Every finding on record at Ahva Care of Winfield

Based on interview and record review, the facility failed to offer and provide snacks to residents at bedtime.This applies to 5 of 5 residents (R25, R65, R82, R94, R100) reviewed for bedtime snacks in a sample of 30.The findings include:R25's face sheet documents admission date of 12/28/25. Diagnoses include bipolar disorder, schizoaffective disorder, anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, Schizophrenia, hypertension, and peripheral vascular disease. MDS (Minimum Data Sheet) dated 4/20/26 documents he has intact cognitive functions. R65's face sheet documents admission date of 9/25/23. Diagnoses include major depressive disorder, schizoaffective disorder, psychosis, hypertension and chronic kidney disease, stage II. MDS dated [DATE] documents she has intact cognitive functions. R82's face sheet documents admission date of 11/14/24. Diagnoses include chronic kidney disease, hypothyroidism, anxiety disorder, polyneuropathy, osteoarthritis, bipolar disorder, hypertension, and depression. MDS dated [DATE] documents she has intact cognitive functions. R94's face sheet documents admission date of 11/5/20. Diagnoses include bipolar disorder, psychosis, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, arrythmia, hypothyroidism, hyperlipidemia, mood disorder, and delusional disorder. MDS dated [DATE] documents that she has intact cognitive functions. R100's face sheet documents admission date of 8/25/16. Diagnoses include polyneuropathy, major depressive disorder, Charcot's joint, atherosclerosis, multiple sclerosis, osteoporosis, anxiety disorder, peripheral vascular disease, and neuromuscular dysfunction of bladder. MDS dated [DATE] documents he has intact cognitive functions. On 5/13/26 at 10:00 AM, during the special Resident Council Meeting held during survey, R25, R65, R82, R94 and R100 said bedtime snacks are only given to some residents. They said snacks are given with their dinner trays. They said bedtime snacks are not provided to all residents. They said bedtime snacks are only provided to residents with physician's order. They said the facility used to call all residents down to the dining room for bedtime snacks but stopped doing it approximately two years ago. They said if they want snacks, they must purchase it from the activity table. They said snacks are not complimentary. They said if they do not get a snack, they are hungry between dinner and breakfast time.Separate interviews with V5 (RN-Registered Nurse) and V6 (RN) on 5/14/26 between 11:50 AM to 12:00 PM said bedtime snacks are placed on resident's meal tray during dinner. They said staff do not offer snacks.On 5/14/26 at 12:05 PM V7 (Dietary Services Manager) said bedtime snacks are placed on dinner tray for people with orders and for people who have diagnosis of diabetes mellitus. She said for the rest of the residents, it is given upon request. She said if a resident requests for bedtime snacks, she consults with the dietician whether she can give them bedtime snacks or not. She said bedtime snacks are important to stabilize blood sugar and to provide added nutrition.On 5/14/26 at 12:15 PM V2 (DON- Director of Nursing) said bedtime snacks go out with dinner trays. She said staff do not routinely offer bedtime snacks. She said staff should offer bedtime snacks to support better rest. Review of R25, R65, R82, R94 and R100's POS (Physician Order Sheet) shows they have no order for snacks at bedtime.Facility Policy and Procedure titled Nourishments (Night -Time Snacks) dated 2021 documents the following: Policy: Nourishments will be provided to the clients at approximately bedtime. Procedure: Food and nutrition services will deliver the bedtime nourishment (snack) as planned on the cycle menu to the nursing units after the evening meal. Nursing will distribute the bedtime nourishments.

Based on interview and record review, the facility failed to provide residents and/or their POA (Power of Attorney) with a bed hold notice and written documentation for the reason of transfer to the hospital.This applies to 5 of 5 residents (R1, R2, R10, R129, R138) reviewed for transfers in a sample of 30.The findings include: 1.R1's progress note dated 1/23/26 at 4:56 PM shows: NOD (Nurse on Duty) noted a change in mental status of resident during her neuro checks. (R1) appeared confused and verbalized feeling nervous. Although (R1) remained alert and orientated x 4, (R1) appeared not at her baseline behavior. Vitals shown an elevated blood pressure from baseline of BP (Blood Pressure) 158/89 and respiratory rate increased to 28 breaths per minute from baseline. Oxygen saturation rate of 98%, Temperature—98.4 F (Fahrenheit), Heart Rate—104.medical doctor notified and orders to send to ER (Emergency Room) for evaluation. Orders carried out 911 was called for ambulance. ADON (Assistant Director of Nursing), DON (Director of Nursing), and POA (Power of Attorney) notified. (R1) was picked up by ambulance around 4:30 PM and sent to ER. R1's progress note dated 1/24/26 at 3:20 AM shows: (R1) admitted at hospital. Diagnosis: sepsis. POA and DON notified. R1's progress note dated 1/26/26 at 2:09 PM shows: (R1) returned from hospital to facility by ambulance. (R1) is alert and orientated x 4. No complaints of pain. R1's progress note dated 2/1/26 at 1:48 PM shows: Observed reddened spots to both thighs, abdomen, back, bilateral upper extremities, no swelling to lips or tongue and no shortness of breath. updated medical doctor with new order to hold Cephalexin x 1 day and Alogliptin x 7 days, stat CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile).Benadryl 25 MG (Milligrams) PO (By Mouth) every 8 hours PRN (As Needed), Prednisone 40 MG daily. R1's progress note dated 2/1/26 at 10:58 PM shows stat CBC and CMP results received and relayed to medical doctor with new order received to send (R1) to ER for medication evaluation.called ambulance. (R1) made aware. POA also called and updated regarding (R1)'s current status and impending transfer to hospital. Verbalized understanding and DON notified. R1's progress note dated 2/2/26 at 2:30 AM shows: Ambulance here and came to pick up (R1) to ER. (R1) alert and orientated x 3. Left at 1:45 AM. R1's progress note dated 2/2/26 at 4:19 AM shows: Writer called ER to get an update on (R1) and per ER operator, (R1) is admitted for pneumonia and dehydration. Medical doctor notified. R1's progress note dated 2/3/26 at 5:50 PM shows: (R1) arrived in facility in an ambulance and was accompanied by a paramedic who was pushing her in a wheelchair. Review of R1's electronic medical record shows there was nothing mentioned in the progress notes that the nurse or other staff member gave R1 a bed hold notice. It does not mention that the written documentation for the reason for transfer was given to R1 or their POA. Nothing was uploaded under documents/forms tab in the medical record. R1's MDS dated [DATE] shows she is cognitively intact. On 5/13/26 at 12:31 PM, R1 stated she was never given a bed hold notice or anything in writing for the reason of transfer. 2.R10's progress note dated 2/12/26 at 9:30 AM shows: (R10) was complaining of chest pain radiating to her left side towards her back. (R10) also stated she feels short of breath. 911 was called and (R10) left to ED (Emergency Department) via ambulance. Medical doctor, POA and DON notified. R10's progress note dated 2/13/26 at 8:31 AM shows: Per nurse on duty, R10 is admitted for PE (Pulmonary Embolism). R10's progress note dated 2/16/26 at 3:00 PM shows: Around 2:35 PM, readmitted a [AGE] year old Caucasian female via ambulance per stretcher from hospital. R10 has a discharge diagnosis of pulmonary embolism and pericardial effusion. Review of R10's electronic medical record shows there was nothing mentioned in the progress notes that the nurse or other staff member gave R10 a bed hold notice. It does not mention that the written documentation for the reason for transfer was given to R10 or their POA. Nothing was uploaded under documents/forms tab in the medical record. R10's MDS dated [DATE] shows she is cognitively intact. On 5/13/26 at 12:53 PM, R10 stated she was never given a bed hold notice or anything in writing for the reason of transfer. On 5/12/2026 at 11:04 AM, V2 (DON—Director of Nursing) stated, she didn't have any bed hold notices for R1 and R10. V2 stated they were not done. She stated we don't notify the residents or their families in writing about the transfer to the hospital. We usually just call their POA (Power of Attorney). I saw in the progress notes that the nurses didn't chart that it was given. Facility's policy titled Transfer and Discharge (including AMA/Against Medical Advice) dated 10/2/25 shows: 11. Emergency Transfers to Acute Care—G. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. Facility's policy titled Bed Hold Notice dated 10/1/25 shows The facility will provide written information to the resident and/or the resident representative regarding bed-hold practices, both well in advance and at the time of a transfer for hospitalization or therapy of therapeutic leave. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. 3. On 05/13/26 at 10:33 AM, R129 said she went to the hospital on [DATE], and the facility did not provide her with a bed hold notification. R129 said she made her own medical decisions, and the facility did not explain to her the bed would be available upon return. R129's face sheet showed she was admitted to the facility with diagnoses including type 2 diabetes mellitus, major depressive disorder, hypertension, attention-deficit hyperactivity disorder, rheumatoid arthritis, osteoarthritis, chronic pain syndrome, fibromyalgia, restlessness and agitation. R129's MDS (Minimum Data Set) dated 02/16/26 showed R129 was cognitively intact. R129's census showed she was admitted to the hospital on [DATE]. The facility was unable to provide a copy of the written bed hold notification provided to the resident upon her transfer to the hospital. 4. On 05/12/26, R138's medical record showed she was admitted to the hospital on [DATE]. As of 05/14/26, the facility was unable to provide a copy of the written bed hold notification provided to the resident upon her transfer to the hospital. R138's face sheet showed she was admitted to the facility with diagnoses including major depressive disorder, osteoporosis, osteoarthritis, lack of coordination, need for assistance with personal care, abnormalities of gait and mobility, low back pain, paranoid schizophrenia, and unsteadiness on feet. R138's census sheet shows she was transferred to the hospital on [DATE]. 5. R2' s face sheet documents admission date of 11/20/25. Diagnoses include non-alcoholic steatohepatitis, hypertension, type II diabetes mellitus, cirrhosis of liver, polyosteoarthritis, metabolic encephalopathy, bipolar disorder, depression, anxiety disorder, and schizoaffective disorder. MDS dated [DATE] documents she has intact cognitive functions. R2's Progress Notes dated 5/10/26 at 17:50 written by V3 (RN-Registered Nurse) documented R2 was sent out to a local hospital with paramedics. Further review of R2's EMR (Electronic Medical Record) documents R2 was also sent out to a local hospital on [DATE], 1/17/26, 2/26/26, 3/17/26 and 4/30/26. There was no documentation on R2's EMR showing a bed hold notice was done for all R2's hospitalizations. R2's EMR also did not show that written documentation for the reason for transfer was given to R1 or her POA for each of her hospitalizations. On 5/13/26 at 2:32 PM V3 said she was the nurse who discharged R2 to hospital on 5/10/26. She said R2 was admitted for diagnosis of cystitis. She said R2 is still in the hospital. V3 said she did not do a bed hold notice on the day she was sent to the hospital. She said she has never provided any written documentation to a resident or family member about reason for transfer.

Based on observation, interview, and record review, the facility failed to provide a comfortable water temperature in the shower. This applies to 1 resident (R82) reviewed for homelike environment in a sample of 30 residents.The findings include:On 5/13/26 at 10:07 AM, R82 said the shower in the hallway that she likes to use does not have hot water. R82 said she has mentioned it in past resident council meetings, but it has yet to be fixed. On 5/14/26 at 12:06 PM, R82 said the shower temperature has been cold for over a year. R82 said she prefers to take showers in that shower room because it is more private, but it is uncomfortable and she can't sit under the water long to enjoy it, so she tries to get in and out quickly. On 5/14/26 at 10:49 AM, V10 (Maintenance Director) said R82 told him the water was not getting hot enough in the shower, but he checked the temperature and it was okay. V10 said hot water temperatures should range between 100-110 degrees F (Fahrenheit). On 5/14/26 at 10:52 AM, V10 checked shower temperature and let the water run for 6 minutes to see how hot it would get when turned all the way towards hot. The highest water temperature registered on thermometer was 93 degrees Fahrenheit. On 5/14/26 at 11:01 AM, V10 provided the Logbook Documentation from his previous temperature measurements and noted there was no space to record the shower temperature in R82's particular shower. The Logbook Documentation only has one space to record a temperature for that room, but the room has a shower and a sink to be tested.R82's MDS (Minimum Data Set) dated 4/29/26 shows her cognition is intact. R82's Care Plan initiated 11/14/24 shows she needs supervision with showers for safety and interventions include staff to assist with adjusting water temperature to a comfortable temperature as needed.The facility's policy titled, Safe Water Temperatures dated 10/1/25 states, Policy: The Facility will maintain appropriate water temperatures in all resident care areas.Procedure:.4. Water temperatures available to residents at shower, bathing, and hand washing facilities will be maintained at safe temperatures.6. Water temperatures will be set to.100-110 degrees F.The facility's policy titled, Homelike Environment last revised March 2020 states, Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment.Policy Interpretation and Implementation: 1. The staff shall provide person-centered care that emphasizes the residents' comfort.personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. These characteristics include:.g. comfortable room and water temperatures.

