:17 am) 3. On [DATE] at 7:20 pm; normal results, (after return from hospital at 6:35 pm) 4. There were no other neurochecks documented. G. Record review of the facility Neuro checks policy undated and provided by Registered Nurse (RN) #2 revealed the following: 1. Neurological check may be ordered by either physician or nurse and conducted in the manner described in order to verify a consistent data base for evaluation of a patients/clients/residents condition. 2. Unless other wise ordered, check the following a. Every hour x 4 then b. Every 2 hours x 2 then c. Every 4 hours x 2 then d. Every 8 hours x 2 and document on flow sheet in all cases (PTS #9563 Ivory) (form identifier) H. On [DATE] at 11:54 am during an interview with RN #2, she stated It was an unusual day for him (R #1) he fell twice, cut his left eye the first time and the 2nd time cut and broke his nose. He is normally a little paranoid off and on, but he was more anxious that day. Paranoid, wanting to run after his fall. He fell back to back. We got him to his room and I went to call the doctor and he fell again, I can't remember time between. It took a while to stop bleeding (from eye). RN #2 stated that after a fall if the resident hits their head, they are suppose to conduct neuro checks every hour for several hours (review finding G). I. On [DATE] at 3:49 pm during interview with Psych (Psychology) Tech (Technician) #3, she confirmed that she worked with R #1 during the night shift (3:00 pm to 3:00 am) on [DATE] to [DATE]. She stated They told me in the day he had fallen and broke his nose, so he was a little more agitated, yelling through the night, normally he yelled once and a while and was anxious, but not constantly like that night. Psych Tech #3 stated that R #1 put himself to bed and she checked on him every couple hours, the last time was 2:45 am in which she reports seeing his chest rising. J. On [DATE] at 12:30 pm during an interview with LPN #3 (worked Night Shift on [DATE] to [DATE]) regarding R #1, LPN #3 stated We (nursing and Psych Techs) were to monitor him every 20 minutes. LPN #3 stated he wasn't sure if staff physically entered R #1's room or not throughout the night. When asked if looking back he would do anything differently, he responded I would have physically checked him. LPN #3 stated There were no orders written for neuro checks. I did not do any. K. On [DATE] at 4:43 pm during an interview with RN (Registered Nurse) #2, Whenever someone falls and has a head injury we do neuro checks. Yes, he (R #1) should have been monitored and had neuro checks done depending on the order or per our protocol. I do not believe he (R #1) came back (from hospital) with orders for neuro checks, so we used our protocol. I was here for both falls ([DATE]). Since he had a head injury, I did neuro checks before he left to the hospital after his falls and when he came back before I left (pointing to the Glasgow Scale form). They (neurochecks assessments) should have continued. After reviewing the progress notes dated [DATE] and [DATE] and Glasgow scale documents dated [DATE] and [DATE]; When asked if between these documents were neuro checks done according to the facility protocol, RN #2 stated No.

Based on record review and interview, the facility failed to implement their written policies and procedures that prohibit sexual abuse for 4 (R #1, 2, 8 and 9) of 4 (R #1, 2, 8 and 9) residents identified as being victims of abuse by: 1. Pairing R #1 and R #2 to be roommates with R #1 having a history of sexual perpetration and R #2 having a history of being easily sexually coerced. 2. Transferring R #5 back to Unit #2 for 9 days, while he was able to continue to sexually harass R #8 and was able to sexually abuse R #9. If residents are not protected from abuse by other residents, they can become victims of abuse and experience physical, emotional and psychological distress. The findings are: A. Record review of facility LTC Abuse Prevention Program dated 07/03/13 revealed "The policy of (facility) Long Term Care Division is to protect our resdients' right to be free from mistreatment, verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion by prohibiting such action and to establish processes for screening and training employees, protecting residents, and fo rth eprevention, identification, investigatiom and reporting of abuse, neglect, mistreatment, and misappropriateion of property." B. Record review of facility Manager Investigation Follow-Up Form dated 08/13/14 revealed that "there is evidence that intercourse did occur between R #1 and allegedly R #2." C. On 09/10/14 at 3:35 pm, during interview with Director of Nursing (DON) when asked if there was a policy and procedure on determining roommate assignments, she responded "No, nothing written. We just try to put residents together that seem to match." D. On 09/11/14 at 9:20 am, during interview of registered nurse (RN) #1 when asked why R #1 and R #2 were selected as roommates, she stated "(Name of R #1)'s roommate had passed away. I'm not really sure why they were put as roommates." E. On 09/11/14 at 3:00 pm, interview of DON when questioned as to how was a convicted perpetrator placed with a vulnerable population, she responded "I don't know." When asked how did these two residents - one with a history of predatory behavior get placed with a resident who had a history of [REDACTED]." Record Reviews and Interviews for R #1: F. Record review of progress notes dated 11/20/12 revealed that resident psychiatric consult was requested for inappropriate sexual behavior. G. Record review of Psychiatry Consult Request dated 05/21/13 revealed consultation needed due to reports of agitation, violence and concern of harm to others. Behaviors reported included physically aggressive with co-residents. H. Record review of Physician order [REDACTED]." I. Record review of physician progress notes [REDACTED]." J. Record review of Physicians Order Form dated 10/07/13 revealed order to "Renew level 1:1 level x 72 hours" due to [MEDICAL CONDITION]. K. Record review of Physicians Order Form dated 10/10/13 revealed order to "place on 1:1 level x 96 hrs" due to sexual aggressiveness. L. Record review of Physicians Order Form dated 10/14/13 revealed order to "Level 1:1 level x 96 hrs" due to sexual aggression. M. Record review of Annual Psychological Evaluation/Consult dated 10/11/13 revealed that R#1 was identified as a "[MEDICATION NAME] safety risk to other residents on his unit." R #1 "has been documented engaging in numerous behaviors while at facility, many of which include violent threats of sexual and physical harm as well as outright physical aggression." N. Record review of Physicians Order Form dated 10/17/13 revealed order to "Level 1:1 x 72 hours" due to sexual aggression. O. Record review of Physicians Order Form dated 10/23/13 revealed order for "Resident Level 1:1 from 2300 (11:00 pm) till 0700 (7:00 am) daily x 7 days) due to "hypersexual and rape ideation." P. Record review of Physicians Order Form dated 10/29/13 revealed an order for [REDACTED]. Q. Record review of medical progress notes dated 11/12/13 revealed report of "inappropriate sexual behavior." R. Record review of Quarterly Behavioral Health assessment dated [DATE] revealed "Resident's current behaviors are a danger to self or others. Sexual behavior - Yes" S. On 09/11/14 at 10:59 am during an interview with RN #1 she was asked if R #1 had any romantic relationships with any of the residents. She stated "Not to my knowledge. Not since I've been here." T. On 09/11/14 at 1:45 during an interview, RN #5 confirmed that R #2 had a history of [REDACTED]. RN #5 confirmed that this incident happened "a few years ago" and to his knowledge no similar incidents have occurred since. U. On 09/12/14 at 8:19 am during interview with Psych Tech #1 when asked if there were any sexually inappropriate behaviors with R #1, she responded "He was really sexually inappropriate. It was always with the male staff. He'd like when the littler guys (staff) would walk by his room, he'd say "I like those jeans." When asked if he directed it towards other residents, she stated "Sometimes a resident would pass by and he'd say "I'm gonna get you tonight." When asked if in any residents on the unit were vulnerable to be victims, she responded "I think (Name of R #2)." Record Review & Interviews for R #2: V. Record Review of Medication Order Renewal Form dated 08/19/14 revealed the resident was given a [DIAGNOSES REDACTED]." W. On 09/11/14 at 9:30 am during interview of RN #2 regarding history of R #2 being proposition by other residents to perform sexual acts on other residents she responded "It's been a while. We had another resident here that used to do that (name of R #10)." When asked the timeframe for that occurrence she replied "It's been a while, maybe over a year." Z. On 09/11/14 at 1:45 during an interview with RN #5 confirmed that R #2 had a history of [REDACTED]. RN #5 confirmed that this incident happened "a few years ago" and to his knowledge no similar incidents have occurred since. Y. On 09/11/14 at 2:20 pm, during interview of psychologist (PSY) #1 - When asked about her knowledge of R #2 she responded "Yes, he has dementia and some intellectual disabilities. And with those [DIAGNOSES REDACTED]. When he first came to us he was very sexual, like masturbating all around the unit. The next period of time where he was involved with sexual behaviors when other residents would bribe him with coffee and soda for sexual favors. And most recently we had a reported incident where he was alleged to be the perpetrator." Z. On 09/11/14 at 4:25 pm during interview with DON, she stated "(Name of R #2). He has never been a predator. He can be very manipulated and the residents know that." Record Reviews and Interviews for R #5 AA. Record review of Progress Notes for R #5 revealed: 1. 11/22/13 "At 1015 (am) I walked out into hallway and Clerk reported that (name of R #5) was touching female resident (identifier for R #8) crotch. I immediately removed female resident away from (name of R #5) and (name of R #5) was placed on level 1:1 and was moved to (name of Unit #1)(Secure, all male unit)." 2. 12/03/13 "(name of R #5) returned to (name of Unit #2) just before noon today. He is glad to be back on the unit and was instructed by myself to stay away from the ladies and to act appropriately with all females." 