Every finding on record at Clarksdale Nursing Center

Based on staff interviews, record review, and facility policy review, the facility failed to notify a dialysis clinic of a significant change in a resident's status for one (1) of three (3) residents reviewed for notification of change (Resident #1). Findings include: Review of the facility policy titled Change in Resident Medical Status, last revised 9/17, revealed a change in medical status is defined as any physical, psychological, and/or medical deviation as compared to the resident's status as noted in the initial assessment. During review of a complaint received related to Resident #1, it was revealed that the facility did not inform the dialysis clinic of the resident's fall that resulted in a brain bleed. Record review of a document dated 2/27/25 from (Proper Name) Medical Center revealed Resident #1 presented to the Emergency Department (ED) related to a fall with injury and was diagnosed with a subdural hematoma and a scalp laceration. An interview with the Nurse Practitioner on 6/18/25 at 11:00 AM confirmed that Resident #1 obtained a subdural hematoma from the fall that occurred on 2/26/25. She stated she asked one of the nursing staff if the dialysis unit was aware of the fall with the subdural hematoma, and the staff member replied yes. She also confirmed that the dialysis unit needed to be aware of the subdural hematoma to determine if any treatments may need to be altered. An interview with Licensed Practical Nurse (LPN) #1 on 6/18/25 at 11:41 AM confirmed that the facility communicates with the dialysis clinic using the Nursing Facility/Dialysis Clinic Communication forms and confirmed that the fall with the subdural hematoma that Resident #1 obtained should have been communicated on that form to the dialysis clinic. Review of the Nursing Facility/Dialysis Clinic Communication form for Resident #1 dated 3/5/25, completed by LPN #1, revealed it was completed by the nursing facility prior to clinic transfer. The section titled Change in Condition contained no documentation of the fall or subdural hematoma diagnosed on [DATE]. A continued review of the Nursing Facility/Dialysis Clinic Communication form for Resident #1 dated 3/5/25-4/4/25 revealed there continued to be no documentation of the fall or subdural hematoma. A phone interview with the Clinic Manager Registered Nurse from the dialysis clinic on 6/18/25 at 11:50 AM confirmed that Resident #1 was a patient at the clinic and recalls finding out about the fall when the resident told their staff. She reviewed the communication forms and medical record of Resident #1 and stated she was unable to find any documentation that the dialysis clinic was ever informed that Resident #1 had a subdural hematoma. She stated that residents on dialysis are given heparin, an anticoagulant, during dialysis treatment to thin the blood. She then stated that if the clinic had been made aware, the provider would have been notified prior to dialysis treatment because thinning the blood could increase the risk of bleeding from the subdural hematoma, and staff would have been aware of the need to assess for any changes in status. Record review of the progress notes for Resident #1 from 2/26/25-3/30/25 revealed no documentation that the dialysis clinic was notified of the subdural hematoma diagnosed after a fall on 2/26/25. An interview with the Director of Nursing on 6/18/25 at 12:10 PM confirmed that staff should have documented the change in status of Resident #1 having a subdural hematoma to the dialysis clinic because the administration of heparin to thin the blood could have worsened the condition. An interview with the Administrator on 6/18/25 at 12:20 PM confirmed that the facility staff should have communicated to the dialysis clinic that Resident #1 had a subdural hematoma. Record review of the admission Record revealed the facility admitted Resident #1 was admitted on [DATE] with diagnoses of end-stage renal disease and a history of falling. No diagnosis of traumatic subdural hematoma was listed. Record review of Resident #1's Section C of the admission Minimum Data Set (MDS) revealed that on 1/24/25 the Brief Interview for Mental Status (BIMS) score was 14, indicating the resident was cognitively intact.

47158 Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement care plans related to fluid restriction (Resident #11), nail care (Resident's #24 & #44) and following Enhanced Barrier Precautions (EBP) for (Resident #157) for four (4) of 19 care plans reviewed. Findings included: Review of the facility policy titled, Care Plan Process, revised 08/17, revealed The facility staff shall follow the care plan . Resident # 11 Record review of the Care Plan for Resident #11 revealed Resident receives dialysis .Has fluid restrictions 960 cubic centimeters (cc's) in a 24 hour per day (see EMAR). Record review of August 2024 Electronic Medical Record (EMAR) for Resident #11 revealed the resident received more than 960 cc's of fluid per day for none (9) of 13 days from 8/1/24 through 8/13/24. (8/1/24, 8/2/24, 8/5/24, 8/6/24, 8/7/24, 8/8/24, 8/9/24, 8/11/24, and 8/12/24). During an interview with Nurse Case Manager on 8/14/24 at 2:05 PM, she verified that Resident #11's care plan indicated that he was on a 960 cc per day fluid restriction. The Nurse Case Manager stated that staff failed to follow the care plan when they gave the resident more than 960 cc's per day. She stated that this could cause a fluid overload for the resident. Resident #24 A record review of Resident #24's Care Plan revealed with a problem onset date of 08/29/2023 revealed Resident needs assistance with ADL'S (Activities of Daily Living) . Approaches . Nail Care weekly. Check condition and clean PRN (as needed) . Fingernails: Clean and Trimmed weekly on Tuesdays as indicated . During an observation on 08/13/24 at 10:40 AM, Resident #24's fingernails were long and jagged, approximately one-half (1/2) inch past the tips of fingers on both hands. An observation on 08/14/24 at 9:13 AM, Resident #24's fingernails were long and jagged, approximately one-half (1/2) inch past the tips of fingers on both hands. During an observation and interview on 08/14/24 at 10:50 AM, Licensed Practical Nurse (LPN) #2 confirmed that resident #24's nails were long and jagged and needed to be trimmed and confirmed that the resident's Care Plan was not being followed and should have been. During an interview on 08/14/24 at 11:10 AM, the Director of Nurses (DON) confirmed that Resident #24's fingernails were to be cleaned daily, and the nurses were to trim them on Tuesdays as indicated. She revealed that her ADL care plan was not being followed if her nails were not trimmed like they should have been. Resident #44 A record review of Resident #44's Care Plan with a Problem onset date of 07/19/2023 revealed Resident needs limited assist with ADL'S (Activities of Daily Living) . Approaches .Fingernail: Clean and trimmed weekly as indicated . During an observation and interview on 08/14/24, at 1:30 PM, Resident #44's fingernails were long and jagged, approximately one inch past the tips of his fingers, with a brown substance underneath. Resident #44 stated my nails grow fast, but I think it's been about three weeks since they were cut. During an interview and observation on 08/14/24 at 2:10 PM, LPN #2 confirmed that Resident #44's fingernails were soiled and needed to be cut and that his plan of care was not being followed. During an interview and observation on 08/14/24 at 2:20 PM, the DON confirmed that the resident's nails were long and needed to be cut. The DON also confirmed that Resident #44's ADL care regarding his nail care was not being followed. During an interview on 08/15/24 at 9:50 AM, the Registered Nurse (RN) Supervisor revealed that both Resident #24 and Resident #44's ADL care plans regarding nail care were not being followed, and they should have been. Resident #157 Record review of the Care Plan for Resident #157 revealed Problem/Need: Resident receives IV (intravenous medications) .Approaches .Enhanced barrier precautions followed . During an observation on 8/14/24 at 12:35 PM, revealed an enhanced barrier sign observed on the outside doorway to Resident #157's room. Observed the RN Supervisor enter Resident #157's room to administer ceftriaxone intravenous (IV) solution via the PICC line. The RN Supervisor was observed connecting the IV tubing to the resident's right upper arm PICC line access device. The RN Supervisor did not put on a gown for enhanced barrier precautions before the procedure. Upon exiting the room, the RN Supervisor was asked if Resident #157 was on enhanced barrier precautions. She stated yes and pointed to the enhanced barrier precaution sign on the outer doorway of Resident #157's room. She then confirmed that she did not use enhanced barrier precautions while hanging Resident 157's IV antibiotics via his PICC line. During an interview with the Nurse Case Manager on 8/14/24 at 2:03 PM, she verified that Resident #157's care plan indicated that Enhanced Barrier Precautions (EBP) were to be used during administration of medication of IV antibiotics by PICC line. She then stated that staff failed to follow the care plan when they failed to use EBP when administering IV antibiotics and this could increase his risk for infection. She stated that the purpose of the care plan is to identify issues and put interventions in place to help achieve goals related to the resident's needs.

Based on observation, staff and resident interviews, facility policy review, and record review, the facility failed to ensure fingernails were clean and trimmed, as evidenced by long and jagged nails with a brown substance under nails for two (2) of eight (8) residents observed. Resident #24 and Resident #44 Findings include: Record review of the facility's, Nail Care Policy, revised 07/10, revealed Purpose: To promote cleanliness, safety, and a neat appearance . Procedure .1. Perform hand hygiene . 7. Remove any debris from under the nails. 8. Trim the nails straight across . 14. Document all appropriate information in the clinical record . Resident #24 During an observation on 08/13/24 at 10:40 AM, Resident #24's fingernails were long and jagged, approximately one-half (1/2) inch past the tips of fingers on both hands. An observation on 08/14/24 at 9:13 AM, Resident #24's fingernails were long and jagged, approximately one-half (1/2) inch past the tips of fingers on both hands. During an observation and interview on 08/14/24 at 10:40 AM, Certified Nurse Aide (CNA) #2 revealed she wasn't sure if the resident was diabetic but thought she was, and the nurses were supposed to trim her fingernails. She confirmed Resident #24's fingernails were long and jagged and revealed she could scratch herself and have a skin tear. During an observation and interview on 08/14/24 at 10:50 AM, Licensed Practical Nurse (LPN) #2 confirmed that Resident #24's nails were long and jagged and needed to be trimmed. She revealed that the nurses are supposed to trim her fingernails weekly since she is diabetic. She revealed that she could scratch herself with the jagged nails, get a skin tear, and possibly get an infection. A record review of Resident #24's Electronic Administration Record (EMAR) for August 2024 revealed under Nursing Instruction, Fingernail: Clean and trimmed weekly on Tuesday as indicated. The weekly dates of August 6 and August 13 were signed off as completed. August 13 was signed off by LPN #2. In an interview on 08/14/24 at 11:10 AM, the Director of Nurses (DON) confirmed that Resident #24's fingernails were to be cleaned daily, and the nurses were to trim the nails on Tuesdays as indicated and sign that it was completed in the EMAR. She confirmed that if the resident's nails were long and not trimmed, it could cause a skin tear injury for the resident. A record review of the Face Sheet revealed Resident #24 was admitted to the facility, on 08/29/2023 with diagnoses that included Type 2 diabetes mellitus and Unspecified dementia, severe. Resident #44 During an observation and interview on 08/14/24, at 1:30 PM, Resident #44's fingernails were long and jagged, approximately one inch past the tips of his fingers, with a brown substance underneath. Resident #44 stated my nails grow fast, but I think it's been about three weeks since they were cut. In an interview on 08/14/24 at 2:00 PM, CNA #2 stated, I never cut his fingernails. He doesn't let you do it, so I don't even try. An observation and interview on 08/14/24 at 2:05 PM revealed Resident #44 sitting in his wheelchair in his room. His fingernails were long, jagged, and had a brown substance underneath. Resident #44 revealed that he doesn't refuse his fingernails to be cut and would like them trimmed. During an interview and observation on 08/14/24 at 2:10 PM, LPN #2 revealed that the CNAs could do Resident #44's fingernails since he is non-diabetic. When asked about the last time the resident's nails were cleaned and trimmed, LPN #2 stated, I can't answer that since I don't work down here every day. LPN #2 confirmed she did not look at his nails yesterday but did sign off on the EMAR that they were done. LPN #2 confirmed that Resident #44's fingernails were soiled and needed to be cut. She revealed that the treatment nurse usually does his nails, and the treatment nurse told her yesterday that all the nails were done, so she just signed them off without looking. Resident #44 stated to LPN #2, I would like my nails cut. A record review of Resident #44's EMAR for August 2024 revealed under nursing Instruction, Fingernail: Clean and trimmed weekly on Tuesday as indicated. The weekly dates of August 6 and August 13 were signed off as completed. August 13 was signed off by LPN #2. During an interview and observation on 08/14/24 at 2:20 PM, the DON confirmed the resident's nails were long and needed to be cut. Resident #44 stated, Yes, I want them cut. The DON revealed the EMAR shouldn't have been checked off without the nurse looking at the nails to make sure they were done. During an interview on 08/14/24 at 2:35 PM, the Registered Nurse (RN) Treatment Nurse revealed, I asked the resident yesterday if he wanted his nails done, and he was on the phone, and his wife said not at this time. The RN Treatment Nurse stated I went back later and asked him again, and he said no. She confirmed the resident's nails are to be kept clean and trimmed weekly and stated, I can't really tell you the last time his fingernails were cut. An interview on 08/15/24 at 9:50 AM with the RN Supervisor revealed the nurses and CNAs can all do nail care, however, the CNAs cannot do residents who are diabetic or on blood thinners, but they can let the nurses know when they do their AM care that the resident's nails need to be tended to. She revealed it doesn't fall under the task for the CNAs to check off, but they know they are to do the nails and then let the nurse know that the nails have been done so she can document them. She revealed it is the responsibility of either the treatment nurse or the charge nurse to physically look at the resident's nails every Tuesday and ensure that the nails are cleaned, trimmed, and appropriately documented on the EMAR. During an interview on 08/15/24 at 10:59 AM, the Administrator revealed that the CNAs and nurses are both responsible for resident nail care. She revealed that the nurse who is taking care of the residents can easily look at their fingernails when they are passing their medication and make sure they are cleaned and trimmed, and they are to document this weekly. A review of the Face Sheet revealed Resident #44 was admitted to the facility on [DATE] with diagnoses that included Peripheral vascular disease and Cerebral infarction. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/2024 Section C ,revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #44 is moderately cognitively impaired.

Based on record review and staff interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in placing following the recertification survey on 4/6/2023 and the complaint survey on 6/26/2024. This was for deficiency recited during a recertification on 8/15/2024 in the area of F677 Activities of Daily Living (ADL). The continued failure of the facility during three State Surveys of record shows a pattern of the facility to sustain an effective QAA program. This was for one (1) of seven (7) deficient practice citations. Findings Included: This citation is cross-referenced to: F677 Review of the facility policy titled QAPI Performance Improvement Project (PIP) with a revision date of 11/22 revealed, The QA Committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment. In addition, the QA Committee will implement any PIP topics as indicated through data analysis. PIPs are implemented in accordance with CMS' protocol for conducting PIPs, including: 1. Measurement of performance using objective quality indicators. 2. Implementation of system interventions to achieve improvement in quality based on Root Cause Analysis. 3. Evaluation of the effectiveness of the interventions. 4. Plan and initiation of activities for increasing or sustaining improvement. An interview with the Administrator (ADM) on 08/15/24 at 10:05 AM revealed she was not aware that the resident's Activities of Daily Living (ADL) were not being done and was a concern for the facility again. She revealed after we were cited for ADLs during our annual survey last year and again cited on a complaint survey this year, the Interdisciplinary Team (IDT) discussed those in Quality Assurance Performance Improvement (QAPI), which involved our Medical Director, and we put measures in place, with monitoring to ensure this would be resolved but obviously something is wrong if this is a continued issue, and our plan is not working. Record review of the Facility's Plan of Correction (POC) dated 5/5/23 revealed under, 3. All Licensed Practical Nurses, Registered Nurses and Certified Nursing Assistants were in-serviced on the policy Nail Care on 04/13/23, 04/18/23 & 04/19/23 by the Director of Nursing. Orders were written for nail care and placed on the Electronic Medical Administration Record (EMAR) for nurses to check and initial weekly to assure that proper nail care is being done on all residents. 4. Nail care has been added to all resident's EMAR. Licensed Practical Nurses or Registered Nurses will assess all fingernails weekly and clean and trim as indicated. The Registered Nurse Supervisor will monitor nail care five times a week while making daily rounds. The Director of Nursing will monitor the EMAR weekly for four weeks and then monthly for two months. Monitoring began on April 7, 2023. The director of Nurses will report any concerns to the Quality Assurance Committee. The Director of Nurses or the Administrator will report any concerns to the Quality Assurance Committee weekly for four weeks and then quarterly. The Quality Assurance Committee met with the Medical Director on April 10, 2023, post annual State Survey to review potential tags. The Medical Director will meet with the Quality Assurance Committee on May 2, 2023 to review/approve the Plan of Correction for the actual tags. The Quality Assurance Committee will monitor quarterly for one year until the deficient practice is resolved and will make revisions and/or corrections when needed to current plan of corrections. Record review of the Facility's Plan of Correction (POC) dated 7/2/24 revealed under, 3. All nursing staff were in-serviced on the policy Activities for Daily Living and the importance of following the residents care plans on June 26, 27, 28, 29 and July 1, 2024 by the Director of Nursing, Staff Development/Infection Preventionist and Staff Nurse. All Staff will be in-serviced four times per year and as needed on Activity of Daily Living including incontinent care, good nutrition, grooming, personal and oral hygiene by Staff Development. The Director of Nursing, Staff Development/Infection Preventionist and Nursing Supervisors will make random rounds on eight residents daily for two weeks, then two times a week for two weeks. An emergency Quality Assurance meeting on June 28, 2024 was held with the Medical Director for approval of Plan of Correction. Any problems will be placed on a Quality Improvement form and weekly in the Department Head Meeting until resolved. 4. The Administrator will report to the Quality Assurance Committee quarterly. The Quality Assurance Committee will monitor quarterly until the deficient practice is no longer an issue and will make revisions and/or corrections when needed.

Based on record review, staff interview, and facility policy review the facility failed to ensure that a fluid restriction was followed for one (1) of five (5) residents on fluid restrictions. Resident #11. Findings included: Record review of facility policy Fluid Restriction with the latest review date of 02/22 revealed Policy: Fluids will be restricted for residents as directed by physician orders .Fluid Restriction 1000 cc's (cubic centimeters), Total Nursing 300 cc's, By Shift 120cc's day, 90 cc's evening (eve), 90 cc's night (noc). Total Dietary 700 cc's . Record review of August 2024 Active Orders for Resident #11 revealed Fluid Restriction 960 Milliliters (ML) per day with an onset date of 3/10/23. Record review of August 2024 Electronic Medical Record (EMAR) for Resident #11 revealed that Resident #11 received more than 960 cc's of fluid per day for nine (9) of 13 days from 8/1/24 through 8/13/24. (8/1/24, 8/2/24, 8/5/24, 8/6/24, 8/7/24, 8/8/24, 8/9/24, 8/11/24, and 8/12/24). In an interview with the Dietary Manager on 8/14/24 at 1:08 PM, she stated that Resident #11 was on a 1000 milliliter (ml) a day fluid restriction. She stated that the facility follows the fluid restriction policy that breaks down how much fluid nursing and dietary are to provide each shift. The Dietary Manager stated that the facility was following the fluid breakdown for a 1000 ml a day fluid restriction and that dietary provides (1) four (4) ounce (oz.) cup of fluid on each tray. (4) oz. equals 120 ml. During an interview with Licensed Practical Nurse (LPN) #1 on 8/14/24 at 1:34 PM, she stated that Resident #11 was on a 1000 ml/day fluid restriction. When asked how she knew how much fluid the resident was to receive on her shift she stated that dietary provided a (4) oz. cup of fluid on each tray, and she provided a (4) oz. cup of fluid during each med pass. LPN #1 verified that she gives Resident #11 (2) four ounce cups of fluid on her shift. An interview with the Director of Nursing (DON) on 8/14/24 at 1:45 PM, she verified Resident #11 should be on a 960 ml per day fluid restriction not a 1000 ml per day fluid restriction. The DON verified that documentation on the EMAR did reflect that the resident received more than 960 ml per day on nine (9) out of 13 days in August 2024. She stated that failure to follow the fluid restriction for Resident #11 could lead to fluid overload. Record review of the Face Sheet for Resident #11 revealed that the facility admitted him on 3/10/23 with a diagnoses that included End Stage Renal Disease.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for intravenous antibiotic therapy on two (2) of five (5) care area observations requiring enhanced barrier precautions. (Resident # 157). Findings include: A review of the facility policy titled, Enhanced Barrier Precautions, revised 03/24, revealed .Indwelling medical device examples include central lines . A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP . During entrance rounds on 8/13/24 at 12:00 PM, an observation revealed Registered Nurse (RN)/ Treatment nurse hanging a bag of intravenous (IV) fluids to Resident #157 right upper arm access device. The RN/Treatment nurse was not observed to be wearing a gown for enhanced barrier precautions, and there were no signs observed in the resident's room or on the doorway to alert staff of enhanced barrier precautions. Record review of the Physician Orders List revealed an order dated 7/23/24 for ceftriaxone 2-gram solution for injection: Administer 2 mg (milligrams)/100 milliliter(s) intravenous once daily until 8/18/2024. d/c (discontinue) PICC midline catheter care after last dose of IV antibiotic . In an observation on 8/14/24 at 12:35 PM, revealed an enhanced barrier sign observed on the outside doorway to Resident #157's room. Observed the RN Supervisor enter Resident #157's room to administer ceftriaxone intravenous (IV) solution via the PICC line. The RN Supervisor was observed connecting the IV tubing to the resident's right upper arm PICC line access device. The RN Supervisor did not put on a gown for enhanced barrier precautions before the procedure. Upon exiting the room, the RN Supervisor was asked if Resident #157 was on enhanced barrier precautions. She stated yes and pointed to the enhanced barrier precaution sign on the outer doorway of Resident #157's room. She then confirmed that she did not use enhanced barrier precautions while hanging Resident 157's IV antibiotics via his PICC line. In an interview with the Infection Control Nurse on 8/14/24 at 1:04 PM, she revealed she was unaware Resident #157 had a PICC line. She confirmed the resident should be on enhanced barrier to reduce the risk of transmission of bacteria while providing care to the PICC line device. An interview with RN/Treatment nurse on 8/14/24 at 1:18 PM, she confirmed she hung the IV antibiotics on 8/13/24 around noon, she confirmed there was no enhanced barrier sign on the doorway on 8/13/24 and that she did not use enhanced barrier precautions because she was unable to find a gown. She revealed she was aware that she should have followed the enhanced barrier precautions because Resident #157 had a PICC line device. During an interview with the Resident #157 on 8/14/24 at 1:50 PM, he revealed that he has only seen staff wear a gown a couple of times to hang his IV medications. On 8/14/24 at 2:00 PM, in an interview with the Director of Nursing she confirmed staff should have been using enhanced barrier precautions while administering the IV antibiotics for Resident #157's through his PICC line device. Review of the Face Sheet revealed the facility admitted Resident #157 key on 7/23/24 with diagnoses that included Osteomyelitis of vertebra, lumbar region.

47157 Based on staff interview, record review and facility policy review the facility failed to accurately code the Minimum Data Set Assessment (MDS) for the use of restraints for five (5) of five (5) resident MDS Assessments reviewed for accurate coding of restraints. Resident #5, #18, #25, #33, and #38. Findings include: Record review of the facility policy titled Resident Assessment revised 09/19, revealed .Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed . Resident #5 Review of the Quarterly MDS dated with an Assessment Reference Date (ARD) of 7/15/24 for Resident #5 revealed Section P Restraints was coded that resident uses side rails daily. An observation on 8/13/24 at 11:20 AM, of Resident #5's bed, revealed one-half (1/2) siderails to the head of the bed only. Interview with Certified Nursing Assistant #1 (CNA) on 8/14/24 at 10:30 AM, she stated that the one-half (1/2) upper side rails on Resident #5's bed do not restrain her or keep her from getting out of the bed. Review of the Face Sheet revealed the facility admitted Resident #5 on 6/27/24 with a diagnosis of Pseudobulbar Affect. Resident #18 During an observation and interview on 8/13/24 at 2:02 PM, Resident #18's bed was noted to have upper side rails. The resident revealed that the side rails help her turn. Record review of Resident #18's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Rheumatoid arthritis and a Personal history of stroke. Record review of Resident #18's MDS with an ARD of 7/9/24 revealed under Section: P that Physical restraints was coded to use bed rail daily. Record review of Resident #18's MDS with an ARD of 7/9/24 revealed under Section C that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident is moderately cognitive impaired. Resident #25 Review of the Quarterly MDS with an ARD of 5/14/2024 for Resident #25 revealed Section P-Restraints was coded the resident uses side rails daily. An observation on 8/13/24 at 10:30 AM, of Resident #25's bed, revealed 1/2 rails to the head of the bed only. In an interview with Registered Nurse (RN)/Treatment nurse on 8/14/24 at 10:05 AM, she revealed that Resident #25 was not physically able to get herself out of the bed and the side rails to the top of the bed were not considered restraints. Review of the Face Sheet revealed the facility admitted Resident #25 on 7/05/23 with a diagnosis of Encounter for the orthopedic aftercare. Resident #33 Review of the Quarterly MDS with an ARD of 7/30/24 revealed Section P Restraints was coded that resident uses side rails daily. An observation on 8/13/24 at 10:58 AM, revealed Resident #33 had two half rails located at the head of the bed only. In an interview with the RN Treatment nurse on 8/14/24 at 10:00 AM, she revealed that Resident #33 was unable to get herself out of the bed and the side rails to the top of the bed were not considered restraints. Review of the Face Sheet revealed the facility admitted Resident #33 on 7/05/23 with a diagnosis of Type two Diabetes Mellitus. Resident #38 Review of the Significant Change MDS with an ARD of 6/7/24 for Resident #38 revealed Section P Restraints was coded the resident uses side rails daily. An observation on 8/13/24 at 11:00 AM, of Resident #38's bed, revealed one-half (1/2) siderails to the head of the bed only. Interview with Licensed Practical Nurse #2 (LPN) on 8/14/24 at 10:35 AM, she stated that Resident #38 is not physically able to get out of bed without of assistance. She stated that the one-half (1/2) side rails on Resident 38's bed are used to enhance her mobility and do not restrain her. She stated that the facility is restraint free. Review of the Face Sheet revealed the facility admitted Resident #38 on 3/7/24 with a diagnosis of Dementia. In an interview with the Nurse Case Manager on 8/14/24 at 11:21 AM, she revealed that she found out yesterday 8/13/24 from the Nurse Consultant that the MDS department has been incorrectly coding section P of the MDS for restraints. She then stated that the previous Case Manager trained her to code all side rails as restraints on the MDS. She also confirmed that Section P of the MDS for restraints for Resident's #5, #18, #25, #33, and #38 were coded incorrectly, and the residents do not have restraints. Furthermore, she stated that the purpose of coding the MDS correctly is to provide an accurate reflection of the resident's specific care that each resident requires. In an interview with the Administrator on 8/14/24 at 11:30 AM, she revealed the facility has no restraints, and confirmed she was unaware that the resident MDS assessments were being coded incorrectly. In an interview with the RN/ MDS Assessment nurse on 8/14/24 at 11:51 AM, she revealed she was trained to code all side rails as restraints because the residents cannot physically remove side rails from the bed. She stated she knew they were not restraints, but that is the way she was trained. 47158

Based on observation, staff and resident interview, and record review the facility failed to ensure that a resident received incontinent care during a night shift for one (1) of five (5) residents reviewed. Resident #1. Findings Include: Record review of a typed statement by the Administrator dated 06/26/24 on Company Letterhead revealed, Clarksdale Nursing Center does not have a policy specific to how frequent ADL (Activities of Daily Living) rounds are made or incontinent care provided. On 06/26/24 at 7:40 AM, an observation and interview with Licensed Practical Nurse #1 (LPN) revealed her entering Resident #1's room and confirmed that his brief was soaked with urine and that he should have been changed during the Certified Nursing Assistant's (CNA) last rounds. State Agency (SA) observed Resident #1 telling LPN #1 that he had not been changed during the night and she stated to Resident #1, I'm sorry. I will get someone to change you now. LPN #1 revealed that leaving a resident wet for long periods could cause all kinds of problems including urinary tract infections, bed sores, and other skin issues. LPN #1 revealed that Resident #1 would get up to the bathroom himself if he was in his wheelchair but would not get up and go to the bathroom if he was in the bed. On 06/26/24 at 9:00 AM, an interview with CNA #1, revealed that the CNAs were supposed to make rounds on each resident every two (2) hours on day and night shifts, and change their brief if wet or soiled. She revealed that if they noticed a resident was wet between rounds, they were supposed to go ahead and change them and not wait until the scheduled time and stated, We can't control when someone pees. She revealed that the night shift normally made their last rounds and changed the residents' briefs or diapers before they clocked out at 7:00 AM. At 9:40 AM on 6/26/24, an interview with the Director of Nursing (DON), revealed she had preached to the staff about the need to make their rounds at least every 2 hours on day and night shifts, and to check on the residents, not just stick their heads in and look at them. The DON revealed that they trained all nursing staff on incontinence care, on rounding every 2 hours, and on changing residents who needed to be changed even if it was between their scheduled rounds. The DON revealed that Resident #1 should not have been left wet, that his assigned CNA should have changed him. Record review of Resident #1's Face Sheet revealed an admitted [DATE] with diagnoses that included Type II Diabetes and Hemiplegia following Cerebral Infarction. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/24, under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 11 which indicated that he had moderate cognitive deficits. Section H Urinary Continence revealed that he was frequently incontinent.

