Every finding on record at Avir at Courtyard

Based on interviews, and record review, the facility failed to ensure that residents had the right to be informed of, and participate in, his or her treatment for 1 (Resident #1) of 5 residents reviewed for resident rights.- The facility failed to notify Resident #1's Responsible Party before initiating Risperidone on 01/31/26.This failure could place residents at risk of adverse reactions.The findings included:Record review of Resident #1's admission Record, dated 07/18/26, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included sepsis (body's extreme response to an infection), developmental disorder of scholastic skills (core academic abilities in reading, writing, and arithmetic), cerebral palsy (group of conditions that affect movement, balance and posture), and bed confinement.Record review of Resident #1's Quarterly MDS Assessment, dated 07/01/26, revealed a BIMS was not completed because resident was rarely/never understood. Further review revealed resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity.) on completing toileting hygiene, shower/bathing, and personal hygiene.Record review of Resident #1's Care Plan, undated, revealed he had impaired cognition d/t cerebral palsy, MI, and developmental disorder, had difficulty making self-understood and/or understanding others d/t CP, ID, and DD, and used antipsychotic medications r/t Anxiety. Interventions for impaired cognition included communicating with the resident/family/caregivers regarding residents capabilities and needs. Interventions for antipsychotic medications included administering psychotropic medications as ordered by the physician and monitoring for side effects and effectiveness q-shift.Record review of Resident #1's Physician Orders, undated, revealed an order for risperidone oral tablet 1 MG, 1 tablet by mouth in the morning for antipsychotic, notes: pt. with no psychosis/mood lability-will decrease and monitor closely, ordered date 01/29/26, start date 01/30/26 and discontinued date 04/20/26.Record review of Resident #1's Physician Orders, undated, revealed an order for Risperdal oral tablet 0.5 MG, 1 tablet by mouth in the morning for antipsychotic, give one tablet by mouth for mood lability (hx) - titrating down, ordered date 04/21/26, start date 04/22/26, discontinue 05/05/26, notes: increase dose.Record review of Resident #1's Physician Orders, undated, revealed an order for Risperdal oral tablet 1 MG, give one tablet by mouth at bedtime for mood disorder due to a known physiological condition, ordered date 05/05/26, start date 05/05/26, discontinue 07/14/26, notes: RP [name] does not want pt. taking medication Record review of Resident #1's Medication Administration Record, dated 01/01/2026-01/31/26, revealed an order for risperidone 1 MG tablet, give 1 tablet by mouth in the morning for antipsychotic, start date 01/30/2026, D/C date 04/21/2026, and administered beginning on 01/30/26.Record review of Resident #1's progress notes revealed no documentation that RP was notified on or before 01/31/26 that risperidone was being initiated.Record review of Resident #1's medical records revealed no documentation of signed consent from RP.Observation and interview on 07/18/26 at 9:55 a.m. was attempted with Resident #1. Resident was lying in bed, his eyes were closed, he appeared to be asleep. Resident opened his eyes after knock on his room door and once greeted. Resident did not respond to questions. Resident was non-verbal. Resident appeared drowsy, slowly closed his eyes, and dosed back off to sleep. Water pitcher with lid was on his bedside tray and within reach. Call light was within reach.During an interview on 07/18/26 at 1:26 p.m., the ADON said she did not see a signed consent in Resident #1's medical file for risperidone. She said risperidone was a psychotropic medication that deals with behaviors and that was why it is important to inform RP and get a consent signed before administering the medication. She said it was the responsibility of the DON and ADON to ensure the consent was signed before the medication was administered. She said she did not find documentation under Resident #1's progress notes saying RP was notified before the medication was administered.During an interview with Resident #1's RP via a returned phone call on 07/21/26 at 10:21 a.m., Resident #1's RP said before resident transferred to the facility from the hospital on [DATE] he was not prescribed or already taking Risperdal. She said when Resident #1 transferred from the hospital straight to facility, the facility initiated Risperdal without her consent, and she was not notified by staff beforehand. She said she was not notified until last Tuesday, 7/14/26, by a nurse (name unknow) asking for consent to initiate Risperdal. She said she was told the NP had ordered Risperdal because resident [NAME] was hitting himself, but she said he had never displayed any behavioral problems prior to his admission to the facility. She said she declined to give the facility consent to initiate Risperdal and found out they had already been administering him the medication. She said the resident should never have been administered Risperdal and told them to stop administering him the medication on 07/14/26.Record review of the facility's policy, Resident Rights, Revised February 2021, revealed .p. be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 2 of 6 residents (Residents #1 and Resident #56) reviewed for PASRR Level 1 screenings. The facility failed to verify the accuracy of the negative PASRR Level 1 Screening for Resident # 1 and Resident #56, who had diagnoses of mental illness. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.Findings Included:Resident #1 Record review of Resident #1's face sheet dated 09/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Schizoaffective disorder, Bipolar type onset date 03/15/2025 (Mental Illness), Post Traumatic Stress disorder( a mental health condition that develops after experiencing or witnessing a traumatic event), chronic onset date 03/15/2025, adjustment disorder with mixed anxiety and depressed mood (mental health condition) onset date 03/15/2025, and Depression onset date 03/15/2025. Record review of Resident #1's Quarterly MDS dated [DATE], revealed, A BIMS score of 15 out of 15 indicating no cognitive impairment, no behaviors in the reviewed period, extensive assistance with most ADLs, use of a wheelchair, frequent incontinence of bowel and use of indwelling catheter, Paraplegia, Depression, Schizophrenia, and Post Traumatic Stress Disorder. Record review of Resident #1's PASRR Level I Screening dated 03/14/2025 completed at the hospital, reflected Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #1's Order summary report dated 9/11/2025 revealed, May have psych therapy or psychological services as indicated and needed, Divalproex Sodium oral tablet delayed release 125 MG give 1 tablet by mouth two times a day for mood, Effexor XR oral capsule extended release 24 hour 75 mg give 1 capsule by mouth one time a day related to depression, Quetiapine Fumarate oral tablet 100 MG give 2 tablets by mouth at bedtime related to schizoaffective disorder, bipolar type. Record review of Resident #1's care plan Date initiated 3/19/2025 revealed: Focus care area: Resident #1 is taking antidepressant medication related to depression. Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Date initiated 3/19/2025 and revised on 4/19/2025, Focus care area: Resident #1 uses psychotropic medications related to Behavior management of schizoaffective disorder, bipolar type. Resident #56 Record review of Resident #56's face sheet dated 09/10/2025, revealed a [AGE] year-old female who was originally admitted on [DATE]. She had diagnoses including: Paranoid Schizophrenia (Mental Illness) onset date 3/18/2016, anxiety disorder (Mental health disorder) onset date 3/18/2016, and Delusional disorders onset date 3/18/2016. Record review of Resident #56's Quarterly MDS dated [DATE], revealed she had a BIMS score of 15 out of 15 indicating she had no cognitive impairment. No behavior issues were noted during the assessment period. Her current active diagnoses included Depression, Psychotic disorder, and schizophrenia. Record review of Resident #56's PASRR Level I Screening dated 02/01/2018 completed at the facility, reflected Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #56's care plan revealed:-Date Initiated 3/30/2018 Revised 1/01/2023: Focus care area: Resident #56 has mood problem related to bipolar disorder/schizophrenia. Intervention: Behavior health consults as need (Psycho-geriatric team, psychiatrist etc.) In an interview on 09/11/2025 with the Regional Reimbursement Coordinator at 4:32 PM revealed: It is the responsibility of the MDS coordinator upon admission to have a completed PASRR Level I. The facility has been without one since May. She started on 08/01/2025 and is regional as the facility is looking to hire an MDS coordinator. Level I's are usually completed on admission but no later than 72 hours after admission. If the Level I is completed at the hospital and it's identified, it was not completed correctly she fills out a form 1012 and looks to see if Resident has a diagnosis of Dementia. If the Resident doesn't have Dementia, then a repeat Level I will be submitted. If a Resident doesn't have a correct Level I completed, they can miss out on the services that PASRR offers. She follows the state guidelines for PASRR services. In an interview with the Former MDS Coordinator on 09/11/2025 at 4:40 PM revealed: She retired 04/03/2025, and she was Responsible for submitting PASRR Level I's. She would submit them within 48-72 hours after Resident was admitted . The Level II is completed by the Local authority, and she would follow up with them if they did not respond to an alert of a Positive Level I. If a Level I was found to not be done correctly she would correct it and would resubmit it as long as residents' primary diagnosis was not Dementia. Possible diagnosis for a Level I could be any serious mental illness or intellectual disability. She couldn't name specifics as she's been away from it and has forgotten. Not having a correct Level I could stop the Resident from getting possible services they are entitled to. Record review of the facility policy titled PASRR dated 07/29/2025 revealed: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individuals' needs. Negative indicates the person has a negative PLI screening, and is not suspected of having intellectual disability, developmental disability and or mental illness. Screening process: Level Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission.

Based on observation, interview and record review, the facility failed to ensure each resident received an accurate assessment reflecting the resident's status for 1 of 16 residents reviewed for assessment accuracy. (Resident #7) ---Resident #7's Dialysis was not coded on the MDS This failure placed residents at risk of having inaccurate assessments and receiving improper care and services. Findings include: Record review of Resident #7's face sheet revealed admission date 4/4/25, with diagnoses including vascular dementia (brain damage caused by multiple strokes), cerebral infarction (interruption of blood flow to the brain), Renal Dialysis (removal of waste products and fluid from the blood), dysphagia (difficulty in swallowing), end stage renal disease (loss of kidney function), Diabetes (high blood sugar). Record review of Resident #7's most recent physician's order dated 8/11/25 revealed Renal Dialysis Tuesday, Thursday, and Saturday. Record review of Resident #7's care plan dated 4/7/25 revealed needs Dialysis related to renal failure, with appropriate interventions for dialysis site care and monitoring for any changes. Record review of Resident #7's admission MDS dated [DATE], the section Special Treatments, Procedures was coded none of the above for Dialysis. Record review of Resident #7's Quarterly MDS dated [DATE], the section Special Treatments, Procedures was coded none of the above for Dialysis. In an interview with the DON on 9/10/25 at 1:20pm, she said she had just started working here, and was still familiarizing herself with the residents, but the MDS should be accurate and reflect all conditions and treatments for residents. She said she would look at Resident #7s EMR and make sure the MDS was accurate to reflect his Dialysis. She said if the MDS was not accurate, it could affect the care the resident received. In an interview with the Regional Nurse Consultant on 9/10/25 at 2pm, she said the regional reimbursement coordinator has been doing the MDS in this facility since 8/1/25, but she is currently sick at home and not able to come into the facility. She said the former MDS nurse retired, and the facility is actively looking to hire an MDS nurse. She said she would contact the regional reimbursement coordinator and let her know Resident #7s MDS did not reflect his Dialysis, which was in place when he was admitted to the facility. She said the MDS should accurately describe the resident, the interdisciplinary team would contribute to the assessment for each resident, and the MDS nurse would finalize the MDS. She said the harm of having an inaccurate MDS assessment would mean the residents would not receive proper care according to their needs. Record review of the facility policy Resident Assessments, revised March 2022, revealed, in part:.a comprehensive assessment of every resident's needs is made at intervals.results of assessments are used to develop, review and revise the comprehensive care plan.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to ensure the facility was free from pests/insects in multiple areas including one of one kitchen and one of one conference room. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable environment free of pests. Findings included: Observation on 08/12/24 at 10:00am, revealed flies and other flying insects in one of one conference room. Observation and interview with the facility Administrator on 08/12/24 at 2:30PM, revealed the following- Under the kitchen sink revealed multiple flying insects. On the wall above the sink by the window was a live roach. Observation of the dishwasher was a live roach. The facility Administrator asked the dietary Manager to call the pest control company. The Dietary Manager said the company had sprayed the facility a few weeks ago. Observation on 08/13/24 at 12:40PM, revealed live spider crawling from the wall in the conference room. The Administrator was notified. He said he would call the pest control company. Observation and interview on 08/13/24 at 12:30PM revealed a live roach and flies in the conference room. During an interview with the facility Administrator, he said the building was old and the facility had a pest control contract with a local company. He said all staff are responsible to report any pest control problem as to call in the pest control company for treatment. During an interview on 08/13/2024 at 10:12 AM, Resident #113 stated that she had seen cockroaches in her room. She said she believed the facility was aware. During an interview on 08/13/2024 at 9:31 AM, an Anonymous pest control staff said ng the kitchen. He said the only way to get rid of the rodents was to keep the floors around the dishwashing machine dry. During an interview on 08/13/24 at 1:00pm, Housekeeper T said that she had seen roaches in the resident's rooms and around, but they would always call pest control. DA stated that the bug on the wall next to the sink was a cockroach. He stated that they were everywhere in the building. He stated that pest control only came once and wished they came more often. He stated that when he saw cockroaches, he usually just killed them. He stated that he had not seen the cockroaches on clean dishes. He stated that they were in the outlet in the hallway and between the wheels of the trash can. He stated that the bug on the wall was next to a clean tray cart and was also a cockroach. During an interview with AFSS on 08/06/2024 at 11:37 AM, he stated that he has worked at the facility for two to three weeks. He stated that he noticed cockroaches shortly after he started. He stated he had not seen cockroaches in food. On 08/06/2024 at 11:39 AM, during an interview with [NAME] A, she stated that she had seen some cockroaches in the kitchen. She stated that she was unsure why they were in the kitchen but had not seen any in the food. Record review of facility's pest control policy undated section 10 read in part: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Procedure: .Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. Deliveries of food and supplies will be monitored for prevention of insect and rodent access .

Based on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 5 residents (Resident #61) reviewed for transfer and discharge requirements. The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), ombudsman, or the home health agency upon discharge for Resident #61. This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs. Findings included: Record review of Resident #61's Face sheet revealed an [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses, osteomyelitis (a bone infection that causes inflammation and swelling in the bone), essential hypertension (a form of hypertension without an identifiable physiologic cause), mixed hyperlipidemia (a generic condition that causes higher than normal levels of certain fats in the blood), muscle wasting and atrophy (a gradual process that causes muscles tissue to decrease in size and waste away), and pressure ulcer of right heel, stage 4. Record review on Resident #61's Admission MDS assessment dated [DATE], revealed he had a BIMS score of 12 out of 15, indicating he had moderate cognitive impairments. Further record review revealed he was independent for oral hygiene. He required partial/moderate assistance for roll to the left and the right. He used a walker and a manual wheelchair for mobility. Record review on of Resident #61's Baseline Plan of Care revised on 5/09/2024, Focus, Goal and interventions were blank. There was no initiated date or revision date for a discharge. There was no discharge summary found in Resident #61's medical record. Record review of Resident #61's Progress Notes dated 06/18/2024 created by RN A revealed; Resident was transported via stretcher by the ER for noncompliance/refusal of medications and wound care. When EMS arrived to put resident on stretcher he refused, stating he is not going on stretcher but by wheelchair, explained the wheelchair will be taken with him in the ambulance, then he started demanding two of his social security checks from writer, I'm not leaving without those damn checks Bitch informed resident writer knew nothing about any checks, he then raised his cane as if he was going to hit writer who stood her ground and informed the resident he does not scare her, he put cane down and called writer a Bitch again, this is normal behavior this resident exhibits toward staff who has not provoked him in any way. Resident then got on the stretcher after two male medics helped him onto the stretcher, resident left facility with medications and medical records and was transported to ER, he refused to have assessment, including vital signs taken prior to discharge. Interview on 8/14/2024 at 11:01a.m., with the Administrator, he said the normal procedure for a discharge, was for the social worker to contact the guardian. He said if it was an emergency discharge, or if the resident was causing issues, they would do an emergency discharge and contact the responsible party. He said Resident #61 was sent to the hospital. He said there should have been more documentation regarding Resident #61's discharge. He said the documentation should have told what happened and that Resident #61 was not coming back to the facility due to his behaviors he exhibited at the facility. He said it was not documented that it was discussed with the hospital that Resident #61 was not to return to the facility. He said it was important to have a proper discharge to make sure the resident was in a safe place. He said a proper discharge and documentation was the general reason what it was important to make sure Resident #61 maintained services. Interview on 8/14/2024 at 11:23a.m., with the ADON, she said the way the facility would do a proper discharge would be to let the doctor know the issues that were going on with the resident, request an order for the resident to transferred out of the facility, notify the family, set up transportation, and to call and report the discharge to the hospital to give the hospital a heads up on what was going on and who was coming in. She said she could not give a reason as to why the discharge was not done. She said she was not in the building when the discharge took place. She said when a proper discharge happens, it was best to notify the family and the doctor so they would understand what was going on with the resident. The ADON said they should have given the hospital a full and accurate report on Resident #61's behaviors and diagnoses so they could have adequate staff to handle his discharge . She said once the facility hangs up with the hospital, they do not check back in with the resident. She said it was important to make sure Resident #61 was in a safe place. She said moving forward she would check to make sure the family had been called and notes have been put into place. She said she would call the hospital to make sure the resident was under their care and arrived safely. Interview on 8/14/2024 at 11:33a.m., with the MDS Coordinator, she said the proper way to have discharged Resident #61 would have been to document, no return not anticipated and provided information on who was notified about the discharge. She said the social worker should have contacted the family, and RP. She would complete paperwork and document the reason for discharge, and where Resident #61 was going. She said if it was not done it there could be a problem with following through with his care and safety. She said next time she would make sure the resident has a proper discharge and would be make sure they have the proper people in place to check everything and to make sure the documentation was there. Follow-up interview at 4:03p.m., with the MDS Coordinator, she said she considered yelling, shouting, refusing medication, and care from Resident #61 to be considered as a behavior. She said she was not sure if they told the resident that he cannot return to the facility. She said it was protocol to tell the resident that he was not able to return to the facility . Record review of the facility's policy titled Transfer, Discharge, and Return revision date not listed, read in part . Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility will inform the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family in selecting the new residence. All information will be in the manner in which they can understand; The facility will provide the resident or representative with the following information: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; If a Medicaid Eligible resident: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain and appeal form and assistance in completing the form and submitting the appeal hearing request, If PASRR positive residents or those with a mental disorder or related disability: mailing and email address and telephone number of the agency responsible for the protection and advocacy of such residents. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman if the discharge is considered involuntary and does not apply to residents who request a discharge .

Based on interviews and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 5 residents (Resident #61) reviewed for return to the facility. - The facility failed to readmit Resident #61 after sending the resident to the hospital and refusing to readmit him back to the facility. -The facility failed to provide evidence they notified Resident #61's Responsible Party or the physician about his discharge to the hospital. These failures could place residents, who transfer to the hospital, at risk of being denied readmission to the facility and could result in a decreased quality of life and resident rights violations. Findings included: Record review of Resident #61's Face sheet revealed an [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses, osteomyelitis (a bone infection that causes inflammation and swelling in the bone), essential hypertension (a form of hypertension without an identifiable physiologic cause), mixed hyperlipidemia (a generic condition that causes higher than normal levels of certain fats in the blood), muscle wasting and atrophy (a gradual process that causes muscles tissue to decrease in size and waste away), and pressure ulcer of right heel, stage 4. Record review on Resident #61's Admission MDS assessment dated [DATE], revealed he had a BIMS score of 12 out of 15, indicating he had moderate cognitive impairments. Further record review revealed he was independent for oral hygiene. He required partial/moderate assistance for roll left and right. He uses a walker and a manual wheelchair for mobility. Record review on of Resident #61's Baseline Plan of Care revised on 5/09/2024, Focus, Goal and interventions were blank. There was no initiated date or revision date for a discharge. There was no discharge discharge summary for Resident #61 in his medical record. Record review of Resident #61's Progress Notes dated 06/18/2024 created by RN A revealed; Resident was transported via stretcher by the ER for noncompliance/refusal of medications and wound care. When EMS arrived to put resident on stretcher he refused, stating he is not going on stretcher but by wheelchair, explained the wheelchair will be taken with him in the ambulance, then he started demanding two of his social security checks from writer, I'm not leaving without those damn checks Bitch informed resident writer knew nothing about any checks, he then raised his cane as if he was going to hit writer who stood her ground and informed the resident he does not scare her, he put can down and called writer a Bitch again, this is normal behavior this resident exhibits toward staff who has not provoked him in any way. Resident then got on the stretcher after two male medics helped him onto the stretcher, resident left facility with medications and medical records and was transported to the ER, he refused to have an assessment, including vital signs taken prior to discharge . Interview on 8/14/2024 at 11:01a.m., with the Administrator, said the normal procedure for a discharge, was for the social worker to contact the guardian. He said if it was an emergency discharge, or if the resident was causing issues, they would do an emergency discharge and contact the responsible party. He said Resident #61 was sent to the hospital. He said there should have been more documentation regarding Resident #61's discharge. He said the documentation should have told what happened and that Resident #61 was not coming back to the facility due to his behaviors he exhibited at the facility. He said it was not documented that it was discussed with the hospital that Resident #61 was not to return to the facility. He said it was important to have a proper discharge to make sure the resident was in a safe place. He said a proper discharge and documentation was the general reason what it was important to make sure Resident #61 maintained services. Interview on 8/14/2024 at 11:23a.m., with the ADON, said the way the facility would do a proper discharge would be to let the doctor know the issues that was going on with the resident, request an order for the resident to transferred out of the facility, notify the family, set up transportation, call and report the discharge to the hospital to give the hospital a heads up on what was going on and who was coming in. She said she could not give a reason as to why the discharge was not done. She said she was not in the building when the discharge took place. She said when a proper discharge happens, it was best to notify the family and the doctor so they would understand what was going on with the resident. She said they should have given the hospital to where Resident #61 was being discharged , information about his behavior so the hospital could have adequate staff. She said once the facility hangs up with the hospital, they do not check back in with the resident. She said it was important to make sure Resident 61 was in a safe place. She said moving forward she would check to make sure family had been called and notes have been put into place. She said she would call the hospital to make sure the resident was under their care and arrived safely. Interview on 8/14/2024 at 11:33a.m., with the MDS Coordinator, said the proper way to have discharged Resident #61 would have been to document, no return not anticipated and provided information on who was notified about the discharge. She said the social worker should have contacted family, and RP. She would complete paperwork and document the reason for discharge, and where Resident #61 was going. She if it was not done it there could be a problem with following through with his care and safety. She said next time to make sure to a resident has a proper discharge would be make sure they have the proper people in place to check everything and to make sure the documentation is there. Follow-up interview at 4:03p.m., with the MDS Coordinator, said she considered yelling, shouting, refusing medication and care from Resident #61 to be considered as a behavior. She said she is not sure if they told the resident that he cannot return to the facility. She said it is protocol to tell the resident that he is not able to return to the facility. Record review of the facility's policy titled Transfer, Discharge and Return revision date not listed, read in part . Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility will inform the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family in selecting the new residence. All information will be in the manner in which they can understand; The facility will provide the resident or representative with the following information: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; If a Medicaid Eligible resident: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain and appeal form and assistance in completing the form and submitting the appeal hearing request, If PASRR positive residents or those with a mental disorder or related disability: mailing and email address and telephone number of the agency responsible for the protection and advocacy of such residents. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman if the discharge is considered involuntary and does not apply to residents who request a discharge .

Based on observations, interviews, and record review the facility failed to conduct initial and periodical and comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 (Residents #46, #113) of 16 residents reviewed for accuracy of resident assessments. Residents #46 and #113 were not assessed accurately on their annual comprehensive MDS assessments. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings included: Resident # 46 Record review of Resident #46's electronic face sheet, revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Type 2 diabetes, pulmonary emphysema, benign prostate hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), essential hypertension (high blood pressure), muscle weakness, and lack of coordination. Record review of Resident #46's annual comprehensive MDS assessment dated [DATE] indicated Resident #46 had a BIMS score of 11 out of 15 indicating he had moderate cognitive impairment. Record review of section L for Oral\Dental status revealed he was checked as having no problem on his oral cavity. Observation and interview on 08/12/24 at 01:29 PM, Resident #46 said he had dentures. He said his dentures were new because he broke the first ones while in the hospital and he had to get new ones. He said he had his dentures on and pointed to his dental care products on his nightstand. Resident #113 Record review of Resident #113's face sheet dated 08/14/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, essential hypertension (primary) (high blood pressure), fall on same level from slipping, tripping, and stumbling without subsequent striking against object, neuropathy diseases, fracture of first lumbar (Fractures), heart failure, heart disease with heart failure, chronic obstructive pulmonary disease, generalized muscle weakness, muscle wasting and atrophy, and other abnormalities of gait and mobility. Record review of Resident #113's annual comprehensive MDS assessment dated [DATE] indicated Resident #113 had a BIMS score of 13 out 15 indicating her cognition was intact. Record review of section L for Oral\Dental status revealed she was checked as having no problem on her oral cavity. Observation and interview on 08/12/24 at 09:31 AM, revealed resident #113 had no teeth in her oral cavity. In an interview she said she had dentures, and they don't fit. Resident #113 said they hurt when she wears them. She pointed to her dentures in two separate containers and stated, they make me sick and they hurt bad. She said no one at the facility had asked her about them and she managed to eat what she could. In an interview on 08/13/24 at 3:45PM, the MDS Coordinator said Resident #113 had no teeth in her oral cavity. She said Resident # 113 had dentures but did not wear them. She looked at the MDS coding and said it was coded wrong which was an inaccurate assessment. She said inaccurate assessments may lead to delay in providing needed services. She said she remembered Resident # 46 telling her about his dentures. She said she would modify both MDS assessments. In an interview with the facility Administrator on 08/14/24 at 1:50 PM, he said he expected all MDS assessments to accurately reflect resident's conditions. HE said the MDS staff was responsable to ensure that all assessment accuretly reflected Residents condition . He said inaccurate assessment may delay services. Policy on Accuracy of MDS assessment was requested on 08/13/24 at 3:50PM and on 08/13/24 at 1:00PM. Provided Policy did not address MDS accuracy.

