Every finding on record at Baya Pointe Nursing and Rehabilitation Center

Based on record review and interview, the facility failed to maintain accurate and complete records for 1 (Resident #1) of 3 residents reviewed.Findings include:Review of Resident #1's Discharge summary dated [DATE] documented the discharge location name and address as Resident #1's home address/his Responsible Party/Daughter's home address. There was no documentation of Resident #1's name or that of his Responsible Party/daughter in the section designated for Resident/Representative Acknowledgement.Review of Resident #1's social worker progress note dated 4/23/2026 read, Resident stated that he would like to discharge home to address [an address not listed on Resident #1's admission record] on 4/23/26. Resident stated that brother [name of brother] will be picking him up from the facility.During an interview on 5/26/2026 at 12:54 PM, the Director of Social Work stated, He [Resident #1] wanted to leave and he didn't trust his daughter. I opened the discharge assessment [Discharge Summary] and put the address [of where the resident is going after discharge].During an interview on 5/26/2026 at 2:02 PM, Staff A, Licensed Practical Nurse (LPN) Unit Manager, stated, He [Resident #1] left with his brother on 4/24 [2026]. I do not remember the brother's name. I think it's on the discharge summary. I remember asking his address. I remember cross-referencing the address on the facesheet with [Resident #1's name]. I couldn't tell you which brother he left with.During an interview on 5/26/2026 at 2:26 PM, the Director of Nursing (DON) stated, It should have been documented where he [Resident #1] went [when he was discharged ]. Knowing where a resident is being discharged is required for a safe discharge and is expected to be accurately documented on the Discharge Summary.Review of the facility policy and procedure titled Transfers and Discharges issue in 5/2020 read, Standard: The facility will develop and implement an effective discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Procedure: 3. The resident and/or representative (sponsor) will be notified in writing of the following information: c. The location to which the resident is being transferred or discharged .

Based on interview and record review, the facility failed to maintain an accurate and complete clinical record for one (Resident #1) of three residents reviewed for discharge. The discharge documentation contained an inaccurate account of the resident's discharge location and lacked documentation of the resident's discharge disposition and the date and time of discharge.Findings include: During an interview on 5/26/2026 at 12:54 the Director of Social Work stated, He [Resident #1] wanted to leave and he didn't trust his daughter. I open the discharge assessment [Discharge Summary] and put the address [of where the resident is going after discharge]. During an interview on 5/26/2026 at 2:02 PM Staff A, LPN (Licensed Practical Nurse) - Unit Manager stated, He (Resident #1) left with his brother on 4/24 [2026]. I do not remember the brother's name, I think it's on the discharge summary. I remember asking his address. I remember cross-referencing the address on the facesheet with [Resident #1's name]. I couldn't tell you which brother he left with. During an interview on 5/26/2026 at 2:26 the DON (Director of Nursing) stated, It should have been documented where he [Resident #1] went [when he was discharged ]. The DON stated that knowing where a resident is being discharged is required for a safe discharge and is expected to be accurately documented on the Discharge Summary. During an interview on 5/26/2026 at 3:45 PM APRN (Advanced Practice Registered Nurse) #2 stated that she remembered Resident #1, and knew his daughter was coming in frequently to visit him. He was a heavy drinker when he was home. She was not in the facility when he left. It was the facility's responsibility to confirm where the resident was being discharged and to ensure everything was safe at home [a safe environment for discharge]. Review of Resident #1's Census Data revealed he was admitted on [DATE] with medical diagnoses that included other sequelae of cerebral infarction; alcohol dependence with alcohol-induced persisting dementia; presence of other vascular implants and grafts; difficulty in walking, not elsewhere classified Review of Resident #1's most recent MDS (Minimum Data Set) Assessment, a Medicare 5-day assessment dated [DATE] documented his BIMS (Brief Inventory of Mental Status) Score as 7 out of 15 which indicated he had cognitive impairment. A Social Worker Progress Note dated 4/24/2026 read, Writer attempted to call [name of Resident #1's brother] in regard to resident being discharged . Writer was unable to reach him. Writer will inform resident. A Social Worker Progress Note dated 4/23/2026 read, Resident stated that he would like to discharge home to address [an address not listed on Resident #1's facesheet] on 4/23/26. Resident stated that brother [name of brother] will be picking him up from the facility. Resident declined home health and equipment. Writer attempted to called POA [Resident #1's daughter's name] to inform her of the discharge and was unable to reach her. Review of Resident #1's Discharge summary dated [DATE] documented the discharge location name and address as Resident #1's home address/his Responsible Party/daughter's home address. There was no documentation of Resident #1's name or that of his Responsible Party/daughter in the section designated for Resident/Representative Acknowledgement. Review of Resident #1's Progress notes from 4/23/2026 through 4/25/2026 revealed there was no documentation of the specific date or time Resident #1 left the facility or any details of his discharge disposition. Review of the policy and procedure titled Transfers and Discharges, with an issue date of 5/2020 read, Standard: The facility will develop and implement an effective discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Procedure: 3. The resident and/or representative (sponsor) will be notified in writing of the following information: c. The location to which the resident is being transferred or discharged

Based on record review and interview the facility failed to ensure current and accurate nurse staffing data was posted for residents, staff, and visitors.Findings include: During an observation on Friday, 5/4/2026, at 9:31 AM the posted nurse staffing information was dated Friday 5/1/2026. During an interview on 5/4/2026 at 9:31 AM, the Director of Nursing acknowledged the nurse staffing information posted on Monday, 5/4/2026 at 9:31 AM was not current and was last updated on Friday, 5/1/2026. She stated the scheduler had the responsibility to ensure the posted nurse staffing information was accurate and current throughout the weekend. Review of the facility policy and procedure titled Care Staffing Policy, revised 10/2025, read, Purpose: To ensure the facility maintains sufficient, competent direct care staff to meet resident needs in compliance with all applicable federal and [Name of State] state regulations. The policy specified Staff Posting Requirements: 3. Staff Posting (BIPA) [Benefits Improvement and Protection Act of 2000] the daily staffing posting required under the Medicare, Medicaid and CHIP [Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000 (BIPA) must be completed each day. The BIPA posting must be displayed in a visible location at or near the main entrance or front desk, where it is easily accessible to residents, visitors, and surveyors. The posting must reflect actual staff on duty and be updated as changes occur.

Based on record review and interview, the facility failed to ensure medical records were accurate for 1 of 3 residents reviewed for wound care, Resident #1.Findings include:Review of Resident #1's physician order dated 12/17/2025 read, Wound Care: Right Buttock; Cleanse with generic wound cleanser, pat dry, place Calcium Alginate [absorbent dressing] over wound bed, then cover with a bordered gauze dressing. Change daily and PRN [as needed] every night shift for wound care. Order Status: Active. Start Date: 12/17/2025.Review of Resident #1's Treatment Administration Record (TAR) for January 2026 for completion of right buttock wound care showed no entries documented on 1/9/2026 and 1/10/2026 on night shift.Review of Resident #1's physician order dated 12/29/2025 read, Wound Care: Clean left buttock with wound cleanser, pat dry, apply skin prep to peri wound, cover with honey gel, then calcium alginate, then cover with silicone superabsorbent [absorbent dressing]: daily and PRN every night shift for wound care tx [treatment]. Order status: Active. Start Date: 12/29/2025.Review of Resident #1's TAR for January 2026 for completion of left buttock wound care showed no entries documented on 1/9/2026 and 1/10/2026 on night shift.Review of Resident #1's physician order dated 1/6/2026 read, Wound Care: Right lateral thigh; Cleanse wound with generic wound cleanser, pat dry. Apply Triamcinolone cream [corticosteroid medication] 0.1% to wound bed, cover with Calcium Alginate, then with bordered gauze dressing. Change daily and PRN every night shift for wound care daily and PRN. Order Status: Discontinued. Start Date: 01/06/2026. Discontinue Date: 01/18/2026.Review of Resident #1's TAR for January 2026 for completion of right lateral thigh wound care showed no entries documented on 1/9/2026 and 1/10/2026 on night shift.Review of Resident #1's physician order dated 11/19/2025 read, Triple Antibiotic External Ointment (Neomycin-Bacitracin-Polymyxin) Apply to Right Buttock topically every night shift for wound care, apply to open wound areas. Order status: Active. Start Date: 11/19/2025.Review of Resident #1's TAR for January 2026 for administration of Triple Antibiotic External Ointment showed no entries documented on 1/9/2026 and 1/10/2026 on night shift.During an interview on 1/22/2026 at 5:17 PM, the Director of Nursing stated, An empty space on the TAR means either the nurse didn't do the wound care or they forgot to document it. When nurses complete wound care, I expect them to document that it was completed.During an interview on 1/22/2026 at 5:19 PM, Staff A, Licensed Practical Nurse (LPN), stated, I always do [Resident #1's name]'s wound care. I completed her wound care on January 9th. I just probably forgot to chart that I did it.During an interview on 1/22/2026 at 5:27 PM, Staff B, LPN, stated, I did the wound care for [Resident #1's name] on January 10. I forgot to chart it.Review of the facility policy and procedure titled Standards and Guidelines: Documentation revised in January 2024 read, Guideline: Services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure. 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for 1 of 5 residents, Resident #2, reviewed for unnecessary medications.Findings include:Review of Resident #2's admission record documented diagnosis that include end stage renal disease, chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and essential primary hypertension.Review of Resident #2's physician order dated 4/29/25 read, Entresto Oral Tablet 24-26 MG [milligrams] (Sacubitril-Valsartan) Give 0.5 tablet by mouth two times a day related to essential primary hypertension.Review of Resident #2's August Medication Administration Record documented Entresto had a chart of code 4 (4=outside parameters) on 8/2/2025 at 0900 (9:00 AM), on 8/3/2025 at 0900 and 2100 (9:00 PM), and on 8/6/2025 at 0900. Review of Resident #2's nursing and medication administration notes for the period of 8/1/2025 through 8/9/2025 did not contain documentation of the physician being notified the Entresto was not being administered as ordered by the physician.During an interview on 8/12/2025 at 2:20 PM Staff F, Registered Nurse (RN), one of the licensed staff who was documented as not administering the Entresto, stated, I did hold her [Resident #2] blood pressure medication. Her pressure was low. There are no parameters for that medication. I could have called the doctor to see. I should follow all doctors' orders.During an interview on 8/13/2025 at 1:05 PM Staff G, Licensed Practical Nurse (LPN), one of the licensed staff who was documented as not administering the Entresto, stated, I did hold her [Resident #2] medicine. I don't see that there are any parameters. I wasn't following the orders to give the med. I should follow them. I didn't call anyone I just held it.Review of the policy and procedure titled, Medication Administration with a last approval date of 4/25/2025 read, Standard: Medications are ordered and administered safely and as prescribed. Procedure: 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party.

Based on observation, interview, and record review, the facility failed to provide respiratory services consistent with professional standards of practice for oxygen administration for 2 of 5 residents, Residents #86 and #87, reviewed for oxygen therapy.Findings include:During an observation on 8/12/2025 at 9:37 AM Resident #87 was observed being administered oxygen via tracheostomy mask at 4 liters per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle (used to hold distilled water to add moisture to the oxygen therapy airflow to prevent dryness and irritation that can occur from breathing dry oxygen for extended periods) dated 8/12/25 and the bottle was empty. During an observation on 8/12/2025 at 11:35 AM Resident #87 was observed in bed with the head of bed elevated, and was observed with oxygen being administered via tracheostomy mask at 4 liters of oxygen per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle dated 8/12/25 and the bottle was empty. Review of Resident #87's admission record documents diagnosis that include encephalopathy, unspecified, acute respiratory failure unspecified whether with hypoxia or hypercapnia, pneumonia due to other specified bacteria, chronic respiratory failure unspecified whether with hypoxia or hypercapnia, and tracheostomy.Review of Resident #87's physician order dated 8/7/2025 read, Trach [tracheostomy]: Encourage and assist resident with use of humidified oxygen 28%/5 liters via trach collar.Review of Resident #87's physician order dated 8/7/2025 read, Trach: Change Oxygen tubing/humidification bottle/mask, etc. Q [every] week and PRN [as needed] every night shift every Sun [Sunday] and as needed.Review of Resident #87's care plan documented a focus of, Resident has a tracheostomy and is at risk for complications regarding tracheostomy status and interventions that include administer O2 [oxygen] as ordered.During an interview on 8/12/2025 at 12:47 PM Staff D, Licensed Practical Nurse (LPN) stated, The amount of oxygen is not right. I will check the order. The humification is empty, I need to change that.During an interview on 8/14/2025 at 1:00 PM the Director of Nursing (DON) stated, They [licensed nursing staff] should be checking oxygen levels and making sure they are accurate. They should follow physician orders. We should have the tracheostomy with humidification at all times and not have it empty. During an observation on 8/11/2025 at 12:32 PM Resident #86 was observed in bed with the head of bed elevated and oxygen being administered at 4 liters per minute via nasal cannula by an oxygen concentrator. The oxygen concentrator was on the side of the bed, not within the resident's reach.During an observation on 8/12/2025 at 8:03 AM Resident #86 was observed having oxygen administered at 4 liters via nasal cannula by an oxygen concentrator. The concentrator was not within the resident's reach.Review of Resident #86's admission record documented diagnosis that include chronic obstructive pulmonary disease (COPD) unspecified, type 2 diabetes mellitus without complications, heart failure unspecified, anemia unspecified, and essential primary hypertension.Review of Resident #86's physician order dated 8/6/2025 read, Respiratory-Oxygen: NC [nasal cannula]/Mask. Encourage and assist resident to use O2 [oxygen] @ [at] 2 (specify Liters) via (specify NC/Mask) as needed for SOB [shortness of breath]/DOE [dyspnea on exertion].Review of Resident #86's comprehensive care plan documented a focus of, The resident is at risk for altered respiratory status/difficulty breathing r/t [related to] COPD/Emphysema. Interventions: administer oxygen as ordered.During an interview on 8/12/2025 at 8:05 AM Staff E, RN stated, Her oxygen [order] is for 2 liters. Staff E confirmed the concentrator was administering oxygen to Resident #86 at 4 liters, then stated, I don't know how that happened.Review of the policy and procedure titled, Oxygen Administration, with a last approval date of 4/25/2025 read, Standard: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 1. Review the physician's order for oxygen administration. General guidelines: 3. Adjust the oxygen delivery device so that it is comfortable on the resident and the appropriate flow of oxygen is being administered according to the resident's needs.