Based on interview and record review the facility failed to offer and assist resident to participate in activities of her interest and preference.This applies to 1 of 1 residents R109 reviewed for activities in a sample of 30.Findings include:05/14/2026 at 1:53 PM, R109 stated it makes her angry not being able to participate in activities. R109 stated she likes music, trivia and would like to exercise but staff is too busy to assist her. R109 stated she can't participate in activities like bingo the staff offers to her because she is blind. R109 stated she doesn't always know what activities are available because no one reads the activity schedule to her. R109 stated there was a previous activity that staff left her in the activity area after the activity was over. R109 stated a housekeeper heard her scream and assisted her back to her room.05/13/2026 at 3:21 PM. V14 RN (Registered Nurse) stated R109 is mostly in her room sleeping.On 05/14/2026 at 11:08 AM, V9 Activities Director stated R109 likes music related activities and going outside. V9 stated activities staff see R109 every other day for bedside activities.05/14/2026 on 1:13 PM, V9 Activities Director stated the activities that have been provided to R 109 are room visits that consists of staff assist her to choose her meal selections and her POA (Power of Attorney) visits. V9 stated there was an activity R109 that was left behind in the activity area after the activity was over. V9 stated during group activities there isn't one staff member responsible for assisting R109 with the activity.R109's March 2026 activity calendar consisted of five room visits and one group activity. R109's April 2026 activity calendar consisted of six room visits and six group activities for the month. May 1st - 14th 2026, R109's three room visits.R109's care plan includes stated R109's vision has been assessed to be severely impaired. R109 tends to isolate in her room, and she needs staff assistance and encouragement to attend and participate in facility activities. R109 needs staff assistance to review the activity schedule, getting to / from facility activities and assistance with set up and program participation.Interventions include as R109 for advice on the best program adaptations, seating, visual orienting cues. Guide R109s hand, describe program and offer tactile, olfactory, and auditory experiential opportunities with programs. Orient R109 to surroundings by introducing self, describing location and surroundings / introducing to peers seated close by resident.The Facility policy Activities dated 10/01/25 states it is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their assessment, care plan and preferences. Facility sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental and psychosocial wellbeing. Activities will encourage both independence and interaction within the community. Special considerations will be made for developing meaningful activities for residents with dementia and / or special needs.

Based on observation interview and record review the facility failed to provide built up eating utensils to support a residents independent eating.This applies to 1 or 1 residents R3 reviewed for meal assistive devices in a sample of 30.Findings include:On 05/12/2026 at 12:09 PM, during the meal observation R3 struggled to feed herself by dropping her food on her chest. R3 stated she was having a hard time handling her spoon to feed herself. R3's meal ticket list built up utensils for all meals.On 05/13/2026 at 12:18 PM, V8 CNA. (Certified Nursing Assistant) stated the meal trays are for the residents are set up by the CNAs. The CNA that prepares the meal tray and the CNA that delivers the tray to the resident are responsible to assure the tray s correct. If the resident does not have the utensils they need, they will struggle to eat their meal.On 05/13/2026 at 4:15 PM, V2 DON (Director of Nursing) stated residents are assessed by speech or occupational therapy for built up utensils. Residents are not able to eat independently if they don't have utensils when they are eating. The CNA building the tray should comply with what is on the meal card. The CNA delivering the resident's tray should double check to make sure the tray is correct. R3's physician diet order dated 1/14/26 includes no added salt low concentrated sugar diet pureed texture, regular thin consistency built up utensils divided plate.The facility policy Adaptive Feeding Equipment dated 10/01/25 states residents who require assistance with eating will be assessed to determine their ability to safely and independently participate in dining activities to the highest practicable level. Adaptive equipment and utensils will be placed on the resident's meal tray at each meal as indicated.

Based on observation, interview, and record review, the facility failed to properly store medications for residents who were not assessed to keep medications at bedside.This applies to 3 of 3 residents (R31, R43, R97) reviewed for medication storage in a sample of 30.The findings include: 1. On 05/12/26 at 9:55 AM, R31 had an Anoro Ellipta 62.5 mcg/25 mcg (Micrograms) on his bedside table. On 05/13/26 10:46 AM, R31 was sitting at the bedside and said he had emphysema, which he used an inhaler to treat. R31 opened his top drawer and pulled out the Anoro Ellipta inhaler. R31 said he got the inhaler from the nurse and would administer it by himself. R31's face sheet showed he was admitted to the facility with diagnoses including dementia, schizoaffective disorder, bipolar disorder, depression, epilepsy, cocaine abuse, delusional disorders, and chronic bronchitis. R31's MDS (Minimum Data Set) dated 04/14/26 showed R31 had mild cognitive impairment. R31's POS (Physician Order Sheet) did not show an order for R31 to store medications at the bedside. R31's Care Plan did not show any care plans regarding medication storage. The facility was not able to provide an assessment for R31 to store medications at his bedside. On 05/13/26 at 11:45 AM, V3 (RN/Registered Nurse) said she was the nurse for R31. V3 said none of her residents were allowed to keep their medications in their room. V3 said they were supposed to stay and watch the residents administer their medications. V3 said they do not store medications in the residents' rooms because the residents could be confused, or may not know how to administer it, or other residents could come into their rooms and take their medication. V3 said if a resident was alert, they would need to get an order from the doctor to keep the medicine in the room. V3 said the medication should also be in a locked drawer. On 05/13/26 at 11:51 AM, V4 (RN) said the residents were not allowed to keep medications at the bedside. V4 said if a resident wanted to keep it at their bedside, they would need to get an order from the doctor and make sure it was in a locked drawer. V4 said the doctor would need to determine if the patient was capable of administering the medication safely. V4 said the nurses should still watch the residents administer the medications even if they had been assessed to self-administer, as it needed to be signed off on the eMAR (Electronic Medication Administration Record). On 05/13/26 at 11:55 AM, V2 (DON/Director of Nursing) said they did not have any residents who were allowed to keep medications at the bedside. V2 said there was an assessment form they used to determine if the resident was safe to keep the medication at bedside, and then an order needed to be provided by the doctor. V2 said the medication should also be locked up to keep out of other residents' reach. V2 said the residents also needed to notify their nurse so the nurse could document it in the eMAR. The facility's Medication Storage policy dated 10/01/25 showed It is the policy of this facility to ensure that all medications housed on our premises are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations, in sufficient quantities to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 2. On 05/12/2026 at 10:35 AM, a fluticasone propitiate / salmeterol 100/ 50 discus in front of her on her over bed table. R43 stated the nurses always leave it there for her to use. R43's current physician orders lists fluticasone/ salmeterol aerosol powder breath activated 100/50 MCG / dose. In inhalation inhale orally every twelve hours 3. On 05/12/2026 at 11:14 AM, Nystatin 60grams prescribed for R119 dispensed 2/24/26 was on R97's nightstand. R97's current physician orders includes nystatin powder 100000 units / gram apply to skin folds topically as needed for redness related to moisture apply twice daily. R119's nystatin order start date of 2/24/26 apply to inner buttocks every night shift until healed order stop date of 3/10/26

Based on interview and record review, the facility failed to protect residents' right to be free from physical abuse by another resident. This applies to 2 of 3 residents (R1, R2) reviewed for resident-to-resident abuse in the sample of 3. The findings include: 1. On June 30, 2025, at 1:10 PM, R1 was lying in bed in her room. R1 refused to discuss the altercation between R1 and R2 that occurred on June 7, 2025. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, polyneuropathy, delusional disorders, hallucinations, schizoaffective disorder, bipolar disorder, asthma, heart failure, major depressive disorder, cognitive communication deficit, paranoid personality disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 23, 2025, shows R1 is cognitively intact, requires partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always continent of stool. On June 7, 2025, at 11:45 AM, V3 (Registered Nurse/RN) documented, Around 11:15 AM received report from PRSC (Psychiatric Rehabilitation Services Coordinator) that this resident (R1) made physical contact to [R2's] right upper arm after exchanging words with each other and [R2] made physical contact on this resident's abdomen. Per report, staff intervened and separated these two residents. Incident reported to abuse coordinator right away by PRSC on duty. Body check done, no redness or any markings on the abdomen denies any pain or discomfort.Resident already calmed down when writer went to speak to her. On June 7, 2025, at 2:19 PM, V4 (Social Services/SS) documented, [R1] exchanged words with another resident, and made contact with her arm. Other resident made contact back. The two were separated, and responsible parties alerted. Report was sent. R1's behavior monitoring dated June 7, 2025, at 1:59 PM shows R1 was observed hitting others, physically aggressive towards others, and expressed frustration/anger at others. The facility's Preliminary Incident Investigation Report dated June 7, 2025, shows: On 06/07/25, [R1] came into physical contact with [R2's] right upper arm after they exchanged words with each other. Both report that [R1] made contact with [R2] first and then [R2] made contact with [R1's] stomach. Staff immediately intervened and separated the two.An investigation has been started and a final report will be sent to (state surveying agency) upon completion. The facility's Final Incident Investigation Report dated June 12, 2025, shows: Final: [R1] was provided 1:1 education regarding anger management. [R1] reports that she does not remember the incident. [V9] (POA-Power of Attorney for R1) reported that [R1] has had more periods of forgetfulness and has a history of poor anger management due to her verbally abusive father. Staff will encourage [R1] to engage in more structured programs. [R2] is assigned to Anger Management and expressed understanding on not hitting another resident. [R2] felt that she should defend herself. Staff will continue to monitor. 2. On June 30, 2025, at 11:39 AM, R2 was lying in bed in room. R2 said she had an altercation with R1 on June 7, 2025, near the facility's elevator on the first floor. R2 continued to say the two residents started hitting each other. R2 said, [R1] hit me first and I hit her back. She kicked me too. The EMR shows R2 was admitted to the facility on [DATE], with multiple diagnoses including, bipolar disorder, suicidal ideations, absence epileptic syndrome, chronic atrial fibrillation, lack of coordination, weakness, cognitive communication deficit, Type 2 diabetes, heart disease, depression, psychosis, and schizoaffective disorder. R2's MDS dated [DATE], shows R2 is cognitively intact and requires partial/moderate assistance with all ADLs. R2 is occasionally incontinent of urine, and always continent of stool. On June 7, 2025, at 11:45 AM, V3 (RN) documented, Around 11:15 AM received report from PRSC that this resident made physical contact to [R1's] abdomen after exchanging words with each other and [R1] made physical contact on this resident's right upper arm. Per report staff intervened and separated these two residents. Incident reported to abuse coordinator right away by PRSC on duty. Body check done, no redness or any markings on the right upper arm denies any pain or discomfort.Resident already calmed down when writer went to speak to her. On June 7, 2025, at 2:24 PM, V4 (SS) documented, [R2] exchanged words with another resident and contact was made to her arm. This resident made contact back to the other resident, and they were separated. Appropriate guardian and staff were made aware of incident and report was sent. R2's behavior monitoring dated June 7, 2025, at 1:59 PM shows R2 was observed hitting others, physically aggressive towards others, and expressed frustration/anger at others. On June 30, 2025, at 11:41 AM, V5 (Certified Nursing Assistant) said, I was there when [R1] and [R2] got in a fight. They were both in their wheelchairs near the elevator. I had to separate them. On June 30, 2025, at 2:04 PM, V4 (SS) said, If I remember, [R2] came up to tell me that she defended herself, that [R1] hit her and then said she hit the other resident. [R1] said she hit [R2]. She said she was very upset. [R2] was upset about the toilet, and that [R1] never flushes the toilet. That is why [R1] hit her. On June 30, 2025, at 2:26 PM, V1 (Administrator) said, They said they came in contact with each other. [R1] hit [R2], and [R2] hit back. It was over the toilet not being flushed. It was a heated argument that became physical. The facts were very clear. Staff were present. On June 30, 2025, at 2:31 PM, V3 (RN) said, I was not present. I did not see the altercation. It happened on the first floor, and I was on the second floor. [R1] and [R2] said they hit each other. Both residents have a temper. The facility's policy entitled, Policy and Guidelines on the Prevention of Abuse and Neglect, dated 02/03/23 shows: Policy: The facility must provide a safe resident environment and protect residents from abuse. The residents of the facility have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Procedure/Guidance: .6. Physical Abuse: a. Physical abuse includes but is not limited to, hitting, slapping, punching, biting, and kicking.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a clean and comfortable room. This applies to 4 out of 4 residents (R7, R117, R127, R130) reviewed for environment from a total sample of 30. Findings include: 1. On 2/18/25 at 11:35AM R127 was in bed covered with two comforters. R127's MDS (Minimum Data Set) assessment of 12/13/2024 defines R127 as cognitively intact. R127 stated her room was always cold. R127's face-sheet shows R127 was an 80 y/o female admitted to the facility on [DATE] with diagnoses to include Schizoaffective Disorder, Hypertension, Chronic Obstructive Pulmonary Disease and Protein-Calorie Malnutrition. 2. On 2/18/25 at 11:38AAM R117 was observed in bed covered with a comforter. R117 stated her room was very cold, and it was always cold. R117 stated that she is comfortable under her blanket. R117's face-sheet showed R117 is admitted to the facility on [DATE] with diagnoses to include Schizoaffective Disorder, Depression, Unspecified Psychosis and Hypertension. R117's MDS dated [DATE] showed she was cognitively intact. 3. On 2/18/24 at 11:42 AM, observed R7 in a wheelchair, going out of her room. R7 was wearing a sweater, a hat, and a scarf around her neck. R7 stated she is wearing her winter attire because her room was very cold. R7's face-sheet showed, R7 was a 66 y/o female admitted to facility on 10/07/1997 with diagnoses to include Schizoaffective Disorder, Paranoid Schizophrenia, Hypertension, Diabetes Mellitus and Thrombocytopenia. R7's MDS dated [DATE] showed she was cognitively intact. On 2/18/25 at 12:15 PM V19 (Maintenance Director) stated, resident's room temperature must be 69-81F (degrees Fahrenheit). V19 (Maintenance Director) stated, they usually keep it above 71F as most residents are comfortable at 71F or above. V19 (Maintenance Director) checked the room temperature, and it was 63F. He re-calibrated his thermometer and the thermometer still showed 63F. On 2/20/25 at 2:00 PM, V1 (Administrator) stated, the thermostat in R7's room was broken. Policy on 'Homelike Environment' revised in March 2020 showed, ' 2. Characteristics of a personalized, homelike setting g. comfortable room and water temperatures. 5. Room Temperatures: maintain comfortable and room temperatures levels near a range of 71 to 81F. 4. On 2/18/25 at 1:13 PM, R130 was observed sitting on the side of his bed with his pants half falling off his hips and his brief sticking out of his pants. R130 had a foul odor coming from his side of the room. R130's urinal was sitting on his meal tray in front of him with a noted dark brown substance/what appeared to be stool around the rim. R130 said his urinal has been dirty around the rim for as long as he could remember. R130's MDS (Minimum Data Set) dated 1/13/25 shows his cognition is intact.