Based on observations, interviews, and record review, the facility failed to provide appropriate care, treatment, and services to maintain or improve his or her ability to carry out the ADLs for 1 of 16 residents (Resident #23) reviewed for ADL care. The facility failed to assist and provide Resident #23 nail care. This failure could lead to self-injuries and diminish health conditions. Resident # 23 Record review of Resident #23's Admission Record dated 08/14/24 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebrovascular diseases (a condition that affect blood flow and blood vessel in the brain), blindness, essential hypertension, osteoarthritis of knee (deterioration of the knee joints), and depression. Record review of Resident #23's Annual MDS dated [DATE] revealed he was cognitively intact, with a BIMs score of 14 out of 15. Section B of the MDS related to Vision, was coded as highly impaired. Section GG of the MDS related to Functional Abilities and goals revealed he required supervision/touching assistance for personal hygiene. Record review of Resident #23's care plan dated 05/16/24 with a revision date of 9/13/24 revealed Resident #23 was care planned as Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner requiring supervision and limited assistance with ADLs. Intervention Resident #23 will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date of 09/12/24. Observation and interview on 08/12/24 at 1:00 PM, revealed resident #23 was in his room sitting up on his bed. Observation revealed he was blind and eating with his hands. He was alert and oriented. He said he was doing fine. Observation revealed he had long dirty fingernails. Observation on 08/13/24 09:58 AM revealed Resident #23 had long dirty fingernails. In an interview he said has asked for his nails to be trimmed down but he was always told that they would come back and they never returned. He said he had nail clippers but he could not see well enough to trim them himself. He said he had scratched himself several times especially his eyes. Resident #23 said that trimming his fingernails was one thing he needed help with because he knew how his room was arranged and where most of his things were located but struggled with some ADL care. In an interview with RN A on 08/12/24 at 10:00AM, she observed Resident # 23's fingernails and assured Resident #23 that she would personally trim his fingernails. She did not say how long it had been since his fingernails had been trimmed and did not say who was responsible for trimming them or ensuring they had been trimmed. She said untrimmed long fingernails could caused injuries by scratching himself. Record review of facility's undated policy on ADL care to dependent's residents titled Fingernails and Toenails, read in part . Basic Responsibility Licensed Nurse, Nursing Assistant. PURPOSE: To clean the nail bed, to keep nails trimmed, and to prevent infections. To aid in the prevention of skin problems around the nail bed. To prevent accidental scratching and injuring skin from rough/jagged nails. ASSESSMENT GUIDELINES: May contain, include, but not limited to: Any diagnoses of Diabetes and/or circulatory impairments. Condition of nails, nail bed, and surrounding skin. Any scratches or skin injury caused by nails .

Based on observations and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles reviewed for medications, 1 of 2 medication aide carts, and 2 out 3 of nurse's carts. Station 1 nurse medication cart A had a blister packet of Lorazepam, 0.5mg for a discharged Resident control medication, was still in the medication cart in station 1 nurse's cart. Station 1 medication aide cart B had 6 blister packets of medications: Lipitor 40 mg, sertraline HCL 25 mg, LevETIRAcetarn 75 mg, metoprolol tartrate 25mg, baclofen 10mg, gabapentin 100mg, Sertraline HCL 25 mg was left in the cart, and the resident was discharged from the facility on [DATE]. fluticasone propionate nasal spray that was open and not dated. Station 2 nurse medication cart B had opened and undated: Imodium A-D Loperamide hydrochloride tablet's 2mg expired ,d+[DATE]. Latanoprost ophthalmic solution 0.0005%125mcg/2.5ml was opened on [DATE], it read to discard after 24 days. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings included: During an observation of Station 1 nurse medication cart A on [DATE] at 1:25 p.m., with RN A and the ADON revealed a blister packet of Lorazepam 0.5mg for discharged Resident #300. The controlled medication was still in the medication cart. During an interview on [DATE] at 1:26 p.m., RN A said the controlled medication should be taken out of the medication cart by the nurse and given to the DON upon discharge. RN A said the discharged resident's medication should not be left in the cart because the nurse might administer the medication to another resident, or it could cause drug diversion. RN A said she was in- serviced on medication administration and storage. RN A said the ADON, and the pharmacist monitored the nurse and ensured there were no discontinued medications in the cart. During an interview on [DATE] at 1:27 p.m., the ADON said the discharged resident's medication should be kept from the cart to prevent the nurses from administering the wrong medication. The ADON said she would be responsible for pulling the medication now since the facility did not have a DON. During an observation of station 1 medication aide cart B on [DATE] at 1:46 p.m. with MA N revealed 6 blister packets of medications: Lipitor 40 mg, sertraline HCL 25 mg, levetiracetam 75 mg, metoprolol tartrate 25mg, baclofen 10mg, and gabapentin 100mg was left in the cart and the resident was discharged from the facility on [DATE]. There was a fluticasone propionate nasal spray that was open and not dated. During an interview on [DATE] at 1:46 p.m., MA N said she placed the resident medication in the bottom drawer of the cart when the resident was sent to the hospital, and she did not know what the protocol was for medication storage when the resident was discharged from the facility. MA N said the nurse, the DON, and the pharmacist checked the medication cart and ensured the medication in the cart was for the residents in the facility. MA N said she had skills checks-off for medication administration and storage. MA N said she did not open the nasal spray, which should be dated to prevent the nurse from administering expired medication. During an interview on [DATE] at 2:12 p.m., the ADON said if a resident went to the hospital and stayed for 72 hours, the computer discharged the resident. The ADON said the medication was kept in the cart for 30 days, but she was not sure. She said she would check the facility policy and protocol and get back to the state surveyor. During an interview on [DATE] at 2:14 p.m., the ADON said the nasal spray should be labeled to prevent the nurse from administering expired medication to the resident. The ADON said if the medication were administered when it was expired, the medication would not be effective. The ADON said that she and the pharmacist would check behind the nurses and MA to make sure the medication was stored appropriately. During an observation and interview of station 2 nurse cart check with LVN R on [DATE] at 2:34 p.m., revealed stock medication: Imodium A-D Loperamide hydrochloride tablet's 2mg expired ,d+[DATE], latanoprost ophthalmic solution 0.0005% 125mcg/2.5ml was opened on [DATE] and it read to discard after 24 days. LVN R said she did not open it, and she did not administer the medication today because it was for bedtime. LVN R said the medication should not be administered after the expiration date because it would not be effective. LVN R said she was trained in medication administration and storage. LVN R said the ADON, and the pharmacist monitor the cart and make sure the medications were not expired or outdated. LVN R said the stock medication should be removed from the cart as soon as it expired and replaced with the current medication. During an interview on [DATE] at 2:40 p.m., the ADON said the nurse should date medication as soon as it was opened and discard it by the expiration date to prevent administering the expired medication, which would not be effective. The ADON said she would monitor the nurses. Record review of the facility undated storage of medication policy read in part . no discontinued outdated, or deteriorated medications are available for use in the facility . Record review the facility undated policy renewal of discontinued medication after discharge and return read in part . establish uniform guideline concerning the facility's procedures for discontinuing medications when a resident is discharged from the facility .

Based on observations, interviews, and record review the facility failed to to provide appropriate dental care for 1 (Residents #113) of 16 residents reviewed for dental. The facility failed to provide proper dental care and assure her denture concerns were addressed with Resident #113. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings included: Resident #113 Record review of Resident #113's face sheet dated 08/14/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, essential hypertension (primary) (high blood pressure), fall on same level from slipping, tripping, and stumbling without subsequent striking against object, neuropathy diseases, fracture of first lumbar (Fractures), heart failure, heart disease with heart failure, chronic obstructive pulmonary disease, generalized muscle weakness, muscle wasting and atrophy, and other abnormalities of gait and mobility. Record review of Resident #113's annual comprehensive MDS assessment dated [DATE] indicated Resident #113 had a BIMS score of 13 out 15 indicating her cognition was intact. Record review of section L for Oral\Dental status revealed she was checked as having no problem on her oral cavity. Observation and interview on 08/12/24 at 09:31 AM, revealed resident #113 had no teeth in her oral cavity. In an interview she said she had dentures, and they don't fit. Resident #113 said they hurt when she wears them. She pointed to her dentures in two separate containers and stated, they make me sick and they hurt bad. She said no one at the facility had asked her about them and she managed to eat what she could. In an interview on 08/13/24 at 3:45PM, the MDS Coordinator said Resident #113 had no teeth in her oral cavity. She said Resident # 113 had dentures but did not wear them. In an interview with the facility Administrator on 08/14/24 at 1:50 PM, he said he expected all MDS assessments to accurately reflect resident's conditions. He said inaccurate assessment may delay services.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that the deep fryer grease was changed regularly and kept clean. The facility failed to ensure that the dishwashing area was free of stagnant water and the walls were clean. This failure placed residents at risk for foodborne illness. Findings included: Kitchen observation and interview on 08/12/24 at 08:14AM to 8:50 AM, revealed the deep fryer had dark looking grease with brownish looking substances on top of the grease. One of one oven range had grease build up around the oven range. In an interview with the Dietary Manager, she said the deep fryer grease was due to be changed and she would change the grease from the deep fryer and make sure that the oven would be cleaned. She said it was usually changed every Friday or Monday but had not been changed. Observation of the dishwasher on 08/12/24 at 8:50AM, revealed standing water between the rinse sink and the dishwasher. In an interview, Dietary Aide N said the water was from spraying dishes and the dish washing machine. An observation revealed black looking substances around the walls behind and around the dishwashing area. The Dietary Manager said this was her first time observing the stagnant water on the floor between the sink and that she would tell the Maintenance Director to look at it and she would have the walls cleaned. Observation and interview on 08/12/24 at 2:30PM, with the Facility's Administrator, revealed the stagnant water was between the sink and the dishwashing machine. Multiple unidentified flying insects under the sink and around the dishwashing machine. The facility Administrator said to clean the area and call the pest control company. He said the facility was sprayed about a week ago. Record review of facility's undated policy on 08/14/24 titled {The facility} , Section 9-Dietary -Food Service: Policy Cleaning read in part. Procedure: All equipment, food contact surfaces and utensils shall be cleaned: Surfaces must be cleaned with a sanitizing agent/solution .Chlorine, iodine, or quaternary ammonium compounds are approved sanitizing agents. All food surfaces will be cleaned at the end of each food preparation session. Grid panels in the fire suppression hood over the stove will be removed and run through the dish machine once a month. Rubber mats on the floor in the kitchen must be cleaned daily. The floor of the kitchen must be cleaned daily and after each spill or contamination. Refrigerator units must be cleaned monthly. Wall surfaces that become splattered during the food preparation process must be cleaned daily .

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 6 residents (Housekeeper C, and CNA L) observed for infection control. 1. The facility failed to ensure Housekeeper C followed proper infection control and PPE while pushing a dirty trash can on section 1 hallway. 2. The facility failed to ensure CNA L followed proper infection control and hand washing procedure during incontinent care for Resident #25. These failures could place residents at risk for infection. Findings included: Observation and interview on 08/12/24 at 1:46 p.m., Housekeeper C was pushing the trash barrel into the station one hallway, and she had gloves on. Housekeeper C said she was not supposed to wear gloves in the hallway because of the risk for cross-contamination. Housekeeper C said she had been in-serviced on PPE use and infection control. Housekeeper C said the Environmental Manager monitored her during rounding. During an interview on 08/14/24 at 8:50 p.m., the Administrator said Housekeeper C should not have worn gloves in the hallway because of the risk for cross-contamination. During an interview on 08/14/24 at 12:15 p.m., Staff M said Housekeeper C should not have worn gloves while she pushed the trash barrel in the hallway because it was an infection control issue because of cross-contamination and the spread of germs. Staff M said Housekeeper C was in- serviced on infection control and PPE use. Staff M said she monitored all housekeepers when she made random rounds. Record review of Resident #25's face sheet dated 08/23/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnoses which included: atrial fibrillation (an irregular heartbeat), hypertension (when the pressure in your blood vessel is too high), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and need for assistance with personal care. Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 which indicated moderate impaired cognition. Further review revealed the resident needed extensive assistance with ADL's which required at least one staff assistance. Record review of Resident #25's care plan initiated on 07/23/24 revealed resident had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Performance deficit related to impaired cognition and muscle weakness. Intervention: provide shower, shave, oral care, and nail care, per schedule and when needed. During an observation on 08/13/24 at 10:10 a.m., incontinent care provided by CNA D and CNA L revealed, CNA L used the same gloved hands, when she wiped Resident #25's peri area, and took wipes from the multi-wipe packet, 15 times. CNA L changed her gloves thrice during the care and did not wash or sanitize her hands before she donned another glove. During an interview on 08/13/24 at 1030 a.m., CNA D said he saw CNA L took wipes from the multi wipe packet many times with the same gloved hands she used to clean Resident #25's bowel movement, and she changed her gloves three times, and she did not sanitize or wash her hands before she donned another glove. CNA D said it was an infection control issue because CNA L would have transferred germs from her gloves to the wipe packet or other surfaces she touched. During an interview on 08/13/24 at 11:00 a.m., CNA L said she forgot to change her gloves before going from dirty to clean, and she did not wash or sanitize her hands before she donned clean gloves. CNA L said it was an infection control issue, and she could have contaminated the multi wipe packet. During a telephone interview on 08/13/24 at 11:35 a.m., the Interim DON said CNA L was supposed to pull wipes out of the wipe packet before she started to wipe Resident #25's peri area and buttocks. The Interim DON said if CNA L needed more wipes, she should have removed the gloves and sanitized her hands before she went back to the multi wipe packet. The Interim DON said it was because of the risk for cross-contamination. The Interim DON said CNA L should have washed or sanitized her hands before she donned new gloves. The Interim DON said the facility did not train or in-service agency aides before the aide would be assigned to the floor because they had a contract with the agency. They know the facility's needs, but she would check with the COO and get back to the surveyor. During an interview on 08/14/24 at 1:28 p.m., the ADON said CNA L should have pulled some wipes out of the container, and if she needed more, she should have changed her gloves before she pulled more wipes from the container. The ADON said if CNA L did not wash or sanitize her hands, it was an infection control issue because it was cross-contamination. The ADON said CNA L could have transferred germs from her used gloves to the multi-wipe packets, and she should have washed or sanitized her hands because the gloves could have had holes. She said CNA L was an agency aide, and the facility did not provide training or in-services before the aide started working. Still, if the agency aide were in the facility during in-service, the agency aide would attend the in-service. Record review of the facility undated policy on housekeeping read in part . provide a safe environment for resident . Record review of the facility undated policy on personal protective equipment - gloves read in part . to prevent the spread of infection . miscellaneous #5 . wash hands after removing gloves. (Note: gloves do not replace handwashing) . Record review of the facility undated policy on hand washing read in part . hand washing will be regarded by this facility as the single most important means of preventing the spread of infections . procedure #2h . after contact . body fluid excretion .

Based on observation, interview, and record review the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 6 residents (Resident #25) reviewed for safe operating patient care equipment. The facility failed to maintain Resident #25's electric bed remote in safe operating condition. This failure could put residents in the facility at risk of injury. The findings included: Record review of Resident #25's face sheet dated 08/23/24 revealed she was a[AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnoses which included: atrial fibrillation (an irregular heartbeat), hypertension (when the pressure in your blood vessel is too high), dementia (impair ability to remember, think, or make decisions that interferes with doing everyday activities), and need for assistance with personal care Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 indicated moderate impaired cognition. Further review revealed the resident needed extensive assistance with ADL one staff assist. Record review of Resident #25's care plan initiated on 07/23/24 revealed resident had ADL self-care performance deficit and at risk for not having her needs met in a timely manner. Performance deficit related to impaired cognition and muscle weakness. Intervention: provide shower, shave, oral care, and nail care, per schedule and when needed. During an observation on 08/12/24 at 10:40 a.m., revealed Resident #25's bed was in a high position. During an observation and interview on 08/12/24 at 1:30 p.m., RN A said the remote control for Resident #25's bed had not been working, and she was not sure if it was reported to the maintenance, and she could not remember reporting it. RN A said Resident #25's bed was in a high position because the remote control would not let the bed down, and if Resident #25 fell out of the bed, Resident#25 could sustain an injury. During an observation and interview on 08/13/24 at 10:10 a.m., revealed Resident # 25 bed was still in a high position. After CNA L and CNA D provided incontinent care for Resident #25, CNA L tried to lower Resident #25's bed, but the bed would not go down. CNA L said she could not lower the bed because the remote malfunctioned. Then CNA D took the bed remote from CNA L and manipulated the bed remote for about 5 minutes. CNA D was able to lower the bed, and he said the remote was not working properly because there was wiring shortage, and the remote needed to be fixed. CNA B said he did not tell the nurse or the maintenance because today was his second orientation day. During an interview on 08/13/24 at 11:00 a.m., CNA L said she worked with Resident #25 yesterday (08/12/24). CNA L said she could not lower Resident #25's bed because the remote control was not working correctly, and she did not tell the nurse or the maintenance because she was an agency aide and did not know who to report to about the bed remote. CNA L said she did not get any training on equipment safety from her agency and the facility. CNA L said if Resident #25 had fallen out of the bed because the bed was left on a high level, Resident #25 could hurt herself. CNA L said the charge nurse monitored the aides when she made rounds. During an interview on 08/14/24 at 8:10 a.m., the ADON said the remote to Resident #25's bed had an electrical shortage, which affected the remote's function and caused the bed not to go down. The ADON said that since the remote was not functioning, this could cause harm to Resident #25 if Resident #25 happened to fall out of the bed because the bed was left in a high position because the remote was not functioning. The ADON said she was not aware the bed remote for Resident #25 had an electrical issue until this week, Monday (08/12/24), and she did not notify maintenance. During an interview on 08/14/24 at 8:14 a.m., the Maintenance assistant said he would become aware that Resident #25's bed remote was not working when one of the nurses told him, and he would get the remote fixed. The Maintenance Assistant said they had an order book at the nursing station for repairs, and there was no repair request for Resident #25's bed remote. The Maintenance Assistant said he was not aware that the bed remote for Resident #25 was not working until yesterday at around 11:00 a.m. (08/13/24). The Maintenance Assistant said the maintenance Director made rounds and checked on the bed remote, but he did not know how often the maintenance director made rounds. The Maintenance Assistant said the Maintenance Director was off this week because he was sick. The Maintenance Assistant said Resident #25 could have fallen out of bed, and Resident #25 could have hurt herself if the bed was left high because the bed remote was not functioning. During an interview on 08/14/24 at 8:42 a.m., The Administrator said the staff that goes into Resident #25's room should have told the manager. The manager would put the order in the telling system, and the maintenance would fix Resident #25's call light. Then the Administrator said he would prefer the nurses to tell maintenance immediately so the maintenance would fix it immediately. The Administrator said if Resident #25 fell from a bed left in a high position, Resident #25 could hurt herself. Record review of the facility undated policy on preventative maintaince read in part . the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely. and accordingly, to protocol by the maintenance supervisor .