Based on observation, interview, facility policy review, and record review, the facility failed to develop and implement an elopement/wandering risk plan of care for Resident #1 who had worn a wander guard since 8/9/23. Resident #1 was one (1) of five (5) residents reviewed who wore a wander guard. Resident #1 was missing from the facility for approximately two (2) and a half (1/2) hours - three (3) and a half (1/2) hours prior to discovery. No facility staff saw the resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 9:30 PM when they received a call that Resident #1 was at a convenience store. It was also determined that Resident #1 was found at a convenience store approximately eight- tenths of a mile from the facility on a busy four (4) lane highway. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 9:50 PM on 01/30/24, after the convenience store employee called the facility to report that Resident #1 was at the convenience store unsupervised and needed to be picked up and taken back to the facility. The Survey Agency (SA) identified an Immediate Jeopardy (IJ) which began on 01/30/24 when Resident #1 eloped from the facility unsupervised and undetected by facility staff. IJ existed at: 42 CFR (s):483.21(b)(1)-Development/Implement Comprehensive Care Plan (F656) Scope and Severity J The situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for the likelihood of a serious injury, harm, impairment, or death. Based on the facility's implementation of corrective actions on 01/30/24 through 02/02/24, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 02/02/24, prior to the SA's entrance on 02/05/24. Findings include: Record review of the facility policy Care Plan Process with a revision date of 08/17 revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .The care plan is driven not only by identified resident issues and/or concerns but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents . Record review of the facility policy Elopement/Wandering -General Policy .with a review date of 01/23 revealed . 1.b. A resident determined to be at risk to wander or elope shall be identified on the resident's comprehensive plan of care . Record review of the care plans for Resident #1, who was identified on 8/9/23 as an elopement risk and had a wander guard placement, revealed that a care plan was not developed for the wander guard or risk for wandering/elopement. Record review of the Care Plan dated 1/30/2024 with a problem onset date of 08/09/2023 revealed a care plan had been developed on 01/30/24. Problem/Need Resident eloped from facility .Approaches .1/31/24 Check wander guard for correct placement to right ankle q (every) shift . In an interview with the Administrator (ADM) at 4:55 PM, on 02/05/24 revealed that she obtained a copy of the video from the facility surveillance camera and saw Resident #1 eloping from the facility. The ADM stated that Resident #1 had been identified as an elopement risk and had worn a wander guard ankle security bracelet since his admission in August 2023. The ADM stated that upon admission the Resident Representative (RR) of Resident #1 stated that Resident #1 had attempted to elope from his home on several occasions. At 7:45 PM on 01/30/23 the resident discovered the remote-control device that was lying on a table near the front door and used the device to open the door and exit the facility. Interview on 02/06/24 at 11:55 AM, with the care plan Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #3 revealed that she was one of the two care plan nurses that developed and revised care plans for residents. LPN #3 confirmed that there was no care plans developed for the wander guard or for elopement risk of Resident #1 prior to 01/30/24. LPN #3 stated that there was an order for the wander guard on 08/09/23 and that it should have been care planned. During an interview on 02/06/24 at 1:00 PM, with the Director of Nursing (DON) revealed that there should have been a care plan developed prior to 01/30/24 for Resident #1's risk of elopement and reasons for wearing a wander guard. Record review of the Electronic Medication Administration Record (EMAR) for January 2024 revealed that Resident #1 had a wander guard Check wander guard to right ankle function daily with an order and start date of 8/9/23. Elopement Risk Check wander guard placement to right ankle Q (every) shift with an order and start date of 8/9/23. The EMAR was documented with staff initials that wander guard checks were completed per order for the entire month of January 2024. Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, Cognitive Communication Deficit, Lack of Coordination, Dementia, and History of Falling. Immediate Actions: At 10:00 PM LPN #1 notified the ADM, the DON, the RR and the MD via telephone of the elopement of Resident #1. At 10:00 PM the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. Upon return to the facility LPN #1 assessed Resident #1 from head to toe and found no injuries or incidents. Beginning at 10:00 PM on 1/30/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning. On 01/30/24 at 10:30 PM, five (5) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 1/30/24. On 01/30/24 at 10:00 PM, the facility staff and ADM began officially investigating and obtaining statements of the elopement of Resident #1. On 01/30/24 at 10:30 PM, staff in-services were begun by the DON and ADM to include all staff on elopement protocols, wander guard checks, care plans, and abuse/neglect with no staff allowed to work until in-services were completed. On 01/30/24 at 10:30 PM, a QA meeting was held via telephone with the MD, DON, ADM, MDS/Care Plan Nurses times (x) 2, Social Worker, and QA/Infection Control Nurse were present. All members of the QA committee who were not present at the facility for the meeting attended via telephone. On 01/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was not functioning properly, and the alarm was not sounding. It was discovered that the malfunctioning alarm caused the alarm not to sound when Resident #1 exited the facility unsupervised and undetected. The vendor came to the facility on [DATE] and 02/02/24 and provided estimates for replacement of the entire wander guard system. The doors will be monitored by a staff member seated at the front door 24/7 until the wander guard system is functioning properly. On 01/31/24 at 2:57 PM the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. All corrective actions were completed on 02/02/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 02/02/24. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action Plan on 02/05/24-02/06/24: The SA validated through interviews and record reviews that at 10:00 PM the LPN #1 notified the ADM,DON, RR and the MD via telephone of the elopement of Resident #1. The SA validated through interviews and record reviews that at 10:00 PM the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. The SA validated through interviews and record reviews that upon return to the facility LPN #1 assessed Resident #1 from head to toe and found no injuries or incidents. The SA validated through observations, record reviews, and interviews that beginning at 10:00 PM on 1/30/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning. The SA validated through observations, record reviews and interviews that on 01/30/24 at 10:30 PM five (5) residents with risks of elopement were re-evaluated, care plans reviewed and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 1/30/24. The SA validated through record reviews and interviews that on 01/30/24 at 10:00 PM the facility and the ADM began officially investigating and obtaining statements of the elopement of Resident #1. The SA validated through interviews and record reviews that on 01/30/24 at 10:30 PM staff in-services were begun by the DON and the ADM to include all staff on elopement protocols, wander guard checks; care plans; and abuse/neglect with no staff allowed to work until in-services were completed. The SA validated through interviews and record reviews that on 01/30/24 at 10:30 PM a QA meeting was held via telephone with the MD. The DON, ADM MDS/Care Plan Nurses x 2, Social Worker, and QA/Infection Control Nurse were present. All other QA committee members who were not present in attendance at the facility attended the meeting via telephone The SA validated through interviews, and record reviews, and review of vendor estimates that on 01/31/24 the Maintenance Director staff checked the functioning of the wander guard alarm/security system and found that the alarm was not functioning properly, and the alarm was not sounding. It was discovered that the malfunctioning alarm caused the alarm not to sound when Resident #1 exited the facility unsupervised and undetected. The vendor came to the facility on [DATE] and 02/02/24 and provided estimates for replacement of the entire wander guard system. The doors will be monitored by a staff member seated at the front door 24/7 until the wander guard system is functioning properly. The SA validated through interviews and record reviews that on 01/31/24 at 2:57 PM the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 02/02/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 02/02/24.

Based on staff interviews, family interview, observations, facility security camera video review, record reviews, and facility policy review the facility failed to ensure Resident #1 had adequate supervision to prevent an elopement from the facility on 01/30/24 and failed to ensure the wander guard system was properly functioning for one (1) of five (5) residents who were elopement risk and wore wander guards. Resident #1. Resident #1 was missing from the facility for approximately two and a half (2 1/2) hours to three (3) and a half (1/2) hours prior to discovery. No facility staff saw the resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 9:30 PM when they received a call that Resident #1 was at a convenience store. Resident #1 was found at a convenience store approximately eight-tenths of a mile from the facility on a busy four lane. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 9:50 PM on 01/30/24 after the convenience store employee called the facility to report that Resident #1 was at the convenience store unsupervised and needed to be picked up and taken back to the facility. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 01/30/24 when Resident #1 eloped from the facility unsupervised and undetected by facility staff. The facility's failure to provide supervision placed Resident #1 and other residents at risk for wandering and elopement, at risk in a situation which was likely to cause serious injury, harm, impairment, or death. IJ and SQC existed at: 42 CFR 483.25(d)(1)(2) Accidents -F689, Scope and Severity J Based on the facility's implementation of corrective actions on 01/30/24 through 02/02/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 02/02/24, prior to the SA's entrance on 02/05/24. Findings include: Record review of the facility policy Elopement -General Policy (F-689) with a review date of 01/23, revealed Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. Record review of the facility policy and procedure Elopement/Wandering-Security System (F 689) with a review date of 01/23, revealed Policy: To provide a safety system to ensure wandering residents/elopement risk residents leave the premises without necessary supervision. To implement protective measures to help guard against wandering/eloping from the facility . Interview with the Administrator (ADM) at 4:55 PM, on 02/05/24 revealed that she obtained a copy of the video from the facility surveillance camera and saw Resident #1 eloping from the facility. The ADM stated that Resident #1 had been identified as an elopement risk and had worn a wander guard ankle security bracelet since his admission in August 2023. The ADM stated that upon admission the family of Resident #1 had stated that he had attempted to elope from his home on several occasions and had suffered several falls and was at risk of falling. The ADM stated that the video revealed the wander guard had not sounded when Resident #1 eloped from the facility on 01/30/24. On 01/30/24 at approximately 7:00 PM, Resident #1 came to the front of the building at the front door and tried numerous times to get the front door to open to no avail. The ADM stated that Resident #1 attempted to open the front door for approximately 45 minutes from 7:00 PM until 7:45 PM. At 7:45 PM on 01/30/23 the resident discovered the remote-control device that opens the front door lying on top of a table near the front door. The ADM stated that someone left the remote control unattended and out on top of a table at the front door. Resident #1 used the remote-control device to open the door and let himself out of the facility. The ADM stated that no staff at the facility was aware that Resident #1 had left the building until approximately 9:20 PM when a clerk at a convenience store called the facility and told the nurse that Resident #1 was at the store asking for food and drinking coffee. The nurse asked a Certified Nursing Assistant (CNA) to go to the store and get Resident #1 and bring him back to the facility. The CNA went to the store and got Resident #1 and brought him back to the facility without incident. At approximately 9:50 PM, when the CNA entered the building with Resident #1 it was discovered that the wander guard worn by Resident #1 did not sound the alarm at the front door. Resident #1 and all residents with wander guards were assessed. Resident #1 was placed on one-to-one close observation, and he was checked every 15 minutes and then placed on hourly checks. Resident #1, as well as the other residents who wear wander guards, will remain on hourly visual checks until the front door wander guard system is replaced. The ADM stated that upon checking the wander guard system it was discovered that the system would not sound properly. The system would sound randomly and at times would not sound at all or it would sound for a short time and stop. The company came out to check the system and they also found that the system was not properly sounding at the front door. The wander guard system was properly sounding with the unit hand-held checking/monitoring system but would not properly sound at the front door when stepping on the floor mat. The ADM stated that she had obtained bids for repairs of the wander guard system and that the system would have to be completely replaced with a new system. Until the company can get the new system installed and properly working Resident #1 will remain on hourly visual checks as well as all of the other residents with wander guards. The ADM confirmed that the facility had 5 residents including Resident #1 that wore wander guard security systems. The ADM stated that there will be a staff member monitoring the front door 24/7 (24 hours a day and 7 days a week) at the facility until the wander guard system is replaced. The ADM stated that Resident #1 was not injured as a result of his elopement. The ADM stated that the weather on 01/30/24 at 7:00 PM was approximately 52 degrees Fahrenheit and there was no rain in the forecast. An interview on 02/05/24 at 5:15 PM, with CNA #1 revealed that she had worked the 7:00 AM to 11:00 PM shift on 01/30/24 and she was not assigned to the hall that Resident #1 was living on. CNA #1 stated that she had observed Resident #1 in the hallway near the vending machines at approximately 6:00 PM and she verbally directed Resident #1 to go back to his room. CNA #1 never saw Resident #1 again after 6:00 PM on 01/30/24 inside of the facility. CNA #1 stated that she was familiar with Resident #1 and had been assigned to work directly with him in the past. CNA #1 stated that Resident #1 wore a wander guard on his ankle and was known to wander. She stated that Resident #1 had confusion at times but was able to ambulate independently. CNA #1 stated that Resident #1 was identified by the facility to be at risk for elopement and for being at risk for falling. CNA #1 stated that at approximately 9:30 PM the charge nurse Licensed Practical Nurse (LPN) #2 had asked her to go to the convenience store and pick up Resident #1 and bring him back to the facility. CNA #1 stated that it was very dark at 9:30 PM and the weather was a little windy and the temperature was cool but not freezing or extremely cold. She stated that Resident #1 had left the facility without the knowledge of the facility staff, and he had walked to the convenience store from the facility. CNA #1 stated that she went in her personal vehicle to the convenience store which was approximately 1 mile from the facility. When she arrived at the convenience store, Resident #1 was there drinking coffee with the store clerk wearing dark gym pants, brown house slippers, and a long sleeve shirt. CNA #1 stated that Resident #1 did not have on a jacket or coat and he did not have on street walking shoes. CNA #1 stated that upon returning to the facility at approximately 9:50 PM when Resident #1 went through the front door the wander guard system did not alarm. She stated that she reported the wander guard system not sounding to the nurse and they tested the alarm at the front door, and it would not sound with Resident #1's wander guard bracelet. CNA #1 stated that the facility ADM and the Director of Nursing (DON) came to the facility that night and they began the staff in-services and assessments of the residents. CNA #1 stated that Resident #1 was very tired when he returned to the facility but was not harmed or injured and went to his room and went to bed immediately. Interview on 02/05/24 at 5:30 PM, with LPN #1 revealed that she had answered the telephone at approximately 9:20 PM on 01/30/24 when a lady identified herself as the clerk at the convenience store. The clerk told LPN #1 that Resident #1 was drinking coffee at the store and needed to be picked up and taken back to the facility. The clerk told LPN #1 that Resident #1 would only reveal to her his name but would not give her any other information. The Clerk gave Resident #1 coffee to drink. The clerk told LPN #1 that Resident #1 had showed up at the store at approximately 8:00 PM on 01/30/24 and had been standing around outside and inside the store for a good long while and had gone outside and was talking to a man putting gas in a vehicle. The clerk stated that Resident #1 presented himself as a little confused and unsure of his whereabouts. The clerk asked if the facility could come and pick up the resident. CNA #1 left the facility and went to the convenience store and picked up Resident #1 and brought him back to the facility at approximately 9:50 PM on 01/30/24. LPN #1 conducted a head-to-toe assessment of Resident #1 and found him free of injury. Resident #1 went to sleep shortly after he was brought back to the facility. LPN #1 stated that no one at the facility had knowledge that Resident #1 had left the facility until the clerk at the convenience store called the facility. When Resident #1 returned to the facility his wander guard did not sound at the front door. LPN #1 stated that the facility began corrective action and in-services on 1/30/24 at approximately 9:50 PM. Observation on 02/05/24 at 6:00 PM, revealed the facility was approximately eight- tenths of a mile from the convenience store where Resident #1 had been located. The streets were dimly lit and there were no traffic lights between the facility and the convenience store. In order for Resident #1 to get to the convenience store where he was located, he would have had to cross a 4- lane intersection on the highway. Record review of the Departmental Notes dated 01/31/24 at 12:09 AM and signed by Licensed Practical Nurse (LPN) #1 revealed: @ (At) 07:07 PM writer last seen resident and gave resident medication. Resident accepted and tolerated medication well. As the resident was taking medication the resident stated, do you know where the exit is? Writer stated (name of Resident #1) you aren't allowed to go outside by yourself. You would need someone to go outside with you but how about we sit here in your room and tomorrow we'll see if a staff member can take you outside. Writer checked to see if the wander guard was in place. Wander guard was in place and intact on the right lower extremity around ankle. @ 09:30 PM A lady called and stated I have male in the store at double quick on state street, he says his name is (name of Resident #1). Do you all have a patient by that name. Writer responded, yes and someone will be up there to verify that it is him and lady on phone stated, We have him up here in the store Staff member went to store to pick the resident up. @ 09:50 PM Once resident ambulated into the building with one female employee. Writer completed a head-to-toe assessment with no injury, bruising, or new lesions noted. Resident was confused and alert and oriented to name only .Writer checked wander guard to see if it would go off when close to the door, it did not . Observation and interview on 2/06/24 at 12:25 PM, revealed Resident #1 was sitting alone in his room watching television. Resident #1 had no recall of his walking to the convenience store on 01/30/24. Observation and interview on 02/06/24 at 12:30 PM, with LPN #4 revealed that she was the first shift nurse and was the nurse for Resident #1 today. LPN #4 stated that the nurses tested the functioning of wander guards daily with a small square box that they placed next to the wander guard on the residents. She stated that the facility had 5 residents currently wearing wander guards. LPN #4 demonstrated how to test the wander guards with the device. The small box device was working properly to test the wander guards. LPN #4 stated that she had no knowledge of Resident #1 demonstrating exit seeking behaviors prior to 01/30/24. LPN #4 stated that Resident #1 had worn a wander guard since shortly after his admission to the facility. Observation on 02/06/24 at 1:20 PM, of the facility's video from the security cameras dated 01/30/24 beginning at 7:00 PM through 7:45 PM revealed a full view of Resident #1 seeking a way to exit the building for over 45 minutes. Resident #1 was seen at the front door standing on the black mat, staff was not present, and no staff came to the front door to summon Resident #1 away from the front door. Resident #1 was seen attempting to open the front door that was locked. After numerous attempts to open the door Resident #1 was seen on the video discovering a remote-control device lying on a tabletop next to the front door. Resident #1 made a few attempts to open the door with the remote control to no avail and then at approximately 7:45 PM Resident #1 opened the front door and left out of the facility. No staff were observed pursuing Resident #1. The video revealed a clock on the wall next to the front door with times ranging from 6:00 PM until 6:45 PM in which Resident #1 made exit attempts. The clock on the wall near the front door revealed that Resident #1 left the facility at 6:45 PM. The video revealed that Resident #1 was wearing long dark sweatpants and a long sleeve dark t-shirt. Resident #1 had on brown house slippers, one white sock, one dark sock, and a cap on his head. Interview on 02/06/24 at 1:45 PM, with the Maintenance Director confirmed that the clock on the wall next to the front door was displaying the correct time on 01/30/24. The Maintenance Director stated that he had to test the wander guard system at the front door on 01/30/24 and 01/31/24 and that he found that the system was not functioning properly. He stated that the facility had to call outside vendors to come and test the system and to give estimates for repairs. He stated that the wander guard system had to be totally replaced and that until the system was replaced there would be staff stationed at the front door 24/7 until the wander guard system was fully functioning. The Maintenance Director stated that he had calculated the convenience store where Resident #1 was located was approximately eight- tenths of a mile from the facility. Observed the wander guard system was not sounding when stepping on the black mat near the front door or when outside of the building. Interview on 02/06/24 at 2:00 PM, with LPN #2 revealed that she had been told by LPN #1 that Resident #1 had eloped and was at a convenience store. LPN #2 asked CNA #1 to go to the convenience store and pick up Resident #1 and bring him back to the facility. LPN #2 stated that she saw Resident #1 at the front door at approximately 6:20 PM- 6:30 PM on 01/30/24 and that she redirected Resident #1 to go to his room away from the front door. She stated that she did not see Resident #1 again until he was returned to the facility at approximately 9:50 PM on 01/30/24. Observation on 02/06/24 at 2:30 PM, on the route to the convenience store where Resident #1 was located revealed there were 12 street intersections between the facility and the convenience store with no traffic lights. There were three (3) intersections with four way stop signs. The mileage between the facility and the convenience store was measured at eight-tenths of a mile. The convenience store was located across a four-lane highway. The streets contained a school, a liquor and tobacco store, and numerous residential houses and apartments and commercial properties. Interview by telephone on 02/06/24 at 4:20 PM, with CNA #3, revealed on 1/30/24 she was assigned as Resident #1's CNA and was responsible for his care during the evening shift on 01/30/24. She stated that she had been assigned to Resident #1 numerous times since his admission and that she was very familiar with Resident #1. She stated that she last saw Resident #1 at approximately 7:00 PM on 01/30 24 standing near the drink machine but did not think anything of his standing there and had not talked to Resident #1. She stated that she had no knowledge that Resident #1 had left the facility until he was returned at approximately 9:50 PM. Record review of the Electronic Medication Administration Record (EMAR) for January 2024 revealed Check wander guard to right ankle function daily with an order and start date of 8/9/23. Elopement Risk Check wander guard placement to right ankle Q (every) shift with an order and start date of 8/9/23. The EMAR was documented with staff initials that wander guard checks were completed per order for the entire month of January 2024. Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, Cognitive Communication Deficit, Lack of Coordination, Dementia, and History of Falling. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of of 11/14/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 for which indicated moderate cognitive impairment. The facility implemented that following Corrective Action Plan prior to the SA entering the building on 02/05/24: On 01/30/24 at approximately 9:50 PM, Resident #1 was assisted back to the facility via facility staff (CNA #1's) personal vehicle. Resident #1 was thoroughly assessed head to toe by LPN #1 and no adverse injuries/incidents were found. LPN #1 contacted the Resident Representative (RR), the Medical Director (MD), the facility Administrator, the facility DON, and placed Resident #1 on one-to-one close observation by facility staff. The elopement risk assessment was updated for Resident #1 and the care plan was revised. The elopement book kept at the nursing station was reviewed and updated. Facility staff conducted room to room audits of all 55 residents in the building to ensure safety. The facility conducted a Quality Assurance (QA) meeting with the MD in attendance via telephone on 01/30/24 at 10:30 PM. An elopement drill was conducted on 1/30/24 and 1/31/24 on all three (3) shifts. All residents with wander guard bracelets were checked for functionality and positioning. The ADM and the DON began in-services on 01/30/24 of all staff on elopement protocol, wander guard monitoring, care plans, and Abuse and Neglect. All doors and windows were checked for proper functioning and operation. The ADM began an investigation to determine how Resident #1 eloped. The ADM called the incident in to the State Agency 01/31/2024 at 2:57 PM. Resident #1 was placed on 15-minute checks for 24 hours and remained on hourly checks by staff until the wander guard system would be replaced by an outside vendor. The remote control to the front door lock was obtained and kept by the ADM and not left at the front door unattended. The facility obtained estimates to replace the malfunctioning wander guard system and alarms. There was a staff member placed at the front door to monitor the entrance and exits of the building and the staff would remain at the front door 24/7 (24 hours a day and 7 days a week) until the new wander guard alarm system is installed. No staff was allowed to work until they were in-serviced on elopements, Abuse/Neglect, care plans, and monitoring of wander guard systems. Immediate Actions: On 01/30/24 at 10:00 PM LPN #1 notified the ADM, the DON, the RR and the MD via telephone of the elopement of Resident #1. On 01/30/24 at 10:00 PM the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. Upon return to the facility on [DATE], LPN #1 assessed Resident #1 from head to toe and found no injuries or incidents. On 01/30/24 beginning at 10:00 PM all doors were monitored by staff 24/7 until the wander guard system was found fully functioning. On 01/30/24 at 10:30 PM, five (5) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 1/30/24. On 01/30/24 at 10:00 PM, the facility staff and ADM began officially investigating and obtaining statements of the elopement of Resident #1. On 01/30/24 at 10:30 PM, staff in-services were begun by the DON and ADM to include all staff on elopement protocols, wander guard checks, care plans, and abuse/neglect with no staff allowed to work until in-services were completed. On 01/30/24 at 10:30 PM, a QA meeting was held via telephone with the MD, DON, ADM, MDS/Care Plan Nurses times (x) 2, Social Worker, and QA/Infection Control Nurse were present. All members of the QA committee who were not present at the facility for the meeting attended via telephone. On 01/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was not functioning properly, and the alarm was not sounding. It was discovered that the malfunctioning alarm caused the alarm not to sound when Resident #1 exited the facility unsupervised and undetected. The vendor came to the facility on [DATE] and 02/02/24 and provided estimates for replacement of the entire wander guard system. The doors will be monitored by a staff member seated at the front door 24/7 until the wander guard system is functioning properly. On 01/31/24 at 2:57 PM the ADM contacted the State Agency (SA) and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. All corrective actions were completed on 02/02/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 02/02/24. The State Agency (SA) validated the facility's Past Non-Compliance (PNC) Corrective Action Plan on 02/05/24 through 02/06/24: The SA validated through interviews and record reviews that at 10:00 PM the LPN #1 notified the ADM,DON, RR and the MD via telephone of the elopement of Resident #1. The SA validated through interviews and record reviews that at 10:00 PM the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. The SA validated through interviews and record reviews that upon return to the facility LPN #1 assessed Resident #1 from head to toe and found no injuries or incidents. The SA validated through observations, record reviews, and interviews that beginning at 10:00 PM on 1/30/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning. The SA validated through observations, record reviews and interviews that on 01/30/24 at 10:30 PM five (5) residents with risks of elopement were re-evaluated, care plans reviewed and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 1/30/24. The SA validated through record reviews and interviews that on 01/30/24 at 10:00 PM the facility and the ADM began officially investigating and obtaining statements of the elopement of Resident #1. The SA validated through interviews and record reviews that on 01/30/24 at 10:30 PM staff in-services were begun by the DON and the ADM to include all staff on elopement protocols, wander guard checks; care plans; and abuse/neglect with no staff allowed to work until in-services were completed. The SA validated through interviews and record reviews that on 01/30/24 at 10:30 PM a QA meeting was held via telephone with the MD. The DON, ADM MDS/Care Plan Nurses x 2, Social Worker, and QA/Infection Control Nurse were present. All other QA committee members who were not present in attendance at the facility attended the meeting via telephone The SA validated through interviews, and record reviews, and review of vendor estimates that on 01/31/24 the Maintenance Director staff checked the functioning of the wander guard alarm/security system and found that the alarm was not functioning properly, and the alarm was not sounding. It was discovered that the malfunctioning alarm caused the alarm not to sound when Resident #1 exited the facility unsupervised and undetected. The vendor came to the facility on [DATE] and 02/02/24 and provided estimates for replacement of the entire wander guard system. The doors will be monitored by a staff member seated at the front door 24/7 until the wander guard system is functioning properly. The SA validated through interviews and record reviews that on 01/31/24 at 2:57 PM the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 02/02/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 02/02/24.