Based on observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection when failing to ensure staff followed infection control standards for enhanced barrier precautions for 1 of 3 residents, Resident #88 reviewed for incontinence care and failing to ensure hand hygiene was performed during medication administration for 2 of 6 observations of medication administration.Findings Include During an observation on 8/13/2025 at 9:22 AM there was a sign on Resident #88’s door which read, “Enhanced Barrier Precautions (a set of infection control practices designed to reduce the spread of multidrug-resistant organisms).” Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) were observed providing incontinent care for Resident #88. Staff A and Staff B were not wearing gowns. During an interview on 8/13/2025 at 9:30 AM the Director of Nursing (DON) verified Resident #88 had a physician’s order for enhanced barrier precautions and staff should have worn a gown and gloves when providing direct patient care. During an interview on 8/13/2025 at 9:33 AM Staff B, CNA stated, “When a resident is on enhanced barrier precautions, we should wear gloves and a gown when providing patient care. When I changed [Resident #88’s name] I was not wearing a gown. I should have been wearing a gown” During an interview on 8/13/2025 at 9:35 AM Staff A, LPN confirmed she and [Staff B, CNA’s name] were changing [Resident #88’s name] and were not wearing gowns. Staff A, LPN stated, “When a resident is on enhanced barrier precautions, we should wear gloves and a gown while providing incontinence care.” Review of Resident #88 medical record documented an admission date of 8/7/2025 with medical diagnoses including gastrostomy (also known as a g-tube, is a surgical procedure that creates an opening in the stomach through the abdominal wall to provide nutrition and medications directly into the stomach). Review of Resident #88’s physician order dated 8/12/2025 read, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions for GTUBE Review of Resident #88’s care plan dated 8/8/2025 read, Focus: Resident requires Enhanced Barrier Precautions during high contact resident care activities r/t [related to] wounds when colonization or actual MDRO [Multi-Drug Resistant Organism] is present, indwelling medical devices examples include, but are not limited to central lines, indwelling urinary catheters, feeding tubes, tracheostomy tubes. Interventions- Enhanced Barrier Precautions DURING HIGH CONTACT CARE ACTIVITIES dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Review of the policy and procedure titled, “Enhanced Barrier Precautions” with a review date of 4/25/2025 read, “Guideline: The facility will decrease the transmission of multidrug-resistant organisms (MDRO) by maintaining infection control standards. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. 1. Enhanced Barrier Precautions (EBP) are used for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be colonized with MDRO. Indwelling Medical Devices include the following: c. Feeding tubes. 9. Appropriate Personal Protective Equipment (PPE) for EBP would include: a. Gown b. Gloves. 10. Employees should wear appropriate PPE when performing the following duties for residents requiring EBP: a. Dressing. b. Providing hygiene; e. Changing linens; f. Providing pericare such as changing briefs” During an observation of medication administration on 8/14/2025 at 5:05 AM for Resident #88 Staff C, LPN approached the medication cart, reached into their uniform pocket, removed the keys, unlocked the medication cart, activated the computer and typed on the computer without performing hand hygiene. Staff C, LPN removed all the medications order for Resident #88 and crushed each medication separately. Staff C, LPN entered Resident #88's room without performing hand hygiene, moved the bedside table closer to the resident and assembled all the gastrostomy tube supplies. Staff C, LPN returned to the medication cart, did not perform hand hygiene, unlocked the cart, and removed additional supplies. Staff C, LPN then donned gloves and a gown without performing hand hygiene and entered the resident’s room. Staff C, LPN administered the medications, repositioned Resident #88 in the bed, doffed the gown and gloves and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident. During an observation of medication administration on 8/14/2025 at 5:13 AM Staff C, LPN did not perform hand hygiene, prepared Resident #37’s medications and supplies to take a blood pressure and to perform an accucheck (used to monitor blood sugar levels). Staff C entered Resident #37's room without performing hand hygiene, donned gloves without performing hand hygiene, used an alcohol swabbed on the resident’s finger and performed an accucheck. Staff C exited the resident’s room after removing the gloves, went to the medication cart, removed the keys for the medication cart from their pocket, was not able to locate the ordered insulin, lock the medication cart and went to the medication room. Staff C, LPN unlocked the medication room door, obtained the ordered insulin, returned to the medication cart, unlocked the cart after retrieving the keys from their pocket, opened the computer, typed and reviewed the insulin orders. Staff C, LPN returned to the Resident #37's room, donned gloves without performing hand hygiene and administered the insulin and oral medications. Staff C doffed the gloves and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident. During an interview on 8/14/2025 at 5:45 AM Staff C, LPN stated, I should have used the hand sanitizer every time I got the medicines, and before and after I put on or took off my gloves. Review of the policy and procedure tilted “Hand Hygiene Infection Control” with a last approval date of 4/25/2025 read, “Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel to use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Procedure: The Facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings to promote resident safety. These guidelines state that hand washing is necessary when healthcare personnel's hands are visibly soiled. When hands are not visibly soiled, the CDC recommends the use of alcohol based hand rubs by health care personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Patients that require hand hygiene include, but are not limited to: before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice): before and after performing any invasive procedure (e.g. finger stick blood sampling): upon and after coming in contact with residents intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident)

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing high contact care for 1 (Resident #5) of 2 residents reviewed for wound care.Findings include: Review of Resident #5's admission record showed the resident was admitted on [DATE] with the diagnoses including unspecified open wound, right knee, subsequent encounter. During an observation on 6/30/2025 at 11:05 AM, there was a sign posted on the door frame of Resident #5's room that indicated she was on Enhanced Barrier Precautions. During an observation on 6/30/2025 at 11:15 AM, Staff A, Licensed Practical Nurse (LPN), gathered wound care supplies and gloves. Staff A proceeded to wash her hands with soap and water and donned a pair of gloves. Staff A provided wound care to Resident #5, wearing gloves as her only form of personal protective equipment (PPE). During an interview on 6/30/2025 at 11:25 AM, Staff A, LPN, stated, Enhanced barrier precautions are for residents with certain isolation needs. Personal protective equipment such as gloves, mask, and [physically indicated] a gown/covering, are used during resident care. During an interview on 6/30/2025 at 12:48 PM, the Director of Nursing stated, For residents on EBP [Enhanced Barrier Precautions], the staff are supposed to wear a gown and gloves when doing direct care activities such as wound care. Review of the facility policy and procedures titled Enhanced Barrier Precautions revised on 5/28/2024, read, Guideline: The facility will decrease the transmission of multidrug-resistant organisms (MDRO) by maintaining infection control standards. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. Enhanced Barrier Precautions (EBP) are used for residents with any of the following . b. Wounds and/or indwelling medical devices even if resident is not known to be colonized with MDRO. 9. Appropriate PPE for EBP would include: a. Gown, b. Gloves 10. Employees should wear appropriate PPE when performing the following duties for residents . i. Wound care. Review of the facility policy and procedure titled Infection Control - Infection Prevention and Control Program revised in 1/2024 read, Standard: An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention of Infection: 1. Important facets of infection prevention include . c. educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observation, interview, and record review, the facility failed to ensure residents received prescribed therapeutic diet for 3 of 5 reviewed residents, Residents #9, #58 and #68. Findings include: 1. Review of Resident #58's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease, other speech disturbances, and deaf nonspeaking. During an observation on 5/6/2024 at 12:25 PM, Resident #58 received the afternoon meal tray on his bedside table. There was no health shake on the resident's meal tray. During an observation on 5/7/2024 at 8:03 AM, Resident #58 received the morning meal tray on his bedside table containing scrambled eggs, a slice of toast, and a mound of hot cereal. There was no hot or cold fluids, drinks, or house Health shake on the resident's tray. Review of the facility's dining slip dated 5/7/2024 on the morning meal tray for Resident #58 read, Consistent Carbohydrates (CCD) Tuesday Breakfast: Scrambled eggs w/cheese, 1 slice toast, 1 each of diet jelly and margarine, house shake one serving, milk- 8 ounces, coffee or hot tea- 6 ounces, orange juice- 4 ounces. Review of Resident #58's medical record revealed that the resident weighed 138 pounds on 11/7/2023 and 120.6 pounds on 4/2/2024, which is a 12.61% weight loss over the last 180 days. Further review of the record showed a 6.5% weight loss in the last 90 days and a 1.9% weight loss in the last 30 days. Review of Resident #58's Nutritional Review dated 4/23/2024 showed that it read, Consider increasing Health shakes if weight loss continues. Review of Resident #58's physician order dated 4/27/2023 revealed a Health Shake supplement to be given one time a day on the breakfast tray. Review of Resident #58's Medication Administration Record (MAR) for April 2024 for Health Shake intake showed 0% on 4/16/2024, 4/20/2024, 4/21/2024, 4/24/2024, 4/29/2024, and 4/30/2024, and NA (Not Applicable) on 4/17/2024, 4/22/2024, and 4/27/2024. During an interview on 5/8/2024 at 1:04 PM, Staff B, Certified Nursing Assistant (CNA), stated, He [Resident #58] loves the Health Shakes, but the facility runs out quite often. I don't think he's gotten them the past couple of days. During an interview on 5/8/2024 at 11:41 AM, the Dietary Manager stated, Health Shakes are delivered on the trays at mealtime as ordered. We put the Health Shake on their tray. If the resident is scheduled for a Health Shake at another time, like 10 AM or 2 PM, then the nurses can get them out of the nourishment rooms. We stock them in the freezer and in the nourishment rooms. We were out of Health Shakes all day Monday (5/6/24) and for breakfast service on Tuesday (5/7/24). The facility runs out of Health Shakes every week and I do not keep an inventory of how many to order each week. During an interview on 5/9/2024 at 2:13 PM, the Dietary Manager stated, We were out of Health Shakes on Monday and Tuesday but there were substitutes of magic cups or ice cream and the nurses were told we were out and to use the substitutes. I think the administrator or DON [Director of Nursing] told the nurses. During an interview on 5/10/2024 at 12:50 PM, the Director of Nursing stated, I was not told by the Dietary Manager that the facility was out of Health Shakes on Monday and Tuesday. During an interview on 5/10/2024 at 1:25 PM, the Administrator stated, I was not told by the Dietary Manager that the facility was out of Health Shakes on Monday and Tuesday. 46523 2. During an observation on 5/6/2024 at 12:43 PM, Resident #9 was eating lunch independently. The resident received dysphagia advanced diet that included ground cheesy ham, mashed potatoes, and cornbread. There was no House Shake on the tray. Review of Resident #9's meal ticket for lunch on Monday 5/6/2024 showed the ticket included 1 serving of House Shake. During an observation on 5/7/2024 at 8:40 AM, Resident #9 was eating breakfast independently. The tray contained cereal and milk, but no House Shake. Review of Resident #9's meal ticket for breakfast on Tuesday 5/7/2024 showed the ticket included 1 serving of House Shake. Review of Resident #9's physician order dated 4/3/2024 read, Health Shake put Amt [amount] ordered PO [by mouth] in add direc [direct] with meals for weight loss give 4 oz [ounces], document refusals in a progress note. Review of Resident #9's Medication Administration Record for May 2024 for Health Shake intake showed 100 percent on 5/6/2024 at 11:00 AM and 100 percent on 5/7/2024 at 8:00 AM. Review of Resident #9's medical record revealed that the resident had 7.6% weight loss within the last 30 days, 6% weight loss within the last 90 days and 14% weight loss within the last 180 days. During an interview on 5/8/2024 at 11:18 AM, the Registered Dietician stated, [Resident #9's name] BMI 14.7 not in range. Weight fluctuates due to diuretics. The facility runs out of Health Shakes at times on Monday and truck comes on Tuesday. They get one truck a week. Not getting a Health Shake would not affect resident's weight. 3. During an observation on 5/7/2024 at 8:35 AM, Resident #68 was eating in his room. The meal tray contained pureed diet including scrambled eggs and biscuit. There was no House Shake on the tray. Review of Resident #68's meal ticket for breakfast on Tuesday 5/7/2024 showed the ticket included 1 serving of House Shake. Review of Resident #68's physician order dated 3/11/2024 read, Health Shake put Amt ordered PO in add direc [direct] two times a day for supplement. Review of Resident #68's Medication Administration Record for May 2024 Health Shake intake showed 100 percent on 5/7/2024 at 8:00 AM. During an interview on 5/8/2024 at 11:41 AM, the Dietary Manager stated, We did run out of Health Shakes all day Monday and breakfast Tuesday. Review of the document provided by the facility titled Quick Reference Guide dated 7/2016 read, Clinical Practice: Therapeutic snacks and nutritional supplements- a tool to assist the Registered Dietitian in the development of modified meal plans, utilizing therapeutic snacks, and/or supplements in the nutrition care planning process . Definitions . Nutritional Supplement- products that are used to complement a resident's dietary needs . Clinical Thinking Steps . 3. Modification in meal and snack plans are the initial and preferred intervention. A. Indications for modified meal plans may include: i. Insufficient nutrition intake through routine meals and HS [hours of sleep] snack as evidenced by unintended weight loss (significant and insidious).

