Every finding on record at Avir at Baird

Based on observations, interviews, and record reviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1of 1 washer unit reviewed for operating equipment. The facility failed to maintain a washer unit in working condition. This failure could place residents at risk of not having clean clothes to wear or sufficient linen available to meet resident's needs. The findings include: During an interview on 08/19/2026 09:30 am CNA A stated the residents' laundry had been taking longer to be returned to the residents due to laundry being taken to a local laundromat to be washed. CNA A stated the washer had been not working for about 3 weeks. During an interview on 08/19/2026 at 09:45 am CNA B stated the washer had been broken for about 3 weeks. CNA B stated the laundry staff were taking the laundry to a local laundromat to wash the laundry and then bringing it back to the facility to dry the laundry. CNA B stated it took longer for the residents to get personal laundry back to them. CNA B stated residents had complained to her about not having clean clothes. During an observation on 08/19/2026 at 11:25 am observed the laundry room with one washer unit that was not in working condition. Observed the washer would turn on but would not fill with water. During an interview on 08/19/2026 at 3:15 pm Resident #3 stated the laundry took longer than it used to. Resident #3 stated he liked to wear clean clothes. Resident #3 stated he did not know why the laundry was taking longer to be brought to his room. During an interview on 08/20/2026 at 08:25 am Resident #1 stated the laundry was being washed at the laundromat and brought back to the facility to be dried and delivered to the residents. Resident #1 stated it took a long time to get clean laundry back and she had to wear dirty clothes. Resident #1 stated wearing dirty clothes made her feel uncomfortable. Resident #1 stated she wanted to wear clean clothes. During an interview on 08/20/2026 at 09:00 am Laundry Aide C stated the washer quit working on 08/10/2026. Laundry Aide C stated we take the laundry to the laundromat to wash and then brought the laundry back to the facility to dry, sort, fold and deliver clothes to the residents. Laundry Aide C stated it took more time to do the laundry that way. Laundry Aide C stated she had a few residents complain to her about how long it took to get the laundry back to them. During an interview on 08/20/2026 at 2:40 pm the ADMN stated he was responsible for ensuring the washing machine was working. The ADM stated the residents had not gone without clean linen or clothes since the washing machine was not working. The ADM stated he did not believe any residents were harmed due to the washing machine not working. The ADM stated the failure occurred due to not having a maintenance person. The ADMN stated he did not have a policy for maintaining working equipment.

Based on observation, interview and record review, the facility failed to ensure that residents had the right to a safe, clean, comfortable and homelike environment for 2 of 5 (Resident #1 and Resident #3) residents reviewed for working overhead lights The facility failed to ensure Resident #1 and Resident #3 had a working overhead light. This failure placed the residents at risk for diminished quality of life and discomfort. Findings included: Record review of Resident #1's face sheet dated 08/19/2026 revealed a [AGE] year-old female, who was admitted to the facility on 03.17.2026 with diagnoses that included: Angina Pectoris (chest pain or discomfort), Anxiety, dependence on supplemental oxygen, Chronic obstructive pulmonary disease (lung disease). During an observation and interview on 08/20/2026 at 09:00 am, revealed Resident #1's overbed light did not work. Resident #1 stated that her overbed light had not been working for a long time. Resident #1 stated she would like to have the light work so she could see her phone better at night. Resident #1 stated she had reported the light not working to the administrator. This surveyor turned on the light with pull cord, and the overbed l light did not come on for approximately 2 minutes. Record review of Resident #3's face sheet dated 08/19/2026, revealed a [AGE] year-old male who was admitted to the facility on 08.08.2026 with the diagnoses that included Dementia (decline in mental ability), Cellulitis (skin infection in the deeper layers of the skin) of other sites, Unsteadiness on feet, Depression, shortness of breath, difficulty in walking. Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 08. During an observation and interview on 08/19/2026 at 3:15 pm revealed Resident #3's overbed light did not work. Resident #3 stated his overbed light did not work in his room. Resident #3 stated he would like for his light to work at night so when he went to the bathroom, he would be able to see in his room. Resident #3 did not recall if he had told anyone about the light not working. This surveyor attempted to turn on overbed light, the pull cord was not attached to the light. During an interview on 08/20/2026 at 2:40 pm the ADMN stated he had ordered light bulbs for the residents' overbed lights. The ADM stated he did not feel any residents were caused any harm due to the failure. The ADM stated he did not have a maintenance director and that was the cause of the failures. The ADMN stated his expectations were that all the lighting in the facility would be in good working order. The ADMN stated he was responsible for ensuring residents' lighting was in good working order until he hired a maintenance person. Record review on 08/20/2026 of facility's policy titled: Resident Rights (not dated) revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: A dignified existence; Be treated with respect, kindness, and dignity; .

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 39 days (06/20/2026, 06/21/2026 and 07/05/2026) reviewed for RN Coverage. The facility failed to have an RN onsite for 8 consecutive hours a day on 06/20/2026, 06/21/2026 and 07/05/2026. This deficient practice could place residents at risk of not receiving the advanced knowledge and skills of an RN to meet their individual needs to maintain health and well-being.The findings included the following: Record review on 07/09/0226 of nursing staff recorded working hours between 06/01/2026 and 07/09/2026, revealed an RN was not onsite for the required 8 consecutive hours on 06/20/2026 and 07/05/2026 and an RN was onsite for only 4.3 hours on 06/21/2026. During a confidential interview, interviewee A stated the staff had worked several weekends without an RN in the building. The interviewee stated staff was told corporate approved no RN onsite as long as an RN was available by phone. Interviewee A stated no adverse event requiring the knowledge and skills of an RN had occurred on the weekends when an RN was not onsite. Interviewee A stated consequences to residents for failing to have an RN onsite was unfair to the residents because the facility was working short staffed. Stated staff had to rush care or care was delayed if a situation required the scope of practice of an RN. During a confidential interview, interviewee B stated the facility did not have an RN onsite a lot of weekends. Interviewee B stated when the concern was brought to the attention of leadership, the staff was called to a meeting and were intimidated and told corporate approved no RN onsite if an RN was available by phone. Interviewee B stated RN response time by phone had been up to 2 hours. Interviewee B stated staff were concerned about retaliation or being managed out. Interviewee B stated consequences of failing to have an RN onsite 8 hours a day, 7 days a week may be during an emergency situation, interventions may require the scope of practice beyond what an LVN was licensed to do and the nursing staff had a hard time completing tasks due to short staffing. During an interview on 07/09/2026 at 10:15 AM, the DON stated she was responsible for the nursing staff schedule. She stated that she and another RN in the facility were alternating weekends to be onsite. She stated residents could suffer consequences for failing to have an RN onsite for 8 consecutive hours a day, 7 days a week, but did not provide examples, only stated because an RN was always available by phone. The DON stated the weekend RN quit without notice in May 2026 and the facility had not found a replacement. She stated her expectation was for the facility to have weekend RN coverage and for staff to work when scheduled. The DON stated no residents had suffered consequences related to the lack of weekend RN coverage. During an interview on 07/09/2026 at 10:15 AM, the RNC verified corporate approval for weekend RN coverage by the DON via phone was acceptable. She stated the facility had the ability to share staff with other facilities. The RNC stated she was always available for situations or questions if the DON was not reachable by phone. Review of facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022, revealed 3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interview and record review the facility failed to accurately complete a Preadmission Screening for individuals with mental disorder for 1 of 7 residents (Resident #5) reviewed for PASRR. The facility failed to accurately complete a PASRR Level I screening for Resident #5 who had a diagnosis of a mental illness. These failures could place the resident with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services.The findings are: Record review of Resident #5's electronic face sheet dated 07/06/2026 revealed: a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses that included: Generalized anxiety disorder, Unspecified psychosis not due to substance or known physiological condition. Record review of Resident #5's physician orders dated 07/06/2026 revealed an order with start date of 03/28/2026 Antipsychotic behavior monitoring every shift. Cialopram, Lorazepam, Seroquel. Record Review of Resident #5's PASRR Level I dated 07/06/2026 was negative for MI, DD, and IDD. Record review of Resident #5's Care Plan dated 04.17.2026 revealed uses Antipsychotic medications for Psychosis. During an interview on 07/09/2026 at 09:09 a.m., the DON stated she and the ADON were responsible for ensuring the PASRR information was completed and accurate. The DON stated she felt this failure occurred due to being new to the PASRR process. The DON stated she did not feel this failure affected the residents in any way. The DON stated the resident care would not be changed by the PASRR evaluation. The DON stated she was responsible for ensuring the PASRRs were completed and accurate. The DON stated she did not have a process to accomplish this. During an interview 0n 07/09/2026 at 09:40 the ADM stated his expectations were that PASRR information would be completed in a timely manner. Record review of facility's policy titled, PASRR dated 01/20.2026 revealed:The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. The facility's Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL 1 upon admission. 2. LIDDA submits PL1 in portal3. LIDDA performs PE withing 72 hours of receipt of PL1.4. LIDDA submits PE on Portal within 7 days of receipt of PL 1. The MDS coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s and PL1s for resident who qualify for exempted or expedited services.

Based on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #38) of 14 residents reviewed for care planning.The facility failed to develop a baseline care plan for Resident #38 within 48 hours of her admission.This failure could place newly admitted residents at risk of not receiving effective, person-centered care.Findings Included:Record review of Resident #38's electronic face sheet accessed on 07/06/26, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (disease of the lungs causing air not to move in and out as well as it should), dementia, and depression.Record review of Resident #38's EHR under the MDS tab on 07/06/202, revealed no evidence the comprehensive MDS assessments had been completed.Record review of Resident #38's EHR under the Care Plan tab on 07/06/2026, revealed no evidence of the care plan had been initiated.Record review of Resident #38's EHR under the Assessments tab on 07/06/2026, revealed no evidence of a baseline care plan.Record review of Resident #38's EHR under the MISC tab on 07/06/2026, revealed no evidence of a baseline care plan.During an interview on 07/09/2026 at 9:48 AM, the DON stated her expectation was for baseline care plans to be completed within 24-48 hours after admission. She stated she was responsible for completing the base line care plan. She stated Resident #38's baseline care plan was completed on the day of admission on paper and a meeting was held. The DON was not ablet to provide the hand-written care plan from admission. She stated she entered the baseline care plan into the computer on 07/07/2026. She stated there would be no negative outcomes for the residents just because the form was not completed. She then stated the staff would not know what care was needed for the residents without the baseline car plan. Record review of facility policy title Care Plans-Baseline and dated March 2022 revealed the following: . A baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #11) reviewed for care plans. The facility failed to ensure Resident #11 had a care plan in place for an implanted venous access port (a device surgically implanted for access to the circulatory system). This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included the following: Review of Resident #11's electronic Face Sheet, dated 07/06/2026, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest in activities, and fatigue lasting at least 2 weeks), chronic obstructive pulmonary disease (a progressive lung disease that makes breathing difficult), hallucinations (a false sensory perception that occurs in the absence of a real external stimulus, yet feels completely real to the person experiencing it), pain, anxiety, long term use of anticoagulants (Blood thinning medications), dementia, post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply traumatic event), peripheral vascular disease (a disorder that narrows the arteries or veins of the circulatory system), heart failure, chronic embolism (blood clot), and weakness. Review of Resident #11's Annual MDS Assessment, dated 04/11/2026, Section C - Cognitive Patterns, subsection C0500 BIMS Score of 15 indicated intact cognition. Section O - Special Treatments, Procedures, and Programs, subsection O0110. Special Treatments, Procedures, and Programs; Other O1. IV Access was not selected and Z1. None of the Above was selected in the While a resident column. Review of Resident #11's Comprehensive Care Plan, reviewed/revised 05/03/2026, revealed it did not address the implanted venous access port located in his upper right chest. Review of Resident #11's physician's order, dated 02/18/2026, revealed Access implanted port with 22Gx3/4 Huber needle. Flush port with 10 cc NS followed by a 5 cc heparin (a blood thinning medication) on the 1st of every month for routine maintenance of patency and as needed for port access/lab draws/IV infusion as needed for lab draw/IV infusion. During an interview on 07/07/2026 at 10:05 AM, R #11 stated he had an access port and indicated his upper right chest area. He stated the nurse was supposed to flush the port on the first of every month. R #11 stated currently only one RN was trained to flush the port. He stated he did not know if all the nursing staff was aware of the port and was not supposed to take his blood pressure on his right arm due to the port but he was able to make sure no procedures were done on his right side where the port was located. During an interview on 07/09/2026 at 9:00 AM, LVN A stated DON was responsible for creating and revising care plans. She stated any medical device a resident had should have been included in the care plan so that staff were aware of the expectations for care. During an interview on 07/09/2026 at 9:45 AM, LVN B stated the DON created and reviewed/revised the resident care plans. He stated all the nursing staff had access to the electronic care plans and used them to know their residents. He stated anything related to a resident's care should have been addressed on the care plan. During an interview on 07/09/2026 at 9:55 AM R #11 stated the DON flushed the port yesterday. During an interview on 07/09/2026 at 10:15 AM, the DON stated she was responsible for the care plans. She stated she received training on care plans during orientation and on the job and was not able to state the reason the venous access port was not included on R #11's care plan. She stated she utilized DONs from other facilities as resources for the care planning process. The DON stated she reviewed/revised care plans every 3 months or when a signification resident status change occurred. She stated consequences of failing to keep the care plan up to date and accurate may be that a resident would not be cared for properly. She stated her expectations were for staff to review the care plans periodically and bring to her attention any issue not on the care plant that needed to be. Review of facility policy titled Care Plans, Comprehensive Person-Centered dated 2001, revealed 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months ([DATE], [DATE], and [DATE]) reviewed for RN coverage.The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 5 days of 90 days in [DATE], [DATE], and [DATE]. This failure could place the residents at risk of not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.Findings included: Record review 2/11/26 of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1 and 2, revealed partial or no evidence of RN coverage for 5 of 90 days: 1. 11/1/2025 with no RN coverage.2. 11/16/2025 with no RN coverage. 3. 11/22/2025 with no RN coverage.4. 11/23/2025 with no RN coverage. 5. 