Every finding on record at Avir at The Lakes

Based on observation, interview and record review, the facility failed to ensure services provided by the facility as outlined in the comprehensive care plan met professional standards of quality for one resident (Resident # 10) observed for hand rolls for contracture management. --facility failed to ensure handrolls were placed for Resident #10 for contracture management by following physician orders. This failure could place residents at risk of not receiving care according to physician orders.Record review of Resident #10's face sheet revealed admission date 12/8/23 with diagnoses including Hypoxic Ischemic Encephalopathy (brain injury caused by interruption in blood flow to the brain), tracheostomy (opening into the windpipe to establish an airway), hypertension (high blood pressure), respiratory failure (not enough oxygen or too much carbon dioxide in the body), tachycardia (fast heart rate), stiffness of joint, anoxic brain damage (brain is completely deprived of oxygen and blood flow), cardiac arrest (heart stops beating, cutting off blood flow to brain and body), dysphagia (difficulty swallowing). Record review of Resident #10's care plan, initiated 12/12/23, revised 9/11/24, revealed ADL self-care performance deficit in all ADLs; therapy to screen, evaluate, and treat as needed. Record review of Resident #10s Annual MDS revealed dependent on staff for all ADLs, impairment on both sides, always incontinent, feeding tube while a resident, oxygen therapy, suctioning, tracheostomy care while a resident, respiratory therapy 7 days, splint/brace assistance 0 days. Record review of Resident #10s baseline care plan dated 12/8/23 revealed total dependence on staff for ADLs, incontinent, tracheostomy, oxygen, and enteral feedings. Record review of physicians' orders dated 11/4/25 revealed OT to address BUE hand rolls for contracture management 6 hours or as tolerated 5 days a week. Record review of Occupational Therapy evaluation and plan of treatment, certification period 10/13/25 - 11/12/25 revealed: patient will tolerate BUE hand roll splints for 3 - 5 hours for contracture management. Recommendation was for splint/orthotic: hand rolls BUE. Observations of Resident #10 on 12/1/25 at 11:55am, 12/2/25 at 9:45am and 12/3/25 at 9:30am revealed she was in bed, sleeping, with tracheostomy, feeding tube infusing Jevity 1.5 at 55ml/hr., oxygen concentrator at bedside and suction machine on bedside table. Resident #10s hands were contracted, and there were no hand rolls present for contracture management. Interview with LVN A on 12/3/25 at 9:30am revealed the Restorative aide puts the hand rolls in Resident #10s hands and removes them. Interview with Occupational Therapist on 12/3/25 at 9:40 am revealed she would put the handrolls in Resident #10's hands when she came in to work around 8am in the morning and removed them when she left for the day around 3pm. Interview with Rehab Director A on 12/3/25 at 9:45am revealed resident #10 was on therapy services until 11/12/25, and OT placed the hand rolls in her hands when they came to work and removed them when they left for the day. She said when her therapy service was discontinued 11/12/25, the nurses were supposed to put the hand rolls in her hands for at least 6 hours daily. Interview with ADON on 12/3/25 at 9:50am revealed she said she would write an order for the nurses to place the hand rolls for Resident #10. She looked in all the drawers and cabinets in resident #10s room and did not find any hand rolls but obtained 2 washcloths from the Laundry to use as hand rolls and would have therapy roll them for use with Resident #10. Interview with DON on 12/4/25 at 8:40am revealed she was aware of the issue with hand rolls for Resident #10. She said when Resident #10 was on therapy service, hand rolls were placed by therapy, but when therapy was discontinued, the order went away. She further said, as of yesterday, she now has an order for hand rolls up to 12 hours daily, placed by the nurses, and nurses remove them and assess her hands for any skin breakdown. She said the previous order was for 6 hours a day because therapy placed them on and removed them, since therapy staff were not here all day. Since the nurses are here 24 hours a day, they can place them and remove them. Record review of facility policy Following Physician Orders, dated 9/28/2001, revealed, in part, .carry out and implement physician orders.

Based on observation, interview and record review, the facility failed to ensure a resident with limited range fo motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #10) of 5 residents reviewed for range of motion. The facility failed to ensure handrolls were placed for Resident #10 for contracture management. This failure placed resident at risk of impaired skin integrity, further decline and decrease in quality of life and quality of care. Record review of Resident #10's face sheet revealed admission date 12/8/23 with diagnoses including Hypoxic Ischemic Encephalopathy (brain injury caused by interruption in blood flow to the brain), tracheostomy (opening into the windpipe to establish an airway), hypertension (high blood pressure), respiratory failure (not enough oxygen or too much carbon dioxide in the body), tachycardia (fast heart rate), stiffness of joint, anoxic brain damage (brain is completely deprived of oxygen and blood flow), cardiac arrest (heart stops beating, cutting off blood flow to brain and body), dysphagia (difficulty swallowing). Record review of Resident #10s Annual MDS dated [DATE] revealed dependent on staff for all ADLs, had impairment on both sides and had splint/brace assistance 0 days.Record review of Resident #10's baseline care plan dated 12/8/23 revealed total dependence on staff for all ADLs. Record review of Resident #10's care plan, initiated 12/12/23, revised 9/11/24, revealed ADL self-care performance deficit in all ADLs; therapy to screen, evaluate, and treat as needed. Record review of the physician's orders dated 11/4/25 revealed OT to address BUE hand rolls for contracture management 6 hours or as tolerated 5 days a week. Record review of the Occupational Therapy evaluation and plan of treatment, certification period 10/13/25 - 11/12/25 revealed: patient will tolerate BUE hand roll splints for 3 - 5 hours for contracture management. Recommendation was for splint/orthotic: hand rolls BUE. Observations of Resident #10 on 12/1/25 at 11:15am, 12/2/25 at 9:45am and 12/3/25 at 9:30am revealed she was in bed, sleeping. Resident #10's hands were contracted, and there were no hand rolls present. Interview with LVN A on 12/3/25 at 9:30am revealed restorative aides would put the hand rolls in Resident #10's hands and removed them. Interview with the Occupational Therapist on 12/3/25 at 9:40 am revealed she would put the handrolls in Resident #10's hands when she came in to work in the morning around 8am and removed them when she left for the day around 4pm. Interview with Rehab Director A on 12/3/25 at 9:45am revealed Resident #10 was on therapy services until 11/12/25, and OT placed the hand rolls in her hands when they came to work and removed them when they left for the day. She said when her therapy service was discontinued on 11/12/25, the nurses were supposed to put the hand rolls in her hands for at least 6 hours daily. Interview and observation with the ADON on 12/3/25 at 9:50am revealed she said she would write an order for the nurses to place the hand rolls for Resident #10. She looked in all the drawers and cabinets in Resident #10's room and did not find any hand rolls but obtained 2 washcloths from the laundry to use as hand rolls and would have therapy roll them for use with Resident #10. Interview with the DON on 12/4/25 at 8:40am revealed she was told of the issue with the hand rolls for Resident #10. She said when Resident #10 was on therapy services, hand rolls were placed by therapy, but when therapy was discontinued, the order went away. She further said as of yesterday, she now had an order for hand rolls up to 12 hours, placed by the nurses, and nurses removed them and assessed Resident #10's hands for any skin breakdown. She said the previous order was for 6 hours a day because therapy placed them on and removed them since therapy staff were not at the facility all day. The DON stated since the nurses were here 24 hours, they could place them and remove them. Record review of facility policy Following Physician Orders, dated 9/28/2001, revealed, in part, .carry out and implement physician orders.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication rooms. The facility failed to ensure expired mediations were removed from all medication fridges.This failure could place residents at risk of receiving medications that are not at their intended potency and potential adverse reactions or side effects. Findings included:Record review of Resident #46's face sheet dated 12/2/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Muscular Dystrophy, Unspecified (disease that causes progressive weakness and degeneration of the skeletal muscles). Record review of Resident #46's quarterly MDS dated [DATE], section C revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #46's Order Summary Report with active orders as of 12/2/25 revealed no current active orders for Acetylcysteine. Record review of Resident #46's April 2025 MAR revealed the last Acetylcysteine administration documentation for shortness of breath as needed was on 4/21/2025 at 6 p.m.Record Review of In-Service Program Attendance Record dated 12/2/2025 revealed topics including checking for expired drugs on cart and fridge daily, insulin syringes and bottles must be dated at the time they are taken out of the fridge, nurses must discard medication as directed on the bottle or syringe not by the expiration date, and a resident's name must be written on insulin pen and dated if taken from the E-KIT. Observation on 12/2/25 at 10:23 a.m. of the Station 1 Medication Room revealed one Acetylcysteine 20% Solution 30 ml bottle for Resident #46 that had an open date of 1/31/25 written on the label. There was a note on the Acetylcysteine label that said, Good for 96 hours. During interview on 12/2/25 at 10:23 a.m., the ADON said Resident #46 was not taking the Acetylcysteine anymore and he always refused to take the Acetylcysteine and took it only as needed. The ADON said she would dispose of the Acetylcysteine. The ADON said an effect it could have on residents regarding expired medications in the medication refrigerator was that it could be a medication error. The ADON said the nurses were supposed to check the medication refrigerator every day and the ADON said she also checked the medication fridge.During interview on 12/3/25 at 11:40 a.m., the DON said expired medication would not give the full effect of the medication because it may not have been as potent. The DON said the charge nurse and medication aides, whoever administered the medication checked the medication fridges for the medications they were giving. The DON said once a month the pharmacist checked the medication carts and medication fridges for expired medications. The DON said the ADON oversaw that the nurses and medication aides had checked the medication fridges for expired medications. During interview on 12/4/2025 at 8:40 a.m., the Consultant Pharmacist said she had been going to the facility for about three years and came to the facility once a month. The Consultant Pharmacist said she did not notice the Acetylcysteine in the medication refrigerator, or she would have notified the facility. The Consultant Pharmacist said Acetylcysteine was only good for 96 hours once it is opened. The Consultant Pharmacist said the efficacy of the Acetylcysteine would decrease but would not hurt the resident if administered. The Consultant Pharmacist said she checked one medication room, and she did spot checks when she checked the refrigerator. The Consultant Pharmacist said she did teachings based on what she saw when she was at the facility. Record review of the facility's policy Medication Storage with date implemented 1/20/2021 revealed medications rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications.

Based on observation, interview, and record review the facility failed to ensure medications were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts observed. The facility failed to ensure all insulins were labeled with a resident name and an open date. This failure could place residents at risk of receiving medications that were not ordered for them, receiving medications that are not at their intended potency, and potential adverse reactions or side effects. Findings included:Resident #22Record review of Resident #22's face sheet dated 12/2/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without Complications. Record review of Resident #22's quarterly MDS dated [DATE], section C revealed a BIMS score of 15 that indicated cognition was intact. Section N revealed insulin injections were received four of the last 7 days prior the MDS completion. Record review of Resident #22's Order Summary Report with active orders as of 12/2/25 revealed orders for Tresiba FlexTouch Subcutaneous Solution Pen injector (Insulin Degludec) with instructions to inject 20 units subcutaneously (under the skin) in the morning with start date of 3/1/24. Resident #43Record review of Resident #43's face sheet dated 12/2/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (stroke), Unspecified and Type 2 Diabetes Mellitus (high blood sugar) without Complications. Record review of Resident #43's quarterly MDS dated [DATE], section C revealed a BIMS score of 3 that indicated severe cognitive impairment. Section N revealed insulin injections were received 7 of the last 7 days prior the MDS completion.Record review of Resident #43's Order Summary Report with active orders as of 12/2/25 revealed orders for Insulin Aspart and Protamine and Aspart Flex Pen 70/30 with sliding scale orders with start date of 2/1/25. Resident #50Record review of Resident #50's face sheet dated 12/2/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Unspecified Asthma (chronic lung disease that causes difficulty breathing) with Status Asthmaticus (severe and potentially life-threatening asthma attack) and Type 2 Diabetes Mellitus (high blood sugar) without Complications. Record review of Resident #50's admission MDS dated [DATE], section C revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #43's Order Summary Report with active orders as of 12/2/25 revealed orders for Insulin Glargine Solostar Subcutaneous Solution Pen injector with instructions to inject 6 units subcutaneously (under the skin) every 12 hours with start date of 11/24/25. Resident #43 also had order for Insulin Lispro Pen injector with instructions per sliding scale with start date of 11/24/25. Resident #66Record review of Resident #66's face sheet dated 12/2/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar). Record review of Resident #66's quarterly MDS dated [DATE], section C revealed a BIMS score of 13 that indicated cognition was intact (13-15). Record review of Resident #66's Order Summary Report with active orders as of 12/2/25 revealed Insulin Glargine Solution with instructions to inject 10 units subcutaneously (under the skin) at bedtime with start date of 10/24/25. Resident #43 also had orders for Novolog Solution (Insulin Aspart) with instructions to inject 5 unit subcutaneously (under the skin) with meals for diabetes and to hold for blood sugar less than 200 with start date of 9/4/25.Record Review of In-Service Program Attendance Record dated 12/2/2025 revealed topics including checking for expired drugs on cart and fridge daily, insulin syringes and bottles must be dated at the time they are taken out of the fridge, nurses must discard medication as directed on the bottle or syringe not by the expiration date, and a resident's name must be written on insulin pen and dated if taken from the E-KIT. Observation of Station 2 nurse medication cart on 12/2/25 at 10:44 a.m. revealed one Insulin Aspart Flex Pen had an open date of 10/30/25 and no resident name. The following insulins were found with no open date documented: one vial of Lantus 100 u/ml and two Humalog KwikPens for Resident #50; one vial of Insulin Glargine 100 u/ml and two Insulin Aspart FlexPens for Resident #66; one Insulin Degludec Flex Touch pen for Resident #22; and one Insulin Aspart Protamine and insulin Aspart 70/30 mix Flex Touch pen for Resident #43. During interview on 12/2/25 at 11:04 a.m., LVN A said insulins were supposed to be documented with an open date as soon as they were opened. LVN A said the insulins from the Station 2 Nurse medication cart that did not have an open date documented were administered by the night nurse, but she should have checked them as well. LVN A said Resident #66's blood sugars had been running low, so she had not been getting insulin. LVN A said an effect it could have on the residents if the insulins did not have an open date was that it could be bad because the insulins could be old if they had been out too long. LVN A said she would have to get new insulins and would throw out of all the unlabeled and undated insulins. LVN A said they had in-services on everything but could not remember the last time there was an in-service on insulin.During interview on 12/3/25 at 11:40 a.m., the DON said expired medication would not give the full effect of the medication because it may not have been as potent. The DON said the charge nurse and medication aides, whoever administered the medication checked their carts for expired medications for the medications they were giving. The DON said once a month the pharmacist checked the medication carts for expired medications. The DON said the ADON oversaw that the nurses and medication aides had checked the medication carts for expired medications. The DON said if no name was on the medication, then it could be given to the wrong person and if the medication was expired then the medication could be less effect for treating their diabetes. The DON said the nurses were responsible for checking that insulins were labeled with resident names and open dates and the ADON was responsible for overseeing this was done. During interview on 12/3/25 at 2:12 p.m., the ADON said the nurse who pulled the insulin out of the fridge was responsible for making sure the insulin was labeled with the resident's name and with the open date. The ADON said the insulin was good for 28 days when it came out of the fridge. The ADON said if insulin was not labeled with a resident name or open date it could make a medication error as it could cause harm. The ADON said she checked the medication carts for expired medications, discontinued medications, and dates for medications when they were opened. The ADON said she checked the medication carts once a week or biweekly. The ADON said when she had seen insulins on the medication carts that did not have resident labels or open dates she educated the nurse. The ADON said the pharmacist also checked the medication carts and they come every month. During interview on 12/4/2025 at 8:40 a.m., the Consultant Pharmacist said she had been going to the facility for about three years and came to the facility once a month. The Consultant Pharmacist said insulin should be stored in the refrigerator until it is opened. The Consultant Pharmacist said the insulins should be dated when they were pulled out of the refrigerator. The Consultant Pharmacist said if insulin was not labeled with the resident name, then the wrong resident could get the wrong insulin or the resident could not be getting what they were supposed to be getting. The Consultant Pharmacist said insulin could be out of the refrigerator for 90 days and be fine but if the insulin is out long enough then the insulin might not be as effective. The Consultant Pharmacist said all insulins should have a resident's name. The Consultant Pharmacist said she picked two medication carts random to check during her visits. The Consultant Pharmacist said when she checked the medication carts she checked for expired medications, that medications have open dates and that medications were labeled. The Consultant Pharmacist said she did teachings based on what she saw when she was at the facility. Record review of the facility's policy Insulin Pen Administration reviewed 2/10/2020 revealed insulin pens should be assigned to one patient and labeled appropriately.Record review of the facility's policy Medication Storage with date implemented 1/20/2021 revealed medication carts are routine inspected for discontinued, outdated, defective, or deteriorated medications.

Based on observations and interviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 4 rooms (Room D1, D5, D6, & D9) of 7 rooms reviewed for privacy. The facility failed to provide full privacy for residents in rooms (D1, D5, D6, & D9) These failures could place residents in these room at risk of being expose, embarrassed and loss of dignity.Findings included: Room D1Observation and interview on 12/01/25 at 11:40AM, revealed Room D1 occupied by 2 residents and had no full visual privacy curtains. Observation revealed both residents were not interview able the privacy curtain was on the rail between A & B bed. An attempt was made to ensure that the privacy around the bed but would extend to cover residents on both residentsObservation indicated the resident in A bed was sleeping and did not answer any question. The resident in B bed asked if this was an investigation. He said he would not answer questions. Room D5Observation and attempted interview on 12/01/25 at 11:50AM, revealed Room D5 was occupied by 2 residents and had no full visual privacy curtain. Observation revealed the privacy visual cotton was by the A bed. AN attempt to pull the privacy curtain ended halfway at A bed exposing A bed. An attempt was made to have an interview with both residents. The resident in B bed was not interview able. He answered questions by moving his head up and down. The resident in A bed looked and smiled without speaking. Room D6Observation on 12/01/2024 and attempted interview on 12/01/25 at 11:50AM, revealed Room D6 was occupied by 2 residents and had no full visual privacy curtain. Observation revealed the privacy visual curtain was by A bed. An attempt to pull the privacy curtain across the bed failed. The privacy curtain was half and would only go halfway on the rail and was at the foot of the bed. Observation indicated both residents were out of the room. Room D 9 Observation on 12/01/25 at 1:140PM, revealed Room D9 was occupied by 2 residents and had no full visual privacy curtain. Observation revealed the visual privacy curtain was between the A & B beds, was half and could only cover part of the B bed. Both residents were out of their room. During an interview and observation on 12/02/25 at 10:00PM revealed CNA S and CNA T pulled the privacy curtain in room D9. CNA T said she did not notice the curtain. She said she usually closed the door during patient care and did not pay any attention to the curtains because people always knocked on the door and would not come in. CNA S did not answer if residents in B Bed open the door. Interview on 12/02/25 at 11:30 AM with LVN H revealed residents needed their privacy for dignity reasons. The curtain provided them with a sense of having their own space. She said she had not paid any attention to the privacy curtains. Interview on 12/02/25 at 1:43 AM with CNA I revealed she had not noticed the privacy curtains, She said she usually closed the door. Interview on 12/0225 at 3:00Pm, the Administrator said all residents should have their privacy curtains for their dignity. She stated she would have asked the Maintenance Director to ensure that all rooms were inspected for full visual privacy curtains. She said all staff need education on residents' privacy and ensuring that all privacy curtains go round the bed to provide privacy and dignity. A policy on residents' privacy and dignity was requested on 12/02/25 from the facility. Interview on 12/03/25 at 10:00am, the facility Administrator said the facility did not have policy specific to privacy curtains.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 assessment accurately reflected the resident's status for 2 (Residents #2 & #48) of 6 residents reviewed for PASRR Level 1 screenings. Findings included: Review of Resident #2's face sheet, dated 12 /02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Cerebral infraction- (Lack of blood to certain parts of the brain) Schizoaffective disorder, Essential hypertension (High blood Pressure), depression, generalized anxiety disorder, restlessness and agitation. Record review of Resident #2's PASRR Level 1 Screening completed on 07/03/24 revealed the section on mental illness was checked as 0 which indicated Resident #2 did not have any mental illness. Record review of Resident #2's annual MDS assessment dated [DATE] indicated her BIMS score was 11 out of 15 which indicated she was moderate on cognition. Record review of Resident #2's clinical record revealed no evidence of a PASRR level 2 evaluation. Resident #48 Record review of Resident #48's face sheet dated 12/03/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses of Undifferentiated Schizophrenia (hallucinations, delusions, disorganized thinking), bipolar disorder (extreme shifts in mood, hopelessness and manic highs), Major Depression, Hemiplegia (complete paralysis of one side of the body) and Hemiparesis (weakness on one side of the body)following Cerebral Infraction (stroke), Bradycardia (slow heart rate), and Cognitive Communication(mental processes- like attention, memory etc ). Record review of Resident #48's annual MDS assessment, dated 9/23/25, revealed the BIMS score was six out of fifteen, indicating she had significant cognitive impairment. Record review of Resident #48's PASRR Level 1 screening completed on 11/05/2024 revealed the section on mental illness was checked 0 (zero) which indicated Resident #48 did not have any mental illness. Record review of Resident #48's clinical record revealed no evidence of a PASRR Level 2 evaluation. During an interview with the DON on 12/03/25 at 2:40PM she said the MDS staff was responsible for completing all PASRR related evaluations. In an interview on12/04/25 at 10:00AM The MDS Coordinator said she was not present at the facility during the time of Resident #2's admission and assessment. She said she would go over the resident's diagnoses and would review all admitting paperwork to ensure that her assessment accurately reflected the resident's condition. She said if the PASRR was inaccurately coded she would complete a new 1012 form which was the Mental illness\Dementia Resident Review and upload that form into a program called SIMPLE which would alert the PASRR program to schedule an evaluation. She said she would complete a 1012 form for all identified residents Review of the Texas Health and Human Services Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form, revised June 2023, and accessed at PASRR Forms and Instructions | Texas Health and Human Services reflected in part, The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD). Developmental disabilities are also referred to as related conditions.If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, or DD, a PASRR Evaluation (PE) must be completed to confirm PASRR eligibility. The PE is designed to confirm the suspicion of MI, ID or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning.Examples of MI diagnoses are: Schizophrenia Mood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder) Paranoid Disorder, Severe Anxiety Disorder, Schizoaffective Disorder, Post-Traumatic Stress Syndrome, What is not considered an MI: Neurocognitive Disorders, such as Alzheimer's disease, other types of dementia, Parkinson's disease, and Huntington's. (DSM-5*), Depression, unless diagnosed as Major Depression; and Anxiety, unless diagnosed as severe anxiety disorder.Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 18 residents (Resident #7, Resident #20 and Resident #22) reviewed for accurate assessments. Residents #7, #20 #22 were inaccurately coded on their MDS assessment.These failures could place residents at risk of not receiving care and services necessary for their physical, mental, and psychosocial well-being. The findings included:Resident #7 Record review of Resident #7's face sheet dated 12/03/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), heart disease, essential (primary) hypertension (High blood), type 2 diabetes mellitus with diabetic neuropath (nerve damage that can happen with diabetes) arthritis (inflammation of the joints), pain, anxiety and major depressive disorder, bipolar disorder and major depressive disorder. Record review of Resident #7's Annual MDS assessment dated [DATE] revealed he had a BIMS score of 15 which indicated intact cognition. The section on nutritional approaches was coded as receiving a mechanically altered diet. The section on oral\dental status, revealed he was coded as 0 which indicated no problem (all natural teeth intact). Record review of Resident #7's care plan dated 09/01/2019 revised 12/03/25 indicated Resident #7 was care planned on his oral cavity as edentulous which indicated no natural teeth. Observation and interview on 12/01/2025 at 2:00PM, revealed Resident #7 was in bed alert and oriented. Observation indicated had no teeth in his oral cavity. During an interview he said he had full dentures and they were somewhere in his nightstand. He said he did not use the dentures because they didn't fit and he did not care too much about his dentures. He said he are what he could and left what he could not eat. Resident #20 Record review of Resident #20's face sheet dated 12/02/25 revealed -[AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, heart disease, essential (primary) hypertension (High blood), type 2 diabetes mellitus with diabetic neuropath (nerve damage that can happen with diabetes) arthritis (inflammation of the joints), anxiety and major depressive disorder, cognitive communication deficit (difficulty in communication), and abnormalities of gait and mobility. Record review of Resident #20's Annual MDS assessment dated [DATE] indicated she had a BIMS score of 15 which indicated that she was cognitively intact. The section on nutritional approaches, revealed she was coded as receiving a mechanically altered diet. The section on oral\dental status, revealed she was coded as 0 which indicated no problem (all natural teeth intact). Record review of Resident #20's care plan dated 01/14/19 with revision date of 09/10/2024 and target date of 10/10/25 revealed Resident #20 had likely carious, and missing teeth which placed her at risk for pain and infection. Date Initiated: 01/14/2019 Revision on: 11/15/2019. Observation and interview on 12/03/25 at 2:10PM, revealed she was served mechanical altered diet. During an interview, Resident #20 said she had no natural teeth and no dentures. She said she was alright with her oral cavity. She said she could eat what she wanted and left what she did not want. Resident #22 Record review of Resident #22's face sheet dated 12/2/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without Complications, Heart diseases, generalized anxiety disorder, hepatitis C and chronic pain. Record review of Resident #22's Annual MDS assessment dated [DATE] indicated he had a BIMS score of 14 which indicated that he was cognitively intact. The section on nutritional approaches, revealed he was coded as receiving a mechanically altered diet. The section on oral\dental status, revealed she was coded as 0 which indicated no problem with her oral cavity (all natural teeth intact). Record review of Resident #22's care plan dated 04/01/22 revised 09/25/24 with a target date of 10/20/25 revealed Resident #22 was care planned for weight gain - Resident #22 has unplanned/unexpected weight gain. Date Initiated: 04/01/2022, Revision on: 04/01/2022. Goal-Resident #22 will not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through the next review date. Date Initiated: 04/01/2022, Revision on: 09/25/2024, Target Date: 10/20/2025. During an interview with the MDS Coordinator on 12/03/25 at 3:00PM, she said she started working at the facility about 3 weeks ago. She said all MDS assessments should reflect the resident's condition and status. She said inaccurate assessment may prevent a resident from receiving needed services and care to manage their health. During an interview with the DON and ADON on 12/04/25 at 2:50PM, the DON said residents' assessment should reflect the resident's condition and an inaccurate assessment may delay services. She said her expectation was to ensure that residents were assessed accurately. Record review of Policy on MDS assessment dated [DATE] updated 01/10/21 revealed -Anticipated Outcome -Residents are assessed, using a comprehensive process, in order to identify care needs and to develop an interdisciplinary [NAME] plan

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of (Resident #22) 18residents reviewed for comprehensive care plan. The facility failed to review and revise Resident #22's comprehensive person-centered care plan to accurately reflect his weight loss. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.Findings Included Record review of Resident #22's face sheet dated 12/2/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without Complications, Heart diseases, generalized anxiety disorder, hepatitis C and chronic pain. Record review of Resident #22's Annual MDS assessment dated [DATE] indicated he had a BIMS score of 14 which indicated that he was cognitively intact. The section on nutritional approaches, he was coded as receiving a mechanically altered diet. The section on oral\dental status, she was coded as 0 which indicated no problem (all natural teeth intact). Record review of Resident #22's care plan dated 04/01/22 revised 09/25/24 with a target date of 10/20/25 revealed he was planned for weight gain [Resident #22] has unplanned/unexpected weight gain. Date Initiated: 04/01/2022, Revision on: 04/01/2022. Goal-Resident #22 will not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through the next review date. Date Initiated: 04/01/2022, Revision on: 09/25/2024, Target Date: 10/20/2025. Intervention: RD to evaluate and make diet/supplement change recommendations PRN. Provide diet counseling. Date Initiated: 04/01/2022 Monitor and record food intake at each meal. Date Initiated: 04/01/2022 Revision on: 11/12/2024 Monitor report to MD PRN situations leading to increased food consumption, reasons for weight gain, significant wt. changes.Date Initiated: 04/01/2022 Notify MD if: Increasing shortness of breath; escalating edema; increased anxiety; inability to lie flat; change in baseline level of orientation/alertness. Record review of Resident #22's RD assessment dated [DATE] Revealed Hx inadequate oral intake that has improved r/t effects of cancer/cancer chemo tx as evidenced by inconsistent intake. some meals, hx altered taste/taste changes, hx significant wt loss x90-180 days w/ stabilized wt. x30-45 days. Risk for malnutrition, further unplanned wt loss &/or hydration deficit due to effects of cancer & chemo tx. Observation on 12/01/25 at 8:50AM revealed Resident #22 was in bed; he was alert and oriented. In an interview, he said he was not doing well. He said he felt weak and just wanted to sleep. Observation and interview on 12/01/25 at 1:40PM, was observed sitting up in bed. He said he did not eat lunch. He said he was not hungry. He pointed to his snacks and said he would drink his liquid protein and some snacks. Observation and interview on 12/02/25 at 8:30AM revealed Resident #22 had his breakfast and eat 80% of served meal. Observation indicated he had two teeth in his oral cavity. He said he used to have partial dentures, but he no longer had them for a while, and he are what he could when he was hungry. He said he was aware of his weight loss. He said his weight loss was due to his chemotherapy treatment for his cancer. He explained that he took chemo treatment once a month. He said the chemo usually took away his appetite till it was time for the next treatment. He said he had nutritional supplements. During an interview with the MDS Coordinator on 12/03/25 at 3:00PM, she said she started working at the facility about 3 weeks ago. She said she would start reviewing the residents' care plans and make changes as needed. During an interview with the DON and ADON on 12/04/25 at 2:50PM, the DON said care plan revisions and updates were the responsibility of the interdisciplinary team and the acute care plan could be updated by any nurse. She said the care plan should be updated to reflect the resident's condition for better quality of care and services. She said not updating the care plan may prevent residents from receiving necessary care and services needed to improve their quality of life. Record review of Facility's provided policy dated 2021 with a revision date of revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.1. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:a. The attending physician.b. A nurse with knowledge of the resident.c. A member of the food and nutrition services staff.d. The resident and the resident's representative, to the extent practicable.e. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: 1. The RAI Coordinator.11. Activities Director/Staff.111. Social Services Director/Social Worker. 1v. Licensed therapists. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.7.The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (CR #1) reviewed for accidents and supervision. - The facility failed to ensure CR #1 had adequate supervision to prevent an accident on 11/4/25 which resulted in a witnessed fall with injury (Acute right subdural hygroma [a collection of cerebrospinal fluid on the right side of the brain beneath the brain's dura mater [the tough, outermost layer that protects the brain and spinal cord]), which resulted in rehospitalization. - The facility failed to ensure 2 staff members remained at bedside during ADL care. This noncompliance was identified as Past Non-Compliance. The IJ began on 11/4/25 and ended on 11/5/25. The facility corrected the noncompliance before the survey began. These failures have the potential to place residents at risk for falls which can lead to actual harm.Findings include: Record review of CR #1's admission Record dated 11/20/2025 revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of focal traumatic brain injury with loss of consciousness (a brain injury at a specific site of the brain that causes a loss of awareness, which can be caused by a jolt to the head, leading to the brain moving within the skull), pneumonia (an infection of the lungs that causes the air sacs to fill with fluid or pus, leading to symptoms like cough, fever, chills and difficulty breathing), unspecified fracture of skull (broken skull), unspecified fracture of facial bones (broken facial bones), diffuse traumatic brain injury with loss of consciousness (a type of traumatic brain injury caused by shearing forces that tear axons [long thin fibers that transmit signals within the brain] in the brain, leading to widespread microscopic damage and loss of consciousness), traumatic brain compression without herniation (a condition where a head injury causes brain swelling or bleeding that compresses brain tissue, but the brain does not push through or herniate through the openings in the skull) and tracheostomy status (a surgical procedure that creates an opening in the neck to insert a breathing tube into the wind pipe [trachea]). Record review of CR #1's admission Minimum Data Set, dated [DATE] revealed he was coded as persistent vegetative state/no discernible consciousness and was coded, yes, totally dependent on at least 2 staff members for ADL care including bed mobility/roll left to right and bathing. Record review of CR #1's baseline care plan dated 10/24/2025 revealed CR #1 was coded under Functional ADLS/Mobility as Total Dependence for bed mobility and bathing. CR #1 was also coded under Safety . The Resident has the following Risk Factors for Falls.Paralysis and Severe Weakness/deconditioning. With a Goal that read in part. Resident will not sustain a fall related injury by utilizing fall precautions through next review date. Record review of CR #1's admission fall risk assessment dated [DATE] revealed he scored a 10 indicating he was at moderate risk for falls. Record review of CR #1's Hospital B discharge orders dated 10/22/2025 revealed no orders for a helmet. Record review of CR #1's admission physician orders dated 10/22/2025 revealed no orders for a helmet. Record review of facility incident and accident report log with a date range of 09/01/2025 through 11/20/2025 revealed CR #1 had a witnessed fall on 11/4/2025 at 4:00pm. Record review of CR #1's incident and accident report dated 11/4/25 at 4:00 pm revealed the following documentation by LVN A: .called to the resident room by CNA. Nurse entered the room observed the resident on the floor laying supine (lying on one's back with face upward), between the bed and wall, trach (tracheostomy) remained in place. The CNA states the resident was overturned and (sic)begin to slide off the bed with forehead leaned against the wall. Another CNA entered the resident room and observed the resident sliding off the bed and assisting the resident to the floor. Head-to-toe assessment complete. Red area noted to right side of forehead. Record review of CR #1's ER hospital A record dated 11/4/25 revealed CT of the head concerning for a right frontoparietal convexity [Refers to the outer convex having an outline or curved surface like the exterior of a circle] surface of the brain located where the frontal and parietal [top of the brain] lobes meet] collection suspicious for seroma [collection of clear fluid] or hygroma [fluid-filled sac or cyst that develops in soft tissue, often over a bony prominence due to repeated trauma or pressure] as well as moderate mass effect with an 8mm right to left midline shift and a large left frontoparietal craniectomy .unclear if seroma/hygroma is new or unchanged in size. Therefore, will initiate discussion/transfer to site of patient's previous care at [Hospital B]. Record review of CR #1's Hospital B CT Scan results dated 11/6/2025 revealed the following: Impression: Increased size of right convexity [Refers to the outer convex having an outline or curved surface like the exterior of a circle] subdural [situated or occurring under the tough outer membrane that covers the brain] collection containing only gas with increased right to left midline shift . Record review of CR#1's neurologist progress notes from Hospital B dated 11/7/25 revealed, [CR#1] is being evaluated for neurosurgery after falling from his bed. s/p craniectomy. It appears point of contact was right forehead. No bone flap left side. Observation of CR #1 at Hospital B on 11/19/2025 at 1:22pm which included bedside interview with Hospital RN who said 11/19/2025 was her first day working with the resident. She said CR#1 was non-verbal and non-communicative so far, and he readmitted to the hospital after sustaining a fall at a nursing home. Upon entering the resident's room, there was sign posted on his door that read NPO, Central Line and L NO Bone Flap. Hospital RN said he originally admitted to that facility after an MVA 8/22/25 and had a craniotomy where the left side of his head was left open with no skull bone and remains that way, hence the sign on the door. She said the left side of his head is just skin and no bone, so they are very careful when turning and repositioning him and they use 2 people. CR #1 was observed in a specialized electric bed with at least 3 large pillows surrounding his head and he was not wearing a helmet. Hospital RN said S/P surgery CR#1 went to a SNF and readmitted because of a fall at the SNF but she was not aware of any additional injuries as a result of the fall. CR #1 opened his eyes but did not respond to any commands and the right side of his head and forehead had no visible external injury, bump, or bruising. CR #1 had a full head of dark curly hair, with no visible scars or markings apparent on the sides and front of his face or skull. The Hospital RN said she had just been to the bedside within the last 15 minutes and performed trach care and was reluctant to move the resident again at that time. She said in the hospital, any helmet used would only be worn while a patient was out of bed and they did not use it while a patient was in the bed for just turning and repositioning. She said he did not have an order for a helmet at that time and had a diagnosis of sepsis upon admission and respiratory cultures were pending. Interview with family member on 11/19/25 at 11:40 am who said they advised the facility that CR #1 was to wear a helmet on his head whenever turning or repositioning even in bed due to his bone flap, craniectomy, and brain surgery history. Interview on 11/20/25 at 12:58 pm with Administrator and DON. DON said that CR #1 had fallen, but it was a change in plane because he was assisted to the floor. The DON said CNA A and CNA B were giving CR #1 a bed bath and while CR #1 was rolled to one side facing the wall CNA A was at the bedside and had rolled CR #1 to the side while CNA B went to the room door to get clean linens and CR #1 began to slide into the wall and between the bed and the wall. CNA B ran back and was able to assist CR #1 to the floor. LVN A was called to assess the resident, and it was reported that CR #1 had a reddened area to the right side of his head with no swelling just redness. LVN A then notified CR#1's NP who advised to monitor CR #1 hourly and report any additional changes. LVN A then notified RP who wanted CR #1 sent to the hospital for scans and diagnostic studies, so LVN A called NP back who advised to send CR #1 to ED. The DON said she completed in-service training with all staff after the incident on 11/5/25 and completed 1:1 in-service training with CNA B after the incident on 11/5/25, but CNA A self-terminated because she never returned to work at the facility but had completed training prior to the incident. DON said she spoke with hospital staff who advised CR #1 had no injury but CR#1's family wanted him sent back to hospital B where he had his original brain surgery. DON said CR #1 was a 2 person assist with all care. The DON said there was a helmet with CR #1's belongings but there was no discussion with family or NP/MD about use of the helmet and no MD order for use of the helmet. Interview with Administrator on 11/20/25 at 1:10pm she said they did a PIP/QAPI after the incident on 11/5/25 with CR #1 and staff had been retrained and in-serviced on 2-person ADL care, Hoyer lifts and they audited the witnessed falls and all residents that required 2-person ADL care with no adverse findings. The Administrator said CNA A never returned to work and had been removed as an employee at the facility. Interview with LVN A on 11/20/25 at 5:25pm she said she had been alerted by CNA B that CR #1 was assisted to the floor after they provided a bed bath for CR #1 and CNA B stepped away to get linens and CNA A rolled CR #1 to his side and CR #1 kept rolling into the wall and slid between the bed and the wall bumping or rubbing the right side of his forehead on the wall. LVN A said CR #1 had a helmet but did not wear it and there were no MD orders for the helmet that she could recall. LVN A said she notified NP who gave orders to monitor CR #1 but after speaking with CR #1's family they wanted CR #1 to have a CT scan and or X-rays, so she called NP back and was given the order to send CR #1 to the ER. LVN A said she was never provided with any update on CR #1 's status and if he had sustained any additional injuries from the fall. LVN A said they and all the nurses and CNAs were trained again by the DON after CR #1 had the fall, on 11/5/25. LVN A said they were all in-serviced on 2-person ADL care on 11/5/25 and how 2 staff are to remain at the bedside at all times during care on 11/5/25 and if items are needed or forgotten, to use the call light or they can leave the resident in a safe position and return to perform care with 2 people present on 11/5/25. Interview with LVN B on 11/20/2025 at 12:05pm who said she worked with CR #1 but was not working at the time of the incident. LVN B said the day after the incident they were all trained and clarified it was all the CNAs and nurses regarding 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex [a specific type of care plan for CNA and direct care staff to review what type of care a resident required] for resident care and following MD orders, abuse, neglect, exploitation, and 2-person transfers. LVN B said CR #1 was totally dependent for care and required 2 people for ADL care. She said there had been additional training the day after the incident on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN B said it was unfortunate that CR#1 bumped his head and said it would not have happened if both CNAs had remained at the bedside. Interview with CNA B on 11/22/25 at 11:56 am who said that CR #1 had a known head injury and was a 2 person assist with his care. CNA B said that they were the one who left the bedside to retrieve the linens and CR #1 was lying flat on his back on the bed while CNA A remained at the bedside. CNA B said she did not know why CNA A rolled CR #1 to his side but believed CNA A was probably just trying to take soiled linens out from underneath CR #1 in preparation to change the linens and may have thought it safe to just roll CR #1 to his side. CNA B said that CR #1's forehead was the only spot that was pressed against the wall when she came back, and she positioned herself between CR #1 and the wall and assisted CR#1 to the floor. CNA B said that CR#1 never actually hit his head, but it was pressed against the wall and that CR #1 had a red mark towards the right side of his forehead after the incident, but no bump or swelling at that time. CNA B said they were in-serviced specifically by DON after the incident on 11/5/25 and had been trained prior to and after the incident, to stop care if items were needed and make sure the resident was always safe and had 2 people present at the bedside at all times during ADL care on 11/5/25. CNA B also said they could use the call light and ask for additional assistance instead of leaving the bedside on 11/5/25. Attempts to reach CNA A via telephone on 11/20/25 at 3:48pm, and 11/22/25 at 10:47am and again at 1:08pm were unsuccessful. Interview with NP on 11/24/25 at 10:10am who said that CR#1 had no hospital discharge orders or instructions for a helmet. NP said helmets were usually used on residents with out of bed activities or when a resident would be up and out of bed. NP said helmets were not usually used while a resident was in bed and would not be something that a resident would keep wearing 24 hours a day because it could lead to skin breakdown and other issues. NP also said there was not an indication the use of a helmet while CR #1 was at the facility because he was immobile during his admission. NP said it was unfortunate that the two CNAs did not remain at the bedside at all times during the bed bath of CR #1 so as to avoid or prevent an accident like what happened to CR #1, but said she would be surprised if CR #1 had any significant injury after the incident and thought the results from Hospital A actually only reported the same injury CR #1 already admitted to the facility with. NP said that CR #1 was immobile and would have most likely required 2 staff for ADL care. In a telephone interview with Medical Director and CR #1's attending physician on 11/24/2025 at 2:53 pm he said that he had been made aware of CR #1's fall back on 11/4/2025 and actively participated in the Ad Hoc QAPI and direct care staff training on 11/5/2025, the day after the incident. He said CR #1 had no orders from the hospital or neurosurgeon for a helmet to be used and there was no indication for the use of a helmet while the resident was in bed because he was immobile and helmets were used mostly for activity out of the bed to prevent any potential injury. He said CR #1 was dependent and immobile so he would most likely require 2-staff for ADL care. The Medical Director said he had no privileges at Hospital B and had not received any updated reports on CR #1's condition directly but the facility DON had followed up with Hospital A after the fall and was given a report by Hospital A staff that CR #1 was being sent back to Hospital B because he had his original brain surgery there and CR #1's family had requested he be sent back to the original hospital. The Medical Director said he believed CR #1 had no new injury and would be surprised if there had been any significant change in CR#1's status or prognosis post incident. The Medical Director said he felt like the facility handled the incident post fall appropriately and put appropriate interventions and training in place to prevent any type of similar accident from occurring. In an interview with CNA C on 11/20/2025 at 4:00pm, she said she had been trained on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan. She said she had been trained upon hire and again at the beginning of November. In an interview with CNA D on 11/20/2025 at 4:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA E on 11/24/2025 at 12:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competence upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA F on 11/24/2025 at 2:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA G on 11/24/2025 at 2:15 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. Interview with LVN C on 11/24/2025 at 3:05pm who said she never worked with CR #1 but was trained and in-serviced after the incident. LVN C said the day after the incident all direct care staff had been trained on 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex for resident care and following MD orders, ANE and 2-person transfers. She said there was also training on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN C said if a resident required the assistance of 2 staff for ADL care that should be followed so accidents did not happen, and residents did not get hurt. Interview with LVN D on 11/24/2025 at 4:18pm she said she was not familiar with and had never worked with CR #1 but had been trained on 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex for resident care and following MD orders, ANE and 2-person transfers. She said there was also training on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN D said that CNA staff can find out what type of care a resident requires from the Kardex/care plan including mobility, transfers and bathing and if the order and Kardex said they required the assistance of 2 staff, then 2 people need to perform the care together at all times. The DON was provided the PNC IJ template on 11/22/2025 at 2:44 pm. A Plan of Removal was not requested. The non-compliance began on 11/4/2025 and ended on 11/5/2025. The facility had corrected the non-compliance before the investigation began. Observations on 11/19/2025, 11/22/2025 and 11/24/25 of facility direct care staff providing incontinent care which required side-to-side rolling of residents, and bed baths on 3 separate residents who required 2 staff assistance with ADL care including bed mobility and bed baths. The following interventions were implemented prior to surveyor entrance and surveyor confirmed Past Noncompliance. 1. CR # 1 was immediately assessed and sent to ED as ordered.2. 1:1 in-service training given to CNA B 11/4/2025 on 2 person ADL care including bed mobility, bed baths and bathing and following resident Kardex/care plan at all times while providing care. 3. Facility notified RP, MD, Administrator, DON, Ombudsman, and facility Medical Director4. An Ad Hoc QAPI was conducted to review CR #1's fall and facility 2 person ADL care and fall prevention protocols.5. In-serviced all direct care staff on ANE, 2 person ADL care including bed mobility and bed baths as well as 2 person Hoyer lift transfers and following resident care plans/Kardex at all times. Ensuring all supplies at bedside and what to do if additional assistance is required during care to ensure 2 people remain at bedside. An ad-Hoc QAPI meeting was held on 11/5/2025 with the following addressed:1. Incident/accidents-falls reviewed; specifically, CR #1's incident.2. Staff in-servicing continued for all direct care staff on providing 2-person ADL care, fall prevention, following resident care plans and Kardex. 3. Completed an audit of all residents with witnessed falls on 11/5/2025 with no findings of injuries or need for 2-person assistance. 4. The facility completed an audit of residents that required 2-person assistance with ADL's on 11/5/2025 with no adverse findings. 5. CNA A no longer works at the facility. Record review on 11/19/2025 at 6:40 pm of 1:1 in-service training given to CNA B 11/4/2025 on 2 person ADL care including bed mobility, bed baths and bathing and following resident Kardex/care plan at all times while providing care.Record review on 11/19/2025 at 6:52 pm of all direct care staff in-serviced on ANE, 2 person ADL care including bed mobility and bed baths as well as 2 person Hoyer lift transfers and following resident care plans/Kardex at all times. Ensuring all supplies at bedside and what to do if additional assistance is required during care to ensure 2 people remain at bedside. Record review on 11/19/2025 at 6:58 pm of facility audits of all residents with witnessed falls who required 2-person assistance on 11/5/2025 which revealed a total of 3 residents including CR #1 with other findings for the other 2 residents who had no findings of injuries or any adverse outcomes.Record review on 11/19/2025 at 7:03 pm of facility completed audit of residents that required 2-person assistance with ADL's on 11/5/2025 with no adverse findings related to the residents that required 2-person staff assistance with ADLs. Record review of personnel file for CNA A revealed she had been terminated after not returning to work, No call, No show on 11/5/2025. Continued record review of time report for CNA A revealed the last date she worked was 11/4/2025. Record review of facility incident and accident report log with a date range of 09/01/2025 through 11/20/2025 revealed there had been no witnessed falls since CR #1's incident in 11/4/2025. Record review of the facility policy and procedure titled Clinical Practice Guideline Activities of Daily Living dated 11/23/2016 read in part: Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.based on residents needs provide the amount of staff assistance/support and remain with resident during ADL care.