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 3 of 5 residents reviewed for nutrition, Residents #9, #58, and #68, and for 3 of 5 residents reviewed for skin conditions, Residents #1, #55, and #227. Findings include: 1. During an observation on 5/6/2024 at 12:25 PM, Resident #58 received the afternoon meal tray on his bedside table. There was no health shake on the resident's meal tray. During an observation on 5/7/2024 at 8:03 AM, Resident #58 received the morning meal tray on his bedside table containing scrambled eggs, a slice of toast, and a mound of hot cereal. There was no hot or cold fluids, drinks, or house Health shake on the resident's tray. Review of Resident #58's physician order dated 4/27/2023 revealed a Health Shake supplement to be given one time a day on the breakfast tray. During an interview on 5/8/2024 at 1:04 PM, Staff B, Certified Nursing Assistant (CNA), stated, He [Resident #58] loves the Health Shakes, but the facility runs out quite often. I don't think he's gotten them the past couple of days. Review of Resident #58's Medication Administration Record (MAR) for April 2024 for Health Shake intake showed the resident consumed 100% of Health Shake 5/6/24 and 5/7/24. During an interview on 5/8/2024 at 11:41 AM, the Dietary Manager stated, We were out of Health Shakes all day Monday (5/6/24) and for breakfast service on Tuesday (5/7/24). The facility runs out of Health Shakes every week and I do not keep an inventory of how many to order each week. 46523 2. Review of Resident #1's Weekly Skin Integrity Reviews dated 3/20/2024 and 3/28/2024 showed the skin was marked as intact. Review of Resident #1's medical records showed no weekly skin integrity review completed for 12/13/2023, 12/20/2023, 12/27/2023, 1/17/2024, 3/13/2024, 4/3/2024, and 4/17/2024. Review of Resident #1's physician order dated 2/28/2024 read, Keep skin glue mesh dressing clean, dry, intact for at least 3 weeks. Review of Resident #1's physician order dated 3/26/2024 read, Monitor pacemaker site until healed, notify MD [Medical Doctor] of any s/sx [signs and symptoms] of infection every shift. Review of Resident #1's physician order dated 3/28/2024 read, Cleanse pacemaker area with NS [Normal Saline], pat dry, apply 4x4 dry dressing until area completely healed every day shift. Review of Resident #1's physician order dated 12/9/2022 read, Weekly skin sweeps every Wednesday 7p-7a every night shift every Wed [Wednesday]. Review of Resident #1's physician order dated 12/28/2022 read, Routine showers on Wed/Sat [Wednesday/Saturday] every day shift. Review of Resident #1's nursing progress note dated 2/28/2024 at 3:25 PM read, return from pacemaker replacement, VS [vital sign] 119/87, 89, 20, 97.8. Left chest site clean dry intact glue intact. order to keep area clean, dry, intact for 3 weeks. Review of Resident #1's nursing progress note dated 2/28/2024 at 4:30 PM read, Nurse from [local hospital's name] in Gainesville called to give a report on post op [operative] pacemaker change for this resident. She stated that the resident is on their way back to the facility & the post op instructions were sent back with the resident. Review of Resident #1's care plan initiated on 12/12/2203 read, Focus: The resident has potential for pressure injury development r/t [related to] HX [history] of ulcers, impaired mobility, incontinence/increased moisture. Review of Resident #1's hospital dressing change order dated 2/28/2204 read, Location: Pacemaker site L [left] chest: Keep skin glue mesh dressing clean, dry, intact for at least 3 weeks. After 3 weeks, carefully peel off from skin/incision using Vaseline to loosen skin glue if needed. During an interview on 5/8/2024 at 11:30 AM, the Regional Nurse stated, These are the skin related documents we found. There are some shower sheets, progress notes, and skin assessments. The procedure will be changing. That is the problem with having orders they think it will remind the nurse but the do the assessment. Nurses should be doing assessments. During an interview on 5/8/2024 at 12:00 PM, the Director of Nursing (DON) stated, Nurses are the ones who do the weekly skin assessments. We try to do it all at once. When a CNA is providing shower, the nurse is assisting the CNA and signing off on skin observation. During an interview on 5/8/2024 at 12:41 PM, Staff E, Licensed Practical Nurse (LPN), stated, I do not see any skin assessment for 5/1/2024 in the chart. I normally put it in the front of chart. She has one due today and assessments are only done by nurses. During an interview on 5/9/2024 at 11:11 AM, Staff E, LPN, stated, If the CNA asks, I will help, but that is their thing. I am not in the room when she is doing the skin assessment. I sign off the shower is done and check the skin assessment if they identify a concern. I go back in and assess. When I do any skin sweep, I always document any abnormalities I see on the skin even if it has been previously listed. During an interview on 5/9/2024 at 1:18 PM, Staff M, CNA, stated, The nurses are to check if the shower has been done. The nurse will ask if we see a new bruise or abnormal in that person's body, but we normally do it alone and they come behind us to make sure. They sign off on the shower sheet. I will notify the nurse of any skin tear or bruise and she will go and look at it. If it is something major, I will step out and have someone call the nurse and then she will come in the shower room and see the situation. During an interview on 5/9/2024 at 11:25 AM, Staff N, CNA, stated, The nurse does not come in to help me. They have shower sheet I fill out and let the nurse know. I am by myself doing the assessment. She is signing off that we gave the resident a shower and if we wrote down any skin issues, she is supposed to go in the room and make sure we did it. During an interview on 5/9/2024 at 11:32 AM, Staff I, LPN, stated, The CNA will do the showers by themselves. We sign off on the shower sheets. If it falls on a shower day, I will go in and see it and then do my sweep separately. During an interview on 5/9/2024 at 1:30 PM, the Director of Nursing (DON) stated, The order for checking the site for the pacemaker should have discontinued if the site was healed and staff were finished monitoring the site. The staff should have documented the information in the system. Review of the facility policy and procedures titled Clinical Guideline Skin and Wound with the last review date of 1/15/2024 read, Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Process . Licensed Nurse to complete skin evaluation weekly. 3. During an observation on 5/6/2024 at 12:43 PM, Resident #9 was eating lunch independently. The resident received dysphagia advanced diet that included ground cheesy ham, mashed potatoes, and cornbread. There was no House Shake on the tray. During an observation on 5/7/2024 at 8:40 AM, Resident #9 was eating breakfast independently. The tray contained cereal and milk, but no House Shake. Review of Resident #9's physician order dated 4/3/2024 read, Health Shake put Amt [amount] ordered PO [by mouth] in add direc [direct] with meals for weight loss give 4 oz [ounces], document refusals in a progress note. Review of Resident #9's Medication Administration Record for May 2024 for Health Shake intake showed 100 percent on 5/6/2024 at 11:00 AM and 100 percent on 5/7/2024 at 8:00 AM. During an interview on 5/8/2024 at 11:18 AM, the Registered Dietician stated, The facility runs out of Health Shakes at times on Monday and truck comes on Tuesday. They get one truck a week. 4. During an observation on 5/7/2024 at 8:35 AM, Resident #68 was eating in his room. The meal tray contained pureed diet including scrambled eggs and biscuit. There was no House Shake on the tray. Review of Resident #68's physician order dated 3/11/2024 read, Health Shake put Amt ordered PO in add direc [direct] two times a day for supplement. Review of Resident #68's Medication Administration Record for May 2024 Health Shake intake showed 100 percent on 5/7/2024 at 8:00 AM. During an interview on 5/8/2024 at 11:41 AM, the Dietary Manager stated, We did run out of Health Shakes all day Monday and breakfast Tuesday. 50695 5. Review of Resident #55's admission record showed the resident was admitted to the facility on [DATE], with diagnoses including obstructive and reflux uropathy, essential (primary) hypertension, chronic atrial fibrillation, Gastro Esophageal Reflux Disease without esophagitis, ulcerative colitis, benign prostatic hyperplasia, and age-related cognitive decline. Review of Resident #55's physician order dated 2/2/2024 read, Wound to right lateral foot: cleanse with normal saline, pat dry, apply calcium alginate with silver and leptospermum honey, cover with gauze island border Q [every] day. Review of Resident #55's physician order dated 3/11/2024 read, Cleanse lateral side of right foot with NS [normal saline] or soap & water, pat dry, apply medi-honey to wound, cover with a dry dressing every day shift every Mon [Monday], Wed [Wednesday], and Fri [Friday], for wound to lateral side of right foot. Review of Resident #55's physician order dated 3/26/2024 read, Order: Cleanse area to right shin with soap & water or normal saline, pat dry, apply dry dressing. Directions: every day shift. Order: Clean area to left shoulder with soap and water or normal saline, pat dry, cover with a dry dressing every day shift. Directions: every day shift. Review of Resident #55's physician order dated 4/17/2024 read, Apply skin prep to blister on peri wound area. Review of Resident #55's Treatment Administration Record for April 2024 showed no entry documented on 4/29/2024 for cleanse lateral side of right foot, cleansing area to right shin, cleaning area to left shoulder, and applying skin prep to blister on peri wound area. Review of hand-written witness statement form dated 5/9/2024 for Staff A, Registered Nurse (RN), signed by the DON, read, Call placed to [Staff A's name] RN regarding treatments to [Resident #55's name] on 4/29/24 and if they were completed. [Staff A's name] stated, Yes that was a Monday, I know I changed his dressings. When I [the DON] asked [Staff A's name] if she charted in the EMR [electronic medical records] that it was done and she stated, Now that I think about it, I might have forgot to hit save. Review of Resident #55's physician order dated 8/11/2023 read, Weekly skin sweeps. Review of Resident #55's weekly skin assessments from February 2024 through May 2024 showed no skin assessments documented for the weeks of 2/25/2024, 3/11/2024, 4/9/2024, 4/22/2024, and 4/29/2024. Review of Resident #55's Weekly Skin Integrity Review dated 3/25/2024 read, Site: side of right foot irritation. The skin integrity review did not include the wound to the right side of the foot. Review of Resident #55's Weekly Skin Integrity Review dated 3/31/2024 read, Site: side of right foot irritation. The skin integrity review did not include the wound to the right side of the foot. During an interview on 5/9/2024 at 11:13 AM, the DON stated that it was a documentation issue and that the assessments were completed but not documented. 48865 6. During an observation on 5/6/2024 at 3:07 PM, Resident #227 had a port on his right clavicle. There was a bandage over the port with a tinge of blood. There was no date on the bandage. Review of Resident #227's History and Physical issued by the local hospital dated 4/30/2024 read, Chief complaint: Frequent Falls . Surgical History: port placement. Review of Resident #227's Admission/Re-Admission Resident Data Collection dated 5/3/2024 did not document any skin conditions. Review of Resident #227's physician orders did not reveal any order for port care. During an interview on 5/9/2024 at 8:30 AM, Staff I, Licensed Practical Nurse (LPN), stated, I do not remember seeing any orders for bandage change or care relating to a port in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Review of the facility policy and procedures titled Charting and Documentation last reviewed on 1/15/2024 showed it read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, wound care, and meal service, failed to ensure staff cleaned medical equipment, and failed to ensure staff followed infection control standards for urinary catheter care to help prevent the possible spread and transmission of communicable diseases. Findings include: 1. During an observation on 5/6/2024 from 11:55 AM to 12:15 PM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, delivered drinks and silverware to residents seated in the dining room at various tables without performing hand hygiene. Staff F donned gloves without performing hand hygiene, scooped some ice into a resident's drink cup, replaced the ice scoop in the ice bucket, and doffed the gloves and did not perform hand hygiene. Staff F and Staff G refilled drink glasses, put cream and sugar in residents' hot drink cups, assisted residents with cutting their food, refilled drinks, brought used plates and dishes to the tray rack, delivered desserts, and picked up garbage from the tables without performing hand hygiene between residents. During an interview on 5/6/2024 at 12:16 PM, Staff G, CNA, stated, I wash my hands before and after meal service. I wash my hands if I get food on them. I wear gloves before scooping the ice. I wash my hands sometimes between every 3 residents. I don't wash my hands between helping every resident. During an interview on 5/8/2024 at 11:41 AM, the Dietary Manager stated, They should be performing hand hygiene between serving the tray to each resident in the dining room. After they deliver the meal tray to the table, they should wash their hands before the next tray delivery. 2. During an observation on 5/8/2024 at 8:18 AM, Staff E, Licensed Practical Nurse (LPN), took the wrist blood pressure cuff from the top of the 100 Hall Medication Cart and entered Resident #45's room without performing hand hygiene. Staff E took the resident's blood pressure, returned to the medication cart, and recorded the findings without performing hand hygiene. Staff E prepared the medications for Resident #45, locked the cart, entered the resident's room, and initiated the medication pass without performing hand hygiene. Staff E returned to the medication cart after the medication pass and picked up the blood pressure cuff and proceeded to Resident #1's room without cleaning and disinfecting the blood pressure cuff or performing hand hygiene. At 8:35 AM, Staff E grabbed the wrist blood pressure cuff, which was not cleaned after use with Resident #45, and proceeded to Resident #1's room and obtained her blood pressure without performing hand hygiene. During an interview on 5/8/2024 at 9:03 AM, Staff E, LPN, stated, I washed my hands between each resident, but I didn't wash my hands after I prepared the medications and locked the medication cart, or before I gave the resident [Resident #45] their meds. I didn't clean the blood pressure cuff between [Resident #45 and Resident #1]. I should clean the blood pressure cuff between residents. 3. During an observation on 5/8/2024 at 9:05 AM, Staff A, Registered Nurse (RN), while standing at the 300 Hall Medication Cart, Staff A dropped a meter-dosed inhaler (MDI) (pressurized aerosol inhaler made up of three parts- metal medication canister, the plastic actuator, and a metering valve) onto the floor. Staff A picked the MDI back up and continued to fit the medication canister into the plastic actuator. Staff A, then, placed the inhaler back into the inhaler medication box and placed the box back into 300 Hall Medication Cart. During an interview on 5/8/2024 at 9:07 AM, Staff A, RN, stated, I dropped it onto the floor. I guess I should have thrown it away. He [Resident #71's name] wouldn't have any medication. I'm not going to give it to him now. I'm going to give it to him later, but it had to be refilled. I guess I could have wiped it down with one of those cloths, but I didn't. During an interview on 5/8/2024 at 9:20 AM, the Director of Nursing stated, The blood pressure cuff should be cleaned between use with each resident. The nurses should be performing hand hygiene before and after each medication pass. They should wear gloves if they are going to assist the resident with the medication. The nurse should not have put the inhaler back without wiping it down first after dropping it on the floor. It touches the resident's mouth. An inhaler can be wiped down. Review of the facility policy and procedures titled Hand Hygiene last reviewed on 1/15/2024, read, Purpose: To reduce the spread of germs in the healthcare setting. Process: Hand hygiene should be performed . Before initiating a clean procedure, before and after patient care, after contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings, after contact with inanimate objects (including medical equipment) in the immediate patient vicinity, when hands are moved from a contaminated-body site to a clean body site during patient care, after glove removal. Review of the facility policy and procedure titled Administering Medications last reviewed on 1/15/2024, read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy and procedure titled Cleaning and Disinfecting Non-Critical Resident-Care Items, last reviewed on 1/15/2024, read, Purpose: The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. General Guidelines . 3. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. 1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment). 46523 4. During an observation on 5/8/2024 at 1:50 PM, Staff A, RN, donned gown and entered Resident #55's room with the wound treatment cart and paper treatment record. Staff A entered the resident's restroom and washed her hands. Staff A donned gloves and removed supplies from the treatment cart. Without cleaning or placing a clean barrier on top of treatment cart, Staff A placed normal saline vials on the treatment cart surface and placed 2x2 gauze on top of the paper treatment record. Staff A removed a green pen from her pocket and documented on the treatment record. Staff A removed dressing from the right shin without performing hand hygiene and then removed dressing on the left shoulder. Staff A removed her gloves and washed her hands. Staff A donned a new pair of gloves. Staff A cleaned the right shin wound, pat dry the area, and placed new dressing. Staff A removed her gloves, and without performing hand hygiene, donned a new pair of gloves. Staff A cleaned the left shoulder wound, pat the area dry, and placed new dressing without performing hand hygiene. Staff A removed her gloves and positioned the bed flat. Staff A performed hand hygiene and donned gloves. Staff A removed the dressing from the right lateral foot. Staff A cleaned the right lateral foot. The gauze was visibly soiled with drainage. Without hand hygiene, Staff A pat dried the area, applied treatment and new dressing. Staff A removed her gloves and adjusted the bed. Staff A exited Resident #55's room without performing hand hygiene and proceeded to take her green pen out of her pocket and documented on the treatment record. During an interview on 5/8/2024 at 2:07 PM, Staff A, RN, stated, It is not a sterile procedure just an aseptic procedure. We do not have clean barriers. The facility does not provide them. I should have preformed hand hygiene. I do not know what the hand hygiene policy is. Staff A asked, How many times do you need to change your gloves or wash your hands? During an interview on 5/8/2024 at 3:00 PM, the Director of Nursing stated, Nursing staff should preform hand hygiene when moving from one wound to another one. They should remove gloves and wash their hands before donning a new set of gloves. Hand hygiene should be performed after cleaning a wound and before exiting the resident room. 5. During an observation on 5/6/2024 at 10:14 AM, Resident #42 was lying in her bed, with the urinary catheter bag on the floor covered with a privacy bag. During an observation on 5/6/2024 at 11:23 AM, a staff member entered Resident #42's room to assist Resident #42's roommate and exited the room. Resident #42's catheter bag remained on the floor. During an observation on 5/6/2024 at 11:31 AM, Staff M, Certified Nursing Assistant (CNA), entered Resident #42's to provide incontinence care. Then, Staff Q, Licensed Practical Nurse (LPN), Unit Manager, entered the room. After staff finished providing care, the resident's urinary catheter was hanging on the side of the bed. Review of Resident #42's physician order dated 3/22/2024 read, Change Catheter as needed. During an interview on 5/7/2024 at 8:19 AM, Staff Q, LPN, Unit Manager, stated, I did not change the tubing or bag for [Resident #42's name] catheter. During an interview on 5/8/2024 at 12:50 PM, the Director of Nursing (DON) stated, A urinary catheter on the floor is a risk for infection. During an interview on 5/9/2024 at 10:24 AM, the Infection Preventionist stated, A lot of time it depends upon how the bag got on the floor and how long the bag was on the floor. The floor is dirty, so you have a risk of infection. The staff are expected to change the tubing and bag once the urinary catheter falls on the floor. During an interview on 5/9/2024 at 10:47 AM, Staff P, Regional Nurse, stated, The urinary catheter is considered a closed system and should be changed only when it is compromised in order to avoid risk for infection. During an interview on 5/9/2024 at 11:43 AM, Staff M, CNA, stated, The nurse came in after me. We did not clean or do anything with the catheter. I did not see it on the floor. 48865 6. During an observation on 5/6/2024 at 10:00 AM, Resident #19 was in his wheelchair and his Foley catheter bag was resting on the floor (Photographic evidence obtained). During an observation on 5/7/2024 at 1:09 PM, Resident #19's catheter bag was on the floor. During an interview on 5/7/2024 at 1:20 PM, the Director of Nursing (DON) stated, It is my expectation that catheter bags should not be resting on the floor. During an interview on 5/7/2024 at 1:23 PM, Staff L, Licensed Practical Nurse (LPN), stated, The catheter bag is not supposed to be on the floor. Review of Resident #19's physician order dated 4/22/2024 read, Catheter care every shift and as needed every shift. Review of the CDC (Centers for Disease Control and Prevention) website for catheter-associated urinary tract infections (CAUTI) prevention guidelines (https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html) updated on 3/25/2024 read, III. Proper Techniques for Urinary Catheter Maintenance. Recommendation . B2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, interview, and record review, the facility failed to ensure a safe physical environment for 4 of 6 residents reviewed for respiratory services, Residents #14, #16, #42 and #47. Findings include: 1. During an observation on 5/6/2024 at 12:42 PM, there was a portable five-liter oxygen concentrator unit resting up against the right side of Resident #16's bed. The concentrator was plugged into the wall outlet and the unit was turned off. There was nasal cannula oxygen tubing attached to the concentrator unit and the tubing was coiled up on the floor under the bed (Photographic evidence obtained). During an observation on 5/7/2024 at 12:42 PM, a portable oxygen concentrator unit was resting up against the right side of Resident #16's bed. The unit was plugged in, turned off, and the attached nasal cannula oxygen tubing was coiled up on the floor under the resident's bed. During an interview on 5/6/2024 at 12:43 PM, Resident #16 stated, I don't use oxygen. That must be my roommate's tank. I can't see. I am blind. During an interview on 5/7/2024 at 10:30 AM, Staff C, Licensed Practical Nurse (LPN), stated, He [Resident #16] is not on oxygen. [Resident #16's name] is blind and he is a fall risk. Review of Resident #16 admission record revealed the resident had diagnoses including vision loss, type 2 diabetes mellitus, schizoaffective disorder, post-traumatic stress disorder, brief psychotic disorder, and generalized anxiety disorder. Review of Resident #16's active physician orders revealed no orders for oxygen therapy. Review of Resident #16's last quarterly Minimum Data Set (MDS) dated [DATE] revealed no oxygen therapy under section O0110. Special Treatments, Procedures, and Programs. Review of Resident #16's care plan dated 2/22/2024 revealed that the resident was at increased risk for falls related to vision loss, with the interventions for minimizing the risk of falls including keeping personal items within reach, the wheelchair at the bedside. 2. During an observation on 5/6/2024 at 10:24 AM, there was a portable five-liter oxygen concentrator unit on the floor on the right-hand side of Resident #14's bed. There was a green portable oxygen tank in a wheeled holder up against the wall of Resident #14's room, behind the oxygen concentrator unit. Both the oxygen unit and tank were off. The oxygen concentrator unit was plugged into the wall outlet. Nasal cannula tubing was attached to the oxygen concentrator unit and coiled up around the handle of the green portable oxygen tank. During an observation on 5/7/2024 at 9:10 AM, the oxygen concentrator unit and portable oxygen tank were in Resident #14's room on the floor on the right side of the resident's bed. The oxygen unit and the portable oxygen tank were off. The attached nasal cannula tubing was coiled up around the portable oxygen tank. During an interview on 5/7/2024 at 9:30 AM, Staff C, Licensed Practical Nurse (LPN), stated, He [Resident #14] is not on oxygen. He was on oxygen a while ago, but not now. During an observation on 5/8/2024 at 7:55 AM, Staff D, Registered Nurse (RN), wheeled the green portable oxygen tank from Resident #14's room to the office titled Nursing Chart Room and placed the oxygen tank in the corner of the office. During an interview on 5/8/2024 at 9:58 AM, Staff D, RN, stated, I was going over the orders this morning for [Resident #14's name] and there were no orders in the chart in place for him, so I removed the oxygen concentrator unit and the portable oxygen tank from his room. Review of Resident #14's physician orders revealed no current order for oxygen therapy or supplementation. Review of Resident #14's care plan dated 3/27/2024 read, Resident is at risk for falls r/t [related to] weakness, RLS [restless leg syndrome], and Parkinson's [Disease]. During an interview on 5/8/2024 at 10:00 AM, the Director of Nursing (DON) stated, I don't know why the oxygen units would be in the resident's room if they are not on oxygen. 46523 3. During an observation on 5/6/2024 at 10:05 AM, there was a green cylinder oxygen tank standing against the wall stored in Resident #42's shared bathroom (Photographic evidence obtained). Review of Resident #42's physician order dated 3/22/2024 read, Oxygen 2-4 LPM [Liters per minute] via nasal cannula as needed as needed for SOB [shortness of breath] /Drop in O2 [oxygen] saturation. During an interview on 5/10/2024 at 12:30 PM, the DON stated, Oxygen tanks should be stored in a secure manner. I am not sure why the oxygen tank was stored in the bathroom. 40559 4. During an observation on 5/6/2024 at 1:54 PM, there was an oxygen concentrator with oxygen tubing plastic storage bag labeled with Resident #47's name dated 4/26/2024 sitting on the floor next to the resident's bed. The nasal cannula and tubing were wrapped around the bed rail. During an observation on 5/7/2024 at 8:26 AM, there was an oxygen concentrator with oxygen tubing plastic storage bag labeled with Resident #47's name dated 4/26/2024 sitting on the floor next to the resident's bed. The nasal cannula and tubing were wrapped around the bed rail. During an interview on 5/7/2024 at 8:28 AM, Resident #47 stated, I don't have to use oxygen all the time. I just have it in case I need it. Review of Resident #47's physician orders showed no current orders for oxygen therapy. During an interview on 5/7/2024 at 1:17 PM, the DON stated, [Resident #47's Name] had been discontinued and the equipment has now been removed from the room. Review of the facility policy and procedures titled Safety Handling, Storage and Transporting of Compressed Gases: Attachment A- Guidelines for storage requirements read, 7. Storage areas for oxygen should be within a locked access, free of excessive combustible materials, and away from potential flame sources.