Based on observation, interview, and record review, the facility failed to dispose of controlled medications accordingly and have as-needed medication available for administration upon resident request. This applies to 5 out of 5 (R103, R65, R26, R10, and R73) residents reviewed for medication storage and pharmacy services in a sample of 30. The findings include: 1. On 2/18/2025 at 12:55 PM, the medication storage task was done with V15 (Registered Nurse/RN) on the second floor. R10's Ativan 0.5 mg (milligrams) medication bottle containing 20 tablets was in the medication room's refrigerator. R10's Ativan Controlled Substances Proof of Use record sheet was wrapped around the medication (not in the unit's narcotic control counting log binder). V15 said the medication did not require refrigeration and was unsure why it was stored in the refrigerator. V15 also said the record sheet had to be in the narcotic control binder to ensure the medication was being accounted for. V15 then gave R10's medication and record sheet to V3 (Licensed Practical Nurse/LPN). V3 said R10's Ativan tablets were discontinued, and he was now receiving it in liquid form. R10's Order Summary Report dated 2/19/2025 did not show an order for Ativan tablets. 2. On 2/18/2025 at 1:05 PM, the second floor's unit medication cart was checked with V15 (RN). R26's Lorazepam 1 mg medication punch card was observed with the #8 pill slot punched opened, with tape over it with a pill inside. R26's Order Review Report dated 2/19/2025 showed an order for Ativan Oral Tablet 1 MG (Lorazepam) Give 1 mg by mouth every 6 hours as needed for anxiety. 3. On 2/18/2025 at 1:25 PM, the first floor's unit medication cart was checked with V4 (RN). R103's Lorazepam 0.5 mg medication punch card with 28 tablets had R103's Controlled Drug Receipt/Record/Disposition form wrapped around the card (not in the unit's narcotic control counting log binder). R103's Order Review Report dated 2/19/2025 did not show an order for Lorazepam. 4. On 2/18/2025 at 1:25 PM, V4 remained present for R65's medication observation. R65's Clonazepam 1 mg medication punch card with 27 tablets had R65's Controlled Drug Receipt/Record/Disposition form wrapped around the card (not in the unit's narcotic control counting log binder). V4 said R103 and R65 were discharged from the facility, and their controlled medications should have been removed and given to the Director of Nursing/DON to ensure proper destruction. R65's Order Review Report dated 2/19/2025 showed an order for clonazepam Oral Tablet 1 MG (Clonazepam) Give 1 tablet via G-Tube one time a day related to BIPOLAR DISORDER. On 2/19/2025 at 1:30 PM, V2 (DON) said all controlled medications should be accounted for and disposed of when discontinued to prevent discrepancies and variances. V2 also said controlled medications should never be placed back into the punch cards once removed. The facility's policy titled Controlled Substances dated 11/2015, said The facility will dispose of or destroy any discontinued controlled substances in a safe and controlled manner in accordance with the regulation set forth by the Drug Enforcement Agency (DEA) .Destroying Controlled Drugs 9. When a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), or the medication needs to be wasted, the medication shall be destroyed and may not be returned to the container .12. Medication has to be destroyed if the packing has been compromised. 13. All discontinued controlled drugs will be collected and should be broken down as best as possible. 34410 5. R73 is a [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 02/18/25 at 10:00 AM, R73 was at the nurse's station, and V3 (Licensed Practical Nurse/LPN) administered her medications. R73 asked for her hemorrhoid medicine, and V3 stated that he didn't have that to administer. On 02/18/25 at 10:12 AM, V3 (LPN) stated that R73's hemorrhoid cream is an over-the-counter medicine, and he told his supervisor a couple of days ago (V3 was off yesterday). V3 added that rectal cream is not available to administer as the resident (R73) requested. On 02/19/25 at 11:04 AM, R73 stated, I was impacted yesterday, and there was little blood around my rectum, and that's why I asked for my hemorrhoid medication yesterday. Record review on Physician Order Sheet (POS) dated 02/14/25 documented external cream (Hydrocortisone, rectal cream) to apply to the affected area topically every 6 hours for hemorrhoid pain/discomfort. On 02/19/25 at 09:33 AM, V2 (Director of Nursing/DON) stated that R73's rectal cream is an over-the-counter medication and is not covered under her insurance. V2 added that the medicines should be available for residents. A review of the facility-provided Medication on Admission policy (revised in December 2012) documented: Upon admission or re-admission, obtain a list of medications that the resident is supposed to be taking; once completed and reconciled, fax the information to the pharmacy so that delivery, if needed, can be arranged at their end. Information about the medication shall include but not be limited to: 1. Prescription medications, including those taken only as needed. 2. Non-prescription/over-the-counter medications, including those taken only as needed.

Based on observation, interview, and record review, the facility failed to maintain the call light within access for one resident. This applies to 1 resident (R130) reviewed for accommodation of needs in a sample of 30. Findings include: On 2/18/25 at 1:13 PM, R130 was observed sitting on the side of his bed with his pants half falling off his hips and his brief sticking out of his pants. R130s call button was noted to be draped over the side of his wheelchair and out of R130's reach. R130 stated, how am I supposed to get this without falling down. R130 added that the nurse had been in the room to give him medications and did not give him the call button. R130 stated that 75% of the time the staff does not give him the call button. R130 also stated that he fell on [DATE] because his button was not in reach and he was reaching for it. R130's MDS (Minimum Data Set) dated 1/13/25 shows his cognition is intact and R130 needs substantial/maximal assistance for personal hygiene. R130's care plan dated 1/7/2025 documents that R130 is at risk for falls and interventions include keeping the call light within reach and encouraging the resident to use the call light for assistance as needed. On 2/18/2025, V2 (Director of Nursing) stated that when staff leave a room the call light should be placed within the resident's reach. V2 added that if the resident cannot reach their call light and they are not able to call for help, they could try to transfer or toilet themselves and risk falling.

Based on observation, interview, and record review, the facility failed to maintain accurate advanced directives in the residents' medical records. This applies to 3 out of 4 (R27, R76, and R47) residents reviewed for advance directives in a sample of 30. The findings include: 1. On [DATE] at 11:15 AM, V12 (Licensed Practical Nurse/LPN) said the facility maintained a binder with Do Not Resuscitate (DNR) advance directive forms on top of the unit's emergency crash cart. V12 also said all residents required a code status order in their EMRs (Electronic Medical Records) to reflect their selected advanced directives. V12 was asked to review R27, R47, and R76's EMRs code status. V12 said R27 and R47's EMRs showed full code orders (to be resuscitated) and R76's EMR did not show a code status order. V12 then reviewed the DNR binder which showed R27, R47, and R76 had POLST (Practitioner Order for Life-Sustaining Treatment) forms indicating they had selected DNR (not to be resuscitated). V12 said the DNR binder information had to match with the resident's EMR to ensure that the staff knew how to respond to a resident's medical emergency based on their life-sustaining wishes. On [DATE] at 10:50 AM, V11 (Social Worker/SW) said she was responsible for assisting residents with their POLST forms. V11 said she then provided the nursing team with a copy of the forms to ensure correct code status orders were entered into the residents' EMRs. V11 confirmed R27, R47, and R76's POLST forms indicating their DNR wishes were accurate. R27's Care Plan Report showed an advance directive focus for DNR initiated on [DATE]. The care plan's interventions included document the DNR status on the Physician's Order Sheet, Inform caregivers of the DNR status, and Place a code/mark on the chart so it clearly identifies the DNR status. R27's POLST (Practitioner Order for Life-Sustaining Treatment) form dated [DATE] showed R27 selected NO CPR; Do Not Attempt Resuscitation (DNAR). R27's Order Summary Report dated [DATE], showed an active code status order of Full Code CPR ATTEMPT CARDIOPULMONARY RESUSCITATION dated [DATE]. 2. R47's Care Plan Report showed an advance directive focus for DNR initiated on [DATE]. The care plan's interventions included document the DNR status on the Physician's Order Sheet and Place a code/mark on the chart so it clearly identifies the DNR status. R47's POLST form dated [DATE] showed R47 selected NO CPR; Do Not Attempt Resuscitation (DNAR). R47's Order Summary Report dated [DATE], showed an active code status order of Full Code CPR ATTEMPT CARDIOPULMONARY RESUSCITATION dated [DATE]. 3. R76's Care Plan Report showed an advance directive focus DNR initiated on [DATE]. The care plan's interventions included Document the DNR status on the Physician's Order Sheet and Inform caregivers of the DNR status. R76's POLST form dated [DATE] showed R76 selected Do Not Attempt Resuscitation/DNR. R76's Order Summary Report dated [DATE] did not show an active code status order. The facility's policy titled Advance Directives dated 2001, said Policy Statement Advance directives will be respected in accordance with state law and facility policy .4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on the interview and record review, the facility failed to notify the POA (Power of Attorney), physician, and hospice provider in a timely manner before transferring R131 to the hospital for evaluation after a fall incident. This applies to 1 of 2 hospice residents (R131) who were reviewed for significant change in condition and hospitalization in a sample of 30. Findings include: On 02/18/2025 at 10:31 AM with V15 (Registered Nurse/RN), R131 was observed with a skin tear on the left elbow. V15 said R131 had a fall on 02/17/2025 and went to the hospital for evaluation. V15 said she was not involved in the incident and was not aware of the details. On 02/18/25 at 01:46 PM, V17(RN) said R131 had an unwitnessed fall, and the facility called 911 and transferred R131 to the hospital. V17 stated she informed later the hospice provider and the physician and forgot to notify R131's POA (Power of Attorney) R131's Electronic Medical Records (EMR) showed R131 was admitted to hospice care on 01/30/2025 due to cerebra vascular disease for comfort care only and diagnoses including cerebral infarction, protein-calorie malnutrition, enterocolitis due to clostridium difficile, chronic obstructive pulmonary disease, and altered mental status. R131's admission Minimum Data Set (MDS) dated [DATE] showed R131 was not interviewable and cognitively severely impaired and dependent on one to two staff assistance for activities of daily care. Nursing progress notes dated 02/17/2025 showed R131 had an unwitnessed fall at 12:25 PM and was admitted to the hospital for dehydration and abnormal sodium level. The nursing progress notes from the next shift showed that a nurse informed R131's POA regarding R131's admission to the hospital around 7:08 PM. The progress notes further indicated that the POA stated she was not aware that the patient got sent out to the hospital and did not want R131 to be admitted , and the facility brought R131 back to the facility. On 02/19/2025 at 12:12 PM, V18(Registered Nurse-Hospice) said that the hospice staff received the call regarding his change in condition around 2:45 PM. V18 said the practice is the facility notifies the fall as soon as it is observed, and the hospice sends a nurse to evaluate the residents and notify the family of any decision to make. V18 said R131 had an order from the hospice physician about not hospitalizing. V18 stated that the facility called her when R131 was already out to the hospital via 911 for evaluation, and she advised the facility to notify the family. On 02/19/25, at 10:09 AM, V2(Director of Nursing) said the appropriate parties are notified as soon as any change in resident conditions or hospital transfer occurs. The facility's policy, Care of Resident with a Change in Condition, revised dated 03/2020, states that after the resident is assessed and noted to have a change in conditions, the resident's provider should be notified for further medical intervention, and the resident's responsible party should be notified about the change of conditions.