Based on observation, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 2 of 6 (Resident #3 and Resident #5) residents reviewed for ADL care. The facility failed to provide Resident #3 & Resident #5 showers as scheduled. This failure could place residents who are dependent on staff for ADL care at risk for loss of dignity, and a decreased quality of life. Findings included : Record review of Resident #3's Face Sheet revealed a [AGE] year-old male who was admitted to the facility since 5/15/23 with a diagnoses of Osteomyelitis Vertebra (rare spinal infection that causes weakness and/or numbness in the arms or legs, incontinence of bowels and/or bladder), Paraplegia (paralysis that affects legs), Muscle weakness, Type 2 diabetes (body doesn't use insulin properly), Hypertension (pressure of your blood in your arteries is too high), chronic obstructive pulmonary disease (COPD) (lung disease that makes it difficult to breath). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] reflected resident has a BIMS score of 15, which indicated the resident was cognitively intact . The MDS reflected Resident #3 was totally dependent on staff and needed assistance in doing all of her showering, toileting hygiene, upper body dressing, lower body dressing and personal hygiene. Record review of Resident #3's Care Plan revised 10/3/24, reflected, Resident is at risk for PSWB (Partial Weight Bearing) ADL Assistance required for bathing-need limited assist during bathing. Resident will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Record review of Resident #5's Face Sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of cardiorespiratory conditions (heart and lung disease), hypertension (pressure of your blood in your arteries is too high), diabetes (body doesn't use insulin properly), non-Alzheimer's dementia (dementia not caused by Alzheimer disease). Record review of Resident #5's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated the resident was cognitively intact . The MDS reflected Resident #5 had impairment on both sides of his lower extremity (hip, knee, ankle, foot) who used a wheelchair; and totally dependent on staff for shower/bathing, and partially dependent (staff does less than half of the effort and is there to support resident by holding limbs and lifting resident) on staff for person hygiene areas such as, washing face and shaving. Record review of Resident #5's Care Plan dated 8/12/20, reflected resident should be provided with simple choices with ADL care and encourage participation; resident is a 1 person assist and should be bathed MWF per residents' preference. Record review of shower/bath documentation for the months of October 2024 and November 2024, show Resident #3 & Resident #5 have received their showers/bed baths on the 2pm - 10pm shift. It did not show any refusal of services. In an interview on 11/25/2024 at 1:37pm Resident #1 stated residents were not being showered and had been told that there weren't enough staff. He stated, residents that got showers on the 2pm - 10pm shift have it bad. He stated some residents have gone weeks without a shower or bed bath. He stated CNAs will mark it down like they've given showers when they haven't. He stated a lot of residents that cannot talk for themselves hardly gets there showers. He stated he is independent and can shower himself. In an interview on 11/26/2024 at 9:46am Resident #2 stated she had her showers. She stated she is very outspoken and demand her showers even though she is Bed B. However, she stated there are not a lot of people on Bed B that get their showers. She stated residents that have an Intellectual Disability (below average intelligence) and can't speak for themselves, they are not getting their showers as they should. The Bed B showers are given on the 2pm-10pm shift. Staff are always saying they are short of hand and unable to give showers, which is not true. She stated the staff are just not doing their jobs and the charge nurses aren't making them or holding them accountable. In an interview on 11/26/2024 at 11:21am Resident#3 stated staff are not available for showers on the 2pm - 10pm shift, which is when he is scheduled for showers. Resident #3 stated he does not need anyone to wash him up while in the shower; however, because his legs are unsteady, there must be a staff member available just in case the need for assistance arises (he falls). Resident #3 stated he is always told there are no staff available. He stated he is Bed B and his showers are on the 2pm -10pm shift. He stated a lot of times there are only two people working, the CMA and CNA and there aren't a lot of workers to give showers. He also stated the last time he had a shower was two weeks ago. He stated he just does a wash-up in the bathroom sink. In an interview on 11/26/2024 at 11:30am Resident #4 stated he gets his shower because he is Bed A and the 6am-2pm shift staff gets him his. He stated his roommate, Resident #3, complains about getting his shower all the time. His roommate is Bed B and there is hardly any staff available to give him his showers or they just won't. In an interview on 11/26/2024 at 11:35am CNA A stated she would shower a Bed B resident if she had a shower refusal from a resident in Bed A. She stated she has heard complaints from a lot of residents on Bed B about not getting their showers on the 2p - 10p shift. In an interview on 11/26/24 at 11:45am with Resident #5, she stated she has not received a bed bath in over 2 weeks and can't remember the last time she's had a shower. She stated she has continuously asked about a shower and has been told that the facility is shorthanded or there isn't anyone to help her . A review of the shower sheets indicated the resident had a shower; however, the resident denied this. In an interview on 11/26/24 at 11:55am with Resident #6, she stated she does not have any issues. She stated she gets her showers because she is Bed A. She stated her roommate, Resident #5, hasn't had a shower in over a month. She stated on one occasion she witnessed Resident #6 asking CNA staff for a shower and being told there isn't enough staff and there isn't a shower tech available cause the last one either quit or got fired. In an interview on 11/26/24 at 3:45pm with CNA B she stated she typically works the 10p-6a shift. She stated she believes the residents are not getting their showers on 2p-10p shift because Bed B residents are always complaining about not getting it when she works. When asked if she had spoken with a charge nurse or the DON about the complaints, she stated she had not. She stated she worked the 2p-10p shift on overtime only and didn't want to cause any problems. She stated when she viewed the ADL's it appeared that residents on Bed B had their showers, but there are a lot of complaints. In an interview on 11/26/24 at 6:00pm with the DON, she stated showers for some beds (Bed A) are completed on the 6 am-2pm shift and other beds (Bed B) 2pm-10pm shift. She stated in the past there were some complaints, but recently she has not received any complaints. She stated not having a shower or bed bath in days, weeks or months is not accepted. Based on the task completed in Task Section of Point Click Care (the computer documentation for staff to use indicating if residents were given a shower, refused a shower and if the CAN noticed any issues with resident skin or any other changes in condition), it appears Resident#3 and Resident#5 received their showers and/or bed baths during the week. A resident should receive their ADL's when scheduled per week. It is unacceptable for a resident not to either be given a bed bath or offered one. In an interview on 11/26/24 at 7:00pm with Administrator she stated all residents should have their bed bath and showers or other ADL's completed by staff as scheduled. It is unacceptable when they don't. She stated she has not been informed that staff on certain shifts are not giving showers. She stated it is unacceptable and if she had known this issue would have been addressed. She stated the quality-of-life policy addresses the facility's position on self-esteem. Review of the Quality-of-Life Policy dated 1/10/2022, #reflected, The facility will create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem. On 11/26/2024, reviewed facility grievances for the past 3 months and no formal complaints related to ADL care. Review of the Bathing Policy dated 3/1/14 and reviewed 2/10/2020 reflected, purpose is to cleanse skin, prevent infection and promote circulation 2 times or more weekly or as patient requires.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that left over food items in the walk-in cooler, were properly sealed, and labele with opened, expiration date. This failure could affect the residents who received meals from the kitchen and could place them at risk for foodborne illness. Findings included: Observation of the facility's only kitchen on [DATE] at 8:24AM revealed one of one walk in cooler in the kitchen had the following food items unlabeled and undated. All food items were identified by the Dietary Manager. -,d+[DATE] left over cake unlabeled and undated -Can sliced apples in a plastic container partially covered. -Food items in a grocery bag unlabeled and undated. The Dietary Manager said it was a TV Dinner and it belonged to a resident. -An unidentified food product in a grocery bag. The Dietary Manager said she does not know what it was. -Left over salad in a Ziplock bag. -Flour tortillas identified as [NAME] by the dietary manager. -3 and ,d+[DATE] gallons of chocolate milk with the manufacture date of use before [DATE]. During an interview with the Dietary Manager on [DATE] at 10:00AM, she said all left over food items and food products out of the original containers are to be labeled and dated. She said serving expired milk to residents may lead to food borne illness and she would not use it. During an interview with the facility administrator on [DATE] at 3:00Pm. She said she expected all food items in the walk-in freezer and refrigerator to be labeled and dated. She said the dietary department was a vending company. Record review of the policy titled Frozen and refrigerated food storage dated ,d+[DATE] review [DATE] read in part, Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. Most pick stickers do have the delivery date on the sticker. They must also be dated with an expiration date unless they have one from the manufacturer ( that is milk cartons, eggs)

Based on observation, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 3 (Residents # 42, #66, and #44) of 3 residents reviewed for resident rights in that- -The facility failed to grant Residents # 42 and #66 the opportunity be with each other. -The facility failed to allow Resident #44 the right to remain in her room as she desires. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: Resident #42 Record review of Resident #42's face sheet, dated 09/10/24, reflected a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses Essential hypertension (high blood pressure), type 2 diabetes mellitus with anxiety disorder, major depressive disorder, lack of coordination, and muscle weakness. Record review of Resident #42's face sheet revealed he was his own responsible party. Record review of Resident #42's annual MDS assessment dated [DATE] revealed he had a BIMS score of 15, which indicated his cognition was intact. On ADL care he was coded as limited assistant. Record review of Resident # 42's care plan dated 01/23/24 with a revision date of 04/15/24 revealed, Resident #42 had Consensual sexual activities with another resident. Goal: Resident will respect their sexual partner and obtain consent each time prior to engaging in sexual relations through the next review date. Date Initiated: 01/23/2024 Revision on: 09/05/2024. Interventions: -Staff will give support and understanding of Resident # 42's right to have relationships/special friendships with whom he desires. o Ensure both residents are their own responsible party and have not been deemed incapacitated by a physician. o Sexual assessment to be completed by clinical nurse and social worker. Date Initiated: 01/23/2024. o Ensure that the sexual relations are consensual and document the findings in the medical record of both residents. Consent means both residents decide together to do the same thing, at the same time, in the same way, with each other. o Sexual education to be provided. -Educate the resident on the risks associated with sexual relations such as sexually transmitted diseases and pregnancy. -Encourage the resident to discuss their sexual history with their potential partner prior to becoming sexually active. o Provide a private, non-confrontational environment for the two residents. o Make condoms available for the residents to use if they so desire. o Notify the resident's physician of any signs/symptoms of an STD: Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Blindness, essential (primary) hypertension, PTSD, mood disorder, cognitive communication, obesity, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66's face sheet revealed she was her own responsible party. Record review of Resident #66's annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which indicated her cognition was intact. On ADL care she was coded as limited assistant. Record review of Resident #66's Care plan dated 01/23/23 revealed Resident # 66 was care planed as- Resident #66 engages in voluntary consensual sexual activities with another resident. Date Initiated: 01/23/2024 Revision on: 04/15/2024. Goal: Resident #66 will respect their sexual partner and obtain consent each time prior to engaging in sexual relations through the next review date. Date Initiated: 01/23/2024 Target Date: 01/12/2025. Intervention: o Ensure both residents are their own responsible party and have not been deemed incapacitated by a physician. Date Initiated: 01/23/2024. o Sexual assessment to be completed. o Ensure that the sexual relations are consensual and document the findings in the medical record of both residents. Consent means both residents decide together to do the same thing, at the same time, in the same way, with each other. Date Initiated: 01/23/2024. o Sexual education to be provided. -Educate the resident on the risks associated with sexual relations such as sexually, transmitted diseases and pregnancy. -Encourage the resident to discuss their sexual history with their potential partner prior to becoming sexually active. Date Initiated: 01/23/2024. o Psychological Services as ordered. Date Initiated: 01/23/2024. o Provide a private, non-confrontational environment for the two residents. Date Initiated: 01/23/2024. o Make condoms available for the residents to use if they so desire. Date Initiated: 01/23/2024. o Notify the resident's physician of any signs/symptoms of an STD. Resident #44 Record review of Resident #44's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential hypertension, anxiety disorder, depression, pain, cognitive communication deficit, and muscle weakness, Record review of Resident #44's annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which her cognition was intact. On ADL care she was coded as limited\minimum assistant. Observation and interview on 09/09/24 at 2:00PM, revealed Resident #44 smoking together with Residents #42 and #66. Resident #66 introduced Resident #42 as her boyfriend, and they had been together for a long time. During an interview, Resident #66 said Resident # 44 (roommate to Resident #66) had to leave her room when he visits Residents #66 which is not right. He said they have been asking to put them together in the same room for over a year and the only answer was Roommate of Resident # 66 can give them privacy if she wants to. Resident #66 said the facility does not provide privacy for the residents. Resident #42 said he does not feel comfortable for Resident #44 to leave her room so that Resident # 66 and Resident #42 can have a private time together. Observation and interview on 09/11/24 at 10:00AM, revealed Resident #44 was observed alone in her room. She said her roommate was moved on 09/10/24. During an interview with Facility administrator on 09/10/24 at 2:00PM, she said there was no room available for a male and female because all their rooms had jack and [NAME] bathroom and the facility was watching out for other residents' privacy as well. The Administrator said Resident #44 agreed to give Residents # 42 and #66 privacy for 2 hours. She said the facility had also offered to discharge Residents #42 and #66 to an assisted living facility that would accommodate both resident in a room together, but they refused. She said she would look to see if she could find a room for both residents. She said this had been going on before her time at the facility. Record review of facility's admission policy dated 02/23/16 revised 02/20/21 titled Resident Rights read in part The Facility shall protect and promote the rights of each Resident, including each of the following rights: The Resident has the right to a dignified existence, self-determination, communication with and access to, persons and services inside and outside the Facility. The Resident has a right to exercise his or her rights as a Resident of the Facility and as a citizen or resident of the United States. The Resident has the right to be free of interference, coercion, discrimination, or reprisal from the Facility in exercising his or her rights . The Resident has a right to choose activities schedules and health care consistent with his or her interests, assessments, and plans of care. The Resident has a right to participate in social, religious, and community activities that do not interfere with the rights of other Residents. The Resident has a right to reasonable accommodation of individual, needs and preferences except where the health or safety of the Resident or other Residents would be endangered.

Based on record review and interviews, the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 8 of 16 residents (CR #79, Residents #9, #33, #44, #66, #50, #75, #382) reviewed for electronic transmission of MDS data to the CMS system. 9The facility failed to complete and transmit CR 79, Residents #9, #33, #44, #66, #50, #75, #382 MDS assessment within 14 days of the ARD date. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted. Findings include: Resident #9 Record review of Resident #9's face sheet, dated 09/10/24, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Generalized abdominal pain, primary pulmonary hypertension, anxiety disorder, overactive bladder, muscle weakness, major depressive disorder, history of falling, muscle wasting, and atrophy. Record review of Resident #9's annual MDS assessment with ARD date of 05/16/24 was completed on 05/16/24 and transmitted on 6/12/24, 27 days after the ARD date. Resident #33 Record review of Resident #33's clinical record revealed admitted [DATE] with diagnoses including cerebral infarction (loss of oxygen in the brain), dysphagia (swallowing disorder), hemiplegia and hemiparesis (paralysis and weakness on one side of the body), Diabetes (inability of body to regulate blood sugar), Cirrhosis of liver (chronic liver damage causing liver failure), hypertension (high blood pressure), major depressive disorder (persistently depressed mood). Record review of Resident #33's Admission MDS with ARD target date of 4/8/24 was completed and transmitted 37 days late, on 5/15/24. Resident #44 Record review of Resident #44's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential hypertension, anxiety disorder, depression, pain, cognitive communication deficit (refer to difficulties in communication that result from impaired functioning of cognitive processes) and muscle weakness. Record review of Resident #44's annual MDS assessment with ARD date of 12/01/23 was completed on 01/12/24, 42 days after the ARD. Resident #50 Record review of Resident #50's clinical record revealed admitted [DATE] with diagnoses including cerebrovascular disease (condition affecting blood flow to the brain), bipolar disorder (mood swings from depressive lows to manic highs), anxiety disorder (worry, fear, anxiety affecting daily life), aphasia (language disorder), dysarthria (speech disorder), hemiplegia (paralysis on one side of the body). Record review of Resident #50's Annual MDS with ARD date of 3/29/24 was completed 5/10/24 and transmitted 5/13/24 42 days after the ARD date. Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension, PTSD , mood disorder, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66's annual MDS assessment with ARD date of 11/21/23 was completed on 12/11/23 and transmitted on 12/12/23, 20 days after the ARD date. Resident #75 Record review of Resident #75's clinical record revealed admitted [DATE] with diagnoses including hypertension (high blood pressure), cerebral infarction (stroke), dysphagia (swallowing problem), diabetes (inability of body to regulate blood sugar), chronic kidney disease (longstanding kidney disease causing kidney failure), hemiplegia (paralysis on one side of the body, aphasia (language disorder). Record review of Resident #75's admission MDS with ARD date of 6/27/24 was completed and transmitted 17 days late on 7/15/24. CR #79 Record review of CR #79's Face Sheet dated 09/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included senile degeneration of brain (is the mental deterioration and loss of intellectual ability), diabetes, major depressive disorder, kidney failure, and anxiety. Record review of CR #79's clinical records revealed the last MDS assessment on his clinical record was dated ARD of 07/14/24 and was coded as death in facility. The MDS was completed 07/22/24 and was submitted 08/01/24, 18 days after the ARD. Resident #382 Record review of Resident 382's clinical chart revealed admitted [DATE] with diagnoses including anoxic brain damage (death of brain cells after 4 minutes of lack of oxygen to the brain), heart failure (failure of heart to pump blood efficiently). Record review of Resident #382's Admission MDS with ARD date of 8/21/24 was completed 15 days late on 9/5/24 and transmitted 9/19/24. In an interview on 9/11/24 at 2:05 pm, the MDS nurse said the former MDS nurse passed away in February of this year, and corporate nurses were filling in until March when she took over the job. A PRN MDS nurse was hired to train her because she was not familiar with the job, and she started working with MDS assessments in April. She said she knew the MDS assessments were late, but she is working on getting them caught up and making them accurate for the residents. She said the risk of not submitting assessments on time would affect the residents' plan of care and receiving proper care. In an interview on 9/11/24 at 2:45 pm, the Administrator said the former MDS nurse passed away in February, and they have been trying to get the MDS assessments caught up. She said the risk of not having timely assessments would be improper care for the residents. Record review of the CMS RAI manual, Chapter 5, dated 2023 revealed in part, .the admission assessment RAP completion date can be no more than 14 days from the date of admission .for all other comprehensive MDS assessments, the RAP completion date may be no later than 14 days from ARD .discharge and re-entry records must be completed within 7 days of the event date . 26867

Based on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 3 of 16 residents (Residents #9, #42, #66) reviewed for dental services. The facility failed to provide proper routine dental care for Residents # 9, #42 and #66. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Resident #9 Record review of Resident #9 ' s face sheet, dated 09/10/24, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Generalized abdominal pain, primary pulmonary hypertension, anxiety disorder, overactive bladder, muscle weakness, major depressive disorder, history of falling, muscle wasting, and atrophy. Record review of Resident #9 ' s annual MDS assessment with ARD date of 05/16/24 revealed she was coded for a BIMS score of 15 which indicated she was cognitively intact. Record review of section L of the MDS oral dental section revealed she was assessed as having Obvious or likely cavity or broken natural teeth. Record review of Resident #9 ' s care plan dated 12/08/20 revealed Resident #9 was care planed as Resident #9 had likely carious teeth and is at risk for pain and infection. Goals: The resident will comply with mouth care at least daily through next review date Date Initiated: 12/08/2020, Revision on: 09/11/2024, Target Date: 06/12/2025. The resident will be free of infection, pain, or bleeding in the oral cavity through next review Date Intervention: Provide mouth care as per ADL personal hygiene. Monitor and report to MD PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), abscess, debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Inspect oral cavity during oral care and report changes to the nurse Administer medications as ordered. Monitor for side effects and effectiveness. Refer to dentist for evaluation and recommendations. Record review of Resident #9 ' s weight record from June through September revealed no significant weight loss. Observation and interview on 09/10/24 revealed Resident #9 was in bed alert and oriented. She said she was doing well. She said her teeth has been hurting her for sometimes. She said all her right-side hurts and she can only eat on the left side of her mouth. She said she had complained but nothing was done. She said she manage as much as she can. Observation revealed she was missing some of her teeth in her upper and lower cavity. She said she had also told her responsible party about her pain. She said she had not seen a dentist since her admission. Resident #42 Record review of Resident #42's face sheet, dated 09/10/24, reflected a [AGE] year-old male, who admitted to the facility on [DATE]. Her diagnoses included Essential hypertension (high blood pressure), type 2 diabetes mellitus with anxiety disorder, major depressive disorder, lack of coordination, and muscle weakness. Record review of Resident #42 ' s annual MDS assessment dated [DATE] revealed he had a BIMS score of 15, which indicated his cognition was intact. Record review of section L oral /dental section reflected he was coded as Obvious or likely cavity or broken natural teeth. Record review of Resident # 42 ' s care plan revealed. Resident #42 was care as Resident #42 has oral/dental health problems carious teeth / broken teeth r/t Poor oral hygiene Goal: Staff will provide oral care at least daily through next review date. Date Initiated: 11/26/2022 Revision on: 09/05/2024, Target Date: 02/28/2025 Resident will comply with mouth care at least daily through next review date Date Initiated: 11/26/2022, Revision on: 09/05/2024 Interventions: Provide mouth care as per ADL personal hygiene. Date Initiated: 11/26/2022 Monitor and report to MD PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Date Initiated: 11/26/2022. Inspect oral cavity during oral care and report changes to the nurse. Date Initiated: 11/26/2022 Observation and interview on 09/09/24 at 2:00PM, revealed Resident #42 was outside smoking with Resident #66 and #44. Observation revealed he had missing teeth on his lower and upper oral cavity. During an interview he said he has been asking to see a dentist, but no one would listen to him. He said he had told the Social Worker several times but she never came back to give him an answer.Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension, PTSD, mood disorder, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66 ' s annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which indicated her cognition was intact. Record review of section L of her oral/dental section revealed she was assessed as having obvious or likely cavity or broken natural teeth. Record review of Resident #66 ' s Care plan dated 01/23/23 revealed no evidence of care plan for her dental care. Observation and interview on 09/09/24 at 2:00PM, revealed Resident #66 was outside smoking with Resident #42 and #44. Observation revealed she had missing teeth. During an interview she said she has been asking to see a dentist, but no one would listen to her. She said she had expressed having pain in her gums and teeth, but it all falls on deaf ear ' . She said she had told the social worker several times that she had pain in her gum. She said she had not heard from her about her dental referral. Observation and interview with Resident # 66 on 09/09/24 at 1:30pm revealed Resident # 66 had missing teeth in her oral cavity. She said she was supposed to see a dentist but has not heard from the social worker and no one had discussed her dental issue since she complained of pain. She said she had loose teeth and pain when she shews on her right side. During an interview with the social worker on 09/10/24 at 3:00PM, she said she does not assess residents for their dental but would refer them to the dentist if they complained. She said there was no dentist that visit residents at the facility. She said had asked some to come but they would schedule but not show up. She said she remembered Resident #9 ' s responsible party had asked her in the past to refer Resident #9 to a dentist. She said she did not have any documentation. During an interview with MDS coordinator on 09/10/24 at 4:00PM, she said she did the assessment on resident ' s oral dental section and the social Worker did the referral. She said Resident ' s care areas are usually discussed during the care plan meeting and any acute care was done by the nurses. During an interview with the Facility ' s Administrator on 09/11/24 at 4:00Pm, she said the facility does not have a dentist that visits residents at the facility. She said some of the insurance providers had their own dentist that visit their residents and the facility is actively looking for a dentist who would visit residents on a regular basis. Policy on routine and emergency dental care services was requested but was not provided prior to exit on 09/11/24.

Based on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (Resident #57) reviewed for PASRR. -The facility failed to update the PASRR Level 1 forms for Resident #57 to indicate mental health illness. This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident #57's face sheet dated 09/11/2024 revealed that Resident # 57 is a 69 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 04/16/2024. Record review of the PASRR Level 1 Screening for Resident #57 dated for 03/29/2024 indicated no mental health illness. It was determined that resident was not eligible for PASRR specialized services because serious mental illness was not documented on admission, at the time of Resident 57 initial PASRR Level 1 Screening. Record review of Resident #57 care plan dated 09/10/2024 read in part Resident #57 uses psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression, generalized anxiety disorder, bipolar disorder. Observation and interview on 09/09/2024 at 10:00 AM, revealed Resident #57 lying in bed watching TV. She stated that she received her medications but did not know what medications she had been taking. Resident #57 denied receiving any services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview. Interview on 09/10/2024 at 2:00 PM, the Social Worker stated she was responsible for completing the PASRR. She confirmed that Resident #57' PASRR Level 1 on admission was negative for mental illness, The Social Worker stated that Resident #57 was diagnosed with bipolar disorder as of 04/16/2024. Social Worker stated that she did not know that she had to submit an updated PASSR Level 1 indicating that Resident #57 had an active diagnosis of bipolar disorder. The Social Worker stated that she had not received any training regarding PASRR. The Social Worker did not reveal how she monitored to ensure it PASRR Level 1 assessments were completed timely and accurately . She did not know why the referral had not been completed on 04/16/2024 and she said that it would be important for a resident to receive PASRR services if they qualified. The Social Worker said that the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be that the resident would not receive the necessary services qualified for. Record review of the facility's Resident Assessment-Coordination with PASRR Program policy dated implemented 06/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASRR.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen. The facility failed to clean the floor in the kitchen. The facility failed to maintain clean mop water in the kitchen. The facility failed to date and label covered bowls of food on serving tray. The facility failed to clean the serving trays used to serve and store covered bowls of food. The facility failed to change the grease in the deep fryer or keep the exterior sides of the deep fryer clean. The facility failed to ensure the only sink in the kitchen for employee handwashing was free from clutter and obstacles to ease staff use. The facility failed to ensure the only alcohol-based hand sanitizer dispenser was clean and functional for staff use. These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness. Findings: During an observation and interview on 6/4/24 at 11:40 am, the entire kitchen floor was stained and splattered with material and crumb like substances. There was a large black build up on the floor directly in front of the kitchen door. Continued observations of the entire kitchen floor revealed skid marks, footprints, crumbs, and residue all over the floor. Dietary Aide A was observed mopping the floor in the dishwashing room, who then quickly tried to remove a yellow bucket of dark blackish gray, turbid water. The yellow bucket had dark black streaks dripping along its sides and had black material crusted into the corners and crevices of the bucket. There was a mop sitting upright inside the water in the bucket. Dietary Aide A said that he was going to dump the water because they were about to serve lunch. He did not answer when asked when the mop water had been changed last. The grease in the deep fryer was opaque dark brown with food debris floating inside. The sides of the deep fryer were dirty with tan and white streaks down the sides. The wall on the left side of the deep fryer had globules of brown grease hanging from it. The wall directly behind the deep fryer had stained streaks of dried grey material streaming down the wall. There was one sink with an attached eye wash station, which was surrounded by clutter and difficult to access. There was a foot pedal operated wastebin directly underneath the sink that was covered by a food box with food debris inside the box. The paper towel dispenser located directly above the sink was hanging open with the roll of paper towel exposed. There was one wall mounted hand sanitizer dispenser that was hanging open with the inside covered in small black and brown particles and specks of unknown debris. There was no sanitizing solution inside the dispenser. There was a light-colored tray located at the bottom of a shelf that had oatmeal like crumbs on it and a large black speck of unknown origin. There were three black bowls with plastic covers on them that were undated or labeled that were still on the tray . In an interview with the Administrator on 6/4/24 at 12:08pm he said that they were physically in the kitchen 2-3 times per week but had not taken notice of anything wrong. The Administrator said that the dietary staff were contracted, and the contracting entity was responsible for training dietary staff. She said she believed the Dietary Manager had been trained . In an interview with the Dietary Manager on 6/4/24 at 12:20 pm she said she was just promoted from cook about a week ago after the previous Dietary Manager abruptly left. Follow up interview with the Dietary Manager on 6/4/24 at 1:05pm she said she was certified but not licensed as a Dietary Manager and had been in the position for the last 3 months. She was unable to provide kitchen cleaning schedules. When asked if she thought the kitchen was clean, she said yes. When asked if she thought the kitchen was sanitary, she said no. The Dietary Manager would not say how she thought the lack of sanitation in the kitchen could impact the residents, she repeated that she was new to her role. Interview with the Dietary Manager on 6/5/24 at 3:01 pm she said the kitchen was cleaned on 6/4/24 and they will continue to clean and that it looked better than when she first started. She said the kitchen was supposed to be cleaned daily. She said she had been trained by someone out of state through Company A for about 2 weeks. The Dietary Manager said she was not sure if she had discussed any cleanliness or santitation issues in the kitchen directly with the Administrator. Record review of undated Sanitation Standard Operating Procedures read as follows: The establishment must maintain daily records sufficient to document the implementation and monitoring of the Sanitation SOP's and any corrective action taken. Cleaning of facilities including floors, walls, and ceilings .Cleaning procedures .1. Debris is swept up and discarded. 2. Facilities are rinsed with potable water. 3. Facilities are cleaned with approved cleaner. 4. Facilities are rinsed with potable water. Cleaning of floors, ceilings, and walls is done at the end of each production day and when needed to maintain sanitary conditions. Establishment monitoring .The Team Captain performs daily organoleptic examination before operations begin 2. All equipment tables and other product contact surfaces are cleaned and sanitized throughout the day as needed to maintain sanitary conditions and protect the product. Record review of The Food and Drug Administration Codes August 2021, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated: . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen, and 1 of 1 food storage area reviewed for pests. 1. Rat\mice droppings were observed in the kitchen area between the deep fryer and the stove on 06/04/24. 2. A live roach was observed in the dry food storage room on 06/04/24. This deficient practice could place residents at risk of residing in an environment with pests and at risk for food borne illness. Findings included: Kitchen observation and interview on 06/04/24 at 12:00PM, revealed rat\mice droppings in the kitchen between the deep -fryer and the stove and mice\rat dropping in the closet identified by the dietary manage as the mop closet. Observation revealed multiple glue rat traps all around the kitchen. In an interview the Dietary Manager said there was a hole in the kitchen leading outside where rats were coming from at night. She said she did not see any, but some kitchen staff had reported seeing rats. She said the exterminator was present at the facility on 06/03/24 to spray the facility for rodents. Observation and interview of the dry goods storage room away from the main kitchen on 06/04/24 at 1:20PM, revealed a live roach under one of the two racks. Observation of the freezer identified as the activity's freezer revealed a dead roach in the freezer. In an interview the Dietary Manager said the exterminator does spray the facility and cannot get rid of the roaches. During an interview on 06/4/24 at 1:00 PM, the facility Administrator said the exterminator was called in on 06/03/24 to treat the facility because some of the staff reported seeing roaches, flies, and gnats around. She stated I am aware of pest control issues, and we have a pest control company that treat the facility once a month and at any time as needed. Record review of Facility's pest control invoice dated 06/03/24 revealed the facility was treated for German roaches target dish pit, electrical outlet, and wall void. Invoice dated 05/16/24 revealed the laundry room noted seeing German cockroaches, during my inspection of the laundry room, harborage was seen near the doorway. The kitchen had noted issue of German cockroaches, and small flies. Record review of facility's policy on pest control dated 01/10/2020 read in part It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Policy Explanation and Compliance Guidelines: 1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. 3. Facility will obtain services as indicated related to issue that may arise in between scheduled visits with the outside pest service and treat as indicated. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. 5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures as indicated i.e. dumpster area, etc.

Based on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (CR #1) of 4 residents reviewed for discharge requirements. 1. The facility failed to ensure CR #1 was provided a discharge in writing. 2. The facility failed to document a discharge summary in resident clinical record. This failure placed residents at risk of not receiving necessary care and services. Findings included: Record review of CR #1 electronic face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included Cerebral infraction (stroke- reduce blood supply to part of the brain), mood disorder, Schizoaffective disorder, Bipolar, and communicative deficit (lack of communication). Record review of CR #1 annual MDS assessment dated [DATE] revealed: Section on cognitive Patterns with a BIMS Score of 15 indicated his cognition was intact. Section GG Functional Abilities and Goals CR#1 required supervision with and assistant in Toileting and Dressing. Record review of CR#1's progress notes dated 10/23/23 at 1:43 p.m. read in part Discharge Planning/Discharge resident was discharged to a local group home , he was escorted out by the CNA via wheelchair. Resident was A&Ox3, stable, no concerns at time of discharge, medications, and personal belongings left with resident at time of discharge. Nursing. Record review of Social Services Note Text: dated 10/23/2023 at 12:15 p.m. CR #1will be discharging today to a local group home in . He will discharge with his personal belongings and a new wheelchair .he will use the group home's pharmacy of choice. CR #1 and his mother, are satisfied with the choice of group home . Record review of Social Services Note Text: dated 10/20/2023 at 4:54 p.m. Social Services has informed CR #1's RP about a facility or group home that may take CR #1. She has given the company's email and phone number in hopes they will connect to discuss payment, name, phone number, and address of the facility or group home. RP said CR #1 can only pay so much and that she was not able to assist him. She is aware that if he is unable to afford the place, he will be discharging Monday to her residence. Social Services. Record review of physician orders dated 10/20/23 revealed okay to discharge to home with personal belonging, current medication, home health for nursing, CNA' PT, OT, and high strength light weight wheelchair to assist in ADLs . Record review of Physician's assessment dated [DATE] read in part History of present Illness: [AGE] year-old male who is an LTC resident with a past medical history of significant for hyperlipidemia, schizophrenia, tobacco abuse, alcohol use disorder, with residual left hemiparesis, functional paraplegia, and behavior disorder, falls and recent, left wrist fracture, and recent lumbar osteomyelitis/diskitis L1-L2 completed antibiotics. Patient is seen today due to report that he was in an altercation and punched another resident twice in the chest. The other resident is doing and denies any pain or injury. Patient is reported to have been having more behavioral issues, yelling, and throwing things in his room. He is also seen today for discharge planning. Patient will be going home to be with his mom who is the responsable party. He will need home health SN/PT, OT and HHA. He will also need a wheelchair and bedside commode. Patient was uncooperative during this visit and will not provide any explanation for his behaviors. During an interview with the facility DON on 06/03/24 at 1100AM, she said discharge planning of the residents had to do with the Social Worker and the Social Worker would answer any question regarding discharges. During an interview with the facility's Social Worker on 06/03/23 at 2:00pm, she said she was told by the Administrator that CR # 1 needed to be discharged due to CR #1's behavior. She said in the past CR #1's behavior was managed by a reward system. She said CR #1 continued to hit other residents and throw things when he did not get his way. She said CR#1 was receiving psychiatric services from a local psych company. She said all she had for discharge planning was her notes and phone communication with the receiving facility. She said there was no formal discharge planning with the resident and the resident's RP. She said the resident's RP was from out of town and she wanted CR #1 to be discharged close to her home. She said CR #1 was discharged home with a wheelchair that she had ordered for CR #1 that he was using at the facility. She said she called the facility to follow up and the facility and CR # 1 said he was doing well. She said they did not provide the home health company that was contacted for continuity of care. During an interview with the Administrator on 06/04/24 at 2:00PM, she said she was not the Administrator at the facility at that time. Record review of facility's policy on admission, transfer, and discharge rights dated, 10/10/17 updated 02/20/2020 read in part: This facility complies with federal regulations to permit each resident to remain in the facility, and not transfer or discharge unless the following criteria is met. Fundamental Information I. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The transfer or discharge is appropriate because the president's health has improved sufficiently so the resident no longer needs the service provided by the facility. 3. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. 4. The health of individuals in the facility would otherwise be endangered. 5. Respite residents are discharged based upon the agreed length of stay and plan of care 6. The resident has foiled, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility or 7. The facility ceases to operate. Non-emergency discharge: 7 Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated. a. Document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident or other individuals.

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and safeguard against transmission of legionella and waterborne pathogens for 1 or 1 facility water systems. The facility failed to establish and provide documentation for a water management program as part of the infection control program. This failure could place residents at risk for Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems) and other waterborne pathogens. Findings included: Interview on 08/04/23 at 11:45am with the MS, he said the facility was equipped with backflow prevention devices to ensure separation of clean and dirty water. He said the facility does not have a water management program for the surveillance of waterborne pathogens. He said he does not know what legionella was and was not familiar with waterborne pathogens that could impact the residents. Interview on 08/04/2023 11:50am with the ADM, she said staff was not aware of the need for a water management program. She said that she would check with the county about water management and monitoring, but no internal management program. The ADM said she was not familiar with Legionella, but any type of infection could pose a risk to the resident population and will be addressed promptly. Interview on 08/04/2023 at 12:00pm with the DON, she said that she has heard of legionella bacteria , but not very familiar with it. She said there have been no cases of Legionnaires' disease in the facility to her knowledge. The DON said that she would educate herself and the team concerning symptoms of Legionella infection, but is certain that it could pose a health risk to an already vulnerable population. Record review of the facility's Infection Prevention and Control Program policy (04/12/2023) revealed the following: 16. Water management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program. Record review of Legionella Surveillance Policy (07/01/2023) revealed in relevant part: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. 2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. 5. Primary prevention strategies: a. Diagnostic testing b. Investigation for a facility source of Legionella, which may include culturing of a facility water for Legionella c. Physical controls d. Temperature controls

