Every finding on record at Cedar Crest at North Florida

Based on observation, interview, and record review, the facility failed to ensure safe use of a mechanical lift for 2 (Resident #4 and #13) of 3 residents reviewed for accidents. Findings include: During an observation on 6/2/2026 at 8:42 AM Resident #4 was lying on his bed on top of a Hoyer pad. Staff K, Certified Nursing Assistant (CNA), was standing on the right side of the resident's bed with a mechanical lift. The mechanical lift hand bags were observed to be over the resident. No other staff member was in the room. During an interview on 6/2/2026 at 8:47 AM, Staff K, CNA, stated, I was weighing [Resident #4's name]. Normally for weights, it is only one person using the Hoyer lift. Review of Resident #4 care plan undated documented, Hoyer lift with 2 asst [assist]. During an interview on 6/4/2026 at 10:19 AM, the Director of Nursing stated, When using the Hoyer lift, staff know it is two people at all times. They know that. That is the policy that they need two. It has been two person assist for years and they know that. I don't know why they would say that [staff verbalized they are able to do weights by themselves when using Hoyer lift]. Even if they are doing just weights, they need two people when using a Hoyer lift. They know to ask a CNA for help. During an interview on 6/4/2026 at 1:38 PM with the Director of Therapy stated, When using a mechanical lift, it should always be two people; never one person. Just in case the Hoyer malfunctions. One person is going to be ensuring the patient's positioning. Any Hoyer operation should have two staff members. During an observation on 06/04/2026 at 10:15 AM, Staff D, CNA (certified nursing assistant), was standing in Resident #13's room at bedside using Hoyer lift to obtain Resident #13's weight. CNA was by himself, with no other aid or personnel in attendance. Resident was up off the bed approximately 12 inches from the mattress in the sling. During an Interview on 06/04/2026 at 10:16 AM, Staff D, CNA (certified nursing assistant) stated, I am with the restorative nursing program and today was performing weekly weights on residents. Most of the time, I do the weights using the Hoyer lift by myself. Review of Resident #13's MDS Assessment Section GG Functional Abilities documents Resident #13 is coded as Code 01 Dependent Helper does ALL of the effort. Review of the facility Sit/Stand Mechanical Lift Competency Checklist read, 2. Mechanical Lift Operation. a. Ensures two caregivers are present. Review of the facility policy and procedure titled Lifting Machine, Using a Mechanical with a last review date of 3/11/2026 read, Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observations, interviews, and record review the facility failed to follow professional standards of practice for oxygen and nebulizer treatments for 4 (Resident #29, #55, #56 and #88) of 8 residents reviewed for respiratory services. Findings include: During an observation on 6/1/2026 at 9:41 AM Resident #56 was sitting up in bed. Oxygen was being administered via nasal cannula at 4 liters per minute. The oxygen tubing was dated 5/22. [photographic evidence obtained] During an observation on 6/2/2026 at 8:10 AM Resident #56 was lying in bed with eyes closed. Oxygen was being administered via nasal cannula at 4 liters per minute. Tubing was dated 5/22. Review of Resident #56's physician order dated 4/2/2026 read, Respiratory: Oxygen-Continuous 4L nasal cannula. During an interview on 6/3/2026 at 11:40 AM, Staff J, Licensed Practical Nurse (LPN), confirmed resident was being administered oxygen and tubing was dated 5/22. During an interview on 6/3/2026 at 11:41 AM, Staff J, LPN, stated, The oxygen tubing is dated 5/22 [5/22/2026]. It should have been changed. The tubing is changed once a week every Thursday. During an interview on 6/4/2026 at 10:29 AM, the Director of Nursing stated, Oxygen tubing is changed weekly. During an observation on 6/01/2026 at 10:49 AM Resident #29 was wearing a nasal canula connected to an oxygen concentrator with a humidification/water bottle dated 5/17/26. (photographic evidence) During an observation on 6/02/2026 at 8:50 AM Resident #29 was lying in bed receiving oxygen via nasal canula. The water/humidification bottle was dated 5/17/26. (photographic evidence) Review of Resident #29's Physician Orders from 3/28/2026 through 6/01/2026 revealed the following: an order dated 5/15/2026 read, Respiratory: Oxygen - Continuous 2 liters - every shift, an order dated 3/28/2026 read, change tubing, mask and/or nasal cannula weekly. may change sooner as needed. as needed for hygiene AND every night shift every Wed (Wednesday). There was not an order for humidification related to Resident #29's oxygen. Review of Resident #29's MAR/TAR(Medication Administration Record/Treatment Administration Record) from 4/01/2026 through 6/02/2026 revealed there was not an entry related to the humidification for Resident #29's oxygen. Review of Resident #29's Census Data revealed she was initially admitted on [DATE] with the most recent readmission on [DATE] with medical diagnoses that included post-traumatic hydrocephalus, seizures, asthma and aphasia. Review of Resident #29's MDS (Minimum Data Set) Assessment, quarterly assessment dated [DATE] documents oxygen therapy and hospice services. During an interview on 6/03/2026 at 2:25 PM Staff C, LPN, stated, The humidification/water bottles for Resident #29's oxygen should be changed weekly; unless it ran out, then it would be changed that day. The humidification bottles were changed at the same time as the tubing. During an interview on 6/03/2026 at 2:35 PM, the DON (Director of Nursing) stated, My expectation is that tubing and humidification/water bottles for oxygen are to be changed weekly and as needed, such as if the water bottle ran dry, it would be changed right away. There should be an order for humidification of Resident #29's oxygen. During an interview on 6/04/2026 at 4:00 PM the DON stated that changing oxygen tubing and humidification bottles should be documented on a resident's TAR. During an observation on 6/1/2026 at 9:53 AM of Resident #55's room, inhalation tubing was hanging from the machine, and distal tip was touching the floor. The mouthpiece was sitting on the bedside table and was not in a plastic storage container. The resident was not present in the room. Record review of Resident #55's provider order reads, Levalbuterol HCL inhalation nebulization solution 1.25 mg/ml 3 ml inhale orally three times a day for COPD (chronic obstructive pulmonary disease - lung disease that restricts airflow, making it difficult to breathe). During an observation on 6/1/2026 at 10:00 AM of Resident #88's room, Resident was not in the room and O2 concentrator was on at 4.5 l per min. The 02 cannula was wrapped around the left bedside rail and was not placed in a storage bag. Record review of Resident #88's Physician order reads, Respiratory oxygen - 2 liters continuous. During an interview on 6/3/2026 at 1:30 PM, Staff R, Unit Manager, stated, All oxygen supplies should be stored in dated plastic bag. The mouthpiece should not be left on the bedside table. Review of the facility policy and procedure titled Oxygen Tubing and Cannula Changes with a last review date of 3/11/2026 read, Policy Statement: Oxygen tubing, nasal cannulas, and associated oxygen delivery equipment shall be maintained, cleaned, and replaced in accordance with manufacturer recommendations, infection prevention standards, and facility policy to ensure safe resident reduce the risk of contamination and infection. Policy Interpretation and Implementation. 3. Nasal cannulas and oxygen tubing shall be changed every seven (7) days and as needed if visibly soiled, malfunctioning, contaminated or damaged. Review of the policy and procedure titled, Oxygen Administration, with the last review date of 3/11/2026 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: 3. Humidifier bottle. Steps in the Procedure: 14. Periodically re-check water level in humidifying jar. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. Review of the policy and procedure titled, Humidified Oxygen Water Bottles (Prefilled), with the last review date of 3/11/2026 read, Policy Statement: Humidified oxygen water bottles shall be stored, used, maintained, and discarded in accordance with manufacturer recommendations, infection prevention standards, and facility policy to prevent contamination and ensure resident safety. Policy Interpretations and Implementation: 1. Humidifier bottles shall be labeled immediately upon opening or placement into service. The label must contain the date and time the bottle was opened and the initials of the staff member. 3. Prefilled humidifier bottles shall be changed every seven (7) days after opening or sooner if empty, contaminated, leaking, damaged, or visibly cloudy. 6. Nursing staff shall monitor residents receiving humidified oxygen for proper equipment function, adequate humidification, and signs of respiratory distress or infection.

Based on interview and record review, the facility failed to ensure ongoing communication and collaboration between the facility and the dialysis provider for 2 of 3 residents [Resident #8 and Resident #82] reviewed for dialysis services. Findings Include: Record review of Resident #8's admission record revealed Resident #8 was admitted to the facility on [DATE] with medical diagnoses that included hemiplegia, affecting left nondominant side, and end stage renal disease. Review of Resident #8's physician order dated 12/14/2025 reads, Hemodialysis - Dialysis on Tuesday, Thursday, & Saturday [name of dialysis provider]; Pickup time 6:00 a.m. chair time is 7:00 a.m. During an interview on 06/03/2026 at 10:24 AM, Staff H, LPN (Licensed Practical Nurse) stated, We communicate with the dialysis nurses via a communication book, and we can report pertinent issues in the book. LPN provided Resident #8's dialysis communication book to the surveyor. Review of Resident #8's Hemodialysis Communication Record dated 05/21/2026, section To be completed by facility prior to transfer was not filled out and signed by the nurse. The section To be completed by the facility upon return from dialysis was not signed by the nurse. Review of Resident #8's Hemodialysis Communication Record dated 05/28/2026, the section To be completed by facility upon return from dialysis was not filled out and not signed by the nurse. Review of Resident #8's Hemodialysis Communication Record dated 05/30/2026 showed the section To be completed by facility prior to transfer was not filled out with vital signs. Section To be completed by facility upon return from dialysis was not filled out with respirations or temperature and was not signed by the nurse. During an observation on 06/03/2026 at 10:55 AM, a staff member, Staff B LPN Unit Manager, entered the conference room and removed the dialysis communication book from the surveyor. Surveyor requested copies of dialysis communication forms for the following dates: 05/21, 05/30, 05/28. Copies were provided by the LPN Unit Manager.During an interview on 06/03/2026 at 2:16 PM, Staff A, Dialysis Registered Nurse stated, Sometimes we have a hard time trying to communicate with the facility. Most of the time we have to get the social worker involved. A lot of times they don't pick the phone up. They have not been filling out the communication book for a long time.During an interview on 06/04/2026 at 8:50 AM, the surveyor requested the dialysis communication book for Resident #8. Hemodialysis communication records for the previous six weeks were provided to the surveyor by Staff B, LPN Unit Manager. Review of Resident #8's Hemodialysis Communication Records for the dates of 05/21/2026, 05/28/2026 and 05/30/2026 revealed that all sections of the communication sheets were filled out. During an interview on 06/04/2026 at 12:10 PM, the Director of Nursing reviewed the copies of Resident #8's hemodialysis communication forms that were provided to the surveyor on 06/03/2026 for the dates of 05/21/2026, 05/28/2026 and 05/30/2026, which were not completed. The Director of Nursing then reviewed the hemodialysis communication forms for the dates of 05/21/2026, 05/28/2026 and 05/30/2026 that were filled out and provided to the surveyor on 06/04/2026.During an interview on 06/04/2026 at 12:10 PM, the Director of Nursing stated, [Staff B, LPN's name] filled out the dialysis communication sheets using the vital signs that were in [name of medical records software]. The nurses were checking the vital signs; they just were not filling out the communication forms. I do expect the nurses to fill out the dialysis communication forms before and after a resident goes to dialysis.Record review revealed that Resident #82 was admitted to the facility on [DATE] with medical diagnoses which included multiple fractures of ribs, unspecified side, subsequent encounter for fracture with routine healing and chronic kidney disease, stage 3 unspecified.Review of Resident #82's physician order dated 05/15/2026 read, Dialysis: MON-WED-FRI [Monday, Wednesday, Friday] Chair Time: 1030 A.M. Location: [dialysis provider's address] Resident transported to Dialysis by in house transportation.Review of Resident #82's physician order dated 04/01/2026 read, Communicate with the dialysis center regarding labs and plan of care.Review of Resident #82's dialysis communication record dated 06/01/2026 showed the section to be completed by the facility upon return from dialysis was not completed and was not signed by the nurse. Review of Resident #82's dialysis communication record dated 05/18/2026 showed the section to be completed by the facility upon return from dialysis was not completed and was not signed by the nurse. Review of policy and procedure titled, End-Stage Renal Disease, Care of a Resident With review date 03/11/2026 read, Policy Statement Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the residents' care will be managed, including: a. how the care plan will be developed and implemented; b. how information will be exchanged between facilities; and c. responsibility for waste handling, sterilization and disinfection of equipment.

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment by effectively preventing and controlling pest activity. Multiple live pests were observed on two out of four hallways and in common areas in the facility. Residents voiced complaints regarding recurring pest sightings, creating an environment with the potential to adversely affect resident health, safety, dignity, and quality of life. Findings include: During an interview on 6/01/2026 at 9:45 AM, Resident #79 stated that he often saw live roaches in his room. Even though the facility had pest control, they still had roaches. During an observation on 6/01/2026 at 9:45 AM a live small brown pest was observed on the floor next to resident #79's bed. (photographic evidence) During an observation of Resident #96's room on 6/01/2026 at approximately 9:35 AM, there were a couple of feet of loose baseboard on the wall behind his bed. (photographic evidence) During an observation on 06/01/2026 at 10:35 AM, Two live, brown insects approximately one half to one inch long, with oval shaped bodies were observed crawling on the floor of Resident #48's room. One live brown insect, one half inch long, with an oval shaped body was observed crawling up the wall behind Resident #48's bed [photographic evidence obtained]. During an observation on 06/01/2026 at 12:34 PM, a live brown colored insect approximately one-half inch in length, with an oval-shaped body was observed on the wall behind the bed in Resident #45's room. During an observation on 6/1/2026 at 3:43 PM there was an elongated light brown insect crawling on the floor Infront of the business manage office in the common area of the facility. During an observation on 6/02/2026 at approximately 8:55 AM a small brown pest was observed on the edge of Resident #79's laundry basket. (photographic evidence) During an observation on 6/04/2026 at approximately 4:00 PM Resident #28's bathroom had loose baseboard and a small hole in the wall just above the floor in the corner of her bathroom. (photographic evidence) Review of the Pest Sighting Log from May and June 2026 documented roaches 18 times in two of four hallways. Review of the Pest Control Inspection report dated 4/10/2026, from [local pest control company] Visit Notes read, Treated interior of 6 units for German roaches this visit. Roach activity found in every room that was treated mainly in the bathrooms and oxygen machines. Pest Summary: Interior - German cockroach - actual count 100. Device Summary: Inspection point 2 with activity. Detailed Pest Activity: Interior 4/10/2026 1:09 PM - German cockroach actual count 100. Review of the Pest Control Inspection report dated 5/29/2026, from [local pest control company] read, New recommendations added today: Interior - Detail – Debris collecting interior. Please remove debris to prevent unsanitary condition and attraction by pests. Detail – Pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Review of the Pest Control Inspection report dated 5/22/2026, from [local pest control company] read, New recommendations added today: Interior: Detail – Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. The baseboard within the building haves {sp} cracks and voids that could allow entry to pest. Other open recommendations: Interior - Detail – Debris collecting interior. Please remove debris to prevent unsanitary condition and attraction by pests. Detail – Pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Review of the Pest Control Inspection report dated 6/01/2026, from [local pest control company] read, Other open recommendations: Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. The baseboard within the building haves {sp} cracks and voids that could allow entry to pest.: Interior - Detail – Debris collecting interior. Please remove debris to prevent unsanitary condition and attraction by pests. Detail – Pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Review of Work Order #7235 with a creation date of 3/18/2026 read, Room/Area – Dietary – kitchen; Notes – Need Pest Control ASAP and need holes closed up ASAP (as soon as possible). Priority – Critical. The status of the work order was Set to be completed, on 4/20/2026. The status of the work order was never completed. During an interview on 06/01/2026 at 12:27 PM, Resident #11 stated, I have seen a lot of roaches in my room and around the floor. It has been quite a few months since they have come in and sprayed. During an interview on 06/01/2026 at 10:08 AM, Resident #71 stated, I see roaches all over my room at night. I notified the administrator a few months ago about the roaches, and no one has ever come in to spray. During an interview on 06/01/2026 at 10:37 AM, Resident #104 stated, There are roaches in my room. During an interview on 6/04/2026 at 1:05 PM the Administrator confirmed the presence of live pests in the facility. During an interview on 6/04/2026 at 1:10 PM, the Director of Plant Operations stated that they were not aware of or working on the repair recommendations made to the facility from the pest control company on 5/22/2026, 5/29/2026, and 6/01/2026. Review of the policy and procedure titled Pest Control, with the last review date of 3/11/2026, read, Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #3, #15, #19, and #56) of 13 residents reviewed. Findings include: Review of Resident #3's Minimum Data Set (MDS) titled Medicare 5 Day dated 5/7/2026 Section O Special Treatments, Procedures, and Programs did not document oxygen use. Review of Resident #3's physician order dated 4/28/2026 read, Oxygen As Needed PRN [as needed] 2L [liters] nasal cannula every 24 hours as needed 2L PRN. Review of Resident #3's Weights and Vital Summary for Oxygen Saturation documented on 5/7/2026 at 09:14 [9:14 AM] oxygen saturation was 97 % (oxygen via nasal cannula), on 5/7/2026 at 1:45 [1:45AM] oxygen saturation was 98% (oxygen via nasal cannula), on 5/6/2026 at 14:42 [2:42PM] oxygen saturation was 97% (oxygen via nasal cannula), on 5/5/2026 at 08:36 [8:36AM] oxygen saturation was 97% (oxygen via nasal cannula), on 5/5/2026 at 1:27 [1:27AM] oxygen saturation was 98% (oxygen via nasal cannula), on 5/4/2026 at 00:22 [12:22AM] oxygen saturation was 95% (oxygen via nasal cannula), on 5/3/2026 at 11:05 [11:05 AM] oxygen saturation was 94% (oxygen via nasal cannula) , on 5/3/2026 at 07:30 [7:30AM] oxygen saturation was 94% (oxygen via nasal cannula), 5/2/2026 at 07:14 [7:14 AM] oxygen saturation was 96% (oxygen via nasal cannula) , on 5/1/2026 at 22:40 [10:40 PM] oxygen saturation was 96% (oxygen via nasal canula) and on 5/1/2026 at 22:16 [10:16 PM]oxygen saturation was 96% (oxygen via nasal cannula). During an interview on 6/4/2026 at 9:16 AM, Staff I, Registered Nurse MDS Coordinator, stated, [Resident #3's Name]'s MDS will need to be corrected since she did use oxygen in the look back period of the assessment. Review of Resident #15's MDS titled Medicare 5 Day dated 4/2/2026 Section O Special Treatments, Procedures, and Programs did not document oxygen use. Review of Resident #15's physician order dated 3/26/2026 read, May apply O2 @ 3L [oxygen at 3 liters] via nasal cannula as needed for respiratory distress Titrate to maintain 95% spo2 [peripheral oxygen saturation]. Review of Resident #15's progress note dated 4/1/2026 read, Oxygen is used via nasal cannula 2L. Review of Resident #15's progress note dated 3/31/2026 read, Oxygen is used via nasal cannula 2L. Review of Resident #15's progress note dated 3/30/2026 read, Oxygen is used via nasal cannula. Review of Resident #15's progress note dated 3/27/2026 read, Oxygen therapy resumed via nasal cannula at 3 L/min. Review of Resident #15's progress note dated 3/27/2026 read, During today's assessment the patient was observed sitting at the bedside with 2 liters of oxygen administered via nasal cannula. During an interview on 6/4/2026 at 8:54 AM, Staff F, MDS Coordinator, stated, My error, I did not see the progress notes; it [Resident #15's MDS Section O] will need to be corrected. Review of Resident #56's MDS titled Modification of admission Medicare 5 Day dated 4/9/2026 Section I Active Diagnoses did not document Depression. Review of Resident #56's physician order dated 4/2/2026 read, Citalopram Hydrobromide Oral Tablet 20 MG [milligram] give 1 tablet by mouth one time a day related to depression. During an interview on 6/4/2026 at 9:12 AM, Staff I, Registered Nurse MDS Coordinator, stated, [Resident #56's Name] did have medication for depression starting on 4/2/2026. The diagnosis should have been checked off. The assessment will need to be corrected. During an observation on 06/02/2026 at 9:35 AM, Resident #19 was observed in the Physical Therapy Gym receiving services. Weights applied to wrists and ankles with Velcro. Resident was able to make full effort at minimally moving all 4 extremities at the same time in a circular motion successfully with maximum effort while sitting in his electric wheelchair. During interview on 06/03/2026 1:10 PM, Staff F, MDS Coordinator, stated I don't see any corrections being done for [Resident #13's Name] MDS in Section GG for No impairment in range of motion upper and lower extremity. I know about the diagnosis of Quadriplegia, and I have also seen him wiggle around in his wheelchair by himself. During interview on 06/04/2026 at 4:35 PM with Staff G, PT(Physical Therapist) stated, [Resident #19's Name] is a quadriplegic with spinal cord injury that happened about 5 years ago. He does have limitations in his range of motion in his upper and lower extremities. Review of Resident #19's MDS Section GG Functional Abilities dated 04/15/2026 read, Functional Limitation in Range of Motion Code 0 (No impairment) A. Upper Extremity Code 0 B. Lower extremity Code 0 Review of Resident 19s Care Plan dated 04/17/2026 read, FOCUS Alteration in usual Functional Performance in Mobility/Transfer status related to chronic pain, Quadriplegia, OA(osteoarthritis), and muscle weakness. Review of the facility policy and procedure titled Comprehensive Assessments with a last review date of 3/11/2026 read, Policy Interpretation and Implementation. 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in Resident Assessment Instrument (RAI) User Manual.

Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive care plan for oxygen and resident behaviors for 1 (Resident #113) of 8 residents reviewed for respiratory services.Findings include:During an observation on 6/01/2026 at 10:23 AM Resident #113 was lying in bed. Oxygen was being administered at 3 liters via nasal cannula.During an observation on 6/02/2026 at 10:48 AM Resident #113 was lying in bed with eyes closed resting calmly. Oxygen was being administered at 3 liters via nasal cannula.Review of Resident #113's physician order dated 5/4/2026 read, Respiratory: Oxygen-3L [liters] Continuous.Review of Resident #113's physician order dated 5/5/2026 read, Respiratory: Oxygen- 3L Continuous, nasal cannula.Review of Resident #113's physician order dated 5/22/2026 read, Respiratory: Oxygen- 4L Continuous.Review of Resident #113's Baseline Care Plan and Summary dated 5/4/2026 read, Other Services/Orders: O2 [oxygen].Review of Resident #113's care plan reviewed on 6/03/2026 did not document a focus for respiratory services or behaviors regarding oxygen.During an interview on 6/3/2026 at 11:30 AM, Staff J, Licensed Practical Nurse (LPN), stated, [Resident #113's name] has orders for oxygen and it should be 4 liters.During an interview on 6/3/2026 at 11:31 AM, Staff J, LPN, confirmed Resident #113's oxygen was being administered at 3 liters per minute.During an interview on 6/3/2026 at 11:31 AM, Staff J, LPN, stated, [Resident #113's name] has behaviors and tends to take off his oxygen and touch the oxygen concentrator and move the flow rate.During an interview on 6/4/2026 at 8:59 AM, Staff I, Registered Nurse Minimum Data Set Coordinator, stated, I was informed yesterday that he (Resident #113) just got oxygen now and that he has behaviors concerning the oxygen. I was not aware he was on oxygen. The oxygen focus is not on is care plan and it should have been included.Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered with a last review date 3/11/2026 read, Policy Statement. 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. Policy Interpretation and Implementation. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS Assessment (Admission, Annual, or Significant Change in Status), and no more that 21 days after admission.

Based on record review and interviews, the facility failed for 1 Resident (Resident #97) out of 3 residents reviewed to ensure a dermatology appointment was scheduled resulting in a 3-month delay for a facial skin growth. Findings Include:During an observation on 6/1/2026 at 10:41 AM Resident #97 was walking with walker down the hall back to his room. Resident has a raised red growth on left side of chin midline between ear and mouth. A part of the growth is hanging from the chin and was tangled with the resident's long hair. (photographic evidence)During an interview on 6/1/2026 at 10:43 AM, Resident #97 states, I have this growth on the left side of my chin, and the nurse practitioner wants it taken off. It is benign.During an interview on 6/4/2026 at 1:00 PM, Consultant stated, [Name of Health Plan](I SNP - type of Medicare advantage) was selected by the patient. It is a program that helps to reduce costs, and they make appointments for Residents.During an interview on 6/4/2026 at 3:12 PM, Resident #97 stated, It is growing and I need to see a dermatologist. (photographic evidence)During an interview on 6/4/2026 at 3:50 PM, the DON stated, [Name of Health Care Plan] should have scheduled an appointment for the dermatology consult. Consults need to be scheduled in a timely manner. There is no policy for scheduling appointments.Record review of Resident #97's provider order dated 2/16/2026 reads Needs follow up with in house dermatology lesion to left jaw, previously biopsied Record review of Resident #97's provider order dated 3/6/2026 reads refer to dermatology for facial lesion, [Name of Health Care Plan] to schedule. Record review of mobile dermatology provider note dated 12/9/2025 reads, Chief Complaint: Being seen to discuss biopsy results, shave biopsy performed on 11/25/25 visit for evaluation of the lesion located on the left angle of jaw. Recommend lesion be re-biopsied with deeper and wider shave after lesion has been adequately cleaned and debrided in preparation.Record review of Resident #97's APRN #2's provider note dated 2/4/2026 reads, There is a lesion on left side of the patient's face. Waiting on dermatology. Patient states he has seen dermatology and is waiting on a new appointment. Record review of Resident #97's APRN #3's provider noted dated 2/6/2026 reads, He reports concern regarding a facial lesion on his left jaw area, stating he previously had this area biopsied, but does not recall receiving follow up results. Record review of Resident #97's nurse's note dated 3/10/2026 at 2:09 PM, authored by Staff S LPN Unit Manager reads, Communicate (sic) with [Name of Nurse Practitioner from Health Care Plan] regarding pending referrals to urology and dermatology. She stated that they are currently in the process of scheduling both appointments and will provide an update once the appointment have been confirmed. Record review of Resident #97's nursing note dated 3/12/2026, authored by Staff S Unit Manager, reads, Conferred with [Name of Health Care Plan Representative] regarding the pending dermatology appointment for the area of concern noted on the resident's face. She was informed that the mass appears to have increased in size over the past month and that is important for the resident to be evaluated by a specialist as soon as possible for proper assessment and treatment. [Name of Health Care Plan Representative] stated that she will begin the process of scheduling the dermatology appointment today. Resident notified.