Based on the interview and record review, the facility failed to follow the hospice physician's order for hospitalization . This applies to 1 of 2 hospice resident (R131) who was reviewed for hospitalization in a sample of 30. Findings include: Hospice provider order dated 01/30/2025 for R131 indicated do not hospitalize, call with change in condition, and comfort care only. On 02/18/25 at 01:46 PM, V17(Registered Nurse) said R131 had an unwitnessed fall, and the facility called 911 and transferred R131 to the hospital. V17 stated she informed the R131's physician later. V17 said she did not realize that R131 was not to be hospitalized . 02/19/25 V2 (Director of Nursing) said nurses should follow physician orders. R131's Electronic Medical Records (EMR) showed R131 was admitted to hospice care on 01/30/2025 due to cerebra vascular disease for comfort care only and diagnoses including cerebral infarction, protein-calorie malnutrition, enterocolitis due to clostridium difficile, chronic obstructive pulmonary disease, and altered mental status. R131's admission Minimum Data Set (MDS) dated [DATE] showed R131 was not interviewable and cognitively severely impaired and dependent on one to two staff assistance for activities of daily care. On 02/19/2025 at 12:12PM, V18 (Registered Nurse-Hospice) said R131 had an order from the hospice physician about not hospitalizing. V18 said when the facility called her when R131 was already out to the hospital via 911 for evaluation. The facility's policy, Physician Order-Medication and Treatment with a revised date of 03/2020, states in part physician order should be carried out as ordered. The policy Care of Resident with a Change in Condition, with a revised date 03/2020 states in part after the resident was assessed and noted to have a change in conditions, the resident's provider should be notified for further medical intervention.

Based on observation, interview, and record review, the facility failed to safely transfer residents who required the use of a mechanical lift. This applies to 3 out of 3 (R32, R75, R104) residents reviewed for transfers in a sample of 30. The findings include: 1. R104's EMR (Electronic Medical Record) showed his diagnoses including lack of coordination, abnormalities of gait and mobility, muscle weakness in his right lower leg, gout, epilepsy, and dementia. R104's EMR said he required the use of a mechanical sit-to-stand machine lift for all transfers. R104's MDS (Minimum Data Set) dated 1/30/2025 said he was dependent on facility staff for transfers. On 2/19/2025 at 9:10 AM, V7 (Certified Nursing Assistant/CNA) and V8 (CNA) said they were going to transfer R104 from his wheelchair to the toilet. V7 said R104 required the use of the sit-to-stand mechanical lift for transfers. V7 said R104's right lower leg was weak and required additional support. V7 and V8 then placed R104's feet on the machine's footplate. The machine's knee pad had straps with attached belt bulk pieces on each side. V7 said they did not have the knee belt piece attachment to secure to the machine. V7 said they were told that the additional safety knee device was not required. They then proceeded to place and secure a red-colored belt sling around R104's torso area. V7 pulled to adjust the belt strap fully but it was not securely fastened around R104's torso. They then hooked the sling's loops to the machine and transferred R104 to the toilet. After assisting R104 with his toileting needs they then transferred him back to his wheelchair. When R104 was lifted the belt remained loose not fastened securely. R104 started slightly lowering further in his squatting position while being transferred into his wheelchair. 2. R32's EMR showed her diagnoses included loss of muscle control related to [NAME]-Sachs disease, scoliosis of the lumbar region, lack of coordination, general muscle weakness, Charcot's joint to the right shoulder, unsteadiness on feet, polyosteoarthritis, and neuropathy. R32's EMR said she required the use of a mechanical sit-to-stand machine lift for all transfers. R32's MDS dated [DATE] said she was dependent on facility staff for transfers. On 2/19/2025 at 1:05 PM, V7 and V8 (CNAs) said they were going to transfer R32 from her wheelchair to the toilet with the sit-to-stand mechanical lift. R32 had a black sling on her right arm. R32 said she used the sling for additional support because her arm was weak. They placed R32's feet on the machine's footplate. The machine's knee pad had slots on each side for attaching a knee belt but did not have belt straps attached. V7 placed and secured the same prior used (with R104's AM transfer) red-colored belt sling around R32's torso area. V7 pulled on the belt strap fully to adjust it but it was not too big and not fastened securely around R32's torso. They proceeded with R32's transfer when another staff member handed V7 another belt sling of a smaller size. After assisting R32 with her toileting needs they then transferred her back to her wheelchair. R32's belt sling remained loose despite V7 again attempting to fully pull on the belt to fasten it. V7 said the belt sling used for R32 was too loose. After the transfer, R32's belt sling was inspected with V7, and it did not have the manufacturer's tag attached indicating the size and said she believed that was a large size. V7 said that they determined the belt sling size based on the residents' posterior torso width. V7 said they had other belt sizes available including small and medium and were not specific to the machine's manufacturing product. V7 said both R32 and R104 required the use of a medium size belt slings based on their torso size. 3. R75's EMR showed her diagnoses included left-side hemiplegia, hand contractures, dystonia (involuntary muscle contractures), abnormalities of gait and mobility, and muscle weakness. R75's EMR said she required the use of a mechanical sit-to-stand machine lift for all transfers. R75's MDS dated [DATE] said she was dependent on facility staff for transfers. On 2/19/2025 at 9:35 AM, V9 (Restorative Aide) and V10 (CNA) said they were going to transfer R75 from her wheelchair to the toilet with the sit-to-stand mechanical lift. V9 said the machine was a rental without a knee belt attached. They placed R75's feet on the footplate and a belt sling around her torso. They then hooked the sling's loops to the machine and instructed R75 to hold on to the machine. R75's left hand was contracted and was unable to grip onto the machine's handlebar, she placed her hand over it. V9 pulled on the belt strap fully to adjust it but it was still too loose and not fastened securely around R75's torso. They proceed to transfer R75 to the toilet. On 2/20/2025 at 9:50 AM, V9 said the facility had different belt sling sizes and R75's size was probably medium. V9 said belt sizes were based on the resident's chest size, and when the belt is fastened it should not be too loose nor too tight. V9 was asked to inspect the belt sling used on R75 (during her AM transfer observation on 2/19/2025). V9 was unable to determine the size of the belt sling because it did not have the manufacturer's tag attached indicating the size. On 2/19/2025 at 1:20 PM, V2 (Director of Nursing) was asked to inspect R104's used sit-to-stand mechanical lift machine. V2 said that based on the knee pad's attached belt straps the machine most likely required the use of the knee belt but was unsure if the machine was purchased with it. Then V2 was asked to inspect the machines used for R32 and R75 transfers, V2 said she was not sure if those machines required the use of the belt knee belt attachment device. V2 was also asked to inspect the belt slings used for R104, R32, and R75. She was unable to determine the size of the slings. V2 said she was unsure how the staff determined or knew which size belt sling to use for the residents. V2 said the facility used universal belt slings that could be used for all the facility's lift machines, including their rental machine. On 2/19/25 at 3:20 PM, V2 said she interviewed the staff and confirmed that they were instructed by V13 (Risk Manager Consultant) that the use of knee belts was not needed because they did not assist in preventing falls. V2 said she contacted V13 for additional guidance regarding the use of the knee belts. V2 said they reviewed the machine's manufacturing instructions, and determined their use was not required only recommended, and if decided to be used they would need to be ordered. V2 also said she expected the staff to use their best judgment when determining which size of belt slings to use. On 2/20/2025 at 10:15 AM, V13 (Risk Manager Consultant) said she was employed by an outside insurance company that provided employee safety education including on how to safely transfer residents. V13 said her company did not maintain the facility's transfer equipment. V13 said she was not familiar with the facility's mechanical lift machines. V13 said she provided the facility's staff with directions on how to use lift transfer machines and instructed them that knee belts were optional but not required. V13 said knee strap belts could be used for residents who require extra security with transfers for example those who have lower leg weakness. V13 said the facility had to individually assess residents who may require the additional support of knee belts and update their care plans. V13 also said that she believed belt sling sizes were determined based on weight and the belt's manufacturing tag should be assessed to determine the belt's size. V13 said the belt should be fastened like a gait belt (a standard transfer belt), it should be snugged but not too tight. V13 said it was important that the belt be secured appropriately around the resident to prevent accidents. The (name of the sit to stand machine) manufacturing document undated was provided by the facility. The instructions said, ALWAYS check the slings weight capacity is suitable for the patient and Fitting Stand Assist Sling .2. Cross the adjustable chest belt over and fasten it securely using the buckle. The document also said there was an option to add the knee support straps and included instructions for the use of a fitting knee belt. The facility's document letter from (name of the sit to stand machine) dated 2/20/2025 said the knee strap for the lift was an optional accessory. The document further said, This accessory is available for situations where nursing or caregiver judgment determines that additional knee support is needed to enhance patient stability against the knee pad. The facility's document titled How to Use a Stand Assist Lifter Safely undated provided instructions on how to make transfers safer and more comfortable. The document said Step 2: Attach the appropriate sling .You should select the correct size sling for the person who will be donning the sling. Check the product guide, where you can find information on what size you will need .Step 6: Adjust any optional feature .Optional leg bands are also available for increased stability and lower leg support during transfers . The facility's policy titled Transferring a Resident from one location to another dated 03/2020, said Policy Statement Residents in the facility will be transferred safely from one location to another using the proper transfer technique. Policy Interpretation and Implementation .2. Mechanical lift or sit-to-stand lift .14. Apply positioning and/or physical devices as indicated .