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan was not developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #69) reviewed for baseline care plan. Resident #69 did not have a baseline care plan. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings included: Record review of Resident #69's face sheet revealed admission to the facility on [DATE] and admitting diagnoses including: metabolic encephalopathy (dysfunction in the brain caused by chemical imbalance in the blood), heart failure (impaired ability of the heart to pump blood through body), cardiac arrest (temporary stopping of the heart), alcoholic cirrhosis of liver (scarring of the liver caused by excessive, prolonged alcohol consumption), stage 4 chronic kidney disease (last stage before kidney failure), acute respiratory failure (impaired ability to breathe). Record review of Resident #69's history and physical dated 06/03/2023 revealed an [AGE] year-old male evaluated for admission with management of heart attack (impaired blood flow to a portion of the heart), septic shock (severe response from immune system to an infection), new dialysis (kidney replacement therapy), heart failure, and cocaine/alcohol/tobacco use. Prior to admission, Resident #69 was placed on alcohol protocol and monitored for withdrawal from cocaine and alcohol use. Interview on 08/03/2023 at 1:30pm LVN T stated the facility unable to provide because a care plan because it was not competed. Interview on 08/03/2023 at 1:45pm RN J said the baseline care plan should be completed within 72 hours. She said it was important because it determined plan of care and also informed the resident and RP of what care was going to be provided. RN J stated failure to complete a baseline care plan can be harmful because there will not be a clear plan to communicate or determine what care a resident should have. RN J was unable to say why this resident did not have a care plan. Interview on 08/03/2023 at 2:50pm LVN T said the IDT team (MDS nurse, DON, ADON, SW, Dietary) comes up with a care plan and is responsible for updating the care plan. IDT meets daily, all work on their respective sections. They are currently going through care plans and correcting them. Care plans are behind because there are a lot of new staff, and they are trying to catch up and do the care plans properly. If anything is wrong or missing, any of the IDT team members can update it. LVN T was unable to say why Resident #69 did not have a care plan. Interview on 08/03/2023 at 3:33pm the ADM, stated nurses are responsible for completing the baseline care plan within 48 hours. She said the baseline care plan consists of eating, what resident's goals are, where they came from, current health needs, where they want to go. Failure to complete a baseline care plan can delay a resident's care or prevent the resident from getting appropriate treatment in a timely manner. The ADM said she does not know why Resident #69's baseline care plan was not completed, but it should have been completed within the first 48 hours of the resident being at the facility regardless of how long he was staying. Record review of the Baseline Care Plan Policy (last review 7/1/2023) revealed the following: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social services vi. PASSAR recommendation, if applicable 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate care, treatment, and services to prevent complications for one 1 (Residents #56) of 2 residents reviewed for tube feedings. Resident # 56 was fed hot dog meal for lunch PO diet while he was on NPO from hospital. An Immediate Jeopardy (IJ) was identified on 06/16/22. While the IJ was lowered on 06/19/22, the facility remained out of compliance at scope of isolated with No Actual Harm with Potential for More the Minimal Harm due to the facility's need to monitor the effectiveness of their Plan of Removal corrective system. These failures placed residents at risk for perforation of the G-tube, aspiration pneumonia, replacement of the g-tube, hospitalization , or even death. Findings include: Record review of indicated Resident #56 was a 54-year- old male was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], and again 6/9/22 after pulling out his G-Tube. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 56's electronic records on 06/11/22 revealed there was no documentation for 06/09/22, there were no documentation on when and how he was admitted to the facility, there was no assessment on admission and no medication orders. Record review of facility's 24 hours report 06/09/22 revealed there was no documentation for Resident #56 on 06/09/22. Record review of NP orders dated 6/09/22 revealed GT I Glucerna 1.5cal bolus Q4hour, CBC, BMP, PT\OT. Record review of Resident #56's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Colum for 06/09/22 did not indicate that he was fed and provided his medication. Record review of Resident #56's nurse's note dated -6/10/2022 at 17:44 (5:00PM) written by R NB indicated Resident #56 responsible party was notified of resident receiving a regular tray of hot dog for lunch when he was noted to be NPO. Record review of Resident #56's nurse's note dated 6/10/2022 at 13:20 (1:20PM) written by RN B (Staff ID), indicated This nurse notified that Pt was noted to have a half-eaten tray at bedside given to patientt. by nursing staff. Pt is NPO, charge nurse aware. will follow up on report Record review of Resident #56's Daily Skilled Note dated 6/10/2022 at 08:20 AM, written by RN B indicated, Daily Skilled Note Resident # 56 requires Skilled Rehab for Physical Therapy (PT) Occupational Therapy (OT) and requires daily Skilled Observation for [CONDITION(S)] Medication Management Open Wounds (e.g. vascular, surgical) Resident/Resident Representative teaching and training Tube Feeding. A drug regimen review was completed. The physician was contacted, and recommended actions were completed . Observation on 06/11/22 at 10:00AM, revealed Resident #56 was not interviewable. His Peg Tube was in place In an interview with the ADON on 06/11/22 at 1:00PM, she said the admitting nurse was supposed to assess all incoming residents, verified medication orders with attending physician and document resident's condition in electronic record. She said she was doing rounds on 06/10/22 at about lunch time when she saw Resident #56 eating lunch. She said she immediately took the tray from Resident #56 and asked the sitter not to assist him because he was NPO. She said at this time Resident #56 had already eaten half of his hot dog that was served. The ADON said, she called the NP to resident's physician and the responsible party to informed them that Resident #56 was given a lunch tray of hot dog and he eat half of it before the tray was taken away, but there was no adverse reaction. She said she assessed Resident #56 and he was alright. During a phone interview on 06/15/22 at 2:10PM, RN C said she worked the night shift on 06/09/22a she said worked a double shift on 06/09/22. She said Resident #56 admitted to the facility about 3:00pm on 06/09/22. She said she spoke to Resident #56 and welcome him back to the facility. She said she did not admit Resident #56, but she saw that Resident #56 was in no distress. She said the NP arrived shortly after to see Resident #56. She said the ADON said she would admit Resident #56, and she left it at that. She said she checked Resident #56 throughout her shift and he was alright. She said she did not check what he was on because she had no access to the computer system. She said she worked for an agency. In an interview with the facility Administrator, on 06/11/22 at 3:30PM, she said staff that worked on 6/9/22 when Resident #56 was readmitted were agency nurses. The Administrator said she did not know whether there was a system in place to ensure agency nurses were aware of the facility process for admission and readmissions. She said she would find out the agency staff that worked the night shift when Resident #56 was admitted . She said she expected assessments and documentation to be in the electronic record on admission. In an interview on 06/12/22 at 2:14PM, LVN A said she was off when Resident #56 was admitted to the facility. She said when doing her rounds between 7 :30AM and 8:00AM in the morning, she saw a meal tray for Resident #56 and knowing that he was NPO prior to being sent out, she took the tray from Resident #56, and ask one of the aide on duty not to feed Resident #56 because he was on G-Tube feeding. She said she immediately left to review his orders in electronic record but there were no orders entered. She said she looked around and found Resident #56's discharge records at the nurse's station. She said she reviewed the orders and called the NP who told her she reviewed Resident #56's orders on 06/09/22 with someone at the facility. She said she proceeded with resident's orders, fed him, and continued with her routine assignment. She said she did not go back to the kitchen to find out how Resident #56 got a tray. She said she was not aware that a lunch tray was passed out until after the incident. In an interview on 06/12/22 at 1:30PM, Cook CC said he usually followed what was on resident's meal ticket but if a staff member asked for a tray for resident, he would give out a tray. He said, there is usually there would be a meal ticket with Resident's name. He said he does not remember who asked for a tray for resident #56. In an interview on 06/13/22 at 12:00 PM, the dietary Manager said she was new to the facility. She said the facility does not have a system of tracking trays for an extended period of time. She said the system generated meal tickets daily and if the resident was new, someone from the nursing staff had to request or provide a meal ticket before getting a tray. She said she printed out her meal ticket daily from the facility's system called (SNOW). She said she was told by the kitchen staff that someone had asked for a tray for Resident #56. She said she did not find any meal ticket for Resident # 56. She said she checked the system and Resident #56 was NPO. In an interview with MA K on 06/14/22 at 3:00PM, she said she saw the tray and assisted Resident #56 with his hotdog. She said she did not feed Resident #56. She said she assisted resident #56 by putting his hot dog together. She said Resident #56 ate the hot dog without assistant. She said halfway through eating the ADON came in and said Resident #56 was NPO and was not supposed to have a tray. She said at that time the tray was taken away from Resident #56. In an interview on 06/15/22 at 02:15 PM with the interim DON stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician was made aware that nurse had ordered an X-ray. She said it was her understanding that the NP saw resident on Thursday 6/09/22 and gave orders to continue with discharged orders. She said the NP usually visited all residents on a weekly basis. She said the documentation by the NP were not readily available because their documentation usually goes through their system and it takes about a week. She said the nursing staff did not do the admission assessment. She said there was no admissions note that the resident had returned. She said good nursing practice was, on admission, there should be a full assessment of resident and document the assessment. She said a new chest X-ray was ordered today 06/15/22 by the NP. During an interview with the NP on 06/17/22 at 12:00PM, she said she saw Resident #56 on 06/09/22 about 11:30 to 12:30PM, and wrote an order to continue with discharge orders. She said she does not remember the nurse that was present. She said her notes had to go through their cooperate system before being available to the facility. She said she remember being notified about the hotdog and that Resident #56 was alright, she said she does not remember the time but she was notified. The NP had not response when this surveyor told her that the residents documentation revealed Resident #56 got to the facility about 3:00pm. In an interview on 06/11/22 - at 1:30pm, Cook AA said all she does was to follow diet order. She Said all residents that eat from the kitchen had a meal ticket but sometimes staff can request for a tray. She said if a staff requested for a tray, they would give out tray upon request. In an interview on 06/11/22 at 1:50PM, LVN T said all new and re-admit residents are assessed and made comfortable, then review discharge records from hospital and reconciled all medication with the attending physician and if they were new to the facility call the on-call physician group. LVN T said the admitting nurse had to consult the on-call physician third eye to reconcile medication and document information in electronic record and document in 24 hours report. In an interview with the facility Administrator, on 06/11/22 at 3:30PM, she said staff working on 6/9/22 when resident #56 was readmitted were agency nurses. The Administrator said she did not know whether there was a system in place to ensure agency nurses were aware of the facility process for admission and readmissions. She said she would the staff that worked the night shift when Resident #56 was admitted . She said she expect assessment and documentation to be in the electronic records. In an interview on 06/12/22 at 1:30PM, Cook CC said he usually follows what is on resident's meal ticket but if a staff member asked for a tray for resident, he would give out a tray. He said, there is usually a communication sheet which is written on the meal ticket. He said he does not remember who asked for a tray for resident #56. In an interview with Cook BB on 06/12/22 at 2:40PM, he said he only pass out tray on the cart. He said he had no idea who is was on NPO and who is was on diet. In an interview on 06/12/22 at 2:14PM, LVN A said she was off when Resident #56 was admitted to the facility, she said when doing her rounds between 7 :30 and 8:00am in the morning, when she saw a meal tray for Resident #56 and knowing the resident being on NPO prior to being sent out, she took the tray and ask the aide on duty not to feed Resident #56 because he was on G-Tube feeding. She said she immediately left to review his orders Resident # 56 electronic records but there were no orders. She said she looked around and find resident #56's discharge records at the nurse's station. She said she reviewed the orders and called the NP for Resident's physician who told her that she reviewed Resident #56's orders on 06/09/22 with someone at the facility. she said she proceeded with Resident's orders, fed him, and continued with her routine assignment. She said she did not go back to the kitchen to find out how Resident #56 got a tray. She said she was not aware that a lunch tray was passed out until after the incident. In an interview on 06/13/22 at 12:00 Pm, the dietary Manager said she was new to the facility. she said the facility does not have a system of tracking trays for extended period. She said the system used generate meal ticket daily and if the resident is new, someone from the nursing staff had to request or provide a meal ticket before getting a tray. She said she prints out her meal ticket daily from the facility's system called (SNOW). She said she was told by the kitchen staff that, someone had asked for a tray for Resident #56. She said she did not find any meal ticket for Resident #56. She said she checked the system and Resident #56 was NPO. In an interview with RRD on 06/13/22 at 1:00PM, she said the facility system generated meal ticket daily. She said she has had an inservices with all staff and will continue to have inservices till all staff are covered. She said she will come up with a system where all meal tickets are tracked and posted daily on the nurse's station and in the dining room. During an interview with MA K, on 06/14/22, she said she saw the tray and assisted resident #56 with his hot. She said she did not feed Resident #56. she said she assisted resident #56 by putting his hot dog together. She said Resident #56 eat hot dog without assistant. She said halfway through the ADON came in and said that Resident #56 was NPO and not supposed to have a tray. During a phone interview on 06/15/22 at 2:10PM, RN C that worked the night shift on 06/09/22 at 2:10PM, she said worked double shift on 06/09/22. She said Resident #56 came in at about 3:00pm on 06/09/22. She said she spoke to Resident #56 and welcome him back to the facility. she said she did not admit Resident #56 but see that Resident #56 was in no distress. She said the NP arrived shortly after to see Resident #56. She said the ADON said she would admit Resident #56, and she left it at that. RN C said she checked Resident #56 throughout her shift and he was alright. She said she did not check what he was on because she had no access to the computer system. She said she worked for an agency. In an interview with facility Administrator on 06/15/22 at 02:09 PM, she stated Resident #56's physician was out of the country on vacation. She said she would have to check to see if Resident #56 has had seen a doctor since he has been here at the facility. Not sure if resident's physician was notified of his condition the day of the incident. 06 /15/22 at 02:15 PM, interview with interim DON stated that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Unknown what Doctor, but doctor was made aware that one of the nurses ordered X-ray. She said she would have to get the chart to verify chest X-ray. She said it was her understanding that NP saw resident on Thursday the 9th. She said NP usually visit all residents on a weekly basis. She said the ([MEDICATION(S)]) documentation by the NP are not always readily available because their documentation usually goes through their system and it takes about a week. She said the nursing staff did not do the admission assessment. She said there was no admissions note that the resident had returned. She said good nursing practice is at admission, do a full assessment of resident and document the assessment. She said a new chest X-ray ordered today by NP on 06/15/22. During an interview with NP on 06/17/22 at 12:00pm, she said she saw Resident #56 on 06/09/22 and wrote an order to continue with medication. She said she does not remember the nurse that was present. She said her notes had to go through their cooperate system before being available to the facility. she said she does not remember being notified about the hotdog, but she was notified. She said she saw Resident #56 at about 11:30 to 12:30pm. She said nothing when told that documentation revealed that resident #56 got to the facility at about 3:00pm. During an interview with Dietary manager on 06/18/22 at 2:30 M, she said the facility had put a system in place where diet tickets must be used to distribute meal trays. She said there would also be a system where meal orders are kept and reference when needed for a month, assessable to all dietary staff and nurses. She said she had in-services with all dietary staff on giving out meal tray without a communication sheet. In an interview with the facility Administrator on 06/18/22 at 2:00pm 00PM, she said all agency staff and facility staff are being in-service on admission of new and readmit residents, documentation, and a step-by-step instruction on how to input information in the electronic system. Record review of facility's policy, on admitted d 08/11/13 Admission Policy dated 08/11/13 read in part- the purpose of the admission policy is to provide continuity of care and services between discharging provider and the admitting facility Admission: . o Obtained and review transfer health record o Complete clinical evaluations o Verify transfer orders o Verify admission physician and resume previous orders with attending physician against those from hospital Record review of the facility's NF Policy titled, Dining Communication dated 06/28/13 revised 5/12/16 read in part Each dining location will have a diet, mealtime communication notebook for reference during meal services. Staff will be aware of all residents requiring swallow precaution as noted in the dining room communication notebook An Immediate Jeopardy (IJ) was identified on 06/16/22 at 1:30PM, due to the above failures. The Administrator was notified on 06/16/22 at 1:30PM, an of the IJ situation was identified due to the above failures and the IJ template was provided on 06/16/22 at 1:30 PM. The Plan of Removal was accepted on 06/17/22 at 4:00PM. and included: PLAN OF REMOVAL The Lakes at Texas City Date:06/17/22 Removal of Immediacy This Plan of Removal represents the center's allegation of compliance as of 6/16/2022. The Texas Health and Human Services Commission entered The Lakes at Texas City[facility name] on a complaint investigation which started on 6/11/2022. The plan of removal serves as The Lakes at Texas City response to the Immediate Jeopardy Notification the center received at 1:30 pm on June 16, 2022 from the Texas Health and Human Services Commission related to 1. Failure to ensure a resident who is fed by enteral means receives appropriate treatment and services to prevent complications Resident # 56 Resident # 56 is a 54 Y/O male who has resided at the center since 5/23/2022 with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] This facility has 1 additional tube fed resident that has been receiving a no restriction diet, pureed texture since 3/25/2022. The MD discharge instructions from the hospital on 6/6/2022 state to resume home diet/feeds. What happened briefly is as follows: On 6/10/2022, Resident #56 was served a regular meal of a hot dog. Resident #56 ate half of the meal prior to the tray being removed. Resident #56 had no adverse outcome from this isolated incident. As part of facility investigation, a chest x-ray was obtained to verify no adverse outcome from isolated incident was obtained on 6/15/2022. Xray findings revealed no focal infiltrates with no pleural effusion noted. Speech therapy completed screen prior to incident on 6/10/2022 and evaluated after the incident. Staff immediately notified Speech Therapy that resident had consumed a regular diet tray. The Speech Therapy also notified charge nurse and ADON. Speech Therapy evaluated the situation and to follow with nursing and dietary staff for appropriate feeding consistency for the weekend. ST provided recommendations for continuation on NPO. On 6/10/2022 Resident #56 family member was notified (Resident #56) receiving a regular tray for lunch. Complete incident investigation initiated by the facility to include staff interviews and staff in servicing. The physician was not notified at the time of the incident by the ADON nurse. The ADON nurse failed to notify physician and this failure resulted in her termination. The NP was notified on 6/10/2022 regarding resident #56 receiving a regular tray. Resident #56 was admitted on [DATE] and assessed by NP and orders were received to restart peg tube feeding with Glucerna 1.5 Cal bolus every 4 hours, add 100 mL water flush before and after each bolus feeding, Monitor GT site and residuals. On 6/10/2022, LVN A entered order into electronic system. On 6/16/2022, the new dietary manager was educated on tracking diets and changes in the SNOW tray card system versus electric system. Immediate Action taken 1. On 6/16/2022 Regional Nurse Consultant identified that no other residents have the potential to be affected by this alleged deficient practice. All current and new facility resident's orders were audited for accuracy in [electric system].PCC and SNOW tray card system. Audit revealed facility currently only has 1 resident with NPO order. 2. On 6/16/2022 The Facility Dietary Manager completed audit of all residents to ensure that all diet orders matched the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. On 6/16/2022 Education was provided to facility dietary and nursing staff to include licensed nurses, medication aides, and nurse aides by the Regional Dietary Consultant which began on 6/13/2022 during this investigation on: A. Serving Diets and Diet Change Process with Post Test B. Dietary Orders 4. On 6/16/2022 Education was provided for facility nurses by the DON/designee on Admission Policy Process to include admission and readmission assessment and transcribing orders. Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. 5. On 6/16/2022 Education was started for C.N.A.'s by the DON/Designee on: A. Resident Care tool use to Identify residents who are NPO Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. 6. On 6/16/2022, The facility will ensure all agency and PRN staff will be orientated on obtaining, verifying, and following readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employees. Education was completed on 6/16/2022 and going forward education will be provided for agency staff who has not received training prior to working. This education was completed on 6/16/2022, any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employee's Monitoring Administrator/DON/Designee will use a QAPI meal monitoring Audit tool daily to include new/readmissions x 2 weeks, then weekly x 2 months to monitor that: A. New/Readmit Residents are receiving appropriate diets per physician orders B. All current and new facility resident's orders were audited for accuracy in [electric system].PCC and SNOW tray card system. Audit revealed facility currently only has 1 resident with NPO order. C. On 6/16/2022 The Facility Dietary Manager completed audit of all residents to ensure that all diet orders matched the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] QAPI Meeting The Admin and/or designee will report any findings to the Quality Assessment and Assurance committee monthly in QAPI meeting for a minimum of 3 months or until compliance is ensured. The Quality Assessment and Assurance Committee validates the actions taken are effectively resolving the cited issues and verifies the dates of completion. Surveyor conducted Monitoring monitored as follows: the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 06/18/22 at 12:10 PM, LVN G said she was an agency nurse. She said she had an in-service this morning -06/18/22 on resident's admission and she was given a step by step on what to do and how to enter information in electric system. Interview on 06/18/22 2022 at 1:10PM, MA 1:10PM, MA I said she had an in service on 06/17/22 on feeding residents and not to ask any kitchen staff for food for resident. She said all meal request must go through the charge nurse and not to feed Residents until she clarify with the charge nurse. Interview on 06/18/22 at 1:20Pm20PM, LVN H said she was an agency Nurse. She said she had an in-service this morning on admissions, following up on physician orders, and ensuring that all orders are put in electric system She said she was given a step by step process on how to input information in electric system. In an interview with the Facility Administrator on 06/18/22 at 3: 00Pm00PM, she said all agency staff and facility staff including dietary staff had been in-service on how to access and use electric system in verifying resident's information and orders, especially new admission and readmission. All nurses are in-serviced on documentation. An interview on 06/19/22 at 03:13 PM, with Corporate nurse, RN X revealed, Hospice usually services when a Resident #1 is was hospitalized . Resident #1was dehydration due to fluid refusal and decline in condition. Plan of Removal went into electric system and the snow SNOW tray card system to ensure orders and tray card system matched and everyone had a diet even if it said NPO. Conducted by Dietitian. Rescreen all residents with a Dysphagia diagnosis, noted screening notes. Nursing in-service root cause of failure: Admission/readmission process 1. Orders 2. Clarification of orders (discharge identify and put them in the system and indention differences from the dr.) education: on admission/readmission process. Created a cheat sheet to ensure staff have completed the required steps when a new/readmit of residents. Not part of the clinical record. A tool as needed. Shift routine requirements. Nursing to dietary communication sheet: required form and follow the admission process and complete the form. Staff required to follow admission policy & required to complete diet communication form that goes to the kitchen and one that stays in resident's chart. She said checking chart to ticket was a part of resident's care tool located at each station diet list in the care tool book. Staff can look up a Resident # in the tool book and see additional needs and preferences. CNAs have a listing of everyone's diet within the whole facility. Don't give any Resident #1any snack/food/drink until you know what they diet was. Diet ordered are required to presented to the kitchen before any tray will be passed. QAPI on a daily basis. Kitchen Manger was monitoring the diet cards every day. An interview on 06/19/22 at 04:13 PM the Corporate RN X revealed readmission process paperwork on Resident #2 will be provided . An interview on 06/19/22 at 04:40 PM with Corporate RN, Administrator, DON, and regional RD were informed the IJ was lowered, and exit planned for tomorrow. It was lowered, however, the facility remained out of compliance at scope of isolated and severity of no actual harm with a potential for more than minimal harm as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (CR #1) reviewed for quality of care. -The facility failed to ensure staff checked on CR #1 who was a full code for approximately 12 hours despite significant changes in the resident's habit of going outside to smoke with other residents (CR#1 missed 3 smoke breaks on [DATE] which was unusual for her). CR #1 was found at approximately 9:45 a.m. on [DATE], unresponsive, cold to touch, skin had begun mottling. She was last seen around 9:00 p.m. on [DATE] by staff until [DATE], she had sat up in her wheelchair leaned over her bed with her head resting on her arms for approximately 12 hours. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:30 pm. While the IJ was removed on [DATE] at 3:05 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal This failure placed facility resident at risk of not receiving timely care, change in condition, hospitalization and/or death. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's MDS dated [DATE] revealed CR #1 had a BIMS score of 14 indicating cognition level intact. CR #1's functional status revealed she required extensive assistance with bed mobility and supervision with transfer, dressing, eating, personal hygiene, and limited assistance with toilet use. Further review revealed CR #1 was frequently incontinent of bladder and bowel. Record review of CR #1's Care Plan dated [DATE] revealed she was a pressure ulcer risk with intervention to check frequently for wetness and soiling, every two hours and provide incontinence care as needed. Record review of CR #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's Nursing Progress Notes dated [DATE] documented by RN-I revealed in part: .At approximately 10:15 am was notified by CNA M that CR #1 had been sleeping and was unresponsive to name and voice, felt cold to touch. This RN went into room with CNA to check on patient. Patient found sitting in wheelchair at bedside, facing away from the door in a hunched sleeping position. Patient was unresponsive to voice and touch stimuli .Fingers appeared cyanotic could not palpate a radial or carotid pulse .No breath sounds on auscultation, no apical pulse .Begin to initiate CPR immediately once resident was in supine position. Instructed nearby help to call 911 and get crash cart. Continued CPR and breaths via oxygen ambu bag .EMS arrived on the scene at 10:25am instructed by EMS to stop compressions as they took over .Patient was connected to ECG by EMS, no activity present. EMS confirmed no signs of life at 10:29am CR #1 was pronounced dead .Mottling noted to feet and face, fingertips cyanotic Interview on [DATE] at 12:20 p.m., Resident #4 said CR #1 was a dear friend to her who passed away in the NF. Resident #4 said CR #1 had ordered pizza for her and some of the other residents on [DATE] and CR #1 was okay. Resident #4 said on Saturday night on [DATE] around 8:00 p.m., she went by CR #1's room and asked CR #1 if she wanted to go on smoke break and CR #1 did not answer. Resident #4 said CR #1 was sitting in wheelchair in room with her head laying on the bed. Resident #4 said CR #1's roommate who was also a smoker said CR #1 was sleeping. Resident #4 said when she returned to CR #1's room around 9:30 p.m. on [DATE], CR #1 was still sitting in her wheelchair with head resting on bed. Resident #4 said she told CR #1 good night and she did not respond. Resident #4 said on Sunday morning [DATE] she went on smoke break around 8:00 a.m., or so and CR #1's roommate Resident #2 was coming out of the room to go on smoke break as well. Resident #4 said CR #1 was still sitting in her wheelchair in the same position that she saw her in on Saturday night. Resident #4 said she went back to her room and later own could not remember the time, but she heard CR #1's roommate screaming CR #1's name. Resident #4 said when she approached CR #1's room, CR #1 was on the floor on her back with her head facing the door with her arms bent froze in the air and the staff was working on CR #1. Resident #4 said the staff was telling the residents to go back to their room. Resident #4 said it looked like CR #1 had been dead for a while. Interview on [DATE] at 12:40 p.m., Resident #2 said CR #1 was her roommate and friend. Resident #2 said CR #1 believed suffered from depression but had many friends in the NF and was very kind. Resident #2 said CR #1 used a wheelchair to move around in the NF. Resident #2 said prior to CR #1 passing, she did not appear visibly sick. Resident #1 said CR #1 was sitting in her wheelchair all night on [DATE] with her head on the bed arms folded with head resting on folded arms. Resident #2 said she assumed that CR #1 was just sleeping until hours had passed. Resident #2 said at one time she had asked CR #1 if she was okay, and she never responded. Resident #2 said she could not remember the time. Resident #2 said she never observed staff coming to room to assist CR #1 with care or asked if she wanted to get in bed. Resident #2 said CR #1 did like to sit up in wheelchair but never saw her sit up all night long in her wheelchair. Resident #2 said CR #1 normally slept in her bed at night. Interview on [DATE] at 2:10 p.m., CNA K said she supervised the residents on smoke breaks and the last time she saw CR #1 was on [DATE]. CNA K said she worked the 6am-6pm shift. CNA K said this shift had 4 smoke breaks, 9:00 a.m., 11:00 a.m., 1:00 p.m., and 3:00 p.m. CNA K said when she returned to work on [DATE] at the first smoke break 9:00 a.m., CR #1 was not present and that was not normal for CR #1. CNA K said CR #1's roommate was at the 9:00 a.m. smoke break and said that CR #1 was in her room and was not feeling good. CNA K said she would normally go and check on residents that did not show up for smoke breaks but got busy doing other things. Interview on [DATE] at 2:20 p.m., CNA F said she worked the 6a-2p shift and on [DATE] she was working on the same hall that CR #1 was on, but on the opposite end. CNA F said she was giving a shower to a resident around 10:00 a.m., or so when a male orientee CNA came to get her assistance yelling CR #1's name. CNA F said she went to CR #1's room and saw her on the floor with her head facing the door looking like she was deceased . CNA F said the staff was doing compressions on CR #1 with her arms bent at the elbow and left leg bent at the knee. CNA F said CR #1 did not have contractures prior. CNA F said when she touched CR #1, she felt cold, and the color of her skin was purplish gray color. CNA F said because she was always on the halls, she checked on the residents every ,d+[DATE] minutes when she was not on her break. Interview on [DATE] at 2:35 p.m., interim DON said she had been working at the NF since February of 2022. The interim DON said she had received a call from the staff that CR #1 was found unresponsive at 10:15 a.m. on [DATE]. CPR was started but CR #1 was pronounced deceased by EMS. Interview on [DATE] via phone EMS said they arrived at the NF on [DATE] around 10:20 a.m., finding CR #1 on the floor on her back with CPR in progress with one staff member doing chest compressions and the other providing breaths. EMS said both of CR #1's arms were locked in the air with knees bent. EMS said they could not manipulate CR #1's extremities and their assessment, it appeared that CR #1 had been dead for hours because her skin was cold along with mottling (blotchy, red- purplish color of the skin). EMS said the NH reported that the last time CR #1 had been seen was on the night shift. Interview on [DATE] at 10:18 a.m., LVN D said he worked a double shift on [DATE] from 2pm-6am. LVN D said when he came to work CR #1 was going around telling them how appreciative she was of the care they had provided for her. LVN D said he thought that CR #1 was being discharged . LVN D said when he viewed CR #1's chart, he did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN D said later in the shift around 3pm, CR #1 was eating pizza with some other residents. LVN D said the last time he saw CR #1 was on [DATE] when he passed her last medication [MEDICATION(S)] around 9 p.m. LVN D said he did not need to check on CR #1 because there had not been any changes in her condition and the residents sleep at nighttime. LVN D said the CNA's made rounds on the residents every 2 hours. LVN D said he gave report to the on-coming nurse at the desk. Interview on [DATE] at 12:12 p.m., CNA-H said she worked a double shift on [DATE] from 2pm-6am. CNA H said she did not do much for CR #1. CNA H said CR #1 had pizza with some other residents around 7pm and later went on her smoke break at 10 p.m. and she guessed CR #1 was hanging out with the other residents. CNA H said CR #1 was rolling back to her room around 12:30 a.m. talking to other residents. CNA H said at this time, she asked CR #1 if she wanted to get in bed and CR #1 said no. CNA H said she made her last rounds around 3:45 a.m. - 4:00 a.m. knocking on CR #1 and Resident #2's door and Resident #2 was going to the bathroom. CNA H said she asked CR #1 if she wanted to get in bed and CR #1 said no with covers over her sitting in the wheelchair. Interview on [DATE] at 8:06 a.m., RNI said she worked PRN at the NF and did work the 6am-2pm shift on [DATE]. RNI said she did not recall all the happenings that took place regarding CR #1 and would have to look at her documentation again. RNI said she remember CNA M coming to her out of concern for CR #1 because CR #1 was still sleeping after going in and out of CR #1's room. RNI said she went to CR #1's room and found CR #1 sitting in wheelchair with blanket over her initially appearing to be sleep. RNI said she tap CR #1 on the shoulder calling her name. RNI said CR #1 was unresponsive and felt cold to touch with no pulse. RNI said with the help of staff, CR #1 was placed on the floor to start CPR and 911 was called. RNI said CR #1 was not completely ridged and was able to straighten CR #1's extremities enough to start CPR. RNI said when she came on her shift, she could not remember if she made rounds on the residents. RNI said the frequency on how often she checked on the residents depended on what was going on. RNI said she try to check on the residents at least every 2 hours with the help of the CNA's. Interview on [DATE] at 11:23 a.m., CNAJ said she supervised the residents that smoked. CNAJ said she worked the 6pm-6am. CNA-J said there were 3 smoke breaks on her shift with the 1st smoke break at 6pm, 8pm, and 10pm. CNAJ said on [DATE], CR #1 did not come to any of the smoke breaks on [DATE]. CNAJ said CR #1 always came to the smoke breaks. Interview on [DATE] at 12:50 p.m., CNA M said she worked agency and worked at the NF on [DATE] on the 6am-2pm shift. CNA M said she arrived on her hall at 6:20 a.m. CNA M said she started rounding on the residents at 6:30 a.m. after getting a brief report from another CNA on the residents because it was her first time working at the NF. CNA M said CR #1 was sitting in her wheelchair with a blanket over her head. CNA M said she did not go in room in the room to see if CR #1 was okay because she had been told that CR #1 was fully independent. CNA M said when the breakfast trays arrived on the hall, she did not take CR #1 her tray another staff did but did not know what staff it was. CNA M said when she went to remove CR #1's tray from her room, she observed that CR#1 had not touched her tray and therefore mentioned to a staff member that was sitting at the nurse station who name she did not know. CNA M said that staff member told her that she just had to let CR #1 do her own thing because she was independent. CNA M said after the breakfast trays were picked up, she then began to take the residents vital signs. CNA M said when she went to CR #1's room, she began to speak to resident telling CR #1 she needed to take her vitals. CNA M said when she took the covers off CR #1, her eyes were closed, her skin felt cold, and her color was not good. CNA M said CR #1 was unresponsive. CNA M said she went and got the nurse, and the nurse was trying to get vitals on CR #1 but was unsuccessful. CNA M said they got CR #1 out of the wheelchair and placed her on the floor and began CPR. CNA M said when CR #1 was placed on the floor, her arms were bent and very stiff and her legs went down some. Interview on [DATE] at 3:00 p.m., via phone the interim Administrator said CR #1 was found in her wheelchair with the covers over her head unresponsive. The interim Administrator said the medication aide went by CR #1's room to administer her medications and thought CR #1 was just sleeping and therefore went to administer medications to other residents. The interim Administrator said there was nothing suspicious about CR #1 passing away and death was due to natural causes. The Administrator was not able to produce any autopsy revealing that CR #1 had died of natural causes. Observation on [DATE] at 4:00 p.m., an EMS video camera of their arrival to the NF on [DATE] at 10:15am responding to the call regarding CR #1. When EMS arrived on the scene, CR #1 was on the floor on her back with the NF performing CPR (chest compressions) with CR #1's arms frozen in the air bent at the elbow and lower extremities bent at the knee. Further observation was made of discoloration to CR #1's breast area with discoloration (red purplish). In the video heard EMS say that CR #1 had been down for a while. EMS took over but did not continue with CPR but did connect CR #1 to the AED machine to confirm CR #1 heart rhythm revealing no heartbeat. Interview on [DATE] at 9:38 a.m., the Administrator and DON said they would have to see what the NF policy was on how often the residents should be checked on for change in condition. The DON said staff goes in and out of the resident rooms administering medications. The DON said the staff should be going in the resident (s) room at least every 2 hours providing incontinent care and that the same goes for the night shift. The DON said she had been a nurse for [AGE] years and that nursing had changed a lot. The DON would not elaborate specifically on how nursing had changed in the last [AGE] years. Interview on [DATE] at 11:36 a.m., the Regional Administrator said the doctor said CR #1 experienced a [CONDITION(S)] event. The Regional Administrator said CR #1 was very sick obviously and had a lot of things going on with her because she was in a NF. The Regional Administrator said the NF did not have a policy saying the staff should be checking on the residents every 2 hours although, she would hope they were checking on the residents more often than that. The Regional Administrator said the staff was always going in and out of the resident (s) room and that the surveyor could view the hall video. Interview on [DATE] at 10:27 a.m., the MDS Coordinator said she was not aware of CR #1 wanting to sit up in her wheelchair all night long and sleep. The MDS Coordinator said she always thought CR #1 rested in bed when sleeping. The MDS Coordinator said the times she had gone in CR #1's room (did not provide any specific time or shift) CR #1 would be in bed sleeping. The MDS Coordinator said CR #1 did have incontinent episodes but did not remember if she had any skin breakdown. Observation on [DATE] at 11:00 a.m., of the NF hall video on [DATE] revealed LVND go into CR #1's room at 7:30 p.m. and comes back out with what appears to be a cup. CNAH went in the room and came right back out at 9:15 p.m. CR #1's roommate leaves the room at 9:17 p.m., and seen returning to the room at 11:53 pm. Further observation at midnight CR #1's door was closed. On [DATE] at 6:10 a.m. CNA M in hallway talking to another staff member. At 6:30 a.m. CNA M walking on the hallway talking on her phone. The breakfast trays arrive on the hall at 6:43 a.m. and a staff member went into CR #1's room with a tray and at 6:49 a.m., a staff member was on the hall pouring what appears to be coffee seen going in CR #1's room with a cup at 6:51 a.m. At 7:15 a.m. CNA M went in the room and comes back out. At 7:44 a.m., the medication aide identified by MDS Coordinator was on the hallway standing at her cart and a staff member was bringing a tray from CR #1's room. At 8:20 a.m. Resident #4 was by CR #1's door which was closed and Resident #2, CR#1's roommate comes out of the room. At this time the CMA takes Resident #4's blood pressure then administers medication to Resident #4. The CMA proceeds to prepare medication for other residents. At 9:20 a.m. CNA M was going in and out of resident rooms. At 9:34 a.m. RNI was on the hallway preparing to pass medications standing at her cart. At 9:45 a.m. CNA M goes into CR #1's room and comes out to speak to RNI at 9:46 a.m. RNI goes into CR#1's room with her stethoscope. At 9:49 a.m. additional staff started going into CR #1's room. At 9:50 a.m., CR #1's roommate enters into the room and at 9:53 a.m. staff was bringing the crash cart in CR #1's room. Interview on [DATE] at 1:00 p.m., the DON said if CR #1's care plan intervention included going into CR #1's room to provide care, the staff should have been going in room to check on CR #1. Interview on [DATE] at 1:18pm the NP said possible cause of CR #1's death was a possible pulmonary embolism and that CR #1 was a smoker. Record review of the NF Policy on Quality of Care revised [DATE] revealed in part: .Each resident will be provided care and services to attain his/her highest practicable physical, mental, and psychosocial well-being . An Immediate Jeopardy (IJ) was identified on [DATE] at 3:30PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided on [DATE] at 3:30 PM. The Plan of Removal was accepted on [DATE] at 8:57 p.m. and included: PLAN OF REMOVAL Name of facility: The Lakes at Texas City Date:[DATE] Immediate action: [DATE]- An Ad Hoc QAPI Meeting was held to identify the root cause of CR#1 death. The root cause discussion was attended by the Regional Director of Operation, Regional Nurse Consultant, Interim DON and Facility Administrator. The root cause analysis discussion identified that nurses and nurse aides should receive the following: 1) Nurses and nurse aides required education on their job responsibilities as it relates to the frequency of conducting resident observations for change of condition and monitoring the resident according to the individual plan of care. There are written Nurse and Nurse Aide job duty protocols that were reviewed/evaluated for clarity by the Ad HOC QAPI members. No changes were made in the Nurse and Nurse Aide job duties Any policy needed will be developed by the VP of Quality/Compliance for Advanced Healthcare Solutions, reviewed and adopted the Lakes at Texas City. 2) The nurses require education on identification of irreversible signs of death and how to respond when irreversible signs of death are present. [DATE] - The interventions from the Ad Hoc root cause analysis were started. Immediately on [DATE], the Interim Director of Nursing, MDS Nurse, ADON and Charge Nurses performed resident observation to identify changes of condition. Residents identified with a change of condition the physician will be notified, orders obtained and implemented by the Charge Nurse. 2) [DATE]- The Regional Nurse Consultant/ Interim Director of Nurses in serviced Charge Nurses and Nurse Aides on job specific duties. The job duties were reviewed by the Ad HOC QAPI members to validate all duties were clear and complete. 3) [DATE]- The Nurse Job duties include tasks such as making resident walking rounds/completing rounds tool at the beginning of each that include assigned resident observations for change of condition, observations of residents throughout the shift according to the resident's individual plan of care. 1) The oncoming Nurse completes walking rounds on assigned residents to validate there are no changes of condition by; The night shift nurse will use a flashlight A) Entering each resident's room, calling resident name and observing that the resident: a) Observation of breathing (chest rise and fall of chest); b) Cognitive level is unchanged (calling resident name asking is having pain or any discomfort). c) The rounds tool includes but not limited to the following i. All residents were observed and there are no changes of conditions ii. If there were changes of condition list the residents room#, name, sign/symptom and resident complaints iii. Complete the SBAR for a change of condition or iv. Start Emergency Response procedures [DATE]- The Nurse Aide job duties include tasks such as completing incontinent care checks every two hours as indicated, and according to the individual plan of care to identify changes of condition and reporting resident change of conditions to the Charge Nurse. Incontinent Checks include the following tasks: 1. The nurse aides do not cross over on shifts. Incontinent care checks are performed routinely on the even hour for all shifts regardless of care provided on the previous shift 2. Total incontinence- check brief for wetness. If brief/pad is wet provide peri care, barrier cream and clean incontinent brief/pad. 3. Frequently incontinence - If appropriate ask resident if brief/pad is wet and if they would like to go to the toilet. Or, check brief/pad for wetness. If brief/pad is wet provide peri care, barrier cream and clean incontinent brief/pad. 4. Continent but requires assistance with toileting - Ask resident if they would like to go to the bathroom Starting [DATE], The Interim DON, Regional Nurse Consultant or ADON will complete in-services prior to Nurses and Nurse Aides starting the shift. No Nurse Aide or Nurse will be allowed to work until the in-service is completed. Working agency staffs are included in all nursing staff in-services. Any new agency staff will be identified by the Interim DON and the ADON/Interim DON will provide in-services prior the agency staff starting work. The Agency staff will sign an in-service attendance record. Facilities Plan to ensure compliance quickly The smoke aide will observe for residents that routinely participate in smoking but fail to come to the designated smoke area according to their customary smoking routine. The smoke aide will immediately report to the charge nurse the absence of a resident that does not come to the designated smoke area according to their customary routine. The nurse will immediately locate the resident and evaluate for a change of condition. If a change of condition is identified an SBAR will be completed, and the physician will be notified. The family will be notified of the change of condition by the Charge Nurse. The Interim DON/RNC/ADON will in-service all nurses and nurse aides on [DATE] on observing resident attendance in the designated smoke area, reporting to the charge nurse a change in the resident's routine attendance, immediately locating the whereabouts of the resident and performing a resident evaluation for change of condition. No Nurse Aide or Nurse will be allowed to work until the in-service is completed. Working agency staff are included in all nursing staff in-services. Any new agency staff the POR in-services will be included in facility orientation completed by the interim/DON/ADON. Therapy will complete a screen on any resident that prefers sleeping in a chair including wheelchair at night versus going to bed. The therapy screen will include alternate recommendations to consider by the IDT team for residents that prefer to sleep in a chair. An example of an alternate type of chair is a recliner chair (only legs elevate, or head/legs recline. The IDT Team will discuss alternatives with the resident and family as an alternate. The resident and family will be documented in the care conference notes by the MDS Nurse. The alternate sleeping choices will not affect resident checks and monitoring. Alternate chairs are care planned by the IDT. The Interim DON/ADON/Regional MDS Consultant will in-service all Nurses and Nurse Aides on the following policies and provide posttest on [DATE] and [DATE]. The policies were reviewed/evaluated by the Ad Hoc QAPI members not changes were made 1. Cardiopulmonary Resuscitation Policy which includes when to initiate basic life support, including CPR, prior to the arrival of emergency medical services, considering 1) resident's advance directives, 2) the absence of advance directives or a Do Not Resuscitate order; and 3) how to respond if resident shows obvious signs of irreversible clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). 2. Incontinent Care Policy which includes provide perineal care every two hours as indicated and according to the individual plan of care to promote cleanliness and comfort, to prevent infection to the extent possible, and to prevent and assess for skin breakdown. 3. The Resident Care Tool is a spreadsheet sheet updated by the Interim DON/ADON daily as needed. The Resident Care Tool lists each resident, identifies individual plan of care needs for Nurse Aides, Nurses and used to guide monitoring according to the resident's individual plan of care . The Interim DON, MDS Nurse Consultant or ADON will complete in-services prior to Nurses and Nurse Aides starting the shift. No Nurse Aide or Nurse will be allowed to work until the in-service is completed. All working agency staff will participate in facility in-services, complete posttests and sign in-service attendance records. The Interim DON will identify any new agency staff assigned to work in the facility. The interim DON/ADON will include the POR in-services in the facility agency orientation prior to the agency staff starting their shift. The Administrator will be responsible for the implementation of the plan of removal. The anticipated date for completion of the interventions on the plan of removal is [DATE]. _________________________________________ The following actions have been taken regarding Quality of Care: Survey conducted Monitoring as follows: Interview on [DATE] at 1:30 p.m., LVNN said she worked the 10pm-6am shift and been in-serviced on the following: abuse and neglect, managing the unit that included making sure the residents were being checked on every 2 hours and breathing. LVNN said she was in-serviced to monitor the residents for any change in condition and report to the physician. Interview on [DATE] at 1:44 p.m., LVNS said she worked the 6am-2pm shift and had received in-services on abuse/neglect, completing the rounds tool assessment ensuring that resident had not experienced any changes in condition, residents that take smoke breaks if not there check on the resident (s), CPR, and making sure the CNAs are checking on the residents every 2 hours providing care and attending to their needs Interview on [DATE] at 1:46 p.m., LVNO said she worked the 10pm-6am shift on the weekends. LVNO said she had been in-serviced on abuse and neglect, making rounds every 2 hours checking on the resident(s) condition had not changed. Interview on [DATE] at 1:47 p.m., the DON said she had been in-serviced on monitoring the residents for any change in condition and reporting to the physician, abuse and neglect, making sure that the nurses were rounding on the residents every 2 hours and as needed, when a resident who smokes is not at the smoke breaks to check on residents. Interview on [DATE] at 1:50 p.m., CNAU said she worked the 2pm-10pm shift and had been in-serviced on making rounds on the residents every two hours, reporting to the nurse change in resident condition, report to nurse if resident does not go on their smoke breaks, and abuse and neglect. Interview on [DATE] at 1:52pm, LVN-W said she worked 2pm-10pm and had been in-serviced on abuse and neglect, making rounds on the residents every two hours and reporting to the doctor changes in resident condition, check to see if residents are going on their smoke breaks, and ensuring that the CNAs were making rounds on the residents. Interview on [DATE] at 1:55 p.m., CNAP said she worked the 6am-2pm shift. CNAP said she had been in-serviced on abuse and neglect, checking on the residents at least every 2 hours providing care, notifying the nurse if notice a change in a resident condition, and report to the nurse when a resident that smokes does not show up for their smoke break. Interview on [DATE] at 1:58 p.m., CNAH said she had received in-services on resident smoking breaks counting the residents that come to smoke breaks and letting the nurse know if resident did not go and being sure to go and check on that resident, abuse and neglect, checking on the residents every two hours seeing if they need anything, providing care, ensuring they are breathing. Observation on [DATE] at 2:00 p.m., of care tools binder at each station reflecting staff documentation of rounding on the residents assessing for changes in condition. Interview on [DATE] at 2:06 p.m., CNAQ said she worked the 10pm-6am and had been in-serviced on abuse and neglect, if resident in any distress notify the nurse immediately, make sure that all residents that smoke are at the smoke breaks and if not inform the nurse as well as check on the resident to make sure they are okay, and going in the room to provide care for the residents and that they are breathing. Interview on [DATE] at 2:20 p.m., CNAF said she worked the 6am-2pm shift and had been in-serviced on if a resident was unresponsive place the light on, call for help not leaving the resident, call EMS, abuse/neglect, checking on the residents every 2 hours making sure their needs were being met, providing incontinent care and repositioning, and notifying the nurse right away if resident had experienced a change in condition. Interview on [DATE] at 2:35 p.m., LVND said he worked 10pm-6am shift and had been in-serviced on abuse and neglect, going in the resident (s) room every 2 hours checking on them making sure there were no changes in condition, providing incontinent care and repositioning the residents that require repositioning, residents that take smoke breaks be sure they are showing up and if not check to see if they are okay, and abuse/neglect. Interview on [DATE] at 2:52 p.m., CNA R said she worked the 2pm-10pm shift and received in-services on CPR when a resident is unresponsive staying with the resident and call for help, checking the residents every 2 hours and provide necessary care, and notifying the nurse of any changes in condition. Interview on [DATE] at 3:00 p.m., CMAE said she worked the 2p-10pm shift and had received in-services on CPR when a resident is unresponsive not to leave

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 11 residents reviewed for pain management. (Resident #5) The facility failed to complete comprehensive pain assessments including pain level, characteristic of pain, location of pain and quality of pain for Resident #5 before and after administering prn [MEDICATION(S)] for pain. The facility failed to monitor and document Resident #5's pain level daily during every shift. This failure could place residents at risk for unnecessary pain, discomfort, and a decreased quality of life. Findings Include: Record review of Resident #5's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's MDS dated [DATE] revealed he had a BIMS of 15. Resident #5 denied pain within the last 5 days of the look back period on this quarterly MDS. Record review of Resident #5's Care Plan dated 09/17/2021 revealed Resident #5 was effectively able to communicate the presence of pain and is at risk for pain related to diabetes with [CONDITION(S)]. Staff were to use a numeric scale (0-10) or verbal scale (no pain, mild, moderate, severe, very severe/horrible) to rate pain. Monitor and record pain characteristics with any complaints of pain: Quality: sharp, burning, throbbing tearing, or stabbing. Staff were to monitor and record anatomical location. Staff were to administer pain medications and treatments per physician's orders and when requested. Record review of Resident #5's Physician Orders dated 03/2022 revealed [MEDICATION(S)] Sulfate (Concentrate) Solution 20 MG/ML give 0.5 ml by mouth every 2 hours as needed for Pain. Start Date 12/19/2021. Record review of Resident #5's MAR dated 03/2022 revealed no documentation of a pain level when [MEDICATION(S)] was administered on the following dates: 03/02 - 12:58 AM 03/02 - 8:23 AM 03/04 - 8:38 AM 03/12 - 1:20 PM 03/14 - 8:28 AM 03/16 - 7:35 AM 03/16 - 9:45 AM 03/19 - 8:15 AM 03/21 - 7:57 AM 03/23 - 4:07 AM 03/24 - 11:34 AM 03/29 - 11:18 AM 03/29 - 1:36 PM 03/30 - 8:34 AM Record review of Resident #5's Narcotic Sheet for [MEDICATION(S)] Sulfate revealed it was documented that medication was administered on: 03/01 - 12:00 PM 03/02 - 12:00 AM 03/02 - 8:24 AM 03/04 - 5:00 AM 03/04 - 9:00 AM 03/07 - 9:30 AM 03/08 - 12:00 PM 03/09 - 1:00 PM 03/10 - 12:00 PM 03/11 - 12:00 PM 03/12 - 2:00 PM 03/14 - 9:00 AM 03/15 - 4:00 AM 03/16 - 4:00 AM 03/16 - 8:00 AM 03/16 - 10:00 AM 03/17 - 6:00 PM 03/18 - 10:00 AM 03/19 - 8:15 AM 03/20 - 12:30 AM 03/20 - 6:00 PM 03/21 - 8:00 AM 03/23 - 4:00 AM 03/24 - 10:30 AM 03/24 - 10:00 PM 03/27 - 4:00 AM 03/27 - 9:00 PM 03/28 - 2:10 PM 03/29 - 11:20 AM 03/29 - 1:36 PM Record review of Resident #5's Progress Notes revealed no documented compressive pain assessment on: 03/01/22, 03/02/22, 03/04/22, 03/07/22, 03/08/22, 03/09/22, 03/10/22, 03/11/22, 03/12/22, 03/14/22, 03/15/22, 03/16/22, 03/17/22, 03/18/22, 03/19/22, 03/20/22, 03/21/22, 03/23/22, 03/24/22, 03/27/22, 03/28/22, 03/29/22, and 03/30/22. Record review of Resident #5's vitals for pain level revealed pain level was taken on 03/22/22 which was 0 of 10 and 03/29/22 which was 5 of 10. No other pain levels documented for the month of March 2022. Observation and interview on 03/29/22 at 2:00 PM, revealed Resident #5 was resting in bed awake receiving oxygen via nasal cannula. Further observation revealed Resident #5's right arm was bent at the elbow and with noticeable difference in size compared to the left arm. Resident #5 said he had fallen Sunday before last and hit his arm on something. Resident #5 said on a scale of 0-10 that his pain was a six at the present time, but sometimes the pain is higher than a 6. Resident #5 said he had been telling the staff he was hurting the facility had been giving him aspirin. In an interview on 03/29/22 at 1:30 PM, the VA Nurse stated she observed Resident #5 with discoloration and swelling to his right arm. The VA Nurse said Resident #5 was complaining of pain and had fallen on 03/22/22. In an interview on 03/29/2022 at 2:10 PM, LVN B stated Resident #5 had a fall on 03/22/22 on the night shift. LVN B said Resident #5 complained of generalized pain and was receiving [MEDICATION(S)] due to being on hospice. LVN B said Resident #5 never complained of pain to his right arm. On 03/28/22 the hospice staff saw Resident #5 and noticed that Resident #5's right arm was swollen. LVN B said she went in the room with hospice staff as well to assess Resident #5. The hospice staff did call the doctor, but no new orders were received. LVN B said the VA Nurse came today on 03/29/22 and went to administration wanting something done about Resident #5's right arm. LVN B said she therefore called the house doctor on 03/29/22 and received an order to do an x-ray of Resident #5's right arm. LVN B said the ADON came to her on 03/29/22 informing her that the VA Nurse was insisting that Resident #5 be taken to the hospital for further evaluation. In an interview on 03/30/22 at 11:16 AM, LVN B stated Resident #5 was sent to the hospital today around 9:45 AM. Resident #5 would tell staff he had pain all over. When staff administered PRN pain medication they were supposed to sign off on the MAR and the narcotic count book. When a resident asked for the pain medication staff are supposed to check the pain level and assess for pain. The pain level does not populate on the E-MAR and is not added to the MAR. When staff completed a summary on the E-MAR staff are to put the pain level and what was the location of the pain. The staff do not fill out pain assessment forms. The pain level information does not pop up, so staff just add to the form at the bottom in summary section. In an interview on 03/30/22 at 1:46 PM, the Hospice Nurse stated she was notified by the facility on 03/28/22 regarding Resident #5's pain and advised them to give medication. When she arrived at the facility the resident was comfortable. She did not see any swelling to the right elbow. She was not notified that Resident #5 fell on [DATE]. If she was notified that Resident #5 fell , she would have come out to assess him and notified the hospice physician. Resident #5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/01/22 at 1:35 PM, LVN C stated staff are supposed to assess a resident when they are in pain. Get the pain level from 1-10. The pain medication is administered. She administered pain medication to Resident #5 during March 2022. The facility had issues with their computers, so the MAR was not working properly. The [MEDICATION(S)] was administered but they had computer issues, so the documentation was not showing up on the MAR. Resident #5 had a fall and was having some elbow pain. He asked for the medication, so it was given to him. Resident #5 had a lot of issues and was on hospice, his pain medication was [MEDICATION(S)]. In an interview on 03/31/22 at 10:40 AM, the VA Nurse stated Resident #5 did not have a fracture, he is currently at the hospital and they are running some more test. He is going to be discharged to a new facility. She said when she arrived at the facility on 03/29/22 Resident #5 stated he had a fall on Tuesday (03/22/22) and the facility was not doing anything about it. She had the resident sent to the hospital, she said Resident #5's arm was bruised and swollen. In an interview on 03/30/22 at 1:36 PM, the ADON stated staff are supposed to verify the order, check last time a resident had [MEDICATION(S)] administered, draw up [MEDICATION(S)], ask pain scale, administer the [MEDICATION(S)], document on MAR, document on narcotic sheet, come back within the hour to see if the medication was effective and document. In an interview on 03/30/22 at 3:58 PM, the DON stated staff are supposed to document on the MAR and the narcotic count sheet every time a narcotic is administered. If a resident is in pain staff are to complete a pain assessment, give medication, and follow up. Staff will document this in the electronic record. It was important for the staff to complete an assessment so they could establish the presence of pain. This was normal nursing protocol and practice to document when medication is given because this could stop any exploitation or misappropriation of resident medications. She was working on investigating the issue with the Resident #5's medication. In an interview on 03/31/22 at 12:25 PM, the Regional Nurse Consultant stated the facility had issues with the internet in the past and sometimes the documentation on the MAR does not cross over onto the page. The facility internet had dead spots where it did not work. In an interview on 04/01/22 at 12:15 PM, the DON stated typically all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/01/22 at 10:09 AM, the ADON stated when a PRN medication is requested the nurse asked what the pain medication was when given and a follow up assessment is completed. The nurse would document if the medication was effective or ineffective. For every pain medication it asked staff for the pain assessment. The staff put in the pain level; the E-MAR system will ask if it was effective during the follow up. You cannot save and document the [MEDICATION(S)] was given without putting in a pain level. The ADON was not sure what happened with Resident #5's daily monitoring for pain. All residents should be monitored for pain at least once every shift. Sometimes when a resident goes to the hospital the old orders are discontinued someone would have to reenter it into the system when they returned. In an interview on 04/01/22 at 11:30 AM, the DON stated the facility just completed an audit for all residents regarding pain checks every shift. Every resident is supposed to be monitored for pain daily once a shift. Record review of Resident #5's Incident Report dated 03/22/22 revealed Resident was observed sitting upright on the floor beside this bed. He was noted to be alert and oriented x2. He denied hitting his head. The resident stated he was trying to get to the restroom. The resident was assessed for an injury and none was noted Neuro vitals signs were initiated and found to be WNL. The resident was assisted off the floor per 2 CNA's and placed back into his bed. Bed placed in lowest position. No injuries observed at time of incident. Record review of the facility policy on Pain Management dated 07/2015 revealed Residents shall be assessed for factors that predispose to pain upon admission to the facility and subsequently thereafter according to the findings of the assessment. Resident shall receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .Identification and evaluation of a patient's response to the plan of care is necessary until it is determined that the patient's pain is resolved or meets the patient's goal for relief .Treatment A. Assessment and evaluation by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacist, etc.) may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. b. Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Identify key characteristics of the pain. d. The resident's goal for pain management and his/her satisfaction with the currently level of pain control. e. The effectiveness of specified pharmacological, non-pharmacological and treatments used in the past to treat pain. Approach to Pain Management 1. Evaluate - identify, anticipate events or circumstances that will trigger or cause pain. 2. Treat by pre medicating the patient prior to the pain trigger or cause. 3. Prevent - implement pharmacological and non-pharmacological measure. 4. Monitor - patients response to pharmacological and non-pharmacological measures. 5. Report - to physician patient response to interventions. 6. Management - the goal of the pain treatment plan is to improve the patient's quality of life and activity of daily living by managing pain around the clock with pharmacological and non-pharmacological interventions .