Based on observation, interview, and record review, the facility failed to obtain and document weekly weights for 1 Resident (Resident #13) out of 3 Residents reviewed for food and nutrition to ensure maintenance of acceptable parameters of nutritional status. Findings include: During an interview via phone on 06/03/2026 at 2:57 PM, Staff E, Regional Registered Dietician, stated, [Resident #13's Name] came in from the hospital with tube feeding and a diet. He doesn't eat much; we tried cutting back on his tube feedings, but he lost weight. I provide a list of residents I want weekly weights done on. I am there once a week and meet with the IDT(interdisciplinary team), Administrator and the DON (director of nursing); we work as a team. I will then reassess and check it monthly to see how he is doing and talk to the staff. He has been eating a lot of snacks brought in by the family. I think that is why he has gained weight.Review of Resident #13's Physician Order dated 03/19/2026, reads, Weigh Weekly d/t (due to) significant weight change.Review of Resident #13's weights: 05/29/2026 - No weight recorded, 05/22/2026- No weight recorded, 05/15/2026 -176.6 pounds, 05/08/2026-No weight recorded, 05/01/2026- 172.8 pounds, 04/27/2026-171.2 pounds, 04/20/2026-171.0 pounds, 04/13/2026- no weight recorded, 04/06/2026-177.4 pounds, 03/30/2026-No weight recorded, 03/23/2026-176.2 pounds 03/18/2026-176.8 pounds, 03/09/2026 -178.0 pounds, and 03/05/2026-177.4 pounds.Review of Resident #13's Dietary Progress Note Dated 05/07/2026 read, Significant weight change note: Diet: NAS(no salt added) diet, regular texture, thin liquids. Supplement/interventions for weight loss: health shake 4oz(ounces) BID(twice a day) (440 kcal(kilocalorie) and 14g(grams) of protein) w/ 50-100% intakes, TF (tube feeding)order: bolus 474ml(milliliters) of Jevity 1.5 BID(twice per day) PO(per os) intake: average 0-100%. CBW(current body weight): 172.8 pounds on 05/01/26. Weight history: 1mon: 04/06/2026 177.4 pounds (-4.6 pounds, -2.6%). 3mon: 02/11/2026 175.6 pounds (-2.8 pounds, -1.6%). 6mon: 11/26/2025, 198.4 pounds, -12.9% , -25.6 pounds - significant weight loss, unplanned, undesirable.Review of Resident #13's Plan of Care Dated 04/17/2026 contains focuses including risk for malnutrition, r/t(related to) significant weight loss, and dysphagia(difficulty in swallowing) with interventions including weights per facility protocol and as ordered.Review of Facility Policy Titled Weight Assessment and Intervention Last review date 03/11/2026 read, Policy Statement - Resident weights are monitored for undesirable or unintended weight loss or gain. 1. Residents are weighted upon admission and at intervals established by the interdisciplinary team.

Based on interview and record review the facility failed to accurately document treatments ordered for 1 (Resident #112) of 3 residents reviewed for skin conditions.Findings include:Review of Resident #112's physician order dated 4/6/2026 read, Soak daily in Epsom salt for 14 days and apply triple antibiotic ointment to great toe.Review of Resident #112's Medication Administrator record for the month of April 2026 did not documented Soaks in Epsom salt or triple antibiotic ointment to the great toe.Review of Resident #112's Treatment Administrator record for the month of April 2026 did not documented Soaks in Epsom salt or triple antibiotic ointment to the great toe.During an interview on 6/3/2026 at 1:57 PM, the Director of Nursing stated, I know there was an order for [Resident #112's name], but it was not documented. I looked at the treatment records and was not able to find it. I did speak to staff and they say they did provide care.During an interview on 6/3/2026 at 2:00 PM, Staff L ,Licensed Practical Nurse, stated, I saw nursing providing the treatment. The Epsom salt is still in the medication cart. The staff wrote the order and forgot to check off the box so it would show on the MAR [Medication Administration Record].During an interview on 6/3/2026 at 2:09 PM, with Staff M Wound Care Nurse stated, I was doing the treatments daily for [Resident #112's name].During an interview on 6/3/2026 at 2:20 PM with Resident #112 confirmed staff did provide the Epsom salt soaks and triple antibiotic ointment to her great toe.During an interview on 6/4/2026 at 3:46 PM with the Director of Nursing stated, A physician order should be on the MAR and staff should document they have completed the treatment and administration.Review of the facility policy and procedure titled Documentation of Medication Administration with a last review date of 3/11/2026 read, Policy Statement. A medication administration record is used to document all medications administered. Policy Interpretation and Implementation. 1. A nurse or certified medication aide (where applicable) documents all medications administer to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given.

Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis.Finding includes:During an observation on 6/1/2026 at 9:05 AM, nursing staffing information dated 6/1/2026 was posted to the right side of the main entrance next to the receptionist desk. Census was documented 103.During an observation on 6/1/2026 at 10:30 AM, nursing staffing information dated 6/1/2026 was posted to the right side of the main entrance next to the receptionist desk. Census was documented 103. [photographic evidence obtained]Review of the facility Resident Listing Report dated 6/1/2026 documented census was 102.During an observation on 6/1/2026 at 3:40 PM, nursing staffing information dated 6/2/2026 was posted to the right side of the main entrance.During an observation on 6/2/2026 at 5:02 PM, nursing staffing information dated 6/3/2026 was posted to the right side of the main entrance. [photographic evidence obtained]During an observation on 6/3/2026 at approximately 5:09 PM, nursing staffing information dated 6/4/2026 was posted at the 100 Hall nursing station near the off hours facility entrance. The Director of Nursing was standing at the nursing station.During an interview on 6/3/2026 at approximately 5:10 PM with the Director of Nursing confirm nursing staffing information posted was dated 6/4/2026. The Director of Nursing stated, The scheduler will prepare the staffing information sheet before leaving and any corrections will be made tomorrow. The staffing sheet should not be posted in the front of the posting it should be place behind the current day and tomorrow when the new shift starts it should be changed.During an interview on 6/4/2026 at 11:28 AM with the Administration stated, The staff coordinator should not post the staffing information the day before. She can make one before she leaves and leave it behind the current one. The following day corrections should be made if needed and post the current staffing information for the day.During an interview on 6/4/2026 at 12:23 PM with the Staffing Coordinator stated, I spoke to the Director of Nursing yesterday evening. I was putting it [staffing information] out before I leave at end of day for the following day. I don't even think I even notice that (census was documented incorrectly) it was incorrect. Everything happened real fast.Review of the facility policy and procedure titled Posting Direct Care Daily Staffing Numbers with a last review date of 3/11/2026 read, Policy: Our Facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation. 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNS) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) and in a clear and readable format. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following: c. The resident census at the beginning of the shift for which the information is posted. e. The shift for which the information is posted.

Based on interview and record review, the facility failed to ensure 2 of 6 reviewed licensed practical nurses (Staff H, and Staff J) had the specific competency requirements as part of their license and certification to administer IV (intravenous) medications, and 4 of 6 reviewed licensed practical nurses (Staff A, Staff B, Staff E, and Staff G) failed to follow the policy/procedure related to IV medication administration, physician notification, and obtaining stat [derived from the Latin word statim, meaning immediately] orders for medication and equipment for 3 of 3 residents reviewed for intravenous antibiotic medication (Residents #1, #3, and #4), the facility failed to ensure 4 of 6 licensed practical nurses (Staff A, Staff B, Staff J, and Staff L) failed to follow physician-ordered parameters for blood pressure medications for 1 of 3 residents reviewed for medication administration (Resident #2). The facility failure to ensure the nursing staff had appropriate IV (intravenously) certification to administer IV medications and followed the policy/procedure related to medication administration, physician notification, and obtaining stat orders for medication and equipment resulted in Immediate Jeopardy. Resident #1 was admitted on [DATE] with physician orders for Vancomycin 1500 mg IV every 8 hours intravenously for infection (osteomyelitis, an infection in the bone). On 9/8/2025 at approximately 10:00 PM, Resident #1 was administered one incorrect dose of Vancomycin 1000 mg. Resident #1 was not administered any further doses of Vancomycin 1500 mg until 9/12/2025 at 12:00 AM. Resident #1 missed 8 doses of Vancomycin between 9/9/2025 and 9/12/2025. On 9/11/2025, Resident #1 began to experience a change in condition of altered mental status, identified by a family member, who requested on 9/12/2025, that Resident #1 be sent to Emergency Department where he was diagnosed with sepsis [a life threatening emergency that damages the body's organs and can cause death]. Missing antibiotic doses can reduce the effectiveness of the treatment and increase the risk of antibiotic resistance, serious harm and/or death, and lack of staff competency related to nursing staff having appropriate IV certification, can result in serious harm including damage to veins and the injection site, an air embolism, phlebitis, and blood clots, injury and/or death.The Administrator was notified of the Immediate Jeopardy on October 10, 2025, at 11:45 AM.Findings include: 1) Review of Resident's #1's Discharge summary dated [DATE] from [Name of local hospital] read, Outpatient IV ABX (antibiotic) orders: 2. Vancomycin 1500 mg [milligrams] q8h [every eight hours] for 2 weeks.Review of Resident #1's admission record documented an admission date of 9/8/2025 with diagnoses to include subacute osteomyelitis [an infection in the bone], other site, spina bifida occulta [a small gap in one or more of the bones in the spine], other hydrocephalus [a buildup of fluid in the brain], paraplegia (an impairment in motor or sensory function of the lower extremities) unspecified, other bacterial infections of unspecified site, other seizures, local infection of the skin and subcutaneous tissue unspecified, iron deficiency, presence of cerebral spinal fluid drainage device, anemia unspecified, soft tissue disorder unspecified, unspecified visual loss, and gastroesophageal reflux disease [heartburn] without esophagitis [inflammation of the esophagus].Review of Resident #1's nursing progress note dated 9/8/2025 at 8:31 PM read, Patient was coming around 4:15 PM. With colostomy on his left side and a urostomy on his left side. PICC [Peripherally Inserted Central Catheter] line on his right arm. Vital signs was {sic} within normal range. Patient got left hip surgery paraplegic and had a drain in the space of the surgery. Patient is alert and oriented times 4.Review of Resident #1's physician order dated 9/8/2025 read, Vancomycin HCl [Hydrocholoride, a potent antibiotic used to treat severe bacterial infections, including those resistant to other antibiotics] intravenous solution 1500mg/300ml [1500 milligrams in 300 milliliters of sodium chloride] Use 1500 mg intravenously every 8 hours for Infection for 21 Days.Review of Resident #1 Medication Administration Record for the month of September 2025 for Vancomycin 1500 mg intravenously was documented as being administered on 9/8/2025 at or around 2200 [10:00 PM] by Staff E., LPN.Review of Resident #1's Medication Administration Record for the month of September 2025 for vancomycin 1500 mg intravenously was documented as chart code 9 (other see nurses notes) on 9/9/2025 at 0800 (8:00 AM) and 1600 (4:00 PM), on 9/10/2025 there is an X [not given] at 12:00 midnight and a chart code of 9 at 0800 [8:00 AM] and 1600 (4:00 PM). On 9/11/2025 a chart code of H [hold] at 1200 [12:00 AM], 0800, and 1600 for a total of 8 missed doses of vancomycin.Review of Resident #1 Medication Administration Record for the month of September 2025 for Vancomycin HCI Intravenous Solution 1500mg documented on 9/12/2025 at 0000 [12:00 AM] administered by Staff J, LPN (Licensed Practical Nurse).Review of Resident #1's EMAR (electronic medication administration record) note for vancomycin 1500 mg IV dated 9/9/2025 at 7:32 AM read, order needs to be updated.Review of Resident #1's eMar note dated 9/9/2025 at 16:21 [4:21 PM]: Vancomycin 1500 mg IV read, Will be in on evening run per pharmacy.Review of Resident #1's EMAR note dated 9/10/2025 at 12:28 PM read, Vancomycin HCl intravenous solution 1500 mg/300 ml use 1500 mg intravenously every 8 hours for Infection for 21 Days. The pharmacy sent a malfunctioning pump, and the writer reached out to inform them of the issue. The pharmacy stated that the problem would be addressed during the next run. The NP [nurse practitioner] was notified and confirmed it was okay to put the medication on hold until then.Review of the form titled [Name of pharmacy] Inventory on Hand dated 9/9/2025 documented vancomycin 1 gm [gram] vial on hand amount 4 vials were in the [name of the automated medication dispensing machine].Review of Resident #1's physician order dated 9/8/2025 read, Cefepime HCI (antibiotic used to treat a wide variety of serious bacterial infections) intravenous solution 1 gm/50 ml [1 gram per 50 milliliter] (Cefepime HCI (hydrochloride)) Use 1 gram intravenously every 8 hours for infection for 21 Days until finished. Review of Resident #1's Medication Administration Record (MAR) for the month of September 2025 for cefepime 1 gm intravenously was documented as being administered on 9/8/2025 at or around 2200 (10:00 PM) by Staff E, LPN.Review of Resident #1's MAR for the month of September 2025 for cefepime HCI intravenous 1 gram documented on 9/10/2025 at 2200 administered by Staff H, Licensed Practical Nurse (LPN), on 9/11/2025 at 2200 administered by Staff J, LPN, and on 9/12/2025 at 0600 (6:00AM) administered by Staff J, LPN.Review of Resident #1's physician order dated 9/8/2025 read, IVs [intravenous]: Flush PICC (10cc) [cubic centimeter] of normal saline every shift and as needed.Review of Resident #1's MAR for the month of September 2025 for IV flush documented on 9/10/2025 at 1200 (12:00 AM - midnight) administered by Staff H, LPN and on 9/11/2025 at 1200 administered by Staff J, LPN.Review of Resident #1's MAR for cefepime dated 09/9/2025 at 6:00 AM documented a code of 5 (Hold/see Nurses Notes) and 1400 (2:00 PM) a code of 9 (Other/See Nurses Notes). For a total of two missed doses.Review of Resident #1's MAR dated 09/10/2025 at 6:00 AM, 2:00 PM, and 10:00 PM documented cefepime was administered. Vancomycin for the date of 9/10/2025 documented at 12:00 midnight X (not administered), at 8:00 AM and 4:00 PM code 9 (Other/see Nurse Notes).Review of Resident #1's physician progress note dated 9/10/2025 at 13:23 (1:23 PM), authored by APRN #1 (Advanced Practitioner Registered Nurse), reads, He has now been admitted to the skilled nursing facility for continuation of IV vancomycin and cefepime, wound care management, and rehabilitation support. Assessment/Plan: Chronic osteomyelitis, unspecified site with recent surgical intervention. Active, high-risk condition. Patient with recurrent osteomyelitis, currently on IV vancomycin and cefepime per infectious disease recommendations. Plan: Continue IV vancomycin and cefepime per protocol. Monitor temperature, WBC [white blood cell] trends, renal function, and vancomycin trough levels. Maintain coordination with infectious disease and wound care teams.Review of Resident #1's eInteract SBAR (Situation, Background, Assessment, Recommendation) dated 9/11/2025 at 3:33 PM read, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Altered mental status. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness. Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: cbc [complete blood count], cmp [complete metabolic profile] vanco [vancomycin] trough [a blood test used for monitoring the vancomycin medication administration). Review of Resident #1's physician order dated 9/11/2025 read, CBC w/ Diff [differential], comprehensive panel/vancomycin pre-dose (trough) one time only related to presence of cerebrospinal fluid drainage device, iron deficiency, other seizures, local infection of the skin and subcutaneous tissue, unspecified anemia, unspecified, other hydrocephalus, subacute osteomyelitis, other site, soft tissue disorder, unspecified, other bacterial infections of unspecified site, spina bifida occulta. Review Resident #1's Laboratory result report with specimen collection date of 9/11/2025 and report date of 9/12/2025 read, Vancomycin trough final result <2.0 [less than] ug (micrograms)/ml (milliliter) (L) (low) - Ref. [reference] Range Units: 5.0 - 20.0 ug.Review of Resident #1's eInteract Transfer Form dated 9/12/2025 at 10:16 AM read, Section A: Demographic and Transfer information: 2. Transfer/discharge details. Send to [Name of local hospital], sent from [Name of Nursing home]. Reason(s) for transfer: other; Other reason for transfer: possible sepsis.Review of Resident #1's nursing progress note dated 9/12/2025 at 10:38 AM read, At approximately 10:00 AM**, the writer received a call from the resident's mother, who requested that the resident be sent to the hospital for further evaluation due to concerns about possible sepsis. VS [vital signs] 123/81 p [pulse]107 T [temperature] 98.8 O2 [oxygen saturation] 98 alert and oriented x 2 with confusion have no recall of short-term memory. The NP [Nurse Practitioner] on site was notified. The resident's mother was informed of the transfer to the hospital. The DON [Director of Nursing] was also notified. The plan of care remains ongoing.Review of Resident #1's Interactive SBAR dated 9/12/2025 at 10:28 [10:28 AM] read, Situation: The Change In Condition (CIC)/s reported on this CIC Evaluation are/were: Other change in condition - Possible Sepsis. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send out for further evaluationReview of Resident #1's medical record from [Name of Hospital] titled 'ED [Emergency Department] to Hosp [Hospital]- admission (Current) dated 9/12/2025 read, ED course & re-evaluation: [Resident #1's name], a [AGE] year-old male with a PMHx [past medical history] of spina bifida occulta with hydrocephalus [a buildup of fluid in the brain] s/p [status post] [NAME] rod [a stainless steel surgical device used to treat a curvature of the spine] and VP [ventriculoperitoneal] shunt [a tube in the brain to drain fluid into the stomach], paraplegia, paralysis (the loss of the ability to move certain parts of the body typically as a result of illness or injury) below T8 [thoracic nerve number 8] + chronically wheelchair bound and chronic sacral wound, who presents today from outside skilled facility with AMS [altered mental status], tachycardia [a high heart rate], and concerns for sepsis [a life threatening emergency that damages the body's organs and can cause death] w [with]/new onset of leukocytosis [an abnormally high number of white blood cells (leukocytes) in the bloodstream] of 15 [indicates the body is fighting an infection]. On arrival, he was tachycardic [related to a high heart rate] but hemodynamically stable [a state in which the cardiovascular system is functioning properly and maintaining adequate blood flow throughout the body]. He was sepsis alerted given concern for infection and initial tachycardia with leukocytosis at outside facility. He was started on Vancomycin, cefepime and 30 cc [cubic centimeters]/kg [kilogram] IVF [intravenous fluids] with source concerning for recurrent osteomyelitis [an infection of the bone] and possible abscess [a pocket of pus] at recent surgical site in the setting of subtherapeutic [low level that is too low to produce the intended medical effect] Vancomycin + [plus] missing antibiotic dose. Regarding his AMS [altered mental status], his mother noted repetitive questioning and confusion otherwise no new neurologic deficits. His VP shunt is compressible. Will further evaluate additional causes of AMS with labs and imaging. Anticipate admission. ED [Emergency Department] Clinical Impression: Osteomyelitis of left femur, unspecified type, septic hip s/p [NAME] procedure, abscess of hip, left, sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, acute encephalopathy [a disturbance in brain function that causes confusion and memory loss].Review of Resident #1 [Name of Hospital] medical record titled History and Physical dated 9/12/2025 read, [Resident #1's name] is a 39 y.o. [year old] male with medical history significant for spina bifida occulta with hydrocephalus s/p VP shunt and [NAME] spinal rod placement, paraplegia and chronically wheelchair bound admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. The patient was recently hospitalized from 8/11-9/8/2025 for sepsis secondary to acute on chronic osteomyelitis and underwent a [NAME] procedure. He was then discharged to SNF [skilled nursing facility] for rehabilitation and continued IV antibiotic course for treatment of his acute infection. He has now been brought back to the ED due to altered mental status. He is currently accompanied by his mother who is at bedside. She states that the patient has been at the facility for several days since being discharged with IV antibiotics, however she has been concerned as she does not believe he has been receiving these medications or at least on a reliable schedule. She states that he began to act abnormal yesterday at which time he had completely forgotten the fact that he had just been hospitalized for two weeks. Today is alert and oriented only to self. He struggles with location, year, and current president. On arrival to the ED, the patient was found to be afebrile [not having a fever] with vitals remarkable for sinus tachycardia. Labs are remarkable for leukocytosis (WBC 15) and elevated CRP [C-Reactive Protein, indicative of inflammation in the body] (21.14). CT [Computed Tomography] imaging has revealed acute on chronic osteomyelitis of the left hip with details concerning for septic joint formation. There is also noted to likely be subperiosteal abscess (infection to the tissue located the surface of the bones) formation along the medical margin of the femoral head with a communicating sinus tract to the posterior medial skin of the left proximal thigh. Assessment and plan: [Resident #1's name] is a 39 y.o. male who is admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. Active Problems: #Sepsis, reason for admission, #Acute on Chronic Osteomyelitis, #Altered Mental Status, resolved - admitted for sepsis secondary to acute on chronic osteomyelitis that has likely worsened secondary to poor wound care lack of proper antibiotic usage.Review of Resident #1 [Name of Local Hospital] Infectious Disease note dated 9/13/2025 read, [Resident #1's name] is a 39 y.o. male with above mentioned PMHx admitted on [DATE] with chief complaint of altered mental status 1 day prior to admission. Recently admitted 8/11-9/8 for acute on chronic osteomyelitis of L [left] ischium, was planned for Flagyl (8/19-9/1), Vancomycin (8/19-9/29), and Cefepime (8/19-9/29). Underwent debridement during this time (see above). Unfortunately, the patient may not have received his antibiotics in an appropriate manner and may be contributory to the patient's current presentation. He currently complains of a 1/2 [one out of two] pain around his incision site and around his L AC [antecubital] (about 4 inches away from his PICC [Peripherally Inserted Central Catheter] line). He doesn't remember being at [Name of local hospital] recently and cannot tell but is able to talk about some specific details about his life.During an interview on 10/07/2025 at 1:36 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #1's name] had been transferred from another room during my shift [9/9/2025]. [Name of Staff B] had [Resident #1's name] prior to me and had called pharmacy who said they would be bringing his medication [vancomycin]. I called the pharmacy again and the pharmacy said they were enroute with the medication. I called the nurse practitioner; I believe her name is [APRN #1's name]. She [APRN #1] told me to extend the order for vancomycin for an extra day, so [Resident #1's name] would have the full course of the antibiotics. The pharmacy courier came in around 7:05 [PM] and brought me his medications. I passed them on to the night shift nurse because it was getting late. I don't think I wrote a note because I was in a rush to leave. I believe I should have documented the conversation with [name of APRN #1]. I don't know really if I can give the medication without a pump and I think that there is vancomycin in the [Name of the Automated Medication Dispensing Machine]. I don't think we can ask for a stat [derived from the Latin word statim, meaning immediately] delivery from the pharmacy.During an interview on 10/07/2025 at 1:38 PM, Staff B, LPN stated, [Resident #1's name] was an admission from the day before [9/8/2025]. The night-shift nurse [Staff E, LPN] told me that the nurse who admitted the resident did not put in [Resident #1's name] medication orders, so [Staff E's name] was not able to administer any medications for him. I can't remember if she called a provider, but I thought she had gotten an order to hold the vancomycin. If the medication was available in the [name of the automated medication dispensing machine] it should be administered. I know I should have notified the provider of the missed medications, and I should have documented the notification and any orders or instructions from the provider. I'm not sure if we can do a stat order from the pharmacy, we just regularly call the pharmacy and tell them we are waiting for the medication.During an interview on 10/07/2025 at 3:20 PM Staff E, LPN stated, Most of [Resident #1's name] medications were not available on the night shift of 9/8/25 - 9/9/25. The pharmacy doesn't come to the facility until 6:00 AM. Medication orders are typically entered to start the following day [after admission] because of the delivery times from the pharmacy, but [Resident #1's name] medications were ordered to start on the day of his admission [DATE]]. For the medications that were scheduled for my shift I was able to administer his cefepime because it was available in the [name of automated medication dispensing machine]. There was not a dose of vancomycin in the [name of automated medication dispensing machine] but there was overflow of vancomycin in the med [medication] room, as well as an overflow pump, so I was able to administer the ordered dose of vancomycin. I was not able to administer the morning dose of cefepime. I might have notified the doctor that I could not give the cefepime, but I am not sure. I did notify management that I did not give the cefepime, but I did not document the notification because I was already off of the [medication] cart. I know I should have written a note. Review of a form titled [Name of Pharmacy Provider] Transactions by Patient date 9/8/2025 documented vancomycin 1 gm one vial was removed at 7:50 PM, cefepime 1 gm two vials were removed, one at 7:49 PM and one at 7:53 PM. One bag of sodium chloride inj (injectable) 100 ml was removed at 7:55 PM from the [name of the automated medication dispensing machine] for [Resident #1's name]. Review of an email from Staff E, LPN addressed to Staff K, Previous Interim DON, dated 9/15/2025 at 4:41 PM read, On admission, resident [Resident #1] was ordered vancomycin and cefepime IV. Medications were not on hand but were available in [name of the automatic medication dispensing machine]. MAR reflected both medications scheduled for administration around 2100 [9:00 PM] on 9/8 [2025]. Cefepime was administered IV first, followed by vancomycin. Vancomycin infusion was prolonged due to patient's arm being constricted, which intermittently stopped the infusion. At 0600 [6:00 AM] on 9/9 [2025], MAR again showed scheduled doses for both vancomycin and cefepime. Unable to administer at that time because the vancomycin infusion from the previous evening was still running. Also, when the medications were delivered from the pharmacy, only the vancomycin was supplied; cefepime was not included in the delivery. This information was passed on in report with recommendation that administration times for vancomycin and cefepime be adjusted accordingly. Additional interviews were attempted 10/8/2025 and 10/9/2025 with Staff E, LPN via telephone to provide clarification of the removal of 100 ml of sodium chloride and vancomycin 1 gram and two vials of cefepime and no additional sodium chloride removed from the automated medication dispensing machine for vancomycin and cefepime IV administration. The physician orders document vancomycin 1500 mg (1.5 grams) in 300 ml of sodium chloride and cefepime in 50 ml of sodium chloride. On the date of the exit, 10/10/2025, no return call was received. Review of the Ad Hoc (originally comes from Latin that means for this specific purpose, indicating the actions or solutions designed for a specific problem or situation) Quality Assurance & Performance Improvement Meeting dated 10/8/2025 documented, Data: Nurse removed 2 IV meds from [name of automatic medication dispensing machine], right med, wrong dose and administered. Root Cause Analysis: Nurse did not have medication that was due in her cart or med room and it had not been delivered from pharmacy. Medication removed from [name of automatic medication dispensing machine] right med but wrong dosage and dosage not verified before administration. During an interview on 10/7/2025 at 4:10 PM, Staff C, Pharmacy Account Manager stated, I am not familiar with the facility having any overflow medications or overstock of antibiotics, and the pharmacy does not leave extra IV pumps at the facility. For a resident admitted to the facility on a Monday at or around 5:00 PM, the medications would have been delivered the following morning. We do have a process for stat deliveries, and we would have routinely delivered within three and a half to four hours when ordered stat. During an interview on 10/07/2025 at 4:20 PM, Staff D, Lead Pharmacist stated, We make two deliveries to the facility daily. The deliveries leave the pharmacy at 2:00 PM and 2:00 AM, and then the deliveries arrive at the facility between 6:00 PM and 7:00 AM. I do not have knowledge of overflow or overstock medications. It was not part of the standard protocol for the pharmacy to supply any medications for general use outside of what was in the [name of the automated medication dispensing machine]. There are no extra IV pumps supplied to the facility. The facility can get a stat delivery from the pharmacy. For any medication ordered stat, we begin working on them as soon as we receive the order. The turnaround time for stat orders is four hours. If an IV pump was malfunctioning a replacement pump could be ordered stat. Vancomycin should be provided through an infusion pump to ensure proper administration and prevention of complications from administering to rapidly such as RMS [Red Man Syndrome, a type of allergic reaction that can occur with vancomycin administration] which typically could occur if vancomycin is infused too rapidly. We generally have orders to monitor vancomycin and manage the medication. Ideally in monitoring we are evaluating the Vanco [vancomycin] trough and adjusting doses from there, anything less than 10 is associated with higher levels of antibiotic resistance, ideally we attempt to maintain levels between 10-20 for optimal effect to maintain the drugs efficacy and minimize nephro [nephrotoxicity-damage to the kidneys] and ototoxicity toxicity [damage to hearing].During an interview on 10/8/2025 at 8:55 AM, APRN #1 [Advanced Practice Registered Nurse] stated, I saw [Resident #1's name] on 9/10/2025. I did not receive a call prior to my visit regarding the resident [Resident #1] or any issues with his antibiotics. I was asked by a facility nurse on 9/10/2025 if [Resident #1's name] vancomycin could be held because it was not available in the facility, but I believed the hold was not necessary as he was receiving his antibiotic infusion when I was in his room on 9/10/2025. I would give an order to hold antibiotics for one dose if the medications were on their way to the facility from the pharmacy. If it was more than one dose, I know what the resident was receiving in the hospital and that the medication was available in the facility. So, I would have given an order for that antibiotic to be given, or I would have determined if there was another medication available in the facility that I could order. I only recall speaking with a nurse regarding [Resident #1's name] on 9/10/2025 prior to seeing him. I do not recall speaking with anyone regarding a malfunctioning IV pump or giving orders to hold his vancomycin related to the issues with the IV pump. During an interview on 10/8/2025 at 9:25 AM, the Director of Nursing (DON) stated, When a resident is admitted the process is to get the orders in the computer so pharmacy can get them delivered. If the medications are not available, the nurses need to contact the physician. The nurses should contact the pharmacy and ask about getting medications from the [name of the automated medication dispensing machine] or ask for a stat delivery. There were also sister pharmacies they can contact for getting medications if there is a problem. We do have sister facilities they can call to get an IV pump. If medications are not in the facility for administration the nurses need to call the doctor and follow the physician's orders and document the process. The nurses should ask the doctor if there is an alternative medication they can give. The reasonable time frame for a nurse to wait on medications is an hour. If they were unable to administer an ordered antibiotic to a resident, the resident should be sent to the hospital. I have concerns regarding the competence of the facility nurses.During an interview on 10/08/2025 at 9:50 AM, the Medical Doctor stated, I do not recall being contacted regarding the resident [Resident #1] or any issues with his antibiotics. It was unfortunate that the resident did not receive his ordered antibiotics and of his readmission to the hospital. Residents have got to get the medications ordered for them. It is a shame that they were not administered, they should have been given. I'm aware that [missed doses of IV antibiotics] would cause concern for his admission for sepsis, not getting the medication may be a concern.During an interview on 10/08/2025 at 10:59 AM, APRN #2 stated, I got a message on 9/9/25 at 6:43 PM requesting that [Resident #1's name] vancomycin schedule be extended due to him missing a dose. I instructed the nurse to contact the pharmacy regarding the dosing of vancomycin. I was contacted only one time regarding only one missed dose of vancomycin. I would have only ordered the vanco to be held for one dose.During an interview on 10/08/2025 at 11:50 AM, Resident #1's mother stated, My son [Resident #1] is still in the hospital due to the bacteria he tested positive for when he was readmitted , and that he had to be on antibiotics for twelve hours out of every twenty-four. [Resident #1's name] had not received his vancomycin while he was in the facility, and I received conflicting information from the staff regarding the reason it was not being administered. [Resident #1's name] called me on 9/11/25 and told me that he did not know what was happening and he was confused. I was concerned about his altered mental status, and I called the Unit Manager in the facility to report my concerns. I was told that the nursing staff had not noticed any changes in his condition, but they would obtain labs. On 9/12/25 at around 2:00 PM [Resident #1's name] called me and told me he did not know where he was. I called the facility, reported my concerns and requested that he be transferred to the hospital.During an interview on 10/09/2025 at 8:05 AM, Staff G, LPN stated, I do not remember how many doses of vancomycin [Resident #1's name] had been scheduled during my shift on 9/10/2025. I was not able to administer the IV vancomycin because the IV pump was malfunctioning. I called the pharmacy and was told that the pharmacy had to receive the malfunctioning pump back before they would send a replacement IV pump. I spoke with the in-house nurse practitioner, [Name of APRN #1], who was in the building at that time. The nurse practitioner gave an order to hold the vanco, but I don't remember if the NP [nurse practitioner] said to hold the vanco for one dose or for one day. On 9/11[2025] there was a stat lab to check his vancomycin level. I had a conversation with a provider regarding the results of the vanco level and it would have been [APRN #1's name] I would have called. I can't remember if I told [APRN #1's name] that the pump was still not there. I called the pharmacy again regarding the IV pump and was told the pump would be delivered that day. The pump arrived before the end of my shift on the day before he went to the hospital. During an interview on 10/10/2025 at 2:06 PM with the DON when asked regarding the significant medication errors related to the administration of vancomycin and cefepime for Resident #1 the DON stated, I am new to the facility. I wasn't here when this happened.2) Review of Resident #3's admission record documented the resident was admitted on [DATE] with diagnoses to include acute osteomyelitis, left ankle and foot, orthopedic aftercare following surgical amputation, type 2 diabetes, acquired absence of left leg below knee, acquired absence of other left toes, and unspecified sequelae of cerebral infraction.Review of Resident #3 physician order dated 10/3/2025 read, IVs: Flush Midline with 10cc of normal saline every shift and as needed. Review of Resident #3 MAR for the month of October 2025 for IV Flush 10cc documented on 10/4/2025 and 10/5/2025 at 12 :00 (midnight) administered by Staff H, LPN.Review of Resident #3's physician order dated 10/4/2025 read, Linezolid [antibiotic used to treat serious bacterial infections] intravenous solution 600 mg/300 ml (Linezolid) Use 300 ml intravenously every 12 hours for skin/skin infection for 5 days 150 ml/hr [milliliter per hour].Review of Resident #3's MAR for the month of October 2025 for Linezolid Intravenous Solution 300 ml documented on 10/04/2025 at 2100 [9:00 PM] administer by Staff H, LPN, and on 10/5/2025 at 2100 administered by Staff H, LPN.Review of Resident #3's physician orders dated 10/2/2025 read, Zosyn [intravenous antibiotic combination piperacillin and tazobactam; a broad-spectrum antibiotic used to treat moderate-to-severe bacterial infections] intravenous solution 3-0.375 gm/50 ml (3 grams of piperacillin and 0.375 grams of the beta-lactamase inhibitor tazobactam in De