01/11/2026 with no RN coverage. In an interview and record review on 2/10/26 at 10:00 AM, the DON provided the timecard reports for the months of [DATE], [DATE], and [DATE]. They revealed there was no RN coverage or a full 8 hours of RN coverage for dates: 11/1/2025, 11/16/2025, 11/22/2025, 11/23/2025, and 01/11/2026. The DON verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for those dates. In an interview on 2/11/2026 at 2:04 PM, the DON said her understanding of the facility policy was an RN to be on staff 8 hours a day. However, it took them a long time to find RNs. She said they try the best they can, and they are not always successful. She stated it was always better to have them. DON states she started working at facility in November 2025. When asked about what the possible negative outcomes would be if a resident needed an assessment that only an RN could do, she said I always answer my phone and if they call, I'm coming. DON states that she worked any days that are not covered by RN on weekends. A facility policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of 4 nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being. Findings include:1. Record review of NA A's employee record revealed she was hired 03/1/25 as a Nurse Aide trainee. Her Texas Performance Nurse Aide Program training was completed on 03/30/25, and NA A completed skills checkoffs on resident care and services. There was no proof of her being a Certified Nurse Assistant. Record review of NA A's Timesheet at [This Facility] revealed her date of hire was 03/1/25 and started working regular hours on 03/1/25. NA A was still employed at facility as of 2/8/2026. Observation was made of NA A providing resident care on 2/8/2026 at 1:45pm. 2. Record review of NA B's employee record revealed she was hired on 08/6/25 as a Nurse Aide trainee. Her Texas Performance Nurse Aide Program training was completed on 01/30/26 and she completed skills checkoffs on resident care and services. There was no proof of her being a Certified Nurse Assistant. Record review of NA B's Timesheet at [This Facility] revealed she was hired on 08/6/25 and started working regular hours on 07/13/24. Observation of NA B providing resident care on 02/8/26. Interview on 02/8/26 at 1:00 PM, the DON stated they had NA's who provided care to the residents but as of today NA A and NA B were not going to work until they passed the CNA test. DON stated she did not have a date on when NA A and NA B were going to take their CNA test. DON states she became DON in November 2025 and knew the NA's had completed their classes and competencies done but did not know that NAs needed to be certified within 120 days of hire. Record review of the facility Policy (no title), undated revealed the following: In Texas, trained but non-certified nurse aides (often referred to as temporary nurseaides) may work in nursing homes for up to four months while pursuing certification,according to Texas Health and Human Services (HHSC) regulations. While they mustoperate under the general supervision of a licensed nurse, they are not strictly required tohave a Certified Nurse Aide (CNA) present at all times, provided they have completed thenecessary training, as explained in eCFR.Key Requirements and Constraints: Four-Month Limit: A facility cannot employ a non-certified aide for more than fourmonths; they must pass the state certification exam within this timeframe. Supervision: While they do not need a CNA alongside them, they must be under thegeneral supervision of a licensed nurse (RN or LVN). Scope of Practice: Uncertified aides may only perform tasks they have been trainedfor and found proficient in by their instructor. COVID-19 Waivers Ended: The emergency waivers that allowed for longer periodsof uncertified work have ended, with most requiring certification to be finalized bymid-2023.The facility must ensure the aide is on the path to being listed on the Nurse Aide Registry

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 2 residents reviewed for Infection Control. The facility failed to ensure NA A performed hand hygiene and glove change while providing incontinent care to Resident #1 on 02/8/26. This failure could place residents at risk of cross-contamination and development of infections.Findings included:Record review of Resident #1's Face Sheet, dated 2/8/26 reflected Resident #1 was an [AGE] year-old female with admission date of 02/26/24. Resident #1 has diagnoses including hemiplegia and hemiparesis (condition that affects movement on one side of the body), sepsis (life threating infection), and kidney failure (kidneys do not filter waste and toxins from blood). Record review of Resident #1's Quarterly MDS Assessment indicated Resident #1 has BIMS score of 00 (severely cognitively impaired). Transferring max assistance, toileting max assistance, and bathing max assistance. Record review of Resident #1's Comprehensive Care Plan dated 2/1/26, risk of pressure ulcer and other skin issues- interventions, check for incontinence during rounds, provide care as needed. During an observation on 02/08/2026 at 1:45 PM NA A performed peri care to Resident #1. NA A did not perform hand washing, hand hygiene, or glove changes in between dirty and clean brief change or redressing resident. Interview on 02/11/26 at 9:00 AM, NA A stated she should have changed her gloves after cleaning the perineal area and before opening the new brief. She also said she also should have changed her gloves after cleaning the resident's bottom and before touching the new brief again. She said she did not do any hand hygiene all throughout incontinent care. She said she would be mindful to change her gloves after touching something dirty and doing hand hygiene.In an interview on 02/11/2026 at 3:35 PM, the DON stated the expectation was for the staff to follow the policy and procedures pertaining to infection control. Cross contamination could contribute to infection. DON states she will in-service staff on proper hand hygiene and peri-care policy. Record review of the facility Perineal Care Policy dated 2001 MED-PASS, indicated the following: PurposeThe purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents' skin condition.Preparation1. Review the resident's care plan/profile to assess any special needs of the resident.2. Assemble the equipment and supplies as needed.Steps in the Procedure1. Beginning stepsa. Wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 3(Resident #1, Resident #11, and Resident #31) of 12 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of leg braces for Resident #1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of intravenous antibiotics and infection for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of feeding tube for Resident #31. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: diabetes, muscle wasting, unsteadiness on feet. Review of Resident #1's MDS dated [DATE] revealed: BIMS of 10 which indicated moderate cognitive impairment. Review of O revealed no Splint or brace assistance. Review of Resident #1's Comprehensive Care Plan, last revised 11/18/2024, revealed no evidence of right and left leg braces. Review of Resident #1's electronic physicians revealed no evidence of an order to right and left leg braces. Observation on 05/19/25 at 10:18 AM, Resident #1 up in wheelchair with right and left leg braces in place. Observation and interview on 05/20/25 at 02:44 PM, Resident #1 resting in bed with braces sitting in wheelchair. She stated she had to wear her braces anytime that she was out of bed because her feet turn inward. Resident #11 Review of Resident #11's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: heart failure, infection of the heart, and kidney failure. Review of Resident #11's MDS dated [DATE] revealed BIMS of 11 which indicated moderate cognitive impairment. Review of Section M revealed no antibiotics during the last 7 days. Review of Resident #11's Comprehensive Care Plan, last revised 03/20/2025, revealed no evidence of IV antibiotic therapy of infection. Review of Resident #11's electronic physicians orders revealed: Daptomycin-sodium Chloride Intravenous Solution Use 700 mg intravenously at bedtime for infection until 06/27/2025, start date 05/01/2025 and Rifampin Oral Capsule 300 mg give 1 tablet by mouth for infection until 06/27/2025, start date 05/01/2025. Resident #31 Review of Resident #31's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: diabetes, high blood pressure, and depression. Review of Resident #31's MDS dated [DATE] revealed: BIMS of 13 which indicated no cognitive impairment. Review of Section: K revealed resident had a feeding tube. Review of Resident #31's Comprehensive Care Plan, initiated 04/24/2025, revealed no evidence of feeding tube. Review of Resident #31's electronic physicians revealed: Enteral Feed Order every day shift complete enteral site care every shift cleanse stoma with wound cleanser pat dry apply split gauze every day as needed, start date 05/21/2025 and Enteral Feed Order every shift flush feeding tube with 10 cc water between each medication and 30 cc water before and after med administration, start date 05/21/2025. During an interview on 05/21/25 at 10:55 AM, the ADON stated that's leg braces, feeding tube, and antibiotics should be care planned. She stated the DON was currently responsible for updating the care plans. During an interview with on 05/21/25 at 11:01 AM, the DON stated she was responsible for updating the care plans and the leg braces, feeding tube, and antibiotics should have been care planned. She stated she must have just missed them with the new charting system change. Review of facility's policy Care Plans, Comprehensive Person-Centered revised December 2020 revealed: The comprehensive, person-centered care plan will: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . E. Include the resident's stated goals upon admission and desired outcomes G. Incorporate identified problem areas; H. Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objective in measurable outcomes; L. Identify the professional services that are responsible for each element of care; M. Aid in preventing or reducing decline in the residents functional status and or functional ; N. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and O. Reflect current recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interviews and records review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 (10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24) of 201 days reviewed. There was no RN coverage on the following dates: 10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24. This failure could place residents at risk for injury, decline or death during a situation requiring the advanced knowledge and skills of an RN to intervene and supervision of the direct care staff. Findings included: Review of the Payroll Based Journal Staffing Data Report from CMS dated FY Quarter 1 (October 1 to December 31) accessed on 05/15/25 revealed the facility failed to report RN hours on 10/19/24 (SA); 10/20/24 (SU); 11/16/24 (SA); 11/17/24 (SU) and 12/27/24 (FR). During an interview on 05/21/25 at 08:49 AM, the Administrator stated there was no RN coverage on 10/19/24 and 10/20/24. He stated the weekend RN scheduled quit without notice. The Administrator stated the DON covered on 11/16/25 and 11/17/25 and there was RN coverage on 12/27/24 but he was unable to produce documentation of the coverage. The Administrator stated there were no RN's available for coverage on 10/19/24 and 10/20/24. The Administrator stated he could not think of consequences for the residents due to no RN weekend coverage because the DON and a regional nurse was available by phone. He explained the issue had been resolved by hiring 3 RN's. During an interview on 05/21/25 at 10:22 AM, the ADON, responsible for nursing staff scheduling, stated she could recall not having RN coverage one weekend in October 2024. She explained the RN scheduled quit without notice. The ADON stated she could not state adverse effects on residents for failing to have an RN in the facility because there was always at least one LVN on duty. She stated the situation had been resolved by hiring 3 RN's and the DON would cover a shift if needed. During an interview on 05/21/25 at 10:27 AM, The DON stated she started in the DON position in March 2025. She stated the reason for the failure to provide RN coverage on weekends may have been because it was difficult to attract and hire RNs in a rural area. The DON stated consequences of failing to have an RN on site may be a condition change would be missed, signs and/or symptoms of a disease process such as a developing infection would be identified by an RN. She explained the situation was fixed when the facility hired 3 RNs. Review of facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, Policy Interpretation and Implementation, Sufficient Staff, item 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 2 (Resident # 1 and Resident # 11) of 12 Residents reviewed for accuracy of assessments. The facility failed to ensure MDS dated [DATE] reflected the use of a right and left leg brace for Resident #1. The facility failed to ensure MDS date 05/07/2025 reflected the use of antibiotics for Resident #11. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: diabetes, muscle wasting, and unsteadiness on feet. Review of Resident #1's MDS dated [DATE] revealed: BIMS of 10 which indicated moderate cognitive impairment. Review of Section O revealed no Splint or brace assistance. Review of Resident #1's Comprehensive Care Plan, last revised 11/18/2024, revealed no evidence of right and left leg braces. Review of Resident #1's electronic physicians orders revealed no evidence of an order to right and left leg braces. Observation on 05/19/25 at 10:18 AM, Resident #1 up in wheelchair with right and left leg braces in place. Observation and interview on 05/20/25 at 02:44 PM, Resident #1 resting in bed with braces sitting in wheelchair. She stated she had to wear her braces anytime that she was out of bed because her feet turn inward. Resident #11 Review of Resident #11's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: heart failure, infection of the heart, and kidney failure. Review of Resident #11's MDS dated [DATE] revealed BIMS of 11 which indicated moderate cognitive impairment. Review of Section M revealed no antibiotics during the last 7 days. Review of Resident #11's Comprehensive Care Plan, last revised 03/20/2025, revealed no evidence of IV antibiotic therapy of infection. Review of Resident #11's electronic physicians orders revealed: Daptomycin-sodium Chloride Intravenous Solution Use 700 mg intravenously at bedtime for infection until 06/27/2025, start date 05/01/2025 and Rifampin Oral Capsule 300 mg give 1 tablet by mouth for infection until 06/27/2025, start date 05/01/2025. During an interview on 05/21/25 at 10:55 AM, ADON stated residents' leg braces and antibiotics should have been claimed on the MDS. She stated she was responsible for MDS, and she must have just missed it. She stated this did not have any negative effect on the residents. During an interview on 05/21/25 at 11:01 AM, the DON stated the ADON was responsible for MDS, and it was just missed. She stated that the leg braces and the antibiotic should have been claimed in the MDS. DON stated the facility does not have a policy for MDS. She stated the facility follows the RAI.

Based on interview and record review, the facility failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, seven days a week for 75 of 183 days reviewed for RN Coverage. The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 65 days out of 92 days in Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) and 10 out of 91 days from January 1, 2024 to March 31, 2024. This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 4 (October 1 - December 31) revealed no RN coverage on October 1, 7, 8, 14, 15, 21, 22, 28, 29, 30, and 31, 2023, November 1, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 20, 21, 22, 23, 24, 25, 26, 27, 29 and 30, 2023, and December 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31, 2023. On 04/04/2024 at 1:28 PM, documentation of RN coverage was requested from the Business Office Manager. The facility was unable to provide documentation of RN coverage on the dates listed above. Record review of RN Time Sheets for 2024 revealed no RN coverage on January 6, 7, 13, 14, 27, and 28, 2024, February 10 and 11, 2024, and March 2 and 3, 2024. During an interview on 04/04/2024 at 01:11 PM, LVN A stated an RN should be in the building at least 8 hours a day. She stated the DON would notify the staff if a scheduled RN was not going to work. LVN A stated consequences of failing to have an RN in the building for 8 hours a day, 7 days a week might be if a resident had an event that required the knowledge and skills within an RN's scope of practice, the resident might needlessly suffer. She explained if a situation occurred requiring an RN, she would call the DON to come in. During an interview on 04/04/2024 at 2:00 PM, the Regional Nurse Consultant stated the facility had difficulty attracting RN applicants due to the rural location and reluctance of RN's to work in long-term care. She stated RN staffing improved when the new DON and Administrator were hired. She stated her expectation was to have 8 hours of RN coverage daily. Leadership plays a crucial role in attracting new employees. She stated they have been persistent with recruiting. The DON stated she was responsible for ensuring the facility had RN coverage. She stated if an RN was unable to work a scheduled shift, she would cover it. The DON stated not having an RN in the building could impact resident's negatively and gave an example of a thorough RN assessment. Review of facility policy titled Hours of Work revised December 2009 did not address an RN in the building for eight (8) consecutive hours a day, seven (7) days a week. The facility did not provide a policy specific to the RN hours requirement.

Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #8, Resident #9, Resident #19, Resident #26, and Resident #31) of 5 residents reviewed for care plans. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as pain management, weight loss or gain, urinary control, psychotropic medications, difficulty sleeping, implanted pacemaker, high blood pressure medications, blood thinning medications, and seasonal allergies for Resident #8. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as infection control, behaviors, compliance with physician's orders, pain management, risk for malnutrition, mobility, and functional abilities for Resident #9. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as meal choices, activities of daily living, laboratory testing, dementia care, post-traumatic stress disorder, chronic pain, and vision impairment for Resident #19. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such infection control, weight loss or gain, dementia care, pain management, and participation in activities for Resident #26. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as weight loss or gain, pain management, therapy services, mobility, allergies, and participation in activities for Resident #31. These failures could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Review of Resident #8's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of heart failure, difficulty communicating, difficulty walking, heart burn, constipation, swelling, heart pacemaker, kidney disease, obesity, high blood pressure and atrial fibrillation (an abnormal heart rhythm). Review of Resident #8's Brief Interview of Mental Status evaluation dated 02/21/2024, revealed Resident #8 scored 14 out of 15 indicating intact cognition. Review of Resident #8's Comprehensive Care Plan reviewed/revised 02/21/2024 revealed the following problem care areas with objectives that were not measurable: Problem: [Resident] is at risk for alteration in comfort and or pain R/T: obesity Residents specific pain goal is: resident requires verbal numeric pain scale with in objective of resident will be able to verbalize pain and or discomfort at an acceptable level ., Problem: I have the Potential for weight fluctuations, loss and gain, related to resident having multiple comorbidities with an objective of Weight will either remain in a therapeutic range or reach a therapeutic range .:, Problem: Urge urinary incontinence R/T diuretics with an objective of Resident will establish a routine for urinary elimination, Problem: [Resident] receives a psychotropic medication for: X other with an objective of resident will receive the lowest possible dose to achieve/maintain the therapeutic benefits, maintain safety and quality of life, function and well being and will have side effects and interactions kept to a minimum ., Problem: I have Insomnia with an objective of Will have adequate sleep patterns aeb: reporting restful sleep at HS, no excessive daytime sleepiness ., Problem: [Resident] has a pacemaker/defibrillator and may be at risk for decreased cardiac output and irregular pulse; and potential for pacemaker/defibrillator malfunction, with an objective of Resident pulse will remain within baseline limits and cardiac output will remain within normal limits ., Problem: Potential for complications, s/sx related to diagnosis of hypertension. Resident receives anti hypertensive and is at risk for side effects with an objective of resident's blood pressure will remain within their normal limits ., Problem: [Resident] has episodes of edema and is at risk for fluctuating weights, injury and a decrease in adls with an objective of Resident will be able to maintain current ADLs ., Problem: Myself, or my representative, expresses a desire for long term placement at this facility Related to: Advanced Disease process/condition with an objective of I will demonstrate understanding of long term placement plans ., Problem: I HAVE THE Potential for alteration in bleeding r/t the use of anticoagulants/antiplatelets therapy for diagnosis of: AFIB with an objective of Current medical regime will be effective in management of disease process with no altered bleeding tendencies ., and Problem: Allergic rhinitis (swelling of the lining in the nose)/seasonal allergies/allergic conjunctivitis (swelling of the lining of the eyelids) with an objective of signs and symptoms of allergic rhinitis/seasonal allergies/allergic conjunctivitis will be assessed and effectively treated through medical regimen and MD orders . Review of Resident #9's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes, difficulty walking, Pseudomonas (type pf bacteria), dementia, epilepsy (seizure disorder), heart failure, respiratory disease, weakness, arthritis, atrial fibrillation (irregular heart rate), and chronic pain. Review of Resident #9's Brief Interview of Mental Status evaluation dated 02/18/2024, revealed Resident #9 scored 15 out of 15 indicating intact cognition. Review of Resident #9's Comprehensive Care Plan reviewed/revised 02/19/2024 revealed the following problem care areas with objectives that were not measurable: Problem: Enhanced Barrier Precautions due to wound care with an objective of To maintain the possible spread of infection, Problem: I sometimes make false accusations towards staff and the facility with an objective of I will have my needs met, emotionally and physically, Problem: [Resident] is non compliant with: Taking a shower X md order- O2 is ordered for 2 LLPM and he changes it himself X Other- describe- [Resident] has the potential for negative impact on health r/t failure to follow recommended treatment with an objective of resident will have knowledge of potential for harm related to refusal to follow recommended treatments/md orders and will have wishes respected ., Problem: Resident has complaints of chronic pain R/T diabetic ulcer to right foot with an objective of Resident will verbalize reduction of pain, Problem: Resident is at risk for malnutrition R/T no natural teeth or dentures (edentulous). With an objective of Weight will be maintained within acceptable parameters, Problem: I have a history of inappropriate behavior with an objective of Educate resident on appropriate behavior, Problem: Behavior problem related to other residents wandering into his room. AEB: he obsesses with residents that wanders into room with an objective of Will have behavior identified so that staff may intervene quickly with listed interventions ., Problem: I am limited in mobility/functional status and requires the use of CAM boot to my left foot with an objective of I will safely walk in room, walk in corridor, locomote on unit, locomote off unit, dress, toilet, with use of CAM boot, Problem: I am at risk for alteration in comfort and or pain with an objective of Resident will have pain/discomfort expressed at an acceptable level of pain, Problem: I desire to improve in functional abilities, I have set goals to be preforming and plans to return to previous residence with an objective of Resident will be assisted, encouraged to achieve functional goals and return to living situation of choice within their physical ability, maintaining pain at a tolerable level and with dignity intact ., and Problem: I a am a new admission with discharge potential. Stay projected to be short duration, and resident plans to D/C to home/assisted living with an objective of Will improve self-care ability to be ready for discharge to home/ assisted living . Review of Resident #19's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood pressure, long term use of blood thinners, obesity, history of falls, weakness, heart failure, difficulty in walking, chronic pain, chronic blood clots, difficulty sleeping, respiratory disease, dementia, post-traumatic stress disorder, heart burn, and high cholesterol. Review of Resident #19's Brief Interview of Mental Status evaluation dated 02/18/2024, revealed Resident #19 scored 15 out of 15 indicating intact cognition. Review of Resident #19's Comprehensive Care Plan reviewed/revised 02/26/2024 revealed the following problem care areas with objectives that were not measurable: Problem: [Resident] is requesting to not eat breakfast. I only wish to have beverages in the mornings with an objective of For resident to maintain adequate BMI, Problem: I have difficulty with making my bed with an objective of Assist with bed making, Problem: I am at risk of increased health issues related to labs not being able to be monitored due to my blood cannot be accessed from my veins with an objective of My health concerns can be addressed by other types of monitoring ., Problem: I may benefit from Therapy services with an objective of I will not decline or show improvement in physical abilities ., Problem: I have Dementia and an alteration in thought processes. I have poor decision-making skills with an objective of I will maintain current level of cognitive function ., Problem: I have Post trauma stress disorder, chronic with an objective of I will not exhibit signs of post-traumatic syndrome, Problem: I am at risk for alteration in comfort and or pain R/T: Dx of chronic pain with an objective of I will be able to verbalize pain and or discomfort at an acceptable level ., and Problem: I have vision impairment with an objective of I will maintain optimal quality of life within limitations. Review of Resident #26's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of cancer, atrial fibrillation, anemia, malnutrition, pressure ulcers, Rheumatoid arthritis, dementia, constipation, and hardening of the arteries. Review of Resident #26's Brief Interview of Mental Status evaluation dated 01/31/2024, revealed Resident #26 scored 15 out of 15 indicating intact cognition. Review of Resident #26's Comprehensive Care Plan reviewed/revised 02/22/2024 revealed the following problem care areas with objectives that were not measurable: Problem Enhanced Barrier Precautions due to wound care with an objective of To prevent the spread of possible infection, Problem: Monthly weights only due to chronic pain with movement. I am bed bound, with an objective of I will have my wishes honored, Problem: I have dementia. I have impaired decision making, short and/ or long term memory loss due to Dementia with an objective of Will maintain current level of cognitive function aeb: . Problem: I am at is at risk for alteration in comfort and/or pain related to Cancer diagnosis, lack of mobility. with an objective of I will be able to verbalize pain and/or discomfort at an acceptable level ., Problem: I have a potential for complications (weakness/fatigue/weight loss/malnutrition/increased pain/ depression and ineffective coping related to diagnosis of cancer. with an objective of Current medical regimen will be effective in management of disease process with no ill effects, needs will be met. I will be kept comfortable and emotional support will be given ., and Problem: I require one to one activity due to being bedbound and I am at risk for social isolation with an objective of I will respond to bedside activities and will not have feelings of social isolation . Review of Resident #31's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, difficulty walking, hemorrhoids, chronic pain, heart attack, difficulty communicating, dementia, Type 2 diabetes, asthma, heart burn, chronic fatigue, high cholesterol, Vitamin A deficiency, low thyroid function, and major depression. Review of Resident #31's Brief Interview of Mental Status evaluation dated 02/16/2024, revealed Resident #31 scored 10 out of 15 indicating moderate impaired cognition. Review of Resident #31's Comprehensive Care Plan reviewed/revised 02/19/2024 revealed the following problem care areas with objectives that were not measurable: Problem: Potential for weight fluctuations, loss and gain, related to having multiple comorbidities with an objective of Weight will either remain in a therapeutic range or reach a therapeutic range ., Problem: I have a nerve stimulator implanted in my back with an objective of I will have reduction of pain, Problem: Resident may benefit from PT/OT/ST services with an objective of Resident will not decline or show improvement in physical abilities ., Problem: Limited physical mobility related to: weakness and fatigue with an objective of Will maintain current level of mobility ., Problem: I have potential for injury related to medication allergies, resident is allergic to: with an objective of Resident will have no harm related to medication allergies ., Problem: I have episodes of anxiety and is at risk or fluctuations in moods with an objective of Resident anxiety will be maintained t level tolerable to resident and will demonstrate reduced anxiety AEB response to proper medication ., and Problem: Encourage resident to attend activities of choice ., with an objective of Resident will enjoy activities . During an interview on 04/04/2024 at 1:11 PM, LVN A stated the ADON created the care plans and the DON monitored. Changes were communicated to staff via face-to-face conversation with the DON. She stated care plans goals should be measurable. LVN A stated resident goals or objectives must be specific to the resident. She explained if the goals were not measurable, there would not be a way to determine if interventions were successful or needed to be revised. During an interview on 04/04/2024 at 1:55 PM, the DON stated the ADON created the care plans. She stated she was responsible for oversight of the care plans. During an interview on 04/04/2024 at 2:00 PM, the Regional Nurse Consultant stated ideally the MDS Coordinator should be creating the care plans with input from IDT. She stated the DON was responsible for monitoring the care plans. Stated nursing staff was educated on locating care plans during orientation but admitted few refer to the care plans regularly. The RNC acknowledged the examples of objectives from current care plans were not measurable. Examples provided were current medical regimen will be effective in management of disease process with no ill effects and maintain adequate BMI. Stated that a goal that cannot be measured also cannot give guidance on if interventions were effective or needed to be reviewed or revised. Review of the facility policy titled Comprehensive Care Plans dated September 2010 revealed the policy statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation section revealed 3. Each resident's comprehensive care plan is designed to: e. Reflect treatment goals, timetables and objectives in measurable outcomes

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were sealed and/or labeled properly in dry food storage and freezers. The facility failed to properly thaw frozen meats to prevent unsafe temperature. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: An observation of kitchen on 04/02/2024 between 8:31 a.m. and 8:48 a.m. revealed: Sink #1 Clear plastic bag of what appeared to be chicken thighs sitting in sink not surrounded by water. Tap water running over top and down the side of clear plastic bag. Freezer #1 Unsealed package of circular frozen meat patties sitting in box. Freezer #2 Unsealed package of circular frozen pastry that was not labeled or dated. Dry Storage Unsealed clear plastic bag or what appeared to be curly pasta. Unsealed bag labeled alfredo sauce mix. An observation of kitchen on 04/02/2024 between 11:40 a.m. and 12:45 p.m. revealed: Sink #1 Clear plastic bag of what appeared to be pork loin sitting in sink not surrounded by water. Tap water running over top and down the side of clear plastic bag. During an interview on 04/02/2024 at 12:45 p.m., the DM stated she was unsure what the facility policy stated on how to defrost meat. She stated she would prefer to defrost meat in refrigerator but that it would take several days to perform. She stated she places next days meat in the refrigerator the night before then completes defrosting in the sink with water running over it. The DM stated not defrosting food properly could cause bacteria to grow and residents to become sick. The DM stated foods stored in pantry and freezer should be in a sealed container. She did not know why food was stored unsecured. She stated not sealing the container could lead to residents becoming sick. During an interview on 04/03/2024 at 11:47 a.m., the ADMN stated it was his expectation that frozen meats should be defrosted in the refrigerator if possible. He stated if meat was to be defrosted in sink, he expected it to be surrounded with cold circulating water. He felt that education was the reason meats were not defrosted to his expectations. He stated the DM was responsible for monitoring meats were defrosted appropriately and he monitored the DM. The ADMN stated incorrectly defrosting meat could cause residents to become ill from food poisoning. The ADMN stated he expected all foods to be stored in a sealed container or bags to be zip tied. He stated he felt education was the reason foods were not stored in sealed containers. He stated that both the DM and he were responsible for monitoring foods were stored correctly. He stated the effect that could have would be illness to the residents. Review of facility policy titled Food Preparation and Service revised in July of 2014 revealed: Thawing Frozen Food 1. Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container; b. Submerging the item in cold running water (70? or below); c. Thawing in a microwave oven and then cooking and serving immediately; or d. Thawing as part of a continuous cooking process. Review of facility policy titled Food Receiving and Storage revised on July 2014 revealed: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system .The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing.

Based on interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 3 residents (Resident #16) reviewed for MDS information. The facility failed to encode, complete, and submit a discharge MDS for Resident #16. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes. Findings included: Closed record review of Resident #16's face sheet dated 04/03/2024 revealed a [AGE] year-old male that admitted into facility on 10/03/2023 and discharged on [DATE]. Closed record review of Resident #16's care plan dated 10/08/2023 revealed I will have access to necessary services to promote adjustment to my new living environment and or post discharge from facility. Closed record review of Resident #16's MDS assessment completion list did not reveal a Discharge MDS had been completed. During an interview on 04/03/2024 at 2:14 p.m., the ADON stated she was responsible for performing MDS assessments. She stated there should have been a discharge MDS assessment performed when a resident was discharged from facility. She stated she was unsure why the discharge MDS assessment was not performed. She stated corporate regional MDS consultant monitored assessments performed as the DON working during that time no longer worked for the corporation. During a phone interview on 04/03/2024 at 3:23 p.m., the [NAME] MDS Consultant stated discharge MDS assessments were to be performed with either return anticipated or return not anticipated when a resident was discharged . She stated discharge MDS assessment should be performed within 14 days of census change. She stated she did not know why discharge MDS assessment had not been performed. She did not state any negative effect not performing a MDS discharge assessment could have on the resident. Record review of facility policy titled Resident Assessment Instrument revised in September 2010 revealed: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. 2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. Other assessment forms may be used in addition to the MDS form. 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 5. Residents and/or their representatives (sponsors) will be encouraged to participate in the initial, quarterly and annual assessments. The Assessment Coordinator or designee will notify the resident and/or sponsor in advance of the scheduled assessment or review. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information.