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 17 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #18, #19) of 28 residents reviewed for smoking. The facility failed to supervise residents 7 residents (Resident #1, #2, #4, #5, #6, #8, # 11) of 28 while smoking, Resident #1 burned a hole in his shirt while smoking unsupervised, he reentered the facility while the shirt was still smoking from the ashes falling on his shirt. The facility failed to secure a box containing hazardous smoking paraphernalia (equipment needed for a particular activity) such as cigarettes and lighters, the box and key were easily accessible to residents. The facility failed to ensure residents who smoke did not have smoking paraphernalia on their person for Residents #1, #2, #3, #4, #6, #7, #8, #9, and #12 residents who smoke. The facility failed to complete a smoking assessment for Resident # 1, #2, #3, #4, #6, #12, #14, #16, #17, #18, and #19. An Immediate Jeopardy (IJ) situation was identified on 2/11/22 at 2:30 p.m. While the IJ was removed on 2/13/22, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of widespread due to the facility's continuing to monitor the implementation and need to evaluate the effectiveness of the corrective systems that were put into place. These failures could place all residents at risk of an unsafe smoking environment, fire and safety hazard that could cause serious injury or death. Findings included: Resident #1 Record review of Resident #1's face sheet dated 2/9/22 revealed resident was a [AGE] year-old male admitted on [DATE]. Resident #1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 was not triggered for smoking. Resident #1 has a BIMS score of 13, indicating cognitively intact. Record review of Resident #1's undated care plan revealed he had cognitive impairment related to the subdural hematoma and had impaired visual functions. Resident #1 was not care planned for smoking. Record review of Resident #1's clinical file revealed that Resident #1 did not have a smoking assessment completed upon admission. In an interview on 2/9/22 at 11:32 a.m. Resident #1 said he had 5 lighters and a package of cigarettes on him but the facility staff removed them from him a few days ago. He said his clothes didn't catch on fire. He only burned a hole in his shirt. He didn't know the day this happened, but it was a few days ago. He said the ash fell off of his cigarette onto his shirt. There were no flames. He said someone he didn't know their name, told him his shirt was smoking from the burn hole. He said he was not injured. He said the staff gave him the cigarette and he lit it. He said sometimes he was not supervised while smoking. In a follow up interview on 2/10/22 at 11:45 a.m. Resident #1 said that the hole on his shirt was smoking for a minute as he walked down the hall but there wasn't a flame. He said he still had the shirt. Observation on 2/10/22 at 11:45 a.m. of Resident #1's shirt revealed a large round hole about 1.5 inches in diameter on the bottom of his shirt. There was a smaller round hole about the same diameter as a pencil above the large hole. Observation of smoke break on 2/10/22 at 1:32 p.m. revealed Resident #1 came out side to smoke and was not offered or given a protective apron by staff. In an interview on 2/10/22 at 1:34 p.m. Resident #1 said he was not offered an apron, but said he didn't want an apron anyways. In an interview on 2/13/22 at 11:48 a.m. the Interim Administrator said that there was not an incident report for this incident. Resident #2 Record review of Resident #2's face Sheet dated 2/9/22 revealed resident is a [AGE] year-old male admitted on [DATE]. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #1 was not triggered for smoking. Resident #2 has a BIMS score of 15 indicating cognitively intact. Record review of Resident #2's undated care plan revealed Resident #2 uses oxygen. Resident was not care planned for smoking. Record review of Residents #2's clinical file revealed Resident #2 did not have a smoking assessment completed upon admission. An observation on 2/9/22 at 11:00 a.m. revealed Resident #2 smoking a cigarette without staff present. In an interview on 2/9/22 at 11:00 a.m. Resident #2 said he was recently discharged from the hospital and had his own cigarettes and matches on him. He said he keeps several packs of cigarettes on him so he can smoke when he wanted to. Resident #3 Record review of Resident #3's face Sheet dated 2/11/22 revealed a [AGE] year-old male resident was admitted on [DATE]. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #3 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #3's undated care plan revealed smoking was addressed, interventions included to complete smoking assessment per facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking is supervised. Record review of Resident #3's clinical file revealed Resident #3 did not have a smoking assessment completed upon admission. In an interview and observation on 2/9/22 at 11:11 a.m. Resident #3 was observed to have cigarettes and a lighter in the basket of his walker. He said he kept cigarettes and lighter on him because he had 8 packs of cigarettes stolen of the box that the facility designated for the smoking paraphernalia. He said the staff were aware he kept his own lighter and cigarettes. He said the facility didn't follow their smoke policy. Resident #4 Record review of Resident #4's undated face sheet revealed a [AGE] year-old female Resident #4 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 was not triggered for smoking. Resident #4's BIMS score was 10 indicating moderately intact. Record review of Resident #4s undated care pan revealed Resident #4 was not care planned for smoking. Record review of Resident #4's clinical file revealed Resident #4 did not have a smoking assessment completed upon admission. In an interview on 2/9/22 at 11:18 a.m. Resident #4 said that she kept her cigarettes on her but she didn't keep lighters or matches on her. She said she will sometimes light her cigarette from someone else's cigarette that already had a lit cigarette. She said all the residents who smoke would watch each other. The facility staff do not supervise smoke breaks, a lot of times the staff may bring out the box of paraphernalia to pass out and go back inside. Resident #5 Record review of Resident #5's undated face sheet revealed a [AGE] year-old male resident was admitted on [DATE]. Resident #5 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was not triggered for smoking. Resident #5 had a BIMS score of 12 indicating moderately cognitive impairment. Record review of Resident #5's undated care plan revealed Resident #5 was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking was supervised. Resident #5 was a safe smoker and did not require the use of an apron. Record review of Resident #5's Smoking Assessment completed on 2/11/21 revealed resident required supervision when smoking. In an interview on 2/9/22 at 1:20 p.m. Resident #5 said he was not always supervised. He said he will come out to smoke and staff would not be there. He kept his cigarettes and lighter with him so he could smoke. Resident #6 Record review of Resident #6's undated face sheet revealed a [AGE] year-old female admitted y on 9/3/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #6's Quarterly MDS dated [DATE] revealed Resident #6 was not triggered for smoking. Resident #6 had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #6's undated care plan revealed Resident #6 was not care planned for smoking. Record review of Resident #6's clinical file revealed Resident #6 was did not complete a smoking assessment upon admission. In an interview on 2/9/22 at 1:23 p.m. Resident #6 said kept her cigarettes and lighter with her. She said she was not always supervised when she smoked. She said she burned holes in her clothes all the time. It just happens as a smoker. Not everyone is required an apron. Observation on 2/10/22 at 1:16 p.m. revealed Resident #6 revealed Resident #6 pulled a cigarette and lighter out of her purse and lit the cigarette to smoke. There was not any staff supervision at the time. Resident #7 Record review of Resident #7's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's MDS dated [DATE] indicated Resident #7 had a BIMS score of 15 indicating cognitively intact. Resident #7 was not triggered for smoking. Record review of Resident #7's undated care plan revealed he was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking was supervised. Record review of Resident #7's Smoking assessment dated [DATE] revealed resident required supervision. In an interview on 2/9/22 at 1:27 p.m. Resident #7 said He kept some cigarettes and a lighter on him, but earlier today, 2/9/22, he had to throw the paraphernalia away. He said he was not aware he could not keep his own cigarettes and lighter on him until today. He said staff are aware that the residents who smoke keep their paraphernalia with them. Resident #8 Record review of Resident #8's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Comprehensive MDS dated [DATE] revealed resident was not triggered for smoking. Resident #8 had a BIMS score of 15, indicating cognitively intact. Record review of Resident #8's undated care plan revealed he was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station. Resident was a safe smoker and did not require an apron or direct supervision. Record review of Resident #8's Smoking assessment dated [DATE] revealed resident did not require direct supervision. In an interview on 2/9/22 at 1:30 p.m. Resident #8 said that he kept his cigarettes and lighters on him. He said staff will pass out the cigarettes and then go back inside instead of supervising the smoke breaks. Resident #9 Record review of Resident #9's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #9 had a BIMS score of 13, indicating mild cognitive impairment. Record review of Resident #9's undated care plan revealed resident was not care planned for smoking. Record review of Resident #9's Smoking Assessment completed on 9/29/21 revealed resident required supervision when smoking. In an interview on 2/9/22 at 1:35 p.m. Resident #9 said he kept his cigarettes and lighter on him instead of the facility's designated box. Resident #11 Record review of Resident #11's undated face sheet revealed resident was a [AGE] year-old female admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed Resident #11 was not triggered for smoking. Resident #11 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #11's undated care plan revealed he was not care planned for smoking. Record review of Resident #11's Smoking assessment dated [DATE] revealed Resident #11 required supervision when smoking. Observation on 2/9/22 at 1:40 p.m. revealed CMA B was pushing Resident #11 in her wheelchair. Resident was smoking. She did not have an apron on. In an interview on 2/9/22 at 1:40 p.m. CMA B said that she was supervising the smoke break. She said she didn't know that Resident #11 needed an apron. She said that the administrator just told her that she needed an apron. She said she did not know who needed supervision or apron, and who did not. Resident #12 Record review of Resident #12's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #12's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #12 had a BIMS score of 14, indicating cognitively intact. Record review of Resident #12's undated care plan revealed resident was not care planned for smoking. Record review of Resident #12's clinical file revealed a smoking assessment was not completed upon admission. An observation on 2/10/22 at 1:16 p.m. Resident #12 had his own cigarette and lighter and was smoking. There were not any staff supervising. Resident # 14 Record review of Resident #14's undated face sheet revealed a [AGE] year-old male resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] included [CONDITION(S)], cognitive communication deficit, and type 2 diabetes. Record review of Resident #14's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #14 had a BIMS score of 9 indicating mild cognitive impairment. Record review of Resident #14's undated care plan revealed Resident #14 was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #14's clinical file revealed a smoking assessment was not completed upon admission. Resident # 16 Record review of Resident #16's undated face sheet revealed a [AGE] year-old female resident admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #16's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #16 had a BIMS score of 15 indicating cognitively intact. Record review of Resident #16's undated care plan revealed he/she was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #16's clinical file revealed a smoking assessment was not completed upon admission. Resident #17 Record review of Resident #17's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's quarterly MDS dated [DATE] revealed he/she was not triggered for smoking. Resident #17 had a BIMS score of 14, indicating cognitively intact. Record review of Resident #17's undated care plan revealed he/she was not care planned for smoking. Record review of Resident #17's clinical file revealed a smoking assessment was not completed upon admission. Resident #18 Record review of Resident #18's undated face sheet revealed an [AGE] year-old female resident admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #18's quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #18 had a BIMS score of 10, indicating mild cognitive impairment. Record review of Resident #18's undated care plan revealed he/she was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #18's clinical file revealed a smoking assessment was not completed upon admission. Resident #19 Record review of Resident #19's undated face sheet revealed a [AGE] year-old male resident was admitted to the facility on [DATE]. Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19's quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #19 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #19's undated care plan revealed Resident #19 was not care planned for smoking. Record review of Resident #19's clinical record revealed a smoking assessment was not completed upon admission. Observation on 2/9/22 at 2:40 p.m. of the facility smoking paraphernalia box. In the box there were 6 boxes of cigarettes, 2 belonged to Resident #7, 2 belonged to Resident #13, and one box belonged to Resident #1. There was one lighter without a name. In an interview on 2/9/22 at 11:30 am CNA A said she was aware that residents kept cigarettes and lighters. She had to take the paraphernalia from multiple residents in the halls. She said the residents are open about keeping their cigarettes and lighters and didn't try to hide it. She said she reported it to the last administrator. She said there was a box that locks for the residents cigarettes and lighters. However, the key sits on a wall file holder and not hidden or secured. The box sits on the floor next to wall the key is located on. She said anyone can access it. In an interview on 2/9/22 at 1:40 p.m. CMA B said that she did not know who needed supervision or apron, and who did not while supervising a smoke break. In an interview on 2/9/22 at 1:54 p.m. the Interim DON said that she only had 4 smoking assessments completed. She said they were unable to find the rest. She said smoking assessments should have been done for all residents. She said she was the interim and cannot say why they were not completed, but she was aware that the smoking was an issue at the facility with the residents. In an interview on 2/10/22 at 1:21 p.m. the ADON said the residents who required aprons had a tremor or shake. She said some refuse to wear an apron. She said all smokers should be care planned and she was unaware if they were. She said Resident #1 had shaking but he refuses apron at times. She said she started an audit on smoking assessments yesterday (2/9/22) and was completing them. She said she didn't supervise all smoke breaks she said she pulled the Receptionist because she didn't have anyone to cover smoke break. She said she is aware of the resident's need just from working with them on a daily basis. In an interview on 2/10/22 at 1:50 p.m. the Receptionist said that the key to the box that residents were supposed to keep their smoking paraphernalia in was not kept secure and was accessible to anyone who knew where it was. She said she rarely supervised smoke breaks. She said she did about 7 months ago when she first started employment. She said that when she first supervised a break (about 7 months ago) she was verbally told which residents required supervision or had certain needs. She said that as of recently, today, she was unsure of the residents needs and would be better to ask for updated assessments and information on residents to ensure safety. In an interview on 2/10/22 at 11:08 a.m. the Interim Administrator said that she was aware of the smoking being a problem with residents keeping their paraphernalia on them, as well as the safety risk to the residents. She said many residents do not like to follow the rules. She said the facility policy is not being implemented. She said she cannot speak as to why the facility was not enforcing their own policy or completing the assessments as she arrived at facility on 2/8/22 after the previous administrator walked out. Since her arrival, the smoking concerns had been her focus. She said all staff have the responsibility of enforcing the policy and the care planning team have the responsibility of completing assessments. Record review of the Facility's Smoking Policy dated 2/26/2014 revealed the policy was created to evaluate a resident's ability to participate and exercise the privilege to smoke while residing within the facility. Evaluate residents that smoke utilizing the Smoking Evaluation Tool upon admission, when previous non-smoking resident takes up smoking, if unsafe smoking practices are observed in a current smoker, or when a resident has a significant change in medical condition. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. Staff members distribute smoking accessories to residents at designated smoking times and when signing out of the centers. Residents may only smoke at designate times. Ongoing non compliance of smoking behavior that has potential to present harm to the resident or others may result in involuntary discharge from the facility. This was determined to be an Immediate Jeopardy on 2/11/22 at 2:30 p.m. The Interim Administrator and the Interim DON was notified. The Interim Administrator as provided with the J template on 2/11/22 at 2:30 p.m. and a POR (Plan or Removal) was requested from the facility. The following Plan of Removal submitted by the facility was accepted on 2/11/22 at 4:41 p.m. Immediate action: 12) The ADON and the licensed nurses completed Smoking Evaluations on all residents that smoke for proper supervision and/or assistance with safe smoking. All residents that smoke the care plans were reviewed, revised or updated as necessary by the ADON and MDS 2/9/2022. 13) On 2/9/2022, LNFA, DON, ADON, Medical Records, A.D., BOM, Maintenance Director, HR, LVN and COTA immediately verified all residents (28) that smoke to discuss smoking safety and collect all smoking items (cigarettes, lighters, matches, e-cigarettes). 14) Resident# 1 received a therapy screen for safe smoking and made recommendations for interventions on 2/10/2022. The smoking screen will be used to individualize Resident #1 care plan. Resident #1 therapy screen results show no fine motor/gross/manual dexterity problems but does have impaired safety awareness. The resident will be assigned a smoking apron by the DON due to impaired safety awareness. Smoking aprons are available. 15) Maintenance Director and LNFA have conducted an environmental observation of the smoking area on 2/10/2022 to ensure six feet spacing between residents is marked, fire rated ash tray for each spot, safe smoking interventions are in good repair and fire extinguisher is in working order. 16) The LNFA completed environmental observations of all exit doors to validate the doors are secure and alarms are in working order on 2/11/2022 17) LNFA identified staff member(s)that are assigned to the exit door that leads out to the smoking area until a manual keypad or alarm can be installed by the maintenance director. The staff member will monitor for residents that attempt to go outside to smoke unsupervised. The staff member assigned to monitor the door is in-serviced by the LNFA or DON supervision of resident during smoke times, smoke aprons, distribution of cigarettes, lighting cigarettes, and for observing safe smoking practices such as discarding ashes, holding cigarettes, discarding cigarette. 18) The smoking materials are labeled with resident name and maintained in in a storage box that is brought to the smoke area by the staff at smoking times. Alert and oriented residents can obtain smoking items upon request and sign out to leave the facility. 19) The DON will develop a list of residents that are dependent/independent residents for smoking and review the smoking care plans to identify and list interventions that should be in place during smoking (ie. required a smoking apron or supervision) 2/10/2022. Smoking care plans are one of the comprehensive care plans. Staff have access to the list of residents that smoke and specific safe smoking interventions. The list is updated and revised by the DON upon admission of a new resident that smokes, when there is a change in the smoking evaluation. 20) The list of residents that smoke and safe smoking interventions are placed at each nurse's station and in the smoking paraphernalia storage container. The staff in-serviced on the location of the list. The licensed nurses have access to PCC care plans. 21) The staff member assigned to the exit door will be in-serviced by [NAME] Long, DON or [NAME], LNFA, on the list of residents, hand out smoking items, supervision of safe smoking and infection control practice during resident smoking times on 2/10/2022. 22) The Administrator will meet with the 28 residents on 2/11/2022 that smoke and review the Smoking Policy. An Attendance Record will identify the residents in attendance. The families and responsible parties will be mailed a letter and the smoking policy by the LNFA who will also post the policy at the facility entrance. This will be completed on 2/11/2022 a. The following points will be discussed: b. Provide information regarding education and options for smoking cessation activities to patients and family members of those choosing to cease smoking. Referral to the attending physician for therapy evaluation for observed unsafe smoking practice. c. Facility's designated smoking area and times for the patient, family members or responsible party d. Smoking groups will be established so six feet spacing can be maintained during smoke times. e. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, electronic cigarettes, pipes, lighters, matches, lighter fluid, etc. f. Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non- compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs? g. Ongoing noncompliance of smoking behavior that present danger to self or others result in involuntary discharge from the facility. Facilities Plan to ensure compliance quickly 11) The Administrator will establish smoking groups to ensure six feet spacing can be maintained. LNFA will discuss smoking groups with each resident, completed 2/11/2022. 12) The DON and Administrator will conduct an in-service/post test 2/10/2022 and 2/11/2022 for 100% of the staff on the Smoking Policy and COVID-19 Smoking Policy which will include: a. Provide information regarding education and options for smoking cessation activities to patients and family members of those choosing to cease smoking. Referral to the attending physician for therapy evaluation for observed unsafe smoking practice. b. Facility's designated smoking area and times for the patient, family members or responsible party c. Smoking groups will be established so six feet spacing can be maintained during smoke times. d. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, electronic cigarettes, pipes, lighters, matches, lighter fluid, etc. e. Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non- compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs? f. Ongoing noncompliance of smoking behavior that present danger to self or others result in involuntary discharge from the facility. g. Reporting to the Administrator and DON residents and family members that are noncompliant with the Smoking Policy No employee will be allowed to work until the in-service on the Smoking Policy and COVID-19 Smoking Policy is completed 13) The licensed nurses will evaluate patients that smoke utilizing the Smoking Evaluation Tool: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker and d) when there is a change in condition. 14) The DON will validate the Smoking Evaluations are completed upon admission, when a previous non-smoking patient takes up smoking; if unsafe smoking practices are observed in a current smoker and when a patient that smokes have a significant change in medical condition. Request therapy screen will be as indicated. The changes made in interventions for a resident is communicated by DON to the staff by updating care plan, updating the resident smoking lists, 24 Hr Report and during morning meeting with the IDT. 15) New admissions will be in serviced by the Administrator or the DON, on the smoking policy. 16) The DON, will discuss the results of the Smoking Evaluations with the IDT team daily in morning meeting and the care plan will be updated. 17) The DON will discuss changes in the care plan with the nursing staff, update the list of smokers and ensure interventions are accessible. 18) New Employees will be in-serviced on the Smoking Policy and COVID-19 Smoking Policy before resident assignment is given by the DON 19) The Administrator will use the Designated Smoking Area QAPI Tool 3 times a day for 3 weeks, then 2 times a day for 2 weeks, and weekly for 2 months 20) The Administrator will review with the QAA Committee monthly the results of the Designated Smoking Area QAPI. The QAA team will make recommendations to sustain compliance. Following acceptance of the facility's Plan of Removal, the facility was monitored from 2/12/22 to 2/13/22. Record review was conducted of the facility's training that has been conducted for all staff. Documentation of the following was reviewed: training for all staff on all shifts of the smoking policy, designated times and reporting residents that had their own smoking paraphernalia, all residents who smoke have current evaluation, all residents who smoke are care planned for smoking, resident counseling for all residents who s [TRUNCATED]

Based on observation, interviews, and record reviews the facility failed to ensure the resident's environment remained free of accidents and hazards as is possible for 17 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #18, #19) of 28 residents reviewed for accidents and hazards. The facility failed to supervise residents 7 residents (Resident #1, #2, #4, #5, #6, #8, # 11) of 28 while smoking, Resident #1 burned a hole in his shirt about 1.5 inches in diameter and entered the facility as his shirt was smoking. The facility failed to secure a box containing hazardous smoking paraphernalia (equipment needed for a particular activity) such as cigarettes and lighters, the box and key were easily accessible to residents for all smoking paraphernalia. The facility failed to ensure residents who smoke did not have smoking paraphernalia on their person for 9 (Residents #1, #2, #3, #4, #6, #7, #8, #9, and #12) of 28 residents who smoke. The facility failed to complete a smoking assessment for 11 residents (Resident #1, #2, #3, #4, #6, #12, #14, #16, #17, #18, #19) of 28 residents who smoke. An Immediate Jeopardy (IJ) situation was identified on 2/11/22 at 2:30 p.m While the IJ was removed on 2/13/22, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's continuing to monitor the implementation and need to evaluate the effectiveness of the corrective systems that were put into place. These failures could place all residents at risk of fire and safety hazard that could cause serious harm or death. Findings included: Record review of the Facility's Smoking Policy dated 2/26/2014 revealed the policy was created to evaluate a resident's ability to participate and exercise the privilege to smoke while residing within the facility. Evaluate residents that smoke utilizing the Smoking Evaluation Tool upon admission, when previous non-smoking resident takes up smoking, if unsafe smoking practices are observed in a current smoker, or when a resident has a significant change in medical condition. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. Staff members distribute smoking accessories to residents at designated smoking times and when signing out of the centers. Residents may only smoke at designated times. Ongoing non-compliance of smoking behavior that has potential to present harm to the resident or others may result in involuntary discharge from the facility. Record review of the Facility List of Residents who smoke dated 2/9/22 revealed the facility had 21 residents who smoke. Resident #1, #2 and #6 were not identified as residents who smoke. Record review of the Facility Smoke Break times are 8:30 am, 10:30 am, 1:15 pm, 4:00 pm and 7:00 pm. Resident #1 Record review of Resident #1's face sheet dated 2/9/22 revealed resident was a [AGE] year-old male admitted on [DATE]. Resident #1 diagnoses included traumatic subdural hemorrhage without loss of consciousness, type 2 diabetes, major depressive disorder, and hypertension. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 was not triggered for smoking. Resident #1 has a BIMS score of 13, indicating cognitively intact. Record review of Resident #1's undated care plan revealed he had cognitive impairment related to the subdural hematoma and had impaired visual functions. Resident #1 was not care planned for smoking. Record review of Resident #1's clinical file revealed that Resident #1 did not have a smoking assessment completed upon admission. In an interview on 2/9/22 at 11:32 a.m., Resident #1 said he had 5 lighters and a package of cigarettes on him, but the facility staff removed them from him a few days ago. He said his clothes did not catch on fire, he only burned a hole in his shirt. Resident #1 said he did not know the day this happened, but it was a few days ago. He said the ash fell off of his cigarette onto his shirt, he said there were no flames. Resident #1 said someone he did not know their name, told him his shirt was smoking from the burn hole, he said he was not injured. He said the staff gave him the cigarette and he lit it, he said sometimes he was not supervised while smoking. In a follow up interview and observation on 2/10/22 at 11:45 a.m., Resident #1 said the hole on his shirt was smoking for a minute as he walked down the hall but there was not a flame. He said he still had the shirt. Resident #1's shirt revealed a large round hole about 1.5 inches in diameter on the bottom of his shirt. There was a smaller round hole about the same diameter as a pencil above the large hole. Observation of smoke break on 2/10/22 at 1:32 p.m., revealed Resident #1 came outside to smoke and was not offered or given a protective apron by staff. In an interview on 2/10/22 at 1:34 p.m., Resident #1 said he was not offered an apron, but said he did not want an apron anyways. In an interview on 2/13/22 at 11:48 a.m., the Interim Administrator said there was not an incident report for the incident involving Resident #1. Resident #2 Record review of Resident #2's face Sheet dated 2/9/22 revealed resident is a [AGE] year-old male admitted on [DATE]. Resident #2 had diagnoses of metabolic [CONDITION(S)], acute [CONDITION(S)], altered mental status, muscle weakness, and [CONDITION(S)]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #1 was not triggered for smoking. Resident #2 has a BIMS score of 15 indicating cognitively intact. Record review of Resident #2's undated care plan revealed Resident #2 uses oxygen. Resident was not care planned for smoking. Record review of Residents #2's clinical file revealed Resident #2 did not have a smoking assessment completed upon admission. An observation and interview on 2/9/22 at 11:00 a.m., revealed Resident #2 smoking a cigarette without staff present. Resident #2 said he was recently discharged from the hospital and had his own cigarettes and matches on him. He said he keeps several packs of cigarettes on him so he can smoke when he wanted to. Resident #3 Record review of Resident #3's face Sheet dated 2/11/22 revealed a [AGE] year-old male resident was admitted on [DATE]. Resident #3 had diagnoses that included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, and polyneuropathy. Record review of Resident #3's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #3 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #3's undated care plan revealed smoking was addressed, interventions included to complete smoking assessment per facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking is supervised. Record review of Resident #3's clinical file revealed Resident #3 did not have a smoking assessment completed upon admission. In an observation and interview on 2/9/22 at 11:11 a.m., Resident #3 was observed to have cigarettes and a lighter in the basket of his walker. He said he kept cigarettes and a lighter on him because he had 8 packs of cigarettes stolen out of the box the facility designated for the smoking paraphernalia. He said the staff were aware he kept his own lighter and cigarettes. He said the facility did not follow their smoke policy. Resident #4 Record review of Resident #4's undated face sheet revealed a [AGE] year-old female Resident #4 was admitted on [DATE]. Diagnoses included [CONDITION(S)] disease affecting left non dominant side, type 2 diabetes, and major depressive disorder. Record review Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 was not triggered for smoking. Resident #4's BIMS score was 10 indicating moderately intact. Record review of Resident #4s undated care pan revealed Resident #4 was not care planned for smoking. Record review of Resident #4's clinical file revealed Resident #4 did not have a smoking assessment completed upon admission. In an interview on 2/9/22 at 11:18 a.m., Resident #4 said she kept her cigarettes on her, but she did not keep lighters or matches on her. She said she will sometimes light her cigarette from someone else's cigarette that was already lit. She said all the residents who smoke would watch each other. The facility staff do not supervise smoke breaks, a lot of times the staff may bring out the box of paraphernalia to pass out and go back inside. Resident #5 Record review of Resident #5's undated face sheet revealed a [AGE] year-old male resident was admitted on [DATE]. Resident #5 diagnoses included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, [CONDITION(S)] disease, unspecified lack of coordination, and cognitive communication deficit. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was not triggered for smoking. Resident #5 had a BIMS score of 12 indicating moderately cognitive impairment. Record review of Resident #5's undated care plan revealed Resident #5 was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking was supervised. Resident #5 was a safe smoker and did not require the use of an apron. Record review of Resident #5's Smoking Assessment completed on 2/11/21 revealed resident required supervision when smoking. In an interview on 2/9/22 at 1:20 p.m., Resident #5 said he was not always supervised when smoking. He said he will come out to smoke and staff would not be there, he said he kept his cigarettes and lighter with him so he could smoke. Resident #6 Record review of Resident #6's undated face sheet revealed a [AGE] year-old female admitted y on 9/3/2021. Diagnosis included Dementia without behavioral disturbances, lack of coordination, [CONDITION(S)], and muscle weakness Record review of Resident #6's Quarterly MDS dated [DATE] revealed Resident #6 was not triggered for smoking. Resident #6 had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #6's undated care plan revealed Resident #6 was not care planned for smoking. Record review of Resident #6's clinical file revealed Resident #6 was did not complete a smoking assessment upon admission. In an interview on 2/9/22 at 1:23 p.m., Resident #6 said she kept her cigarettes and lighter with her. She said she was not always supervised when she smoked. She said she burned holes in her clothes all the time It just happens as a smoker, she said not everyone was required to wear an apron. Observation on 2/10/22 at 1:16 p.m., revealed Resident #6 pulled a cigarette and lighter out of her purse and lit the cigarette to smoke. There was not any staff supervision at the time. Resident #7 Record review of Resident #7's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Diagnoses included repeated falls, type 2 diabetes, and [CONDITION(S)]. Record review of Resident #7's MDS dated [DATE] indicated Resident #7 had a BIMS score of 15 indicating cognitively intact. Resident #7 was not triggered for smoking. Record review of Resident #7's undated care plan revealed he was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station, and smoking was supervised. Record review of Resident #7's Smoking assessment dated [DATE] revealed resident required supervision. In an interview on 2/9/22 at 1:27 p.m., Resident #7 said he kept some cigarettes and a lighter on him, but earlier today(2/9/22) he had to throw the paraphernalia away. He said he was not aware he could not keep his own cigarettes and lighter on him until today. He said staff are aware that the residents who smoke keep their paraphernalia with them. Resident #8 Record review of Resident #8's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Diagnoses included end stage [CONDITION(S)], muscle wasting and atrophy, and [CONDITION(S)]. Record review of Resident #8's Comprehensive MDS dated [DATE] revealed resident was not triggered for smoking. Resident #8 had a BIMS score of 15, indicating cognitively intact. Record review of Resident #8's undated care plan revealed he was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station. Resident was a safe smoker and did not require an apron or direct supervision. Record review of Resident #8's Smoking assessment dated [DATE] revealed resident did not require direct supervision. In an interview on 2/9/22 at 1:30 p.m., Resident #8 said he kept his cigarettes and lighters on him. He said staff will pass out the cigarettes and then go back inside instead of supervising the smoke breaks. Resident #9 Record review of Resident #9's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Diagnoses included [CONDITION(S)], lack of coordination, polyneuropathy, muscle weakness, and acute kidney failure. Record review of Resident #9's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #9 had a BIMS score of 13, indicating mild cognitive impairment. Record review of Resident #9's undated care plan revealed resident was not care planned for smoking. Record review of Resident #9's Smoking Assessment completed on 9/29/21 revealed resident required supervision when smoking. In an interview on 2/9/22 at 1:35 p.m., Resident #9 said he kept his cigarettes and lighter on him instead of the facility's designated box. Resident #11 Record review of Resident #11's undated face sheet revealed resident was a [AGE] year-old female admitted on [DATE]. Diagnoses included mild cognitive impairment, chronic kidney disease, [CONDITION(S)], congestive heart failure, and seizures. Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed Resident #11 was not triggered for smoking. Resident #11 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #11's undated care plan revealed he was not care planned for smoking. Record review of Resident #11's Smoking assessment dated [DATE] revealed Resident #11 required supervision when smoking. Observation and interview on 2/9/22 at 1:40 p.m., revealed CMA B was pushing Resident #11 in her wheelchair, Resident #11 was smoking a cigarette and she did not have an apron on. CMA B said that she was supervising the smoke break. She said she did not know Resident #11 needed an apron, she said the administrator just told her she needed an apron. CMA B said she did not know who needed supervision or an apron, and who did not. Resident #11 was in pain and was being taken back in the facility and did not complete interview. Resident #12 Record review of Resident #12's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Diagnoses included unsteadiness on feet, history of falling, lack of coordination, chronic kidney disease, acquired absence of right and left leg above the knee. Record review of Resident #12's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #12 had a BIMS score of 14, indicating cognitively intact. Record review of Resident #12's undated care plan revealed resident was not care planned for smoking. Record review of Resident #12's clinical file revealed a smoking assessment was not completed upon admission. An observation on 2/10/22 at 1:16 p.m., Resident #12 had his own cigarette and lighter and was smoking. There were not any staff supervising. Resident # 14 Record review of Resident #14's undated face sheet revealed a [AGE] year-old male resident was admitted on [DATE]. Diagnoses included [CONDITION(S)], cognitive communication deficit, and type 2 diabetes. Record review of Resident #14's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #14 had a BIMS score of 9 indicating mild cognitive impairment. Record review of Resident #14's undated care plan revealed Resident #14 was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #14's clinical file revealed a smoking assessment was not completed upon admission. Resident # 16 Record review of Resident #16's undated face sheet revealed a [AGE] year-old female resident admitted on [DATE]. Diagnoses included repeated falls, [CONDITION(S)] of hip, and major depressive disorder. Record review of Resident #16's Quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #16 had a BIMS score of 15 indicating cognitively intact. Record review of Resident #16's undated care plan revealed he/she was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #16's clinical file revealed a smoking assessment was not completed upon admission. Resident #17 Record review of Resident #17's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Diagnoses included seizures, [CONDITION(S)], polyneuropathy, and opioid dependence with withdrawal. Record review of Resident #17's quarterly MDS dated [DATE] revealed he/she was not triggered for smoking. Resident #17 had a BIMS score of 14, indicating cognitively intact. Record review of Resident #17's undated care plan revealed he/she was not care planned for smoking. Record review of Resident #17's clinical file revealed a smoking assessment was not completed upon admission. Resident #18 Record review of Resident #18's undated face sheet revealed an [AGE] year-old female resident admitted on [DATE]. Diagnoses included tobacco use, polyneuropathy, and [CONDITION(S)] of liver. Record review of Resident #18's quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #18 had a BIMS score of 10, indicating mild cognitive impairment. Record review of Resident #18's undated care plan revealed he/she was care planned for smoking. Interventions included perform smoking assessment according to facility policy, remind resident all smoking paraphernalia must be kept at nurse's station and staff to supervise smokers. Record review of Resident #18's clinical file revealed a smoking assessment was not completed upon admission. Resident #19 Record review of Resident #19's undated face sheet revealed a [AGE] year-old male resident was admitted to the facility on [DATE]. Resident's diagnoses included unspecified sequalae of nontraumatic subarachnoid hemorrhage, [CONDITION(S)], dysarthria following cerebral infarction, [CONDITION(S)] disease, and contracture of left upper arm. Record review of Resident #19's quarterly MDS dated [DATE] revealed resident was not triggered for smoking. Resident #19 had a BIMS score of 14 indicating cognitively intact. Record review of Resident #19's undated care plan revealed Resident #19 was not care planned for smoking. Record review of Resident #19's clinical record revealed a smoking assessment was not completed upon admission. Observation on 2/9/22 at 2:40 p.m., of the smoking paraphernalia box revealed there were 6 boxes of cigarettes, 2 belonged to Resident #7, 2 belonged to Resident #13, and one box belonged to Resident #1. There was one lighter without a name. In an interview on 2/9/22 at 11:30 a.m., CNA A said she was aware residents kept cigarettes and lighters. She had to take the paraphernalia from multiple residents in the halls. She said the residents are open about keeping their cigarettes and lighters and do not try to hide it. She said she reported it to the last administrator. She said there was a lockbox for the residents cigarettes and lighters, however, the key sits on a wall file holder and not hidden or secured. CNA A said the box sits on the floor next to the wall the key was located on. She said anyone can access it. In an interview on 2/9/22 at 1:40 p.m., CMA B said she did not know who needed supervision or aprons, and who did not while supervising a smoke break. In an interview on 2/9/22 at 1:54 p.m., the Interim DON said she only had 4 smoking assessments completed. She said they were unable to find the rest. She said smoking assessments should have been done for all residents. She said she was the interim and cannot say why they were not completed, but she was aware smoking was an issue at the facility with the residents. In an interview on 2/10/22 at 11:08 a.m. the Interim Administrator said she was aware of the smoking being a problem with residents keeping their paraphernalia on them, as well as the safety risk to the residents. She said many residents do not like to follow the rules. She said the facility policy was not being implemented. She said she cannot speak as to why the facility was not enforcing their own policy or completing the assessments as she arrived at facility on 2/8/22 after the previous administrator walked out. She said since her arrival, the smoking concerns had been her focus. She said all staff have the responsibility of enforcing the policy and the care planning team have the responsibility of completing assessments. In an interview on 2/10/22 at 1:21 p.m., the ADON said the residents who required aprons had a tremor or shake. She said some refuse to wear an apron. She said all smokers should be care planned and she was unaware if they were. She said Resident #1 had shaking but he refuses an aprons at times. She said she started an audit on smoking assessments yesterday (2/9/22) and was completing them. She said she did not supervise all smoke breaks she said she pulled the receptionist because she did not have anyone to cover smoke breaks. She said she was aware of the resident's need just from working with them on a daily basis. In an interview on 2/10/22 at 1:50 p.m., the receptionist said the key to the box that residents were supposed to keep their smoking paraphernalia in was not kept secure and was accessible to anyone who knew where it was. She said she rarely supervised smoke breaks. She said she did about 7 months ago when she first started employment. She said when she first supervised a break (about 7 months ago) she was verbally told which residents required supervision or had certain needs. She said as of today, she was unsure of the residents needs and would be better to ask for updated assessments and information on residents to ensure safety. The Interim administrator and the Interim DON were notified on 2/11/22 at 2:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The The IJ template was provided to the Interim Administrator. The facility's Plan of Removal was accepted on 2/11/22 at 4:41 p.m. and included: Immediate action: 1) The ADON and the licensed nurses completed Smoking Evaluations on all residents that smoke for proper supervision and/or assistance with safe smoking. All residents that smoke the care plans were reviewed, revised or updated as necessary by the ADON and MDS 2/9/2022. 2) On 2/9/2022, LNFA, DON, ADON, Medical Records, A.D., BOM, Maintenance Director, HR, LVN and COTA immediately verified all residents (28) that smoke to discuss smoking safety and collect all smoking items (cigarettes, lighters, matches, e-cigarettes). 3) Resident # 1 received a therapy screen for safe smoking and made recommendations for interventions on 2/10/2022. The smoking screen will be used to individualize Resident #1 care plan. Resident #1 therapy screen results show no fine motor/gross/manual dexterity problems but does have impaired safety awareness. The resident will be assigned a smoking apron by the DON due to impaired safety awareness. Smoking aprons are available. 4) Maintenance Director and LNFA have conducted an environmental observation of the smoking area on 2/10/2022 to ensure six feet spacing between residents is marked, fire rated ash tray for each spot, safe smoking interventions are in good repair and fire extinguisher is in working order. 5) The LNFA completed environmental observations of all exit doors to validate the doors are secure and alarms are in working order on 2/11/2022. 6) LNFA identified staff member(s)that are assigned to the exit door that leads out to the smoking area until a manual keypad or alarm can be installed by the maintenance director. The staff member will monitor for residents that attempt to go outside to smoke unsupervised. The staff member assigned to monitor the door is in-serviced by the LNFA or DON supervision of resident during smoke times, smoke aprons, distribution of cigarettes, lighting cigarettes, and for observing safe smoking practices such as discarding ashes, holding cigarettes, discarding cigarette. 7) The smoking materials are labeled with resident name and maintained in in a storage box that is brought to the smoke area by the staff at smoking times. Alert and oriented residents can obtain smoking items upon request and sign out to leave the facility. 8) The DON will develop a list of residents that are dependent/independent residents for smoking and review the smoking care plans to identify and list interventions that should be in place during smoking (ie. required a smoking apron or supervision) 2/10/2022. Smoking care plans are one of the comprehensive care plans. Staff have access to the list of residents that smoke and specific safe smoking interventions. The list is updated and revised by the DON upon admission of a new resident that smokes, when there is a change in the smoking evaluation. 9) The list of residents that smoke and safe smoking interventions are placed at each nurse's station and in the smoking paraphernalia storage container. The staff in-serviced on the location of the list. The licensed nurses have access to PCC care plans. 10) The staff member assigned to the exit door will be in-serviced by [DON] or [LNFA], on the list of residents, hand out smoking items, supervision of safe smoking and infection control practice during resident smoking times on 2/10/2022. 11) The Administrator will meet with the 28 residents on 2/11/2022 that smoke and review the Smoking Policy. An Attendance Record will identify the residents in attendance. The families and responsible parties will be mailed a letter and the smoking policy by the LNFA who will also post the policy at the facility entrance. This will be completed on 2/11/2022 a. The following points will be discussed: b. Provide information regarding education and options for smoking cessation activities to patients and family members of those choosing to cease smoking. Referral to the attending physician for therapy evaluation for observed unsafe smoking practice. c. Facility's designated smoking area and times for the patient, family members or responsible party d. Smoking groups will be established so six feet spacing can be maintained during smoke times. e. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, electronic cigarettes, pipes, lighters, matches, lighter fluid, etc. f. Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non- compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs? g. Ongoing noncompliance of smoking behavior that present danger to self or others result in involuntary discharge from the facility. Facilities Plan to ensure compliance quickly 1) The Administrator will establish smoking groups to ensure six feet spacing can be maintained. LNFA will discuss smoking groups with each resident, completed 2/11/2022. 2) The DON and Administrator will conduct an in-service/post test 2/10/2022 and 2/11/2022 for 100% of the staff on the Smoking Policy and COVID-19 Smoking Policy which will include: a. Provide information regarding education and options for smoking cessation activities to patients and family members of those choosing to cease smoking. Referral to the attending physician for therapy evaluation for observed unsafe smoking practice. b. Facility's designated smoking area and times for the patient, family members or responsible party c. Smoking groups will be established so six feet spacing can be maintained during smoke times. d. Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, electronic cigarettes, pipes, lighters, matches, lighter fluid, etc. e. Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non- compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs? f. Ongoing noncompliance of smoking behavior that present danger to self or others result in involuntary discharge from the facility. g. Reporting to the Administrator and DON residents and family members that are noncompliant with the Smoking Policy No employee will be allowed to work until the in-service on the Smoking Policy and COVID-19 Smoking Policy is completed 3) The licensed nurses will evaluate patients that smoke utilizing the Smoking Evaluation Tool: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker and d) when there is a change in condition. 4) The DON will validate the Smoking Evaluations are completed upon admission, when a previous non-smoking patient takes up smoking; if unsafe smoking practices are observed in a current smoker and when a patient that smokes have a significant change in medical condition. Request therapy screen will be as indicated. The changes made in interventions for a resident is communicated by DON to the staff by updating care plan, updating the resident smoking lists, 24 Hr Report and during morning meeting with the IDT. 5) New admissions will be in serviced by the Administrator or the DON, on the smoking policy. 6) The DON will discuss the results of the Smoking Evaluations with the IDT team daily in morning meeting and the care plan will be updated. 7) The DON will discuss changes in the care plan with the nursing staff, update the list of smokers and ensure interventions are accessible. 8) New Employees will be in-serviced on the Smoking Policy and COVID-19 Smoking Policy before resident assignment is given by the DON 9) The Administrator will use the Designated Smoking Area QAPI Tool 3 times a day for 3 weeks, then 2 times a day for 2 weeks, and weekly for 2 months 10) The Administrator will review with the QAA Committee monthly the results of the Designated Smoking Area QAPI. The QAA team will make recommendations to sustain compliance. Following acceptance of the facility's Plan of Removal, the facility was monitored from 2/12/22 to 2/13/22. Record review was conducted of the facility's training that has been conducted for all staff. Documentation of the following was reviewed: training for all staff on all shifts [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent injuries for 2 of 11 residents reviewed for accidents/supervision (Residents # 1, #2) in that: --Resident # 1 sustained 2nd [MEDICAL CONDITION] his legs after spilling hot coffee. --Resident # 2 spilled hot coffee on his legs. These failures affected 2 residents and placed them at risk of injury, pain, and psychological harm. Findings included: Intake # 9 Observations on 2/6/19 at 9:15 am revealed the Hydration station at the entrance to the dining room, with containers water, juice, and coffee on the counter. The coffee carafe had a handle at the bottom which could be pushed to dispense the coffee in a cup placed below it. There was a graduated shelf on the side of the Hydration station, with napkins, condiments, plastic cups with handles, and Styrofoam cups in the top cup holder on the shelf. Resident # 3 was observed standing by the Hydration station, unsupervised, holding a Styrofoam cup of coffee. Interview at that time revealed he poured his own coffee, and he has to use 2 cups because it gets too hot with one Styrofoam cup, and there was a dent in the cup he was holding. Interview on 2/6/19 at 9:36am, Resident #4 said he served himself coffee from the carafe in the dining room. He said he used the plastic cups with the plastic lids. He said he had not had any problems with the temperature of the coffee. Interview on 2/6/19 at 9:42am, Resident #5 said she served herself coffee from the carafe in the dining room. She said she used her own mug. She said he had not had any problems with the temperature of the coffee. Record review of facility Incident report revealed 2 burn incidents; CR # 1 on 1/19/19 and Resident # 2 on 1/29/19. CR # 1 Record review of the face sheet for CR # 1 revealed a [AGE] year old male with current admission date of [DATE]. [DIAGNOSES REDACTED]. He was discharged on [DATE]. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS of 6, indicating moderate cognitive impairment. He had impaired cognitive skills for daily decision making, impaired vision, and required supervision and setup assistance for eating/drinking. Record review of the incident report dated 1/19/19 at 7:10am revealed Dietary aide heard resident (CR #1) screaming and noticed resident had spilled coffee on his lap and went to get CNA .CNA noticed resident holding his pants leg, dietary aide told CNA that resident burned himself with coffee, CNA immediately took resident to his room and informed the nurse on duty .resident stated he lost grip on his coffee from hand shaking and coffee cup fell .cold compress applied to groin site pain medication received for pain .physician called .orders to continue cold compress and apply TAO for blisters .received orders from physician to apply TAO and Xeroform drsg and wrap with Kerlix. Record review of the care plan, revised 1/19/19, revealed CR # 1 had a second degree burn of his right medial thigh and was at risk for infection and pain. Interventions included, Notify physician and responsible party for changes in condition, provide wound car per physician's orders [REDACTED]. Record review of CR #1's progress note dated 1/19/19 at 7:15 am revealed .informed by CNA that resident spilled hot coffee on his self in main dining room, entered resident's room to noted redness to left groin area and right groin area and small reddened area to lower left abdomen, cold towels placed . ' Record review of CR #1's wound/skin note dated 1/19/19 at 11:03 am revealed .informed resident burned his self with coffee this am .resident noted in pain, nurse on duty stated just gave him Tylenol 3 for pain .noted resident 2nd degree burn on his rt thigh that has 5 fluid filled blisters .left thigh has 1st degree burn and 2nd [MEDICAL CONDITION] 1 fluid filled blister .(MD) notified . The wound on the right medial thigh was 4.5cm in length, 9cm in width and 0.2cm in depth. The wound on the left medial thigh was 3.5cm in length, 11cm in width and 0.2cm in depth. Record review of CR #1's physician's orders [REDACTED]. Right inner thigh cleanse with normal saline pat dry apply silver [MEDICATION NAME] and wrap with kerlix everyday until heal (sic). Record review of CR #1's Licensed Nurse Medication Administration Record [REDACTED]. He was administered Tylenol #3 at 7:30am and 11:58pm. Record review of CR #1's Treatment Administration Record dated (MONTH) 2019 revealed his wounds were treated as ordered. Record review of CR #1's wound history dated 1/21/19 read in part, Wound rounds with (MD) on resident with rt medial thigh and left medial thigh second [MEDICAL CONDITION] legs have larger blister wound care doctor debrided both fluid filled blister at this time resident has a 100% granulation tissue with light serous drainage . Interview with Treatment nurse on 2/6/19 at 11:51 am revealed she was in the facility when CR # 1 spilled coffee on his legs. She stated she assessed the area, and he had 1st and 2nd [MEDICAL CONDITION] his legs that turned into blisters. She said CR # 1 was wearing light weight silky jogging pants. Interview with the Administrator on 2/6/19 at 1:48 pm revealed the incident happened on a Saturday, when CR #1 went to get coffee for himself and got a plastic cup instead of a regular coffee cup. She said the resident was paralyzed on one side from a stroke and was in a wheelchair. She said he had put the cup of coffee between his legs to hold while he propelled his wheelchair, and the coffee spilled on his legs as he was leaving. She said after the incident with CR # 1, the coffee was removed from the hydration station until the lids for the coffee cups were at the facility. She said the coffee temperature continued to be measured at 140 degrees before it was put out on the hydration station. She further stated residents used the regular plastic coffee cups and visitors used the styrofoam cups. She said the lids were to be placed on the plastic coffee cups to prevent spillage. Resident # 2 Record review of the face sheet for Resident # 2 revealed a [AGE] year old male with admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of the care plan initiated 9/14/17, revised 9/30/18 revealed Resident # 2 required supervision and tray set-up for eating. Record review of the latest quarterly MDS dated [DATE] revealed Resident # 2's BIMS score was 9 indicating moderately impaired cognitive skills for daily decision making and supervision and set-up was required for eating. Record review of the incident report dated 1/29/19 revealed .informed that resident (Resident #2) waste (sic) coffee on himself .assessed affected area no blisters or redness noted .client was wearing blue jeans that are very thick .coffee was hot . Record review Resident #2's Skin/Wound note dated 1/29/19 revealed .informed resident waste (sic) coffee on his leg .assessed area .noted no redness or open areas at this time .resident stated it was hot on his leg .applied cold towel .reported to nurse . Observation and interview with Resident # 2 on 2/6/19 at 1:22 pm revealed his hands were shaking. He said on the day of the incident, he was drinking coffee and a little bit spilled on his pants. He stated the coffee was hot on his leg, and said there was a little bit of redness and they put a cold compress on it. He said it hurt a little bit, and it had a little redness. Record review of facility In-service dated 1/19/19 revealed the topics were removing coffee from the dining room, removing styrofoam cups, check the temperature of the coffee before taking it to the dining room, and staff had to get resident's coffee. Interview with CNA G and CNA H on 2/6/19 at 3:28 pm revealed the CNA's have recently been having to supervise residents drinking coffee due to an incident when a resident burned himself with hot coffee. They stated the CNA's monitor in the dining room and in the hall, and they can't leave the dining area until the residents finish. Observations of the lids for the coffee cups on 2/6/19 at 2:10pm revealed they were stuck together and hard to separate and place onto the coffee cups. Observation on 2/8/19 at 6:50 am revealed the Treatment Nurse was monitoring residents in the dining room, and staff were offering to get coffee for residents as they entered the dining room, including putting the lids on the cups. Interview with CNA J on 2/8/19 at 8:15 am revealed they had an in-service after a resident burned his legs with hot coffee, and staff were to monitor residents in the halls and in the dining room. Record review of facility policy Safe Hot Beverage Handling, revised 9/18/17, revealed, in part: .after brewing, cool beverages to 140 degrees before serving .pour beverage into serving container, allow cooling to 140 degrees, cool to 140 degrees by adding ice, cool to 140 degrees by placing in freezer or refrigerator . Record review of the website https://ahca.myflorida.com revealed when the temperature of a hot liquid is increased to 140 F/ 60 C it takes only 5 seconds or less for a serious burn to occur . Record review of the website https://www.nutrition caresystems.com revealed, in part: .coffee or other hot beverage above 135 degrees can present a risk to residents who are cognitively impaired, have weakness or are fatigued, have difficulty with motor skills .these residents need to be monitored closely by staff .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 7 residents (Resident #17, #18 and #16) observed during medication (med) pass and 2 of 2 medication rooms observed. The facility failed to administer the correct dose of Gabapentin to Resident # 17, given for pain control for 30 days. Resident #17 he was in constant pain. The facility failed to administer insulin per physician order [REDACTED]. -LVN H charted medications before they were given to Resident #16. LVN H did not update the narcotic sheet immediately after removing medication and administering narcotic to Resident #16. Discontinued/expired medications were not properly stored, logged or secured; they were stored in an open bin and an open box in the medication rooms [ROOM NUMBERS]. Grapes and medications were stored in the refrigerator for resident nourishments, such as tube feedings and supplements. These failures affected three reidents and placed 52 other residents at risk for drug diversion from staff by not securing discontinued medications properly, had the potential to cause medication errors and cross contamination, drug diversion, increase in pain, Hyperglycemia, Diabetic Ketoacidosis, diabetic coma and worsening of medical condition. Findings include: Resident #17 Record review of the clinical record for Resident # 17 revealed that he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's MDS dated [DATE] read in part, BIMS score of 13, which indicated no cognitive impairment .extensive assistance from staf for all activities of daily living except eating .always incontinent of bowel and occasionally incontinent of bladder . the Resident has impairment in ROM to one side of the upper and lower extremities .pain assessment interview was not done. Record review of Resident #17's care plan revised on 3/27/17 revealed the following care plan: Focus: Resident #17 has chronic pain related to Osteoarthritis of right hip, has pain to right hand and wears a compression glove to help with pain and swelling. Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Acceptable level of pain-3. Interventions included: Identify and record previous pain history and management of that pain and impact on function .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care .Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat, and cold application, muscle stimulation, ultra-sound. Record review of Resident #17's Post-Acute care physician's Progress Note dated 3/28/17 revealed the following in part: Medical Decision Making/Assessment and Plan: Severe right hip pain- likely secondary to osteoarthritis and neuropathic pain. Increase Gabapentin to 800mg three times daily. Record review of Resident #17's physician orders [REDACTED]. Observation on 4/26/17 at 8:52 a.m. revealed MA L administer Gabapentin 600mg orally to Resident #17. Interview on 4/28/17 at 8:45 a.m. MA S revealed the order had to be changed. She revealed that she should have been giving the 800mg tablet of Gabapentin. In an interview on 4/28/17 at 8:46 a.m. the ADON revealed that the dose should have been Gabapentin 800mg. She revealed that the pharmacy had not sent the 800mg dose of Gabapentin to the facility. In an interview on 4/28/17 at 8:51 a.m. the DON revealed that the medication should have been checked for the correct dosage with each medication pass. She revealed that the facility would investigate. In an interview on 4/28/17 at 9:53 a.m. the DON revealed that the Gabapentin was increased to 800mg on 3/28/17 and the pharmacy never sent the new dose of Gabapentin 800mg to the facility. She revealed that the nurses were responsible for checking for the receipt of the medication as well as placing a change of direction sticker on the old medication when the orders have been changed. Observation and Interview on 4/28/17 at 9:15 a.m. Resident # 17 revealed that he was in bed and grimacing due to currently in pain to his right hip at a 6/10. He said that he takes scheduled pain medication and pain medication as needed. He said that he needs medication around the clock, however he still had pain. When asked if he notified the physician of continued pain, Resident #17 revealed that the physician said he would try a nerve pill to help with the pain. Resident #17 revealed that he was constantly in pain at 4/10 or greater. When asked if the pain interfered with his day to day activities he said he did not want to get out of bed because of the pain. Record review of Resident #17's consolidated order summary report for April 2017 revealed a physician's orders [REDACTED]. Regular pain assessments and/or Pain Management Flow sheet requested from the facility, however it was not received prior to exit. No consistent pain assessment data revealed with record review of Resident #17's clinical record. Resident # 18 Record review of the clinical record for Resident #18 revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #18's MDS dated [DATE] read in part, BIMS score of 12, which indicated moderate cognitive impairment . Required extensive assistance for all activities of daily living except transfers, requiring limited assistance and eating .Occasionally incontinent of bowel and occasionally incontinent of bladder . Impairment in ROM to one side of the lower extremities .Any falls since admission/Entry or reentry or prior assessment: Yes, Section for Number of falls: 1-No injury, 1- Injury (except major) .Diabetic foot ulcer(s) Record review of Resident #18's Care plan revised 2/28/17 revealed the following in part: Focus: Resident # 18 has Peripheral Vascular Disease related to Diabetes, which included a goal and interventions Focus: Resident # 18 has Diabetes Mellitus Goal: The resident will have no complications related to diabetes through the review date Interventions: Accuchecks as ordered and as needed, document results, refer to sliding scale as ordered, notify MD as needed Record review of Resident #18's physician orders [REDACTED]. Humalog Solution. Inject as per sliding scale If 251-300= 2 units If 301-350= 4 units If 351-400=6 units If 401-450= 8 units If 451-500= 10 units and call md if over 500, subcutaneously before meals and at bedtime for Diabetes Mellitus 2 (DM2) Record review of Resident #18's physician orders [REDACTED]. -Novolin R Solution. Inject 25 units before meals and at bedtime for diabetes Observation and interview on 4/26/17 at 11:24am Resident #18 was alert and oriented and stated he was feeling okay today. Observation and interview on 4/26/17 at 11:26 a.m. revealed Resident # 18 had a blood glucose level of 358. LVN V administered Novolin R insulin 25 units subcutaneously to Resident #18. Humalog per sliding scale was not given. When asked what should be done for the blood sugar result of 358 LVN V said there was an order to call the physician for a blood sugar greater than 500 but there were no other orders for insulin except for his scheduled dose. In an interview on 4/28/17 at 10:30 a.m. the ADON revealed that the order to resume Humalog insulin per sliding scale was entered wrong in the computer and the resume order was not seen on the nurses Electronic Medication Administration Record [REDACTED]. In an interview on 4/28/17 at 10:50 a.m. the Corporate Nurse revealed that it was a transcription error due to the nurse not knowing the correct way to enter the order in the new system. She said the order for Humalog sliding scale was placed in a different administration category which caused the order to be unseen on the EMAR in which nurses use to administer medications. When asked what the expectation of nurses for checking orders was and for administering medications, she revealed that orders should be checked daily. She said that orders should have been checked for accuracy against the EMAR. Record review of blood glucose results for Resident # 18 from 4/4/17-4/28/17 revealed that Resident # 18's blood glucose was above 251 on each day at least once except on 4/18/17 in which all results were not documented, indicating a need for the sliding scale dose per physician orders [REDACTED]. Resident #16 Observation on 4/26/17 at 12:53p.m. revealed LVN H prepared and administered medications and a narcotic (Lortab) to Resident #16 via Gastrostomy tube (G tube). LVN H did not update narcotic book after taking out the narcotic Lortab and LVN H did not chart medications after administering them. In an interview on 4/26/17 at 12:55 p.m. LVN H was asked to complete the process for medication administration. She revealed that she clicked the save button while preparing medications, which means it was given. LVN H did not update the narcotic count sheet for the Lortab that was given prior to leaving Resident # 16's room. In an interview on 4/27/17 at 10:07 a.m. LVN H revealed that she should have charted medications after they were given, not before. When asked about the narcotic count sheet she revealed that she updated it later and it should have been done when the medication was taken out to administer. In an interview on 4/27/17 at 10:43 a.m. the DON revealed that the narcotic sheet should be updated immediately, when dosage is prepared. She also said that medication administration should be charted after the medications are given to the Residents, not before. Observation on 4/26/17 at 2:50 p.m. and on 4/27/17 at 11:23 a.m. revealed medication rooms [ROOM NUMBERS] had discontinued/expired medications in an open bin on the counter and an open box not labeled with medications and were not closed or secured. Observation on Station 2 Medication room on 4/27/17 at 11:23 a.m. revealed the following: -There was a plastic bag with a used tuberculin syringe and expired and discontinued medications for a resident who had expired on 3/19/17 stored on the shelves in the medication room where the overflow/stock medications are stored. -The resident refrigerator for supplements and formula had a bag of grapes and vials of insulin stored in it. Interview on 4/27/17 at 12:21 p.m. the DON and administrator stated that the medications were secured enough in the medication room and that's what the regulations require. The administrator stated that they only have to lock up narcotics. The DON stated that expired medications should not be stored with other stock medications. She revealed they should be placed in a box for destruction. The DON said grapes should not be in the medication room refrigerator. Information reviewed from the American Diabetes Association from the web address below on 5/1/17 revealed the following: http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html - In type 2 diabetes, a condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently, your body does not use insulin properly. Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people. This is called insulin resistance. This occurs most often in people with type 2 diabetes but people with type 1 diabetes can have insulin resistance, too. At first, the pancreas makes extra insulin to make up for it. But, over time your pancreas isn't able to keep up and can't make enough insulin to keep your blood glucose levels normal. - When glucose builds up in the blood instead of going into cells, it can cause two problems: *Right away, your cells may be starved for energy. *Over time, high blood glucose levels may hurt your eyes, kidneys, nerves or heart. * Diabetes increases your risk for many serious health problems. * Complications include: Skin Complications, Eye Complications, Neuropathy Foot Complications, DKA (Ketoacidosis) & Ketones, Kidney Disease ([DIAGNOSES REDACTED]), High Blood Pressure (Hypertension), Stroke, Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED] (HHNS), Gastroparesis, and Heart Disease. Record review of the facility's policy for Pain Management, revised 11/2009, revealed the following in part: -Appropriate pain management helps the resident avoid periods of pain as much as possible and establishes a treatment plan for such episodes of acute pain and/or chronic pain, if and when they occur. Intervening to treat pain before the pain becomes moderate is expected. The facility's expectations for pain management shall include but not limited to: Identifying and intervening to treat pain aggressively and before the pain becomes moderate. Documenting pain assessment(s), interventions, and evaluation activities in a clear and concise manner and using the information collected to implement a multidisciplinary individualized plan of care. Staff recognizing that pain medications may be given around the clock The use of non-drug interventions to assist in pain alleviation is appropriate. Intervening to minimize drug side effects. Implementing quality assurance/improvement standards to monitor the pain management The licensed nurse shall administer medications and treatments as prescribed by the physician to provide safe and effective pain relief. The Pain Management Flow Sheet shall be completed each time a as needed pain medication is administered for acute as well as breakthrough chronic pain and reviewed weekly to determine if the resident's pain is adequately controlled by occasional as needed medication and if not, would a regular regimen of routine pain medications be more appropriate. Record review of the facility's policy for Medication Administration-General Guidelines revised March 2011 revealed the following in part: -Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED]. -Medications are administered in accordance with written orders of the attending physician. Record review of the policy for Medication Administration revised March 2011 revealed the following: -The individual who administers the medication dose records the administration on the resident's MAR indicated [REDACTED] Record review of the Discontinued Medications policy revised March 2011 revealed the following: -When medications are discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued and destroyed. Record review of the policy for Medication Storage, revised March 2011, revealed the following. -Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from pharmacy, if current order exist. According to the CMS 672 dated 4/26/17 the facility census was 55.

Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for two of seven (Resident #17, #18) reviewed for medication pass. The facility failed to administer the correct dose of [MEDICATION NAME] to Resident # 17, given for pain control for 30 days. Resident #17 stated he was in constant pain. The facility failed to administer insulin per physician order [REDACTED]. These failures affected 2 residents and placed 27 residents on pain management and 20 residents who receive insulin for diabetes, having the potential to cause an increase in pain, [MEDICAL CONDITION], Diabetic Ketoacidosis, diabetic coma and worsening of medical condition. Findings include: Resident #17 Record review of the clinical record for Resident # 17 revealed that he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's MDS dated [DATE] read in part, BIMS score of 13, which indicated no cognitive impairment .extensive assistance from staf for all activities of daily living except eating .always incontinent of bowel and occasionally incontinent of bladder . the Resident has impairment in ROM to one side of the upper and lower extremities .pain assessment interview was not done. Record review of Resident #17's care plan revised on 3/27/17 revealed the following care plan: Focus: Resident #17 has chronic pain related to [MEDICAL CONDITION] of right hip, has pain to right hand and wears a compression glove to help with pain and swelling. Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Acceptable level of pain-3. Interventions included: Identify and record previous pain history and management of that pain and impact on function .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care .Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat, and cold application, muscle stimulation, ultra-sound. Record review of Resident #17's Post-Acute care physician's Progress Note dated 3/28/17 revealed the following in part: Medical Decision Making/Assessment and Plan: Severe right hip pain- likely secondary to [MEDICAL CONDITION] and neuropathic pain. Increase [MEDICATION NAME] to 800mg three times daily. Record review of Resident #17's physician orders [REDACTED]. Observation on 4/26/17 at 8:52 a.m. revealed MA L administer [MEDICATION NAME] 600mg orally to Resident #17. Interview on 4/28/17 at 8:45 a.m. MA S revealed the order had to be changed. She revealed that she should have been giving the 800mg tablet of [MEDICATION NAME]. In an interview on 4/28/17 at 8:46 a.m. the ADON revealed that the dose should have been [MEDICATION NAME] 800mg. She revealed that the pharmacy had not sent the 800mg dose of [MEDICATION NAME] to the facility. In an interview on 4/28/17 at 8:51 a.m. the DON revealed that the medication should have been checked for the correct dosage with each medication pass. She revealed that the facility would investigate. In an interview on 4/28/17 at 9:53 a.m. the DON revealed that the [MEDICATION NAME] was increased to 800mg on 3/28/17 and the pharmacy never sent the new dose of [MEDICATION NAME] 800mg to the facility. She revealed that the nurses were responsible for checking for the receipt of the medication as well as placing a change of direction sticker on the old medication when the orders have been changed. Observation and Interview on 4/28/17 at 9:15 a.m. Resident # 17 revealed that he was in bed and grimacing due to currently in pain to his right hip at a 6/10. He said that he takes scheduled pain medication and pain medication as needed. He said that he needs medication around the clock, however he still had pain. When asked if he notified the physician of continued pain, Resident #17 revealed that the physician said he would try a nerve pill to help with the pain. Resident #17 revealed that he was constantly in pain at 4/10 or greater. When asked if the pain interfered with his day to day activities he said he did not want to get out of bed because of the pain. Record review of Resident #17's consolidated order summary report for April 2017 revealed a physician's orders [REDACTED]. Regular pain assessments and/or Pain Management Flow sheet requested from the facility, however it was not received prior to exit. No consistent pain assessment data revealed with record review of Resident #17's clinical record. Resident # 18 Record review of the clinical record for Resident #18 revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #18's MDS dated [DATE] read in part, BIMS score of 12, which indicated moderate cognitive impairment . Required extensive assistance for all activities of daily living except transfers, requiring limited assistance and eating .Occasionally incontinent of bowel and occasionally incontinent of bladder . Impairment in ROM to one side of the lower extremities .Any falls since admission/Entry or reentry or prior assessment: Yes, Section for Number of falls: 1-No injury, 1- Injury (except major) .[MEDICAL CONDITION](s) Record review of Resident #18's Care plan revised 2/28/17 revealed the following in part: Focus: Resident # 18 has [MEDICAL CONDITION] related to Diabetes, which included a goal and interventions Focus: Resident # 18 has Diabetes Mellitus Goal: The resident will have no complications related to diabetes through the review date Interventions: Accuchecks as ordered and as needed, document results, refer to sliding scale as ordered, notify MD as needed Record review of Resident #18's physician orders [REDACTED]. Humalog Solution. Inject as per sliding scale If 251-300= 2 units If 301-350= 4 units If 351-400=6 units If 401-450= 8 units If 451-500= 10 units and call md if over 500, subcutaneously before meals and at bedtime for Diabetes Mellitus 2 (DM2) Record review of Resident #18's physician orders [REDACTED]. -[MEDICATION NAME] R Solution. Inject 25 units before meals and at bedtime for diabetes Obseervation and interview on 4/26/17 at 11:24am Resident #18 was alert and oriented and stated he was feeling okay today. Observation and interview on 4/26/17 at 11:26 a.m. revealed Resident # 18 had a blood glucose level of 358. LVN V administered [MEDICATION NAME] R insulin 25 units subcutaneously to Resident #18. Humalog per sliding scale was not given. When asked what should be done for the blood sugar result of 358 LVN V said there was an order to call the physician for a blood sugar greater than 500 but there were no other orders for insulin except for his scheduled dose. In an interview on 4/28/17 at 10:30 a.m. the ADON revealed that the order to resume Humalog insulin per sliding scale was entered wrong in the computer and the resume order was not seen on the nurses Electronic Medication Administration Record [REDACTED]. In an interview on 4/28/17 at 10:50 a.m. the Corporate Nurse revealed that it was a transcription error due to the nurse not knowing the correct way to enter the order in the new system. She said the order for Humalog sliding scale was placed in a different administration category which caused the order to be unseen on the EMAR in which nurses use to administer medications. When asked what the expectation of nurses for checking orders was and for administering medications, she revealed that orders should be checked daily. She said that orders should have been checked for accuracy against the EMAR. Record review of blood glucose results for Resident # 18 from 4/4/17-4/28/17 revealed that Resident # 18's blood glucose was above 251 on each day at least once except on 4/18/17 in which all results were not documented, indicating a need for the sliding scale dose per physician orders [REDACTED]. Information reviewed from the American Diabetes Association from the web address below on 5/1/17 revealed the following: http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html - In type 2 diabetes, a condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently, your body does not use insulin properly. Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people. This is called insulin resistance. This occurs most often in people with type 2 diabetes but people with type 1 diabetes can have insulin resistance, too. At first, the pancreas makes extra insulin to make up for it. But, over time your pancreas isn't able to keep up and can't make enough insulin to keep your blood glucose levels normal. - When glucose builds up in the blood instead of going into cells, it can cause two problems: *Right away, your cells may be starved for energy. *Over time, high blood glucose levels may hurt your eyes, kidneys, nerves or heart. * Diabetes increases your risk for many serious health problems. * Complications include: Skin Complications, Eye Complications, [MEDICAL CONDITION] Foot Complications, DKA (Ketoacidosis) & [MEDICATION NAME], Kidney Disease ([MEDICAL CONDITION]), High Blood Pressure (Hypertension), Stroke, Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED] (HHNS), Gastroparesis, and [MEDICAL CONDITION]. Record review of the facility's policy for Pain Management, revised 11/2009, revealed the following in part: -Appropriate pain management helps the resident avoid periods of pain as much as possible and establishes a treatment plan for such episodes of acute pain and/or chronic pain, if and when they occur. Intervening to treat pain before the pain becomes moderate is expected. The facility's expectations for pain management shall include but not limited to: Identifying and intervening to treat pain aggressively and before the pain becomes moderate. Documenting pain assessment(s), interventions, and evaluation activities in a clear and concise manner and using the information collected to implement a multidisciplinary individualized plan of care. Staff recognizing that pain medications may be given around the clock The use of non-drug interventions to assist in pain alleviation is appropriate. Intervening to minimize drug side effects. Implementing quality assurance/improvement standards to monitor the pain management The licensed nurse shall administer medications and treatments as prescribed by the physician to provide safe and effective pain relief. The Pain Management Flow Sheet shall be completed each time a as needed pain medication is administered for acute as well as breakthrough chronic pain and reviewed weekly to determine if the resident's pain is adequately controlled by occasional as needed medication and if not, would a regular regimen of routine pain medications be more appropriate. Record review of the facility's policy for Medication Administration-General Guidelines revised March 2011 revealed the following in part: -Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED]. -Medications are administered in accordance with written orders of the attending physician. According to the list provided by the facility there were 20 residents on Antidiabetics. The facility 802 received 4/26/17 listed 27 residents with moderate to severe pain as an area of concern.

Based on observations, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of 22 residents (Residents #17, #18) reviewed for care. The facility failed to administer the correct dose of [MEDICATION NAME] to Resident # 17, given for pain control for 30 days. Resident #17 stated he was in constant pain. The facility failed to administer insulin per physician order [REDACTED]. These failures affected 2 residents and placed 27 residents on pain management and 20 residents who receive insulin for diabetes, having the potential to cause an increase in pain, [MEDICAL CONDITION], Diabetic Ketoacidosis, diabetic coma and worsening of medical condition. Findings include: Resident #17 Record review of the clinical record for Resident # 17 revealed that he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's MDS dated [DATE] read in part, BIMS score of 13, which indicated no cognitive impairment .extensive assistance from staf for all activities of daily living except eating .always incontinent of bowel and occasionally incontinent of bladder . the Resident has impairment in ROM to one side of the upper and lower extremities .pain assessment interview was not done. Record review of Resident #17's care plan revised on 3/27/17 revealed the following care plan: Focus: Resident #17 has chronic pain related to [MEDICAL CONDITION] of right hip, has pain to right hand and wears a compression glove to help with pain and swelling. Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Acceptable level of pain-3. Interventions included: Identify and record previous pain history and management of that pain and impact on function .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care .Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat, and cold application, muscle stimulation, ultra-sound. Record review of Resident #17's Post-Acute care physician's Progress Note dated 3/28/17 revealed the following in part: Medical Decision Making/Assessment and Plan: Severe right hip pain- likely secondary to [MEDICAL CONDITION] and neuropathic pain. Increase [MEDICATION NAME] to 800mg three times daily. Record review of Resident #17's physician orders [REDACTED]. Observation on 4/26/17 at 8:52 a.m. revealed MA L administer [MEDICATION NAME] 600mg orally to Resident #17. Interview on 4/28/17 at 8:45 a.m. MA S revealed the order had to be changed. She revealed that she should have been giving the 800mg tablet of [MEDICATION NAME]. In an interview on 4/28/17 at 8:46 a.m. the ADON revealed that the dose should have been [MEDICATION NAME] 800mg. She revealed that the pharmacy had not sent the 800mg dose of [MEDICATION NAME] to the facility. In an interview on 4/28/17 at 8:51 a.m. the DON revealed that the medication should have been checked by the nursing staff for the correct dosage with each medication pass. She revealed that the facility would investigate. In an interview on 4/28/17 at 9:53 a.m. the DON revealed that the [MEDICATION NAME] was increased to 800mg on 3/28/17 and the pharmacy never sent the new dose of [MEDICATION NAME] 800mg to the facility. She revealed that the nurses were responsible for checking for the receipt of the medication as well as placing a change of direction sticker on the old medication when the orders have been changed. Observation and Interview on 4/28/17 at 9:15 a.m. Resident # 17 revealed that he was in bed and grimacing due to currently in pain to his right hip at a 6/10. He said that he takes scheduled pain medication and pain medication as needed. He said that he needs medication around the clock, however he still had pain. When asked if he notified the physician of continued pain, Resident #17 revealed that the physician said he would try a nerve pill to help with the pain. Resident #17 revealed that he was constantly in pain at 4/10 or greater.When asked if the pain interfered with his day to day activities he said he did not want to get out of bed because of the pain. Record review of Resident #17's consolidated order summary report for April 2017 revealed a physician's orders [REDACTED]. Regular pain assessments and/or Pain Management Flow sheet requested from the facility, however it was not received prior to exit. No consistent pain assessment data revealed with record review of Resident #17's clinical record. Resident # 18 Record review of the clinical record for Resident #18 revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #18's MDS dated [DATE] read in part, BIMS score of 12, which indicated moderate cognitive impairment . Required extensive assistance for all activities of daily living except transfers, requiring limited assistance and eating .Occasionally incontinent of bowel and occasionally incontinent of bladder . Impairment in ROM to one side of the lower extremities .Any falls since admission/Entry or reentry or prior assessment: Yes, Section for Number of falls: 1-No injury, 1- Injury (except major) .[MEDICAL CONDITION](s) Record review of Resident #18's Care plan revised 2/28/17 revealed the following in part: Focus: Resident # 18 has [MEDICAL CONDITION] related to Diabetes, which included a goal and interventions Focus: Resident # 18 has Diabetes Mellitus Goal: The resident will have no complications related to diabetes through the review date Interventions: Accuchecks as ordered and as needed, document results, refer to sliding scale as ordered, notify MD as needed Record review of Resident #18's physician orders [REDACTED]. Humalog Solution. Inject as per sliding scale If 251-300= 2 units If 301-350= 4 units If 351-400=6 units If 401-450= 8 units If 451-500= 10 units and call md if over 500, subcutaneously before meals and at bedtime for Diabetes Mellitus 2 (DM2) Record review of Resident #18's physician orders [REDACTED]. -[MEDICATION NAME] R Solution. Inject 25 units before meals and at bedtime for diabetes Observation and interview on 4/26/17 at 11:24am Resident #18 was alert and oriented and stated he was feeling okay today. Observation and interview on 4/26/17 at 11:26 a.m. revealed Resident # 18 had a blood glucose level of 358. LVN V administered [MEDICATION NAME] R insulin 25 units subcutaneously to Resident #18. Humalog per sliding scale was not given. When asked what should be done for the blood sugar result of 358 LVN V said there was an order to call the physician for a blood sugar greater than 500 but there were no other orders for insulin except for his scheduled dose. In an interview on 4/28/17 at 10:30 a.m. the ADON revealed that the order to resume Humalog insulin per sliding scale was entered wrong in the computer and the resume order was not seen on the nurses Electronic Medication Administration Record [REDACTED]. In an interview on 4/28/17 at 10:50 a.m. the Corporate Nurse revealed that it was a transcription error due to the nurse not knowing the correct way to enter the order in the new system. She said the order for Humalog sliding scale was placed in a different administration category which caused the order to be unseen on the EMAR in which nurses use to administer medications. When asked what the expectation of nurses for checking orders was and for administering medications, she revealed that orders should be checked daily. She said that orders should have been checked for accuracy against the EMAR. Record review of blood glucose results for Resident # 18 from 4/4/17-4/28/17 revealed that Resident # 18's blood glucose was above 251 on each day at least once except on 4/18/17 in which all results were not documented, indicating a need for the sliding scale dose per physician orders [REDACTED]. Information reviewed from the American Diabetes Association from the web address below on 5/1/17 revealed the following: http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html - In type 2 diabetes, a condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently, your body does not use insulin properly. Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people. This is called insulin resistance. This occurs most often in people with type 2 diabetes but people with type 1 diabetes can have insulin resistance, too. At first, the pancreas makes extra insulin to make up for it. But, over time your pancreas isn't able to keep up and can't make enough insulin to keep your blood glucose levels normal. - When glucose builds up in the blood instead of going into cells, it can cause two problems: *Right away, your cells may be starved for energy. *Over time, high blood glucose levels may hurt your eyes, kidneys, nerves or heart. * Diabetes increases your risk for many serious health problems. * Complications include: Skin Complications, Eye Complications, [MEDICAL CONDITION] Foot Complications, DKA (Ketoacidosis) & [MEDICATION NAME], Kidney Disease ([MEDICAL CONDITION]), High Blood Pressure (Hypertension), Stroke, Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED] (HHNS), Gastroparesis, and [MEDICAL CONDITION]. Record review of the facility's policy for Pain Management, revised 11/2009, revealed the following in part: -Appropriate pain management helps the resident avoid periods of pain as much as possible and establishes a treatment plan for such episodes of acute pain and/or chronic pain, if and when they occur. Intervening to treat pain before the pain becomes moderate is expected. The facility's expectations for pain management shall include but not limited to: Identifying and intervening to treat pain aggressively and before the pain becomes moderate. Documenting pain assessment(s), interventions, and evaluation activities in a clear and concise manner and using the information collected to implement a multidisciplinary individualized plan of care. Staff recognizing that pain medications may be given around the clock The use of non-drug interventions to assist in pain alleviation is appropriate. Intervening to minimize drug side effects. Implementing quality assurance/improvement standards to monitor the pain management The licensed nurse shall administer medications and treatments as prescribed by the physician to provide safe and effective pain relief. The Pain Management Flow Sheet shall be completed each time a as needed pain medication is administered for acute as well as breakthrough chronic pain and reviewed weekly to determine if the resident's pain is adequately controlled by occasional as needed medication and if not, would a regular regimen of routine pain medications be more appropriate. Record review of the facility's policy for Medication Administration-General Guidelines revised March 2011 revealed the following in part: -Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED]. -Medications are administered in accordance with written orders of the attending physician. According to the list provided by the facility there were 20 residents on Antidiabetics. The facility 802 received 4/26/17 listed 27 residents with moderate to severe pain as an area of concern.

Based on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with the comprehensive assessment and plan of care for 5 of 21 residents (Residents # 5, #16, #17, #18, and #19) reviewed for quality of care related to diabetes monitoring and control in that: --Without physician orders [REDACTED].#17's had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. Insulin was held insulin with a fsbs of 130 at 8:00 a.m. on 06/02/15; the 8:00 p.m., fsbs was 358 mg/dl. Insulin was held with a fsbs of 78 at 8:00 a.m. on 06/15/15; the 8:00 p.m. fsbs was 334 mg/dl. Insulin was held with a fsbs of 76 mg/dl on 06/17/15; the 8:00 p.m. fsbs was 354 mg/dl. --Without physician orders [REDACTED].#5 had a finger stick blood sugar (fsbs) level of 104 milligrams per deciliter (mg/dl) during the scheduled 8:00 a.m. accucheck on 06/18/15. --Without physician's orders [REDACTED].#16 had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. --LVN L did not consult the physicians or physicians' representative for permission to hold insulin. --Without physician's orders [REDACTED].#18 had a fsbs of 124 during the scheduled 8:00 a.m. accucheck on 06/20/15. --LVN B did not administer insulin as ordered according to the prescribed sliding scale when Resident #19 had a fsbs of 197 mg/dl during the scheduled 11:00 a.m. accucheck on 06/20/15. An Immediate Jeopardy (IJ) was identified on 06/18/15. While the IJ was removed on 06/23/15, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 5 residents and placed an additional 16 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Findings include: Resident #17 Record review of Resident #17's admission orders [REDACTED]. The Orders reflected, [MEDICATION NAME] (insulin) 25 u q 12h (units every 12 hours). Record review of Resident #17's Physician's Telephone Order (TO) dated 05/24/15 reflected the insulin dose was to be increased to 35 units every 12 hours. Record review of Resident #17's June 2015 nurses' Treatment Sheet revealed the insulin dosage had not been changed to 35 units every 12 hours. The Sheet reflected the 25 units every 12 hour regimen. -06/02/15, Resident #17 had a fsbs of 130 mg/dl at 8:00 a.m. on 06/02/15. That the scheduled insulin was withheld by LVN L. The subsequent fsbs, at 8:00 p.m., reflected a value of 358 mg/dl. -06/15/15, Resident #17 had a fsbs of 78 at 8:00 a.m. on 06/15/15. LVN L held the insulin. The subsequent fsbs, at 8:00 p.m., reflected a value of 334 mg/dl. -06/17/15, LVN L withheld Resident #17's insulin on 06/17/15, when the 8:00 a.m. fsbs reflected 76 mg/dl. The subsequent fsbs, at 8:00 p.m. on that same date, reflected a value of 354 mg/dl. -06/18/15, a 81 mg/dl fsbs level for 06/18/15 at the scheduled 8:00 a.m. accucheck. The scheduled was reflected as not been given, and the word 'Hold' was scribed in the box. The back of the sheet revealed 6/18/15-Held [MEDICATION NAME] @0800 FSBS-81. The initials were LVN L's. On 06/18/15 at 8:00 a.m., review of the Daily Skilled Nurses' Notes (NN) dated 06/18/15 revealed no documentation regarding the 81 mg/dl fsbs. In an interview on 06/18/15 at 8:05 a.m., LVN L stated she had not spoken to anyone regarding withholding Resident #17's insulin. She stated she had not had a chance to call Phys Q, Resident #17's primary care physician. On 06/19/15 at 10:15 a.m., the NN dated 06/18/15 was reviewed. The NN reflected 6/18/15 Nurse to call Physician Assistant (PA) V regarding fsbs 81 and [MEDICATION NAME] @800 (8:00 a.m.) held. NP said ok. In an interview via telephone on 06/19/15 at 10:35 a.m., Physician's Assistant (PA) V was asked if he received a call regarding Resident #17's fsbs and/or insulin. PA V stated he did not receive any call about fsbs or insulin, but did receive a call about a different resident's blood pressure. In an interview on 06/19/15 at 10:22 a.m., LVN L stated the NN dated 06/18/15 should have been dated 06/19/15 at 6:15 a.m. LVN L stated, I talked to PA V, the PA for Phys Q. LVN L stated PA V informed her It's fine to hold the [MEDICATION NAME] at 8 a.m. and 8 p.m. if the blood sugar is less than 110 (mg/dl). I called him again at 6:02 (a.m.). It's documented. Why would he say he didn't? I have a nurse, LVN F who witnessed me on the phone. She was sitting by me. In an interview on 06/19/15 at 10:50 a.m., LVN F stated She called NP S twice (not PA V). He ended up calling her back. LVN F stated she answered the call, so she was sure it was NP S, not PA V. NP S is not a care provider for Resident #17. In an interview via telephone on 06/19/15 at 11:10 a.m., PA V stated he had spoken with the facility after the 10:35 a.m. interview with the surveyor. PA V then stated, I was mistaken. They did call me on a blood sugar and a blood pressure. When asked specifics, the PA stated he could not remember. He stated he did not give parameters to hold insulin. He stated the call was on his cell phone. When asked if he could provide the time and date of the facility phone calls, PA V stated, I go back and erase the phone calls after I hang up. Observation on 06/19/15 at 4:30 p.m. revealed PA V at the facility. In an interview at that time, PA V stated, They called me this morning about an 80 (mg/dl) blood sugar, and later about a blood pressure. The 80 blood sugar they asked, 'Shall I hold the [MEDICATION NAME] this morning?' I said 'Yes.' I would be there later to check all the blood sugars. PA V added, I just wanted to reiterate that's what they told me. At that time, PA V was asked twice if he was sure it was this morning. PA V answered, Yes, this morning. I don't know what time. PA V was asked again if he was sure he was addressing an 80 mg/dl for the same morning, 06/19/15. PA V answered, Yes. He stated he was not sure which resident, but that Resident #17's name sounds familiar. When asked if he thought it was for Resident #17, PA V answered, I believe so. At that time, PA V was informed that the 8:00 a.m. fsbs for Resident #17 on this same morning was 236 mg/dl, not 80 mg/dl. PA V stated, That doesn't sound like 80 at all. I wonder if someone else over there had an 80 (mg/dl). PA V stated he did not discuss any other resident's fsbs. On 06/19/15 at 4:35 p.m., PA V was asked to review the previous seven days of fsbs values for Resident #17. Regarding the 06/15/15 (Monday) 8:00 a.m. value of 78 mg/dl at 8:00 a.m., the insulin being withheld, then the 8:00 p.m. value of 334 mg/dl, PA V stated the facility did not call him. Regarding the 06/17/15 (Wednesday) 8:00 a.m. value of 76 mg/dl, the insulin being withheld, then the 8:00 p.m. value of 354 mg/dl, PA V was asked if the [MEDICATION NAME] should have been held. PA V answered, No. Maybe they don't know how it works. He stated he did not receive a call from the facility. PA V stated he would not have given an order to hold the insulin for fsbs below 110 mg/dl. PA V stated, If they had said the last five days he was over 300 (mg/dl), I would have said give him the [MEDICATION NAME]. I didn't know the whole story. Resident #5 Record review of Resident #5's Admission Record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Order Summary Report dated 05/01/15 reflected [MEDICATION NAME] Mix 70/30 [MEDICATION NAME] Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin [MEDICATION NAME] Prot & [MEDICATION NAME]) Inject 40 unit subcutaneously every 12 hours related to Diab (diabetes) w/o comp (without complications) Type II . Further review of Resident #5's Order Summary Report dated 05/01/15 revealed it did not include parameters for withholding the insulin. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated she was finished conducting her morning accuchecks. Record review of Resident #5's June 2015 nurses' Treatment Sheet on 06/18/15 at 7:40 a.m. revealed the 8:00 a.m.-scheduled fsbs was 104 mg/dl (milligrams per deciliter). In the box below the '104', initials were reflected, and they had been circled. Review of the back of the page revealed, 6/18/15 - Held 70/30 @ 0800 FSBS - 104 The initials to the right of the note were LVN L's. In an interview on 06/18/15 at 7:40 a.m., LVN L stated she held the scheduled insulin for Resident #5. She stated that she had called Physician (Phys) P and the physician told her to withhold the insulin. She stated she had not yet written the order. When asked for Phys P's telephone number, LVN L stated she did not call Phys P, but rather called Nurse Practitioner (NP) R. LVN L was asked for the telephone number she called, and LVN L called out the number. On 06/18/15 at 7:45 a.m. the surveyor called the telephone number that had been provided by LVN L. The person who answered the phone was NP S. NP S stated that he was the NP on call, and that NP R had not been on call since 06/15/15. NP S stated that there had been no calls regarding fsbs readings that morning. NP S stated he had been awake since 6:30 a.m., and there had been no calls. NP S stated he would check the call history and call the surveyor back. In an interview on 06/18/15 at 7:48 a.m., LVN L confirmed the phone number and again stated she had spoken with NP R. At that time, NP S called back, and confirmed that there was no call reflected on the call log since 3:30 a.m., and that was for a different issue. NP S concluded, No, they didn't call me. Resident #16 Record review of Resident #16's Admission Record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #16's June 2015 nurses' Treatment Sheet revealed no scheduled insulin to be administered in the mornings. The sheet reflected the 7:00 a.m.-scheduled fsbs reading was 81 mg/dl. The sheet did reflect the resident was to receive [MEDICATION NAME] insulin, 12 units, every night at bedtime. The sheet did not reflect the night dose for 06/17/15 had been administered. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated that she already called Phys O, and that Phys O told her to withhold any insulin. When asked for Phys O's telephone number, LVN L stated she did not call Phys O, but had called NP D. Observation and interview on 06/18/15 at 8:10 a.m. revealed NP D at nurses' station 2, at the opposite end of the facility. NP D initially stated that she had not received any calls about fsbs levels. Then NP D stated she did receive a call but could not answer it because she was already on a call. NP D showed the surveyor her call log, which reflected a call from the facility at 7:50 a.m., ten minutes after LVN L was asked about Resident #16. Resident #18 Record review of Resident #18's June 2015 Nurses' Treatment Sheet revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #18's June 2015 Nurses' Treatment Sheet conducted on 06/20/14 at 3:00 p.m. reflected the her 8:00 a.m. fsbs was 124 mg/dl. Her testing order was FSBS two times a day FSBS Parameters: If blood sugar below 60 or above 400 call physician. Her treatment order was [MEDICATION NAME] Solution 100 Unit/ml (Insulin Detimir) Inject 12 unit subcutaneously two times a day related to Diab (Diabetes) . There were no parameters to hold the insulin. The sheet reflected the 8:00 a.m. insulin for 06/20/15 was not given. Record review of Resident #18's NN revealed no documentation of a reason to withhold the [MEDICATION NAME] insulin. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to identify the initials of the nurse who recorded Resident #18's fsbs. ADON A stated the initials the under the 124 for Resident #18's 8:00 a.m. fsbs, and under the 197 for Resident #18's 11:00 a.m. fsbs were those of LVN B. Resident #19 Record review of Resident #19's June 2015 Medication Sheet reflected FSBS ac/hs (before meals and at hour of sleep) The second June 2015 Medication Sheet reflected Resident #19 was to receive Humulog insulin, based on a sliding scale, dependent on the results of the fsbs values. Record review of Resident #19's June 2015 Medication sheet reviewed on 06/20/15 at 3:00 p.m., reflected the 11:00 a.m. fsbs reading for Resident #19 was 197. The sliding scale reflected the resident was to receive 2 units of insulin for coverage. The sheet reflected a '0' for amount given. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to review the 11:00 a.m. fsbs for Resident #19. She acknowledged that the resident should have received the sliding scale coverage. ADON A stated that LVN B had already left the facility for the day. Record review of the training plan dated 5/11/15 3:14 p.m. revealed, . Education: The Director of Nursing (DON) and ADON are in-servicing the ChargeNurses on Diabetic/ Insulin Management for all diabetics and the signs and symptoms of hypo and [MEDICAL CONDITION] which includes; · The licensed nurse will follow the physician ' s individualized insulin orders for each resident receiving insulin therapy. · Nurse will monitor for sign and symptoms of hyper and [DIAGNOSES REDACTED] including monitoring the results of any finger sticks blood sugars. · The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident ' s blood glucose readings are outside of the parameters outlined by the physician. · Follow up nursing actions will be documented in the clinical record · [MEDICAL CONDITION] will be managed based on the physician ' s specific orders which may include adjustment to the resident ' s insulin dosage · Insulin and finger stick blood sugar readings will be recorded on the resident ' s Medication Administration Record [REDACTED] · Insulin is administered according to manufacturer guidelines and administered by the nurse who takes the blood glucose. · All new admission charts will be audited by the ADONs the next day after new admission if the occurs during the week and place on an audit form. The new admission charts that occur over the weekend will be verified by the Charge Nurse and audited by the ADONs the following day after the weekend to ensure that physician orders [REDACTED]. · The Medical Records person, will monitor and track newly admitted residents and notify physician office of need to be seen at the facility and will track timeliness of physicians visits to ensure that all newly admitted residents are seen within the 30 day regulation. · The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. In an interview on 06/22/15 at 3:05 p.m., the DON was asked how she ensured the nurses were competent in their skills for caring for residents with Diabetes. She answered, Some have been done and some not. Skills check lists. This is the month we do our competencies. Review of the www.mayoclinic.org <http://www.mayoclinic.org> '[MEDICAL CONDITION] (high blood glucose) in Diabetes' section revealed: Long-term complications Untreated [MEDICAL CONDITION] can cause long-term complications. These include: · Cardiovascular disease · Nerve damage ([MEDICAL CONDITION]) · Kidney damage (diabetic [MEDICAL CONDITION]) or kidney failure · Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to [MEDICAL CONDITION] · Clouding of the normally clear lens of your eye (cataract) · Feet problems caused by damaged nerves or poor blood flow that can lead to serious infections, and in some severe cases, amputation · Bone and joint problems · Skin problems, including bacterial infections, fungal infections and nonhealing wounds · Teeth and gum infections Emergency complications If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions. · Diabetic ketoacidosis. Diabetic ketoacidosis develops when you don't have enough insulin in your body. When this happens, sugar (glucose) can't enter your cells for energy. Your blood sugar level rises, and your body begins to break down fat for energy. This process produces toxic acids known as [MEDICATION NAME]. Excess [MEDICATION NAME] accumulate in the blood and eventually spill over into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening. · Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high - greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential. The facility Director of Nurses was notified on 6/19/15 at 2:41 p.m. that an immediate jeopardy had been identified due to the above failures. A plan of Removal (PoR) for the IJ was submitted on 6/19/15 and after revisions was accepted on 6/23/15 at 11:00 a.m. The PoR included: On June 19, 2015 at 3 pm the DON, two ADONs initiated an audit of all residents with diabetes to validate that: · 100% of diabetic residents have been audited to ensure that any issues found would be reported to physician/nurse practitioner. Insulin for all diabetics has been administered according to physician orders. Physicians have been notified. Completed on 6-19-15. · The nurse that failed to communicate with physicians in regards the holding the insulin has been disciplined. Completed on 6-19-15. · The Nurse Practitioner came to the facility to speak with surveyors in regards to the nurse calling him about a resident ' s blood sugar results. The Nurse Practitioner informed the nursing staff that in the case of residents on [MEDICATION NAME]that the evening dose affects the morning blood sugar results and the morning dose effects the evening dose and in most cases he wants the medication given. · The nurses have been in-serviced that if insulin has been held they will need to recheck blood sugars according to physician instructions and report as per those orders. The Nurses will use the Communication Tool to Providers to gather information and report to MD/PA/NP. 6-19-15. · The three residents identified by the surveyor that the physician had not been notified have been notified of insulin being held. For residents three Residents identified, the nurse practitioner made an on site visit on 6-19-15. The Nurse Practitioner for the fourth resident was notified by telephone with no new orders. · The DON and ADONs will monitor daily for any issues with compliance. The Diabetic-Insulin Management audit tool will be used. The Diabetic-Insulin Management will ensure that blood sugars have been documented, insulin administered by the nurse taking the blood sugar, parameters for blood sugars are in place, parameters that are high or low have an intervention implemented, resident medicated as per orders, sliding scale administered according to parameters, and nurse action has been documented. The Medical Director was notified of the Immediate Jeopardy on 6-19-15 at 3:10 pm CST by the facility, Director of Nursing Services. Education: The Director of Nursing (DON) and ADON have in-serviced the Charge Nurses on being sure to inform physician or nurse practitioner of any changes in the residents. · The physician will be notified if any resident's insulin is held related to low blood sugars to get further orders on how to continue the resident's treatment. · The Nurse Practitioner for one of the doctors came to the facility to assess their residents. Orders were changed on only one resident, new parameters were given. Physician is to be notified for FSBS less than 60 and greater than 400. · The Nurse Practitioner was called and gave orders for one change. Orders noted in that residents ' medical record. Timeline: The facility started training all existing nurses (effective 6-19-15) on insulin management and administration. Each facility nurse effective 6-19-15 has to receive this training prior to working as a charge nurse on the floor. All new nurses hired after 6-19-15 will receive training on insulin management and administration prior to working as a charge nurse on the floor. Other Residents that could be affected: Residents on medications with parameters will be reviewed and evaluated by the DON and two ADONs to validate physician orders [REDACTED]. The surveyors confimed that the PoR had been implemented sufficiently to remove the IJ by: Reviewing the the care of the residents with diabetes each day until the IJ was removed, then determining: -fsbs results -if insulin or other treatment provided according to physician's orders [REDACTED].>-if physicians or physician extenders were notified as indicated in their orders. The results of the review were that the facility was following physician orders. Interviews during the monitoring period indicated that the nurses understood the procedures and that they were following physician orders. The Administrator and DON were informed on 6/23/15 at 11:30 a.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The List of Diabetics supplied by the facility on 06/18/15 reflected there were 21 residents under the care of the facility with diabetes.