3. 12/04/13 "While doing setups had heard resident telling (identifier for R #8) 'Come here, come here'. He was redirected and he told me 'I'm not touching her yet.'" 4. 12/07/13 "Resident was touching other resident on her stomach area was redirected to a chair." 5. 12/08/13 "Today (name of R #5) tried touching another resident (female) right in front of me. We were in the south side living room. I told him to 'Stop, leave her alone' and he told me 'why' then walked away." 6. 12/10/13 "While doing rounds saw resident trying to block and trap (identifier for R #8) inbetween door and his walker. Resident verbally redirected. Then resident started to follow co-resident down hallway." 7. 12/11/13 "While I (PSYT #6) was dressing the resident at approximately 0500, resident (R #5) tried to grab my private area." 8. 12/12/13 "I saw (name of R #5) bent over w (with) his walker in front of (name of R #9) he had his hand between her legs." BB. On 09/10/14 at 1:30 pm during an interview with (RN) #1 when asked if R #5 exhibited any sexually inappropriate behavior, she responded "Yes, I can't remember dates but he was at (name of Unit #2) when I first started, he use to follow one of the ladies around and he tried to grab their crotches. We thought that if he was brought to the male unit he would do better. He has done well here. Not acted out to other resident on male unit." CC. On 09/11/14 at 9:21 am during interview with the Administrator when asked why R #5 was transferred from Unit #2 to Unit #1, she responded "He was found fondling a resident that was cognitively incompetent. I remember them saying he was inappropriate with the ladies." ADMIN stated that the family wanted him on Unit #2, so he was moved back to Unit #2 at one time and then returned to Unit #1. DD. On 09/11/14 at 1:26 pm during interview with PSYT #2 when asked if R #5 ever exhibited sexually inappropriate behaviors, he stated "When he first got here he would try to grab the females all the times. I think he had grabbed (name of R #8). They moved him." PSYT #2 stated that the family requested that he move back to Unit #2. EE. On 09/11/14 at 1:31 pm during interview with RN #4, she stated that R #5 was touching some of the females on Unit #2. She confirmed that resident touched R #9 and R #8. She stated that he first touched R #9 and then he was moved to Unit #1 and then because of concerns about residents age compared to the other residents on Unit #1, he was moved back to Unit #2 and he touched R #8. FF. On 09/11/14 at 4:13 pm during interview with the DON when asked why R #5 was transfered from Unit #2 to Unit #1 she responded, "The family wanted him in the new building. When he started showing aggression with women, we decided to start him on (name of Unit #1). The son was persistent that he be back on (name of Unit #2). He didn't have that behavior on (name of Unit #3). When he started again, he knew what he was doing but he didn't care." When asked how the decision to move him back to Unit #2 was made, she stated that she was not part of that decision, but they met with the son- "I think when they talked to him, told him that if the behaviors continued, he would be moved back (to Unit #1)." When asked what interventions were implemented when he returned to Unit #2, she responded "8 minute rounds. The staff is always around them. It was probably more for fall precautions." When asked about when resident returned to Unit #2 and he started demonstrating inappropriate behaviors why was he not transferred until he touched another resident, she responded "It seems like we should have been doing something. We were trying to see (if behaviors continued) and obviously it didn't work."

Based on record review and interview, the facility failed to ensure residents are free from sexual abuse for 4 (R #1, 2, 8 and 9) of 4 (R #1, 2, 8 and 9) residents identified as being victims of abuse by: 1. Pairing R #1 and R #2 to be roommates with R #1 having a history of sexual perpetration and R #2 having a history of being easily sexually coerced. 2. Transferring R #5 back to Unit #2 for 9 days, while he was able to continue to sexually harass R #8 and was able to sexually abuse R #9. If residents are not protected from abuse by other residents, they can become victims of abuse and experience physical, emotional and psychological distress. The findings are: A. Record review of facility Manager Investigation Follow-Up Form dated 08/13/14 revealed that "there is evidence that intercourse did occur between R #1 and allegedly R #2." B. On 09/10/14 at 3:35 pm, during interview with Director of Nursing (DON) when asked if there was a policy and procedure on determining roommate assignments, she responded "No, nothing written. We just try to put residents together that seem to match." C. On 09/11/14 at 9:20 am, during interview of registered nurse (RN) #1 when asked why R #1 and R #2 were selected as roommates, she stated "(Name of R #1)'s roommate had passed away. I'm not really sure why they were put as roommates." D. On 09/11/14 at 3:00 pm, interview of DON when questioned as to how was a convicted perpetrator placed with a vulnerable population, she responded "I don't know." When asked how did these two residents - one with a history of predatory behavior get placed with a resident who had a history of [REDACTED]." Record Reviews and Interviews for R #1: E. Record review of progress notes dated 11/20/12 revealed that resident psychiatric consult was requested for inappropriate sexual behavior. F. Record review of Psychiatry Consult Request dated 05/21/13 revealed consultation needed due to reports of agitation, violence and concern of harm to others. Behaviors reported included physically aggressive with co-residents. G. Record review of Physician order [REDACTED]." H. Record review of physician progress notes [REDACTED]." I. Record review of Physicians Order Form dated 10/07/13 revealed order to "Renew level 1:1 level x 72 hours" due to [MEDICAL CONDITION]. J. Record review of Physicians Order Form dated 10/10/13 revealed order to "place on 1:1 level x 96 hrs" due to sexual aggressiveness. K. Record review of Physicians Order Form dated 10/14/13 revealed order to "Level 1:1 level x 96 hrs" due to sexual aggression. L. Record review of Annual Psychological Evaluation/Consult dated 10/11/13 revealed that R#1 was identified as a "[MEDICATION NAME] safety risk to other residents on his unit." R #1 "has been documented engaging in numerous behaviors while at facility, many of which include violent threats of sexual and physical harm as well as outright physical aggression." M. Record review of Physicians Order Form dated 10/17/13 revealed order to "Level 1:1 x 72 hours" due to sexual aggression. N. Record review of Physicians Order Form dated 10/23/13 revealed order for "Resident Level 1:1 from 2300 (11:00 pm) till 0700 (7:00 am) daily x 7 days) due to "hypersexual and rape ideation." O. Record review of Physicians Order Form dated 10/29/13 revealed an order for [REDACTED]. P. Record review of medical progress notes dated 11/12/13 revealed report of "inappropriate sexual behavior." Q. Record review of Quarterly Behavioral Health assessment dated [DATE] revealed "Resident's current behaviors are a danger to self or others. Sexual behavior - Yes" R. On 09/11/14 at 10:59 am during an interview with RN #1 she was asked if R #1 had any romantic relationships with any of the residents. She stated "Not to my knowledge. Not since I've been here." S. On 09/11/14 at 1:45 during an interview, RN #5 confirmed that R #2 had a history of [REDACTED]. RN #5 confirmed that this incident happened "a few years ago" and to his knowledge no similar incidents have occurred since. T. On 09/12/14 at 8:19 am during interview with Psych Tech #1 when asked if there were any sexually inappropriate behaviors with R #1, she responded "He was really sexually inappropriate. It was always with the male staff. He'd like when the littler guys (staff) would walk by his room, he'd say "I like those jeans." When asked if he directed it towards other residents, she stated "Sometimes a resident would pass by and he'd say "I'm gonna get you tonight." When asked if in any residents on the unit were vulnerable to be victims, she responded "I think (Name of R #2)." Record Review & Interviews for R #2: U. Record Review of Medication Order Renewal Form dated 08/19/14 revealed the resident was given a [DIAGNOSES REDACTED]." V. On 09/11/14 at 9:30 am during interview of RN #2 regarding history of R #2 being proposition by other residents to perform sexual acts on other residents she responded "It's been a while. We had another resident here that used to do that (name of R #10)." When asked the timeframe for that occurrence she replied "It's been a while, maybe over a year." W. On 09/11/14 at 1:45 during an interview with RN #5 confirmed that R #2 had a history of [REDACTED]. RN #5 confirmed that this incident happened "a few years ago" and to his knowledge no similar incidents have occurred since. X. On 09/11/14 at 2:20 pm, during interview of psychologist (PSY) #1 - When asked about her knowledge of R #2 she responded "Yes, he has dementia and some intellectual disabilities. And with those [DIAGNOSES REDACTED]. When he first came to us he was very sexual, like masturbating all around the unit. The next period of time where he was involved with sexual behaviors when other residents would bribe him with coffee and soda for sexual favors. And most recently we had a reported incident where he was alleged to be the perpetrator." Y. On 09/11/14 at 4:25 pm during interview with DON, she stated "(Name of R #2). He has never been a predator. He can be very manipulated and the residents know that." Record Reviews and Interviews for R #5 Z. Record review of Progress Notes for R #5 revealed: 1. 11/22/13 "At 1015 (am) I walked out into hallway and Clerk reported that (name of R #5) was touching female resident (identifier for R #8) crotch. I immediately removed female resident away from (name of R #5) and (name of R #5) was placed on level 1:1 and was moved to (name of Unit #1)(Secure, all male unit)." 2. 12/03/13 "(name of R #5) returned to (name of Unit #2) just before noon today. He is glad to be back on the unit and was instructed by myself to stay away from the ladies and to act appropriately with all females." 