Based on resident observation and staff interviews the facility failed to promote dignity related to a catheter bag stored without a privacy bag for one (1) of two (2) residents with urinary catheters. Resident # 13. Findings include: Record review of the statement typed on facility letterhead signed by the Administrator and dated April 5, 2023, revealed, .We do not have a policy on the use of a privacy catheter bag. An observation on 4/04/23 at 10:52 AM , revealed a catheter bag hanging on the left side of Resident #13's bed with no privacy bag and visible to the SA and any visitors walking in the hallway. An observation and interview on 4/05/23 at 2:20 PM, Certified Nurse Assistant (CNA) # 3 confirmed the catheter bag was hanging on the right side of the bed with no privacy bag and there should be one and confirmed that it could be embarrassing for a resident if their bag of urine was visible for everyone to see. An interview with Licensed Practical Nurse (LPN) #1 on 4/4/23 at 2:25 PM, she confirmed all residents with catheters should have a privacy bag and revealed it is a dignity issue. An interview with the Director of Nursing (DON) on 4/5/23 at 8:00 AM, revealed she was made aware by staff that Resident #13 did not have a privacy bag for his catheter and confirmed all residents with catheters should have one because they have the right to dignity. Record review of the April 2023 Physician Orders revealed an order dated 1/27/23, revealed Change 18F (French) Coude catheter every month. Record review of the Face Sheet revealed that the facility admitted Resident #13 to the on 8/16/19 with diagnoses of Malignant neoplasm of the prostate, Benign prostatic hyperplasia with lower urinary tract, Chronic kidney disease and Alzheimer's disease.

Based on record review, resident and staff interviews and facility policy review the facility failed to honor a resident's choice for showers for one (1) of 20 residents reviewed. Resident #30 Findings include: Record review of the facility policy titled Bathing, with a revision date of 10/17, Processes 1. Inquire with the resident concerning bathing preferences (e.g., time of day, type of bathing-shower, bed bath, etc.) 2. Offer the resident choice in their bathing routine . During an interview with Resident #30 on 4/04/23 at 11:43 AM, she stated that she was unsure of the last time she had a shower. Resident #30 stated that she gets a 'wash up' but no shower and that she would like to have a shower. On 4/04/23 at 4:35 PM, an interview with the Director of Nursing (DON) revealed that before COVID the shower schedule was Monday, Wednesday, and Friday for A beds and Tuesday, Thursday, and Saturday for B beds. She verified that they haven't gotten back to the shower schedule since COVID started. She revealed if a resident wants a shower the aide will give them a shower, they just need to ask. She revealed she thinks a shower, or a whirlpool bath would make the residents feel better, get their circulation going, it's just better for the residents and they just need to get back to giving the showers. During an interview with Resident #30 on 4/5/23 at 8:00 AM, revealed she told her Certified Nursing Assistants (CNAs) that she wants a shower, and they respond, 'we'll see', but do not come back and give her a shower. In an interview on 4/5/2023 at 9:15 AM with CNA # 1, revealed that she is usually assigned to Resident # 30 during the day shift and sometimes on the evening shift. CNA # 1 stated that Resident # 30 likes to take her showers during the evening shift before she goes to bed. CNA # 1 stated that they did have a shower schedule in the past, before COVID, but they did not have a shower schedule any more. She stated that if Resident # 30 asked her for a shower on the evening shift, she would give her one, but that she could not remember the last time she had given Resident # 30 a shower. In an interview on 4/5/2023 at 3:10 PM with CNA # 2, she stated that showers are not given on the evening shift. She stated that she had not given any showers when working the evening shift. An interview with the DON and Minimum Data Set (MDS) Coordinator on 4/6/23 at 8:45 AM, they verified that since the resident indicated on the MDS that choosing what type of bath she wanted was very important that they should have asked the resident what she wanted. They both confirmed that not taking the residents choices into consideration could possibly make the resident feel like her choices were not important. The DON confirmed that the resident had not received any showers. Record review of the facility electronic record titled Resident Care Details, Question: Type of Bath revealed that from 3/1/23 through 4/5/2023 Resident # 30 received a complete bed bath, sponge bath or partial bed bath, but no showers. A record review of the MDS, with a Assessment Reference Date (ARD) of 3/10/2023, revealed, section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. A record review of the MDS, with an ARD of 12/12/2022, revealed, section F, Preferences for Customary Routine and Activities, Interview for Daily Preferences, C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Is coded 1, indicating that it is Very important. A record review of the Face Sheet revealed Resident # 30 was admitted on [DATE] with diagnosis of Malignant neoplasm of parathyroid gland, Muscle Weakness, Bilateral primary osteoarthritis of hip and knee.

Based on staff interview, record review and facility policy review the facility failed to submit a Change in Status referral for a Level II Pre-Admission Screening and Resident Review (PASRR) related to a new diagnosis of Schizophrenia and after a significant change from a psychiatric in-patient stay for one (1) of five (5) residents reviewed. Resident # 31. Findings include: A record review of the facility's policy titled Pre-Admission Screening PAS/PASRR (MS Only), revised 10/18, revealed A Change in status referral for Level II Resident Review Evaluations is Required for Individuals who have not been previously identified by PASRR to have Mental illness . A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental diagnosis as defined under 42 CFR 483.100 .A resident is transferred, admitted to a Nursing Facility (NF) following an impatient psychiatric stay or equally intensive treatment . A record review of Resident #31's Diagnosis list revealed a new diagnosis of Schizophrenia on 3/31/22 and a review of the Physician Psychiatric Progress Note from Provider #1 dated 3/31/22, revealed a diagnosis of Schizophrenia. A record review of a History and Physical dated 9/13/22 from Provider #1, revealed Resident #31 was admitted to the Senior Care Unit for behavioral disturbance, hallucinations, and paranoia. Resident # 31 was discharged back to the facility on [DATE] with a diagnosis of Schizophrenia, paranoid type and which revealed a new medication of Haldol 1 mg (milligram) by mouth daily and continued medications of Seroquel 400 mg daily at bedtime and Lorazepam 1 mg twice daily as needed. A record review revealed a Significant Change Assessment completed on 10/03/23 after the return from inpatient therapy at Senior Care. An interview with the Minimum Data Set (MDS) Coordinator on 4/5/23 at 9:00 AM, she revealed she receives a copy of every progress note from the psych provider and adds the new diagnosis to the resident's diagnosis list. She also revealed MDS is notified of hospital returns and MDS opens the assessments. An interview with MDS Coordinator on 4/05/23 at 02:00 PM, also revealed she was under the understanding that a Change of Status referral for Level II PASRR only had to be completed if a resident was admitted to hospital for psychiatric services and received a new diagnosis and medication for Major Mental illness and did not have to be completed if there is a diagnosis of Dementia and confirmed there was no Change in Status Referral for Level II for the new diagnosis of schizophrenia obtained in March 2022. An interview with the Assessment Nurse on 4/05/23 at 2:15 PM, she revealed she completes the PASRR form also and thought it was only completed on admission and was unaware of completing the Change in Status Referral for Level II. The Assessment nurse revealed she was unaware of what the facility policy for PASRR reads. An interview with the Administrator revealed on 4/05/23 at 2:30 PM, she revealed she was aware that a Change in Status Referral had to be completed but thought it was only when a resident went out for psychiatric treatment and returned with a new diagnosis and new medication. She confirmed if the PASRR Level II change of status referral is not completed the resident could possibly not get the care or services they may need. An interview with the MDS Coordinator on 4/05/23 at 2:48 PM she revealed after reviewing the facility policy she understood she should have submitted a Change in Status Referral for a Level II PASRR when Resident # 31 got the new diagnosis of Schizophrenia and after the Resident returned from inpatient at Senior Care and a Significant Change Assessment was completed. She revealed the reason of the Level II PASRR Change in Status Referral was to receive any recommendations on proper care and treatment for her mental illness and confirmed by not submitting it Resident # 31 may have possibly had increased behaviors from not receiving the proper care she needed. MDS Coordinator also confirmed there have been no other PASRR's or Change in Status Referral completed for Resident # 31 since admission. An interview with the Director of Nursing (DON) on 4/05/23 at 3:16 PM, she revealed the purpose of the PASRR was to determine the special needs for each individual resident's mental illness and to identify if a resident is appropriate for nursing home placement and if not completed it is possible a resident may not receive the individualized care they need. An interview with the Administrator on 04/06/23 at 8:52 AM, she confirmed a Change in Status Referral for a Level II should have been completed after Resident # 31 obtained the new diagnosis of Schizophrenia and after she returned from Senior Care. Record review of the Face Sheet revealed that the facility admitted Resident # 31 to the on 1/20/22 with diagnoses of Hallucinations unspecified, Major depressive disorder, Unspecified psychosis not due to a substance or physiological condition, Unspecified dementia with behavioral disturbance, and Paranoid personality disorder.

Based on staff interview, record review and policy review the facility failed to accurately complete a Pre-admission Screening and Resident Review (PASRR) and failed to identify a mental disorder resulting in no Level II referral for evaluation for one (1) of five (5) residents reviewed. Resident # 31. Findings include: A record review of the facility's policy titled Pre-Admission Screening PAS/PASRR (MS Only), revised 10/18, revealed Level II PASRR- When a Level 1 screening on a PAS indicates possible Mental Illness or Intellectual Disability and related conditions (RC) the DOM will notify Ascend to review the case .The Level II evaluation must be completed prior to admission. A record review of the PASRR dated 1/20/23 for Resident #31, revealed diagnosis of Schizophrenia/other psychosis marked under active medical conditions. Under Level II Referral Criteria NO was answered to the following questions: Does this person have a history of cognitive behavior or behavior functions that indicate need for MR evaluation? Person has a diagnosis of major mental illness? Person takes, or has a history of taking, psychotropic medications? An interview with the Minimum Data Set (MDS) Coordinator on 4/5/23 at 9:00 AM, she revealed prior to admission she completes a PASRR on all residents to screen for possible mental illness diagnosis that may need a Level II referral. A record review and interview with the MDS Coordinator on 4/05/23 at 02:00 PM, revealed she completed the PASRR on 1/20/22 and review of the PASRR with the State Agency (SA) confirmed it was coded incorrectly resulting in no referral for a Level II PASRR. The MDS Coordinator revealed she marked NO to questions under Level II referral criteria when the answer should have been yes related to Diagnosis of Psychosis. The MDS Coordinator revealed when she did the PASSR she was not aware of the psych medications. She also confirmed she completed the Admission Assessment and should have seen the diagnoses and medications then and completed a new PASRR with referral for a level II. The MDS Coordinator confirmed there were no other PASRR's submitted other than the one completed on 1/20/22. A record review of the Admission Assessment for Resident #31 dated 1/27/22, revealed under section I Active Diagnoses, Psychotic Disorder other than schizophrenia, Paranoid Personality disorder, and unspecified psychosis not due to a substance or physiological condition was coded. A record review of Resident # 31's Diagnosis list with onset date of 1/20/22 the day of admission, revealed Hallucinations unspecified, Major depressive disorder, Unspecified psychosis not due to a substance or physiological condition, Unspecified dementia with behavioral disturbance, and Paranoid personality disorder. A record review of the History and Physical dated 1/14/23 from Provider #1, revealed under impressions: Psychosis, not otherwise specified, behavioral and psychological symptoms of dementia. Under medications Haldol 0.5 mg (milligrams) twice daily and Seroquel 25 mg twice daily. An interview with the MDS Coordinator on 4/05/23 at 2:48 PM, she revealed the reason for the Level II PASRR referral was to receive any recommendations on proper care and treatment for her mental illness and confirmed by not submitting it Resident # 31 could potentially have increased behaviors from not receiving the proper care she needed. An interview with the Director of Nursing (DON) on 4/05/23 at 3:16 PM, revealed the purpose of the PASSR was to determine the special needs for each individual resident's mental illness and to identify if a resident is appropriate for nursing home placement and if not completed it is possible a resident may not receive the individualized care they need. An interview with the Administrator on 4/06/23 at 8:52 AM, confirmed on admission Resident #31 should have had a PASSR with level II referral. Record review of the Face Sheet revealed that the facility admitted Resident # 31 to the on 1/20/22 with diagnoses of Hallucinations unspecified, Major depressive disorder, Unspecified psychosis not due to a substance or physiological condition, Unspecified dementia with behavioral disturbance, and Paranoid personality disorder.

Based on resident and staff interview, and record review and the facility policy review the facility failed to develop and implement care plans for residents requiring diabetic nail care and residents who preferred showers for three (3) of 20 residents reviewed. Resident #16, #30 and #42. Findings include: Record review of the facility policy titled Care Plan Process with a revision date of 08/17, Page 1, Regulations require facilities to complete, at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine .)The result of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .Page 3 Under , When implemented properly . Consider each resident as a whole, with unique characteristics and strengths that affect his or her capacity for function; Identify areas of concerns that may warrant interventions; Develop, to the extent possible, interventions .,in the context of the resident's condition, choices, and preferences for interventions . Resident #16 On 04/04/23 at 10:16 AM, observed Resident #16 lying in bed, fingernails were long and jagged, approximately. one-half inch past the tips of fingers on both hands, there was a brown substance under each fingernail. LPN #2 confirmed during an interview on 04/04/23 at 02:25 PM, the Comprehensive care plan for Resident #16 under his diabetic nail care was not being followed and it should have been. She revealed the care plan is developed so we the staff know exactly how to take care of the resident. An interview on 04/05/23 at 03:35 PM, the Minimum Data Set (MDS) Assessment Nurse confirmed that Resident #16's care plan for Diabetic nail care weekly; keeping his fingernails clean and trimmed was not being followed and it should have been. A record review of Resident #16's Comprehensive Care Plan with a Problem onset date of 11/09/2017 revealed, Resident has a DX of Diabetes Mellitus (DM) . Approaches . Diabetic Nail care weekly; Keep fingernails clean and trimmed. Record review of the Electronic Administration Record (EMAR) revealed Diabetic Nail Care Weekly: Keep Fingernails clean and trimmed. Order date of 11/09/17. There was no documentation for nail care completion for March and April 2023. An interview on 04/05/23 at 03:35 PM, the MDS Assessment Nurse confirmed that Resident #16's care plan for Diabetic nail care weekly; keeping his fingernails clean and trimmed was not being followed and it should have been. Resident #30 A record review of Resident # 30's Care plan revealed a problem onset date of 10/14/2019 revealed, Resident needs assist with ADL's D/T (due to) a decline in mobility R/T (related to) OA (Osteoarthritis)bilateral knees. The goal revealed the resident will be assisted with ADLS (Activities of Daily Living) while promoting max level of independence through next review-3/12/23. Review of the approaches revealed no approaches related to bathing or residents preference for showers. A record review of the MDS with a Assessment Reference Date (ARD) of 12/12/2022, revealed, section F, Preferences for Customary Routine and Activities, Interview for Daily Preferences, C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Is coded 1, indicating that it is Very important. In an interview with Resident # 30 on 4/04/23 at 11:43 AM, she stated that she was unsure of the last time she had a shower. Resident #30 stated that she gets a 'wash up' but no shower and that she would like to have a shower. An interview with the Director of Nursing (DON) and the MDS Coordinator on 4/6/23 at 8:45 AM they verified that since the resident indicated on the MDS that choosing what type of bath she wanted was very important and that they should have asked the resident what she wanted and indicated her choice on her care plan. They verified that the residents choice was not indicated on her care plan , but it should be and that not taking the residents choices into consideration could possibly make the resident feel like her choices were not important. A record review of the MDS, with an ARD of 3/10/2023. Section C, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. A record review of the Face Sheet revealed Resident # 30 was admitted on [DATE] with diagnoses that included Malignant neoplasm of parathyroid gland and Bilateral primary osteoarthritis of hip and knee . Resident #42 On 04/04/23 at 10:22 AM, during an interview and observation revealed Resident #42 sitting in his wheelchair, fingernails were long and jagged approximately. one-half inch past the fingertips, and a brown substance under the nails on both hands. Resident #42 revealed they were too long and he would like them to be cut. He revealed, It's been a while since they were cut and I don't like them this long. In an interview on 04/04/23 at 02:35 PM, the Registered Nurse (RN) Supervisor revealed she and the Treatment Nurse do the nails of the diabetics and confirmed that there was no nail care plan for Resident #42 and there should have been. An interview on 04/05/23 at 03:35 PM, the MDS Assessment Nurse confirmed that Resident #42's care plan for keeping his fingernails clean and trimmed was not being followed and Resident #42's care plan did not specify diabetic nail care and it should have. An interview on 04/05/23 at 3:55 PM, the MDS Coordinator revealed the plan of care for Resident #14, Resident #16, and Resident #42 should have been developed more individualized to each of the Residents' needs. She revealed as the care plans are written it just reflects that the Residents are to receive weekly nail care and PRN (as needed) but it needs to be a specific day so it will alert the nurse and they will need to sign off that the nail care has been done. She revealed the care plans don't have a measurable timeframe and they should. A record review of Resident #42's Comprehensive Care Plan with a Problem onset date of 11/20/2020 revealed, Resident is dependent on staff for dressing, grooming, and bathing. Approaches . Nail care weekly. Check condition and clean PRN. 47158

Based on facility policy review, observation, staff interviews, and record review the facility failed to provide proper position a resident, in her wheelchair, who required feeding assistance for one (1) of 13 residents observed during the lunch dining observation. Resident # 46. Resident #46 Review of the facility policy titled, Feeding the Dependent Resident, with a latest revision date of 10/17, revealed Purpose: To ensure adequate nutrition for residents who are unable to feed themselves. 5. Ensure that resident is seated comfortable in upright position. 17. Position resident comfortably. An observation on 4/4/23 at 11:52 AM, of Resident #46 during lunch dining, in the main dining room revealed her sitting in her wheelchair with her upper body and left elbow extended over the left armrest of the wheelchair while being fed by Certified Nursing Assistant (CNA) #5. This observation also revealed that small amounts of the food fell off the utensil when CNA #5 attempted to place food in Resident #46's mouth while she was leaning over to the left side. Two (2) of the CNAs in the dining area were observed to physically straighten Resident #46 up and centered her in her wheelchair, but Resident #46 was observed to immediately lean back over to the left side with her upper body and left elbow extended over the left armrest of her wheelchair. CNA #5 was observed to slightly push against Resident #46's left shoulder to straighten her up in the wheelchair but Resident #46 immediately leaned back to the left side with her upper body and left elbow extended over the left armrest of her wheelchair. An observation and interview on 4/4/23 at 12:00 PM with CNA# 5, confirmed the observation that Resident #46 was sitting in her wheelchair in the dining room leaning over to the left side with her upper body and left elbow extended over the left armrest. CNA #5 revealed she was not aware of whether Resident #46 usually leaned over to the left side when she was up in her wheelchair. She did note that Resident #46 needed something in her wheelchair to assist to position her and to hold her up straight. CNA #5 was observed to continue to feed Resident #46 as she leaned over in her wheelchair with her upper body and left elbow extended over the left armrest of her wheelchair. CNA #5 informed Register Nurse (RN) #1, the nurse assigned to monitor the residents eating in the dining room for this lunch dining, that Resident #46 kept leaning to the left. RN #1 replied to CNA #5 that Resident #46 needed a pillow in her chair to help with posture. An observation and interview on 4/4/23 at 12:04 PM with RN #1 confirmed the observation that Resident #46 was sitting in her wheelchair and was leaning over to the left side with her upper body and left elbow extended over the left armrest of her wheelchair, while CNA #5 was feeding her. She also confirmed that she was aware that Resident #46 had issues with poor trunk control for a while since her recent physical decline related to her existing diagnosis of Dementia. She reported that the CNAs must constantly reposition Resident #46 during dining. An observation and interview on 4/4/23 at 12:08 PM with the Director of Nursing (DON), who was present in the dining room to assist with the lunch dining, confirmed the observation that Resident #46 was leaning to the left side with her upper body and left elbow extended over the left armrest of her wheelchair. She confirmed Resident #46 had a decline due to her existing diagnosis of Dementia and had been having issues with positioning for a while but could not recall how long. She confirmed that the nursing staff could have used a pillow to assist Resident #46 with positioning in her wheelchair. She revealed that Resident #46 being fed while not being properly positioned in an upright position could possibly pose a choking hazard. An interview on 4/4/23 at 02:15 PM with the Administrator revealed the nursing staff should have used a pillow or a wedge to assist Resident #46 to maintain trunk control in her wheelchair when being fed by the nursing staff. The Administrator confirmed she was aware that Resident #46 had issues with maintaining trunk control but revealed she was not aware that the nursing staff allowed her to lean over to the left side with her upper body and left elbow extended over the left armrest of the wheelchair while being fed. She confirmed there was a possibility of a choking hazard for Resident #46, when being fed by the nursing staff while leaning over to the left side. She confirmed that Resident #46 was not properly positioned in an upright position during dining. Record review of the Face Sheet for Resident #46 revealed diagnoses of Unspecified Dementia, Unspecified Severity, Anorexia, Vascular Dementia, Unspecified Severity, and Muscle Weakness (Generalized). Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/6/2023 revealed Resident #46's Brief Interview for Mental Status (BIMS) score was 00, indicating the resident is severely cognitively impaired.