Based on observation, interview, and record review, the facility failed to provided care that met professional standards of quality for 3 of 21 residents (Residents #17, # 5, and #16) with Diabetes. Licensed Vocational Nurse (LVN) L failed to meet professional standards of quality in that: --Without physician orders [REDACTED].#17's had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. Insulin was held insulin with a fsbs of 130 at 8:00 a.m. on 06/02/15; the 8:00 p.m., fsbs was 358 mg/dl. Insulin was held with a fsbs of 78 at 8:00 a.m. on 06/15/15; the 8:00 p.m. fsbs was 334 mg/dl. Insulin was held with a fsbs of 76 mg/dl on 06/17/15; the 8:00 p.m. fsbs was 354 mg/dl. --Without physician orders [REDACTED].#5 had a finger stick blood sugar (fsbs) level of 104 milligrams per deciliter (mg/dl) during the scheduled 8:00 a.m. accucheck on 06/18/15. --Without physician's orders [REDACTED].#16 had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. --LVN L did not consult the physicians or physicians' representative for permission to hold insulin. --Without physician's orders [REDACTED].#18 had a fsbs of 124 during the scheduled 8:00 a.m. accucheck on 06/20/15. --LVN B did not administer insulin as ordered according to the prescribed sliding scale when Resident #19 had a fsbs of 197 mg/dl during the scheduled 11:00 a.m. accucheck on 06/20/15. An Immediate Jeopardy (IJ) was identified on 06/18/15. While the IJ was removed on 06/23/15, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 18 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Findings include: Record review of the Texas Administrative Code, Standards of Nursing Practice, updated 12.5.14, revealed, .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; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (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; . (http://tx.eregulations.us/rule/title22_chapter217_sec.217.11) Resident #17 Record review of Resident #17's admission orders [REDACTED]. The Orders reflected, [MEDICATION NAME] (insulin) 25 u q 12h (units every 12 hours). Record review of Resident #17's Physician's Telephone Order (TO) dated 05/24/15 reflected the insulin dose was to be increased to 35 units every 12 hours. Record review of Resident #17's June 2015 nurses' Treatment Sheet revealed the insulin dosage had not been changed to 35 units every 12 hours. The Sheet reflected the 25 units every 12 hour regimen. -06/02/15, Resident #17 had a fsbs of 130 mg/dl at 8:00 a.m. on 06/02/15. That the scheduled insulin was withheld by LVN L. The subsequent fsbs, at 8:00 p.m., reflected a value of 358 mg/dl. -06/15/15, Resident #17 had a fsbs of 78 at 8:00 a.m. on 06/15/15. LVN L held the insulin. The subsequent fsbs, at 8:00 p.m., reflected a value of 334 mg/dl. -06/17/15, LVN L withheld Resident #17's insulin on 06/17/15, when the 8:00 a.m. fsbs reflected 76 mg/dl. The subsequent fsbs, at 8:00 p.m. on that same date, reflected a value of 354 mg/dl. -06/18/15, a 81 mg/dl fsbs level for 06/18/15 at the scheduled 8:00 a.m. accucheck. The scheduled was reflected as not been given, and the word 'Hold' was scribed in the box. The back of the sheet revealed 6/18/15-Held [MEDICATION NAME] @0800 FSBS-81. The initials were LVN L's. On 06/18/15 at 8:00 a.m., review of the Daily Skilled Nurses' Notes (NN) dated 06/18/15 revealed no documentation regarding the 81 mg/dl fsbs. In an interview on 06/18/15 at 8:05 a.m., LVN L stated she had not spoken to anyone regarding withholding Resident #17's insulin. She stated she had not had a chance to call Phys Q, Resident #17's primary care physician. On 06/19/15 at 10:15 a.m., the NN dated 06/18/15 was reviewed. The NN reflected 6/18/15 Nurse to call Physician Assistant (PA) V regarding fsbs 81 and [MEDICATION NAME] @800 (8:00 a.m.) held. NP said ok. In an interview via telephone on 06/19/15 at 10:35 a.m., Physician's Assistant (PA) V was asked if he received a call regarding Resident #17's fsbs and/or insulin. PA V stated he did not receive any call about fsbs or insulin, but did receive a call about a different resident's blood pressure. In an interview on 06/19/15 at 10:22 a.m., LVN L stated the NN dated 06/18/15 should have been dated 06/19/15 at 6:15 a.m. LVN L stated, I talked to PA V, the PA for Phys Q. LVN L stated PA V informed her It's fine to hold the [MEDICATION NAME] at 8 a.m. and 8 p.m. if the blood sugar is less than 110 (mg/dl). I called him again at 6:02 (a.m.). It's documented. Why would he say he didn't? I have a nurse, LVN F who witnessed me on the phone. She was sitting by me. In an interview on 06/19/15 at 10:50 a.m., LVN F stated She called NP S twice (not PA V). He ended up calling her back. LVN F stated she answered the call, so she was sure it was NP S, not PA V. NP S is not a care provider for Resident #17. In an interview via telephone on 06/19/15 at 11:10 a.m., PA V stated he had spoken with the facility after the 10:35 a.m. interview with the surveyor. PA V then stated, I was mistaken. They did call me on a blood sugar and a blood pressure. When asked specifics, the PA stated he could not remember. He stated he did not give parameters to hold insulin. He stated the call was on his cell phone. When asked if he could provide the time and date of the facility phone calls, PA V stated, I go back and erase the phone calls after I hang up. Observation on 06/19/15 at 4:30 p.m. revealed PA V at the facility. In an interview at that time, PA V stated, They called me this morning about an 80 (mg/dl) blood sugar, and later about a blood pressure. The 80 blood sugar they asked, 'Shall I hold the [MEDICATION NAME] this morning?' I said 'Yes.' I would be there later to check all the blood sugars. PA V added, I just wanted to reiterate that's what they told me. At that time, PA V was asked twice if he was sure it was this morning. PA V answered, Yes, this morning. I don't know what time. PA V was asked again if he was sure he was addressing an 80 mg/dl for the same morning, 06/19/15. PA V answered, Yes. He stated he was not sure which resident, but that Resident #17's name sounds familiar. When asked if he thought it was for Resident #17, PA V answered, I believe so. At that time, PA V was informed that the 8:00 a.m. fsbs for Resident #17 on this same morning was 236 mg/dl, not 80 mg/dl. PA V stated, That doesn't sound like 80 at all. I wonder if someone else over there had an 80 (mg/dl). PA V stated he did not discuss any other resident's fsbs. On 06/19/15 at 4:35 p.m., PA V was asked to review the previous seven days of fsbs values for Resident #17. Regarding the 06/15/15 (Monday) 8:00 a.m. value of 78 mg/dl at 8:00 a.m., the insulin being withheld, then the 8:00 p.m. value of 334 mg/dl, PA V stated the facility did not call him. Regarding the 06/17/15 (Wednesday) 8:00 a.m. value of 76 mg/dl, the insulin being withheld, then the 8:00 p.m. value of 354 mg/dl, PA V was asked if the [MEDICATION NAME] should have been held. PA V answered, No. Maybe they don't know how it works. He stated he did not receive a call from the facility. PA V stated he would not have given an order to hold the insulin for fsbs below 110 mg/dl. PA V stated, If they had said the last five days he was over 300 (mg/dl), I would have said give him the [MEDICATION NAME]. I didn't know the whole story. Resident #5 Record review of Resident #5's Admission Record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Order Summary Report dated 05/01/15 reflected [MEDICATION NAME] Mix 70/30 [MEDICATION NAME] Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin [MEDICATION NAME] Prot & [MEDICATION NAME]) Inject 40 unit subcutaneously every 12 hours related to Diab (diabetes) w/o comp (without complications) Type II . Further review of Resident #5's Order Summary Report dated 05/01/15 revealed it did not include parameters for withholding the insulin. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated she was finished conducting her morning accuchecks. Record review of Resident #5's June 2015 nurses' Treatment Sheet on 06/18/15 at 7:40 a.m. revealed the 8:00 a.m.-scheduled fsbs was 104 mg/dl (milligrams per deciliter). In the box below the '104', initials were reflected, and they had been circled. Review of the back of the page revealed, 6/18/15 - Held 70/30 @ 0800 FSBS - 104 The initials to the right of the note were LVN L's. In an interview on 06/18/15 at 7:40 a.m., LVN L stated she held the scheduled insulin for Resident #5. She stated that she had called Physician (Phys) P and the physician told her to withhold the insulin. She stated she had not yet written the order. When asked for Phys P's telephone number, LVN L stated she did not call Phys P, but rather called Nurse Practitioner (NP) R. LVN L was asked for the telephone number she called, and LVN L called out the number. On 06/18/15 at 7:45 a.m. the surveyor called the telephone number that had been provided by LVN L. The person who answered the phone was NP S. NP S stated that he was the NP on call, and that NP R had not been on call since 06/15/15. NP S stated that there had been no calls regarding fsbs readings that morning. NP S stated he had been awake since 6:30 a.m., and there had been no calls. NP S stated he would check the call history and call the surveyor back. In an interview on 06/18/15 at 7:48 a.m., LVN L confirmed the phone number and again stated she had spoken with NP R. At that time, NP S called back, and confirmed that there was no call reflected on the call log since 3:30 a.m., and that was for a different issue. NP S concluded, No, they didn't call me. Resident #16 Record review of Resident #16's Admission Record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #16's June 2015 nurses' Treatment Sheet revealed no scheduled insulin to be administered in the mornings. The sheet reflected the 7:00 a.m.-scheduled fsbs reading was 81 mg/dl. The sheet did reflect the resident was to receive [MEDICATION NAME] insulin, 12 units, every night at bedtime. The sheet did not reflect the night dose for 06/17/15 had been administered. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated that she already called Phys O, and that Phys O told her to withhold any insulin. When asked for Phys O's telephone number, LVN L stated she did not call Phys O, but had called NP D. Observation and interview on 06/18/15 at 8:10 a.m. revealed NP D at nurses' station 2, at the opposite end of the facility. NP D initially stated that she had not received any calls about fsbs levels. Then NP D stated she did receive a call but could not answer it because she was already on a call. NP D showed the surveyor her call log, which reflected a call from the facility at 7:50 a.m., ten minutes after LVN L was asked about Resident #16. Resident #18 Record review of Resident #18's June 2015 Nurses' Treatment Sheet revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #18's June 2015 Nurses' Treatment Sheet conducted on 06/20/14 at 3:00 p.m. reflected the her 8:00 a.m. fsbs was 124 mg/dl. Her testing order was FSBS two times a day FSBS Parameters: If blood sugar below 60 or above 400 call physician. Her treatment order was [MEDICATION NAME] Solution 100 Unit/ml (Insulin Detimir) Inject 12 unit subcutaneously two times a day related to Diab (Diabetes) . There were no parameters to hold the insulin. The sheet reflected the 8:00 a.m. insulin for 06/20/15 was not given. Record review of Resident #18's NN revealed no documentation of a reason to withhold the [MEDICATION NAME] insulin. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to identify the initials of the nurse who recorded Resident #18's fsbs. ADON A stated the initials the under the 124 for Resident #18's 8:00 a.m. fsbs, and under the 197 for Resident #18's 11:00 a.m. fsbs were those of LVN B. Resident #19 Record review of Resident #19's June 2015 Medication Sheet reflected FSBS ac/hs (before meals and at hour of sleep) The second June 2015 Medication Sheet reflected Resident #19 was to receive Humulog insulin, based on a sliding scale, dependent on the results of the fsbs values. Record review of Resident #19's June 2015 Medication sheet reviewed on 06/20/15 at 3:00 p.m., reflected the 11:00 a.m. fsbs reading for Resident #19 was 197. The sliding scale reflected the resident was to receive 2 units of insulin for coverage. The sheet reflected a '0' for amount given. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to review the 11:00 a.m. fsbs for Resident #19. She acknowledged that the resident should have received the sliding scale coverage. ADON A stated that LVN B had already left the facility for the day. Record review of the training plan dated 5/11/15 3:14 p.m. revealed, . Education: The Director of Nursing (DON) and ADON are in-servicing the ChargeNurses on Diabetic/ Insulin Management for all diabetics and the signs and symptoms of hypo and [MEDICAL CONDITION] which includes; · The licensed nurse will follow the physician ' s individualized insulin orders for each resident receiving insulin therapy. · Nurse will monitor for sign and symptoms of hyper and [DIAGNOSES REDACTED] including monitoring the results of any finger sticks blood sugars. · The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident ' s blood glucose readings are outside of the parameters outlined by the physician. · Follow up nursing actions will be documented in the clinical record · [MEDICAL CONDITION] will be managed based on the physician ' s specific orders which may include adjustment to the resident ' s insulin dosage · Insulin and finger stick blood sugar readings will be recorded on the resident ' s Medication Administration Record [REDACTED] · Insulin is administered according to manufacturer guidelines and administered by the nurse who takes the blood glucose. · All new admission charts will be audited by the ADONs the next day after new admission if the occurs during the week and place on an audit form. The new admission charts that occur over the weekend will be verified by the Charge Nurse and audited by the ADONs the following day after the weekend to ensure that physician orders [REDACTED]. · The Medical Records person, will monitor and track newly admitted residents and notify physician office of need to be seen at the facility and will track timeliness of physicians visits to ensure that all newly admitted residents are seen within the 30 day regulation. · The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. In an interview on 06/22/15 at 3:05 p.m., the DON was asked how she ensured the nurses were competent in their skills for caring for residents with Diabetes. She answered, Some have been done and some not. Skills check lists. This is the month we do our competencies. Review of the www.mayoclinic.org <http://www.mayoclinic.org> '[MEDICAL CONDITION] (high blood glucose) in Diabetes' section revealed: Long-term complications Untreated [MEDICAL CONDITION] can cause long-term complications. These include: · Cardiovascular disease · Nerve damage ([MEDICAL CONDITION]) · Kidney damage (diabetic [MEDICAL CONDITION]) or kidney failure · Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to [MEDICAL CONDITION] · Clouding of the normally clear lens of your eye (cataract) · Feet problems caused by damaged nerves or poor blood flow that can lead to serious infections, and in some severe cases, amputation · Bone and joint problems · Skin problems, including bacterial infections, fungal infections and nonhealing wounds · Teeth and gum infections Emergency complications If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions. · Diabetic ketoacidosis. Diabetic ketoacidosis develops when you don't have enough insulin in your body. When this happens, sugar (glucose) can't enter your cells for energy. Your blood sugar level rises, and your body begins to break down fat for energy. This process produces toxic acids known as [MEDICATION NAME]. Excess [MEDICATION NAME] accumulate in the blood and eventually spill over into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening. · Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high - greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential. The facility Director of Nurses was notified on 6/19/15 at 2:41 p.m. that an immediate jeopardy had been identified due to the above failures. A plan of Removal (PoR) for the IJ was submitted on 6/19/15 and after revisions was accepted on 6/23/15 at 11:00 a.m. The PoR included: On June 19, 2015 at 3 pm the DON, two ADONs initiated an audit of all residents with diabetes to validate that: · 100% of diabetic residents have been audited to ensure that any issues found would be reported to physician/nurse practitioner. Insulin for all diabetics has been administered according to physician orders. Physicians have been notified. Completed on 6-19-15. · The nurse that failed to communicate with physicians in regards the holding the insulin has been disciplined. Completed on 6-19-15. · The Nurse Practitioner came to the facility to speak with surveyors in regards to the nurse calling him about a resident ' s blood sugar results. The Nurse Practitioner informed the nursing staff that in the case of residents on [MEDICATION NAME]that the evening dose affects the morning blood sugar results and the morning dose effects the evening dose and in most cases he wants the medication given. · The nurses have been in-serviced that if insulin has been held they will need to recheck blood sugars according to physician instructions and report as per those orders. The Nurses will use the Communication Tool to Providers to gather information and report to MD/PA/NP. 6-19-15. · The three residents identified by the surveyor that the physician had not been notified have been notified of insulin being held. For residents three Residents identified, the nurse practitioner made an on site visit on 6-19-15. The Nurse Practitioner for the fourth resident was notified by telephone with no new orders. · The DON and ADONs will monitor daily for any issues with compliance. The Diabetic-Insulin Management audit tool will be used. The Diabetic-Insulin Management will ensure that blood sugars have been documented, insulin administered by the nurse taking the blood sugar, parameters for blood sugars are in place, parameters that are high or low have an intervention implemented, resident medicated as per orders, sliding scale administered according to parameters, and nurse action has been documented. The Medical Director was notified of the Immediate Jeopardy on 6-19-15 at 3:10 pm CST by the facility, Director of Nursing Services. Education: The Director of Nursing (DON) and ADON have in-serviced the Charge Nurses on being sure to inform physician or nurse practitioner of any changes in the residents. · The physician will be notified if any resident's insulin is held related to low blood sugars to get further orders on how to continue the resident's treatment. · The Nurse Practitioner for one of the doctors came to the facility to assess their residents. Orders were changed on only one resident, new parameters were given. Physician is to be notified for FSBS less than 60 and greater than 400. · The Nurse Practitioner was called and gave orders for one change. Orders noted in that residents ' medical record. Timeline: The facility started training all existing nurses (effective 6-19-15) on insulin management and administration. Each facility nurse effective 6-19-15 has to receive this training prior to working as a charge nurse on the floor. All new nurses hired after 6-19-15 will receive training on insulin management and administration prior to working as a charge nurse on the floor. Other Residents that could be affected: Residents on medications with parameters will be reviewed and evaluated by the DON and two ADONs to validate physician orders [REDACTED]. The surveyors confimed that the PoR had been implemented sufficiently to remove the IJ by: Reviewing the the care of the residents with diabetes each day until the IJ was removed, then determining: -fsbs results -if insulin or other treatment provided according to physician's orders [REDACTED].>-if physicians or physician extenders were notified as indicated in their orders. The results of the review were that the facility was following physician orders. Interviews during the monitoring period indicated that the nurses understood the procedures and that they were following physician orders. The Administrator and DON were informed on 6/23/15 at 11:30 a.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The List of Diabetics supplied by the facility on 06/18/15 reflected there were 21 residents under the care of the facility with diabetes.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there is a need to alter treatment significantly for 3 of 21 residents (Residents #17, #5, and #16) reviewed for diabetic management. --LVN L held scheduled insulin when Resident #17's had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. Insulin was held insulin with a fsbs of 130 at 8:00 a.m. on 06/02/15; the 8:00 p.m., fsbs was 358 mg/dl. Insulin was held with a fsbs of 78 at 8:00 a.m. on 06/15/15; the 8:00 p.m. fsbs was 334 mg/dl. Insulin was held with a fsbs of 76 mg/dl on 06/17/15; the 8:00 p.m. fsbs was 354 mg/dl. --Without physician orders [REDACTED].#5 had a finger stick blood sugar (fsbs) level of 104 milligrams per deciliter (mg/dl) during the scheduled 8:00 a.m. accucheck on 06/18/15. --Without physician's orders [REDACTED].#16 had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. --Without physician's orders [REDACTED].#18 had a fsbs of 124 during the scheduled 8:00 a.m. accucheck on 06/20/15. --LVN B did not administer insulin as ordered according to the prescribed sliding scale when Resident #19 had a fsbs of 197 mg/dl during the scheduled 11:00 a.m. accucheck on 06/20/15. An Immediate Jeopardy (IJ) was identified on 06/18/15. While the IJ was removed on 06/23/15, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 5 residents and placed an additional 16 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Findings include: Resident #17 Record review of Resident #17's admission orders [REDACTED]. The Orders reflected, [MEDICATION NAME] (insulin) 25 u q 12h (units every 12 hours). Record review of Resident #17's Physician's Telephone Order (TO) dated 05/24/15 reflected the insulin dose was to be increased to 35 units every 12 hours. Record review of Resident #17's June 2015 nurses' Treatment Sheet revealed the insulin dosage had not been changed to 35 units every 12 hours. The Sheet reflected the 25 units every 12 hour regimen. -06/02/15, Resident #17 had a fsbs of 130 mg/dl at 8:00 a.m. on 06/02/15. That the scheduled insulin was withheld by LVN L. The subsequent fsbs, at 8:00 p.m., reflected a value of 358 mg/dl. -06/15/15, Resident #17 had a fsbs of 78 at 8:00 a.m. on 06/15/15. LVN L held the insulin. The subsequent fsbs, at 8:00 p.m., reflected a value of 334 mg/dl. -06/17/15, LVN L withheld Resident #17's insulin on 06/17/15, when the 8:00 a.m. fsbs reflected 76 mg/dl. The subsequent fsbs, at 8:00 p.m. on that same date, reflected a value of 354 mg/dl. -06/18/15, a 81 mg/dl fsbs level for 06/18/15 at the scheduled 8:00 a.m. accucheck. The scheduled was reflected as not been given, and the word 'Hold' was scribed in the box. The back of the sheet revealed 6/18/15-Held [MEDICATION NAME] @0800 FSBS-81. The initials were LVN L's. On 06/18/15 at 8:00 a.m., review of the Daily Skilled Nurses' Notes (NN) dated 06/18/15 revealed no documentation regarding the 81 mg/dl fsbs. In an interview on 06/18/15 at 8:05 a.m., LVN L stated she had not spoken to anyone regarding withholding Resident #17's insulin. She stated she had not had a chance to call Phys Q, Resident #17's primary care physician. On 06/19/15 at 10:15 a.m., the NN dated 06/18/15 was reviewed. The NN reflected 6/18/15 Nurse to call Physician Assistant (PA) V regarding fsbs 81 and [MEDICATION NAME] @800 (8:00 a.m.) held. NP said ok. In an interview via telephone on 06/19/15 at 10:35 a.m., Physician's Assistant (PA) V was asked if he received a call regarding Resident #17's fsbs and/or insulin. PA V stated he did not receive any call about fsbs or insulin, but did receive a call about a different resident's blood pressure. In an interview on 06/19/15 at 10:22 a.m., LVN L stated the NN dated 06/18/15 should have been dated 06/19/15 at 6:15 a.m. LVN L stated, I talked to PA V, the PA for Phys Q. LVN L stated PA V informed her It's fine to hold the [MEDICATION NAME] at 8 a.m. and 8 p.m. if the blood sugar is less than 110 (mg/dl). I called him again at 6:02 (a.m.). It's documented. Why would he say he didn't? I have a nurse, LVN F who witnessed me on the phone. She was sitting by me. In an interview on 06/19/15 at 10:50 a.m., LVN F stated She called NP S twice (not PA V). He ended up calling her back. LVN F stated she answered the call, so she was sure it was NP S, not PA V. NP S is not a care provider for Resident #17. In an interview via telephone on 06/19/15 at 11:10 a.m., PA V stated he had spoken with the facility after the 10:35 a.m. interview with the surveyor. PA V then stated, I was mistaken. They did call me on a blood sugar and a blood pressure. When asked specifics, the PA stated he could not remember. He stated he did not give parameters to hold insulin. He stated the call was on his cell phone. When asked if he could provide the time and date of the facility phone calls, PA V stated, I go back and erase the phone calls after I hang up. Observation on 06/19/15 at 4:30 p.m. revealed PA V at the facility. In an interview at that time, PA V stated, They called me this morning about an 80 (mg/dl) blood sugar, and later about a blood pressure. The 80 blood sugar they asked, 'Shall I hold the [MEDICATION NAME] this morning?' I said 'Yes.' I would be there later to check all the blood sugars. PA V added, I just wanted to reiterate that's what they told me. At that time, PA V was asked twice if he was sure it was this morning. PA V answered, Yes, this morning. I don't know what time. PA V was asked again if he was sure he was addressing an 80 mg/dl for the same morning, 06/19/15. PA V answered, Yes. He stated he was not sure which resident, but that Resident #17's name sounds familiar. When asked if he thought it was for Resident #17, PA V answered, I believe so. At that time, PA V was informed that the 8:00 a.m. fsbs for Resident #17 on this same morning was 236 mg/dl, not 80 mg/dl. PA V stated, That doesn't sound like 80 at all. I wonder if someone else over there had an 80 (mg/dl). PA V stated he did not discuss any other resident's fsbs. On 06/19/15 at 4:35 p.m., PA V was asked to review the previous seven days of fsbs values for Resident #17. Regarding the 06/15/15 (Monday) 8:00 a.m. value of 78 mg/dl at 8:00 a.m., the insulin being withheld, then the 8:00 p.m. value of 334 mg/dl, PA V stated the facility did not call him. Regarding the 06/17/15 (Wednesday) 8:00 a.m. value of 76 mg/dl, the insulin being withheld, then the 8:00 p.m. value of 354 mg/dl, PA V was asked if the [MEDICATION NAME] should have been held. PA V answered, No. Maybe they don't know how it works. He stated he did not receive a call from the facility. PA V stated he would not have given an order to hold the insulin for fsbs below 110 mg/dl. PA V stated, If they had said the last five days he was over 300 (mg/dl), I would have said give him the [MEDICATION NAME]. I didn't know the whole story. Resident #5 Record review of Resident #5's Admission Record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Order Summary Report dated 05/01/15 reflected [MEDICATION NAME] Mix 70/30 [MEDICATION NAME] Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin [MEDICATION NAME] Prot & [MEDICATION NAME]) Inject 40 unit subcutaneously every 12 hours related to Diab (diabetes) w/o comp (without complications) Type II . Further review of Resident #5's Order Summary Report dated 05/01/15 revealed it did not include parameters for withholding the insulin. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated she was finished conducting her morning accuchecks. Record review of Resident #5's June 2015 nurses' Treatment Sheet on 06/18/15 at 7:40 a.m. revealed the 8:00 a.m.-scheduled fsbs was 104 mg/dl (milligrams per deciliter). In the box below the '104', initials were reflected, and they had been circled. Review of the back of the page revealed, 6/18/15 - Held 70/30 @ 0800 FSBS - 104 The initials to the right of the note were LVN L's. In an interview on 06/18/15 at 7:40 a.m., LVN L stated she held the scheduled insulin for Resident #5. She stated that she had called Physician (Phys) P and the physician told her to withhold the insulin. She stated she had not yet written the order. When asked for Phys P's telephone number, LVN L stated she did not call Phys P, but rather called Nurse Practitioner (NP) R. LVN L was asked for the telephone number she called, and LVN L called out the number. On 06/18/15 at 7:45 a.m. the surveyor called the telephone number that had been provided by LVN L. The person who answered the phone was NP S. NP S stated that he was the NP on call, and that NP R had not been on call since 06/15/15. NP S stated that there had been no calls regarding fsbs readings that morning. NP S stated he had been awake since 6:30 a.m., and there had been no calls. NP S stated he would check the call history and call the surveyor back. In an interview on 06/18/15 at 7:48 a.m., LVN L confirmed the phone number and again stated she had spoken with NP R. At that time, NP S called back, and confirmed that there was no call reflected on the call log since 3:30 a.m., and that was for a different issue. NP S concluded, No, they didn't call me. Resident #16 Record review of Resident #16's Admission Record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #16's June 2015 nurses' Treatment Sheet revealed no scheduled insulin to be administered in the mornings. The sheet reflected the 7:00 a.m.-scheduled fsbs reading was 81 mg/dl. The sheet did reflect the resident was to receive [MEDICATION NAME] insulin, 12 units, every night at bedtime. The sheet did not reflect the night dose for 06/17/15 had been administered. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated that she already called Phys O, and that Phys O told her to withhold any insulin. When asked for Phys O's telephone number, LVN L stated she did not call Phys O, but had called NP D. Observation and interview on 06/18/15 at 8:10 a.m. revealed NP D at nurses' station 2, at the opposite end of the facility. NP D initially stated that she had not received any calls about fsbs levels. Then NP D stated she did receive a call but could not answer it because she was already on a call. NP D showed the surveyor her call log, which reflected a call from the facility at 7:50 a.m., ten minutes after LVN L was asked about Resident #16. Resident #18 Record review of Resident #18's June 2015 Nurses' Treatment Sheet revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #18's June 2015 Nurses' Treatment Sheet conducted on 06/20/14 at 3:00 p.m. reflected the her 8:00 a.m. fsbs was 124 mg/dl. Her testing order was FSBS two times a day FSBS Parameters: If blood sugar below 60 or above 400 call physician. Her treatment order was [MEDICATION NAME] Solution 100 Unit/ml (Insulin Detimir) Inject 12 unit subcutaneously two times a day related to Diab (Diabetes) . There were no parameters to hold the insulin. The sheet reflected the 8:00 a.m. insulin for 06/20/15 was not given. Record review of Resident #18's NN revealed no documentation of a reason to withhold the [MEDICATION NAME] insulin. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to identify the initials of the nurse who recorded Resident #18's fsbs. ADON A stated the initials the under the 124 for Resident #18's 8:00 a.m. fsbs, and under the 197 for Resident #18's 11:00 a.m. fsbs were those of LVN B. Resident #19 Record review of Resident #19's June 2015 Medication Sheet reflected FSBS ac/hs (before meals and at hour of sleep) The second June 2015 Medication Sheet reflected Resident #19 was to receive Humulog insulin, based on a sliding scale, dependent on the results of the fsbs values. Record review of Resident #19's June 2015 Medication sheet reviewed on 06/20/15 at 3:00 p.m., reflected the 11:00 a.m. fsbs reading for Resident #19 was 197. The sliding scale reflected the resident was to receive 2 units of insulin for coverage. The sheet reflected a '0' for amount given. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to review the 11:00 a.m. fsbs for Resident #19. She acknowledged that the resident should have received the sliding scale coverage. ADON A stated that LVN B had already left the facility for the day. Record review of the training plan dated 5/11/15 3:14 p.m. revealed, . Education: The Director of Nursing (DON) and ADON are in-servicing the ChargeNurses on Diabetic/ Insulin Management for all diabetics and the signs and symptoms of hypo and [MEDICAL CONDITION] which includes; · The licensed nurse will follow the physician ' s individualized insulin orders for each resident receiving insulin therapy. · Nurse will monitor for sign and symptoms of hyper and [DIAGNOSES REDACTED] including monitoring the results of any finger sticks blood sugars. · The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident ' s blood glucose readings are outside of the parameters outlined by the physician. · Follow up nursing actions will be documented in the clinical record · [MEDICAL CONDITION] will be managed based on the physician ' s specific orders which may include adjustment to the resident ' s insulin dosage · Insulin and finger stick blood sugar readings will be recorded on the resident ' s Medication Administration Record [REDACTED] · Insulin is administered according to manufacturer guidelines and administered by the nurse who takes the blood glucose. · All new admission charts will be audited by the ADONs the next day after new admission if the occurs during the week and place on an audit form. The new admission charts that occur over the weekend will be verified by the Charge Nurse and audited by the ADONs the following day after the weekend to ensure that physician orders [REDACTED]. · The Medical Records person, will monitor and track newly admitted residents and notify physician office of need to be seen at the facility and will track timeliness of physicians visits to ensure that all newly admitted residents are seen within the 30 day regulation. · The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. In an interview on 06/22/15 at 3:05 p.m., the DON was asked how she ensured the nurses were competent in their skills for caring for residents with Diabetes. She answered, Some have been done and some not. Skills check lists. This is the month we do our competencies. Review of the www.mayoclinic.org <http://www.mayoclinic.org> '[MEDICAL CONDITION] (high blood glucose) in Diabetes' section revealed: Long-term complications Untreated [MEDICAL CONDITION] can cause long-term complications. These include: · Cardiovascular disease · Nerve damage ([MEDICAL CONDITION]) · Kidney damage (diabetic [MEDICAL CONDITION]) or kidney failure · Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to [MEDICAL CONDITION] · Clouding of the normally clear lens of your eye (cataract) · Feet problems caused by damaged nerves or poor blood flow that can lead to serious infections, and in some severe cases, amputation · Bone and joint problems · Skin problems, including bacterial infections, fungal infections and nonhealing wounds · Teeth and gum infections Emergency complications If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions. · Diabetic ketoacidosis. Diabetic ketoacidosis develops when you don't have enough insulin in your body. When this happens, sugar (glucose) can't enter your cells for energy. Your blood sugar level rises, and your body begins to break down fat for energy. This process produces toxic acids known as [MEDICATION NAME]. Excess [MEDICATION NAME] accumulate in the blood and eventually spill over into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening. · Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high - greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential. The facility Director of Nurses was notified on 6/19/15 at 2:41 p.m. that an immediate jeopardy had been identified due to the above failures. A plan of Removal (PoR) for the IJ was submitted on 6/19/15 and after revisions was accepted on 6/23/15 at 11:00 a.m. The PoR included: On June 19, 2015 at 3 pm the DON, two ADONs initiated an audit of all residents with diabetes to validate that: · 100% of diabetic residents have been audited to ensure that any issues found would be reported to physician/nurse practitioner. Insulin for all diabetics has been administered according to physician orders. Physicians have been notified. Completed on 6-19-15. · The nurse that failed to communicate with physicians in regards the holding the insulin has been disciplined. Completed on 6-19-15. · The Nurse Practitioner came to the facility to speak with surveyors in regards to the nurse calling him about a resident ' s blood sugar results. The Nurse Practitioner informed the nursing staff that in the case of residents on [MEDICATION NAME]that the evening dose affects the morning blood sugar results and the morning dose effects the evening dose and in most cases he wants the medication given. · The nurses have been in-serviced that if insulin has been held they will need to recheck blood sugars according to physician instructions and report as per those orders. The Nurses will use the Communication Tool to Providers to gather information and report to MD/PA/NP. 6-19-15. · The three residents identified by the surveyor that the physician had not been notified have been notified of insulin being held. For residents three Residents identified, the nurse practitioner made an on site visit on 6-19-15. The Nurse Practitioner for the fourth resident was notified by telephone with no new orders. · The DON and ADONs will monitor daily for any issues with compliance. The Diabetic-Insulin Management audit tool will be used. The Diabetic-Insulin Management will ensure that blood sugars have been documented, insulin administered by the nurse taking the blood sugar, parameters for blood sugars are in place, parameters that are high or low have an intervention implemented, resident medicated as per orders, sliding scale administered according to parameters, and nurse action has been documented. The Medical Director was notified of the Immediate Jeopardy on 6-19-15 at 3:10 pm CST by the facility, Director of Nursing Services. Education: The Director of Nursing (DON) and ADON have in-serviced the Charge Nurses on being sure to inform physician or nurse practitioner of any changes in the residents. · The physician will be notified if any resident's insulin is held related to low blood sugars to get further orders on how to continue the resident's treatment. · The Nurse Practitioner for one of the doctors came to the facility to assess their residents. Orders were changed on only one resident, new parameters were given. Physician is to be notified for FSBS less than 60 and greater than 400. · The Nurse Practitioner was called and gave orders for one change. Orders noted in that residents ' medical record. Timeline: The facility started training all existing nurses (effective 6-19-15) on insulin management and administration. Each facility nurse effective 6-19-15 has to receive this training prior to working as a charge nurse on the floor. All new nurses hired after 6-19-15 will receive training on insulin management and administration prior to working as a charge nurse on the floor. Other Residents that could be affected: Residents on medications with parameters will be reviewed and evaluated by the DON and two ADONs to validate physician orders [REDACTED]. The surveyors confimed that the PoR had been implemented sufficiently to remove the IJ by: Reviewing the the care of the residents with diabetes each day until the IJ was removed, then determining: -fsbs results -if insulin or other treatment provided according to physician's orders [REDACTED].>-if physicians or physician extenders were notified as indicated in their orders. The results of the review were that the facility was following physician orders. Interviews during the monitoring period indicated that the nurses understood the procedures and that they were following physician orders. The Administrator and DON were informed on 6/23/15 at 11:30 a.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The List of Diabetics supplied by the facility on 06/18/15 reflected there were 21 residents under the care of the facility with diabetes.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 5 of 21 residents (Residents #17, #5, #16, #18, and #19) reviewed for medications administration. --Without physician orders [REDACTED].#17's had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. Insulin was held insulin with a fsbs of 130 at 8:00 a.m. on 06/02/15; the 8:00 p.m., fsbs was 358 mg/dl. Insulin was held with a fsbs of 78 at 8:00 a.m. on 06/15/15; the 8:00 p.m. fsbs was 334 mg/dl. Insulin was held with a fsbs of 76 mg/dl on 06/17/15; the 8:00 p.m. fsbs was 354 mg/dl. --Without physician orders [REDACTED].#5 had a finger stick blood sugar (fsbs) level of 104 milligrams per deciliter (mg/dl) during the scheduled 8:00 a.m. accucheck on 06/18/15. --Without physician's orders [REDACTED].#16 had a fsbs level of 81 mg/dl during the scheduled 8:00 a.m. accucheck on 06/18/15. --LVN L did not consult the physicians or physicians' representative for permission to hold insulin. --Without physician's orders [REDACTED].#18 had a fsbs of 124 during the scheduled 8:00 a.m. accucheck on 06/20/15. --LVN B did not administer insulin as ordered according to the prescribed sliding scale when Resident #19 had a fsbs of 197 mg/dl during the scheduled 11:00 a.m. accucheck on 06/20/15. An Immediate Jeopardy (IJ) was identified on 06/18/15. While the IJ was removed on 06/23/15, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 5 residents and placed an additional 16 residents at risk of diabetes associated complications, hyperglycemia, [DIAGNOSES REDACTED], and hospitalization . Findings include: Resident #17 Record review of Resident #17's admission orders [REDACTED]. The Orders reflected, Levemir (insulin) 25 u q 12h (units every 12 hours). Record review of Resident #17's Physician's Telephone Order (TO) dated 05/24/15 reflected the insulin dose was to be increased to 35 units every 12 hours. Record review of Resident #17's June 2015 nurses' Treatment Sheet revealed the insulin dosage had not been changed to 35 units every 12 hours. The Sheet reflected the 25 units every 12 hour regimen. -06/02/15, Resident #17 had a fsbs of 130 mg/dl at 8:00 a.m. on 06/02/15. That the scheduled insulin was withheld by LVN L. The subsequent fsbs, at 8:00 p.m., reflected a value of 358 mg/dl. -06/15/15, Resident #17 had a fsbs of 78 at 8:00 a.m. on 06/15/15. LVN L held the insulin. The subsequent fsbs, at 8:00 p.m., reflected a value of 334 mg/dl. -06/17/15, LVN L withheld Resident #17's insulin on 06/17/15, when the 8:00 a.m. fsbs reflected 76 mg/dl. The subsequent fsbs, at 8:00 p.m. on that same date, reflected a value of 354 mg/dl. -06/18/15, a 81 mg/dl fsbs level for 06/18/15 at the scheduled 8:00 a.m. accucheck. The scheduled was reflected as not been given, and the word 'Hold' was scribed in the box. The back of the sheet revealed 6/18/15-Held Levemir @0800 FSBS-81. The initials were LVN L's. On 06/18/15 at 8:00 a.m., review of the Daily Skilled Nurses' Notes (NN) dated 06/18/15 revealed no documentation regarding the 81 mg/dl fsbs. In an interview on 06/18/15 at 8:05 a.m., LVN L stated she had not spoken to anyone regarding withholding Resident #17's insulin. She stated she had not had a chance to call Phys Q, Resident #17's primary care physician. On 06/19/15 at 10:15 a.m., the NN dated 06/18/15 was reviewed. The NN reflected 6/18/15 Nurse to call Physician Assistant (PA) V regarding fsbs 81 and Levemir @800 (8:00 a.m.) held. NP said ok. In an interview via telephone on 06/19/15 at 10:35 a.m., Physician's Assistant (PA) V was asked if he received a call regarding Resident #17's fsbs and/or insulin. PA V stated he did not receive any call about fsbs or insulin, but did receive a call about a different resident's blood pressure. In an interview on 06/19/15 at 10:22 a.m., LVN L stated the NN dated 06/18/15 should have been dated 06/19/15 at 6:15 a.m. LVN L stated, I talked to PA V, the PA for Phys Q. LVN L stated PA V informed her It's fine to hold the Levemir at 8 a.m. and 8 p.m. if the blood sugar is less than 110 (mg/dl). I called him again at 6:02 (a.m.). It's documented. Why would he say he didn't? I have a nurse, LVN F who witnessed me on the phone. She was sitting by me. In an interview on 06/19/15 at 10:50 a.m., LVN F stated She called NP S twice (not PA V). He ended up calling her back. LVN F stated she answered the call, so she was sure it was NP S, not PA V. NP S is not a care provider for Resident #17. In an interview via telephone on 06/19/15 at 11:10 a.m., PA V stated he had spoken with the facility after the 10:35 a.m. interview with the surveyor. PA V then stated, I was mistaken. They did call me on a blood sugar and a blood pressure. When asked specifics, the PA stated he could not remember. He stated he did not give parameters to hold insulin. He stated the call was on his cell phone. When asked if he could provide the time and date of the facility phone calls, PA V stated, I go back and erase the phone calls after I hang up. Observation on 06/19/15 at 4:30 p.m. revealed PA V at the facility. In an interview at that time, PA V stated, They called me this morning about an 80 (mg/dl) blood sugar, and later about a blood pressure. The 80 blood sugar they asked, 'Shall I hold the Levemir this morning?' I said 'Yes.' I would be there later to check all the blood sugars. PA V added, I just wanted to reiterate that's what they told me. At that time, PA V was asked twice if he was sure it was this morning. PA V answered, Yes, this morning. I don't know what time. PA V was asked again if he was sure he was addressing an 80 mg/dl for the same morning, 06/19/15. PA V answered, Yes. He stated he was not sure which resident, but that Resident #17's name sounds familiar. When asked if he thought it was for Resident #17, PA V answered, I believe so. At that time, PA V was informed that the 8:00 a.m. fsbs for Resident #17 on this same morning was 236 mg/dl, not 80 mg/dl. PA V stated, That doesn't sound like 80 at all. I wonder if someone else over there had an 80 (mg/dl). PA V stated he did not discuss any other resident's fsbs. On 06/19/15 at 4:35 p.m., PA V was asked to review the previous seven days of fsbs values for Resident #17. Regarding the 06/15/15 (Monday) 8:00 a.m. value of 78 mg/dl at 8:00 a.m., the insulin being withheld, then the 8:00 p.m. value of 334 mg/dl, PA V stated the facility did not call him. Regarding the 06/17/15 (Wednesday) 8:00 a.m. value of 76 mg/dl, the insulin being withheld, then the 8:00 p.m. value of 354 mg/dl, PA V was asked if the Levemir should have been held. PA V answered, No. Maybe they don't know how it works. He stated he did not receive a call from the facility. PA V stated he would not have given an order to hold the insulin for fsbs below 110 mg/dl. PA V stated, If they had said the last five days he was over 300 (mg/dl), I would have said give him the Levemir. I didn't know the whole story. Resident #5 Record review of Resident #5's Admission Record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Order Summary Report dated 05/01/15 reflected Novolog Mix 70/30 FlexPen Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin Aspart Prot & Aspart) Inject 40 unit subcutaneously every 12 hours related to Diab (diabetes) w/o comp (without complications) Type II . Further review of Resident #5's Order Summary Report dated 05/01/15 revealed it did not include parameters for withholding the insulin. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated she was finished conducting her morning accuchecks. Record review of Resident #5's June 2015 nurses' Treatment Sheet on 06/18/15 at 7:40 a.m. revealed the 8:00 a.m.-scheduled fsbs was 104 mg/dl (milligrams per deciliter). In the box below the '104', initials were reflected, and they had been circled. Review of the back of the page revealed, 6/18/15 - Held 70/30 @ 0800 FSBS - 104 The initials to the right of the note were LVN L's. In an interview on 06/18/15 at 7:40 a.m., LVN L stated she held the scheduled insulin for Resident #5. She stated that she had called Physician (Phys) P and the physician told her to withhold the insulin. She stated she had not yet written the order. When asked for Phys P's telephone number, LVN L stated she did not call Phys P, but rather called Nurse Practitioner (NP) R. LVN L was asked for the telephone number she called, and LVN L called out the number. On 06/18/15 at 7:45 a.m. the surveyor called the telephone number that had been provided by LVN L. The person who answered the phone was NP S. NP S stated that he was the NP on call, and that NP R had not been on call since 06/15/15. NP S stated that there had been no calls regarding fsbs readings that morning. NP S stated he had been awake since 6:30 a.m., and there had been no calls. NP S stated he would check the call history and call the surveyor back. In an interview on 06/18/15 at 7:48 a.m., LVN L confirmed the phone number and again stated she had spoken with NP R. At that time, NP S called back, and confirmed that there was no call reflected on the call log since 3:30 a.m., and that was for a different issue. NP S concluded, No, they didn't call me. Resident #16 Record review of Resident #16's Admission Record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #16's June 2015 nurses' Treatment Sheet revealed no scheduled insulin to be administered in the mornings. The sheet reflected the 7:00 a.m.-scheduled fsbs reading was 81 mg/dl. The sheet did reflect the resident was to receive Levemir insulin, 12 units, every night at bedtime. The sheet did not reflect the night dose for 06/17/15 had been administered. Observation and interview on 06/18/15 at 7:40 a.m. revealed LVN L standing in the nurses' station 1. LVN L stated that she already called Phys O, and that Phys O told her to withhold any insulin. When asked for Phys O's telephone number, LVN L stated she did not call Phys O, but had called NP D. Observation and interview on 06/18/15 at 8:10 a.m. revealed NP D at nurses' station 2, at the opposite end of the facility. NP D initially stated that she had not received any calls about fsbs levels. Then NP D stated she did receive a call but could not answer it because she was already on a call. NP D showed the surveyor her call log, which reflected a call from the facility at 7:50 a.m., ten minutes after LVN L was asked about Resident #16. Resident #18 Record review of Resident #18's June 2015 Nurses' Treatment Sheet revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #18's June 2015 Nurses' Treatment Sheet conducted on 06/20/14 at 3:00 p.m. reflected the her 8:00 a.m. fsbs was 124 mg/dl. Her testing order was FSBS two times a day FSBS Parameters: If blood sugar below 60 or above 400 call physician. Her treatment order was Levemir Solution 100 Unit/ml (Insulin Detimir) Inject 12 unit subcutaneously two times a day related to Diab (Diabetes) . There were no parameters to hold the insulin. The sheet reflected the 8:00 a.m. insulin for 06/20/15 was not given. Record review of Resident #18's NN revealed no documentation of a reason to withhold the Levemir insulin. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to identify the initials of the nurse who recorded Resident #18's fsbs. ADON A stated the initials the under the 124 for Resident #18's 8:00 a.m. fsbs, and under the 197 for Resident #18's 11:00 a.m. fsbs were those of LVN B. Resident #19 Record review of Resident #19's June 2015 Medication Sheet reflected FSBS ac/hs (before meals and at hour of sleep) The second June 2015 Medication Sheet reflected Resident #19 was to receive Humulog insulin, based on a sliding scale, dependent on the results of the fsbs values. Record review of Resident #19's June 2015 Medication sheet reviewed on 06/20/15 at 3:00 p.m., reflected the 11:00 a.m. fsbs reading for Resident #19 was 197. The sliding scale reflected the resident was to receive 2 units of insulin for coverage. The sheet reflected a '0' for amount given. In an interview on 06/20/15 at 3:40 p.m., Assistant Director of Nursing (ADON) A was asked to review the 11:00 a.m. fsbs for Resident #19. She acknowledged that the resident should have received the sliding scale coverage. ADON A stated that LVN B had already left the facility for the day. Record review of the training plan dated 5/11/15 3:14 p.m. revealed, . Education: The Director of Nursing (DON) and ADON are in-servicing the ChargeNurses on Diabetic/ Insulin Management for all diabetics and the signs and symptoms of hypo and hyperglycemia which includes; · The licensed nurse will follow the physician ' s individualized insulin orders for each resident receiving insulin therapy. · Nurse will monitor for sign and symptoms of hyper and [DIAGNOSES REDACTED] including monitoring the results of any finger sticks blood sugars. · The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident ' s blood glucose readings are outside of the parameters outlined by the physician. · Follow up nursing actions will be documented in the clinical record · Hyperglycemia will be managed based on the physician ' s specific orders which may include adjustment to the resident ' s insulin dosage · Insulin and finger stick blood sugar readings will be recorded on the resident ' s Medication Administration Record [REDACTED] · Insulin is administered according to manufacturer guidelines and administered by the nurse who takes the blood glucose. · All new admission charts will be audited by the ADONs the next day after new admission if the occurs during the week and place on an audit form. The new admission charts that occur over the weekend will be verified by the Charge Nurse and audited by the ADONs the following day after the weekend to ensure that physician orders [REDACTED]. · The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. In an interview on 06/22/15 at 3:05 p.m., the DON was asked how she ensured the nurses were competent in their skills for caring for residents with Diabetes. She answered, Some have been done and some not. Skills check lists. This is the month we do our competencies. Review of the www.mayoclinic.org <http://www.mayoclinic.org> 'Hyperglycemia (high blood glucose) in Diabetes' section revealed: Long-term complications Untreated hyperglycemia can cause long-term complications. These include: · Cardiovascular disease · Nerve damage (neuropathy) · Kidney damage (diabetic [DIAGNOSES REDACTED]) or kidney failure · Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness · Clouding of the normally clear lens of your eye (cataract) · Feet problems caused by damaged nerves or poor blood flow that can lead to serious infections, and in some severe cases, amputation · Bone and joint problems · Skin problems, including bacterial infections, fungal infections and nonhealing wounds · Teeth and gum infections Emergency complications If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions. · Diabetic ketoacidosis. Diabetic ketoacidosis develops when you don't have enough insulin in your body. When this happens, sugar (glucose) can't enter your cells for energy. Your blood sugar level rises, and your body begins to break down fat for energy. This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually spill over into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening. · Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high - greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential. The facility Director of Nurses was notified on 6/19/15 at 2:41 p.m. that an immediate jeopardy had been identified due to the above failures. A plan of Removal (PoR) for the IJ was submitted on 6/19/15 and after revisions was accepted on 6/23/15 at 11:00 a.m. The PoR included: On June 19, 2015 at 3 pm the DON, two ADONs initiated an audit of all residents with diabetes to validate that: · 100% of diabetic residents have been audited to ensure that any issues found would be reported to physician/nurse practitioner. Insulin for all diabetics has been administered according to physician orders. Physicians have been notified. Completed on 6-19-15. · The nurse that failed to communicate with physicians in regards the holding the insulin has been disciplined. Completed on 6-19-15. · The Nurse Practitioner came to the facility to speak with surveyors in regards to the nurse calling him about a resident ' s blood sugar results. The Nurse Practitioner informed the nursing staff that in the case of residents on Levemir insulin that the evening dose affects the morning blood sugar results and the morning dose effects the evening dose and in most cases he wants the medication given. · The nurses have been in-serviced that if insulin has been held they will need to recheck blood sugars according to physician instructions and report as per those orders. The Nurses will use the Communication Tool to Providers to gather information and report to MD/PA/NP. 6-19-15. · The three residents identified by the surveyor that the physician had not been notified have been notified of insulin being held. For residents three Residents identified, the nurse practitioner made an on site visit on 6-19-15. The Nurse Practitioner for the fourth resident was notified by telephone with no new orders. · The DON and ADONs will monitor daily for any issues with compliance. The Diabetic-Insulin Management audit tool will be used. The Diabetic-Insulin Management will ensure that blood sugars have been documented, insulin administered by the nurse taking the blood sugar, parameters for blood sugars are in place, parameters that are high or low have an intervention implemented, resident medicated as per orders, sliding scale administered according to parameters, and nurse action has been documented. The Medical Director was notified of the Immediate Jeopardy on 6-19-15 at 3:10 pm CST by the facility, Director of Nursing Services. Education: The Director of Nursing (DON) and ADON have in-serviced the Charge Nurses on being sure to inform physician or nurse practitioner of any changes in the residents. · The physician will be notified if any resident's insulin is held related to low blood sugars to get further orders on how to continue the resident's treatment. · The Nurse Practitioner for one of the doctors came to the facility to assess their residents. Orders were changed on only one resident, new parameters were given. Physician is to be notified for FSBS less than 60 and greater than 400. · The Nurse Practitioner was called and gave orders for one change. Orders noted in that residents ' medical record. Timeline: The facility started training all existing nurses (effective 6-19-15) on insulin management and administration. Each facility nurse effective 6-19-15 has to receive this training prior to working as a charge nurse on the floor. All new nurses hired after 6-19-15 will receive training on insulin management and administration prior to working as a charge nurse on the floor. Other Residents that could be affected: Residents on medications with parameters will be reviewed and evaluated by the DON and two ADONs to validate physician orders [REDACTED]. The surveyors confimed that the PoR had been implemented sufficiently to remove the IJ by: Reviewing the the care of the residents with diabetes each day until the IJ was removed, then determining: -fsbs results -if insulin or other treatment provided according to physician's orders [REDACTED].>-if physicians or physician extenders were notified as indicated in their orders. The results of the review were that the facility was following physician orders. Interviews during the monitoring period indicated that the nurses understood the procedures and that they were following physician orders. The Administrator and DON were informed on 6/23/15 at 11:30 a.m. that the IJ was removed; however, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. The List of Diabetics supplied by the facility on 06/18/15 reflected there were 21 residents under the care of the facility with diabetes.