Based on interview and record review, the facility failed to ensure all residents were free from medical neglect by failing to ensure staff implemented the policies and procedures for medication administration for 1 of 3 residents reviewed for intravenous (IV) antibiotic medication administration (Resident #1). The facility failure to ensure residents were free from medical neglect by failing to ensure residents were free from significant medication errors when the residents were not administered the prescribed antibiotics per the physician order and failure to ensure the nursing staff had appropriate IV (intravenously) certification to administer IV medications and follow the policy/procedure related to medication administration, physician notification, obtaining stat [derived from the Latin word statim, meaning immediately] orders for medication and equipment, resulted in Immediate Jeopardy. Resident #1 was admitted on [DATE] with physician orders for Vancomycin 1500 mg IV every 8 hours intravenously for infection (osteomyelitis, an infection in the bone). On 9/8/2025 at approximately 10:00 PM, Resident #1 was administered one incorrect dose of Vancomycin 1000 mg. Resident #1 was not administered any further doses of Vancomycin 1500 mg until 9/12/2025 at 12:00 AM. Resident #1 missed 8 doses of Vancomycin between 9/9/2025 and 9/12/2025. On 9/11/2025, Resident #1 began to experience a change in condition of altered mental status, identified by a family member, who requested on 9/12/2025, that Resident #1 be sent to Emergency Department where he was diagnosed with sepsis [a life threatening emergency that damages the body's organs and can cause death]. Missing antibiotic doses can reduce the effectiveness of the treatment and increase the risk of antibiotic resistance, serious harm and/or death, and lack of staff competency related to nursing staff having appropriate IV certification, can result in serious harm including damage to veins and the injection site, an air embolism, phlebitis, and blood clots, injury and/or death.The Administrator was notified of the Immediate Jeopardy on October 10, 2025, at 11:45 AM.Findings include:Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation last reviewed 02/07/2025 read, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights to establish a disciplinary policy which results in a fair and timely treatment of occurrences of resident abuse. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action including dismissal provided herein. Definitions: Neglect is the failure of the center, 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.Review of Resident's #1's Discharge summary dated [DATE] from [Name of local hospital] read, Outpatient IV ABX (antibiotic) orders: 1. Cefepime 1 g [gram] q8h [every eight hours] or 3 g q24h [every twenty-four hours] 2. Vancomycin 1500 mg [milligrams] q8h [every eight hours] for 2 weeks.Review of Resident #1's nursing progress note dated 9/8/2025 at 8:31 PM read, Patient was coming around 4:15 PM. With colostomy on his left side and a urostomy on his left side. PICC [Peripherally Inserted Central Catheter] line on his right arm. Vital signs was {sic} within normal range. Patient got left hip surgery paraplegic (related to paraplegia, which is an impairment in motor or sensory function of the lower extremities) and had a drain in the space of the surgery. Patient is alert and oriented times 4.Review of Resident #1's admission record documented an admission date of 9/8/2025 with diagnoses to include subacute osteomyelitis [an infection in the bone], other site, spina bifida occulta [a small gap in one or more of the bones in the spine], other hydrocephalus [a buildup of fluid in the brain], paraplegia unspecified, other bacterial infections of unspecified site, other seizures, local infection of the skin and subcutaneous tissue unspecified, iron deficiency, presence of cerebral spinal fluid drainage device, anemia unspecified, soft tissue disorder unspecified, unspecified visual loss, and gastroesophageal reflux disease [heartburn] without esophagitis [inflammation of the esophagus].Review of Resident #1's physician order dated 9/8/2025 read, Vancomycin HCl [Hydrocholoride, a potent antibiotic used to treat severe bacterial infections, including those resistant to other antibiotics] intravenous solution 1500mg/300ml [1500 milligrams in 300 milliliters of sodium chloride] Use 1500 mg intravenously every 8 hours for Infection for 21 Days.Review of Resident #1's physician order dated 9/8/2025 read, Cefepime HCI (antibiotic used to treat a wide variety of serious bacterial infections) intravenous solution 1 gm/50 ml [1 gram per 50 milliliter] (Cefepime HCI (hydrochloride)) Use 1 gram intravenously every 8 hours for infection for 21 Days until finished. Review of Resident #1's Medication Administration Record for the month of September 2025 for vancomycin 1500 mg intravenously was documented as chart code 9 (other see nurses notes) on 9/9/2025 at 0800 (8:00 AM) and 1600 (4:00 PM), on 9/10/2025 there is an X [not given] at 12:00 midnight and a chart code of 9 at 0800 [8:00 AM] and 1600 (4:00 PM). On 9/11/2025 a chart code of H [hold] at 1200 [12:00 AM], 0800, and 1600 for a total of 8 missed doses of vancomycin.Review of Resident #1's EMAR (electronic medication administration record) note for vancomycin 1500 mg IV dated 9/9/2025 at 7:32 AM read, order needs to be updated.Review of Resident #1's EMAR note for vancomycin 1500 mg IV dated 9/9/2025 at 4:21 PM read, will be in on evening run per pharmacy.Review of the form titled [Name of pharmacy] Inventory on Hand dated 9/9/2025 documented vancomycin 1 gm [gram] vial on hand amount 4 vials were in the [name of the automated medication dispensing machine].Review of Resident #1's EMAR note dated 9/10/2025 at 12:28 PM read, Vancomycin HCl intravenous solution 1500 mg/300 ml use 1500 mg intravenously every 8 hours for Infection for 21 Days. The pharmacy sent a malfunctioning pump, and the writer reached out to inform them of the issue. The pharmacy stated that the problem would be addressed during the next run. The NP [nurse practitioner] was notified and confirmed it was okay to put the medication on hold until then.Review of Resident #1's MAR for cefepime dated 09/9/2025 at 6:00 AM documented a code of 5 (Hold/see Nurses Notes) and 1400 (2:00 PM) a code of 9 (Other/See Nurses Notes). For a total of two missed doses.Review of Resident #1's MAR dated 09/10/2025 at 6:00 AM, 2:00 PM, and 10:00 PM documented cefepime was administered. Vancomycin for the date of 9/10/2025 documented at 12:00 midnight X (not administered), at 8:00 AM and 4:00 PM code 9 (Other/see Nurse Notes).Review of Resident #1's physician progress note dated 9/10/2025 at 13:23 (1:23 PM), authored by APRN #1 (Advanced Practitioner Registered Nurse), read, He has now been admitted to the skilled nursing facility for continuation of IV vancomycin and cefepime, wound care management, and rehabilitation support. Assessment/Plan: Chronic osteomyelitis, unspecified site with recent surgical intervention. Active, high-risk condition. Patient with recurrent osteomyelitis, currently on IV vancomycin and cefepime per infectious disease recommendations. Plan: Continue IV vancomycin and cefepime per protocol. Monitor temperature, WBC [white blood cell] trends, renal function, and vancomycin trough levels. Maintain coordination with infectious disease and wound care teams.Review of Resident #1's eInteract SBAR (Situation, Background, Assessment, Recommendation) dated 9/11/2025 at 3:33 PM read, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Altered mental status. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness. Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: cbc [complete blood count], cmp [complete metabolic profile] vanco [vancomycin] trough [a blood test used for monitoring the vancomycin medication administration). Review of Resident #1's physician order dated 9/11/2025 read, CBC w/ Diff [differential], comprehensive panel/vancomycin pre-dose (trough) one time only related to presence of cerebrospinal fluid drainage device, iron deficiency, other seizures, local infection of the skin and subcutaneous tissue, unspecified anemia, unspecified, other hydrocephalus, subacute osteomyelitis, other site, soft tissue disorder, unspecified, other bacterial infections of unspecified site, spina bifida occulta. Review Resident #1's Laboratory result report with specimen collection date of 9/11/2025 and report date of 9/12/2025 read, Vancomycin trough final result <2.0 [less than] ug (micrograms)/ml (milliliter) (L) (low) - Ref. [reference] Range Units: 5.0 - 20.0 ug.Review of Resident #1's eInteract Transfer Form dated 9/12/2025 at 10:16 AM read, Section A: Demographic and Transfer information: 2. Transfer/discharge details. Send to [Name of local hospital], sent from [Name of Nursing home]. Reason(s) for transfer: other; Other reason for transfer: possible sepsis.Review of Resident #1's nursing progress note dated 9/12/2025 at 10:38 AM read, At approximately 10:00 AM**, the writer received a call from the resident's mother, who requested that the resident be sent to the hospital for further evaluation due to concerns about possible sepsis. VS [vital signs] 123/81 p [pulse]107 T [temperature] 98.8 02 [oxygen saturation] 98 alert and oriented x 2 with confusion have no recall of short-term memory. The NP [Nurse Practitioner] on site was notified. The resident's mother was informed of the transfer to the hospital. The DON [Director of Nursing] was also notified. The plan of care remains ongoing.Review of Resident #1's eInteract SBAR dated 9/12/2025 at 10:28 AM read, Situation: The Change In Condition (CIC)/s reported on this CIC Evaluation are/were: Other change in condition. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send out for further evaluation.Review of Resident #1's medical record from [Name of Hospital] titled 'ED [Emergency Department] to Hosp [Hospital]- admission (Current) dated 9/12/2025 read, ED course & re-evaluation: [Resident #1's name], a [AGE] year-old male with a PMHx [past medical history] of spina bifida occulta with hydrocephalus [a buildup of fluid in the brain] s/p [status post] [NAME] rod [a stainless steel surgical device used to treat a curvature of the spine] and VP [ventriculoperitoneal] shunt [a tube in the brain to drain fluid into the stomach], paraplegia, paralysis (the loss of the ability to move certain parts of the body typically as a result of illness or injury) below T8 [thoracic nerve number 8] + chronically wheelchair bound and chronic sacral wound, who presents today from outside skilled facility with AMS [altered mental status], tachycardia [a high heart rate], and concerns for sepsis [a life threatening emergency that damages the body's organs and can cause death] w [with]/new onset of leukocytosis [an abnormally high number of white blood cells (leukocytes) in the bloodstream] of 15 [indicates the body is fighting an infection]. On arrival, he was tachycardic [related to a high heart rate] but hemodynamically stable [a state in which the cardiovascular system is functioning properly and maintaining adequate blood flow throughout the body]. He was sepsis alerted given concern for infection and initial tachycardia with leukocytosis at outside facility. He was started on Vancomycin, cefepime and 30 cc [cubic centimeters]/kg [kilogram] IVF [intravenous fluids] with source concerning for recurrent osteomyelitis [an infection of the bone] and possible abscess [a pocket of pus] at recent surgical site in the setting of subtherapeutic [low level that is too low to produce the intended medical effect] Vancomycin + [plus] missing antibiotic dose. Regarding his AMS [altered mental status], his mother noted repetitive questioning and confusion otherwise no new neurologic deficits. His VP shunt is compressible. Will further evaluate additional causes of AMS with labs and imaging. Anticipate admission. ED [Emergency Department] Clinical Impression: Osteomyelitis of left femur, unspecified type, septic hip s/p [NAME] procedure, abscess of hip, left, sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, acute encephalopathy [a disturbance in brain function that causes confusion and memory loss].Review of Resident #1 [Name of Hospital] medical record titled History and Physical dated 9/12/2025 read, [Resident #1's name] is a 39 y.o. [year old] male with medical history significant for spina bifida occulta with hydrocephalus s/p VP shunt and [NAME] spinal rod placement, paraplegia and chronically wheelchair bound admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. The patient was recently hospitalized from 8/11-9/8/2025 for sepsis secondary to acute on chronic osteomyelitis and underwent a [NAME] procedure. He was then discharged to SNF [skilled nursing facility] for rehabilitation and continued IV antibiotic course for treatment of his acute infection. He has now been brought back to the ED due to altered mental status. He is currently accompanied by his mother who is at bedside. She states that the patient has been at the facility for several days since being discharged with IV antibiotics, however she has been concerned as she does not believe he has been receiving these medications or at least on a reliable schedule. She states that he began to act abnormal yesterday at which time he had completely forgotten the fact that he had just been hospitalized for two weeks. Today is alert and oriented only to self. He struggles with location, year, and current president. On arrival to the ED, the patient was found to be afebrile [not having a fever] with vitals remarkable for sinus tachycardia. Labs are remarkable for leukocytosis (WBC 15) and elevated CRP [C-Reactive Protein, indicative of inflammation in the body] (21.14). CT [Computed Tomography] imaging has revealed acute on chronic osteomyelitis of the left hip with details concerning for septic joint formation. There is also noted to likely be subperiosteal abscess (infection to the tissue located the surface of the bones) formation along the medical margin of the femoral head with a communicating sinus tract to the posterior medial skin of the left proximal thigh. Assessment and plan: [Resident #1's name] is a 39 y.o. male who is admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. Active Problems: #Sepsis, reason for admission, #Acute on Chronic Osteomyelitis, #Altered Mental Status, resolved - admitted for sepsis secondary to acute on chronic osteomyelitis that has likely worsened secondary to poor wound care lack of proper antibiotic usage.Review of Resident #1 [Name of Local Hospital] Infectious Disease note dated 9/13/2025 read, [Resident #1's name] is a 39 y.o. male with above mentioned PMHx admitted on [DATE] with chief complaint of altered mental status 1 day prior to admission. Recently admitted 8/11-9/8 for acute on chronic osteomyelitis of L [left] ischium, was planned for Flagyl (8/19-9/1), Vancomycin (8/19-9/29), and Cefepime (8/19-9/29). Underwent debridement during this time (see above). Unfortunately, the patient may not have received his antibiotics in an appropriate manner and may be contributory to the patient's current presentation. He currently complains of a 1/2 [one out of two] pain around his incision site and around his L AC [antecubital] (about 4 inches away from his PICC [Peripherally Inserted Central Catheter] line). He doesn't remember being at [Name of local hospital] recently and cannot tell but is able to talk about some specific details about his life.During an interview on 10/07/2025 at 1:36 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #1's name] had been transferred from another room during my shift [9/9/2025]. [Name of Staff B] had [Resident #1's name] prior to me and had called pharmacy who said they would be bringing his medication [vancomycin]. I called the pharmacy again and the pharmacy said they were enroute with the medication. I called the nurse practitioner; I believe her name is [APRN #1's name]. She [APRN #1] told me to extend the order for vancomycin for an extra day, so [Resident #1's name] would have the full course of the antibiotics. The pharmacy courier came in around 7:05 [PM] and brought me his medications. I passed them on to the night shift nurse because it was getting late. I don't think I wrote a note because I was in a rush to leave. I believe I should have documented the conversation with [name of APRN #1]. I don't know really if I can give the medication without a pump and I think that there is vancomycin in the [name of the automated medication dispensing machine]. I don't think we can ask for a stat [derived from the Latin word statim, meaning immediately] delivery from the pharmacy.During an interview on 10/07/2025 at 1:38 PM, Staff B, LPN stated, [Resident #1's name] was an admission from the day before [9/8/2025]. The night-shift nurse [Staff E, LPN] told me that the nurse who admitted the resident did not put in [Resident #1's name] medication orders, so [Staff E's name] was not able to administer any medications for him. I can't remember if she called a provider, but I thought she had gotten an order to hold the vancomycin. If the medication was available in the [name of the automated medication dispensing machine] it should be administered. I know I should have notified the provider of the missed medications, and I should have documented the notification and any orders or instructions from the provider. I'm not sure if we can do a stat order from the pharmacy, we just regularly call the pharmacy and tell them we are waiting for the medication.During an interview on 10/07/2025 at 3:20 PM Staff E, LPN stated, Most of [Resident #1's name] medications were not available on the night shift of 9/8/25 - 9/9/25. The pharmacy doesn't come to the facility until 6:00 AM. Medication orders are typically entered to start the following day [after admission] because of the delivery times from the pharmacy, but [Resident #1's name] medications were ordered to start on the day of his admission [DATE]]. For the medications that were scheduled for my shift I was able to administer his cefepime because it was available in the [name of automated medication dispensing machine]. There was not a dose of vancomycin in the [name of automated medication dispensing machine] but there was overflow of vancomycin in the med [medication] room, as well as an overflow pump, so I was able to administer the ordered dose of vancomycin. I was not able to administer the morning dose of cefepime. I might have notified the doctor that I could not give the cefepime, but I am not sure. I did notify management that I did not give the cefepime, but I did not document the notification because I was already off of the [medication] cart. I know I should have written a note. Review of a form titled [Name of Pharmacy Provider] Transactions by Patient date 9/8/2025 documented vancomycin 1 gm one vial was removed at 7:50 PM, cefepime 1 gm two vials were removed, one at 7:49 PM and one at 7:53 PM. One bag of sodium chloride inj (injectable) 100 ml was removed at 7:55 PM from the [name of the automated medication dispensing machine] for [Resident #1's name]. Additional interviews were attempted 10/8/2025 and 10/9/2025 with Staff E, LPN via telephone to provide clarification of the removal of 100 ml of sodium chloride and vancomycin 1 gram and two vials of cefepime and no additional sodium chloride removed from the automated medication dispensing machine for vancomycin and cefepime IV administration. The physician orders document vancomycin 1500 mg (1.5 grams) in 300 ml of sodium chloride and cefepime in 50 ml of sodium chloride. On the date of the exit, 10/10/2025, no return call was received.Review of the Ad Hoc (originally comes from Latin that means for this specific purpose, indicating the actions or solutions designed for a specific problem or situation) Quality Assurance & Performance Improvement Meeting dated 10/8/2025 documented, Data: Nurse removed 2 IV meds from [name of automatic medication dispensing machine], right med, wrong dose and administered. Root Cause Analysis: Nurse did not have medication that was due in her cart or med room and it had not been delivered from pharmacy. Medication removed from [name of automatic medication dispensing machine] right med but wrong dosage and dosage not verified before administration.Review of an email from Staff E, LPN addressed to Staff K, Previous Interim DON, dated 9/15/2025 at 4:41 PM read, On admission, resident [Resident #1] was ordered vancomycin and cefepime IV. Medications were not on hand but were available in [name of the automatic medication dispensing machine]. MAR reflected both medications scheduled for administration around 2100 [9:00 PM] on 9/8 [2025]. Cefepime was administered IV first, followed by vancomycin. Vancomycin infusion was prolonged due to patient's arm being constricted, which intermittently stopped the infusion. At 0600 [6:00 AM] on 9/9 [2025], MAR again showed scheduled doses for both vancomycin and cefepime. Unable to administer at that time because the vancomycin infusion from the previous evening was still running. Also, when the medications were delivered from the pharmacy, only the vancomycin was supplied; cefepime was not included in the delivery. This information was passed on in report with recommendation that administration times for vancomycin and cefepime be adjusted accordingly.Review of an email from Staff A, LPN addressed to Staff K, Previous Interim DON dated 9/17/25 at 8:28 AM read, To whom it may concern: I was [Resident #1's name] nurse for a very short period of time of roughly 2 - 3 hours on September 9th [2025] after he moved from room [room number] to [room number]. During that time I asked the nurse who had him at the beginning of the day if he had his 4:00 PM dose of vancomycin and she said no, it was not delivered. I called the pharmacy to confirm and they stated the medication was on the evening medication delivery. As such, I contacted one of the providing APRN's of the situation and got orders to extend dose of antibiotics for another day. I changed the order to extend so that once the antibiotic was delivered, he would get the full course of his antibiotic treatment. During shift change, the pharmacy delivery with [Resident #1's name] medication came along with the pump and I was also the one who signed for those, and I relayed the information to the oncoming shift.During an interview on 10/7/2025 at 4:10 PM, Staff C, Pharmacy Account Manager stated, I am not familiar with the facility having any overflow medications or overstock of antibiotics, and the pharmacy does not leave extra IV pumps at the facility. For a resident admitted to the facility on a Monday at or around 5:00 PM, the medications would have been delivered the following morning. We do have a process for stat deliveries, and we would have routinely delivered within three and a half to four hours when ordered stat. During an interview on 10/07/2025 at 4:20 PM, Staff D, Lead Pharmacist stated, We make two deliveries to the facility daily. The deliveries leave the pharmacy at 2:00 PM and 2:00 AM, and then the deliveries arrive at the facility between 6:00 PM and 7:00 AM. I do not have knowledge of overflow or overstock medications. It was not part of the standard protocol for the pharmacy to supply any medications for general use outside of what was in the [name of the automated medication dispensing machine]. There are no extra IV pumps supplied to the facility. The facility can get a stat delivery from the pharmacy. For any medication ordered stat, we begin working on them as soon as we receive the order. The turnaround time for stat orders is four hours. If an IV pump was malfunctioning a replacement pump could be ordered stat. Vancomycin should be provided through an infusion pump to ensure proper administration and prevention of complications from administering to rapidly such as RMS [Red Man Syndrome, a type of allergic reaction that can occur with vancomycin administration] which typically could occur if vancomycin is infused too rapidly. We generally have orders to monitor vancomycin and manage the medication. Ideally in monitoring we are evaluating the Vanco [vancomycin] trough and adjusting doses from there, anything less than 10 is associated with higher levels of antibiotic resistance, ideally we attempt to maintain levels between 10-20 for optimal effect to maintain the drugs efficacy and minimize nephro [nephrotoxicity-damage to the kidneys] and ototoxicity toxicity [damage to hearing].During an interview on 10/8/2025 at 8:55 AM, APRN #1 [Advanced Practice Registered Nurse] stated, I saw [Resident #1's name] on 9/10/2025. I did not receive a call prior to my visit regarding the resident [Resident #1] or any issues with his antibiotics. I was asked by a facility nurse on 9/10/2025 if [Resident #1's name] vancomycin could be held because it was not available in the facility, but I believed the hold was not necessary as he was receiving his antibiotic infusion when I was in his room on 9/10/2025. I would give an order to hold antibiotics for one dose if the medications were on their way to the facility from the pharmacy. If it was more than one dose, I know what the resident was receiving in the hospital and that the medication was available in the facility. So, I would have given an order for that antibiotic to be given, or I would have determined if there was another medication available in the facility that I could order. I only recall speaking with a nurse regarding [Resident #1's name] on 9/10/2025 prior to seeing him. I do not recall speaking with anyone regarding a malfunctioning IV pump or giving orders to hold his vancomycin related to the issues with the IV pump. During an interview on 10/8/2025 at 9:25 AM, the Director of Nursing (DON) stated, When a resident is admitted the process is to get the orders in the computer so pharmacy can get them delivered. If the medications are not available, the nurses need to contact the physician. The nurses should contact the pharmacy and ask about getting medications from the [name of the automated medication dispensing machine] or ask for a stat delivery. There were also sister pharmacies they can contact for getting medications if there is a problem. We do have sister facilities they can call to get an IV pump. If medications are not in the facility for administration the nurses need to call the doctor and follow the physician's orders and document the process. The nurses should ask the doctor if there is an alternative medication they can give. The reasonable time frame for a nurse to wait on medications is an hour. If they were unable to administer an ordered antibiotic to a resident, the resident should be sent to the hospital. I have concerns regarding the competence of the facility nurses.During an interview on 10/08/2025 at 9:50 AM, the Medical Doctor stated, I do not recall being contacted regarding the resident [Resident #1] or any issues with his antibiotics. It was unfortunate that the resident did not receive his ordered antibiotics and of his readmission to the hospital. Residents have got to get the medications ordered for them. It is a shame that they were not administered, they should have been given. I'm aware that [missed doses of IV antibiotics] would cause concern for his admission for sepsis, not getting the medication may be a concern.During an interview on 10/08/2025 at 10:59 AM, APRN #2 stated, I got a message on 9/9/25 at 6:43 PM requesting that [Resident #1's name] vancomycin schedule be extended due to him missing a dose. I instructed the nurse to contact the pharmacy regarding the dosing of vancomycin. I was contacted only one time regarding only one missed dose of vancomycin. I would have only ordered the vanco to be held for one dose.During an interview on 10/08/2025 at 11:50 AM, Resident #1's mother stated, My son [Resident #1] is still in the hospital due to the bacteria he tested positive for when he was readmitted , and that he had to be on antibiotics for twelve hours out of every twenty-four. [Resident #1's name] had not received his vancomycin while he was in the facility, and I received conflicting information from the staff regarding the reason it was not being administered. [Resident #1's name] called me on 9/11/25 and told me that he did not know what was happening and he was confused. I was concerned about his altered mental status, and I called the Unit Manager in the facility to report my concerns. I was told that the nursing staff had not noticed any changes in his condition, but they would obtain labs. On 9/12/25 at around 2:00 PM [Resident #1's name] called me and told me he did not know where he was. I called the facility, reported my concerns and requested that he be transferred to the hospital.During an interview on 10/09/2025 at 8:05 AM, Staff G, LPN stated, I do not remember how many doses of vancomycin [Resident #1's name] had been scheduled during my shift on 9/10/2025. I was not able to administer the IV vancomycin because the IV pump was malfunctioning. I called the pharmacy and was told that the pharmacy had to receive the malfunctioning pump back before they would send a replacement IV pump. I spoke with the in-house nurse practitioner, [Name of APRN #1], who was in the building at that time. The nurse practitioner gave an order to hold the vanco, but I don't remember if the NP [nurse practitioner] said to hold the vanco for one dose or for one day. On 9/11[2025] there was a stat lab to check his vancomycin level. I had a conversation with a provider regarding the results of the vanco level and it would have been [APRN #1's name] I would have called. I can't remember if I told [APRN #1's name] that the pump was still not there. I called the pharmacy again regarding the IV pump and was told the pump would be delivered that day. The pump arrived before the end of my shift on the day before he went to the hospital. During an interview on 10/09/2025 at 10:37 AM the Administrator stated, Nurses are educated in orientation regarding medication administration and the associated processes, including ordering medications and equipment from the pharmacy. The expectation was that when a resident was admitted their medication orders were sent to the pharmacy. The facility had previously had issues regarding medication availability and administration, and it was a topic they all focused on. The process with the pharmacy was to deliver the medications and any equipment on their next run. If medication was not available from the pharmacy, the nurses had access to the [name of automated medication dispensing machine] and the pharmacy was able to get medications from a sister pharmacy if necessary. During an interview on 10/10/2025 at 2:06 PM with the DON when asked regarding the significant medication errors related to the administration of vancomycin and cefepime for Resident #1 the DON stated, I am new to the facility. I wasn't here when this hap