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 43 residents (CR #229) reviewed for free of accidents, hazards, supervision, and devices. -The facility failed to develop any interventions following CR #229's fall on [DATE]. CR #229 fell again on [DATE], suffered a traumatic head injury and died as a result of his injuries. On [DATE] at 3:09 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 2:36 p.m., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could affect residents who require assistance with ADLs and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Record review CR #229's undated comprehensive care plan revealed the following: Fall risk: CR #229 has the potential for falls r/t unsteady gait, history of falls, and poor safety awareness with poor impulse control .Date: [DATE] .Created on: [DATE] .Revision on: [DATE]. Goal the resident will be free of falls during the next 90 days .Date initiated [DATE] .Revision on: [DATE] .Target date: [DATE]. Interventions anticipate and meet the resident's needs .Date initiated:[DATE] .Created on: [DATE] .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes .Date initiated: [DATE] .Created on: [DATE]. Therapy for strengthening .Date initiated; [DATE] .Created on [DATE] .Revision on: [DATE]. Record review of CR #229's Progress Notes dated [DATE] at 4:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:,d+[DATE] HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to [Hospital A] . Record review of CR #229's incident report dated [DATE] at 3:35a.m., read in part, .Nurse Description: CNA reported to this nurse that during rounds, res as observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. When asked what happened resident did gesture to the bathroom. Res has a wound to the left temporal region. Resident is able to move extremities x4 without pain. Res BP:,d+[DATE] HR 65 RR 15 o2 97RA T: 98.9. Resident Description: Asked to give more details as to what happened resident pointed to bathroom but did not say anything else. Immediate Action Taken: Res transported to Hospital A of head injury. Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . [NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Record review of CR #229's PT Evaluation & Plan of Treatment dated [DATE] at 6:47a.m., read in part, New Goal/Short Term Goals: Patient will safely ambulate on level surfaces 60 feet using RW with Min assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date: [DATE]). New Goal/Bed Mobility: Patient will safely perform functional transfers with Stand Assist for push up from arms of chair and for correct hand/foot placement with reduced risk for falls in order to facilitate increased (I) with functional mobility throughout facility and decreased level of assistance from caregivers (Target Date: [DATE]). New Goal/Transfers: Patient will safely ambulate on level surfaces 125 feet using RW with Stand by assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date [DATE]) . Interview on [DATE] at 10:27a.m., with RN A said she came into work and LVN A told her CR #229 had gotten out of bed and fell on [DATE]. She said during the day he stayed in his wheelchair, and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he is supposed to turn on his call light when he needs help, but he is non-compliant. She said he would sometimes try to walk on his own, and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:30 a.m. with CNA F said she used to assist CR #229 with everything. She said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she was not present when the resident fell . She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41 a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell . She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 p.m. the Administrator said he was told by staff that CR #229 had fallen and was able to explain what happened to staff. He said it was an agency nurse that was working the night when CR #229 fell . He said CR #229 had a fall once before on [DATE]. Follow-up interview on [DATE] at 2:18p.m., the Administrator said he is in challenging times. He said he has had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to his rules is overwhelming. He said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he was not sure as to why the initial fall assessment wasn't done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:40 p.m. with the DON said she did not talk to CR #229 about his fall. She said CR #229 was gone from the facility when she arrived at work. She said she was notified by staff that he had fallen, and staff noticed he was injured, and was sent to Hospital A. She said staff didn't know how or where he hit his head. She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Interview on [DATE] at 12:50 p.m. with RN A, said she worked with CR #229 for the short time he was at the facility. She said she provided day to day care for him. She said CR #229 had to be redirected a lot because he wanted to be self-sufficient. She said on her shift, he did well with staying in his wheelchair. She said the night the CR #229 had the fall; she came into work and LVN A reported it to her. She said she is not sure if it was LVN A who gave her the report. She said staff told her that CR #229 got up in the middle of the night and was found on the floor in front of the sink. She said she was told he was bleeding from his head, and they sent him out for evaluation. She said she cannot remember if there was anything put in place prior to the second fall. She said CR #229 had a low bed. She said if he asked for assistance to the bathroom, they would help him, but he would not ask for assistance. She said he thought he could do everything on his own, but he couldn't anymore. She said she checked on him a lot. She said he was able to get up and go to the restroom by himself, but he had an unsteady gait. She said CR #229 did not need two persons assist. She said he only needed one person assists to go to the bathroom. She said when she would assist him to the restroom, she would take his wheelchair and put in the bathroom doorway. She said she helped him pivot and put him on the stool. She said if something was put in place for CR #229, he could carry out that plan. She said sometimes his cognition would be better than it would at other times. She said he was able to communicate his needs to her. She said she would ask CR #229 if he was in pain and needed assistance to the bathroom and he would answer her appropriately. She said she was surprised he had a BIMs score of 06. Interview on [DATE] at 1:27 p.m. with MDS Coordinator A, said she has been the MDS nurse at the facility for [AGE] years. She said she is responsible for doing the MDS assessments, LTC's, MI's, and she also does PASSAR's for the residents. She said the DON and the ADON are responsible for the care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on the MDS assessment if it says limited assistance for toilet use, it means that resident needs assistance to go to the bathroom. She said extensive assistance means he needs someone to help him all the time. She said she knows that CR #229 used his walker, and he would say different words or wrote them down. She said he could articulate his words. She said limited toilet use means moderate assist which means someone might need to watch him but not assist or they can help clean him. She said it is a difference when it comes to extensive assistance and limited assistance. She said if there is a care plan that says limited assistance and a MDS that says extensive assistance in a certain care area, it is a problem because it can affect the proper guidance or care that is needed for the resident. She said she cannot answer why the MDS assessment does not match the care plan. She said CR #229 was not on a toileting program. She said CR #229 was able to move around, and he was able to go leave his bed and go to the bathroom. She said when she did the MDS assessment for CR #229, he seemed to need extensive assistance. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the ADON are responsible for completing the fall risk assessments. Interview on [DATE] at 1:51 p.m. with the ADON, said is the Interim Assistant DON, till they find someone permanently. She said she checks the resident's admission assessments, and she does what is needed at the facility. She said she also review the resident's orders. She said she has also written care plans. She said she looks at the resident's diagnosis and their assessments, and their history. She said she does not receive information from the MDS on how to write the care plan. She said she has spoken to CR #229 when she needed to get consent on a vaccine. She said she called his family member for that information as well. She said MDS assessments are done quarterly or if there was a significant change. She said the MDS, and the care plan should correlate. She said she is responsible for the baseline care plan. She said the baseline care plan is done upon admission, which is what she had assessed on the resident. She said the comprehensive care plan is more detailed and is pulls more data on the resident. She said the importance of the care plan is so staff can establish a plan of care for the resident. She said the importance of an MDS assessment is to show what service is needed for the resident. She said CR #229 was able to move around on his own. She said he went to the restroom on his own. She said when she went to ask him about a vaccine, he was coming out of the restroom with his wheelchair. She said on [DATE], she was told he had a fall and was bleeding from his head and was sent to the hospital. She said she was aware that CR #229 had fall on [DATE] as well. She said he was able to understand what was being care planned. She said CR #229 could use the call light and moving the bed up and down. Interview on [DATE] at 2:15 p.m., with the DON, said she is responsible for everything. She said she oversees the nursing department. She said she is responsible for the comprehensive care plan. She said she has been the DON since [DATE] and was the interim during February of 2022. She said the care plan comes from the trigger assessment that was on the MDS. She said the MDS assessment can trigger certain problems a resident has, and their diagnosis and she would create the care plan. She said CR #229 was alert and oriented. She said he could speak, but it was not that clear. She said he was also able to write. She said he could walk but it was a scary walk. She said he was able to tell you when he needed to go to the bathroom. She said a BIM's score of 06 means it is a low score and that the person is not cognitively inclined. She said staff would tell CR #229 to call for assistance and to use the call light when he needed to use the restroom, but he would go on his own. She said extensive assistance means the staff is doing the work 75 percent of the time. She said limited assistance means the resident is doing 75 percent of the work. She said it would not be an issue if the MDS and the care plan had something different. She said if she goes into a resident's room and they can make their needs known, she will document what they can relate to, and that would be it was resident centered. She said CR #229 was not always verbal, but he can write things down. She said what she was told by LVN D, was that CR #229 was on the ground, and he had a head injury. She said she told her to see if CR #229 could write it down. She said she was not sure if CR #229 ever wrote anything down. She said CR #229 could walk and staff would sometimes help him. She said the MDS extensive assistance, and two-person assist doesn't really mean that is what he needs. When the DON was asked to explain what she meant by her last statement, she said she did not know how to explain what she meant. Interview on [DATE] at 2:35 p.m., with the Administrator, said he has been the administrator at the facility for [AGE] years. He said he is a hands-on administrator, and he goes to resident council meetings when asked. He said the residents and the resident's family members has his personal phone number. He said his first interaction with CR #229 was when he first came to him and introduced himself. He said the second time was after his first fall. He said the first fall that occurred on [DATE] was not investigated and it was not reported to the state. He said it was a fall without injury, so he did not feel there was a reason to report it. He said he does not know why there wasn't an intervention completed. He said he has told staff to be more cautious about the residents having falls. He said there was a morning meeting about CR #229's fall. He said if there was a fall in the facility, they would have a follow up in a morning meeting. He said if a resident has a fall and there is no updated assessment, or a prevention put in place, a resident can have another fall with an injury. He said it is not a problem to have a care plan that is different from the MDS. He said when he first met CR #229, he was not total assist. He said CR #229 showed no difference in how he moved after he fell on [DATE]. He said he was the same on [DATE]. He said he was able to do things on his own. He said does not help with the MDS assessments. He said if a resident has a fall, an assessment should be updated. He said the care plan should be updated as well. He said the care plan should reflect the needs of the resident, so staff would know how to care for the resident. He said he did not receive CR #229's death certificate. He said medical records could ask for it, but they do not automatically receive that information. He said when CR #229 had his second fall on [DATE], he was told he had a fall and had a gash. He said they called the doctor, and CR #229 was sent out to the hospital. He said he does not know how long after CR #229 left the facility, that he expired. Telephone Interview on [DATE] at 10:07 a.m., with LVN D, said when CNA G was doing rounds, she let her know she observed CR #229 on the floor. She said when she went into the room, his bed was in a low position. She said he was near the bathroom. She said it looked like he hit his head. She said he was on his back, and it looked like he was trying to get up. She said CNA G got another nurse to help. She said she cannot remember the nurse's name who came to help her with CR #229. She said she called 911. She said she tried to ask CR #229 what happened and what he was doing, and she said he was pointing towards the bathroom and couldn't really speak. She said he used a communication board to communicate daily. She said she did not have much communication with him during the night. She said CR #229 had a roommate as well. She said he could walk on his own, unsteadily. She said she CR #229 did not always try to get up through the night to use the restroom. She said he always made gestures and never really spoke to her. She said she does not remember if she worked with him in the past. She said the night CR #229 had fall on [DATE], he did not say he was in pain. She said when she assessed him, he had a laceration on his head. She said CR #229 was not moaning. She said the bathroom is no more than 10 feet away from his bed. She said she did a risk management report. She said she does not recall if she did a change of condition report. She said she contacted the on-call service (physician) for the facility. She said she left a voice mail for whomever was listed under his contacts. She said when CR #229 went to the hospital, she called the DON. She said she did not think the fall was suspicious. She said the facility made sure she included a witness statement inside the risk assessment. She said it is in the risk management portion. Interview on [DATE] at 10:52 a.m., with family member, said she was told by the facility that CR #229 accident happened in the middle of the night. She said they told her he fell , and he had to go to the hospital. She said they told her he had a gash on his head, and he was conscious. She said she did not hear from the facility once her brother arrived at Hospital A because they l took over. She said she went by the facility to pick up CR #229's belongings and she was able to retrieve everything except his necklace and hearing aid. She said CR #229 passed away on [DATE]. She said at the hospital, they did a full body MRI on CR #229, and it showed that the gash was more than 5 inches. She said it went straight up from his head to his eyebrow. She said the MRI also showed a brain bleed. She said CR #229 seemed disoriented and was acting up and being erratic and trying to get out of his bed. She said CR #229 was transferred on a Sunday from Hospital A, to a specialized trauma hospital. She said once she arrived at the main hospital, CR #229 couldn't open his eyes or do anything. She said she flew out again on [DATE] and his lungs started to fail. She said her mom was in rehab and she took her out of rehab because she is the legal guardian of CR #229. She said her mom talked to the brain surgeon, but he could not say if CR #229 would wake up again. She said CR #229 was on a breathing machine and was not breathing on his own. She said he was intubated. She said CR #229 death certificate said the cause of death was blunt force trauma to the brain and a hematoma in the brain. She said when she went to the facility on [DATE] to pick up CR #229 things, staff told her the night her brother fell , he was using a walker. She said she was not notified by staff when he fell on [DATE]. Interview on [DATE] at 11:44 a.m. with PT A said, CR #229 was evaluated for physical therapy on [DATE] and for occupational therapy on [DATE] as well as speech therapy. He said he was not evaluated upon admission on [DATE] because he was a Hospital C resident and they do not come into the facility with approvals for therapy, which means if he came to the facility on the [DATE] he would be evaluated the following week. He said he submitted documentation to Hospital C on a Monday. He said CR #229 never participated in therapy. He said he is not sure why he wasn't evaluated after the first week. He said CR #229 might not have been feeling well. He said it was reported to the therapy department on [DATE] about a resident with a recent fall during transfers. He said he evaluates a resident, depending on when they fall, if they don't normally fall, and he will screen and evaluate a resident and recommend therapy. He said residents that fall and don't move around a lot will be screened. He said CR #229 was using a rolling walker. He said he had been evaluated for the safety of the walker. Followed-up interview on [DATE] at 1:18 p.m., with the DON and the Administrator. The DON said, the root cause was that CR #229 was impulsive and was not asking for help as suggested. She said she discussed the IDT fall in the morning meetings. She said she removed some of the things that was in the room and straightened up the clutter. The Administrator said he did not document the clutter, that he just rearranged the clutter. The DON said staff assigned to therapy evaluated CR #229 on using a rolling walker and determined if it was safe to be used or not. She said she knew right away if it was safe or not. She said she is not sure if anyone took the walker away. The Administrator said he could not force CR #229 to not use the walker because that would be taking away his rights. He said when they asked him not to get up, CR #299 would listen. Followed-up interview on [DATE] at 1:25 p.m., with the Administrator, said CR #229 was able to verbalize the things he needed. He said when he received CR #229's medical record, he did not think to report it. He said he thought CR #229 was coming back to the facility. He said he had a conversation with staff from Hospital C, and he never thought the blame would be put on him regarding CR #229. Followed-up interview on [DATE] at 2:11 p.m., with the DON said, MDS Coordinator A, social services, activity services, and the dietary manager assist with completing the MDS assessment. She said section G of the MDS assessment is completed by the MDS Coordinator A. She said she and MDS Coordinator A, used to be responsible for the comprehensive care plan. She said she was responsible for the comprehensive care plan while CR #229 was present at the facility. She said MDS Coordinator A was responsible for the admission MDS assessment. She said she cannot speak on the discrepancy of the care plan and the MDS assessment because she did not see it as a big discrepancy. She said she did not check to see if there was a discrepancy because she did not see what the surveyors were seeing. She said she did the care plan based on what staff was telling her and not what was documented. She said she did not realize that certain care areas regarding CR #229 was not documented. She said CR #229 could ambulate because he could move. She said if he had a significant change, she has 14 days to update the assessment. She said she did not think the fall could have been prevented. She said he was put bed in the low position. She said CR #229 wanted to be independent. She said she would not do an SBAR or MDS assessment, only a fall risk assessment. She said no one told her that CR #229 had a walker the night he fell , on [DATE]. She said the walker was in his room and she cannot take the walker away. She said a Hospital C resident does not come into the facility with orders for rehab. She said something must happen for a Hospital C resident to receive rehab. She said it is difficult for a Hospital C resident to receive rehab. She said there are some residents who come on admission with rehab orders. She said it does not always happen. She said the facility will have to push for it, not Hospital C. Interview on [DATE] at 12:09 p.m., with the Medical Director, said he has been sharing his responsibility with Physician B. He said at the nursing facility, the meetings are usually once a month. He said he often attends the meetings virtually. He said he goes to the meetings in person when the issues are more complex. He will go over the issues with MDS Coordinator A, and the Administrator. He said in the meetings if there was an unwitnessed fall or a serious injury occurred, it will be discussed well before QAPI comes up. He said if a major fall happened that caused a brain bleed, it would be something that you would immediately report to the state. He said regardless of if the resident could communicate or not, it will still need to be reported to the state. Interview on [DATE] at 12:38 p.m., with Physician B said she was only at the facility once a week. She said her last day working at the nursing facility was on [DATE]. She said when she was working at the facility, she participated in QAPI once a month. She said she attended in person, and they discussed falls, who fell and followed up on plans after the falls. She said she will look at CR #229's medical history, and what happened with the fall. She said she would ask questions about medication before making a [NAME] to report an incident to the state. She said if the resident is deemed by therapy not safe to use different devices to keep them safe and they still want to use them, she said it is their right and they cannot hold a resident down or retrain them. She said if a resident takes a walker even after he's been redirected it will put them in an interesting position. She said some residents have tried to hit her and other staff members. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:09 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 3:10 PM. The following Plan of Removal was submitted and accepted on [DATE] at 1:29 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: o Forty-three (43) current facility residents have been identified and assessed by the DON, ADON, MDS Coordinator and Rehab Director as having the potential to be affected by the deficient practice on [DATE]. o The DON, ADON, MDS Coordinator and Rehab Director will review the Plans of Care and Kardex of the 43 residents at risk for falls to ensure universal fall precautions, appropriate and adequate assistive devices and interventions are in place to prevent unnecessary falls and accidents to be completed on [DATE]. The DON, ADON, MDS Coordinator and Rehab Director will investigate all new falls and ensure interventions are in placed within 24 hours during the daily Stand-Up meeting utilizing the Post Huddle Fall Worksheet. The Administrator will monitor the IDT Team to ensure all falls are appropriately investigated and correct interventions are updated and in place to prevent falls. o The DON and Nurse Managers will in-service Direct Care Staff regarding universal fall precautions, the Kardex system and the importance of residents having appropriate and adequate assistive devices, fall interventions and needed assistance with transfer and toileting. In-services began on [DATE] and will be completed with current Direct Care Staff on [DATE]. All other nursing staff not currently on shift or on leave will be in-serviced upon return to work prior to providing care. Facilities Plan to Ensure Compliance: o A Quality Assurance and Performance Improvement meeting was held on [DATE] with the Medical Director, Administrator, DON, ADON, Rehab Director, and MDS Coordinator to review the allegations surrounding F689 tag and the plan moving forward related to the IJ Plan of Removal. It was determined by the committee that the DON, ADON, Rehab Director and MDS Coordinator will review fall policy(s), implementation of fall interventions within 24 hours, assessment of high fall risk residents in regards to inappropriate durable medical equipment usage and provide a care plan meeting with the resident and/or responsible party to discuss unsafe practices and resolution, such as removal of equipment, upon admission and as needed. o Facility process on how to access the Kardex in Point Click Care - In-services performed by DON and ADON began on [DATE] and will be completed with current nursing staff by [DATE]. All other nursing staff not currently on shift will be in-serviced and a post- test administered by [DATE]. All new hires will receive training on the same topics during new employee orientation and prior to providing care. Agency staff will also receive training on the same topics at start of their shift prior to providing care. A posttest will be provided for understanding and competency. If in-house and agency staff members don't achieve 100%, they will be re-educated, and the post test administered again until 100% compliance is achieved. o Facility process on Universal fall precautions - In-services performed by DON and ADON began on [DATE] and will be completed with current nursing on [DATE]. All other nursing staff not c [TRUNCATED]

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 7 residents (CR #229) reviewed for reporting of alleged violations. - The facility failed to report to the State Agency within 2 hours of CR #229's unwitnessed fall which resulted in an injury that occurred on [DATE]. This failure could place residents at risk of death due to not reporting or completing investigations of injuries of unknown origin and falls. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS assessment dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Progress Notes dated [DATE] at 04:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:,d+[DATE] HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27 a.m. with RN A, revealed she came into work and LVN A told her CR #229 got out of bed and fell . She said during the day he stayed in his wheelchair and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he was supposed to turn on his call light when he needed help, but he is non complaint. She said he would sometimes try to walk on his own and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:41a.m. with CNA D, revealed she came into work the next morning and was told CR #229 got up to go to the restroom and fell . She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10p.m., with the Administrator, revealed he did not self-report the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said it was an agency nurse that was working the night of the incident. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18 p.m. with the Administrator, revealed he was in challenging times. He said he had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to facility rules were overwhelming. He said he was going off the information regarding CR #229 that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed CR #229 fell in the restroom. He said he was not sure as to why the initial fall assessment was not done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they followed up on. He said they have not documented what was discussed in the morning meetings, especially when it had been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he had worked at. He said if a resident died outside of the facility, staff will be notified by word of mouth. He said they [facility] would have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family would call and provide information about the resident. He said the only way someone at the facility would know about a deceased resident was by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m. with Marketing Admissions, revealed when she found out the information about CR #229 passing away, she informed the staff, the Administrator, and the DON. She said someone from the hospital called and gave her the information that CR #229 passed away. She said she had called three times to do a follow up. She said there was nothing clinical reported to her by the hospital about CR #229 . She said they told her CR #229's family was by his bedside, and he was stable. She said she received clinical documentation via the Care Port system that was a referral system. She said when she visited CR #229 at the hospital, he was fine. She said she did not see the family at the hospital. She said there was no documentation regarding the phone call that she received. She said she called the hospital on [DATE] and they called her back at 8:30a.m. and informed her that CR #229 was deceased . She said she was nonclinical, and she did not put information into the PCC. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, undated, read in part, .The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed .

Based on, interview, and record review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated and reported results of the investigation to the state agency within 5 working days of the incident for 1 of 7 residents (CR #229) reviewed for investigate, prevent, and correct alleged violation, in that: The facility did not complete an investigation report regarding CR #229. This failure placed residents at risk of injury, harm, and leaving him susceptible to repeated abuse/neglect and injury of unknown origin. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Progress Notes dated [DATE] at 04:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:,d+[DATE] HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27a.m., with RN A, she said during shift report LVN A told her CR #229 got out of bed and fell . She said CR #229 has not been at the facility since he fall. Interview on [DATE] at 10:30a.m. with CNA F said she used to assist CR #229 with everything. She said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she wasn't present when the resident fell . She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell . Interview on [DATE] at 12:10p.m. the Administrator said he did not complete a self-report or an investigation because the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18p.m., the Administrator said he said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m., with Marketing Admissions, she said someone from the hospital called on [DATE] and gave her the information that the CR #229 passed away. She said after she found out, she informed the Administrator and the DON that CR #229 passed away. Interview on [DATE] at 2:40 p.m. with the DON, said CR #229 was gone from the facility when she arrived to work that morning. She said she was told he had fallen, and staff noticed he was injured, and they sent him out to Hospital A. She said staff did not know how or where he hit his head . She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, (revision date not listed) read in part . The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed. The Administrator and Director of Nursing are responsible for investigation and reporting: Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. This may utilize a Complaint Form, initial Investigation for Possible Abuse Violations form, or other written documentation.

Based on interview and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 1 of 3 discharged residents (CR #33) reviewed for encoding and transmitting resident assessments, in that: - The Facility failed to complete and transmit a discharge MDS for CR #33. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge. Findings include: Record review of CR# 33's admission record dated [DATE] revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on [DATE]. He had a diagnoses of repeated falls and tracheostomy status (a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing). Record review of CR #33's Admission MDS assessment dated [DATE], revealed he had a BIMS of 13 of 15 which indicated he was cognitively intact. He required supervision to limited assistance with 1 person with most ADLs (Activities of Daily Living). Record review of CR #33's EMR on [DATE] revealed: he had no discharge MDS on record. Record review of CR #33's Assessment History- MDS Assessment Snapshot , revealed there was no discharge MDS on record. Record review of CR #33's Physician Discharge Summary dated [DATE], revealed he was discharged home with home health care. Interview on [DATE] at 11:40am. with the MDS Coordinator A, she said that there were no discharge assessments found in the facilities EMR system for CR #33. She said she was responsible for completing the discharge MDS assessments and had not completed one for CR #33. She added that she missed this in the system. Record review of facility provided CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised ,d+[DATE] revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing . For all other comprehensive MDS assessments, Annual assessment updates . The completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan for each resident, consistent with the resident rights for 1 of 5 residents (Resident #70) reviewed for develop and implement comprehensive care plan, in that: - The facility failed to address the smoking status in Resident #70's care plan. This failure could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The findings include: Record review of the facility admission record dated 5/17/2023 revealed Resident #70 was admitted on [DATE]. Resident #70 was a 64-year- old male. Resident #70 had diagnoses that included Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems) and pneumonia (an infection that affects one or both lungs). Record review of Resident #70's Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #70 had a BIM (Brief Interview for Mental Status) score of 13 out of 15, cognition was intact. Resident #70 required supervision with ADL's (Activities of Daily Living). Record review of the smoker list, no date provided revealed that Resident #70 was a smoker at the facility. Interview on 5/19/2023 at 11:22 a.m. with the DON (Director of Nursing), revealed that Resident #70's comprehensive care plan was not completed for smoking. She said she had the responsibility to make sure this was done along with the MDS Coordinator. She said that Resident #70 had the potential to have an unsafe smoking environment without the comprehensive care plan to address smoking. She said that she was the only one who missed it. She completed Resident # 70's smoking assessment and confirmed adding smoking to his comprehensive care plan on 5/16/2023. Record review of the revised Comprehensive Care Plan dated and created on 5/16/2023 read in part . Resident #70 has been advised of the facility smoking policy. Resident #70 requires supervision with smoking . Record review of the facility policy and procedure entitled Comprehensive Care Plans, undated, read in part, . The facility will develop and implement a comprehensive person-centered care plan for each resident, to meet a resident' medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment .

Based on observation, interview, and record review the facility failed to ensure one of fifteen residents (Resident #27 ) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: -The facility did not have the supplies available to replace the Gastrostomy Tube for Resident #27 for at least 5 days and used an indwelling urinary Foley catheter for at least 5 days, instead of an actual gastrostomy tube. -The facility did not have appropriate physician orders for Resident #27's medications to be administered through the temporary indwelling urinary Foley catheter, while it was being used as a gastrostomy tube. The failure could place residents with gastrostomy tubes at risk for developing significant complications, including infections, aspiration, hospitalization s, or death. Findings included: Record review on 5/19/23 at 9:08 a.m. of Resident #27's Admission Record dated 5/19/23 revealed she was a [AGE] year old female who admitted to the facility on [DATE] had some of the following diagnoses: gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dysphagia (difficulty or discomfort in swallowing), agnosia (inability to interpret sensations and hence to recognize things, typically as a result of brain damage), flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), Type II diabetes mellitus, (chronic condition that affects the way the body processes blood sugar and moderate protein calorie malnutrition. Record review on 5/16/23 at 9:22 a.m. of Resident #27's Admission MDS dated [DATE] revealed she had a BIMS score of 2 indicating she was severely cognitively impaired and was totally dependent on at least one staff member for eating. She was coded as having an active diagnosis of malnutrition and gastrostomy status. She was also coded as receiving 51% or more of her total calories from a tube feeding. Record review of Resident #27's physician order summary dated May 2023 revealed no orders for enteral (state of being fed through a tube) feedings to be administered through a temporary/short-term Foley catheter being used as her gastrostomy site, Record review of Resident #27's physician order summary dated May 2023 revealed no orders for medications to be administered through the temporary/short-term Foley catheter being used as her gastrostomy site. Record review on 5/18/23 at 2:12 p.m. of Resident #27's progress notes dated 5/8/23 and created by LVN A, revealed the following entry: gtube is noted to be clogged at this time. (sic)unable to flush or unclog at this time. (sic)gtube replaced by (employee initials) LVN with 16 F foley with 5 cc balloon. 5 cc of residual returned; placement verified per auscultation. No s/s of acute distress noted at this time. Gtube site care provided at this time. Stoma (artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut), remain clean, dry, and free of s/s of infection at this time. There was no documentation that Resident #27's physician had been notified. There was no SBAR or change of condition report. There was no incident or accident report regarding Resident #27's gastrostomy tube becoming clogged and or dislodged. Record review of Resident #27's progress notes on 5/18/23 at 2:44 p.m. that were dated 5/13/23 and created by LVN C, revealed the following entry: CNA notified this nurse that resident had vomited. Upon entering resident's room large amount of coffee ground emesis noted on resident gown. TF was stopped and resident's head was elevated to a 90-degree angle. Resident has two more episodes of emesis while this nurse was in the room. VS-BP145/86 P 105 T 97.9 R 20. DON made aware. Pager called for NP A and RP contacted with no answer and voicemail not set up to leave message. EMS A contacted to transport resident to ER. Repeated attempts to contact LVN C during the investigation on 5/17/23, 5/18/23 and 5/19/23 went unanswered through exit. Record review of Resident #27's progress notes on 5/18/23 at 3:33 p.m. that were dated 5/14/23 and created by RN A read in part, .Late entry, Received a phone call from a physician (on 5/13/23) with Hospital A with question regarding resident's feeding tube, a Foley catheter had been inserted because there was not a gastrostomy tube, in the correct size, available. Resident was sent to hospital for vomiting, possibly coffee ground emesis per the report from the nurse who sent her to the ER, writer checked placement by auscultation and gastric aspiration the day before she went to the hospital and results indicated it was safe to use . Record review of Resident #27's hospital records on 5/18/23 at 4:08 p.m. that were dated 5/14/23 read in part, .discharge diagnoses: coffee ground emesis, PEG tube malfunction, pneumonia, constipation, protein-calorie malnutrition, moderate . Interview with LVN A on 5/17/23 at 2:08 p.m., she said that she was the author of the progress note dated 5/8/23. She said that Resident #27's gastrostomy tube became clogged, and she could not get it to function on her shift. She then said that the gastrostomy tube became dislodged. When asked if she received a physician order to change the gastrostomy tube, she said that she was uncomfortable changing the tube after it became dislodged and asked LVN B to assist her in replacing it. She said that LVN B changed the tube by inserting a 16 french foley catheter because the facility did not have Resident #27's size for the gastrostomy tube replacement catheter. LVN A said that after LVN B changed the tubing, Resident #27's gastrostomy site began working and functioning properly again. LVN A said that she was able to restart Resident #27's enteral feeding, medications and hydration at that time as previously ordered. When asked if she notified the physician, LVN A said she could not remember. LVN A said it should have been documented that Resident #27's physician had been notified but she could not recall if she had notified the physician. LVN A said that she did not remember if she was ever able to reach Resident #27's physician for any orders. LVN A said that she did not know why she did not complete an SBAR/change of condition or incident report for Resident #27. She acknowledged that a resident's G-tube becoming dislodged was a change in condition. She said she could not recall if she had been trained on gastrostomy tube care. Interview with RN A on 5/17/23 at 2:33 p.m., she said she cared for Resident #27 when she had the temporary/short-term Foley catheter used as a gastrostomy tube. She said because the site functioned properly, she used it for medications and feedings. RN A said it was not uncommon to temporarily use an indwelling urinary catheter tubing in lieu of actual gastrostomy tubing, until the actual gastrostomy tubing became available. She said she had been told via report from other nursing staff that Resident #27's actual gastrostomy tubing was on back order and would be arriving any day. When she reviewed the facility policy, she said she did not know what temporary or short-term timeframes specifically meant. When asked if she felt like 5 days was too long a period to use temporary tubing, RN A said that it was working and she did not question it. RN A said she was not sure if she had been trained by the facility on gastrostomy tubes. RN A said that she did not think that using the Foley catheter as a gastrostomy tube, for 5 days, was an issue because she thought everyone (DON, MD, RP), knew about it already. She stated she did not notify Resident #27's physician or NP because she thought it had already been done. Observation of Resident #27 on 5/18/23 during medication administration on 5/18/23 at 8:41am. The administration was performed by RN A and Resident #27 tolerated well. Observation of Resident #27's gastrostomy tube tubing intact that was patent and functioned properly throughout the medication administration. There was no drainage around the site and no signs or symptoms of infection. There were no additional surgical sites or bandages observed, indicating, the gastrostomy tubing was replaced in the hospital, using Resident #27's existing gastrostomy tube site. Resident #27 was non-verbal but waved her hand and nodded her head in affirmation that she was doing well and had no pain or concerns with the site. Interview with LVN B on 5/18/23 at 9:41 a.m., she said that she was called to Resident #27's bedside on 5/8/23 by LVN A to help her with Resident #27's gastrostomy tube. LVN B said that when she got to Resident #27's bedside the gastrostomy tube was out and laying on top of Resident #27's gown. LVN B said that there was no blood or other drainage and that Resident #27's gastrostomy tube site/opening in her abdomen appeared very small to her and she was fearful it would close, as she was not familiar with, and did not regularly work with Resident #27. She said that she replaced the tube using a 16 French Foley catheter tubing because they did not have a small enough gastrostomy catheter available in the facility stock/supply. She said that both she and LVN A looked and could not find another option. LVN B said she thought LVN A had already called and or contacted Resident #27's physician and RP. LVN B said that she had been trained by facility on gastrostomy tubes including use, changes and troubleshooting issues, but could not recall when she had the training last. LVN B said she believed it was upon hire. LVN B said she did not document on Resident #27 because it was not her resident and again, she thought LVN A was documenting everything including contacting the physician and obtaining orders. Interview with DON on 5/18/23 at 1:04 p.m., she said that there was no documentation that LVN A, LVN B, LVN C or RN A had contacted Resident #27's physician. The DON said she contacted Physician A and he said he was not sure if he had been contacted and would have to check his phone records but could not confirm or deny that he had been contacted by LVN A about Resident #27's gastrostomy tube becoming clogged or dislodged. The DON said that there was no SBAR or change of condition for Resident #27 but there was a progress note. When asked if she thought a dislodged g-tube on a resident was a change in condition, she said yes. The DON said that it was not uncommon and per facility policy and procedure to utilize a Foley catheter to temporarily keep a gastrostomy tube site open and patent. The DON said she could not find any documentation of physician notification or orders from Physician A to continue to use Resident #27's short-term Foley catheter for medications and feedings. The DON said that the Foley catheter could be used short term to administer medications and or feedings. The DON said that she did not believe 5 days was long term use and said that the facility no longer completed orders for supplies and that Corporate ordered supplies. The DON said she did not know why she had not reviewed LVN A's documentation to check if the physician had been notified. The DON said she did not know why there was no documentation of an SBAR, change in resident condition or incident report for Resident #27. The DON said she had been aware of Resident #27's need for gastrostomy tube tubing. The DON said that Corporate were the ones who notified the facility that the replacement gastrostomy tubes for Resident #27 were on back order. The DON said that she did not believe that Resident #27's hospitalization from [DATE] through 5/14/23 had anything to do with the use or misuse of Resident #27's temporary Foley catheter. Interview with Administrator on 5/18/23 at 1:34 p.m., he said that Corporate completed the ordering of supplies such as gastrostomy tubes, for the facilities. He said that he had no dated invoices or order slips to show as evidence for when Resident #27's gastrostomy tubing was ordered or when Corporate was notified it was on back order. He said that all residents should have the supplies they need on site and that the facility did its best to maintain the appropriate supplies for their residents. Observation on 5/18/23 at 1:44 p.m. revealed a current adequate gastrostomy tube supplies for Resident #27 and all gastrostomy tube residents for the facility. Interview with Medical Director on 5/18/23 at 2:02 p.m., he said that historically the facility has and can use a Foley catheter as temporary tubing for a gastrostomy tube. He said that they do not always send a resident to the hospital for replacement because they try to avoid unnecessary hospital transfers. He said that Resident #27 had an established gastrostomy tube for years and it was not a new gastrostomy tube site, so the Foley catheter use was not a problem. He said that he did not see an issue with the facility using a temporary Foley catheter tube for 5 days to administer Resident #27's medications and feedings. He said that he did not believe Resident #27's hospitalization on [DATE] was as a direct result of the Foley catheter tubing, when asked about Resident #27's hospital diagnosis of pneumonia, he said it could have been early aspiration related to her nausea and vomiting or could have been related to fluid overload. He said there was no definitive aspirate in the hospital findings and that Resident #27 could have had nausea and vomiting related to constipation. He said that staff should notify a physician with any changes in condition for a resident. Telephone interview with Resident #27's attending Physician A on 5/18/23 at 3:08 p.m., he said that he could not recall, confirm or deny if LVN A contacted him on 5/8/23 when Resident #27's gastrostomy tube became dislodged or clogged. He said that best practice was to reinsert the appropriate gastrostomy tube as soon as possible but did not feel that 5 days was too a long a period of time or would have caused Resident #27 to go to the hospital on 5/8/23. He said that he could not say what kind of orders he would have given LVN A on 5/8/23 and that he may or may not have ordered LVN A to send Resident #27 to the hospital right away. He said that he did not recall if he or his NP saw or evaluated Resident #27 during the 5 days, she had the Foley catheter used as her gastrostomy tube. He said as long as it had functioned properly, there was probably no issue with the continued use of the Foley catheter for Resident #27's medications and feedings. He said that he did not know why he had not written any orders for the use of Resident #27's medications and feeding to continue via the temporary Foley catheter. Record review of facility policy and procedure Policy: Gastrostomy Tube Replacement (G-Tube) also known as PEG tube, read in part:1. The g-tube should be replaced as soon as possible (within 4 hours) to keep the tract patent. 2. If it has been greater than 4 hours, consult your physician for further instructions regarding replacing and/or hospital transfer. 3. Tubes dislodged greater than 24 hours should not be replaced at bedside .7. A foley catheter may be used in place of g-tube for SHORT TERM Use if a g-tube is not available at time replacement is needed. When the proper g-tube arrives, the replacement should occur at this time. Record review of facility policy and procedure titled Unusual Occurrences, Guidelines for .Basic Responsibility. Licensed Nurse .To document all unusual occurrences .Documentation Guidelines .Documentation may include: the event and any surrounding circumstances .Physical assessment. Interventions provided. Notification of the physician and responsible party . Preventative measures put in place to prevent recurrence. Document occurrence . Record review of facility policy and procedure titled: Notification to Physician, Family and others, read in part: .The facility will inform the resident, consult with the resident's physician; and consistent with his or her authority, the resident representative and document in the residents medical record .A significant change in the resident's physical status .(that is deterioration .or clinical complications), Record review of facility policy and procedure titled Change in Resident Condition, revealed the following: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical condition or status .7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1.The facility failed to ensure employees cleaned their hands in a handwashing sink. 2.The facility failed to ensure the dish machine sanitized wares. These failures could place residents at risk of foodborne illness and disease. Findings included: 1. Observation on 4/20/22 at 9:15 AM revealed Dietary Cook B, after racking soiled breakfast dishes, she proceeded to empty clean dishes without washing her hands. She then washed her hands in one of the utility sinks, in the dish washing area, and did not use soap. Interview with Dietary Manager on 4/20/22 at 9:20 AM revealed food employees must wash hands after racking soiled dishes and then touching clean dishes to prevent cross contamination. Utility sink does not have the proper soap for hand washing. Dietary manager was aware that the staff did not washed hands prior to touching clean dishes. 2.Observation on 4/20/22 at 9:25 AM revealed the dish machine was not properly sanitizing dishes/wares evidenced by the test strip did not change color. The test strip should have turned purple as indicating that the approved chemical/sanitizing agent containing at least 150 - 400 ppm (parts per million of quaternary ammonia. Interview with Dietary Manager on 4/20/22 at 9:30 AM revealed that she will call the service/repairman for the dish machine not sanitizing. She instructed dietary employee not to wash dishes until machine fixed. Observation on 4/20/22 at 11:00 AM revealed Service/repair representative entered the facility kitchen and stated there was not enough sanitizing agent/solution being fed in the dish machine. Representative repaired the issue by showing the staff that the container of sanitizing agent is empty. Prior to operating the dish machine, the employees must check and make sure that soap, sanitizing agent and drying agent is replenishing if it is empty.

Based on interview and record review the facility failed to consult with the Physician when a change of condition occurred for 1 of 7 residents (CR#1) reviewed for change of condition in that: --CR#1 had a change in condition during the night of 3/17/17. His Physician was not consulted. He was transferred to the hospital on [DATE] where he was diagnosed as having a stroke. This failure affected one prior resident and placed 58 current residents with communication deficits at risk of not receiving needed medical care which could result in injury, the inability to receive time constrained treatments, hospitalization , and decreased quality of life. Intake # 3 Findings Included: Record review of CR#1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring an 11 out of 15 on his brief interview for mental status indicating he had moderately impaired cognition. He was assessed as having unclear speech, usually understood and usually understands. He required the extensive assistance of two staff for bed mobility and transfers. He required the extensive assistance of one staff for locomotion and personal hygiene. He was totally dependent on two staff for toileting. Record review of CR #1's plan of care dated 3/8/17 revealed there was no care plan intervention to monitor for signs or symptoms of a new stroke. During an interview on 4/20/17 at 9:40 a.m. with the ADON she said CR#1's doctor saw him on 3/17/17 and prescribed [MEDICATION NAME] 250 mg 2 tabs by mouth daily for four days for a [DIAGNOSES REDACTED]. She said LVN B notified Nurse Practitioner B that CR#1 had a change in condition on 3/18/17. She said LVN B and RN D were terminated as they had not done a proper assessment on CR#1. During an interview on 4/20/17 at 10:05 a.m. with Resident #2 he said he had been in the room with CR#1 for 7 months. He said on the night of 3/17/17 CR#1 was moaning very loudly and could be heard out in the hallway. He said no one came to check on him until it was time for medications. He said when the nurse came in CR#1 was not responding so the nurse, name unknown, opened his mouth by pulling his lower lip down and put a pill in his mouth and poured water in his mouth. He said the nurse then left the room. He said he had been an Emergency Medical Technician and said he felt CR#1 had a stroke. He said he told the nurse that but nothing was done. He said on 3/18/17, staff came and dressed CR#1. He said CR#1 was staring at the ceiling and would not respond. He said CR#1's family came and tried to get CR#1 to respond but he would not. He said CR#1 was mumbling but they could not understand what he was saying. He said CR#1 was not transported to the hospital until later that evening via regular transport instead of 911 ambulance. During an interview on 4/20/17 at 10:40 a.m. with CR#1's Nurse Practitioner A she said that she worked with CR#1 and that he had been experiencing some coughing and congestion and breathing problems. She said when the Physician came to see him, any orders given were for those concerns. She said the facility never informed the Physician or her that CR#1 was not responding and could hardly talk. She said his change in condition was not reported to her or CR#1's doctor. During an interview on 4/20/17 at 12:30 p.m. with CNA A she said she worked with CR#1 on 3/18/17 and said that morning CR#1, .did not look himself. He was not the same person she had known. She said he was not communicating properly so she reported it to LVN B. During an interview on 4/20/17 at 3:15 p.m. with CNA C she said she worked the Friday and Saturday, 3/17/17 and 3/18/17, with CR#1. She said when she saw CR#1 on 3/17/17 he was not eating and was not talking in the way that was normal for him. She said all night CR#1 stared at the ceiling of his room. She said when she came in to her shift, she notified LVN B about CR#1's changes on the morning of 3/18/17. She said LVN B came over and saw CR#1 and told her he was being taken care of. She said RN D came during the morning shift on 3/18/17 and didn't know what to do' for CR#1. She said she got CR#1 ready that morning thinking that LVN B would call the physician and have CR#1 taken to the hospital. She said that did not happen. She said LVN B called CR#1's family members instead. CNA C said CR#1's condition looked so bad that one of my co-workers started crying. Record review of a written statement by CNA F dated 3/20/17 10:00 a.m. revealed, .-told nurses 'something' is not right /c (with) (CR#1's name)-Nurses went to room to check-BS (blood sugar)71-ask CNA for OJ (orange juice)-could not hold cup-choking on OJ- -2 CNA's came back & got nurse (RN D) said 'just send him out'- (LVN B) said no and called on-call-we gonna do labs. The statement was signed by CNA F. Record review of a handwritten document with an illegible signature dated 3/20/17 revealed, .3/18/17 (RN D)-informed by CNA and shower tech around 730 AM (unsure of time) that 'something was wrong with (CR#1) (sic).-Stated she assessed (CR#1)-Stated resident was responding verbally but had blank stare.-Stated she informed (LVN B) to notify the on-call person. Record review of CR#1's Nurse's Progress Notes for March 2017 revealed no documentation of any notes from 3/17/17 at 11:31 a.m. until 3/18/17 at 7:28 a.m. Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 7:28 a.m. written by LVN B revealed, .Resident in bed awake & alert-noticed that had nebulizer mask on and treatment was completed attempted to removed (sic) and patient declined for it to be removed-noticed that resident was not responding appropriately check blood sugar FBS=71 held insulin administration V/S (vital signs) 99.0 oral, 18 respirations, 146/84 blood pressure-resident had an eye glare and pupils were constricted-residents states feel fine but not able to hold cup to drink OJ (orange juice) had poor hand coordination & grip-as per resident's roommate (CR#1's name) has not been resting last night he was restless and 'moaning' stated that nurse had hard time to arouse him to administer his medications-called MD (Medical Doctor) (name) via exchange pending return call. Record review of CR#1's Nurse's Progress Note dated 3/18/17 8:08 a.m. written by LVN B revealed, .(Nurse Practitioner B's name) on call for (Physician A's name) returned called (sic) informed of resident's condition N/O (new order) given for stat CBC with Diff (Differential), BPM and STAT CXR on view to R/O (rule out) URI/[MEDICAL CONDITION]-orders noted and called in: labs confirmation # 4 and CXR confirmation# 566. Called RP (Responsible Party) (name) to notify stated will be here today to visit resident and stated 'thank you for calling.' Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 5:41 p.m. written by LVN B revealed, .RP arrived to facility-came to nursing station demanding an explanation of why her father was in this condition-'lethargy and not able to understand him verbally-RN on charge informed talk to RP and explained that labs have been just received along with CXR MD was informed via (NP E) no new orders were given at this time only to monitor and continue ABT (antibiotic) orders along with NEb (nebulizer) txs (treatments) and monitor for any changes-as ABT has just started today initial dose @ 1400(2:00 p.m.)-RP (name) became upset and stated that roommate her (sic) that resident has been like that all night in pain and moaning and 'nothing was done' until this AM (morning) that nurse arrived. I informed RP that we will call MD (medical doctor) to notify of her wanting to send patient to ER (emergency room ) for evaluation-other (family member) became verbally aggressive and stated that wasn't accepted (sic) and if this has been happening since 03/14/17 something should off (sic) have been done-she scream (sic) that is not acceptable-called Dr. (Medical Director's name) via exchange (Nurse Practitioner B) answer (sic) and informed of family request to sent (sic) patient to ER-NP (Nurse Practitioner) stated why the patient needs time for ABT to be effective-explain that (family member) was at nurses (sic) station demanding to be sent out- (Nurse Practitioner B) stated go ahead and write order to sent (sic) to ER hospital of choice per family request. Called on call number and notified. Ambulance called for transportation and (Hospital Name) ER called for report given to (Hospital RN Staff name) at emergency room . During an interview on 5/16/17 at 11:54 a.m. with LVN B she said she came in 3/18/17 in the morning and went into CR#1's room. She said the roommate told her CR#1 had been moaning all night. She said CR#1 could not communicate like he normally did. She said CR#1 was not able to hold his cup. She said later she was in the dining hall and was called to CR#1's room where RN D and a CNA were and was told by RN D to call the doctor and responsible party. She said she called the nurse practitioner on duty and said she reported what was going on with CR#1 and then called the responsible party. She said she reported his change in condition to the nurse practitioner and to RN D. When asked if RN D had told her to call an ambulance she gave no answer but said she called the doctor. During an interview on 5/17/17 at 1:05 p.m. with RN D she said on 3/18/17 she worked the morning shift on the front hall and LVN B worked on the hall with CR#1 in the back. She said she was called to CR#1's room by a CNA and when she was there she asked CR#1 how he was feeling and he said he was ok. She said on 3/18/17 during the morning, the CNA who was working with him told her CR#1 was not looking good and was not himself. She said based on the information, she told LVN B to call for an ambulance. She said LVN B called Nurse Practitioner B and the resident's family member but did not call the ambulance. When asked if she had or read any documentation on CR#1 for that morning she said she was working the front hall and LVN B was working the back where CR#1 was. When asked about her being the Registered Nurse working in the facility, should she not have completed a comprehensive assessment on CR#1 when the CNA reported concerns of a change in condition to her, she said when she spoke to CR#1 he told her he was ok, so an assessment was not done. She said her shift ended at 2:00 p.m. so she did not know what happened after she left. Record review of CR#1's progress notes revealed no documentation of an assessment by RN D. Record review of CR#1's hospital records dated 3/18/17 revealed he arrived at the emergency roiagnom on [DATE] at 6:54 p.m. CR#1's Emergency Department Provider Documentation form revealed, .Impression and Plan Diagnosis .Acute ischemic right middle cerebral artery (MCA) stroke . His History & Physical dated 3/19/17 revealed, .History of Present Illness (CR#1's name) is a [AGE] year old man with a history of [MEDICAL CONDITION] who was brought to the ER for diminished mentation and swelling. In the ER, there was concern [MEDICAL CONDITION] and patient received 2 liters of NS (normal saline) and IV (intravenous) antibiotics. There was also concern for stroke, but initial brain imaging revealed early right MCA stroke. Family report that swelling has been gradual over at least the past week. Diminished mentation has been progressive over the past several days, and now patient only mumbles. His History & Physical dated 3/18/17 revealed, .Patient's (family member) reports that his roomate (sic) noticed that on Thursday night the patient was less active and was just staring at the ceiling. When she saw the patient on Friday morning the patient was less communicative than baseline and not following commands. In the NH (nursing home) the (sic) was concern for PNA (pneumonia) as the patietn (sic) had increased oral secretions; he was started on [MEDICATION NAME]. (Family Member) also noticed LE (lower extremity) [MEDICAL CONDITION] for a 'few days'.As (family member) was concerned of a new stroke decided to bring the patient to the ER. Record review of the facility's policy and procedure dated 2015 for Notification of Changes revealed, .Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and / responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: .2. An emergency response situation that require EMS involvement. 3. A significant change in the physical, mental or psychosocial status of the resident. The CMS 802 revealed 58 residents with communication deficits.