Based on observation, staff and resident interviews, facility policy review, and record review, the facility failed to ensure fingernails were clean and trimmed as evidenced by long and jagged nails with a brown substance under nails for three (3) of 54 residents observed. Resident #14, Resident #16, and Resident #42 Findings include: Resident #14 Record review of the facility's, Nail Care Policy, revised 10/17, revealed: Purpose .To promote cleanliness, safety, and a neat appearance .1. Perform hand hygiene. 7. Remove any debris from under the nails. 8. Trim the nails straight across. 14. Document all appropriate information in the clinical record. During an interview and observation on 04/04/23 at 12:05 PM, Resident #14's fingernails were long and jagged approximately one and one-half (1 1/2) inches past the tips of fingers on both hands. Resident #14 revealed he doesn't like his nails that long and has already asked about getting them cut. He revealed they haven't been cut since he was admitted . He revealed he told the Social Director about it and she said she would get someone to cut them. An interview and observation on 04/04/23 at 02:25 PM, Licensed Practical Nurse (LPN) #2 revealed the aides are allowed to do nail care on the residents that are not diabetic. She revealed that Resident #14 is a diabetic and the Registered Nurse (RN) Supervisor or Treatment Nurse does his nail care. LPN #2 asked Resident #14 if he wanted his nails cut Resident #14 replied Yes. LPN #2 confirmed that his nails were very long and needed to be cut. In an interview on 04/04/23 at 04:29 PM, the Social Director revealed, yesterday Resident #14 came to her office around 11:15 AM and asked if someone could cut his fingernails. She stated I went immediately to the RN Supervisor and asked her to please cut his nails that he had come to my office requesting them to be cut. In an interview on 04/04/23 at 04:35 PM, the Director of Nurses (DON) revealed that she wasn't sure about the schedules for the nails to be done and she would have to get with the RN Supervisor. She confirmed that all the residents should be getting their nails cleaned daily when they are bathed and they should be kept trimmed regularly. Record review of the Electronic Administration Record (EMAR) for March and April 2023 revealed no nail care order. An interview on 04/05/23 at 3:55 PM, the Minimum Data Set (MDS) Coordinator revealed she wasn't sure why the nail care was not showing up on the Electronic Administration Record (EMAR) and confirmed it should be since the resident is diabetic and the nurses need to sign it off. A review of the Face Sheet revealed Resident #14 was admitted to the facility, on 3/10/23 with diagnoses that included End stage renal disease and Type 2 Diabetes Mellitus. A review of the MDS, Section C with an Assessment Reference Date (ARD) of 3/20/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #14 is Cognitively intact. Resident #16 An observation on 04/04/23 at 10:16 AM, revealed Resident #16 was lying in bed, fingernails were long and jagged, approximately one-half inch past the tips of fingers on both hands, there was a brown substance under each fingernail. An observation on 04/04/23 at 02:05 PM revealed Resident #16 lying in bed with nails long jagged untrimmed, and a brown substance under nails on both hands. An interview on 04/04/23 at 2:15 PM, the RN Supervisor revealed she or the Treatment Nurse are the ones that usually cut the diabetic's nails, but the aides can clean them, and they will let us know when they need to be trimmed. The RN Supervisor revealed I don't know if their nails need to be done unless the aides let me know. An interview and observation on 04/04/23 02:25 PM, in an interview with LPN #2 revealed the aides are supposed to keep the nails clean and can trim them but if they are diabetic the RN Supervisor or Treatment Nurse does the nail care. She confirmed that Resident #16's nails were long, dirty, and jagged and needed to be cleaned and trimmed. An interview on 04/05/23 at 02:04 PM, the RN Supervisor revealed Resident #16 gets his nails cut as needed which could be every other week or even a month, it's just according to when the aide lets us know they need to be cut. She revealed this is the same for every resident that is a diabetic. Record review of the Electronic Administration Record (EMAR) revealed Diabetic Nail Care Weekly: Keep Fingernails clean and trimmed. Order date of 11/09/17. There was no documentation for nail care completion for March, and April 2023 A review of the Face Sheet revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included, Hemiplegia following unspecified cerebrovascular disease affecting the right dominant side, Cerebral infarction due to thrombus of left middle cerebral artery and Type 2 Diabetes mellitus. A review of the MDS, Section C with an ARD of 1/9/2023, revealed a BIMS score of 0, indicating Resident #16 has severe cognitive impairment. Resident #42 An interview and observation on 04/04/23 at 10:22 AM, revealed Resident #42 was sitting in his wheelchair with fingernails long and jagged approximately one-half inch past the fingertips, and a brown substance under the nails on both hands. Resident #42 stated They are too long. I would like them to be cut. It's been a while since they were cut and I don't like them this long. An observation on 04/04/23 at 02:15 PM, Resident #42 was sitting in his wheelchair, fingernails remaining untrimmed, approximately one-half inch past the fingertips, with a brown substance under his nails on both hands. An interview and observation on 04/04/23 at 02:20 PM, CNA #2 revealed she was assigned to Resident #42 today. She revealed it is the responsibility of the nurse to cut the diabetic residents' nails and the aides are responsible for cleaning them and notifying the nurses that they need to be trimmed. She confirmed that Resident #42's nails were long and dirty and needed to be cleaned and trimmed. She wasn't sure the last time they were done. An interview on 04/04/23 at 02:35 PM, the RN Supervisor revealed she and the Treatment Nurse do the nails of the diabetics. She revealed she relies on the aides to let her know when the nails need to be cut since she doesn't see the residents every day. She revealed there are no set days for nail care. She confirmed that Resident #42's nails needed to be cleaned and cut and it was the responsibility of the aide to let her know. Record review of the EMAR for Resident #42 with an order date of 11/20/20 revealed Nail Care Weekly: Check condition and Clean PRN (as needed). There was no documentation for nail care completion for March and April 2023. A review of the Face Sheet revealed Resident #42 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia following cerebral infarction affection left nondominant side and Type 2 Diabetes mellitus. A review of the MDS, Section C with an ARD of 2/8/2023, revealed a BIMS score of 7, indicating Resident #42 has severe cognitive impairment.

Based on observation, record review, staff interview, and facility policy review, the facility failed to provide goods and services related to enteral feedings and water flushes for three (3) out of four (4) residents reviewed of eight (8) residents requiring enteral feedings: Resident #1, #2 and #3, and failed to provide goods and services related to diabetic medications for five (5) of eight (8) residents reviewed of 11 insulin dependent diabetics, Residents #1, #2, #4, #5 and #6. The facility's failure to provide goods and services related to enteral feedings, enteral water flushes and diabetic medications placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, hospitalization of Resident #2, and was likely to cause serious injury, harm, impairment, or death for other residents requiring enteral feedings and insulin. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to provide goods and services related to enteral feedings, enteral water flushes and diabetic medications and the resident was hospitalized with [CONDITION(S)]. This failure resulted in the hospitalization of two (2) residents for critical blood glucose levels, with one passing away. These actions placed all residents receiving enteral feedings and requiring insulin in a situation that was likely to cause serious harm, injury, impairment, and further death. On [DATE] at 2:45 PM, SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the NHA with the IJ template. The IJ and SQC existed at: §483.12 Freedom from Abuse, Neglect, and Exploitation (F600) - Scope and Severity - K The facility submitted a credible Removal Plan on [DATE] at 9:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s): §483.12 Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a K level of scope and severity to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Incident Investigation & Reporting . dated ,d+[DATE] revealed, 1. Each resident residing in this facility has the right to be free from any type of abuse including verbal, sexual, mental, physical abuse, neglect, misappropriation of resident property and exploitation Neglect: A failure to provide good and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's policy titled, Tube Feedings dated ,d+[DATE] revealed, 1. All tube feedings will be administered in accordance with verified medical necessity .3. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A specific physicians' order will be obtained before attempts to discontinue a tube feeding .6. Tube feeding, I&O (intake and output) should be documented each shift in the electronic medical record for electronic facilities. Non-electronic facilities should document I&O each shift using FORM NS-683 - Tube Feeding Records. Review of the facility's policy titled, Intake and Output Measurement dated ,d+[DATE], revealed, Purpose: 1. To maintain an accurate measurement of the resident's intake and output to assess fluid balance .Procedure . 3. Measure and record all liquids ingested .8. When enteral nutritional therapy, hypodermoclysis or intravenous fluid is administered, record amount on individual record .11. Document intake and/or output. 12. Intake and output are totaled every twenty-four hours. 13. The nurse is responsible to evaluate the total I&O per shift. If the intake and output is not adequate, notify the nursing supervisor and the physician . Review of the facility's policy titled, Drug Administration and Documentation dated ,d+[DATE], revealed, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed properly labeled container (including a unit dose container), verifying it with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For electronic medication administration (EMAR), any medication not administered is indicated by an N in the block with a note of explanation as to why medication was not administered . Resident #1 Review of Resident #1's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:45 AM, during an interview with Resident #1's daughter, she stated the following, I received a phone call from the facility at a few minutes till 9:00 at night that my mom was unresponsive. I asked the nurse what that meant, and she said she is not responding when we touch her or talk to her, she is just staring at the ceiling and breathing funny. The nurse said she was calling 911 and sending her out to the hospital. I waited a little bit and then called the emergency room to see how my mom was. A male nurse answered the phone, I told him who I was and asked if my mother was there. He told me to wait a minute. A doctor, I think his name was (formal name) got on the phone and told me I needed to come to the hospital as quickly as I could. I asked him why, is my mother already gone? He told me she was gone and had been gone for a little while. He said she was DOA (dead on arrival), and they worked on her for about 15 minutes. They had to give her 4 [MEDICATION(S)] shots and that did not work. I asked him if he knew her blood sugar was sky high and registered HI on the glucometer when she left the nursing home. He stated he was not aware of her high sugar. They were focused on doing CPR and trying to resuscitate her at the time. The doctor stated her blood sugar was elevated when she had been in the emergency room a week and a half prior, and that one of two things was happening. Either the nurses were not giving my mother her water in the tube and giving her concentrated feeding would cause her blood sugars to be high, or they were not giving her the diabetic insulin or pills in the tube. She was getting all her food through the tube, so it was not like she was eating a piece of pie or sugar. The facility should have been able to regulate her blood sugar better than they did. I am convinced the facility has not been feeding and giving my mom water like they should be, and they are not giving her the insulin and pills like they should be either. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cubic Centimeters an Hour) continuous via #20 fr (French), Blood Sugar after breakfast every 2 weeks at 9:00 AM, call Dr (Formal name) with results if <60 or >400, call s/s (signs and symptoms) if needed, [MEDICATION(S)] 24 units sub Q (subcutaneous) at 9:00 PM. Rotate SQ site, and [MEDICATION(S)] 5 mg (milligram) tablet per (by) G-tube daily at 9:00 AM. Review of Resident #1's Medication Administration Record (MAR) for the month of February, prior to her hospitalization on [DATE]rd, 2021, revealed, from February 5th, 2021 through February 16th, 2021, there were no initials of completion for the following: Flush G-tube with 250 milliliters (ml) H2O (water) three times a day at 5 AM, 1 PM, and 5 PM via #20 FR (French) tube 10 CC (cubic centimeters) Bulb on [DATE] at both 5:00 AM and 9:00 PM; Flush G-tube with 30 cc H2O ACPC (before and after) meds for night shift on [DATE], days and evening shifts on [DATE], and evening shift on [DATE]; Flush G-tube with 5 ml H2O between each medication on night shift [DATE], day shift on [DATE], and evening shift on [DATE]; [MEDICATION(S)] 5 mg tablet 1 per G-tube daily @ 9 AM for [DATE]; [MEDICATION(S)] 24 units sub Q at 9:00 PM, Rotate SQ site for [DATE]; Diabetasource 25 ML per #20 FR tube continuous at 11:00pm on [DATE], 3:00pm and 11:00pm on [DATE]. Further review of Resident #1's February MAR, upon her return to the facility, revealed multiple days with N recorded in the boxes. During an interview with Medical Records (MR) on [DATE] at 11:30 AM, revealed, the N meant Not Administered and if a nurse put N in the box, she was to put an explanation why it was not done or given in the detail notes. If there was no documentation in the detail notes there was no other place to document, why it was not given. It was noted that all the days with N recorded, the nurse's initials were all the same. When asked by the SA, why the same initials were on all three shift and different days, Medical Records stated, when we went to electronic MAR's when a medication was not given, it will flash red on the screen because it is overdue. The Director of Nursing (DON) got tired of seeing the screen flash red, so she went into the MAR and filled in all the holes with an N so it would clear her screen up. Review of Resident #1's February 2021 MAR from [DATE] through [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detail notes revealed no documentation as to the reason why the [MEDICATION(S)] was not given. An order to Flush G-tube with 200 cc H2O every 4 hours (dated [DATE] and discontinued on [DATE]) had Ns documented on [DATE] at 5:00 PM and 9:00 PM, and [DATE] at 5:00 AM; review of the detail notes revealed no documentation as to the reason why the flushes were not administered. A new order to Flush G-tube with 200 ML H2O every six hours had Ns at 6:00 PM on [DATE] and 6:00 PM on [DATE]. Review of the detail notes revealed no documentation as to the reason why the flushes had not been administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was transitioning from paper MARs to electronic MARs in the month of February. Resident #1's Tube Feeding Records where intake and output were to be recorded manually, and her Tube Feeding Report Roster where intake and output were to be recorded in the computer were compared to reveal a lack of documentation for night shift on [DATE] and [DATE]; day shift and evening shift on [DATE]; day shift on [DATE]; evening and night shift on [DATE]; evening and night shift on [DATE]; evening shift on [DATE]; evening and night shift on [DATE]; and night shift on [DATE]. Resident #1's 24-hour totals for enteral feeding and water flushes were to be: [DATE] through [DATE] - 250 cc flushes three times a day to equal 750 cc, and 25 cc an hour of Diabetasource continuous to equal 600 cc. Together Resident #1 should have received 1350 cc total through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 680 cc, [DATE] at 732 cc, and [DATE] at 500 cc. For the dates of [DATE] through [DATE], Resident #1's 24-hour totals for enteral feeding and water flushes were to be: 200 cc flushes four times a day to equal 800 cc, and 55 cc an hour of Diabetasource to equal 1320 cc. Together, Resident #1 should have received 2120 cc total through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 757 cc, [DATE] at 1561 cc, [DATE] at 1186 cc and [DATE] at 1152 cc. Review of Resident #1's MAR for [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the detailed notes of the reason it was not administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detailed notes for these days revealed there was no reason documented for why the enteral feeding and flushes were not administered. Review of Resident #1's Tube Feeding Report Roster for [DATE] revealed the total intake of enteral feedings and enteral water flushes to be 1180 cc on [DATE], and 800 cc on [DATE]. Resident #1 should have received 2120 cc of feeding and water for each day. Review of Resident #1's Admission History and Physical dated [DATE], revealed Resident #1 was admitted to the hospital on [DATE] for Urosepsis, [CONDITION(S)], and an Acute Kidney Injury requiring a bolus of three (3) liters of fluid in the emergency room . Further review of Resident #1's Admission History and Physical dated [DATE] she had been brought to the emergency room (ER)with reports of fever and tachycardia, and her labs revealed lactic acidosis, leukocytosis, [CONDITION(S)], and an acute kidney injury. Further review revealed her Sodium Level was 146 (high), and her glucose was 524 (high). Under an Assessments section she had the follow diagnoses, [CONDITION(S)], Urinary Tract Infectious Disease, Lactic Acidosis, [CONDITION(S)] and [CONDITION(S)]. Under the Plan: section it stated, [AGE] year-old African American female admitted with Urosepsis and Acute Kidney Injury .Patient now status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue IV (intravenous) hydration .[CONDITION(S)]: Serum Sodium 146 on admission. Will adjust fluids as needed .[CONDITION(S)]: Known history of Diabetes Mellitus. Glucose 524 on arrival to the ER. Patient now s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Ordering Accuchecks Q 4 (every 4) hours and [MEDICATION(S)] per sliding scale. Holding [MEDICATION(S)] until tube feeds are resumed . On [DATE] at 3:15 PM, in an interview with the Director of Nursing (DON), when asked if the facility could show Resident #1 had received her enteral feeding, water flushes and diabetic medications from [DATE] through [DATE], to help prevent her hospitalization on [DATE], she stated, not if it is not written in the nurses notes or on the MAR. The nurses should be putting that information into the computer. I am not sure what the N means. This computer system is new, and I do not know anything at all about it yet. When asked how high a blood glucose had to register for the meter to state HI, she indicated she would have to check the user guide and let me know. On [DATE] at 4:00 PM, the DON brought the User Guide for the [NAME] Smart Meter which revealed, The testing range of the meter is from 20 to 600 mg/dl (milligrams per deciliter). If HI is displayed, your blood glucose result may be higher than 600 mg/dl. If LO is displayed, your blood glucose result may be lower than 20 mg/dl. Review of Resident #1's Nurses notes dated [DATE] at 10:53 PM revealed, 7:20 PM - Summoned to resident's room per C.N.A. (Certified Nurse Aide), resident noted lying in bed, increased resp (respirations) sweating. Blood sugar called for primary nurse. Checked registered HI on the blood glucose meter. She did not respond to verbal or tactile stimuli . Review of Resident #1's Nurses Notes dated [DATE] at 11:04 PM revealed, Summoned to resident room after supervisor noted that resident was not responding. Resident was still breathing but not responding, cold sweats noted coming from resident blood sugar check and were unreadable, 911 called immediately. Around 7:30 PM ambulance arrived and headed to ER with resident, received a called from ER, nurse stated that resident had coded and passed away. Family members notified. Neither nurses note regarding the event made mention of notifying the Physician of Resident #1's condition, departure for the emergency room , or later demise. Review of Resident #1's Physician Documentation from the Emergency Department revealed, Arrival date: [DATE] at 9:04 PM . Location: Morgue, Pronouncing Physician: (Formal Name), Time of Death: 9:06 PM, Diagnosis - [CONDITION(S)], Acute Respiratory Failure . [AGE] year-old female who presents to the emergency room in respiratory distress with palpable pulses initially. Pulse's loss CPR initiated. Patient intubated. CPR performed for 14 minutes with multiple rounds of [MEDICATION(S)] and 1 of [MEDICATION(S)] given. 1 Liter bolus began. Patient pronounced at 9:06 PM. Patient without any palpable pulses or visible chest rise. Patient without an auditory breath sounds or cardiac sounds. Patient pupils fixed and dilated. No corneal reflex of patient are responsive to verbal or painful stimuli. Family notified. On [DATE] at 11:45 AM, during an interview with Resident #1's physician, the Medical Director of the facility, she indicated, she was not fully aware of the entire incident with (formal name) (Resident #1), with all the details. When Resident #1's current diabetic orders and enteral feeding orders were reviewed with the physician, she stated, the orders were not correct. She would not give blood sugar check orders like they were written. She indicated the order should have read to check blood glucose every morning at 9:00 AM, and to send them to the doctor every two weeks for review. If blood sugar is <60 or >400, notified the Physician. She indicated the blood sugar check order written as it was, did not make any sense with regard to glucose control. She indicated she was not aware the Residents blood sugar had read HI prior to being sent out and stated that Resident #1's blood sugars had not been being sent to her office for review. She stated she had Resident #1's chart in front of her as she spoke on the phone, and there were no reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents in order to know what orders to write. She stated the staff had not made her aware the Resident was missing enteral feedings, water flushes and her diabetic meds from time to time, and definitely not for several days in a row prior to her last hospitalization . She stated, had she been made aware of the resident's elevated blood sugar, she would have written orders accordingly. When the SA informed her of the daughter's concerns, and the items mentioned to her by the emergency room Physician, she agreed with the resident having a controlled food and fluid source and should have been better regulated with her glucose levels. She agreed that giving the concentrated enteral feeding without the proper water or not giving Resident #1 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 Review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] <60 or >500, Report blood sugar to MD every 2 weeks; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate site; [MEDICATION(S)] 100 mg tablet by mouth daily; and [MEDICATION(S)] (Hydrochloride) 500 mg tablet by mouth twice a day; Push by mouth fluids, give six (6) 16 oz (ounce) of water per day; and Record I&O Q shift with 24-hour total. Review of Resident #2's MAR for February 2021 revealed, missing blood glucose readings for 4:00 PM on [DATE], and 6:00 AM and 4:00 PM blood glucose readings on [DATE], [DATE], [DATE], and [DATE]; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate SQ site, with missing initials of completion at 9:00 PM on [DATE], 9:00 AM on [DATE], and 9:00 AM and 9:00 PM for [DATE], [DATE], [DATE], [DATE], and [DATE]; Report blood sugar to MD every 2 weeks, with missing initials of completion on [DATE] and [DATE]; Push by mouth fluids, give (6) 16 oz. of water per day - there were no initials of completion for all three shifts for the entire month. During a review of an Insulin Report provided by the facility's pharmacy for [DATE] through [DATE] revealed, Resident #2 had 3 [MEDICATION(S)] 100 units/ML Flex Pen ordered. Each Flex Pen holds 3 ML of insulin, to equal 300 ML of insulin per pen. Review of Resident #2's Physicians Orders revealed, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Rotate SQ site. The order was dated [DATE] to present. She experienced multiple hospitalization s over the last six months and was not in the building from [DATE] through [DATE], from [DATE] through [DATE], and [DATE] through [DATE]. The sum total of days she was not in the facility in the last 6 months equals 20 days. There have been 205 days in the last 6 months, minus the 20 days Resident #2 was out of the building equals 185 days. 185 days multiplied by the 56 units of [MEDICATION(S)] needed a day for Resident #2 to receive her ordered amount equaled 10,360 units. With each [MEDICATION(S)] Flex Pen holding 300 Units each, Resident #2 should have had 35 Flex Pens ordered from the pharmacy, and only had 3 ordered. During a joint interview with the Administrator and DON on [DATE], at 1:30 PM, the calculations were shared by the SA, and that the facility was 32 Flex Pens short of insulin for Resident #2. When asked what those findings meant, the DON stated, unless they borrowed from another resident, it means she didn't get all of her insulin like she should have. Review of Resident #2's Intake/Output record for February 2021 was completely blank for the entire month. Review of Resident #2's MAR for [DATE] revealed, Report Blood sugar to MD every two weeks with missing initials for [DATE] or [DATE]; [MEDICATION(S)] 28 units SubQ at bedtime, rotate SUBQ sites, with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 100 mg tablet by mouth daily with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 500 mg tablet by mouth twice a day, with missing initials for 9:00 AM and 5:00 PM on [DATE]. Resident #2 was hospitalized from [DATE] through [DATE] for the placement of a Gastric Tube to help supplement her intakes. Review of Resident #2's March MAR after her return on [DATE] revealed orders for [MEDICATION(S)] Renal Bolus 1 can (250 ML) Q 6 hours, providing 2000 KCAL (kilocalories), 91 G (grams) of protein, 1855 ML H2O, to equal 2135 ML of fluid and 100% of RDI (recommended daily intake); with missing initials for [DATE] at 6:00 AM with no detailed nurses notes for why it was not administered; Another order to Flush tube with 100 ML H2O every 4 hours, with missing initials on [DATE] at 5:00 AM, and on [DATE] at 5:00 AM and 9:00 PM; and an order to report blood sugars to MD every 2 weeks on the 9th and 23rd of every month. Both dates were missing initials of completion for the month of [DATE]. Review of Resident #2's Tube Feeding Report Roster revealed no intake and output were recorded for her from her readmission on [DATE] through [DATE]. Her daily intake of fluids between her enteral feeding and water flushes was to be 2135 ML per her orders. Her intake recorded for [DATE] was 537 ml; for [DATE] through [DATE] there was no intake recorded; for [DATE] it was 397 ml; for [DATE] it was 567 ML; for [DATE] it was 1141 ML. Review of Resident #2's weight record revealed, on [DATE], she weighed 162.0 pounds, on [DATE], she weighed 161.5 pounds, on [DATE], she weighed 160.5 pounds, on [DATE], she weighed 162.0 pounds, on [DATE] she weighed 136.5 pounds, and on [DATE], she weighed 146.0 pounds. Resident had a gastric tube placed during a hospitalization on [DATE]. The weight loss noted between January and February was due to her lack of appetite with COVID-19, double lung Pneumonia, and lethargy. Review of Resident #2's Departmental Notes, dated, [DATE] at 1:50 PM revealed, Resident remains lethargic, did not eat breakfast or lunch, unable to administer medications due to resident is not alert enough at this time. Review of Resident #2's Departmental Notes, dated [DATE] at 10:35 AM, revealed, DON spoke with family member, NP at Dr (Doctor's formal name) office and the ER (emergency room ) Director regarding tube placement for resident. Plan: Resident departed facility at 10:05 AM with (Ambulance Company Name), 1 female and 1 male attendant, to ER Clarksdale for tube placement evaluation . Review of Resident #2's Admission History and Physical dated [DATE], revealed, she was admitted with a fever of 102.4 degrees. She tested positive for COVID-19. Imaging Results: CXR (chest X-ray) - bilateral pneumonia consistent with COVID-19. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Summary: 84 y/o female admitted to COVID unit due to COVID positive testing with UTI (urinary tract infection), [CONDITION(S)] and staph epi bacteremia .Pt. (patient) also noted to have decreased oral intake which contributed to dehydration and ARF (acute renal failure) on admission. This has improved to baseline. Pt. still has decreased oral intake but will drink fluids and take meds with some prompting. Pt is COVID positive and will need COVID testing to be negative prior to consideration for PEG placement. Health Concerns: Inadequate oral intake. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was changed on [DATE] to House Supplement 2 oz. by mouth three times a day - Chart ,d+[DATE]%, ,d+[DATE]%, 3- 75%, 4- 100%, and 5 - refused. Resident #2 was sent to the emergency room (ER) on [DATE] for a blood glucose that read HI on the glucometer. Review of Resident #2's Nurses notes dated [DATE], at 6:56 AM, revealed, Resident remains on observation for COVID precautions, no s/s (sign or symptoms) of COVID noted at this time. Informed MD of Blood sugar reading of HI. Received new orders to start [MEDICATION(S)] 10 units @ HS (hour of sleep). Novolog with sliding scale and send her to the ER now for elevated blood sugar. Attempted to inform RR (Resident Representative) of new orders and unable to reach him at this time. (formal name of ambulance) called for transfer . Review of nurses notes dated [DATE], at 8:58 AM revealed, 7:25 AM resident exited fac (facility) per (ambulance formal name) accompanied per 2 female EMT's (Emergency Medical Team). No acute distress noted at this time. Review of nurse's notes dated [DATE], at 12:30 PM revealed, RR (Resident Representative) returned call to fac, informed him of order to send to ER for eval secondary to elevated BS (blood sugar). Review of Resident #2's Physician Documentation from the emergency room dated [DATE] revealed, Arrival Date [DATE], Time: 07:44 AM, hospitalization Status: Inpatient Admission, Current Condition: Serious, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a high probability of clinically significant/life threatening deterioration in the patient's condition which required my urgent intervention. This [AGE] year-old black female presents to ER via EMS ground with complaints of High Blood Sugar. Associated symptoms of diaphoresis. Patient was found hypoglycemic today, and she was also [CONDITION(S)] on arrival of EMS. Fluid started by EMS and patient transported here. Correct [CONDITION(S)] initially with fluids and consider insulin when potassium is known . There are signs of severe [CONDITION(S)] in the setting of acute renal failure . At 07:51 AM Blood Glucose: 466 mg/dl, critical glucose levels for an adult: <60 (below 60) or >300 mg/dl (above 300). On [DATE], at 11:45 AM, during an interview with Resident #2's physician, the Medical Director of the facility, she indicated, she was made aware of the blood sugar reading of HI and remembers giving new orders for her insulin and sending her to the emergency room to be evaluated. She stated she had Resident #2's chart in front of her as she spoke on the phone, and there were no prior reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents in order to know what orders to write. She stated the staff had not made her aware the resident was missing enteral feedings and water flushes from time to time. She stated giving the concentrated enteral feeding without the proper water or not giving Resident #2 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 remained in the hospital throughout the remainder of the survey. Resident #3 Review of Resident #3's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE], during morning rounds at 10:00 AM, Resident #3 was noted to be in her bed, lying on her back with eyes closed. Her mouth was slightly open with dry oral mucosa, with dry, scaly lips. G-tube feeding running at 40 ML per hour. Observation on [DATE], during rounds at 2:15 PM, Resident #3 was noted to be in bed, on her left side, with her eyes closed. Mouth remains with dry scaly lips. Mouth is closed at this time, cannot visualize oral mucosa. Review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20 FR G-tube to provide 1320 cal, 59 Grams protein, 1909 free H2O/2100 total FLD (fluid), 90% RDI (Recommended Daily Intake). During an interview with the DON on [DATE], at 3:15 PM, when asked by the SA how intake was calculated, and what do the initials on the MAR mean for the enteral feeding orders, she stated they are checking to make sure the pump is on and running at the rate it is supposed to be running at. When asked how the nurses are to know if the resident has received the required amount of enteral feeding and fluid for the day, she sta [TRUNCATED]