Based on observation, interview, and record review, the facility failed to ensure the staff provided privacy while performing wound care for 1 of 5 residents reviewed for skin conditions, Resident #55. Finding include: During an observation on 5/8/2024 at 1:50 PM, Staff A, Registered Nurse (RN), donned gown and entered Resident #55's room with the wound treatment cart and paper treatment record. Staff A entered the resident's restroom and washed her hands. Staff A did not close the resident room door or the blinds of the window facing employee parking lot. Staff members were across the parking lot near cars. While Staff A was providing wound care, another staff member stood at the doorway and thanked Resident #55 for cupcakes his family had provided. During an interview on 5/8/2024 at 2:07 PM, Staff A, RN, stated, I should have closed the door when entering the room to provide privacy while performing care. During an interview on 5/8/2024 at 3:00 PM, the Director of Nursing stated, Staff should be ensuring privacy is provided when providing care for residents. Review of the facility policy and procedures titled Resident Rights with the last review date of 1/15/2024 read, Standard: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents . Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . t. privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment in 1 of 4 residential halls (300 Hall) and in the main dining room (Photographic evidence obtained). Findings include: 1. During an observation on 5/6/2024 at 10:00 AM, there were black lines along the lower wall of the 300 Hall. On the wall to the right of Resident #3's room, the wallpaper on the lower wall was rippled, peeling away from the wall. During an interview on 5/8/2024 at 12:58 PM, the Maintenance Director stated, The black marks along the wall are from the residents' wheelchairs. The rippled wallpaper outside of [Resident #3's room number]; I don't believe it's due to water damage, it's just old and needs to be replaced. Review of the facility policy and procedures titled Cleaning and Disinfection of Environmental Surfaces last reviewed on 1/15/2024, showed that it read, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation . 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times a week) and when surfaces are visibly soiled. 40559 2. During an observation of the main dining room adjacent to the kitchen on 5/6/2024 at 9:08 AM, there was a rolled-up bed linen against the wall with a brown colored stain on one end and brown colored dried flaky liquid on the floor next to it. During an interview on 5/6/2024 at 9:10 AM, the Administrator confirmed the rolled-up bed linen was on the dining room and stated, I do not know why that is there, but it does not need to be there. During an observation on 5/6/2024 at 10:24 AM, three square floor tiles were missing around the drain in the 100 and 200 hall shower rooms. During an interview on 5/10/2024 at 10:25 AM, the Maintenance Director confirmed the tiles were missing and stated, I was not made aware of this.

Based on record review and interview, the facility failed to ensure the residents with newly evident serious mental disorder were referred for assessment for 1 of 6 residents reviewed for Pre-Admission Screening and Resident Review (PASARR), Resident #23. Findings include: Review of Resident #23's admission record showed the resident was originally admitted to the facility on [DATE]. The resident's diagnoses included major depressive disorder, anxiety disorder, and paranoid schizophrenia (onset date: 3/2/2023). Review of Resident #23's Level I PASARR completed on 2/11/2020 did not indicate diagnosis of schizophrenia. Section IV showed no level II PASARR evaluation was required due to no diagnosis or suspicion of serios mental illness or intellectual disability. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the diagnosis of schizophrenia under section I. Active diagnoses. Review of Resident #23's records showed no level I PASARR completed after diagnosis of schizophrenia on 3/2/2023. During an interview on 5/8/2024 at 1:30 PM, the Social Services Director confirmed Resident #23 should have had a new Level I screening when diagnosed with paranoid schizophrenia and one was not conducted. During an interview on 5/10/2024 at 1:16 PM, the Director of Nursing (DON) stated the facility did not have a policy on PASARR and they followed the RAI (Resident Assessment Instrument).

Based on record review and interview, the facility failed to ensure a person-centered care plan was developed for management of epilepsy for 1 of 4 residents reviewed for accidents, Resident #54. Findings include: Review of Resident #54's admission record showed the resident was most recently admitted on [DATE] with diagnoses including Parkinsonism, epilepsy, lack of coordination, abnormal posture, muscle weakness, dementia, anxiety disorder, and paranoid schizophrenia. Review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a diagnosis of seizure disorder or epilepsy under Section I. Active Diagnoses. Review of Resident #54's physician order dated 11/2/2023 read, Divalproex Sodium ER [extended release] Oral Tablet Extended Release 24 Hour 500 mg [milligram] (Divalproex Sodium). Give 1 tablet by mouth at bedtime related to epilepsy, unspecified, intractable, with status epilepticus. Review of Resident #54's physician order dated 11/2/2023 read, Divalproex Sodium Oral Tablet Delayed Release 125 mg (Divalproex Sodium). Give 3 tablets by mouth one time a day related to epilepsy, unspecified, intractable, with statis epilepticus . Administer 3 tabs [tablets] to equal 375 mg. Review of Resident #54's care plan revealed no focus and intervention for epilepsy. During an interview on 5/8/2024 at 10:25 AM, the MDS Coordinator stated, [Resident #54's name] is not care planned for seizures. It should be part of the care plan. Review of the facility policy and procedures titled Plans of Care with the last review date of 1/15/2024 read, Policy: An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards of practice for 1 of 2 residents with peripherally inserted central catheter (PICC) lines, Resident #47 (Photographic evidence obtained). Findings include: Review of Resident #47's admission record showed the resident was most recently admitted on [DATE] with diagnoses including paraplegia, chronic respiratory failure with hypoxia, cellulitis of right lower limb, acute kidney failure, and metabolic encephalopathy. During an observation on 5/6/2024 at 1:53 PM, Resident #47 had a PICC line dressing to the right upper arm dated 4/26/2024. During an observation on 5/7/2024 at 1:24 PM, Resident #47 had a PICC line dressing to the right upper arm dated 4/26/2024. Review of Resident #47's physician order dated 4/28/2024 read, Ertapenem Sodium Injection Solution Reconstituted 1 GM [gram] (Ertapenem Sodium). Use 1 gram intravenously one time a day related to severe sepsis with septic shock until 05/25/2024, 23:59 [11:59 PM] . IVs [Intravenous]: Evaluate site for leakage/bleeding/signs of infection every shift. Review of Resident #47's physician order dated 4/29/2024 read, IVs: Flush PICC or Midline with 10 cc [cubic centimeter] of normal saline every shift, before and after IV med administration, and as needed two times a day. During an interview on 5/7/2024 at 1:25 PM, the Director of Nursing confirmed the dressing was dated 4/26/2024 and stated, It should have been changed weekly. Review of the facility policy and procedure titled Standards and Guidelines: Peripheral IV Dressing Changes/PICC/Midline revised on 11/2023 read, Standard: This purpose of this procedure is to minimize catheter-related infections associated with contaminated, loosened, or soiled catheter- site dressings. Procedure: 1. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5 to 7 days.

Based on record review and interview, the facility failed to ensure 1 of 1 resident receiving dialysis services, Resident #42, received treatment and care in accordance with professional standards of practice. Findings include: Review of Resident #42's physician order dated 3/22/2024 read, Dialysis communication form in the dialysis communication book to be completed by nurse prior to and upon return from dialysis clinic. Two times a day every Tue, Thu, Sat [Tuesday, Thursday, Saturday]. Review of Resident #42's Dialysis Communication Form dated 5/7/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 5/2/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 4/27/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 4/23/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 4/18/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 4/13/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's care plan dated 4/9/2021 showed the resident needed hemodialysis related to renal failure. During an interview on 5/9/2024 at 12:54 PM, the Director of Nursing (DON) stated, Nursing staff is expected to fill out the dialysis communication form upon the return of [Resident #42's name] to the facility after dialysis. During an interview on 5/10/2024 at 9:23 AM, Staff O, Licensed Practical Nurse (LPN), stated, [Resident #42's name] has a folder goes out with them and the night shift gets ready. When they come back, we get a weight to make sure it is accurate and full set of vitals. Review of the facility policy and procedures titled Dialysis Care with the last review date of 1/15/2024 read, Procedure . 3. Facility personnel will provide information that is useful or necessary for the care of the resident to the dialysis center as needed.

Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis. Findings include: During an initial tour on 5/6/2024 at 9:00 AM, the nurse staffing information was posted on the left side of the receptionist area upon entrance to the facility, which was dated 5/3/2024. During an interview on 5/8/2024 at 10:02 AM, the Administrator stated, The sheets were filled out, but the receptionist is new and did not know they were in the back of the one dated 5/3/2024. Usually, the staffing coordinator will come in early and review the census and update the sheet. This is done between 8:30 AM and 9:00 AM. We do not have a written policy. We follow the federal guidelines. During an interview on 5/9/2024 at 3:45 PM, the Staff Coordinator stated, I was out on vacation and came back Monday morning. I get in and change the federal staffing around 8:30 AM-9:00 AM. Get with admission before the census. The sheets were filled out. We had a new receptionist. They all will be behind one another all the way until Monday. Monday when I get here, I make sure it is accurate and update it before posting.

Based on observation, interview, and record review, the facility failed to ensure food items were stored in accordance with professional standards for food safety (Photographic evidence obtained). Findings include: During an observation while conducting a tour of the nourishment room on the rehabilitation wing conducted with the Certified Dietary Manager (CDM) on 5/7/2024 at 6:50 AM, there were one opened box of cinnamon mini squares, one opened family size box of Honey Bunches of Oats, one opened box of Welch's Juicefuls, and one opened box of Wheat Bran Flakes stored in a cabinet with no open date or resident name. There was also one opened half gallon container of vanilla ice in the freezer with no open date or resident name. During an interview on 5/7/2024 at 6:52 AM, the CDM confirmed the cereal boxes and ice cream were not labeled with an open date or resident identifier. Review of the facility policy and procedures titled Food: Safe Handling for Foods from Visitors revised on 2/2023 and reviewed on 1/16/2024 showed it read, Policy Statement: Residents will be assisted in properly storing and safely consuming food bought into the facility for residents by visitors . Procedures . 4. When food items are intended for later consumption, the responsible facility staff member will . - Label foods with the resident name and the current date.

Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to ensure residents were free from medical neglect when the staff failed to follow physicians' orders, resulting in insulin medication errors for 6 of 7 residents, Residents #1, #2, #3, #4, #5, and #6. Resident #1 was administered the wrong insulin and Residents #2, #3, #4, #5, and #6 were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [emergency room ] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. During an interview on 7/6/2023 at 10:35 AM, the MD stated, I was not aware that nurses were holding long-acting insulins outside of my written parameters. I write an order for accuchecks and to be notified if they are below 60 or above 400. I do not write specific hold orders. I expect them to administer the insulin. If they are symptomatic meaning, they are dizzy, lightheaded, I expect to be called and notified. I do expect the staff to inform me anytime they hold medications. The risk of not administering long-acting insulin would most obviously be hyperglycemia, going into HHNK if they have any infection brewing. It is and can be catastrophic in the right setting. Residents would need to get hospitalized if the hyperglycemia were severe enough, they risk dehydration with persistent hyperglycemia and diabetics poorly controlled are at risk for worsening kidney failure, electrolyte abnormalities, worsening eyesight, worsening peripheral neuropathy, coma and sometimes death. We need to provide this education and training to the nurses. During a telephone interview on 7/6/2023 at 11:00 AM, Staff E, LPN, stated, I was holding the Levemir and Lantus and would document that insulin was not needed because blood sugars were low. They weren't really low, not in the 50s, but below 150. I didn't know I wasn't supposed to do that. I did not call or notify the doctor when I held those. I should have. There were not any parameters to hold the insulin. I was not following the doctors' orders. I should have followed the orders. I thought I was doing the right thing. I would never want to hurt anyone at all. I was provided one on one education about neglect, long and short acting insulin, what parameters are for holding insulin, calling doctors with any time we need to hold medications, or they are refused, changes in condition notifications, medication errors and reporting them to doctors. We had to do an insulin and five rights of medication administration demonstration for the DON. During a telephone interview on 7/6/2023 at 11:30 AM, Staff F, LPN, stated, I did hold insulin when the blood sugars were low, less than 150. I was taught that we don't give insulin for anything less than 150. I don't think that the orders had any parameters from the doctor. I did not call the doctor and I would have documented if they had any symptoms. There were no orders to hold the insulin, I was not following doctors' orders. I should have given the insulin and followed the orders. I have been in-serviced today on neglect, the five rights of medication administration, long and short acting insulin, changes in condition and notifying doctors and did a demonstration of proper medication and insulin administration.<br [TRUNCATED]

Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to ensure the residents who required insulin administration received treatment in accordance with professional standards of practice by administering the wrong insulin and/or failing to administer long-acting insulin per physician orders for 6 of 7 residents receiving insulin, Residents #1, #2, #3, #4, #5 and #6. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [emergency room ] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. During an interview on 7/6/2023 at 10:35 AM, the MD stated, I was not aware that nurses were holding long-acting insulins outside of my written parameters. I write an order for accuchecks and to be notified if they are below 60 or above 400. I do not write specific hold orders. I expect them to administer the insulin. If they are symptomatic meaning, they are dizzy, lightheaded, I expect to be called and notified. I do expect the staff to inform me anytime they hold medications. The risk of not administering long-acting insulin would most obviously be hyperglycemia, going into HHNK if they have any infection brewing. It is and can be catastrophic in the right setting. Residents would need to get hospitalized if the hyperglycemia were severe enough, they risk dehydration with persistent hyperglycemia and diabetics poorly controlled are at risk for worsening kidney failure, electrolyte abnormalities, worsening eyesight, worsening peripheral neuropathy, coma and sometimes death. We need to provide this education and training to the nurses. During a telephone interview on 7/6/2023 at 11:00 AM, Staff E, LPN, stated, I was holding the Levemir and Lantus and would document that insulin was not needed because blood sugars were low. They weren't really low, not in the 50s, but below 150. I didn't know I wasn't supposed to do that. I did not call or notify the doctor when I held those. I should have. There were not any parameters to hold the insulin. I was not following the doctors' orders. I should have followed the orders. I thought I was doing the right thing. I would never want to hurt anyone at all. I was provided one on one education about neglect, long and short acting insulin, what parameters are for holding insulin, calling doctors with any time we need to hold medications, or they are refused, changes in condition notifications, medication errors and reporting them to doctors. We had to do an insulin and five rights of medication administration demonstration for the DON. During a telephone interview on 7/6/2023 at 11:30 AM, Staff F, LPN, stated, I did hold insulin when the blood sugars were low, less than 150. I was taught that we don't give insulin for anything less than 150. I don't think that the orders had any parameters from the doctor. I did not call the doctor and I would have documented if they had any symptoms. There were no orders to hold the insulin, I was not following doctors' orders. I should have given the insulin and followed the orders. I have been in-serviced today on neglect, the five rights of medication administration, long and short acting insulin, changes in condition and notifying doctors and did a demonstration of proper medication and insulin administration. During a telephone interview [TRUNCATED]

Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical wellbeing of each resident when not assuming full responsibility for the day-to-day operations of the facility. The facility failed to ensure residents were provided physician ordered insulin for 6 of 7 residents, Residents #1, #2, #3, #4, #5 and #6. Resident #1 was administered the wrong insulin and Residents #2, #3, #4, #5, and #6 were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the job description for the Executive Director (Administrator) read, Purpose of Your Job Position: The Executive Director is responsible for management of the facility in a manner which exemplifies Raydiant Health Care's standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate Honesty, Authentic Innovative, Compassion, Diversity, Equity & Inclusion. The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job functions: As Executive Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensure compliance with all state and federal regulations. Supervises Director of Clinical Services, Business Office Manager, Business Office Coordinator, Director of Admission, Director of Rehabilitation Services, Director of Resident and Family Services, Director of Therapeutic Recreational Services, Director of Hospitality Services, Director of Dining Services, Director of Environmental Services, Customer Service Associate. You will also provide leadership to all facility staff in meeting the goal of providing quality resident care. This job description does not list all the duties of your job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description at anytime. This job description is not a contract for employment and either you or the employer may terminate employment at any time for any reason. Duties and Responsibilities . 2. Establish financial and programmatic goals for the facility and conduct an annual evaluation of goal achievement . 7. Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations . 9. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines . 11. Support and guide the facility's quality improvement process . 23. Adhere to facility policies and procedures and participate in facility quality improvement and safety programs. Review of the job description for Director of Nursing I read, Purpose of Your Job Position . The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Director of Nursing I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing, and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality efficient nursing care. Supervises Nurse Practitioner, Assistant Director of Nursing, Clinical Nurses, and Nurse Techs. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility. This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. Duties and Responsibilities . 5. Set and monitor achievement of goals and objectives for the nursing department consistent with the established philosophy and standards of practice. 7. Establish, implement, and continually update competency/skills checklists for nursing staff . 9. Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines . 11. Establish and monitor compliance with an effective medical record documentation system . 14. Actively participate in the quality improvement process for the facility. 15. Participate in and/or provide inservice education sessions. Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [emergency room ] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. [TRUNCATED]

Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to develop and implement an appropriate plan of action to correct an identified quality deficiency when it was identified Resident #1 was administered a long-acting-insulin when a short acting insulin was ordered by the physician, and failed to identity 5 of 7 residents, Residents #2, #3, #4, #5, #6, were not administered physician ordered long-acting-insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [emergency room ] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During an interview on 7/5/2023 at 10:30 AM, the Administrator stated, I don't know exactly what has been done. I know that the DON left and that we have a new interim DON. She does know about this. There are no additional medication observations that have been done. There are no audits that I can find. I have given you everything that we have done since your last visit. I do have the ultimate responsibility for this along with the DON. We have not met about what was completed and what was not done. We were going to have another QAPI on Friday. I don't know if we evaluated residents who needed insulin to see the extent of our problem. I don't see any audits were completed. I don't see that we notified the resident representative or the doctors that residents weren't being given their insulin and we weren't following doctor's orders. I don't think we notified the medical director. We should have done all of that. During an interview on 7/5/2023 at 11:55 AM, Staff J, DON, stated, We don't have any additional training or education to show you. We don't have any audits of residents who are getting insulin to see if they were administered their insulin correctly after the medication error for that resident. I do see that staff are still holding long-acting insulins for parameters that don't exist. There really wasn't any investigation into why they were doing this that I am able to find. I do see that some staff have been trained in medication administration and insulin use, but not enough. There are no other medication observations done. There are only four with one that is a repeated staff, so only three staff have had the medication pass observation done. I can't find any audits and I'm not sure what was audited. We have called all staff and asked them to come in to be in-serviced and observed, so we are starting that. I will look at all residents who are on insulin to see how big a problem we have, to see if it's just a few staff or more than that. I am planning to reeducate them, and I will do an RCA [Root Cause Analysis] to figure out any other problems we are having or anything else we might need to do. I literally just started on Friday and didn't realize how little was completed. There is no reason why the insulins were held on any of the residents. We do not have any parameters for holding long-acting insulin. There were no physician orders for parameters to hold the insulin. We should have been following doctors' orders. We should have called the doctors and asked. This was not done. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. During an interview on 7/6/2023 at 10:35 AM, the MD stated, I was not aware that nurses were holding long-acting insulins outside of my written parameters. I write an order for accucheck [TRUNCATED]