Based on interview and record review the facility failed to ensure 1 of 7 (CR#1) residents was free of neglect in that: --CR#1 had a change in condition during the night of 3/17/17. His Physician was not consulted. He was transferred to the hospital on [DATE] where he was diagnosed as having a stroke. --CR#1 was not assessed when he had a change in condition on 3/17/17. This failure affected one prior resident and placed 58 current residents with a communication deficit at risk of not receiving needed medical care which could result in injury, the inability to receive time constrained treatments, hospitalization , and decreased quality of life. Intake # 3 Findings Included: Record review of the facility's policy and procedure for Resident Protection revised 1/29/15 revealed, .Residents have the right to be free from abuse, neglect, corporal punishment, misappropriateion of property and involuntary seclusion.Attachment A .Neglect*-A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/ illness or physical injury, or harm or death to a resident. Record review of CR#1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring an 11 out of 15 on his brief interview for mental status indicating he had moderately impaired cognition. He was assessed as having unclear speech, usually understood and usually understands. He required the extensive assistance of two staff for bed mobility and transfers. He required the extensive assistance of one staff for locomotion and personal hygiene. He was totally dependent on two staff for toileting. Record review of CR #1's plan of care dated 3/8/17 revealed there was no care plan intervention to monitor for signs or symptoms of a new stroke. During an interview on 4/20/17 at 9:40 a.m. with the ADON she said CR#1's doctor saw him on 3/17/17 and prescribed [MEDICATION NAME] 250 mg 2 tabs by mouth daily for four days for a [DIAGNOSES REDACTED]. She said LVN B notified Nurse Practitioner B that CR#1 had a change in condition on 3/18/17. She said LVN B and RN D were terminated as they had not done a proper assessment on CR#1. During an interview on 4/20/17 at 10:05 a.m. with Resident #2 he said he had been in the room with CR#1 for 7 months. He said on the night of 3/17/17 CR#1 was moaning very loudly and could be heard out in the hallway. He said no one came to check on him until it was time for medications. He said when the nurse came in CR#1 was not responding so the nurse, name unknown, opened his mouth by pulling his lower lip down and put a pill in his mouth and poured water in his mouth. He said the nurse then left the room. He said he had been an Emergency Medical Technician and said he felt CR#1 had a stroke. He said he told the nurse that but nothing was done. He said on 3/18/17, staff came and dressed CR#1. He said CR#1 was staring at the ceiling and would not respond. He said CR#1's family came and tried to get CR#1 to respond but he would not. He said CR#1 was mumbling but they could not understand what he was saying. He said CR#1 was not transported to the hospital until later that evening via regular transport instead of 911 ambulance. During an interview on 4/20/17 at 10:40 a.m. with CR#1's Nurse Practitioner A she said that she worked with CR#1 and that he had been experiencing some coughing and congestion and breathing problems. She said when the Physician came to see him, any orders given were for those concerns. She said the facility never informed the Physician or her that CR#1 was not responding and could hardly talk. She said his change in condition was not reported to her of CR#1's doctor. During an interview on 4/20/17 at 12:30 p.m. with CNA A she said she worked with CR#1 on 3/18/17 and said that morning CR#1, .did not look himself. He was not the same person she had known. She said he was not communicating properly so she reported it to LVN B. During an interview on 4/20/17 at 3:15 p.m. with CNA C she said she worked the Friday and Saturday, 3/17/17 and 3/18/17, with CR#1. She said when she saw CR#1 on 3/17/17 he was not eating and was not talking in the way that was normal for him. She said all night CR#1 stared at the ceiling of his room. She said when she came in to her shift, she notified LVN B about CR#1's changes on the morning of 3/18/17. She said LVN B came over and saw CR#1 and told her he was being taken care of. She said RN D came during the morning shift on 3/18/17 and didn't know what to do' for CR#1. She said she got CR#1 ready that morning thinking that LVN B would call the physician and have CR#1 taken to the hospital. She said that did not happen. She said LVN B called CR#1's family members instead. CNA C said CR#1's condition looked so bad that one of my co-workers started crying. Record review of a written statement by CNA F dated 3/20/17 10:00 a.m. revealed, .-told nurses 'something' is not right /c (with) (CR#1's name)-Nurses went to room to check-BS (blood sugar)71-ask CNA for OJ (orange juice)-could not hold cup-choking on OJ- -2 CNA's came back & got nurse (RN D) said 'just send him out'- (LVN B) said no and called on-call-we gonna do labs. The statement was signed by CNA F. Record review of a handwritten document with an illegible signature dated 3/20/17 revealed, .3/18/17 (RN D)-informed by CNA and shower tech around 730 AM (unsure of time) that 'something was wrong with (CR#1) (sic).-Stated she assessed (CR#1)-Stated resident was responding verbally but had blank stare.-Stated she informed (LVN B) to notify the on-call person. Record review of CR#1's Nurse's Progress Notes for March 2017 revealed no documentation of any notes from 3/17/17 at 11:31 a.m. until 3/18/17 at 7:28 a.m. Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 7:28 a.m. written by LVN B revealed, .Resident in bed awake & alert-noticed that had nebulizer mask on and treatment was completed attempted to removed (sic) and patient declined for it to be removed-noticed that resident was not responding appropriately check blood sugar FBS=71 held insulin administration V/S (vital signs) 99.0 oral, 18 respirations, 146/84 blood pressure-resident had an eye glare and pupils were constricted-residents states feel fine but not able to hold cup to drink OJ (orange juice) had poor hand coordination & grip-as per resident's roommate (CR#1's name) has not been resting last night he was restless and 'moaning' stated that nurse had hard time to arouse him to administer his medications-called MD (Medical Doctor) (name) via exchange pending return call. Record review of CR#1's Nurse's Progress Note dated 3/18/17 8:08 a.m. written by LVN B revealed, .(Nurse Practitioner B's name) on call for (Physician A's name) returned called (sic) informed of resident's condition N/O (new order) given for stat CBC with Diff (Differential), BPM and STAT CXR on view to R/O (rule out) URI/[MEDICAL CONDITION]-orders noted and called in: labs confirmation # 4 and CXR confirmation# 566. Called RP (Responsible Party) (name) to notify stated will be here today to visit resident and stated 'thank you for calling.' . Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 5:41 p.m. written by LVN B revealed, .RP arrived to facility-came to nursing station demanding an explanation of why her father was in this condition-'lethargy and not able to understand him verbally-RN on charge informed talk to RP and explained that labs have been just received along with CXR MD was informed via (NP E) no new orders were given at this time only to monitor and continue ABT (antibiotic) orders along with NEb (nebulizer) txs (treatments) and monitor for any changes-as ABT has just started today initial dose @ 1400(2:00 p.m.)-RP (name) became upset and stated that roommate her (sic) that resident has been like that all night in pain and moaning and 'nothing was done' until this AM (morning) that nurse arrived. I informed RP that we will call MD (medical doctor) to notify of her wanting to send patient to ER (emergency room ) for evaluation-other daughter became verbally aggressive and stated that wasn't accepted (sic) and if this has been happening since 03/14/17 something should off (sic) have been done-she scream (sic) that is not acceptable-called Dr. (Medical Director's name) via exchange (Nurse Practitioner B) answer (sic) and informed of family request to sent (sic) patient to ER-NP (Nurse Practitioner) stated why the patient needs time for ABT to be effective-explain that daughter was at nurses (sic) station demanding to be sent out- (Nurse Practitioner B) stated go ahead and write order to sent (sic) to ER hospital of choice per family request. Called on call number and notified. Ambulance called for transportation and (Hospital Name) ER called for report given to (Hospital RN Staff name) at emergency room . During an interview on 5/16/17 at 11:54 a.m. with LVN B she said she came in 3/18/17 in the morning and went into CR#1's room. She said the roommate told her CR#1 had been moaning all night. She said CR#1 could not communicate like he normally did. She said CR#1 was not able to hold his cup. She said later she was in the dining hall and was called to CR#1's room where RN D and a CNA were and was told by RN D to call the doctor and responsible party. She said she called the nurse practitioner on duty and said she reported what was going on with CR#1 and then called the responsible party. She said she reported his change in condition to the nurse practitioner and to RN D. When asked if RN D had told her to call an ambulance she gave no answer but said she called the doctor. During an interview on 5/17/17 at 1:05 p.m. with RN D she said on 3/18/17 she worked the morning shift on the front hall and LVN B worked on the hall with CR#1 in the back. She said she was called to CR#1's room by a CNA and when she was there she asked CR#1 how he was feeling and he said he was ok. She said on 3/18/17 during the morning, the CNA who was working with him told her CR#1 was not looking good and was not himself. She said based on the information, she told LVN B to call for an ambulance. She said LVN B called Nurse Practitioner B and the resident's family member but did not call the ambulance. When asked if she had or read any documentation on CR#1 for that morning she said she was working the front hall and LVN B was working the back where CR#1 was. When asked about her being the Registered Nurse working in the facility, should she not have completed a comprehensive assessment on CR#1 when the CNA reported concerns of a change in condition to her, she said when she spoke to CR#1 he told her he was ok, so an assessment was not done. She said her shift ended at 2:00 p.m. so she did not know what happened after she left. Record review of CR#1's progress notes revealed no documentation of an assessment by RN D. Record review of CR#1's hospital records dated 3/18/17 revealed he arrived at the emergency roiagnom on [DATE] at 6:54 p.m. CR#1's Emergency Department Provider Documentation form revealed, .Impression and Plan Diagnosis .Acute ischemic right middle cerebral artery (MCA) stroke . His History & Physical dated 3/19/17 revealed, .History of Present Illness (CR#1's name) is a [AGE] year old man with a history of [MEDICAL CONDITION] who was brought to the ER for diminished mentation and swelling. In the ER, there was concern [MEDICAL CONDITION] and patient received 2 liters of NS (normal saline) and IV (intravenous) antibiotics. There was also concern for stroke, but initial brain imaging revealed early right MCA stroke. Family report that swelling has been gradual over at least the past week. Diminished mentation has been progressive over the past several days, and now patient only mumbles. His History & Physical dated 3/18/17 revealed, .Patient's (family member) reports that his roomate (sic) noticed that on Thursday night the patient was less active and was just staring at the ceiling. When she saw the patient on Friday morning the patient was less communicative than baseline and not following commands. In the NH (nursing home) the (sic) was concern for PNA (pneumonia) as the patietn (sic) had increased oral secretions; he was started on [MEDICATION NAME]. (Family Member) also noticed LE (lower extremity) [MEDICAL CONDITION] for a 'few days'.As (family member) was concerned of a new stroke decided to bring the patient to the ER. Record review of the facility's policy and procedure dated 2015 for Notification of Changes revealed, .Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and / responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: .2. An emergency response situation that require EMS involvement. 3. A significant change in the physical, mental or psychosocial status of the resident. The facility CMS 802 revealed 58 residents with communication problems.

Based on interview and record review the facility failed to ensure for 1 of 7 (CR#1) residents had services provided that met professional standards reveiwed for professional standards in that: --CR#1 had a change in condition during the night of 3/17/17 that was not reported to his Physician. He was transferred to the hospital on [DATE] where he was diagnosed as having a stroke. --CR#1 was not assessed when he had a change in condition the evening of 3/17/17 or morning of 3/18/17. --LVN B did not adequately assess CR#1 when a change in condition was reported to her and did not follow instructions to send CR#1 to the hospital on the morning of 3/18/17. --RN D failed to assess CR #1 when he had a change in condition and to follow-up with LVN B after instructing her to transfer CR#1 to the hospital. This failure affected one prior resident and placed 58 current residents with communication deficits at risk of not receiving needed medical care which could result in injury, the inability to receive time constrained treatments, hospitalization , and decreased quality of life. Intake # 3 Findings Included: Record review of §217.11. Standards of Nursing Practice dated October 2016 revealed, in part, .The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board ' s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse ' s current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i)the client ' s status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v)client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; . (L) Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served; . (M) Institute appropriate nursing interventions that might be required to stabilize a client ' s condition and/or prevent complications; (P) Collaborate with the client, members of the health care team and, when appropriate, the client ' s significant other(s) in the interest of the client ' s health care; . (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . Record review of CR#1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring an 11 out of 15 on his brief interview for mental status indicating he had moderately impaired cognition. He was assessed as having unclear speech, usually understood and usually understands. He required the extensive assistance of two staff for bed mobility and transfers. He required the extensive assistance of one staff for locomotion and personal hygiene. He was totally dependent on two staff for toileting. Record review of CR #1's plan of care dated 3/8/17 revealed there was no care plan intervention to monitor for signs or symptoms of a new stroke. During an interview on 4/20/17 at 9:40 a.m. with the ADON she said CR#1's doctor saw him on 3/17/17 and prescribed [MEDICATION NAME] 250 mg 2 tabs by mouth daily for four days for a [DIAGNOSES REDACTED]. She said LVN B notified Nurse Practitioner B that CR#1 had a change in condition on 3/18/17. She said LVN B and RN D were terminated as they had not done a proper assessment on CR#1. During an interview on 4/20/17 at 10:05 a.m. with Resident #2 he said he had been in the room with CR#1 for 7 months. He said on the night of 3/17/17 CR#1 was moaning very loudly and could be heard out in the hallway. He said no one came to check on him until it was time for medications. He said when the nurse came in CR#1 was not responding so the nurse, name unknown, opened his mouth by pulling his lower lip down and put a pill in his mouth and poured water in his mouth. He said the nurse then left the room. He said he had been an Emergency Medical Technician and said he felt CR#1 had a stroke. He said he told the nurse that but nothing was done. He said on 3/18/17, staff came and dressed CR#1. He said CR#1 was staring at the ceiling and would not respond. He said CR#1's family came and tried to get CR#1 to respond but he would not. He said CR#1 was mumbling but they could not understand what he was saying. He said CR#1 was not transported to the hospital until later that evening via regular transport instead of 911 ambulance. During an interview on 4/20/17 at 10:40 a.m. with CR#1's Nurse Practitioner A she said that she worked with CR#1 and that he had been experiencing some coughing and congestion and breathing problems. She said when the Physician came to see him, any orders given were for those concerns. She said the facility never informed the Physician or her that CR#1 was not responding and could hardly talk. She said his change in condition was not reported to her of CR#1's doctor. During an interview on 4/20/17 at 12:30 p.m. with CNA A she said she worked with CR#1 on 3/18/17 and said that morning CR#1, .did not look himself. He was not the same person she had known. She said he was not communicating properly so she reported it to LVN B. During an interview on 4/20/17 at 3:15 p.m. with CNA C she said she worked the Friday and Saturday, 3/17/17 and 3/18/17, with CR#1. She said when she saw CR#1 on 3/17/17 he was not eating and was not talking in the way that was normal for him. She said all night CR#1 stared at the ceiling of his room. She said when she came in to her shift, she notified LVN B about CR#1's changes on the morning of 3/18/17. She said LVN B came over and saw CR#1 and told her he was being taken care of. She said RN D came during the morning shift on 3/18/17 and didn't know what to do' for CR#1. She said she got CR#1 ready that morning thinking that LVN B would call the physician and have CR#1 taken to the hospital. She said that did not happen. She said LVN B called CR#1's family members instead. CNA C said CR#1's condition looked so bad that one of my co-workers started crying. Record review of a written statement by CNA F dated 3/20/17 10:00 a.m. revealed, .-told nurses 'something' is not right /c (with) (CR#1's name)-Nurses went to room to check-BS (blood sugar)71-ask CNA for OJ (orange juice)-could not hold cup-choking on OJ- -2 CNA's came back & got nurse (RN D) said 'just send him out'- (LVN B) said no and called on-call-we gonna do labs. The statement was signed by CNA F. Record review of a handwritten document with an illegible signature dated 3/20/17 revealed, .3/18/17 (RN D)-informed by CNA and shower tech around 730 AM (unsure of time) that 'something was wrong with (CR#1) (sic).-Stated she assessed (CR#1)-Stated resident was responding verbally but had blank stare.-Stated she informed (LVN B) to notify the on-call person. Record review of CR#1's Nurse's Progress Notes for March 2017 revealed no documentation of any notes from 3/17/17 at 11:31 a.m. until 3/18/17 at 7:28 a.m. Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 7:28 a.m. written by LVN B revealed, .Resident in bed awake & alert-noticed that had nebulizer mask on and treatment was completed attempted to removed (sic) and patient declined for it to be removed-noticed that resident was not responding appropriately check blood sugar FBS=71 held insulin administration V/S (vital signs) 99.0 oral, 18 respirations, 146/84 blood pressure-resident had an eye glare and pupils were constricted-resident states feel fine but not able to hold cup to drink OJ (orange juice) had poor hand coordination & grip-as per resident's roommate (CR#1's name) has not been resting last night he was restless and 'moaning' stated that nurse had hard time to arouse him to administer his medications-called MD (Medical Doctor) (name) via exchange pending return call. Record review of CR#1's Nurse's Progress Note dated 3/18/17 8:08 a.m. written by LVN B revealed, .(Nurse Practitioner B's name) on call for (Physician A's name) returned called (sic) informed of resident's condition N/O (new order) given for stat CBC with Diff (Differential), BPM and STAT CXR on view to R/O (rule out) URI/[MEDICAL CONDITION]-orders noted and called in: labs confirmation # 4 and CXR confirmation# 566. Called RP (Responsible Party) (name) to notify stated will be here today to visit resident and stated 'thank you for calling.' . Record review of CR#1's Nurse's Progress Note dated 3/18/17 at 5:41 p.m. written by LVN B revealed, .RP arrived to facility-came to nursing station demanding an explanation of why her father was in this condition-'lethargy and not able to understand him verbally (sic)-RN on charge informed talk to RP and explained that labs have been just received along with CXR MD was informed via (NP E) no new orders were given at this time only to monitor and continue ABT (antibiotic) orders along with NEb (nebulizer) txs (treatments) and monitor for any changes-as ABT has just started today initial dose @ 1400(2:00 p.m.)-RP (name) became upset and stated that roommate (sic) her that resident has been like that all night in pain and moaning and 'nothing was done' until this AM (morning) that nurse arrived. I informed RP that we will call MD (medical doctor) to notify of her wanting to send patient to ER (emergency room ) for evaluation-other (family member) became verbally aggressive and stated that wasn't accepted (sic) and if this has been happening since 03/14/17 something should off (sic) have been done-she scream (sic) that is not acceptable-called Dr. (Medical Director's name) via exchange (Nurse Practitioner B) answer (sic) and informed of family request to sent (sic) patient to ER-NP (Nurse Practitioner) stated why the patient needs time for ABT to be effective-explain that (family member) was at nurses (sic) station demanding to be sent out- (Nurse Practitioner B) stated go ahead and write order to sent (sic) to ER hospital of choice per family request. Called on call number and notified. Ambulance called for transportation and (Hospital Name) ER called for report given to (Hospital RN Staff name) at emergency room . During an interview on 5/16/17 at 11:54 a.m. with LVN B she said she came in 3/18/17 in the morning and went into CR#1's room. She said the roommate told her CR#1 had been moaning all night. She said CR#1 could not communicate like he normally did. She said CR#1 was not able to hold his cup. She said later she was in the dining hall and was called to CR#1's room where RN D and a CNA were and was told by RN D to call the doctor and responsible party. She said she called the nurse practitioner on duty and said she reported what was going on with CR#1 and then called the responsible party. She said she reported his change in condition to the nurse practitioner and to RN D. When asked if RN D had told her to call an ambulance she gave no answer but said she called the doctor. During an interview on 5/17/17 at 1:05 p.m. with RN D she said on 3/18/17 she worked the morning shift on the front hall and LVN B worked on the hall with CR#1 in the back. She said she was called to CR#1's room by a CNA and when she was there she asked CR#1 how he was feeling and he said he was ok. She said on 3/18/17 during the morning, the CNA who was working with him told her CR#1 was not looking good and was not himself. She said based on the information, she told LVN B to call for an ambulance. She said LVN B called Nurse Practitioner B and the resident's family member but did not call the ambulance. When asked if she had or read any documentation on CR#1 for that morning she said she was working the front hall and LVN B was working the back where CR#1 was. When asked about her being the Registered Nurse working in the facility, should she not have completed a comprehensive assessment on CR#1 when the CNA reported concerns of a change in condition to her, she said when she spoke to CR#1 he told her he was ok, so an assessment was not done. She said her shift ended at 2:00 p.m. so she did not know what happened after she left. Record review of CR#1's progress notes revealed no documentation of an assessment by RN D. Record review of CR#1's hospital records dated 3/18/17 revealed he arrived at the emergency roiagnom on [DATE] at 6:54 p.m. CR#1's Emergency Department Provider Documentation form revealed, .Impression and Plan Diagnosis .Acute ischemic right middle cerebral artery (MCA) stroke . His History & Physical dated 3/19/17 revealed, .History of Present Illness (CR#1's name) is a [AGE] year old man with a history of [MEDICAL CONDITION] who was brought to the ER for diminished mentation and swelling. In the ER, there was concern [MEDICAL CONDITION] and patient received 2 liters of NS (normal saline) and IV (intravenous) antibiotics. There was also concern for stroke, but initial brain imaging revealed early right MCA stroke. Family report that swelling has been gradual over at least the past week. Diminished mentation has been progressive over the past several days, and now patient only mumbles. His History & Physical dated 3/18/17 revealed, .Patient's (family member) reports that his roomate (sic) noticed that on Thursday night the patient was less active and was just staring at the ceiling. When she saw the patient on Friday morning the patient was less communicative than baseline and not following commands. In the NH (nursing home) the (sic) was concern for PNA (pneumonia) as the patietn (sic) had increased oral secretions; he was started on [MEDICATION NAME]. (Family Member) also noticed LE (lower extremity) [MEDICAL CONDITION] for a 'few days'.As (family member) was concerned of a new stroke decided to bring the patient to the ER. Record review of the facility's policy and procedure dated 2015 for Notification of Changes revealed, .Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and / responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: .2. An emergency response situation that require EMS involvement. 3. A significant change in the physical, mental or psychosocial status of the resident. Record review of the facility's policy and procedure for Resident Protection revised 1/29/15 revealed, .Residents have the right to be free from abuse, neglect, corporal punishment, misappropriateion of property and involuntary seclusion.Attachment A .Neglect*-A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/ illness or physical injury, or harm or death to a resident. The CMS 802 revealed 58 residents with communication deficits.