Based on interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #9, and Resident #185) of 7 residents reviewed for care plans. -The facility failed to ensure Resident #9's care plan accurately addressed intravenous antibiotic therapy. -The facility failed to ensure Resident #185's care plan addressed an accurate smoking status. These failures could affect residents of the facility by not accurately addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Review of Resident #9's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes, difficulty walking, Pseudomonas (type pf bacteria), dementia, epilepsy (seizure disorder), heart failure, respiratory disease, weakness, arthritis, atrial fibrillation (irregular heart rate), and chronic pain. Review of Resident #9's Brief Interview of Mental Status evaluation dated 02/18/2024, revealed Resident #9 scored 15 out of 15 indicating intact cognition. Review of Resident #9's Comprehensive Care Plan reviewed/revised 02/19/2024 revealed Problem Start Date: 02/19/2024 I must have trough blood levels to be checked every 4 days while on IV [antibiotic]. Goal: Long Term Goal Target Date: 05/19/2024 Trough levels to be within normal range. Approach: Approach Start Date: 02/19/2024 Trough levels to be within normal range. Record review of Resident #9 physician's orders since admission revealed no order for intravenous antibiotic therapy. Review of Resident #185's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes, depression, low blood potassium, low thyroid function, weakness, constipation, difficulty walking, and difficulty communicating. Review of Resident #185's Admission MDS dated [DATE] Section C Cognitive Patterns C0500 BIMS Score Summary revealed Resident #9 scored 10 out of 15 indicating moderate impaired cognition. Review of Resident #185's Smoking assessment dated [DATE] revealed a Smoking Risk Score of 2 out of 27 indicating Safe Smoker - Follow Facility Policy. Plan of Care: Indicate Plan of Care action take: Initiate Plan of Care was selected. Review of Resident #185's comprehensive care plan reviewed/revised 03/26/2024 revealed her smoking status was not addressed. During an interview on 04/04/2024 at 11:11 AM, the ADON stated comprehensive care plans were done with the MDS Coordinator and should be done by 21st day after admission. She stated care plans were updated when there was a medication change, an incident such as a fall, if the resident was a smoker, and if there were any behaviors. She stated the DON reviewed the care plans and the RNC monitored the DON. The ADON stated she thought she had updated the care plans for residents who smoke. She stated smoking should be care planned. The ADON stated she did not know why Resident #185's smoking status was not care planned. She stated she was not sure how this could affect the resident except the nurses who look at care plan might not know that she smoked. During an interview on 04/04/24 at 1:11 PM, LVN A stated a possible explanation for the intravenous antibiotic on Resident #9's care plan without a physician's order or notation in the progress notes occurred due to a clerical data entry error. She stated the consequence to resident may receive medications without a physician's order and that medication could be contraindicated with other meds ordered. During an interview on 04/04/2024 at 1:15 PM, the DON stated care plans should be resident focused, applied to each resident and implemented as stated in the care plan. She stated smoking should be care planned for all smokers with safety first. She stated the facility had a list of smokers. The DON stated she was not sure why it was not care planned. The DON stated she reviewed care plans and RNC reviewed them as well. She states she was unaware of any resident that smoked had not been able to smoke regardless of the care plan. During an interview on 04/04/2024 at 2:00 PM, the Regional Nurse Consultant and DON did not have an explanation as to why Resident #9 had intravenous antibiotic therapy on his care plan without a physician's order. The Regional Nurse Consultant stated it was entered incorrectly. She stated on-going training starting with nursing leadership was planned to cover care plans. The Regional Nurse Consultant and DON stated their expectations were for care plans to be created to accurately reflect the needs of each resident. Review of the facility policy titled Comprehensive Care Plans dated September 2010 revealed the policy statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Policy Interpretation and Implementation section revealed 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on record reviews and interviews, the facility failed to complete discharge summaries that included a recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 residents (Resident #16) reviewed for discharge. The facility failed to provide Resident #16 with discharge summary when discharged from facility. This failure places residents at risk for incomplete and cohesive care after discharge from the facility. Findings included: Closed record review of Resident #16's face sheet dated 04/03/2024 revealed a [AGE] year-old male that admitted into facility on 10/03/2023 and discharged on [DATE] with diagnoses that included: personal history of transient ischemic attack (mini stroke), cerebral infarction without residual deficits (stroke without deficits), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic lung disease interfering with airflow). Closed record review of Resident #16's Admission MDS dated [DATE] revealed resident had a BIMS score of 5 meaning severe cognitive impairment. Closed record review of Resident #16's electronic MAR (medication administration record) dated for October 2023 revealed: Code Status: DNR .If resident has not had a BM in 3 days, initiate bowel protocol .O2 at 2 liters per minute to keep O2 saturations above 92% .offer snack between meals and at night .albuterol sulfate (medication to help open airways) inhaler 90 mcg/actuation 2 puffs PRN four times a day for chronic obstructive pulmonary disease .amlodipine (blood pressure medication) tablet 10mg administer 1 tablet at 9:00 a.m .aspirin tablet 325mg administer 1 chewable tablet at 9:00 a.m .atorvastatin (medication to lower cholesterol) tablet 20mg administer 1 tablet at 8:00 p.m .bisacodyl (medication for constipation) suppository 10mg administer 1 rectally PRN once a day for constipation .ipratropium-albuterol (medication to help open airways) solution for nebulization 0.5mg-3mg / 3ml administer 3ml inhalation every 4 hours PRN chronic obstructive pulmonary disease .lactulose solution (medication for constipation) 20 gram / 30 ml administer 30ml orally twice a day .morphine (pain for shortness of breath) solution 10mg / 5ml administer 5mg every 1 hour PRN chronic obstructive pulmonary disease .omeprazole (medication to help lower acid production in stomach) tablet 20mg administer 40mg orally one a day .prednisone (medication to help reduce inflammation) tablet 10mg administer 1 tablet once a day orally .senna (laxative) tablet 8.6mg administer 1 table orally once a day. Closed record review of Resident #16's file revealed no evidence that a discharge summary was completed. During an interview on 04/03/2024 at 2:08 p.m., the Regional Nurse Consultant stated discharge summaries should be completed and signed by resident or resident representative when a resident was discharged . She stated charge nurses or nurse managers were responsible for having discharge summaries completed. During an interview on 04/03/2024 at 2:12 p.m., the ADON stated Resident #16 was discharged on a weekend. She stated her expectation would be for the charge nurse to call her and she could perform the discharge summary and have charge nurse get the summary signed at the time of discharge. She stated she felt Resident #16's discharge summary might have been missed because he was an unplanned discharge and had unexpected issues related to the discharge . She stated she would look in medical records to see if his discharge summary was documented on a paper and was not uploaded into chart. During an interview on 04/04/2024 at 9:03 a.m., the Regional Nurse Consultant stated no discharge summary was found at that time. She stated she felt no negative effect occurred from the failure. She stated it could potentially place another resident at risk to not have information about follow up appointments and medication effecting coordination of care when discharged . Record review of facility policy titled Discharge Summary and Plan revised in September 2012 revealed: 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: Medically defined condition and prior medical history (medical history before entering the facility and current medical diagnoses, including any history of mental retardation and current mental illness); Medical status measurement (objective measurements of a resident's physical and mental abilities including, but not limited to, information on vital signs, clinical laboratory values, or diagnostic tests); Physical and mental functional status (ability to perform activities of daily living including bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems. Includes determining the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities and the resident's ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility); Sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); Nutritional status and requirements (weight, height, hematological and biochemical assessment, clinical observations of nutrition, nutritional intake, resident eating habits and preferences, and dietary restrictions); Special treatments or procedures (treatments and procedures that are not part of basic services provided; for example, treatment for pressure sores, naso-gastric feedings, specialized rehabilitation services, and respiratory care); Mental and psychosocial status (the resident's ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); Discharge potential (the expectation of discharging the resident from the facility within the next three months); Dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); Activities potential (the resident's ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being. Activity pursuits refer to any activity outside of ADLs which a person pursues in order to obtain a sense of well-being. Includes activities which provide benefits in the areas of self-esteem, pleasure, comfort, health education, creativity, success, and financial or emotional independence, and the resident's normal everyday routines and lifetime preferences); Rehabilitation potential (the ability to improve independence in functional status through restorative care programs); Cognitive status (the resident's ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and Drug therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 3. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will contain, as a minimum: 1. A description of the resident's and family's preferences for care; A description of how the resident and family will access such services; A description of how the care should be coordinated if continuing treatment involves multiple caregivers; The identity of specific resident needs after discharge (i.e., personal care, sterile dressings, physical therapy, etc.); and A description of how the resident and family need to prepare for the discharge. 4. The resident or representative (sponsor) should provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge plan can be developed. 5. The Social Services Department will review the plan with the resident and family twenty-four (24) hours before the discharge is to take place. 6. A copy of the post-discharge plan and summary will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records.

Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week and did not designate an RN as a Director of Nurses on a full-time basis. The facility failed to have an RN for 8 consecutive hours 7 days a week. The facility failed to designate an RN as a Director of Nurses on a full-time basis. These failures could place all residents at risk for their clinical needs not being met. Findings included: During an interview on 05/27/23 at 10:31 AM with the BOM, she said the facility did not have a DON. She stated a DON had been hired and was scheduled to start working on Monday, May 29, 2023. The BOM stated the facility had not had a DON or weekend RN for quite some time. During an interview on 05/28/23 at 11:08 AM, the BOM stated the ADON was responsible for creating the nursing staff schedules and completing the daily staffing form. The BOM acknowledged the daily staffing form had not been posted since the ADON left week before last. The BOM stated the ADON left without notice. The BOM stated she had been trying to locate the daily staffing postings. During an interview on 05/28/23 at 12:31 PM, the Regional Director of Operations, stated the facility was advertising for a weekend RN on a job search web site. She stated the facility had recently hired a DON. The RDO explained with a small facility in a small town close to a city with a large hospital, it was difficult to attract nurses, especially RNs. During an interview on 05/28/23 at 12:31 PM, the RDO stated the facility was advertising for an RN on a job search web site. The RDO stated she would prefer to hire an RN to fill the ADON position and schedule the RN for Saturday & Sunday with time off during the work week so 2 issues were resolved at once. The RDO located nursing schedules for April and May 2023 but stated she was still looking for March 2023. During an interview on 05/28/23 at 1:28 PM, the RDO explained the facility's plan to resolve staffing shortage was to keep trying. The RDO and RNC were not able to provide an explanation of the effect on residents when an RN was not on site 7 days a week. Review of Facility's Nursing Staff schedules from January 2023 to May 2023 revealed no evidence of RN coverage. Review of Facility's Daily Staffing Data from January 2023 to February 2023 revealed no evidence of RN coverage on 01/15/2023, 01/29/2023, 02/01/2023, 02/02/2023, 02/03/2023, and 02/04/2023. Facility was not able to provide Facility's Daily Staffing Data for March 2023, April 2023, and May 2023. Review of facility policy labeled Departmental Supervision revised August 2006 revealed: The nursing services department shall be under the direct supervision of a RN or LVN at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN, LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff.

Based on observation, interview, and record review the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census. The facility did not post the required nurse staffing information on 05/27/2023 and 05/28/2023. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. Findings included: Observation on 05/27/2023 at 9:30 AM and on 05/28/2023 at 7:15 AM, revealed the daily nurse staffing information could not be located at the main entrance, nurses' station, or hallway bulletin board. During an interview on 05/28/23 at 1:28 PM, the RDO stated the expectation of posting daily nursing staffing data was that it gets done. The RDO stated the ADON was responsible for posting and filing the completed daily nurse staffing data forms. The RDO stated the completed daily nursing staffing data forms that were to be posted daily should have been in the ADON's office, but RDO could only locate completed nursing staffing data forms for 01/15/2023, 01/29/2023, 02/01/2023, 02/02/2023, 02/03/2023, and 02/04/2023. Review of facility policy titled Posting Direct Care Daily Staffing Numbers revised August 2006 revealed Policy Statement: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation item 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Item 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift scheduled operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. Actual time worked during that shift for each category and type of nursing staff. h, Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on observation, interview and record review the facility failed to notify and consult the physician regarding low blood sugar levels for four of six diabetic residents (Residents' #5, #9, #11, and #12) reviewed for blood sugar monitoring. The facility failed to: a. Provide interventions or notify Resident #5's physician regarding an identified critically low blood glucose level of 45 mg/dl on 12/31/12. b. Provide Resident #5 assessments and interventions of low blood sugars that were less than 70 mg/dl at 5:30 a.m. on 12/06/12, 12/07/12, 12/14/12, 12/15/12, 12/18/12, 12/26/12, 12/27/12, 12/31/12, and 01/04/13. c. Provide Resident #9 assessments or interventions for 7:00 a.m. Accuchecks that were less than 70 mg/dl on 12/01/12, 12/02/12, 12/11/12, and 12/15/12. d. Provide Resident #11 assessments for blood sugars less than 70mg/dl between 4:00 p.m. and 7:00 p.m. on 12/07/12, 12/12/12, 12/18/12, 12/20/12 and 12/21/12 e. Provide interventions or notify Resident # 12 ' s physician of high blood sugars greater than 350 mg/dl on 12/02/12, 12/04/12,12/21/12,12/23/12,12/24/12,12/28/12, 12/30/12, and 12/31/12. "[DIAGNOSES REDACTED] (low blood sugar)...[DIAGNOSES REDACTED] is defined as a serum glucose level (the amount of sugar or glucose in your blood) below 70 mg/dl. Symptoms of [DIAGNOSES REDACTED] typically appear at levels below 60 mg/dl. Some people may feel symptoms above this level. Levels below 50 mg/dl affect brain function." Source dated 01/09/13: <http://www.emedicinehealth.com/low_blood_sugar_[DIAGNOSES REDACTED]/article_em.htm> An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place six residents with diabetes at risk of not receiving timely medical evaluation and treatment resulting in complications secondary to [DIAGNOSES REDACTED] such as coma and death. The findings included: 1. Record review of Resident #5's current "Record of Admission" revealed a [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "[DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed he had a BIMS score of 5 which indicated he was severely cognitively impaired, had disorganized thinking continuously, had behavioral symptoms, wandered and rejected care. Resident #5 required assistance of one person for transfers, dressing, toileting, personal hygiene, supervision of one person for eating, and was incontinent of bladder and bowel. In an interview on 01/02/13 at 3:35 p.m. during initial tour LVN E said that Resident #5 was alert but confused, had recently been identified with weight loss and required encouragement to eat, was not interviewable and had a [DIAGNOSES REDACTED]. Observation on 01/02/13 at 3:35 p.m. revealed Resident #5 was in his room in a high-back wheelchair. He had an alarm on the back of his wheelchair and a bracelet on his ankle. He was a tall man and appeared very thin. Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 01/28/13 revealed the following orders: " Hgb A1C every six months. "Accuchecks (blood sugar test using a glucometer and a small drop of blood obtained from the resident's finger) two times daily, [MEDICATION NAME] 15 units subcutaneously at bedtime for diabetes (start date 08/08/11), [MEDICATION NAME] ([MEDICATION NAME]) 500 mg. one by mouth two times daily for diabetes (start date 08/29/11), and [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes (start date 12/13/12)." "[MEDICATION NAME] (insulin [MEDICATION NAME]) is a man-made form of a hormone that is produced in the body. It works by lowering levels of glucose (sugar) in the blood. [MEDICATION NAME] is a long-acting form of insulin ..." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] is an oral diabetes medicine that helps control blood sugar levels." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's physician's orders did not reveal blood sugar parameters indicating when to notify the physician of low and/or high blood sugar levels. Record review of Resident #5's current "Care Plan" dated 10/30/12 revealed no information related to his diabetes and blood sugar monitoring. There was no information that Resident #5 was receiving blood sugar monitoring (Accuchecks) twice daily, was to be monitored for signs and symptoms of low or high blood sugar, was to be provided snacks and what type of snacks according to the results of his blood sugars, or when to notify the physician for low and high blood sugars. In an interview on 01/04/13 at 3:35 p.m. the DON said that she was responsible for completing resident care plans and had not completed a care plan related to Resident #5's diabetes and blood glucose monitoring. Record review of Resident #5's "Diabetic Flow Record" dated 11/01/12 through 11/30/12 revealed blood sugars at 5:30 a.m. were mostly above 100 mg/dl and all above 70 mg/dl. The 8:00 p.m. blood sugars were between 105 mg/dl and 364 mg/dl. Record review of Resident #5's laboratory report for a "Hgb A1C" dated 12/07/12 revealed "8.1% (H-indicated high). The reference range is 4.5%-5.7%. "A1C test is a blood test that provides information about a person's average levels of blood glucose, also call sugar, over the past 3 months. The A1C test is the primary test used for diabetes management ..." Source dated 01/18/13: http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/#1 <http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/> Record review of Resident #5's Physician's Order" dated 12/13/13 revealed, " [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes." "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's "Diabetic Flow Record" dated 12/01/12 through 12/31/12 revealed blood sugars were done at 5:30 a.m. (breakfast was served at 7:30 a.m.) and 8:00 p.m. The blood sugars at 5:30 a.m. were: 12/06/12- 60 mg/dl 12/07/12- 65 mg/ dl 12/14/12- 62 mg/dl 12/15/12- 63 mg/dl 12/18/12- 60 mg/dl 12/19/12- 70 mg/dl 12/26/12- 62 mg/dl 12/27/12- 53 mg/dl (small OJ near this reading) 12/31/12- 59 mg/dl Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 02/28/13 revealed, "Complete Blood Count every two months" (This includes a glucose level). Record review of Resident #5's "Lab Report-Basal Metabolic Plan" revealed blood was drawn routinely on 12/31/12 and the results of the Glucose blood level was "45 mg/dl Critical Low 12/31/12 12:47AM- Critical Value! Repeated for verification and called to LVN C on 12/31/12 at 3:36 p.m." This was a routine lab that was scheduled to be done every two months. Record review of Resident #5's "Nursing Progress Notes" revealed: 12/31/12 3:30 p.m. "Lab called and says that the glucose was 45. Her telephone number is..." This entry was unsigned by the nurse. There was no documentations of any assessments or interventions provided to Resident #5 for blood sugars less than 70 mg/dl at 5:30 a.m. between 12/06/12 and 12/31/12. Record review of Resident #5's "Diabetic Flow Record" dated 01/01/13 through 01/31/13 revealed the blood sugar on 01/04/13 at 5:30 a.m. was 66 mg/dl. There was no documentation on the "Diabetic Flow Record" (on the front or back) that any interventions were provided for Resident #5 for this low blood sugar. In an interview on 01/04/13 at 3:25 p.m. LVN C said she performed Accuchecks for Resident #5 at 5:30 a.m. in the mornings. LVN C said that she had performed the Accucheck this morning with a result of 66 mg/dl. LVN C said that she gave him a "sip of red punch" that was on his bedside table. LVN C said that she did not know what to do for residents who had low blood sugars and had no training by the facility regarding interventions related to low blood sugars. LVN C said that she did not know the facility's policy or procedure for the treatment of [REDACTED]. LVN C said that she did not report to the oncoming shift nurses the low blood sugar or write it on the 24-hour report. LVN C said that she did not recheck or re-assess Resident #5 and ended her shift at 6:00 a.m. LVN C said that Resident #5's blood sugars in the early a.m. were often low. LVN C had not notified Resident #5's physician regarding the critically low blood sugar on 12/31/12. "It's important to treat [DIAGNOSES REDACTED] quickly because [DIAGNOSES REDACTED] can get worse and you could pass out. If you pass out, you will need immediate treatment, such as an injection of [MEDICATION NAME] or emergency treatment in a hospital. " Source dated 01/17/13: <http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html> In an interview on 01/07/13 at 1:22 p.m., the Acting Medical Director said he had given the facility a telephone order to call him for blood glucose levels of 50 and below and 350 and above. In an interview on 01/05/13 at 6:45 p.m. LVN D (Charge Nurswe) said that on 12/31/12 she had performed Resident #5's Accucheck at about 5:00 a.m. with a result of 59 mg/dl. LVN D said that she gave Resident #5 about four ounces of orange juice. LVN D said that she had not re-assessed him, had not put the information on the 24-hour report, and had not reported to the on-coming shift nurses before she left the facility at the end of her shift (6:00 a.m.) but knows she should have done all of these things. LVN D said that LVN C was a new nurse and had made the 12/31/12 3:30 p.m. unsigned entry in the nursing progress notes regarding the critically low blood sugar for Resident #5. LVN D said that she had instructed LVN C to notify Resident #5's physician regarding the low blood sugar. LVN D said that she did not know if Resident #5's physician was notified." In an interview on 01/04/2013 at 3:27p.m., the ADON said that she did not know if all of the diabetics had parameters or not on when to contact the physician in regards to low or elevated blood sugar results. The ADON said that the facility has had no training or in-services with the nurses in regards to diabetes, signs and symptoms of [DIAGNOSES REDACTED] or interventions to provide for low blood sugar results. In an interview on 01/04/13 at 3:35 p.m. The DON said (regarding the lab report dated 12/31/12 with the critically low blood sugar of 45 mg/dl for Resident #5) that she did not know and could not determine if Resident #5's physician was notified of the critically low blood sugar identified on 12/31/12. The DON said that the nurses should notify the resident's physician if there was a blood sugar of less than 70 mg/dl and more than 350 mg/dl. The DON said that she did not know what kind of intervention LVN C provided Resident #5 this morning related to his blood sugar of 66 mg/dl at 5:30 a.m. because there was no documentation on his "Diabetic Flow Sheet", the "Nursing Progress Notes", or the 24-hour report. The DON said that the nurse should have documented the intervention in the nursing progress notes, report to the on-coming shift so they could monitor him, and put the information on the 24 hour report. The DON said that no one to her knowledge had reported Resident #5's low blood sugars to his physician or rechecked Resident #5 (the numerous low blood sugars at 5:30 a.m. in December, 2012 or the identified critically low blood sugar on 12/31/12). The DON said that she had been employed since March, 2012 and had not provided any in-services related to Accuchecks. Record review of the four page policy "Nursing Care of Diabetes Mellitus, Effective date-01/2005" provided by the facility on 01/04/13 at 3:00 p.m. revealed: "Note: The physician should specify high and low parameters for all diabetic residents. Below are general guidelines to follow. Guidelines: -Signs of Hypoglycemic Event (Insulin Reaction) 1. Rapid onset 2.Polyphagia 3.Weakness, nervousness 4.Fast heart rate 5.Skin is pallid, cool, diaphoretic 6.Dilated pupils 7.Memory lapse, fatigue, lethargy, and new onset of confusion and/or agitation 8.Headache 9.Visual disturbance 10.Thick speech 11.Awkward body movement 12.Paralysis with spasms 13.Incontinent of urine 14.Restlessness, bizarre behavior 15.Unconsciousness or convulsions. Be alert to nonverbal signs of [DIAGNOSES REDACTED]: sudden onset of anxiety, bizarre behavior, lack of concentration, trembling, shaking, slurred speech, difficulty walking, staggering gait, lack of coordination, irritability and change in behavior that is different for the resident ' s usual behavior. -Notify the Physician: 1. ...blood glucose is less than 70 mg/dl unless the physician ordered specific parameters for the individual resident .... -Managing a Hypoglycemic(low blood sugar) Event 1. If fingerstick blood sugar is less than 70...: *Give 4 ounces of juice or milk, OR *Give three 5 gram oral glucose tablets, OR *Glucose gel...and reassess finger stick blood sugar in 15 minutes... 4. If blood sugar is not responding in 15 minutes: *Give 50 milliters of 50% glucose intravenously if available, OR *Activate 911 system 5. Follow initial treatment and recovery to over 70 mg/dl, with complex carbohydrate intake. 6. Review factors that may have precipitated the event in order to reduce the chance of recurrence. -Documentation: 1.Vital signs 2.State of consciousness 3.Blood sugar readings 4.Interventions taken-Juice, milk, oral glucose, glucose gel ...5.Residents response to the intervention 6.Skin color, temperature, dryness 7.Irritation.. 8.Restlessness ...17.Monitor pertinent laboratory studies ..." Record review of the one page policy "Blood Sugar (fingerstick) process, Effective date 01/2010" provided by the facility on 01/04/13 at 6:20 p.m. revealed the following: "Policy-To Assure appropriate process in the obtaining and reporting blood sugar levels and appropriate follow-up and treatment. Guidelines: *...Document Blood Sugar levels on appropriate form. *For Blood Sugar levels below 60 mg/dl, contact physician, unless component of Guideline is superseded by physician's orders. *Blood sugars below 60 mg/dl will be reported to administrative nursing if unable to contact physicians. *Document Blood Sugars below in 24 hour Report." In an interview on 01/06/13 at 2:50 p.m. RN A (Regional Representative) said that both the four page "Nursing Care of Diabetes Mellitus, Effective date-01/2005 and the one page Blood Sugar (fingerstick) process, are guidelines to be used by the facility. An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. The facility's Plan of Removal was received on 01/07/13 at 8:50 a.m. and accepted on 01/07/13 at 2:15 p.m. by Program Manager and included: "Facility will in-service all RNs and LVNs effective 01/04/13 regarding blood sugar finger-stick process policy. All nurses will be informed of blood glucose parameters per physician or use medical director's protocol. Nurses will notify physician via phone and personally speak with physician or assistant regarding glucose levels out of blood glucose parameters. Resident #5 was assessed for signs and symptoms of hypo/[MEDICAL CONDITION] with no noted negative manifestations. Resident #5's physician was contacted and orders were received for blood sugar parameters. All diabetic residents who receive blood sugar fingersticks have had blood sugar parameters re-established. The nurse LVN C identified in this alleged deficient practice and interviewed by Survey Team Member, contacted the facility and has resigned 01/04/13. All Facility Nurses have been re-educated on need and rational of appropriate follow-up to potential signs and symptoms/negative outcomes of Hypo/[MEDICAL CONDITION]: *Blood Sugar parameters as ordered by resident physician(s) *Signs and Symptoms of Hypo/[MEDICAL CONDITION] *Guidelines for recognizing, management, staff communications and contacts. All diabetic residents have the potential to be affected by this alleged deficient practice. The facility Director of Nursing and or designee will, during normal tour of duty, monitor blood sugar documentation and follow-up to assure compliance with this plan of correction. Noted concerns will be referred to the facility Administrator for Administrative Action. The facility QAA Committee, at least quarterly, monitor this plan of correction to assure compliance." On 01/07/13 at 2:15 p.m. the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 01/07/13 at 9:40 a.m. the DON said that all staff nurses except two part-time nurses had been in-serviced and that she would in-service them prior to allowing them to work. Record review of Residents' #5, #9, #11, #12, #13, and #14's "Physicians Orders dated 01/04/13 at 7:00 p.m. revealed the acting medical director had added the following new order: "1.If blood glucose level of 50 or below notify MD by phone 2. If blood glucose level of 350 or greater notify MD by phone." Interviews with nurses revealed that they would follow physician ' s orders regarding notification of physician related to low and high blood sugars and if the physician had not specified the parameters they would use the medical director ' s directions. These parameters were to notify the resident ' s physician if their blood sugar is 50 mg/dl or below and below and 350 mg/dl or greater. In an interview on 01/07/13 at 11:10 a.m. the DON said that the facility will notify residents' physician if their blood sugar is 50 mg/dl or below and 350 mg/dl or greater. The DON said that she had trained the nurses that if a resident has a blood sugar between 50 mg/dl and 70 mg/dl they should do as follows: 1. should assess the resident for signs and symptoms of low blood sugar, 2. if the resident showed signs and symptoms of low blood sugar then: a. ask the resident what type of snack they wanted and give the snack, b. reassess the resident in about 15-20 minutes for signs and symptoms of low blood sugar but will not do another fingerstick to check for the blood sugar because this is an invasive procedure that would require a physician's order, c. if still has signs and symptoms of low blood sugar, contact the resident's physician for treatment orders d. if cannot contact physician and continues to have low blood sugar symptoms, call 911. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED]. Non IJ Findings included: 1. Record Review of Resident #9's Record of Admission revealed a [AGE] year old female admitted to the facility on [DATE] and latest return admitted [DATE]. Record Review of Resident #9's January 2013 Physician Orders revealed the following Diagnoses: [REDACTED]. Record Review of Resident #9's January 2013 Physicians Orders contained no parameters on when to notify the physician for an elevated or low blood sugar result. Record Review of Resident #9's January 2013 Diabetic Flow Record contained no parameters on when to notify the physician for an elevated or low blood glucose result. Record Review of Resident #9's December 2012 Diabetic Flow Record revealed that Resident #9's accucheck (blood glucose result) on: 12/01/2012 at 0700 was 53 12/02/2012 at 0700 was 68 12/11/2012 at 0700 was 67 12/15/2012 at 0700 was 56 Record Review of Resident #9's facility nurse notes from 10/28/2012 through 12/29/2012 did not contain documentation from the nurses on 12/01, 12/02, 12/11 or 12/15/2012 as to Resident #9's blood glucose results. The nurses notes did not contain any type of assessment made by the nurse or any type of interventions received by Resident #9 in regards to the low blood glucose results on 12/01/12/02, 12/11 and 12/15/2012 at 0700. 2. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed she was an [AGE] year old female admitted to the facility 03/09/04 with [DIAGNOSES REDACTED]. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed, "...Accuchecks (a small sample of blood obtained by using a device to prick a finger for blood glucose measuring) BID (two times daily). Review of Resident #11's "Resident Care Plan" dated 07/10/12 revealed, "...Problem: (name) has a [DIAGNOSES REDACTED]. Interventions...Monitor problem/condition and report negative findings to physician..." Review of Resident #11's "Diabetic Flow Sheet" dated 12/01/12 through 12/31/12 revealed the following low blood sugars: 12/07/12, 4:00 p.m.: 65 12/12/12, 4:00 p.m.: 61 Review of Resident #11's "Progress Notes" for December, 2012 revealed no documented nurse's notes regarding blood sugar results or interventions. In an interview on 01/06/12 at 1:57 p.m., RN B said if a resident had a blood sugar of below 50 or greater than 350 she would call the Medical Director or designee. RN B said of a resident had a blood sugar of 50 or below, she would offer eight ounces of juice or crackers. RN B said she had been in-serviced 01/04/13 on the facility's policy regarding blood sugars. 