3. 12/04/13 "While doing setups had heard resident telling (identifier for R #8) 'Come here, come here'. He was redirected and he told me 'I'm not touching her yet.'" 4. 12/07/13 "Resident was touching other resident on her stomach area was redirected to a chair." 5. 12/08/13 "Today (name of R #5) tried touching another resident (female) right in front of me. We were in the south side living room. I told him to 'Stop, leave her alone' and he told me 'why' then walked away." 6. 12/10/13 "While doing rounds saw resident trying to block and trap (identifier for R #8) inbetween door and his walker. Resident verbally redirected. Then resident started to follow co-resident down hallway." 7. 12/11/13 "While I (PSYT #6) was dressing the resident at approximately 0500, resident (R #5) tried to grab my private area." 8. 12/12/13 "I saw (name of R #5) bent over w (with) his walker in front of (name of R #9) he had his hand between her legs." AA. On 09/10/14 at 1:30 pm during an interview with (RN) #1 when asked if R #5 exhibited any sexually inappropriate behavior, she responded "Yes, I can't remember dates but he was at (name of Unit #2) when I first started, he use to follow one of the ladies around and he tried to grab their crotches. We thought that if he was brought to the male unit he would do better. He has done well here. Not acted out to other resident on male unit." BB. On 09/11/14 at 9:21 am during interview with the Administrator when asked why R #5 was transferred from Unit #2 to Unit #1, she responded "He was found fondling a resident that was cognitively incompetent. I remember them saying he was inappropriate with the ladies." ADMIN stated that the family wanted him on Unit #2, so he was moved back to Unit #2 at one time and then returned to Unit #1. CC. On 09/11/14 at 1:26 pm during interview with PSYT #2 when asked if R #5 ever exhibited sexually inappropriate behaviors, he stated "When he first got here he would try to grab the females all the times. I think he had grabbed (name of R #8). They moved him." PSYT #2 stated that the family requested that he move back to Unit #2. DD. On 09/11/14 at 1:31 pm during interview with RN #4, she stated that R #5 was touching some of the females on Unit #2. She confirmed that resident touched R #9 and R #8. She stated that he first touched R #9 and then he was moved to Unit #1 and then because of concerns about residents age compared to the other residents on Unit #1, he was moved back to Unit #2 and he touched R #8. EE. On 09/11/14 at 4:13 pm during interview with the DON when asked why R #5 was transfered from Unit #2 to Unit #1 she responded, "The family wanted him in the new building. When he started showing aggression with women, we decided to start him on (name of Unit #1). The son was persistent that he be back on (name of Unit #2). He didn't have that behavior on (name of Unit #3). When he started again, he knew what he was doing but he didn't care." When asked how the decision to move him back to Unit #2 was made, she stated that she was not part of that decision, but they met with the son- "I think when they talked to him, told him that if the behaviors continued, he would be moved back (to Unit #1)." When asked what interventions were implemented when he returned to Unit #2, she responded "8 minute rounds. The staff is always around them. It was probably more for fall precautions." When asked about when resident returned to Unit #2 and he started demonstrating inappropriate behaviors why was he not transferred until he touched another resident, she responded "It seems like we should have been doing something. We were trying to see (if behaviors continued) and obviously it didn't work."

This is a repeat deficiency from a complaint investigation survey completed 08/26/11. Based on record review and interview the facility failed to ensure a comprehensive care plan was revised after multiple falls for 1 (Resident #7) of 15 (Resident #1-15) residents. If the care plan is not revised with new interventions, the resident is likely to continue to fall, which could result in injury. The findings are: A. Review of the 60-day Medical Progress Note dated 11/22/11 for R #7 revealed a history of falls. B. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident required supervision to limited assist with transfers and ambulation. C. Review of R #7's nursing notes revealed the following: 1. Entry dated 10/01/11 (no time listed) noted the resident leaned forward and fell , hitting her head. 2. Entry dated 10/08/12 at 0325 (3:25 am) noted the resident was found sitting on the floor. 3. Entry dated 10/08/11 at 1335 (1:35 pm) noted the resident was observed sliding herself down off the chair. 4. Entry dated 01/05/12 at 0205 (2:05 am) noted the resident was found lying on the floor next to her bed. D. Review of the care plan dated 01/11/11 on page 8, updated on 10/05/11 revealed "Goal not met (under problem #2, Potential for falls) she had 3 w/injury (with injury) and 4 w/out (without) injury continue with goal." The last revision to the care plan was on 08/16/11. On page 8, a note dated 01/04/12 read "Goal met, (name of resident) has no documented falls over the qtr (quarter). All interventions will continue. The resident had 2 documented falls on 10/08/12 with no revision to the care plan. The resident also had a fall on 01/05/12 and it was not added to the care plan. E. On 02/09/12 at 9:35 am, during interview, the Assistant Director of Nursing (ADON) confirmed the care plan had not been updated. F. On 02/19/12 at 9:30 am, during interview, the Minimum Data Set (MDS) coordinator confirmed that there was no revision or update to the care plan to prevent the resident from having further falls. He stated, "Me or one of the managers should of made changes to the care plan. I don't know why we didn't."

This is a repeat deficiency from a complaint investigation survey completed 08/26/11. Based on record review and interview, the facility failed to report an incident of possible abuse within 24 hours and failed to maintain documentation that a thorough investigation of the incident with appropriate corrective action was completed for 2 (#1 & #8) of 15 (#1-#15) residents. The facility also failed to ensure that the results of the investigation were reported to the Department of Health (DOH) within 5 working days. This deficient practice presents a risk of potential harm to resident safety. If incidents of possible abuse are not reported, the SA is not aware of the incident, therefore, the SA is not able to follow up with the facility to ensure resident safety. If incidents of possible abuse are not thoroughly investigated, the facility is unable to determine what happened in or to prevent it from re-occurring. The findings are: A. Review of a complaint investigation for Resident #1 dated 11/07/11 revealed the date of the allegation was 10/03/11. The allegation stated that Resident #1 received a burn on his right arm. The 5 day follow-up investigation was not submitted to Department of Health (DOH) until 11/07/11, 35 days late. B. Review of the complaint investigation for Resident #8 dated 12/07/11 revealed the date of the allegation was 05/21/11. The allegation stated that Housekeeper #1 entered R #8's bathroom three times while the resident was not clothed and while she was washing herself. R #8 sent a letter on 05/22/11 to housekeeping management to notify them of her allegation. Housekeeping management did not notify standards and compliance of the allegation until 06/17/11, when the investigation was initiated. The 5 day follow-up investigation was not submitted to DOH until 11/01/11, 137 days late. C. On 02/03/12 at 10:00 am, during interview with the Director of Nursing (DON), she stated that the General Services Division Director (GSDD) stated there was an allegation made against Housekeeper #1 and the DON told the nurse manager to do an assessment on the resident and to document it. The DON stated she figured the GSDD had notified DOH. D. On 02/03/12 at 1:00 pm, during interview with the standards and compliance officer, she stated she was told that when the housekeeping management got the letter from R #8 they called the unit, told the nurse on duty and reassigned Housekeeper #1. The standards and compliance officer stated that Housekeeping Supervisor #1 came to her office on 06/07/12 and asked if she had received a letter from R #8, but had not. She then spoke to the GSDD for the Incident Report, but did not receive it until 06/21/11. She stated she thought housekeeping management was handling it and that they had taken corrective action, so the case was closed. No explanation was given why the investigation took so long to complete or why they didn't interview everyone involved with the case. E. On 02/07/12 at 10:45 am, during interview, the GSDD stated he was initially given the letter, but didn't open it until 3 days later. He stated that he notified Registered Nurse (RN) #1 (the nurse on duty that day) and they came up with a plan to move the housekeeper to the second floor. The GSDD stated neither the nurse or himself had discussed doing an incident report. F. On 02/07/12 at 11:00 am, during interview, Housekeeping Supervisor #2 stated he looked at the complaint on a Tuesday (05/24/11), which was 3 days later. He stated that Housekeeper #1 was moved upstairs and told not to go downstairs where the resident resided. Housekeeping Supervisor #2 stated that on 12/12/11, he was informed by Housekeeper #1 that he needed to put a mop away on the first floor where R #8 resided and that when he did he ran into R #8 and she became extremely upset. The nurse on duty called Housekeeping Supervisor #2 at his house to inform him of what had happened. G. On 02/07/12 at 12:00 pm, during interview, the standards and compliance investigator stated she had not interviewed all the potential witnesses involved, closed the case too soon and should have substantiated it. H. On 02/07/12 at 3:30 pm, during interview, Housekeeping Supervisor #1 stated he received the letter from Housekeeping Supervisor #2. They opened the letter with the GSDD present, but it was 4 days later. He stated Housekeeper #1 got "moved upstairs" (but not out of the building) on 06/17/11, almost a month later.