Based on record review, resident interview, and staff interview, the facility failed to prevent physical and verbal abuse by failing to ensure structures and processes were in place to provide needed care and services to 2 of 4 residents reviewed of 43 total sampled residents. The facility failed to properly identify and provide protection from verbal abuse for Resident #75 by not suspending the alleged perpetrator and failed to protect a resident alleging staff physically abused him causing injury and ongoing emotional distress for Resident #78. This failure resulted in findings of Immediate Jeopardy starting on 10/1/19. The Immediate Jeopardy was determined to be removed on 11/21/19, during the survey. (Resident #s 75 and 78.) Findings: 1. A review of the Policies and Procedures titled Subject: Abuse, Neglect, Exploitation & Misappropriation, Document Name N1-1265, revision date 11/28/17, read verbal abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of ages, ability to comprehend or disability. The policy read, Mental and Verbal Abuse include, but are not limited to: yelling or hovering over a resident, with the intent of intimidate. On page 6 the policy read, Identification: All reported events will be investigated by the Director of Clinical Services. This information will be forwarded to the Executive Director, who will serve as the facility's abuse coordinator. Page 7 of the policy read, Protection. Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. Reporting/Response. Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. A record review of the clinical record on 11/19/19 for Resident #75 revealed an admit day of 9/19/19 and discharge date of [DATE]. Medical [DIAGNOSES REDACTED]. An interview was conducted with the Executive Director on 11/19/19 at 1:15 PM. She stated there was no investigation or reporting of abuse for the allegation of the dietary staff member yelling at Resident #75 because it was identified as a grievance not abuse. An interview was conducted with the Dietary Manager on 11/19/19 at 2:39 PM. She stated she completed the grievance dated 10/1/19. She stated she separated Staff F from the dining room Resident #75 was in and moved Staff F to the long-term care dining room. She stated in the evening, she assigned Staff F to the kitchen and had another dietary aide in the dining room taking food orders. She stated that verbal abuse would be if someone yelled at someone else. She stated should have taken it right to the abuse coordinator instead of writing the incident up as a grievance. An interview was conducted with Staff F, Dietary Aide on 11/19/19 at 2:45 PM. She stated the next day (10/2/19) she was told that she yelled at Resident #75 in the dining room. She stated she did not yell at her although her voice is loud and carries. She stated she was removed from the rehab dining room and moved to the long-term care dining room so she would not be working with Resident #75. She stated her assignment was in the long-term dining room until Resident #75 was discharged . An interview was conducted with the Executive Director on 11/20/19 at 9:45 AM. She stated the incident with Resident #75 stating the dietary staff member yelled at her was interpreted as a grievance because the staff member talks loudly. 2. During an interview with Resident #78 on (MONTH) 18, 2019, at 11:08 AM he stated, I was attacked by (Staff B Registered Nurse (RN)). She told them that I was resistant to taking my medicine. I felt so helpless, I've never felt so helpless in my whole life, I was truly afraid that she would come back. Over the weekend the nurse told me that I needed to take my medicine. She said I wasn't being cooperative and grabbed my right wrist causing a scratch and forced the medicine cup to my mouth. First, (Staff C, Licensed Practical Nurse (LPN)) brought medication in, I told him I needed to go to the bathroom, they put me on the bedpan and when I was done I told them I needed to get pulled up in bed, he said you are refusing medicines, I told him No I'm not, I just need to get higher in bed so I can swallow. (Staff C, LPN) adamantly raised his voice at me and walked out stating you are refusing your medicines. (Staff C, LPN) brought back (Staff B RN), when she came in, (Staff B RN), said you are just being stubborn, and you are refusing your medicines. One was on each side of me and she (Staff B) grabbed my left-hand forcefully and tried to pull the medicine cup away from me and they spilled all over. That's when she grabbed my right arm. Then they ripped off my brief looking for all the medicines and tossed me around the bed to find them all. I called the police and reported it to the police. She left scratches on my finger and my wrist and they hurt. They did do x-rays of my hands. The resident was tearful throughout the interview. During an interview with Resident #78 on (MONTH) 19, 2019 at 2:00 PM, he stated, I asked to see the psychiatrist because I just can't stop being angry and anxious. I saw him and I'm going to have my medications increased for my anxiety and start some new pill tomorrow to help me cope with this. I am still so afraid to get hurt by them again. I'm just glad that I will be getting discharged tomorrow, then I won't have to see them ever again. You know that because of this they got the doctor to order my medicines get crushed up and put in pudding, what am I a kid? They just don't believe me that I wasn't refusing to take my medicine. I had a tube in my stomach because I was putting food in my lungs causing pneumonia, I just wanted to get pulled up to take my medicine. I didn't have any problems with (Staff B RN) before this, she used to help me out. I haven't seen (Staff B RN) since then, but that guy nurse was in the night this happened, I saw him in the hallway and thought he was going to take care of me, but he didn't. I was scared that he would come in in the middle of the night. It's just not right to be treated that way. I am still so upset. The resident was tearful and anxious with periods of crying during this interview. During an interview on (MONTH) 20, 2019 at 8:15 AM with Resident #78, he stated I'm leaving today just as soon as I can. It will be good to get out of here. I know that the staff thought I was a big pain in the ass and maybe I was sometimes, but nobody should get treated like that. Nobody should be mocked and denied things. All I wanted was for someone to pull me up in bed. They all think I can do it myself, they don't understand what it's like not to be able to breathe right or have a tube in your belly and not be able to eat. They all think I'm a faker. I'm not, I'm just old and getting weak. I would call the nurses' station because they don't want to answer the call light, so I called the main line that rang to the nurse's station. I complained a lot so now they just don't believe me. I saw the male nurse that night in my hallway and I was scared he was going to come back in here. He didn't, but how could they let him come into the hospital what if I couldn't talk. During the interview, the resident remained weepy and intermittently crying as he spoke. An observation of Resident #78 was conducted on (MONTH) 18, 2019, at 11:30 AM with Staff G, Registered Nurse (RN). The Resident had a dressing on his left index finger and his right inner wrist area. An observation of these areas was completed with the Staff G, RN. She removed the wrist bandage, there was a reddened open area approximately 1 cm in length and a less than 0.2 cm in width that contained no visible drainage on the old dressing. The right index finger has an approximately 0.5 cm area reddened open area extending down from the nail bed on the inner aspect of the right index finger. Staff cleansed the wounds with normal saline and reapplied the dressings. A record review on (MONTH) 18, 2019, of Resident #78's care plan indicated that Resident #78 has activities of daily living self-care deficits related to shortness of breath, weakness, and decreased mobility. Potential to be verbally aggressive to staff related to poor impulse control and manipulative behaviors. Resident uses antianxiety medication related to anxiety disorder and uses antidepressant medications related to depression, Resident has chronic pain related to wounds. A record review on (MONTH) 18, 2019, of Resident #78 weekly skin assessment dated (MONTH) 11, 2019, at 10:17 PM authored by Staff C, LPN read, Abdomen G tube removal site, no signs of infection at this time, Right lower leg right dry flaky skin, left lower leg front- dry flaky skin, Sacrum Blanchable. Weekly skin assessment dated (MONTH) 17, 2019 at 09:00 AM authored by Staff B read, abdomen small pink open area circular peg tube removal site, Coccyx pink shearing, Right hand (Back) right wrist small abrasion, Left hand back small abrasion left index finger. A record review on (MONTH) 18, 2019, of a nursing progress note, dated (MONTH) 17, 2019, authored by Staff B Registered Nurse read, Resident called facility to request pain medication with AM medications. Assisted to pull narcotics from Emergency Drug Kit (EDK) with Staff C, LPN at 05:10 AM. Witnessed nurse attempt to give resident medication. Resident refused to take after requesting them, stating he needed to get on a bedpan and could not take until he was done, Resident placed on the bedpan. Nurse returned once again, and resident refused, needing bedpan again. This continued till 06:40. After resident was removed once again from bedpan, he was offered his medication. Resident once again refused now stating he needed to be repositioned and pulled up in bed, however he had laid his head down and his feet up in the air Resident was asked to raise the head of his bed which he refused Resident called facility and was informed that after shift change, he would be repositioned. Once again, he was offered medication before shift change. Medication had now been offered several times and held for almost 2 hours to accommodate resident's requests and refusals. Resident stated he would take the medications and was offered the med cup. At this point he grabbed them in his hand and put them under the covers to his brief stating ha-ha, I'm not taking them, I'll wait until the CNA is done moving me. Resident was asked several times to either take medications or give them back due to narcotics being given. Resident refused. Medication was retrieved from resident and wasted without incident. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 17, 2019 authored by Staff D at 8:25 AM, read, Resident informed this nurse that he had been injured and was calling authorities, res alert and oriented x 3, answering questions appropriately to name, date and time. RN weekend supervisor made aware of resident complaint and present during head to toe assessment of resident, Resident asked that areas to bilateral arms, hands and wrists be closely assessed. Resident complained of pain to left ring finger, no redness or [MEDICAL CONDITION] apparent and active range of motion. Small abrasion to left index finger with small amount scant serosanguinous drainage on finger, small abrasion to right wrist area with small amount drainage also on sheet. Areas cleansed with saline. Medical Doctor (MD) notified mobile imaging called stat for x-rays bilateral hands, wrist. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 18, 2019, at 12:02 PM authored by Staff G Registered Nurse Unit manager read, Resident requested to speak with in house psychologist declaring that he was traumatized related to a prior event that occurred. Contacted to make him aware. The psychologist will be in tomorrow morning to talk with resident. Resident aware. Record review on (MONTH) 20, 2019, of nursing progress note dated (MONTH) 19, 2019 at 12:08 AM authored by Staff G, RN, Unit manager read, In house psychiatrist in on rounds, Resident noted with ongoing agitation and anxiety. Resident requested increase in anxiety medication. New orders received to increase [MEDICATION NAME] to 30 mg BID (twice a day) and add Trazadone 25 mg in am. Orders noted. Will continue to be followed by psychiatrist monthly and as needed. Record review on (MONTH) 20, 2019, of the psychiatric progress note authored by Staff H behavioral health, dated November19, 2019, treatment time from 11:55 AM stop time 12:20 PM read, treatment plan: [REDACTED]. Subjective: Today the patient addressed: Coping skills, adjustment to facility, relationship skills with peers/staff, Coping with stress/anxiety, Coping with mood, and other allegation of staff abuse. Summary and progress toward goals: Patient demonstrated adequate cognitive capacity for meaningful participation in therapy as evidenced by alert and oriented times 4 presentation with logical coherent and organized thought processes and speech. Mental status was highlighted by anxiety per self-report and clinical observation. Patient reported an allegation of staff abuse two days ago during medication distribution which reportedly resulted in allegations of staff assault. Patient reported a struggle in which two nurses attempted to remove a medication cup from the Patient's left hand which resulted in a skin tear which required bandage. Intervention was to invite patient to vent and process the sequential mechanics of the incident and how same impacted him emotionally. Patient response indicated that he felt anxious as a whole, fearful of the two alleged staff member perpetrators, with reports of [MEDICAL CONDITION], diminished appetite, recurrent thoughts about the incident and nightmares the past two nights. Patient was alert and oriented with logical thought processes during the interview. Patient was tearful briefly two times during the assessment process. Patient acknowledged that a statement had been made and a police report has been taken by local law enforcement. Patient also acknowledged having processed this incident with the nursing home administrator, Director of Nursing, and the Unit Manger. Although patient reported and demonstrated symptoms of emotional distress, patient does not meet the criteria for additional [DIAGNOSES REDACTED]. During an interview with the Executive Director on (MONTH) 19, 2019 at 2:30 PM, she stated, I just got this allegation on Sunday, I am still investigating this. Both nurses have been placed on administrative leave pending our full investigation. I have spoken to one of the nurses and am waiting to speak to the other. The resident saw the psychiatrist today and he increased his anxiety medications. We are in the process of training all staff regarding abuse and are providing education to nursing staff that in cases like this they should have another nurse stay with the resident and notify the physician. When I spoke to (Staff B), she was concerned that there was a narcotic that the resident had and concerned that she could not leave the narcotic with the resident for his safety. During an interview with the Executive Director on (MONTH) 20, 2019, at 11:00 AM she stated I was aware of the allegation and that the resident had called the police. I was not called, we exchanged text messages and I was only aware that Resident #78 had called the police again. The Nursing Supervisor did not tell me that anyone else was involved. I did not ask any further or follow up questions to the nursing supervisor. When I saw the statements on Monday morning, I told the Director of Nursing to suspend Staff B, RN, this occurred on Monday morning. I waited until Monday morning because I knew that Staff B, RN was not working on Sunday night, so I knew that I had time. I was not aware that anyone else was involved and did not ask the Nursing Supervisor to do any further investigation on Sunday. I should have instructed them to suspend everyone involved in the allegation including Staff C, LPN, but I was not aware that he was involved. I would have done that had I known. During an interview with the Director of Nursing on (MONTH) 20, 2019, at 11:20 AM she stated, Staff C, LPN did work on (MONTH) 17, 2019, at 7:00 PM and was not suspended that day. He was placed on the opposite end of the hallway and was not responsible for the care of Resident #78. I was aware of the fact that (Resident #78) had called police and that the Executive Director had been informed. I have not had any problems with either employee related to abuse allegations. Our policy does indicate that all involved personnel be placed on leave pending the investigation. During a telephone Interview with Staff D on (MONTH) 20, 2019, at 11:44 AM she stated, The resident request me to come to room when pushing my cart. He was on the phone with police stating he was assaulted by (Staff B) and the police were on the way. He said the nurses that just left, the male and (Staff B) did it. I left to find the weekend supervisor and that is when the police officer came and I got (Staff E, RN), who came to room with the officer. After the police left, I went in, he wrote it all out on a note pad and he showed me the note pad. He had abrasions on his one hand and wrist area, he was worried his hand was broken and painful. The Nursing Supervisor and I did a head to toe assessment to check for other injuries and we asked a Certified Nursing Assistant to get vital signs and did a full skin sweep. Then I notified the Medical Doctor of his complaints of left-hand pain. I and the Nursing Supervisor assessed there was no [MEDICAL CONDITION] or lack of range of motion and I treated these abrasions. The doctor ordered a stat mobile imaging of both hands and they were here within two (2) hours to complete the x-ray. The officer came back and generated a police report. The resident was very tearful and scared which is very different from his normal behaviors. He can be mean, aggressive and demanding, but he is not usually tearful or anxious, this is very different from his normal. He told me that he requested to get pulled up by the nurse. He said they insisted I take them, I wouldn't take them, they wrestled them away, (Staff B) grabbed his arm, held his other arm down and then (Staff C) held down his other arm. He can be resistant to care. I took care of him that day and on the day after the event. On Monday, the resident called me into his room and said that he was afraid, I think I need to talk to the psychologist, can you get in touch with him, I'm feeling traumatized. During a telephone interview on (MONTH) 20, 2019, at 8:27 AM with Staff B Registered Nurse, she stated (Resident #78) has been a problem behaviorally for several months and cannot be taken care of by multiple people. On the morning of (MONTH) 17, 2019, he refused to take his medications multiple times. He is very manipulative and was not being fair with the nurse. I was not taking care of him that night, but I went to assist (Staff C, LPN) to get narcotics from the emergency drug kit, so I know that was at 5:10 AM. (Staff C, LPN) came to me and told me he couldn't administer the medications because the resident refused because he needed a bedpan. When (Staff C, LPN) went back in the resident wanted to get on the bedpan again. So, staff placed him on again. When (Staff C, LPN) went in the last time he wanted to get pulled up and (Staff C, LPN) needed to wait for someone to help him. When it didn't happen, immediately the resident got upset and (Staff C, LPN) got me, that's when I got involved. When I went into the room, I stood at the foot of the bed with the medicine cup, I asked him if he would take them and he refused saying he needed to be pulled up in bed. We did not pull him up he was high in the bed and simply needed to raise the head of his bed, so we left the room. When we got to the nurse's station, he called on his cell phone to the facility and I asked him if he would take his medications, the resident stated he would take them. We went back to the room I stood at the foot of the bed and handed him the medicine cup. He took it and stuffed it under his covers. I asked him to give them back and he placed them from the cup to his left hand. All this time the resident was screaming at us that he wasn't refusing to take the medications. The medications spilled into the bed and I told him we needed to find the medications because there were narcotics. When I went to pull back the covers, he grabbed my hand digging in his nails. I never grabbed his hands, have never restrained anyone physically in my life. I would never do that. I was placed on administrative leave on Monday afternoon sometime, I can't remember what time. I did not work on Sunday night. I received training on abuse and neglect when I was first hired, I don't think I have done it since then. I know that I am a mandatory abuse reporter and that I should report all forms of abuse. During a telephone interview with Staff C, LPN on (MONTH) 20, 2019, at 9:03 AM, he stated I was the nurse taking care of Resident #78 the morning of 11/17/2019. He asked for pain medication around 5:00 AM and didn't have any so I asked (Staff B Registered Nurse) to help me get them from the emergency drug kit because I had never done that before. I took care of him on Friday and Saturday night, he has some behavior problems and staff can't take care of him. He gets pretty angry when he doesn't get things immediately and he can yell sometimes, but I haven't had any problems with him until that night. I tried to get him to take his medications and to go back a few times because I know that he gets irritated sometimes. When I asked (Staff B Registered Nurse) to help me, he was still refusing to take medicines, so we went to the Nurses' station and he called and talked to (Staff B Registered Nurse), that is when we went back to the room. I was on the right side and (Staff B Registered Nurse) was on the left side. She put the cup up to his mouth and he grabbed the medicine from her hands that's when she tried to get the cup from his left hand and she grabbed his hands, he was yelling and screaming, and the pills flew all over the bed and floor. We tried to get the medicines back by looking in the bed and on the floor, we found one of the pills on the floor under the bed near his head. The resident did not become physical with us, I just moved his right arm down away from (Staff B Registered Nurse) so she could get the medicine cup. I wasn't restraining him, he did say let me go and I did immediately. I would not have touched his arm if he had told me not to. During an interview on (MONTH) 20, 2019, at 1:12 PM with Staff E, Registered Nurse, she stated, I was the weekend supervisor on the (MONTH) 17, 2019, and was made aware that the police were in the building and I began texting the administrator about 8:10 AM. I did tell the Administrator and the Director of Nursing which staff were involved. That resident was alleging assault by (Staff B, RN) and (Staff C, LPN), he was more concerned that (Staff B, RN) hurt him, but also that (Staff C, LPN) held down his arm and was saying he was refusing medications. I was aware that (Staff C, LPN) was scheduled to work that night and we placed him on the opposite hallway and away from the resident. I cannot say that the staff would not go over to see the resident. I have been trained on abuse, neglect and misappropriation. I am slightly familiar with the abuse and neglect policy and that it states that staff should be suspended pending investigation. I do not have the authority to make those decisions.