3. Review of Resident #12's "Record of Admission" dated 07/18/12 revealed that she is a [AGE] year old female whose [DIAGNOSES REDACTED]. Review of Resident #12's Minimum Data Set Section I 2900 indicated she is a diabetic and Section N 0350 indicated that she received injections daily. Review of Resident #12's December 2012 monthly physician orders signed by the physician on 12/15/12 revealed Accucheck orders for "Accuchecks at mealtime and bedtime" and for Insulin orders which included " If below 50 or greater than 350, notify M.D. " (medical doctor). Resident #12 ' s sliding scale insulin orders included " give Humalog insulin before meals per sliding scale " . Resident #12 ' s sliding scale included in part giving 16 units of Humalog insulin for a finger stick blood sugar (FSBS) between 350-399 (mg/dl) and 17 units for a finger stick blood sugar between 400-499. Review of Resident #12 ' s " Diabetic Flow Record " for December 2012 revealed the following: On 12/04/12 at noon Resident #12 was documented as having a FSBS of 358 mg/dl, there was no documentation that the physician was notified or that sliding scale insulin was given. On 12/21/12 at 5:30 pm Resident #12 was documented as having a FSBS of 414 mg/dl, there was no documentation that the physician was notified and 16 units of sliding scale insulin was documented as being given, however according to the sliding scale orders 17 units should have been given. On 12/23/12 at 5:30 pm Resident #12 was documented as having a FSBS of 399 mg/dl, there was no documentation that the physician was notified as ordered. On 12/24/12 at 5:30 pm Resident #12 was documented as having a FSBS of 398 mg/dl, there was no documentation that the physician was notified as ordered. On 12/28/12 at 7:30 am Resident #12 was documented as having a FSBS of 381 mg/dl, there was no documentation that sliding scale insulin was given. On 12/30/12 at 8:00 pm Resident #12 was documented as having a FSBS of 440 mg/dl, there was no documentation that the physician was notified and 17 units of sliding scale insulin was given, however the orders specified that sliding scale insulin was to be given " before meals " . On 12/31/12 at 7:30 am Resident #12 was documented as having a FSBS of 375 mg/dl and at noon of 431 mg/dl, there was no documentation that the physician was notified as ordered. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide care and services to maintain the highest practicable well-being for four of six diabetic residents (Residents' #5, #9, #11, and #12) reviewed for blood sugar monitoring. The facility failed to: a. Provide interventions or notify Resident #5's physician regarding an identified critically low blood glucose level of 45 mg/dl on 12/31/12. b. Provide Resident #5 assessments and interventions of low blood sugars that were less than 70 mg/dl at 5:30 a.m. on 12/06/12, 12/07/12, 12/14/12, 12/15/12, 12/18/12, 12/26/12, 12/27/12, 12/31/12, and 01/04/13. c. Provide Resident #9 assessments or interventions for 7:00 a.m. Accuchecks that were less than 70 mg/dl on 12/01/12, 12/02/12, 12/11/12, and 12/15/12. d. Provide Resident #11 assessments for blood sugars less than 70mg/dl between 4:00 p.m. and 7:00 p.m. on 12/07/12, 12/12/12, 12/18/12, 12/20/12 and 12/21/12 e. Provide interventions or notify Resident # 12's physician of high blood sugars greater than 350 mg/dl on 12/02/12, 12/04/12,12/21/12,12/23/12,12/24/12,12/28/12, 12/30/12, and 12/31/12. "[DIAGNOSES REDACTED] (low blood sugar)...[DIAGNOSES REDACTED] is defined as a serum glucose level (the amount of sugar or glucose in your blood) below 70 mg/dl. Symptoms of [DIAGNOSES REDACTED] typically appear at levels below 60 mg/dl. Some people may feel symptoms above this level. Levels below 50 mg/dl affect brain function." Source dated 01/09/13: <http://www.emedicinehealth.com/low_blood_sugar_[DIAGNOSES REDACTED]/article_em.htm> An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place six residents with diabetes at risk of not receiving timely medical evaluation and treatment resulting in complications secondary to [DIAGNOSES REDACTED] such as coma and death. The findings included: 1. Record review of Resident #5's current "Record of Admission" revealed a [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "[DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed he had a BIMS score of 5 which indicated he was severely cognitively impaired, had disorganized thinking continuously, had behavioral symptoms, wandered and rejected care. Resident #5 required assistance of one person for transfers, dressing, toileting, personal hygiene, supervision of one person for eating, and was incontinent of bladder and bowel. In an interview on 01/02/13 at 3:35 p.m. during initial tour LVN E said that Resident #5 was alert but confused, had recently been identified with weight loss and required encouragement to eat, was not interviewable and had a [DIAGNOSES REDACTED]. Observation on 01/02/13 at 3:35 p.m. revealed Resident #5 was in his room in a high-back wheelchair. He had an alarm on the back of his wheelchair and a bracelet on his ankle. He was a tall man and appeared very thin. Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 01/28/13 revealed the following orders: " Hgb A1C every six months. "Accuchecks (blood sugar test using a glucometer and a small drop of blood obtained from the resident's finger) two times daily, [MEDICATION NAME] 15 units subcutaneously at bedtime for diabetes (start date 08/08/11), [MEDICATION NAME] ([MEDICATION NAME]) 500 mg. one by mouth two times daily for diabetes (start date 08/29/11), and [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes (start date 12/13/12)." "[MEDICATION NAME] (insulin [MEDICATION NAME]) is a man-made form of a hormone that is produced in the body. It works by lowering levels of glucose (sugar) in the blood. [MEDICATION NAME] is a long-acting form of insulin ..." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] is an oral diabetes medicine that helps control blood sugar levels." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's physician's orders did not reveal blood sugar parameters indicating when to notify the physician of low and/or high blood sugar levels. Record review of Resident #5's current "Care Plan" dated 10/30/12 revealed no information related to his diabetes and blood sugar monitoring. There was no information that Resident #5 was receiving blood sugar monitoring (Accuchecks) twice daily, was to be monitored for signs and symptoms of low or high blood sugar, was to be provided snacks and what type of snacks according to the results of his blood sugars, or when to notify the physician for low and high blood sugars. In an interview on 01/04/13 at 3:35 p.m. the DON said that she was responsible for completing resident care plans and had not completed a care plan related to Resident #5's diabetes and blood glucose monitoring. Record review of Resident #5's "Diabetic Flow Record" dated 11/01/12 through 11/30/12 revealed blood sugars at 5:30 a.m. were mostly above 100 mg/dl and all above 70 mg/dl. The 8:00 p.m. blood sugars were between 105 mg/dl and 364 mg/dl. Record review of Resident #5's laboratory report for a "Hgb A1C" dated 12/07/12 revealed "8.1% (H-indicated high). The reference range is 4.5%-5.7%. "A1C test is a blood test that provides information about a person's average levels of blood glucose, also call sugar, over the past 3 months. The A1C test is the primary test used for diabetes management ..." Source dated 01/18/13: http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/#1 <http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/> Record review of Resident #5's Physician's Order" dated 12/13/13 revealed, " [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes." "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's "Diabetic Flow Record" dated 12/01/12 through 12/31/12 revealed blood sugars were done at 5:30 a.m. (breakfast was served at 7:30 a.m.) and 8:00 p.m. The blood sugars at 5:30 a.m. were: 12/06/12- 60 mg/dl 12/07/12- 65 mg/ dl 12/14/12- 62 mg/dl 12/15/12- 63 mg/dl 12/18/12- 60 mg/dl 12/19/12- 70 mg/dl 12/26/12- 62 mg/dl 12/27/12- 53 mg/dl (small OJ near this reading) 12/31/12- 59 mg/dl Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 02/28/13 revealed, "Complete Blood Count every two months" (This includes a glucose level). Record review of Resident #5's "Lab Report-Basal Metabolic Plan" revealed blood was drawn routinely on 12/31/12 and the results of the Glucose blood level was "45 mg/dl Critical Low 12/31/12 12:47AM- Critical Value! Repeated for verification and called to LVN C on 12/31/12 at 3:36 p.m." This was a routine lab that was scheduled to be done every two months. Record review of Resident #5's "Nursing Progress Notes" revealed: 12/31/12 3:30 p.m. "Lab called and says that the glucose was 45. Her telephone number is..." This entry was unsigned by the nurse. There was no documentations of any assessments or interventions provided to Resident #5 for blood sugars less than 70 mg/dl at 5:30 a.m. between 12/06/12 and 12/31/12. Record review of Resident #5's "Diabetic Flow Record" dated 01/01/13 through 01/31/13 revealed the blood sugar on 01/04/13 at 5:30 a.m. was 66 mg/dl. There was no documentation on the "Diabetic Flow Record" (on the front or back) that any interventions were provided for Resident #5 for this low blood sugar. In an interview on 01/04/13 at 3:25 p.m. LVN C said she performed Accuchecks for Resident #5 at 5:30 a.m. in the mornings. LVN C said that she had performed the Accucheck this morning with a result of 66 mg/dl. LVN C said that she gave him a "sip of red punch" that was on his bedside table. LVN C said that she did not know what to do for residents who had low blood sugars and had no training by the facility regarding interventions related to low blood sugars. LVN C said that she did not know the facility's policy or procedure for the treatment of [REDACTED]. LVN C said that she did not report to the oncoming shift nurses the low blood sugar or write it on the 24-hour report. LVN C said that she did not recheck or re-assess Resident #5 and ended her shift at 6:00 a.m. LVN C said that Resident #5's blood sugars in the early a.m. were often low. LVN C had not notified Resident #5's physician regarding the critically low blood sugar on 12/31/12. "It's important to treat [DIAGNOSES REDACTED] quickly because [DIAGNOSES REDACTED] can get worse and you could pass out. If you pass out, you will need immediate treatment, such as an injection of [MEDICATION NAME] or emergency treatment in a hospital. " Source dated 01/17/13: <http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html> In an interview on 01/07/13 at 1:22 p.m., the Acting Medical Director said he had given the facility a telephone order to call him for blood glucose levels of 50 and below and 350 and above. In an interview on 01/05/13 at 6:45 p.m. LVN D (Charge Nurswe) said that on 12/31/12 she had performed Resident #5's Accucheck at about 5:00 a.m. with a result of 59 mg/dl. LVN D said that she gave Resident #5 about four ounces of orange juice. LVN D said that she had not re-assessed him, had not put the information on the 24-hour report, and had not reported to the on-coming shift nurses before she left the facility at the end of her shift (6:00 a.m.) but knows she should have done all of these things. LVN D said that LVN C was a new nurse and had made the 12/31/12 3:30 p.m. unsigned entry in the nursing progress notes regarding the critically low blood sugar for Resident #5. LVN D said that she had instructed LVN C to notify Resident #5's physician regarding the low blood sugar. LVN D said that she did not know if Resident #5's physician was notified." In an interview on 01/04/2013 at 3:27p.m., the ADON said that she did not know if all of the diabetics had parameters or not on when to contact the physician in regards to low or elevated blood sugar results. The ADON said that the facility has had no training or in-services with the nurses in regards to diabetes, signs and symptoms of [DIAGNOSES REDACTED] or interventions to provide for low blood sugar results. In an interview on 01/04/13 at 3:35 p.m. The DON said (regarding the lab report dated 12/31/12 with the critically low blood sugar of 45 mg/dl for Resident #5) that she did not know and could not determine if Resident #5's physician was notified of the critically low blood sugar identified on 12/31/12. The DON said that the nurses should notify the resident's physician if there was a blood sugar of less than 70 mg/dl and more than 350 mg/dl. The DON said that she did not know what kind of intervention LVN C provided Resident #5 this morning related to his blood sugar of 66 mg/dl at 5:30 a.m. because there was no documentation on his "Diabetic Flow Sheet", the "Nursing Progress Notes", or the 24-hour report. The DON said that the nurse should have documented the intervention in the nursing progress notes, report to the on-coming shift so they could monitor him, and put the information on the 24 hour report. The DON said that no one to her knowledge had reported Resident #5's low blood sugars to his physician or rechecked Resident #5 (the numerous low blood sugars at 5:30 a.m. in December, 2012 or the identified critically low blood sugar on 12/31/12). The DON said that she had been employed since March, 2012 and had not provided any in-services related to Accuchecks. Record review of the four page policy "Nursing Care of Diabetes Mellitus, Effective date-01/2005" provided by the facility on 01/04/13 at 3:00 p.m. revealed: "Note: The physician should specify high and low parameters for all diabetic residents. Below are general guidelines to follow. Guidelines: -Signs of Hypoglycemic Event (Insulin Reaction) 1. Rapid onset 2.Polyphagia 3.Weakness, nervousness 4.Fast heart rate 5.Skin is pallid, cool, diaphoretic 6.Dilated pupils 7.Memory lapse, fatigue, lethargy, and new onset of confusion and/or agitation 8.Headache 9.Visual disturbance 10.Thick speech 11.Awkward body movement 12.Paralysis with spasms 13.Incontinent of urine 14.Restlessness, bizarre behavior 15.Unconsciousness or convulsions. Be alert to nonverbal signs of [DIAGNOSES REDACTED]: sudden onset of anxiety, bizarre behavior, lack of concentration, trembling, shaking, slurred speech, difficulty walking, staggering gait, lack of coordination, irritability and change in behavior that is different for the resident ' s usual behavior. -Notify the Physician: 1. ...blood glucose is less than 70 mg/dl unless the physician ordered specific parameters for the individual resident .... -Managing a Hypoglycemic(low blood sugar) Event 1. If fingerstick blood sugar is less than 70...: *Give 4 ounces of juice or milk, OR *Give three 5 gram oral glucose tablets, OR *Glucose gel...and reassess finger stick blood sugar in 15 minutes... 4. If blood sugar is not responding in 15 minutes: *Give 50 milliters of 50% glucose intravenously if available, OR *Activate 911 system 5. Follow initial treatment and recovery to over 70 mg/dl, with complex carbohydrate intake. 6. Review factors that may have precipitated the event in order to reduce the chance of recurrence. -Documentation: 1.Vital signs 2.State of consciousness 3.Blood sugar readings 4.Interventions taken-Juice, milk, oral glucose, glucose gel ...5.Residents response to the intervention 6.Skin color, temperature, dryness 7.Irritation.. 8.Restlessness ...17.Monitor pertinent laboratory studies ..." Record review of the one page policy "Blood Sugar (fingerstick) process, Effective date 01/2010" provided by the facility on 01/04/13 at 6:20 p.m. revealed the following: "Policy-To Assure appropriate process in the obtaining and reporting blood sugar levels and appropriate follow-up and treatment. Guidelines: *...Document Blood Sugar levels on appropriate form. *For Blood Sugar levels below 60 mg/dl, contact physician, unless component of Guideline is superseded by physician's orders. *Blood sugars below 60 mg/dl will be reported to administrative nursing if unable to contact physicians. *Document Blood Sugars below in 24 hour Report." In an interview on 01/06/13 at 2:50 p.m. RN A (Regional Representative) said that both the four page "Nursing Care of Diabetes Mellitus, Effective date-01/2005 and the one page Blood Sugar (fingerstick) process, are guidelines to be used by the facility. An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. The facility's Plan of Removal was received on 01/07/13 at 8:50 a.m. and accepted on 01/07/13 at 2:15 p.m. by Program Manager and included: "Facility will in-service all RNs and LVNs effective 01/04/13 regarding blood sugar finger-stick process policy. All nurses will be informed of blood glucose parameters per physician or use medical director's protocol. Nurses will notify physician via phone and personally speak with physician or assistant regarding glucose levels out of blood glucose parameters. Resident #5 was assessed for signs and symptoms of hypo/[MEDICAL CONDITION] with no noted negative manifestations. Resident #5's physician was contacted and orders were received for blood sugar parameters. All diabetic residents who receive blood sugar fingersticks have had blood sugar parameters re-established. The nurse LVN C identified in this alleged deficient practice and interviewed by Survey Team Member, contacted the facility and has resigned 01/04/13. All Facility Nurses have been re-educated on need and rational of appropriate follow-up to potential signs and symptoms/negative outcomes of Hypo/[MEDICAL CONDITION]: *Blood Sugar parameters as ordered by resident physician(s) *Signs and Symptoms of Hypo/[MEDICAL CONDITION] *Guidelines for recognizing, management, staff communications and contacts. All diabetic residents have the potential to be affected by this alleged deficient practice. The facility Director of Nursing and or designee will, during normal tour of duty, monitor blood sugar documentation and follow-up to assure compliance with this plan of correction. Noted concerns will be referred to the facility Administrator for Administrative Action. The facility QAA Committee, at least quarterly, monitor this plan of correction to assure compliance." On 01/07/13 at 2:15 p.m. the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 01/07/13 at 9:40 a.m. the DON said that all staff nurses except two part-time nurses had been in-serviced and that she would in-service them prior to allowing them to work. Record review of Residents' #5, #9, #11, #12, #13, and #14's "Physicians Orders dated 01/04/13 at 7:00 p.m. revealed the acting medical director had added the following new order: "1.If blood glucose level of 50 or below notify MD by phone 2. If blood glucose level of 350 or greater notify MD by phone." Interviews with nurses revealed that they would follow physician ' s orders regarding notification of physician related to low and high blood sugars and if the physician had not specified the parameters they would use the medical director ' s directions. These parameters were to notify the resident ' s physician if their blood sugar is 50 mg/dl or below and below and 350 mg/dl or greater. In an interview on 01/07/13 at 11:10 a.m. the DON said that the facility will notify residents' physician if their blood sugar is 50 mg/dl or below and 350 mg/dl or greater. The DON said that she had trained the nurses that if a resident has a blood sugar between 50 mg/dl and 70 mg/dl they should do as follows: 1. should assess the resident for signs and symptoms of low blood sugar, 2. if the resident showed signs and symptoms of low blood sugar then: a. ask the resident what type of snack they wanted and give the snack, b. reassess the resident in about 15-20 minutes for signs and symptoms of low blood sugar but will not do another fingerstick to check for the blood sugar because this is an invasive procedure that would require a physician's order, c. if still has signs and symptoms of low blood sugar, contact the resident's physician for treatment orders d. if cannot contact physician and continues to have low blood sugar symptoms, call 911. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED]. Non IJ Findings included: 1. Record Review of Resident #9's Record of Admission revealed a [AGE] year old female admitted to the facility on [DATE] and latest return admitted [DATE]. Record Review of Resident #9's January 2013 Physician Orders revealed the following Diagnoses: [REDACTED]. Record Review of Resident #9's January 2013 Physicians Orders contained no parameters on when to notify the physician for an elevated or low blood sugar result. Record Review of Resident #9's January 2013 Diabetic Flow Record contained no parameters on when to notify the physician for an elevated or low blood glucose result. Record Review of Resident #9's December 2012 Diabetic Flow Record revealed that Resident #9's accucheck (blood glucose result) on: 12/01/2012 at 0700 was 53 12/02/2012 at 0700 was 68 12/11/2012 at 0700 was 67 12/15/2012 at 0700 was 56 Record Review of Resident #9's facility nurse notes from 10/28/2012 through 12/29/2012 did not contain documentation from the nurses on 12/01, 12/02, 12/11 or 12/15/2012 as to Resident #9's blood glucose results. The nurses notes did not contain any type of assessment made by the nurse or any type of interventions received by Resident #9 in regards to the low blood glucose results on 12/01/12/02, 12/11 and 12/15/2012 at 0700. 2. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed she was an [AGE] year old female admitted to the facility 03/09/04 with [DIAGNOSES REDACTED]. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed, "...Accuchecks (a small sample of blood obtained by using a device to prick a finger for blood glucose measuring) BID (two times daily). Review of Resident #11's "Resident Care Plan" dated 07/10/12 revealed, "...Problem: (name) has a [DIAGNOSES REDACTED]. Interventions...Monitor problem/condition and report negative findings to physician..." Review of Resident #11's "Diabetic Flow Sheet" dated 12/01/12 through 12/31/12 revealed the following low blood sugars: 12/07/12, 4:00 p.m.: 65 12/12/12, 4:00 p.m.: 61 Review of Resident #11's "Progress Notes" for December, 2012 revealed no documented nurse's notes regarding blood sugar results or interventions. In an interview on 01/06/12 at 1:57 p.m., RN B said if a resident had a blood sugar of below 50 or greater than 350 she would call the Medical Director or designee. RN B said of a resident had a blood sugar of 50 or below, she would offer eight ounces of juice or crackers. RN B said she had been in-serviced 01/04/13 on the facility's policy regarding blood sugars. 3. Review of Resident #12's "Record of Admission" dated 07/18/12 revealed that she is a [AGE] year old female whose [DIAGNOSES REDACTED]. Review of Resident #12's Minimum Data Set Section I 2900 indicated she is a diabetic and Section N 0350 indicated that she received injections daily. Review of Resident #12's December 2012 monthly physician orders signed by the physician on 12/15/12 revealed Accucheck orders for "Accuchecks at mealtime and bedtime" and for Insulin orders which included " If below 50 or greater than 350, notify M.D. " (medical doctor). Resident #12 ' s sliding scale insulin orders included " give Humalog insulin before meals per sliding scale " . Resident #12 ' s sliding scale included in part giving 16 units of Humalog insulin for a finger stick blood sugar (FSBS) between 350-399 (mg/dl) and 17 units for a finger stick blood sugar between 400-499. Review of Resident #12 ' s " Diabetic Flow Record " for December 2012 revealed the following: On 12/04/12 at noon Resident #12 was documented as having a FSBS of 358 mg/dl, there was no documentation that the physician was notified or that sliding scale insulin was given. On 12/21/12 at 5:30 pm Resident #12 was documented as having a FSBS of 414 mg/dl, there was no documentation that the physician was notified and 16 units of sliding scale insulin was documented as being given, however according to the sliding scale orders 17 units should have been given. On 12/23/12 at 5:30 pm Resident #12 was documented as having a FSBS of 399 mg/dl, there was no documentation that the physician was notified as ordered. On 12/24/12 at 5:30 pm Resident #12 was documented as having a FSBS of 398 mg/dl, there was no documentation that the physician was notified as ordered. On 12/28/12 at 7:30 am Resident #12 was documented as having a FSBS of 381 mg/dl, there was no documentation that sliding scale insulin was given. On 12/30/12 at 8:00 pm Resident #12 was documented as having a FSBS of 440 mg/dl, there was no documentation that the physician was notified and 17 units of sliding scale insulin was given, however the orders specified that sliding scale insulin was to be given " before meals " . On 12/31/12 at 7:30 am Resident #12 was documented as having a FSBS of 375 mg/dl and at noon of 431 mg/dl, there was no documentation that the physician was notified as ordered. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility DON failed to supervise and train licensed nursing staff and the Administrator failed to monitor the DON to ensure four of six diabetic residents (Residents' #5, #9, #11, and #12) reviewed for blood sugar monitoring received services to maintain their highest practicable well-being. The facility failed to: a. Provide interventions or notify Resident #5's physician regarding an identified critically low blood glucose level of 45 mg/dl on 12/31/12. b. Provide Resident #5 assessments and interventions of low blood sugars that were less than 70 mg/dl at 5:30 a.m. on 12/06/12, 12/07/12, 12/14/12, 12/15/12, 12/18/12, 12/26/12, 12/27/12, 12/31/12, and 01/04/13. c. Provide Resident #9 assessments or interventions for 7:00 a.m. Accuchecks that were less than 70 mg/dl on 12/01/12, 12/02/12, 12/11/12, and 12/15/12. d. Provide Resident #11 assessments for blood sugars less than 70mg/dl between 4:00 p.m. and 7:00 p.m. on 12/07/12, 12/12/12, 12/18/12, 12/20/12 and 12/21/12 e. Provide interventions or notify Resident # 12's physician of high blood sugars greater than 350 mg/dl on 12/02/12, 12/04/12,12/21/12,12/23/12,12/24/12,12/28/12, 12/30/12, and 12/31/12. "[DIAGNOSES REDACTED] (low blood sugar)...[DIAGNOSES REDACTED] is defined as a serum glucose level (the amount of sugar or glucose in your blood) below 70 mg/dl. Symptoms of [DIAGNOSES REDACTED] typically appear at levels below 60 mg/dl. Some people may feel symptoms above this level. Levels below 50 mg/dl affect brain function." Source dated 01/09/13: <http://www.emedicinehealth.com/low_blood_sugar_[DIAGNOSES REDACTED]/article_em.htm> An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place six residents with diabetes at risk of not receiving timely medical evaluation and treatment resulting in complications secondary to [DIAGNOSES REDACTED] such as coma and death. The findings included: 1. Record review of Resident #5's current "Record of Admission" revealed a [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "[DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed he had a BIMS score of 5 which indicated he was severely cognitively impaired, had disorganized thinking continuously, had behavioral symptoms, wandered and rejected care. Resident #5 required assistance of one person for transfers, dressing, toileting, personal hygiene, supervision of one person for eating, and was incontinent of bladder and bowel. In an interview on 01/02/13 at 3:35 p.m. during initial tour LVN E said that Resident #5 was alert but confused, had recently been identified with weight loss and required encouragement to eat, was not interviewable and had a [DIAGNOSES REDACTED]. Observation on 01/02/13 at 3:35 p.m. revealed Resident #5 was in his room in a high-back wheelchair. He had an alarm on the back of his wheelchair and a bracelet on his ankle. He was a tall man and appeared very thin. Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 01/28/13 revealed the following orders: " Hgb A1C every six months. "Accuchecks (blood sugar test using a glucometer and a small drop of blood obtained from the resident's finger) two times daily, [MEDICATION NAME] 15 units subcutaneously at bedtime for diabetes (start date 08/08/11), [MEDICATION NAME] ([MEDICATION NAME]) 500 mg. one by mouth two times daily for diabetes (start date 08/29/11), and [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes (start date 12/13/12)." "[MEDICATION NAME] (insulin [MEDICATION NAME]) is a man-made form of a hormone that is produced in the body. It works by lowering levels of glucose (sugar) in the blood. [MEDICATION NAME] is a long-acting form of insulin ..." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] is an oral diabetes medicine that helps control blood sugar levels." Source dated 01/09/13: <http://www.drugs.com/[MEDICATION NAME].html> "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's physician's orders did not reveal blood sugar parameters indicating when to notify the physician of low and/or high blood sugar levels. Record review of Resident #5's current "Care Plan" dated 10/30/12 revealed no information related to his diabetes and blood sugar monitoring. There was no information that Resident #5 was receiving blood sugar monitoring (Accuchecks) twice daily, was to be monitored for signs and symptoms of low or high blood sugar, was to be provided snacks and what type of snacks according to the results of his blood sugars, or when to notify the physician for low and high blood sugars. In an interview on 01/04/13 at 3:35 p.m. the DON said that she was responsible for completing resident care plans and had not completed a care plan related to Resident #5's diabetes and blood glucose monitoring. Record review of Resident #5's "Diabetic Flow Record" dated 11/01/12 through 11/30/12 revealed blood sugars at 5:30 a.m. were mostly above 100 mg/dl and all above 70 mg/dl. The 8:00 p.m. blood sugars were between 105 mg/dl and 364 mg/dl. Record review of Resident #5's laboratory report for a "Hgb A1C" dated 12/07/12 revealed "8.1% (H-indicated high). The reference range is 4.5%-5.7%. "A1C test is a blood test that provides information about a person's average levels of blood glucose, also call sugar, over the past 3 months. The A1C test is the primary test used for diabetes management ..." Source dated 01/18/13: http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/#1 <http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/> Record review of Resident #5's Physician's Order" dated 12/13/13 revealed, " [MEDICATION NAME] (Linagliptin) 5 mg. one by mouth every morning for diabetes." "[MEDICATION NAME] (linagliptin) is a prescription medicine that is used along with diet and exercise to lower blood sugar in adults." Source dated 01/09/13: <https://www.[MEDICATION NAME].com/> Record review of Resident #5's "Diabetic Flow Record" dated 12/01/12 through 12/31/12 revealed blood sugars were done at 5:30 a.m. (breakfast was served at 7:30 a.m.) and 8:00 p.m. The blood sugars at 5:30 a.m. were: 12/06/12- 60 mg/dl 12/07/12- 65 mg/ dl 12/14/12- 62 mg/dl 12/15/12- 63 mg/dl 12/18/12- 60 mg/dl 12/19/12- 70 mg/dl 12/26/12- 62 mg/dl 12/27/12- 53 mg/dl (small OJ near this reading) 12/31/12- 59 mg/dl Record review of Resident #5's "Physicians Orders" dated 01/01/13 through 02/28/13 revealed, "Complete Blood Count every two months" (This includes a glucose level). Record review of Resident #5's "Lab Report-Basal Metabolic Plan" revealed blood was drawn routinely on 12/31/12 and the results of the Glucose blood level was "45 mg/dl Critical Low 12/31/12 12:47AM- Critical Value! Repeated for verification and called to LVN C on 12/31/12 at 3:36 p.m." This was a routine lab that was scheduled to be done every two months. Record review of Resident #5's "Nursing Progress Notes" revealed: 12/31/12 3:30 p.m. "Lab called and says that the glucose was 45. Her telephone number is..." This entry was unsigned by the nurse. There was no documentations of any assessments or interventions provided to Resident #5 for blood sugars less than 70 mg/dl at 5:30 a.m. between 12/06/12 and 12/31/12. Record review of Resident #5's "Diabetic Flow Record" dated 01/01/13 through 01/31/13 revealed the blood sugar on 01/04/13 at 5:30 a.m. was 66 mg/dl. There was no documentation on the "Diabetic Flow Record" (on the front or back) that any interventions were provided for Resident #5 for this low blood sugar. In an interview on 01/04/13 at 3:25 p.m. LVN C said she performed Accuchecks for Resident #5 at 5:30 a.m. in the mornings. LVN C said that she had performed the Accucheck this morning with a result of 66 mg/dl. LVN C said that she gave him a "sip of red punch" that was on his bedside table. LVN C said that she did not know what to do for residents who had low blood sugars and had no training by the facility regarding interventions related to low blood sugars. LVN C said that she did not know the facility's policy or procedure for the treatment of [REDACTED]. LVN C said that she did not report to the oncoming shift nurses the low blood sugar or write it on the 24-hour report. LVN C said that she did not recheck or re-assess Resident #5 and ended her shift at 6:00 a.m. LVN C said that Resident #5's blood sugars in the early a.m. were often low. LVN C had not notified Resident #5's physician regarding the critically low blood sugar on 12/31/12. "It's important to treat [DIAGNOSES REDACTED] quickly because [DIAGNOSES REDACTED] can get worse and you could pass out. If you pass out, you will need immediate treatment, such as an injection of [MEDICATION NAME] or emergency treatment in a hospital. " Source dated 01/17/13: <http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html> In an interview on 01/07/13 at 1:22 p.m., the Acting Medical Director said he had given the facility a telephone order to call him for blood glucose levels of 50 and below and 350 and above. In an interview on 01/05/13 at 6:45 p.m. LVN D (Charge Nurswe) said that on 12/31/12 she had performed Resident #5's Accucheck at about 5:00 a.m. with a result of 59 mg/dl. LVN D said that she gave Resident #5 about four ounces of orange juice. LVN D said that she had not re-assessed him, had not put the information on the 24-hour report, and had not reported to the on-coming shift nurses before she left the facility at the end of her shift (6:00 a.m.) but knows she should have done all of these things. LVN D said that LVN C was a new nurse and had made the 12/31/12 3:30 p.m. unsigned entry in the nursing progress notes regarding the critically low blood sugar for Resident #5. LVN D said that she had instructed LVN C to notify Resident #5's physician regarding the low blood sugar. LVN D said that she did not know if Resident #5's physician was notified." In an interview on 01/04/2013 at 3:27p.m., the ADON said that she did not know if all of the diabetics had parameters or not on when to contact the physician in regards to low or elevated blood sugar results. The ADON said that the facility has had no training or in-services with the nurses in regards to diabetes, signs and symptoms of [DIAGNOSES REDACTED] or interventions to provide for low blood sugar results. In an interview on 01/04/13 at 3:35 p.m. The DON said (regarding the lab report dated 12/31/12 with the critically low blood sugar of 45 mg/dl for Resident #5) that she did not know and could not determine if Resident #5's physician was notified of the critically low blood sugar identified on 12/31/12. The DON said that the nurses should notify the resident's physician if there was a blood sugar of less than 70 mg/dl and more than 350 mg/dl. The DON said that she did not know what kind of intervention LVN C provided Resident #5 this morning related to his blood sugar of 66 mg/dl at 5:30 a.m. because there was no documentation on his "Diabetic Flow Sheet", the "Nursing Progress Notes", or the 24-hour report. The DON said that the nurse should have documented the intervention in the nursing progress notes, report to the on-coming shift so they could monitor him, and put the information on the 24 hour report. The DON said that no one to her knowledge had reported Resident #5's low blood sugars to his physician or rechecked Resident #5 (the numerous low blood sugars at 5:30 a.m. in December, 2012 or the identified critically low blood sugar on 12/31/12). The DON said that she had been employed since March, 2012 and had not provided any in-services related to Accuchecks. Record review of the four page policy "Nursing Care of Diabetes Mellitus, Effective date-01/2005" provided by the facility on 01/04/13 at 3:00 p.m. revealed: "Note: The physician should specify high and low parameters for all diabetic residents. Below are general guidelines to follow. Guidelines: -Signs of Hypoglycemic Event (Insulin Reaction) 1. Rapid onset 2.Polyphagia 3.Weakness, nervousness 4.Fast heart rate 5.Skin is pallid, cool, diaphoretic 6.Dilated pupils 7.Memory lapse, fatigue, lethargy, and new onset of confusion and/or agitation 8.Headache 9.Visual disturbance 10.Thick speech 11.Awkward body movement 12.Paralysis with spasms 13.Incontinent of urine 14.Restlessness, bizarre behavior 15.Unconsciousness or convulsions. Be alert to nonverbal signs of [DIAGNOSES REDACTED]: sudden onset of anxiety, bizarre behavior, lack of concentration, trembling, shaking, slurred speech, difficulty walking, staggering gait, lack of coordination, irritability and change in behavior that is different for the resident ' s usual behavior. -Notify the Physician: 1. ...blood glucose is less than 70 mg/dl unless the physician ordered specific parameters for the individual resident .... -Managing a Hypoglycemic(low blood sugar) Event 1. If fingerstick blood sugar is less than 70...: *Give 4 ounces of juice or milk, OR *Give three 5 gram oral glucose tablets, OR *Glucose gel...and reassess finger stick blood sugar in 15 minutes... 