Based on observation, record review, and interview, the facility failed to consult with the resident's physician when a significant change occurred in the resident's physical status and a need to alter treatment for 3 of 32 sampled residents on insulin (Residents #3, #33, #25). ----Resident #3 experienced low BS on 10/1, 10/8, 10/20/10, and 10/23/10. The resident's physician was not notified of the low BS and altered consciousness. He had an elevated BS on 10/5/10 and the physician was not notified. ----Resident #33's SS insulin was discontinued on 10/1/10 without parameters for when to notify the physician. He had 12 incidents of BS in the 300 range without physician notification. He had 3 incidents of low blood sugars without parameters and the physician was not notified. ----Resident #25 BS was 500 on 10/17/10 at 6 p.m. The resident's FSBS was taken again at 8 p.m. and she was given 8 units of insulin for a reading of 350. There was no documentation that the resident's physician was notified and no orders to give insulin for the 350 BS. ----The facility had no clear guidelines for staff on when to call the Physician when BS levels were too high or too low An IJ was identified on 10/22/10 in the area of notifying physician of high or low blood sugar levels and level of consciousness. While the IJ was removed on 10/24/10, the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern, because additional staff needed to be trained and the facility had not yet had time to evaluate and monitor the effectiveness of their training. This failure affected 3 residents and placed 36 residents at risk for hyper/hypo glycemic reactions, hospitalization , coma, [MEDICAL CONDITION], and death. Findings include: Resident #3 Record review of Resident #3's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Comprehensive Plan of Care dated 8/11/10 revealed that, "Resident is a Diabetic and is at risk for : Frequent Infections, Pressure/Venous/Stasis Ulcers, Vision Impairment, Hyper/Hypo-glycemia, [MEDICAL CONDITION], and Cognitive Impairment." The approach to care was to, "give meds per order, monitor labs-report abnormal to doctor and monitor for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring-report to doctor ...." Record review on 10/20/10 of the physician's orders [REDACTED]. 200-250-4 units subcutaneously 251-300-6 units 301-350-8 units 351-400-10 units 401-450-12 units >450-call MD Record review of the resident's Nurses' Notes on 10/20/10 revealed that Resident #3 had occurrences of low and high blood sugars since the 9/24/10 order to D/C [MEDICATION NAME] 8 units every night. On 10/1/10 at 12:00 a.m., Resident #3 "moaning out loud" and sweating, FSBS 24, and no documentation that the doctor was notified. Record review of Resident #3's MAR indicated [REDACTED] Record review of the resident's Nurses' Notes for 10/5/10 revealed nothing documented for notifying the doctor of the elevated blood sugar. Further review of the resident's Nurses' Notes dated 10/8/10 at 8:45 a.m., revealed Resident #3, "observed by staff in the dining room shaking and unable to respond to name or place. Blood pressure 141/116, apical pulse 84, FSBS 76, some respiratory distress, respirations 24." No documentation that the doctor was notified. The resident was transferred to the hospital. On 10/20/10 at 6:30 a.m., "Resident in bed unconscious, FSBS was 30..." There was no documentation that the doctor was notified. At 6:45 a.m. the FSBS was 50 with no documentation that the doctor was notified. Record review on 10/21/10 of the facility's policy and procedure titled "Glucometer" revealed "...Report any reading below 60 or above 200 or unless specific parameters given by the physician for reporting ...." During an interview on 10/21/10 at 12:20 p.m. with LVN Y, she stated there was no routine to call the doctor with low or high blood sugars. She stated that she notified the doctor if the MAR indicated [REDACTED]. Record review of the Nurses' Notes revealed that on 10/23/10 at 2:30 a.m. the nurse was "informed that resident was very diaphoretic (sweating) and unresponsive per caregiver, upon arrival to resident's room, found him to be verbally unresponsive and diaphoretic." Resident #3's FSBS was 26 and blood pressure was 130/65. No documentation was found regarding notifying the doctor or administering [MEDICATION NAME]. At 2:45 a.m., Resident #3 was still unresponsive and 911 was called. No documentation was found regarding rechecking a FSBS or giving [MEDICATION NAME]. Resident #3 was taken to the hospital at 3:15 a.m. Observation of Resident #3 on 10/23/10 at 8:40 a.m. revealed Resident #3 lying in bed with the blankets over his head. He did not acknowledge a knock on the door or the verbal greeting. Resident #33 Record review of Resident #33's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated 7/3/09 and revised on 7/28/10 revealed he was diabetic and at risk for frequent infection, skin breakdown, vision impairment, hyper/hypo glycemia, [MEDICAL CONDITION] and cognitive/physical impairment. There was a hand written note, "Has diabetic retinopathy [MEDICAL CONDITION] in left eye. Cataract surgery 2003." Approaches were to give medications as ordered, to monitor labs and report abnormal levels to the physician and to report changes in level of consciousness or mood, perspiring to the physician. Observation on 10/20/10 at 12:25 p.m. revealed Resident #33 was in his room in a wheelchair. The resident had bilateral lower leg amputations. Interview with the resident at this time, he said his only complaint was that he had lost both his legs because of diabetes and could no longer walk. He said he had his left leg taken first and then told them to take the right leg also, because it "hurt so bad." Review of the resident's monthly physician's orders [REDACTED]. 71-150 = no coverage 151 - 200 = 2 units 201 - 250 = 3 units 251 - 300 = 4 units 301 - 350 = 6 units 351- 400 = 8 units BS greater than 400 = 10 units and call the physician. There was an order for [REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's MAR indicated [REDACTED]. Further review of the resident's MAR indicated [REDACTED]'s FSBS was 56. The only documentation on the back of the MAR indicated [REDACTED]. There was nothing documented to show if the resident's FSBS was retaken or if the physician was notified. There were no parameters of when to notify the physician of elevated or low BS. Review of the resident's Nurses' Notes on 10/21/10 revealed two documentations for October 2010. The first one on 10/6 noted the resident was lethargic and sleeping through meals. The resident's [MEDICATION NAME] pain medication was held. The last one, on 10/7/10, revealed the resident's Nurse Practitioner was informed of the resident being lethargic since being placed on [MEDICATION NAME]. She wrote new order for the pain medication. There was nothing documented to show she was informed of the resident's low or elevated FSBS. Observation and interview on 10/23/10 at 8:00 a.m. revealed Resident #33 was in bed. LVN N was coming from beside the resident's bed carrying a cup with a straw in it. Interview with the resident at this time, he said his BS was low and the nurse gave him some orange juice. He said he got low BS every now and then. Record review on 10/23/10 at 9:20 a.m. of Resident #33's MAR indicated [REDACTED]. Interview on 10/23/10 at 9:25 a.m. with LVN N, she said she started at the facility in June 2010 and only worked weekends. She said she had not charted the resident's low BS yet. She was asked what the level was. She said 76. She was asked if that was too low? Then she said the value was "60 something." She was asked if she had the exact value. She looked on a sheet of paper she had on the top of the medication cart. There was a 76, but no "60 something" value written on the sheet. She said it was 64. She was asked when she took the FSBS. She said around 6:40 a.m. She was asked when she gave the orange juice. She said right after she got the low reading. When she was informed that she was seen at 8:00 a.m. giving the resident the orange juice, she did not say anything. When she was asked if she had called the physician, she said not yet. She said she would go and call Resident #33's physician. Interview on 10/23/10 at 9:45 a.m. with Resident #33, he said he was really feeling "bad." He said his FSBS had been checked before he ate. He said the nurse would not tell him what his FSBS value was. When he was told it was 64, he said, "No wonder I felt so bad." He said his BS had been low for a couple of days. Interview on 10/21/10 at 9:45 a.m. with LVN E, she did not know why the resident was not on sliding scale insulin. She said that some residents were on FSBS four times a day without sliding scale. She said if they were not on a sliding scale, then she would report any blood sugar that was above 180. Resident #25 Record review of Resident #25's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission physician's orders [REDACTED]. 70-200 = no coverage 201-250 = 6 units 251-300 = 8 units 301-350 = 10 units 351-400 = 12 units BS greater than 400 = 12 units and call the physician. Further review of the resident's MAR indicated [REDACTED]. At 8 p.m. the resident's FSBS was 350 and the resident was given 8 units of [MEDICATION NAME]. Review of the resident's Nurses' Notes revealed documentation on 10/16/10 and then the next documentation was on 10/18/10. There was nothing documented to show that the resident's physician had been notified of the elevated BS level on 10/17/10. Review of Resident #25's physician's orders [REDACTED]. By sliding scale, the resident should have received 10 units. Interview on 10/21/10 at 12:35 p.m., LVN G said the 17th of October was a Sunday and he was not sure whose initials were on the MAR for that date. Interview on 10/20/10 at 11:45 a.m., Physician C was asked if he would like to be notified if his resident had a low or high BS level. He said it would change how the resident's insulin was used. On 10/21/10 at 2:10 p.m. the DON was asked for the P&P for high and low blood sugar levels. Interview on 10/21/10 at 3:45 p.m., the DON was asked again about a P&P for high and low blood sugar levels or a protocol. She said she did not have either. She was informed that some of the residents' MARs stated to "refer to the protocol for [DIAGNOSES REDACTED] (low BS)". She nodded her head and said she would recheck. Review of the facility's policy and procedure "[DIAGNOSES REDACTED] (WHAT YOU SHOULD KNOW) dated 5/01" revealed the following information: "THE FACTS Also known as 'low blood sugar' Can occur as a result of Too much insulin Delaying or stopping a meal or snack Increased physical activity or exercise THE SIGNS Sweating, nervousness, increased heart rate, blurred vision, tremors Irritability, difficulty concentrating Feeling faint, dizzy, or confused Onset of symptoms quite sudden and quickly worsening THE TREATMENT Eat or drink something right away that contains sugar; like candy, sugar-sweetened soft drink, orange juice, glucose gel or glucose tablet If [DIAGNOSES REDACTED] goes untreated, you may pass out ...in these severe cases, emergency treatment must be immediate ...in most cases, the nurse will give an injection [MEDICATION NAME] or a liquid medication under your tongue. DO NOT TAKE MORE INSULIN Inform your nurse or physician on any hypoglycemic episodes The key to [DIAGNOSES REDACTED] is careful self-monitoring of your blood glucose." Review of the facility's P&P "[MEDICAL CONDITION] (WHAT YOU SHOULD KNOW)" (no date) revealed the following information: "THE FACTS Also known as 'high blood sugar' Can occur as a result of Too little insulin Overeating Change in exercise regimen Illness Stress THE SIGNS Sudden hunger Excessive urination Extreme thirst Dry and flushed skin Blurred vision Unusual fatigue Weight loss THE TREATMENT Notify your physician Follow his/her instructions carefully Check your blood glucose level at home as recommended by physician Check your [MEDICATION NAME] in you urine as specified by your physician Always remember to take your insulin or oral medication as prescribed. The key to [MEDICAL CONDITION] is careful self-monitoring of your blood glucose." Interview on 10/22/10 at 2:30 p.m., the DON was asked if the facility's P&P for Hyper/Hypo Glycemia was obtained from the Internet. She said it came out of their P&P book. She was asked if she felt it addressed the areas of concern for FSBS and administration of insulin and she said it did not. Phone interview on 10/22/10 at 1:05 p.m., the Medical Director of the facility was asked about low and high blood sugars and doctor notification. When asked about wanting to be notified about low or high blood sugars, the medical director stated he would want to be called if a resident had two consecutive days with a blood sugar less than or equal to 70 or if a resident's blood sugar was less than or equal to 70, and they were unresponsive. In regard to the elevated blood sugar, he stated he would want to be called if the resident had two consecutive days of blood sugars greater than or equal to 300. On 10/22/10 at 11:08 a.m., the Administrator was informed that an immediate jeopardy situation existed in the area of not consulting with the resident's physician when blood sugars were too high or too low and residents were unresponsive. A plan of removal was submitted by the facility on 10/22/10 at 12:30 p.m. It was accepted on 10/22/10 at 4:00 p.m. and the Plan to Lift the IJ included the following: 1. The DNS, Nurse Consultant, and Nurse Managers will complete a 100% audit of all insulin dependent diabetic residents to identify other at risk residents by 10/22/10. 2. The DNS and Nurse Managers will contact the residents' attending physicians to inform them of any sliding scale coverage not administered, per physician orders, or recorded; any clarification orders from physician will be taken and completed by 10/22/10. 3. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on contacting the residents' attending physician to address high and low blood sugars by 10/22/10. 4. The DNS, Nurse Consultant, and Nurse Managers will monitor MARs to ensure accurate dispensing, documentation and physician notification of abnormal blood sugar, per physician orders, q shifts over the next 72 hours to ensure compliance. On 10/23/10 the facility was monitored and several residents did not have either high or low BS parameters on their MARs, residents did not get FSBS on Unit 2, residents had low blood sugars that were not recorded or reported to the physician. The IJ was not lifted. On 10/24/10 the facility was monitored. The corporate nurse continued to observe licensed nurses in acquiring FSBS. Documentation of FSBS and insulin being given improved. Parameters for high and low BS levels were on the MARs. Monitoring for these items continued. While the IJ was removed on 10/24/10 at 10:25 a.m., the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern because additional staff needed to be trained and the facility had not had time to evaluate and monitor the effectiveness of their training. The facility listed 39 residents on FSBS and insulin.

Based on observation, record review, and interview, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 32 sampled residents on insulin (Residents #3, #33). ----Resident #3 had an order dated 9/24/10 to discontinue [MEDICATION NAME] 8 units at bedtime. He was given [MEDICATION NAME] 8 units 21 days from 9/24/10 to 10/19/10. The resident experienced low BS on 10/1([MEDICATION NAME] SS was given twice and [MEDICATION NAME] not documented as given on 9/30/10), 10/8 ([MEDICATION NAME] 8 units at 8 p.m. on 10/7/10 and 8 units [MEDICATION NAME] given 10/8/10 at 6:30 a.m.), and 10/20/10 (had elevated BS three times and no documentation SS insulin given) The resident's physician was not notified of the low BS levels. He was sent to the hospital on [DATE] shaking and unresponsive. His [DIAGNOSES REDACTED]. Those orders were not verified with his physician and insulin was given to him again. On 10/23 and 10/24/10 the resident was found sweating and unresponsive with low BS levels and was sent to the hospital both times. The resident received the incorrect amount of insulin by SS on 10/5/10. Insulin was not documented as given 26 times when the FSBS was in the SS range. ----Resident #33 was taken off SS insulin on 10/1/10 without any parameters for high or low BS levels. The resident had 12 episodes of BS being in the 300 range. The resident had 3 episodes of low blood sugar and the physician was not notified. ----The facility had no clear guidelines for staff on when to call the Physician when BS levels were too high or too low An IJ was identified on 10/22/10 in the area of residents experiencing multiple side effects of low BS levels and their physicians were not being notified. While the IJ was removed on 10/24/10, the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern because additional staff needed to be trained, and the facility had not had time to evaluate and monitor the effectiveness of their training. This failure affected 2 residents and placed 37 residents at risk for hyper/hypo glycemic reactions, hospitalization , coma, [MEDICAL CONDITION], and possible death. Complaint # 1 and # 1 Findings include: Resident # 3 Record review of Resident #3's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Comprehensive Plan of Care dated 8/11/10 revealed that, "Resident is a Diabetic and is at risk for: Frequent Infections, Pressure/Venous/Stasis Ulcers, Vision Impairment, Hyper/Hypo-glycemia, [MEDICAL CONDITION], and Cognitive Impairment." The approach to care was to, "give meds per order, monitor labs-report abnormal to doctor and monitor for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring-report to doctor ...." Record review on 10/20/10 of the physician's orders [REDACTED]. 200-250-4 units subcutaneously 251-300-6 units 301-350-8 units 351-400-10 units 401-450-12 units >450-call MD There were no parameters for a low blood sugar. There was an order on 8/29/10 for FSBS twice daily. Record review of Resident #3's MAR indicated [REDACTED] Record review of the resident's Nurses' Notes for 10/5/10 revealed nothing documented for notifying the doctor of the elevated blood sugar. Further review on Resident #3's MAR indicated [REDACTED]. The correct dose was 10 units. During an interview on 10/20/10 at 12:20 p.m., Resident #3 stated that he received his medications on time, but that he thought "they are giving me too much insulin." He went on to state that his blood sugar had been dropping more than usual, the last time being last night. Review of the resident's MARs dated September 2010 and October 2010 revealed that Resident #3 received [MEDICATION NAME] 8 units 21 times every night at 8 p.m. on 9/24/10, 9/27/10, 9/28/10, 10/1/10 thru 10/17/10 and 10/19/10 even though it had been discontinued on 9/24/10. He was also receiving sporadic [MEDICATION NAME] SS insulin during this time for FSBS in the 200, 300 and 400 ranges. Further review of the resident's Nurses' Notes on 10/20/10 revealed that Resident #3 had four occurrences of low blood sugars since the 9/24/10 order to D/C [MEDICATION NAME] 8 units every night. On 10/1/10 at 12:00 a.m., Resident #3 "moaning out loud" and sweating, FSBS 24, and no documentation that the doctor was notified. On 10/8/10 at 8:45 a.m., Resident #3, "observed by staff in the dining room shaking and unable to respond to name or place. Blood pressure 141/116, apical pulse 84, FSBS 76, some respiratory distress, respirations 24." No documentation that the doctor was notified. The resident was transferred to the hospital. Record review of Resident #3's hospital discharge instructions for the emergency room visit dated 10/8/2010 at 9:41 a.m. revealed that Resident #3 had a [DIAGNOSES REDACTED]." Further review revealed that the discharge instructions stated, "No insulin to be given this evening .....Patient had hypoglycemic episode this morning ...." Review of the resident's October 2010 MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. Further review of the resident's Nurses' Notes dated 10/20/10 at 6:30 a.m. revealed, "Resident in bed unconscious, FSBS was 30 ..."There was no documentation that the doctor was notified. At 6:45 a.m., the FSBS was 50 with no documentation that the doctor was notified. During an interview on 10/20/10 at 2:50 p.m., ADON B stated she did see the order to D/C the insulin on 9/24/10 in Resident #3's chart. When asked why Resident #3 continued receiving [MEDICATION NAME] 8 units every night even though it had been D/C, she stated she thought the [MEDICATION NAME] had been re-ordered. Review of the resident's Nurses' Notes dated 10/20/10 at 7:30 p.m. revealed Resident #3's Nurse Practitioner (NP) called the facility and was informed that the resident had been receiving [MEDICATION NAME] 8 units since it had been discontinued on 9/24/10. The NP said she thought it had been restarted. She gave an order to continue the [MEDICATION NAME] 8 units at night because the resident had irregular BS levels. During an interview on 10/21/10 at 12:20 p.m., LVN Y stated there was no routine procedure for when to call the doctor with low or high blood sugars. She stated that she notified the doctor if the MAR indicated [REDACTED]. Review of the resident's physician's orders [REDACTED]. Record review of the Nurses' Notes revealed that on 10/23/10 at 2:30 a.m., the nurse was "informed that resident was very diaphoretic (sweating) and unresponsive per caregiver, upon arrival to resident's room, found him to be verbally unresponsive and diaphoretic." Resident #3's FSBS was 26 and blood pressure was 130/65. No documentation was found regarding notifying the doctor or administering [MEDICATION NAME]. At 2:45 a.m., Resident #3 was still unresponsive and 911 was called. No documentation found regarding rechecking a FSBS or giving [MEDICATION NAME]. Resident #3 was taken to the hospital at 3:15 a.m. The resident's physician was called at 3:00 a.m. The hospital called at 6:20 a.m. saying the resident was ready to be discharged back to the facility. The physician did not return the call until 9:32 a.m. Record review of Resident #3's hospital discharge instructions for the emergency room dated 10/23/10 at 3:10 a.m., revealed that Resident #3 had a [DIAGNOSES REDACTED]. Record review of the resident's Nurses' Notes dated 9/12/10, 9/23/10, 9/25/10, 9/29/10, 10/16/10 revealed the resident was alert, oriented, ambulated around the facility and could go out on pass with family. Observation of Resident #3 on 10/23/10 at 8:40 a.m. revealed Resident #3 lying in bed with the blankets over his head. He did not acknowledge a knock on the door or the verbal greeting. During an interview on 10/23/10 at 9:00 a.m., LVN Y stated she was not sure why Resident #3 went to the hospital; "I think it was for low blood sugar," but continued on to state she had not read his chart yet. When asked why the resident did not have parameters for elevated BS levels on his [MEDICATION NAME] SS insulin, she stated that as of this morning, no one in the facility had a sliding scale for insulin administration. When asked what she was to do when a blood sugar level was too low or too high, she stated, if it was less than 70 or higher than 300, she would follow the orders on the MAR. If it was in between 70 and 300 she would do nothing. She continued to state Resident #3 no longer had sliding scale insulin, and turned over the old MARs from October 1 through October 22, stating "We won't use these anymore." Record review on 10/23/10 of the resident's physician's orders [REDACTED]. Record review on 10/23/10 of Resident #3's new October 2010 MAR indicated [REDACTED]. Further review of the resident's Nurses' Notes dated 10/23/10 at 9:32 a.m. revealed the resident's Physician called the facility and was given a report of the resident's low BS levels. The Physician gave an order to discontinue his [MEDICATION NAME] 8 units and [MEDICATION NAME] 10 units and to start [MEDICATION NAME] 8 units every evening. A second observation of Resident #3 on 10/23/10 at 10:30 a.m. revealed him lying in bed with the blankets over his head. He did not acknowledge a knock on the door and a verbal greeting. During an interview with the DON on 10/23/10 at 11:05 a.m., when asked to clarify Resident #3's new blood sugar parameters and sliding scale insulin, she stated Resident #3's sliding scale was still in place. She was informed that LVN Y was not aware of that. The DON stated she would clarify the orders and ensure the nurses were aware of them. Observation of Resident #3 on 10/24/10 at 8:00 a.m. revealed that he was not in his room. During an interview with Case Mix Manager B on 10/24/10 at 8:30 a.m., she stated Resident #3 was in the hospital. Record review on 10/24/10 of the Nurse's Notes revealed that Resident #3 was found on the floor in his room at 4:55 a.m., "moaning and groaning and diaphoretic" with skin cool to touch. The FSBS was 28. At 5:06 a.m., the FSBS was 30 and at 5:10 a.m., FSBS was 26. Resident #3 was sent to the hospital. Record review of Resident #3's MAR indicated [REDACTED] 6:30 a.m. 10/5/10 - 455 11:30 a.m. 10/10/10 - 236 10/17/10 - 225 4:30 p.m. 10/2/10 - 292 10/3/10 - 362 10/7/10 - 282 10/8/10 - 369 10/10/10 - 250 10/12/10 - 431 10/16/10 - 233 10/17/10 - 372 8:30 p.m. 10/1/10 - 435 10/2/10 - 391 10/3/10 - 441 10/5/10 - 293 10/6/10 - 401 10/7/10 - 330 10/8/10 - 372 10/10/10 - 390 10/11/10 - 288 10/12/10 - 357 10/13/10 - 220 10/14/10 - 273 10/16/10 - 259 10/17/10 - 350 10/19/10 - 367 Record review revealed no documentation on the back of the MAR indicated [REDACTED]. Resident #33 Record review of Resident #33's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated 7/3/09 and revised on 7/28/10 revealed he was diabetic and at risk for frequent infection, skin breakdown, vision impairment, hyper/hypo glycemia, [MEDICAL CONDITION] and cognitive/physical impairment. There was a hand written note, "Has diabetic retinopathy [MEDICAL CONDITION] in left eye. Cataract surgery 2003." Approaches were to give medications as ordered, to monitor labs and report abnormal levels to the physician, and to report changes in level of consciousness or mood, perspiring to the physician. Observation on 10/20/10 at 12:25 p.m. revealed Resident #33 was in his room in a wheelchair. The resident had bilateral lower leg amputations. Interview with the resident at this time, he said his only complaint was that he had lost both his legs because of diabetes and could no longer walk. He said he had his left leg taken first and then told them to take the right leg also, because it "hurt so bad." Review of Resident #33's physician's orders [REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's MAR indicated [REDACTED]. Further review of the resident's MAR indicated [REDACTED]'s FSBS was 56. The only documentation on the back of the MAR indicated [REDACTED]. There was nothing documented if the resident's FSBS was retaken or if the physician was notified. Review of the resident's Nurses' Notes on 10/21/10 revealed two documentations for October 2010. The first one on 10/6 noted the resident was lethargic and sleeping through meals. The resident's [MEDICATION NAME] pain medication was held. The last one on 10/7/10 revealed the resident's Nurse Practitioner was informed of the resident being lethargic since being placed on [MEDICATION NAME]. She wrote a new order for the pain medication. There was nothing documented to show she was informed of the resident's low and high BS levels. Observation and interview on 10/23/10 at 8:00 a.m. revealed Resident #33 was in bed. LVN N was coming from beside the resident's bed carrying a cup with a straw in it. Interview with the resident at this time, he said his BS was low and the nurse gave him some orange juice. He said he got low BS every now and then. Record review on 10/23/10 of Resident #33's MAR indicated [REDACTED]. Interview on 10/23/10 at 9:25 a.m., LVN N said she started at the facility in June 2010 and only worked weekends. She said she had not charted the resident's low BS yet. She was asked what the level was. She said 76. She was asked if that was too low? Then she said the value was "60 something." She was asked if she had the exact value. She looked on a sheet of paper she had on the top of the medication cart. There was a 76, but no "60 something" value written on the sheet. She said it was 64. She was asked when she took the FSBS. She said around 6:40 a.m. She was asked when she gave the orange juice. She said right after she got the low reading. She was asked if she gave orange juice twice. She said no. When she was informed that she was seen at 8:00 a.m. giving the resident the orange juice, she did not say anything. Then she said she must have taken his FSBS at around 7:45 a.m. When she was asked if she had called the physician, she said "not yet." She said she would go and call Resident #33's physician. Interview on 10/23/10 at 9:30 a.m., the DON was informed that LVN N had not taken Resident #33's FSBS until 7:45 a.m. The DON said the FSBS should be taken as close to 6:30 a.m. as possible. Interview on 10/23/10 at 9:45 a.m. with Resident #33, he said he was really feeling "bad." He said his FSBS had been checked before he ate. He said the nurse would not tell him what his FSBS value was. When he was told it was 64, he said, "No wonder I felt so bad." He said his BS had been low for a couple of days. Interview on 10/21/10 at 9:45 a.m., LVN E said she did not know why the resident was not on sliding scale insulin. She said that some residents were on FSBS four times a day without sliding scale. She said if they were not on a sliding scale, then she would report any blood sugar that was above 180. On 10/21/10 at 2:10 p.m. the DON was asked for the P&P for high and low blood sugar levels. Interview on 10/21/10 at 3:45 p.m., the DON was asked again about a P&P for high and low blood sugar levels or a protocol. She said she did not have either. She was informed that some of the residents' MARs referred staff to the protocol for [DIAGNOSES REDACTED] (low BS). She nodded her head and said she would recheck. Review of the facility's policy and procedure "[DIAGNOSES REDACTED] (WHAT YOU SHOULD KNOW)" dated 5/01, revealed the following information: THE FACTS Also known as "low blood sugar" Can occur as a result of Too much insulin Delaying or stopping a meal or snack Increased physical activity or exercise THE SIGNS Sweating, nervousness, increased heart rate, blurred vision, tremors Irritability, difficulty concentrating Feeling faint, dizzy, or confused Onset of symptoms quite sudden and quickly worsening THE TREATMENT Eat or drink something right away that contains sugar; like candy, sugar-sweetened soft drink, orange juice, glucose gel or glucose tablet If [DIAGNOSES REDACTED] goes untreated, you may pass out ...in these severe cases, emergency treatment must be immediate ...in most cases, the nurse will give an injection [MEDICATION NAME] or a liquid medication under your tongue. DO NOT TAKE MORE INSULIN Inform your nurse or physician on any hypoglycemic episodes The key to [DIAGNOSES REDACTED] is careful self-monitoring of your blood glucose. Review of the facility' s P&P [MEDICAL CONDITION] (WHAT YOU SHOULD KNOW) (no date) revealed the following information: THE FACTS Also known as "high blood sugar" Can occur as a result of Too little insulin Overeating Change in exercise regimen Illness Stress THE SIGNS Sudden hunger Excessive urination Extreme thirst Dry and flushed skin Blurred vision Unusual fatigue Weight loss THE TREATMENT Notify your physician Follow his/her instructions carefully Check your blood glucose level at home as recommended by physician Check your [MEDICATION NAME] in you urine as specified by your physician Always remember to take your insulin or oral medication as prescribed. The key to [MEDICAL CONDITION] is careful self-monitoring of your blood glucose. Interview on 10/22/10 at 2:30 p.m., the DON was asked if the facility's P&P for Hyper/Hypo Glycemia was obtained from the Internet. She said it came out of their P&P book. She was asked if she felt it addressed the areas of concern for FSBS and administration of insulin and she said it did not. On 10/22/10 at 11:08 a.m., the Administrator was informed that an immediate jeopardy situation existed in the areas of not ensuring the accurate dispensing of insulin, failure to inform Physicians of high and low BS levels, to have parameters for high and low BS levels, to follow Physician orders [REDACTED]. A plan of removal was submitted by the facility on 10/22/10 at 12:30 p.m. The facility's Plan to Lift the IJ was accepted on 10/22/10 at 4:00 p.m. and included the following: 1. The DNS, Nurse Consultant, and Nurse Managers will complete a 100% audit of all insulin dependent diabetic residents to identify other at risk residents by 10/22/10. 2. The DNS and Nurse Managers will contact the residents ' attending physicians to inform them of any sliding scale coverage not administered, per physician orders, or recorded; any clarification orders from physician will be taken and completed by 10/22/10. 3. The DNS and Nurse Managers will complete Med Error Reports on all insulin that was not given by 10/22/10. 4. The DNS and Nurse Consultant will in-service the licensed nursing staff on proper and accurate dispensing of insulin by 10/22/10. 5. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on following physician orders [REDACTED]. 6. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on documenting blood sugar levels and administration of insulin by 10/22/10. 7. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff, with return demonstration, on performing finger stick blood sugars according to the manufacturer's recommendation by 10/22/10. 8. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on contacting the residents' attending physician to address high and low blood sugars by 10/22/10. 9. The DNS, Nurse Consultant, and Nurse Managers will monitor MARs to ensure accurate dispensing, documentation and physician notification of abnormal blood sugar, per physician orders, q shifts over the next 72 hours to ensure compliance. 10. The DNS, Nurse Consultant, and Nurse Managers, through direct observation, will monitor the licensed nursing staff to ensure finger stick blood sugars are being performed, according to the manufacturer's recommendation, q shift over the next 72 hours to ensure compliance. 11. The facility will conduct an off cycle QA & A Committee meeting to review the current policies and procedures to ensure an effective system in place to address high and low blood sugars by 10/22/10. On 10/23/10 the facility was monitored and several residents did not have either high or low BS parameters on their MARs, residents did not get FSBS on Unit 2, residents had low blood sugars that were not recorded or reported to the physician. The IJ was not lifted. On 10/24/10 the facility was monitored. The corporate nurse continued to observe licensed nurses in acquiring FSBS. Documentation of FSBS and insulin being given improved. Parameters for high and low BS levels were on the MARs. Monitoring for these items continued. While the IJ was removed on 10/24/10 at 10:25 a.m., the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern because additional staff needed to be trained and the facility had not had time to evaluate and monitor the effectiveness of their training. The facility listed 39 residents on FSBS and insulin.