Based on record review and staff interview, the facility failed to implement policies and procedure to prevent physical and verbal abuse for 2 of 4 residents reviewed for abuse out of 43 total sampled residents. The facility failed to properly identify and provide protection from verbal abuse for Resident #75 by not suspending the alleged perpetrator and failure to protect a resident alleging staff physically abused him causing injury and ongoing emotional distress for Resident #78 represented a system-wide failure. This failure resulted in findings of Immediate Jeopardy starting 10/1/19. The Immediate Jeopardy was determined to be removed on 11/21/19, during the survey. (Resident #s 75 and 78) Findings: 1. A review of the Policies and Procedures titled Subject: Abuse, Neglect, Exploitation & Misappropriation, Document Name N1-1265, revision date 11/28/17, read verbal abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of ages, ability to comprehend or disability. The policy also read, Mental and Verbal Abuse include, but are not limited to: yelling or hovering over a resident, with the intent of intimidate. On page 6 the policy read, Identification: All reported events will be investigated by the Director of Clinical Services. This information will be forwarded to the Executive Director, who will serve as the facility's abuse coordinator. Page 7 of the policy read, Protection. Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. Reporting/Response. Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. A record review of the clinical record on 11/19/19 for Resident #75 revealed an admit day of 9/19/19 and discharge date of [DATE]. Medical [DIAGNOSES REDACTED]. An interview was conducted with the Executive Director on 11/19/19 at 1:15 PM. She stated there was no investigation or reporting of abuse for the allegation of the dietary staff member yelling at Resident #75 because it was identified as a grievance not abuse. An interview was conducted with the Dietary Manager on 11/19/19 at 2:39 PM. She stated she completed the grievance dated 10/1/19. She stated she separated Staff F from the dining room Resident #75 was in and moved Staff F to the long-term care dining room. She stated in the evening, she assigned Staff F to the kitchen and had another dietary aide in the dining room taking food orders. She stated that verbal abuse would be if someone yelled at someone else. She stated should have taken it right to the abuse coordinator instead of writing the incident up as a grievance. An interview was conducted with Staff F, Dietary Aide on 11/19/19 at 2:45 PM. She stated the next day (10/2/19) she was told that she yelled at Resident #75 in the dining room. She stated she did not yell at her although her voice is loud and carries. She stated she was removed from the rehab dining room and moved to the long-term care dining room so she would not be working with Resident #75. She stated her assignment was in the long-term dining room until Resident #75 was discharged . An interview was conducted with the Executive Director on 11/20/19 at 9:45 AM. She stated the incident with Resident #75 stating the dietary staff member yelled at her was interpreted as a grievance because the staff member talks loudly. 2. During an interview with Resident #78 on (MONTH) 18, 2019, at 11:08 AM he stated, I was attacked by (Staff B Registered Nurse (RN)). She told them that I was resistant to taking my medicine. I felt so helpless, I've never felt so helpless in my whole life, I was truly afraid that she would come back. Over the weekend the nurse told me that I needed to take my medicine. She said I wasn't being cooperative and grabbed my right wrist causing a scratch and forced the medicine cup to my mouth. First, (Staff C, Licensed Practical Nurse (LPN)) brought medication in, I told him I needed to go to the bathroom, they put me on the bedpan and when I was done I told them I needed to get pulled up in bed, he said you are refusing medicines, I told him No I'm not, I just need to get higher in bed so I can swallow. (Staff C, LPN) adamantly raised his voice at me and walked out stating you are refusing your medicines. (Staff C, LPN) brought back (Staff B RN), when she came in, (Staff B RN), said you are just being stubborn, and you are refusing your medicines. One was on each side of me and she (Staff B) grabbed my left-hand forcefully and tried to pull the medicine cup away from me and they spilled all over. That's when she grabbed my right arm. Then they ripped off my brief looking for all the medicines and tossed me around the bed to find them all. I called the police and reported it to the police. She left scratches on my finger and my wrist and they hurt. They did do x-rays of my hands. The resident was tearful throughout the interview. During an interview with Resident #78 on (MONTH) 19, 2019 at 2:00 PM, he stated, I asked to see the psychiatrist because I just can't stop being angry and anxious. I saw him and I'm going to have my medications increased for my anxiety and start some new pill tomorrow to help me cope with this. I am still so afraid to get hurt by them again. I'm just glad that I will be getting discharged tomorrow, then I won't have to see them ever again. You know that because of this they got the doctor to order my medicines get crushed up and put in pudding, what am I a kid? They just don't believe me that I wasn't refusing to take my medicine. I had a tube in my stomach because I was putting food in my lungs causing pneumonia, I just wanted to get pulled up to take my medicine. I didn't have any problems with (Staff B RN) before this, she used to help me out. I haven't seen (Staff B RN) since then, but that guy nurse was in the night this happened, I saw him in the hallway and thought he was going to take care of me, but he didn't. I was scared that he would come in in the middle of the night. It's just not right to be treated that way. I am still so upset. The resident was tearful and anxious with periods of crying during this interview. During an interview on (MONTH) 20, 2019 at 8:15 AM with Resident #78, he stated I'm leaving today just as soon as I can. It will be good to get out of here. I know that the staff thought I was a big pain in the ass and maybe I was sometimes, but nobody should get treated like that. Nobody should be mocked and denied things. All I wanted was for someone to pull me up in bed. They all think I can do it myself, they don't understand what it's like not to be able to breathe right or have a tube in your belly and not be able to eat. They all think I'm a faker. I'm not, I'm just old and getting weak. I would call the nurses' station because they don't want to answer the call light, so I called the main line that rang to the nurse's station. I complained a lot so now they just don't believe me. I saw the male nurse that night in my hallway and I was scared he was going to come back in here. He didn't, but how could they let him come into the hospital what if I couldn't talk. During the interview, the resident remained weepy and intermittently crying as he spoke. An observation of Resident #78 was conducted on (MONTH) 18, 2019, at 11:30 AM with Staff G, Registered Nurse (RN). The Resident had a dressing on his left index finger and his right inner wrist area. An observation of these areas was completed with the Staff G, RN. She removed the wrist bandage, there was a reddened open area approximately 1 cm in length and a less than 0.2 cm in width that contained no visible drainage on the old dressing. The right index finger has an approximately 0.5 cm area reddened open area extending down from the nail bed on the inner aspect of the right index finger. Staff cleansed the wounds with normal saline and reapplied the dressings. A record review on (MONTH) 18, 2019, of Resident #78's care plan indicated that Resident #78 has activities of daily living self-care deficits related to shortness of breath, weakness, and decreased mobility. Potential to be verbally aggressive to staff related to poor impulse control and manipulative behaviors. Resident uses antianxiety medication related to anxiety disorder and uses antidepressant medications related to depression, Resident has chronic pain related to wounds. A record review on (MONTH) 18, 2019, of Resident #78 weekly skin assessment dated (MONTH) 11, 2019, at 10:17 PM authored by Staff C, LPN read, Abdomen G tube removal site, no signs of infection at this time, Right lower leg right dry flaky skin, left lower leg front- dry flaky skin, Sacrum Blanchable. Weekly skin assessment dated (MONTH) 17, 2019 at 09:00 AM authored by Staff B read, abdomen small pink open area circular peg tube removal site, Coccyx pink shearing, Right hand (Back) right wrist small abrasion, Left hand back small abrasion left index finger. A record review on (MONTH) 18, 2019, of a nursing progress note, dated (MONTH) 17, 2019, authored by Staff B Registered Nurse read, Resident called facility to request pain medication with AM medications. Assisted to pull narcotics from Emergency Drug Kit (EDK) with Staff C, LPN at 05:10 AM. Witnessed nurse attempt to give resident medication. Resident refused to take after requesting them, stating he needed to get on a bedpan and could not take until he was done, Resident placed on the bedpan. Nurse returned once again, and resident refused, needing bedpan again. This continued till 06:40. After resident was removed once again from bedpan, he was offered his medication. Resident once again refused now stating he needed to be repositioned and pulled up in bed, however he had laid his head down and his feet up in the air Resident was asked to raise the head of his bed which he refused Resident called facility and was informed that after shift change, he would be repositioned. Once again, he was offered medication before shift change. Medication had now been offered several times and held for almost 2 hours to accommodate resident's requests and refusals. Resident stated he would take the medications and was offered the med cup. At this point he grabbed them in his hand and put them under the covers to his brief stating ha-ha, I'm not taking them, I'll wait until the CNA is done moving me. Resident was asked several times to either take medications or give them back due to narcotics being given. Resident refused. Medication was retrieved from resident and wasted without incident. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 17, 2019 authored by Staff D at 8:25 AM, read, Resident informed this nurse that he had been injured and was calling authorities, res alert and oriented x 3, answering questions appropriately to name, date and time. RN weekend supervisor made aware of resident complaint and present during head to toe assessment of resident, Resident asked that areas to bilateral arms, hands and wrists be closely assessed. Resident complained of pain to left ring finger, no redness or [MEDICAL CONDITION] apparent and active range of motion. Small abrasion to left index finger with small amount scant serosanguinous drainage on finger, small abrasion to right wrist area with small amount drainage also on sheet. Areas cleansed with saline. Medical Doctor (MD) notified mobile imaging called stat for x-rays bilateral hands, wrist. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 18, 2019, at 12:02 PM authored by Staff G Registered Nurse Unit manager read, Resident requested to speak with in house psychologist declaring that he was traumatized related to a prior event that occurred. Contacted to make him aware. The psychologist will be in tomorrow morning to talk with resident. Resident aware. Record review on (MONTH) 20, 2019, of nursing progress note dated (MONTH) 19, 2019 at 12:08 AM authored by Staff G, RN, Unit manager read, In house psychiatrist in on rounds, Resident noted with ongoing agitation and anxiety. Resident requested increase in anxiety medication. New orders received to increase [MEDICATION NAME] to 30 mg BID (twice a day) and add Trazadone 25 mg in am. Orders noted. Will continue to be followed by psychiatrist monthly and as needed. Record review on (MONTH) 20, 2019, of the psychiatric progress note authored by Staff H behavioral health, dated November19, 2019, treatment time from 11:55 AM stop time 12:20 PM read, treatment plan: [REDACTED]. Subjective: Today the patient addressed: Coping skills, adjustment to facility, relationship skills with peers/staff, Coping with stress/anxiety, Coping with mood, and other allegation of staff abuse. Summary and progress toward goals: Patient demonstrated adequate cognitive capacity for meaningful participation in therapy as evidenced by alert and oriented times 4 presentation with logical coherent and organized thought processes and speech. Mental status was highlighted by anxiety per self-report and clinical observation. Patient reported an allegation of staff abuse two days ago during medication distribution which reportedly resulted in allegations of staff assault. Patient reported a struggle in which two nurses attempted to remove a medication cup from the Patient's left hand which resulted in a skin tear which required bandage. Intervention was to invite patient to vent and process the sequential mechanics of the incident and how same impacted him emotionally. Patient response indicated that he felt anxious as a whole, fearful of the two alleged staff member perpetrators, with reports of [MEDICAL CONDITION], diminished appetite, recurrent thoughts about the incident and nightmares the past two nights. Patient was alert and oriented with logical thought processes during the interview. Patient was tearful briefly two times during the assessment process. Patient acknowledged that a statement had been made and a police report has been taken by local law enforcement. Patient also acknowledged having processed this incident with the nursing home administrator, Director of Nursing, and the Unit Manger. Although patient reported and demonstrated symptoms of emotional distress, patient does not meet the criteria for additional [DIAGNOSES REDACTED]. During an interview with the Executive Director on (MONTH) 19, 2019 at 2:30 PM, she stated, I just got this allegation on Sunday, I am still investigating this. Both nurses have been placed on administrative leave pending our full investigation. I have spoken to one of the nurses and am waiting to speak to the other. The resident saw the psychiatrist today and he increased his anxiety medications. We are in the process of training all staff regarding abuse and are providing education to nursing staff that in cases like this they should have another nurse stay with the resident and notify the physician. When I spoke to (Staff B), she was concerned that there was a narcotic that the resident had and concerned that she could not leave the narcotic with the resident for his safety. During an interview with the Executive Director on (MONTH) 20, 2019, at 11:00 AM she stated I was aware of the allegation and that the resident had called the police. I was not called, we exchanged text messages and I was only aware that (Resident #78) had called the police again. The Nursing Supervisor did not tell me that anyone else was involved. I did not ask any further or follow up questions to the nursing supervisor. When I saw the statements on Monday morning, I told the Director of Nursing to suspend (Staff B, RN), this occurred on Monday morning. I waited until Monday morning because I knew that (Staff B, RN) was not working on Sunday night, so I knew that I had time. I was not aware that anyone else was involved and did not ask the Nursing Supervisor to do any further investigation on Sunday. I should have instructed them to suspend everyone involved in the allegation including (Staff C, LPN), but I was not aware that he was involved. I would have done that had I known. During an interview with the Director of Nursing on (MONTH) 20, 2019, at 11:20 AM she stated, (Staff C, LPN) did work on (MONTH) 17, 2019, at 7:00 PM and was not suspended that day. He was placed on the opposite end of the hallway and was not responsible for the care of Resident #78. I was aware of the fact that (Resident #78) had called police and that the Executive Director had been informed. I have not had any problems with either employee related to abuse allegations. Our policy does indicate that all involved personnel be placed on leave pending the investigation. During a telephone Interview with Staff D on (MONTH) 20, 2019, at 11:44 AM she stated, The resident request me to come to room when pushing my cart. He was on the phone with police stating he was assaulted by (Staff B) and the police were on the way. He said the nurses that just left, the male and (Staff B) did it. I left to find the weekend supervisor and that is when the police officer came and I got (Staff E, RN), who came to room with the officer. After the police left, I went in, he wrote it all out on a note pad and he showed me the note pad. He had abrasions on his one hand and wrist area, he was worried his hand was broken and painful. The Nursing Supervisor and I did a head to toe assessment to check for other injuries and we asked a Certified Nursing Assistant to get vital signs and did a full skin sweep. Then I notified the Medical Doctor of his complaints of left-hand pain. I and the Nursing Supervisor assessed there was no [MEDICAL CONDITION] or lack of range of motion and I treated these abrasions. The doctor ordered a stat mobile imaging of both hands and they were here within two (2) hours to complete the x-ray. The officer came back and generated a police report. The resident was very tearful and scared which is very different from his normal behaviors. He can be mean, aggressive and demanding, but he is not usually tearful or anxious, this is very different from his normal. He told me that he requested to get pulled up by the nurse. He said they insisted I take them, I wouldn't take them, they wrestled them away, (Staff B) grabbed his arm, held his other arm down and then (Staff C) held down his other arm. He can be resistant to care. I took care of him that day and on the day after the event. On Monday, the resident called me into his room and said that he was afraid, I think I need to talk to the psychologist, can you get in touch with him, I'm feeling traumatized. During a telephone interview on (MONTH) 20, 2019, at 8:27 AM with Staff B Registered Nurse, she stated (Resident #78) has been a problem behaviorally for several months and cannot be taken care of by multiple people. On the morning of (MONTH) 17, 2019, he refused to take his medications multiple times. He is very manipulative and was not being fair with the nurse. I was not taking care of him that night, but I went to assist (Staff C, LPN) to get narcotics from the emergency drug kit, so I know that was at 5:10 AM. (Staff C, LPN) came to me and told me he couldn't administer the medications because the resident refused because he needed a bedpan. When (Staff C, LPN) went back in the resident wanted to get on the bedpan again. So, staff placed him on again. When (Staff C, LPN) went in the last time he wanted to get pulled up and (Staff C, LPN) needed to wait for someone to help him. When it didn't happen, immediately the resident got upset and (Staff C, LPN) got me, that's when I got involved. When I went into the room, I stood at the foot of the bed with the medicine cup, I asked him if he would take them and he refused saying he needed to be pulled up in bed. We did not pull him up he was high in the bed and simply needed to raise the head of his bed, so we left the room. When we got to the nurse's station, he called on his cell phone to the facility and I asked him if he would take his medications, the resident stated he would take them. We went back to the room I stood at the foot of the bed and handed him the medicine cup. He took it and stuffed it under his covers. I asked him to give them back and he placed them from the cup to his left hand. All this time the resident was screaming at us that he wasn't refusing to take the medications. The medications spilled into the bed and I told him we needed to find the medications because there were narcotics. When I went to pull back the covers, he grabbed my hand digging in his nails. I never grabbed his hands, have never restrained anyone physically in my life. I would never do that. I was placed on administrative leave on Monday afternoon sometime, I can't remember what time. I did not work on Sunday night. I received training on abuse and neglect when I was first hired, I don't think I have done it since then. I know that I am a mandatory abuse reporter and that I should report all forms of abuse. During a telephone interview with Staff C, LPN on (MONTH) 20, 2019, at 9:03 AM, he stated I was the nurse taking care of Resident #78 the morning of 11/17/2019. He asked for pain medication around 5:00 AM and didn't have any so I asked (Staff B Registered Nurse) to help me get them from the emergency drug kit because I had never done that before. I took care of him on Friday and Saturday night, he has some behavior problems and staff can't take care of him. He gets pretty angry when he doesn't get things immediately and he can yell sometimes, but I haven't had any problems with him until that night. I tried to get him to take his medications and to go back a few times because I know that he gets irritated sometimes. When I asked (Staff B Registered Nurse) to help me, he was still refusing to take medicines, so we went to the Nurses' station and he called and talked to (Staff B Registered Nurse), that is when we went back to the room. I was on the right side and (Staff B Registered Nurse) was on the left side. She put the cup up to his mouth and he grabbed the medicine from her hands that's when she tried to get the cup from his left hand and she grabbed his hands, he was yelling and screaming, and the pills flew all over the bed and floor. We tried to get the medicines back by looking in the bed and on the floor, we found one of the pills on the floor under the bed near his head. The resident did not become physical with us, I just moved his right arm down away from (Staff B Registered Nurse) so she could get the medicine cup. I wasn't restraining him, he did say let me go and I did immediately. I would not have touched his arm if he had told me not to. During an interview on (MONTH) 20, 2019, at 1:12 PM with Staff E, Registered Nurse, she stated, I was the weekend supervisor on the (MONTH) 17, 2019, and was made aware that the police were in the building and I began texting the administrator about 8:10 AM. I did tell the Administrator and the Director of Nursing which staff were involved. That resident was alleging assault by (Staff B, RN) and (Staff C, LPN), he was more concerned that (Staff B, RN) hurt him, but also that (Staff C, LPN) held down his arm and was saying he was refusing medications. I was aware that (Staff C, LPN) was scheduled to work that night and we placed him on the opposite hallway and away from the resident. I cannot say that the staff would not go over to see the resident. I have been trained on abuse, neglect and misappropriation. I am slightly familiar with the abuse and neglect policy and that it states that staff should be suspended pending investigation. I do not have the authority to make those decisions.

