Every finding on record at Bear Creek Nursing and Rehabilitation

Based on observation, interviews, and record review, the facility failed to provide an environment that remained as free of accident hazards as possible for 1 of 3 (100/200 hall) nurse's cart sharps container that was observed full with syringes overflowing. The facility failed to ensure nursing staff replaced the full sharps container on the100/200 hall nurses' cart with a new one at 09:21AM on 7/28/26[KA4.1].This failure could place residents at risk of harm or injury and contribute to avoidable accidents and spread of infection. The findings included:Observation on 07/28/26 at 9:21AM revealed nurses' cart for halls 100/200 sharp container was observed full and overflowing with sharps. Observation revealed insulin syringes were near spilling on the floor.No resident was observed in the area.Interview on 07/28/25 at 9:35 AM with RN D revealed she was the charge nurse for 100/200 hall. She said she was responsible for checking and changing the sharps container when she arrived on shift. She said was aware the sharps container was full on 7/27/26 and on 7/28/26 when she reported for duty and she was to replace the filled sharps container with an empty one, but she got busy and forgot. She said the risk of leaving the sharps container full and overflowing was sharps would spill over and could cause hazards like needle sticks. She said this could cause the spread of infection. Interview on 07/28/26 at 4:50 PM with the DON revealed her expectation was all nurses to be checking on sharp containers every shift and replaced them when they were half full. She said they should not wait until they were full. She said the sharps containers have a line marked where nurses should ensure sharps did not pass. She said all nurses were responsible for replacing the sharps container when they were half full. She said she was responsible for checking behind the nurses performing spot checks to ensure sharps containers were replaced when half full, but she could not recall when she last checked the sharps containers. The DON stated failing to change the full sharps container could risk accidental needle sticks which could lead to the spread of infection.Record review of facility policy titled, Regulated (Biohazard) Medical Waste, undated, revealed the following: 11. Sharps containers must be maintained upright throughout use and replaced routinely. Do not overfill the container.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control.The facility failed to ensure:- there was a sign outside of Resident #1's room indicating that the resident was on enhanced barrier precautions, which was due to the resident having an open chronic ulcer (non-pressure related) on his right heel;- LVN A, who was the Wound Care Nurse, performed hand hygiene prior to putting on gloves and between glove changes; and- LVN A wore as gown as required due to the resident being on enhanced barrier precautions; This failure could place residents at risk of cross-contamination and infection.Findings included:Record review of Resident #1's comprehensive assessment MDS, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. His diagnoses included non-pressure chronic ulcer of right heel and midfoot with unspecified severity (result from poor blood circulation, often caused by conditions like diabetes or vascular disease). Resident #1 had a BIMS score of 15 which indicated his cognition was intact. The MDS reflected that the resident had diabetic foot ulcer(s) (an open sore caused by nerve damage, poor blood flow, or high blood sugar). The MDS further reflected Resident #1 had treatment for application of dressings to feet (with or without topical medications). The MDS further reflected Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's care plan, dated 07/14/26, reflected the resident had impaired skin integrity rule out diabetic foot ulcer (right heel). Goal: - Skin will heal without sign and symptoms of infections as evidenced by a decrease in size and depth through next review date. No date. Interventions included treatments and dressing changes as ordered by physician [SIC]. Record review of Resident #1's physicians order summary report, dated 07/24/26, reflected the following: Right heel Cleanse Wound with Dakins 0.125%, apply lightly moistened Dakins 0.125%(percentage) sterile gauze to wound bed, cover with abdominal pad, secure with tape daily and as needed in the morning. No order on enhanced barrier Observation on 07/28/26 at 10:58 AM revealed LVN A, who was the Wound Care Nurse, providing Resident #1 with wound care, revealed there was no signage on the door for enhanced barrier and no PPE by the door. Observation indicated LVN A disinfected the table and left it to dry. She removed gloves, sanitized hands, and put the supplies together. She wheeled the table to Resident #1's bedside. She then put on gloves without washing hands and she failed to wear a gown. She removed the old dressing on Resident #1's right heel. She changed gloves and did not perform hand hygiene. She cleansed the wound with gauze soaked with Dakin's solution, removed her gloves, did not wash hands, put on new gloves, and applied lightly moistened Dakins 0.125% sterile gauze to wound bed, covered with abdominal pad and tape, dated 7/28/26. Interview with LVN A on 07/28/26 at 11:37 AM revealed she was supposed to remove the old dressing, remove gloves and wash hands. She said she knew she was supposed to wash hands before contact, during care and with each change of gloves and if the gloves were contaminated, but she forgot. She said she did not wear a gown because she was not aware she was supposed, and there was no indication, no signage for enhanced barrier precautions and no PPE at the door. She said she had not been wearing gowns while performing wound care on Resident #1. She said she was instructed by the DON to wear PPE only on chronic wounds, but she could not tell whether Residnet#1's wound was chronic. She said the DON was the one that decided which resident needed PPE, and she did not know what was included in the facility policy. She stated failure to wear gowns and perform hand hygiene with change of gloves would cause cross contamination and spread of infection. She stated she was trained on infection control and handwashing.Interview on 07/28/26 at 5:50 PM with the DON revealed her expectation was that those residents with chronic wounds should have enhanced barrier precautions signage and have PPE outside the resident's door. She said they had not put PPE because they discussed it during morning meetings, and Resident #1 was not one of the residents on PPE, but she could not state why. She said for residents with chronic wounds, staff were required to wear gowns and gloves when having direct contact with the residents and while providing wound care. She could not tell whether Residnet#1 wound was chronic or not although the diagnosis stated non-pressure chronic ulcer of right heel. The DON stated that EBP protects residents from exposure to infectious agents. She said her expectation was for the staff to wash hands before contact, between care and when they removed or changed gloves. She stated failure to perform hand hygiene risk contamination and spread of infection. She said she trained staff on EBP and handwashing. EBP training requested, but no record was provided by the time we exited. Employee files were not reviewed for training offered by the facility. Record review of the facility's Enhanced Barrier Precautions policy, dated 4/10/2025, reflected: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gowns and gloves use during high contact residents care activities. 2 b. An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis and or indwelling medical devices.4 h. Wound care: any skin opening requiring dressing Record review of the facility's Hand Hygiene policy, undated, reflected: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.6.Additional considerations:The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #2) of 4 residents reviewed for pharmacy services.The facility failed to ensure Resident #2 was not given an antibiotic that was identified as an allergy when he was administered doxycycline on 07/13/25. This failure could place the residents at risk of harm and/or serious injury.Findings included:Review of Resident #2's quarterly MDS assessment dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included high blood pressure (condition where blood pushes too hard against the artery walls), end stage renal disease (permanent kidney failure), obstructive uropathy (blockage in the urinary tract that stops urine from flowing normally), non-Alzheimer's dementia, and cognitive communication deficit (breakdown in communication caused by impaired mental processes). The resident had a BIMS score of 6 which indicated his cognition was severely impaired. Review of Resident #2's face sheet, dated 07/28/26 reflected the resident had the following allergies: Fexofenadine, Tetracycline (doxycycline and tetracycline belong to the same family of antibiotics), and Sulfa Antibiotics.Review of Resident #2's progress notes, dated 07/12/26 documented by LVN C reflected the following, Resident noted with productive cough, lung sounds are diminished, temp elevated, on call NP notified, received the following orders.Doxycycline.Review of Resident #2's progress notes dated 07/12/26 documented by LVN C further reflected the following: Reason for alert charting: The system has identified a possible drug allergy for the following order: Doxycycline Hyclate Tablet 100 mg Give 1 tablet by mouth two times a day for URI for 7 days.Review of Resident #2's Order Audit Report dated 07/12/26 created by LVN C, reflected the following: Doxycycline Hyclate Tablet 100mg Give 1 tablet by mouth two times a day for URI for 7 days Review of Resident #2's MAR for July 2026 reflected he was administered doxycycline on 07/12/26 at 5:00 PM by MA D.Observation on 07/28/26 at 10:44 AM of Resident #2 revealed he was in his room, sitting in the wheelchair who was accompanied by a private sitter. Resident #2 did not respond when he was spoken to but only smiled and made some hand gestures. The resident did not appear to be in any distress at the time of the observation and per the private sitter, Resident #2 was at his baseline. The Private Sitter said sat with the resident most days and she had not noticed the resident have any type of change in condition the past weeks. Interview on 07/28/26 at 2:22 PM with RN E revealed she worked on 07/13/26 and noticed the drug allergy in Resident #2's clinical record. RN E said she did not administer the doxycycline but had called the doctor to notify him of the possible allergy and it was changed to a different antibiotic. RN E said she did not notice Resident #2 have any negative side effects from taking doxycycline and had remained at his baseline. Interview on 07/28/26 at 2:41 PM with MA D revealed Resident #2 had been on so many different antibiotics in the past and did not recall the time she gave Resident #2 doxycycline or any of the details around the time she gave it. Attempts to contact LVN C on 07/28/26 at 3:17 PM were unsuccessful. Interview on 07/28/26 at 3:56 PM with the NP revealed he was called and made aware Resident #2 was given doxycycline and of the possible drug allergy. He said he was not the provider that prescribed it, but he changed the order to a different antibiotic. The NP said he saw Resident #2 the following day (07/14/26) and did not notice any negative reactions from taking doxycycline. The NP further stated risk of an allergy to the medication could vary depending on the type of allergy the resident had to tetracycline in the past. Interview on 07/28/26 at 4:18 PM with the ADON revealed she was not aware Resident #2 was given doxycycline after the computer system gave a possible drug allergy alert. The ADON said the facility had an after-hours call system, they used if a resident experienced any type of change in health. The ADON said she believed that might have been who prescribed the doxycycline for Resident #2 so if the nurse used the on-call system, they should have given the on-call NP Resident #2's allergies so they would have known what to prescribe. The ADON further stated risk of a resident being given a medication with a drug allergy included a rash to something severe like anaphylactic shock (a severe life-threatening allergic reaction causing a sudden drop in blood pressure and narrowed airways). Interview on 07/28/26 at 4:47 PM with the DON revealed she was not aware Resident #2 was given doxycycline despite the possible allergy and did not know the details around the time it was ordered. The DON said a resident could experience different negative signs/symptoms if they were given a medication, they were allergic to. Review of the facility's policy titled Medication Errors revised 05/2025 reflected the following: PolicyIt is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Significant medication error means on which causes the resident discomfort or jeopardizes his/her health and safety.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Residents (Resident #1, Resident #2 and Resident #3) observed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinent care on Resident #1, Resident #2, and Resident #3 on 06/27/26. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record Review of Resident #1's Quarterly MDS assessment, dated 03/29/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was frequently incontinent of urine and always incontinent of bowels. Diagnoses included Alzheimer's disease (progressive brain disorder) and diabetes (metabolic disorder). During an observation with Resident #1 on 06/27/2026 at 01:15 p.m. CNA A pushed Resident #1 from the dining room to her room while CNA B retrieved the mechanical lift. Both staff entered the room washed their hands and put on gloves. Both staff positioned the mechanical lift and attached it to the sling and lifted Resident #1 from her wheelchair onto the bed. CNA A unfastened Resident #1's brief revealing it to be saturated in urine. A strong smell of urine was noted. CNA A wiped down both groins and then down the middle towards the resident's buttocks. Both staff assisted the resident onto her side, removed the soiled brief and wiped the resident's buttocks area from front to back. CNA A then placed the clean brief and a clean bed pad under the resident, changed her gloves but did not perform hand hygiene and both staff rolled the resident back onto her back, fastened the brief and repositioned the resident. Both staff then removed their gloves and washed their hands. 2. Record Review of Resident #2's Quarterly MDS assessment, dated 04/21/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was always incontinent of urine and bowels. Diagnoses included Alzheimer's disease and heart failure. During an observation on 06/27/2026 at 1:30 p.m. CNA A and CNA B entered Resident #2's room to transfer her to bed and provide incontinent care. Both staff washed their hands and put on gloves. Both staff positioned the wheelchair next to the bed with the resident facing toward the head of the bed and transferred the resident to the bed. Both staff removed the resident's wet pants and CNA A unfastened the saturated brief and wiped down each groin and then down the middle. Both staff rolled the resident onto her side, revealing the resident was having a small bowel movement. CNA A wiped from front to back and removed the soiled brief. CNA A then removed her gloves and put on clean gloves without performing hand hygiene and placed a clean brief under the resident, and with the assistance of CNA B rolled the resident back onto her back and fastened the brief. Both staff then removed their gloves and washed their hands. 3. Record Review of Resident #3's Quarterly MDS assessment, dated 05/29/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 3 which indicated she was severely cognitively impaired. She required substantial to maximum assistance with transfers, toileting, and personal hygiene. She was always incontinent of urine and bowels. She had sustained two falls without injury since the prior assessment. Diagnoses included dementia (decline in cognitive function) and diabetes. During an observation on 06/27/2026 at 1:45 p.m. CNA A pushed Resident #3 from the dining room to her room to transfer her to bed and perform incontinent care. CNA B entered Resident #3's room to assist with the transfer. Both staff washed their hands and put on gloves. Both staff positioned the wheelchair next to the bed with the resident facing toward the head of the bed and transferred the resident to the bed. CNA A unfastened the resident's brief and wiped down each groin and then down the middle. Both staff assisted the resident onto her right side and CNA A wiped from front to back. CNA A changed her gloves but did not perform hand hygiene and placed a clean brief under the resident. Both staff assisted the resident onto her back, fastened the brief and lowered the bed. Both staff then removed their gloves and washed their hands. During an interview with CNA A on 06/27/26 at 2:00 p.m. she stated she was supposed to do hand hygiene before and after incontinent care but then stated she should have done it after she finished cleaning the resident and changed her gloves. She stated the risk of not doing hand hygiene when going from dirty to clean was the spread of germs and infection. During an interview with the DON on 06/27/26 at 02:50 p.m. she stated staff were to change their gloves and perform hand hygiene before going from dirty to clean, before entering a resident's room and before leaving a resident's room. She stated they train and do in-services constantly on infection control. She stated she would be doing skills checks and re-education with the staff on overall infection control. Record review of the facility's undated policy titled, Hand Washing, reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents and visitors.The use of gloves does not replaced hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #2 and Resident #3) reviewed for accident hazards/supervision/devices 1. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #2 from her wheelchair to the bed and instead lifted the resident under her arms and by her pants on 06/27/26. 2. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #3 from her wheelchair to the bed and instead lifted the resident under her arms on 06/27/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: 1. Record Review of Resident #2's Quarterly MDS assessment, dated 04/21/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was always incontinent of urine and bowels. Diagnoses included Alzheimer's disease (progressive brain disorder) and heart failure. Review of Resident #2's care plan initiated on 08/07/22 reflected, [Resident #2] has an ADL Self Care performance deficit related to dementia, impaired balance, limited mobility.Interventions.Transfer: Extensive assistance of one staff. During an observation and interview attempt on 06/27/26 at 10:25 a.m. Resident #2 was observed sitting in her wheelchair in the dining room. Resident #2 was anxious and repeating words over and over. The Staffing Coordinator stated she spoke Spanish only but stated the Housekeeping Supervisor could interpret. The Housekeeping Supervisor asked resident what she needed and stated she kept repeating her husband's name but was not saying anything else. She stated this was her typical behavior. During an observation on 06/27/2026 at 1:30 p.m. CNA A and CNA B entered Resident #2's room to transfer her to bed. Both staff positioned the wheelchair next to the bed with the resident facing toward the head of the bed. Both staff then placed one arm under the resident's arm pit, and the other hand grabbed the back of her pants and lift the resident from the chair onto the bed. Resident was not bearing her full weight on her legs. No gait belt was used during the transfer. A gait belt was observed hanging on the door in the resident's room. 2. Record Review of Resident #3's Quarterly MDS assessment, dated 05/29/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 3 which indicated she was severely cognitively impaired. She required substantial to maximum assistance with transfers, toileting, and personal hygiene. She was always incontinent of urine and bowels. She had sustained two falls without injury since the prior assessment. Diagnoses included dementia (decline in cognitive function) and diabetes (metabolic disorder). Review of Resident #3's care plan initiated on 08/19/25 reflected, Impaired Physical functioning related to cognitive impairment, debility/ weakness.Interventions.2 staff for transfer. During an observation with Resident #3 on 06/27/26 at 12:30 p.m. resident was observed sitting in her wheelchair in the dining room. Attempts to interview were unsuccessful. During an observation on 06/27/2026 at 1:45 p.m. CNA A pushed Resident #3 from the dining room to her room to transfer her to bed and perform incontinent care. CNA A stated Resident #3 was a two-person transfer. CNA B entered Resident #3's room to assist with the transfer. Both staff positioned the wheelchair next to the bed with the resident facing toward the head of the bed. Both staff then placed their arm under the resident's arm pits and lifted the resident from the chair onto the bed. Resident was not bearing her full weight on her legs. No gait belt was used during the transfer. During an interview with CNA A and CNA B on 06/27/26/26 at 10:10 a.m. they both stated they were not supposed to lift residents under their arms because it could cause injury to their shoulders. They stated they did not know they were not supposed to grab the back of the residents' pants. They stated they were supposed to use a gait belt but stated they did not see one in the resident's room. They stated they had been trained on gait belt transfers. During an interview with the Director of Rehab on 06/27/26 at 02:15 p.m. she stated the facility was doing gait belt training during orientation but stated she was not sure when the last one was done. She stated they recently placed gait belts in all of the residents' rooms who required gait belt transfers. She stated it was not acceptable to lift someone under their arm pits due to the potential for injury not only to the resident but also to the caregiver. She stated it increased the risk of falls, fractures and nerve damage. During an interview with the DON on 06/27/26 at 03:00 p.m. she stated she would expect staff to use a gait belt when transferring a resident. She stated the risk of staff not following the correct procedure for transfers were injury to a resident's shoulders and arm and or the risk of the resident falling. She stated she would be doing one on one training with the CNA and also begin In-services with all of the staff to ensure staff were providing correct transfer techniques. Record review of the facility's undated policy, Safe Resident Handling/Transfers, reflected, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.Handling aids may include gait belts, transfer boards and other devices.Staff members are expected to maintain compliance with safe handling/transfer practices.Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents (Resident #1 and Resident #2) reviewed for incontinence care. 1. The facility failed to ensure staff provided Resident #1 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:30 a.m. to 1:15 p.m. on 06/27/26. 2. The facility failed to ensure staff provided Resident #2 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:45 a.m. to 1:30 p.m. on 06/27/26. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included:1. Record Review of Resident #1's Quarterly MDS assessment, dated 03/29/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was frequently incontinent of urine and always incontinent of bowels. Diagnoses included Alzheimer's disease (progress brain disorder) and diabetes (metabolic disorder). Record review of Resident #1's care plan initiated 05/15/23 reflected, Risk of Urinary Incontinence Always Incontinent .Interventions.Assist me with peri care very shift and as needed. During an observation on 06/27/26 at 9:07 a.m. Resident #1 was observed sitting up in her wheelchair in the dining room. Resident #1 was leaned over the arm of the wheelchair sleeping. During an interview with CNA A on 06/27/26 at 9:35 a.m. she stated Resident #1 was gotten up around 7:30 a.m. before breakfast. She stated they always get her up for her meals because she needed feeding assistance. During an observation on 06/27/26 at 10:25 a.m. Resident #1 was observed still sitting in the dining room sitting up in her wheelchair with eyes closed. Attempts to interview were unsuccessful. During an observation on 06/27/26 at 11:45 a.m. Resident #1 was pushed to her room by LVN C so she could perform her finger stick blood sugar check. LVN C completed the blood sugar monitoring and then returned the resident to the dining room. Resident #1 was not checked to see if she needed incontinence care. During an observation on 06/27/26 at 12:30 p.m. Resident #1 was observed in the dining room being provided with feeding assistance by the Staffing Coordinator. During an observation with Resident #1 on 06/27/2026 at 01:15 p.m. CNA A pushed Resident #1 from the dining room to her room while CNA B retrieved the mechanical lift. Both staff entered the room washed their hand and put on gloves. Both staff positioned the mechanical lift and attached it to the sling and lifted Resident #1 from her wheelchair onto the bed. CNA A the unfastened Resident #1's brief revealing it to be saturated in urine. A strong smell of urine was noted. CNA A wiped from front to back and then down the middle. Both staff assisted the resident onto her side, removed the soiled brief and wiped the resident's buttocks area from front to back. There was no skin breakdown noted but there was some slight redness and indentions from the brief. CNA A then placed the clean brief and a clean bed pad under the resident and both staff rolled the resident back onto her back, fastened the brief and repositioned the resident. 2. Record Review of Resident #2's Quarterly MDS assessment, dated 04/21/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was always incontinent of urine and bowels. Diagnoses included Alzheimer's disease and heart failure. Review of Resident #2's care plan revised on 08/07/22 reflected, [Resident #2] is at risk of Urinary incontinence.has functional bladder incontinence related to confusion, impaired mobility, loss of peritoneal tone.Interventions. ACTIVITIES: notify nursing if incontinent during activities.Assist me with peri care (cleansing of the genital and anal area) every shift and as needed. During an observation on 06/27/26 at 9:07 a.m. Resident #2 was observed sitting up in her wheelchair in the dining room. Her empty breakfast tray was sitting in front of her. During an interview with CNA A on 06/27/26 at 9:35 a.m. she stated Resident #2 was gotten up around 7:45 a.m. before breakfast. She stated they always get her up for her meals. During an observation and interview attempt on 06/27/26 at 10:25 a.m. Resident #2 was observed sitting in her wheelchair in the dining room. Resident #2 was anxious and repeating words over and over. The Staffing Coordinator stated she spoke Spanish only but stated the Housekeeping Supervisor could interpret. The Housekeeping Supervisor asked resident what she needed and stated she kept repeating her husband's name but was not saying anything else. She stated this was her typical behavior. Resident #1 was observed with food particles in her lap and a spilled liquid on her pants. During observation on 06/27/26 at 11:00 a.m. Resident #2 was observed still sitting in her wheelchair in the dining room. Clothing had not been changed and was observed to still have food particles on her pants. During an observation on 06/27/26 at 12:30 p.m. Resident #2 was observed in the dining room being assisted with meal by a family friend. During an observation on 06/27/26 at 1:10 p.m. CNA D was observed removing Resident #2 from the dining room and taking her to her room. CNA D stated CNA A would be in later to put her to bed. During an observation on 06/27/2026 at 1:30 p.m. CNA A and CNA B entered Resident #2's room to transfer her to bed and provide incontinent care. Both staff washed their hands and put on gloves. Both staff positioned the wheelchair next to the bed with the resident facing toward the head of the bed. Both staff then placed one arm under the resident's arm pit, and the other hand grabbed the back of her pants and lifted the resident from the chair onto the bed. The resident's pants were soaked from her waist down to her knees. CNA A stated Resident #2 was a heavy wetter, and she drank a lot of fluid. Both staff removed the resident's pants and CNA A unfastened the saturated brief and wiped down each groin and then down the middle. Both staff rolled the resident onto her side, revealing the resident was having a small bowel movement. CNA A wiped from front to back and removed the soiled brief. She placed a clean brief under the resident, and with the assistance of CNA B rolled the resident back onto her back and fastened the brief. During an interview with CNA A and CNA B on 06/27/26 at 2:00 p.m. they both stated they had only checked and changed Resident's #1 and Resident #2 once this shift. CNA A stated the hall the two residents were on was a very heavy hall and had several residents who were a two-person transfer. CNA A stated between the showers they had to give and waiting for the other CNA to be able to help they did not get the residents checked like they should. She stated the medication aides, nor the nurses were able to help. She stated they did the best they could do. They both stated they knew residents who were incontinent needed to be checked and changed every 2 hours. They stated the risk of not changing them timely was urinary infections and skin irritation. During an interview with the DON on 06/27/26 at 02:50 p.m. she stated any resident who was incontinent of bowel and bladder needed to be checked for incontinence every 2 hours and changed as needed. She stated by not providing timely incontinent care placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated they were going to have to increase their monitoring to ensure residents were getting changed timely. She stated she had already started servicing the staff on the expectation. Record review of the facility's policy titled, Perineal Care, revised May 2025, reflected, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.

Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #85) reviewed for dialysis. 1. The facility failed to ensure dialysis communication forms were completed for Resident #85 after returning from dialysis treatment. 2. The facility failed to ensure Resident #85 had an order to complete dialysis treatment. These failures could place residents at risk of inadequate monitoring after returning to facility. Findings included: Review of Resident #85's None of the Above MDS Assessment, dated 04/26/26, reflected she was a [AGE] year-old who was admitted to the facility on [DATE]. Her MDS indicated she had a BIMS of 06, which meant she had severe cognitive impairment. Her active diagnoses included renal insufficiency, renal failure, or end-stage renal disease (the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) and diabetes mellitus (a chronic condition that occurs when the body cannot properly use blood sugar). Her MDS indicated she received hemodialysis and dialysis services. Review of Resident #85's order summary report, dated 05/05/26, did not reflect any orders for dialysis services. Review of Resident #85's care plan, revised 04/28/26, reflected the following: Focus: [Resident #85] has Potential for complications r/t Renal Failure with dialysis. Review of Resident #85's Progress Notes reflected the following:RN H wrote on 04/25/26 at 7:23 PM Resident admitted to the facility from [the hospital].According to Hospital report, Resident was admitted to hospital due to acute encephalopathy, hx of hepatic and renal; dysfunction. Dialysis Tu/Th & Sa at 1130. Permacath Right chest- dressing CDI- no s/s of infection. Review of Resident #85's Dialysis Pre & Post Assessment, dated 04/30/26, reflected only the Dialysis Pre-Evaluation was filled out; there was no information for the sections labeled To be Completed by Dialysis Provider or the Dialysis Post-Evaluation. Review of Resident #85's Dialysis Pre & Post Assessment, dated 05/02/26, reflected only the Pre-Dialysis section was filled out; for the Post-Dialysis section, there were only vitals listed for her blood pressure, pulse, and temperature as the rest of the section was empty/blank. Review of Resident #85's Dialysis Pre & Post Assessment, dated 05/05/26, reflected only the Dialysis Pre-Evaluation was filled out; there was no information for the sections labeled To be Completed by Dialysis Provider or the Dialysis Post-Evaluation. Observation and interview on 05/05/26 at 11:53 AM with Resident #85, she was sitting in her wheelchair in her room eating her lunch tray. Resident #85 said she went to dialysis three days a week. Observation and interview on 05/06/26 at 12:31 PM with Resident #85, she was sitting in her wheelchair in her room. Resident #85 said she did not go to dialysis today and she was not sure when she was supposed to go to dialysis. Interview on 05/06/26 at 1:46 PM with CNA B, she said Resident #85 went to dialysis on Tuesdays, Thursdays, and Saturdays. CNA B said she helped to get Resident #85 ready to go and made sure she had a warm lunch when she came back from dialysis. Observation and interview on 05/06/26 at 1:50 PM with RN A, she said Resident #85 left the facility to go to dialysis on Tuesdays, Thursdays, and Saturdays. RN A said Resident #85 went to dialysis yesterday but was confused and not aware of her days for dialysis services. RN A said she sent Resident #85 with her pre and post dialysis assessment paperwork to be filled out and put in the electronic record. RN A said Resident #85 was supposed to have dialysis orders that included the information for dialysis, the pre and post assessment, and her port site care. RN A looked at Resident #85's orders in her electronic health record and did not see any orders for dialysis. Phone interview on 05/07/26 at 10:16 AM with RN H was unsuccessful as she did not answer or call back prior to exit. A message was left for her to call back. RN H admitted Resident #85 on 04/25/26. Interview on 05/07/26 at 10:30 AM with RN A, she said Resident #85 left to go to dialysis during her shift and she was responsible for filling out the first portion of the pre and post dialysis assessment. RN A said Resident #85 came back from dialysis on the next shift so the next shift's nurse would complete the next portion of the pre and post dialysis assessment. Interview on 05/07/26 at 11:32 AM with the ADON, she said Resident #85 went to dialysis on Tuesdays/Thursdays, and Saturdays. The ADON said the nurse who sends the resident to dialysis during their shift should open up the pre and post assessment in the resident's electronic health record, input the information, and print the document out to be sent with the resident to dialysis. The ADON said when the resident came back from dialysis, the next nurse should input the information from the sheet and any new vitals taken into the resident's electronic health record. The ADON said Resident #85 should have dialysis orders that included the days of dialysis for the resident, the timing of the dialysis, the pick up information, where the resident's port was located, any fluid or dietary restrictions, and the name/address/phone number of the dialysis center. The ADON said this was so that the information was accessible in case someone from the facility needed to call the dialysis center. The ADON said the nurse who admitted Resident #85 should have included the order for dialysis services and after a resident admitted , the ADON would have completed an audit to check and make sure all orders were included. The ADON said anything could happen if the resident did not have dialysis orders such as missing their chair time, could become hospitalized or have a change in condition that was not noticed quickly. The ADON said all nurses were trained and expected to include orders for any care the resident received. The ADON said she noticed that Resident #85's pre and post dialysis assessments were not being completed as expected. The ADON said if staff were not completing the pre and post dialysis assessments then they may not know what the resident's vitals were or what happened at the dialysis center. The ADON said that then can affect other care because the doctor may not have a full understanding of the resident's current condition when adding orders for them. The ADON said the pre and post dialysis assessment was a form of communication between the facility and the dialysis center. The ADON said usually the morning shift would complete the pre part of the assessment and the afternoon shift would complete the post part of the assessment and input the information from the dialysis center. The ADON said the facility recently had staff/personnel changes and had newer staff working so they might not have known to collect that information. The ADON said there was not a monitoring or auditing system in place to make sure the pre and post dialysis assessments were completed by staff. Interview on 05/07/26 at 1:44 PM with the DON, she said she had only been at the facility since 04/22/26. The DON said Resident #85 did not have an order for dialysis. The DON said after reviewing the situation, she could see how the dialysis order would be beneficial because it would make sure there was communication in place for all parties that are involved in that care pathway. The DON said the nurse who admitted the resident should make sure all necessary orders were included, then the next shift would double check all orders were included, then lastly the DON or ADON would check to ensure all orders were included. The DON said ultimately, as the DON everything was her responsibility. The DON said if a resident did not have dialysis orders they could miss their dialysis appointment. The DON said she expected staff to implement all orders into the resident's electronic health record. The DON said the purpose of the pre and post dialysis assessment was to monitor the resident after dialysis to make sure there was not a change in condition from the time they left dialysis to their return to the facility. The DON said a resident on dialysis services was at higher risk of having a change in condition and staff need to ensure they were stable and to monitor them. The DON said the nurse who sent the resident to dialysis and the nurse who received them back from dialysis were responsible for ensuring he pre and post dialysis assessment forms were completed. The DON said the ADON should be auditing the pre and post dialysis assessments to ensure they were being completed. Review of the facility's policy, revised 05/01/25, and titled Hemodialysis reflected: Purpose: Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring, of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices.13. The facility will ensure that the physician's instructions for dialysis include: a. The type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location; b. The dialysis schedule; c. The dialysis facility name and phone number; d. Transportation arrangements to and from the dialysis facility; e. Any medication administration or withholding of specific medications prior to dialysis treatments; f. Any fluid restriction if requested by the physician.

Based on observation, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 4 residents (Resident #76) reviewed for food and nutrition. The facility failed to ensure Resident #76 received his nutritional supplement beverage (magic cup) during the lunch service on 05/06/26. This failure could lead to nutritional deficits and unintended weight loss. Findings include: Review of Resident #76's Quarterly MDS Assessment, dated 04/10/26, reflected he was a [AGE] year-old male who had recently readmitted to the facility on [DATE] after originally admitting on 10/30/25. He had a BIMS of 00 indicating severe cognitive impairment. His active diagnoses included malnutrition, adult failure to thrive, and cognitive communication deficit. His MDS indicated he had recently lost weight. Review of Resident #76's Order Summary Report, dated 05/07/26, reflected an order for Magic Cups two times a day lunch and dinner, with an order start date of 03/23/26. Review of Resident #76's Nutritional Assessment, dated 04/08/26, reflected Supplements.MAGIC CUP W/L&D [sic]. Review of Resident #76's Care Plan, revised 04/07/26, reflected the following: Focus: Unexpected/unintended weigh loss r/t loss of appetite, eating 50% of meals.Interventions: Offer high calorie/nutrient dense supplements as ordered by physician/dietitian.record meal/snack intake in clinical record.Review of Resident #76's Lunch Meal Ticket, dated 05/06/26, revealed it did not include his magic cup.Observation on 05/06/26 at 12:21 PM revealed Resident #76 sitting in the dining room in his wheelchair. Resident #76 had a family member next to him. Resident #76 was waiting for his meal because he did not like what was being served and had requested a grilled cheese sandwich and chips instead. Observation on 05/06/26 at 12:25 PM of Resident #76's lunch tray revealed it included 1 and 1/2 grilled cheese sandwiches, chips, ice cream, and tea. Interview on 05/06/26 at 12:30 PM, Resident #76's Family Member said the resident had previously lost weight because he had some infections recently that caused him to have a decrease in his appetite. Resident #76's Family Member said since the resident was readmitted to the facility he had been eating better but he was supposed to get a milkshake or something like that with his meal and it was missing today. Resident #76's Family Member said she was not sure why it was left off his meal tray today Interview on 05/06/26 at 12:35 PM, [NAME] G said the DM did not show up to the facility today so she was handling the lunch service today. [NAME] G said normally Resident #76 was supposed to get a magic cup with his meal for lunch but he was not served one today. [NAME] G said the magic cup was not listed on his meal ticket for some reason so it was not included on his meal tray. [NAME] G said the kitchen staff and nursing staff look at the meal tickets to make sure that all items were on the tray before it went to the resident. [NAME] G said since the magic cup was not listed on Resident #76's meal ticket for the lunch service today, no one noticed it was missing. [NAME] G said the previous DM was supposed to make sure that all the Dietitian's recommendations were reflected on the meal ticket for residents, including an order for a magic cup. [NAME] G said the magic cup would have only come from the kitchen. Interview on 05/07/26 on the phone at 11:23 AM with the Dietitian, she said the facility was supposed to make sure Resident #76 received his ordered magic cup for lunch and dinner because he recently had problems with his appetite and had lost weight. The Dietitian said the resident's meal ticket was supposed to show any supplements they were to receive for that meal and she was not sure why Resident #76's magic cup was not on his meal ticket yesterday. The Dietitian said the magic cup for Resident #76 would have only come from the kitchen and if it was not on his meal ticket, the nursing department might not have known it was missing just like the kitchen. Interview on 05/07/26 at 11:32 AM with the ADON, she said Resident #76's magic cup came from the kitchen. The ADON said the Dietitian put orders in for nutrition for weight loss and those showed up on the resident's meal tickets so the kitchen staff knew what to include on the resident's tray. The ADON said the kitchen staff were responsible for making sure all items were included on the resident's tray. The ADON said she was not sure why Resident #76's magic cup was not on his meal ticket and therefore, not on his meal tray for yesterday. The ADON said Resident #76 had recently had a decrease in his appetite after having an infection which was why the Dietitian recommended the magic cup for lunch and dinner meals. Interview on 05/07/26 at 12:22 PM with the previous DM, he said he left the facility last Thursday (04/30/26) but was called yesterday (05/06/26) to return today as the DM. The Previous DM said the Dietitian made recommendations and sent them to him to upload in the meal ticket system and then the order would show up on the resident's meal ticket. The Previous DM said he was not sure how or why Resident #76's order for magic cups at lunch and dinner was missed and not uploaded to be included on his meal ticket. The Previous DM said he was responsible for inputting the Dietitian's orders into the system, and would have been at the time the order was placed. The Previous DM said the purpose of ensuring the Dietitian's orders for nutritional supplements were included on the resident's meal tickets was so they could get the proper nutrition. The Previous DM said if the resident did not receive their ordered nutritional supplement, they could have weight loss and be too weak to perform therapy or daily functions. The Previous DM said due to staffing levels, he has not had the opportunity to complete an audit and ensure all nutritional supplements were included on the residents' meal tickets and that they were receiving them as ordered. The Previous DM said the kitchen was responsible for Resident #76 receiving his magic cup on his meal tray for lunch and dinner meals. The Previous DM said he was not here yesterday (05/06/26) and was not sure why Resident #76's meal ticket did not include his order for a magic cup. Interview on 05/07/26 at 1:44 PM with the DON, she said she had only been at the facility since 04/22/26. The DON said the kitchen was responsible for ensuring Resident #76 received his magic cup from the kitchen during the lunch meal yesterday (05/06/26). Review of the facility's undated policy, titled Nutritional and Dietary Supplements, reflected: 2. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 medication carts (Hall 300 nurse cart) reviewed for pharmacy services. The facility failed to ensure that one bottle of OTC Simethicone 125 mg, with an expiration date of February 2026, and Benzonatate 100 mg capsule prescribed to Resident #29, with an expiration date of 03/26/26, had been removed from the 300-hall nurse cart. This failure could place residents at risk of receiving medications that were ineffective. Findings included: Record review of Resident #29's Face Sheet, dated 05/07/26, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #29's Quarterly MDS, dated [DATE], revealed she had the following diagnoses: COPD (progressive lung disease caused by damage to the lungs), Chronic respiratory failure without hypoxia (long-term condition where the lungs cannot efficiently remove carbon dioxide from the blood), and Dementia (decline in brain function that interferes with daily life). The MDS also revealed Resident #29 has a BIMS score of 8, indicating moderate cognitive impairment. Record review of Resident #29's Care Plan, revised 05/05/26, revealed that she had impaired cognitive function related to Dementia with an intervention to administer medications as ordered. The care plan also revealed that Resident #29 was at risk for impaired gas exchange (condition where the lungs cannot adequately transfer oxygen into the blood) related to COPD with an intervention to administer medications as ordered. Record review of Resident #29's order summary, dated 05/07/26, revealed the following with a start date of 04/02/25: Tessalon Perles Capsule 100 mg (Benzonatate) [prescription used to relieve coughs] Give 2 capsules by mouth every 8 hours as needed for cough related to chronic obstructive pulmonary disease Record review of Resident #29's MAR from 03/26/26-05/07/26 revealed that she did not receive any as needed doses of Benzonatate 100 mg. Observation on 05/06/26 at 11:19 AM of the 300-hall nurse cart with LVN E revealed a bottle of Simethicone 125 mg (medication used for gas relief) that had an expiration date of 02/26. Observation also revealed a bubble pack of Benzonatate 100 mg prescribed to resident #29 with an expiration date of 03/26/26. Interview on 05/06/26 at 11:24 with LVN E revealed that she had been working at the facility for 4 weeks. LVN E stated the Benzonatate 100 mg expired on 03/26/26. She stated that it was an as needed medication for Resident #29 and that she had not given her any doses. LVN E stated the Simethicone expired on 02/26. LVN E stated the nurses were responsible for ensuring there was no expired mediation in the carts. LVN E stated that pharmacy also came to audit the carts, but she was unsure how often. She stated she checked the expiration date before administering any medications and was trained on reviewing expiration dates. LVN E stated the risk of having expired medications in the cart was they could be administered and cause a medication error. Interview on 05/07/26 at 12:03 PM with the ADON revealed she had worked at the facility since January 2026. The ADON stated she checked the medication carts and did an audit in April 2026. She stated the pharmacist also checked the carts at least once a month. The ADON stated the nurses were responsible for checking the expiration dates in their carts, and that she was overall responsible. She stated when she did her cart audits, they missed one medication cart, so the expired medications must have been missed. The ADON stated she was going to add an audit system for the staff to complete and educate all the nurses and medication aides. She stated the risk of having expired medications was administering medications with lower efficacy. The ADON stated it was important not to keep any expired medications to ensure medications were effective. Interview on 05/07/26 at 1:57 PM with the DON revealed she started working at the facility on 04/22/26. She stated that any staff member responsible for the cart was responsible for ensuring there were no expired medications. The DON stated she expected the staff to be checking each medication for the expiration date when they were administering any medications. The DON stated nursing management was responsible for performing audits on the medication carts. The DON stated she knew the ADON was performing regular audits but missed one of the medication carts during the last audit. The DON stated the risk of having expired medication in the cart was the medication could be administered and be less effective. She stated there have not been any training/in-services on expired medication since she started, but that she would start to educate and train staff to prevent further issues with expired medications. Record review of the facility's Medication Storage policy, undated, revealed the following: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.