Based on record review and interview the facility failed to implement their policy and procedure related to reporting and thoroughly investigating an allegation of possible sexual abuse for 1 (Resident #8) of 15 (Resident #1-#15) residents. This deficient practice likely caused R #8 to experience emotional distress. The findings are: A. Review of the Policy and Procedures dated 04/29/10 page 2 read the following: "Policy: The policy of the (name of facility) Long Term Care (LTC) Division is to Protect our residents' right to be free from mistreatment., verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion by prohibiting such actions and to establish processes for screening and training employees, protecting residents, and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property." ." On page 3-4, the " Procedures: I. Residents of Long Term Care have the right to be free from mistreatment, verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. A. Employees are prohibited from engaging in any of these behaviors with LTC residents. II. Allegations of abuse, neglect, or exploitation will be reported in accordance with current state approved incident management policy and (name of facility) incident management policies. III. (Name of facility) LTC Division will actively work to prevent having residents subjected to mistreatment, verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. A. All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]. All employees or volunteers will receive education, training and periodic in-services about dealing with resident behaviors, reporting knowledge of allegations without fear of reprisal, recognizing signs of burnout, frustrations, and stress that may lead to abuse, and what constitutes abuse, neglect, and misappropriation of resident property. V. Prevention of abuse will be communicated to residents and family members during Resident and Family Council meetings. Attendees are encouraged to report concerns. issues, etc. without fear of retribution. Anyone who reports concerns, issues, etc. will be provided with feedback regarding the outcome. VI. (Name of facility) LTC Division will identify situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. A general analysis for higher risk may include: A. Areas in the facility where abuse is more likely to occur, B. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of individual care needs, C. Identification of inappropriate behaviors such as using derogatory language, rough handling, ignoring residents during care, D. Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to neglect by staff (such as residents with self injury behaviors; residents with communication disorders; residents requiring extensive or total nursing care). VII. (Name of facility) LTC Division will identify and investigate all suspicions or allegations of abuse (such as injuries of unknown origin, neglect, or misappropriation of resident property); reviewing the occurrence, patterns and trends that may constitute abuse. VIII. During and after investigations, residents will be protected from harm through frequent supervision by staff. IX. Allegations of abuse, neglect, exploitation, injuries of unknown origin and resulting investigation outcomes will be reported to the state as specified by regulations and laws. A. Investigations of alleged abuse, neglect, or exploitation will be completed by (name of facility) Internal Review Department. Investigations of injuries of unknown origin will be completed by LTC internal investigation. B. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. Visits may only be made in designated areas, supervised by staff after approval by the Administrator. C. Employees of (name of facility) accused of resident abuse shall be removed from direct contact with residents pending determination of the investigation. D. The resident or his/her healthcare decision maker will be informed of the findings of the investigation and corrective action taken (details of personnel actions will not be shared). E. Should the investigation reveal that abuse occurred, this outcome will be reported to the state and, if the abuse involved an employee, the Employee Abuse Registry and professional boards as required. B. Review of the nurses notes dated 05/21/12 at 13:18 (1:18 pm) revealed Licensed Practical Nurse (LPN) #1 was aware and documented that a male housekeeper (Housekeeper #1) entered Resident #8's room and that the resident had made allegations that he entered the bathroom while she was nude. There was no evidence that the nurse reported the allegation. C. Review of the letter dated 05/22/11, written by R #8, revealed that the resident made allegations against Housekeeper #1. In the letter, she had written that Housekeeper #1 had entered her closed bathroom door three times on 05/21/11 while she was with no clothes on and washing herself. D. Review of the nurses notes dated 06/17/11 at 16:08 (4:08 pm) revealed that Registered Nurse (RN) #1 attempted to do a physical assessment on R #8 for the allegation towards Housekeeper #1, but the resident refused and became very upset stating she had already reported it. E. Review of the facility investigation started on 06/21/11 revealed a letter dated 05/22/11 written by R #8 to the housekeeping management regarding her allegation. F. On 02/02/12 at 4:30 pm, during interview, RN #1 stated that the General Services Division Director (GSDD) approached her on 06/17/11 and stated he received a letter from the resident and she had made allegations against Housekeeper #1. G. An interview with R #8 was attempted on the following dates: 02/02/12 at 5:00 pm, 02/07/12 at 4:45 pm and 02/08/12 at 11:45 am, but R #8 refused to talk and slammed the door to her room closed. H. On 02/03/12 at 10:00 am, during interview, the Director of Nursing (DON) stated she thought that the head of housekeeping had reported the incident to the Department of Health (DOH). The DON stated she did not check to see if the investigation had been completed, although she was aware that the nursing staff had not been interviewed regarding this incident. The DON also stated she assumed the investigation was not substantiated since Housekeeper #1 was allowed to return to the floor. I. On 02/03/12 at 1:00 pm, during interview, the standards and compliance officer stated she asked for an Incident Report (IR) and was told by the GSDD that they had not done an IR. She stated the IR was not received at internal review until 06/21/11, approximately 30 days later. J. On 02/07/12 at 10:45 am, during interview, the GSDD stated he was the initial person who received the letter on 05/23/12 by a dietary staff member. He stated that the Houskeeping Supervisor #1, Housekeeping Supervisor #2 and himself opened the letter three days later. He stated at that time it was decided to move Housekeeper #1 upstairs. The GSDD stated they told RN #1 (the nurse on duty that day) and they came up with the idea to have rooms cleaned when a Psychiatric Technician (PT) was available. He stated he then initially took the letter to his supervisor and Human Resources (HR) but was told to turn it over to standards and compliance. From there he was directed to drop it in a box labeled "Incident Reports." The GSDD stated about 5-7 days later the standards and compliance officer was asking about the letter. K. On 02/07/12 at 2:07 pm, during interview, LPN #1 stated that Resident #8 was very upset about the incident, but LPN #1 stated she was right there (when Housekeeper #1 came out of the residents room) and therefore she did not complete an Incident Report or report it to anyone.

Based on record review and interview the facility failed to ensure that 1 (Resident #8) of 15 (Resident #1-#15) residents was free from possible sexual abuse due to Housekeeper #1 repeatedly entering her bathroom while she was with no clothes on and washing herself. This deficient practice likely caused R #8 to experience emotional distress. The findings are: A. Review of the nurses notes dated 05/21/12 at 13:18 (1:18 pm) revealed Licensed Practical Nurse (LPN) #1 was aware and documented that a male housekeeper (Housekeeper #1) entered Resident #8's room and that the resident had made allegations that he entered the bathroom while she was nude. There was no evidence that the nurse reported the allegation. B. Review of the letter dated 05/22/11, written by R #8, revealed that the resident made allegations against Housekeeper #1. In the letter, she had written that Housekeeper #1 had entered her closed bathroom door three times on 05/21/11 while she was with no clothes on and washing herself. C. Review of the nurses notes dated 06/17/11 at 16:08 (4:08 pm) revealed that Registered Nurse (RN) #1 attempted to do a physical assessment on R #8 for the allegation towards Housekeeper #1, but the resident refused and became very upset stating she had already reported it. D. Review of the facility investigation started on 06/21/11 revealed a letter dated 05/22/11 written by R #8 to the housekeeping management regarding her allegation. E. On 02/02/12 at 4:30 pm, during interview, RN #1 stated that the General Services Division Director (GSDD) approached her on 06/17/11 and stated he received a letter from the resident and she had made allegations against Housekeeper #1. F. An interview with R #8 was attempted on the following dates: 02/02/12 at 5:00 pm, 02/07/12 at 4:45 pm and 02/08/12 at 11:45 am, but R #8 refused to talk and slammed the door to her room closed. G. On 02/03/12 at 10:00 am, during interview, the Director of Nursing (DON) stated she thought that the head of housekeeping had reported the incident to the Department of Health (DOH). The DON stated she did not check to see if the investigation had been completed, although she was aware that the nursing staff had not been interviewed regarding this incident. The DON also stated she assumed the investigation was not substantiated since Housekeeper #1 was allowed to return to the floor. H. On 02/03/12 at 1:00 pm, during interview, the standards and compliance officer stated she asked for an Incident Report (IR) and was told by the GSDD that they had not done an IR. She stated the IR was not received at internal review until 06/21/11, approximately 30 days later. I. On 02/07/12 at 10:45 am, during interview, the GSDD stated he was the initial person who received the letter on 05/23/12 by a dietary staff member. He stated that the Houskeeping Supervisor #1, Housekeeping Supervisor #2 and himself opened the letter three days later. He stated at that time it was decided to move Housekeeper #1 upstairs. The GSDD stated they told RN #1 (the nurse on duty that day) and they came up with the idea to have rooms cleaned when a Psychiatric Technician (PT) was available. He stated he then initially took the letter to his supervisor and Human Resources (HR) but was told to turn it over to standards and compliance. From there he was directed to drop it in a box labeled "Incident Reports." The GSDD stated about 5-7 days later the standards and compliance officer was asking about the letter. J. On 02/07/12 at 2:07 pm, during interview, LPN #1 stated that Resident #8 was very upset about the incident, but LPN #1 stated she was right there (when Housekeeper #1 came out of the residents room) and therefore she did not complete an Incident Report or report it to anyone.