Based on interview and record review the facility failed to ensure residents were free from significant medication errors when the facility failed to ensure residents were administered physician ordered antibiotics for 1 of 3 residents reviewed for intravenous (IV) antibiotic medication (Resident #1). The facility failure to ensure residents were free from significant medication errors when the residents were not administered the prescribed antibiotics per the physician order resulted in Immediate Jeopardy. Resident #1 was admitted on [DATE] with physician orders for Vancomycin 1500 mg IV every 8 hours intravenously for infection (osteomyelitis, an infection in the bone). On 9/8/2025 at approximately 10:00 PM, Resident #1 was administered one incorrect dose of Vancomycin 1000 mg. Resident #1 was not administered any further doses of Vancomycin 1500 mg until 9/12/2025 at 12:00 AM. Resident #1 missed 8 doses of Vancomycin between 9/9/2025 and 9/12/2025. On 9/11/2025, Resident #1 began to experience a change in condition of altered mental status, identified by a family member, who requested on 9/12/2025, that Resident #1 be sent to Emergency Department where he was diagnosed with sepsis [a life threatening emergency that damages the body's organs and can cause death]. Missing antibiotic doses can reduce the effectiveness of the treatment and increase the risk of antibiotic resistance, serious harm and/or death.The Administrator was notified of the Immediate Jeopardy on October 10, 2025, at 11:45 AM.Findings include: Review of Resident #1's admission record documented an admission date of 9/8/2025 with diagnoses to include subacute osteomyelitis [an infection in the bone], other site, spina bifida occulta [a small gap in one or more of the bones in the spine], other hydrocephalus [a buildup of fluid in the brain], paraplegia (an impairment in motor or sensory function of the lower extremities) unspecified, other bacterial infections of unspecified site, other seizures, local infection of the skin and subcutaneous tissue unspecified, iron deficiency, presence of cerebral spinal fluid drainage device, anemia unspecified, soft tissue disorder unspecified, unspecified visual loss, and gastroesophageal reflux disease [heartburn] without esophagitis [inflammation of the esophagus].Review of Resident's #1's Discharge summary dated [DATE] from [Name of local hospital] read, Outpatient IV ABX (antibiotic) orders: 1. Cefepime 1 g [gram] q8h [every 8 hours] or 3 g q24h [every twenty-four hours]. 2. Vancomycin 1500 mg [milligrams] q8h for 2 weeks.Review of Resident #1's physician order dated 9/8/2025 read, Vancomycin HCl [Hydrocholoride, a potent antibiotic used to treat severe bacterial infections, including those resistant to other antibiotics] intravenous solution 1500mg/300ml [1500 milligrams in 300 milliliters of sodium chloride] Use 1500 mg intravenously every 8 hours for Infection for 21 Days. Cefepime HCl [used to treat severe bacterial infections] intravenous solution 1 gm/50 ml (Cefepime HCl) Use 1 gram intravenously every 8 hours for infection for 21 days until finished.Review of Resident #1's MAR dated 9/8/205 documented Vancomycin HCl intravenous solution 1500 mg/300 ml (Vancomycin HCl) Use 1500 mg intravenously every 8 hours for infection for 21 days at 0600 (6:00 AM), 1400 (2:00 PM), and 2200 (10:00 PM).Review of a form titled [Name of Pharmacy Provider] Transactions by Patient, C14 [Form Code] date 9/8/2025 documented vancomycin 1 gm one vial was removed at 7:50 PM, cefepime 1 gm two vials were removed, one at 7:49 PM and one at 7:53 PM. One bag of sodium chloride inj (injectable) 100 ml bag was removed at 7:55 PM from the [name of the automated medication dispensing machine] for [Resident #1's name]. Additional interviews were attempted 10/8/2025 and 10/9/2025 with Staff E, LPN via telephone to provide clarification of the removal of 100 ml of sodium chloride and vancomycin 1 gram and two vials of cefepime and no additional sodium chloride removed from the automated medication dispensing machine for vancomycin and cefepime IV administration. The physician orders document vancomycin 1500 mg (1.5 grams) in 300 ml of sodium chloride and cefepime in 50 ml of sodium chloride. On the date of the exit, 10/10/2025, no return call was received.Review of Resident #1's MAR dated 9/8/2025 documented vancomycin 1500 mg and cefepime 1 gram was administered IV at approximately 10:00 PM by the initialing of the MAR by Staff E, LPN.Review of the form titled [Name of pharmacy] Inventory on Hand dated 9/9/2025 documented vancomycin 1 gm [gram] vial on hand amount 4 vials were in the [name of the automated medication dispensing machine].Review of Resident #1's physician order dated 9/9/2025 read, Vancomycin intravenous solution 1500 mg [milligrams]/300 ml [milliliters] (Vancomycin HCl [hydrochloride] use 1500 mg intravenously every 8 hours for Infection for 21 Days. [Scheduled for 0000 (12:00 AM), 0800 (8:00 AM), and 1600 (4:00 PM).Review of Resident #1's Medication Administration Record for the month of September 2025 for vancomycin 1500 mg intravenously was documented as chart code 9 (other see nurses notes) on 9/9/2025 at 0800 (8:00 AM) and 1600 (4:00 PM), on 9/10/2025 there is an X [not given] at 12:00 midnight and a chart code of 9 at 0800 [8:00 AM] and 1600. On 9/11/2025 a chart code of H [hold] at 1200 [12:00 AM], 0800, and 1600 for a total of 8 missed doses of vancomycin.Review of Resident #1's physician order dated 9/8/25 read, Cefepime HCl intravenous solution 1 gm/50 ml. (Cefepime HCl: Use 1 gram intravenously every 8 hours for Infection for 21 Days until finished. [Scheduled for 6:00 AM, 1400 (2:00 PM), and 2200 (10:00 PM)]Review of Resident #1's MAR dated 9/9/2025 at 6:00 AM for Cefepime HCl Intravenous documented a chart code of 5 (Hold/See Nurse Notes) at 0600 (6:00 AM) and a chart code 9 at 1400. For a total of two missed doses.Review of Resident #1's MAR dated 09/10/2025 at 6:00 AM, 2:00 PM, and 10:00 PM documented cefepime was administered. Vancomycin for the date of 9/10/2025 documented at 12:00 midnight X (not administered), at 8:00 AM and 4:00 PM code 9 (Other/see Nurse Notes).Review of Resident #1's progress note dated 9/9/2025 at 7:32 AM for Vancomycin 1500 mg IV read, Order needs to be updated.Review of Resident #1's progress note dated 9/9/2025 at 4:21 PM for Vancomycin 1500 mg IV read, Will be in on evening run per pharmacy.Review of Resident #1's progress note dated 9/10/2025 at 12:28 PM read, Vancomycin HCl intravenous solution 1500 mg/300 ml use 1500 mg intravenously every 8 hours for infection for 21 days. The pharmacy sent a malfunctioning pump, and the writer reached out to inform them of the issue. The pharmacy stated that the problem would be addressed during the next run. The NP [nurse practitioner] was notified and confirmed it was okay to put the medication on hold until then.Review of Resident #1's physician progress note dated 9/10/2025 at 13:23 (1:23 PM) authored by APRN #1 (Advanced Practitioner Registered Nurse) read, He has now been admitted to the skilled nursing facility for continuation of IV vancomycin and cefepime, wound care management, and rehabilitation support. Assessment/Plan: Chronic osteomyelitis, unspecified site with recent surgical intervention. Active, high-risk condition. Patient with recurrent osteomyelitis, currently on IV vancomycin and cefepime per infectious disease recommendations. Plan: Continue IV vancomycin and cefepime per protocol. Monitor temperature, WBC [white blood cell] trends, renal function, and vancomycin trough levels. Maintain coordination with infectious disease and wound care teams.Review of Resident #1's eInteract SBAR (Situation, Background, Assessment, Recommendation) dated 9/11/2025 at 3:33 PM read, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Altered mental status. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness. Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: cbc [complete blood count], cmp [complete metabolic profile] vanco [vancomycin] trough [a blood test used for monitoring the vancomycin medication administration]. Review of Resident #1's physician order dated 9/11/2025 read, CBC w/ Diff [differential], comprehensive panel/vancomycin pre-dose (trough) one time only related to presence of cerebrospinal fluid drainage device, iron deficiency, other seizures, local infection of the skin and subcutaneous tissue, unspecified anemia, unspecified, other hydrocephalus, subacute osteomyelitis, other site, soft tissue disorder, unspecified, other bacterial infections of unspecified site, spina bifida occulta. Review Resident #1's Laboratory result report with a specimen collection date of 9/11/2025 and report date of 9/12/2025 read, Vancomycin trough final result <2.0 [less than] ug (micrograms)/ml (milliliter) (L) (low) - Ref. [reference] Range Units: 5.0 - 20.0 ug.Review of Resident #1's eInteract Transfer Form dated 9/12/2025 at 10:16 AM read, Section A: Demographic and Transfer information: 2. Transfer/discharge details. Send to [Name of local hospital], sent from [Name of Nursing home]. Reason(s) for transfer: other; Other reason for transfer: possible sepsis.Review of Resident #1's Interactive SBAR dated 9/12/2025 at 10:28 AM read, Situation: The Change In Condition (CIC)/s reported on this CIC Evaluation are/were: Other change in condition. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send out for further evaluation.Review of Resident #1's medical record from [Name of Hospital] titled 'ED [Emergency Department] to Hosp [Hospital]- admission (Current) dated 9/12/2025 read, ED course & re-evaluation: [Resident #1's name], a [AGE] year-old male with a PMHx [past medical history] of spina bifida occulta with hydrocephalus [a buildup of fluid in the brain] s/p [status post] [NAME] rod [a stainless steel surgical device used to treat a curvature of the spine] and VP [ventriculoperitoneal] shunt [a tube in the brain to drain fluid into the stomach], paraplegia, paralysis (the loss of the ability to move certain parts of the body typically as a result of illness or injury) below T8 [thoracic nerve number 8] + chronically wheelchair bound and chronic sacral wound, who presents today from outside skilled facility with AMS [altered mental status], tachycardia [a high heart rate], and concerns for sepsis [a life threatening emergency that damages the body's organs and can cause death] w [with]/new onset of leukocytosis [an abnormally high number of white blood cells (leukocytes) in the bloodstream] of 15 [indicates the body is fighting an infection]. On arrival, he was tachycardic [related to a high heart rate] but hemodynamically stable [a state in which the cardiovascular system is functioning properly and maintaining adequate blood flow throughout the body]. He was sepsis alerted given concern for infection and initial tachycardia with leukocytosis at outside facility. He was started on Vancomycin, cefepime and 30 cc [cubic centimeters]/kg [kilogram] IVF [intravenous fluids] with source concerning for recurrent osteomyelitis [an infection of the bone] and possible abscess [a pocket of pus] at recent surgical site in the setting of subtherapeutic [low level that is too low to produce the intended medical effect] Vancomycin + [plus] missing antibiotic dose. Regarding his AMS [altered mental status], his mother noted repetitive questioning and confusion otherwise no new neurologic deficits. His VP shunt is compressible. Will further evaluate additional causes of AMS with labs and imaging. Anticipate admission. ED [Emergency Department] Clinical Impression: Osteomyelitis of left femur, unspecified type, septic hip s/p [NAME] procedure, abscess of hip, left, sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, acute encephalopathy [a disturbance in brain function that causes confusion and memory loss].Review of Resident #1 [Name of Hospital] medical record titled History and Physical dated 9/12/2025 read, [Resident #1's name] is a 39 y.o. [year old] male with medical history significant for spina bifida occulta with hydrocephalus s/p VP shunt and [NAME] spinal rod placement, paraplegia and chronically wheelchair bound admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. The patient was recently hospitalized from 8/11-9/8/2025 for sepsis secondary to acute on chronic osteomyelitis and underwent a [NAME] procedure. He was then discharged to SNF [skilled nursing facility] for rehabilitation and continued IV antibiotic course for treatment of his acute infection. He has now been brought back to the ED due to altered mental status. He is currently accompanied by his mother who is at bedside. She states that the patient has been at the facility for several days since being discharged with IV antibiotics, however she has been concerned as she does not believe he has been receiving these medications or at least on a reliable schedule. She states that he began to act abnormal yesterday at which time he had completely forgotten the fact that he had just been hospitalized for two weeks. Today is alert and oriented only to self. He struggles with location, year, and current president. On arrival to the ED, the patient was found to be afebrile [not having a fever] with vitals remarkable for sinus tachycardia. Labs are remarkable for leukocytosis (WBC 15) and elevated CRP [C-Reactive Protein, indicative of inflammation in the body] (21.14). CT [Computed Tomography] imaging has revealed acute on chronic osteomyelitis of the left hip with details concerning for septic joint formation. There is also noted to likely be subperiosteal abscess (infection to the tissue located the surface of the bones) formation along the medical margin of the femoral head with a communicating sinus tract to the posterior medial skin of the left proximal thigh. Assessment and plan: [Resident #1's name] is a 39 y.o. male who is admitted for altered mental status secondary to sepsis from acute on chronic osteomyelitis of the left hip. Active Problems: #Sepsis, reason for admission, #Acute on Chronic Osteomyelitis, #Altered Mental Status, resolved - admitted for sepsis secondary to acute on chronic osteomyelitis that has likely worsened secondary to poor wound care lack of proper antibiotic usage.Review of Resident #1 [Name of Local Hospital] Infectious Disease note dated 9/13/2025 read, [Resident #1's name] is a 39 y.o. male with above mentioned PMHx admitted on [DATE] with chief complaint of altered mental status 1 day prior to admission. Recently admitted 8/11-9/8 for acute on chronic osteomyelitis of L [left] ischium, was planned for Flagyl (8/19-9/1), Vancomycin (8/19-9/29), and Cefepime (8/19-9/29). Underwent debridement during this time (see above). Unfortunately, the patient may not have received his antibiotics in an appropriate manner and may be contributory to the patient's current presentation. He currently complains of a 1/2 [one out of two] pain around his incision site and around his L AC [antecubital] (about 4 inches away from his PICC [Peripherally Inserted Central Catheter] line). He doesn't remember being at [Name of local hospital] recently and cannot tell but is able to talk about some specific details about his life.Review of an email from Staff E, LPN addressed to Staff K, Previous Interim DON, dated 9/15/2025 at 4:41 PM read, On admission, resident [Resident #1] was ordered vancomycin and cefepime IV. Medications were not on hand but were available in [name of the automatic medication dispensing machine]. MAR reflected both medications scheduled for administration around 2100 [9:00 PM] on 9/8 [2025]. Cefepime was administered IV first, followed by vancomycin. Vancomycin infusion was prolonged due to patient's arm being constricted, which intermittently stopped the infusion. At 0600 [6:00 AM] on 9/9 [2025], MAR again showed scheduled doses for both vancomycin and cefepime. Unable to administer at that time because the vancomycin infusion from the previous evening was still running. Also, when the medications were delivered from the pharmacy, only the vancomycin was supplied; cefepime was not included in the delivery. This information was passed on in report with recommendation that administration times for vancomycin and cefepime be adjusted accordingly.During an interview on 10/07/2025 at 1:36 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #1's name] had been transferred from another room during my shift [9/9/2025]. [Name of Staff B] had [Resident #1's name] prior to me and had called pharmacy who said they would be bringing his medication [vancomycin]. I called the pharmacy again and the pharmacy said they were enroute with the medication. I called the nurse practitioner; I believe her name is [APRN #1's name]. She [APRN #1] told me to extend the order for vancomycin for an extra day, so [Resident #1's name] would have the full course of the antibiotics. The pharmacy courier came in around 7:05 [PM] and brought me his medications. I passed them on to the night shift nurse because it was getting late. I don't think I wrote a note because I was in a rush to leave. I believe I should have documented the conversation with [name of APRN #1]. I don't know really if I can give the medication without a pump and I think that there is vancomycin in the [name of the automated medication dispensing machine]. I don't think we can ask for a stat [derived from the Latin word statim, meaning immediately] delivery from the pharmacy.During an interview on 10/07/2025 at 1:38 PM, Staff B, LPN stated, [Resident #1's name] was an admission from the day before [9/8/2025]. The night-shift nurse [Staff E, LPN] told me that the nurse who admitted the resident did not put in [Resident #1's name] medication orders, so [Staff E's name] was not able to administer any medications for him. I can't remember if she called a provider, but I thought she had gotten an order to hold the vancomycin. If the medication was available in the [name of the automated medication dispensing machine] it should be administered. I know I should have notified the provider of the missed medications, and I should have documented the notification and any orders or instructions from the provider. I'm not sure if we can do a stat order from the pharmacy, we just regularly call the pharmacy and tell them we are waiting for the medication.During an interview on 10/07/2025 at 3:20 PM Staff E, LPN stated, Most of [Resident #1's name] medications were not available on the night shift of 9/8/25 - 9/9/25. The pharmacy doesn't come to the facility until 6:00 AM. Medication orders are typically entered to start the following day [after admission] because of the delivery times from the pharmacy, but [Resident #1's name] medications were ordered to start on the day of his admission [DATE]]. For the medications that were scheduled for my shift I was able to administer his cefepime because it was available in the [name of automated medication dispensing machine]. There was not a dose of vancomycin in the [name of automated medication dispensing machine] but there was overflow of vancomycin in the med [medication] room, as well as an overflow pump, so I was able to administer the ordered dose of vancomycin. I was not able to administer the morning dose of cefepime. I might have notified the doctor that I could not give the cefepime, but I am not sure. I did notify management that I did not give the cefepime, but I did not document the notification because I was already off of the [medication] cart. I know I should have written a note. During an interview on 10/7/2025 at 4:10 PM, Staff C, Pharmacy Account Manager stated, I am not familiar with the facility having any overflow medications or overstock of antibiotics, and the pharmacy does not leave extra IV pumps at the facility. For a resident admitted to the facility on a Monday at or around 5:00 PM, the medications would have been delivered the following morning. We do have a process for stat deliveries, and we would have routinely delivered within three and a half to four hours when ordered stat. During an interview on 10/07/2025 at 4:20 PM, Staff D, Lead Pharmacist stated, We make two deliveries to the facility daily. The deliveries leave the pharmacy at 2:00 PM and 2:00 AM, and then the deliveries arrive at the facility between 6:00 PM and 7:00 AM. I do not have knowledge of overflow or overstock medications. It was not part of the standard protocol for the pharmacy to supply any medications for general use outside of what was in the [name of the automated medication dispensing machine]. There are no extra IV pumps supplied to the facility. The facility can get a stat delivery from the pharmacy. For any medication ordered stat, we begin working on them as soon as we receive the order. The turnaround time for stat orders is four hours. If an IV pump was malfunctioning a replacement pump could be ordered stat. Vancomycin should be provided through an infusion pump to ensure proper administration and prevention of complications from administering to rapidly such as RMS [Red Man Syndrome, a type of allergic reaction that can occur with vancomycin administration] which typically could occur if vancomycin is infused too rapidly. We generally have orders to monitor vancomycin and manage the medication. Ideally in monitoring we are evaluating the Vanco [vancomycin] trough and adjusting doses from there, anything less than 10 is associated with higher levels of antibiotic resistance, ideally we attempt to maintain levels between 10-20 for optimal effect to maintain the drugs efficacy and minimize nephro [nephrotoxicity-damage to the kidneys] and ototoxicity toxicity [damage to hearing].During an interview on 10/8/2025 at 8:55 AM, APRN #1 [Advanced Practice Registered Nurse] stated, I saw [Resident #1's name] on 9/10/2025. I did not receive a call prior to my visit regarding the resident [Resident #1] or any issues with his antibiotics. I was asked by a facility nurse on 9/10/2025 if [Resident #1's name] vancomycin could be held because it was not available in the facility, but I believed the hold was not necessary as he was receiving his antibiotic infusion when I was in his room on 9/10/2025. I would give an order to hold antibiotics for one dose if the medications were on their way to the facility from the pharmacy. If it was more than one dose, I know what the resident was receiving in the hospital and that the medication was available in the facility. So, I would have given an order for that antibiotic to be given, or I would have determined if there was another medication available in the facility that I could order. I only recall speaking with a nurse regarding [Resident #1's name] on 9/10/2025 prior to seeing him. I do not recall speaking with anyone regarding a malfunctioning IV pump or giving orders to hold his vancomycin related to the issues with the IV pump. During an interview on 10/8/2025 at 9:25 AM, the Director of Nursing (DON) stated, When a resident is admitted the process is to get the orders in the computer so pharmacy can get them delivered. If the medications are not available, the nurses need to contact the physician. The nurses should contact the pharmacy and ask about getting medications from the [name of the automated medication dispensing machine] or ask for a stat delivery. There were also sister pharmacies they can contact for getting medications if there is a problem. We do have sister facilities they can call to get an IV pump. If medications are not in the facility for administration the nurses need to call the doctor and follow the physician's orders and document the process. The nurses should ask the doctor if there is an alternative medication they can give. The reasonable time frame for a nurse to wait on medications is an hour. If they were unable to administer an ordered antibiotic to a resident, the resident should be sent to the hospital. I have concerns regarding the competence of the facility nurses.During an interview on 10/08/2025 at 9:50 AM, the Medical Doctor stated, I do not recall being contacted regarding the resident [Resident #1] or any issues with his antibiotics. It was unfortunate that the resident did not receive his ordered antibiotics and of his readmission to the hospital. Residents have got to get the medications ordered for them. It is a shame that they were not administered, they should have been given. I'm aware that [missed doses of IV antibiotics] would cause concern for his admission for sepsis, not getting the medication may be a concern.During an interview on 10/08/2025 at 10:59 AM, APRN #2 stated, I got a message on 9/9/25 at 6:43 PM requesting that [Resident #1's name] vancomycin schedule be extended due to him missing a dose. I instructed the nurse to contact the pharmacy regarding the dosing of vancomycin. I was contacted only one time regarding only one missed dose of vancomycin. I would have only ordered the vanco to be held for one dose.During an interview on 10/08/2025 at 11:50 AM, Resident #1's mother stated, My son [Resident #1] is still in the hospital due to the bacteria he tested positive for when he was readmitted , and that he had to be on antibiotics for twelve hours out of every twenty-four. [Resident #1's name] had not received his vancomycin while he was in the facility, and I received conflicting information from the staff regarding the reason it was not being administered.During an interview on 10/09/2025 at 8:05 AM, Staff G, LPN stated, I do not remember how many doses of vancomycin [Resident #1's name] had been scheduled during my shift on 9/10/2025. I was not able to administer the IV vancomycin because the IV pump was malfunctioning. I called the pharmacy and was told that the pharmacy had to receive the malfunctioning pump back before they would send a replacement IV pump. I spoke with the in-house nurse practitioner, [Name of APRN #1], who was in the building at that time. The nurse practitioner gave an order to hold the vanco, but I don't remember if the NP [nurse practitioner] said to hold the vanco for one dose or for one day. On 9/11[2025] there was a state lab to check his vancomycin level. I had a conversation with a provider regarding the results of the vanco level and it would have been [APRN #1's name] I would have called. I can't remember if I told [APRN #1's name] that the pump was still not there. I called the pharmacy again regarding the IV pump and was told the pump would be delivered that day. The pump arrived before the end of my shift on the day before he went to the hospital. During an interview on 10/10/2025 at 2:06 PM with the DON when asked regarding the significant medication errors related to the administration of vancomycin and cefepime for Resident #1 the DON stated, I am new to the facility. I wasn't here when this happened.Review of the facility policy and procedure titled Medication Shortages/Unavailable Medications, with a last review date of 02/07/2025 read, Policy: When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. Procedure: A. If the medication shortage is noted at the time of the medication administration (Med-Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. B. If a medication shortage is noted during normal pharmacy hours: 1. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order. Facility link may also be utilized to order or reorder medications and or determine the status of a new or reordered medication, if not ordered, place the order or reorder to be sent with the next scheduled delivery. 2. If the next available delivery results in a delay or missed dose in the customers medication schedule, not available in the emergency stock, notify the pharmacist that an emergency delivery is required. 3. If medication from emergency stock is utilized ensure that the pharmacy received the faxed information (i.e., customer name, drug, dose) for replacement and appropriate billing. C. If a medication shortage is noted after normal pharmacy hours: 1. A licensed nurse obtains the ordered medication from the emergency stock supply. 2. If the ordered medication is unavailable in the emergency stock supply, a licensed nurse calls the pharmacy's emergency answering service and request to speak with a registered pharmacist on call to determine the plan of action which may include: a. Emergency/Stat delivery. B. Use of emergency (backup) pharmacy. D. If an emergency delivery is not feasible, a licensed nurse contacts the attending physician to obtain orders or directions which may include: 1. Holding the dose/doses. 2. Use of alternative medication available from the emergency stock supply. 3. Change in order (time of administration or medication). F. When a missed dose is unavoidable: 1. Document missed dose on the medication administration record (MAR) or treatment administration record (TAR): a. Initial and circle to indicate any missed dose document explanation for missed dose according to physician's order: e.g. hold dose on back of MAR/TAR and indicate See nurses note for explanation. 2. Document explanation of missed dose in the nurses' notes: a. Describe circumstances of medication shortage. B. Notification of pharmacy and response.Review of the facility policy and procedure titled Administering Medications with a last review date of 02/07/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 2. The Director of Nursing Services supervises and directs all personnel who administer medication and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.Review of the policy and procedure titled, 1.0 Providing Pharmacy Services, with the last review date of 02/07/2025 read, Policy: [Name of Pharmacy Provider] will: Provide a continuum of pharmaceutical services to the facility and essential medication and services for the customers. Ensure that the facility staff has access to medications, emergency service for medications, and drug information on a twenty-four (24) hour basis. Procedure: A. [Name of Pharmacy Provider] provides the facility with details how the customer can contact [Name of Pharmacy Provider] twenty-four (24) hours a day, seven (7) days a week. D. If orders for medication are received from the physician the facility may: 1. A delay in medication therapy can be prevented by using a drug that is included in the facility's Back-up Box/stat/emergency kit drug supply [located in the [name of the automated medication dispensing machine]. 3. If a drug is considered essential and cannot be substituted or delayed, please contact the [Name of Pharmacy Provider] Emergency Number.