Based on observation, record review, and interview, the facility failed to assure the accurate dispensing and administering of medications and biologicals to meet the needs of 18 of 37 sampled residents (Resident #'s 3, 33, 25, 11, 9, 2, 37, 30, 29, 8, 10, 16, 26, 34, 32, 28, 24, 27), 4 random residents (Resident #38, #40, #41, and #42). ----Resident #3 had an order dated 9/24/10 to discontinue Lantus 8 units at bedtime. He was given Lantus 8 units 21 days from 9/24/10 to 10/19/10. The resident experienced low BS on 10/1, 10/8, and 10/20/10 and the resident's physician was not notified of the low BS levels. He was sent to the hospital on [DATE] and returned to the facility with hospital discharge orders not to be given insulin that night. Those orders were not verified with his physician and insulin was given to him again. The resident experienced low BS levels again on 10/23 and 10/24/10 and was sent to the hospital both times. The resident received the incorrect amount of insulin by SS once. Insulin was not documented as given 26 times when the FSBS was in the SS range. ----Resident #33 was on Lantus 40 u at bedtime. He was taken off SS insulin without any parameters for when to call the physician. The resident had 12 episodes of BS in the 300 range and 3 episodes of low blood sugar and his physician was not called. ----Resident #25 had a BS level of 500 at 6 p.m. and her physician was not called. The resident was given 8 units of insulin at 8 a.m. for BS of 350 without a physician's orders [REDACTED]. There was no parameter for low BS level. ----Resident #11 had 38 episodes of SS insulin not documented as given for elevated BS. He was given an incorrect dose of insulin. ----Resident #9 had 4 episodes of SS insulin not documented as given for elevated BS. NPH insulin not documented as given 4 times. The resident was given the incorrect amount of SS insulin. There was no parameter for low BS level. ----Resident #2 had 24 episodes of SS insulin not documented as given for elevated BS. FSBS not documented as done 8 times. There was no parameter for a low BS level. ----Resident #37 had 13 episodes of SS insulin not documented as given for elevated BS. FSBS not documented as done on 10/23/10. ----Resident #30 had 9 episodes of SS insulin not documented as given for elevated BS. There was no parameter for low BS level. ----Resident #29 had 6 episodes of SS insulin not documented as given for elevated BS. ----Resident #8 had 4 episodes of SS insulin not documented as given for elevated BS. FSBS not documented as done 3 times. There was no parameter for low BS level. ----Resident #10 had 4 episodes of SS insulin not documented as given for elevated BS. FSBS not documented as done on 10/17/10. ----Resident #16 had 4 episodes of SS insulin not documented as given for elevated BS. On 10/1/10 the FSBS not documented as done 4 times. Lantus 25 units not documented as given 2 times. ----Resident #26 did not have her SS insulin transcribed to the MAR. ----Residents #34, #32, #28, #24, #27, and #38 did not have parameters for either high or low BS levels. ----ADON B did not perform FSBS according to manufacturer's instruction manual. 3 Non-IJ residents (#6, #1, #18) ----Residents #6, #9, #16, #1, #10 and #11 received the wrong dosage of medication, given medications that had been discontinued, had medications given and not documented, or had medications pre-initialed before they were given. ----12 opened insulin vials were in the Unit 1 nursing medication cart not dated. Three of those vials were sent to the facility in August, more than 28 days had passed and they were on the medication cart being used for Residents #9 and #10. Four unopened insulin vials were in the cart and not refrigerated. An IJ was identified on 10/22/10 in the area of Pharmaceutical Services. While the IJ was removed on 10/24/10, the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern because additional staff needed to be trained and the facility had not had time to evaluate and monitor the effectiveness of their training. These failures affected 22 residents on FSBS of whom 17 residents were on insulin and put 17 residents on FSBS and insulin at risk for side effects of coma, brain injury, and death. Non-IJ These failures affected six residents on medications and placed 95 residents on medications at risk for receiving discontinued medication, wrong dose of medication, duplicate therapy, and missed doses. Complaints # 1 and # 1 Findings include: Insulin Administration Resident #3 Record review of Resident #3's admission sheet revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Comprehensive Plan of Care dated 8/11/10 revealed that, "Resident is a Diabetic and is at risk for: Frequent Infections, Pressure/Venous/Stasis Ulcers, Vision Impairment, Hyper/Hypo-glycemia, Renal Failure, and Cognitive Impairment." Further review of the resident's care plan revealed that the approach to care was to "give meds per order, monitor labs-report abnormal to doctor and monitor for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring-report to doctor ...." During an interview on 10/20/10 at 12:20 p.m. Resident #3 stated that he received his medications on time, but that he thought, "They are giving me too much insulin." He went on to state that his blood sugar had been dropping more than usual, the last time being last night. Record review of the physician's orders [REDACTED]. 200-250-4 units subcutaneously 251-300-6 units 301-350-8 units 351-400-10 units 401-450-12 units >450-call MD There were no parameters for a low blood sugar. There was an order on 8/29/10 for FSBS twice daily. Review of the Resident's MARs dated September 2010 and October 2010 revealed that Resident #3 received Lantus 8 units every night at 8 p.m. on 9/24/10, 9/27/10, 9/28/10, 10/1/10 thru 10/17/10 and 10/19/10. On 9/25/10, 9/26/10, 9/29/10, 9/30/10, and 10/18/10, the Lantus was not given to Resident #3. The front of the MARs are initialed and circled, but there was no documentation on the back of the sheets explaining why the medication was not given. Further review on Resident #3's MAR revealed that on 10/5/10 at 6:30 a.m., the resident's FSBS was 455 and no documentation on the back of the MAR that the physician was notified. At 4:30 p.m., the resident's FSBS was 384 and he received 8 units of sliding scale insulin. The correct dose was 10 units. Record review of Resident #3's Nurses' Notes for 10/5/10 revealed no documentation for notifying the doctor of the elevated blood sugar levels. Further review of the resident's Nurses' Notes on 10/20/10 revealed that Resident #3 had four occurrences of low blood sugars since the 9/24/10 order to D/C Lantus 8 units every night. On 10/1/10 at 12:00 a.m., Resident #3 "moaning out loud" and sweating, FSBS 24, and no documentation was in the Nurses' Notes that the doctor was notified. On 10/8/10 at 8:45 a.m., Resident #3, "observed by staff in the dining room shaking and unable to respond to name or place. Blood pressure 141/116, apical pulse 84, FSBS 76, some respiratory distress, respirations 24." No documentation was in the nurse's notes that the doctor was notified. The resident was transferred to the hospital. Record review of Resident #3's hospital discharge instructions for the emergency room visit dated 10/8/2010 at 9:41 a.m. revealed that Resident #3 had a [DIAGNOSES REDACTED]." Further review revealed that the discharge instructions stated, "No insulin to be given this evening .....Patient had hypoglycemic episode this morning ...." Review of the resident's October 2010 MAR revealed the resident was given the Lantus 8 units even when there was an order from the hospital to not give insulin. Review of the physician's orders [REDACTED]. Further review of the resident's Nurses' Notes dated 10/20/10 at 6:30 a.m., revealed "Resident in bed unconscious, FSBS was 30 ..." and no documentation was in the Nurses' Notes that the doctor was notified. At 6:45 a.m. the FSBS was 50 and no documentation was in the Nurses' Notes that the doctor was notified. During an interview on 10/20/2010 at 2:50 p.m., ADON B stated she did see the order to D/C the insulin on 9/24/10 in Resident #3's chart. When asked why Resident #3 continued receiving Lantus 8 units every night even though it had been D/C, she stated she thought the Lantus had been re-ordered. Review of the resident's Nurses' Notes dated 10/20/10 at 7:30 p.m. revealed Resident #3's Nurse Practitioner (NP) called the facility and was informed that the resident had been receiving Lantus 8 units since it had been discontinued on 9/24/10. The NP said she thought it had been restarted. She gave an order to continue the Lantus 8 units at night because the resident had irregular BS levels. Review of the resident's physician's orders [REDACTED]. Record review of the Nurses' Notes revealed that on 10/23/10 at 2:30 a.m., the nurse was "informed that resident was very diaphoretic (sweating) and unresponsive per caregiver, upon arrival to resident's room, found him to be verbally unresponsive and diaphoretic." Resident #3's FSBS was 26 and blood pressure was 130/65. No documentation was found regarding notifying the doctor or administering Glucagon. At 2:45 a.m., Resident #3 was still unresponsive and 911 was called. No documentation found regarding rechecking a FSBS or giving Glucagon. Resident #3 was taken to the hospital at 3:15 a.m. The resident's physician was called at 3:00 a.m. The hospital called at 6:20 a.m. saying the resident was ready to be discharged back to the facility. The physician did not return the call until 9:32 a.m. Record review of Resident #3's hospital discharge instructions for the emergency room dated 10/23/10 at 3:10 a.m., revealed that Resident #3 had a [DIAGNOSES REDACTED]. Record review of the resident's Nurses' Notes dated 9/12/10, 9/23/10, 9/25/10, 9/29/10, 10/16/10 revealed the resident was alert, oriented, ambulated around the facility and could go out on pass with family. Observation of Resident #3 on 10/23/10 at 8:40 a.m. revealed Resident #3 lying in bed with the blankets over his head. He did not acknowledge a knock on the door and a verbal greeting. Record review on 10/23/10 of Resident #3's MAR for 10/23/2010 revealed that his scheduled 6:30 a.m. FSBS was not done because the resident went to the hospital. Further review of the MAR showed that new FSBS parameters had been ordered for low blood sugars, but not high blood sugars. During an interview on 10/23/10 at 9:00 a.m., LVN Y stated she was not sure why Resident #3 went to the hospital; "I think it was for low blood sugar," but continued on to state she had not read his chart yet. When asked for clarification regarding Resident #3's sliding scale and elevated blood sugars, she stated that as of 10/23/10 this morning, no one in the facility had a sliding scale insulin administration. When asked what she was to do when a blood sugar was low or high, she stated if it was less than 70 or higher than 300, she would follow the orders on the MAR and if it is in between 70 and 300 she would do nothing. She continued on to state Resident #3 no longer had sliding scale insulin and turned over the old MARs from October 1 through October 22, stating "we won't use these anymore." Record review on 10/23/10 of the resident's physician's orders [REDACTED]. Further review of the resident's Nurses' Notes dated 10/23/10 at 9:32 a.m. revealed the resident's Physician called the facility and was given a report of the resident's low BS levels. The Physician gave an order to discontinue his Lantus 8 units and Levemir 10 units and to start Levemir 8 units every evening. Second observation of Resident #3 on 10/23/10 at 10:30 a.m. revealed Resident #3 lying in bed with the blankets over his head. He did not acknowledge a knock on the door and a verbal greeting. During an interview on 10/23/10 at 11:05 a.m., the DON was asked to clarify Resident #3's new blood sugar parameters and sliding scale insulin. She stated th Resident #3's sliding scale was still in place. She was informed that LVN Y was not aware of that. The DON stated she would clarify the orders and ensure the nurses were aware of them. Observation of Resident #3 on 10/24/10 at 8:00 a.m. revealed that he was not in his room. During an interview with Case Mix Manager B on 10/24/10 at 8:30 a.m., she stated Resident #3 was in the hospital. Record review on 10/24/10 of the Nurse's Notes revealed that Resident #3 was found on the floor in his room at 4:55 a.m., "moaning and groaning and diaphoretic " with skin cool to touch. The FSBS was 28. At 5:06 a.m. the FSBS was 30 and at 5:10 a.m. FSBS was 26. Resident #3 was sent to the hospital. Record review of Resident #3's MAR dated October 2010 revealed no documentation 26 times that sliding scale was given for the following FSBS levels: 6:30 a.m. 10/5/10 - 455 11:30 a.m. 10/10/10 - 236 10/17/10 - 225 4:30 p.m. 10/2/10 - 292 10/10/10 - 250 10/3/10 - 362 10/12/10 - 431 10/7/10 - 282 10/16/10 - 233 10/8/10 - 369 10/17/10 - 372 8:30 p.m. 10/1/10 - 435 10/11/10 - 288 10/2/10 - 391 10/12/10 - 357 10/3/10 - 441 10/13/10 - 220 10/5/10 - 293 10/14/10 - 273 10/6/10 - 401 10/16/10 - 259 10/7/10 - 330 10/17/10 - 350 10/8/10 - 372 10/19/10 - 367 10/10/10 - 390 There was nothing documented on the back of the MAR as to why the sliding scale insulin was not given. Resident #33 Record review of Resident #33's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated 7/3/09 and revised on 7/28/10 revealed he was diabetic and at risk for frequent infection, skin breakdown, vision impairment, hyper/hypo glycemia, renal failure and cognitive/physical impairment. There was a handwritten note, "Has diabetic retinopathy blindness in left eye. Cataract surgery 2003." Approaches were to give medications as ordered, to monitor labs and report abnormal levels to the physician and to report changes in level of consciousness or mood, perspiring, to the physician. Observation on 10/20/10 at 12:25 p.m. revealed Resident #33 was in his room in a wheelchair. The resident had bilateral lower leg amputations. Interview with the resident at this time, he said his only complaint was that he had lost both his legs because of diabetes and could no longer walk. He said he had his left leg taken first and then told them to take the right leg also, because it "hurt so bad." Review of Resident #33's physician's orders [REDACTED]. There was an order for [REDACTED]. Review of the resident's MAR dated October 2010 revealed 12 episodes from 10/2/10 to 10/20/10 of elevated blood sugars in the 300 range. Further review of the resident's MAR revealed on 10/5/10 his FSBS was 65, on 10/16/10 it was 61 and on 10/20/10 at 6 a.m. the resident's FSBS was 56. The documentation on the back of the MAR noted the resident was given orange juice with sugar on 10/20/10. There was nothing documented if the resident's FSBS was retaken or if the physician was notified. Review of the resident's Nurses' Notes revealed two documentations for October 2010. The first one on 10/6 noted the resident was lethargic and sleeping through meals. The resident's Ultram pain medication was held. The last one on 10/7/10 revealed the resident's Nurse Practitioner was informed of the resident being lethargic since being placed on Ultram. She wrote a new order for the pain medication. There was nothing documented to show she was informed of the resident's low FSBS. Review of the resident's physician's orders [REDACTED]. Observation on 10/23/10 at 8:00 a.m. revealed Resident #33 was in bed. LVN N was coming from beside the resident's bed with a cup with a straw in it. Interview with the resident at this time, he said his BS was low and the nurse gave him some orange juice. He said he got low BS every now and then. Record review on 10/23/10 of Resident #33's MAR dated October 2010 revealed nothing was documented about a low BS level on the front or back of the sheet for 10/23/10. Interview on 10/23/10 at 9:25 a.m., LVN N said she started at the facility in June 2010 and only worked weekends. She said she had not charted the resident's low BS yet. She was asked what the level was. She said 76. She was asked if that was too low? Then she said the value was "60 something." She was asked if she had the exact value. She looked on a sheet of paper she had on the top of the medication cart. There was a 76, but no "60 something" value written on the sheet. She said it was 64. She was asked when she took the FSBS. She said around 6:40 a.m. She was asked when she gave the orange juice. She said right after she got the low reading. When she was informed that she was seen at 8:00 a.m. giving the resident the orange juice, she did not say anything. When she was asked if she had called the physician, she said "not yet." LVN N was observed getting the glucometer ready to do a FSBS for Resident #36. She said she had Resident #36 and Resident #8 who needed to have FSBS. Record review at this time revealed the two residents' FSBSs were scheduled for 6:30 a.m. When LVN N was asked if the FSBS were scheduled to be done at 6:30 a.m., she said they had [DEVICE] feedings and the FSBS could be done at any time. LVN N was asked why she was so late getting FSBS. She said because she came in late and one of the resident's [DEVICE] feeding had leaked and it took her a while to clean it up. When she was asked if she had attended any in-services on insulin, she said she attended one yesterday. She said she would go and call Resident #33's physician. Interview on 10/23/10 at 9:30 a.m., the DON was informed that LVN N was still getting FSBS that were scheduled at 6:30 a.m. She said that since the residents were on continuous [DEVICE] feedings, then the FSBS could be gotten at any time. When she was asked if it would be important to get the FSBS at the same time every day, since they were on [DEVICE] feedings, she said she guessed it might. She was informed that Resident #33's FSBS was not taken until 7:45 a.m. She said the FSBS should be taken as close to 6:30 a.m. as scheduled. Interview on 10/23/10 at 9:45 a.m. with Resident #33, he said he was really feeling "bad." He said his FSBS had been checked before he ate. He said the nurse would not tell him what his FSBS value was. When he was told it was 64, he said, "No wonder I felt so bad." He said his BS had been low for a couple of days. Interview on 10/21/10 at 9:45 a.m. LVN E said she did not know why the resident was not on sliding scale insulin. She said that some residents were on FSBS four times a day without sliding scale. She said if they were not on a sliding scale, then she would report any blood sugar that was above 180. Resident #25 Record review of Resident #25's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission physician's orders [REDACTED]. 70-200 = no coverage 201-250 = 6 units 251-300 = 8 units 301-350 = 10 units 351-400 = 12 units BS greater than 400 = 12 units and call the physician. There was also an order [REDACTED]. There was an order for [REDACTED]. There were no parameters for a low blood sugar. Record review of Resident #25's MAR dated 10/12/10 revealed no documentation that sliding scale insulin was given for the following FSBS levels: 12 a.m. FSBS 10/15/10 - 284 10/17/10 - 208 10/21/10 - 207 Further review of the resident's MAR revealed FSBS were done at 12 a.m., 6 a.m., 12 p.m. and 6 p.m. On 10/17/10 the resident's FSBS was 500 at 6 p.m. The resident was given 12 units of Novolog. At 8 p.m. the resident's FSBS was 350 and the resident was given 8 units of Novolog. On 10/20/10 the resident's FSBS was 245. By documentation, the resident received 8 units of insulin when she should have received 6 units. There were no signatures identifying initials on the back of the MAR. Review of the resident's Nurses' Notes revealed documentation on 10/16/10 and then the next documentation was on 10/18/10. There was nothing documented to show the resident's physician had been notified. Review of Resident #25's physician's orders [REDACTED]. By sliding scale the resident should have received 10 units. Interview on 10/21/10 at 12:35 p.m. with LVN G, he said the 17th of October was a Sunday and he was not sure whose initials were on the MAR for that date. Record review of Resident #25's new MAR dated October 2010 revealed all the dates had been "X"ed out to 10/23/10. There was no documentation that the FSBS had been done at 6:00 a.m. Interview with LVN L at this time, when she was asked about Resident #25's FSBS, she said she had not done it. She said she saw the X's and thought it had been discontinued. Resident #11 Record review of Resident #11's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Physicians' orders revealed an order for [REDACTED]. FSBS 121-150 - 2 units subcutaneously 151-200 - 4 units 201-250-6 units 251-300-8 units 301-350-10 units 351-400-12 units >401- 14 units and call MD There was also an order [REDACTED]. There was an order for [REDACTED]. Record review of Resident #11's MAR dated October 2010 revealed no documentation 38 times that sliding scale was given for the following FSBS levels: 7:00 a.m. FSBS 10/2/10 - 186 10/12/10 - 241 10/3/10 -181 10/16/10 - 195 10/4/10 - 142 10/17/10 -179 10/10/10 - 241 10/19/10 - 139 11:00 a.m. FSBS 10/2/10 - 183 10/5/10 - 240 10/10/10 - 201 10/17/10 - 163 4:00 p.m. FSBS 10/1/10 - 249 10/12/10 - 149 10/3/10 - 400 10/14/10 - 274 10/4/10 - 233 10/15/10 - 238 10/6/10 - 233 10/16/10 - 273 10/7/10 - 244 10/17/10 - 210 10/8/10 - 241 10/18/10 - 223 10/9/10 - 160 10/19/10 - 146 9:00 p.m. FSBS 10/2/10 - 163 10/12/10 - 146 10/3/10 - 271 10/13/10 - 123 10/4/10 - 146 10/15/10 - 124 10/6/10 - 193 10/16/10 - 238 10/10/10 - 249 10/17/10 - 140 10/11/10 - 138 10/19/10 - 125 Record review of Resident #11's MAR dated October 2010 revealed no documentation for FSBS on the 10/1/10 at 11:00 a.m. There was nothing documented on the back of the sheet as to why the FSBS was not done. Further review of Resident #11's MAR dated October 2010 revealed that the FSBS at 7:00 a.m. on 10/6/10 was 183 and Resident #11 received 2 units of sliding scale insulin. The correct dose was 4 units. Record review of Resident #11's MAR revealed that on 10/15/10, his 5:00 p.m. dose on Lantus insulin was not documented as being received. There was nothing documented on the back of the sheet as to why the medication were not given. Resident #9 Record review of Resident #9's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's admission orders [REDACTED] FSBS 60-100 - zero units 101-120 - 2 units subcutaneously 121-150 - 3 units 151-200 - 4 units 201-250-5 units 251-300-6 units 301-350-8 units 351-400-10 units >400- 10 units and call MD There was also an order [REDACTED]. There were no parameters for a low blood sugar. There was an order for [REDACTED]. Record review of Resident #9 ' s MAR dated October 2010 revealed no documentation 4 times that sliding scale was given for the following FSBS levels: 6:00 a.m. FSBS 10/1/10 - 125 10/6/10 - 213 4:30 p.m. FSBS 10/2/10 - 224 10/17/10 - 190 Further review of Resident #9's MAR dated October 2010 revealed no documentation 4 times that NPH insulin was given on the following dates: 10/1/10 10/6/10 10/15/10 10/16/10 There was nothing documented on the back of MAR as to why the medications was not given. Further review of Resident #9's Nurses Notes revealed no documentation was found regarding why the sliding scale or NPH insulin was not given. Further review of Resident #9's MAR dated October 2010 revealed that the FSBS at 6:00 a.m. on 10/9/10 was 186 and Resident # 9 received 2 units of sliding scale insulin. The correct dose was 4 units. Resident #2 Record review of Resident #2's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/20/10 at 12:10 p.m. revealed Resident #2 was at a dining room table feeding herself lunch. She was taking large bites of corn bread. A staff person cued the resident to be sure to drink fluids between each bite of food. Record review of the resident's admission physician's orders [REDACTED]. 121-150 = 1 unit 151-200 = 2 units 201-250 = 3 units 251-300 = 4 units 301-350 = 5 units 351-400 = 6 units BS greater than 400 = 6 units and call the physician. There was also an order [REDACTED]. There was an order for [REDACTED]. There were no parameters for a low blood sugar. Record review of Resident #2's MAR dated October 2010 revealed no documentation 24 times that sliding scale insulin was given for the following FSBS levels: 6:30 a.m. FSBS 10/11/10 - 136 11:30 a.m. FSBS 10/8/10 - 128 10/17/10 - 153 10/10/10 - 144 10/18/10 - 177 10/14/10 - 174 10/19/10 - 144 10/16/10 - 134 10/20/10 - 133 4:30 p.m. FSBS 10/6/10 - 127 10/10/10 - 128 10/14/10 - 122 10/16/10 - 151 10/17/10 - 138 10/20/10 - 127 8:00 p.m. FSBS 10/6/10 - 148 10/13/10 - 137 10/7/10 - 175 10/16/10 - 250 10/8/10 - 126 10/17/10 - 121 10/9/10 - 138 10/19/10 - 121 10/10/10 - 141 There was nothing documented on the back of the MAR as to why the insulin was not given. Further review of the MAR revealed on 10/6 at 11:30 a.m.; 10/7 at 6:30 a.m. and 11:30 a.m., 10/13 at 11:30 a.m., 10/14 at 8 p.m., 10/15 at 6:30 a.m., 11:30 a.m. and 8 p.m., there was no documentation that FSBS was done 8 times. Resident #37 Record review of Resident #37's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's Care Plan dated 2/18/10 and reviewed on 8/18/10 revealed the resident was diabetic and at risk for frequent infection, skin breakdown, vision impairment, hyper/hypo glycemia, renal failure and cognitive/physical impairment. Approaches were to give medications as ordered, monitor labs and report abnormal labs to the physician, and report changes in level of consciousness or mood, perspiring, to the physician. FSBS were to be checked every 6 hours and regular insulin administered by SS. Review of the resident's readmission physician's orders [REDACTED]. 70-120 = no coverage 121-150 = 4 units 151 - 200 = 6 units 201 - 250 = 8 units 251 - 300 = 10 units 301 - 350 = 12 units 351 - 400 = 14 units BS greater than 400 = 12 units and call the physician. BS less than 70 give glucagon 1 mg IM and call physician. There was an order for [REDACTED]. Review of the resident's MAR dated October 2010 revealed no sliding scale listed. Insulin was not documented 13 times as given for the following FSBS levels: 6:30 a.m. FSBS 10/9/10 - 148 10/10/10 - 152 10/11/10 - 128 10/15/10 - 164 10/16/10 - 166 10/17/10 - 136 4:30 p.m. FSBS 10/9/10 - 136 10/10/10 - 142 10/13/10 - 129 10/15/10 - 136 10/16/10 - 165 10/17/10 - 300 10/18/10 - 143 There was nothing documented on the back of the MAR as to why the insulin was not given. Record review on 10/23/10 of Resident #37's new MAR dated October 2010 revealed all the dates had been "X"ed out to 10/23/10. There was no documentation that the FSBS had been done at 6:00 a.m. Interview on 10/23/10 at 9:50. a.m., LVN L said she had not done the FSBS. She said she saw the X's and thought it had been discontinued. Resident #30 Record review of Resident #30's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #30's admission orders [REDACTED] 61-150 = no coverage 151-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units BS greater than 400 = 12 units and call the physician. There was also an order [REDACTED]. There was an order for [REDACTED]. There were no parameters for a low blood sugar. Record review of Resident #30's MAR dated October 2010 revealed no documentation 9 times that sliding scale insulin was given for the following FSBS levels: 8 a.m. FSBS 10/1/10 - 164 10/11/10 - 287 10/14/10 - 200 10/15/10 - 176 10/18/10 - 155 4 p.m. FSBS 10/3/10 - 210 10/8/10 - 221 10/10/10 - 243 10/11/10 - 170 There was nothing documented on the back of the MAR as to why the insulin was not given. Resident #29 Review of Resident #29's admission sheet revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's Care Plan dated 7/8/9 revealed he was diabetic and at risk for frequent infection, skin breakdown, vision impairment, hyper/hypo glycemia, renal failure and cognitive/physical impairment. Approaches were to give medications as ordered, to monitor labs and report abnormal levels to the physician and to report changes in level of consciousness or mood, perspiring, to the physician. Observation on 10/20/10 at 12:35 p.m. revealed Resident #29 was in bed with bilateral splints to both arms and hands. The resident had a tracheostomy with an oxygen mask with humidified air. The resident did not respond verbally and did not look at the surveyor when spoken to. Review of the resident's admission orders [REDACTED] 70-120 = no coverage 121-150 = 1 units 151 - 200 = 2 units 201 - 250 = 3 units 251 - 300 = 4 units 301 - 350 = 5 units 351 - 400 = 6 units BS greater than 400 = 8 units and call the physician. BS less than 70 give glucagon 1 mg IM and call physician. There was an order for [REDACTED]. Record review of Resident #29's MAR dated October 2010 revealed no documentation 6 times that sliding scale insulin was given for the following FSBS levels:

Based on observation, record review and interview, the Administrator and DON failed to use facility resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. ----The Administrator failed to supervise the DON to ensure she was monitoring staff in the performance of their duties. ----The Administrator and DON failed to provide a P&P and a protocol for high and low BS levels. ----DON failed to ensure licensed nurses were performing their duties in the following areas: a. Ensure physicians were called when BS levels were too high or too low and to report when residents were unresponsive. (#'s 3, 33, 25) b. Administering the correct dosage of insulin (#'s 3, 25, 11, 9) c. Were able to give medications and treatments as ordered by the physicians (#'s 3, 25, 11, 2, 37, 30, 29, 8, 10, 16) d. Obtained parameters for high and low BS levels. (#'s 3, 33, 25, 9, 2, 30, 8, 34, 32, 28, 24, 27, 38) e. Ensure management nurses monitored the MARs for complete and accurate documentation. (#'s 3, 33, 11, 9, 2, 37, 30, 29, 8, 10, 16, 26) f. Ensure licensed nurses were performing FSBS according to the manufacturer's recommendations. (ADON B and LVN Y) An IJ was identified on 10/22/10 in the area of Administration. While the IJ was removed on 10/24/10, the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern, because additional staff needed to be trained and the facility had not yet had time to evaluate and monitor the effectiveness of their training. These findings placed 39 residents on FSBS and insulin at risk for side effects of too high or low blood sugars, coma, [MEDICAL CONDITION] and death. Findings include: Resident #3 Resident #3 had an order dated 9/24/10 to discontinue [MEDICATION NAME] 8 units at bedtime. He was given [MEDICATION NAME] 8 units 21 days from 9/24/10 to 10/19/10. On 10/5/10 at 6:30 a.m. the resident had an elevated BS level of 455 with no documentation that the physician was notified. On 10/5/10 at 4:30 p.m. the resident's FSBS was 384 and he received the 8 units of SS insulin, when the correct dose was 10 units. He had no parameters for low BS levels. The resident had four occurrences of low BS levels with signs and symptoms of [DIAGNOSES REDACTED]. The resident experienced sweating and being unresponsive with a low BS on 10/1 and 10/8/10. His physician was not notified of the low BS level. He was sent to the hospital on [DATE] and returned to the facility with hospital discharge orders not to be given insulin that night. Those orders were not verified with his physician and insulin was given to him again. The resident experienced sweating and being unresponsive with a low BS level on 10/20/10. The resident's physician was not notified. The resident experienced sweating and being unresponsive again had low BS levels on 10/23/10 and there was no documentation that treatment was given for the low BS level or the BS level was rechecked. On 10/24/10 the resident again had a low BS level with signs and symptoms. He was sent to the hospital both times. Insulin was not documented as given 26 times when the FSBS was in the SS range. During an interview on 10/23/10 at 9:00 a.m. with LVN Y, she stated she was not sure why Resident #3 went to the hospital, "I think it was for low blood sugar" but continued on to state she had not read his chart yet. When asked for clarification regarding Resident #3's sliding scale and elevated blood sugars, she stated that as of 10/23/10 this morning no one in the facility has a sliding scale. When asked what she was to do when a blood sugar was low or high she stated if it was less than 70 or higher than 300, she will follow the orders on the MAR and if it is in between 70 and 300 she will do nothing. She continued on to state Resident #3 no longer had sliding scale insulin and turned the old MARs from October 1 through October 22 over, stating "we won't use these anymore." Record review of the Resident #3's physician's orders [REDACTED]. Resident #33 Resident #33 was taken off SS insulin on 10/1/10 without any parameters obtained for high or low BS levels. The resident had 12 episodes of BS being in the 300 range from 10/2/10 to 10/20/10. The resident had 3 episodes of low blood sugar and the physician was not notified on 10/5, 10/16 and 10/20/10. Resident #25 Resident #25 had a BS level of 500 on 10/17/10 at 6 p.m. and her physician was not called. The resident was given 8 units of insulin at 8 a.m. for BS of 350 without a physician's orders [REDACTED]. She was given 8 units of insulin when the dose should have been 6 units. There were no parameters for low BS level. Record review on 10/23/10 at 9:50 a.m. of Resident #25's new MAR dated October 2010 revealed all the dates had been "X"ed out to 10/23/10. There was no documentation that the FSBS had been done at 6:00 a.m. Interview with LVN L at this time, when she was asked about Resident #25's FSBS, she said she had not done it. She said she saw the X's and thought it had been discontinued. Resident #11 Resident #11 had 38 episodes of SS insulin not documented as given for elevated BS from 10/2 to 10/19/10. On 10/1/10 there was no documentation of his FSBS being done at 11:00 a.m. On 10/6/10 the resident's FSBS was 183 and he was given 2 units of SS insulin when the dose should have been 4 units. Resident #9 had 4 episodes of SS insulin not documented as given for elevated BS from 10/1 to 10/17/10. NPH insulin not documented as given 4 times on 10/1, 10/6, 10/15, and 1016/10. On 10/9/10 the resident's FSBS was 186 and he was given 2 units when the dose should have been 4 units. There were no parameters for low BS levels. Resident #2 Resident #2 had 24 episodes of SS insulin not documented as given for elevated BS from 10/6 to 10/20/10. FSBS not documented as done 8 times from 10/6 to 10/15/10. There were no parameters for low BS level. Resident #37 Resident #37 had 13 episodes of SS insulin not documented as given for elevated BS from 10/9/10 to 10/18/10. FSBS not documented as done on 10/23/10. Record review on 10/23/10 at 9:50 a.m. of Resident #37's new MAR dated October 2010 revealed all the dates had been "X"ed out to 10/23/10. There was no documentation that the FSBS had been done at 6:00 a.m. Interview on 10/23/10 at 9:50. a.m. with LVN L, she said she had not done the FSBS. She said she saw the X's and thought it had been discontinued. Residents #30, #29, #8 Resident #30 had 9 episodes of SS insulin not documented as given for elevated BS from 10/1 to 10/18/10. There were no parameters for low BS levels. Resident #29 had 6 episodes of SS insulin not documented as given for elevated BS from 10/5 to 10/19/10. Resident #8 had 4 episodes of SS insulin not documented as given for elevated BS from 10/6 to 10/14/10. FSBS was not documented as done 3 times from 10/4 to 10/8/10. There were no parameters for low BS levels. Resident #10 Resident #10 had 4 episodes of SS insulin not documented as given for elevated BS from 10/4 to 10/17/10. On 10/17/10 his scheduled [MEDICATION NAME] at 9:00 p.m. and FSBS were not documented as done . Resident #16 Resident #16 had 4 episodes of SS insulin not documented as given for elevated BS from 10/2 to 10/18/10. On 10/1/10 the FSBS not documented as done 4 times that day. [MEDICATION NAME] 25 units not documented as given 2 times on 10/1 and 10/4/10. Resident #26 Review of the resident's latest monthly physician's orders [REDACTED]. 70-120 = no coverage 151 - 200 = 2 units 201 - 250 = 3 units 251 - 300 = 4 units 301 - 350 = 5 units 351 - 400 = 6 units BS greater than 400 give 8 units. Resident #26 did not have her SS insulin transcribed to the October 2010 MAR. Resident #34 Record review on 10/20/10 at 3:55 p.m. of Resident #34's MAR dated October 2010 revealed his FSBS was not documented on 10/20/10 at 6 a.m. There were no parameters for a low BS. The resident's highest FSBS was 123 and his lowest was 78. Resident #32 Record review on of Resident #32's MAR dated October 2010 revealed he had FSBS twice a day and was on SS with regular insulin. There were no parameters for low BS. Resident #28 Record review of Resident #28's MAR dated October 2010 revealed there were no parameters for high or low BS. The resident's highest FSBS was 121 and the lowest was 78. Residents #24 and #27 Record review of Residents' #24 and #27 MARs dated October 2010 revealed they had FSBS every Wednesday. Neither one had parameters for elevated BS. Resident #38 Record review of the facility's list for receiving FSBS revealed Resident #38 was not listed. Review of the resident's MAR dated October 2010 revealed FSBS every Monday. The resident was on Glucerna tube feeding formula. There was no parameter for elevated BS. Blood Sugar Monitoring Resident #10 Observation done on 10/20/10 at 4:50 p.m. of ADON B performing FSBS on Resident #10 revealed she did not replace the lid to the bottle of test strips after getting one out and she did not allow Resident #10's finger to dry after cleaning it with alcohol and before pricking his finger and obtaining a blood sample. Resident 11 Observation on 10/20/10 at 5:00 p.m. of ADON B performing FSBS on Resident #11 revealed she took a test strip out of the bottle that had been open for 10 minutes while she was performing FSBS on another resident. She did not allow Resident #11's finger to dry after cleaning it with alcohol before pricking his finger and obtaining a blood sample. Observation on 10/21/10 at 11:30 a.m. revealed LVN Y was performing FSBS on the residents on Unit 1 and walked into a resident's room and left the lid off of the test strip bottle and the strips were exposed. During an interview on 10/21/10 at 11:30 a.m., LVN F described how she performed FSBS and when she called the doctor. She stated she began with ensuring the machine was clean, she would take out a strip, close the container, clean the finger and, "make sure it is dry." She would stick the finger, wipe and discard the first blood drop. She stated she used the second blood drop to obtain the result and documented the result. She stated she would call the doctor according to the doctor's orders. For example, if the FSBS was >400, she would give insulin and called the doctor; if the FSBS was low, she would given [MEDICATION NAME] and called the doctor. " I would recheck the FSBS in 15 minutes and, if it was still low, I would give more [MEDICATION NAME] and call the doctor. " During an interview on 10/21/10 at 1:30 p.m. with LVN F, she was asked to clarify what she considered a low blood sugar. She stated " it depends on the patient, " because some run low; but usually if the FSBS is <70, she stated called the doctor. During an interview on 10/21/10 at 12:20 p.m. with LVN Y, she stated there was no routine to call the doctor with low or high blood sugars. She stated that she notified the doctor if the MAR stated to notify the doctor, if it did not state notify the doctor, then she did not call. During an interview on 10/22/10 at 11:25 a.m., ADON B described how she would perform FSBS and administer insulin and when she called the doctor. Observation revealed she did not wait for the alcohol to dry on the resident's finger and she left the test strip bottle opened. ADON B stated she called the doctor if the parameters said to call him with a FSBS >450 or if the sugar is low, " 30". I will give [MEDICATION NAME] and still call him. " On 10/21/10 at 2:10 p.m. the DON was asked for the P&P for high and low blood sugar levels. Interview on 10/21/10 at 3:45 p.m. with the DON, she was asked again about a P&P for high and low blood sugar levels or a protocol. She said she did not have either one. She was informed that some of the residents' MARs had to "refer to the protocol for [DIAGNOSES REDACTED] (low BS)". She nodded her head and said she would recheck. Review of the facility's policy and procedure [DIAGNOSES REDACTED] (WHAT YOU SHOULD KNOW) dated 5/01 revealed the following information: "THE FACTS Also known as " low blood sugar " Can occur as a result of Too much insulin Delaying or stopping a meal or snack Increased physical activity or exercise THE SIGNS Sweating, nervousness, increased heart rate, blurred vision, tremors Irritability, difficulty concentrating Feeling faint, dizzy, or confused Onset of symptoms quite sudden and quickly worsening THE TREATMENT Eat or drink something right away that contains sugar; like candy, sugar-sweetened soft drink, orange juice, glucose gel or glucose tablet If [DIAGNOSES REDACTED] goes untreated, you may pass out ...in these severe cases, emergency treatment must be immediate ...in most cases, the nurse will give an injection [MEDICATION NAME] or a liquid medication under your tongue. DO NOT TAKE MORE INSULIN Inform your nurse or physician on any hypoglycemic episodes The key to [DIAGNOSES REDACTED] is careful self-monitoring of your blood glucose." Review of the facility's P&P [MEDICAL CONDITION] (WHAT YOU SHOULD KNOW) (no date) revealed the following information: "THE FACTS Also known as "high blood sugar" Can occur as a result of Too little insulin Overeating Change in exercise regimen Illness Stress THE SIGNS Sudden hunger Excessive urination Extreme thirst Dry and flushed skin Blurred vision Unusual fatigue Weight loss THE TREATMENT Notify your physician Follow his/her instructions carefully Check your blood glucose level at home as recommended by physician Check your [MEDICATION NAME] in you urine as specified by your physician Always remember to take your insulin or oral medication as prescribed. The key to [MEDICAL CONDITION] is careful self-monitoring of your blood glucose." Interview on 10/22/10 at 2:30 p.m. with the DON, she was asked if the facility's P&P for Hyper/Hypo Glycemia was obtained from the Internet. She said it came out of their P&P book. She was asked if she felt it addressed the areas of concern for FSBS and administration of insulin and she said it did not. On 10/22/10 at 1:05 p.m., the Medical Director of the facility was interviewed regarding low and high blood sugars and doctor notification. When asked about wanting to be notified about low or high blood sugars, the medical director stated he would want to be called if a resident had two consecutive days with a blood sugar less than or equal to 70 or if a resident's blood sugar was less than or equal to 70 and they were unresponsive. In regards to the elevated blood sugar, he stated he would want to be called if the resident had two consecutive days of blood sugars greater than or equal to 300. He continued to state that the facility "definitely" should have a policy on [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. As a final statement, the medical director stated that he was working on "getting rid of " the sliding scale insulin all together and that eventually removing sliding scale would occur at a global level. Interview on 10/23/10 at 8:45 a.m. with the DON, she was asked how she monitored her staff to ensure they were providing appropriate care to the residents. She said between her and the management nurses, they did rounds in the morning. She said the management nurses were the three ADONs and two Case Mix Managers, who completed the MDS assessments and wrote the main care plans. Then they would have their "Start Up" meeting around 8:30 a.m. and discuss orders, the 24 hour book, and any concerns they saw during their rounds. She said all the nursing managers (ADONs) had assignments. Some of the assignments were to looked at the environment, resident condition, pain, falls, splinting/handrolls and positioning. The DON said at 9:00 a.m. they would have their "Stand Up" meeting which involved all the department managers. They would discuss any problems that might have been identified. She said the clinical nurses were responsible for the acute care plan, the initial admission care plan and the CNA work sheet. She said the main focus for the ADONs was to look for changes in condition in residents, to check documentation, to run the unit, to make sure new orders were written and carried out, skin checks were being done, monitor wound care, and eating and meal service. She said she also had the QA meeting that was done monthly to check for any problems. She said dietary, nursing, administrator, human resources, the Medical Director, Social Services, Environmental Manager, Therapy Director and a guest CNA would attend. Interview on 10/23/10 at 9:00 a.m., LVN L said she worked as needed for the facility since September 2009. She said she just worked on the weekends. She said she was in-serviced on Thursday and Friday, this week about parameters for insulin, how to perform FSBS, and calling the physician. She said if the resident's BS was below 60 she would call the physician after following the orders for low BS. She said if the resident was on SS insulin, then she would follow it, but, if the resident was not on SS, then for any BS above 140, she would call the physician. She said she would document, document, document. She said each of the three nursing carts used for the two units had different ways to document medications and treatments. She said that made it very difficult to know where to document information. Interview on 10/23/10 at 9:50 a.m. with the Administrator, he was asked how he monitored his staff to ensure they were providing care to the residents. He said the company had a lot of check lists and procedures to follow. He said the Nursing Department had a "Start Up" meeting where they addressed issues or concerns from the previous day. He said all the managers had assigned rooms to check for Quality of Life issues. He said a form was used to ask residents questions. Then all this information was brought to the "Stand Up" meeting with all the department heads. Then at the end of the day they had a "Stand Down" meeting to see if all the concerns were addressed. Reports of these meetings were sent to corporate headquarters. He said the DON had a validation check list that she completed, he reviewed, that was then sent to the Corporate Nurse Consultant, and then sent to headquarters. He said identified issues were taken to the QA committee monthly. He said at the meeting they had specific guidelines they had to go over. He said nursing department had specific items that they were responsible for, such as pressure ulcers, medications, and quality indicators. He said there were 13 to 16 different sections that had to be covered that also involved the Social Worker and Activities. He said he also looked at complaint issues. He said if anything was identified, then an Action Plan would be developed. The Administrator said he was a "hands on" administrator. So he assigned himself a section so he could see the care the residents were receiving first hand. When the Administrator was asked where he thought the system failed, he said he thought it was the new software they had just gone to. He said it was not printing out the MAR correctly. When he was asked if he thought that was why the nurses were not documenting giving insulin and FSBS, he said that was the ADON's responsibility to monitor the MAR and TARs for discrepancies. Interview on 10/24/10 at 10:55 a.m. with Case Mix Manager A, she said that sometimes she had to fill in for one of the ADONs if they were off. She said the duty of the ADON was to monitor care. She was asked how she would monitor care. She said she would look at the MAR and TARs for any omissions and to see that orders were being carried out. She said they had a "Start Up" meeting in the mornings to see if there were any new admissions, readmission, or medicare admissions. They would check the 24 hour book to see what had gone on during the night. Then they would get the copies of the orders from Medical Records to see what types of orders had been given. They would discuss all this and put any concerns on a sheet. Throughout the day, the ADONs would have to work on the list and make sure they were resolved. She said they would have a "Stand Up" meeting after the "Start Up" meeting that all the department heads attended. Then at the end of the day they had a "Stand Down" meeting where the ADONs would tell the DON what had been done to correct issues on the sheet they got that morning. She said besides that, the ADONs were responsible for checking the MARs and TARs and for what else was going on in the unit. She said the monthly orders were divided up between the managing nurses to check for accuracy. On 10/22/10 at 11:08 a.m. the Administrator was informed that an immediate jeopardy situation existed in the areas of not ensuring the accurate dispensing of insulin, failure to inform Physicians of high and low BS levels, to have parameters for high and low BS levels, to follow Physician orders [REDACTED]. A plan of removal was submitted by the facility on 10/22/10 at 12:30 p.m. The Plan to Lift IJ was accepted on 10/22/10 at 4:00 p.m. and included the following: 1. The DNS, Nurse Consultant, and Nurse Managers will complete a 100% audit of all insulin dependent diabetic residents to identify other at risk residents by 10/22/10. 2. The DNS and Nurse Managers will contact the residents ' attending physicians to inform them of any sliding scale coverage not administered, per physician orders, or recorded; any clarification orders from physician will be taken and completed by 10/22/10. 3. The DNS and Nurse Managers will complete Med Error Reports on all insulin that was not given by 10/22/10. 4. The DNS and Nurse Consultant will in-service the licensed nursing staff on proper and accurate dispensing of insulin by 10/22/10. 5. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on following physician orders [REDACTED]. 6. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on documenting blood sugar levels and administration of insulin by 10/22/10. 7. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff, with return demonstration, on performing finger stick blood sugars according to the manufacture ' s recommendation by 10/22/10. 8. The DNS, Nurse Consultant, and Nurse Managers will in-service the licensed nursing staff on contacting the residents ' attending physician to address high and low blood sugars by 10/22/10. 9. The DNS, Nurse Consultant, and Nurse Managers will monitor MARs to ensure accurate dispensing, documentation and physician notification of abnormal blood sugar, per physician orders, q shifts over the next 72 hours to ensure compliance. 10. The DNS, Nurse Consultant, and Nurse Managers, through direct observation, will monitor the licensed nursing staff to ensure finger stick blood sugars are being performed, according to the manufacture ' s recommendation, q shifts over the next 72 hours to ensure compliance. 11. The facility will conduct an off cycle QA & A Committee meeting to review the current policies and procedures to ensure an effective system in place to address high and low blood sugars by 10/22/10. On 10/23/10 the facility was monitored and several residents did not have either high or low BS parameters on their MARs, residents did not get FSBS on Unit 2, residents had low blood sugars that were not recorded or reported to the physician. The IJ was not lifted. During an interview on 10/23/10 at 9:00 a.m., LVN Y stated the last time she was in-serviced was yesterday (10/22) and they told her about sliding scale insulin, protocols, and what to do. During an interview on 10/23/10 at 9:01 a.m., LVN F stated the last time she was in-serviced was yesterday (10/22) and they told her about FSBS and sliding scale insulin. She stated she had to return demonstrate a FSBS and discussed documentation and when to call the doctor. On 10/24/10 the facility was monitored. The corporate nurse continued to observe licensed nurses in acquiring FSBS. Documentation of FSBS and insulin being given improved. Parameters for high and low BS levels were on the MARs. Monitoring for these items continued. While the IJ was removed on 10/24/10 at 10:25 a.m., the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of pattern, because additional staff needed to be trained and the facility had not yet had time to evaluate and monitor the effectiveness of their training. The facility listed 39 residents on insulin and FSBS. Refer to CMS 2567 F309 and 425 for further information.