Based on record review and interview the facility failed to ensure a comprehensive care plan was developed and revised for 1 (Resident #3) of 17 (R #1-17) residents. Resident #3 required extensive assist of one person with transfers and bathing which was not revised in the comprehensive care plan to meet the needs of the resident. This deficient practice resulted in Resident #3 not receiving the appropriate assistance during transfers and bathing and on 05/11/11 R #3 was found in a tub of water, unattended, face down and without signs of life. The findings are: A. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a [DIAGNOSES REDACTED]. Section G, Functional Status revealed the resident required "extensive assistance" of "one person physical assist" for transfers and "extensive assist" of "one person physical assist" for bathing. Section G also revealed the residents balance for moving from a seated to standing position was "not steady and only able to stabilize with human assistance." B. Review of the nursing assessments dated 01/11/11 and 04/11/11 revealed the resident required extensive assist of one person for transfers and extensive assist of one person for bathing. C. On 08/24/11 review of the care plan dated 01/19/11 revealed the following on page 5 and 6: "Problem #1: self care deficit in all ADL's (Activites of Daily Living) related to cognitive and physical limitations secondary to an overall decline in his medical and functional status. Goal: R #3 will have all of his ADL's met daily with assistance from staff over the next 90 days with a target date of April 19, 2011. Target date: 07/20/11 (updated). Interventions: #5. R #3 will be assisted with bathing at his request and as needed 3 times a week. He will be bathed assisted in setting up his bath as he prefers to bathe alone; staff will monitor frequently while he is bathing. #6. R #3 uses a wheelchair for primary locomotion. Outcome: 04/20/11 All ADL's are met daily with assistance from staff. Goal met. Continue with set interventions." D. On 08/24/11 at 9:40 am, during interview, Registered Nurse (RN) #1 stated that R #3 would get up between 3-4 am everyday to take a bath. He was in a wheelchair and was not able to walk. "He lost upper body control, like a stroke... he needed extensive assist. With bathing he needed limited assist of one. R #3 could bear weight but was not steady." E. On 08/25/11 at 10:15 am, during interview, Certified Nurse Practitioner (CNP) #1 stated that R #3 was in a wheelchair, had gait problems, needed limited assist of one person because he was unsteady on his feet. F. On 08/25/11 at 12:15 pm, during interview, Doctor #1 stated "R #3 had no fine motor movement... So if he slipped down he couldn't get up. People are blind because he didn't have the coordination... He had been doing it (taking a bath) so long by himself that it didn't get questioned." G. On 08/26/11 at 10:25 am, during interview, Physical Therapist (PT) #1 stated "R #3 had difficulty walking by himself. He had a very unsteady gait. His right leg would give out. He did well if he had assist of 1-2, he was not safe to ambulate by himself. Personally he should have had someone with him. I saw him the week before it happened and he needed supervision. Pretty much he was just using a wheelchair." H. On 08/26/11 at 10:45 am, during interview, Occupational Therapist (OT) #1 stated that R #3 had a progressive neurological condition. Some days he was more fatigued and was unsteady on his feet at all times. I. On 08/26/11 at 11:00 am, during interview, the Minimum Data Set (MDS) Coordinator stated that "during transfers R #3 required extensive assist of one person. For bathing, R #3 required extensive assist of one person and with ambulation, extensive assist of two persons."

Based on observation, record review and interview, the facility failed to follow the care plan for 1 (R #3) of 17 (R #1 - 17) residents. R #3 required assistance with all ADLs (Activites of Daily Living) secondary to an overall decline in his medical and functional status. This failure lead to R #3 not receiving assistance with his bathing or transfers which resulted in R #3 being found in a tub of water, unattended, face down and without signs of life. The findings are: A. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a [DIAGNOSES REDACTED]. Section G, Functional Status revealed the resident required "extensive assistance" of "one person physical assist" for transfers and "extensive assist" of "one person physical assist" for bathing. Section G also revealed the residents balance for moving from a seated to standing position was "not steady and only able to stabilize with human assistance." B. Review of the nursing assessments dated [DATE] and [DATE] revealed the resident required extensive assist of one person for transfers and extensive assist of one person for bathing. C. On [DATE] review of the care plan dated [DATE] revealed the following on page 5 and 6: "Problem #1: self care deficit in all ADL's (Activites of Daily Living) related to cognitive and physical limitations secondary to an overall decline in his medical and functional status. Goal: R #3 will have all of his ADL's met daily with assistance from staff over the next 90 days with a target date of [DATE]. Target date: [DATE] (updated). Interventions: #5. R #3 will be assisted with bathing at his request and as needed 3 times a week. He will be bathed assisted in setting up his bath as he prefers to bathe alone; staff will monitor frequently while he is bathing. #6. R #3 uses a wheelchair for primary locomotion. Outcome: [DATE] All ADL's are met daily with assistance from staff. Goal met. Continue with set interventions. D. On [DATE] review of the care plan dated [DATE] revealed the following on page 9 and 10: Problem #3: "Potential for falls or injuries related to potential side effects of antipsychotic medication, history of inappropriate use of aerosols, refusal to ask staff for assistance and a history of fall with [MEDICAL CONDITION].Goal: R #3 will have no falls or injuries over the next 90 days with a target date of [DATE]. Target date: [DATE] (updated). Interventions: #1 Psych tech staff will monitor R #3's safety and whereabouts every 8 minutes 24 hours per day via unit rounds. Outcome: [DATE] Goal not met. R #3 had 4 falls, 2 with injury, this quarter. Interventions added." E. No new interventions were found on the care plan dated [DATE] with a target date of [DATE] and [DATE] (updated). F. On [DATE] at 6:35 pm, during interview, Psychiatric Technician (Psych Tech) #1 stated "No, he was not safe to be in bath tub alone, everyone here needs assistance. No one else used that tub except him." Review of the nursing notes dated [DATE] (no time) written by Psych Tech #1 read, "resident was not responding, called out Code Blue, I need "Help, Help." G. On [DATE] at 7:25 pm, during interview, Psych Tech #4 stated "Last time I read his care plan he was independent of all ADL's but I only read it once, 2 years ago." H. On [DATE] at 8:00 pm, during interview, Licensed Practical Nurse (LPN) #1 stated, "He would get up early and take a bath, his daily routine. I don't remember what the care plan said, I don't remember when I saw it last. He needed assistance to get out (of the bath tub)." Review of the nursing notes dated [DATE] at 7:20 am written by LPN #1 read, "I heard staff member (Name of Psych Tech #1) yell "somebody help me"... R #3 unresponsive, code blue initiated, started CPR." I. On [DATE] at 8:15 am, during interview, Psych Tech #6 stated "He took a bath every evening and every morning at 4 am. It was on his care plan that was his routine. Everyone knew. I didn't document, I could have but I didn't. The primary (Psych Tech) is in charge of doing that...We should all know to document, it's our responsibility. They stress it over and over...towards the end he was not happy because he was no longer independent." J. On [DATE] at 8:50 am, during interview, Psych Tech #3 stated "His bath was between 4:30 and 5 am. We did ,[DATE] minute rounds, he was on 8 minute rounds because of falls..he needed a lot of supervision and a lot more assistance. He went downhill fast. As far as his medical condition he had a [MEDICAL CONDITION] disorder and that worried me. In the wheelchair he started getting [MEDICAL CONDITION]. I can't remember much about the care plan. He needed assist with ADL's according to the care plan..." K. On [DATE] at 9:15 am, during interview, Psych Tech #7 stated "His routine was to get up at ,[DATE] am to bathe...he required set-up to limited assist...The care plan was to assist. A couple of months ago, when still alive, he never refused help. I never documented about him using the tub, it was the same thing every day." L. On [DATE] at 9:40 am, during interview, Registered Nurse (RN) #1 stated that R #3 would get up between ,[DATE] am everyday to take a bath. He was in a wheelchair and was not able to walk. "He lost upper body control, like a stroke... he needed extensive assist. With bathing he needed limited assist of one. R #3 could bear weight but was not steady." M. On [DATE] at 10:15 am, during interview, Certified Nurse Practitioner (CNP) #1 stated that R #3 was in a wheelchair, had gait problems, needed limited assist of one person because he was unsteady on his feet. N. On [DATE] at 12:15 pm, during interview, Doctor #1 stated "R #3 had no fine motor movement... So if he slipped down he couldn't get up. People are blind because he didn't have the coordination... He had been doing it so long by himself (taking a bath) that it didn't get questioned." O. On [DATE] at 10:25 am, during interview, Physical Therapist (PT) #1 stated "R #3 had difficulty walking by himself. He had a very unsteady gait. His right leg would give out. He did well if he had assist of ,[DATE], he was not safe to ambulate by himself. Personally he should have had someone with him. I saw him the week before it happened and he needed supervision. Pretty much he was just using a wheelchair." P. On [DATE] at 10:45 am, during interview, Occupational Therapist (OT) #1 stated "R #3 had a progressive neurological condition. Some days he was more fatigued and was unsteady on his feet at all times." Q. On [DATE] at 11:00 am, during interview, the Minimum Data Set (MDS) Coordinator stated that "during transfers R #3 required extensive assist of one person. For bathing R #3 required extensive assist of one person and with ambulation extensive assist of two persons." The MDS coordinator also confirmed that no new interventions had been added for the 4 falls the resident had sustained.