Based on observation, interview, and record review, the facility failed to safely administer a resident's extended-release antihypertensive medication. This applies to 1 out of 3 (R92) residents reviewed for medications in a sample of 30. The findings include: On 2/19/2025 at 8:15 AM during medication administration, V16 (Registered Nurse/RN) said she was going to administer R92's scheduled antihypertensive medication, Diltiazem ER (extended-release) 120 mg (milligrams) one tablet. V16 crushed and mixed R92's Diltiazem ER tablet with applesauce. V16 then administered R92's medication orally. On 2/19/2025 at 11:00 AM, V14 (Pharmacist) said R92's Diltiazem ER was an antihypertensive medication to lower the blood pressure. V14 said the tablet should have not been crushed because it lost its extended-release properties, and the dosage would have been absorbed quicker in the body. V14 also said the medication was listed in the Do Not Crush list which was provided to the facility. R92's Order Summary Report dated 2/19/2025 showed an order for diTIAZem HCI ER Oral Tablet Extended Release 24 Hour 120 MG (Diltiazem HCI) Give 1 tablet by mouth in the morning related to HYPERTENSIVE HEART DISEASE. The report showed another for May crush medications if indicated according to manufacturer's guidelines. Diltiazem Hydrochloride Extended-Release tablet manufacturing document dated 05/2019 said administration instructions were Tablet should be swallowed whole and not chewed or crushed. The pharmacy's document titled Meds That Should Not Be Crushed dated 2023, said Crushing pills can improve ease of administration, but some shouldn't be crushed. Crushing extended-release meds can result in administration of a large dose all at once. The document listed Diltiazem as a medication that should not be crushed. The facility's policy titled Administering Medications dated 03/2020, said Policy Statement Medications shall be administered in a safe and timely manner and as prescribed.

Based on observation, interview and record review, the facility failed to ensure residents' privacy were maintained while performing blood glucose monitoring and insulin injections. The facility also failed to ensure a resident's private medical information was kept confidential. This applies to 4 of 4 residents (R32, R65, R103 and R107) reviewed for privacy in the sample of 25. Findings include: 1. R107's face sheet showed multiple diagnoses including dementia, and diabetes mellitus. On January 8, 2024 at 10:46 AM, R107 was sleeping in a wheelchair in the hallway outside of her room. V9 (Nurse) rolled R107 to the nurses' station, used a lancet to extract blood from R107's finger and then used a blood glucose monitoring machine to determine R107's blood glucose level. During R107's blood glucose monitoring procedure, no privacy was provided to the resident and during the same procedure, R107 was visible to multiple residents and staff at the nurses' station. V9 stated she usually checks resident's lunchtime and dinnertime blood glucose at the nurses' station or wherever residents are located because they are not usually in their rooms after breakfast. 2. R32's face sheet showed multiple diagnoses including, type 2 diabetes mellitus. On January 8, 2024 at 11:32 AM, V9 was at her medication cart at the nurses' station and stated she was about to give insulin to R32. V9 stated that she had already taken R32's blood glucose and proceeded to prepare R32's insulin. After V9 had prepared R32's insulin, she (V9) walked towards R32 and told the resident that she will be administering the insulin. R32 was sitting at the nursing station in a regular chair against the wall. R32 pulled her shirt up and pulled her pants down, exposing her lower abdominal area. R32 was observed having a little trouble keeping her pants down. V9 pinched R32's left lower abdomen and injected the insulin about three to four inches below the resident's waistline. During the administration of insulin to R32, the resident was not provided privacy and R32 was visible to multiple residents and staff at the nurses' station. 3. R65's face sheet showed multiple diagnoses including type 2 diabetes mellitus. On January 8, 2024 at 11:38 AM, while at the nurses' station, V9 used a lancet to extract blood from R65's right index finger and then used a blood glucose monitoring machine to determine R65's blood glucose level. After obtaining R65's blood glucose level, V9 proceeded to prepare R65's insulin. While R65 was holding her shirt up, exposing her abdominal area, V9 attempted to administer the insulin to the resident twice. During V9's second attempt to administer the insulin to R65's abdominal area, V10 (Social Service Director) walked up to V9 and prompted V9 to give the insulin medication in the resident's room. V9 looked up and responded what? V10 again prompted V9 to give R65's insulin medication inside the resident's room. V10 told R65, let her give you your medicine in your room and then led R65 that way. During R65's blood glucose monitoring procedure and attempts to administer the insulin medication to the resident's abdominal area, R65 was at the nurses' station and during the same procedures, R65 was visible to multiple residents and staff at the nurses' station. On January 9, 2024 at 12:33 PM, V10 stated that on January 8, 2024 when she saw V9 lifting R65's shirt up and was about to give her (R65) an injection, she told V9 to take R65 to her room for the resident's privacy. On January 9, 2024 01:04 PM, V2 (Director of Nursing) stated that checking blood glucose and giving injections should be done privately in resident's room or bathroom, but not at the nurses' station. According to V2 she does not recommend doing injections or blood glucose checks in the open at the nurses' station because of privacy, infection control, and safety issues. 29562 4. On January 9, 2024, at 9:17 AM, V11 (Registered Nurse) administered medications to R103. V11 turned on the computer and went to R103's page to check the medications that were due for administration. Without turning off the computer, V11 walked away from the cart to check R103's vital signs, then she came back to the cart to prepare the medication. In the process of preparing medication, V11 walked away again and went inside the nurses' station leaving the computer open while R103's electronic medical record such as his name, date of birth and medications were visible to all the residents and other non-nursing staff who were sitting nearby and/or walking by the cart. The computer was on top of the medication cart which was parked outside the nurses' station. There were alert and oriented residents walking by the cart who could read R103's record. On January 9, 2024, at 1:10 PM, V2 (Director of Nursing) stated that staff should minimize or close the computer every time the staff walks away from the computer to keep resident's information private. The facility's Residents Rights, Privacy, and Dignity policy dated March 2020 documents the following: 2d. The resident has the right to privacy and confidentiality.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 5 residents (R86, R88, R110 and R113) reviewed for ADLs (activities of daily living) in the sample of 25. The findings include: 1. On January 8, 2024 at 1:02pm, R110 had facial hair up to a quarter inch in length. On January 9, 2024 at 9:47am, R110 continued to have unshaved facial hair. According to R110 the CNAs (Certified Nursing Assistants) normally shave him with his shower or bed bath but they hadn't shaved him during his last 3 bath times. R110 stated his bath days are Wednesday and Saturday (the last being January 6, 2024). The facility provided a record of R110's baths which showed R110 did get a bath on January 6, 2024, 2 days before the January 8 observation. According to the facility face sheet for R110 shows the resident was admitted to the facility on [DATE] and is treated for medical and psychiatric illnesses. According to the most recent MDS (Minimum Data Set) dated December 6, 2023, R110 was cognitively intact and requires assistance with bathing and with shaving. On January 10, 2024 at 2:21pm, V2 (Director of Nursing) stated ADLs (activities of daily living) should always be done, including bathing and personal hygiene. 29562 2. On January 8, 2024, at 12:47 PM, R113 was sitting in his recliner. R113 displayed dirty fingernails with black/brown substances underneath the nails. R113 stated that he wants his fingernails clipped but he needs the staff to do it for him. On January 9, 2024, at 2:55 PM, V12 (Wound Care Nurse) stated that R113 scratches his skin a lot. R113 requires extensive assistance with ADL (activities of daily living) care. On January 9, 2024, at 3:04 PM, R113 was sitting in his recliner wearing dirty shirt and still had long fingernails with brown/black substance underneath the nails. R113 stated that the staff has not clipped it yet and he still wants his fingernails to be cleaned and clipped. R113's shirt was stained with dry substances all over the front of his shirt. R113's MDS (Minimum Data Set) dated September 27, 2023, showed that R113 was alert and oriented. R113's active care plan shows that R113 exhibit self-care deficit and requires assistance with activities of daily living such as bed mobility, transfers, toileting, eating, dressing/grooming, bathing, and personal care needs due to current medical condition which include CVA (cerebrovascular accident) with left hemiplegia. 36567 3. R86's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, pressure ulcer of sacral region, unspecified stage, limitation of activities due to disability, need for assistance with personal care, cognitive communication deficit. R86's 5-day MDS (Minimum Data Set) dated January 3, 2024 showed that R86 was severely impaired in cognition. On January 11, 2024 at 10:35 AM, V2 (Director of Nursing) stated that R86 needs extensive assistance from staff for personal hygiene/grooming. R86's activities of daily living care plan revised May 1, 2023 included that R86 has an ADL (activities of daily living) self-care performance deficit related to hemiplegia, limited range of motion, stroke, deconditioning. Interventions included: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On January 9, 2024 at 11:41 AM, R86 was in room resting in bed and noted to have several long chin hairs and long jagged finger nails on left hand with blackish substance underneath the nail. R86's right hand was not visible as it was tucked under the bed sheet. R86 stated that she would like her facial hair removed and nails trimmed and cleaned. R86 was able to respond clearly to queries. On January 9, 2024 at 1:26 PM, V8 (Certified Nursing Assistant) was notified of R86's requests. When R86's right hand was viewed in the presence of V8, it was noted to be contracted with long jagged fingernails embedded into her palms. R86's left hand continued to show long jagged nails with blackish substance underneath it however most of R86's chin hairs were removed. V8 stated that R86 just had a shower and agreed that the nails need to be cut and cleaned. 16746 4. R88 had multiple diagnoses including Parkinson's disease, dementia without behavioral disturbance and need for assistance with personal care, based on the face sheet. R88's quarterly MDS dated [DATE] showed that the resident was cognitively intact and required Supervision or touching assistance with regards to personal hygiene. On January 8, 2024 at 11:19 AM, R88 was sitting in her chair inside the first floor main dining room. R88 was alert and verbally responsive. R88 had long and curling chin hair. On January 9, 2024 at 12:42 PM, R88 was sitting in her chair inside the first floor main dining room. R88 had long and curling chin hair. R88 stated that she wanted the staff to shave her chin hair. V2 (Director of Nursing) was present during the observation. According to V2, R88 needed the staff assistance to shave because R88 cannot shave herself.

Based on observation, interview and record review the facility failed to assess and provide adaptive devices to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 2 residents (R80 and R86) reviewed for range of motion in the sample of 25. The findings include: 1. R80 had multiple diagnoses including hemiplegia affecting left non-dominant side and joint contracture, based on the face sheet. R80's quarterly MDS (minimum data set) dated November 17, 2023 showed that the resident was moderately impaired with cognition. The MDS showed that R80 had functional limitation in ROM (range of motion) on one side of both upper and lower extremities. The same MDS showed that R80 required substantial/maximal assistance to total dependence from the staff with most of her ADLs (activities of daily living). On January 8, 2024 at 11:41 AM, R80 was sitting in her wheelchair inside her room. R80's left hand was contracted with four fingers (except thumb) curled into the palm. R80 could not extend her index, middle, ring, and little fingers. R80 had no splint and/or no adaptive/positioning/comfort device on her left hand. R80 stated, They don't give me any exercise for it. It's been like this for 7 years and they haven't done a d*** thing. They haven't put the splint/hand brace around it. It will help it. On January 9, 2024 at 9:19 AM, R80 was sitting in her wheelchair in-front of the unit nursing station. R80's left hand was contracted with four fingers (except thumb) curled into the palm. R80 could not extend her index, middle, ring, and little fingers. R80 had no splint and/or no adaptive/positioning/comfort device on her left hand. On January 9, 2024 at 1:29 PM, V5 (Occupational Therapist) stated that she has not provided occupational services to R80 for a while. According to V5 once the therapy discharges the resident, the resident is referred to the restorative program and the restorative department handles the ROM (range of motion) program for the individual resident. V5 stated that the therapy department will screen R80 to determine the need for a left-hand splint. On January 11, 2024 at 9:39 AM, V5 stated that she had evaluated R80 for occupational therapy services on January 10, 2024 at approximately 11:00 AM, after she was prompted by the surveyor on January 9, 2024, to look at the resident's left hand contracture to determine the need for a splint or any adaptive device. According to V5, based on her evaluation of R80, the resident had a flexion contracture of the proximal and distal interphalangeal joints of the 2nd through 5th digits (index, middle, ring, and little fingers) of the left hand. V5 stated that R80's left hand 2nd through 5th digits were bent forward and were non-functional due to left sided hemiplegia. V5 stated that because of R80's left hand contracture, she (V5) had recommended for the resident to have a trial use of a splint, either a carrot or a palmar guard splint, to prevent further contracture, for comfort and for skin integrity. V5 added that based on R80's evaluation, the occupational therapist will provide services to the resident's bilateral extremities. R80's occupational therapy evaluation dated January 10, 2024 created by V5 showed that the resident had functional limitations due to contracture on her left digits from 2nd through 5th proximal and distal interphalangeal joints. The evaluation showed in-part under reason for therapy, Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for further decline in function. The same evaluation showed, Splint/orthotic recommendations: Therapy will trial palmar guard and carrot splint. 36567 2. R86's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, limitation of activities due to disability, need for assistance with personal care, other lack of coordination, cognitive communication deficit. R86's 5-day MDS (Minimum Data Set) dated January 3, 2024 showed that R86 was severely impaired in cognition and had upper and lower impairment on one side and was dependent on staff with all activities of daily living. R86's active care plan created on May 25, 2023 included that R86 requires splint to right hand/arm related to hemiplegia and hemiparesis following cerebral infarction affecting right (side). Interventions included to ensure that the splint was on every AM shift and off every night shift. On January 9, 2024 at 1:26 PM, R86 was seen lying in bed. A blue colored resting hand splint was seen at R86's bedside table. R86's right hand was tucked under the bed sheets and viewed in the presence of V8 (Certified Nursing Assistant) and was noted to be contracted with long jagged fingernails embedded into her palms. V8 stated that in the recent past, R86 used to wear the hand brace (that was seen at the bedside) when R86 was up in the chair and has it off while in bed. V8 stated that currently R86 just stays in bed all day and so they do not apply the hand brace.