Based on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #76) records reviewed for accurate documentation. RN D failed to accurately document in Resident #76's clinical record when he documented on 05/06/26 that Resident #76 received his magic cup during the lunch meal when he had not received it. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Review of Resident #76's Quarterly MDS Assessment, dated 04/10/26, reflected he was a [AGE] year-old male who had recently readmitted to the facility on [DATE] after originally admitting on 10/30/25. He had a BIMS of 00 indicating severe cognitive impairment. His active diagnoses included malnutrition, adult failure to thrive, and cognitive communication deficit. His MDS indicated he had recently lost weight. Review of Resident #76's Order Summary Report, dated 05/07/26, reflected an order for Magic Cups two times a day lunch and dinner, with an order start date of 03/23/26. Review of Resident #76's Nutritional Assessment, dated 04/08/26, reflected Supplements.MAGIC CUP W/L&D [sic]. Review of Resident #76's Medication Administration Record for May 2026 reflected RN D signed off that he received his magic cup on 05/06/26. Review of Resident #76's Care Plan, revised 04/07/26, reflected the following: Focus: Unexpected/unintended weigh loss r/t loss of appetite, eating 50% of meals.Interventions: Offer high calorie/nutrient dense supplements as ordered by physician/dietitian.record meal/snack intake in clinical record. Observation on 05/06/26 at 12:21 PM of Resident #76 sitting in the dining room in his wheelchair. Resident #76 had a family member next to him. Resident #76 was waiting for his meal because he did not like what was being served and had requested a grilled cheese sandwich and chips instead. Observation on 05/06/26 at 12:25 PM of Resident #76's lunch tray revealed it included 1 and 1/2 grilled cheese sandwiches, chips, ice cream, and tea. Interview on 05/06/26 at 12:30 PM, Resident #76's Family Member said the resident had previously lost weight because he had some infections recently that caused him to have a decrease in his appetite. Resident #76's Family Member said since the resident was readmitted to the facility he had been eating better but he was supposed to get a milkshake or something like that with his meal and it was missing today. Resident #76's Family Member said she was not sure why it was left off his meal tray today Interview on 05/06/26 at 12:35 PM, [NAME] G said the DM did not show up to the facility today so she was handling the lunch service today. [NAME] G said normally Resident #76 was supposed to get a magic cup with his meal for lunch but he was not served one today. [NAME] G said the magic cup was not listed on his meal ticket for some reason so it was not included on his meal tray. [NAME] G said the kitchen staff and nursing staff look at the meal tickets to make sure that all items were on the tray before it went to the resident. [NAME] G said since the magic cup was not listed on Resident #76's meal ticket for the lunch service today, no one noticed it was missing. [NAME] G said the previous DM was supposed to make sure that all the Dietitian's recommendations were reflected on the meal ticket for residents, including an order for a magic cup. [NAME] G said the magic cup would have only come from the kitchen. Interview on 05/06/26 at 1:20 PM, RN D said Resident #76's magic cup was normally included on his meal tray during lunch. RN D said he did not check Resident #76's meal tray for lunch service today because he was busy providing care to other residents. RN D said another nurse must have checked his tray and so he assumed Resident #76 received his magic cup with his meal. RN D said Resident #76 received the magic cup because the facility was following up on his weight loss. RN D said the magic cup would have come from the kitchen. RN D said Resident #76 had an infection recently which caused him to have a decrease in appetite which caused him to lose weight. RN D said normally, the nurse checks each resident's meal tray and looked at the meal ticket to make sure that each item was included on the tray. RN D said he knew he was not supposed to document on the resident's MAR that the resident received the magic cup if he did not confirm the resident actually received it. RN D said he did document on Resident #76's MAR that he received it today when he had not. RN D said he just checked it off since he assumed Resident #76 had received it. Interview on 05/07/26 at 11:32 AM with the ADON, she said Resident #76's magic cup came from the kitchen. The ADON said the Dietitian put orders in for nutrition or weight loss and those showed up on the resident's meal tickets so the kitchen staff knew what to include on the resident's tray. The ADON said the kitchen staff were responsible for making sure all items were included on the resident's tray. The ADON said she was not sure why Resident #76's magic cup was not on his meal ticket and therefore, not on his meal tray for yesterday. The ADON said Resident #76 had recently had a decrease in his appetite after having an infection which was why the Dietitian recommended the magic cup for lunch and dinner meals. The ADON said she was not aware the magic cup showed up on the nurse's MAR to sign off the resident had received the nutritional supplement. The ADON said she saw on Resident #76's MAR where RN D signed off that the resident had received his supplement for the lunch meal on 05/06/26 when he had not received it. The ADON said RN D should have made sure Resident #76 received the magic cup before signing off that he did. The ADON said the purpose of accurate documentation was to represent the medications and treatments the resident received. The ADON said the importance of accurate documentation was to ensure clear communication between every department. The ADON said staff were trained and expected to accurately document in the resident's chart. The ADON said if staff were not accurately documenting in the resident's chart there could be instances where the resident does not get the care they needed. The ADON said she only monitored to ensure the resident's MAR was completed, not that it was accurate. Interview on 05/07/26 at 1:44 PM with the DON, she said she had only been at the facility since 04/22/26. The DON said the kitchen was responsible for ensuring Resident #76 received his magic cup from the kitchen during the lunch meal yesterday (05/06/26). The DON said she was informed the magic cup showed up on the nurse's MAR to sign off the resident received it. The DON said if RN D was signing off on the resident's MAR that the resident received something they should ensure they actually received it first. The DON said the purpose of accurate documentation was because the medical record should always reflect accurate care. The DON said if Resident #76's record was not accurate in regards to him receiving his magic cup and for example, was still losing weight the facility might not be able to brainstorm other weight loss interventions in this case. The DON said RN D was responsible for ensuring he accurately documented on Resident #76's MAR. The DON said she was still too new to be able to put something in place to monitor accurate documentation by staff. Review of the facility's undated policy, titled Documentation in Medical Record, reflected: .4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interview, record review, and observation, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure Resident #13, who was receiving hospice services, had a physician order for hospice care. This failure could place residents who receive hospice services at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs. Findings included: Record review of Resident #13's Face Sheet, dated 05/07/26, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #13's Quarterly MDS, dated [DATE], revealed she had the following diagnoses: Alzheimer's Disease (progressive brain disease that causes a slow decline in memory, thinking, and reasoning skills) and Parkinson's Disease (progressive brain disorder that occurs when nerve cells die). The MDS further revealed Resident #13 was on Hospice care and had a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #13's Care Plan, last reviewed 04/13/26, revealed she was receiving Hospice care with a diagnosis of Alzheimer's Disease with an intervention to obtain physician order and appropriate referral. Record review of a progress note from 07/11/25 at 9:26 PM revealed the following from LVN C, Patient admitted to [Hospice Company]. Orders updated on the MAR.Record review of Resident #13's order summary, dated 05/07/26, revealed no physician order for hospice care services. Observation on 05/05/26 at 11:29 AM revealed Resident #13 was sitting in her wheelchair in the dining room. An interview was attempted with Resident #13; however, she did not respond. Interview on 05/07/26 at 1:15 PM with LVN C revealed that she had not worked at the facility since December 2025 and was a PRN nurse. She stated she did recall Resident #13 and was the one working when she was admitted to hospice services. LVN C stated she would normally put in a physician order but must had forgotten that day. LVN C stated all residents on hospice should have a physician order so that all staff were aware she was on hospice services. LVN C stated the risk of not having a physician order was miscommunication between staff. Interview on 05/07/26 at 1:30 PM with RN D revealed that he was Resident #13's nurse. He stated she was on hospice services and had been for several months. RN D stated Resident #13 should have a hospice physician order in her EHR. RN D stated he could see she was on hospice in their special instructions but stated there was no physician order for hospice. He stated because it was in the special instructions, he never reviewed the physician orders. RN D stated the nurse who got the order would be responsible for putting it into physician orders, but all the nurses were responsible for reviewing the orders. RN D stated the hospice order was important for continuity of care and so all staff were aware she was on hospice. He stated the risk of not having a physician order was that not all staff were familiar with Resident #13 and may not be aware she was receiving hospice services. Interview on 05/07/26 at 1:49 PM with the DON revealed she was new to the facility and started 04/22/26. The DON stated the other building she worked at; a hospice order was required. The DON stated their policy at this facility did not state that an order was needed, just to obtain orders from Hospice. The DON stated when they get orders from hospice, they were added into the MAR. She stated she would be educating staff to ensure there was a hospice order for any hospice resident. She stated the admitting nurse would be responsible for putting in the hospice order. The DON stated the hospice order was important for communication between facility staff and hospice. Interview on 05/07/26 at 3:34 PM with the ADON revealed she had worked at the facility since January 2026. She stated there should be a hospice order since it was a service provided to Resident #13. The ADON stated any nurse was responsible for putting in orders, but the nurse that received the order was the one who put it in their system. The ADON stated it was important to have the hospice order to communicate through different departments and allow transparency between all staff. The ADON stated there was a risk for confusion and miscommunication without a hospice order. Interview on 05/07/26 at 4:05 PM with Hospice Nurse F revealed that Resident #13 was her patient. Hospice Nurse F stated that Resident #13 had been on hospice since 07/11/25.Record review of the facility's policy titled, Hospice Program, revised July 2017, revealed the following: .C. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians.D. Obtaining the following information from the hospice: .7. Hospice physician and attending physician (if any) orders specific to each resident.

Based on interview and record review, the facility failed to ensure residents were provided with pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to have policies and processes in place to ensure the accurate dispensing and administering of medications. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of health decline, allergic reactions, hospitalization, and death.Findings included: Record review of Resident #1's MDS Assessment, dated 12/20/25, reflected he was an [AGE] year-old male, admitted [DATE] with a BIMS score of 9, which indicated moderate cognitive impairment characterized by impaired short-term memory and inconsistent orientation, requiring cueing or assistance to understand, retain, and follow instructions. The resident's diagnoses included Parkinson's disease (a brain disorder that causes tremors, stiffness, and slow movement), dysphagia (difficulty speaking or understanding language, usually due to brain injury or stroke), vascular dementia (brain damage from reduced blood flow that affects memory, judgment, and understanding), hypothyroidism (underactive thyroid gland that did not make enough hormone), bradycardia (the heart is beating slower than normal, can cause fatigue, dizziness, confusion, or fainting, the brain and body may not get enough blood and oxygen), hyperlipidemia (too much fat like cholesterol or triglycerides in the blood, which can raise the risk of heart disease and stroke), presence of cardiac pacemaker (a small device implanted in the chest to help the heart beat at a regular pace), anemia (the body has too few red blood cells or not enough hemoglobin), cognitive communication deficit (trouble understanding, processing, or expressing information) and encounter for surgical aftercare following surgery. Record Review of Residents #1 Medication Administration Review (MAR), dated 12/01/2025 through 12/06/2025, reflected the resident was administered the following incorrect medications: Metformin HCI oral tablet, 500 mg, 2 tablets administered by mouth 2 times a day for diabetes. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a.m. and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/04/2025, 8:00 a.m. and 6:00 p.m. on 12/05/2025, and at 8:00 a.m. on 12/06/2025. Insulin Glargine subcutaneous solution 100 UNIT/mL (Insulin Glargine) inject 15 units subcutaneously in the evening for diabetes. The medication was administered to Resident #1 at 8:00 p.m. on 12/03/2025 and at 8:00 p.m. on 12/04/2025. Farxiga Oral Tablet 10 MG, (Dapagliflozin Propanediol) give 1 tablet by mouth one time a day for diabetes. The medication was administered to Resident #1 at 8:00 a.m on 12/02/2025, 8:00 a.m. on 12/03/2025, 8:00 a.m. on 12/04/2025, 8:00 a.m. on 12/05/2025, and 8:00 a.m. on 12/06/2025. Lasix Oral Tablet 40 MG (Furosemide) give 1 tablet by mouth two times a day for fluid overload. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/4/2025, 8:00 a.m. and 6:00 p.m. on 12/5/2025, and 8:00 a.m. on 12/06/2025. Insulin Lispro Injection Solution 100 UNIT/mL (Insulin Lispro) inject as per sliding scale:If 0-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401 + = 12 units and notify the doctor, subcutaneously before meals for diabetes. Resident #1 was administered 8 units at 11:00 a.m. on 12/02/25 with a blood sugar reading of 312. Record review of Resident #1's Physician's Orders, dated 12/20/25, reflected the resident was currently prescribed Topiramate. The Black Box Warning (the most serious warning issued by the U.S. Food and Drug Administration (FDA) to alert patients and healthcare providers about the potential for serious or life-threatening side effects associated with certain medications) for the incorrectly administered Metformin HCI (hydrochloride) specifically identified the use of Topiramate (a carbonic anhydrase inhibitor) as a clinical risk factor. According to the manufacturer's warning, the use of these two medications at the same time was associated with an increased risk for the development of lactic acidosis (a medical condition characterized by the accumulation of lactic acid in the bloodstream, leading to a decrease in blood pH and potential health complications). Further review of the Order Summary reflected a Black Box warning for the incorrectly administered Lasix Oral Tablet. The warning stated if given in excessive amounts, could lead to a profound diuresis (process of formation and excretion of urine from the body through the kidneys) with water and electrolyte depletion. Therefore, careful medical supervision was required, and dose schedule must be adjusted to the individual patient's needs. Record Review of Resident #1's Care Plan, dated 12/01/25, reflected the resident was receiving insulin. The Care Plan did not specify the diagnosis associated with insulin use. The Care Plan interventions included monitoring blood glucose, monitoring for hypoglycemia, and notifying the physician as needed. Record Review of Resident #1's Patient Discharge Instructions from the resident's previous rehabilitation facility reflected four pages of another resident's medication action plan mixed in with Resident #1's records. The four pages of the medication action plan each identify the incorrect resident by first, middle initial, last name, MRN number, and date of birth . Record Review of Resident #1's Change in Condition Evaluation, dated 12/06/2025 at 10:02 p.m., reflected the resident had abnormal vital signs and listed the other change as Unresponsive. The resident's most recent blood pressure reading was 92/48, pulse of 78, respiration 18, body temperature of 97.7, oxygen saturation at 94.0, and blood glucose of 134.0 mg/dL. The evaluation further reflected Resident #1's neurological status changed. It reflected Resident #1 had an altered level of consciousness and the level of change stated sudden change in the level of consciousness or responsiveness. Record review of Resident #'1 Nursing Note, dated 12/10/2025 reflected, Received phone call from MD [name] stating that he'd received a call from son stating, that he was receiving medication to treat diabetes and patient is not a diabetic. Writer looked into patient records and noted that mixed in with patient records were orders for another patient that was sent with Resident #1 clinicals from [name of rehabilitation facility]. MD [name] was made aware and stated he will follow up with the son. Record review of Resident #1's Nursing Facility to Hospital Transfer Form, dated 12/06/2025 at 9:30 p.m., reflected the resident was transported to the hospital due to unresponsive. Record review of Resident #1's hospital records, dated 12/06/25, reflected the following: .Acute Kidney failure creatinine 0.8 on 11/18/25 - had been getting Lasix, farxiga at nursing home - Creatinine 2.52 to 2.62 after contrast. During an interview on 12/20/2025 at 11:20 a.m., the Administrator and DON stated Resident #1 was administered five incorrect medications that were not prescribed to him. The DON reported that based on their internal investigation, it was determined Resident #1 was admitted to the facility from a short-term care facility and the records provided by the short-term care facility had another resident's MAR mixed in with Resident #1's records. The DON stated the records also contained Resident #1's MAR, so it appeared to be a long list of medications that were all prescribed for Resident #1. The DON reported Resident #1 was transferred to the emergency room on [DATE] because he was unresponsive. During an interview on 12/20/2025 at 10:09 a.m., Resident #1's family member reported on 12/06/25 at approximately 8:42 p.m. they were notified by the facility that the resident was unresponsive and they wanted to transfer him to the hospital. Resident #1's family member reported the family requested the facility wait until they arrived to transfer the resident. Resident #1's family member stated a nurse informed the family she was scheduled to administer insulin but that the resident was not eating. Resident #1's family member questioned why insulin was ordered, as the resident was not diabetic and the nurse provided a copy of the MAR, which noted orders for insulin, metformin, farxiga, and furosemide, medications the family member stated Resident #1 was not prescribed prior to admission. Resident #1's family member reported Resident #1 was transferred to the hospital, admitted to the ICU, and treated for acute renal failure, aspiration pneumonia, and sepsis. Resident #1's family member stated the resident required oxygen and IV fluids and later developed significant weakness and inability to swallow, resulting in a decision to transition Resident #1 to hospice care. Resident #1's family member reported the family received copies of the resident's medication lists, MAR, and prior rehabilitation records and stated the medications at the previous rehabilitation facility and hospital were correct. Resident #1's family member reported the facility later informed him another resident's medical records were mixed into Resident #1's paperwork. During an interview on 12/20/2025 at 12:02 p.m., the facility MD reported he was notified on 12/06/2025 that Resident #1 was unresponsive and had been transferred to the hospital, where he was later informed the resident was diagnosed with severe sepsis. He stated he did not have access to the resident's hospital records and could not determine whether the medications contributed to the resident's decline without reviewing additional clinical data. The MD reported the medication orders were transcribed from faxed transfer records and entered into the system by the admitting nurse, verified by the DON, and then routed to him for signature. He stated he relied on nursing staff to accurately enter and reconcile medication orders and acknowledged that he trusted the information presented to him when signing off. He reported that during this process the residents' diagnoses were not reviewed or verified with the nurse prior to signing the orders and stated this step was missed due to multiple moving parts in the admission process. The physician reported that during his follow-up review he learned a document from another resident was mixed into Resident #1's transfer paperwork, which resulted in incorrect medications being ordered. He stated the medications were entered as new orders and reported insulin was administered once due to elevated blood glucose levels. He stated medication reconciliation was completed per facility workflow by nursing staff and verified by the DON prior to his review. Record review of the facility's Abuse, Neglect, and Exploitation Policy, dated 07/2025, reflected, .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 12/20/25 at 5:45 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/25 at 6:21 p.m.; an updated version of the IJ template was provided on 01/08/26 at 10:40 a.m.The following Plan of Removal submitted by the facility was accepted on 12/21/25 at 12:21 p.m: .Interventions:The resident was transferred to the hospital and no longer resides in the facility. The Director of Nursing (DON) or designee conducted an immediate facility-wide review of all residents admitted or readmitted within the past 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. Also, to include any transfers from other facilities. Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected immediately. The Administrator reviewed the audit findings and confirmed that no additional residents were at risk. The Director of Nursing (DON) or designee will implement the following systemic changes and education on 12-21-25. The staff member who input the orders was terminated by the DON on 12-10-25. All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge Summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse. The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified. Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission. The DON/Designee will verify that the admission checklist is completed for all admissions. Required DON or designee review of all new admissions and readmissions by next business day The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization. The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization. The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance will result in immediate corrective action and re-education. The facility's implementation of the Plan of Removal was verified through the following: In an interview on 12/21/2025 at 3:20 PM with the hospital social worker, she reported Resident #1 had been a patient at the hospital admitted on [DATE] and was discharged to inpatient hospice. Record review of Admission, Discharge, and Transfer Report dated 11/20/2025 through 12/20/2025, reflected 8 residents were selected for residents admitted within the last 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. In part of the review of the 8 residents, the following records were reviewed to ensure medication accuracy: Interim Medication Regimen Review, discharge orders/instructions, order summary report, MAR, and progress notes. Record review of terminated staff member's employee file reflected a Termination of Employment letter dated 12/10/2025. Record review of in-service logs, dated 12/20/25 and 12/21/2025, reflected that facility staff members had been in-serviced on areas including abuse/neglect and new admission process. During interviews with multiple staff members who represented all assigned shifts (MDS Nurse, Staffing Coordinator, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, RN I, RN J, LVN K, and LVN L) on 12/21/25 between 2:10PM and 4:15PM, they each reported being in-serviced on topics including abuse/neglect, new admission processes, medication regimen reviews, and discharge orders/instructions. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas. Staff members appeared knowledgeable on the facility's policies and procedures. These interviews were conducted without incident or concern regarding the trainings provided. The Administrator was notified the IJ was removed on 12/21/25 at 5:40PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of five residents reviewed for medication accuracy. The facility failed to ensure they had processes in place to ensure accurate verification and reconciliation of physician's orders and medications upon admission. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of health decline, allergic reactions, hospitalization, and death.Findings included: Record review of Resident #1's MDS Assessment, dated 12/20/25, reflected he was an [AGE] year-old male, admitted [DATE] with a BIMS score of 9, which indicated moderate cognitive impairment characterized by impaired short-term memory and inconsistent orientation, requiring cueing or assistance to understand, retain, and follow instructions. The resident's diagnoses included Parkinson's disease (a brain disorder that causes tremors, stiffness, and slow movement), dysphagia (difficulty speaking or understanding language, usually due to brain injury or stroke), vascular dementia (brain damage from reduced blood flow that affects memory, judgment, and understanding), hypothyroidism (underactive thyroid gland that did not make enough hormone), bradycardia (the heart is beating slower than normal, can cause fatigue, dizziness, confusion, or fainting, the brain and body may not get enough blood and oxygen), hyperlipidemia (too much fat like cholesterol or triglycerides in the blood, which can raise the risk of heart disease and stroke), presence of cardiac pacemaker (a small device implanted in the chest to help the heart beat at a regular pace), anemia (the body has too few red blood cells or not enough hemoglobin), cognitive communication deficit (trouble understanding, processing, or expressing information) and encounter for surgical aftercare following surgery. Record Review of Residents #1 Medication Administration Review (MAR), dated 12/01/2025 through 12/06/2025, reflected the resident was administered the following incorrect medications: Metformin HCI oral tablet, 500 mg, 2 tablets administered by mouth 2 times a day for diabetes. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a.m. and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/04/2025, 8:00 a.m. and 6:00 p.m. on 12/05/2025, and at 8:00 a.m. on 12/06/2025. Insulin Glargine subcutaneous solution 100 UNIT/mL (Insulin Glargine) inject 15 units subcutaneously in the evening for diabetes. The medication was administered to Resident #1 at 8:00 p.m. on 12/03/2025 and at 8:00 p.m. on 12/04/2025. Farxiga Oral Tablet 10 MG, (Dapagliflozin Propanediol) give 1 tablet by mouth one time a day for diabetes. The medication was administered to Resident #1 at 8:00 a.m on 12/02/2025, 8:00 a.m. on 12/03/2025, 8:00 a.m. on 12/04/2025, 8:00 a.m. on 12/05/2025, and 8:00 a.m. on 12/06/2025. Lasix Oral Tablet 40 MG (Furosemide) give 1 tablet by mouth two times a day for fluid overload. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/4/2025, 8:00 a.m. and 6:00 p.m. on 12/5/2025, and 8:00 a.m. on 12/06/2025. Insulin Lispro Injection Solution 100 UNIT/mL (Insulin Lispro) inject as per sliding scale:If 0-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401 + = 12 units and notify the doctor, subcutaneously before meals for diabetes. Resident #1 was administered 8 units at 11:00 a.m. on 12/02/25 with a blood sugar reading of 312. Record review of Resident #1's Physician's Orders, dated 12/20/25, reflected the resident was currently prescribed Topiramate. The Black Box Warning (the most serious warning issued by the U.S. Food and Drug Administration (FDA) to alert patients and healthcare providers about the potential for serious or life-threatening side effects associated with certain medications) for the incorrectly administered Metformin HCI (hydrochloride) specifically identified the use of Topiramate (a carbonic anhydrase inhibitor) as a clinical risk factor. According to the manufacturer's warning, the use of these two medications at the same time was associated with an increased risk for the development of lactic acidosis (a medical condition characterized by the accumulation of lactic acid in the bloodstream, leading to a decrease in blood pH and potential health complications). Further review of the Order Summary reflected a Black Box warning for the incorrectly administered Lasix Oral Tablet. The warning stated if given in excessive amounts, could lead to a profound diuresis (process of formation and excretion of urine from the body through the kidneys) with water and electrolyte depletion. Therefore, careful medical supervision was required, and dose schedule must be adjusted to the individual patient's needs. Record Review of Resident #1's Care Plan, dated 12/01/25, reflected the resident was receiving insulin. The Care Plan did not specify the diagnosis associated with insulin use. The Care Plan interventions included monitoring blood glucose, monitoring for hypoglycemia, and notifying the physician as needed. Record Review of Resident #1's Patient Discharge Instructions from the resident's previous rehabilitation facility reflected four pages of another resident's medication action plan mixed in with Resident #1's records. The four pages of the medication action plan each identify the incorrect resident by first, middle initial, last name, MRN number, and date of birth . Record Review of Resident #1's Change in Condition Evaluation, dated 12/06/2025 at 10:02 p.m., reflected the resident had abnormal vital signs and listed the other change as Unresponsive. The resident's most recent blood pressure reading was 92/48, pulse of 78, respiration 18, body temperature of 97.7, oxygen saturation at 94.0, and blood glucose of 134.0 mg/dL. The evaluation further reflected Resident #1's neurological status changed. It reflected Resident #1 had an altered level of consciousness and the level of change stated sudden change in the level of consciousness or responsiveness. Record review of Resident #'1 Nursing Note, dated 12/10/2025 reflected, Received phone call from MD [name] stating that he'd received a call from son stating, that he was receiving medication to treat diabetes and patient is not a diabetic. Writer looked into patient records and noted that mixed in with patient records were orders for another patient that was sent with Resident #1 clinicals from [name of rehabilitation facility]. MD [name] was made aware and stated he will follow up with the son. Record review of Resident #1's Nursing Facility to Hospital Transfer Form, dated 12/06/2025 at 9:30 p.m., reflected the resident was transported to the hospital due to unresponsive. Record review of Resident #1's hospital records, dated 12/06/25, reflected the following: .Acute Kidney failure creatinine 0.8 on 11/18/25 - had been getting Lasix, farxiga at nursing home - Creatinine 2.52 to 2.62 after contrast. During an interview on 12/20/2025 at 11:20 a.m., the Administrator and DON stated Resident #1 was administered five incorrect medications that were not prescribed to him. The DON reported that based on their internal investigation, it was determined Resident #1 was admitted to the facility from a short-term care facility and the records provided by the short-term care facility had another resident's MAR mixed in with Resident #1's records. The DON stated the records also contained Resident #1's MAR, so it appeared to be a long list of medications that were all prescribed for Resident #1. The DON reported Resident #1 was transferred to the emergency room on [DATE] because he was unresponsive. During an interview on 12/20/2025 at 10:09 a.m., Resident #1's family member reported on 12/06/25 at approximately 8:42 p.m. they were notified by the facility that the resident was unresponsive and they wanted to transfer him to the hospital. Resident #1's family member reported the family requested the facility wait until they arrived to transfer the resident. Resident #1's family member stated a nurse informed the family she was scheduled to administer insulin but that the resident was not eating. Resident #1's family member questioned why insulin was ordered, as the resident was not diabetic and the nurse provided a copy of the MAR, which noted orders for insulin, metformin, farxiga, and furosemide, medications the family member stated Resident #1 was not prescribed prior to admission. Resident #1's family member reported Resident #1 was transferred to the hospital, admitted to the ICU, and treated for acute renal failure, aspiration pneumonia, and sepsis. Resident #1's family member stated the resident required oxygen and IV fluids and later developed significant weakness and inability to swallow, resulting in a decision to transition Resident #1 to hospice care. Resident #1's family member reported the family received copies of the resident's medication lists, MAR, and prior rehabilitation records and stated the medications at the previous rehabilitation facility and hospital were correct. Resident #1's family member reported the facility later informed him another resident's medical records were mixed into Resident #1's paperwork. During an interview on 12/20/2025 at 12:02 p.m., the facility MD reported he was notified on 12/06/2025 that Resident #1 was unresponsive and had been transferred to the hospital, where he was later informed the resident was diagnosed with severe sepsis. He stated he did not have access to the resident's hospital records and could not determine whether the medications contributed to the resident's decline without reviewing additional clinical data. The MD reported the medication orders were transcribed from faxed transfer records and entered into the system by the admitting nurse, verified by the DON, and then routed to him for signature. He stated he relied on nursing staff to accurately enter and reconcile medication orders and acknowledged that he trusted the information presented to him when signing off. He reported that during this process the residents' diagnoses were not reviewed or verified with the nurse prior to signing the orders and stated this step was missed due to multiple moving parts in the admission process. The physician reported that during his follow-up review he learned a document from another resident was mixed into Resident #1's transfer paperwork, which resulted in incorrect medications being ordered. He stated the medications were entered as new orders and reported insulin was administered once due to elevated blood glucose levels. He stated medication reconciliation was completed per facility workflow by nursing staff and verified by the DON prior to his review. Record review of the facility's Abuse, Neglect, and Exploitation Policy, dated 07/2025, reflected, .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 12/20/25 at 5:45 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/25 at 6:21 p.m.; an updated version of the IJ template was provided on 01/08/26 at 10:40 a.m.The following Plan of Removal submitted by the facility was accepted on 12/21/25 at 12:21 p.m: .Interventions:The resident was transferred to the hospital and no longer resides in the facility. The Director of Nursing (DON) or designee conducted an immediate facility-wide review of all residents admitted or readmitted within the past 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. Also, to include any transfers from other facilities. Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected immediately. The Administrator reviewed the audit findings and confirmed that no additional residents were at risk. The Director of Nursing (DON) or designee will implement the following systemic changes and education on 12-21-25. The staff member who input the orders was terminated by the DON on 12-10-25. All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge Summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse. The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified. Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission. The DON/Designee will verify that the admission checklist is completed for all admissions. Required DON or designee review of all new admissions and readmissions by next business day The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization. The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization. The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance will result in immediate corrective action and re-education. The facility's implementation of the Plan of Removal was verified through the following: In an interview on 12/21/2025 at 3:20 PM with the hospital social worker, she reported Resident #1 had been a patient at the hospital admitted on [DATE] and was discharged to inpatient hospice. Record review of Admission, Discharge, and Transfer Report dated 11/20/2025 through 12/20/2025, reflected 8 residents were selected for residents admitted within the last 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. In part of the review of the 8 residents, the following records were reviewed to ensure medication accuracy: Interim Medication Regimen Review, discharge orders/instructions, order summary report, MAR, and progress notes. Record review of terminated staff member's employee file reflected a Termination of Employment letter dated 12/10/2025. Record review of in-service logs, dated 12/20/25 and 12/21/2025, reflected that facility staff members had been in-serviced on areas including abuse/neglect and new admission process. During interviews with multiple staff members who represented all assigned shifts (MDS Nurse, Staffing Coordinator, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, RN I, RN J, LVN K, and LVN L) on 12/21/25 between 2:10PM and 4:15PM, they each reported being in-serviced on topics including abuse/neglect, new admission processes, medication regimen reviews, and discharge orders/instructions. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas. Staff members appeared knowledgeable on the facility's policies and procedures. These interviews were conducted without incident or concern regarding the trainings provided. The Administrator was notified the IJ was removed on 12/21/25 at 5:40PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances and keep the residents' RP appropriately apprised of progress toward resolution for 1 of 6 residents (Resident #1) reviewed for grievances. The facility failed to notify Resident #1's RP the resolution of her filed grievances on [DATE]. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included:Record review of Resident #1's admission record, initially admitted on [DATE], reflected the resident was an [AGE] year old female with diagnoses that included vascular dementia (decreased blood flow to the brain), hypertension (the pressure in the blood vessels are consistently too high), irritable bowel syndrome (condition that affects stomach and intestines),. Record review of Resident #1's admission MDS assessment, dated [DATE], reflected Resident #1 had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. Record review of Resident #1's progress note, dated [DATE] at 2:16 PM, Resident #1 had expired. Record review of the Grievance/Concern Report, submitted in SW box on [DATE], reflected three grievances written by Resident #1's RP. The Grievances were as follows:*1. [DATE] Saturday- [Resident #1's neighbor/friend] visited around 4:00pm and [Saturday] found two pils on the floor. [Resident #1's neighbor/friend] went and got LVN B. LVN B said [the] yellow oval pill was for her stomach and the round white pill was for BP. LVN B said she would write a report. In Resident #1's present stated the dispenser of the medication should make sure Resident #1 swallows all medication. 2. [DATE] Sunday- Resident #1's RP visited around 1:15pm, resident had a large bruise on the side (left) of her head and bruises on the chins of her legs. RP ask the nurse as they were changing shift night nurse [wound nurse] if resident had fallen and she said no it was from her banging her head on the bed railing. I don't believe resident is on anticoagulants. Bruise there on [DATE]. *not sure of the name of the morning nurse. *3. Sunday-Need a podiatrist appointment to take care of cracked/flaky skin on heels. * Findings of Investigation dated [DATE] documented by the DON indicated. Resident was noted to being to have skin changes on [DATE] due to terminal state. Wound Dr. [NAME] coded her wounds as terminal. Her skin was fragile and easily bruise with normal care activities. Recommendation for corrective action:The pills found on the floor to be BP meds or pills for her stomach would be Labetalol and Protonix. The record reflects the BP meds were held several days for [low] BP. Results of action taken:It is suspected that the held medications fell to the floor instead of the trash can when held due to BP outside parameter. Protonix however is not document as held on MAR. Further record review of Resolution in grievance on [DATE], revealed the section blank. There was no response regarding the investigation reported to Resident #1's RP. In an interview on [DATE] at 8:08 AM, Resident #1's RP stated the facility had not returned her call regarding the grievances she submitted on [DATE]. She stated she filed a grievance report regarding medication administration and bruises and need of an appointment on the morning of [DATE] when Resident #1 passed away. She stated she was in route to the facility to visit Resident #1 and submit the grievance when she go the call she had passed away. She stated as of [DATE] she had still not received a call from the facility about her filed grievances. In an interview with the DON on [DATE] at 2:11 PM, she stated the SW received all grievances. She revealed the SW received the grievance form from Resident #1's RP on [DATE]. She also revealed she received Resident #1's RP, filed grievances and started investigating. The DON stated shortly after she started her investigation, she had to go out for surgery and handed it off the ADON. She stated she did not know how far the ADON had gotten into the grievance process. The DON stated as of [DATE] she had not followed up with a resolution call to Resident #1's RP. She stated she had completed the investigations into the filed concerns in the grievance. The DON stated it was the responsibility of the DON or ADON to investigate any concern that dealt with the nursing side. She stated she, ADON or SW were responsible for providing an update of progress to a resident, a resident's RP or family member. She stated she thought the call to Resident #1's RP was completed by ADON or SW while she was on leave. In an interview on [DATE] at 2:45 PM, the SW stated she attempted to contact Resident #1's RP to discuss the grievance. SW stated she did not document the attempt to contact. The SW also stated she did not remember if she left a message on the Resident #1's RP voicemail. She stated she did not know what days she attempted to contact the resident's RP, but she felt it was the same day she saw the grievance. She stated as of [DATE] she had not updated Resident #1's RP about resolution of the grievances she filed. In an interview on [DATE] at 4:06 PM, the ADON stated she had not investigated the concerns in the grievance submitted by Resident #1's RP. She stated she knew the DON had started investigating but was not aware of how far she had gotten. She stated she had not received the task of completing the grievance from the DON. She stated she was not aware that she had to keep Resident #1's RP apprised of the resolution. She stated she thought it was the DON or SW that would contact resident's RP. The DON stated they had failed to keep Resident #1's RP apprise of the findings and resolutions of investigation regarding her grievance. Record review of the facility's policy, implemented and revised on [DATE], titled Resident Rights, reflected in part the following: 9. Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discriminationor reprisal. Such grievances include those with respect to care and treatment which has been furnishedas well as that which has not been furnished; and the behavior of staff and of other residents; andother concerns regarding their LTC facility stay.b. The resident has the right to and the facility must make prompt efforts by the facility to resolve

Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #1) reviewed for medication storage. The facility failed to secure all medications in a locked storage area when Resident #1's Labetalol HCl and Pantoprazole Sodium medications were found on the floor approximately 2-3 inches from resident's bed on [DATE]. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Record review of Resident #1's admission record, initially admitted on [DATE], reflected the resident was an [AGE] year old female with diagnoses that included hypertension and irritable bowel syndrome. Record review of Resident #1's admission MDS assessment, dated [DATE], reflected the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. In the MDS assessment Section GG-Functional Abilities, it revealed Resident #1 needed partial and maximum assistance with ADLs. Resident #1 required partial assistance with mobility. In the MDS assessment Section J Health Condition, it revealed no for scheduled pain medication regimen, PRN pain medications or offered and declined, and received non-medication intervention for pain. There was no information about medication types. Record review of Resident #1's care plan, dated [DATE], reflected to administer medications per orders. Record review of Resident #1's order summary report, reflected may crush meds or open capsules as needed unless contraindicated. Record review of Resident #1's medication administration on [DATE], reflected LVN A administered the following medications:*Bactrium DS Tablet 800-160 MG, *Pantoprazole Sodium Oral Tablet Delayed Release 40 MG, *Prostat 30ml, *MiraLax Oral Pack 17 GM (Polyethylene Glycol 3350) 17 GM,Labetalol HCl Oral Tablet 200 MG,Juven andIpratropium-Albuterol Solution 0.5-2.5 (3) MG/3M In an interview with Resident #1's RP on [DATE] at 11:42 AM, she stated on [DATE] Resident #1's friend visited and upon arrival, she found two pills on Resident #1's floor. She stated their friend told her there was a white and yellow pill on the floor next to the resident's bed. She stated the nurse informed Resident #1's neighbor/friend that one pill was for the resident's stomach and the other pill found was identified as blood pressure. RP stated she was concerned as she did not know if Resident #1 received her medications on the morning of [DATE]. Resident #1's RP revealed she had attempted to contact management at the facility over that weekend but to no avail. She stated she submitted her concerns in a grievance. She stated she wanted the facility to investigate her concerns and inform her of the findings. In an interview on [DATE] at 4:06 PM, the ADON revealed she was not in the facility on [DATE]. She stated she received information from one of the nurses that Resident #1's friend had seen medications at resident's bedside. She stated she spoke with the nurse and had her told her to document the incident. She also stated she told the nurse to assess the resident. On [DATE] at 2:55 PM and (second time) attempts were made to contact staff LVN but phone was disconnected. In an interview with Resident #1's friend on [DATE] at 3:12 PM, she stated on [DATE] she visited Resident #1. She stated when she walked in the resident's room, she noticed two pills on the resident's floor. She stated it was a white and yellow pill approximately 2-3 inches on the right side of resident's bed on the floor. She also stated she picked the medications off the floor and sat them on the resident's tray table. She stated afterwards, she walked to the nurse's station and informed LVN B. She stated LVN B told her that she had just come onto her shift for the day, so she was not aware of the medications. She stated LVN B told her she would come to get the medications. Resident #1's friend stated shortly after LVN B went into Resident #1's room and retrieved the medications. Resident #1's friend also stated that LVN B told her she would check the computer to find out which pills it was. Resident #1's friend stated LVN B came back into the room and informed her it was Resident #1's Protonix (treat conditions that cause too much stomach acid) and Labetalol HCl (lower high blood pressure). She stated the LVN told her one was for Resident #1's stomach and the other for the resident's blood pressure. She stated the LVN stated the resident record showed she had taken two medications in the morning and did not want to give it to her if she had already taken them. Resident #1's friend stated LVN B stated she would document the medications on the floor in the system. Resident #1's friend stated she did not know how long it had been on the floor and was concerned. Interview with LVN B, she stated she had worked for agency. She stated she worked with Resident #1 on [DATE] on 2nd shift. She stated she worked from 2:00pm-10:00pm. LVN B stated Resident #1's friend came out and got her from the nurse's station. She stated it was shortly after she got on shift that day. She stated she and Resident #1's friend went back to the resident's room where two pills lay on the tray table. LVN B stated she picked up the two pills and took them to the nurse's station to investigate. She stated she found that it was Resident #1's Protonix and Labetalol HCI. LVN B stated she went back to Resident #1's room and informed resident's friend of her findings. She stated it was two pills that Resident #1 took in the morning. LVN B revealed it had shown on the MARs the medications were given to the resident, so she did not want to double her more pills. LVN B stated she checked Resident #1's blood pressure which was good. The LVN stated she told resident's friend she would give her the evening medications. LVN B stated she reported it to the DON or the ADON but she was not aware of who it was as she spoke to the person over the phone. She stated she was told to document it on the 24-hour log report. She stated she documented the incident in the 24-hour report and later administered Resident #1's evening medications. In an interview with DON on [DATE] at 2:11 PM, she stated she was made aware that Resident #1's friend told one of her nurse's she had found two pills on the resident's floor. She stated she started an investigation to investigate how the pills got on the floor. She stated her belief was maybe the nurse tried to throw the pills in the trash. The DON stated her staff was not aware of any medication being on Resident #1's floor until it was brought to their attention by the resident's friend. In an interview with ADON on [DATE] at 4:06 PM, she stated Resident #1's friend told one of the nurse's she had found some medication at the resident's bedside. She stated she spoke with the nurse and told her to document and assess the resident. Record review of 24-hour report book did not have any documentation 24-hour report of Resident #1's medications on the floor. Record review of the facility's policy, implemented and revised on [DATE], titled Destruction of Unused Drugs, reflected in part the following: Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements).