Based on observation, interview, and record review the facility failed to immediately consult with the physician for 3 of 16 residents (CR#3, #9, and #11) reviewed diabetes maintenance in that: --CR #3 was in the facility for approximately 5 months with no physician visits and no physician orders to treat his diabetes. His fasting blood sugar levels ranged from greater than 150 to Hi (indicating a reading too high for the glucometer to read) with no interventions. There was no documentation of staff consulted with CR #3's physician or physician's assistant. --Resident #9 had low blood sugar levels on 5/4/15, 5/5/15, and 5/7/15 that were not treated. The physician was not consulted. --Resident #11 had consistently high blood sugar levels during May 2015. The physician was not consulted prior to 5/7/15. An Immediate Jeopardy (IJ) was identified on 5/8/15. While the IJ was removed on 5/12/15, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 23 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Intake # 1 Findings Include: CR #3 Record review of CR #3's closed record admission sheet revealed he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #3's closed record revealed documentation that he signed himself out of the facility against medical advice on 4/30/15. Record review of CR #3's quarterly MDS assessment dated [DATE] revealed he scored an 11 out of 15 on his brief interview for mental status indicating moderately impaired cognitive skills. He required supervision of one person for bed mobility, dressing and toilet use. He required supervision and set up for transfer, walking in his room and off the unit, eating, and personal hygiene. The assessment indicated he used a cane or crutch. He was assessed as having no behaviors including no rejection of care. He was assessed as having a [DIAGNOSES REDACTED]. Record review of CR #3's plan of care dated 12/2/14 revealed his plan of care for being at risk for unstable blood sugars related to diabetes revealed an intervention of, .Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within acceptable parameters as dictated by the physician, document and notify physician. During a telephone interview on 5/6/15 at 12:07 p.m. with CR #3 he said he left the facility because they were not taking care of him. He would not answer any additional questions. He said he was safe, had a place to stay and food and medications. Record review of CR #3's Admission Physician orders dated 11/24/14 revealed he had a doctor's order for fasting blood sugar checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. Humalog Insulin had been written down but was crossed off. The orders were signed by Physician A with no date and by RN E on 11/24/14. Record review of CR #3's April 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 4/1/15 and ADON A on 4/1/15. Record review of CR #3's November 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 24 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 15 times; 201-250: 6 times; and 251-300: 3 times. Record review of CR #3's nurses' notes dated November 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of diabetes.org description of diabetes management tight control of blood glucose revealed: Ideally, this means levels between 70 and 130 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. Also called hemoglobin A1C or glycosylated (gly-KOH-sih-lay-ted) hemoglobin, the test shows the amount of glucose that sticks to the red blood cell, which is proportional to the amount of glucose in the blood.X) level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses. - See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.zzKDulLu.dpuf Record review of CR #3's December 2014 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The order summary was 2 pages long. There were no orders for any medications for the month of December 2014. The orders were signed by Physician A on 11/29/14 and by ADON A on 11/29/14. Record review of CR #3's December 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 124 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 66 times; 201-250: 29 times; 251-300: 11 times; and 301-350: 5 times. Record review of CR #3's nurses' notes dated December 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's January 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 1/6/15 and by ADON A on 1/6/15. Record review of CR #3's January 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of January 2015. CR #3's blood sugars ranged from: 150-200: 29 times; 201-250: 41 times; 251-300: 25 times; 301-350: 15 times; and was documented as: 386 on 1/11/15 at 11:00 a.m.; 473 on 1/22/15 at 11:00 a.m.; 389 on 1/23/15 at 11:00 a.m.; 503 on 1/24/15 at 11:00 a.m.; 480 on 1/24/15 at 9:00 p.m.; 358 on 1/25/15 at 11:00 a.m.; 448 on 1/25/15 at 9:00 p.m.; and 353 on 1/26/15 at 11:00 a.m. Record review of CR #3's nurses' notes dated 1/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's February 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 2/11/15 and by ADON A on 2/3/15. Record review of CR #3's February 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 104 times during the month of February 2015. CR #3's blood sugars ranged from: 150-200: 11 times; 201-250: 37 times; 251-300: 15 times; 301-350: 19 times; and was documented as: 360 on 2/1/15 at 11:00 a.m.; 373 on 2/8/15 at 4:00 p.m.; 420 on 2/10/15 at 11:00 a.m.; 365 on 2/12/15 at 11:00 a.m.; 467 on 2/14/15 at 8:00 p.m.; 525 on 2/15/15 at 4:00 p.m.; 414 on 2/15/15 at 8:00 p.m.; 434 on 2/16/15 at 11:00 a.m.; 460 on 2/17/15 at 11:00 a.m.; 369 on 2/19/15 at 11:00 a.m.; 351 on 2/21/15 at 11:00 a.m.; 495 on 2/21/15 at 8:00 p.m. 356 on 2/22/15 at 11:00 a.m.; and 378 on 2/24/15 at 11:00 a.m. There was no documentation of his blood sugar being checked or of it being refused on 2/23/15 at 4:00 p.m., 2/27/15 at 4:00 p.m.,and 2/27/15 at 8:00 p.m. Record review of CR #3's nurses' notes dated 2/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars . Record review of CR #3's March 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 3/3/15 and by ADON A on 3/3/15. Record review of CR #3's March 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of March 2015. CR #3's blood sugars ranged from: 150-200: 5 times; 201-250: 36 times; 251-300: 41 times; 301-350: 19 times; and was documented as: 396 on 3/8/15 at 11:00 a.m.; 369 on 3/9/15 at 11:00 a.m.; 431 on 3/10/15 at 11:00 a.m.; 365 on 3/11/15 at 11:00 a.m.; 441 on 3/20/15 at 11:00 a.m.; Hi on 3/21/15 at 11:00 a.m. (indicating his reading was too high for the glucometer to be able to read); 371 on 3/5/15 at 4:00 p.m.; 380 on 3/14/15 at 8:00 p.m.; 354 on 3/15/15 at 4:00 p.m.; 463 on 3/15/15 at 8:00 p.m.; 359 on 3/20/15 at 4:00 p.m.; 496 on 3/22/15 at 8:00 p.m; 436 on 3/26/15 at 11:00 a.m.; 400 on 3/30/15 at 11:00 a.m.; and 352 on 3/31/15 at 11:00 a.m. The documented result was illegible on 3/29/15 at 11:00 a.m. There was no documentation of the Hi result on 3/21/15 at 11:00 a.m. being rechecked. Record review of the glucometer user's manual revealed a reading of, Hi, indicated a blood sugar level above 600 mg/deciliter with instructions to repeat the test and if the message showed again, to call a healthcare professional immediately. The Expected Blood Glucose Readings, for a person with diabetes fasting (before meals) was 70-110 mg/dL and 2 hours after meals was 70-140 mg/dL. Record review of CR #3's nurses' notes dated 3/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's April 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 116 times during the month of April 2015. CR #3's blood sugars ranged from: 150-200: 4 times; 201-250: 35 times; 251-300: 46 times; 301-350: 17 times; and was documented as: 365 on 4/4/15 at 8:00 p.m.; 439 on 4/5/15 at 4:00 p.m.; 400 on 4/7/15 at 11:00 a.m.; 407 on 4/13/15 at 11:00 a.m.; 356 on 4/15/15 at 11:00 a.m.; 437 on 4/18/15 at 11:00 a.m.; 356 on 4/18/15 at 8:00 p.m; and 387 on 4/28/15 at 6:30 a.m.,. He refused having his blood sugar level tested 3 times. Record review of CR #3's nurses' notes dated 4/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's Medicare Charting Guide dated 11/24/14 revealed staff were to address Highlighted Areas, in their documentation. Highlighted areas included, .DIABETES a. Level of consciousness b. Thirst, weakness or diaphoresis c. Elevated d. Blood sugar results/Dietary intake e. Status of wounds f. Insulin / oral hypoglycemic dosage g. Response to treatment / teaching. During a telephone interview on 5/6/15 at 12:55 p.m. with Physician Assistant B he was asked about CR #3. He said CR #3's diabetes was managed with an oral hypoglycemic agent. He said he told CR #3 that they would watch his blood sugars for awhile before considering insulin in order to avoid the ups and downs of insulin and that CR #3 told him that was good because he did not want insulin. After discussing with Physician Assistant B that CR #3 had no orders for an oral hypoglycemic agent he said then he (Physician A) may have been planning to start one. He said he should have at least been on an oral hypoglycemic agent. He said he would be at the facility on 5/7/15 and would review the chart and follow-up. During an interview on 5/6/15 at 1:11 p.m. with the DON she said ADON A had told her a couple of times that CR #3 had high blood sugars and that the doctor was called but nothing was ordered. Record review of CR #3's nurses' notes from 11/24/14 through 4/30/15 revealed there was no documentation of the physician being called to report high blood sugar levels. There was no documentation of an initial history and physical or physician progress notes [REDACTED]. During an interview on 5/6/15 at 1:25 p.m. with LVN D she said CR #3 told her other nurses had called his doctor. She said CR #3 refused to have an order for [REDACTED].#3 she said over 300. When asked if she had called his doctor to report his high blood sugar levels she said she had left messages for Physician Assistant B but had received no response from him. She said she also texted him from her phone. She was unable to find the text messages. During an interview on 5/6/15 at 1:28 p.m. with the DON about CR #3 she said Physician A had signed his admission orders [REDACTED]. She said she was not aware that Physician Assistant B was not responding. She said normally staff will tell her if a doctor/physician was not responding. She said Physician A comes to the building once a quarter and that Physician Assistant B comes in at least every 2 weeks. During an interview on 5/7/15 at 8:37 a.m. with LVN B she said she had been working in the facility since February 2015. When asked about CR #3 she said she called the doctor about his blood sugars and that she thought she had documented it but, .it gets crazy on this side. She said she did not hear back from his doctor but that sometimes doctor's called after their shift was over and the information was received by the nurse on the next shift. When asked what she did when she came in the next day and saw there still were no orders for CR #3's high blood sugars she said she, .just kept checking his sugars. She said this was a problem they had with Physician A's office. When asked if she reported the concern to her ADON or DON that she was not receiving a response from Physician A's office, she said, No, I didn't. She said CR #3's sugars had just been being checked since before she came. She said in the beginning his sugars were relatively normal but then got higher. She said he had gone out on pass for the weekend before he left the facility and that he told her he had to go to the hospital for his blood sugars and received two insulin shots. She said she did not know which hospital he had gone to. During an interview on 5/7/15 at 8:49 a.m. with ADON A she said that the Medical Director was not contacted related to problems getting a response for CR #3 from Physician A's office. She said if staff were not getting answers from a doctor they would call the Medical Director. She said the Medical Director would then call the doctor. She said she had interviewed the nurses (who cared for CR #3). She said she knew they did not document communications with Physician Assistant B. When asked why there were no physician progress notes [REDACTED]. When asked if Physician Assistant B dictated his progress notes or wrote them, she said he wrote them. During an interview on 5/7/15 at 9:17 a.m. with the Medical Records Clerk when asked if she had any additional records for CR #3, she said she had provided everything they have. During an interview on 5/7/15 at 1:33 p.m. with LVN B she said when they had a new admission they reviewed the orders and called the doctor to see what they wanted to keep and what they wanted to discontinue or change. She said they then wrote the orders and fax them to the pharmacy. When asked what was an acceptable blood sugar range for a person with diabetes, she said 130-170. She said sliding scale insulin usually started at 200 but that some residents' sliding scales could start with, for example, 2 units of insulin for a blood sugar level of 100. During an interview on 5/7/15 at 1:37 p.m. with LVN E she said they always made sure they get parameters from the doctor for insulin. When asked if she was familiar with CR #3 she said no. Record review of the drug regimen review reports by the Consultant Pharmacist for 12/2014, 1/2015, 2/2015, 3/2015, 3/2015, and 4/2015 revealed there was no documentation of a concern related to CR #3's high blood sugars with no treatment ordered. A message was left via voicemail for the Consultant Pharmacist on 5/7/15 at 12:07 p.m. The Consultant Pharmacist returned the call and left a message. During a telephone interview on 5/13/15 at 10:02 a.m. she was asked if a resident with diabetes and high blood sugars with treatment for [REDACTED]. She said she usually did look at MARs and TARs and communicated with the physician if he or she was present when she was in the building. She did not remember CR #3 and was unable to say if she had noticed that he was not receiving treatment for [REDACTED]. During an interview on 5/7/15 at 1:40 p.m. with the DON she said they have no policy and procedure for diabetes management and no standing guidelines for Physician A's patients. She said she called Physician A's office and asked them to fax over anything they have on CR #3. During a telephone interview on 5/7/15 at 2:36 p.m. with Physician A and Physician Assistant B, Physician A said he was not familiar with CR #3. After discussing findings with him, he said, .There five months and not getting anything.Obviously that's wrong. He said he had spoken to Physician Assistant B and that Physician Assistant B told him he had never been told that CR #3 was his patient. He then put Physician Assistant B on the telephone. Physician Assistant B said the facility never told him CR #3 was his patient. He said he had reviewed the chart but was not familiar with CR #3. When asked if he had seen CR #3 for visits during the 5 months he was in the facility, he said, No. Record review of CR #3's Discharge - Patient Medication Report from Hospital A dated 11/24/14 revealed Insulin [MEDICATION NAME] before meals and at bedtime had been crossed off of his list of medications. Record review of CR #3's nurses' note dated 11/24/14 revealed documentation of RN E calling to verify orders for CR #3 with Physician Assistant B. There was no documentation as to why an insulin sliding scale or oral medication was not ordered for his diabetes. Record review of CR #3's physician telephone orders revealed an order dated 1/8/15 for a CBC, comprehensive metabolic panel, NH3 level, and chest x-ray signed by Physician Assistant B. During an interview on 5/8/15 at 1:19 p.m. with LVN F she said if a resident's blood sugar levels were in the 200's, 300's and higher and there were no orders, you called the doctor. She said part of the admission process was calling the doctor to ensure orders were in place. She said if you called the doctor and were not getting a response, you called back in 15 minutes. She said if there was still no response you called the Medical Director. During an interview on 5/9/15 at 11:04 a.m. with LVN C she said CR #3 knew his blood sugars were high and that he snacked all the time,and would then say, .why is my sugar so high? She said she would tell him it was because he snacked. When asked about CR #3's blood sugars she said they were, .all over the place, and usually in the 200's. She said he had nothing ordered for his high blood sugars. When asked if that seemed strange to her she said, Yes. When asked if she called the doctor she said no. She said she worked Saturdays and Sundays 6 a.m. to 10 p.m. When asked how she ensured a physician was seeing a resident she said, I can't. I work the weekend. When asked why she did not call the doctor about CR #3's high blood sugars she said, .because he was not compliant. She said she went by the orders they had and the only orders were for accuchecks. She said the doctor's were supposed to review the sugars. She said the night shift was supposed to do chart checks nightly. She said night nurses should look for doctor's progress notes. When asked how she knew a doctor was seeing a patient during the day shift she said because the doctor's were in the building. She said day nurses should look for doctor's orders and new notes. She said new orders tell her a doctor has come in. She said orders were placed in the doctor's book (at the nurses' station) for them to sign. She did not know if doctor's were given lists of who their resident were. She said they called a doctor when a resident admitted and would think it would be up to the doctor to know which residents were theirs. When asked if she had noticed that CR #3 had no history and physical and no physician progress notes [REDACTED]. During an interview on 5/11/15 at 10:55 a.m. with LVN D she said CR #3 told her the doctor would not give him any insulin. She said she called Physician Assistant B and reported CR #3's high blood sugars but received no response from Physician Assistant B via phone messages or texts. When asked if she documented her attempts she said, I don't think so. She said she was the only nurse there and has 31 patients. She said she talked to ADON A about not getting a response from Physician Assistant B and that ADON A had told her she would try to reach him herself. When asked what she did when she continued to receive no response she said she told ADON A. She said, Somehow, somewhere, the ball just got dropped. She said she asked CR #3 if the doctor had seen him and he said no and that he was not being given insulin. When asked if she called her Medical Director she said no. She said she just found out that she could call the Medical Director. When asked if it seemed odd to her that CR #3 had no orders to treat his diabetes she said yes. When asked if she tried to call Physician A instead of his physician's assistant, she said no because someone had told her they were not call Physician A but were to go through his physician's assistant, Physician Assistant B. She did not remember who told her that. When asked if it concerned her that CR #3 was telling her he was not being seen by a doctor or treated she said, yes. When asked if she had reported CR #3 not receiving care and services to the Administrator, she said no. When asked if she would consider it neglect to not be seen by a doctor or receive treatment for [REDACTED]. During an interview on 5/11/15 at 2:41 p.m. with RN E she said she remembered CR #3 and that his blood sugars were high. She said she told Physician Assistant B. She said she was not sure if she had documented telling him. She said CR #3 was a, food hoarder. When asked if that changed whether the physician was to be called, she said no. She said CR #3's doctor should have been called. When asked why CR #3's doctor or the Medical Director were not called she said she did not know. When asked if she had noticed that there was no History and Physical or physician progress notes [REDACTED]. She said she had seen Physician Assistant B in person and told him about CR #3's high blood sugars but nothing was done. When asked if she had taken it to the DON she said, I don't' know. When asked if it seemed odd that CR #3 had no orders to treat his diabetes, she said, Yeah, in a way, yeah. When asked if it would be considered neglect for CR #3 not to receive treatment for [REDACTED]. During an interview on 5/11/15 at 8:32 a.m. with the Medical Records Clerk when asked if she remembered noticing that CR #3 was not being seen by his physician she said no. During an interview on 5/11/15 at 2:16 p.m. with LVN I, when asked if failing to treat a high blood sugar level would be considered neglect, she said, Yes, it is. Resident #9 Record review of Resident #9's admission sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Record review of Resident #9's History and Physical dated 2/2/15 revealed her [DIAGNOSES REDACTED]. Observation on 5/9/15 at 2:22 p.m. of Resident #9 revealed she was in her wheelchair in the hall. There were no concerns noted. She was groomed and without odor. Record review of Resident #9's May 2015 Physician Order summary revealed she had an order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes. She was receiving [MEDICATION NAME] 5 mg 1 by mouth twice a day, [MEDICATION NAME] 12 units SQ each morning, and had a [MEDICATION NAME] sliding scale insulin in the morning. She had no physician's order for accuchecks (blood sugar testing). an order for [REDACTED]. Record review of Resident #9's monthly physician order summaries for 5/2015, 4/2015, 3/2015, 2/2015, 1/2015, or 11/2014 revealed the order for the sliding scale blood sugar testing testing (accuchecks) was not listed. Record review of Resident #9's 5/2015 MARs revealed her blood sugar results at 6:30 a.m. on 5/4/15 was 53, on 5/5/15 was 55 on 5/7/15 was 49 and on 5/8/15 was 57. There was no documentation of a recheck or intervention on her MAR or in her nurses' notes for the low blood sugars or of physician notification. On 5/4/15 and 5/5/15 staff documented giving Resident #9 her scheduled [MEDICATION NAME] 12 units SQ at 6:30 a.m. each day. The [MEDICATION NAME] was documented on the MAR as being held on the morning of 5/7/15. Her physician order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes was not on her MAR. Record review of diabetes.org description of low blood sugar revealed: [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucoseThe food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar.X (blood sugar1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose.X) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html#sthash.niD9si6T.dpuf During an interview on 5/8/15 at 10:29 a.m. with LVN D when asked about Resident #9's low blood sugar levels, she said the doctor was aware that Resident #9's blood sugar was always low. She said there was no parameter for holding her insulin. She said Resident #9 usually runs low until she has had her coffee and she does get a snack. When asked if she had discussed Resident #9's low blood sugars with her ADON or DON she said she had asked ADON A and ADON A told her Resident #9's blood sugars run low. She said Resident #9 gets her coffee with sugar at about 7:00 a.m. When asked if she was rechecking Resident #9's blood sugars she said no because she perks up after she gets her coffee. She said even with a fasting blood sugar in the 40's and 50's Resident #9 was still maintaining. When asked if she had called the doctor to report the low blood sugars she said no. She also said Resident #9 was known for refusing her snacks. During an interview on 5/8/15 at 10:53 a.m. with the DON and LVN D; when asked about the Resident #9's blood sugar reading of 57, LVN D said she just called Resident #9's doctor to notify her of the low blood sugars. She also said that she had just given orange juice to Resident #9. After reviewing the physician's order to report a blood sugar less than 90 with the DON and LVN D, the DON said staff were supposed to have called the doctor and rechecked her blood sugar. During an interview on 5/8/15 at 11:04 a.m. with ADON A she said she was calling and checking to see why Resident #9's physician order to contact the doctor was not on Resident #9's MAR. Record review of Resident #9's 5/2015 physician's order revealed: if FSBS less than 70, then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes She said it was an active order. During an interview on 5/8/15 at 11:29 a.m. with LVN D she said that she had rechecked Resident #9's blood sugar that morning after giving her orange juice and that it was 98. She said she had also now documented. Record review on 5/8/15 at 11:49 a.m. of the Station I glucometer memory log with LVN D revealed the memory had no record of a blood sugar reading of 98 on 5/8/15. There was a reading in the memory of 85 but LVN D said she thought she had read 98. During an interview on 5/8/15 at 1:19 p.m. with LVN F, she said she had worked in the facility for 3 years. She said if a resident's blood sugar was greater than 500 they were to call the doctor but there was no standing order if it was high. She said if a blood sugar was low, for example less than 70, they should give orange juice with 2 packages of sugar. When asked if a blood sugar of 47, 49, or 59 should be reported to the doctor she said yes, after you intervene by giving [MEDICATION NAME] or orange juice. She said it was .very unacceptable, not to call the doctor with low readings. When asked what they did if there were no parameters to hold insulin she said they should use their nursing judgment, hold the insulin and call the doctor. Record review of the Texas Administrative Code, Standards of Nursing Practice, updated 12.5.14, revealed, .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; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care re

Based on observation, interview, and record review the facility failed to ensure 3 of 16 residents (CR #3, #9, and #11) with diabetes received care and services that meet professional standards of quality. The DON, ADON A, LVN B, LVN C, LVN D, and RN E failed to meet professional standards of quality in that: --CR #3 was in the facility for approximately 5 months with no physician visits and no physician orders to treat his diabetes. His fasting blood sugar levels ranged from greater than 150 to Hi (a setting on the glucometer indicating it was unreadable) with no interventions. --Resident #9 had low blood sugar levels on 5/4/15, 5/5/15, and 5/7/15 that were not treated or reported to the doctor. --Resident #11 had high blood sugar levels during May 2015 which were not called in to the doctor for interventions prior to 5/7/15. An Immediate Jeopardy (IJ) was identified on 5/8/15. While the IJ was removed on 5/12/15, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 23 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Intake # 1 Findings Include: Record review of the Texas Administrative Code, Standards of Nursing Practice, updated 12.5.14, revealed, .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; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (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; . (http://tx.eregulations.us/rule/title22_chapter217_sec.217.11) CR #3 Record review of CR #3's closed record admission sheet revealed he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #3's closed record revealed documentation that he signed himself out of the facility against medical advice on 4/30/15. Record review of CR #3's quarterly MDS assessment dated [DATE] revealed he scored an 11 out of 15 on his brief interview for mental status indicating moderately impaired cognitive skills. He required supervision of one person for bed mobility, dressing and toilet use. He required supervision and set up for transfer, walking in his room and off the unit, eating, and personal hygiene. The assessment indicated he used a cane or crutch. He was assessed as having no behaviors including no rejection of care. He was assessed as having a [DIAGNOSES REDACTED]. Record review of CR #3's plan of care dated 12/2/14 revealed his plan of care for being at risk for unstable blood sugars related to diabetes revealed an intervention of, .Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within acceptable parameters as dictated by the physician, document and notify physician. During a telephone interview on 5/6/15 at 12:07 p.m. with CR #3 he said he left the facility because they were not taking care of him. He would not answer any additional questions. He said he was safe, had a place to stay and food and medications. Record review of CR #3's Admission Physician orders dated 11/24/14 revealed he had a doctor's order for fasting blood sugar checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. Humalog Insulin had been written down but was crossed off. The orders were signed by Physician A with no date and by RN E on 11/24/14. Record review of CR #3's April 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 4/1/15 and ADON A on 4/1/15. Record review of CR #3's November 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 24 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 15 times; 201-250: 6 times; and 251-300: 3 times. Record review of CR #3's nurses' notes dated November 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of diabetes.org description of diabetes management tight control of blood glucose revealed: Ideally, this means levels between 70 and 130 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. Also called hemoglobin A1C or glycosylated (gly-KOH-sih-lay-ted) hemoglobin, the test shows the amount of glucose that sticks to the red blood cell, which is proportional to the amount of glucose in the blood.X) level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses. - See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.zzKDulLu.dpuf Record review of CR #3's December 2014 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The order summary was 2 pages long. There were no orders for any medications for the month of December 2014. The orders were signed by Physician A on 11/29/14 and by ADON A on 11/29/14. Record review of CR #3's December 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 124 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 66 times; 201-250: 29 times; 251-300: 11 times; and 301-350: 5 times. Record review of CR #3's nurses' notes dated December 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's January 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 1/6/15 and by ADON A on 1/6/15. Record review of CR #3's January 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of January 2015. CR #3's blood sugars ranged from: 150-200: 29 times; 201-250: 41 times; 251-300: 25 times; 301-350: 15 times; and was documented as: 386 on 1/11/15 at 11:00 a.m.; 473 on 1/22/15 at 11:00 a.m.; 389 on 1/23/15 at 11:00 a.m.; 503 on 1/24/15 at 11:00 a.m.; 480 on 1/24/15 at 9:00 p.m.; 358 on 1/25/15 at 11:00 a.m.; 448 on 1/25/15 at 9:00 p.m.; and 353 on 1/26/15 at 11:00 a.m. Record review of CR #3's nurses' notes dated 1/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's February 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 2/11/15 and by ADON A on 2/3/15. Record review of CR #3's February 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 104 times during the month of February 2015. CR #3's blood sugars ranged from: 150-200: 11 times; 201-250: 37 times; 251-300: 15 times; 301-350: 19 times; and was documented as: 360 on 2/1/15 at 11:00 a.m.; 373 on 2/8/15 at 4:00 p.m.; 420 on 2/10/15 at 11:00 a.m.; 365 on 2/12/15 at 11:00 a.m.; 467 on 2/14/15 at 8:00 p.m.; 525 on 2/15/15 at 4:00 p.m.; 414 on 2/15/15 at 8:00 p.m.; 434 on 2/16/15 at 11:00 a.m.; 460 on 2/17/15 at 11:00 a.m.; 369 on 2/19/15 at 11:00 a.m.; 351 on 2/21/15 at 11:00 a.m.; 495 on 2/21/15 at 8:00 p.m. 356 on 2/22/15 at 11:00 a.m.; and 378 on 2/24/15 at 11:00 a.m. There was no documentation of his blood sugar being checked or of it being refused on 2/23/15 at 4:00 p.m., 2/27/15 at 4:00 p.m.,and 2/27/15 at 8:00 p.m. Record review of CR #3's nurses' notes dated 2/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars . Record review of CR #3's March 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 3/3/15 and by ADON A on 3/3/15. Record review of CR #3's March 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of March 2015. CR #3's blood sugars ranged from: 150-200: 5 times; 201-250: 36 times; 251-300: 41 times; 301-350: 19 times; and was documented as: 396 on 3/8/15 at 11:00 a.m.; 369 on 3/9/15 at 11:00 a.m.; 431 on 3/10/15 at 11:00 a.m.; 365 on 3/11/15 at 11:00 a.m.; 441 on 3/20/15 at 11:00 a.m.; Hi on 3/21/15 at 11:00 a.m. (indicating his reading was too high for the glucometer to be able to read); 371 on 3/5/15 at 4:00 p.m.; 380 on 3/14/15 at 8:00 p.m.; 354 on 3/15/15 at 4:00 p.m.; 463 on 3/15/15 at 8:00 p.m.; 359 on 3/20/15 at 4:00 p.m.; 496 on 3/22/15 at 8:00 p.m; 436 on 3/26/15 at 11:00 a.m.; 400 on 3/30/15 at 11:00 a.m.; and 352 on 3/31/15 at 11:00 a.m. The documented result was illegible on 3/29/15 at 11:00 a.m. There was no documentation of the Hi result on 3/21/15 at 11:00 a.m. being rechecked. Record review of the glucometer user's manual revealed a reading of, Hi, indicated a blood sugar level above 600 mg/deciliter with instructions to repeat the test and if the message showed again, to call a healthcare professional immediately. The Expected Blood Glucose Readings, for a person with diabetes fasting (before meals) was 70-110 mg/dL and 2 hours after meals was 70-140 mg/dL. Record review of CR #3's nurses' notes dated 3/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's April 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 116 times during the month of April 2015. CR #3's blood sugars ranged from: 150-200: 4 times; 201-250: 35 times; 251-300: 46 times; 301-350: 17 times; and was documented as: 365 on 4/4/15 at 8:00 p.m.; 439 on 4/5/15 at 4:00 p.m.; 400 on 4/7/15 at 11:00 a.m.; 407 on 4/13/15 at 11:00 a.m.; 356 on 4/15/15 at 11:00 a.m.; 437 on 4/18/15 at 11:00 a.m.; 356 on 4/18/15 at 8:00 p.m; and 387 on 4/28/15 at 6:30 a.m.,. He refused having his blood sugar level tested 3 times. Record review of CR #3's nurses' notes dated 4/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's Medicare Charting Guide dated 11/24/14 revealed staff were to address Highlighted Areas, in their documentation. Highlighted areas included, .DIABETES a. Level of consciousness b. Thirst, weakness or diaphoresis c. Elevated d. Blood sugar results/Dietary intake e. Status of wounds f. Insulin / oral hypoglycemic dosage g. Response to treatment / teaching. During a telephone interview on 5/6/15 at 12:55 p.m. with Physician Assistant B he was asked about CR #3. He said CR #3's diabetes was managed with an oral hypoglycemic agent. He said he told CR #3 that they would watch his blood sugars for awhile before considering insulin in order to avoid the ups and downs of insulin and that CR #3 told him that was good because he did not want insulin. After discussing with Physician Assistant B that CR #3 had no orders for an oral hypoglycemic agent he said then he (Physician A) may have been planning to start one. He said he should have at least been on an oral hypoglycemic agent. He said he would be at the facility on 5/7/15 and would review the chart and follow-up. During an interview on 5/6/15 at 1:11 p.m. with the DON she said ADON A had told her a couple of times that CR #3 had high blood sugars and that the doctor was called but nothing was ordered. Record review of CR #3's nurses' notes from 11/24/14 through 4/30/15 revealed there was no documentation of the physician being called to report high blood sugar levels. There was no documentation of an initial history and physical or physician progress notes [REDACTED]. During an interview on 5/6/15 at 1:25 p.m. with LVN D she said CR #3 told her other nurses had called his doctor. She said CR #3 refused to have an order for [REDACTED].#3 she said over 300. When asked if she had called his doctor to report his high blood sugar levels she said she had left messages for Physician Assistant B but had received no response from him. She said she also texted him from her phone. She was unable to find the text messages. During an interview on 5/6/15 at 1:28 p.m. with the DON about CR #3 she said Physician A had signed his admission orders [REDACTED]. She said she was not aware that Physician Assistant B was not responding. She said normally staff will tell her if a doctor/physician was not responding. She said Physician A comes to the building once a quarter and that Physician Assistant B comes in at least every 2 weeks. During an interview on 5/7/15 at 8:37 a.m. with LVN B she said she had been working in the facility since February 2015. When asked about CR #3 she said she called the doctor about his blood sugars and that she thought she had documented it but, .it gets crazy on this side. She said she did not hear back from his doctor but that sometimes doctor's called after their shift was over and the information was received by the nurse on the next shift. When asked what she did when she came in the next day and saw there still were no orders for CR #3's high blood sugars she said she, .just kept checking his sugars. She said this was a problem they had with Physician A's office. When asked if she reported the concern to her ADON or DON that she was not receiving a response from Physician A's office, she said, No, I didn't. She said CR #3's sugars had just been being checked since before she came. She said in the beginning his sugars were relatively normal but then got higher. She said he had gone out on pass for the weekend before he left the facility and that he told her he had to go to the hospital for his blood sugars and received two insulin shots. She said she did not know which hospital he had gone to. During an interview on 5/7/15 at 8:49 a.m. with ADON A she said that the Medical Director was not contacted related to problems getting a response for CR #3 from Physician A's office. She said if staff were not getting answers from a doctor they would call the Medical Director. She said the Medical Director would then call the doctor. She said she had interviewed the nurses (who cared for CR #3). She said she knew they did not document communications with Physician Assistant B. When asked why there were no physician progress notes [REDACTED]. When asked if Physician Assistant B dictated his progress notes or wrote them, she said he wrote them. During an interview on 5/7/15 at 9:17 a.m. with the Medical Records Clerk when asked if she had any additional records for CR #3, she said she had provided everything they have. During an interview on 5/7/15 at 1:33 p.m. with LVN B she said when they had a new admission they reviewed the orders and called the doctor to see what they wanted to keep and what they wanted to discontinue or change. She said they then wrote the orders and fax them to the pharmacy. When asked what was an acceptable blood sugar range for a person with diabetes, she said 130-170. She said sliding scale insulin usually started at 200 but that some residents' sliding scales could start with, for example, 2 units of insulin for a blood sugar level of 100. During an interview on 5/7/15 at 1:37 p.m. with LVN E she said they always made sure they get parameters from the doctor for insulin. When asked if she was familiar with CR #3 she said no. Record review of the drug regimen review reports by the Consultant Pharmacist for 12/2014, 1/2015, 2/2015, 3/2015, 3/2015, and 4/2015 revealed there was no documentation of a concern related to CR #3's high blood sugars with no treatment ordered. A message was left via voicemail for the Consultant Pharmacist on 5/7/15 at 12:07 p.m. The Consultant Pharmacist returned the call and left a message. During a telephone interview on 5/13/15 at 10:02 a.m. she was asked if a resident with diabetes and high blood sugars with treatment for [REDACTED]. She said she usually did look at MARs and TARs and communicated with the physician if he or she was present when she was in the building. She did not remember CR #3 and was unable to say if she had noticed that he was not receiving treatment for [REDACTED]. During an interview on 5/7/15 at 1:40 p.m. with the DON she said they have no policy and procedure for diabetes management and no standing guidelines for Physician A's patients. She said she called Physician A's office and asked them to fax over anything they have on CR #3. During a telephone interview on 5/7/15 at 2:36 p.m. with Physician A and Physician Assistant B, Physician A said he was not familiar with CR #3. After discussing findings with him, he said, .There five months and not getting anything.Obviously that's wrong. He said he had spoken to Physician Assistant B and that Physician Assistant B told him he had never been told that CR #3 was his patient. He then put Physician Assistant B on the telephone. Physician Assistant B said the facility never told him CR #3 was his patient. He said he had reviewed the chart but was not familiar with CR #3. When asked if he had seen CR #3 for visits during the 5 months he was in the facility, he said, No. Record review of CR #3's Discharge - Patient Medication Report from Hospital A dated 11/24/14 revealed Insulin [MEDICATION NAME] before meals and at bedtime had been crossed off of his list of medications. Record review of CR #3's nurses' note dated 11/24/14 revealed documentation of RN E calling to verify orders for CR #3 with Physician Assistant B. There was no documentation as to why an insulin sliding scale or oral medication was not ordered for his diabetes. Record review of CR #3's physician telephone orders revealed an order dated 1/8/15 for a CBC, comprehensive metabolic panel, NH3 level, and chest x-ray signed by Physician Assistant B. During an interview on 5/8/15 at 1:19 p.m. with LVN F she said if a resident's blood sugar levels were in the 200's, 300's and higher and there were no orders, you called the doctor. She said part of the admission process was calling the doctor to ensure orders were in place. She said if you called the doctor and were not getting a response, you called back in 15 minutes. She said if there was still no response you called the Medical Director. During an interview on 5/9/15 at 11:04 a.m. with LVN C she said CR #3 knew his blood sugars were high and that he snacked all the time,and would then say, .why is my sugar so high? She said she would tell him it was because he snacked. When asked about CR #3's blood sugars she said they were, .all over the place, and usually in the 200's. She said he had nothing ordered for his high blood sugars. When asked if that seemed strange to her she said, Yes. When asked if she called the doctor she said no. She said she worked Saturdays and Sundays 6 a.m. to 10 p.m. When asked how she ensured a physician was seeing a resident she said, I can't. I work the weekend. When asked why she did not call the doctor about CR #3's high blood sugars she said, .because he was not compliant. She said she went by the orders they had and the only orders were for accuchecks. She said the doctor's were supposed to review the sugars. She said the night shift was supposed to do chart checks nightly. She said night nurses should look for doctor's progress notes. When asked how she knew a doctor was seeing a patient during the day shift she said because the doctor's were in the building. She said day nurses should look for doctor's orders and new notes. She said new orders tell her a doctor has come in. She said orders were placed in the doctor's book (at the nurses' station) for them to sign. She did not know if doctor's were given lists of who their resident were. She said they called a doctor when a resident admitted and would think it would be up to the doctor to know which residents were theirs. When asked if she had noticed that CR #3 had no history and physical and no physician progress notes [REDACTED]. During an interview on 5/11/15 at 10:55 a.m. with LVN D she said CR #3 told her the doctor would not give him any insulin. She said she called Physician Assistant B and reported CR #3's high blood sugars but received no response from Physician Assistant B via phone messages or texts. When asked if she documented her attempts she said, I don't think so. She said she was the only nurse there and has 31 patients. She said she talked to ADON A about not getting a response from Physician Assistant B and that ADON A had told her she would try to reach him herself. When asked what she did when she continued to receive no response she said she told ADON A. She said, Somehow, somewhere, the ball just got dropped. She said she asked CR #3 if the doctor had seen him and he said no and that he was not being given insulin. When asked if she called her Medical Director she said no. She said she just found out that she could call the Medical Director. When asked if it seemed odd to her that CR #3 had no orders to treat his diabetes she said yes. When asked if she tried to call Physician A instead of his physician's assistant, she said no because someone had told her they were not call Physician A but were to go through his physician's assistant, Physician Assistant B. She did not remember who told her that. When asked if it concerned her that CR #3 was telling her he was not being seen by a doctor or treated she said, yes. When asked if she had reported CR #3 not receiving care and services to the Administrator, she said no. When asked if she would consider it neglect to not be seen by a doctor or receive treatment for [REDACTED]. During an interview on 5/11/15 at 2:41 p.m. with RN E she said she remembered CR #3 and that his blood sugars were high. She said she told Physician Assistant B. She said she was not sure if she had documented telling him. She said CR #3 was a, food hoarder. When asked if that changed whether the physician was to be called, she said no. She said CR #3's doctor should have been called. When asked why CR #3's doctor or the Medical Director were not called she said she did not know. When asked if she had noticed that there was no History and Physical or physician progress notes [REDACTED]. She said she had seen Physician Assistant B in person and told him about CR #3's high blood sugars but nothing was done. When asked if she had taken it to the DON she said, I don't' know. When asked if it seemed odd that CR #3 had no orders to treat his diabetes, she said, Yeah, in a way, yeah. When asked if it would be considered neglect for CR #3 not to receive treatment for [REDACTED]. During an interview on 5/11/15 at 8:32 a.m. with the Medical Records Clerk when asked if she remembered noticing that CR #3 was not being seen by his physician she said no. During an interview on 5/11/15 at 2:16 p.m. with LVN I, when asked if failing to treat a high blood sugar level would be considered neglect, she said, Yes, it is. Resident #9 Record review of Resident #9's admission sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Record review of Resident #9's History and Physical dated 2/2/15 revealed her [DIAGNOSES REDACTED]. Observation on 5/9/15 at 2:22 p.m. of Resident #9 revealed she was in her wheelchair in the hall. There were no concerns noted. She was groomed and without odor. Record review of Resident #9's May 2015 Physician Order summary revealed she had an order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes. She was receiving [MEDICATION NAME] 5 mg 1 by mouth twice a day, [MEDICATION NAME] 12 units SQ each morning, and had a [MEDICATION NAME] sliding scale insulin in the morning. She had no physician's order for accuchecks (blood sugar testing). an order for [REDACTED]. Record review of Resident #9's monthly physician order summaries for 5/2015, 4/2015, 3/2015, 2/2015, 1/2015, or 11/2014 revealed the order for the sliding scale blood sugar testing testing (accuchecks) was not listed. Record review of Resident #9's 5/2015 MARs revealed her blood sugar results at 6:30 a.m. on 5/4/15 was 53, on 5/5/15 was 55 on 5/7/15 was 49 and on 5/8/15 was 57. There was no documentation of a recheck or intervention on her MAR or in her nurses' notes for the low blood sugars or of physician notification. On 5/4/15 and 5/5/15 staff documented giving Resident #9 her scheduled [MEDICATION NAME] 12 units SQ at 6:30 a.m. each day. The [MEDICATION NAME] was documented on the MAR as being held on the morning of 5/7/15. Her physician order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes was not on her MAR. Record review of diabetes.org description of low blood sugar revealed: [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucoseThe food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar.X (blood sugar1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose.X) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html#sthash.niD9si6T.dpuf During an interview on 5/8/15 at 10:29 a.m. with LVN D when asked about Resident #9's low blood sugar levels, she said the doctor was aware that Resident #9's blood sugar was always low. She said there was no parameter for holding her insulin. She said Resident #9 usually runs low until she has had her coffee and she does get a snack. When asked if she had discussed Resident #9's low blood sugars with her ADON or DON she said she had asked ADON A and ADON A told her Resident #9's blood sugars run low. She said Resident #9 gets her coffee with sugar at about 7:00 a.m. When asked if she was rechecking Resident #9's blood sugars she said no because she perks up after she gets her coffee. She said even with a fasting blood sugar in the 40's and 50's Resident #9 was still maintaining. When asked if she had called the doctor to report the low blood sugars she said no. She also said Resident #9 was known for refusing her snacks. During an interview on 5/8/15 at 10:53 a.m. with the DON and LVN D; when asked about the Resident #9's blood sugar reading of 57, LVN D said she just called Resident #9's doctor to notify her of the low blood sugars. She also said that she had just given orange juice to Resident #9. After reviewing the physician's order to report a blood sugar less than 90 with the DON and LVN D, the DON said staff were supposed to have called the doctor and rechecked her blood sugar. During an interview on 5/8/15 at 11:04 a.m. with ADON A she said she was calling and checking to see why Resident #9's physician order to contact the doctor was not on Resident #9's MAR. Record review of Resident #9's 5/2015 physician's order revealed: if FSBS less than 70, then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes She said it was an active order. During an interview on 5/8/15 at 11:29 a.m. with LVN D she said that she had rechecked Resident #9's blood sugar that morning after giving her orange juice and that it was 98. She said she had also now documented. Record review on 5/8/15 at 11:49 a.m. of the Station I glucometer memory log with LVN D revealed the memory had no record of a blood sugar reading of 98 on 5/8/15. There was a reading in the memory of 85 but LVN D said she thought she had read 98. During an interview on 5/8/15 at 1:19 p.m. with LVN F, she said she had worked in the facility for 3 years. She said if a resident's blood sugar was greater than 500 they were to call the doctor but there was no standing order if it was high. She said if a blood sugar was low, for example less than 70, they should give orange juice with 2 packages of sugar. When asked if a blood sugar of 47, 49, or 59 sho