Based on observation, interview, and record review, the facility failed flush an intravenous (IV) line prior to administration of medication and failed to label and change an IV dressing. This applies to 2 of 2 residents (R81, R86) reviewed for intravenous line in the sample of 25. The findings include: 1. On January 8, 2024, at 5:35 PM, V6 (Registered Nurse) administered multiple medications to R86 which included Meropenem 2 gm (grams) intravenously (IV). This Meropenem was incorporated into 0.9 NS (normal saline) 100 ml (milliliter). V6 did not flush the IV line prior to administering Meropenem. On January 8, 2024, at 6:00 PM, V6 stated that they are supposed to flush the IV line before and after infusion, however, she (V6) forgot to do it. Physician order summary shows R86 has peripherally inserted central catheter (PICC). Medication administration record (MAR) showed: Sodium Chloride Solution 0.9 NSS (Normal Saline Solution). Use 10 ml intravenously every day and night shift for flush. Flush double lumen PICC before and after infusions. 36567 2. R81's EMR (Electronic Medical Record) showed diagnoses that included multiple sclerosis, quadriplegia, scoliosis, unspecified urethral stricture, male, unspecified site, neuromuscular dysfunction of bladder, presence of urogenital implants, need for assistance with personal care, other lack of coordination. R81's 5-day MDS (Minimum Data Set) dated December 29, 2023 showed that R81 was cognitively intact. R81's EMR included nursing progress notes that he was sent to the hospital on December 29, 2023 due to difficulty breathing, fever and weakness. The same nursing progress notes included that R81 was readmitted to the facility on [DATE] from hospital with diagnoses of pneumonia and urinary tract infection and an order for antibiotic Meropenem 1,000 mg (milligrams) IVP (intravenous peripheral) three times daily for three days. R81's care plan revised January 5, 2024 included that R81 has UTI (urinary tract infection) with ESBL (Extended-Spectrum Beta-Lactamase) Escherichia Coli and was being treated with antibiotics Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) IV from January 4, 2024 until January 6, 2024. Goal for the same included that R81 will be free from complications related to infection through the review date. On January 8, 2024 at 12:05 PM, R81 was in his room seated in a wheelchair and was observed with a peripheral IV (intravenous) line on the left antecubital area. The peripheral IV insertion site had an undated clear transparent dressing which was rolling off at the edges. The peripheral IV insertion site also had dried blood caked at the tip of IV insertion site. R81 stated I just got out of the hospital. They put in an IV on Thursday (January 4, 2024) for antibiotic for ESBL urine and I just got done with it on Saturday (January 6, 2024). On January 8, 2024 at 2:30 PM, R81's peripheral IV line on the left antecubital area was noted to have fresh blood at the insertion site under the clear dressing which remains undated and curled at the edges. R81 stated that the dressing has not been changed since the hospital applied it. On January 8, 2024 at 2:33 PM, V6 (Registered Nurse) stated I am not sure if the dressing was changed. His last intravenous antibiotic was this Saturday, January 6th at 4:00 PM. We are waiting for doctor's order for removal of peripheral line. Normally we change the dressing in 72 hours, but I am not sure. On January 9, 2024 at 1:14 PM, V2 (Director of Nursing) stated that the dressing on IV site should be labeled and dated. V2 added that if the dressing is noted to be curling or detached it is recommended to be changed for infection prevention.

Based on observation, interview, and record review the facility failed to prevent and identify an area of pressure prior to becoming a deep tissue injury, failed to implement offloading interventions, and failed to assess new pressure injuries for 2 of 6 resident (R38, R70) reviewed for pressure in the sample of 24. This failure resulted in R70 suffering three deep tissue injuries. The findings include: 1. R70's face sheet listed diagnosis including encephalopathy, kidney disease stage 3, heart failure, acute respiratory failure, bipolar disorder, adult-onset fluency disorder, and dementia. On 02/28/23 at 02:02 PM, R70 was in bed with her eyes closed and positioned to her right side. R70 had heel boots on, and her toes were exposed with no dressings. R70's heels were not offloaded and were in lying on the mattress. On 03/01/23 09:08 AM, R70 was in bed supine with the head of the bed elevated. R70 had bilateral heel boots on with heels resting directly on the mattress. R70's heels were not offloaded. R70 did not have socks or dressing to her feet and her toes were in direct contact with the sheet covering her. R70 was able to say her name but was otherwise disoriented. R70 was unable to move her legs when requested. On 03/01/23 at 01:56 PM, R70 was supine in bed. A top sheet and blanket rested directly on R70's uncovered toes. R70's heels were not offloaded. Examination of the wounds with assistance of V4 (Wound Nurse) showed left great toe tip had a reddened-purplish area of intact skin, right great toe tip wound (larger than left) showed a flattened dried blood blistered area which was unopened, left heel had area had a discolored, non-blanchable reddened area. None of the wounds had dressings. R70's right heel had a large, discolored area that was blanchable, and the right medial bony prominence of the right foot had a reddened area. On 3/2/23 at 11:04 AM, V2 (Director of Nursing/DON) said, to offload pressure we use air loss mattress, turning frequently, and heel boots. Heel boots off load pressure to the heel. You still need to put pillows under the lower legs to ensure the feet are off the bed. Heels should not be resting on anything. Offloading pressure to the toes is done by using open toed boots, no tight-fitting socks and no blankets tight on the toes. It's important to offload so the skin doesn't open. You don't want other injuries, deeper injuries, or worsening of an injury. The key to pressure prevention is to remove pressure. If pressure is not relieved the wound is going to open, ulcer and worsen. Other wounds may develop as well. On 3/2/23 at 11:30 AM, V2 said I don't consider a blister a pressure ulcer. It can come from things other than pressure. On 3/2/23 at 1:11 PM, V13 (Wound Doctor) said ideally, yes he would expect the facility to identify areas of pressure prior to becoming a stage 3. Ways to offload pressure from the heels may include use of a pillow to float the heel or use offloading boots. They don't have foot cradles here but that would keep the bed covers from rubbing the tips of R70's toes. V13 said he assessed R70 once and determined she had three deep tissue injuries. We discussed the sheets rubbing as the cause of the DTI's. Since they don't have foot cradles, they were going to use ABD (thick gauze pads) pads over the areas. If offloading isn't done, wounds could deteriorate. The blisters did not have clear fluid. That's why they were DTI's. Pressure injury prevention is better than treatment. During the survey, V4 (Wound Nurse) said he was not certified in wound care and does not officially stage wounds. V4 states his assessments are preliminary until confirmed by V13 (Wound Doctor). V4 does not know V13's name. R70's 1/25/23 facility assessment showed severe cognitive impairment extensive assistance of two plus persons required for bed mobility, transfer, toilet use, personal hygiene, and total dependence for bathing. R70's 1/18/23 pressure sore risk assessment showed a high risk. The facility's weekly wound report showed R70 had three facility acquired (2/14/23) Deep Tissue Injuries (DTI's). Noted on this report was a DTI to the right first toe, left first toe, and the left heel. R70's 2/17/23 hospice note showed redness to the lower legs and both big toes. The facility nurse was notified. R70's 2/18/23 nurses note showed discoloration to the top of bilateral big toes. The nurse notified hospice. R70's 2/18/23 nurses note showed the hospice nurse visited and recommended the facility wound nurse assess the resident for Deep Tissue Injury (DTI) to bilateral great toes, and bilateral heels. The facility wound nurse was updated. The facility's initial wound assessment by the facility was requested an a 2/20/23 Skin Evaluation was received. This document was authored by V4 (Wound Nurse.) R70's 2/20/23 wound evaluation by V13 (Wound Doctor) showed wound #1 unstageable DTI of the right first toe, partial thickness blood filled blister, etiology, pressure. V13 recommended to offload the wound and place an ABD pad to the area daily. Wound #2 unstageable DTI of the left, first toe partial thickness, etiology, pressure. V13 recommended to offload the wound and place and ABD pad over the area daily. Wound #3 unstageable DTI of the left heel partial thickness, etiology, pressure. V13 recommended to offload the wound and float heels while in bed. The National Pressure Injury Advisory Panel (NPIAP) pressure injury stages showed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact or open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. A Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The facility's 1/2023 Assessment of Skin Alteration/Skin Checks Policy showed residents with skin alteration will be assessed, and the physician will provide treatment. The assessment of any alteration should be started immediately upon identification of a pressure ulcer and findings need to be documented in the medical record. Wound assessment/measurement should be completed and documented in the medical record upon identification and weekly until healed to reflect progress. The resident's plan of care should be reviewed and updated as needed. The facility's 2/2022 Wound Prevention Program showed implementation of preventative measures and/or appropriate treatment modalities for ulcers are put into place according to the standard of care. Develop a plan of care and implement intervention according to the resident risk factors identified. 2. Identification of risk factors that can impact developing unavoidable ulcer or will affect healing process if resident does have an ulcer. The following are risk factors: a. acute illness or change in condition i.e., upper respiratory infection, pneumonia c. cognitive loss d. decreased mobility or bedfast g. edema h. elderly residents with very dry skin and/or poor skin turgor i. ends stage disease/ terminal illness m. history of pressure ulcers. 4. Activity Mobility and Positioning Interventions: establish an individualized turning and repositioning schedule if the resident is immobile. If the resident is on bed, position the resident body on bed with pillows, or other supportive devices and/or low air loss mattress to protect boney prominence susceptible to pressure. Offload heels using pillows as needed. Elevate resident heels off the bed as indicated (e.g., place pillows under calf (not under ankles) to raise heels off the bed, unless contraindicated due to medical condition). 34891 2. R38's face sheet printed on 3/1/23 showed diagnoses including but not limited to respiratory failure, heart failure, hypertension, obesity, schizophrenia, mood disorder, intellectual disabilities, and bilateral embolism and thrombosis of lower extremity deep veins. R38's facility assessment dated [DATE] showed extensive staff assistance needed for bed mobility, transfers, dressing, and toilet use. R38's Braden Scale for Predicting Pressure Sore Risk dated 2/19/23 showed a moderate risk. On 2/28/23 at 10:36 AM, R38 was seated in a wheelchair on the second-floor unit. R38 had yellow anti-skid socks on and both feet were flat on the floor. R38's foot appeared to have a bandage sticking out over the top of the sock. At 12:30 PM, R38 was in his wheelchair in the main dining room wearing the yellow socks. His feet were flat on the floor. At 1:12 PM, R38 was in his wheelchair by the second-floor elevator. R38's feet were bare, and his feet were flat on the floor. V6 (Registered Nurse) was questioned about the bandage on R38's heel. V6 stated she did not know but guessed it was likely from a recent treatment. On 3/1/23 at 8:55 AM, V11 and V12 (Certified Nurse Assistants) toileted R38 while V4 (Wound Nurse) was present. V4 was asked to remove R38's socks and a white bandage was observed on the right heel. V4 removed the dressing. A half-dollar size split open white area with a dime size dark purple center was observed. V4 cleansed and measured the white area and stated it was 3.8 by 4.0 centimeters. V4 said it looked like a blister that had opened. V4 said he would classify the dark purple bruising area as a DTI (deep tissue injury). V4 said it was approximately 25% the size of the blistered area. V4 said it was the first time he was aware of any wounds on R38's heels. V4 said it appeared to have been caused by R38 rubbing his heels on the floor. V4 said R38 propels himself all around the units and should have something protecting his heels to prevent the breakdown. V4 said it should have been off-loaded as soon as it was found. V4 said it should have been documented in the resident chart and verbally passed on between shifts. At 9:20 AM, V4 and the surveyor reviewed R38's electronic medical record together and V4 confirmed there was no documentation of the wound to R38's right heel. V4 said resident skin should be inspected during all care by the aides. Nurses inspect skin two times weekly on shower days. The physician should be immediately notified of any skin changes to get treatment started and get the wound healing right away. On 3/2/23 at 11:30 AM, V2 (Director of Nurses) stated skin checks should be done head to toe with every shower by the CNAs. Nurses do skin checks with every medication pass. If a resident is prone to pressure ulcers, then it is a head-to-toe assessment. Any skin changes should be reported to the physician, family, director of nurses and the wound care nurse right away. V2 said if skin changes are not found at an early stage there is the potential for worsening of the wound and the risk of infection. V2 was asked to describe the characteristics of a DTI and stated it is an area not open, dark purple, and non-blanchable. V4 was present and stated he does the initial assessment on wounds which he did verbally for R38 with the surveyor on 3/1 and the wound care physician does the final diagnosis. On 3/2/23 at 1:10 PM, V13 (Wound Doctor) was asked to describe the characteristics of a DTI and stated it is a purple, boggy area and may appear as a fluid filled blister. (V13 had just entered the facility and had not yet assessed R38's heel, therefore no formal wound assessment by V13 was available.) V13 said it important to have resident heels protected from pressure and bare feet on the floor is not ideal. V13 said it is important to prevent pressure wounds from forming. It is easier to prevent them versus trying to heal them later. R38's care plan showed a focus area related to skin alterations. Interventions included: Identify/document potential causative factors and eliminate/resolve where possible; monitor skin with care/showers; report any signs of skin breakdown (sore, tender, red, or broken areas). The facility's Assessment of Skin Alteration/Skin Checks Policy dated 1/2023 states under the procedure section: 1. Skin checks should be completed at least daily for any skin alteration. 3. The Resident's doctor should be notified of any skin alteration and obtain new orders for monitoring and treatment. Document the orders in the medical chart. The facility's Wound Prevention Program Policy dated 2/2022 states under the Activity, Mobility and Positioning Interventions section: c. While in bed or in a wheelchair, resident should be turned/repositioned at least every 2 hours and as needed. i. Off load elbows and heels using pillows as needed. k. Occupational therapy to evaluate for wheelchair positioning as needed.