Based on observation, record review, staff interview, and facility policy review, the facility failed to provide treatment and services related to enteral feedings and enteral water flushes for three (3) out of four (4) residents reviewed of eight (8) residents requiring enteral feedings, Residents #1, #2 and #3. The facility's failure to provide goods and services related to enteral feedings and enteral water flushes placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, hospitalization of Resident #2, and was likely to cause serious injury, harm, impairment, or death for other residents requiring enteral feedings. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE] when the facility failed to provide goods and services related to enteral feedings and enteral water flushes and the resident was hospitalized with [CONDITION(S)]. This failure resulted in the hospitalization of two (2) residents for critical blood glucose levels, with one passing away. These actions placed all residents receiving enteral feedings and requiring insulin in a situation that was likely to cause serious harm, injury, impairment, and further death. On [DATE], at 2:45 PM, SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the NHA with the IJ template. The IJ and SQC existed at: §483.25(g)(5) Assisted Nutrition and Hydration (F693) - Scope and Severity - K The facility submitted a credible Removal Plan on [DATE], at 9:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s): §483.25(g)(5) Assisted Nutrition and Hydration (F693) was lowered from a K level of scope and severity to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Tube Feedings dated ,d+[DATE] revealed, 1. All tube feedings will be administered in accordance with verified medical necessity .3. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A specific physicians' order will be obtained before attempts to discontinue a tube feeding .6. Tube feeding, I&O (intake and output) should be documented each shift in the electronic medical record for electronic facilities. Non-electronic facilities should document I&O each shift using FORM NS-683 - Tube Feeding Records. Review of the facility's policy titled, Intake and Output Measurement dated ,d+[DATE], revealed, Purpose: 1. To maintain an accurate measurement of the resident's intake and output to assess fluid balance .Procedure . 3. Measure and record all liquids ingested .8. When enteral nutritional therapy, hypodermoclysis or intravenous fluid is administered, record amount on individual record .11. Document intake and/or output. 12. Intake and output are totaled every twenty-four hours. 13. The nurse is responsible to evaluate the total I&O per shift. If the intake and output is not adequate, notify the nursing supervisor and the physician . Resident #1 Review of Resident #1's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 11:45 AM, during an interview with Resident #1's daughter, she stated the following, I received a phone call from the facility at a few minutes till 9:00 at night that my mom was unresponsive. I asked the nurse what that meant, and she said she is not responding when we touch her or talk to her, she is just staring at the ceiling and breathing funny. The nurse said she was calling 911 and sending her out to the hospital. I waited a little bit and then called the emergency room to see how my mom was. A male nurse answered the phone, I told him who I was and asked if my mother was there. He told me to wait a minute. A doctor, I think his name was (formal name) got on the phone and told me I needed to come to the hospital as quickly as I could. I asked him why, is my mother already gone? He told me she was gone and had been gone for a little while. He said she was DOA (dead on arrival), and they worked on her for about 15 minutes. They had to give her 4 [MEDICATION(S)] shots and that did not work. I asked him if he knew her blood sugar was sky high and registered HI on the glucometer when she left the nursing home. He stated he was not aware of her high sugar. They were focused on doing CPR and trying to resuscitate her at the time. The doctor stated her blood sugar was elevated when she had been in the emergency room a week and a half prior, and that one of two things was happening. Either the nurses were not giving my mother her water in the tube and giving her concentrated feeding would cause her blood sugars to be high, or they were not giving her the diabetic insulin or pills in the tube. She was getting all her food through the tube, so it was not like she was eating a piece of pie or sugar. The facility should have been able to regulate her blood sugar better than they did. I am convinced the facility has not been feeding and giving my mom water like they should be, and they are not giving her the insulin and pills like they should be either. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cubic Centimeters an Hour) continuous via #20 fr (French). Review of Resident #1's Medication Administration Record (MAR) for the month of February, prior to her hospitalization on [DATE]rd, 2021, revealed, from February 5th, 2021 through February 16th, 2021, there were no initials of completion for the following: Flush G-tube with 250 milliliters (ml) H2O (water) three times a day at 5 AM, 1 PM, and 5 PM via #20 FR (French) tube 10 CC (cubic centimeters) Bulb on [DATE] at both 5:00 AM and 9:00 PM; Flush G-tube with 30 cc H2O ACPC (before and after) meds for night shift on [DATE], days and evening shifts on [DATE], and evening shift on [DATE]; Flush G-tube with 5 ml H2O between each medication on night shift [DATE], day shift on [DATE], and evening shift on [DATE]. Further review of Resident #1's February MAR, upon her return to the facility, revealed multiple days with N recorded in the boxes. During an interview with Medical Records (MR) on [DATE] at 11:30 AM, revealed, the N meant Not Administered and if a nurse put N in the box, she was to put an explanation why it was not done or given in the detail notes. If there was no documentation in the detail notes there was no other place to document, why it was not given. It was noted that all the days with N recorded, the nurse's initials were all the same. When asked by the SA, why the same initials were on all three shift and different days, Medical Records stated, when we went to electronic MAR's when a medication was not given, it will flash red on the screen because it is overdue. The Director of Nursing (DON) got tired of seeing the screen flash red, so she went into the MAR and filled in all the holes with an N so it would clear her screen up. Review of Resident #1's February 2021 MAR from [DATE] through [DATE] revealed an order to Flush G-tube with 200 cc H2O every 4 hours (dated [DATE] and discontinued on [DATE]) had Ns documented on [DATE] at 5:00 PM and 9:00 PM, and [DATE] at 5:00 AM; review of the detail notes revealed no documentation as to the reason why the flushes were not administered. A new order to Flush G-tube with 200 ML H2O every six hours had Ns at 6:00 PM on [DATE] and 6:00 PM on [DATE]. Review of the detail notes revealed no documentation as to the reason why the flushes had not been administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was transitioning from paper MARs to electronic MARs in the month of February. Resident #1's Tube Feeding Records where intake and output were to be recorded manually, and her Tube Feeding Report Roster where intake and output were to be recorded in the computer were compared to reveal a lack of documentation for night shift on [DATE] and [DATE]; day shift and evening shift on [DATE]; day shift on [DATE]; evening and night shift on [DATE]; evening and night shift on [DATE]; evening shift on [DATE]; evening and night shift on [DATE]; and night shift on [DATE]. Resident #1's 24-hour totals for enteral feeding and water flushes were to be: [DATE] through [DATE] - 250 cc flushes three times a day to equal 750 cc, and 25 cc an hour of Diabetasource continuous to equal 600 cc. Together Resident #1 should have received 1350 cc total through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 680 cc, [DATE] at 732 cc, and [DATE] at 500 cc. For the dates of [DATE] through [DATE], Resident #1's 24-hour totals for enteral feeding and water flushes were to be: 200 cc flushes four times a day to equal 800 cc, and 55 cc an hour of Diabetasource to equal 1320 cc. Together, Resident #1 should have received 2120 cc total through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 757 cc, [DATE] at 1561 cc, [DATE] at 1186 cc and [DATE] at 1152 cc. Review of Resident #1's MAR for [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detailed notes for these days revealed there was no reason documented for why the enteral feeding and flushes were not administered. Review of Resident #1's Tube Feeding Report Roster for [DATE] revealed the total intake of enteral feedings and enteral water flushes to be 1180 cc on [DATE], and 800 cc on [DATE]. Resident #1 should have received 2120 cc of feeding and water for each day. Review of Resident #1's Admission History and Physical dated [DATE], revealed Resident #1 was admitted to the hospital on [DATE] for Urosepsis, [CONDITION(S)], and an Acute Kidney Injury requiring a bolus of three (3) liters of fluid in the emergency room . Further review of Resident #1's Admission History and Physical dated [DATE], revealed she had been brought to the emergency room (ER)with reports of fever and tachycardia, and her labs revealed lactic acidosis, leukocytosis, [CONDITION(S)], and an acute kidney injury. Further review revealed her Sodium Level was 146 (high), and her glucose was 524 (high). Under an Assessments section she had the follow diagnoses, [CONDITION(S)], Urinary Tract Infectious Disease, Lactic Acidosis, [CONDITION(S)] and [CONDITION(S)]. Under the Plan: section it stated, [AGE] year-old African American female admitted with Urosepsis and Acute Kidney Injury .Patient now status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue IV (intravenous) hydration .[CONDITION(S)]: Serum Sodium 146 on admission. Will adjust fluids as needed .[CONDITION(S)]: Known history of Diabetes Mellitus. Glucose 524 on arrival to the ER. Patient now s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Ordering Accuchecks Q 4 (every 4) hours and [MEDICATION(S)] per sliding scale. Holding [MEDICATION(S)] until tube feeds are resumed . On [DATE], at 3:15 PM, in an interview with the Director of Nursing (DON), when asked if the facility could show Resident #1 had received her enteral feeding, water flushes and diabetic medications from [DATE] through [DATE], to help prevent her hospitalization on [DATE], she stated, not if it is not written in the nurses notes or on the MAR. The nurses should be putting that information into the computer. I am not sure what the N means. This computer system is new, and I do not know anything at all about it yet. When asked how high a blood glucose had to register for the meter to state HI, she indicated she would have to check the user guide and let me know. On [DATE], at 4:00 PM, the DON brought the User Guide for the [NAME] Smart Meter which revealed, The testing range of the meter is from 20 to 600 mg/dl (milligrams per deciliter). If HI is displayed, your blood glucose result may be higher than 600 mg/dl. If LO is displayed, your blood glucose result may be lower than 20 mg/dl. Review of Resident #1's Nurses notes dated [DATE] at 10:53 PM revealed, 7:20 PM - Summoned to resident's room per C.N.A. (Certified Nurse Aide), resident noted lying in bed, increased resp (respirations) sweating. Blood sugar called for primary nurse. Checked registered HI on the blood glucose meter. She did not respond to verbal or tactile stimuli . Review of Resident #1's Nurses Notes dated [DATE] at 11:04 PM revealed, Summoned to resident room after supervisor noted that resident was not responding. Resident was still breathing but not responding, cold sweats noted coming from resident blood sugar check and were unreadable, 911 called immediately. Around 7:30 PM ambulance arrived and headed to ER with resident, received a called from ER, nurse stated that resident had coded and passed away. Family members notified. Neither nurses note regarding the event made mention of notifying the Physician of Resident #1's condition, departure for the emergency room , or later demise. Review of Resident #1's Physician Documentation from the Emergency Department revealed, Arrival date: [DATE] at 9:04 PM . Location: Morgue, Pronouncing Physician: (Formal Name), Time of Death: 9:06 PM, Diagnosis - [CONDITION(S)], Acute Respiratory Failure . [AGE] year-old female who presents to the emergency room in respiratory distress with palpable pulses initially. Pulses loss CPR initiated. Patient intubated. CPR performed for 14 minutes with multiple rounds of [MEDICATION(S)] and 1 of [MEDICATION(S)] given. 1 Liter bolus began. Patient pronounced at 9:06 PM. Patient without any palpable pulses or visible chest rise. Patient without an auditory breath sounds or cardiac sounds. Patient pupils fixed and dilated. No corneal reflex of patient are responsive to verbal or painful stimuli. Family notified. On [DATE], at 11:45 AM, during an interview with Resident #1's physician, the Medical Director of the facility, she indicated, she was not fully aware of the entire incident with (formal name) (Resident #1), with all the details. When Resident #1's current diabetic orders and enteral feeding orders were reviewed with the physician, she stated, the orders were not correct. She would not give blood sugar check orders like they were written. She indicated the order should have read to check blood glucose every morning at 9:00 AM, and to send them to the doctor every two weeks for review. If blood sugar is <60 or >400, notified the Physician. She indicated the blood sugar check order written as it was, did not make any sense with regard to glucose control. She indicated she was not aware the Residents blood sugar had read HI prior to being sent out and stated that Resident #1's blood sugars had not been being sent to her office for review. She stated she had Resident #1's chart in front of her as she spoke on the phone, and there were no reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents in order to know what orders to write. She stated the staff had not made her aware the Resident was missing enteral feedings, water flushes and her diabetic meds from time to time, and definitely not for several days in a row prior to her last hospitalization . She stated, had she been made aware of the resident's elevated blood sugar, she would have written orders accordingly. When the SA informed her of the daughter's concerns, and the items mentioned to her by the emergency room Physician, she agreed with the resident having a controlled food and fluid source and should have been better regulated with her glucose levels. She agreed that giving the concentrated enteral feeding without the proper water or not giving Resident #1 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 Review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20 FR Tube 10 cc bulb and Record I&O Q shift with 24-hour total. Review of Resident #2's MAR for February 2021 revealed an order to Push by mouth fluids, give 6 16 oz. of water per day. There were no initials of completion for all three shifts for the entire month. Review of Resident #2's Intake/Output record for February 2021 was completely blank for the entire month. Resident #2 was hospitalized from [DATE] through [DATE] for the placement of a Gastric Tube to help supplement her intakes. Review of Resident #2's March MAR after her return on [DATE] revealed orders for [MEDICATION(S)] Renal Bolus 1 can (250 ML) Q 6 hours, providing 2000 KCAL (kilocalories), 91 G (grams) of protein, 1855 ML H2O, to equal 2135 ML of fluid and 100% of RDI (recommended daily intake); with missing initials for [DATE] at 6:00 AM with no detailed nurses notes for why it was not administered; Another order to Flush tube with 100 ML H2O every 4 hours, with missing initials on [DATE] at 5:00 AM, and on [DATE] at 5:00 AM and 9:00 PM. Review of Resident #2's Tube Feeding Report Roster revealed no intake and output were recorded for her from her readmission on [DATE] through [DATE]. Her daily intake of fluids between her enteral feeding and water flushes was to be 2135 ML per her orders. Her intake recorded for [DATE] was 537 ml; for [DATE] through [DATE] there was no intake recorded; for [DATE] it was 397 ml; for [DATE] it was 567 ML; for [DATE] it was 1141 ML. Review of Resident #2's weight record revealed, on [DATE], she weighed 162.0 pounds, on [DATE], she weighed 161.5 pounds, on [DATE], she weighed 160.5 pounds, on [DATE], she weighed 162.0 pounds, on [DATE] she weighed 136.5 pounds, and on [DATE], she weighed 146.0 pounds. Resident had a gastric tube placed during a hospitalization on [DATE]. The weight loss noted between January and February was due to her lack of appetite with COVID-19, double lung Pneumonia, and lethargy. Review of Resident #2's Departmental Notes, dated, [DATE] at 1:50 PM revealed, Resident remains lethargic, did not eat breakfast or lunch, unable to administer medications due to resident is not alert enough at this time. Review of Resident #2's Departmental Notes, dated [DATE] at 10:35 AM, revealed, DON spoke with family member, NP at Dr (Doctor's formal name) office and the ER (emergency room ) Director regarding tube placement for resident. Plan: Resident departed facility at 10:05 AM with (Ambulance Company Name), 1 female and 1 male attendant, to ER Clarksdale for tube placement evaluation . Review of Resident #2's Admission History and Physical dated [DATE], revealed, she was admitted with a fever of 102.4 degrees. She tested positive for COVID-19. Imaging Results: CXR (chest X-ray) - bilateral pneumonia consistent with COVID-19. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Summary: 84 y/o female admitted to COVID unit due to COVID positive testing with UTI (urinary tract infection), [CONDITION(S)] and staph epi bacteremia .Pt. (patient) also noted to have decreased oral intake which contributed to dehydration and ARF (acute renal failure) on admission. This has improved to baseline. Pt. still has decreased oral intake but will drink fluids and take meds with some prompting. Pt is COVID positive and will need COVID testing to be negative prior to consideration for PEG placement. Health Concerns: Inadequate oral intake. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was changed on [DATE] to House Supplement 2 oz. by mouth three times a day - Chart ,d+[DATE]%, ,d+[DATE]%, 3- 75%, 4- 100%, and 5 - refused. Resident #2 was sent to the emergency room (ER) on [DATE] for a blood glucose that read HI on the glucometer. Review of Resident #2's Nurses notes dated [DATE], at 6:56 AM, revealed, Resident remains on observation for COVID precautions, no s/s (sign or symptoms) of COVID noted at this time. Informed MD of Blood sugar reading of HI. Received new orders to start [MEDICATION(S)] 10 units @ HS (hour of sleep). Novolog with sliding scale and send her to the ER now for elevated blood sugar. Attempted to inform RR (Resident Representative) of new orders and unable to reach him at this time. (formal name of ambulance) called for transfer . Review of nurses notes dated [DATE], at 8:58 AM revealed, 7:25 AM resident exited fac (facility) per (ambulance formal name) accompanied per 2 female EMT's (Emergency Medical Team). No acute distress noted at this time. Review of nurse's notes dated [DATE], at 12:30 PM revealed, RR (Resident Representative) returned call to fac, informed him of order to send to ER for eval secondary to elevated BS (blood sugar). Review of Resident #2's Physician Documentation from the emergency room dated [DATE] revealed, Arrival Date [DATE], Time: 07:44 AM, hospitalization Status: Inpatient Admission, Current Condition: Serious, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a high probability of clinically significant/life threatening deterioration in the patient's condition which required my urgent intervention. This [AGE] year-old black female presents to ER via EMS ground with complaints of High Blood Sugar. Associated symptoms of diaphoresis. Patient was found hypoglycemic today, and she was also [CONDITION(S)] on arrival of EMS. Fluid started by EMS and patient transported here. Correct [CONDITION(S)] initially with fluids and consider insulin when potassium is known . There are signs of severe [CONDITION(S)] in the setting of acute renal failure . At 07:51 AM Blood Glucose: 466 mg/dl, critical glucose levels for an adult: <60 (below 60) or >300 mg/dl (above 300). On [DATE], at 11:45 AM, during an interview with Resident #2's physician, the Medical Director of the facility, she indicated, she was made aware of the blood sugar reading of HI and remembers giving new orders for her insulin and sending her to the emergency room to be evaluated. She stated she had Resident #2's chart in front of her as she spoke on the phone, and there were no prior reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents to know what orders to write. She stated the staff had not made her aware the resident was missing enteral feedings and water flushes from time to time. She stated giving the concentrated enteral feeding without the proper water or not giving Resident #2 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 remained in the hospital throughout the remainder of the survey. Resident #3 Review of Resident #3's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE], during morning rounds at 10:00 AM, Resident #3 was noted to be in her bed, lying on her back with eyes closed. Her mouth was slightly open with dry oral mucosa, dry, scaly lips. G-tube feeding running at 40 ML per hour. Observation on [DATE], during rounds at 2:15 PM, Resident #3 was noted to be in bed, on her left side, with her eyes closed. Mouth remains with dry scaly lips. Mouth is closed at this time, cannot visualize oral mucosa. Review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20 FR G-tube to provide 1320 cal, 59 Grams protein, 1909 free H2O/2100 total FLD (fluid), 90% RDI (Recommended Daily Intake). During an interview with the DON on [DATE], at 3:15 PM, when asked by the SA how intake was calculated, and what do the initials on the MAR mean for the enteral feeding orders, she stated they are checking to make sure the pump is on and running at the rate it is supposed to be running at. When asked how the nurses are to know if the resident has received the required amount of enteral feeding and fluid for the day, she stated they would rely on the intake and output record to tell that. The facility was transitioning from paper MARs to electronic MARs in the month of February. Resident #3's Tube Feeding Records where intake and output were to be recorded manually, and her Tube Feeding Report Roster where intake and output were to be recorded in the computer were compared to reveal a lack of documentation for [DATE] for day and night shifts, [DATE] for day and evening shifts, [DATE] for day shift, [DATE] for day shift, [DATE] for day shift, [DATE] for day and evening shifts, [DATE] for day and evening shifts, [DATE] for evening shift, [DATE] for day shift, [DATE] for evening shift, and [DATE] for evening shift. Resident #3, per her Physicians Orders, was to receive 2100 ML of fluid a day between her enteral feeding and her water flushes. In the month of February, there were 12 days in which she received significantly less than her allotted amount: [DATE] at 675 cc, [DATE] at 720 cc, [DATE] at 1,402 cc, [DATE] at 1,325 cc, [DATE] at 1,451 cc, [DATE] at 739 cc, [DATE] at 835 cc, [DATE] at 1,555 cc, [DATE] at 1,344 cc, [DATE] at 1,384 cc, [DATE] at 1,081 cc, and [DATE] at 1,647 cc. Review of Resident #3's Tube Feeding Report Roster for the month of [DATE] revealed a lack of documentation on [DATE] for day shift, and on [DATE] for evening shift. Further review of Resident #3's Tube Feeding Report Roster for the month of [DATE] revealed 10 days from [DATE] through [DATE], in which she received significantly less than her allotted amount: [DATE] at 1,220 cc, [DATE] at 1,781 cc, [DATE] at 1,576 cc, [DATE] at 1,760 cc, [DATE] at 1,798 cc, [DATE] at 1,131 cc, [DATE] at 1,542 cc, [DATE] at 1,193 cc, [DATE] at 1,587 cc, [DATE] at 1,001 cc, and [DATE] at 1,748 cc. The facility provided an acceptable removal plan on [DATE], for the IJ and review of the facility's removal plan revealed the facility took the following actions to remove the IJ: Removal Plan On [DATE] at 2:45pm State Agency notified the Administrator that the facility was in an Immediate Jeopardy (IJ) and templates were provided to the Administrator. The facility failed to appropriately document the amount of enteral feedings, and flushes for Resident #1 and Resident The facility failed to maintain Resident's blood glucose levels within an acceptable parameter for Resident #1 and Resident #2. The facility failed to provide appropriate goods and services to Residents necessary to avoid physical harm, pain, mental anguish, or emotional distress by not providing enteral feedings, water flushes and insulin per physician orders. 1. On [DATE], at 7:20PM Resident #1 was found unresponsive. A blood glucose was checked on Resident #1 with a blood glucose testing device indicating a HI reading. Emergency services were notified at approximately 7:20PM and Resident #1 was transported by ambulance to local hospital #1. Resident #1 expired on [DATE] at approximately 9:06PM in the emergency room at local hospital #1. On [DATE] at 6:50 AM blood glucose was checked on Resident #2 with a blood glucose testing device indicating a HI reading. Physician #1 was notified on [DATE] at approximately 6:56am and orders were received to transfer Resident #1 to local hospital #1. Resident #2 was transferred on [DATE] at approximately 7:25am by ambulance to the emergency room of local hospital #1. Resident # 2 remains in the hospital at this time. 2. Director of Nurses (DON) and Registered Nurse (RN) #2 immediately initiated in-services with Registered Nurses and Licensed Nurses on [DATE], at 3:10PM on Tube Feedings, Drug Administration & Documentation including electronic medication administration records and Incident Investigation & Reporting, related to abuse and neglect Director of Nurses (DON) and Registered Nurse (RN) #2 initiated in-services with Registered Nurses and Licensed Nurses on [DATE] at 4:00PM on [CONDITION(S)] and [CONDITION(S)]. In-services will be on-going, and no nurses win be allowed to work until participation of the in-services for Tube Feedings, Drug Administration & Documentation including electronic medication administration records, and Incident Investigation & Reporting related to abuse and neglect, [CONDITION(S)] and [CONDITION(S)]. During the week of February 22, 2021 through February 26, 2021 initial training was provided to all nursing department staff concerning implementation of the new electronic charting system and the electronic Medication Administration Record by Registered Nurse (RN) #2. This training is an ongoing process for all new staff and existing staff as changes are made to the system. 3. The facility Quality Assurance Committee Meeting was held on Thursday, [DATE], at 3:50PM, with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director Infection Preventionist, Registered Nurses (RN) Registered Nurse (RN) #2, Registered Nurse (RN) #3, Registered Nurse (RN) #4, and Licensed Practical Nurse (LPN) #1. Topics discussed included Enteral Feedings, Insulin Administration, [TRUNCATED]