4. If blood sugar is not responding in 15 minutes: *Give 50 milliters of 50% glucose intravenously if available, OR *Activate 911 system 5. Follow initial treatment and recovery to over 70 mg/dl, with complex carbohydrate intake. 6. Review factors that may have precipitated the event in order to reduce the chance of recurrence. -Documentation: 1.Vital signs 2.State of consciousness 3.Blood sugar readings 4.Interventions taken-Juice, milk, oral glucose, glucose gel ...5.Residents response to the intervention 6.Skin color, temperature, dryness 7.Irritation.. 8.Restlessness ...17.Monitor pertinent laboratory studies ..." Record review of the one page policy "Blood Sugar (fingerstick) process, Effective date 01/2010" provided by the facility on 01/04/13 at 6:20 p.m. revealed the following: "Policy-To Assure appropriate process in the obtaining and reporting blood sugar levels and appropriate follow-up and treatment. Guidelines: *...Document Blood Sugar levels on appropriate form. *For Blood Sugar levels below 60 mg/dl, contact physician, unless component of Guideline is superseded by physician's orders. *Blood sugars below 60 mg/dl will be reported to administrative nursing if unable to contact physicians. *Document Blood Sugars below in 24 hour Report." In an interview on 01/06/13 at 2:50 p.m. RN A (Regional Representative) said that both the four page "Nursing Care of Diabetes Mellitus, Effective date-01/2005 and the one page Blood Sugar (fingerstick) process, are guidelines to be used by the facility. An Immediate Jeopardy was identified on 01/04/13 at 5:05 p.m. The Immediate Jeopardy was removed on 01/07/13 at 2:15 p.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. The facility's Plan of Removal was received on 01/07/13 at 8:50 a.m. and accepted on 01/07/13 at 2:15 p.m. by Program Manager and included: "Facility will in-service all RNs and LVNs effective 01/04/13 regarding blood sugar finger-stick process policy. All nurses will be informed of blood glucose parameters per physician or use medical director's protocol. Nurses will notify physician via phone and personally speak with physician or assistant regarding glucose levels out of blood glucose parameters. Resident #5 was assessed for signs and symptoms of hypo/[MEDICAL CONDITION] with no noted negative manifestations. Resident #5's physician was contacted and orders were received for blood sugar parameters. All diabetic residents who receive blood sugar fingersticks have had blood sugar parameters re-established. The nurse LVN C identified in this alleged deficient practice and interviewed by Survey Team Member, contacted the facility and has resigned 01/04/13. All Facility Nurses have been re-educated on need and rational of appropriate follow-up to potential signs and symptoms/negative outcomes of Hypo/[MEDICAL CONDITION]: *Blood Sugar parameters as ordered by resident physician(s) *Signs and Symptoms of Hypo/[MEDICAL CONDITION] *Guidelines for recognizing, management, staff communications and contacts. All diabetic residents have the potential to be affected by this alleged deficient practice. The facility Director of Nursing and or designee will, during normal tour of duty, monitor blood sugar documentation and follow-up to assure compliance with this plan of correction. Noted concerns will be referred to the facility Administrator for Administrative Action. The facility QAA Committee, at least quarterly, monitor this plan of correction to assure compliance." On 01/07/13 at 2:15 p.m. the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: In an interview on 01/07/13 at 9:40 a.m. the DON said that all staff nurses except two part-time nurses had been in-serviced and that she would in-service them prior to allowing them to work. Record review of Residents' #5, #9, #11, #12, #13, and #14's "Physicians Orders dated 01/04/13 at 7:00 p.m. revealed the acting medical director had added the following new order: "1.If blood glucose level of 50 or below notify MD by phone 2. If blood glucose level of 350 or greater notify MD by phone." Interviews with nurses revealed that they would follow physician ' s orders regarding notification of physician related to low and high blood sugars and if the physician had not specified the parameters they would use the medical director ' s directions. These parameters were to notify the resident ' s physician if their blood sugar is 50 mg/dl or below and below and 350 mg/dl or greater. In an interview on 01/07/13 at 11:10 a.m. the DON said that the facility will notify residents' physician if their blood sugar is 50 mg/dl or below and 350 mg/dl or greater. The DON said that she had trained the nurses that if a resident has a blood sugar between 50 mg/dl and 70 mg/dl they should do as follows: 1. should assess the resident for signs and symptoms of low blood sugar, 2. if the resident showed signs and symptoms of low blood sugar then: a. ask the resident what type of snack they wanted and give the snack, b. reassess the resident in about 15-20 minutes for signs and symptoms of low blood sugar but will not do another fingerstick to check for the blood sugar because this is an invasive procedure that would require a physician's order, c. if still has signs and symptoms of low blood sugar, contact the resident's physician for treatment orders d. if cannot contact physician and continues to have low blood sugar symptoms, call 911. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED]. Non IJ Findings included: 1. Record Review of Resident #9's Record of Admission revealed a [AGE] year old female admitted to the facility on [DATE] and latest return admitted [DATE]. Record Review of Resident #9's January 2013 Physician Orders revealed the following Diagnoses: [REDACTED]. Record Review of Resident #9's January 2013 Physicians Orders contained no parameters on when to notify the physician for an elevated or low blood sugar result. Record Review of Resident #9's January 2013 Diabetic Flow Record contained no parameters on when to notify the physician for an elevated or low blood glucose result. Record Review of Resident #9's December 2012 Diabetic Flow Record revealed that Resident #9's accucheck (blood glucose result) on: 12/01/2012 at 0700 was 53 12/02/2012 at 0700 was 68 12/11/2012 at 0700 was 67 12/15/2012 at 0700 was 56 Record Review of Resident #9's facility nurse notes from 10/28/2012 through 12/29/2012 did not contain documentation from the nurses on 12/01, 12/02, 12/11 or 12/15/2012 as to Resident #9's blood glucose results. The nurses notes did not contain any type of assessment made by the nurse or any type of interventions received by Resident #9 in regards to the low blood glucose results on 12/01/12/02, 12/11 and 12/15/2012 at 0700. 2. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed she was an [AGE] year old female admitted to the facility 03/09/04 with [DIAGNOSES REDACTED]. Review of Resident #11's "Physician's Orders" signed 12/18/12 revealed, "...Accuchecks (a small sample of blood obtained by using a device to prick a finger for blood glucose measuring) BID (two times daily). Review of Resident #11's "Resident Care Plan" dated 07/10/12 revealed, "...Problem: (name) has a [DIAGNOSES REDACTED]. Interventions...Monitor problem/condition and report negative findings to physician..." Review of Resident #11's "Diabetic Flow Sheet" dated 12/01/12 through 12/31/12 revealed the following low blood sugars: 12/07/12, 4:00 p.m.: 65 12/12/12, 4:00 p.m.: 61 Review of Resident #11's "Progress Notes" for December, 2012 revealed no documented nurse's notes regarding blood sugar results or interventions. In an interview on 01/06/12 at 1:57 p.m., RN B said if a resident had a blood sugar of below 50 or greater than 350 she would call the Medical Director or designee. RN B said of a resident had a blood sugar of 50 or below, she would offer eight ounces of juice or crackers. RN B said she had been in-serviced 01/04/13 on the facility's policy regarding blood sugars. 3. Review of Resident #12's "Record of Admission" dated 07/18/12 revealed that she is a [AGE] year old female whose [DIAGNOSES REDACTED]. Review of Resident #12's Minimum Data Set Section I 2900 indicated she is a diabetic and Section N 0350 indicated that she received injections daily. Review of Resident #12's December 2012 monthly physician orders signed by the physician on 12/15/12 revealed Accucheck orders for "Accuchecks at mealtime and bedtime" and for Insulin orders which included " If below 50 or greater than 350, notify M.D. " (medical doctor). Resident #12 ' s sliding scale insulin orders included " give Humalog insulin before meals per sliding scale " . Resident #12 ' s sliding scale included in part giving 16 units of Humalog insulin for a finger stick blood sugar (FSBS) between 350-399 (mg/dl) and 17 units for a finger stick blood sugar between 400-499. Review of Resident #12 ' s " Diabetic Flow Record " for December 2012 revealed the following: On 12/04/12 at noon Resident #12 was documented as having a FSBS of 358 mg/dl, there was no documentation that the physician was notified or that sliding scale insulin was given. On 12/21/12 at 5:30 pm Resident #12 was documented as having a FSBS of 414 mg/dl, there was no documentation that the physician was notified and 16 units of sliding scale insulin was documented as being given, however according to the sliding scale orders 17 units should have been given. On 12/23/12 at 5:30 pm Resident #12 was documented as having a FSBS of 399 mg/dl, there was no documentation that the physician was notified as ordered. On 12/24/12 at 5:30 pm Resident #12 was documented as having a FSBS of 398 mg/dl, there was no documentation that the physician was notified as ordered. On 12/28/12 at 7:30 am Resident #12 was documented as having a FSBS of 381 mg/dl, there was no documentation that sliding scale insulin was given. On 12/30/12 at 8:00 pm Resident #12 was documented as having a FSBS of 440 mg/dl, there was no documentation that the physician was notified and 17 units of sliding scale insulin was given, however the orders specified that sliding scale insulin was to be given " before meals " . On 12/31/12 at 7:30 am Resident #12 was documented as having a FSBS of 375 mg/dl and at noon of 431 mg/dl, there was no documentation that the physician was notified as ordered. In an interview on 01/04/13 at 1:00 p.m. the DON said there were six residents who had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to establish infection control measures to help prevent the transmission of infection and disease by bloodborne pathogens for 2 of 2 sampled diabetic residents (#8 and #9). The facility failed to: A. Ensure that lancing devices were not used on multiple residents to obtain blood for blood glucose tests. One of one LVN, LVN A, performed blood glucose tests using the same pen lancing device for Residents #8 and #9. Fingerstick devices (lancing pen devices) touch the skin and come in close proximity to blood with every use. Even if the lancet itself is changed between each use there is potential for blood to contaminate the pen device. Bloodborne pathogens such as Hepatitis B, Hepatitis C, and HIV could be transmitted from one person to another. Immediate Jeopardy (IJ) was identified on 11/01/11 at 12:40 p.m. While the IJ was removed prior to exit on 11/01/11 the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". B. Clean and disinfect a glucometer (equipment used to test blood sugar levels) for 2 (Resident's #8 and #9) of 2 residents who were observed to receive blood glucose testing. These failures involved 9 residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing. These failures placed these residents at risk of bloodborne infections. The findings included: A. IJ findings 1. Record review of Resident #8's admission record revealed a [AGE] year old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's physician's orders [REDACTED]. Observation on 11/01/11 at 11:48 a.m. revealed that LVN A performed an Accucheck (obtaining a blood sample to determine blood sugar levels) on Resident #8. LVN A punctured Resident #8's fingertip with a lancet that was placed into a multi-use [MEDICATION NAME] fingerstick device (device with a lancet that punctures the skin) and obtained a blood sample which she placed onto the test strip in the glucometer. LVN A removed the lancet from the [MEDICATION NAME] fingerstick device and discarded the used sharp into a sharps container (container used to dispose of used sharps) located on the medication cart. LVN A then placed the glucometer and the [MEDICATION NAME] fingerstick device on top of the medication cart. LVN A did not clean the glucometer. 2. Record review of Resident #9's admission record revealed a [AGE] year old male who was admitted on [DATE] readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's physician's orders [REDACTED]. Observation on 11/01/11 at 12:04 p.m. revealed that LVN A performed an Accucheck on Resident #9 using the same glucometer that she had used on Resident #8 at 11:48 a.m. LVN A punctured Resident #9's fingertip with a lancet that was placed into a multi-use [MEDICATION NAME] fingerstick device and obtained a blood sample which she placed onto the test strip in the glucometer. LVN A removed the lancet from the [MEDICATION NAME] fingerstick device and discarded the used sharp into a sharps container (container used to dispose of used sharps) located on the medication cart. LVN A then placed the glucometer and the [MEDICATION NAME] fingerstick device on top of the medication cart. LVN A did not clean the glucometer before or after the procedure. In an interview on 11/01/11 at 12:10 p.m. LVN A said that she had used the multi-use [MEDICATION NAME] fingerstick device for a while now. LVN A said that there were two [MEDICATION NAME] fingerstick devices which the nurses used to obtain blood samples from the residents. LVN A pointed to the two devices located in the top of the only medication cart. LVN A said that the facility had not trained her not to use these [MEDICATION NAME] fingerstick devices. These failures resulted in the identification of an IJ (Immediate Jeopardy) of which the facility Administrator and DON were informed on 11/01/11 at 12:35 p.m. During an interview on 11/01/11 at 12:35 p.m. the DON said that the facility used the multi-use [MEDICATION NAME] fingerstick device for performing Resident Accuchecks and she was not aware of recommendations prohibiting their use on multiple residents. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. Fingerstick devices should never be used for more than one person. Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided." The facility submitted an action plan to remove the immediacy dated 11/01/11 to the regional office consisting of the following actions: 1) The facility discontinued the use of all lancet pens and removed the items for destruction on 11/01/11 at 1:00 p.m. 2) The Nurse noted as having used the lancet pen has been instructed on appropriate use of lancets for the purpose of obtaining blood specimens for blood sugars on 11/01/11 at 1:15 p.m. 3) The Medical Director was notified of plan of action and alleged non-compliance on 11/01/11 at 2:15 p.m. and returned call at 11/01/11 at 3:20 p.m. with new orders for lab monitoring to assess residents at risk. 4) All Licensed Nurses have been informed that the Lancet Pen is not to be used for the purpose of obtaining blood specimens for blood sugars on 11/01/11 as one to one instruction. 5) The DON/Designee will on a daily basis during the morning compliance rounds monitor medication cart to assure Lancet Pen is not available for use. Noted concerns will be reported to the facility Administrator for action. 6) The QAA Committee will, at least quarterly, monitor this plan of action to assure regulatory compliance. This action plan was verified to have been completed on 11/01/11 at 3:20 p.m. as follows: 1) In an interview on 11/02/11 at 8:15 a.m. LVN A said she had been instructed on appropriate use of lancets for the purpose of obtaining blood specimens for blood sugars. 2) Observation on 11/02/11 at 11:45 a.m. revealed the [MEDICATION NAME] fingerstick devices were removed and replaced with single use lancets on the medication cart. 3) Record review of resident who received Accuchecks revealed physician orders [REDACTED]. While the IJ was removed prior to exit on 11/01/11 the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". B. Non-IJ Findings: 1. Observation on 11/01/11 at 11:48 a.m. revealed that LVN A performed an Accucheck on Resident #8. LVN A then placed the glucometer and the [MEDICATION NAME] fingerstick device on top of the medication cart. LVN A did not clean the glucometer. 2. Observation on 11/01/11 at 12:04 p.m. revealed that LVN A performed an Accucheck on Resident #9. LVN A then placed the glucometer and the [MEDICATION NAME] fingerstick device on top of the medication cart. LVN A did not clean the glucometer before or after the procedure. In an interview on 11/01/11 at 12:10 p.m. LVN A said that she had not cleaned the glucometer before or after she used the glucometer to check Resident #8 and #9 ' s blood sugars. LVN A said that the facility procedure was to clean the glucometer once during each shift with an antibacterial cloth. In an interview on 11/01/11 at 12:35 p.m. the DON said that the glucometer was to be cleaned once per shift. The DON said that she had not trained the nurses to clean the glucometer before and after each resident had a blood glucose test. Record review of facility provided, "Blood Glucose Test; Finger Stick" dated 02/2011 revealed the following: "....Follow manufacturer's directions for cleaning the glucose monitoring device." Record review of "Assure Pro Section B" undated located in front of the "Glucose Monitoring" notebook revealed: "Cleaning. Healthcare professionals should wear gloves when cleaning the Assure Pro meter .... We suggest cleaning the meter between patients." Record review of the facility provided list of residents received 11/01/11 who receive Accuchecks revealed 9 residents.