Based on observation, interview, and record review, the facility failed to ensure a resident with a history of overstuffing his mouth with food was provided supervision and intervention during consumption of a peanut butter sandwich. The facility also failed to have a system in place to identify residents with swallowing precautions and failed to supervise two other residents on swallowing precautions during a meal service. This failure resulted in R1 experiencing a choking incident requiring the Heimlich maneuver and transportation to the local hospital. Hospital documentation showed R1 expired at the local hospital within an hour of the incident on February 1, 2023, at 3:55 AM. This applies to 3 of 5 residents (R1, R2, and R3) reviewed for accidents and supervision in a sample of 5. This failure resulted in Immediate Jeopardy. The findings include: The Immediate Jeopardy began on February 1, 2023, when R1 was observed by V4 (Licensed Practical Nurse/LPN) taking a large bite of a peanut butter and jelly sandwich and V4 did not follow R1's care plan and intervene. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on February 9, 2023, at 3:05 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on February 10, 2023, at 5:32 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. 1. The facility's final report to the State Agency dated February 3, 2023, showed R1 came out of his room and approached the nurses' station and had obtained a peanut butter and jelly sandwich from nursing staff at 3:00 AM. R1 sat in a chair in front of the nurses' station and consumed the sandwich without difficulty while supervised. After the sandwich was consumed, R1 then got up from the chair with the use of his rolling walker and ambulated to another chair down the hall close to his room and took a seat. NOD (Nurse on Duty) then noted R1 to be in distress and had abnormal movements to his arms and he began to fall over in the chair to the right, NOD and another nurse immediately ran to R1 as he was falling to the floor, per investigation this was at 3:05 AM. Staff immediately began abdominal thrusts to perform the Heimlich maneuver as they noted food particles to be on his lips, the NOD also attempted a finger sweep which resulted in her being bitten. Another staff member had alerted rapid response and notified 911 (emergency) services. Staff continue with life saving measures. Emergency services arrived and resumed care for R1. Emergency services left the facility with R1 and transported him to the Emergency Department. A follow up call was place to the Emergency Department; staff was notified that the resident expired at 3:55 AM. On February 8, 2023 at 10:20 AM, V3 (LPN) said she was the nurse caring for R1 the night of the choking incident on February 1, 2023. V3 continued to say R1 had asked for a peanut butter and jelly sandwich. V3 said R1 was given a sandwich and he sat by the nurses' station to eat the sandwich. V3 said she could not see R1 while he was eating his sandwich. On February 8, 2023 at 5:07 PM, V4 (LPN) said [R1] came out of his room at about 3:00 AM on February 1, 2023, and asked for a peanut butter and jelly sandwich. [R1] sat in front of nurses' station where I could see him. I saw him take one bite of the sandwich. It was a huge, big bite. He ate over half of the sandwich in one bite. I did not say anything to him because he always eats like that. I did not know I had to say anything to him. Then, he got up from the nurses' station while holding the rest of the sandwich and walked to a chair across from his room. I watched him walk over there. The way he moved was weird, then he started falling out of the chair. He was turning blue. [V3] and I ran to him and turned him on his side, but he didn't respond. A progress note dated February 1, 2023, at 7:04 AM by V4 showed, Around 3:00 AM resident came to the nursing station and asked for a sandwich. He sat in front of the nursing station and had a bite. Then he moved and seated in a chair by [resident room - approximately 10 feet from the nursing station]. I notified the resident had hard time breathing, run to assist. When I got close, he fell out of the chair. [V3] and I tried to put on the side and checked if he was alerted but the resident couldn't respond. One of the nurses called [Emergency Services] when we tried to help the resident. On February 9, 2023 at 11:29 AM, V16 (Deputy Coroner) said R1 died from choking on peanut butter. Hospital documentation dated February 1, 2023, at 4:04 AM, by V23 (emergency room Physician) showed [AGE] year old male, history of hypertension, GERD (Gastroesophageal Reflux Disease), hyperlipidemia, schizophrenia presenting as a full arrest. Per EMS (Emergency Medical Services), patient seen walking in the hallway in his facility when they noted him choking on a peanut butter jelly sandwich. On their arrival, patient pulseless in PEA (Pulseless Electrical Activity). Three doses of epinephrine initiated in route without ROSC (Return of Spontaneous Circulation) . Food debris noted in the oropharynx (back of throat) extending down towards the trachea . Bedside cardiac ultrasound without any cardiac activity. Time of death at 0355 (3:55 AM). Hospital documentation dated February 1, 2023, at 3:46 AM by V24 (emergency room Registered Nurse) showed Peanut butter noted to be coming from Endotracheal Tube (breathing tube). R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia, traumatic brain injury, GERD, and dry mouth. R1's MDS (Minimum Data Set) dated [DATE], showed R1 was cognitively intact and required set up help and supervision from facility for eating. R1's care plan dated [DATE], showed [R1] at times over stuffs food in his mouth while eating. The care plan continued to show multiple interventions dated [DATE], including [R1] will take small bites. On February 8, 2023, at 4:01 PM, V2 said R1's care plan was in place due to a behavior R1 had of overstuffing his mouth with food. On February 9, 2023, at 10:57 AM, V2 said staff would know which residents have behaviors while eating by going through the resident's care plan. V2 continued to say staff would have to look in R1's care plan for the interventions he required while eating. V2 said R1 was not on the list of residents with dysphagia or the list of residents on aspiration precautions. On February 9, 2023, at 11:13 AM, V10 (Certified Nursing Assistant/CNA) said she used to take care of R1. V10 continued to say she was unaware R1 had a behavior of taking big bites or overstuffing his mouth while eating. On February 9, 2023, at 8:58 AM, V15 (Speech-Language Pathologist/SLP) said if a nurse sees a resident overstuffing their mouth, the nurse should be telling the resident to spit the food out of their mouth. 2. On February 8, 2023, at 12:33 PM, R2 was seated in the main dining room. R2 had not received a meal tray yet. R2 was eating a cup of fruit. On February 8, 2023, at 12:44 PM, V9 (CNA) said staff had not provided R2 with fruit prior to R2 receiving her meal tray. V9 continued to say R2 had taken the fruit from another resident's meal tray, and staff were unaware and not supervising the resident until R2's meal tray was delivered. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including psychosis, type 2 diabetes, dementia, depression, and hypertension. R2's MDS (Minimum Data Set) dated [DATE], showed R2 had moderate cognitive impairment and required supervision with set up help for eating. R2's aspiration care plan dated February 1, 2023, showed [R2] has potential for aspiration or choking related to advanced age, on therapeutic diet, mechanical soft, and current medical condition (dysphagia, history of choking). Resident had choking episode [DATE]. Speech therapy and swallow evaluation ordered. The care plan showed multiple interventions dated February 1, 2023, including Aspiration precautions; encourage resident to eat slowly; cue resident to take small bites or small sips at one time; provide supervision and assist the resident as needed during meals. R2's Order Summary Report dated February 14, 2023, showed an order dared [DATE], for LCS (Low Concentrated Sweets) diet, mechanical soft texture, regular/thin consistency. A progress note dated [DATE], at 6:39 PM, by V13 (Registered Nurse/RN) showed, At 5:45 PM, noted resident having face red and choking episode, staff done the abdominal Heimlich, food came out, resident talked and coughing, resident was responsive and alert no shortness of breath was noted. On February 9, 2023, at 8:58 AM, V15 (SLP) said R2 had a choking incident on [DATE], and R3 had a second choking incident shortly after which led to R2's diet being changed on [DATE], from regular consistency to mechanical soft. On February 8, 2023, the facility provided an undated list titled, ASPIRATION PRECAUTIONS LIST. R2 was identified on the list as having aspiration precautions. On February 8, 2023, at 12:44 PM, V9 (CNA) said if a resident is on aspiration precautions it is written on their meal card. V9 said multiple residents with aspiration precautions eat in the main dining room at meals. V9 continued to say she does not know how to identify if a resident is on aspiration precautions if she did not deliver the resident's meal tray. On February 9, 2023, at 2:47 PM, V19 (CNA) said she would work in the main dining room during meal service and assist with passing out resident meal trays. V19 said the only residents on aspiration precautions eat in the small dining room. V19 continued to say she does not have to supervise any of the residents who eat in the main dining room. V19 was not aware R2 has aspiration precautions and eats in the main dining room. On February 9, 2023, at 2:49 PM, V20 (CNA) said she helps pass out trays in the main dining room during meal service. V20 continued to say the only residents who need to be supervised for swallowing sit in the small dining room. V20 said the CNAs do not have to supervise any residents who eat in the main dining room. V20 was not aware R2 has aspiration precautions and eats in the main dining room. 3. On February 8, 2023, at 12:26 PM, R3 was in the main dining room eating lunch. R3 was coughing while eating, no staff observed R3 or responded to R3. At 12:38 PM, R3 was putting three quarters of a piece of plain bread in his mouth. No staff observed R3 eating the bread. No staff intervened while R3 was taking large bites of bread, and no staff cued R3 to take small bites of his bread. R3's meal ticket showed Aspiration Precautions. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, diabetes, and dysphagia. R3's MDS dated [DATE], showed R3 was cognitively intact and required set up help only and supervision of facility staff for eating. R3's aspiration care plan dated February 1, 2023, showed [R3] has potential for aspiration or choking related to advanced age and current medical condition (dysphagia). The care plan continued to show multiple interventions dated February 1, 2023, including Encourage the resident to eat slowly; Cue resident to take small bites or small sips one at a time; Assist the resident during meals and provide supervision. R3's EMR showed a diet order dated [DATE] for LCS diet, regular texture, regular/thin consistency. On February 8, 2023, the facility provided an undated list titled, ASPIRATION PRECAUTIONS LIST. R3 was identified on the list as having aspiration precautions. On February 8, 2023, at 1:39 PM, V11 (CNA) said there is a list of residents on aspiration precautions at the nurses' station. V11 provided a list dated February 8, 2023, titled Active Clients Filtered by Consistency: Mech (Mechanical) Soft. V11 provided a second list dated February 8, 2023, titled Active Clients Filtered by Consistency: Pureed. V11 said these are the residents that require supervision when eating. R3 was not identified on either list. V11 was not aware the facility had another list titled Aspiration Precautions List. On February 8, 2023, at 1:46 PM, when asked to identify which residents in the facility required monitoring for aspiration precautions, V12 (LPN) said only those residents on pureed or mechanical soft diets. V12 was not aware the facility had another list titled Aspiration Precautions List On February 8, 2023, at 1:58 PM, V13 (RN) said there is a list of which residents on aspiration precautions. V13 provided a list dated February 8, 2023, titled Active Clients Filtered by Consistency: Mech (Mechanical) Soft. V13 provided a second list dated February 8, 2023, titled Active Clients Filtered by Consistency: Pureed. V13 was not aware the facility had another list titled Aspiration Precautions List On February 9, 2023, at 2:38 PM, V18 (RN) said she did not know which of her residents had aspiration precautions, and she would have to look in the computer. V18 continued to say it would show in the resident's diet order if the resident was on aspiration precautions. R3's diet order did not show R3 had aspiration precautions. On February 9, 2023, at 8:58 AM, V15 (SLP) said facility staff should be reminding R3 to eat slowly and take smaller bites. V15 continued to say facility staff should be supervising R3 while he eats. The facility presented an abatement plan to remove the immediacy on February 10, 2023, at 9:34 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on February 10, 2023, at 5:32 PM, and the survey team accepted the abatement plan on February 10, 2023 at 5:32 PM. The Immediate Jeopardy that began on February 1, 2023, was removed on February 10, 2023, when the facility took the following actions to remove the immediacy: 1. The facility is unable to take specific action for R1 as he is no longer at the facility. Based upon the observation of the IDPH (Illinois Department of Public Health) surveyor, the facility has now placed R2 in a smaller dining room for additional supervision and monitoring. Speech therapist completed a screening on February 9, 2023, and R3 is tolerating current diet and being followed the speech therapy. Based upon the observation of the IDPH surveyor, R2 is now placed in a smaller dining room for additional supervision and monitoring. Speech therapy conducted a screening on February 9, 2023 and noted no risk for aspiration and is tolerating her current safest diet. 2. The facility has identified all residents with a history of choking incidents and residents assessed as needing supervision relating aspiration precautions as having potential to be affected by this deficiency. This was completed on February 9, 2023, by the DON and interdisciplinary team. 3. The facility has taken the following actions to abate the immediacy of this alleged deficiency: A. In order to address all facility residents' risk potential, speech therapy screenings were started for all residents on February 9, 2023, by the facility's speech therapist for residents that have not been screened in the last year. This will be completed February 10, 2023. B. An audit of all resident clinical records was started on February 9, 2023, to identify residents with a history of choking and/or at risk for aspiration and in need of supervision. This was started on February 9, 2023, and was completed February 9, 2023, by the DON and interdisciplinary team. The plans of care for these identified residents were audited to ensure that appropriate and effective care plans are in place for eating supervision as assessed. C. Residents who are at risk for choking and/or aspirating and in need of supervision have been identified. One on one meetings between the DON, Social Service staff, or the Registered Dietician with the residents were started on February 9, 2023. These meetings specifically educated the resident regarding safety issues of eating in their room without staff supervision. Residents were encouraged to eat their meals and snacks in the dining room or otherwise under staff monitoring. This was completed February 9, 2023 by V1. D. The interdisciplinary team has been in-serviced regarding the importance of assessing residents for choking and aspiration risk and developing a plan of care based on this assessment (please note, staff that are on vacation, not on duty, etc. will be in-serviced upon their return to work. Also note that all education and in-service training shall use programs developed by well-established centers of geriatric health services education and will be initially provided by the facility's outside clinical consultant to the facility's nursing leadership who will provide education to the facility staff). This was completed by V25 (Vice President of the consulting group) on February 9, 2023. E. Nursing staff and agency staff have been in-serviced regarding the importance of supervising and monitoring residents for choking and aspiration. This staff/agency personnel were also trained regarding the importance of encouraging residents at risk for choking/aspirating to eat in the dining room or where staff can easily monitor them (e.g., by the nurses' station). Training also included a review of the interventions needed for residents with behaviors that may lead to choking issues. Staff were also instructed to document their approaches and interventions to encourage resident compliance (please note, those that are on vacation, not on duty, etc. will be in-serviced up their return to work. Also note that all education and in-service training shall use programs developed by well-established centers of geriatric health services education and will be initially provided by the facility's outside clinical consultant to the facility's nursing leadership who will provide education to the facility staff). Social Service staff shall maintain a list of residents who require visual supervision during meals and the needed interventions for dealing with behaviors associated with overeating and stuffing food. These residents will be segregated to a specific table during meals so that staff will easily identify who they are. This was completed by V25 on February 9, 2023. F. PRSCs (Psychiatric Rehabilitation Services Coordinator) have been in-serviced regarding the importance of supervising and monitoring residents for choking and aspiration. This staff was also trained regarding the importance of encouraging residents at risk for choking/aspirating to eat in the dining room or where staff can easily monitor them (e.g., by the nurses' station). Staff were also instructed to document their approaches and interventions to encourage resident compliance (please note, those that are on vacation, not on duty, etc. will be in-serviced upon their return to work. Also note that all education and in-service training shall use programs developed by well-established centers of geriatric health services education and will be initially provided by the facility's outside clinical consultant to the facility's nursing leadership who will provide education to the facility staff). This was completed by V25 on February 9, 2023. G. New admissions and residents returning from hospitalization will be assessed for eating needs and choking/aspiration risk. Plans of care shall be developed and implemented as warranted. In addition, residents noted with eating issues/concerns during these assessments shall be identified and their attending physicians and the Registered Dietician shall be notified of assessment findings as warranted for further orders/recommendations. This shall be managed and monitored by the DON and appointed designee(s). H. Direct care staff/agency staff have been educated regarding the following (please note, those that are on vacation, not on duty, etc. will be in-serviced upon their return to work): -Implemented the plan of care/ADL (Activities of Daily Living) plan for eating for each resident -Supervision during meals -Accurately identifying/reporting a change in the resident's eating (e.g., coughing, trouble swallowing, dentation issues, choking episodes, etc.). -Encouraging residents at risk for choking/aspirating to eat in the dining room or in an area where staff can closely monitor them. This was started by the DON on February 9, 2023 and will be ongoing for those staff on vacation, not on duty, leave, etc. as the return to work. I. The facility has developed and put in place a system that identifies residents with swallowing precautions and/or who require supervision while eating. This system/process identifies and alerts facility staff to residents requiring interventions while eating to monitor for safety concerns including choking and make staff aware which residents require interventions for safety concerns while eating. The staff have been trained and educated on this system. This was completed on February 10, 2023. This system/process includes that the facility assess newly admitted residents during the admission process and existing residents during their next scheduled care plan session (or earlier if significant changes in condition occur) to determine if they should be identified as needing eating supervision and/or swallowing precautions. This process started on February 9, 2023 ad shall be ongoing. J. The facility has identified residents needing supervision with eating and interventions. This was completed on February 10, 2023. This list includes residents with swallowing issues as well as behaviors that put them at risk for choking. Enclosed with this abatement are copies of their plans of care with specific interventions identified. K. Residents identified as needing supervision with eating and interventions shall be evaluated when new food items are added to the menus, including snack menus, to determine if they can safely tolerate this new food. 4. The DON, Administrator, and/or their designee(s) will initiate the following monitoring activities to ensure that this deficiency has been abated and compliance is ongoing: A. New admission and readmission records shall be monitored weekly to ensure: -Choking/aspiration risk has been assessed and a plan of care was developed/implemented. Noted problems shall be corrected immediately and identified patterns/trends of non-compliance shall be reported to the Quality Assurance Committee and Medical Director for further follow-up. This monitoring began February 9, 2023 and will be ongoing a minimum of three months (90 days) and may continue longer (until audits evidence consistent with compliance). B. R2, R3 and other residents identified as at risk for choking/aspirating shall be observed daily during meals and scheduled HS (Hour of Sleep/Bedtime) snacks to ensure that approaches and interventions in their eating/behavior plans of care are being continuously implemented. Staff designated to perform daily observations may be disciplined, up to and including termination, if they fail to maintain this plan. Noted problems shall be corrected immediately and identified patterns/trends of non-compliance shall be reported to the Quality Assurance Committee and Medical Director for further follow-up. This monitoring began February 9, 2023 and will be ongoing a minimum of three months (90 days) and may continue longer (until audits evidence consistent compliance).