Based on record review, staff interview, and facility policy review, the facility failed to provide goods and services related to diabetic medications for five (5) of eight (8) residents reviewed of 11 insulin dependent diabetics, Residents #1, #2, #4, #5 and #6. The facility's failure to provide goods and services related to diabetic medications placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1, hospitalization of Resident #2, and was likely to cause serious injury, harm, impairment, or death for other residents requiring enteral feedings and insulin. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE] when the facility failed to provide goods and services related to diabetic medications and the resident was hospitalized with [CONDITION(S)]. This failure resulted in the hospitalization of two (2) residents for critical high blood glucose levels, with one passing away. These actions placed all residents receiving diabetic medications and requiring insulin in a situation that was likely to cause serious harm, injury, impairment, and further death. On [DATE], at 2:45 PM, SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the NHA with the IJ template. The IJ and SQC existed at: §483.45(f)(2) Residents are free of any significant medication errors (F760) - Scope and Severity - K. The facility submitted a credible Removal Plan on [DATE] at 9:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s): §483.45(f)(2) Residents are free of any significant medication errors (F760) was lowered from a K level of scope and severity to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Drug Administration and Documentation dated ,d+[DATE], revealed, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed properly labeled container (including a unit dose container), verifying it with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For electronic medication administration (EMAR), any medication not administered is indicated by an N in the block with a note of explanation as to why medication was not administered . Resident #1 Review of Resident #1's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:45 AM, during an interview with Resident #1's daughter, she stated the following, I received a phone call from the facility at a few minutes till 9:00 at night that my mom was unresponsive. I asked the nurse what that meant, and she said she is not responding when we touch her or talk to her, she is just staring at the ceiling and breathing funny. The nurse said she was calling 911 and sending her out to the hospital. I waited a little bit and then called the emergency room to see how my mom was. A male nurse answered the phone, I told him who I was and asked if my mother was there. He told me to wait a minute. A doctor, I think his name was (formal name) got on the phone and told me I needed to come to the hospital as quickly as I could. I asked him why, is my mother already gone? He told me she was gone and had been gone for a little while. He said she was DOA (dead on arrival), and they worked on her for about 15 minutes. They had to give her 4 [MEDICATION(S)] shots and that did not work. I asked him if he knew her blood sugar was sky high and registered HI on the glucometer when she left the nursing home. He stated he was not aware of her high sugar. They were focused on doing CPR and trying to resuscitate her at the time. The doctor stated her blood sugar was elevated when she had been in the emergency room a week and a half prior, and that one of two things was happening. Either the nurses were not giving my mother her water in the tube and giving her concentrated feeding would cause her blood sugars to be high, or they were not giving her the diabetic insulin or pills in the tube. She was getting all her food through the tube, so it was not like she was eating a piece of pie or sugar. The facility should have been able to regulate her blood sugar better than they did. I am convinced the facility has not been feeding and giving my mom water like they should be, and they are not giving her the insulin and pills like they should be either. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cubic Centimeters an Hour) continuous via #20 fr (French), Blood Sugar after breakfast every 2 weeks at 9:00 AM, call Dr (Formal name) with results if <60 or >400, call s/s (signs and symptoms) if needed, [MEDICATION(S)] 24 units sub Q (subcutaneous) at 9:00 PM. Rotate SQ site, and [MEDICATION(S)] 5 mg (milligram) tablet per (by) G-tube daily at 9:00 AM. Review of Resident #1's Medication Administration Record (MAR) for the month of February, prior to her hospitalization on [DATE]rd, 2021, revealed, from February 5th, 2021 through February 16th, 2021, there were no initials of completion for the following: Flush G-tube with 250 milliliters (ml) H2O (water) three times a day at 5 AM, 1 PM, and 5 PM via #20 FR (French) tube 10 CC (cubic centimeters) Bulb on [DATE] at both 5:00 AM and 9:00 PM; Flush G-tube with 30 cc H2O ACPC (before and after) meds for night shift on [DATE], days and evening shifts on [DATE], and evening shift on [DATE]; Flush G-tube with 5 ml H2O between each medication on night shift [DATE], day shift on [DATE], and evening shift on [DATE]; [MEDICATION(S)] 5 mg tablet 1 per G-tube daily @ 9 AM for [DATE]; [MEDICATION(S)] 24 units sub Q at 9:00 PM, Rotate SQ site for [DATE]; Diabetasource 25 ML per #20 FR tube continuous at 11:00pm on [DATE], 3:00pm and 11:00pm on [DATE]. The facility was transitioning from paper MARs to electronic MARs in the month of February. Further review of Resident #1's February MAR, upon her return to the facility, revealed multiple days with N recorded in the boxes. During an interview with Medical Records (MR) on [DATE] at 11:30 AM, revealed, the N meant Not Administered and if a nurse put N in the box, she was to put an explanation why it was not done or given in the detail notes. If there was no documentation in the detail notes there was no other place to document, why it was not given. It was noted that all the days with N recorded, the nurse's initials were all the same. When asked by the SA, why the same initials were on all three shift and different days, Medical Records stated, when we went to electronic MAR's when a medication was not given, it will flash red on the screen because it is overdue. The Director of Nurses (DON) got tired of seeing the screen flash red, so she went into the MAR and filled in all the holes with an N so it would clear her screen up. Review of Resident #1's February 2021 MAR from [DATE] through [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detail notes revealed no documentation as to the reason why the [MEDICATION(S)] was not given. An order to Flush G-tube with 200 cc H2O every 4 hours (dated [DATE] and discontinued on [DATE]) had Ns documented on [DATE] at 5:00 PM and 9:00 PM, and [DATE] at 5:00 AM; review of the detail notes revealed no documentation as to the reason why the flushes were not administered. A new order to Flush G-tube with 200 ML H2O every six hours had Ns at 6:00 PM on [DATE] and 6:00 PM on [DATE]. Review of the detail notes revealed no documentation as to the reason why the flushes had not been administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MAR for [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the detailed notes of the reason it was not administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detailed notes for these days revealed there was no reason documented for why the enteral feeding and flushes were not administered. Review of Resident #1's Admission History and Physical dated [DATE], revealed Resident #1 was admitted to the hospital on [DATE] for Urosepsis, [CONDITION(S)], and an Acute Kidney Injury requiring a bolus of 3 liters of fluid in the emergency room . Further review of Resident #1's Admission History and Physical dated [DATE], revealed she had been brought to the emergency room (ER)with reports of fever and tachycardia, and her labs revealed lactic acidosis, leukocytosis, [CONDITION(S)], and an acute kidney injury. Further review revealed her Sodium Level was 146 (high), and her glucose was 524 (high). Under an Assessments section she had the follow diagnoses, [CONDITION(S)], Urinary Tract Infectious Disease, Lactic Acidosis, [CONDITION(S)] and [CONDITION(S)]. Under the Plan: section it stated, [AGE] year-old African American female admitted with Urosepsis and Acute Kidney Injury .Patient now status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue IV (intravenous) hydration .[CONDITION(S)]: Serum Sodium 146 on admission. Will adjust fluids as needed .[CONDITION(S)]: Known history of Diabetes Mellitus. Glucose 524 on arrival to the ER. Patient now s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Ordering Accuchecks Q 4 (every 4) hours and [MEDICATION(S)] per sliding scale. Holding [MEDICATION(S)] until tube feeds are resumed . On [DATE] at 3:15 PM, in an interview with the Director of Nursing (DON), when asked if the facility could show Resident #1 had received her enteral feeding, water flushes and diabetic medications from [DATE] through [DATE], to help prevent her hospitalization on [DATE], she stated, not if it is not written in the nurses notes or on the MAR. The nurses should be putting that information into the computer. I am not sure what the N means. This computer system is new, and I don't know anything at all about it yet . Review of Resident #1's Nurses notes dated [DATE] at 10:53 PM revealed, 7:20 PM - Summoned to resident's room per C.N.A. (Certified Nurse Aide), resident noted lying in bed, increased resp (respirations) sweating. Blood sugar called for primary nurse. Checked registered HI on the blood glucose meter. She did not respond to verbal or tactile stimuli . Review of Resident #1's Nurses Notes dated [DATE] at 11:04 PM revealed, Summoned to resident room after supervisor noted that resident was not responding. Resident was still breathing but not responding, cold sweats noted coming from resident blood sugar check and were unreadable, 911 called immediately. Around 7:30 PM ambulance arrived and headed to ER with resident, received a called from ER, nurse stated that resident had coded and passed away. Family members notified. Neither nurses note regarding the event made mention of notifying the Physician of Resident #1's condition, departure for the emergency room , or later demise. Review of Resident #1's Physician Documentation from the Emergency Department revealed, Arrival date: [DATE] at 9:04 PM . Location: Morgue, Pronouncing Physician: (Formal Name), Time of Death: 9:06 PM, Diagnosis - [CONDITION(S)], Acute Respiratory Failure XXX[AGE] year-old female who presents to the emergency room in respiratory distress with palpable pulses initially. Pulses loss CPR initiated. Patient intubated. CPR performed for 14 minutes with multiple rounds of [MEDICATION(S)] and 1 of [MEDICATION(S)] given. 1 Liter bolus began. Patient pronounced at 9:06 PM. Patient without any palpable pulses or visible chest rise. Patient without an auditory breath sounds or cardiac sounds. Patient pupils fixed and dilated. No corneal reflex of patient are responsive to verbal or painful stimuli. Family notified. On [DATE] at 11:45 AM, during an interview with Resident #1's physician, the Medical Director of the facility, she indicated, she was not fully aware of the entire incident with (formal name) (Resident #1), with all the details. When Resident #1's current diabetic orders and enteral feeding orders were reviewed with the physician, she stated, the orders were not correct. She would not give blood sugar check orders like they were written. She indicated the order should have read to check blood glucose every morning at 9:00 AM, and to send them to the doctor every two weeks for review. If blood sugar is <60 or >400, notified the Physician. She indicated the blood sugar check order written as it was, did not make any sense with regard to glucose control. She indicated she was not aware the Residents blood sugar had read HI prior to being sent out and stated that Resident #1's blood sugars had not been being sent to her office for review. She stated she had Resident #1's chart in front of her as she spoke on the phone, and there were no reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents in order to know what orders to write. She stated the staff had not made her aware the Resident was missing enteral feedings, water flushes and her diabetic meds from time to time, and definitely not for several days in a row prior to her last hospitalization . She stated, had she been made aware of the resident's elevated blood sugar, she would have written orders accordingly. When the SA informed her of the daughter's concerns, and the items mentioned to her by the emergency room Physician, she agreed with the resident having a controlled food and fluid source and should have been better regulated with her glucose levels. She agreed that giving the concentrated enteral feeding without the proper water or not giving Resident #1 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 Review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] <60 or >500, Report blood sugar to MD every 2 weeks; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate site; [MEDICATION(S)] 100 mg tablet by mouth daily; and [MEDICATION(S)] (Hydrochloride) 500 mg tablet by mouth twice a day. Review of Resident #2's MAR for February 2021 revealed, missing blood glucose readings for 4:00 PM on [DATE], and 6:00 AM and 4:00 PM blood glucose readings on [DATE], [DATE], [DATE], and [DATE]; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate SQ site, with missing initials of completion at 9:00 PM on [DATE], 9:00 AM on [DATE], and 9:00 AM and 9:00 PM for [DATE], [DATE], [DATE], [DATE], and [DATE]; Report blood sugar to MD every 2 weeks, with missing initials of completion on [DATE] and [DATE]. During a review of an Insulin Report provided by the facility's pharmacy for [DATE] through [DATE] revealed, Resident #2 had 3 [MEDICATION(S)] 100 units/ML Flex Pen ordered. Each Flex Pen holds 3 ML of insulin, to equal 300 ML of insulin per pen. Review of Resident #2's Physicians Orders revealed, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Rotate SQ site. The order was dated [DATE] to [DATE]. She experienced multiple hospitalization s over the last six months and was not in the building from [DATE] through [DATE], from [DATE] through [DATE], and [DATE] through [DATE]. The sum total of days she was not in the facility in the last 6 months equals 20 days. There have been 205 days in the last 6 months, minus the 20 days Resident #2 was out of the building equals 185 days. 185 days multiplied by the 56 units of [MEDICATION(S)] needed a day for Resident #2 to receive her ordered amount equaled 10,360 units. With each [MEDICATION(S)] Flex Pen holding 300 Units each, Resident #2 should have had 35 Flex Pens ordered from the pharmacy, and only had 3 ordered. During a joint interview with the Administrator and DON on [DATE], at 1:30 PM, the calculations were shared by the SA, and that the facility was 32 Flex Pens short of insulin for Resident #2. When asked what those findings meant, the DON stated, unless they borrowed from another resident, it means she didn't get all of her insulin like she should have. Review of Resident #2's MAR for [DATE] revealed, Report Blood sugar to MD every two weeks with missing initials for [DATE] or [DATE]; [MEDICATION(S)] 28 units SubQ at bedtime, rotate SUBQ sites, with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 100 mg tablet by mouth daily with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 500 mg tablet by mouth twice a day, with missing initials for 9:00 AM and 5:00 PM on [DATE]. Resident #2 was hospitalized from [DATE] through [DATE] for the placement of a Gastric Tube to help supplement her intakes. Review of Resident #2's March MAR after her return on [DATE] revealed orders to report blood sugars to MD every 2 weeks on the 9th and 23rd of every month. Both dates were missing initials of completion for the month of [DATE]. She did not return from the hospital with any insulin orders. Resident #2 was sent to the emergency room (ER) on [DATE] for a blood glucose that read HI on the glucometer. Review of Resident #2's Nurses notes dated [DATE], at 6:56 AM, revealed, Resident remains on observation for COVID precautions, no s/s (sign or symptoms) of COVID noted at this time. Informed MD of Blood sugar reading of HI. Received new orders to start [MEDICATION(S)] 10 units @ HS (hour of sleep). Novolog with sliding scale and send her to the ER now for elevated blood sugar. Attempted to inform RR (Resident Representative) of new orders and unable to reach him at this time. (formal name of ambulance) called for transfer . Review of nurses notes dated [DATE], at 8:58 AM revealed, 7:25 AM resident exited fac (facility) per (ambulance formal name) accompanied per 2 female EMT's (Emergency Medical Team). No acute distress noted at this time. Review of nurse's notes dated [DATE], at 12:30 PM revealed, RR returned call to fac, informed him of order to send to ER for eval secondary to elevated BS (blood sugar). Review of Resident #2's Physician Documentation from the emergency room dated [DATE] revealed, Arrival Date [DATE], Time: 07:44 AM, hospitalization Status: Inpatient Admission, Current Condition: Serious, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a high probability of clinically significant/life threatening deterioration in the patient's condition which required my urgent intervention. This [AGE] year-old black female presents to ER via EMS ground with complaints of High Blood Sugar. Associated symptoms of diaphoresis. Patient was found hypoglycemic today, and she was also [CONDITION(S)] on arrival of EMS. Fluid started by EMS and patient transported here. Correct [CONDITION(S)] initially with fluids and consider insulin when potassium is known . There are signs of severe [CONDITION(S)] in the setting of acute renal failure . At 07:51 AM Blood Glucose: 466 mg/dl, critical glucose levels for an adult: <60 (below 60) or >300 mg/dl (above 300). On [DATE], at 11:45 AM, during an interview with Resident #2's physician, the Medical Director of the facility, she indicated, she was made aware of the blood sugar reading of HI and remembers giving new orders for her insulin and sending her to the emergency room to be evaluated. She stated she had Resident #2's chart in front of her as she spoke on the phone, and there were no prior reports of staff calling blood glucose results to her office for review. She indicated she had a Nurse Practitioner (NP) that worked with her, and both had been doing virtual visits with the residents due to COVID-19, so they were relying on the staff to tell them what was going on with the residents in order to know what orders to write. She stated the staff had not made her aware the resident was missing enteral feedings and water flushes from time to time. She stated giving the concentrated enteral feeding without the proper water or not giving Resident #2 her insulin and oral medications could affect her blood sugar levels and cause them to run high. Resident #2 remained in the hospital throughout the remainder of the survey. Resident #4 Review of Resident #4's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Physicians Orders for [DATE] revealed the following orders: Blood sugar checks ACHS (before meals and at hour of sleep); notify MD if BS <60 and >500; [MEDICATION(S)] 45 units subQ every morning at 9:00 AM. Rotate SQ site, and [MEDICATION(S)] 5 MG tablet, give 1 tab (tablet) by mouth once daily. Review of Resident #4's MAR for [DATE] revealed Ns (Not Administered) for [MEDICATION(S)] 5 MG at 9:00 AM on [DATE], [DATE], and [DATE] and [MEDICATION(S)] 45 units Sub Q at 9:00 AM for [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the detailed notes for these days revealed no documentation as to why the medications were not given. Review of Resident #4's list of Minimum Data Set (MDS) completion dates revealed no transfers/discharges from the facility for any reason since [DATE]. During a review of an Insulin Report provided by the facility's pharmacy for [DATE] through [DATE] revealed, Resident #4 had 6 bottles of [MEDICATION(S)] 100 units/ml ordered. Each bottle of [MEDICATION(S)] has 10 ML in it to total 1,000 units per bottle. Resident #4 has an order dated [DATE] through present for [MEDICATION(S)] 45 units every morning at 9:00 AM. From [DATE]st, 2020 through [DATE]th, 2021, there have been 205 days. 205 days multiplied by 45 units a day equals 9,225 units required to meet her insulin needs over the last 6 months. At 1,000 units per bottle, it would have required 10 bottles of [MEDICATION(S)] to be ordered, and only 6 bottles had been ordered and sent. During a joint interview with the Administrator and DON on [DATE], at 1:30 PM, the calculations were shared by the SA, and that the facility was 4 bottles short of insulin for Resident #4. When asked what those findings meant, the DON stated, unless they borrowed from another resident, or took a bottle from house stock and didn't assign it to her, it means she didn't get all of her insulin like she should have. Resident #5 Review of Resident #5's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD if BS blood sugar) <60 or >400; and [MEDICATION(S)] 55 units SubQ at bedtime, rotate SQ site. Review of Resident #5's [DATE] MAR revealed an N (not administered) on [DATE] for both 4:00 PM and 8:00 PM for Blood Sugar checks before meals and at bedtime. Another order was noted for [MEDICATION(S)] 55 units at bedtime, with an N marked for [DATE] at 8:00 PM. Review of Resident #5's list of Minimum Data Set (MDS) completion dates from [DATE] through [DATE], revealed a one-day discharge from the facility from [DATE] through [DATE]. During a review of an Insulin Report provided by the facility's pharmacy for [DATE] through [DATE] revealed, Resident #5 had 7 bottles of [MEDICATION(S)] 100 units/ml ordered. Each bottle of [MEDICATION(S)] has 10 ML in it to total 1,000 units per bottle. Resident #5 had an order dated [DATE], through present, for [MEDICATION(S)] 55 units daily at bedtime. From [DATE]st, 2020 through [DATE]th, 2021, she has been in the facility 204 days. 204 days multiplied by 55 units a day equals 11,220 units required to meet her insulin needs over the past 6 months. At 1,000 units per bottle, it would have required 12 bottles of [MEDICATION(S)] to be ordered, and only 7 bottles had been ordered and sent. During a joint interview with the Administrator and DON on [DATE] at 1:30 PM, the calculations were shared by the SA, and that the facility was 5 bottles short of insulin for Resident #5. When asked what those findings meant, the DON stated, unless they borrowed from another resident, or took a bottle from house stock and didn't assign it to her, it means she didn't get all of her insulin like she should have. Resident #6 Review of Resident #6's Face Sheet revealed, she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Physicians Orders [DATE] revealed orders for the following: BGFS before meals and at bedtime with the following Novolog ,d+[DATE] mix 25 units with supper rotate SQ site; and Novolog ,d+[DATE] 50 units Sub Q with breakfast, rotate SQ site. Review of Resident #6's [DATE] MAR revealed no missed doses of insulin. Review of Resident #6's Minimum Data Set (MDS) completion dates revealed he had been discharged from the facility from [DATE] through [DATE], for a total of 20 days. During a review of an Insulin Report provided by the facility's pharmacy for [DATE] through [DATE] revealed, Resident #6 had 8 bottles of Novolog ,d+[DATE] Mix 100 units/ml ordered. Each bottle of Novolog has 10 ML in it to total 1,000 units per bottle. Resident #6 had an order dated [DATE], through present, for [MEDICATION(S)] 55 units daily at bedtime. From [DATE]st, 2020 through [DATE]th, 2021, he had been in the facility 187 days. His insulin needs changed to reflect: From [DATE] through [DATE] he required 40 units of Novolog ,d+[DATE] at Breakfast, and 20 units of Novolog ,d+[DATE] at supper to equal 60 units a day. 60 units a day multiplied by 73 days equals 4,380 units of insulin. From [DATE] through [DATE], when he was discharged to the hospital, he required 45 units of Novolog ,d+[DATE] at breakfast, and 25 units of Novolog ,d+[DATE] at supper time to equal 70 units a day. 70 units a day multiplied by 64 days equals 4,480 units of insulin. From [DATE] through [DATE] he required 45 units of Novolog ,d+[DATE] at breakfast, and 25 units of Novolog ,d+[DATE] at supper to equal 70 units per day. 70 units per day multiplied by 9 days equals 630 units of insulin. From [DATE] through [DATE] he required 50 units of Novolog ,d+[DATE] for breakfast, and 25 units of Novolog ,d+[DATE] for supper to equal 900 units of insulin. So, from [DATE] through [DATE], Resident #6 required 10,390 units of insulin to meet his needs over the last 6 months. At 1,000 units per bottle, he would have required 11 bottles of Novolog ,d+[DATE] to be ordered, and only 8 bottles were ordered and sent. During a joint interview with the Administrator and DON on [DATE] at 1:30 PM, the calculations were shared by the SA, and that the facility was 3 bottles short of insulin for Resident #5. When asked what those findings meant, the DON stated, unless they borrowed from another resident, or took a bottle from house stock and didn't assign it to him, since there were no holes in the MAR, they were signing they gave him the insulin and then didn't administer it. On [DATE], at 10:15 AM, during an interview and observation with the Director of Nursing (DON) on the North Nursing station in the Medication Room revealed, no Stock Insulin in the medication refrigerator, the emergency drug kit, the emergency intravenous (IV) drug kit or anywhere else in the medication room. DON stated she could not find where there was any stock insulin in the medication room. SA and DON reviewed the list of medications stored in the Emergency Drug Kit (EDK) and no insulin was listed. DON and SA walked to South wing and looked through the medication storage room and no stock insulin was found in the refrigerator on in the room. The DON revealed that when the nurse removes a drug from the EDK they must fill out a form listing the drug, the resident's name and the date and time. The form is then faxed to the Pharmacy so they can have a record and replace the drug. The DON revealed she has the copy of all the forms in a binder in her office. Record review of the fax transmission list, with the DON revealed no forms faxed to the Pharmacy for February and March revealed any Insulin taken from the EDK. On [DATE] at 10:25 AM an interview and observation with LPN #3 and the medication nurse revealed there was no Insulin in the North medication room, the EDK box or in the IV EDK box. LPN #3 revealed no Insulin listed on the list of medications on the outside of the EDK box or inside of the EDK IV box. On [DATE] at 10:35 AM during an interview with the Pharmacist at the Pharmacy that supplies stock medications in the EDK boxes and for the facility, he revealed they stopped suppling stock insulin years ago because it would not be used, would expire, and the insurance company would not pay for it and they would be stuck with a $300.00 vial they had to destroy. The Pharmacist revealed when they get a new order for a sliding scale insulin, they send an ordered insulin vial to the facility and then the facility lets them know when the Insulin needs to be replaced. < [TRUNCATED]