Based on observation, record review and interview the facility failed to ensure that 1 (R #3) of 17 (R #1 - 17) residents received the proper supervision to prevent accidents. R #3 required extensive assist of one person for bathing and transfers secondary to a decline in his condition, his unsteadiness and a history of falls. Resident #3 was found in a tub of water, unattended, face down and without signs of life. The findings are: A. On [DATE] at 10:30 am observation of the tub room located on Meadows II revealed a small room in which the tub fit and an additional 2 feet of space in front of the tub. In the room was a plastic chair. There was no additional space for anything else except to park a wheelchair half way in with the door propped open. The facility demonstrated a metal screen curtain used to cover the door. The call bell was located on the opposite side of the tub and was not reachable from the tub. B. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a [DIAGNOSES REDACTED]. Section G, Functional Status revealed the resident required "extensive assistance" of "one person physical assist" for transfers and "extensive assist" of "one person physical assist" for bathing. Section G also revealed the residents balance for moving from a seated to standing position was "not steady and only able to stabilize with human assistance." C. Review of the nursing assessments dated [DATE] and [DATE] revealed the resident required extensive assist of one person for transfers and extensive assist of one person for bathing. D. On [DATE] review of the care plan dated [DATE] revealed the following on page 5 and 6: "Problem #1: self care deficit in all ADL's (Activites of Daily Living) related to cognitive and physical limitations secondary to an overall decline in his medical and functional status. Goal: R #3 will have all of his ADL's met daily with assistance from staff over the next 90 days with a target date of [DATE]. Target date: [DATE] (updated). Interventions: #5. R #3 will be assisted with bathing at his request and as needed 3 times a week. He will be bathed assisted in setting up his bath as he prefers to bathe alone; staff will monitor frequently while he is bathing. #6. R #3 uses a wheelchair for primary locomotion. Outcome: [DATE] All ADL's are met daily with assistance from staff. Goal met. Continue with set interventions. E. On [DATE] review of the care plan dated [DATE] revealed the following on page 9 and 10: Problem #3: "Potential for falls or injuries related to potential side effects of antipsychotic medication, history of inappropriate use of aerosols, refusal to ask staff for assistance and a history of fall with fracture of the hip.Goal: R #3 will have no falls or injuries over the next 90 days with a target date of [DATE]. Target date: [DATE] (updated). Interventions: #1 Psych tech staff will monitor R #3's safety and whereabouts every 8 minutes 24 hours per day via unit rounds. Outcome: [DATE] Goal not met. R #3 had 4 falls, 2 with injury, this quarter. Interventions added." F. No new interventions were found on the care plan dated [DATE] with a target date of [DATE] and [DATE] (updated). G. On [DATE] review of a Psychosocial assessment dated [DATE] revealed under the Assessment and Summary of Psychosocial Needs: "Most recently (Name of R #3) has had several falls and since then he has apparently lost the ability to ambulate, reports extreme weakness of his dominant side..." H. On [DATE] review of a Neurology consult dated [DATE] revealed "Chief Complaint: weakness and numbness in the hands." The report read that R #3 was "chronically impaired neurologically...he has had severe slurred speech and difficulty walking...The patient offers no other neurological complaint aside from the numbness and weakness in the hands and that he can't pick anything up. Apparently, this was associated with a fall...predated the [DATE] CT (Cat Scan)...He fell on his face and head as well as his right shoulder. Since then, his gait has deteriorated severely as has his ability to use his hands." Past Medical History: "Chronic neurological [DIAGNOSES REDACTED]. His body is somewhat contorted with thoracic kyphosis (hunchback). There is severe scanning dysarthia (jerky, explosive, slurred and loud speech)(long standing)...Intrinsic hand muscle atrophy and severe weakness. He cannot fully abduct the fingers for instance. He cannot resist force with the intrinsic hand muscles. Severe vibration sense deficit in the fingers as well as position sense difficulty in the upper extremities." I. Review of the Monthly Flow Sheet for [DATE]-3 shift revealed the ADL's (Activities of Daily Living) section under bathing had been marked as "A= Minimal assistance" 7 times during the month, "S = Self" one time and "0 with a line through it" 9 times during the month, the rest of the dates were left blank. The ,[DATE] shift was marked with a "0" one time and ,[DATE] shift was entirely blank. Review of the Monthly Flow Sheet for [DATE]-3 shift revealed "A = minimal assist" marked only once on the 10th, the rest of the days were left blank. The ,[DATE] and ,[DATE] shifts were blank. J. Review of the computerized nursing progress notes revealed the following: [DATE] at 13:23 (1:23 pm) " Resident #3 continues to be very unsteady on his feet...He is ambulated to and from meals with assistance with FWW (Front Wheeled Walker) and Wheel chair behind him." [DATE] at 1440 (2:40 pm) "Resident continues to have difficulty using his right side. Continues to state that right side feels heavy and at times tingley." On [DATE] at 13:59 (1:59 pm) "His gait is unsteady." On [DATE] at 2150 (9:50 pm) "...fell from his chair." On [DATE] at 10:32 am "R #3 stated his right leg was weak and could not stand..." On [DATE] at 21:57 (9:57 pm) "At about 2130 (9:30 pm), staff heard a loud sound in the bathroom of resident...resident sitting between the commode and the wheelchair which prevented him from falling." On [DATE] 22:30 (10:30 pm) "R #3 fell on the floor pad on the bed next to him." On [DATE] at 15:56 (3:56 pm) "Resident reports that he is having difficulty walking..." [DATE] at 1630 (4:30 pm) R #3 was sitting on the floor by his bed. On [DATE] at 14:32 (2:32 pm) "Resident is ambulating to meals. He is using the atlas walker with two staff assistance. His feet hit the other leg on the back when he walks. He also leans forward and almost bumps his head on the front of the atlas walker." On [DATE] at 16:28 (4:28 pm) a note written by Occupational Therapy (OT) stated "Addressed resident's bathing system with nursing staff who had concerns regarding safety." On [DATE] at 16:05 (4:05 pm) a note from OT stated "Worked on the possibility of getting a tub transfer bench and hand held shower." On [DATE] at 9:41 am, "VERY HIGH RISK FOR FALLING. Needs a lot of assistance." On [DATE] at 16:58 (4:58 pm) written by OT "Several options addressed for resident's bathing situation. Offer the tub transfer bench to resident when it arrives." On [DATE] at 10:01 am "R #3 has become very spastic with his arms and upper body." On [DATE] at 11:14 am "Hands feel numb." On [DATE] at 2:43 am "Resident was found by staff on floor..." On [DATE] at 12:51 pm "R #3 was very tired and he said he felt weak." K. On [DATE] at 6:35 pm, during interview, Psychiatric Technician (Psych Tech) #1 stated "No, he was not safe to be in bath tub alone, everyone here needs assistance. No one else used that tub except him." Review of the nursing notes dated [DATE] (no time) written by Psych Tech #1 read, "resident was not responding, called out Code Blue, I need "Help, Help." L. On [DATE] at 7:25 pm, during interview, Psych Tech #4 stated "Last time I read his care plan he was independent of all ADL's but I only read it once, 2 years ago." M. On [DATE] at 8:00 pm, during interview, Licensed Practical Nurse (LPN) #1 stated " He would get up early and take a bath, his daily routine. I don't remember what the care plan said, don't remember when I saw it last. He needed assistance to get out (of the bath tub)." Review of the nursing notes dated [DATE] at 7:20 am written by LPN #1 read, "I heard staff member (Name of Psych Tech #1) yell "somebody help me"... R #3 unresponsive, code blue initiated, started CPR." N. On [DATE] at 8:15 am, during interview, Psych Tech #6 stated "He took a bath every evening and every morning at 4 am. It was on his care plan that was his routine. Everyone knew. I didn't document, I could have but I didn't. The primary (Psych Tech) is in charge of doing that...We should all know to document, it's our responsibility. They stress it over and over...towards the end he was not happy because he was no longer independent." O. On [DATE] at 8:50 am, during interview, Psych Tech #3 stated "His bath was between 4:30 and 5 am. We did ,[DATE] minute rounds, he was on 8 minute rounds because of falls..he needed a lot of supervision and a lot more assistance. He went downhill fast. As far as medical he had a seizure disorder and that worried me. In the wheelchair started getting seizures. I can't remember much about the care plan. He needed assist with ADL's according to the care plan..." P. On [DATE] at 9:15 am, during interview, Psych Tech #7 stated "His routine was to get up at ,[DATE] to bathe...he required set-up to limited assist...The care plan was to assist. A couple of months ago, when still alive, he never refused help. I never documented about him using the tub, it was the same thing every day." Q. On [DATE] at 9:40 am, during interview, Registered Nurse (RN) #1 stated that R #3 would get up between ,[DATE] am everyday to take a bath. He was in a wheelchair and was not able to walk. "He lost upper body control, like a stroke... he needed extensive assist. With bathing he needed limited assist of one. R #3 could bear weight but was not steady." R. On [DATE] at 12:45 pm, during interview, Doctor #2 confirmed that ,[DATE] minutes of Basic Life Support and Advanced Cardiac Life Support was given without success. R #3 was pronounced deceased at 5:40 am after confirmation that there was no electrical heart activity, no pulse, no breath and no pupil movement. S. On [DATE] at 10:15 am, during interview, Certified Nurse Practitioner #1 stated that R #3 was in a wheelchair, had gait problems, needed limited assist of one person because he was unsteady on his feet. T. On [DATE] at 12:15 pm, during interview, Doctor #1 stated "R #3 had no fine motor movement... So if he slipped down he couldn't get up. People are blind because he didn't have the coordination... He had been doing it so long by himself (taking a bath) that it didn't get questioned." U. On [DATE] at 1:20 pm, the Director of Nursing (DON) escorted this surveyor to the tub area. The call bell was noted to be on the opposite side of the bathtub and could not be accessible to the resident while in the bath tub. This was confirmed by the DON. V. On [DATE] at 10:25 am, during interview, Physical Therapist (PT) #1 stated "R #3 had difficulty walking by himself. He had a very unsteady gait. His right leg would give out. He did well if he had assist of ,[DATE], he was not safe to ambulate by himself. Personally he should have had someone with him. I saw him the week before it happened and he needed supervision. Pretty much he was just using a wheelchair." W. On [DATE] at 10:45 am, during interview, Occupational Therapy (OT) #1 stated "R #3 had a progressive neurological condition. Some days he was more fatigued and was unsteady on his feet at all times." X. On [DATE] at 11:00 am, during interview, the Minimum Data Set (MDS) Coordinator stated that "during transfers R #3 required extensive assist of one person. For bathing R #3 required extensive assist of one person and with ambulation extensive assist of two persons."