Based on interview and record review, the facility failed to notify the resident's representative and physician of changes in condition for low blood pressures for 1 of 3 residents reviewed for changes in condition (Resident #2).Findings include: Review of Resident #2's admission record documented diagnoses to include pneumonia, unspecified organism, chronic obstructive pulmonary disease with acute exacerbation (an increase in the severity of an illness), acute and chronic respiratory failure with hypercapnia (high carbon dioxide levels in the blood), low back pain unspecified, cognitive communication deficit, other malaise, muscle weakness generalized, orthopnea (shortness of breath that occurs when lying down), dehydration, dependence on supplemental oxygen, hyperlipidemia unspecified (high cholesterol), essential primary hypertension (high blood pressure), and hypercalcemia (high calcium levels in the blood).Review of Resident #2's vitals documented a blood pressure (B/P) of 83/61 mmhg (millimeters of mercury) on 6/9/2025 at 2217 (10:17 PM), a B/P of 80/56 mmhg on 6/10/2025 at 2046 (8:46 PM), a B/P of 83/43 mmhg on 6/12/2025 at 2046 (8:46 PM), and a B/P of 80/48 mmhg on 6/16/2025 at 0044 (12:44 AM).Review of Resident #2's nursing progress notes did not contain documentation on 6/9/2025, 6/10/2025, 6/12/2025, and on 6/16/2025 that Resident #2's representative or physician were notified of the changes in the resident's blood pressure results.During a telephone interview on 10/6/2025 at 6:41 PM, Resident #2's Representative stated, They never called and told me this. They should have let me know when his blood pressures are low.During an interview on 10/7/2025 at 3:10 PM, the Director of Nursing (DON) stated, All staff should administer medications as they are ordered and call the doctor or nurse practitioner if there is any change in vital signs. I don't see notes about his [Resident #2] low blood pressure. We should call and notify the on-call [provider]. It would be a change of condition. There should be a note and notification to his [Resident #2's] [representative] and to his doctor or the on-call nurse practitioner. I don't see that was done. At this point, I question the skill and knowledge of the staff.During a telephone interview on 10/8/2025 at 9:17 AM, Staff M, Licensed Practical Nurse (LPN), stated. I didn't call his [Resident #2's representative] or the nurse practitioner. Sometimes patients have low blood pressure at night. I did not recheck the blood pressure.During a telephone interview on 10/8/2025 at 9:58 AM, Medical Doctor (MD) #1 stated, They [nursing staff] should notify the clinical team for any blood pressures that are in the 80s. I was not notified of this.During a telephone interview on 10/8/2025 at 9:55 AM, the Advanced Practice Registered Nurse (APRN) #3 stated, I was not aware that he [Resident #2] had any blood pressure concerns until the day he left. I was not called by any staff that his blood pressure was low. They should have called and followed the orders or gotten additional orders to hold medications and should recheck blood pressures when they are in the 80s.Review of the policy and procedure titled Change of Condition with the last approval date of 2/7/2025 read, Policy: The center is to promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the status or condition. Procedure: the nurse is to notify the attending physician and resident representative when there is a (n): significant change in the patient/resident physical, mental, or psychosocial status, need to alter treatment significantly, new treatment. The nurse is to complete an evaluation of the patient/resident. Document the evaluation in the medical record. Notify the patient/resident and the resident representative of the change in condition. Document the notification in the medical record.

Based on observation, interview, and record review, the facility failed to ensure midline and central venous access device dressings and flushing were completed according to professional standards of practice for 2 of 3 residents reviewed for intravenous therapy (Residents #3 and #4).Findings include: 1. Review of Resident #3's admission record documented an admission date of 9/25/2025 with diagnoses to include other acute osteomyelitis (an infection of the bone) left ankle and foot, type 2 diabetes mellitus with unspecified complications, acquired absence of left leg below knee, depression unspecified, and unspecified sequela of cerebral infarction (a stroke).Review of Resident #3's physician order dated 10/2/2025 read, May place midline [a midline catheter] for IV [intravenous] antibiotics with Lidocaine if needed.Review of Resident #3's physician order dated 10/3/2025 read, Change dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. Change dressing as needed and every day shift every Tue [Tuesday] Change dressing weekly.During an observation on 10/7/2025 at 9:15 AM, Resident #3 had a left upper arm single lumen midline catheter with a dressing that was dated 10/3/2025 and gauze under the transparent dressing preventing the insertion site from being observed.During an interview on 10/7/2025 at 9:15 AM, Resident #3 stated, I am getting antibiotics for an infection. I got that IV line a few days ago. The dressing hasn't been changed yet.Review of Resident #3's medical record did not contain documentation of a midline catheter insertion or dressing change 24 hours after insertion of the midline catheter.During an interview on 10/7/2025 at 9:45 AM, Staff B, Licensed Practical Nurse (LPN), stated, It [the midline catheter] has been in since Thursday or Friday [10/2/2025 or 10/3/2025]. The dressing does have gauze under it, and it should have been changed before now.During an observation on 10/8/2025 at 10:15 AM, Staff L, LPN, performed hand hygiene and donned a gown and gloves to administer medications via IV to Resident #3. Staff L cleansed the needleless connector with alcohol. Staff L failed to check the IV patency and position, and administered 10 milliliters (ml) of 0.9% normal saline, and connected the IV antibiotic medication, doffed the gown and gloves, and performed hand hygiene.During an interview on 10/8/2025 at 10:25 AM, Staff L, LPN, stated, I should have checked for a blood return [this indicates the catheter is in the vein]. I should have tried to do that. I think I gave the normal saline fine.2. Review of Resident #4's admission record documented an admission date of 10/4/2025 with diagnoses to include other streptococcal arthritis left knee, pain in left knee, laceration without foreign body left knee subsequent encounter, localized edema and muscle weakness.Review of Resident #4's physician order dated 10/4/2025 read, Change dressing on admission or 24 hours after insertion and weekly thereafter and PRN every day shift every Tue.During an observation on 10/7/2025 at 9:25 AM, Resident #4 was in bed and had a left upper arm single lumen peripherally inserted central catheter (PICC) line. The dressing was dated 9/29/2025.Review of Resident #4's medication administration record (MAR) for October 2025 documented the dressing change was completed on 10/4/2025 at 1724 (5:24 PM).During an interview on 10/7/2025 at 9:30 AM, Staff B, LPN, stated, The dressing date is showing 9/29/2025 and should have been changed.During an interview on 10/8/2025 at 10:15 AM, Staff G, LPN, stated, I did not do the dressing. I should have done it. I should not have documented that I did it.Review of the policy and procedure titled Catheter Insertion and Care: Midline Dressing Changes with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Policy: Midline catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 1. Change midline catheter dressings 24 hours after insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. 4. Use a sterile transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM and change the dressing every 48 hours.Review of the policy and procedure titled Flushing Central Venous and Midline Catheters with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Policy: Midline and central line access devices (CVADs) [Sic.] will be flushed to maintain patency, prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. General Guidelines: Flushing Technique: 2. Use a push-pause or pulsing motion for flushing technique. 3. Aspirate the CVAD catheter for blood to confirm patency prior to administration of medications and solutions. Procedure: Flushing when giving medications: 6. Aspirate slowly for blood return to ensure patency of catheter. 7. Flush with normal saline (amount established by pharmacy of facility protocol) using push-pause method.Review of the policy and procedure titled Catheter Insertion and Care: Central Venous Catheter Dressing Changes with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 2. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact).

Based on interview and record review, the facility failed to ensure physician-ordered parameters were followed related to hypertensive medications, resulting in the administration of unnecessary medications for 1 of 3 residents reviewed for medication administration (Resident #2).Findings include:Review of Resident #2's admission record documented diagnoses to include pneumonia, unspecified organism, chronic obstructive pulmonary disease with acute exacerbation (an increase in the severity of an illness), acute and chronic respiratory failure with hypercapnia (high carbon dioxide levels in the blood), low back pain unspecified, cognitive communication deficit, other malaise, muscle weakness generalized, orthopnea (shortness of breath that occurs when lying down), dehydration, dependence on supplemental oxygen, hyperlipidemia unspecified (high cholesterol), essential primary hypertension (high blood pressure), and hypercalcemia (high calcium levels in the blood).Review of Resident #2's physician order dated 4/25/2025 read, Metoprolol Tartare Oral Tablet 25 mg [milligram] (Metoprolol Tartare), give 0.5 tablet by mouth two times a day for HTN [hypertension]. Hold for SBP [Systolic Blood Pressure] < [less than] 110 or HR [heart rate] <70.Review of Resident #2's Medication Administration Record (MAR) for April 2025 documented Metoprolol was administered on 4/28/2025 at 0900 (9:00 AM) with a blood pressure (B/P) of 107/72, on 4/28/2025 at 2100 (9:00 PM) with a B/P of 101/68.Review of Resident #2's MAR for May 2025 documented Metoprolol was administered at 0900 on 5/12/2025 with a B/P of 102/77, on 5/16/2025 with a B/P of 109/58, on 5/24/2025 with a B/P of 101/64, on 5/30/2025 with a B/P of 100/57 and at 2100 on 5/8/2025 with a B/P of 98/62, on 5/13/2025 with a B/P of 106/67, on 5/22/2025 with a B/P of 98/64, and on 5/23/2025 with a B/P of 102/62.Review of Resident #2's MAR for June 2025 documented Metoprolol was administered at 0900 on 6/1/2025 with a B/P of 106/54, on 6/2/2025 with a B/P of 102/65, and on 6/16/2025 with a B/P of 96/52, and at 2100 on 6/5/2025 with a B/P of 98/63, on 6/14/2025 with a B/P of 107/82, and on 6/15/2025 with a B/P of 80/48.During an interview on 10/7/2025 at 1:00 PM, Staff A, Licensed Practical Nurse (LPN), stated, I'm not sure if I gave the medication, but I will usually put in that I held it, my initials mean it was given. We should follow orders and not administer medications outside parameters.During an interview on 10/7/2025 at 1:53 PM, Staff B, LPN, stated, I was not told that he [Resident #2] had any hypotension [low blood pressure] the night before. I would not have given his blood pressure medications. I would have held them. I can't remember if there were parameters for the medication.During an interview on 10/7/2025 at 3:10 PM, the Director of Nursing (DON) stated, I was not here during that time. I was not aware of any concerns related to his [Resident #2] care. All staff should administer medications as they are ordered and call the doctor or nurse practitioner if there is any change in vital signs.During a telephone interview on 10/7/2025 at 3:55 PM, Staff J, LPN, stated, I must have given it if I didn't document that I held the medicine. I don't really know, but if I documented I gave it I must have. We should follow the parameters if a medicine has them.During an interview on 10/8/2025 at 8:51 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, I would not expect the staff to administer blood pressure medications outside the parameters.During a telephone interview on 10/8/2025 at 9:58 AM, the Medical Doctor (MD) stated, The staff should follow all orders with parameters and not administer them [medications] outside of those. I was not notified of this.During an interview on 10/8/2025 at 10:27 AM, Staff L, LPN, stated, I did give the medication [Metoprolol]. I'm not sure why I didn't hold it.Review of the policy and procedure titled Administering Medications with the last review date of 02/07/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 2. The Director of Nursing Services supervises and directs all personnel who administer medication and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to ensure complete and accurate documentation of medical records for 3 of 4 residents reviewed for intravenous therapy documentation (Residents #1, #2, and #3).Findings include:1. Review of Resident #2's admission record documented diagnoses that include pneumonia, unspecified organism, chronic obstructive pulmonary disease with acute exacerbation (an increase in the severity of an illness), acute and chronic respiratory failure with hypercapnia (high carbon dioxide levels in the blood), low back pain unspecified, cognitive communication deficit, other malaise, muscle weakness generalized, orthopnea (shortness of breath that occurs when lying down), dehydration, dependence on supplemental oxygen, hyperlipidemia unspecified (high cholesterol), essential primary hypertension (high blood pressure), and hypercalcemia (high calcium levels in the blood).Review of Resident #2's physician order dated 6/13/2025 read, Please insert PIV [Peripheral Intravenous] for dehydration. One time only for IV [intravenous] access for 1 Day.Review of Resident #2's nursing progress notes from 6/12/2025 through 6/16/2025 showed no documentation of peripheral intravenous line insertion.During an interview on 10/7/2025 at 3:10 PM, the Director of Nursing (DON) stated, I was not aware of any concerns related to his [Resident #2] care. There should be documentation of all care provided. I do not see any documentation about the IV insertion and there should be. They [the nursing staff] should document where the IV is, how many times it took to get a line, if they were successful or not, and what fluids were running and if the site was okay.During an interview on 10/7/2025 at 1:53 PM, Staff B, Licensed Practical Nurse (LPN), stated, It was close to end of day, his [Resident #2's] [representative] had questions that I could not answer. Why were fluids hanging? It was a full bag [of IV fluids] that was hanging and why had an IV been placed, because there were no orders. I didn't see any orders for IV fluids or the IV when I was talking to her. But once the order is complete, they will fall off the MAR [Medication Administration Record], so I needed to look at them. I did not flush or do anything that day with his IV.2. Review of Resident #3's admission record documented an admission date of 9/25/2025 with diagnose to include other acute osteomyelitis (an infection of the bone) left ankle and foot, type 2 diabetes mellitus with unspecified complications, acquired absence of left leg below knee, depression unspecified, and unspecified sequela of cerebral infarction (a stroke).Review of Resident #3's record titled Admission/Readmission read, Section H: Vascular Access: 1. IV present: 2: checked yes. 2. Type:1. Peripheral checked. 3. Location: arm right.Review of Resident #3's physician order dated 9/26/2025 read, May remove peripheral IV. One time only for 1 day.Review of Resident #3's nursing progress notes from 9/25/2025 through 10/2/2025 showed no notes related to the removal of the peripheral IV.3. Review of Resident #1's admission record documented an admission date of 9/8/2025 with diagnoses to include subacute osteomyelitis [an infection in the bone], other site, spina bifida occulta [a small gap in one or more of the bones in the spine], other hydrocephalus [a buildup of fluid in the brain], paraplegia (an impairment in motor or sensory function of the lower extremities) unspecified, other bacterial infections of unspecified site, other seizures, local infection of the skin and subcutaneous tissue unspecified, iron deficiency, presence of cerebral spinal fluid drainage device, anemia unspecified, soft tissue disorder unspecified, unspecified visual loss, and gastroesophageal reflux disease [heartburn] without esophagitis [inflammation of the esophagus].Review of Resident #1's physician order dated 9/8/2025 read, Vancomycin HCl [Hydrocholoride, a potent antibiotic used to treat severe bacterial infections, including those resistant to other antibiotics] intravenous solution 1500mg/300ml [1500 milligrams in 300 milliliters of sodium chloride] Use 1500 mg intravenously every 8 hours for Infection for 21 Days.Review of Resident #1's physician order dated 9/8/2025 read, Cefepime HCI (antibiotic used to treat a wide variety of serious bacterial infections) intravenous solution 1 gm/50 ml [1 gram per 50 milliliter] (Cefepime HCI (hydrochloride)) Use 1 gram intravenously every 8 hours for infection for 21 Days until finished. Review of Resident #1's Medication Administration Record for the month of September 2025 for vancomycin 1500 mg intravenously was documented as chart code 9 (other see nurses notes) on 9/9/2025 at 0800 (8:00 AM) and 1600 (4:00 PM), on 9/10/2025 there is an X [not given] at 12:00 midnight and a chart code of 9 at 0800 [8:00 AM] and 1600 (4:00 PM). On 9/11/2025 a chart code of H [hold] at 1200 [12:00 AM], 0800, and 1600 for a total of 8 missed doses of vancomycin.Review of Resident #1's MAR for cefepime dated 09/9/2025 at 6:00 AM documented a code of 5 (Hold/see Nurses Notes) and 1400 (2:00 PM) a code of 9 (Other/See Nurses Notes). For a total of two missed doses.During an interview on 10/07/2025 at 1:36 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #1's name] had been transferred from another room during my shift [9/9/2025]. [Name of Staff B] had [Resident #1's name] prior to me and had called pharmacy who said they would be bringing his medication [vancomycin]. I called the pharmacy again and the pharmacy said they were enroute with the medication. I called the nurse practitioner; I believe her name is [APRN #1's name]. She [APRN #1] told me to extend the order for vancomycin for an extra day, so [Resident #1's name] would have the full course of the antibiotics. The pharmacy courier came in around 7:05 [PM] and brought me his medications. I passed them on to the night shift nurse because it was getting late. I don't think I wrote a note because I was in a rush to leave. I believe I should have documented the conversation with [name of APRN #1].During an interview on 10/07/2025 at 1:38 PM, Staff B, LPN stated, [Resident #1's name] was an admission from the day before [9/8/2025]. The night-shift nurse [Staff E, LPN] told me that the nurse who admitted the resident did not put in [Resident #1's name] medication orders, so [Staff E's name] was not able to administer any medications for him. I can't remember if she called a provider, but I thought she had gotten an order to hold the vancomycin. If the medication was available in the [name of the automated medication dispensing machine] it should be administered. I know I should have notified the provider of the missed medications, and I should have documented the notification and any orders or instructions from the provider. I'm not sure if we can do a stat order from the pharmacy, we just regularly call the pharmacy and tell them we are waiting for the medication.During an interview on 10/07/2025 at 3:20 PM Staff E, LPN stated, Most of [Resident #1's name] medications were not available on the night shift of 9/8/25 - 9/9/25. The pharmacy doesn't come to the facility until 6:00 AM. Medication orders are typically entered to start the following day [after admission] because of the delivery times from the pharmacy, but [Resident #1's name] medications were ordered to start on the day of his admission [DATE]]. For the medications that were scheduled for my shift I was able to administer his cefepime because it was available in the [name of automated medication dispensing machine]. There was not a dose of vancomycin in the [name of automated medication dispensing machine] but there was overflow of vancomycin in the med [medication] room, as well as an overflow pump, so I was able to administer the ordered dose of vancomycin. I was not able to administer the morning dose of cefepime. I might have notified the doctor that I could not give the cefepime, but I am not sure. I did notify management that I did not give the cefepime, but I did not document the notification because I was already off of the [medication] cart. I know I should have written a note. Review of the policy and procedure titled Catheter Insertion and Care with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Documentation: The following information should be recorded in the resident's medical record: 1. The date and time of the procedure. 2. The number of venipuncture attempts (maximum of two). 3. The type, length and gauge of the catheter, and type of cleansing agent used. 4. The site of insertion (be specific to name of vein, area of arm). 5. The type of solution used or medication infusing (if being used at this time). 10. Resident's response to the procedure. 11. The signature and title of the person recording the data.

Based on interviews and record reviews, the facility failed to ensure that adequate pain management was provided for 2 residents (Resident #2, #9) of 3 residents that were prescribed opioid pain medications.Findings include:1.Review of Residents #2's admission record documented the resident was admitted on [DATE] with the diagnoses including, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, acquired absence of right leg above knee, Parkinson's disease with dyskinesia, type 2 diabetes mellitus with diabetic polyneuropathy, atrial fibrillation, muscle weakness, chronic pulmonary disease, hyperlipidemia, and hypertension. During an interview on 8/25/2025 at 9:20 AM, Resident#2 stated he was supposed to get a scheduled medication every 4 hours, and he was not getting it because they don't wake him up for it. During an interview on 8/29/2025 at 7:20 AM Resident #2 stated he did not receive his medication last night at midnight (oxycodone); he stated it is always the same nurse. Review of Resident #2's physician's order dated 8/10/2025 reads, oxycodone HCL (Hydrochloride) oral tablet 5 mg (milligrams) give 1 tablet by mouth every 4 hours for pain hold if lethargic. Review of Resident #2's medication administration record (MAR) for August 2025 for administration of oxycodone HCL oral tablet 5 mg give 1 tablet by mouth every 4 hours for pain hold if lethargic, documented the medication was not administered at 12:00 AM on 8/13/2025, 8/15/2025, 8/20/2025, 8/22/2025, 8/24/2025, 8/29/2025 and at 4:00 AM on 8/17/2025. Review of Resident #2's care plan dated 3/30/2025 and revised on 4/27/2025 read, Focus: the resident has acute/chronic pain related to generalized pain, neuropathy, restless leg syndrome. Interventions: Administer analgesia (medication) as per orders. 2. Review of Residents #9's admission record documented the resident was admitted on [DATE] with diagnoses including paraplegia, colostomy, chronic pain, major depressive disorder, benign prostatic hyperplasia and tachycardia. Review of Resident #9's physician's order dated 8/20/2025 reads, oxycodone HCL - Acetaminophen Oral tablet 5-325 mg give 1 tablet by mouth every 4 hours for non-acute pain 7-10. Review of Resident #9's MAR for August 2025 for administration of oxycodone HCL - Acetaminophen Oral tablet 5-325 mg give 1 tablet by mouth every 4 hours for non-acute pain 7-10 documented the medication was not administered at 12:00 AM on 8/22/2025, 8/24/2025, and 8/29/2025. Review of Resident #9's care plan dated 8/21/2024 and revised on 8/21/2024 read, Focus: the resident is on pain medication therapy with interventions that included administer analgesic medication as ordered by physician . During an interview on 8/29/2025 at 11:00 AM, Resident #9 stated he did not receive his scheduled pain medication last night at midnight. Resident #9 stated that he told other nurses about it but nothing was done. During an interview on 8/29/2025 at 11:45 AM, the Assistant Director of Nursing (ADON) stated that Staff B, Licensed Practical Nurse (LPN) stated Resident #2 and Resident #9 were sleeping, so she did not wake them. ADON stated Staff B, LPN did not follow the physician's orders. During an interview on 8/29/2025 at 3:24 PM, Staff B, LPN, stated both residents (Resident #2 and Resident #9) were asleep, and she did not administer the pain medication.

Based on observation, interview, and record review, the facility failed to ensure proper repair of handrails in 2 of 2 wings of the facility, cleanliness of resident rooms and the application of protective pipes apron coverings under the sink in Resident #65's room (Photographic evidence obtained). Findings include: 1) During an observation while conducting a tour of the facility on 1/6/2025 beginning at 9:10 AM, seven handrail caps were missing off of the end of the railing in the 200 hall and four caps were missing off of the end of the railing in the 100 hall. There was exposed jagged metal at the open ends of the hall railing. During an observation on 1/7/2025 at 10:20 AM with the Maintenance Director, there were missing caps off the railings in both halls of the facility (100 and 200 wing) with jagged metal exposed. During an interview on 1/7/2025 at 10:20 AM, the Maintenance Director stated, I know all of these need to be fixed. It is not my priority. During an interview on 1/7/2025 at 11:18 AM, the Administrator stated, All those caps need to be fixed. It is a safety issue. 2) During an observation on 1/6/2025 at 10:00 AM, the sink apron pipe covering under sink was on the floor in Resident #65's bathroom. During an observation on 1/7/2025 at 9:40 AM, the sink apron pipe covering under sink was on the floor in Resident's #65's bathroom. During an observation on 1/8/2025 at 2:00 PM, the sink apron pipe covering under sink was on the floor in Resident's 65's bathroom. During an interview on 1/8/2025 at 3:50 PM, the Environmental Services Manager stated that staff should have placed the pipe apron covering back on the sink in Resident #65's room and he had showed them how to do it. 3) During an observation on 1/6/2025 at 1:43 PM, Resident #87's room had a significant amount of debris, napkins and crumbs on the floor. During an interview on 1/6/2025 at 1:44 PM, Resident #87 stated, My room is not swept, not on a regular basis. During an observation on 1/7/2025 at approximately 9:00 AM, Resident #87's room had debris, napkins and crumbs on the floor. During an interview on 1/8/2025 at 3:15 PM, the Environmental Service Manager stated, My expectation whether I am here or not, the resident rooms and floors are the first thing that my staff should be sweeping. Review of the facility policy and procedure titled General Hospitality Services Policies dated 11/30/2024 read, Policy: To provide clean, contamination-free surroundings for residents, visitors, and personnel. A clean environment is essential in preventing transmission of infection in the facility. Procedure . 1. Resident Rooms: Routine cleaning is to be done on a daily basis. Floors are to be dust mopped, then wet mopped daily with a disinfectant solution. Dusting of furniture is to be done every day. Mop water is to be changed when it is dirty (at least every three rooms). Wastebaskets are to be emptied daily, wiped with a disinfectant, and plastic liners replaced . Safety: Needed repairs; leaky faucets; toilets; light bulb; etc., are to be reported to the Maintenance Supervisor for attention and repair.

Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 2 of 3 residents who were diagnosed with serious mental disorder, Residents #18 and #77. Findings include: Review of Resident #18's Level I PASRR dated 12/24/2024 showed no mental illness documented in Section I: PASRR Screen Decision-Making. Review of Resident #18's admission record showed the resident was admitted on [DATE] with diagnoses that included depression (onset date of 12/24/2024), anxiety disorder (onset date of 12/24/2024), and bipolar disorder (onset date of 12/24/2024). Review of Resident #18's clinical records showed no documentation that Resident #18's diagnoses of depression, anxiety disorder, and bipolar disorder had been included on an updated Level I PASRR. Review of Resident #77's Level I PASRR dated 4/22/2024 showed no mental illness documented in Section I: PASRR Screen Decision-Making. Review of Resident #77's admission record showed the resident was admitted on [DATE] with diagnoses that included schizoaffective disorder (onset date of 4/26/2024), and adjustment disorder with anxiety (onset date of 10/31/2024). Review of Resident #77's clinical records showed no documentation that Resident #18's diagnoses of schizoaffective disorder and adjustment disorder with anxiety had been included on an updated Level I PASRR. During interview on 1/8/2025 at 9:32 AM, the Director of Nursing confirmed Resident #18's and Resident #77's mental health diagnoses had not been included on their preadmission screening and resident reviews. She confirmed a revised PASRR that documented Resident #18's and Resident #77's mental health diagnoses had not been completed.

Based on interview, record review, and review of policy and procedures, the facility failed to ensure the residents were free from medical neglect by failing to implement the policies and procedures for neglect for 1 (Resident #1) of 3 residents reviewed for insulin administration. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. Staff B, LPN, assumed care of Resident #1 at 7:00 AM on 10/6/2024 and did not follow up with the provider. Staff B, LPN, did not reassess Resident #1's blood glucose or address the need for any orders. Resident #1 called 911 at approximately 6:30 PM, Emergency Medical Services (EMS) contacted the facility, spoke with Staff B, LPN, who instructed EMS the resident did not need help. Again at 11:15 PM, Resident #1 called 911 and was subsequently transferred to the hospital and was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. Diabetic ketoacidosis (DKA) develops when the body can't make enough insulin, a hormone that helps sugar enter cells for energy. Instead, fat is broken down for energy. This can cause acids called ketones to build up in the blood and collect in the urine. The risk is highest in people who have type 1 diabetes and those who often miss insulin doses. DKA symptoms often start quickly, sometimes within a day. A person may get very thirsty, urinate often, vomit or have stomach pain. Symptoms also can include tiredness or weakness, confusion, shortness of breath, or fruity breath. Treatment often involves going to a hospital to receive fluids, insulin and electrolytes through a vein. Without treatment, diabetic ketoacidosis can lead to loss of consciousness and death. (Mayo Clinic/Mayoclinic.org) The facility's failure to implement the policy and procedure for medical neglect and failure to ensure residents who required insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on November 18, 2024, at 2:50 PM. The Immediate Jeopardy began on October 6, 2024, and was removed on site on November 18, 2024. Findings include: Review of the Admission Record for Resident #1 documented an admitted [DATE] with diagnoses that include diabetes mellitus type 1, malignant neoplasm of oropharynx (cancer), unspecified dysphagia (unable to swallow), oropharyngeal phase, type 1 diabetes mellitus without complications, chronic pulmonary embolism (a blockage in a lung artery caused by a blood clot that has traveled from elsewhere in the body), chronic kidney disease, unspecified, other acute osteomyelitis (bone infection), unspecified site, acquired absence of left leg (below knee), essential primary hypertension (high blood pressure), gastrostomy status (a flexible tube that's surgically inserted into the stomach through the abdominal wall. It allows for the delivery of nutrition, fluids, and medication directly into the stomach), hyperlipidemia, unspecified (an abnormally high concentration of fats or lipids in the blood), peripheral vascular disease, unspecified (blood vessels narrow or become blocked, reducing blood flow to the limbs or other parts of the body). Review of the document titled Department of Internal Medicine Discharge Summary Heme/Onc [Hematology/Oncology] Team dated 10/3/2024 read: (page 1) Instructions for PCP [Primary Care Physician]: will need to keep an eye on his insulin regimen as these have been up and down since starting bolus tube feeds; currently on 12 units long acting and seven units short acting before bolus feeds. Consider endocrinology referral. (page 8) Discharge medication, mediation list documents Lantus Solostar 100/unit/ML [milliliter] Insulin glargine. Inject 10 units into the skin every 24 hours. Review of Resident #1's physician order dated 10/4/2024 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to Type 1 Diabetes Mellitus Without Complications. Review of Resident #1's Medication Administration Record (MAR) showed Staff A, LPN, documented a BS (blood sugar) of 552 on 10/6/2024 at 6:00 AM. Staff A, LPN, documented 2, CM (chart code/follow up codes 2 = drug refused). Review of Resident #1's eMAR (electronic Medication Administration Record) note dated 10/6/2024 at 6:32 AM documented by Staff A, LPN, read, Patient stated, I'm refusing all medications until I get the proper insulin. Review of Resident #1's progress note dated 10/6/2024 at 7:00 AM documented by Staff A, LPN, read, ARNP [Advanced Registered Nurse Practitioner] notified of resident's refusal of all morning medications. Per resident he is refusing all medications until he is receiving the proper insulin. Orders received to increase current insulin twice daily with blood sugars checked twice daily. No other orders given at this current time. Review of text message communication from Staff A, LPN's personal cellular phone to the On Call Medical Doctor (OCMD) on 10/6/2024 at 7:33 AM read, Good Morning, [Resident #1's name] is refusing all of his medications. He says he's not taking anything until he receives the proper insulin. Per his orders he's receiving 10 Units of Lantus @ [at] 6 am. He did allow me to check his blood sugar 552. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 8:19 AM read, No sliding scale ordered? Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 8:22 AM read, No, I didn't see any sliding scale he said his Lantus is supposed to be given @ night. And he has another type of insulin he gets. I didn't see anything other than the Lantus. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 10:55 AM read, Based on his sugars, if they have been above 250 everyday, go up to 15 BID [15 units two times a day] of long-acting insulin and make sure we cover with sliding scale for meals. Let's also make sure he's getting accuchecks. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 7:55 PM read, I'll change his orders & notify him of the changes & hopefully he complies. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 11:25 PM read, [Resident #1's last name] has continued to call 911 since I arrived this afternoon. They are loading him up & transporting him, [Resident #1's full name]. Review of Resident #1 medical record did not contain any documentation of the test message communication between the facility and the OCMD. Review of Resident #1's Interact SBAR (Situation, Background, Assessment, Recommendations) Communication form documented by Staff A, LPN, dated 10/6/2024 at 11:25 PM read, Situation: the change in condition (CIC) reported on this CIC evaluation are: other change in condition. At the time of evaluation patient vital signs, weight and blood sugar were blood pressure 130/77, pulse 82, temperature 98.2, pulse oximetry 96% on room air, blood glucose of 552 obtained at 6:45 AM on 10/06/24. Outcomes of physical assessment: positive findings reported were mental status evaluation with no change observed. Functional status evaluation with no changes observed. Patient called 911 on his personal cell phone and stated, I want out of this place. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: No new orders given at this time. Review of Resident #1's medical record did not contain any documentation of further blood glucose checks after the glucose level of 552 was documented at approximately 6:00 AM. Review of the hospital ED (Emergency Department) provider notes for Resident #1 dated 10/6/2024 at 11:51 PM read, Chief complaint: Patient presents with high blood sugar. Patient is an 81 y.o. [year old] M [male] with a PMH [Past Medical History] of oropharyngeal SCC [squamous cell cancer of throat], DVT [Deep Vein Thrombosis], PVD [Peripheral Vascular Disease], T1D [Type 1 Diabetes], HTN [Hypertension], and osteomyelitis who presents from an outside rehab after having unreadable glucose levels on his monitor. He states that at the outside rehab were not following his strict insulin regimen trying to give a different type of insulin. Per EMS [Emergency Medical Services] he was declining the insulin the outside rehab was trying to give him. He was recently admitted on ,d+[DATE] for pneumonia and was discharged to rehab NPO [nothing by mouth] with swallow study pending (gastrostomy tube in place). BASIC METABOLIC PANEL - Abnormal; Notable for the following components: Glucose 745, Anion Gap 34. Medical Evaluation Initiated: Attestation: The patient is critical due to DKA [Diabetic Ketoacidosis]. admitted to the ICU [Intensive Care Unit]. Review of the hospital history and physical for Resident #1 dated 10/7/2024 read, HPI [history of presenting illness]: [Resident #1's name] is an 81 y.o. male presented with hyperglycemia at rehab admitted for DKA. PMH relevant for T1DM (Type 1 Diabetes Mellitus), HTN, oropharyngeal squamous cell carcinoma, peripheral vascular disease, DVT (04/2022) and below the knee amputation secondary to osteomyelitis. Patient reports lack of compliance with his long-term insulin regimen for DM1 [Type 1 Diabetes Mellitus] at his rehab facility. He reports they weren't giving me the right insulin and explains some of the doses of his regimen were being missed. During an interview on 11/13/2024 at 9:25 AM, the Director of Nursing (DON) stated, I was not here for the incident, I found out after I returned that Tuesday. That was the 8th [10/8/2024]. With a blood sugar that high the nurse should have notified the doctor that he [Resident #1] was refusing his insulin and why he was refusing it. The nurse in charge of his care was not acting within the professional standards of practice for treating hyperglycemia in a type 1 diabetic. He [Staff A, LPN] should have notified the doctor immediately when he [Resident #1] refused his insulin. He [Staff A, LPN] did not transcribe the orders, and he should have stayed and transcribed the orders he got. The nurse got the high blood sugar and spoke to someone. I don't know who he spoke with, I don't know their name, you will have to ask [the Administrator's name] and got new orders. I don't know if or what he told the nurse that came on in the day shift. I don't know what the day shift nurse did after that. This shouldn't have happened; this should have been avoided. The nurse that admitted him should have read everything when it comes to the discharge summary, and they would have seen all the other orders instead of just the one piece of paper. The blood sugar should have been rechecked. It was not rechecked the rest of the day. I would consider this neglect. I don't know why the abuse and neglect policies were not followed. We should have completed a RCA [root cause analysis] and we should have implemented the abuse policy and procedure back on the 7th [10/7/2024]. During a telephone interview on 11/13/2024 at 11:35 AM, the OCMD stated, I did receive a call related to this resident [Resident #1]. The Nurse called me on the afterhours line, and I was told of the residents' glucose and I actually decided to double the insulin, the Lantus, and increase it to 15 Units twice a day and to add SSIC [Sliding Scale Insulin Coverage] with insulin coverage AC [before meals] and HS [at bedtime]. I would say that the professional standard of practice would be to have the blood glucose rechecked after 30 minutes to one hour after high readings to accurately assess if the patient was stabilizing versus the patient needing further emergency treatment. The staff did not adhere to a professional standard of practice when they did not notify us that he was refusing treatment. I would expect staff to inform us that a patient had refused insulin to determine the next steps we needed to do, either increase medications or we send to the hospital. I would call this unintentional neglect. They did not treat this according to professional standards of practice. I should have been notified that the patient was refusing his insulin. I was not called about this again after I gave the orders to them. During an interview on 11/13/2024 at 3:18 PM, the Administrator stated, I found out about the situation when I returned to work. I was finally able to speak with the daughter on 10/20/2024. I didn't file a report on 10/7/2024 because we saw on the chart that they only had orders for Lantus, we didn't think it was an issue until he started refusing the medication. The report should have been done, that is the best practice. [Staff A, LPN's name] got the order. It was not placed in [name of the electronic medical record software]. We investigated and did a QAPI [Quality Assurance and Process Improvement] Ad hoc [from Latin meaning for this] meeting on 10/7/2024. I talked to [Staff B's name], she said that the resident refused medications and [Staff A's name] spoke to the nurse practitioner and got orders. The nurse forgot to transcribe the orders into [name of the electronic medical record software]. There was no documentation in [name of the electronic medical record software]. During an interview on 11/13/2024 at 3:43 PM, Staff B, LPN, stated, I did take care of this resident [Resident #1]. He did not refuse care when I took care of him. I was told by the night nurse [Staff A, LPN] that his blood sugar was high. I don't remember him telling me what the blood sugar was, he just said it was high. He did not refuse care that day. I did not try to get another accucheck, he didn't have orders to recheck his blood sugar. I didn't have orders to recheck the blood sugar. I wasn't told how high the blood sugar was. I did not ask how high it was. I was in the front [area of building] charting and apparently, he called 911. I was called and asked if he needed help, I told them [EMS] no, I would check on him. I went to the room, and he said, You are trying to kill me. I asked him why and he told me that 'his blood sugar, his insulin was wrong, and he needed to get short acting insulin, and we weren't ordering it for him. I told him that he had orders for long-acting insulin and that he refused to take it. He told me Yes, I do, but because I need short acting insulin I need to get out of here and you all are trying to kill me. This could have been avoided, I should have rechecked his blood sugar, I don't know why I didn't. During a telephone interview on 11/14/2024 at 9:18 AM, the Advanced Practice Registered Nurse (APRN) stated, I believe that situation happened over the weekend. I wasn't the on-call provider, but it was discussed Monday. The protocol they follow is normally blood sugar greater than 400 they notify their provider and then we give standard orders. We give them extra orders. Like I said, I wasn't on call that weekend but when it was reviewed come Monday, that night the nurse didn't notify the on-call provider, and they documented that they did. They did come back with orders on that and then they had hand off [change of] shift. I would have expected potentially that since it was a night shift going into day shift, because this was a morning blood sugar, if I do recall correctly. As well, that morning at breakfast time the patients now eating so that sugar should probably be rechecked 90 minutes after they eat to see how they process that meal and what their new sugar is going to be if they weren't getting that coverage and then reaching back out to the provider and letting them know, 'hey this person's blood sugar is still reading this number' and just keep reaching out to the provider until they get what they need. A resident has the risk of going into Diabetic Ketoacidosis if not properly monitored and treated for high blood sugar. During a telephone interview on 11/14/2024 at 11:20 AM, the Medical Director stated, I remember a few things because I know the facility felt bad about the whole thing, you know while this was all happening. So, they had called me about it I think this happened over the weekend to my understanding. I know that there was also some frustration on the patient end I think they refused some glucose checks or refused insulin and then at that point I think they called 911. My expectations would be to 100% ensure that there's glucose monitoring, accuchecks, and of course a sliding scale. I mean every single diabetic in the building should be on a sliding scale. I think it was [the OCMD's name] that was notified. I think they went up on the long acting and they were just assuming that the patient was on a sliding scale. 100% if you're in the five hundreds [blood glucose level] and they're on long acting they need to be on a sliding scale, likely in the highest level of the sliding scale you know from there we could go up on the long acting and ensure there's proper glucose monitoring. I would probably give a onetime dose of a short acting and have them recheck sugars in an hour so I'm not sure what took place in this case or how long after that reading the patient called 911. I would want to be notified that they [resident] were refusing [medications]. I don't know if that call was ever made, after the fact, to let the doctor know that he's refusing it. If any doctor's increasing long-acting insulin, they're already assuming that the short acting is on the MAR. During an interview on 11/14/2024 at 7:10 AM, the DON stated, I was not here the day that this was found, that they spoke with his daughter, the Unit Manager spoke to her. They did know the concerns with not providing insulin or ADL [Activities of Daily Living] care. We were still investigating it; I can't tell you why we didn't investigate more. I knew his blood sugar was 552. I was given that information, but I thought it was that [Staff A's name] didn't transcribe orders. I guess we did not do a thorough investigation, I can't find any more than what was done initially and in the town hall meeting. I see that there were more than 12 hours that the resident was still here after that blood sugar of 552. There are no other accuchecks done after that. It is my expectation that staff provide a detailed report when going off their shift. The nurse [Staff A, LPN] should have told [Staff B's name] what the blood sugar was, and he [Staff A, LPN] should have documented his information in the notes. [Staff A's name] should have asked what high meant if that is what he told her. She should have followed up on that. I would expect that she called the doctor again and get further orders. She [Staff B] had the opportunity to call the doctor when he called 911 to get further orders. All the information should have been put in a progress note from both nurses. I would consider this neglect for both nurses. I don't know why the staff weren't suspended; I can't give you a reason. During an interview on 11/14/2024 at 4:10 PM, the Administrator stated, I can't say that I thought I needed to complete a federal report. I was told by [Staff D's name] that she [Resident #1's daughter] was upset and wanted to talk to us, but I wasn't able to connect with her. We attempted multiple times, but we couldn't reach her and left messages. When we got [in touch with] her is when I found out about her concerns with care related to the insulin and with being on the bedpan too long. We did do a QAPI on 10/7 related to the insulin. I just thought it was because he refused to take his insulin. I guess we did not investigate fully until after I spoke to his daughter. We thought the problem was that the nurse on admission got the right orders and there weren't accuchecks ordered. He refused this medication, and I spoke to [Staff B's name], LPN, and she told me that he [Resident #1] didn't talk to her at all about his insulin during the day before he called 911. Then they realized that he had orders that were not transcribed from the night nurse when he came on shift. I did not talk to him [Staff A, LPN] the DON did. I did not implement the abuse and neglect policies because he refused his medication. I didn't think to. I can't tell you why. We should have done more investigation. We should have done a QAPI when we realized that his blood sugar was so high, I wasn't aware of everything. We only did the initial QAPI, we didn't do any others, I think we should have done it, I can't tell you why we didn't. We did not suspend the nurses; it is our policy to suspend staff pending the results of an investigation. We initially thought it happened because the resident refused his insulin, not for neglect. We should follow our abuse and neglect policies and procedures. I didn't think to. I can't tell you why. Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation last revision date of 11/16/2022, last approval date of 4/23/2024 read, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights to establish a disciplinary policy which results in a fair and timely treatment of occurrences of resident abuse. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action including dismissal provided herein. Definitions: Neglect is the failure of the center, 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. Procedure: 4. Identification: All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Nursing/designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Nursing will serve as the Abuse Coordinator. 5. Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during a questioning of or interviewing of residents. Investigations will be accomplished in the following manner. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion and submitted to the Abuse Coordinator. Investigation: The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. 6. Protection: Any suspect(s), who is employed or contract service provider, once he/she has(have) been identified, will be suspended pending the investigation. 7. Reporting/ Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or alleged allegation of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, to a resident is obligated to report such information immediately but no later than two hours after the allegation is made if the events that caused the allegation involve abuse or resulted in serious bodily injury for not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with state law. In the absence of the executive director, the director of nursing is designated abuse coordinator. Once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with federal and state regulations, including notification of law enforcement if a reasonable suspicion of crime has occurred. Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as required by law. Staff should be aware of, and comply with, individual requirements and responsibilities for reporting as may be required by law. In all cases, the executive director or director of nursing will ensure notification to the residents' legal guardian, family member, responsible party, or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the resident's attending physician. Coordination with QAPI: The center will review allegations of abuse, neglect, and misappropriation of resident property and exploitation during QAPI meetings. QAPI committee will review information including but not limited to: The thoroughness of the investigation, Protection of the resident(s), Risk factors identified, Root- cause analysis of the investigation, Systemic changes that may be required. Review of the policy and procedure titled Notification of Change of Condition last revision date of 12/16/2020 and last approval date of 4/23/2024 read, Policy: The Center to promptly notify the Patient/ Resident, the attending physician and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is an accident, significant change in the patient residence physical, mental or psychosocial status, need to alter treatment significantly new treatment, discontinuation of current treatment due to but not limited to adverse consequences acute condition exacerbation of a chronic condition, a transfer or discharge of the patient resident from the center, patient/ resident consecutively refuses medication and or treatment (IE two or more times), patient/ resident is discharged without proper medical authority. Review of the policy and procedure titled Physician orders last revision date of 3/3/2021 and last approval date of 4/23/2024 read, Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: Admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during or as soon as practicable after it is provided, to maintain an accurate medical record. Routine orders: A nurse may accept a telephone order from a Physician, Physician Assistant or Nurse Practitioner (as permitted by state law) The order will be repeated back to the physician, PA or ARNP for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR [electronic Treatment Administration Record]). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The Immediate Jeopardy (IJ) was removed onsite on 11/18/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 11/18/2024, the Executive Director completed a 30-day look back at all reportables to ensure proper investigation was conducted. On 11/18/2024, the Director of Nursing completed all hospital transfers, conducted a facility wide audit of change in conditions in the last 30 days pertaining to insulin with no additional concerns related to blood sugars. On 11/14/2024, education was provided to the Executive Director by the Regional [NAME] President on Abuse/Neglect policy and procedure to include investigations. The Regional Nurse Consultant provided abuse/ neglect education, as well as investigation to the nurse management staff on 11/13/2024. Education included: abuse/ neglect policy and procedure related to neglect for failure to reassess, notify the physician, not documenting physician's orders, not documenting communication to the physician, not documenting the transfer of the resident to the hospital, not following physician orders, and lack of shift-to-shift report. All incidents to be called to the Regional [NAME] President, Regional Director of Clinical Services, and Risk Manager with a timeline of events on any incident to determine if reportable. Investigations to be started immediately on any complaints or incidents. On 11/18/2024, the grievance log was reviewed for the last 30 days by Regional Director of Social Services with no concerns noted related to change of condition, insulin, abuse or neglect. On 11/18/2024, the Director of Nursing conducted a facility wide audit of all hospital transfers and change of condition in the last 30 days pertaining to insulin with no additional concerns related to blood sugars. On 11/13/2024, education was provided for all staff by the Director of Nursing/designee on the abuse neglect policy. Facility personnel received education beginning on 11/13/2024 and completed on 11/15/2024 related to the abuse/neglect policy to include preventing abuse, identification, protection, investigating and reporting inappropriate resident behaviors to the nurse. Neglect is the failure of the center, 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. Key staff were educated on reporting process of a potential deficient practice or suspected abuse/neglect to the Quality Assurance performance Improvement (QA/PI) by notifying the Executive Director and/or the Director of Nursing. On 11/13/2024, an Ad Hoc that included the Executive Director, Medical Director, Director of Nursing the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation. The facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change in condition, lack of shift-to-shift report, insulin administration, Abuse/neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital, and lack of communication between staff and providers. As of 11/17/2024, education has been completed on 40 out of 40 licensed nurses on medical neglect, accuchecks, insulin, Type 1 and 2 diabetes, and Change of Condition policy. On 11/17/2024, 68 of 68 Certified Nursing Assistants and 64 of 64 ancillary staff were also educated. Review of t [TRUNCATED]