Based on observations, interviews, and record reviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 4 of 20 residents (Residents #8, #9, #23, and #25) reviewed for privacy. The facility failed to ensure the rooms of Residents #8, #9, #23, and #25 were equipped with privacy curtains to assure full visual privacy. This failure could place the residents at risk of being embarrassed if they were exposed during care. Findings included: Observation and interview on 03/18/25 at 10:04 AM revealed Resident #23's bed had no privacy curtain in place. Curtain rail and clips were present on the ceiling, but no curtain was in place. Resident #23 stated she worried someone could walk in and see her being changed or being bathed. Resident #8 had a privacy curtain that only separated her bed from Resident #23's bed, but did not provide privacy at the end of her bed. Resident #8 was non-verbal. Observation on 03/18/25 at 10:23 AM revealed Resident #9's bed had no privacy curtain. Curtain rail and clips were present on the ceiling, but no curtain was in place Resident #9's bed was located next to the door. Observation and interview on 03/18/25 at 10:27 AM revealed Resident #25 had no privacy curtain. Curtain rail and clips were present on the ceiling, but no curtain was in place. Resident #25's bed was located next to the door. Resident #25 stated it didn't bother him if staff kept the door closed. but he would be embarrassed if someone walked in while he was being changed. Interview on 03/20/25 at 10:10 AM with the Housekeeping Supervisor revealed she worked with maintenance to change out privacy curtains. She stated she had seven curtains in reserve, she would take down seven curtains and replace them with the reserved curtains. She would wash the seven curtains and repeat the process. She changed out curtains once a month, or more often if needed. She stated she had not been made aware there were missing curtains, and she did not have any curtains waiting to be washed. Follow-up observations on 03/20/25 at 10:20 AM revealed the privacy curtains were still not in place for Residents #8, #9, #23, and #25. The surveyor knocked on Resident #8's closed door, received no responsem and entered the room. CNA D was providing incontinence care to Resident #8 leaving the resident exposed. Interview on 03/20/25 at 10:25 AM with CNA D revealed she knew the privacy curtain was there but did not pull it. She stated she relied on telling anyone entering the room during care that she was providing care, so they did not enter. The surveyor stated he had not heard her say anything about cares being in progress when he knocked on the door. The surveyor advised CNA D he could see Resident #8 exposed. CNA D admitted that would have been prevented if she had pulled the privacy curtain. She stated the privacy curtains were there to provide the resident with privacy and dignity during cares. Interview on 03/20/25 at 10:30 AM with RN E revealed the residents needed their privacy curtains to maintain their privacy and dignity. She stated nurses and CNAs should notify maintenance if they noted missing curtains. She stated she was not aware the curtains for Residents #8, #9, #23, and #25 were missing and did not know how long they had been missing. Interview on 03/20/25 at 10:35 AM with the DON revealed the privacy curtains were in place to maintain resident privacy and dignity. She stated the curtains protected residents if they were exposed and someone walked in the door. She stated anyone noting a missing curtain could notify maintenance to have it replaced. Interview on 03/20/25 at 11:00 AM with the Maintenance Director revealed he was not aware of any privacy curtains needing to be hung up. He stated staff should tell him directly or put a request in for the replacement. Record review of the facility's Dignity policy, dated February 2021, reflected: .11. Staff shall promote. maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The policy did not address privacy curtains directly.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of 4 residents (Residents #33 and #99) reviewed for pharmacy services. 1. The facility failed to ensure RN C checked the current physician's orders before administering a PRN Lorazepam (a medication used to treat anxiety) medication to Resident #33 on 03/03/25, who did not have an active order of PRN Lorazepam. 2. The facility failed to ensure RN F administered the correct dosage of PRN Lorazepam (a medication used to treat anxiety) to Resident #99 on 10/31/24 and 11/14/24. These failures could place residents at risk and jeopardize their health and safety. Findings included: 1. Record review of Resident #33's Admission Record, dated 03/19/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #33's Quarterly MDS Assessment, dated 12/13/24, reflected she did not have a BIMS score calculated . Her active diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills), anxiety disorder (a group of mental disorders characterized by intense feelings of anxiety and fear), and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Her MDS also indicated she was receiving hospice services. Record review of Resident #33's care plan, revised on 01/07/25, reflected the following: Focus: Psychotropic medication for Anxiety [sic] .Goal: Resident will feel more peaceful and at ease with improved quality of life through next review .Interventions: Observe the resident closely for significant side effects and report to MD . Record review of Resident #33's Order Summary Report, dated 03/19/25, reflected the following: - Lorazepam Tablet 0.5 mb Give 1 tablet by mouth every 6 hours as needed for Anxiety and agitation for 14 days with an order and start date of 03/06/25. Record review of Resident #33's Electronic Health Record for her discontinued and completed orders reflected she did not have an order for Lorazepam on 03/03/25. Record review of Resident #33's March 2025 MAR reflected there was no indication she received the Lorazepam on 03/03/25. Record review of Resident #33's Progress Notes from 03/03/25 to 03/20/25 did not reflect any information related to her receiving the Lorazepam on 03/03/25. Record review of Resident #33's Controlled Drug Receipt/Record/Disposition Form reflected the following: - Date Received: 06/24/24; Pt Name: [Resident #33]; Drug Name/Strength: Lorazepam Tab 0.5 MG; Directions: Take 1 tablet by mouth every 6 hours as needed for anxiety/restlessness - Date: 3/3/25 ; Time: [1:20 PM]; Amount Given: 1; Amount Left: 2; Signature: [RN C] Observation on 03/19/25 at 9:57 AM of Resident #33 revealed she was laying in bed resting. Resident #33 did not wake up to the surveyor attempting to ask her questions. Interview on 03/19/25 at 2:44 PM with RN E revealed she normally worked with Resident #33. RN E reviewed Resident #33's Controlled Drug Receipt/Record/Disposition Form for the Lorazepam 0.5 mg and said it was not her signature next to the medication administration on 03/03/25. RN E said she thought it might have been RN C's signature because she asked him to give the medication to Resident #33 one day. RN E said the facility had a low census one day and she and RN C balanced out their residents, so RN C had Resident #33 that day (03/03/25). RN E said Resident #33 was anxious at times and sometimes needed to be administered her PRN Lorazepam medication. Interview on 03/19/25 at 3:11 PM with RN C revealed he reviewed Resident #33's Controlled Drug Receipt/Record/Disposition Form for the Lorazepam 0.5 mg and said it was his signature next the medication administration on 03/03/25. RN C said he and RN E switched residents that day (03/03/25) and he normally did not care for Resident #33. RN C said he was told by RN E to give Resident #33 her PRN Lorazepam medication to address her anxiousness . RN C said after he administered Resident #33 her medication he noticed in her chart that she did not have a current PRN Lorazepam order. RN C said he was not able to document the medication administration on Resident #33's MAR because there was not an active order. RN C said he also did not make a note of the medication administration, nor did he call the doctor or report to the DON at the time. RN C said Resident #33 did not appear to have any adverse effects from the medication that day. RN C said he knew and had been trained that he was always supposed to check a resident's orders prior to administering a medication. Interview on 03/20/25 at 3:08 PM with the DON revealed she was told by RN C and RN E that they had switched rooms and RN C had cared for Resident #33 who he was not as familiar with one day (03/03/25). The DON said RN C should have confirmed the PRN Lorazepam order before he administered it to Resident #33. The DON said she was not sure why he did not check her orders first and she was unaware of it until yesterday (03/19/25) when it was brought to her attention. The DON said once RN C noticed there was no active order, he should have called her doctor to see what the next steps could have been. RN C said as far as she knew, Resident #33 did not have any adverse effects from the medication. The DON said this situation was considered a medication error. 2. Record review of Resident #99's Admission Record, dated 03/18/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #99's Quarterly MDS Assessment, dated 10/13/24, reflected she had a BIMS of 08, indicating moderate cognitive impairment. Her diagnoses included non-alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities) and secondary malignant neoplasm of unspecified lung (refers to cancer that has spread to the lungs from a primary cancer elsewhere in the body). Record review of Resident #99's Order Summary Report, dated 03/18/25, reflected: - Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for Anxiety with a start date of 10/12/24 Record review of Resident #99's October 2024 MAR reflected there was no administration entry noted for 10/31/24 regarding her PRN Lorazepam Oral Tablet 0.5 mg. Record review of Resident #99's Individual Patient's Antibiotic/Narcotic Record reflected the following: Patient: [Resident #99], Medication: Lorazepam 0.5 MG tablet Take 1 tablet PO mouth [sic] every 4 hrs as needed for anxiety Date: 10/31/24; Time: 1000 [10:00 AM]; Amt Given: 2; Amt Remaining: 57; Nurse/Med-Aid Signature: [RN F] Date: 11/14/24; Time: 9:00 [AM]; Amt Given: 2; Amt Remaining: 55; Nurse/Med-Aid Signature: [RN F] Record review of Resident #99's November 2024 MAR reflected RN F had signed off that the resident had received their PRN Lorazepam Oral Tablet 0.5 mg on 11/14/25. Record review of Resident #99's care plan, initiated on 08/08/24, did not reflect her use of PRN Lorazepam. Record review of Resident #99's progress notes from 10/31/24 to 11/15/24 did not reflect any information related to the 10/31/24 PRN Lorazepam administration. Record review of Resident #99's progress notes from 10/15/24 to 11/15/24 reflected the following entries: - 11/14/24 3:02 PM - Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 4 hours as needed for anxiety. This eMAR - Medication Administration Note was written by RN F. - 11/14/24 3:45 PM - Resident is alert, oriented and talking about prn medication. Her vitals were monitored. Informed her [RP] about prn medication, vitals status and notified to hospice nurse [sic]. Resident is on continue monitoring [sic]. A Nurse's note made by RN G on 11/14/24 at 3:45 PM - 2-10 assigned nurse informed the writer that as per [RP], resident was given prn medication without indication. Did assessment for any adverse reactions or health risk. Resident was up and awake, vitals were stable, [RP] was at bedside and aware of the situation. Collaborated with morning and evening staff. Give 1:1 education to the staff to improve and to foster a safer environment for resident. MD and hospice were informed and no new orders received. Will continue to monitor closely for any change in condition. A Nurses note made by the previous DON on 11/14/24 at 3:48 PM Record review of a Record review Discussion Form, created 11/15/24, for RN F reflected the following: Date of Incident: 11/14/24; Date of Conversation: 11/15/24; Description of Incident: [RN F] did not follow PCC orders for patient in room [Resident #99's room]; Supervisor Comments: During an audit it was found that [RN F] did not follow orders listed in PCC for patient in room [Resident #99's room] Failing to perform work assignments whether by supervisor or electronic orders is against company code of conduct. Plan for Improvement: [RN F] must follow all orders in PCC for each patient. Record review of a grievance, dated 11/15/24, filed by Resident #99's RP reflected the following: Describe in detail your concern: Received a voice message on 11/14/24 from [RN G] stating 'hi [Resident #99's RP] I'm evening nurse and Ativan [Lorazepam] was given by morning nurse [sic]'. 'She told me that [Resident #99] was having anxiety and not feeling well so she gave her prn medicine (Ativan) and when I got here I took her vital signs and she's better now.' Failure to notify sister [Resident #99's RP] of the administration of prn Ativan 0.5 mg prior to given (2) tablets of 0.5 mg Ativan to [Resident #99] by [RN F]. Record review of a Medication Error Incident Report, dated 11/14/24, reflected the previous DON completed the report and there were no adverse effects to Resident #99. Interview on the phone on 03/17/25 at 3:50 PM with Resident #99's RP revealed there was a nurse at the facility who administered too much Lorazepam to Resident #99 on 10/31/24 and 11/14/24. Resident #99's RP said she felt this was considered an overdose and was very concerned about Resident #99 afterwards. Attempted phone call to RN F on 03/19/25 at 3:02 PM went unanswered and no call backs were received by time of exit. Interview on 03/20/25 at 12:59 PM with the ADON revealed she was aware that Resident #99 had received too much medication on 10/31/24 and 11/14/24. The ADON said Resident #99 should have just been given 1 tablet of the Lorazepam as ordered since it was 0.5 MG, but she was administered 2 tablets for a total of 1 MG by RN F on 10/31/24 and 11/14/24. The ADON said RN F should have followed the rights of medications such as making sure the dose was appropriate, it was the right situation and time, and so on. The ADON said she was not sure why RN F chose to administer more than what the doctor ordered since the order was clear to only give 0.5 MG which would have been only 1 tablet. The ADON said those would have been considered medication errors. The ADON said she only recalled hearing about the 11/14/24 medication error because Resident #99's RP was upset about it. The ADON said Resident #99 did not have any adverse effects from the medication administrations on 10/31/24 and 11/14/24 that she knew about. The ADON said she could only assume that RN F administered the medications to Resident #99 because she was showing signs of anxiousness. The ADON said all staff were responsible for ensuring they followed an order if they were administering a medication. The ADON said all staff had been trained on how to administer medications to residents. The ADON said the purpose of administering orders correctly was to ensure the quality of care for the resident. The ADON said the resident could suffer adverse effects if the staff administered too much medication to them. Interview on 03/20/25 at 3:08 PM with the DON revealed she started working at the facility about a month and a half ago and was not at the facility back in October or November 2024. The DON said she looked at Resident #99's controlled substance sheet for her PRN Lorazepam and saw that RN F administered 2 tablets to Resident #99 on 10/31/24 and 11/14/24. The DON said that medication administration did not follow the orders of only giving 1 tablet to Resident #99 on those dates. The DON said she expected all nurses to follow doctor's orders. The DON said the purpose was to ensure the staff were giving correct doses/routes/frequencies to the residents in regards to their medications. The DON said if staff gave more medications to a resident than what was ordered, such as in this case, that could lead to increased lethargy or drowsiness. The DON said since she was not at the facility at the time of these administrations, she was not sure if the resident suffered any adverse effects. The DON said she expected staff to always check the order before they administered a medication, and they had been trained to do so. The DON said periodically, she checked to ensure residents were receiving their medications as ordered. Record review of the facility's policy Administering Medications, revised April 2019, reflected: .4. Medications are administered in accordance with prescriber orders .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the facility's policy Medication and Treatment Orders , revised July 2016, reflected: 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state .3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.

Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 1 of 1 resident (Resident #179) reviewed for enteral nutrition. The facility failed to follow physician orders for Resident 179's enteral feeding tube to be flushed with 55 ml of water every 1 hour. This failure could place residents who had gastrostomy tube at risk for fluid deficit. Findings included: Record review of Resident #179's Admission MDS assessment dated [DATE], reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses that included gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach) and dysphasia (swallowing difficulties). Resident #179's BIMS score was 09 revealing moderate cognition. The MDS further revealed Section K (Nutritional approaches) indicated the resident's nutritional approach was a feeding tube. Record review of Resident #179's care plan dated 03/14/25 reflected: Focus: Resident#179 at risk for nutritional deficit rule out NPO/enteral tube feeding. Goal: Will maintain adequate nutrition by enteral feeding through next review date. Interventions: Administer enteral feeding/water flushes as ordered by physician. Record review of Resident #179's physician orders, dated 03/13/25, reflected an order for Enteral Feed Order flush feeding tube with 55 cc of water every 1 hour and with 30 cc of water before and after medication administration. Observation and interview on 03/18/2025 at 11:05 AM revealed Resident #179 lying in bed. Resident #179 was connected to her feeding pump, and the feeding rate was set at 70 mL/hr, and the water flush rate was set at 100 ml every 4 hours. The formula bag was dated 03/18/25 at a rate 70 mL/hr. The water bag was dated 03/18/25. Observation and interview on 03/19/25 at 12:44 PM with LVN A, who was the charge nurse for Resident #179, revealed Resident #179 was connected to her feeding pump. The feeding rate was set at 70 mL/hr, and the water flush rate was set at 100 mL every 4 hours. She stated she was aware the physician order for the flush was supposed to be 55 mL/hr. She stated when she came in the morning, she only checked to ensure the feeding was flowing. She stated she did not check the settings. She stated she knew she was supposed to check the settings, but she forgot. LVN A stated Resident #179 had a g-tube, and the night shift had hung a new formula and water bag. She stated failure to follow the physician orders could lead to dehydration. LVN A stated she had done training on gastronomy tubes regarding medication and feeding administration. An phone interview was attempted on 03/20/25 at 10:57 AM with RN B, who was the night nurse, but the attempt was not successful. She did not pick her phone; a voicemail was left. Interview on 03/20/25 at 11:58 AM with the ADON revealed she was not aware Resident #179's water flushes were not set on the pump as per the doctor's orders. She stated she was made aware Resident #179's feeding pump was not accurate on 03/19/25 in the morning by LVN A. She stated she reviewed the orders and Resident #179 was supposed to be on flushes at a rate of 55 mL/hr. She stated, it was expected for the nurses to follow physician orders, and if they had questioned the nurses should notify the doctor and dietician. She stated it was her and the DON's responsibility to monitor nurse and ensure the pumps were set with the correct orders. She stated she had been to Resident #179's room, and she did not check the settings, she only checked whether it was flowing. She stated the potential risk would be dehydration. She stated she had done training on g tube medication and feeding administration. Interview on 03/20/25 at 1:25 PM with the DON revealed she expected the nurses to follow physician and dietitian orders. The DON stated she also expected the nurses to set feeding pumps per the orders. The DON said the person responsible to ensure orders were followed, were nursing staff and nursing management. The DON said that she was responsible to ensure orders were followed by nursing staff through audits. The DON said she had not gone to the resident's room for auditing whether she was set as per the orders. She stated failure to follow the physician orders could lead to dehydration. She stated she had not done training with staff because she was new to the facility. A phone interview was attempted on 03/20/25 03:12 PM with the Dietitian, but the attempt was not successful. Record review of the facility's training records for enteral tube feeding via continuous pump, dated November 2024, reflected a competency assessment for and RN B was in attendance, but LVN A was not in attendance. Record review of the facility's Enteral tube feeding via continuous pump policy, dated November 2018, reflected: 1.Verify that there is a physician order for this procedure. .3.Check the enteral nutrition label against the order before administration. Check the following information .g. Rate of administration (ml/hour) .

Based on observations, interviews, and record reviews the facility failed to ensure the residents environment remained free of accident hazards as possible for 4 of 20 residents (Residents #6, #8, #23, and #47) reviewed for accidents and safety. The facility failed to maintain the sharps containers, which are used to store used syringes and lancets, in a safe manner to prevent the containers from being overfilled and creating a safety hazard in the rooms of Residents #6, #8, #23, and #47. This failure could place residents at risk of exposure to bloodborne pathogens. Findings included: Observation on 03/18/25 at 10:04 AM revealed the sharps container, located in the bathroom for Residents #8 and #23, was filled past the fill line. The flap for depositing sharps in the container was inoperable. Observation on 03/18/25 at 12:33 PM revealed the sharps container, located in the bathroom for Residents #6 and #47, was filled past the fill line, up to the flap for depositing sharps rendering the flap inoperable. There were two used lancets placed on top of the flap. Observation on 03/19/25 at 3:30 PM reflected the sharps containers in Residents #8 and #23 room remained unchanged. A third lancet had been placed on the flap for Residents #6 and #47's sharps container. Interview on 03/19/25 at 3:40 PM with RN C revealed he did not know who was responsible for changing out sharps containers when they were full. He stated the sharps containers were rarely used. He stated the risk of having an overfilled container was exposure to used needles and infections. Interview on 03/19/25 at 3:44 PM with the ADON revealed she did not know who was responsible for changing out the sharps containers. She thought it should be a nursing duty, possibly a housekeeping duty. She stated the lancets placed on top of the flap for Resident #6 and #47 indicated someone had intentionally ignored safety protocols by leaving them exposed instead of changing out the container or at least placing them in a functioning container. The ADON stated over filled sharps containers placed residents at risk of exposure to bloodborne pathogens from used needles. Interview on 03/19/25 at 3:50 PM with the DON revealed she did not know who was responsible for changing out sharps containers. She thought either nursing staff or housekeeping staff should change them out. She stated she did not think there was a policy in place to address sharps containers. She stated the risk to residents was exposure to bloodborne pathogens. Record review of the facility's Sharps Disposal policy, dated January 2012, reflected: .3. c. Designated individuals will be responsible for sealing and replacing containers when they are 75-80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #5) reviewed for care plan accuracy. The facility failed to develop and implement a care plan for Resident #5, which addressed her use of an anti-depressant medication, Sertraline. This failure placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans. Findings included: Record review of Resident #5's Admission Record, dated 03/19/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (the loss of cognitive functioning that interferes with daily life and activities) and major depressive disorder (a mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities, and a range of emotional and physical problems). Record review of Resident #5's None of the Above MDS Assessment, dated 02/28/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. It also indicated she was being administered an antidepressant. It did not address her active diagnoses. Record review of Resident #5's Order Summary Report, dated 03/19/25, reflected the following orders: - Sertraline HCI Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for Depression - Depression: Monitor for depressive symptomology, cyclical and rapid mood shifts (tearfulness, sadness, hopelessness, loss of interest or pleasure, weight loss/gain, reduced/increased appetite, worthlessness, guilt, concentration and/or sleeping difficulties, thoughts of being better off dead, suicidal ideations, etc.)? every shift Enter [sic] progress note describing behaviors observed if applicable. Record review of Resident #5's March 2025 MAR reflected she received Sertraline each day as ordered and had no adverse effects from being monitored for the medication. Record review of Resident #5's care plan, initiated 01/30/25, reflected it did not address her use of the antidepressant, Sertraline. Observation on 03/18/25 at 12:30 PM of Resident #5 revealed she was sitting in the dining room at a table with others. Resident #5 was eating her lunch and appeared dressed and groomed. Resident #5 was not able to answer any of the surveyor's questions based on her condition. Interview on 03/19/25 at 1:25 PM with RN D revealed he cared for Resident #5. RN D said Resident #5 was prescribed the antidepressant Sertraline and was receiving it as far as he knew, but she was not having any adverse effects from it. Interview on 03/20/25 at 1:17 PM with the MDS Coordinator revealed she was responsible for ensuring care plans were completed and accurate. The MDS Coordinator said Resident #5's use of an antidepressant should be addressed on her care plan. The MDS Coordinator said the purpose of that was so that staff could implement all things related to her care, such as her medications she received. The MDS Coordinator said if Resident #5's care plan did not address her use of the antidepressant staff might not know what her care goals were. The MDS Coordinator said she had been previously trained to ensure resident's care plans were complete and accurate. Interview on 03/20/25 at 3:08 PM with the DON revealed Resident #5's use of an antidepressant should have been care planned. The DON said the MDS Coordinator would have been responsible for ensuring Resident #5's care plan was complete and accurate. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, reflected: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration of his willingness to eat then a change in condition which included him becoming unresponsive. At the hospital, Resident #1 was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility charge nurses across all shifts failed to check Resident #1's blood glucose when he experienced a decline and a change of condition during the two weeks after an abnormal lab glucose value of 334 on 09/17/24 to being sent out to the hospital on 10/06/24. Additionally, the facility did not contact the MD or NP to notify them of the elevated blood glucose level. Only prior to calling sending Resident #1 to the ER, did the charge nurse attempt to check Resident #1's blood glucose, but it could not register on the glucometer and indicated HI [high]. 3. The facility failed to have routine blood glucose monitoring in the facility via daily, weekly or monthly checks for Resident #1 for the past 12 months. 4. The facility failed to have a system in place to routinely monitor Resident #1 blood glucose via an A1C lab every six months. An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLS to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication). Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP when she completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on 01/29/22 when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital . At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on 01/29/22. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's clinical chart reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was readmitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 (reference range is 65-110). Record review of Resident 1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP were notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Dietary and nursing progress notes after the elevated blood glucose level reflected Resident #1 was not eating; the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation from reflected he was admitted to theER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3 (three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CMP, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and high sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good on that sugar, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization , the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's attending ([NAME]) for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now has a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow up interview with the DON on 10/23/24 at 12:38 PM revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so Physician B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with Physician B on 10/23/24 at 1:33 PM, revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. Physician B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, Physician B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 9/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew Resident #1 had an BMP lab ordered, but was not aware of the results. She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-horu communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1Csevery six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with some other weekend nurse on the hall. They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do nothing. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A is Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? RN A responded to that CNA that she was overridden by the DON. CNA F stated, Now he was getting worse, [RN A] ended up sending him out. I told her he is a full code and has been like this all day and you have let this happen your whole shift and passing it along to the next shift, so she finally sent him out. It look [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of five residents reviewed for neglect. 1. The facility neglected to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on 10/06/24 and was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C (three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility neglected to have a system in place for Resident #1, who was no longer on hyperglycemic medication, to have routine blood glucose monitoring in the facility via daily, weekly or monthly checks for the past 12 months. 4. The facility neglected to complete an Hemoglobin A1C on Resident #1 every six months to monitor any increases in his blood glucose. An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLS to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication) Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP when she completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on 01/29/22 when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital . At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on 01/29/22. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's clinical chart reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was readmitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 (reference range is 65-110). Record review of Resident #1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP were notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Dietary and nursing progress notes after the elevated blood glucose level reflected Resident #1 was not eating; the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation reflected he was admitted to theER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3(three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM, revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CMP, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and high sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good on that sugar, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization , the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's attending ([NAME]) for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now has a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow-up interview with the DON on 10/23/24 at 12:38 PM revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so Physician B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with Physician B on 10/23/24 at 1:33 PM revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. Physician B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, Physician B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 9/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew Resident #1 had an BMP lab ordered, but was not aware of the results. She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-hour communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1Csevery six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with some other weekend nurse on the hall. They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do nothing. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A is Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? RN A responded to that CNA that she was overridden by the DON. CNA F stated, Now he was getting worse, [RN A] ended up sending him out. I told her he is a full code and has been like this all day and you have let this happen your whole shift and passing it along to the next shift, so she finally sent him out. It looked like he was dying. He had never been like that before. He had been declining for that past week since I had taken care of him, not eating. CNA F said she had told the weekday nurse earlier in the week to see if maybe they could do a UA or labs, but she did not know if any of that got done. CNA F stated, He should have been sent out Saturday. If the DON would not have intervened and said no, he would have been able to be sent out the day before things [TRUNCATED]

Based on observation, interview, and record review, the facility failed to consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for resident rights. The facility failed to notify the MD when Resident #1, who was a diabetic resident, had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on 10/06/24 and was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C (three month average of blood sugar) of 13 (normal range is below 5.7). An Immediate Jeopardy (IJ) situation was identified on 10/23/24 at 4:42 PM. The IJ template was provided to the facility's Administrator on 10/23/24 at 4:50 PM. While the Immediate Jeopardy was removed on 10/25/24, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's Face Sheet dated 10/23/24 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with active diagnoses that included Type 2 Diabetes, Hemiplegia and Hemiparesis (weakness on one side of the body), Aphasia (a communication disorder that impairs a person's ability to process language), Dysphagia (difficulty swallowing), Systemic Lupus Erythematosus (a chronic autoimmune disease that can cause severe fatigue and joint pain), Hyperlipidemia (high levels of fat in the blood), Vascular Dementia (a type of dementia caused by brain damage due to impaired blood flow), Epilepsy (seizure disorder), COPD (persistent respiratory symptoms like breathlessness and cough), Functional Quadriplegia (complete immobility due to move )Atherosclerotic Heart Disease (heart disease where plague builds up in the arterial walls). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected minimal difficulty with hearing, unclear speech, sometimes understood and usually understood others, and no vision issues. Resident #1 was assessed as having a BIMS score of 15. He had no mood issues, no behaviors, psychosis, rejection of care or wandering. Resident #1 had range of motion impairment in both sides of his upper and lower extremities. Resident #1 used a wheelchair for mobility and was dependent on staff for all ADLs to include dressing, hygiene, transfers, eating and basic mobility. Resident #1 was always incontinent of bowel and bladder, he had a gastrostomy tube (a surgically placed device that provides direct access to the stomach for supplemental feeding, hydration or medication). Resident #1's assessment reflected he was not prescribed any insulin during the assessment period. Record review of an updated BIMS form in Resident #1's clinical chart completed on 10/21/24 by the SLP completed he Speech therapy assessment reflected a BIMS score of 00, which indicted severe cognitive impairment. Record review of Resident #1's care plan initiated 01/11/22 and last revised on 10/07/24 reflected, [Resident #1] has the potential for complication hypo-hyperglycemia r/t Diabetes, Date Initiated: 02/11/2022/Revision on: 08/02/2022; .Interventions: Resident will be free from s/s of hypo-hyperglycemia daily through next 90day review (Date Initiated: 02/11/2022, Revision on: 09/30/2024), Blood glucose as ordered (Date Initiated: 10/21/2024), Labs as ordered (Date Initiated: 02/11/2022), Monitor for s/s of HYPERGLYCEMIA i.e polyuria, polydipsia, dimmed/blurred vision, fruity breath, nausea, vomiting, abdominal pain, extreme weakness, confusion, stupor, weight loss-HYPOGLYCEMIA i.e.: tachycardia, palpitations, cool/clammy skin, diaphoresis, nervousness, tremors, lethargy, vision changes (Date Initiated: 02/11/2022), Notify MD at once if s/s occur (Date Initiated: 02/11/2022). Record review of Resident #1's physician orders for the past 12 months (10/01/2023 through 10/23/2024) reflected no orders for insulin, oral diabetic medication, blood glucose monitoring or routine A1C labs. Resident #1 did not have a physician's order to check his blood glucose routinely or PRN. (Note: Hypoglycemia occurs when the glucose levels in the blood are elevated, typically above 180 to 200 mg. If not managed, it can lead to severe complications such as nerve damage, kidney failure, and cardiovascular diseases). Review of Resident #1's clinical chart to include previous hospital documentation, revealed that part of his pertinent medical history occurred when he went to the hospital on 01/29/22 when he experienced a change of condition at the facility. At that time, he was not a known diabetic and it was not a diagnosis listed in his clinical chart at the facility nor at the hospital. At the hospital, he was UA positive for high white blood cell count and a rare bacteria (name not listed in hospital documentation), his A1C was 7.9 and his blood glucose was 611 and he was septic due to likely severe dehydration. Resident #1 was stabilized and discharged back to the facility with new orders for insulin to be administered and a diagnosis of diabetes mellitus. Record review of nurse practitioner encounter progress note dated 10/26/22 by a previous extender for MD G reflected she reviewed Resident #1's past medical history, which she documented had not been done since 02/05/22. The DNP reviewed Resident #1's previous stay at the hospital on 01/29/22. The DNP stated that Resident #1 had been admitted to the ER due to weakness, cough, SOB, low sats and hypotension. The DNP noted Resident #1 was started on sepsis protocol at the hospital and antibiotics and was admitted to ICU. His labs showed a glucose of 611 and he was admitted with severe dehydration, sepsis, hyperglycemia, AKI, hypotension and metabolic acidosis. The DNP documented that on 08/10/22, the facility staff asked if the insulin Lantus could be discontinued. DNP stated, Pt seen in dining hall, doing well, no complaints. BS trends reviewed, BS well controlled with some BS on low side. Lantus d/c'ed. There was no documentation to reflect if Resident #1 would continue to receive routine or periodic blood glucose monitoring at the facility to monitor his diabetes. Record review of Resident #1's e-chart under the vitals sections reflected the following blood glucose readings were last ones recorded and taken by the facility and were over a year old: (10/05/2023)-BS 142, (09/07/2022 two years earlier)-BS 100. Prior to that, Resident #1's blood glucose was being taken three to four times a day by the nurses since his discharge from a ER hospital stay on 01/09/22 when he was readmitted to the facility and he was receiving a diabetic-formulated enteral feed as a supplement through his g-tube daily. Blood glucose readings during that time vacillated from 74 at the lowest to 295 at the highest, all while he was being administered insulin on a routine basis to control his hyperglycemia. There was no evidence that the blood glucose checks were discontinued by the MD in 2022 and 2023. Record review of Resident #1's completed metabolic panel lab completed on 09/17/24 reflected a high glucose level of 334 [reference range is 65-110). Record review of Resident #1's nursing progress notes after the abnormal lab value for his blood glucose on 09/17/24 reflected there was no documentation that the MD or NP was notified of Resident #1's elevated blood glucose or that his blood glucose was checked by the charge nurses after that. Record review of progress notes after the elevated blood glucose level on 09/17/24, reflected Resident #1 was not eating and the speech therapist was notified and his diet was changed to finger foods. Resident #1 continued to not eat and sustained a fall after losing his balance. On 10/06/24, he was noted in a nursing progress note to be throwing up and hiccupping continuously. At that time, his vitals were taken and were: Blood pressure 122/64, Pulse 99, Respirations 20, Temperature 97.8, Oxygen saturation at 97. On 10/06/24, Resident #1 was not able to eat breakfast and refused when the staff attempted to feed him. His attending physician [MD G] was notified and gave a new order to start IV Nacl0.9 % @ 100 ml/hr. x 2 liters, CBC, CMP and UA Stat. The progress note reflected, In a little moment before IV inserted, resident observed lethargic, more confused, B/S was reading HI on the machine, then started having SOB, [MD G] called again and recommended resident to be send out to ER [written by RN A]. Record review of Resident #1's hospital documentation reflected he was admitted to theER on [DATE] at 2:18 PM. In the critical care unit, he was diagnosed with DKA (diabetic ketoacidosis) and severe sepsis. Resident #1's blood glucose was 1139 and his A1C was 13. Hospital documentation by the physician reflected a concern that Resident #1 was diabetic and his decline was, Likely triggered by infection, ? Compliance, not clear that SNF was giving insulin- Fluid resuscitation with 2100 L NS bolus EMS and ED. Resident #1 received hourly finger sticks initially upon admission to the hospital and was placed on an NPO diet until the DKA resolved. Resident #1 was started on Lantus. Resident #1 met the Sepsis criteria and was administered antibiotics which included Rocephin by EMS and Zosyn and Vancomycin in ED. Resident #1 was also diagnosed with an AKI (acute kidney injury) which was noted to likely be secondary to severe dehydration. The ICU physician documented that all interventions provided by the hospital were necessary to prevent further life-threatening deterioration and/or death from conditions listed in the assessment and plan. Resident #1 remained in ICU for four days. On 10/10/24, Resident #1 was seen in the hospital by the Nephrologist who documented Resident #1 had Hyperkalemia, Likely secondary to uncontrolled blood sugars and potassium shifts. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders for insulin glargine-Lantus 100 unit/mL injection-Inject 20 Units under the skin daily (start 10/18/24) and insulin lispro-Humalog Inject 0-15 Units into the skin 3(three) times daily with meals (start 10/18/24). An interview with the Administrator and DON on 10/23/24 at 9:40 AM, revealed Resident #1 was sent to the hospital because he was unresponsive, sweating and had vomited. When he arrived at the ER, the hospital found him to have a high blood sugar and urine concentration. The family told the Administrator and DON Resident #1's blood glucose was over 1,000 and he was dehydrated. The DON stated Resident #1 had a peg-tube that was used for flushing and for administering his Keppra medication since he did not like the taste of it. The DON stated his peg-tube was flushed four times a day to make sure he was well-hydrated. The DON stated Resident #1 was also on two cans of Glucerna a day and he ate three meals a day with no restrictions and could drink by mouth. The DON stated she started employment at the facility in April 2024 and found that one of the previous DONs discontinued Resident #1's Lantus and insulin because his blood sugars were in the 80s and 90s. Since then, the DON stated the facility was doing a CBC, CMP and A1C every six months for Resident #1 and the values were normal. She stated the facility checked labs for Resident #1 in September 2024 and his sugar was a little high, but that was drawn right after his meal. Doctor said all previous readings were good, the doctor did not give new orders. After that he was well. The DON stated on weekend after that, Resident #1 was a little tired on a Friday night and by that next Sunday the nurse reported he looked very lethargic, So we sent him out. At the hospital, the DON stated his blood sugar was high but nothing had triggered the facility to place him back on insulin prior to that. She stated Resident #1's family was upset that the facility was not checking and monitoring Resident #1's blood sugar. The DON stated she explained to the family that Resident #1's diabetes was diet controlled and he was not showing signs or symptoms of hyperglycemia and was coming to the dining room every day and eating everything. She said Resident #1's weight was stable plus the nurses were flushing his peg tube four times a day. After the hospitalization , the Administrator and DON stated they had a care plan meeting with Resident #1's RP and the doctor covering for Resident #1's primary attending physician [Phy B] for about two hours. The meeting concerned whether or not the RP wanted to re-admit Resident #1 back to the facility's care. The DON stated there was an NP or PA at the hospital who had told Resident #1's RP that he should have not been in the condition he was in, although he had been here without many real issues for the past two years. The Administrator state that he explained to the RP about labs and how doctors prescribed medications to residents based on those lab values. The Administrator stated, I think she was off guard that he wasn't taking insulin. He stated at a second meeting, the Ombudsman was present and told the facility they needed to look at how frequently CNAs correctly observed and documented his meal intake because she felt it was not accurate. The DON stated a week before Resident #1 was sent to the ER, they started noticing he was being picky and they changed his diet to finger foods and he was doing okay with it. The Administrator stated Resident #1 was in the ICU for a while, But our system worked; we identified, sent him out and they saved his life. Since his discharge from the hospital back to the facility, the DON stated Resident #1 now had a continuous order for g-tube feedings during the night, 150 cc of water flushes every four hours, blood glucose checks three times daily and an order for Lantus sliding scale plus Lantus 20 units every morning. The DON stated that Resident #1 was not interviewable and only responded in the affirmative or negative, but not much. A follow up interview with the DON on 10/23/24 at 12:38 PM, revealed she checked Resident #1's clinical records and discontinued orders to see when Resident #1 took his last dose of insulin at the facility. She stated the last time she saw that he got insulin was the month of February 2022 and blood sugar checks were stopped at some point in 2022 but she did not know why. The DON stated there were no routine blood sugar checks for Resident #1 at the facility since then but his CBC, CMP and A1C were routinely checked. The DON stated an A1C labs gave a three month look back at a resident's average blood glucose and the last one completed was in February 2024. The DON stated, We are a little late on getting the most recent one done. There is no time-frame but is the labs are in good range or a little high, they do them every six months. More than 10 (value) for an A1C and it is critical then we do the A1C every three months. She stated Resident #1 would have been due for an A1C in August 2024. She said a BMP was done in September 2024 which showed Resident #1 had a blood glucose reading of 334 but it was right after breakfast so PHY B told the DON to look at the time of the blood drawn and did not want another one drawn. The DON stated that diabetic residents should have an A1C lab completed every six months and that is was not a policy, it was standard practice. She stated she had not read the facility's policy on Diabetic Management since she started employment as the DON. In hindsight, the DON stated, If it were me, I would have questioned the blood sugar of over 300 and maybe rechecked it if I were the doctor, but he said it was due to the resident eating breakfast. The DON could not say if anyone at the facility had re-checked Resident #1's blood sugar once the abnormal lab came back. An interview with PHY B on 10/23/24 at 1:33 PM, revealed the last time he saw Resident #1 was when he came back from the hospital in October 2024. PHY B stated, I don't recall seeing him in 2024. Usually we see the long term once a year and a NP who sees him once a month, I may not have seen him this year at all. With abnormal labs, PHY B stated sometimes the facility would text him right away, routine labs were supposed to be faxed to his office number and put in PCC and he could review the lab for the skilled residents when he came to the facility twice a week. For long-term residents, like Resident #1, the NP mostly ordered labs and were supposed to review then and if there was any action needing to be taken, they will. He stated Resident #1 was long-term, so NP C would have been the one notified of his abnormal lab, not him. Phy B stated he was not notified about Resident #1's abnormal blood sugar of 334 on 09/17/24 until after the resident had a change of condition and was sent out to the hospital and the RP voiced concerns about Resident #1's care. Phy B stated for diabetic residents, if they were not prescribed insulin, then the recommendation was for them to have a A1C every six months, even if they were stable with their routine blood sugar checks. He stated that monitoring guideline was from the geriatric college of medicine and the blood glucose values for residents in a long-term care facility were done twice a year. Phy B stated he had gone back and reviewed Resident #1's chart after his ER visit and saw that he was on insulin in 2022 and at that time his sugars were running normal but it appeared that someone at that time decided to discontinue his insulin. Phy B stated that was not unusual because, We all know in diabetic patients they have a honeymoon period where their blood sugars are okay and we continue to monitor and take them off treatment because we don't want low blood sugars in nursing home patients because a lot of them can't communicate and tell us symptoms like [Resident #1]. Phy B stated once a resident's blood sugar went low and they are in a hypoglycemic state, it could be detrimental for their health, That is why we let their blood sugars run a little higher, even if the A1C is a little higher. So I think it wasn't unusual to do that and two years he did not have any problems. Phy B speculated that he felt Resident #1 had an infection which he felt was a common reason of putting a person into DKA-diabetic ketoacidosis, and Resident #1 also had a wound at the hospital which could have contributed to it as well. Phy B then stated, The only thing I identified to be honest with you, could still be the same outcome on our end, I am the first one to take blame, there wasn't oversight on our part that the A1C was not done in 6 months, it had last been done in February and it should have been done in August so we take blame for that. I told the [RP] that as well because it happened on my watch and I was supposed to oversee his care. It is a problem and I have asked the DON to implement a protocol for A1C every six months. So now, since this happened, we have asked the facility on their end to put an automatic protocol where they do them every six months- hemoglobin A1C. Phy B said the only thing he saw missing in Resident #1's care was that the A1C was not completed. He said that going in DKA was possible even in a fully controlled diabetic resident in a few days to a few hours, however, it was an unfortunate thing that happened and he took full responsibility for the lab not being done, it was a mistake and the facility was rectifying the problem. Phy B said that it would be hard to say if he would have acted on Resident #1's blood glucose level being over 300, he would have told the facility to check it a few more times to make sure it was not trending up. If he was trending up, then he would no longer be in the honeymoon period with his diabetes and they would need to start treating him for it. Phy B said all labs were supposed to be reviewed by himself or the NP C and for Resident #1, NP C should have reviewed them at that time. Additionally, the change of status should have been reported to him or the NP C because that was important information. If the facility did not notify him, then there is no way for him to know if the resident was having a change in condition. An interview with ADON E on 10/23/24 at 2:06 PM, revealed nothing dramatic had occurred with Resident #1 prior to him being sent to the hospital. ADON E stated Resident #1 was not on insulin and his A1C lab should be done every six months if there was no order for it. If there was a change in condition, then the facility needed to notify the doctor and get an order immediately and monitor to see if more frequent labs needed to be done. ADON E stated Resident #1's elevated CMP lab on 09/16/24 may have been higher than expected depending on if the lab tech was able ot get a fasting lab or if it was glucose random. She stated with an abnormal glucose reading over 300, the NP or MD was present in the facility each week so the charge nurse should have relayed the abnormal lab value to them and they could have given an order. The nurse then would need to document what the plan was, that there was an abnormal lab, even if no new orders. ADON E stated the reason to notify the doctor was to see if the resident needed insulin or oral medication for hyperglycemia. ADON E stated when a resident's lab was abnormal for high blood glucose, she would expect the charge nurse to assess the resident to see if they were eating or drinking well and doing their regular activities and also alert the doctor and communicate to them the results. If the resident was sweating, lethargic, then the nurse should know there was something going on and needed to check the resident's vitals and maybe their blood sugar. She stated, Maybe they didn't check his glucose because he had been stable. ADON E stated a resident with hypoglycemia would present with lethargy, sweating and confused. She said Resident #2 was not showing any of those signs when she rounded during the mornings and no one had reported anything to her. An interview with NP C on 10/23/24 at 2:25 PM, revealed she was made aware of Resident #1's change in condition when he came back from the hospital and the facility had informed her that there were going to be new protocols that would be implemented. NP C stated the issues had to do with some lack of oversight on the facility and on her/Phy B's end like Resident #1 could have had an A1C a little sooner. NP C stated she saw Resident #1 occasionally and he did not seem off to her and she had not heard from the facility that he was declining. NP C stated, In the future, we need to have a protocol in place for diabetics. I don't believe I was made aware of his high blood sugar, that would have prompted me for further testing . I would have done accuchecks, A1C and a repeat BMP. NP C stated Resident #1 had not been administered insulin even though he was diabetic because he was previously diet-managed, so he was being monitored through routine A1Cs. NP C stated, We are fixing that, there should have been a routine order. NP C stated the failure was the breakdown in communication and an oversight on their part. She said if she had heard Resident #1 was not drinking or eating, she would also check for UTI, That is my standard .this one was very unfortunate for [Resident #1], it's not okay and I hope some of those measures we are taking moving forward help. An observation and attempted interview of Resident #1 on 10/24/24 at 9:45 AM revealed he was lying in bed, the fingers on his left hand were contracted, his right leg was contracted and he was not able to articulate words verbally nor was his communication device charged and functional. There was a strong smell of feces coming from him. At the time of the observation, Resident #1 could not answer questions related to his diabetic care and change of condition that sent him to the hospital. He tugged on his bed sheet and motioned to some dark brown spots on it. When asked if he made a bowel movement and needed to be changed he nodded his head yes. After that, Resident #1 did not respond to any more questions. An interview with the DOR on 10/24/24 at 12:29 PM revealed Resident #1 had expressive aphasia and could only speak a few words. The DOR did not specify a specific time/date, but stated before Resident #1 was sent to the hospital, the staff had come to her within a week or so prior saying that he was not wanting to eat, he complained about the food and he was sending it back to the kitchen. The DOR stated, So we adjusted for finger foods for better compliance. The DOR said Resident #1 came back from the hospital in October 2024 and was picked up for speech services. Record review of a Dietary Note dated 09/24/24 reflected, Resident was observed in the dining room during lunch time that he was not properly eating regular texture, after speaking to the resident and ST he agreed to change him to finger foods. An interview with LVN D on 10/25/24 at 12:43 PM revealed she worked with Resident #1 two days before he was sent to the hospital and to her, he did not seem different and had gone to the dining room to eat, picked at his lunch, but that was not unusual. She said she gave him supplement shakes and often had a hard time to get him to drink water. LVN D stated she knew She stated typically when a lab came back abnormal or critical, the nurse receiving the lab results was supposed to document it in a nursing note and put it in the 24-hour communication log. Then the nurse was supposed to report the results to the NP or MD and they were supposed to provide interventions or a new plan to start that resident on insulin. LVN D stated she did not know why Resident #1 was not prescribed insulin anymore. She said he had not been on insulin since she came back to work for the facility in December 2023 and she said maybe the facility thought it was controlled. With diabetics, LVN D said of they were not on insulin and not on weekly checks to make sure their blood sugars are stable, then they were supposed to get A1C every six months. She stated the MD was supposed to write that routine order into the online e-chart system and then it would generate on the MAR each time it was due. LVN D stated again she did not see much of a change in Resident #1 but could see how he became dehydrated since because it was hard for them to get him to drink water, but his blood sugars going up, I was not expecting that. An interview with CNA F on 10/25/24 at 1:35 PM, revealed she was Resident #1's CNA on the morning shifts and was present at the facility when he was sent out to the hospital. CNA F stated that whole week Resident #1 had not been feeling good, he was not eating. She took care of him every day and said he did not communicate, he did not eat, he did not want to drink water. On Saturday 10/05/24, he was still not feeling well, not eating, just lying in bed and was restless. CNA F told the charge nurse (RN A) and she looked at him but that was when CNA F was leaving for the end of her shift. CNA F stated she thought the facility would send him out to the hospital. But when she came in the next morning, Sunday 10/06/24, she went to the nurses' station and asked the overnight nurse how Resident #1 was doing because CNA F assumed he had been sent out the day prior based on his deteriorating condition. The overnight nurse said he was fine. So CNA F walked to Resident #1's room and the roommate at that time told her that Resident #1 had been making barking sounds all night long. When CNA F saw Resident #1, he was making squeaking sounds, which was unusual. He was sweating and throwing the blankets off of him. She said he was usually cold natured, so that was different for him as well. She said Resident #1 could not keep his eyes open when she tried to rouse him and talk to him. She was trying to ask him basic questions but he was not responding and was making a hiccupping sound. CNA F said the roommate told her no one came to check on Resident #1 throughout the night prior. CNA F then went to the overnight nurse again and told her that Resident #1 did not look right. The overnight nurse went to check on him along with another weekend nurse on the hall (name unknown). They checked Resident #1's oxygen saturation levels which were at 78. He was given oxygen and the nurses re-checked his O2 and it was still down at 78. It eventually started to come back up but he was still making the strange noise and then started throwing up watery yellowish bile, Like someone who had not eaten for a long time. CNA F said the morning nurse, RN A (same nurse as day before) came onto the floor and checked on him. CNA F said she told RN A the way Resident #1 was looking, he needed to be sent out. RN A then told CNA F she was going to send him out and contacted the DON and said Resident #1 was not looking good. The DON then told RN A, per CNA F, no, do not send him out because the facility's census was low, so RN A did not send him out to the hospital. Instead, CNA F said RN A said she would get an order for an IV and she did, but she did not know how to insert the line. CNA F said she was present and RN A did not even attempt to insert the IV. She told CNA F that she did not know how to do it, which part of the arm to access and that she could not find a vein. CNA F stated, I am asking her you are not going to send him out? And she says I need to try the IV with water, then that was when she said she didn't know how. So then, she didn't do anything. CNA F stated RN A tried to check his blood sugar, then told CNA F that Resident #1 might not even be a diabetic. She stated she was present when RN A and another nurse were in the room trying to get a blood sugar reading when the other nurse asked RN A if Resident #1 was a diabetic and RN A responded no. CNA F stated she never heard them say a blood sugar out loud, so she did not think they were able to get one. CNA F then stated later on, It was so frustrating because he was weak and now it's noon and he can't hold up his arms or legs. Around noon, CNA F said she was shaking Resident #1, his eyes would not open and he was breathing fast. She said told the nurses if his RP found out Resident #1 was in that condition, she was going to be very upset. CNA F stated, I said you got to send him out! She said at this point, the 2-10pm CNAs were coming into work and one of them tells her, wow, he is still like this? RN A responded to that CNA that she was overridden by the DON. CNA F stated, Now he was getting worse, [RN A] ended up sending him out. I told her he is a full code and has been like this all day and you have let this happen your whole shift and passing it along to the next shift, so she finally sent him out. It looked like he was dying. He had never been like that before. He had been declining for that past week since I had taken care of him, not eating. CNA F said she had told the weekday nurse earlier in the week to see if maybe they could do a UA or labs, but she did not know if any of that got done. CNA F stated, He should have been sent out Saturday. If the DON would not have intervened and said no, he would have been able to be sent out the day before things got worse. Record review of the facility's Diabetes-Clinical Protocol policy, revised November 2020, reflected: .Monitoring and [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had impaired cognition and was a high fall risk, was provided with adequate supervision to prevent her from eloping from the facility. On 10/16/23 Resident #1, who resided on the second floor and used a wheelchair for mobility, used the stairs to get to the bottom floor and was found outside of the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 10/16/23 and ended on 10/20/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 10/30/23, revealed the resident was an [AGE] year-old female, who was admitted to the facility 02/21/2022. Resident #1 had diagnoses which included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes (elevated levels of blood sugar), unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was 00, indicative of severe cognitive impairment. Resident #1 normally used a wheelchair for mobility. Record review of Resident #1's care plan, dated 10/04/23, reflected: Focus: Revised Date: 08/07/22 Resident is at risk for spontaneous fractures r/t my diagnosis of Osteoporosis, osteoarthritis and being a high risk for falls. Goal: Resident will be free from injury/complications r/t osteoporosis daily through next 90-day review. Interventions: Assist with mobility as needed and using assistive devices. Focus: Revised Date: 03/10/2023 Resident at risk for falls r/t to my poor balance, weakness, dementia and osteoarthritis. Non-injury fall on 11/13/22 - trying to get out of bed independently. Resident actual had a fall on 02/22/23. Actual fall 03/09/23. Goal: I will be free from falls during my stay. Interventions: Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Provide me with assistive devices for mobility as needed. Focus: Date Initiated: 10/01/23, Revised 10/30/23: Resident is at risk for elopement looking for people and things that aren't here., Not being able to make good safety decisions. 