The facility failed to ensure that residents received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 05/02/11 at 5:40 pm. The Administrator was notified of the findings for the IJ on 05/03/11 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal on 05/03/11 at 12:05 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope E. The Plan of Removal included that prior to feeding or providing liquids to any resident, all Registered Nurses (RN)s, Licensed Practical Nurses (LPN)s, Certified Nursing Assistant (CNA)s, Activity Therapy Staff, Social Workers, Dietary Staff, Housekeeping Staff, Administrative Staff, and Volunteers will receive training regarding food consistency, therapeutic diets, thickening liquids, and where to find information regarding each residents' dietary needs. Training will be provided by Director of Nurses, Assistant Director of Nurses, RN managers, Activity Therapy Director and Registered Dietitian. Shift nurses will be present in each unit's dining room for the next three meals to observe the process of serving meals as well as to verify that MD orders for therapeutic diets is followed. Based on observation, interview and record review the facility failed to provide the correct consistency of thickened liquids necessary to maintain the highest practicable physical well-being for six (#4, 11, 20, 73,134 and 142 ) of 10 (#4, 11, 20, 62, 73, 80, 84, 119,134 and 142 ) residents who were at risk for aspiration. This deficient practice was likely to create a choking hazard for residents. The findings are: A. On 05/03/11 at 8:00 am, during observation, Resident #20 was served juice that was not thickened properly. B. On 05/03/11 at 8:02 am, during interview, CNA #1 stated, "that the amount in (Name of Resident #20's) cup is about 12 ounces (oz) and she put 3 teaspoons in it." C. On 05/03/11 at 8:10 am, during interview, LPN #1 verified that the liquid did not have the correct thickened consistency. She stated that for 6 oz of liquid CNAs should have used 2-3 teaspoons for the correct consistency. D. Record review of Resident #20's medical record revealed the following information: 1. Care plan dated 09/07/10 noted that nectar thick fluids were required. 2. The swallowing assessment dated [DATE] indicated a treatment plan to "retain the nectar thick fluids." 3. A physician's orders [REDACTED]. E. On 05/03/11 at 7:12 am, during observation, Resident #73 was served water at regular consistency with no thickener added. F. On 05/03/11 at 7:20 am, during interview, CNA #1 verified that the water given to the resident had not been thickened. G. On 05/03/11 at 7:34 am, during interview, RN #2 verified that the water was not thickened. She stated "He (Resident # 73) is a high aspiration risk." H. Record review of Resident #73's medical record revealed the following information: 1. Care plan dated 10/19/10 noted that fluids were to be thickened to nectar consistency. 2. A swallowing assessment dated [DATE] indicated the treatment plan called for fluids thickened to nectar/honey. 3. A physicians order dated 03/08/11 noted that thickened fluids to nectar consistency were ordered. I. On 05/02/11 at 5:40 pm, during observation, Resident #134 was served a 240cc carton of milk poured into a cup which was not thickened to the correct consistency. Resident #134's diet card indicated that nectar/honey thickened liquids were to be provided. J. On 05/02/11 at 5:43 pm, during an interview, RN #3 confirmed that Resident #134's milk was not thickened properly and his food was watery in consistency. She pointed out his diet order on his Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN #3 confirmed that dietary staff are responsible for adding thickener to liquids and food. K. On 05/02/11 at 5:45 pm, during an interview, CNA #4 said he followed the instructions on the back of the "Thick-It" can. When asked how much thickener did add to the 240cc of milk, he was unable to provide an answer. CNA #4 then stated, "The CNAs don't add the thickener, dietary does." The can of thickener was observed sitting on the table next to Resident #134's tray. L. On 05/02/11 at 5:48 pm, during an interview, Food Server #1 said, "He should have gotten a resource pre-thickened." She came to the feeding table where Resident #134 was located and confirmed his milk was not thickened correctly. Food Server #1 also confirmed that the dietary department does not add thickener to any of the residents liquids. Food Server #1 reported that the CNAs and nurses add the thickener at the tables. M. On 05/02/11 at 6:00 pm, during an observation, Resident #134 began coughing hard while CNA continued to feed him. Nurse Manager #2 approached the table and told CNA #4, "Stop feeding him, he is coughing." Resident #134 was coughing forcefully and his face turned red in color. N. On 05/02/11 at 6:02 pm, during an interview with Nurse Manager #2, she confirmed that Resident #134's liquids were not thickened to nectar/honey consistency. Nurse Manager #2 confirmed that Resident #134 could have either honey or nectar thickened liquids and that the consistencies were interchangeable. O. Record Review of Resident #134's medical record revealed the following information: 1. A Swallow assessment dated [DATE] identified Resident #134 was at moderate risk for aspiration. The report identified a change in the resident's condition beginning "In October, 2009, (Name of Resident) was hospitalized for [REDACTED]." 2. Physician diet orders dated 04/18/11 ordered "...ADA (American Diabetes Association) health shake at breakfast thickened and fluids to nectar/honey consistency." 3. Dietary card for Resident #134 recorded the diet as "...ADA health shake, thickened liquids nectar/honey consistency." 4. Resident #134's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"ADA health shake, nectar thick liquids." P. On 05/03/11 at 07:45 am, during a dining observation, Resident #11 was observed drinking from a large plastic, adaptive glass which contained 300 Milileters (ml) of purple liquid without direct supervision. Resident #11 was observed coughing right after drinking the liquid. The liquid was not the honey consistency ordered by the physician. Q. On 05/03/11 at 07:48 am, during an interview, Nurse Manager #2 stated that she did not know if the resident's liquid had been thickened. She picked up a container of thickener and added three teaspoons to the the resident's liquid. R. On 05/03/11 at 07:55 am, during an interview Dietitian #1 identified the purple liquid as ensure with purple protein powder added. Dietitian #1 stated, "Dietary (staff ) does not put thickener into liquids which are served to residents and the CNA or the servers are responsible for adding thickener to liquids served to the residents as ordered by their MD." S. On 05/03/11 at 08:00 am, during an interview with CNA #5, he stated that he served the tray to resident Resident #11. CNA #5 stated that he did not add thickener to the resident's liquid. CNA #5 stated that dietary had pre-thickened the liquid that he served to Resident #11. He also reported that it was the dietary department's responsibility to pre-thicken all liquids that were served to residents. T. Record review of the physician's orders [REDACTED]." U. Record review of the swallowing evaluation for Resident #11 dated 09/20/07 revealed, "Difficulty swallowing, aspirates on food and fluids... Recommendations: Puree textures - honey thick liquids." V. On 05/03/11 at 7:12 am, during an observation in the dining room, Resident #4 had a Styrofoam cup of in thickened liquid in front of her. W. On 05/03/11 at 7:13 am, during an interview, CNA #6, who was assisting Resident #4, was asked what type of fluid was in the resident's cup. CNA #6 stated that the liquid was "regular" meaning the liquid was unthickened. X. On 05/03/11 at 7:14 am, during observation in the dining room, a new cup filled with regular fluid was placed in front of Resident #4. Food Server #2 responded, "Regular." Y. On 5/3/11 at 7:16 am, during an interview, RN #2 was asked to identify the type of fluid placed in front of Resident #4. RN #2 responded, "It is regular." Z. On 05/03/11 at 7:39 am, during an interview, CNA #6, who was assisting Resident #4 was asked what type of fluid was in the cup. CNA #6 responded, "It is regular fluid." AA. Record review of the 05/02/11 fluid orders list, provided by Food Server #3, revealed that Resident #4 was expected to have an intake of "nectar thick fluid." BB. Record review of Resident #4's dietary card revealed that Resident #4 had a dietary card order for "nectar thick fluids." CC. On 05/03/11 at 7:30 am, during observation, Resident #142 was served water and coffee that was not thickened properly. DD. On 05/03/11 at 7:45 am, during an interview, Nurse Manager #1 was asked if Resident #142's fluids were to be thickened. Nurse Manager #1 responded, "Yes, but he refuses to let staff thicken any fluids." EE. Record review of Resident #142's medical records revealed 04/04/11 physician diet orders for a mechanical soft diet with honey thick fluids. Review of the Medicaid Abstract Progress Note dated 04/05/11 indicated that the nutrition and hydration status diet was to include a mechanical soft diet with honey thickened liquids.