Based on interview and record review the physician failed to identify, monitor, and treat an elevated blood sugar. This applies to 1 of 5 residents (R1) reviewed for change in status in a sample of 5. This resulted in R1 being hospitalized in the intensive care unit with diabetic ketoacidosis. Findings include: R1's Admission Record document R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Recap Report for 9/1/2021-1/31/2022 documents a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The results of the blood sugar level on this report were 211 milligrams/deciliter (mg/dl) with a normal range of 70-110. The Order Recap Report does not document any further physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Recap Report for 9/1/2021-1/31/2022 documents R1 receiving tube feedings 21-22 hours per day from the time of admission until she was discharged on [DATE]. R1's Progress Note dated 9/18/2021 documents V12 (Nurse Practitioner) was notified of the results of this elevated blood sugar level and no new orders were received. On 1/19/2022 at 9:25 V2 (Director of Nursing) confirmed there was not further blood sugar, or any sugar monitoring completed for R1 after 9/18/2021. R1's Physician Notes, completed by V13 (Physician), document R1 was evaluated and seen for routine physician monitoring on 10/13/2022, 11/5/2022, and 12/7/2022. None of these physician notes identified or addressed R1's elevated blood sugar level from the laboratory report dated 9/18/2021. R1's Progress Note dated 1/11/2022 documents R1 with a sudden change of status and sent to the hospital emergency room for evaluation. R1's emergency room Provider Notes dated 1/11/2022 document R1 arriving at 12:41 PM with a low oxygen saturation level after a [CONDITION(S)] tube was replaced and R1 had an episode of vomiting prior to arriving to the emergency room . This note documents R1's blood sugar was greater than 600. This report also documents R1 was admitted to the intensive care unit with clinical impressions (admitting diagnoses) of diabetic ketoacidosis, new onset Diabetes Mellitus, acute kidney injury, Pancreatitis, and a [CONDITION(S)] complication. R1's complete metabolic panel laboratory report 1/11/2022 at 12:57 PM documents R1's blood sugar level at 1180 mg/dl with a normal range of 70-100 mg/dl. R1's Hemoglobin A1C report 1/11/2022 at 1:45 PM documents R1's Hemoglobin A1C at 13.6% with a reference range of 0-5.6%. R1's hospital Endocrinology Provider Clinical Note dated 1/12/2022 documents R1 with newly diagnosed diabetes and diabetic ketoacidosis. This note also documents, R1's Hemoglobin A1C was 14% upon admission, indicating poorly controlled diabetes prior to admission. R1's hospital record Critical Care Note dated 1/12/2022 at 9:21 AM documents R1 in [CONDITION(S)] and cardiopulmonary resuscitation and emergency interventions were completed successfully R1 was placed on a ventilator for respiratory support. The hospital Death Note dated 1/12/2022 documents R1 was pronounced dead at 4:10 PM on 1/12/2022. On 1/19/2022 at 10:40 AM V10 (Medical Director) stated with a blood sugar of 211 mg/dl further management would be indicated, likely a monthly blood sugar and/or a serial accucheck would be appropriate. V10 stated R1 received tube feedings and generally blood sugars are completed as part of the monitoring for tube feedings. V10 further stated, after a blood sugar of 211, even if it was not fasting, there should have been further follow up to determine the cause of the elevated blood sugar levels. V10 stated there should have been some monitoring in place of R1's blood sugar or someone should have picked up on it. V10 stated a blood sugar that high contributed to R1's demise and resulted in R1's hospital admission. The website mayoclinic.org documents a Hemoglobin A1C is the measurement of the average blood sugar level over the prior 2- 3 month time period.