Based on record review, staff interview, and facility policy review, the facility failed to maintain medical records that were complete, accurately documented and reflected the resident's condition, care and services for three (3) out of four (4) residents reviewed of eight (8) residents requiring enteral feedings: Resident #1, #2 and #3, and for five (4) of eight (8) residents reviewed of 11 insulin dependent diabetics, Residents #1, #2, #4, and #5. The facility's failure to maintain the medical records in a manner that was complete, accurately documented and reflected the resident's condition, care, and services related to enteral feedings, enteral water flushes and diabetic medications placed residents at risk, and in a situation, which caused serious injury and death for one (1) resident, Resident #1 , hospitalization of Resident #2, and was likely to cause serious injury, harm, impairment, or death for other residents requiring enteral feedings and insulin. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to provide goods and services related to enteral feedings, enteral water flushes and diabetic medications and the resident was hospitalized with [CONDITION(S)]. This failure resulted in the hospitalization of two (2) residents for critical blood glucose levels, with one passing away. These actions placed all residents in the facility, receiving enteral feedings and requiring insulin in a situation that was likely to cause serious harm, injury, impairment, and further death. On [DATE] at 2:45 PM, SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the NHA with the IJ template. The IJ and SQC existed at: §483.70 (i) Medical Records (F842) - Scope and Severity - K The facility submitted a credible Removal Plan on [DATE] at 9:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to their exit. Therefore, the scope and severity for 42 CFR(s): §483.70 Medical Records (F842) was lowered from a K level of scope and severity to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy titled, Medical Records dated ,d+[DATE] revealed, the facility maintains a separate resident record on each resident in accordance with regulations and accepted professional standards and practices that are complete accurate, readily accessible and systematically organized. The purpose of the clinical record is to document the course of the resident's plan of care and to provide for communication among health care professionals and interdisciplinary team members involved in the plan of care. Record review of the facility's policy titled, Tube Feedings dated ,d+[DATE] revealed, 1. All tube feedings will be administered in accordance with verified medical necessity .3. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tube feeding, I&O (intake and output) should be documented each shift in the electronic medical record for electronic facilities. Non-electronic facilities should document I&O each shift using FORM NS-683 - TUBE Feeding Records. Record review of the facility's policy titled, Intake and Output Measurement dated ,d+[DATE], revealed, Purpose: To maintain an accurate measurement of the resident's intake and output to assess fluid balance .Procedure . 3. Measure and record all liquids ingested . 8. When enteral nutritional therapy, hypodermoclysis or intravenous fluid is administered, record amount on individual record . 11. Document intake and/or output . 12. Intake and output are totaled every twenty-four hours . 13. The nurse is responsible to evaluate the total I & O per shift. If the intake and output is not adequate, notify the nursing supervisor and the physician . 14. If the resident is receiving TPN, IV therapy, tube feeding, or flushes the nurse is responsible to clear the pump at the end of the shift and a record the total on the I & O record. Record review of the facility's policy titled, Drug Administration and Documentation dated ,d+[DATE], revealed, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed properly labeled container (including a unit dose container), verifying it with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For electronic medication administration (EMAR), any medication not administered is indicated by an N in the block with a note of explanation as to why medication was not administered . Chart each resident's medication on the Medication Administration Record (MAR) immediately after it is administered, as well as any administration special requirements as they are obtained and any refused or withheld medication. Resident #1 Record review of Resident #1's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on [DATE] at 11:45 AM, with Resident #1's daughter, she stated the following, I received a phone call from the facility at a few minutes till 9:00 at night that my mom was unresponsive. I asked the nurse what that meant, and she said she is not responding when we touch her or talk to her, she is just staring at the ceiling and breathing funny. The nurse said she was calling 911 and sending her out to the hospital. I waited a little bit and then called the emergency room to see how my mom was. A male nurse answered the phone, I told him who I was and asked if my mother was there. He told me to wait a minute. A doctor, I think his name was (formal name) got on the phone and told me I needed to come to the hospital as quickly as I could. I asked him why, is my mother already gone? He told me she was gone and had been gone for a little while. He said she was DOA (dead on arrival), and they worked on her for about 15 minutes. They had to give her 4 [MEDICATION(S)] shots and that did not work. I asked him if he knew her blood sugar was sky high and registered HI on the glucometer when she left the nursing home. He stated he was not aware of her high sugar. They were focused on doing CPR and trying to resuscitate her at the time. The doctor stated her blood sugar was elevated when she had been in the emergency room a week and a half prior, and that one of two things was happening. Either the nurses were not giving my mother her water in the tube and giving her concentrated feeding would cause her blood sugars to be high, or they were not giving her the diabetic insulin or pills in the tube. She was getting all her food through the tube, so it was not like she was eating a piece of pie or sugar. The facility should have been able to regulate her blood sugar better than they did. I am convinced the facility has not been feeding and giving my mom water like they should be, and they are not giving her the insulin and pills like they should be either. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cubic Centimeters an Hour) continuous via #20 fr (French), Blood Sugar after breakfast every 2 weeks at 9:00 AM, call Dr (Formal name) with results if <60 or >400, call s/s (signs and symptoms) if needed, [MEDICATION(S)] 24 units sub Q (subcutaneous) at 9:00 PM. Rotate SQ site, and [MEDICATION(S)] 5 mg (milligram) tablet per (by) G-tube daily at 9:00 AM. Record review of Resident #1's MAR for the month of February, prior to her hospitalization on [DATE]rd, 2021, revealed, from February 5th, 2021 through February 16th, 2021, there were no initials of completion for the following: Flush G-tube with 250 milliliters (ml) H2O (water) three times a day at 5 AM, 1 PM, and 5 PM via #20 FR (French) tube 10 CC (cubic centimeters) Bulb on [DATE] at both 5:00 AM and 9:00 PM; Flush G-tube with 30 cc H2O ACPC (before and after) meds for night shift on [DATE], days and evening shifts on [DATE], and evening shift on [DATE]; Flush G-tube with 5 ml H2O between each medication on night shift [DATE], day shift on [DATE], and evening shift on [DATE]; [MEDICATION(S)] 5 mg tablet 1 per G-tube daily @ 9 AM for [DATE]; [MEDICATION(S)] 24 units sub Q at 9:00 PM, Rotate SQ site for [DATE]; Diabetasource 25 ML per #20 FR tube continuous at 11:00pm on [DATE], 3:00pm and 11:00pm on [DATE]. Further review of Resident #1's February MAR, upon her return to the facility, revealed multiple days with N recorded in the boxes. On [DATE] at 11:30 AM an interview with Medical Records (MR), revealed, the N meant Not Administered and if a nurse put N in the box, she was to put an explanation why it was not done or given in the detail notes. If there was no documentation in the detail notes there was no other place to document, why it was not given. It was noted that all the days with N recorded, the nurse's initials were all the same. When asked by the SA, why the same initials were on all three shift and different days, Medical Records stated, when we went to electronic MAR's when a medication was not given, it will flash red on the screen because it is overdue. The Director of Nursing (DON) got tired of seeing the screen flash red, so she went into the MAR and filled in all the holes with an N so it would clear her screen up. Record review of Resident #1's February 2021 MAR from [DATE] through [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detail notes revealed no documentation as to the reason why the [MEDICATION(S)] was not given. An order to Flush G-tube with 200 cc H2O every 4 hours (dated [DATE] and discontinued on [DATE]) had Ns documented on [DATE] at 5:00 PM and 9:00 PM, and [DATE] at 5:00 AM; review of the detail notes revealed no documentation as to the reason why the flushes were not administered. A new order to Flush G-tube with 200 ML H2O every six hours had Ns at 6:00 PM on [DATE] and 6:00 PM on [DATE]. Review of the detail notes revealed no documentation as to the reason why the flushes had not been administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was making a transition from paper MARs to electronic MARs in the month of February. Resident #1's Tube Feeding Records where intake and output were to be recorded manually, and her Tube Feeding Report Roster where intake and output were to be recorded in the computer were compared to reveal a lack of documentation for night shift on [DATE] and [DATE]; day shift and evening shift on [DATE]; day shift on [DATE]; evening and night shift on [DATE]; evening and night shift on [DATE]; evening shift on [DATE]; evening and night shift on [DATE]; and night shift on [DATE]. Resident #1's 24-hour totals for enteral feeding and water flushes were to be: [DATE] through [DATE] - 250 cc flushes three times a day to equal 750 cc, and 25 cc an hour of Diabetasource continuous to equal 600 cc. Together Resident #1 should have received a total of 1350 cc through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 680 cc, [DATE] at 732 cc, and [DATE] at 500 cc. For the dates of [DATE] through [DATE], Resident #1's 24-hour totals for enteral feeding and water flushes were to be: 200 cc flushes four times a day to equal 800 cc, and 55 cc an hour of Diabetasource to total 1320 cc. Together, Resident #1 should have received 2120 cc total through her G-tube. Review of her daily intakes revealed she did not meet this amount on [DATE] at 757 cc, [DATE] at 1561 cc, [DATE] at 1186 cc and [DATE] at 1152 cc. Record review of Resident #1's MAR for [DATE] revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the detailed notes of the reason it was not administered; an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the detailed notes for these days revealed there was no reason documented for why the enteral feeding and flushes were not administered. Record review of Resident #1's Tube Feeding Report Roster for [DATE] revealed the total intake of enteral feedings and enteral water flushes to be 1180 cc on [DATE], and 800 cc on [DATE]. Resident #1 should have received 2120 cc of feeding and water for each day. An interview with the Director of Nursing (DON), on [DATE] at 3:15 PM revealed when asked if the facility could show Resident #1 had received her enteral feeding, water flushes and diabetic medications from [DATE] through [DATE], to help prevent her hospitalization on [DATE], she stated, not if it is not written in the nurses notes or on the MAR. The nurses should be putting that information into the computer. I am not sure what the N means. This computer system is new, and I do not know anything at all about it yet. On [DATE] at 11:45 AM, during an interview with Resident #1's physician, the Medical Director of the facility, she indicated, the staff had not made her aware the Resident was missing enteral feedings, water flushes and her diabetic meds from time to time, and definitely not for several days in a row prior to her last hospitalization . Resident #2 Record review of Resident #2's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] <60 or >500, Report blood sugar to MD every 2 weeks; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate site; [MEDICATION(S)] 100 mg tablet by mouth daily; and [MEDICATION(S)] (Hydrochloride) 500 mg tablet by mouth twice a day; Push by mouth fluids, give six (6) 16 oz (ounce) of water per day; and Record I & O Q shift with 24-hour total. Record review of Resident #2's MAR for the month of February 2021 revealed, missing blood glucose readings for 4:00 PM on [DATE], and 6:00 AM and 4:00 PM blood glucose readings on [DATE], [DATE], [DATE], and [DATE]; [MEDICATION(S)] Flex pen 28 units SUB Q twice a day with Novofine needle. Rotate SQ site, with missing initials of completion at 9:00 PM on [DATE], 9:00 AM on [DATE], and 9:00 AM and 9:00 PM for [DATE], [DATE], [DATE], [DATE], and [DATE]; Report blood sugar to MD every 2 weeks, with missing initials of completion on [DATE] and [DATE]; Push by mouth fluids, give (6) 16 oz. of water per day - there were no initials of completion for all three shifts for the entire month. Record review of Resident #2's Intake/Output record for February 2021 was completely blank for the entire month. Record review of Resident #2's MAR for [DATE] revealed, Report Blood sugar to MD every two weeks with missing initials for [DATE] or [DATE]; [MEDICATION(S)] 28 units SubQ at bedtime, rotate SUBQ sites, with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 100 mg tablet by mouth daily with missing initials for [DATE] at 9:00 AM; [MEDICATION(S)] 500 mg tablet by mouth twice a day, with missing initials for 9:00 AM and 5:00 PM on [DATE]. Record review of Resident #2's March MAR after her return from the hospital on [DATE] revealed orders for [MEDICATION(S)] Renal Bolus 1 can (250 ML) Q 6 hours, providing 2000 KCAL (kilocalories), 91 G (grams) of protein, 1855 ML H2O, to equal 2135 ML of fluid and 100% of RDI (recommended daily intake); with missing initials for [DATE] at 6:00 AM with no detailed nurses notes for why it was not administered; Another order to Flush tube with 100 ML H2O every 4 hours, with missing initials on [DATE] at 5:00 AM, and on [DATE] at 5:00 AM and 9:00 PM; and an order to report blood sugars to MD every 2 weeks on the 9th and 23rd of every month. Both dates were missing initials of completion for the month of [DATE]. Record review of Resident #2's Tube Feeding Report Roster revealed no recordings of intake or output for her from her readmission on [DATE] through [DATE]. Her daily intake of fluids between her enteral feeding and water flushes was to be 2135 ML per her orders. Her intake recorded for [DATE] was 537 ml; for [DATE] through [DATE] there was no intake recorded; for [DATE] it was 397 ml; for [DATE] it was 567 ML; for [DATE] it was 1141 ML. An interview on [DATE] at 11:45 AM with Resident #2's physician, the Medical Director of the facility, she stated the staff had not made her aware the resident was missing enteral feedings and water flushes from time to time. Throughout the remainder of the survey Resident #2 remained in the hospital. Resident #3. Record review of Resident #3's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Physicians Orders revealed orders for [MEDICATION(S)] per Kangaroo Pump at 40 ml per hour for 22 hours via #20 FR G-tube to provide 1320 cal, 59 grams protein, 1909 free H2O/2100 total FLD (fluid), 90% RDI (Recommended Daily Intake). On [DATE] at 3:15 PM, during an interview with the DON, when asked by the SA how intake was calculated, and what do the initials on the MAR mean for the enteral feeding orders, she stated they are checking to make sure the pump is on and running at the rate it is supposed to be running at. When asked how the nurses are to know if the resident has received the required amount of enteral feeding and fluid for the day, she stated they would rely on the intake and output record to tell that. The facility was transitioning from paper MARs to electronic MARs in the month of February. Resident #3's Tube Feeding Records where intake and output were to be recorded manually, and her Tube Feeding Report Roster were intake and output were to be recorded in the computer were compared to reveal a lack of documentation of [DATE] for day and night shifts, [DATE] for day and evening shifts, [DATE] for day shift, [DATE] for day shift, [DATE] for day shift, [DATE] for day and evening shifts, [DATE] for day and evening shifts, [DATE] for evening shift, [DATE] for day shift, [DATE] for evening shift, and [DATE] for evening shift. Record review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In the month of February, there were 12 days in which she received significantly less than her allotted amount: [DATE] at 675 cc, [DATE] at 720 cc, [DATE] at 1,402 cc, [DATE] at 1,325, [DATE] at 1,451 cc, [DATE] at 739 cc, [DATE] at 835 cc, [DATE] at 1,555 cc, [DATE] at 1,344 cc, [DATE] at 1,384 cc, [DATE] at 1,081 cc, [DATE] at 1,647 cc. Record review of the Tube Feeding Report Roster for Resident #3, for the month of [DATE] revealed a lack of documentation on [DATE] for day shift, and on [DATE] for evening shift. Record review of Resident #3's Tube Feeding Report Roster for the month of [DATE] revealed 10 days from [DATE] through [DATE], in which she received significantly less than her allotted amount: [DATE] at 1,220 cc, [DATE] at 1,781 cc, [DATE] at 1,576 cc, [DATE] at 1,760 cc, [DATE] at 1,798 cc, [DATE] at 1,131 cc, [DATE] at 1,542 cc, [DATE] at 1,193 cc, [DATE] at 1,587 cc, 03 ,d+[DATE] at 1,001 cc and [DATE] at 1,748 cc. Resident #4 Record review of Resident #4's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Physicians Orders for [DATE] revealed the following orders: Blood sugar checks ACHS (before meals and at hour of sleep); notify MD if BS <60 and >500; [MEDICATION(S)] 45 units subQ every morning at 9:00 AM. Rotate SQ site, and [MEDICATION(S)] 5 MG tablet, give 1 tab (tablet) by mouth once daily. Record review of Resident #4's MAR for [DATE] revealed Ns (Not Administered) for [MEDICATION(S)] 5 MG at 9:00 AM on [DATE], [DATE], and [DATE] and [MEDICATION(S)] 45 units Sub Q at 9:00 AM for [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the detailed notes for these days revealed no documentation as to why the medications were not given. Record review of Resident #4's list of Minimum Data Set (MDS) completion dates revealed no transfers/discharges from the facility for any reason since [DATE]. Resident #5 Record review of Resident #5's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD if BS blood sugar) <60 or >400; and [MEDICATION(S)] 55 units Sub-Q at bedtime, rotate SQ site. Record review of Resident #5's [DATE] MAR revealed an N (not administered) on [DATE] for both 4:00 PM and 8:00 PM for Blood Sugar checks before meals and at bedtime. Another order was noted for [MEDICATION(S)] 55 units at bedtime, with an N marked for [DATE] at 8:00 PM. Record review of Resident #5's list of Minimum Data Set (MDS) completion dates from [DATE] through [DATE], revealed a one-day discharge from the facility from [DATE] through [DATE]. On [DATE] at 10:43 AM a post exit interview with Medical Records revealed before the transition to electronic charting and records she would randomly check during the month for accurate and complete charting in the charts and the MAR's. Medical Records stated during the time the charting was not completed the facility was changing to electronic records, it was new, and she did not have time to monitor the charts. Medical Records confirmed nursing should always complete their documentation and the reason accurate and complete documentation and records are important is to ensure the residents get the medications and care that are ordered. Medical Records revealed she has had issues in the past with nurses not completing their charting and she would write a deficiency notice and give a copy to the Director of Nursing and to the Administrator. The facility provided an acceptable removal plan on [DATE], for the IJ and review of the facility's removal plan revealed the facility took the following actions to remove the IJ: Removal Plan On [DATE] at 2:45pm State Agency notified the Administrator that the facility was in an Immediate Jeopardy (IJ) and templates were provided to the Administrator. The facility failed to appropriately document the amount of enteral feedings, and flushes for Resident #1 and Resident The facility failed to maintain Resident's blood glucose levels within an acceptable parameter for Resident #1 and Resident #2. The facility failed to provide appropriate goods and services to Residents necessary to avoid physical harm, pain, mental anguish, or emotional distress by not providing enteral feedings, water flushes and insulin per physician orders. 1. On [DATE], at 7:20PM Resident #1 was found unresponsive. A blood glucose was checked on Resident #1 with a blood glucose testing device indicating a HI reading. Emergency services were notified at approximately 7:20PM and Resident #1 was transported by ambulance to local hospital #1. Resident #1 expired on [DATE] at approximately 9:06PM in the emergency room at local hospital #1. On [DATE] at 6:50 AM blood glucose was checked on Resident #2 with a blood glucose testing device indicating a HI reading. Physician #1 was notified on [DATE] at approximately 6:56am and orders were received to transfer Resident #1 to local hospital #1. Resident #2 was transferred on [DATE] at approximately 7:25am by ambulance to the emergency room of local hospital #1. Resident # 2 remains in the hospital at this time. 2. Director of Nurses (DON) and Registered Nurse (RN) #2 immediately initiated in-services with Registered Nurses and Licensed Nurses on [DATE], at 3:10PM on Tube Feedings, Drug Administration & Documentation including electronic medication administration records and Incident Investigation & Reporting, related to abuse and neglect Director of Nurses (DON) and Registered Nurse (RN) #2 initiated in-services with Registered Nurses and Licensed Nurses on [DATE] at 4:00PM on [CONDITION(S)] and [CONDITION(S)]. In-services will be on-going, and no nurses win be allowed to work until participation of the in-services for Tube Feedings, Drug Administration & Documentation including electronic medication administration records, and Incident Investigation & Reporting related to abuse and neglect, [CONDITION(S)] and [CONDITION(S)]. During the week of February 22, 2021 through February 26, 2021 initial training was provided to all nursing department staff concerning implementation of the new electronic charting system and the electronic Medication Administration Record by Registered Nurse (RN) #2. This training is an ongoing process for all new staff and existing staff as changes are made to the system. 3. The facility Quality Assurance Committee Meeting was held on Thursday, [DATE], at 3:50PM, with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director Infection Preventionist, Registered Nurses (RN) Registered Nurse (RN) #2, Registered Nurse (RN) #3, Registered Nurse (RN) #4, and Licensed Practical Nurse (LPN) #1. Topics discussed included Enteral Feedings, Insulin Administration, and Neglect with the following policies reviewed Tube Feedings, Drug Administration & Documentation, and Incident Investigation & Reporting, related to abuse, and neglect. No policy changes were indicated however, facility made procedural changes on [DATE] to medication administration monitoring to include electronic medication charting reviews. The Director of Nurses (DON), Registered Nurse (RN) #3 and Registered Nurse (RN) #4 with review electronically generated reports for omissions and discrepancies with enteral feedings and flushes, insulin administration, and blood glucose results. 4. On [DATE] from 4:30PM to 9:00PM, Registered Nurses (RN) #3, Registered Nurse (RN) #4 and Licenses Practical Nurse (LPN) #1 physically assessed and observed all Residents receiving enteral feedings with no significant findings identified. They also, physically assessed and observed ad diabetic Residents with insulin with no significant findings identified. On [DATE] and [DATE], the Director of Nurses (DON), Registered Nurse (RN) #2, Registered Nurse (RN) #3, Registered Nurse (RN) #4, Licensed Practical Nurse (LPN) #1 and Medical Records Clerk audited the electronic medical records, the enteral feeding orders, medication administration records, and intake records for any Resident on enteral feeding for omissions and discrepancies from February 5, 2021 to present. Omissions of enteral feedings and flushes were noted on the audit for four of eight Residents. The physician was notified of all four of eight Residents with omissions [DATE] with no new orders received. The Director of Nurses (DON), Registered Nurse (RN) #2, Registered Nurse (RN) #3, Registered Nurse (RN) #4, Licensed Practical Nurse (LPN) #1 and Medical Records also audited the physician orders, electronic records, and medication administration of all insulin dependent diabetics for omissions and discrepancies from February S, 2021 to present. Omissions were noted for fourteen of twenty-six Residents blood glucose results and two of seventeen insulin administrations. The physician was notified of all fourteen Residents with omissions [DATE] with no new orders received. One of seventeen Residents audited was noted with a discrepancy in blood glucose results documentation. The physician was notified of the Resident discrepancy on [DATE] with no new orders received. On [DATE], Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #2 and Registered Nurse (RN) #1 checked insulin supplies for all insulin dependent diabetics to ensure they had the proper amount in the facility per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Licensed Practical Nurse (LPN) #3 was disciplined for improper documentation on [DATE]. LPN # 4, LPN #5, LPN #6, LPN #10, RN # 5, RN #6, and RN # 7 received an employee written warning discipline on [DATE]* The Mississippi State Board of Nursing was called regarding LPN #3 at 5:42PM unable to leave a message. Return call made on [DATE] at 9:12Am. The Mississippi State Board of Nursing was called regarding Licensed Nurses #,d+[DATE] and Registered Nurses #,d+[DATE] on [DATE]. The following agencies were notified on [DATE]. Mississippi State Department of Health Abuse Hotline was called at 5:39PM. Mississippi State Board of Nursing Home Administrators was called at 5:43PM. The Office of the Attorney General was called at 6:05PM. The local Police Department was contacted on [DATE] at 9:19 am. The facility alleges removal of the immediacy as of [DATE], at 8:00am. The SA validated all corrective actions had been completed as of [DATE], and the IJ was removed as of [DATE]. 1. On [DATE], at 7:20PM Resident #1 was found unresponsive. A blood glucose was checked on Re [TRUNCATED]

Based on record review, staff interview, observation and facility policy review, the facility failed to provide the necessary services to avoid physical harm to one (1) of four (4) residents reviewed (Resident #1). On 6/10/13 Certified Nurses Aide (CNA) #1 used a sit to stand lift to transfer Resident #1 instead of a total lift and without the assistance of a second staff member. The failure to transfer Resident #1 with the appropriate assistive device resulted in an injury to the left eye which required Resident #1 to have two (2) stitches to close the wound. Findings include: Cross refer to F-323 for the faciliyt's failure to utilize the sit to stand lift to transfer Resident #1 which resulted in a head injury requiring two (2) stitches above the left eye. Review of the facility's policy entitled "Abuse/Neglect Reporting (MS ONLY)", revised 07/11, noted, "... 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Regional. The appropriate Sate officials per state guidelines must be notified within 2 hours of occurrence or discovery of such alleged incident."

Based on record review, staff interview and facility policy review, the facility failed to report one (1) of four (4) incidents reviewed to the appropriate state agencies. The facility failed to report to the State Survey Agency that Resident #1 was injured during an improper transfer as a result of staff failure to follow the Certified Nurse Aide (CNA) Activities of Daily Living plan. Findings include: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/2012 revealed a Brief Interview for Mental Status of three (3) meaning resident required assistance to make simple decisions of activities of daily living. Record review of the facility's "Resident Incident Report", dated 06/11/2013, noted, "Incident type: Head Injury...Date/Time: 06/10/2013, 05:00 p.m. ... CNA stated that the lift hit resident in his head... Laceration over left eye 1 CM (centimeter)." Record review of a nurse's note, dated 06/10/2013 at 9:30 p.m., noted, "Resident returned to facility, new orders received, phones by ER (emergency room ) nurse stated resident received two (2) stitches. " Interview with the Administrator on 06/24/2013 at 1:17 p.m. revealed "We did not report the (Name of CNA #1) lift incident to licensure. Corporate office said we didn't need to report it to (State Survey Agency). Review of the facility's policy entitled "Abuse/Neglect Reporting (MS ONLY)", revised 07/11, noted, "... 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Regional. The appropriate Sate officials per state guidelines must be notified within 2 hours of occurrence or discovery of such alleged incident."

Based on record review, staff interview and facility policy review, the facility failed to implement the care plan for one (1) of four (4) residents as evidenced by Certified Nurse Aide (CNA) #1 utilized the sit to stand lift to transfer Resident #1 which resulted in a head injury required two (2) stitches above the left eye. Resident #1 was care planned for transfer with a total lift. Findings include: Cross refer to F-323 for failure of the facility to implement the care plan developed for the care of Resident #1 for the use of a total lift for transfer. Review of the care plan, dated 05/02/2013, noted, "Problem Onset: Dependent x (times) 1 for meals. Dependent X 2 for all other ADL's because he will fight. Has been seen hitting himself in private area...Approaches: ... Approach him carefully. When rendering care be aware of his fighting and try to have someone else with you..." Review of Resident #1's Activities of Daily Living (ADL) care plan with an onset date of 6/27/12, noted, "Prior to lifting/transferring him, use red-bed lift (brand name of lift) 2 person assist. Sling type multipurpose-size large." Review of Resident #1's most recent "Lift Transfer Assistance Screening" dated 04/25/13 revealed that Resident #1 required "RED-Total Lift" with "two (2)" staff to be in attendance during the transfer. Review of the June 2013 physician's orders [REDACTED]." Observation on 06/24/2013 of Resident #1's lift information revealed that above his bed was a Red dot which is the correct dot to indicate which lift to use for Resident #1. Interview with Certified Nurse Aide (CNA) #1 on 06/24/2013 at 4:05 p.m. revealed "I was not assigned to him but I put him to bed for the lady CNAs. I used the Stand Up lift. No one was helping me. The lady CNAs use the bed lift, total lift (Red dot). I use the stand up lift with him. He usually would stand up for me without problems. He got agitated when I tried to take his shirt off. Instead of holding to the handles of the lift, he grabbed the sling. He started hollering 'get out of my room' and he pulled the lift to him and the lift came toward him and hit him in the face. I went and got the nurse. I didn't see him bleeding. He got a good lick to his head when he pulled it to him." Review of the facility's "Lifting Policy", revised 06/11, noted, "... Procedures: ... 2. Plan of care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff."