The facility failed to ensure that residents received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 05/02/11 at 5:40 pm. The Administrator was notified of the findings for the IJ on 05/03/11 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal on 05/03/11 at 12:05 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope E. The Plan of Removal included that prior to feeding or providing liquids to any resident, all Registered Nurses (RN)s, Licensed Practical Nurses (LPN)s, Certified Nursing Assistant (CNA)s, Activity Therapy Staff, Social Workers, Dietary Staff, Housekeeping Staff, Administrative Staff, and Volunteers will receive training regarding food consistency, therapeutic diets, thickening liquids, and where to find information regarding each residents' dietary needs. Training will be provided by Director of Nurses, Assistant Director of Nurses, RN managers, Activity Therapy Director and Registered Dietitian. Shift nurses will be present in each unit's dining room for the next three meals to observe the process of serving meals as well as to verify that MD orders for therapeutic diets is followed. Based on observation, interview and record review the facility failed to provide supervision to ensure that the correct consistency of thickened liquids was given for six (#4, 11, 20, 73, 134 and 142 ) of 10 (#4, 11, 20, 62, 73, 80, 84, 119, 134 and 142 ) residents who were at risk for aspiration. This deficient practice is likely to cause a resident to choke. The findings are: A. On 05/03/11 at 8:00 am, during observation, Resident #20 was served juice that was not thickened properly. B. On 05/03/11 at 8:02 am, during interview, CNA #1 stated, "that the amount in (Name of Resident #20's) cup is about 12 ounces (oz) and she put 3 teaspoons in it." C. On 05/03/11 at 8:10 am, during interview, LPN #1 verified that the liquid did not have the correct thickened consistency. She stated that for 6 oz of liquid CNAs should have used 2-3 teaspoons for the correct consistency. D. Record review of Resident #20's medical record revealed the following information: 1. Care plan dated 09/07/10 noted that nectar thick fluids were required. 2. The swallowing assessment dated [DATE] indicated a treatment plan to "retain the nectar thick fluids." 3. A physician's orders [REDACTED]. E. On 05/03/11 at 7:12 am, during observation, Resident #73 was served water at regular consistency with no thickener added. F. On 05/03/11 at 7:20 am, during interview, CNA #1 verified that the water given to the resident had not been thickened. G. On 05/03/11 at 7:34 am, during interview, RN #2 verified that the water was not thickened. She stated "He (Resident # 73) is a high aspiration risk." H. Record review of Resident #73's medical record revealed the following information: 1. Care plan dated 10/19/10 noted that fluids were to be thickened to nectar consistency. 2. A swallowing assessment dated [DATE] indicated the treatment plan called for fluids thickened to nectar/honey. 3. A physicians order dated 03/08/11 noted that thickened fluids to nectar consistency were ordered. I. On 05/02/11 at 5:40 pm, during observation, Resident #134 was served a 240cc carton of milk poured into a cup which was not thickened to the correct consistency. Resident #134's diet card indicated that nectar/honey thickened liquids were to be provided. J. On 05/02/11 at 5:43 pm, during an interview, RN #3 confirmed that Resident #134's milk was not thickened properly and his food was watery in consistency. She pointed out his diet order on his medication administration record as pureed diet and honey thickened liquids. RN #3 confirmed that dietary staff are responsible for adding thickener to liquids and food. K. On 05/02/11 at 5:45 pm, during an interview, CNA #4 stated he had followed the instructions on the back of the "Thick-It" can. When asked how much thickener did add to the 240cc of milk, he was unable to provide an answer. CNA #4 then stated, "The CNAs don't add the thickener, dietary does." The can of thickener was observed sitting on the table next to Resident #134's tray. L. On 05/02/11 at 5:48 pm, during an interview, Food Server #1 said, "He should have gotten a resource pre-thickened." She came to the feeding table where Resident #134 was located and confirmed his milk was not thickened correctly. Food Server #1 also confirmed that the dietary department does not add thickener to any of the residents liquids. Food Server #1 reported that the CNAs and nurses add the thickener at the tables. M. On 05/02/11 at 6:00 pm, during an observation, Resident #134 began coughing hard while CNA continued to feed him. Nurse Manager #2 approached the table and told CNA #4, "Stop feeding him, he is coughing." Resident #134 was coughing forcefully and his face was reddened. N. On 05/02/11 at 6:02 pm, during an interview with Nurse Manager #2, she confirmed that Resident #134's liquids were not thickened to nectar/honey consistency. Nurse Manager #2 confirmed that Resident #134 could have either honey or nectar thickened liquids and that the consistencies were interchangeable. O. Record Review of Resident #134's medical record revealed the following information: 1. A Swallow assessment dated [DATE] identified Resident #134 was at moderate risk for aspiration. The report identified a change in the resident's condition beginning "In October, 2009, (Name of Resident) was hospitalized for [REDACTED]." 2. Physician diet orders dated 04/18/11 ordered "...ADA (American Diabetes Association) health shake at breakfast thickened and fluids to nectar/honey consistency." 3. Dietary card for Resident #134 recorded the diet as "...ADA health shake, thickened liquids nectar/honey consistency." 4. Resident #134's Medication Administration Record for April 2011 had diet recorded as "ADA health shake, nectar thick liquids." P. On 05/03/11 at 07:45 am, during a dining observation, Resident #11 was observed drinking from a large plastic, adaptive glass which contained 300 Milileters (ml) of purple liquid without direct supervision. Resident #11 was observed coughing right after drinking the liquid. The liquid was not the honey consistency ordered by the physician. Q. On 05/03/11 at 07:48 am, during an interview, Nurse Manager #2 stated that she did not know if the resident's liquid had been thickened. She picked up a container of thickener and added three teaspoons to the the resident's liquid. R. On 05/03/11 at 07:55 am, during an interview Dietitian #1 identified the purple liquid as ensure with purple protein powder added. Dietitian #1 stated, "Dietary (staff ) does not put thickener into liquids which are served to residents and the CNA or the servers are responsible for adding thickener to liquids served to the residents as ordered by their MD." S. On 05/03/11 at 08:00 am, during an interview with CNA #5, he stated that he served the tray to resident Resident #11. CNA #5 stated that he did not add thickener to the resident's liquid. CNA #5 stated that dietary had pre-thickened the liquid that he served to Resident #11. He also reported that it was the dietary department's responsibility to pre-thicken all liquids that were served to residents. T. Record review of the physician's orders [REDACTED]." U. Record review of the swallowing evaluation for Resident #11 dated 09/20/07 revealed, "Difficulty swallowing, aspirates on food and fluids... Recommendations: Puree textures - honey thick liquids." V. On 05/03/11 at 7:12 am, during an observation in the dining room, Resident #4 had a Styrofoam cup of in thickened liquid in front of her. W. On 05/03/11 at 7:13 am, during an interview, CNA #6, who was assisting Resident #4, was asked what type of fluid was in the resident's cup. CNA #6 stated that the liquid was "regular" meaning the liquid was unthickened. X. On 05/03/11 at 7:14 am, during observation in the dining room, a new cup filled with regular fluid was placed in front of Resident #4. Food Server #2 responded, "Regular." Y. On 5/3/11 at 7:16 am, during an interview, RN #2 was asked to identify the type of fluid placed in front of Resident #4. RN #2 responded, "It is regular." Z. On 05/03/11 at 7:39 am, during an interview, CNA #6, who was assisting Resident #4 was asked what type of fluid was in the cup. CNA #6 responded, "It is regular fluid." AA. Record review of the 05/02/11 fluid orders list, provided by Food Server #3, revealed that Resident #4 was expected to have an intake of "nectar thick fluid." BB. Record review of Resident #4's dietary card revealed that Resident #4 had a dietary card order for "nectar thick fluids." CC. On 05/03/11 at 7:30 am, during observation, Resident #142 was served water and coffee that was not thickened properly. DD. On 05/03/11 at 7:45 am, during an interview, Nurse Manager #1 was asked if Resident #142's fluids were to be thickened. Nurse Manager #1 responded, "Yes, but he refuses to let staff thicken any fluids." EE. Record review of Resident #142's medical records revealed 04/04/11 physician diet orders for a mechanical soft diet with honey thick fluids. Review of the Medicaid Abstract Progress Note dated 04/05/11 indicated that the nutrition and hydration status diet was to include a mechanical soft diet with honey thickened liquids.