Based on resident record review, resident interview, staff interview, and review of the policies and procedures, administration failed to provide guidance and direction to facility staff ensure residents did not suffer from physical and verbal abuse. Administration failed to ensure structures and processes were in place to provide needed care and services to 2 of 4 residents reviewed out of 43 total sampled residents. Administration failed to properly identify and provide protection from verbal abuse for Resident #75 by not suspending the alleged perpetrator and failed to protect a resident alleging staff physically abused him causing injury and ongoing emotional distress for Resident #78 represented a system wide failure. This failure resulted in findings of Immediate Jeopardy starting on 10/1/19. The Immediate Jeopardy was determined to be removed on 11/21/19, during the survey. (Resident #s 75 and 78) Findings: 1. A review of the Policies and Procedures titled Subject: Abuse, Neglect, Exploitation & Misappropriation, Document Name N1-1265, revision date 11/28/17, read verbal abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of ages, ability to comprehend or disability. The policy also read, Mental and Verbal Abuse include, but are not limited to: yelling or hovering over a resident, with the intent of intimidate. On page 6 the policy read, Identification: All reported events will be investigated by the Director of Clinical Services. This information will be forwarded to the Executive Director, who will serve as the facility's abuse coordinator. Page 7 of the policy read, Protection. Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. Reporting/Response. Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. An interview was conducted with the Executive Director on 11/19/19 at 1:15 PM. She stated there was no investigation or reporting of abuse for the allegation of the dietary staff member yelling at Resident #75 because it was identified as a grievance not abuse. An interview was conducted with the Dietary Manager on 11/19/19 at 2:39 PM. She stated she completed the grievance dated 10/1/19. She stated she separated Staff F from the dining room Resident #75 was in and moved Staff F to the long-term care dining room. She stated in the evening, she assigned Staff F to the kitchen and had another dietary aide in the dining room taking food orders. She stated that verbal abuse would be if someone yelled at someone else. She stated should have taken it right to the abuse coordinator instead of writing the incident up as a grievance. An interview was conducted with Staff F, Dietary Aide on 11/19/19 at 2:45 PM. She stated the next day (10/2/19) she was told that she yelled at Resident #75 in the dining room. She stated she did not yell at her although her voice is loud and carries. She stated she was removed from the rehab dining room and moved to the long-term care dining room so she would not be working with Resident #75. She stated her assignment was in the long-term dining room until Resident #75 was discharged . An interview was conducted with the Executive Director on 11/20/19 at 9:45 AM. She stated the incident with Resident #75 stating the dietary staff member yelled at her was interpreted as a grievance because the staff member talks loudly. 2. During an interview with Resident #78 on (MONTH) 18, 2019, at 11:08 AM he stated, I was attacked by (Staff B Registered Nurse (RN)). She told them that I was resistant to taking my medicine. I felt so helpless, I've never felt so helpless in my whole life, I was truly afraid that she would come back. Over the weekend the nurse told me that I needed to take my medicine. She said I wasn't being cooperative and grabbed my right wrist causing a scratch and forced the medicine cup to my mouth. First, (Staff C, Licensed Practical Nurse (LPN)) brought medication in, I told him I needed to go to the bathroom, they put me on the bedpan and when I was done I told them I needed to get pulled up in bed, he said you are refusing medicines, I told him No I'm not, I just need to get higher in bed so I can swallow. (Staff C, LPN) adamantly raised his voice at me and walked out stating you are refusing your medicines. (Staff C, LPN) brought back (Staff B RN), when she came in, (Staff B RN), said you are just being stubborn, and you are refusing your medicines. One was on each side of me and she (Staff B) grabbed my left-hand forcefully and tried to pull the medicine cup away from me and they spilled all over. That's when she grabbed my right arm. Then they ripped off my brief looking for all the medicines and tossed me around the bed to find them all. I called the police and reported it to the police. She left scratches on my finger and my wrist and they hurt. They did do x-rays of my hands. The resident was tearful throughout the interview. During an interview with Resident #78 on (MONTH) 19, 2019 at 2:00 PM, he stated, I asked to see the psychiatrist because I just can't stop being angry and anxious. I saw him and I'm going to have my medications increased for my anxiety and start some new pill tomorrow to help me cope with this. I am still so afraid to get hurt by them again. I'm just glad that I will be getting discharged tomorrow, then I won't have to see them ever again. You know that because of this they got the doctor to order my medicines get crushed up and put in pudding, what am I a kid? They just don't believe me that I wasn't refusing to take my medicine. I had a tube in my stomach because I was putting food in my lungs causing pneumonia, I just wanted to get pulled up to take my medicine. I didn't have any problems with (Staff B RN) before this, she used to help me out. I haven't seen (Staff B RN) since then, but that guy nurse was in the night this happened, I saw him in the hallway and thought he was going to take care of me, but he didn't. I was scared that he would come in in the middle of the night. It's just not right to be treated that way. I am still so upset. The resident was tearful and anxious with periods of crying during this interview. During an interview on (MONTH) 20, 2019 at 8:15 AM with Resident #78, he stated I'm leaving today just as soon as I can. It will be good to get out of here. I know that the staff thought I was a big pain in the ass and maybe I was sometimes, but nobody should get treated like that. Nobody should be mocked and denied things. All I wanted was for someone to pull me up in bed. They all think I can do it myself, they don't understand what it's like not to be able to breathe right or have a tube in your belly and not be able to eat. They all think I'm a faker. I'm not, I'm just old and getting weak. I would call the nurses' station because they don't want to answer the call light, so I called the main line that rang to the nurse's station. I complained a lot so now they just don't believe me. I saw the male nurse that night in my hallway and I was scared he was going to come back in here. He didn't, but how could they let him come into the hospital what if I couldn't talk. During the interview, the resident remained weepy and intermittently crying as he spoke. An observation of Resident #78 was conducted on (MONTH) 18, 2019, at 11:30 AM with Staff G, Registered Nurse (RN). The Resident had a dressing on his left index finger and his right inner wrist area. An observation of these areas was completed with the Staff G, RN. She removed the wrist bandage, there was a reddened open area approximately 1 cm in length and a less than 0.2 cm in width that contained no visible drainage on the old dressing. The right index finger has an approximately 0.5 cm area reddened open area extending down from the nail bed on the inner aspect of the right index finger. Staff cleansed the wounds with normal saline and reapplied the dressings. A record review on (MONTH) 18, 2019, of Resident #78's care plan indicated that Resident #78 has activities of daily living self-care deficits related to shortness of breath, weakness, and decreased mobility. Potential to be verbally aggressive to staff related to poor impulse control and manipulative behaviors. Resident uses antianxiety medication related to anxiety disorder and uses antidepressant medications related to depression, Resident has chronic pain related to wounds. A record review on (MONTH) 18, 2019, of Resident #78 weekly skin assessment dated (MONTH) 11, 2019, at 10:17 PM authored by Staff C, LPN read, Abdomen G tube removal site, no signs of infection at this time, Right lower leg right dry flaky skin, left lower leg front- dry flaky skin, Sacrum Blanchable. Weekly skin assessment dated (MONTH) 17, 2019 at 09:00 AM authored by Staff B read, abdomen small pink open area circular peg tube removal site, Coccyx pink shearing, Right hand (Back) right wrist small abrasion, Left hand back small abrasion left index finger. A record review on (MONTH) 18, 2019, of a nursing progress note, dated (MONTH) 17, 2019, authored by Staff B Registered Nurse read, Resident called facility to request pain medication with AM medications. Assisted to pull narcotics from Emergency Drug Kit (EDK) with Staff C, LPN at 05:10 AM. Witnessed nurse attempt to give resident medication. Resident refused to take after requesting them, stating he needed to get on a bedpan and could not take until he was done, Resident placed on the bedpan. Nurse returned once again, and resident refused, needing bedpan again. This continued till 06:40. After resident was removed once again from bedpan, he was offered his medication. Resident once again refused now stating he needed to be repositioned and pulled up in bed, however he had laid his head down and his feet up in the air Resident was asked to raise the head of his bed which he refused Resident called facility and was informed that after shift change, he would be repositioned. Once again, he was offered medication before shift change. Medication had now been offered several times and held for almost 2 hours to accommodate resident's requests and refusals. Resident stated he would take the medications and was offered the med cup. At this point he grabbed them in his hand and put them under the covers to his brief stating ha-ha, I'm not taking them, I'll wait until the CNA is done moving me. Resident was asked several times to either take medications or give them back due to narcotics being given. Resident refused. Medication was retrieved from resident and wasted without incident. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 17, 2019 authored by Staff D at 8:25 AM, read, Resident informed this nurse that he had been injured and was calling authorities, res alert and oriented x 3, answering questions appropriately to name, date and time. RN weekend supervisor made aware of resident complaint and present during head to toe assessment of resident, Resident asked that areas to bilateral arms, hands and wrists be closely assessed. Resident complained of pain to left ring finger, no redness or [MEDICAL CONDITION] apparent and active range of motion. Small abrasion to left index finger with small amount scant serosanguinous drainage on finger, small abrasion to right wrist area with small amount drainage also on sheet. Areas cleansed with saline. Medical Doctor (MD) notified mobile imaging called stat for x-rays bilateral hands, wrist. Record review on (MONTH) 18, 2019, of nursing progress note dated (MONTH) 18, 2019, at 12:02 PM authored by Staff G Registered Nurse Unit manager read, Resident requested to speak with in house psychologist declaring that he was traumatized related to a prior event that occurred. Contacted to make him aware. The psychologist will be in tomorrow morning to talk with resident. Resident aware. Record review on (MONTH) 20, 2019, of nursing progress note dated (MONTH) 19, 2019 at 12:08 AM authored by Staff G, RN, Unit manager read, In house psychiatrist in on rounds, Resident noted with ongoing agitation and anxiety. Resident requested increase in anxiety medication. New orders received to increase [MEDICATION NAME] to 30 mg BID (twice a day) and add Trazadone 25 mg in am. Orders noted. Will continue to be followed by psychiatrist monthly and as needed. Record review on (MONTH) 20, 2019, of the psychiatric progress note authored by Staff H behavioral health, dated November19, 2019, treatment time from 11:55 AM stop time 12:20 PM read, treatment plan: [REDACTED]. Subjective: Today the patient addressed: Coping skills, adjustment to facility, relationship skills with peers/staff, Coping with stress/anxiety, Coping with mood, and other allegation of staff abuse. Summary and progress toward goals: Patient demonstrated adequate cognitive capacity for meaningful participation in therapy as evidenced by alert and oriented times 4 presentation with logical coherent and organized thought processes and speech. Mental status was highlighted by anxiety per self-report and clinical observation. Patient reported an allegation of staff abuse two days ago during medication distribution which reportedly resulted in allegations of staff assault. Patient reported a struggle in which two nurses attempted to remove a medication cup from the Patient's left hand which resulted in a skin tear which required bandage. Intervention was to invite patient to vent and process the sequential mechanics of the incident and how same impacted him emotionally. Patient response indicated that he felt anxious as a whole, fearful of the two alleged staff member perpetrators, with reports of [MEDICAL CONDITION], diminished appetite, recurrent thoughts about the incident and nightmares the past two nights. Patient was alert and oriented with logical thought processes during the interview. Patient was tearful briefly two times during the assessment process. Patient acknowledged that a statement had been made and a police report has been taken by local law enforcement. Patient also acknowledged having processed this incident with the nursing home administrator, Director of Nursing, and the Unit Manger. Although patient reported and demonstrated symptoms of emotional distress, patient does not meet the criteria for additional [DIAGNOSES REDACTED]. During an interview with the Executive Director on (MONTH) 19, 2019 at 2:30 PM, she stated, I just got this allegation on Sunday, I am still investigating this. Both nurses have been placed on administrative leave pending our full investigation. I have spoken to one of the nurses and am waiting to speak to the other. The resident saw the psychiatrist today and he increased his anxiety medications. We are in the process of training all staff regarding abuse and are providing education to nursing staff that in cases like this they should have another nurse stay with the resident and notify the physician. When I spoke to (Staff B), she was concerned that there was a narcotic that the resident had and concerned that she could not leave the narcotic with the resident for his safety. During an interview with the Executive Director on (MONTH) 20, 2019, at 11:00 AM she stated I was aware of the allegation and that the resident had called the police. I was not called, we exchanged text messages and I was only aware that Resident #78 had called the police again. The Nursing Supervisor did not tell me that anyone else was involved. I did not ask any further or follow up questions to the nursing supervisor. When I saw the statements on Monday morning, I told the Director of Nursing to suspend Staff B, RN, this occurred on Monday morning. I waited until Monday morning because I knew that Staff B, RN was not working on Sunday night, so I knew that I had time. I was not aware that anyone else was involved and did not ask the Nursing Supervisor to do any further investigation on Sunday. I should have instructed them to suspend everyone involved in the allegation including Staff C, LPN, but I was not aware that he was involved. I would have done that had I known. During an interview with the Director of Nursing on (MONTH) 20, 2019, at 11:20 AM she stated, Staff C, LPN did work on (MONTH) 17, 2019, at 7:00 PM and was not suspended that day. He was placed on the opposite end of the hallway and was not responsible for the care of Resident #78. I was aware of the fact that (Resident #78) had called police and that the Executive Director had been informed. I have not had any problems with either employee related to abuse allegations. Our policy does indicate that all involved personnel be placed on leave pending the investigation. During a telephone Interview with Staff D on (MONTH) 20, 2019, at 11:44 AM she stated, The resident request me to come to room when pushing my cart. He was on the phone with police stating he was assaulted by (Staff B) and the police were on the way. He said the nurses that just left, the male and (Staff B) did it. I left to find the weekend supervisor and that is when the police officer came and I got (Staff E, RN), who came to room with the officer. After the police left, I went in, he wrote it all out on a note pad and he showed me the note pad. He had abrasions on his one hand and wrist area, he was worried his hand was broken and painful. The Nursing Supervisor and I did a head to toe assessment to check for other injuries and we asked a Certified Nursing Assistant to get vital signs and did a full skin sweep. Then I notified the Medical Doctor of his complaints of left-hand pain. I and the Nursing Supervisor assessed there was no [MEDICAL CONDITION] or lack of range of motion and I treated these abrasions. The doctor ordered a stat mobile imaging of both hands and they were here within two (2) hours to complete the x-ray. The officer came back and generated a police report. The resident was very tearful and scared which is very different from his normal behaviors. He can be mean, aggressive and demanding, but he is not usually tearful or anxious, this is very different from his normal. He told me that he requested to get pulled up by the nurse. He said they insisted I take them, I wouldn't take them, they wrestled them away, (Staff B) grabbed his arm, held his other arm down and then (Staff C) held down his other arm. He can be resistant to care. I took care of him that day and on the day after the event. On Monday, the resident called me into his room and said that he was afraid, I think I need to talk to the psychologist, can you get in touch with him, I'm feeling traumatized. During an interview on (MONTH) 20, 2019, at 1:12 PM with Staff E, Registered Nurse, she stated, I was the weekend supervisor on the (MONTH) 17, 2019, and was made aware that the police were in the building and I began texting the administrator about 8:10 AM. I did tell the Administrator and the Director of Nursing which staff were involved. That resident was alleging assault by (Staff B, RN) and (Staff C, LPN), he was more concerned that (Staff B, RN) hurt him, but also that (Staff C, LPN) held down his arm and was saying he was refusing medications. I was aware that (Staff C, LPN) was scheduled to work that night and we placed him on the opposite hallway and away from the resident. I cannot say that the staff would not go over to see the resident. I have been trained on abuse, neglect and misappropriation. I am slightly familiar with the abuse and neglect policy and that it states that staff should be suspended pending investigation. I do not have the authority to make those decisions.