Based on record review, staff interview, observation and facility policy review, the facility failed to provide adequate supervision and assistive devices for one (1) of four (4) residents reviewed (Resident #1). On 06/10/2013 Certified Nurse Aide (CNA) #1 used a sit to stand lift to transfer Resident #1 instead of a total lift and without assistance of a second staff person. The failure to transfer Resident #1 with the appropriate assistive device resulted in an injury requiring stitches to Resident #1. Findings include: Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set with an Assessment Reference Date of 10/31/2012 revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #1's cognitive status was severely impaired and required assistance to make simple decisions for activities of daily living. Review of the 05/02/2013 care plan, noted, "Problem Onset: Dependent x (times) 1 for meals. Dependent X 2 for all other ADL's because he will fight. Has been seen hitting himself in private area...Approaches: ... Approach him carefully. When rendering care be aware of his fighting and try to have someone else with you..." Record review of Resident #1's most recent "Lift Transfer Assistance Screening", dated 04/25/2013 revealed that Resident #1 required a "RED-Total Lift" with "two (2)" staff to be in attendance during the transfer. Record review of Resident #1's Activities of Daily Living (ADL) care plan with an onset date of 06/27/2012 noted, "Prior to lifting/transferring him, use red-bed lift (brand name) 2 person assist. Sling type multipurpose-size large." Record review of Resident #1's Activity of Daily Living administration sheet for June 2013, noted, Prior to lifting/transfer, use red-bed lift-(brand name)-2 person manual assist-2 staff in attendance-sling type: Multipurpose-sling size large. Record review of the "Physician order [REDACTED]. Record review of the facility's "Resident Incident Report", dated 06/11/2013, noted, "Summoned to resident's room by CNA (Certified Nurse Aide), observed resident setting in Geri-chair, CNA stated that when he reached to take Resident's shirt off resident became agitated. CNA then decided to put resident in bed to remove shirt. CNA stated resident became more agitated once lift was in place the resident jumped and pulled the stand up lift forward. CNA stated that the lift hit resident in his head. Laceration over left eye 1CM (centimeter)." Record review of a facility's nurse's note, dated 06/10/2013 at 9:30 p.m., noted, "Resident returned to facility, new orders received, phones by ER (emergency room ) nurse stated resident received two (2) stitches." Observation on 6/24/13 of Resident #1's lift information revealed that above his bed was a Red dot which is the correct dot to indicate which lift to use for Resident #1. Interview with Certified Nurse Aide (CNA) #1 on 06/24/2013 at 4:05 p.m. revealed "I was not assigned to him but I put him to bed for the lady CNA's. I used the Stand Up lift. No one was helping me. The lady CNA's use the bed lift, total lift (Red dot). I use the stand up lift with him. He usually would stand up for me without problems. He got agitated when I tried to take his shirt off. Instead of holding to the handles of the lift, he grabbed the sling. He started hollering 'get out of my room' and he pulled the lift to him and the lift came toward him and hit him in the face. I went and got the nurse. I didn't see him bleeding. He got a good lick to his head when he pulled it to him." Review of the facility's policy entitled "Lifting Policy", revised 06/2011, noted, "Procedures: ... 2. Staff will follow the documented lifting protocol deemed appropriate for each resident as noted on their ADL (Activities of Daily Living) information. This information is documented in the resident's chart on the ADL sheets and, via a color coded sticker system. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include which sling type and sling size is appropriate for each resident."

Based on observation, staff interview, record review and policy review, the facility failed to ensure that the physician and Responsible Party (RP) were notified of a change in condition for one (1) of seven (7) residents reviewed for pressure sores as evidenced by LPN #1 not reporting to the physician or Responsible Party when a pressure sore was discovered on or about 3/23/13 (Resident #2). The failure to notify the physician of a development of a pressure sore upon discovery delayed orders for treatment. Findings include: Interview with Licensed Practical Nurse (LPN) #1 on 5/16/13 at 11:10 a.m. revealed that her shift was about to be over around 10:00 p.m., not sure of date but thought around middle of month in March, when a CNA (Certified Nurse Aide) came and reported a place on Resident #2's bottom. LPN #1 stated that she went and observed a small wound near the crease of the coccyx and cleaned it with wound cleanser and covered it. LPN #1 stated that she had passed on the information to the 11-7 Nurse. LPN #1 stated that she had probably forgotten to chart, that she usually documented when something is found and put it on the 24 hour report. LPN #1 stated that she did not notify the physician or the Responsible Party when the wound was found. Interview with LPN #1 on 5/16/13 at 1:50 p.m. revealed that she thought it was around 3/23/13 when she and CNA #1 worked together and that CNA #1 was the first to notify her of the wound for Resident #2. Interview with the Nurse Practitioner (NP) on 5/16/13 at 11:30 a.m. revealed that she recalled that she had talked with the treatment nurses about Resident #2's pressure ulcer and that the resident had the wound several days prior to her being notified and observing it. The NP stated that she had documented what she had been told, that the wound had been there previously and when it had first been discovered. Interview with the Assistant Director of Nursing (ADON) on 5/16/13 at 11:50 a.m. revealed that the policy was to document any wound when it is found and to notify the physician and the responsible party and treat as ordered. The ADON stated that she could not find any documentation to support that there was an assessment or treatment of [REDACTED]. Review of the Nurse Practitioner's progress notes with the ADON revealed that she agreed that Resident #2's wound had probably been there before 3/29/13. Review of the facility's "Change in Resident Medical Status" policy, revised 5/11, revealed "... A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the Resident's legal representative or an interested family member when there is: ...2. Significant change in the resident's physical, mental, or psychosocial status ..." Cross refer to F314 for the facility's failure to provide timely treatment and services to Resident #2 for the development of a pressure sore.

Based on observation, staff interview, record review, the facility failed to include an approach on the care plan for the reporting of identified skin issues for one (1) of 16 sampled residents reviewed (Resident #2). Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was readmitted to the facility on [DATE] following a hospitalization on [DATE] for possible pneumonia and decreased nutrition and with a Percutaneous Endoscopic [MEDICAL CONDITION] (PEG) tube placement. Record review of Resident #2's Minimum Data Set with an Assessment Reference Date of 1/31/13 revealed that she was cognitively impaired with a Brief Interview for Mental Status of five (5) indicating severe cognitive impairment and required extensive assistance of one person for bed mobility. Record review of Resident #2's chart revealed a plan of care for " At risk for skin breakdown due to (D/T) incontinence and skin risk assessment " with a problem onset date of 2/7/13. Approaches listed on the care plan included a) daily skin checks with a.m. care and weekly body the audits, b) incontinent checks every (q) two (2) hours and as needed (prn), c) barrier protectant after each incontinent act, d) apply lotion after baths, d) consult with dietary to help manage any skin problems, and e) range of motion (ROM) within pain free range during am care. The care plan failed to include in any approach for when, how, or to whom to report identified skin issues. Interview with Licensed Practical Nurse (LPN) # 1 on 5/16/13 at 11:10 a.m. revealed that her shift was about to be over around 10:00 p.m. , not sure of date but thought around middle of month in March, when a CNA (Certified Nurse Assistant) came and reported a place on Resident #2 ' s bottom. LPN #1 stated that she went and observed a small wound near the crease of the coccyx and cleaned it with wound cleanser and covered it. LPN #1 stated that she had passed on the information to the 11-7 nurse. LPN #1 stated the she had probably forgotten to chart, that she usually documented when something is found and put it on the 24 hour report. LPN #1 stated that she did not notify the physician or the Responsible Party when the wound was found. Further interview with LPN #1 on 5/16/13 at 1:50 p.m. revealed that she thought it was around 3/22/13 when she and CNA #1 worked together and that CNA #1 was the first to notify her of the wound for Resident #2. Review of the facility policy " Skin Care Policy and Procedure " dated 5/11 revealed the following: IIA. Documentation, reporting, and treatment of [REDACTED]. IIB. As part of orientation, staff will be taught surveillance techniques. Nursing Assistants will be taught to recognize and report condition changes which can affect skin integrity. Cross refer to F-314 for the facility's failure to ensure that Resident #2 was assessed and treated timely for development of a pressure sore.

Based on observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of seven (7) residents reviewed for pressure sores (Resident #2) was assessed and treated timely for development of a pressure sore. The first noted documentation and order for treatment of [REDACTED].#2 was on 3/29/13. The initial date of the discovery of the pressure sore was on or about 3/23/13. The pressure sore worsened after discovery and currently is unstageable as of 5/16/2013. The failure for the facility to assess Resident #2's pressure ulcer and notify the physician when first discovered delayed treatment and services to promote healing, thus causing the pressore sore to worsen. Findings include: Observation and interview with Resident #2 on 5/15/13 at 11:40 a.m. revealed that she was alert and responded appropriately to questions and followed commands. Resident #2 was lying on an air mattress on her left side and was receiving a tube feeding of [MEDICATION NAME] at 60 cubic centimeters (cc) per hour per pump. Resident #2 grabbed the rail when commanded and assisted to turn more to the left side to allow Registered Nurse (RN) #1 and RN #2 to provide treatment to the sacral-coccyx area. RN #1 removed the dressing from the sacral area to reveal a wound that measured approximately 2.5 x 2.5 cm (centimeter) with an undetermined depth due to a small amount of yellowish slough material in the bed of the wound. The outside edges of the wound were pink with red granulation tissue beneath and toward the bed of the wound. There was no foul odor noted. The wound was cleansed with wound cleanser with a small amount of bleeding noted. The treatment was done with Santyl and Calcium Alginate with a bordered dressing as ordered. Resident #2 had no complaint of pain during the treatment. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was transferred to the hospital on [DATE] for possible pneumonia and decreased nutrition and was returned to the facility on [DATE] with a Percutaneous Endoscopic [MEDICAL CONDITION] (PEG) tube. Review of Resident #2's admission Minimum Data Set, with an Assessment Reference Date of 1/31/13, revealed that she was cognitively impaired with a Brief Interview for Mental Status of 5 (A score of 0-7 indicates cognitive impairment)and required extensive assistance of one (1) person for bed mobility. Resident #2 had no documented pressure ulcers but was deemed at risk. Review of Resident #2's most recent Minimum Data Set, with an Assessment Reference Date of 4/10/13, revealed that she remained cognitively impaired and required extensive assistance of two (2) persons for bed mobility and had an unstageable pressure ulcer which measured 3.4 centimeters (cm) x 1.3 cm x 0.2 cm and had slough that adhered to the ulcer bed. Resident #2 was assessed upon admission at risk for skin breakdown and Resident #2's "Skin at Risk Screening" on 3/27/13 was scored at 20. (12 or greater indicates high risk). Resident #2 was care planned on 2/7/13 at risk for skin breakdown with an updated care plan on 4/3/13 for a wound on the left coccyx. Review of a progress note documented on 3/29/13 and signed by the Nurse Practitioner (NP), revealed Fu (follow up) on nurses report of a new wound to her (Resident #2's) coccyx ... Apparently the wound was discovered on Saturday (3/23/13) but today is the first day (name of RN #1) or myself have seen the wound and the first time I have been notified of a wound ... Integument: inspection of skin - overall: warm, intact, no rash, [MEDICAL CONDITION], dry and wound stage III to coccyx with mostly slough and moderate drainage-new ...Plan: ...Order signed today for a [MEDICATION NAME] for coccyx that nurse had been previously applying. Apparently the wound was discovered on Saturday but today is the first day (name of RN #1) or myself have seen the wound and the first time I have been notified of a wound. Change order to coccyx to calcium alg (alginate) with silver and foam dressing daily and prn (as needed)..." Review of a progress note, dated and signed by the Nurse Practitioner on 4/8/13, noted, "... Integument: inspection of skin - overall: warm, intact, no rash, [MEDICAL CONDITION], dry and wound unstageable to coccyx mostly slough with some necrotic tissue in the center with moderate drainage larger worse ..." Review of a handwritten physician's orders [REDACTED]." Review of a hand written physician's orders [REDACTED]. Apply calcium alginate (with) silver and cover with foam dressing daily and prn." Review of Resident #2's telephone orders/physician verbal orders revealed an order, dated 5/7/13 at 3:32 p.m., to "Cleanse unstageable wound to coccyx with wound cleanser, pat dry, apply Santyl and Calcium Alginate then cover with a dry dressing QD (everyday). Review of a nurse's note for Resident #2, dated 3/29/13 at 10:50 a.m., signed by Registered Nurse #1 noted, "Informed by 3-11 shift nurse that resident has a wound to the coccyx-sacral area. Skin assessment completed noted unstageable wound to the coccyx area site pink/red in color measuring 1.7 cm (centimeters) x 1.8 cm with a depth of 0.2 cm. -Dry dressing applied to the site. Informed NP (Nurse Practitioner) of new site. Accompanied her (NP) to resident's room area examined by NP new order for treatment." Review of nurse's notes, 24 hour reports, weekly body audits, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Jot Book" revealed there was no documentation of any wounds or treatments of skin concerns for Resident #2 prior to 3/29/13. Review of the "Weekly Skin Report", dated 4/1/13, revealed Resident #2's wound to the sacrum (coccyx) was a Stage III with an onset date of 3/29/13 that measured 1.7 cm x 1.8 cm x 0.2 cm with granulation and slough, light exudates and no odor. Review of the "Weekly Skin Report", dated 4/9/13, revealed Resident #2's wound measured 3.4 cm x 1.3 cm x 0.2 cm, was unstageable with slough, granulation tissue and light to heavy exudates with a mild odor. Review of the "Weekly Skin Report", dated 5/1/13, revealed that Resident #2's wound measured 3.0 cm x 2.6 cm x 1.2 cm, unstageable with mild to heavy exudates and a mild odor. Review of the "Weekly Skin Report", dated 5/15/13, revealed that Resident #2's wound measured 2.7 cm x 2.4 cm x 1.3 cm with moderate exudates, granulation and slough with a foul odor. Interview with Registered Nurse (RN) #1/Treatment Nurse and Supervisor, on 5/15/13 at 11:10 a.m. and again at 4:00 p.m., revealed Resident #2's wound was already unstageable by the time that she had gotten the report. RN #1 stated that the Nurse Practitioner was in the building and that she looked at Resident #2's wound and wanted to stage it as a Stage III to begin with but the wound had slough. RN #1 stated that the 3-11 Shift Nurse had left a note on the treatment cart about Resident #2's wound and that was the first she knew about the wound. Interview with Licensed Practical Nurse (LPN) #1 on 5/16/13 at 11:10 a.m. revealed that her shift was about to be over around 10:00 p.m., not sure of date but thought around middle of month in March, when a CNA (Certified Nurse Aide) came and reported a place on Resident #2's bottom. LPN #1 stated that she went and observed a small wound near the crease of the coccyx and cleaned it with wound cleanser and covered it. LPN #1 stated that she had passed on the information to the 11-7 Nurse. LPN #1 stated that she had probably forgotten to chart, that she usually documented when something is found and put it on the 24 hour report. LPN #1 stated that she did not notify the physician or the RP (Responsible Party) when the wound was found. Further interview with LPN #1 on 5/16/13 at 1:50 p.m. revealed that she thought it was around 3/22/13 when she and CNA #1 worked together and that CNA #1 was the first to notify her of the wound for Resident #2. LPN #1 stated that CNA #2 may have told her too later. Certified Nurse Aide #1 no longer works at the facility and had no forwarding phone number; therefore, an interview could not be conducted. Interview with Certified Nurse Aide (CNA) #2 on 5/16/13 at 10:00 a.m. revealed that she had worked with Resident #2 and recalled seeing a sore on the resident's backside/coccyx. CNA #2 described the area the size of a silver dime and had a pinkish area, not black or cruddy. CNA #2 stated that she thought she had told the Treatment Nurse (who no longer works at facility), who came and looked at the wound, measured it and put some cream on it. CNA #2 stated that she didn't recall if she had documented in the "Jot Book" or not about the wound. A later interview with CNA #2 on 5/16/13 at 11:00 a.m. revealed that she thought it was LPN #1 who she might have reported Resident #2's sore on her bottom but she could not recall the exact date. Review of the schedule with CNA #2 revealed that she had worked with LPN #1 on 3/23/13 and 3/28/13. Interview with the Nurse Practitioner (NP) on 5/16/13 at 11:30 a.m. revealed that she recalled that she had talked with the treatment nurses about Resident #2's pressure ulcer and that the resident had the wound several days prior to being notified and observing it. The NP recalled being told that the wound had been treated with [MEDICATION NAME] and that she thought she changed the order. The NP stated that the wound was maybe a Stage III and had some slough but no eschar when she first observed it. The NP stated that she had documented what she had been told, that the wound had been there previously and when it had first been discovered. The NP stated that Resident #2's wound had worsened but thought that it had gotten better and was probably unavoidable due to her condition. Interview with the Assistant Director of Nursing (ADON) on 5/16/13 at 11:50 a.m. revealed that the policy was to document any wound when it is found and to notify the physician and the responsible party and treat as ordered. The ADON stated that she could not find any documentation to support that there was an assessment or treatment of [REDACTED]. Review of the NP progress notes with the ADON revealed that she agreed that Resident #2's wound had probably been there before 3/29/13. Interview with Registered Nurse (RN) #1 on 5/16/13 at 1:15 p.m. revealed that she wasn't aware how the Nurse Practitioner (NP) had the idea that Resident #2's wound had been discovered on the prior Saturday (3/23/13), because the first time that she had been aware of the wound was on 3/29/13 after a note had been left on the treatment cart by LPN #1 and she and the NP looked at the wound together. RN #1 stated that none of the CNAs had reported a wound to her. RN #1 stated that she had covered the wound with a [MEDICATION NAME] until the NP saw the wound and changed the order. RN #1 stated that Resident #2's wound did get bigger once the Calcium Alginate with silver was started because it was eating away the bad stuff. Review of the facility's "Skin Care Policy & (and) Procedure" policy, revised 5/11, noted: "It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: Prevention, Evaluation and Screening, Ongoing surveillance, treatment orders and treatment regimen ....Skin problems which are present or which develop later will be followed carefully and treated according to medical direction ...The Nursing Department's procedures will be such that staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for development ...The Nursing Department will maintain the capability to respond to patient needs in the area of skin integrity by the following means: with medically directed treatment for [REDACTED].documentation, reporting and treatment of [REDACTED]." Cross refer to F-514 for the facility's failure to ensure that Resident #2's medical record was accurate and complete regarding the discovery of a pressure sore.

Based on observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of 11 medical records reviewed was accurate and complete as evidenced by the lack of documentation of a pressure sore when it was first discovered for Resident #2. Findings include: Review of a progress note documented on 3/29/13 and signed by the Nurse Practitioner (NP), revealed that she was "following up (FU) on nurses report of a new wound to (Resident #2's) coccyx ...Apparently the wound was discovered on Saturday (3/23/13) but today is the first day (RN #1) or myself have seen the wound and the first time I have been notified of a wound...Plan...Order signed today for a [MEDICATION NAME] for coccyx that nurse had been previously applying. Apparently the wound was discovered on Saturday by today is the first day RN#1 or myself have seen the wound and the first time I have been notified of a wound. Change order to coccyx to calcium alg (alginate) with silver and foam dressing daily and prn (as needed)." The note documented that the wound was a stage III to the coccyx with mostly slough and moderate drainage-new. Review of nurse's notes, 24 hour reports, weekly body audits, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Jot Book" revealed no documentation of any wounds or treatments of skin concerns for Resident #2 prior to 3/29/13. Interview with LPN #1 on 5/16/13 at 11:10 a.m. revealed that her shift was about to be over around 10:00 p.m., not sure of date but thought around middle of month in March, when a CNA came and reported a place on Resident #2's bottom. LPN #1 stated that she went and observed a small wound near the crease of the coccyx and cleaned it with wound cleanser and covered it. LPN #1 stated that she had passed on the information to the 11-7 Nurse. LPN #1 stated that she had probably forgotten to chart, that she usually documented when something is found and put it on the 24 hour report. Further interview with LPN #1 on 5/16/13 at 1:50 p.m. revealed that she thought it was around 3/22/13 when she and CNA #1 worked together and that CNA #1 was the first to notify her of the wound for Resident #2. Interview with the Nurse Practitioner (NP) on 5/16/13 at 11:30 a.m. revealed that she recalled that she had talked with the treatment nurses about Resident #2's pressure ulcer and that the resident had the wound several days prior to being notified and observing it. The NP stated that she had documented what she had been told, that the wound had been there previously and when it had first been discovered. Interview with the Assistant Director of Nursing (ADON) on 5/16/13 at 11:50 a.m. revealed that the policy was to document any wound when it is found and to notify the physician and the responsible party and treat as ordered. The ADON stated that she could not find any documentation to support that there was an assessment or treatment of [REDACTED]. Review of the NP progress notes with the ADON revealed that she agreed that Resident #2's wound had probably been there before 3/29/13. Review of the facility's "Skin Care Policy & Procedure" policy, revised 5/11, noted, "... II. Ongoing Surveillance A. Documentation, reporting and treatment of [REDACTED]. Treatment Orders A. After observation/evaluation of the affected skin area, notify physician for the treatment order..."

Complaint Investigation MS # Based on observation, record review, staff interview, and policy review, the facility failed to ensure that supervision was maintained during care. The lack of supervision resulted in a fall with injury for one (1) of four (4) residents (Resident #2). Findings include: Resident #2 Record review revealed that Resident #2 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 4, which indicated that Resident #2's cognitive status was severely impaired. Review of the Functional Status section of this MDS noted Transfer: support provide one (1) person physical assist. Observation on 1/31/13 at 10:00 a.m. revealed Resident #2 was in bed in supine position with eyes closed and was being fed Suplena via a feeding pump at 44 milliliters per hour. Review of the facility's "Lift Transfer Assistance Screening", dated 10/17/12 at 11:55 a.m., revealed "What is resident's level of manual assistance (?) - Handheld or manual assistance x (times) 1. Can the resident bear weight? Yes. Does the resident have upper extremity strength to support his/her weight during transfer? Yes. Resident's Lifting Plan "BLUE-No mechanical lift required, handheld or manual assist x 1." Review of Incident Report, dated 12/8/12 at 4:46 a.m., revealed Resident #2's Incident type: Fall with head injury", "sitting on side of bed waiting to transfer to wheelchair; Laceration above left eye, laceration above right eye, unable to move right side of upper and lower extremity." Immediate action taken: First aid, called MD (name of ambulance) and RP (Responsible Party) x (times) 2; The name of Resident #2's physician and family notified listed; Take to hospital: (name of local hospital emergency room ); Mobility: "Bedfast- no independent move., Mental: alert, orientation to person only; Medical risk factors possibly related to incident: "fall history, inability to understand directions, confusion/disorientation, incontinency, and sensory limitations." Record review revealed Resident #2's local hospital discharge [DIAGNOSES REDACTED]." Review of nurse's notes, dated 12/8/12 at 4:45 a.m., noted "Summoned to room by CNA (Certified Nurse Aide) noted resident on floor, face down, right arm under upper body, BLE (bilateral lower extremities) extended out, blood noted on floor resident yelling; "It hurts" does move left lower extreme, no movement on right, called Emergency Service, vital not obtained resident uncooperative, resp (respirations) . 18, called MD (medical doctor), and RP (Responsible Party), send to ER (emergency room ) not able to move resident R/T (related to) injuries and pain. Ambulance arrived, placed on back board and neck support, turn over 2 lacerations 1 above right eye 1 above left eye, pressure dressing applied conts (continues) to be unable to move right lower extreme, does move right upper extreme, transported to (name of local hospital) ER called to inform of transported." Review of nurse's notes, dated 12/8/12 at 9:30 a.m., noted, "Returned to facility from (local hospital) alert with confusion accompanied by staff members via company vehicle. Moderate amount of blood noted in hair. Left facial contusion noted purplish in color swollen left eyelid and surrounding area of left eye. Numerous bruises reddish in color noted to both arms." Interview, via telephone, on 2/1/13 at 12:45 p.m. with License Practical Nurse (LPN) #2 revealed: "I was working South Wing Alzheimer's unit on 12/8/12 during 11:00 p.m. - 7:00 a.m. shift. Between 4:00 a.m. and 5:00 a.m., I was called to (name of Resident #2's) room by Certified Nurse Aides (CNA) #2 due to (name of Resident #2) had a fall. I asked her what happened. She (CNA #2) reported she went to get the lift after getting her up and dressed. All upper clothes were on and her pants were below her knees. The resident was seated on the side of the bed. After getting the lift she assisted the resident in Bed A (Unsampled Resident A's roommate) to wheelchair first. (Name of CNA #2) stated I found her face down with blood on the floor. We also have to use a lift due to resident's knees are weak and she is unable to stand. The staff used the stand-n-lift. I'm thinking times 2 per transfer with lift. Resident was taken to (name of the local hospital) per ambulance. First aid was given to the resident to decrease bleeding. I'm not sure why the CNA was getting the residents up early. Usually about one (1) hour before one (1) hour before breakfast. I'm not sure of our policy." Interview, via telephone, on 2/1/13 at 1:00 p.m. with Certified Nurse Aide #2 revealed: "On 12/8/12 between 4:20 and 4:30 a.m. Resident #2 and roommate were dressing for the day. Both residents were sitting on the side of the bed. I left the room to get the stand-n-lift and Resident #2 was dressed first. After entering the room, while using the lift to transfer (name of Resident #2's roommate) to the wheelchair first. The privacy curtain was pulled halfway and during this time (name of Resident #2) had a fall. "She (Resident #2) was on the floor face down bleeding. I saw blood on the floor." I got Licensed Practical Nurse #2 to the resident's room and later she sent (Name of Resident #2) out to the emergency room . I have never been told not to get the residents up early and 2 CNAs worked on the unit. Sometimes (name of Resident #2) stand and other times we used the stand-n-lift due to the resident's knees buckles. Resident #2 was lying face down. I don't remember the number residents assigned to me on that unit. It depends on Resident #2's behavior, if two (2) persons are needed to transferring the resident. I am sorry this happened to (name of Resident #2) ..." Review of Resident #2's "Lift Transfer Assistance Screening", completed 1/7/13, noted, "... Resident's Lifting Plan Green - stand-n-lift. If lift is needed how many staff are to be in attendance -Two (2). If stand-n-lift is required, What sling type is needed? Transport Harness ... Additional comments regarding Lift/Transfer - Resident can stand when assisted but her legs will "buckle" and/or become very weak when standing and can only stand for a very short period of time..." Record review revealed there was no documented evidence that the facility updated Resident #2's care plan to address two (2) person transfer with the a sit-n-lift with transport harness sling and/or mechanical lift with large sling. Also, there was no documented evidence that the facility updated the resident's care plan to address the need for supervision during hygiene care related to the fall on 12/8/12. Interview on 2/1/13 at 4:00 p.m. with the Administrator and the Director on Nursing confirmed the listed findings and stated that in-service training was completed on 12/11/12 for all staff members. Review of the facility's "Lifting Policy", revised 6/11, noted, "... Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff..." Review of the facility's "Assessment" policy, revised 6/94, noted, "... Results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care."