Based on interview, record review, and review of policy and procedures, the facility failed to ensure residents who required insulin administration received treatment in accordance with professional standards of practice by failing to notify and immediately consult with the resident's physician when a resident suffered elevated blood glucose levels. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. Staff B, LPN, assumed care of Resident #1 at 7:00 AM on 10/6/2024 and did not follow up with the provider. Staff B, LPN, did not reassess Resident #1's blood glucose or address the need for any orders. Resident #1 called 911 at approximately 6:30 PM, Emergency Medical Services (EMS) contacted the facility, spoke with Staff B, LPN, who instructed EMS the resident did not need help. Again at 11:15 PM, Resident #1 called 911 and was subsequently transferred to the hospital and was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. Diabetic ketoacidosis (DKA) develops when the body can't make enough insulin, a hormone that helps sugar enter cells for energy. Instead, fat is broken down for energy. This can cause acids called ketones to build up in the blood and collect in the urine. The risk is highest in people who have type 1 diabetes and those who often miss insulin doses. DKA symptoms often start quickly, sometimes within a day. A person may get very thirsty, urinate often, vomit or have stomach pain. Symptoms also can include tiredness or weakness, confusion, shortness of breath, or fruity breath. Treatment often involves going to a hospital to receive fluids, insulin and electrolytes through a vein. Without treatment, diabetic ketoacidosis can lead to loss of consciousness and death. (Mayo Clinic/Mayoclinic.org) The facility's failure to implement the policy and procedure for change of condition and physician notification and failure to ensure residents who required insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on November 18, 2024, at 2:50 PM. The Immediate Jeopardy began on October 6, 2024, and was removed on site on November 18, 2024. Findings include: Review of the Admission Record for Resident #1 documented an admitted [DATE] with diagnoses that include diabetes mellitus type 1, malignant neoplasm of oropharynx (cancer), unspecified dysphagia (unable to swallow), oropharyngeal phase, type 1 diabetes mellitus without complications, chronic pulmonary embolism (a blockage in a lung artery caused by a blood clot that has traveled from elsewhere in the body), chronic kidney disease, unspecified, other acute osteomyelitis (bone infection), unspecified site, acquired absence of left leg (below knee), essential primary hypertension (high blood pressure), gastrostomy status (a flexible tube that's surgically inserted into the stomach through the abdominal wall. It allows for the delivery of nutrition, fluids, and medication directly into the stomach), hyperlipidemia, unspecified (an abnormally high concentration of fats or lipids in the blood), peripheral vascular disease, unspecified (blood vessels narrow or become blocked, reducing blood flow to the limbs or other parts of the body). Review of Resident #1's physician order dated 10/4/2024 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to Type 1 Diabetes Mellitus Without Complications. Review of Resident #1's Medication Administration Record (MAR) showed Staff A, LPN, documented a BS (blood sugar) of 552 on 10/6/2024 at 6:00 AM. Staff A, LPN, documented 2, CM (chart code/follow up codes 2 = drug refused). Review of Resident #1's eMAR (electronic Medication Administration Record) note dated 10/6/2024 at 6:32 AM documented by Staff A, LPN, read, Patient stated, I'm refusing all medications until I get the proper insulin. Review of Resident #1's progress note dated 10/6/2024 at 7:00 AM documented by Staff A, LPN, read, ARNP [Advanced Registered Nurse Practitioner] notified of resident's refusal of all morning medications. Per resident he is refusing all medications until he is receiving the proper insulin. Orders received to increase current insulin twice daily with blood sugars checked twice daily. No other orders given at this current time. Review of text message communication from Staff A, LPN's personal cellular phone to the On Call Medical Doctor (OCMD) on 10/6/2024 at 7:33 AM read, Good Morning, [Resident #1's name] is refusing all of his medications. He says he's not taking anything until he receives the proper insulin. Per his orders he's receiving 10 Units of Lantus @ [at] 6 am. He did allow me to check his blood sugar 552. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 8:19 AM read, No sliding scale ordered? Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 8:22 AM read, No, I didn't see any sliding scale he said his Lantus is supposed to be given @ night. And he has another type of insulin he gets. I didn't see anything other than the Lantus. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 10:55 AM read, Based on his sugars, if they have been above 250 everyday, go up to 15 BID [15 units two times a day] of long-acting insulin and make sure we cover with sliding scale for meals. Let's also make sure he's getting accuchecks. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 7:55 PM read, I'll change his orders & notify him of the changes & hopefully he complies. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 11:25 PM read, [Resident #1's last name] has continued to call 911 since I arrived this afternoon. They are loading him up & transporting him, [Resident #1's full name]. Review of Resident #1 medical record did not contain any documentation of the test message communication between the facility and the OCMD. Review of Resident #1's Interact SBAR (Situation, Background, Assessment, Recommendations) Communication form documented by Staff A, LPN, dated 10/6/2024 at 11:25 PM read, Situation: the change in condition (CIC) reported on this CIC evaluation are: other change in condition. At the time of evaluation patient vital signs, weight and blood sugar were blood pressure 130/77, pulse 82, temperature 98.2, pulse oximetry 96% on room air, blood glucose of 552 obtained at 6:45 AM on 10/06/24. Outcomes of physical assessment: positive findings reported were mental status evaluation with no change observed. Functional status evaluation with no changes observed. Patient called 911 on his personal cell phone and stated, I want out of this place. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: No new orders given at this time. Review of Resident #1's medical record did not contain any documentation of further blood glucose checks after the glucose level of 552 was documented at approximately 6:00 AM. Review of the hospital ED (Emergency Department) provider notes for Resident #1 dated 10/6/2024 at 11:51 PM read, Chief complaint: Patient presents with high blood sugar. Patient is an 81 y.o. [year old] M [male] with a PMH [Past Medical History] of oropharyngeal SCC [squamous cell cancer of throat], DVT [Deep Vein Thrombosis], PVD [Peripheral Vascular Disease], T1D [Type 1 Diabetes], HTN [Hypertension], and osteomyelitis who presents from an outside rehab after having unreadable glucose levels on his monitor. He states that at the outside rehab were not following his strict insulin regimen trying to give a different type of insulin. Per EMS [Emergency Medical Services] he was declining the insulin the outside rehab was trying to give him. He was recently admitted on ,d+[DATE] for pneumonia and was discharged to rehab NPO [nothing by mouth] with swallow study pending (gastrostomy tube in place). BASIC METABOLIC PANEL - Abnormal; Notable for the following components: Glucose 745, Anion Gap 34. Medical Evaluation Initiated: Attestation: The patient is critical due to DKA [Diabetic Ketoacidosis]. admitted to the ICU [Intensive Care Unit]. Review of the hospital history and physical for Resident #1 dated 10/7/2024 read, HPI [history of presenting illness]: [Resident #1's name] is an 81 y.o. male presented with hyperglycemia at rehab admitted for DKA. PMH relevant for T1DM (Type 1 Diabetes Mellitus), HTN, oropharyngeal squamous cell carcinoma, peripheral vascular disease, DVT (04/2022) and below the knee amputation secondary to osteomyelitis. Patient reports lack of compliance with his long-term insulin regimen for DM1 [Type 1 Diabetes Mellitus] at his rehab facility. He reports they weren't giving me the right insulin and explains some of the doses of his regimen were being missed. During an interview on 11/13/2024 at 9:25 AM, the Director of Nursing (DON) stated, I was not here for the incident, I found out after I returned that Tuesday. That was the 8th [10/8/2024]. With a blood sugar that high the nurse should have notified the doctor that he [Resident #1] was refusing his insulin and why he was refusing it. The nurse in charge of his care was not acting within the professional standards of practice for treating hyperglycemia in a type 1 diabetic. He [Staff A, LPN] should have notified the doctor immediately when he [Resident #1] refused his insulin. He [Staff A, LPN] did not transcribe the orders, and he should have stayed and transcribed the orders he got. The nurse got the high blood sugar and spoke to someone. I don't know who he spoke with, I don't know their name, you will have to ask [the Administrator's name] and got new orders. I don't know if or what he told the nurse that came on in the day shift. I don't know what the day shift nurse did after that. This shouldn't have happened; this should have been avoided. The nurse that admitted him should have read everything when it comes to the discharge summary, and they would have seen all the other orders instead of just the one piece of paper. The blood sugar should have been rechecked. It was not rechecked the rest of the day. I would consider this neglect. I don't know why the abuse and neglect policies were not followed. We should have completed a RCA [root cause analysis] and we should have implemented the abuse policy and procedure back on the 7th [10/7/2024]. During a telephone interview on 11/13/2024 at 11:35 AM, the OCMD stated, I did receive a call related to this resident [Resident #1]. The Nurse called me on the afterhours line, and I was told of the residents' glucose and I actually decided to double the insulin, the Lantus, and increase it to 15 Units twice a day and to add SSIC [Sliding Scale Insulin Coverage] with insulin coverage AC [before meals] and HS [at bedtime]. I would say that the professional standard of practice would be to have the blood glucose rechecked after 30 minutes to one hour after high readings to accurately assess if the patient was stabilizing versus the patient needing further emergency treatment. The staff did not adhere to a professional standard of practice when they did not notify us that he was refusing treatment. I would expect staff to inform us that a patient had refused insulin to determine the next steps we needed to do, either increase medications or we send to the hospital. I would call this unintentional neglect. They did not treat this according to professional standards of practice. I should have been notified that the patient was refusing his insulin. I was not called about this again after I gave the orders to them. During an interview on 11/13/2024 at 2:28 PM, Staff E, LPN, Wound Care Nurse, stated, The nurse that admitted this resident did not identify it, that more than Lantus should have been ordered for him. The night nurse did get the high blood sugar and called the nurse practitioner and got orders. I don't know if he told the day nurse, I don't know. The hospital MAR conflicts with the discharge summary. He [Staff A, LPN] didn't transcribe the orders he got. He should have. During an interview on 11/13/2024 at 2:49 PM, Staff D, LPN, Unit Manager, stated, I found out [about incident] when his daughter called me, she called on that Monday [10/7/2024]. She was upset about him not getting his insulin and about what happened, this was after he went to the hospital. She said she was a nurse and couldn't understand how we could make a mistake like this. She was very upset about it. She was upset that he was not given his proper insulin and that he was now in Diabetic ketoacidosis. I told [the Administrator's name]. During an interview on 11/13/2024 at 3:18 PM, the Administrator stated, I found out about the situation when I returned to work. I was finally able to speak with the daughter on 10/20/2024. I didn't file a report on 10/7/2024 because we saw on the chart that they only had orders for Lantus, we didn't think it was an issue until he started refusing the medication. The report should have been done, that is the best practice. [Staff A, LPN's name] got the order. It was not placed in [name of the electronic medical record software]. We investigated and did a QAPI [Quality Assurance and Process Improvement] Ad hoc [from Latin meaning for this] meeting on 10/7/2024. I talked to [Staff B's name], she said that the resident refused medications and [Staff A's name] spoke to the nurse practitioner and got orders. The nurse forgot to transcribe the orders into [name of the electronic medical record software]. There was no documentation in [name of the electronic medical record software]. During an interview on 11/13/2024 at 3:43 PM, Staff B, LPN, stated, I did take care of this resident [Resident #1]. He did not refuse care when I took care of him. I was told by the night nurse [Staff A, LPN] that his blood sugar was high. I don't remember him telling me what the blood sugar was, he just said it was high. He did not refuse care that day. I did not try to get another accucheck, he didn't have orders to recheck his blood sugar. I didn't have orders to recheck the blood sugar. I wasn't told how high the blood sugar was. I did not ask how high it was. I was in the front [area of building] charting and apparently, he called 911. I was called and asked if he needed help, I told them [EMS] no, I would check on him. I went to the room, and he said, You are trying to kill me. I asked him why and he told me that 'his blood sugar, his insulin was wrong, and he needed to get short acting insulin, and we weren't ordering it for him. I told him that he had orders for long-acting insulin and that he refused to take it. He told me Yes, I do, but because I need short acting insulin I need to get out of here and you all are trying to kill me. This could have been avoided, I should have rechecked his blood sugar, I don't know why I didn't. During a telephone interview on 11/14/2024 at 9:18 AM, the Advanced Practice Registered Nurse (APRN) stated, I believe that situation happened over the weekend. I wasn't the on-call provider, but it was discussed Monday. The protocol they follow is normally blood sugar greater than 400 they notify their provider and then we give standard orders. We give them extra orders. Like I said, I wasn't on call that weekend but when it was reviewed come Monday, that night the nurse didn't notify the on-call provider, and they documented that they did. They did come back with orders on that and then they had hand off [change of] shift. I would have expected potentially that since it was a night shift going into day shift, because this was a morning blood sugar, if I do recall correctly. As well, that morning at breakfast time the patients now eating so that sugar should probably be rechecked 90 minutes after they eat to see how they process that meal and what their new sugar is going to be if they weren't getting that coverage and then reaching back out to the provider and letting them know, 'hey this person's blood sugar is still reading this number' and just keep reaching out to the provider until they get what they need. A resident has the risk of going into Diabetic Ketoacidosis if not properly monitored and treated for high blood sugar. During a telephone interview on 11/14/2024 at 11:20 AM, the Medical Director stated, I remember a few things because I know the facility felt bad about the whole thing, you know while this was all happening. So, they had called me about it I think this happened over the weekend to my understanding. I know that there was also some frustration on the patient end I think they refused some glucose checks or refused insulin and then at that point I think they called 911. My expectations would be to 100% ensure that there's glucose monitoring, accuchecks, and of course a sliding scale. I mean every single diabetic in the building should be on a sliding scale. I think it was [the OCMD's name] that was notified. I think they went up on the long acting and they were just assuming that the patient was on a sliding scale. 100% if you're in the five hundreds [blood glucose level] and they're on long acting they need to be on a sliding scale, likely in the highest level of the sliding scale you know from there we could go up on the long acting and ensure there's proper glucose monitoring. I would probably give a onetime dose of a short acting and have them recheck sugars in an hour so I'm not sure what took place in this case or how long after that reading the patient called 911. I would want to be notified that they [resident] were refusing [medications]. I don't know if that call was ever made, after the fact, to let the doctor know that he's refusing it. If any doctor's increasing long-acting insulin, they're already assuming that the short acting is on the MAR. During an interview on 11/14/2024 at 7:10 AM, the DON stated, I was not here the day that this was found, that they spoke with his daughter, the Unit Manager spoke to her. They did know the concerns with not providing insulin or ADL [Activities of Daily Living] care. We were still investigating it; I can't tell you why we didn't investigate more. I knew his blood sugar was 552. I was given that information, but I thought it was that [Staff A's name] didn't transcribe orders. I guess we did not do a thorough investigation, I can't find any more than what was done initially and in the town hall meeting. I see that there were more than 12 hours that the resident was still here after that blood sugar of 552. There are no other accuchecks done after that. It is my expectation that staff provide a detailed report when going off their shift. The nurse [Staff A, LPN] should have told [Staff B's name] what the blood sugar was, and he [Staff A, LPN] should have documented his information in the notes. [Staff A's name] should have asked what high meant if that is what he told her. She should have followed up on that. I would expect that she called the doctor again and get further orders. She [Staff B] had the opportunity to call the doctor when he called 911 to get further orders. All the information should have been put in a progress note from both nurses. I would consider this neglect for both nurses. I don't know why the staff weren't suspended; I can't give you a reason. Review of the policy and procedure titled Notification of Change of Condition last revision date of 12/16/2020 and last approval date of 4/23/2024 read, Policy: The Center to promptly notify the Patient/ Resident, the attending physician and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is an accident, significant change in the patient residence physical, mental or psychosocial status, need to alter treatment significantly new treatment, discontinuation of current treatment due to but not limited to adverse consequences acute condition exacerbation of a chronic condition, a transfer or discharge of the patient resident from the center, patient/ resident consecutively refuses medication and or treatment (IE two or more times), patient/ resident is discharged without proper medical authority. Review of the policy and procedure titled Physician orders last revision date of 3/3/2021 and last approval date of 4/23/2024 read, Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: Admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during or as soon as practicable after it is provided, to maintain an accurate medical record. Routine orders: A nurse may accept a telephone order from a Physician, Physician Assistant or Nurse Practitioner (as permitted by state law) The order will be repeated back to the physician, PA or ARNP for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR [electronic Treatment Administration Record]). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The Immediate Jeopardy (IJ) was removed onsite on 11/18/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 11/13/2024, an Ad Hoc was completed in the presence of the Executive Director, Medical Director and the Director of Nursing, to identify the root cause analysis was that the facility failed to ensure residents were free from complications of a change in condition due to not reassessing residents, not transcribing and administering ordered medication, not properly notifying the physician and not properly identifying the change in condition. On 11/13/2024, 40 of 40 licensed staff were educated on the change of condition process notifying the provider of abnormal blood glucose levels, notification of change, refusal of medications, assessment and reassessments for abnormal glucose levels and other change in condition, and transcribing and administration of physician orders. On 11/18/2024, The Director of Nursing completed a full house audit of 18 hospital transfers and 16 changes in conditions over the last 30 days with no deficient practice noted related to blood sugars, insulin, and transcribing/administering. Review of the facility records documented that there were 18 transfers to the hospital with the last 30 days and none were a result of blood sugars or hyperglycemia. Review of the facility records documented that there were 16 changes in condition within the last 30 days and none were a result of blood sugars or hyperglycemia. Review of the facility records documented an in-service dated 11/13/2024 on the topic of abuse/neglect presented by the Regional Director of Clinical Services was provided to the nursing management staff, the Director of Clinical Services, Assistant Director of Clinical services, and two Unit Managers. Review of the education in-service attendance record dated 11/14/2024 documented that the Executive Director received education on abuse and neglect training (reporting requirements) from the Regional [NAME] President of Operations. Review of the facility records beginning 11/13/2024 and completed on 11/17/2024 documented that 40 out of 40 licensed staff received training on Abuse and Neglect, 68 out of 68 Certified Nursing Assistants and 64 out of 64 ancillary staff received training on abuse and neglect, assessment and reassessment of residents, change-in-condition process, hospital transfer process, communication during shift-to-shift report, insulin administration, abuse/neglect identification and process and communication between staff and providers During staff interviews conducted 11/13/2024 through 11/19/2024, 19 Licensed Practical Nurses, 2 Registered Nurses, the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, Wound Care Nurse, Staffing Coordinator, Business Office manager and Social Service Manager verified receiving the training and verbalized understanding of the abuse and neglect, changes in condition policies and procedures, resident reassessment after changes in condition.

Based on interview, record review, and review of policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical wellbeing of each resident by failing to implement policy and procedures for medical neglect and resident change of condition. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. Staff B, LPN, assumed care of Resident #1 at 7:00 AM on 10/6/2024 and did not follow up with the provider. Staff B, LPN, did not reassess Resident #1's blood glucose or address the need for any orders. Resident #1 called 911 at approximately 6:30 PM, Emergency Medical Services (EMS) contacted the facility, spoke with Staff B, LPN, who instructed EMS the resident did not need help. Again at 11:15 PM, Resident #1 called 911 and was subsequently transferred to the hospital and was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. The facility's failure to implement the policy and procedure for medical neglect and failure to ensure residents who required insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on November 18, 2024, at 2:50 PM. The Immediate Jeopardy began on October 6, 2024, and was removed on site on November 18, 2024. Findings include: Review of the job description titled Executive Director I read, Purpose of Your Job Position: The Executive Director I is responsible for management of the facility in a manner which exemplifies the company's standard of operational excellence. The primary purpose of the executive director is to direct the day-to-day functions of the facility in accordance with current federal, state, their local standards, guidelines, and regulations that govern nursing facilities to ensure the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Executive Director 1, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Duties and Responsibilities: 6. Interpret and ensure implementation of governing board policies and procedures. 9. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. 11. Support and guide the facility's quality improvement process. 13. Ensure a safe, clean and comfortable environment for residents, visitors and staff. Maintain a file for and monitor incident reports.14. Attend and or conduct facility meetings, as required to carry out responsibilities. 23. Adhere to facility policies and procedures and participates in facility quality improvement and safety programs. 24. Attend to overall operation of the facility. Review of the job description titled Director of Nursing I read, Purpose of Your Job Position: As the company Director of Nursing, you are entrusted with the responsibility of caring for our residents, families, coworkers, visitors, and all others. The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible health care with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Director of Nursing I, you are delegated the administrative authority responsibility and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner, Assistant Director of Nursing, Clinical Nurses, and Nurse techs. In the absence of the Executive Director, you are in charge of carrying out the resident care policies established by the facility. Duties and responsibilities: 4. Set and monitor achievement of goals and objectives for the nursing department consistent with established philosophy and standards of practice. 6. Establish, implement, and continually update competency/skills checklists for nursing staff. 8. Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines. 9. Assure compliance with resident rights policies and work to resolve resident grievances. 10. Establish and monitor compliance with an effective medical record documentation system. 13. Actively participate in quality improvement process for the facility. Review of the job description titled Assistant Director of Clinical Services (ADON) read, Purpose of Your Job Position. As an Assistant Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, coworkers, visitors and all others. The primary purpose of your position is to monitor clinical compliance with state and federal regulations. You are entrusted to provide innovative, responsible health care with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job functions as assistant director of clinical services, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties. Responsible for the functions of the corporate clinical and clinical reimbursement services department. Duties and responsibilities: 1. access to liaison between the director of nursing and the nursing staff. 2. participates in the development and achievement of nursing department goals and objectives. 4. assist in the implementation of and monitor compliance with policies, procedures, and standards of practice consistent with corporate and external regulatory guidelines. 6. Assist in the development, implementation, and monitoring of an accurate and effective documentation system. 10. Actively participate in the quality improvement process for the facility. 12. Attend and participate in department facility meetings as required. 15. Adheres to facility policies and procedures and participates in facility quality improvement and safety programs. 21. Perform other duties, as assigned. Review of the Medical Director Administrative Service Agreement read, 2. Responsibilities: a. OF GROUP: Group agrees that medical director shall generally be responsible for the administrative oversight of medical services at the care center, including, without limitation, the duties described in Exhibit A (the Administrative Services). Review of Exhibit A, Medical Director Services, read, The responsibilities of the Medical Director shall be, without limitation, to perform the following duties to be solely administrative in nature and not including any clinical or other direct medical services: (A) Make good faith efforts to ensure adequate medical care for patients. (B) Provide clinical leadership through active participation in the care centers quality assurance committee, and participate in all other activities which may be designated by the Executive Director of the Care Center from time to time to facilitate the cost-effective delivery of quality services at the care center. (D) Participate in such case management and risk management activities and programs as the executive director of the care center may request from time to time. (E) Maintain a current knowledge of all federal, state, and local laws, and rules and regulations regarding the medical directors practice and medical staff requirements. (I) The Medical Director will be responsible for monitoring and managing quality improvement goals. a. The Medical Director shall participate in monthly medical director's call. c. The Medical Director must address any concerning trends with regard to quality improvement. (L) Assist in the implementation and further development of care center programs, protocols, and quality assurance initiatives. (O). Participate in the development of written policies, rules and regulations to govern the nursing care and related medical and other health services provided. The medical director is responsible for seeing that these policies reflect an awareness of, and provisions for, meeting the total needs of Care Centers patients. Review of the Admission Record for Resident #1 documented an admitted [DATE] with diagnoses that include diabetes mellitus type 1, malignant neoplasm of oropharynx (cancer), unspecified dysphagia (unable to swallow), oropharyngeal phase, type 1 diabetes mellitus without complications, chronic pulmonary embolism (a blockage in a lung artery caused by a blood clot that has traveled from elsewhere in the body), chronic kidney disease, unspecified, other acute osteomyelitis (bone infection), unspecified site, acquired absence of left leg (below knee), essential primary hypertension (high blood pressure), gastrostomy status (a flexible tube that's surgically inserted into the stomach through the abdominal wall. It allows for the delivery of nutrition, fluids, and medication directly into the stomach), hyperlipidemia, unspecified (an abnormally high concentration of fats or lipids in the blood), peripheral vascular disease, unspecified (blood vessels narrow or become blocked, reducing blood flow to the limbs or other parts of the body). Review of the document titled Department of Internal Medicine Discharge Summary Heme/Onc [Hematology/Oncology] Team dated 10/3/2024 read: (page 1) Instructions for PCP [Primary Care Physician]: will need to keep an eye on his insulin regimen as these have been up and down since starting bolus tube feeds; currently on 12 units long acting and seven units short acting before bolus feeds. Consider endocrinology referral. (page 8) Discharge medication, mediation list documents Lantus Solostar 100/unit/ML [milliliter] Insulin glargine. Inject 10 units into the skin every 24 hours. Review of Resident #1's physician order dated 10/4/2024 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to Type 1 Diabetes Mellitus Without Complications. Review of Resident #1's Medication Administration Record (MAR) showed Staff A, LPN, documented a BS (blood sugar) of 552 on 10/6/2024 at 6:00 AM. Staff A, LPN, documented 2, CM (chart code/follow up codes 2 = drug refused). Review of Resident #1's eMAR (electronic Medication Administration Record) note dated 10/6/2024 at 6:32 AM documented by Staff A, LPN, read, Patient stated, I'm refusing all medications until I get the proper insulin. Review of Resident #1's progress note dated 10/6/2024 at 7:00 AM documented by Staff A, LPN, read, ARNP [Advanced Registered Nurse Practitioner] notified of resident's refusal of all morning medications. Per resident he is refusing all medications until he is receiving the proper insulin. Orders received to increase current insulin twice daily with blood sugars checked twice daily. No other orders given at this current time. Review of text message communication from Staff A, LPN's personal cellular phone to the On Call Medical Doctor (OCMD) on 10/6/2024 at 7:33 AM read, Good Morning, [Resident #1's name] is refusing all of his medications. He says he's not taking anything until he receives the proper insulin. Per his orders he's receiving 10 Units of Lantus @ [at] 6 am. He did allow me to check his blood sugar 552. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 8:19 AM read, No sliding scale ordered? Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 8:22 AM read, No, I didn't see any sliding scale he said his Lantus is supposed to be given @ night. And he has another type of insulin he gets. I didn't see anything other than the Lantus. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 10:55 AM read, Based on his sugars, if they have been above 250 everyday, go up to 15 BID [15 units two times a day] of long-acting insulin and make sure we cover with sliding scale for meals. Let's also make sure he's getting accuchecks. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 7:55 PM read, I'll change his orders & notify him of the changes & hopefully he complies. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 11:25 PM read, [Resident #1's last name] has continued to call 911 since I arrived this afternoon. They are loading him up & transporting him, [Resident #1's full name]. Review of Resident #1 medical record did not contain any documentation of the test message communication between the facility and the OCMD. Review of Resident #1's Interact SBAR (Situation, Background, Assessment, Recommendations) Communication form documented by Staff A, LPN, dated 10/6/2024 at 11:25 PM read, Situation: the change in condition (CIC) reported on this CIC evaluation are: other change in condition. At the time of evaluation patient vital signs, weight and blood sugar were blood pressure 130/77, pulse 82, temperature 98.2, pulse oximetry 96% on room air, blood glucose of 552 obtained at 6:45 AM on 10/06/24. Outcomes of physical assessment: positive findings reported were mental status evaluation with no change observed. Functional status evaluation with no changes observed. Patient called 911 on his personal cell phone and stated, I want out of this place. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: No new orders given at this time. Review of Resident #1's medical record did not contain any documentation of further blood glucose checks after the glucose level of 552 was documented at approximately 6:00 AM. Review of the hospital ED (Emergency Department) provider notes for Resident #1 dated 10/6/2024 at 11:51 PM read, Chief complaint: Patient presents with high blood sugar. Patient is an 81 y.o. [year old] M [male] with a PMH [Past Medical History] of oropharyngeal SCC [squamous cell cancer of throat], DVT [Deep Vein Thrombosis], PVD [Peripheral Vascular Disease], T1D [Type 1 Diabetes], HTN [Hypertension], and osteomyelitis who presents from an outside rehab after having unreadable glucose levels on his monitor. He states that at the outside rehab were not following his strict insulin regimen trying to give a different type of insulin. Per EMS [Emergency Medical Services] he was declining the insulin the outside rehab was trying to give him. He was recently admitted on ,d+[DATE] for pneumonia and was discharged to rehab NPO [nothing by mouth] with swallow study pending (gastrostomy tube in place). BASIC METABOLIC PANEL - Abnormal; Notable for the following components: Glucose 745, Anion Gap 34. Medical Evaluation Initiated: Attestation: The patient is critical due to DKA [Diabetic Ketoacidosis]. admitted to the ICU [Intensive Care Unit]. Review of the hospital history and physical for Resident #1 dated 10/7/2024 read, HPI [history of presenting illness]: [Resident #1's name] is an 81 y.o. male presented with hyperglycemia at rehab admitted for DKA. PMH relevant for T1DM (Type 1 Diabetes Mellitus), HTN, oropharyngeal squamous cell carcinoma, peripheral vascular disease, DVT (04/2022) and below the knee amputation secondary to osteomyelitis. Patient reports lack of compliance with his long-term insulin regimen for DM1 [Type 1 Diabetes Mellitus] at his rehab facility. He reports they weren't giving me the right insulin and explains some of the doses of his regimen were being missed. During an interview on 11/13/2024 at 9:25 AM, the Director of Nursing (DON) stated, I was not here for the incident, I found out after I returned that Tuesday. That was the 8th [10/8/2024]. With a blood sugar that high the nurse should have notified the doctor that he [Resident #1] was refusing his insulin and why he was refusing it. The nurse in charge of his care was not acting within the professional standards of practice for treating hyperglycemia in a type 1 diabetic. He [Staff A, LPN] should have notified the doctor immediately when he [Resident #1] refused his insulin. He [Staff A, LPN] did not transcribe the orders, and he should have stayed and transcribed the orders he got. The nurse got the high blood sugar and spoke to someone. I don't know who he spoke with, I don't know their name, you will have to ask [the Administrator's name] and got new orders. I don't know if or what he told the nurse that came on in the day shift. I don't know what the day shift nurse did after that. This shouldn't have happened; this should have been avoided. The nurse that admitted him should have read everything when it comes to the discharge summary, and they would have seen all the other orders instead of just the one piece of paper. The blood sugar should have been rechecked. It was not rechecked the rest of the day. I would consider this neglect. I don't know why the abuse and neglect policies were not followed. We should have completed a RCA [root cause analysis] and we should have implemented the abuse policy and procedure back on the 7th [10/7/2024]. During an interview on 11/13/2024 at 2:49 PM, Staff D, LPN, Unit Manager, stated, I found out [about incident] when his daughter called me, she called on that Monday [10/7/2024]. She was upset about him not getting his insulin and about what happened, this was after he went to the hospital. She said she was a nurse and couldn't understand how we could make a mistake like this. She was very upset about it. She was upset that he was not given his proper insulin and that he was now in Diabetic ketoacidosis. I told [The Administrator's name]. During an interview on 11/13/2024 at 3:18 PM, the Administrator stated, I found out about the situation when I returned to work. I was finally able to speak with the daughter on 10/20/2024. I didn't file a report on 10/7/2024 because we saw on the chart that they only had orders for Lantus, we didn't think it was an issue until he started refusing the medication. The report should have been done, that is the best practice. [Staff A, LPN's name] got the order. It was not placed in [name of the electronic medical record software]. We investigated and did a QAPI [Quality Assurance and Process Improvement] Ad hoc [from Latin meaning for this] meeting on 10/7/2024. I talked to [Staff B's name], she said that the resident refused medications and [Staff A's name] spoke to the nurse practitioner and got orders. The nurse forgot to transcribe the orders into [name of the electronic medical record software]. There was no documentation in [name of the electronic medical record software]. During an interview on 11/13/2024 at 3:43 PM, Staff B, LPN, stated, I did take care of this resident [Resident #1]. He did not refuse care when I took care of him. I was told by the night nurse [Staff A, LPN] that his blood sugar was high. I don't remember him telling me what the blood sugar was, he just said it was high. He did not refuse care that day. I did not try to get another accucheck, he didn't have orders to recheck his blood sugar. I didn't have orders to recheck the blood sugar. I wasn't told how high the blood sugar was. I did not ask how high it was. I was in the front [area of building] charting and apparently, he called 911. I was called and asked if he needed help, I told them [EMS] no, I would check on him. I went to the room, and he said, You are trying to kill me. I asked him why and he told me that 'his blood sugar, his insulin was wrong, and he needed to get short acting insulin, and we weren't ordering it for him. I told him that he had orders for long-acting insulin and that he refused to take it. He told me Yes, I do, but because I need short acting insulin I need to get out of here and you all are trying to kill me. This could have been avoided, I should have rechecked his blood sugar, I don't know why I didn't. During a telephone interview on 11/14/2024 at 11:20 AM, the Medical Director stated, I remember a few things because I know the facility felt bad about the whole thing, you know while this was all happening. So, they had called me about it I think this happened over the weekend to my understanding. I know that there was also some frustration on the patient end I think they refused some glucose checks or refused insulin and then at that point I think they called 911. My expectations would be to 100% ensure that there's glucose monitoring, accuchecks, and of course a sliding scale. I mean every single diabetic in the building should be on a sliding scale. I think it was [the OCMD's name] that was notified. I think they went up on the long acting and they were just assuming that the patient was on a sliding scale. 100% if you're in the five hundreds [blood glucose level] and they're on long acting they need to be on a sliding scale, likely in the highest level of the sliding scale you know from there we could go up on the long acting and ensure there's proper glucose monitoring. I would probably give a onetime dose of a short acting and have them recheck sugars in an hour so I'm not sure what took place in this case or how long after that reading the patient called 911. I would want to be notified that they [resident] were refusing [medications]. I don't know if that call was ever made, after the fact, to let the doctor know that he's refusing it. If any doctor's increasing long-acting insulin, they're already assuming that the short acting is on the MAR. During an interview on 11/14/2024 at 7:10 AM, the DON stated, I was not here the day that this was found, that they spoke with his daughter, the Unit Manager spoke to her. They did know the concerns with not providing insulin or ADL [Activities of Daily Living] care. We were still investigating it; I can't tell you why we didn't investigate more. I knew his blood sugar was 552. I was given that information, but I thought it was that [Staff A's name] didn't transcribe orders. I guess we did not do a thorough investigation, I can't find any more than what was done initially and in the town hall meeting. I see that there were more than 12 hours that the resident was still here after that blood sugar of 552. There are no other accuchecks done after that. It is my expectation that staff provide a detailed report when going off their shift. The nurse [Staff A, LPN] should have told [Staff B's name] what the blood sugar was, and he [Staff A, LPN] should have documented his information in the notes. [Staff A's name] should have asked what high meant if that is what he told her. She should have followed up on that. I would expect that she called the doctor again and get further orders. She [Staff B] had the opportunity to call the doctor when he called 911 to get further orders. All the information should have been put in a progress note from both nurses. I would consider this neglect for both nurses. I don't know why the staff weren't suspended; I can't give you a reason. During an interview on 11/14/2024 at 4:10 PM, the Administrator stated, I can't say that I thought I needed to complete a federal report. I was told by [Staff D's name] that she [Resident #1's daughter] was upset and wanted to talk to us, but I wasn't able to connect with her. We attempted multiple times, but we couldn't reach her and left messages. When we got [in touch with] her is when I found out about her concerns with care related to the insulin and with being on the bedpan too long. We did do a QAPI on 10/7 related to the insulin. I just thought it was because he refused to take his insulin. I guess we did not investigate fully until after I spoke to his daughter. We thought the problem was that the nurse on admission got the right orders and there weren't accuchecks ordered. He refused this medication, and I spoke to [Staff B's name], LPN, and she told me that he [Resident #1] didn't talk to her at all about his insulin during the day before he called 911. Then they realized that he had orders that were not transcribed from the night nurse when he came on shift. I did not talk to him [Staff A, LPN] the DON did. I did not implement the abuse and neglect policies because he refused his medication. I didn't think to. I can't tell you why. We should have done more investigation. We should have done a QAPI when we realized that his blood sugar was so high, I wasn't aware of everything. We only did the initial QAPI, we didn't do any others, I think we should have done it, I can't tell you why we didn't. We did not suspend the nurses; it is our policy to suspend staff pending the results of an investigation. We initially thought it happened because the resident refused his insulin, not for neglect. We should follow our abuse and neglect policies and procedures. I didn't think to. I can't tell you why. Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation last revision date of 11/16/2022, last approval date of 4/23/2024 read, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights to establish a disciplinary policy which results in a fair and timely treatment of occurrences of resident abuse. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action including dismissal provided herein. Definitions: Neglect is the failure of the center, 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. Procedure: 4. Identification: All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Nursing/designee. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Nursing will serve as the Abuse Coordinator. 5. Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during a questioning of or interviewing of residents. Investigations will be accomplished in the following manner. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect(s) should be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion and submitted to the Abuse Coordinator. Investigation: The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. 6. Protection: Any suspect(s), who is employed or contract service provider, once he/she has(have) been identified, will be suspended pending the investigation. 7. Reporting/ Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or alleged allegation of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, to a resident is obligated to report such information immediately but no later than two hours after the allegation is made if the events that caused the allegation involve abuse or resulted in serious bodily injury for not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials in accordance with state law. In the absence of the executive director, the director of nursing is designated abuse coordinator. Once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with federal and state regulations, including notification of law enforcement if a reasonable suspicion of crime has occurred. Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting as required by law. Staff should be aware of, and comply with, individual requirements and responsibilities for reporting as may be required by law. In all cases, the executive director or director of nursing will ensure notification to the residents' legal guardian, family member, responsible party, or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the resident's attending physician. Coordination with QAPI: The center will review allegations of abuse, neglect, and misappropriation of resident property and exploitation during QAPI meetings. QAPI committee will review information including but not limited to: The thoroughness of the investigation, Protection of the resident(s), Risk factors identified, Root- cause analysis of the investigation, Systemic changes that may be required. Review of the policy and procedure titled Notification of Change of Condition last revision date of 12/16/2020 and last approval date of 4/23/2024 read, Policy: The Center to promptly notify the Patient/ Resident, the attending physician and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is an accident, significant change in the patient residence physical, mental or psychosocial status, need to alter treatment significantly new treatment, discontinuation of current treatment due to but not limited to adverse consequences acute condition exacerbation of a chronic condition, a trans [TRUNCATED]