10/16/23 Goal: I will remain safe within the Unit thru my next review. Goal: At risk for elopement related to: History of Elopement, Wandering. Goal: Will remain safe during placement at facility. Interventions: Encourage family to bring in personal possessions. Involve patient in preferred activities. Redirect patients from doors. Focus: Date Initiated: 10/16/23 Resident is an elopement risk/wanderer as evidenced by History of attempts to leave facility unattended, Impaired safety awareness, Intrudes on the privacy or activities of others. Goal: Resident will be able to be redirected when wandering. Resident will be safe at facility. Interventions: Involve resident in group activities. Provide resident with safe place to wander if necessary. Encourage resident to stay in common areas of building for observation if needed. When wandering, redirect resident to another activity. Focus: Date Initiated 10/17/23 At risk for elopement related to: History of Elopement, Wandering. Goal: Will remain safe during placement at facility. Interventions: Redirect patients from doors. Focus: Date Initiated 10/17/23 Patient is at risk for falls/injuries r/t cognitive impairment, fall history, gait and balance. Goal Resident will acknowledge risks for falling and agree to prevention strategies. Noncompliance with safety needs. Resident will have no falls/injuries daily through next 90day review. Safety measures will be maintained to prevent or lessen any injury from fall. Interventions: Assess for any adaptive equipment needed. Encourage use if necessary. Focus: Date Initiated 10/17/23 At risk for injury d/t wanders: Goal: Resident will be able to be redirected when wandering. Resident will be safe at facility daily during stay. Interventions: Encourage resident to stay in common areas of building for observation if needed. Record review of the facility Incident by Incident report, from 08/01/23 - 10/30/23, revealed Resident #1 eloped on 10/16/23. Review of the facility's Provider Investigation Report dated 10/21/23 reflected the following: Incident Date 10/16/23 at 11:00 AM Social Worker saw Resident #1 ambulating outside the 500 Hallway exit stairwell, presumably after having descended the stairwell from the resident hallways upstairs. This occurred on Monday, October 16, around 11am. Social Worker brought resident back into the facility and close to the nurses. It appears that resident was able to exit the 500 Hallway stairwell after walking down the stairs by herself. Staff reported that they didn't hear an alarm sound, but it's possible that the alarm was drowned out by other call lights or alarms going off at the time. The Assigned CNA of that hallway was, at the time, having a conservation with Director of Nursing and Administrator in the DON office downstairs. Other staff on the second-floor report not hearing alarm that sounds when exit doors pushed. All staff training regarding alarm sounds are responses. Front entryway also locked at all times going forward with codes available for able to minded to enter and exit. Secondary alarms installed to ensure sufficient alarms will sound. Total Fire was contacted to adjust setting on the alarm system. Elopement Books were created and placed at the nurse's station. All residents were reviewed with new wander/elopement assessments. Record review of Resident #1's Elopement Risk Assessment Tool completed on 07/14/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently with or without the use of an assistive device. Resident #1's was cognitively impaired with poor decision-making skills. Resident #1 assessment summary revealed resident was not at risk for elopement. Record review of Resident #1's Elopement Risk Assessment Tool completed on 10/16/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently with or without the use of an assistive device. Resident #1 have hearing, vision, or communication problems. Resident #1 had wandering behaviors. Resident #1 verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors. Resident #1 was at risk for elopement and wandering. Record review of Resident #1's Pain Assessment-Post Incident completed on 10/16/23 revealed no pain reported. Record review of Resident #1's progress notes, documented by RN A on 10/16/23 at 14:41 [2:41PM], reflected: Resident exited the facility through the 500 Hall emergency exit door to the parking lot. She was seen by a staff member and assisted back in the building. On assessment resident has no visible injuries and denies pain. [family member] notified. Record review of Resident #1's progress notes, documented by Social Worker on 10/16/23 at 17:14 [5:14PM], reflected: Seen resident outside, holding on the wall on the side of the building I ran over and gave her my jacket because she said she was cold called DON to let her know that [resident] was outside in her wheelchair was not with her, DON and CNA came with wheelchair. We assist resident back upstairs to her floor. We noticed that she came down. Service hall 500 wheelchair was on top of the steps. [Resident] went downstairs to get outside to the side of the building. Nurse assist [resident] to make sure she does not have any bruising on her. Make sure she was not in pain check vitals Social worker educated staff on elopement reached out to [family member] to notify her about the elopement her that we was concerned that we think that is best for her to go to a memory care unit that has a lockdown system, [family member] would like to go over therapy notes to see how her mother went down the steps. She stated that she will notify me on her next step. If she decides to move her mom. Observation and interview on 10/30/23 beginning at 9:43 AM revealed Resident #1 in the hallway sitting in her wheelchair. Resident #1 was not a good historian and could not recall leaving the facility. Resident #1 denied having any pain. Observation from the 500 Hall stairwell exit door of the facility on 10/30/23 at 10:40 AM revealed exit door on the second level had a 15 second egress release followed by an alarm. Observed a two-story stairwell that leads to the 100 Hall and an exit door. The exit door was located on the left side of the main entrance door. There was some landscaped grass and a small parking lot in front of the facility and then the main service road. Observed the 100 Hall and 500 Hall to have an additional alarm on the back of the door. Interview on 10/30/23 at 11:02 AM with the Maintenance Director revealed when he was made aware of Resident #1's elopement, he was called to check the exit doors and he found all the exits door to be operating correctly. The Maintenance Director stated he was surprised to know Resident #1 was able to go down the stairs, he stated he had never seen Resident #1 walk before. He stated Resident #1 would always be in her wheelchair. The Maintenance Director stated it is unsure how she was able to open the door and the alarms did not go off. He stated he believed someone had gone through the door earlier but had not pulled it all the way to ensure it latched and that was why it did not sound. The Maintenance Director stated staff are not allowed to use the fire exit stairwells, and if they do, they will get a write up. The Maintenance Director stated all the exit doors codes were changed monthly and he would check the doors weekly. He stated after Resident #1's incident, all the exit doors are checked daily by nursing staff and himself. He stated they have added additional alarms on the exit doors that will sound if the doors are not latched within 30 second after being open. He stated he had conducted alarm drills with the Administrator, he stated the drills consist of him opening an exit door and the nurse assigned to the hall will call code pink and find the missing resident. He stated he had conducted 2 drills, he stated they were supposed to have one today 10/30/23; however, the Administrator was out today, so they will complete the drill tomorrow. Interview on 10/30/23 at 11:10AM with RN A revealed he was the nurse assigned on 300 Hall and was the nurse for Resident #1 on 10/16/23. RN A stated on 10/16/23 he was called by the Social Worker and she informed him Resident #1 was found outside leaning on the door by the 500 Hall stairwell exit. RN A stated he had asked Resident #1 how she was able to exit the facility; however, resident would only speak Spanish and it was hard to understand her. RN A stated Resident #1 wheelchair was found by the stairwell on the 500 Hall exit door. RN A stated the last time he observed Resident #1 was around 11:00 AM - 11:15 AM around the nurse's station. RN A stated he could not recall the exact time but it was before lunch time when the Social Worker contacted him. He stated it had to be prior to 11:35 AM because that was the time, he had contacted the doctor to notify him of the elopement. RN A stated Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. RN A stated he was surprised to know Resident #1 was able to ambulate and made it down the stairwell from the second floor. He stated Resident #1 was assessed and no injuries were noted. He stated he did not hear any alarms going off. An attempt was made to contact CNA B on 10/30/23 by phone; however, there was no response. Interview on 10/30/23 at 11:58 AM with CNA E by phone revealed she was the CNA assigned on 300 Hall on 10/16/23. CNA E stated Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. She stated she was on break when Resident #1 eloped. CNA E stated she could not recall the exact time she last seen resident prior to her elopement. CNA E stated when she returned from break Resident #1 was on the hallway around noon. She stated around 1:30 PM she assisted Resident #1 with her ADL's and she appeared fine and did not complain of any pain. CNA E stated she was informed Resident #1 exited through the 500 Hall exit door. She stated she did not hear any alarms go off. Interview on 10/30/23 at 12:23 PM with Social Worker revealed on 10/16/23 around 11:15 AM -11:20 AM she was at the pharmacy store parking lot located next to the facility and from far away she observed someone leaning on the wall closed by the 500 Hall exit stairwell door. She stated the 500 Hall exit stairwell door is located on the left side of the entrance door to the facility. Social Worker stated when she arrived at the facility, she observed it was Resident #1 leaning on the wall. She stated she approached Resident #1 and asked her how she got out; she stated Resident #1 was not able to say how but only said she was cold and wanted to get back inside. She stated she immediately contacted the DON and asked her to bring a wheelchair outside. She stated they took Resident #1 inside around 11:30 AM and was assessed by the nurse. She stated no injuries were noted. Social Worker stated they found Resident #1 wheelchair on the stairwell of 500 Hall. Social Worker showed Surveyor a picture from her phone with a timestamp of 11:42 AM of how they found Resident #1 wheelchair being at the edge of the stairwell on the second floor. She stated when they opened the exit door from the 500 Hall the alarm went off, so they believed someone had gone through the door earlier but had not pulled it all the way to ensure it latched and that was why it did not sound. Interview on 10/30/23 at 12:59 PM with the DON revealed Resident #1 used her wheelchair for mobility and was known to wander around the halls but was not known to exit seek. She stated Resident #1 had been working with therapy and has been able to move more and walk with assistance. The DON stated this was the first time Resident #1 had eloped. She stated Resident #1 was last seen right before lunch time around 11:15AM in the hallway. She stated the facility Social Worker found her outside around 11:25 AM. The DON stated Resident #1 was outside for less than 10 -15 minutes. The DON stated they found Resident #1 wheelchair by the 500 Hall stairwell. She stated no one heard any alarms. She stated all staff were re-educated on code pink and alarm drills were done by the Maintenance Director and the Administrator so all staff knew what to do in case a resident went missing. She stated exit door checks were being done daily by the Maintenance Director. Additional alarms were placed on the doors. She further stated there was an elopement assessment done on all the residents after the incidents and there was one additional resident identified and measures were put in place to prevent any further incidents. She stated Resident #1 was placed on 15 minutes safety checks for about 10 days to ensure no other elopement behaviors. Interview on 10/30/23 at 3:26 PM with the Administrator via phone call revealed on Monday 10/16/23 at around 11:00 AM the Social Worker found Resident #1 outside the facility by the 500 Hall stairwell exit. The Administrator stated his understanding was Resident #1 exited through the fire stairwell on the 500 Hall. He stated Resident #1 walked down the stairwell by herself. The Administrator stated there are two doors at the bottom of the stairwell one that leads to the 100 Hall; however, a code was needed to open the door and the other door leads to the outside of the facility. He stated the CNA on the 500 Hall was CNA B; however, during the elopement CNA B was in the DON's office. He stated the exit doors had a 15 second egress in which an alarm will sound if code is not put in and the alarm will stop after 15 seconds. He stated staff are not allowed to use the fire exit stairwells. The Administrator stated Total Fire completed their quarterly fire alarm testing on 10/27/23 and he was able to consult with them regarding additional security alarms. However, in the meantime he had implemented additional alarms on the back of the doors that will go off after 30 second if the doors are not latched correctly. This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/30/23 at 4:45 PM. The DON and the Social Worker were notified. The DON was provided with the IJ template on 10/30/23 at 5:00 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 10/16/2023, Resident Safety Checks, Wandering and Elopements, Monitoring Wandering patients, Elopement binders at the nurse stations and Ensure Exit Stairwells are secure. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Interviews on 10/30/23 from 11:10 AM through 5:20 PM with RN A, Social Worker, CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, LVN I, LVN J, CNA K, LVN L and CNA N who work the shifts of 6:00 AM-2:00 PM and 2:00 PM-10:00 PM were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, emergency preparedness missing person/elopement drills, and door checks. Observation on 10/30/23 at 10:40 AM and then 5:45 PM revealed exit doors on the second level were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There was an additional louder alarm added so they could be heard throughout the facility, if the doors do not latch after being open within 30 seconds the second alarm added will sound. To turn off the alarm a code must be put in. Record review of the facility Resident Safety Checks every 15 minutes for Resident #1, start date 10/16/23 at 12:15 PM through 10/26/23. Record review of the facility Exit alarms checks; All exits, starting date 10/16/23 through 10/30/23, revealed door checks were conducted by Maintenance Director and Nursing staff. Record review of the facility Resident Safety/Exit Alarms drills revealed drills were conducted by the Administrator on 10/16/23 and 10/20/23. Record review revealed an elopement assessment was completed on all the residents on 10/16/23 to identify any additional risk residents. One additional resident was identified as being at risk for elopement. Record review of facility Elopement binder located on the first and second floor nurses station revealed two residents face-sheets which one was Resident #1 being at risk of elopement. Record review of the facility's Elopement/Unsafe Wandering policy and procedure, revised March 2019, reflected the following: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .

Based on observation, interview, and record review, the facility must ensure residents were free of any significant medication errors for two (Residents #1 and #2) of five residents reviewed for medications. 1. LVN A failed to transcribe correct physician orders [REDACTED]. 2. RN B failed to transcribe correct physician orders [REDACTED]. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the abbreviated survey. The deficient practice occurred on 01/14/18 to 03/09/18. The failure could affect the three residents, who received their medications from LVN A and RN B, by placing them at risk for adverse drug reactions. Findings included: 1. Review of Resident #1's MDS assessment, dated 03/12/18, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's Provider Investigation Report, dated 02/05/18, revealed: On 1/31/18 the resident (Resident #1) complained of pain in her right knee .Nurse obtained orders from physician to x-ray and get a doppler (ultrasound) of the knee. Results of the doppler revealed a blood clot .After a chart review was completed by the DON, the following findings were identified; resident was sent to the hospital emergency room for excessive nose bleeding on 1/14/18, she returned from the hospital with a new order to hold Aspirin (anti-[MEDICAL CONDITION]/blood thinner) and Xarelto (blood thinner) for 2 days due to excessive bleeding. (LVN A) discontinued the orders to assure that the medications were held, however she failed to write an order to restart the medications after 2 days. In-services were initiated with staff regarding the process to discontinue, hold, and restart medications. Review of Resident #1's Nurse Notes revealed: 01/13/2018, 11:49 p.m. At 7:00 p.m. observed guest (Resident #1) with large amount of nose bleed .Physician notified, gave order to send guest to hospital for further evaluation. 01/14/2018, 10:52 a.m. Resident returned back from hospital at 8:30 a.m. 01/14/18, 12:38 p.m. Per hospital report, resident's Aspirin and Xarelto are to be on hold for 2 days. - LVN A. 01/31/2018, 11:41 a.m. Received new order for venous doppler to right knee for evaluation due to swelling and warmth to area . 01/31/2018, 4:40 p.m. Medication error noted, notified Physician of findings . 01/31/2018, 10:20 p.m. New order for [MEDICATION NAME] (blood thinner) 40 milligrams ordered due to blood clot to right knee. Review of Resident #1's MAR indicated [REDACTED] Aspirin 81 mg daily - The aspirin was administered on 01/01/18 through 01/13/18 only. Xarelto 10 mg daily - The Xarelto was administered on 01/01/18 through 01/13/18 only. Review of Resident #1's Doppler studies revealed: 01/31/18 Blood clot in the right mid superficial femoral vein. (Blood clot in the right leg.) 02/23/18 Normal bilateral lower extremity venous duplex ultrasonography. (Blood clot resolved.) Interview with LVN A on 03/27/18 at 12:27 p.m. revealed on 01/14/18 she received a report from the hospital which instructed her to hold Resident #1's blood thinners (Aspirin and Xarelto) for two days. LVN A reported instead of putting the medications on hold, she discontinued both medications and forgot to write orders to start the medications again two days later. Interview with the Administrator and ADON on 03/27/18 at 1:20 p.m. revealed when a nurse received an order to hold a medication, the nurse was supposed to discontinue the current order and write the new order with the new start date. 2. Review of Resident #2's MDS assessment, dated 02/21/18, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #2's Provider Investigation Report, dated 03/09/18, revealed: Administrator and DON determined that (RN B) .transcribed orders from medication list received from discharging facility .(RN B) admitted she transcribed the medication orders from the list received from the discharging facility and she did not notice that the name at the bottom of the five page list was not that of the patient she was admitting .Facility notified the attending physician and director of case management at the hospital where patient was currently admitted . Per attending physician and director of case management, patient's admission to the hospital was not related to any adverse reactions or harm caused by the medications the resident had received in error. Review of Resident #2's admitting orders, dated 02/14/18, revealed the resident was admitted with the wrong medications. The medications belonged to a different resident at the discharging facility: [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] DM (cough suppressant/[MEDICATION NAME]), [MEDICATION NAME] (anti-convulsant), [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (for [MEDICAL CONDITION] reflux disease), [MEDICATION NAME] (for cholesterol lowering), [MEDICATION NAME] (for [MEDICAL CONDITION]), [MEDICATION NAME] sulfate (iron supplement), [MEDICATION NAME] (for [MEDICAL CONDITION] arthritis or ulcerative [MEDICAL CONDITION]), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (for nausea/vomiting), Tylenol #3 (opioid pain reliever), [MEDICATION NAME] (anti-convulsant), [MEDICATION NAME] insulin, Toujeo injection (insulin), Rocalcitrol (Vitamin D3), and Vitamin B12 injection. Review of Resident #2's MARs, dated (MONTH) - (MONTH) (YEAR) revealed the resident received the wrong medications from 02/15/18 through 03/05/18. Review of Resident #2's (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] (opioid pain reliever), Tylenol, [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME]/Atorvastatin (anti-hypertensive), [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (anti-depressant), [MEDICATION NAME] (cholesterol-lowering), [MEDICATION NAME] (anti-diabetic), and [MEDICATION NAME] (for [MEDICAL CONDITION]). Review of Resident #2's Nurse Notes revealed: 02/14/2018, 6:26 p.m. Guest (Resident #2) arrived at approximately 2:15 p.m. via personal transport service .Called physician to verify meds (medications) and spoke with the nurse practitioner, medications verified. - RN B 03/05/2018, 9:24 p.m. Resident started acting confused and jittery, mumbling and saying incomprehensible words .Vital signs were checked .resident transferred to emergency room . 03/07/2018, 1:43 p.m. Guest's family returned to facility to provide an update of guest's status and for a few personal belongings. Guest's daughter in law expressed concern due to hospital stating guest is receiving medication for [MEDICAL CONDITION]. Family member stated guest does not have a history of [MEDICAL CONDITION]. After reviewing clinical from transferring facility, guest admitted to facility with another resident's orders. - ADON 03/09/2018, 9:17 a.m. Spoke with DON from discharging facility in regards to Resident being sent with wrong patient's paperwork and medication orders. - Administrator Interview with RN B on 03/27/18 at 2:35 p.m. revealed on 02/14/18 the transferring facility sent the wrong MEDICATION ORDERS FOR [REDACTED]. RN B reported when a resident was admitted to the facility the admitting nurse would do the admitting orders, and a nurse manager would check them. RN B reported at the time of the error she was working as both the admitting nurse and the nurse manager. RN B reported she was no longer employed at the facility. 3. The facility took the following action to correct the non-compliance: Interview on 03/27/18 at 1:25 p.m. with the Administrator and ADON revealed in order to prevent future admission order errors, all new admission paperwork and orders were being reviewed in the daily morning meeting by the interdisciplinary team. Review of physician orders, MARs, and the clinical records of three additional residents, Residents #3, #4, and #5, who were selected due to being new admissions to the facility and requiring the use of blood thinners revealed no current pharmacy concerns regarding the correct administration of their medications. Review of in-service records revealed nursing staff received in-service training regarding the five rights of medication administration to include transcription and verification of resident names was conducted on 03/07/18. In addition to this training, the facility also conducted one-on-one staff competency checks with 13 licensed nurses specifically on medication administration to verify competency. These competency checks were conducted on 03/08/18 and 03/09/18. Interview with LVN C on 03/27/18 at 9:45 a.m., LVN D on 03/07/18 at 10:05 a.m., and LVN E on 03/07/18 at 4:30 p.m. revealed the nurses were able to correctly identify the process for transcribing new orders and the process for verifying the transcription by another staff member. Observation of LVN C during medication pass on 03/27/18 at 11:05 a.m. and LVN D on 03/27/18 at 12:00 p.m. revealed medications were given to the right resident and in the form and dose. 4. Interview on 03/27/18 at 4:45 p.m. with the Administrator revealed three residents received their medications from LVN A and RN B.