Based on observation, interview, and record review the facility failed to provide necessary care and services for 3 of 16 residents (CR#3, #9, and #11) reviewed for quality of care related to diabetes in that: --CR#3 was in the facility for approximately 5 months with no physician visits and no physician orders to treat his diabetes. His fasting blood sugar levels ranged from greater than 150 to Hi with no interventions. --Resident #9 had low blood sugar levels on 5/4/15, 5/5/15, and 5/7/15 that were not treated or reported to the doctor. --Resident #11 had consistently high blood sugar levels during May 2015 which were not called in to the doctor for interventions prior to 5/7/15. An Immediate Jeopardy (IJ) was identified on 5/8/15. While the IJ was removed on 5/12/15, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 23 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Intake # 1 Findings Include: CR #3 Record review of CR #3's closed record admission sheet revealed he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #3's closed record revealed documentation that he signed himself out of the facility against medical advice on 4/30/15. Record review of CR #3's quarterly MDS assessment dated [DATE] revealed he scored an 11 out of 15 on his brief interview for mental status indicating moderately impaired cognitive skills. He required supervision of one person for bed mobility, dressing and toilet use. He required supervision and set up for transfer, walking in his room and off the unit, eating, and personal hygiene. The assessment indicated he used a cane or crutch. He was assessed as having no behaviors including no rejection of care. He was assessed as having a [DIAGNOSES REDACTED]. Record review of CR #3's plan of care dated 12/2/14 revealed his plan of care for being at risk for unstable blood sugars related to diabetes revealed an intervention of, .Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within acceptable parameters as dictated by the physician, document and notify physician. During a telephone interview on 5/6/15 at 12:07 p.m. with CR #3 he said he left the facility because they were not taking care of him. He would not answer any additional questions. He said he was safe, had a place to stay and food and medications. Record review of CR #3's Admission Physician orders dated 11/24/14 revealed he had a doctor's order for fasting blood sugar checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. Humalog Insulin had been written down but was crossed off. The orders were signed by Physician A with no date and by RN E on 11/24/14. Record review of CR #3's April 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 4/1/15 and ADON A on 4/1/15. Record review of CR #3's November 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 24 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 15 times; 201-250: 6 times; and 251-300: 3 times. Record review of CR #3's nurses' notes dated November 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of diabetes.org description of diabetes management tight control of blood glucose revealed: Ideally, this means levels between 70 and 130 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. Also called hemoglobin A1C or glycosylated (gly-KOH-sih-lay-ted) hemoglobin, the test shows the amount of glucose that sticks to the red blood cell, which is proportional to the amount of glucose in the blood.X) level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses. - See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.zzKDulLu.dpuf Record review of CR #3's December 2014 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The order summary was 2 pages long. There were no orders for any medications for the month of December 2014. The orders were signed by Physician A on 11/29/14 and by ADON A on 11/29/14. Record review of CR #3's December 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 124 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 66 times; 201-250: 29 times; 251-300: 11 times; and 301-350: 5 times. Record review of CR #3's nurses' notes dated December 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's January 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 1/6/15 and by ADON A on 1/6/15. Record review of CR #3's January 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of January 2015. CR #3's blood sugars ranged from: 150-200: 29 times; 201-250: 41 times; 251-300: 25 times; 301-350: 15 times; and was documented as: 386 on 1/11/15 at 11:00 a.m.; 473 on 1/22/15 at 11:00 a.m.; 389 on 1/23/15 at 11:00 a.m.; 503 on 1/24/15 at 11:00 a.m.; 480 on 1/24/15 at 9:00 p.m.; 358 on 1/25/15 at 11:00 a.m.; 448 on 1/25/15 at 9:00 p.m.; and 353 on 1/26/15 at 11:00 a.m. Record review of CR #3's nurses' notes dated 1/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's February 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 2/11/15 and by ADON A on 2/3/15. Record review of CR #3's February 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 104 times during the month of February 2015. CR #3's blood sugars ranged from: 150-200: 11 times; 201-250: 37 times; 251-300: 15 times; 301-350: 19 times; and was documented as: 360 on 2/1/15 at 11:00 a.m.; 373 on 2/8/15 at 4:00 p.m.; 420 on 2/10/15 at 11:00 a.m.; 365 on 2/12/15 at 11:00 a.m.; 467 on 2/14/15 at 8:00 p.m.; 525 on 2/15/15 at 4:00 p.m.; 414 on 2/15/15 at 8:00 p.m.; 434 on 2/16/15 at 11:00 a.m.; 460 on 2/17/15 at 11:00 a.m.; 369 on 2/19/15 at 11:00 a.m.; 351 on 2/21/15 at 11:00 a.m.; 495 on 2/21/15 at 8:00 p.m. 356 on 2/22/15 at 11:00 a.m.; and 378 on 2/24/15 at 11:00 a.m. There was no documentation of his blood sugar being checked or of it being refused on 2/23/15 at 4:00 p.m., 2/27/15 at 4:00 p.m.,and 2/27/15 at 8:00 p.m. Record review of CR #3's nurses' notes dated 2/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars . Record review of CR #3's March 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 3/3/15 and by ADON A on 3/3/15. Record review of CR #3's March 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of March 2015. CR #3's blood sugars ranged from: 150-200: 5 times; 201-250: 36 times; 251-300: 41 times; 301-350: 19 times; and was documented as: 396 on 3/8/15 at 11:00 a.m.; 369 on 3/9/15 at 11:00 a.m.; 431 on 3/10/15 at 11:00 a.m.; 365 on 3/11/15 at 11:00 a.m.; 441 on 3/20/15 at 11:00 a.m.; Hi on 3/21/15 at 11:00 a.m. (indicating his reading was too high for the glucometer to be able to read); 371 on 3/5/15 at 4:00 p.m.; 380 on 3/14/15 at 8:00 p.m.; 354 on 3/15/15 at 4:00 p.m.; 463 on 3/15/15 at 8:00 p.m.; 359 on 3/20/15 at 4:00 p.m.; 496 on 3/22/15 at 8:00 p.m; 436 on 3/26/15 at 11:00 a.m.; 400 on 3/30/15 at 11:00 a.m.; and 352 on 3/31/15 at 11:00 a.m. The documented result was illegible on 3/29/15 at 11:00 a.m. There was no documentation of the Hi result on 3/21/15 at 11:00 a.m. being rechecked. Record review of the glucometer user's manual revealed a reading of, Hi, indicated a blood sugar level above 600 mg/deciliter with instructions to repeat the test and if the message showed again, to call a healthcare professional immediately. The Expected Blood Glucose Readings, for a person with diabetes fasting (before meals) was 70-110 mg/dL and 2 hours after meals was 70-140 mg/dL. Record review of CR #3's nurses' notes dated 3/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's April 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 116 times during the month of April 2015. CR #3's blood sugars ranged from: 150-200: 4 times; 201-250: 35 times; 251-300: 46 times; 301-350: 17 times; and was documented as: 365 on 4/4/15 at 8:00 p.m.; 439 on 4/5/15 at 4:00 p.m.; 400 on 4/7/15 at 11:00 a.m.; 407 on 4/13/15 at 11:00 a.m.; 356 on 4/15/15 at 11:00 a.m.; 437 on 4/18/15 at 11:00 a.m.; 356 on 4/18/15 at 8:00 p.m; and 387 on 4/28/15 at 6:30 a.m.,. He refused having his blood sugar level tested 3 times. Record review of CR #3's nurses' notes dated 4/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's Medicare Charting Guide dated 11/24/14 revealed staff were to address Highlighted Areas, in their documentation. Highlighted areas included, .DIABETES a. Level of consciousness b. Thirst, weakness or diaphoresis c. Elevated d. Blood sugar results/Dietary intake e. Status of wounds f. Insulin / oral hypoglycemic dosage g. Response to treatment / teaching. During a telephone interview on 5/6/15 at 12:55 p.m. with Physician Assistant B he was asked about CR #3. He said CR #3's diabetes was managed with an oral hypoglycemic agent. He said he told CR #3 that they would watch his blood sugars for awhile before considering insulin in order to avoid the ups and downs of insulin and that CR #3 told him that was good because he did not want insulin. After discussing with Physician Assistant B that CR #3 had no orders for an oral hypoglycemic agent he said then he (Physician A) may have been planning to start one. He said he should have at least been on an oral hypoglycemic agent. He said he would be at the facility on 5/7/15 and would review the chart and follow-up. During an interview on 5/6/15 at 1:11 p.m. with the DON she said ADON A had told her a couple of times that CR #3 had high blood sugars and that the doctor was called but nothing was ordered. Record review of CR #3's nurses' notes from 11/24/14 through 4/30/15 revealed there was no documentation of the physician being called to report high blood sugar levels. There was no documentation of an initial history and physical or physician progress notes [REDACTED]. During an interview on 5/6/15 at 1:25 p.m. with LVN D she said CR #3 told her other nurses had called his doctor. She said CR #3 refused to have an order for [REDACTED].#3 she said over 300. When asked if she had called his doctor to report his high blood sugar levels she said she had left messages for Physician Assistant B but had received no response from him. She said she also texted him from her phone. She was unable to find the text messages. During an interview on 5/6/15 at 1:28 p.m. with the DON about CR #3 she said Physician A had signed his admission orders [REDACTED]. She said she was not aware that Physician Assistant B was not responding. She said normally staff will tell her if a doctor/physician was not responding. She said Physician A comes to the building once a quarter and that Physician Assistant B comes in at least every 2 weeks. During an interview on 5/7/15 at 8:37 a.m. with LVN B she said she had been working in the facility since February 2015. When asked about CR #3 she said she called the doctor about his blood sugars and that she thought she had documented it but, .it gets crazy on this side. She said she did not hear back from his doctor but that sometimes doctor's called after their shift was over and the information was received by the nurse on the next shift. When asked what she did when she came in the next day and saw there still were no orders for CR #3's high blood sugars she said she, .just kept checking his sugars. She said this was a problem they had with Physician A's office. When asked if she reported the concern to her ADON or DON that she was not receiving a response from Physician A's office, she said, No, I didn't. She said CR #3's sugars had just been being checked since before she came. She said in the beginning his sugars were relatively normal but then got higher. She said he had gone out on pass for the weekend before he left the facility and that he told her he had to go to the hospital for his blood sugars and received two insulin shots. She said she did not know which hospital he had gone to. During an interview on 5/7/15 at 8:49 a.m. with ADON A she said that the Medical Director was not contacted related to problems getting a response for CR #3 from Physician A's office. She said if staff were not getting answers from a doctor they would call the Medical Director. She said the Medical Director would then call the doctor. She said she had interviewed the nurses (who cared for CR #3). She said she knew they did not document communications with Physician Assistant B. When asked why there were no physician progress notes [REDACTED]. When asked if Physician Assistant B dictated his progress notes or wrote them, she said he wrote them. During an interview on 5/7/15 at 9:17 a.m. with the Medical Records Clerk when asked if she had any additional records for CR #3, she said she had provided everything they have. During an interview on 5/7/15 at 1:33 p.m. with LVN B she said when they had a new admission they reviewed the orders and called the doctor to see what they wanted to keep and what they wanted to discontinue or change. She said they then wrote the orders and fax them to the pharmacy. When asked what was an acceptable blood sugar range for a person with diabetes, she said 130-170. She said sliding scale insulin usually started at 200 but that some residents' sliding scales could start with, for example, 2 units of insulin for a blood sugar level of 100. During an interview on 5/7/15 at 1:37 p.m. with LVN E she said they always made sure they get parameters from the doctor for insulin. When asked if she was familiar with CR #3 she said no. Record review of the drug regimen review reports by the Consultant Pharmacist for 12/2014, 1/2015, 2/2015, 3/2015, 3/2015, and 4/2015 revealed there was no documentation of a concern related to CR #3's high blood sugars with no treatment ordered. A message was left via voicemail for the Consultant Pharmacist on 5/7/15 at 12:07 p.m. The Consultant Pharmacist returned the call and left a message. During a telephone interview on 5/13/15 at 10:02 a.m. she was asked if a resident with diabetes and high blood sugars with treatment for [REDACTED]. She said she usually did look at MARs and TARs and communicated with the physician if he or she was present when she was in the building. She did not remember CR #3 and was unable to say if she had noticed that he was not receiving treatment for [REDACTED]. During an interview on 5/7/15 at 1:40 p.m. with the DON she said they have no policy and procedure for diabetes management and no standing guidelines for Physician A's patients. She said she called Physician A's office and asked them to fax over anything they have on CR #3. During a telephone interview on 5/7/15 at 2:36 p.m. with Physician A and Physician Assistant B, Physician A said he was not familiar with CR #3. After discussing findings with him, he said, .There five months and not getting anything.Obviously that's wrong. He said he had spoken to Physician Assistant B and that Physician Assistant B told him he had never been told that CR #3 was his patient. He then put Physician Assistant B on the telephone. Physician Assistant B said the facility never told him CR #3 was his patient. He said he had reviewed the chart but was not familiar with CR #3. When asked if he had seen CR #3 for visits during the 5 months he was in the facility, he said, No. Record review of CR #3's Discharge - Patient Medication Report from Hospital A dated 11/24/14 revealed Insulin [MEDICATION NAME] before meals and at bedtime had been crossed off of his list of medications. Record review of CR #3's nurses' note dated 11/24/14 revealed documentation of RN E calling to verify orders for CR #3 with Physician Assistant B. There was no documentation as to why an insulin sliding scale or oral medication was not ordered for his diabetes. Record review of CR #3's physician telephone orders revealed an order dated 1/8/15 for a CBC, comprehensive metabolic panel, NH3 level, and chest x-ray signed by Physician Assistant B. During an interview on 5/8/15 at 1:19 p.m. with LVN F she said if a resident's blood sugar levels were in the 200's, 300's and higher and there were no orders, you called the doctor. She said part of the admission process was calling the doctor to ensure orders were in place. She said if you called the doctor and were not getting a response, you called back in 15 minutes. She said if there was still no response you called the Medical Director. During an interview on 5/9/15 at 11:04 a.m. with LVN C she said CR #3 knew his blood sugars were high and that he snacked all the time,and would then say, .why is my sugar so high? She said she would tell him it was because he snacked. When asked about CR #3's blood sugars she said they were, .all over the place, and usually in the 200's. She said he had nothing ordered for his high blood sugars. When asked if that seemed strange to her she said, Yes. When asked if she called the doctor she said no. She said she worked Saturdays and Sundays 6 a.m. to 10 p.m. When asked how she ensured a physician was seeing a resident she said, I can't. I work the weekend. When asked why she did not call the doctor about CR #3's high blood sugars she said, .because he was not compliant. She said she went by the orders they had and the only orders were for accuchecks. She said the doctor's were supposed to review the sugars. She said the night shift was supposed to do chart checks nightly. She said night nurses should look for doctor's progress notes. When asked how she knew a doctor was seeing a patient during the day shift she said because the doctor's were in the building. She said day nurses should look for doctor's orders and new notes. She said new orders tell her a doctor has come in. She said orders were placed in the doctor's book (at the nurses' station) for them to sign. She did not know if doctor's were given lists of who their resident were. She said they called a doctor when a resident admitted and would think it would be up to the doctor to know which residents were theirs. When asked if she had noticed that CR #3 had no history and physical and no physician progress notes [REDACTED]. During an interview on 5/11/15 at 10:55 a.m. with LVN D she said CR #3 told her the doctor would not give him any insulin. She said she called Physician Assistant B and reported CR #3's high blood sugars but received no response from Physician Assistant B via phone messages or texts. When asked if she documented her attempts she said, I don't think so. She said she was the only nurse there and has 31 patients. She said she talked to ADON A about not getting a response from Physician Assistant B and that ADON A had told her she would try to reach him herself. When asked what she did when she continued to receive no response she said she told ADON A. She said, Somehow, somewhere, the ball just got dropped. She said she asked CR #3 if the doctor had seen him and he said no and that he was not being given insulin. When asked if she called her Medical Director she said no. She said she just found out that she could call the Medical Director. When asked if it seemed odd to her that CR #3 had no orders to treat his diabetes she said yes. When asked if she tried to call Physician A instead of his physician's assistant, she said no because someone had told her they were not call Physician A but were to go through his physician's assistant, Physician Assistant B. She did not remember who told her that. When asked if it concerned her that CR #3 was telling her he was not being seen by a doctor or treated she said, yes. When asked if she had reported CR #3 not receiving care and services to the Administrator, she said no. When asked if she would consider it neglect to not be seen by a doctor or receive treatment for [REDACTED]. During an interview on 5/11/15 at 2:41 p.m. with RN E she said she remembered CR #3 and that his blood sugars were high. She said she told Physician Assistant B. She said she was not sure if she had documented telling him. She said CR #3 was a, food hoarder. When asked if that changed whether the physician was to be called, she said no. She said CR #3's doctor should have been called. When asked why CR #3's doctor or the Medical Director were not called she said she did not know. When asked if she had noticed that there was no History and Physical or physician progress notes [REDACTED]. She said she had seen Physician Assistant B in person and told him about CR #3's high blood sugars but nothing was done. When asked if she had taken it to the DON she said, I don't' know. When asked if it seemed odd that CR #3 had no orders to treat his diabetes, she said, Yeah, in a way, yeah. When asked if it would be considered neglect for CR #3 not to receive treatment for [REDACTED]. During an interview on 5/11/15 at 8:32 a.m. with the Medical Records Clerk when asked if she remembered noticing that CR #3 was not being seen by his physician she said no. During an interview on 5/11/15 at 2:16 p.m. with LVN I, when asked if failing to treat a high blood sugar level would be considered neglect, she said, Yes, it is. Resident #9 Record review of Resident #9's admission sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Record review of Resident #9's History and Physical dated 2/2/15 revealed her [DIAGNOSES REDACTED]. Observation on 5/9/15 at 2:22 p.m. of Resident #9 revealed she was in her wheelchair in the hall. There were no concerns noted. She was groomed and without odor. Record review of Resident #9's May 2015 Physician Order summary revealed she had an order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes. She was receiving [MEDICATION NAME] 5 mg 1 by mouth twice a day, [MEDICATION NAME] 12 units SQ each morning, and had a [MEDICATION NAME] sliding scale insulin in the morning. She had no physician's order for accuchecks (blood sugar testing). an order for [REDACTED]. Record review of Resident #9's monthly physician order summaries for 5/2015, 4/2015, 3/2015, 2/2015, 1/2015, or 11/2014 revealed the order for the sliding scale blood sugar testing testing (accuchecks) was not listed. Record review of Resident #9's 5/2015 MARs revealed her blood sugar results at 6:30 a.m. on 5/4/15 was 53, on 5/5/15 was 55 on 5/7/15 was 49 and on 5/8/15 was 57. There was no documentation of a recheck or intervention on her MAR or in her nurses' notes for the low blood sugars or of physician notification. On 5/4/15 and 5/5/15 staff documented giving Resident #9 her scheduled [MEDICATION NAME] 12 units SQ at 6:30 a.m. each day. The [MEDICATION NAME] was documented on the MAR as being held on the morning of 5/7/15. Her physician order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes was not on her MAR. Record review of diabetes.org description of low blood sugar revealed: [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucoseThe food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar.X (blood sugar1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose.X) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html#sthash.niD9si6T.dpuf During an interview on 5/8/15 at 10:29 a.m. with LVN D when asked about Resident #9's low blood sugar levels, she said the doctor was aware that Resident #9's blood sugar was always low. She said there was no parameter for holding her insulin. She said Resident #9 usually runs low until she has had her coffee and she does get a snack. When asked if she had discussed Resident #9's low blood sugars with her ADON or DON she said she had asked ADON A and ADON A told her Resident #9's blood sugars run low. She said Resident #9 gets her coffee with sugar at about 7:00 a.m. When asked if she was rechecking Resident #9's blood sugars she said no because she perks up after she gets her coffee. She said even with a fasting blood sugar in the 40's and 50's Resident #9 was still maintaining. When asked if she had called the doctor to report the low blood sugars she said no. She also said Resident #9 was known for refusing her snacks. During an interview on 5/8/15 at 10:53 a.m. with the DON and LVN D; when asked about the Resident #9's blood sugar reading of 57, LVN D said she just called Resident #9's doctor to notify her of the low blood sugars. She also said that she had just given orange juice to Resident #9. After reviewing the physician's order to report a blood sugar less than 90 with the DON and LVN D, the DON said staff were supposed to have called the doctor and rechecked her blood sugar. During an interview on 5/8/15 at 11:04 a.m. with ADON A she said she was calling and checking to see why Resident #9's physician order to contact the doctor was not on Resident #9's MAR. Record review of Resident #9's 5/2015 physician's order revealed: if FSBS less than 70, then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes She said it was an active order. During an interview on 5/8/15 at 11:29 a.m. with LVN D she said that she had rechecked Resident #9's blood sugar that morning after giving her orange juice and that it was 98. She said she had also now documented. Record review on 5/8/15 at 11:49 a.m. of the Station I glucometer memory log with LVN D revealed the memory had no record of a blood sugar reading of 98 on 5/8/15. There was a reading in the memory of 85 but LVN D said she thought she had read 98. During an interview on 5/8/15 at 1:19 p.m. with LVN F, she said she had worked in the facility for 3 years. She said if a resident's blood sugar was greater than 500 they were to call the doctor but there was no standing order if it was high. She said if a blood sugar was low, for example less than 70, they should give orange juice with 2 packages of sugar. When asked if a blood sugar of 47, 49, or 59 should be reported to the doctor she said yes, after you intervene by giving [MEDICATION NAME] or orange juice. She said it was .very unacceptable, not to call the doctor with low readings. When asked what they did if there were no parameters to hold insulin she said they should use their nursing judgment, hold the insulin and call the doctor. Record review of the Texas Administrative Code, Standards of Nursing Practice, updated 12.5.14, revealed, .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; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (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 r

Based on observation, interview, and record review the Administrator, DON and ADON A failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the the highest practicable physical, mental, and psychosocial well-being of each resident in that: --The Administrator failed to supervise the DON and ADON A so that the residents received needed care and services relating to diabetes and physician visits. -- The Administrator and the DON failed to establish a system of complete and accurate clinical record documentation. --The DON failed to supervise and monitor ADON A, the Medical Records Clerk, and nurses so that they reported and followed-up on concerns for 3 residents. --ADON A failed to follow-up on concerns relayed to her by staff about CR#3 and his physician's assistant failing to respond to alleged attempts to contact him. --CR#3 was in the facility for approximately 5 months with no physician visits and no physician orders to treat his diabetes. His fasting blood sugar levels ranged from greater than 150 to Hi with no interventions. --Resident #9 had low blood sugar levels on 5/4/15, 5/5/15, and 5/7/15 that were not treated or reported to the doctor. --Resident #11 had consistently high blood sugar levels during May 2015 which were not called in to the doctor for interventions prior to 5/7/15. An Immediate Jeopardy (IJ) was identified on 5/8/15. While the IJ was removed on 5/12/15, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 23 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Intake # 1 Findings Include: During an interview on 5/6/15 at 1:11 p.m. with the DON she said ADON A had told her a couple of times that CR #3 had high blood sugars and that the doctor was called but nothing was ordered. Record review of CR #3's nurses' notes from 11/24/14 through 4/30/15 revealed there was no documentation of the physician being called to report high blood sugar levels. There was no documentation of an initial history and physical or physician progress notes [REDACTED]. During an interview on 5/6/15 at 1:25 p.m. with LVN D she said CR#3 told her other nurses had called his doctor. She said CR#3 refused to have an order for [REDACTED]. She said she also texted him from her phone. She was unable to find the text messages. During an interview on 5/6/15 at 1:28 p.m. with the DON about CR#3 she said Physician A had signed his admission orders [REDACTED]. She said she was not aware that Physician Assistant B was not responding. She said normally staff will tell her if a doctor/physician is not responding. She said Physician A comes to the building once a quarter and that Physician Assistant B comes in at least every 2 weeks. During an interview on 5/7/15 at 8:49 a.m. with ADON A she said that the Medical Director was not contacted related to problems getting a response for CR#3 from Physician A's office. She said if staff are not getting answers from a doctor they would call the Medical Director. She said the Medical Director would then call the doctor. She said she had interviewed the nurses (who cared for CR#3). She said she knows they did not document communications with Physician Assistant B. When asked why there were no physician progress notes [REDACTED]. When asked if Physician Assistant A dictates his progress notes or writes them out she said he writes them. During an interview on 5/7/15 at 1:40 p.m. with the DON she said they have no policy and procedure for diabetes management. During a telephone interview on 5/7/15 at 2:36 p.m. with Physician A and Physician Assistant B, Physician A said he was not familiar with CR#3. After discussing findings with him, he said, .There five months and not getting anything.Obviously that's wrong. He said he had spoken to Physician Assistant B and that Physician Assistant B told him he had never been told that CR#3 was his patient. He then put Physician Assistant B on the telephone. Physician Assistant B said the facility never told him CR#3 was his patient. He said he had reviewed the chart but was not familiar with CR#3. When asked if he had seen CR#3 for visits during the 5 months he was in the facility, he said, No. Record review of the facility's policy and procedure for Diagnostic Testing revised 02/2012 revealed, .It is the policy of this facility that residents receive diagnostic testing as ordered by their physician(s) and results of the testing are communicated to that physician so that prompt appropriate action can be taken if indicated for the resident's care.Diagnostic testing is any kind of medical test performed to aid in the [DIAGNOSES REDACTED]. Diagnostic testing includes but is not limited to: Lab.5. When test results are received the physician will be notified of any abnormal findings on the day the results are received by the facility. Notification may be by phone, fax, or in person. Record review of the facility's policy and procedure for Month-End Physician Order Reconciliation Protocol dated 06/11 revealed, .1. Upon admission (including re-admission) of a Resident, all orders must be reviewed by the attending physician, transcribed utilizing the Briggs Admission Order form. Record review of the facility's undated policy and procedure for Charting revealed, .PURPOSE Documenting information on the resident in the medical record provides- *A means of communication between the physician and other professionals contributing to the resident's care. * A basis for planning resident care. * Documentary evidence of the course of a resident's illness and treatment during each admission. * A way to record the care received by the resident. The resident's medical record is a legal document and may be used as evidence in law courts. therefore, the record must be accurate, legible, and complete.To Include all the Appropriate Information * Record care given, including but not limited to medications and treatments.*Document follow-up action to nursing observation. Record review of the facility's policy and procedure for Insulin Management Process revised 1/2014 revealed, .The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident's blood glucose readings are outside of the parameters outlined by the physician.Insulin and finger stick blood sugar readings will be recorded on the resident's medication administration record. Nurses Notes as indicated. During an interview on 5/11/15 at 12:47 p.m. with the DON she said they had no policy and procedure for physician visits. She said they follow the regulation. An IJ was identified on 5/8/15 at 2:51 p.m. and the DON and ADON A were informed at that time. A Plan of Removal (PoR) for the IJ was submitted 5/8/15 and after revisions was accepted on 5/11/15 at 4:49 p.m. The PoR included: .Removal of Immediacy Action Steps on May 8, 2015 On May 8, 2015 5:00 p.m.initiated and completed an audit of all residents with diabetes to validate that: -The blood sugar (sic) were completed and documented. Completed 5-8-15 -Insulin was administered according to physician order parameters. Completed 5-8-15. -Blood glucose levels outside the parameters, the patients were evaluated for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] and physician notifications was completed and followed up on by 5-8-15. -The Charge Nurse entered nursing actions in the patient's clinical record In-service completed on 5-9-15. -100% of diabetic residents have been audited. This was completed on 5-8-156. A list of all diabetics residents that had order changes were faxed to (DADS) on 5-11-15. -100% audit done on resident's to ensure that upon admission the physician/PA (physician's assistant)/NP (nurse practitioner) has seen the residents within the 30 day regulation. The resident that was listed in the Immediate Jeopardy was the only resident not seen within the 30 day regulated and he left the facility Against Medical Advise, so we were unable to do any correction for this resident. -The Medical Records person in-servicing began on 5-9-15 regarding the auditing and monitoring for new admission and the timelines of physician visits. completed on 5-11-15. -The Medical Records person, will monitor and track newly admitted residents and notify physician office of need to be seen at the facility and will track timeliness of physicians visits to ensure that all newly admitted residents are seen within the 30 day regulation. -The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. The Medical Director was notified of the Immediate Jeopardy on 5-8-15 at 4:39 p.m. CST by the facility, Director of Nursing Services, (name). The Director of Nursing, (name), and (name) RN, ADON are in-servicing the Charge Nurses on Diabetic/Insulin Management for all diabetics and the signs and symptoms of hypo and [MEDICAL CONDITION] which includes: -the licensed nurse will follow the physician's individualized insulin orders for each resident receiving insulin therapy. -Nurse will monitor for sign and symptoms of hyper and [DIAGNOSES REDACTED] including monitoring the results of any finger sticks blood sugars. -The physician will be notified of any symptoms of hyper and or [DIAGNOSES REDACTED] and if a resident's blood glucose readings are outside of the parameters outlined by the physician. -Follow up nursing actions will be documented in the clinical record. -[MEDICAL CONDITION] will be managed based on the physician's specific orders which may include adjustment to the resident's insulin dosage. -Insulin and finger stick blood sugar readings will be recorded on the resident's Medication Administration Record [REDACTED] -Insulin is administered according to manufacturer guidelines and administered by the nurse who takes the blood glucose. -All new admission charts will be audited by the ADONs the next day after new admission if the (sic) occurs over the weekend will be verified by the Charge Nurse and audited by the ADONs the following day after the weekend to ensure that physician orders have been approved and followed as it refers to newly admitted Diabetics. -The Medical Records person, will monitor and track newly admitted residents and notify physician office of need to be seen at the facility and will track timeliness of physicians visits to ensure that all newly admitted residents are seen within the 30 day regulation. -The Nurses were in-serviced that the Medical Director is to be called when they are unable to reach the primary care physician after several attempts. Timeline: The facility started training all existing nurses (effective 5-8-15) on insulin management and administration. Each facility nurse effective 5-8-15 has to receive this training prior to working as a charge nurse on the floor. All new nurses hired after 5-8-15 will receive training on insulin management and administration prior to working as a charge nurse on the floor. Other Residents that could be affected: Residents on medications with parameters will be reviewed and evaluated by (name), Director of Nursing Services, (name), RN, ADON and (name) RN, ADON to validate physician orders are followed and follow up documentation is entered on the Medication Administration Record [REDACTED]. During an interview on 5/9/15 at 11:34 a.m. with the DON, ADON A, and ADON B, the DON said she did a 100% audit for diabetics. She said they were adding a physician's visit log to each doctor's book at each nurse's station. She said she did not find any issues beyond what had already been identified. She said in-services had also been done. When asked what was the prior system to ensure residents were being seen by the physician, ADON A said once a resident admitted , the doctor was called and that was their notification. The DON said the Medical Director comes in once a month and her Nurse Practitioner comes in weekly. She said Physician C's nurse practitioner comes in every 2 weeks. She said Physician Assistant B comes in every week or so. She said a doctor not seeing a resident has never happened before. During an interview on 5/9/15 at 12:04 p.m. with the DON she said they had no policy and procedure on diabetic management. She said they had forms and quality assurance tools they used. She said the last Quality Assurance meeting was in April (2015) and that, no, they did not go over diabetic management. When asked what her thoughts were on how a resident could have high blood sugars for so long with no interventions she said, We all just missed it, we really did. She said the ADONs saw the MARs each month and the Consultant Pharmacist also looked at them. She said they had a cart and medication auditor that visited the facility. She said you can ask all the nurses and they all tell you to document but it was not documented. She said CR#3 was asymptomatic. She said auditing tools were now in place. When asked why Resident #9's low blood sugars were not addressed, she said she did not know why but that they should have been. When asked if they had a policy and procedure for what to do when an attending physician was not responding she said no. She said, unless it's emergent, if an attending physician is not returning your calls after several attempts to reach him/her, then you call the Medical Director but the process is not to exceed 24 hours. When asked how she thought this immediate jeopardy had occurred she said she just believed somewhere there was a breakdown in the system they used. The surveyors confirmed that the PoR had been implemented sufficiently to remove the IJ by: During an interview on 5/9/15 at 1:24 p.m. with the Administrator he said this (CR#3 having no physician visits) should have been caught in the medical records audit. He said Medical Records should be auditing new admits weekly to find out about doctor visits. He said Physician A's physician's assistant, Physician Assistant B, apparently signed off on initial orders and Physician A signed monthly orders. He said they have two ADONs that monitor charts daily and also have a medical records person who monitors a certain number of charts daily. He said he has 3 people monitoring charts on a daily basis. When asked how he felt CR#3 not being seen by a doctor occurred, he said, We didn't get it monitored correctly. When asked how he thought CR#3 went without physician orders to treat his diabetes occurred, he said due to each doctor having their own set of parameters. He said he was going to meet with the Medical Director to come up with a protocol. During an interview on 5/9/15 at 2:22 p.m. with Resident #8 she said her doctor was coming to see and she was receiving blood sugar checks and with interventions. She said she was a nurse. She said she takes scheduled insulin and has a sliding scale. She said she sees either Physician C or his nurse practitioner weekly and was receiving the care and services she needed. In an interview on 5/10/15 at 10:00 a.m., the DON said we missed it. The facility had no notes about to prove that they had attempted to contact the physician or physician assistant when CR #3 had high blood sugar results. She said they had no progress notes indicating that the physician or physician assistant had visited him for the period of time CR #3 was a resident at the facility. During an interview on 5/11/15 at 8:32 a.m. with the Medical Records Clerk she was able to describe her in-service training. She reviewed the new tracking forms they were putting in placed and described how she will use them to ensure physician visits. During an interview on 5/11/15 at 12:36 p.m. with Resident #20 she said she was doing alright. She said she was getting her medications. She said her doctor does come to see her in the facility at least once a month. She had no concerns about her care. During an interview on 5/11/15 at 12:38 p.m. with Resident #30 he said he was okay. He said he was getting the help he needed and sees his doctor. He said he was getting his medications and had no concerns. During an interview on 5/11/15 at 12:57 p.m. with LVN F and LVN H both said they had received the in-services training. Both were able to describe the training. LVN H described what to do in the event of a resident having a low blood sugar level. During an additional interview on 5/12/15 at 8:34 a.m. with LVN F she was able to describe procedures for what to do if a doctor is not responding and contacting the Medical Director. She was also able to describe what to do if a resident with diabetes has no orders for treatment, and what to do if she notices there are no physician progress notes [REDACTED]. During an interview on 5/11/15 at 1:10 p.m. with Resident #32 she said she was getting everything she needed. She said she was getting her medications okay and that her doctor does come and see her. During an interview on 5/11/15 at 1:52 p.m. with LVN E she said she had received the in-service training. She was able to describe the training and reporting procedures. During an interview on 5/11/15 at 2:16 p.m. with LVN I she was able to describe the in-service training. She was able to describe what to do reporting procedures. During an interview on 5/12/15 at 8:34 a.m. with LVN F she was able to describe the in-service training and describe what to do in the event a doctor could not be reached or upon noticing there were no physician progress notes [REDACTED]. During an interview on 5/12/15 at 8:41 a.m. with ADON A she said, Yes staff came to her and told her about CR#3's high blood sugars. She said she told them to call Physician Assistant B. She said they did not tell her that Physician Assistant B had not been responding. She said she could not remember which nurse but one told her Physician Assistant B told her not to do anything. She could not remember which nurse told her that and did not remember when it was. She said several nurses had come to her, especially RN E. She said she expected licensed professionals to follow-up. Record review of insulin MARs on Station I and Station II revealed parameters had been added and physician orders for accuchecks. Record review of facility Diabetic Monitoring sheets dated 5-8-15 revealed documentation of completion of the facility's audit. Record review of in-services revealed in-servicing had been completed with the exception of 2 employees who were no longer employed, and 2 as needed nurses who were to be trained prior to being allowed to work. Record review of a list provided by the DON documented a 100% audit on residents to ensure physician visits. Record review of clinical records for Resident #'s 4, 5, 12, 27, 29, and 30, new admissions under Physician A, revealed documentation to show they were being seen by the physician. Resident #'s 27, 12, 5, 29, and 4 were on the list as being under Physician A, but since readmission were being seen by the Medical Director and Nurse Practitioner C. Record review of the doctors' books at Station I and Station II revealed the physician visit logs had been placed in each binder. The Administrator, DON, ADON A and ADON B were informed on 5/12/15 at 9:36 a.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. Record review of the diabetic monitoring sheet revealed 25 residents with diabetes. Refer to CMS 2567 F157, F224, F281, F309 for additional evidence.

Based on observation, interview, and record review the facility failed to implement their policies and procedures that prohibit neglect for 3 of 16 residents (CR#3, #9, and #11) reviewed for diabetes management in that: --CR #3 was in the facility for over 5 months with no physician visits and no physician orders to treat his diabetes. His fasting blood sugar levels ranged from greater than 150 to Hi with no interventions. --Resident #9 had low blood sugar levels on 5/4/15, 5/5/15, and 5/7/15 that were not treated or reported to the doctor. --Resident #11 had consistently high blood sugar levels during May 2015 which were not called in to the doctor for interventions prior to 5/7/15. An Immediate Jeopardy (IJ) was identified on 5/8/15. While the IJ was removed on 5/12/15, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 3 residents and placed an additional 23 residents at risk of diabetes associated complications, [MEDICAL CONDITION], [DIAGNOSES REDACTED], and hospitalization . Intake # 1 Findings Include: CR #3 Record review of CR #3's closed record admission sheet revealed he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #3's closed record revealed documentation that he signed himself out of the facility against medical advice on 4/30/15. Record review of CR #3's quarterly MDS assessment dated [DATE] revealed he scored an 11 out of 15 on his brief interview for mental status indicating moderately impaired cognitive skills. He required supervision of one person for bed mobility, dressing and toilet use. He required supervision and set up for transfer, walking in his room and off the unit, eating, and personal hygiene. The assessment indicated he used a cane or crutch. He was assessed as having no behaviors including no rejection of care. He was assessed as having a [DIAGNOSES REDACTED]. Record review of CR #3's plan of care dated 12/2/14 revealed his plan of care for being at risk for unstable blood sugars related to diabetes revealed an intervention of, .Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within acceptable parameters as dictated by the physician, document and notify physician. During a telephone interview on 5/6/15 at 12:07 p.m. with CR #3 he said he left the facility because they were not taking care of him. He would not answer any additional questions. He said he was safe, had a place to stay and food and medications. Record review of CR #3's Admission Physician orders dated 11/24/14 revealed he had a doctor's order for fasting blood sugar checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. Humalog Insulin had been written down but was crossed off. The orders were signed by Physician A with no date and by RN E on 11/24/14. Record review of CR #3's April 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 4/1/15 and ADON A on 4/1/15. Record review of CR #3's November 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 24 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 15 times; 201-250: 6 times; and 251-300: 3 times. Record review of CR #3's nurses' notes dated November 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of diabetes.org description of diabetes management tight control of blood glucose revealed: Ideally, this means levels between 70 and 130 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. Also called hemoglobin A1C or glycosylated (gly-KOH-sih-lay-ted) hemoglobin, the test shows the amount of glucose that sticks to the red blood cell, which is proportional to the amount of glucose in the blood.X) level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses. - See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.zzKDulLu.dpuf Record review of CR #3's December 2014 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The order summary was 2 pages long. There were no orders for any medications for the month of December 2014. The orders were signed by Physician A on 11/29/14 and by ADON A on 11/29/14. Record review of CR #3's December 2014 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was to be tested 124 times during the month of December 2014. CR #3's blood sugars ranged from: 150-200: 66 times; 201-250: 29 times; 251-300: 11 times; and 301-350: 5 times. Record review of CR #3's nurses' notes dated December 2014 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's January 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 1/6/15 and by ADON A on 1/6/15. Record review of CR #3's January 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of January 2015. CR #3's blood sugars ranged from: 150-200: 29 times; 201-250: 41 times; 251-300: 25 times; 301-350: 15 times; and was documented as: 386 on 1/11/15 at 11:00 a.m.; 473 on 1/22/15 at 11:00 a.m.; 389 on 1/23/15 at 11:00 a.m.; 503 on 1/24/15 at 11:00 a.m.; 480 on 1/24/15 at 9:00 p.m.; 358 on 1/25/15 at 11:00 a.m.; 448 on 1/25/15 at 9:00 p.m.; and 353 on 1/26/15 at 11:00 a.m. Record review of CR #3's nurses' notes dated 1/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's February 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 2/11/15 and by ADON A on 2/3/15. Record review of CR #3's February 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 104 times during the month of February 2015. CR #3's blood sugars ranged from: 150-200: 11 times; 201-250: 37 times; 251-300: 15 times; 301-350: 19 times; and was documented as: 360 on 2/1/15 at 11:00 a.m.; 373 on 2/8/15 at 4:00 p.m.; 420 on 2/10/15 at 11:00 a.m.; 365 on 2/12/15 at 11:00 a.m.; 467 on 2/14/15 at 8:00 p.m.; 525 on 2/15/15 at 4:00 p.m.; 414 on 2/15/15 at 8:00 p.m.; 434 on 2/16/15 at 11:00 a.m.; 460 on 2/17/15 at 11:00 a.m.; 369 on 2/19/15 at 11:00 a.m.; 351 on 2/21/15 at 11:00 a.m.; 495 on 2/21/15 at 8:00 p.m. 356 on 2/22/15 at 11:00 a.m.; and 378 on 2/24/15 at 11:00 a.m. There was no documentation of his blood sugar being checked or of it being refused on 2/23/15 at 4:00 p.m., 2/27/15 at 4:00 p.m.,and 2/27/15 at 8:00 p.m. Record review of CR #3's nurses' notes dated 2/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars . Record review of CR #3's March 2015 physician order recap revealed he had a doctor's order for accu checks before meals and at bedtime to test his blood sugar levels. There were no orders for an oral hypoglycemic medication or scheduled or sliding scale insulin. The orders were signed by Physician A on 3/3/15 and by ADON A on 3/3/15. Record review of CR #3's March 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 124 times during the month of March 2015. CR #3's blood sugars ranged from: 150-200: 5 times; 201-250: 36 times; 251-300: 41 times; 301-350: 19 times; and was documented as: 396 on 3/8/15 at 11:00 a.m.; 369 on 3/9/15 at 11:00 a.m.; 431 on 3/10/15 at 11:00 a.m.; 365 on 3/11/15 at 11:00 a.m.; 441 on 3/20/15 at 11:00 a.m.; Hi on 3/21/15 at 11:00 a.m. (indicating his reading was too high for the glucometer to be able to read); 371 on 3/5/15 at 4:00 p.m.; 380 on 3/14/15 at 8:00 p.m.; 354 on 3/15/15 at 4:00 p.m.; 463 on 3/15/15 at 8:00 p.m.; 359 on 3/20/15 at 4:00 p.m.; 496 on 3/22/15 at 8:00 p.m; 436 on 3/26/15 at 11:00 a.m.; 400 on 3/30/15 at 11:00 a.m.; and 352 on 3/31/15 at 11:00 a.m. The documented result was illegible on 3/29/15 at 11:00 a.m. There was no documentation of the Hi result on 3/21/15 at 11:00 a.m. being rechecked. Record review of the glucometer user's manual revealed a reading of, Hi, indicated a blood sugar level above 600 mg/deciliter with instructions to repeat the test and if the message showed again, to call a healthcare professional immediately. The Expected Blood Glucose Readings, for a person with diabetes fasting (before meals) was 70-110 mg/dL and 2 hours after meals was 70-140 mg/dL. Record review of CR #3's nurses' notes dated 3/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's April 2015 Medication Administration Record (MAR) revealed his blood sugar levels were ordered to be tested 4 times a day, before meals and at bedtime. His blood sugar level was tested 116 times during the month of April 2015. CR #3's blood sugars ranged from: 150-200: 4 times; 201-250: 35 times; 251-300: 46 times; 301-350: 17 times; and was documented as: 365 on 4/4/15 at 8:00 p.m.; 439 on 4/5/15 at 4:00 p.m.; 400 on 4/7/15 at 11:00 a.m.; 407 on 4/13/15 at 11:00 a.m.; 356 on 4/15/15 at 11:00 a.m.; 437 on 4/18/15 at 11:00 a.m.; 356 on 4/18/15 at 8:00 p.m; and 387 on 4/28/15 at 6:30 a.m.,. He refused having his blood sugar level tested 3 times. Record review of CR #3's nurses' notes dated 4/2015 revealed there was no documentation of the physician being called to report the high blood sugar levels or inquire as to why there were no orders to treat his high blood sugars. Record review of CR #3's Medicare Charting Guide dated 11/24/14 revealed staff were to address Highlighted Areas, in their documentation. Highlighted areas included, .DIABETES a. Level of consciousness b. Thirst, weakness or diaphoresis c. Elevated d. Blood sugar results/Dietary intake e. Status of wounds f. Insulin / oral hypoglycemic dosage g. Response to treatment / teaching. During a telephone interview on 5/6/15 at 12:55 p.m. with Physician Assistant B he was asked about CR #3. He said CR #3's diabetes was managed with an oral hypoglycemic agent. He said he told CR #3 that they would watch his blood sugars for awhile before considering insulin in order to avoid the ups and downs of insulin and that CR #3 told him that was good because he did not want insulin. After discussing with Physician Assistant B that CR #3 had no orders for an oral hypoglycemic agent he said then he (Physician A) may have been planning to start one. He said he should have at least been on an oral hypoglycemic agent. He said he would be at the facility on 5/7/15 and would review the chart and follow-up. During an interview on 5/6/15 at 1:11 p.m. with the DON she said ADON A had told her a couple of times that CR #3 had high blood sugars and that the doctor was called but nothing was ordered. Record review of CR #3's nurses' notes from 11/24/14 through 4/30/15 revealed there was no documentation of the physician being called to report high blood sugar levels. There was no documentation of an initial history and physical or physician progress notes [REDACTED]. During an interview on 5/6/15 at 1:25 p.m. with LVN D she said CR #3 told her other nurses had called his doctor. She said CR #3 refused to have an order for [REDACTED].#3 she said over 300. When asked if she had called his doctor to report his high blood sugar levels she said she had left messages for Physician Assistant B but had received no response from him. She said she also texted him from her phone. She was unable to find the text messages. During an interview on 5/6/15 at 1:28 p.m. with the DON about CR #3 she said Physician A had signed his admission orders [REDACTED]. She said she was not aware that Physician Assistant B was not responding. She said normally staff will tell her if a doctor/physician was not responding. She said Physician A comes to the building once a quarter and that Physician Assistant B comes in at least every 2 weeks. During an interview on 5/7/15 at 8:37 a.m. with LVN B she said she had been working in the facility since February 2015. When asked about CR #3 she said she called the doctor about his blood sugars and that she thought she had documented it but, .it gets crazy on this side. She said she did not hear back from his doctor but that sometimes doctor's called after their shift was over and the information was received by the nurse on the next shift. When asked what she did when she came in the next day and saw there still were no orders for CR #3's high blood sugars she said she, .just kept checking his sugars. She said this was a problem they had with Physician A's office. When asked if she reported the concern to her ADON or DON that she was not receiving a response from Physician A's office, she said, No, I didn't. She said CR #3's sugars had just been being checked since before she came. She said in the beginning his sugars were relatively normal but then got higher. She said he had gone out on pass for the weekend before he left the facility and that he told her he had to go to the hospital for his blood sugars and received two insulin shots. She said she did not know which hospital he had gone to. During an interview on 5/7/15 at 8:49 a.m. with ADON A she said that the Medical Director was not contacted related to problems getting a response for CR #3 from Physician A's office. She said if staff were not getting answers from a doctor they would call the Medical Director. She said the Medical Director would then call the doctor. She said she had interviewed the nurses (who cared for CR #3). She said she knew they did not document communications with Physician Assistant B. When asked why there were no physician progress notes [REDACTED]. When asked if Physician Assistant B dictated his progress notes or wrote them, she said he wrote them. During an interview on 5/7/15 at 9:17 a.m. with the Medical Records Clerk when asked if she had any additional records for CR #3, she said she had provided everything they have. During an interview on 5/7/15 at 1:33 p.m. with LVN B she said when they had a new admission they reviewed the orders and called the doctor to see what they wanted to keep and what they wanted to discontinue or change. She said they then wrote the orders and fax them to the pharmacy. When asked what was an acceptable blood sugar range for a person with diabetes, she said 130-170. She said sliding scale insulin usually started at 200 but that some residents' sliding scales could start with, for example, 2 units of insulin for a blood sugar level of 100. During an interview on 5/7/15 at 1:37 p.m. with LVN E she said they always made sure they get parameters from the doctor for insulin. When asked if she was familiar with CR #3 she said no. Record review of the drug regimen review reports by the Consultant Pharmacist for 12/2014, 1/2015, 2/2015, 3/2015, 3/2015, and 4/2015 revealed there was no documentation of a concern related to CR #3's high blood sugars with no treatment ordered. A message was left via voicemail for the Consultant Pharmacist on 5/7/15 at 12:07 p.m. The Consultant Pharmacist returned the call and left a message. During a telephone interview on 5/13/15 at 10:02 a.m. she was asked if a resident with diabetes and high blood sugars with treatment for [REDACTED]. She said she usually did look at MARs and TARs and communicated with the physician if he or she was present when she was in the building. She did not remember CR #3 and was unable to say if she had noticed that he was not receiving treatment for [REDACTED]. During an interview on 5/7/15 at 1:40 p.m. with the DON she said they have no policy and procedure for diabetes management and no standing guidelines for Physician A's patients. She said she called Physician A's office and asked them to fax over anything they have on CR #3. During a telephone interview on 5/7/15 at 2:36 p.m. with Physician A and Physician Assistant B, Physician A said he was not familiar with CR #3. After discussing findings with him, he said, .There five months and not getting anything.Obviously that's wrong. He said he had spoken to Physician Assistant B and that Physician Assistant B told him he had never been told that CR #3 was his patient. He then put Physician Assistant B on the telephone. Physician Assistant B said the facility never told him CR #3 was his patient. He said he had reviewed the chart but was not familiar with CR #3. When asked if he had seen CR #3 for visits during the 5 months he was in the facility, he said, No. Record review of CR #3's Discharge - Patient Medication Report from Hospital A dated 11/24/14 revealed Insulin [MEDICATION NAME] before meals and at bedtime had been crossed off of his list of medications. Record review of CR #3's nurses' note dated 11/24/14 revealed documentation of RN E calling to verify orders for CR #3 with Physician Assistant B. There was no documentation as to why an insulin sliding scale or oral medication was not ordered for his diabetes. Record review of CR #3's physician telephone orders revealed an order dated 1/8/15 for a CBC, comprehensive metabolic panel, NH3 level, and chest x-ray signed by Physician Assistant B. During an interview on 5/8/15 at 1:19 p.m. with LVN F she said if a resident's blood sugar levels were in the 200's, 300's and higher and there were no orders, you called the doctor. She said part of the admission process was calling the doctor to ensure orders were in place. She said if you called the doctor and were not getting a response, you called back in 15 minutes. She said if there was still no response you called the Medical Director. During an interview on 5/9/15 at 11:04 a.m. with LVN C she said CR #3 knew his blood sugars were high and that he snacked all the time,and would then say, .why is my sugar so high? She said she would tell him it was because he snacked. When asked about CR #3's blood sugars she said they were, .all over the place, and usually in the 200's. She said he had nothing ordered for his high blood sugars. When asked if that seemed strange to her she said, Yes. When asked if she called the doctor she said no. She said she worked Saturdays and Sundays 6 a.m. to 10 p.m. When asked how she ensured a physician was seeing a resident she said, I can't. I work the weekend. When asked why she did not call the doctor about CR #3's high blood sugars she said, .because he was not compliant. She said she went by the orders they had and the only orders were for accuchecks. She said the doctor's were supposed to review the sugars. She said the night shift was supposed to do chart checks nightly. She said night nurses should look for doctor's progress notes. When asked how she knew a doctor was seeing a patient during the day shift she said because the doctor's were in the building. She said day nurses should look for doctor's orders and new notes. She said new orders tell her a doctor has come in. She said orders were placed in the doctor's book (at the nurses' station) for them to sign. She did not know if doctor's were given lists of who their resident were. She said they called a doctor when a resident admitted and would think it would be up to the doctor to know which residents were theirs. When asked if she had noticed that CR #3 had no history and physical and no physician progress notes [REDACTED]. During an interview on 5/11/15 at 10:55 a.m. with LVN D she said CR #3 told her the doctor would not give him any insulin. She said she called Physician Assistant B and reported CR #3's high blood sugars but received no response from Physician Assistant B via phone messages or texts. When asked if she documented her attempts she said, I don't think so. She said she was the only nurse there and has 31 patients. She said she talked to ADON A about not getting a response from Physician Assistant B and that ADON A had told her she would try to reach him herself. When asked what she did when she continued to receive no response she said she told ADON A. She said, Somehow, somewhere, the ball just got dropped. She said she asked CR #3 if the doctor had seen him and he said no and that he was not being given insulin. When asked if she called her Medical Director she said no. She said she just found out that she could call the Medical Director. When asked if it seemed odd to her that CR #3 had no orders to treat his diabetes she said yes. When asked if she tried to call Physician A instead of his physician's assistant, she said no because someone had told her they were not call Physician A but were to go through his physician's assistant, Physician Assistant B. She did not remember who told her that. When asked if it concerned her that CR #3 was telling her he was not being seen by a doctor or treated she said, yes. When asked if she had reported CR #3 not receiving care and services to the Administrator, she said no. When asked if she would consider it neglect to not be seen by a doctor or receive treatment for [REDACTED]. During an interview on 5/11/15 at 2:41 p.m. with RN E she said she remembered CR #3 and that his blood sugars were high. She said she told Physician Assistant B. She said she was not sure if she had documented telling him. She said CR #3 was a, food hoarder. When asked if that changed whether the physician was to be called, she said no. She said CR #3's doctor should have been called. When asked why CR #3's doctor or the Medical Director were not called she said she did not know. When asked if she had noticed that there was no History and Physical or physician progress notes [REDACTED]. She said she had seen Physician Assistant B in person and told him about CR #3's high blood sugars but nothing was done. When asked if she had taken it to the DON she said, I don't' know. When asked if it seemed odd that CR #3 had no orders to treat his diabetes, she said, Yeah, in a way, yeah. When asked if it would be considered neglect for CR #3 not to receive treatment for [REDACTED]. During an interview on 5/11/15 at 8:32 a.m. with the Medical Records Clerk when asked if she remembered noticing that CR #3 was not being seen by his physician she said no. During an interview on 5/11/15 at 2:16 p.m. with LVN I, when asked if failing to treat a high blood sugar level would be considered neglect, she said, Yes, it is. Resident #9 Record review of Resident #9's admission sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Record review of Resident #9's History and Physical dated 2/2/15 revealed her [DIAGNOSES REDACTED]. Observation on 5/9/15 at 2:22 p.m. of Resident #9 revealed she was in her wheelchair in the hall. There were no concerns noted. She was groomed and without odor. Record review of Resident #9's May 2015 Physician Order summary revealed she had an order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes. She was receiving [MEDICATION NAME] 5 mg 1 by mouth twice a day, [MEDICATION NAME] 12 units SQ each morning, and had a [MEDICATION NAME] sliding scale insulin in the morning. She had no physician's order for accuchecks (blood sugar testing). an order for [REDACTED]. Record review of Resident #9's monthly physician order summaries for 5/2015, 4/2015, 3/2015, 2/2015, 1/2015, or 11/2014 revealed the order for the sliding scale blood sugar testing testing (accuchecks) was not listed. Record review of Resident #9's 5/2015 MARs revealed her blood sugar results at 6:30 a.m. on 5/4/15 was 53, on 5/5/15 was 55 on 5/7/15 was 49 and on 5/8/15 was 57. There was no documentation of a recheck or intervention on her MAR or in her nurses' notes for the low blood sugars or of physician notification. On 5/4/15 and 5/5/15 staff documented giving Resident #9 her scheduled [MEDICATION NAME] 12 units SQ at 6:30 a.m. each day. The [MEDICATION NAME] was documented on the MAR as being held on the morning of 5/7/15. Her physician order that if her fasting blood sugar check was less than 60 staff were to contact the doctor then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes was not on her MAR. Record review of diabetes.org description of low blood sugar revealed: [DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucoseThe food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar.X (blood sugar1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose.X) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html#sthash.niD9si6T.dpuf During an interview on 5/8/15 at 10:29 a.m. with LVN D when asked about Resident #9's low blood sugar levels, she said the doctor was aware that Resident #9's blood sugar was always low. She said there was no parameter for holding her insulin. She said Resident #9 usually runs low until she has had her coffee and she does get a snack. When asked if she had discussed Resident #9's low blood sugars with her ADON or DON she said she had asked ADON A and ADON A told her Resident #9's blood sugars run low. She said Resident #9 gets her coffee with sugar at about 7:00 a.m. When asked if she was rechecking Resident #9's blood sugars she said no because she perks up after she gets her coffee. She said even with a fasting blood sugar in the 40's and 50's Resident #9 was still maintaining. When asked if she had called the doctor to report the low blood sugars she said no. She also said Resident #9 was known for refusing her snacks. During an interview on 5/8/15 at 10:53 a.m. with the DON and LVN D; when asked about the Resident #9's blood sugar reading of 57, LVN D said she just called Resident #9's doctor to notify her of the low blood sugars. She also said that she had just given orange juice to Resident #9. After reviewing the physician's order to report a blood sugar less than 90 with the DON and LVN D, the DON said staff were supposed to have called the doctor and rechecked her blood sugar. During an interview on 5/8/15 at 11:04 a.m. with ADON A she said she was calling and checking to see why Resident #9's physician order to contact the doctor was not on Resident #9's MAR. Record review of Resident #9's 5/2015 physician's order revealed: if FSBS less than 70, then give [MEDICATION NAME] 1 mg IM/IV/SQ if unresponsive and if responsive give 120 ml of orange juice with 2 packages of sugar then recheck in 15 minutes She said it was an active order. During an interview on 5/8/15 at 11:29 a.m. with LVN D she said that she had rechecked Resident #9's blood sugar that morning after giving her orange juice and that it was 98. She said she had also now documented. Record review on 5/8/15 at 11:49 a.m. of the Station I glucometer memory log with LVN D revealed the memory had no record of a blood sugar reading of 98 on 5/8/15. There was a reading in the memory of 85 but LVN D said she thought she had read 98. During an interview on 5/8/15 at 1:19 p.m. with LVN F, she said she had worked in the facility for 3 years. She said if a resident's blood sugar was greater than 500 they were to call the doctor but there was no standing order if it was high. She said if a blood sugar was low, for example less than 70, they should give orange juice with 2 packages of sugar. When asked if a blood sugar of 47, 49, or 59 should be reported to the doctor she said yes, after you intervene by giving [MEDICATION NAME] or orange juice. She said it was .very unacceptable, not to call the doctor with low readings. When asked what they did if there were no parameters to hold insulin she said they should use their nursing judgment, hold the insulin and call the doctor. Record review of the Texas Administrative Code, Standards of Nursing Practice, updated 12.5.14, revealed, .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; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (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