Based on interview and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop, and implement an effective performance improvement plan (PIP) when investigating neglect, change of condition, notification of providers and not following physician orders for Resident #1, placing all 27 residents who were prescribed long and short acting insulin at risk. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. Staff B, LPN, assumed care of Resident #1 at 7:00 AM on 10/6/2024 and did not follow up with the provider. Staff B, LPN, did not reassess Resident #1's blood glucose or address the need for any orders. Resident #1 called 911 at approximately 6:30 PM, Emergency Medical Services (EMS) contacted the facility, spoke with Staff B, LPN, who instructed EMS the resident did not need help. Again at 11:15 PM, Resident #1 called 911 and was subsequently transferred to the hospital and was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. The facility's failure to develop and implement appropriate plans of actions after identifying the systemic breakdown for failure to implement policy and procedures for neglect and change of condition led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on November 18, 2024, at 2:50 PM. The Immediate Jeopardy began on October 6, 2024, and was removed on site on November 18, 2024. Findings include: Review of the Admission Record for Resident #1 documented an admitted [DATE] with diagnoses that include diabetes mellitus type 1, malignant neoplasm of oropharynx (cancer), unspecified dysphagia (unable to swallow), oropharyngeal phase, type 1 diabetes mellitus without complications, chronic pulmonary embolism (a blockage in a lung artery caused by a blood clot that has traveled from elsewhere in the body), chronic kidney disease, unspecified, other acute osteomyelitis (bone infection), unspecified site, acquired absence of left leg (below knee), essential primary hypertension (high blood pressure), gastrostomy status (a flexible tube that's surgically inserted into the stomach through the abdominal wall. It allows for the delivery of nutrition, fluids, and medication directly into the stomach), hyperlipidemia, unspecified (an abnormally high concentration of fats or lipids in the blood), peripheral vascular disease, unspecified (blood vessels narrow or become blocked, reducing blood flow to the limbs or other parts of the body). Review of Resident #1's physician order dated 10/4/2024 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to Type 1 Diabetes Mellitus Without Complications. Review of Resident #1's Medication Administration Record (MAR) showed Staff A, LPN, documented a BS (blood sugar) of 552 on 10/6/2024 at 6:00 AM. Staff A, LPN, documented 2, CM (chart code/follow up codes 2 = drug refused). Review of Resident #1's eMAR (electronic Medication Administration Record) note dated 10/6/2024 at 6:32 AM documented by Staff A, LPN, read, Patient stated, I'm refusing all medications until I get the proper insulin. Review of Resident #1's progress note dated 10/6/2024 at 7:00 AM documented by Staff A, LPN, read, ARNP [Advanced Registered Nurse Practitioner] notified of resident's refusal of all morning medications. Per resident he is refusing all medications until he is receiving the proper insulin. Orders received to increase current insulin twice daily with blood sugars checked twice daily. No other orders given at this current time. Review of text message communication from Staff A, LPN's personal cellular phone to the On Call Medical Doctor (OCMD) on 10/6/2024 at 7:33 AM read, Good Morning, [Resident #1's name] is refusing all of his medications. He says he's not taking anything until he receives the proper insulin. Per his orders he's receiving 10 Units of Lantus @ [at] 6 am. He did allow me to check his blood sugar 552. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 8:19 AM read, No sliding scale ordered? Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 8:22 AM read, No, I didn't see any sliding scale he said his Lantus is supposed to be given @ night. And he has another type of insulin he gets. I didn't see anything other than the Lantus. Review of text message communication from the OCMD to Staff A, LPN's personal cellular phone on 10/6/2024 at 10:55 AM read, Based on his sugars, if they have been above 250 everyday, go up to 15 BID [15 units two times a day] of long-acting insulin and make sure we cover with sliding scale for meals. Let's also make sure he's getting accuchecks. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 7:55 PM read, I'll change his orders & notify him of the changes & hopefully he complies. Review of text message communication from Staff A, LPN's personal cellular phone to the OCMD on 10/6/2024 at 11:25 PM read, [Resident #1's last name] has continued to call 911 since I arrived this afternoon. They are loading him up & transporting him, [Resident #1's full name]. Review of Resident #1 medical record did not contain any documentation of the test message communication between the facility and the OCMD. Review of Resident #1's Interact SBAR (Situation, Background, Assessment, Recommendations) Communication form documented by Staff A, LPN, dated 10/6/2024 at 11:25 PM read, Situation: the change in condition (CIC) reported on this CIC evaluation are: other change in condition. At the time of evaluation patient vital signs, weight and blood sugar were blood pressure 130/77, pulse 82, temperature 98.2, pulse oximetry 96% on room air, blood glucose of 552 obtained at 6:45 AM on 10/06/24. Outcomes of physical assessment: positive findings reported were mental status evaluation with no change observed. Functional status evaluation with no changes observed. Patient called 911 on his personal cell phone and stated, I want out of this place. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: No new orders given at this time. Review of Resident #1's medical record did not contain any documentation of further blood glucose checks after the glucose level of 552 was documented at approximately 6:00 AM. Review of the hospital ED (Emergency Department) provider notes for Resident #1 dated 10/6/2024 at 11:51 PM read, Chief complaint: Patient presents with high blood sugar. Patient is an 81 y.o. [year old] M [male] with a PMH [Past Medical History] of oropharyngeal SCC [squamous cell cancer of throat], DVT [Deep Vein Thrombosis], PVD [Peripheral Vascular Disease], T1D [Type 1 Diabetes], HTN [Hypertension], and osteomyelitis who presents from an outside rehab after having unreadable glucose levels on his monitor. He states that at the outside rehab were not following his strict insulin regimen trying to give a different type of insulin. Per EMS [Emergency Medical Services] he was declining the insulin the outside rehab was trying to give him. He was recently admitted on ,d+[DATE] for pneumonia and was discharged to rehab NPO [nothing by mouth] with swallow study pending (gastrostomy tube in place). BASIC METABOLIC PANEL - Abnormal; Notable for the following components: Glucose 745, Anion Gap 34. Medical Evaluation Initiated: Attestation: The patient is critical due to DKA [Diabetic Ketoacidosis]. admitted to the ICU [Intensive Care Unit]. Review of the document titled Ad Hoc Quality Assurance & Performance Improvement Meeting dated 10/7/2024 attended and signed by the Administrator, Social Services Director, MDS Coordinator, Housekeeping/Laundry, Business Office, the DON, Activities, Therapy, Medical Director, Dining/Nutrition and 4 other attendees with no job title, read, Reason for Meeting: Type 1 & 2 diabetes. Opportunity for Improvement: Notification of Type 1 and Type 2 diabetes upon admission with NP/MD [Nurse Practitioner/Medical Doctor] to ensure insulin orders are verified and correct to decrease delayed treatment. Data (Assess Current Situation- What were the results/trend): Failure to notify provider with type 1 diabetic glucose monitoring results in a timely manner. Analysis (Root Cause analysis): Failure to notify provider related to abnormal glucose levels, failure follows transcribe orders from provider to [name of the electronic medical record software]. Plan: Key staff to be educated on type 1 and type 2 diabetes and when to notify NP/MD. Parameters when notifying provider. Audits for all new admits/resident with diabetic dx [diagnosis] to be reviewed in the clinical meeting daily. Review on next monthly QAPI meeting. Responsible Team Members(s): DCS [Director of Clinical Services]/designee, ADCS [Assistant Director of Clinical Services]/designee, UM [Unit Manager), IDT [Interdisciplinary Team]. During an interview on 11/13/2024 at 9:25 AM, the Director of Nursing (DON) stated, I was not here for the incident, I found out after I returned that Tuesday. That was the 8th [10/8/2024]. With a blood sugar that high the nurse should have notified the doctor that he [Resident #1] was refusing his insulin and why he was refusing it. The nurse in charge of his care was not acting within the professional standards of practice for treating hyperglycemia in a type 1 diabetic. He [Staff A, LPN] should have notified the doctor immediately when he [Resident #1] refused his insulin. He [Staff A, LPN] did not transcribe the orders, and he should have stayed and transcribed the orders he got. The nurse got the high blood sugar and spoke to someone. I don't know who he spoke with, I don't know their name, you will have to ask [the Administrator's name] and got new orders. I don't know if or what he told the nurse that came on in the day shift. I don't know what the day shift nurse did after that. This shouldn't have happened; this should have been avoided. The nurse that admitted him should have read everything when it comes to the discharge summary, and they would have seen all the other orders instead of just the one piece of paper. The blood sugar should have been rechecked. It was not rechecked the rest of the day. I would consider this neglect. I don't know why the abuse and neglect policies were not followed. We should have completed a RCA [root cause analysis] and we should have implemented the abuse policy and procedure back on the 7th [10/7/2024]. During an interview on 11/13/2024 at 2:49 PM, Staff D, LPN, Unit Manager, stated, I found out [about incident] when his daughter called me, she called on that Monday [10/7/2024]. She was upset about him not getting his insulin and about what happened, this was after he went to the hospital. She said she was a nurse and couldn't understand how we could make a mistake like this. She was very upset about it. She was upset that he was not given his proper insulin and that he was now in Diabetic Ketoacidosis. I told [The Administrator's name]. During an interview on 11/13/2024 at 3:18 PM, the Administrator stated, I found out about the situation when I returned to work. I was finally able to speak with the daughter on 10/20/2024. I didn't file a report on 10/7/2024 because we saw on the chart that they only had orders for Lantus, we didn't think it was an issue until he started refusing the medication. The report should have been done, that is the best practice. [Staff A, LPN's name] got the order. It was not placed in [name of the electronic medical record software]. We investigated and did a QAPI Ad hoc [from Latin meaning for this] meeting on 10/7/2024. I talked to [Staff B's name], she said that the resident refused medications and [Staff A's name] spoke to the nurse practitioner and got orders. The nurse forgot to transcribe the orders into [name of the electronic medical record software]. There was no documentation in [name of the electronic medical record software]. During an interview on 11/13/2024 at 3:43 PM, Staff B, LPN, stated, I did take care of this resident [Resident #1]. He did not refuse care when I took care of him. I was told by the night nurse [Staff A, LPN] that his blood sugar was high. I don't remember him telling me what the blood sugar was, he just said it was high. He did not refuse care that day. I did not try to get another accucheck, he didn't have orders to recheck his blood sugar. I didn't have orders to recheck the blood sugar. I wasn't told how high the blood sugar was. I did not ask how high it was. I was in the front [area of building] charting and apparently, he called 911. I was called and asked if he needed help, I told them [EMS] no, I would check on him. I went to the room, and he said, You are trying to kill me. I asked him why and he told me that 'his blood sugar, his insulin was wrong, and he needed to get short acting insulin, and we weren't ordering it for him. I told him that he had orders for long-acting insulin and that he refused to take it. He told me Yes, I do, but because I need short acting insulin I need to get out of here and you all are trying to kill me. This could have been avoided, I should have rechecked his blood sugar, I don't know why I didn't. During an interview on 11/14/2024 at 7:10 AM, the DON stated, I was not here the day that this was found, that they spoke with his daughter, the Unit Manager spoke to her. They did know the concerns with not providing insulin or ADL [Activities of Daily Living] care. We were still investigating it; I can't tell you why we didn't investigate more. I knew his blood sugar was 552. I was given that information, but I thought it was that [Staff A's name] didn't transcribe orders. I guess we did not do a thorough investigation, I can't find any more than what was done initially and in the town hall meeting. I see that there were more than 12 hours that the resident was still here after that blood sugar of 552. There are no other accuchecks done after that. It is my expectation that staff provide a detailed report when going off their shift. The nurse [Staff A, LPN] should have told [Staff B's name] what the blood sugar was, and he [Staff A, LPN] should have documented his information in the notes. [Staff A's name] should have asked what high meant if that is what he told her. She should have followed up on that. I would expect that she called the doctor again and get further orders. She [Staff B] had the opportunity to call the doctor when he called 911 to get further orders. All the information should have been put in a progress note from both nurses. I would consider this neglect for both nurses. I don't know why the staff weren't suspended; I can't give you a reason. During an interview on 11/14/2024 at 4:10 PM, the Administrator stated, I can't say that I thought I needed to complete a federal report. I was told by [Staff D's name] that she [Resident #1's daughter] was upset and wanted to talk to us, but I wasn't able to connect with her. We attempted multiple times, but we couldn't reach her and left messages. When we got [in touch with] her is when I found out about her concerns with care related to the insulin and with being on the bedpan too long. We did do a QAPI on 10/7 related to the insulin. I just thought it was because he refused to take his insulin. I guess we did not investigate fully until after I spoke to his daughter. We thought the problem was that the nurse on admission got the right orders and there weren't accuchecks ordered. He refused this medication, and I spoke to [Staff B's name], LPN, and she told me that he [Resident #1] didn't talk to her at all about his insulin during the day before he called 911. Then they realized that he had orders that were not transcribed from the night nurse when he came on shift. I did not talk to him [Staff A, LPN] the DON did. I did not implement the abuse and neglect policies because he refused his medication. I didn't think to. I can't tell you why. We should have done more investigation. We should have done a QAPI when we realized that his blood sugar was so high, I wasn't aware of everything. We only did the initial QAPI, we didn't do any others, I think we should have done it, I can't tell you why we didn't. We did not suspend the nurses; it is our policy to suspend staff pending the results of an investigation. We initially thought it happened because the resident refused his insulin, not for neglect. We should follow our abuse and neglect policies and procedures. I didn't think to. I can't tell you why. Review of the policy and procedure titled Quality Assurance and Performance Improvement Program (QAPI) last revision date of 10/24/2022 and last approval date of 4/23/2024, read, Policy: The Center and organization has a comprehensive, data-driven quality assurance performance improvement program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The center's QAPI program is ongoing comprehensive review of care and services provided to residents. Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a). Implementation. b). Identify priorities. c). Ensures adequate resources. d). Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e). Ensures corrective actions are implemented to address identified problems in systems. f). Evaluates the effectiveness of actions. g). Establishes expectations for safety, quality, rights, and choice and respect. 5. The quality assessment and assurance committee (QAA) meetings are at least quarterly but may be held more frequently as appropriate. Systemic Analysis and Action: 11. The center will establish and utilize a systemic approach to identify underlying causes of problems, including but not limited to: a. Root cause analysis. b. Failure Mode Effective Analysis. 12. The center will develop corrective actions based on the information gathered and review effectiveness of the actions. 13. The center will review and develop corrective actions on medical errors and adverse events. a. Center obtain and review information on any medical error and adverse event. b. Utilize a systemic approach to identify underlying cause. c. Develop and monitor action plans. Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues and adverse events. 14. Center will review department system data. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e. 'Plan, Do, Study, Act' or 'Performance Improvement Project.' Performance Improvement Projects: The center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the center services and resources identified in the Facility Assessment. 17. At a minimum, the center must conduct one performance improvement project annually. a). The PIP should focus on high risk or problem prone areas, identified by the center. b). The team may consist of one or more team members. c. The team will complete the following functions: i. Collect and analyze data, ii. Determine Root Cause, iii. Determine steps for resolution, iv. Implement corrective action(s), v. Evaluate the effectiveness of the action(s), vi. Report progress to the QAPI committee. The Immediate Jeopardy (IJ) was removed onsite on 11/18/2024 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On 11/15/2024, the Executive Director received education from the Regional [NAME] President on the CMS Five (5) Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital , and lack of communication between staff and providers. The Executive Director was educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC). The Executive Director was educated on the reporting process of a potential deficient practice to the Quality Assurance Performance Improvement (QA/PI) by notifying the Executive Director and/or Director of Nursing. On 11/18/2024 Key staff ( to include the Medical Director, Director of Nursing, Infection preventionist, Wound Care Nurse, Activities Director, Medical Records, Human Resourses, Business Office Mangers, and the Environmental Services Manager) were educated on the CMS Five (5) Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital , and lack of communication between staff and providers. Key staff were educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC). On 11/18/2024, an Ad Hoc that involved the Executive Director, Medical Director, Director of Nursing identified the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation. The facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse/Neglect identification and process, failed to follow policies and procedures when transferring the resident to the hospital and lack of communication between staff and providers. Review of the facility records documented the Executive Director received education from the Regional [NAME] President on the CMS Five (5) Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital , and lack of communication between staff and providers. The Executive Director was educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC). The Executive Director was educated on the reporting process of a potential deficient practice to the Quality Assurance Performance Improvement (QA/PI) by notifying the Executive Director and/or Director of Nursing. Review of the Ad Hoc QAPI meeting held on 11/18/2024 that involved the Executive Director, Medical Director, Director of Nursing identified the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation. During staff interviews conducted 11/13/2024 through 11/19/2024, 19 Licensed Practical Nurses, 2 Registered Nurses, the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, Wound Care Nurse, Staffing Coordinator, Business Office manager and Social Service Manager verified receiving the training and verbalized understanding of the abuse and neglect, changes in condition policies and procedures, resident reassessment after changes in condition and the process for QAPI investigation and reporting.

Based on record review, observation, and interview, the facility failed to ensure 2 of 3 sampled residents, Residents #1 and #2, received care, consistent with professional standards of practice, to prevent the development or worsening of pressure ulcers. Findings: Review of the facility medical records for Resident #1 revealed that she was an [AGE] year-old female with [DIAGNOSES REDACTED]. Review of physician orders for Resident #1 dated 01/16/2018 read, Weekly skin sweeps. Review of Resident #1's care plan dated 05/29/2020 read, (Resident #1's name) has potential for pressure injury related to bladder and bowel incontinence, impaired mobility and fragile skin. Interventions included skin assessments as ordered. Review of the weekly skin integrity documentation for Resident #1 dated 06/09/2020 read, No new open areas. Dated: 07/5/2020 read, Coccyx: Four (4) open areas on buttock. There was no additional documentation of weekly skin integrity records for the period of 06/10/2020 to 07/04/2020. Review of the wound care evaluation and management summary for Resident #1 dated 07/06/2020 read, Focused wound exam (Site 1): Unstageable DTI (Deep Tissue Injury), etiology: pressure, wound size: 6 cm (centimeters) x 5 cm x unmeasurable, wound surface area: 30.00 cm, light serous exudate (Fluid that leaks out of body tissues). Review of the facility medical records for Resident #2 revealed she was an [AGE] year-old female with [DIAGNOSES REDACTED]. Review of the nursing admission assessment fir Resident #2 dated 07/06/2020 read, Skin: G tube (Gastrostomy Tube). General skin condition was documented as dry with no concerns on feet. Review of physician orders for Resident #2 dated 07/06/2020 read, Weekly skin sweeps. Review of the weekly skin integrity documentation for Resident #2 dated 07/08/2020 read, Sacrum: Pressure wound; R (Right) lower leg front pressure wound. No other weekly skin integrity reviews were documented in the facility medical records. Review of the wound evaluation and management for Resident #2 dated 07/13/2020 read, Focused wound exam (Site #1): Wound of right dorsal foot: wound size: 3.5 x 2 x unmeasurable cm (Centimeters), surface area: 7.00 cm, exudate (Fluid that leaks out of body tissues): light serous, thick adherent devitalized necrotic tissue 100%. Focused wound exam (Site #2): Unstageable DTI (Deep Tissue Injury) of the right lateral heel, wound size: 4 cm x 5 cm x unstageable, surface area: 20 cm. Focused wound exam (Site #3): Unstageable DTI of right lateral foot, wound size: 3 cm x 3 cm x unmeasurable, surface area: 9.00 cm. Focused wound exam (Site #4): Stage 4 pressure wound sacrum, 7.5 cm x 5.5 cm x unmeasurable, 41.25 cm, exudate: heavy serous, 75% thick adherent black necrotic tissue. During an interview on 07/20/2020 at 10:07 AM, Staff F, Licensed Practical Nurse (LPN) stated, We do weekly skin assessments on all residents and document them on the weekly skin assessment form. There would not be any reason we would not complete a skin sweep weekly, they are ordered by a physician, not completing them is not following a physician order and may lead to not finding new skin issues. During an interview on 07/20/2020 at 11:45 AM, Staff G, LPN, stated, I was not aware that (Resident #1's name) did not get weekly skin sweeps as ordered, she should have. It is our policy to do weekly skin sweeps on all residents and document them on the skin assessment forms. We should be checking skin weekly per doctor's orders. Not completing weekly skin sweeps could lead to new skin concerns not being recognized. I was not aware that (Resident #2's name) did not have any pressure wounds documented on her July readmission nursing assessment. We did not do a complete skin assessment, or it is not accurate. We did not complete a weekly skin sweep and document the results. During an interview on 07/20/2020 at 1:35 PM, the ADON (Assistant Director of Nursing) stated, I can't tell you why (Resident #1's name) did not get any skin sweeps or assessment between 06/10/2020 and 07/05/2020 when four areas were found on her coccyx. Once we found the areas, we began treatment immediately and had the wound care doctor see the wounds and treatment began. I'm not sure why we did not complete weekly skin sweeps. They did not follow doctor's orders or our policies and procedures for weekly skin sweeps. I'm not sure why (Resident #1 name) did not have a nursing assessment completed when she got readmitted until two days after her readmission. (Resident #2's name) came back from the hospital with a wound on her sacrum. I'm not sure why we did not complete the admission assessment correctly or why weekly skin sweeps were not being documented. It seems like we did not notify the family of the additional wounds that were on (Resident #2's name). We should have documented them, and we should have completed a change of condition form and notified the family. Review of the facility policy and procedures titled Skin Evaluation WC-190, revision date 04/01/2017 read, A licensed nurse will complete a total body evaluation on each resident weekly. 1. A licensed nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form.