Every finding on record at College Park Rehabilitation and Care Center

Based on observation, interview and record review the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 (hall 400 nurse cart) of 4 medication carts reviewed for medication storage.The facility failed to keep each resident's medications in their original containers and stored separately.This failure could place residents at risk of receiving expired and/or improper medications.During an observation on [DATE] at 8:45 AM of the nurse's medication cart for hall 400 revealed, 2 loose pills were found in the bottom of the second drawer of the cart. During an observation and interview on [DATE] at 9:00 AM, LVN-A stated hall 400 nurse cart was her cart for the shift, she checks her cart for loose pills and organizes weekly and had not done it that week. She then removed both loose pills and placed them in the sharps box on the side of the medication cart for destruction. LVN-A stated a negative outcome to loose pills in the cart could be one of the pills falling out of the cart when passing medications and a resident picking it up off the floor and possibly taking it. During an interview on [DATE] at 10:40 AM with the DON, it was revealed her expectations for medication carts was to be cleaned and organized daily by the nurse or medication aide in charge of the cart. She stated loose medications should not be in the carts; everything medication required a package and label. The DON stated a negative outcome to loose pills in the medication carts could be a resident finding on the floor if it falls out and taking it. During an interview on [DATE] at 10:45 AM with the Administrator, it was revealed his expectations for medication carts were that they are wiped clean daily, medications organized daily, and all medications to have labels. The Administrator stated it was the responsibility of the staff member in charge of the cart to make sure all medications were accounted for and administered correctly. The Administrator stated an adverse outcome for loose medications in the cart could be a resident running out of medications before reordering or the medication falling out of the drawer on to the floor and a resident picking it up and taking it. Record review of the facility's policy titled Storage of Medication (revised [DATE]) stated [in part]Policy Heading The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: The facility failed to ensure: A. 1 of 1 walk-in coolers were clean and free from sticky substances. B. Kitchen floor on the left side and underneath 1 of 1 ice machines were clean and from a brown sticky substance and dust. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: Observations on n 03/26/25 beginning at 9:30 AM, during the initial tour of the kitchen, revealed 1 of 1 walk-in cooler had a brown sticky substance on the floor and underneath the bottom shelves a brown sticky substance and dust on the left side and underneath 1 of 1 ice machine. In a follow-up interview and observation of the kitchen on 03/26/25 at 11:00 AM, there was no change in the soiled floor on the left side and underneath 1 of 1 ice machine or the brown sticky substance on the floor and underneath the bottom shelves in 1 of 1 walk-in cooler. The cleaning schedule titled Daily Cleaning Schedule for March of 2025. revealed the tasks were completed on a daily basis and initialed by the assigned staff as task completed. In an interview with the Dietary Manager on 03/27/25 at 2:15 PM, The dietary manager stated the walk-in cooler and the entire kitchen floor were swept and mopped on a daily basis by the assigned staff she further stated, she was responsible to make sure the tasks were completed on a daily basis however the dietary department has been short staffed with the dietary manager having quite often be the cook and the cleaning tasks was an oversight on her part. Stated, not sweeping and mopping the floor on a daily basis could cause foodborne illness. In an interview with the Administrator on 03/27/25 at 2:45 PM, he said it was his expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. Failure to do so had the potential for infection and pests. A record review of the facility policy General Kitchen Sanitation, dated October 2018, revealed the following [in part]: 6. Clean non-food contact surfaces of equipment at intervals as necessary to keep them free of dust and food particles and otherwise in a clean and sanitary condition. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 2 (2 Dumpsters) of 2 garbage containers reviewed for food safety requirements. The facility failed to ensure two dumpsters in the parking lot was not overflowing with garbage. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided a unsafe, unsanitary and uncomfortable environment. Findings included: Observation on date 03/26/2025 at 09:48 a.m., the two outside dumpsters located behind the building and approximately 200 feet from the kitchen had its four top lids closed with a clear trash bag full of soiled briefs and soiled under pads hanging out of the top and resting on the lid and the four side doors (2 side doors on each dumpster opened). The dumpster to the right had trash on the concrete all around the perimeter of the dumpster. The dumpster to the left had an old wheelchair on the concrete behind the dumpster. The dumpster fence/door(s) were opened and not closed. Interview on 03/27/2025 at 8:10 a.m., the Dietary Manager stated she noticed all the trash on the floor outside at the dumpsters from the other day (03/26/2025) when staff was out there. The Dietary Manager stated her kitchen staff only empties trash three times per day, and they were trained to close the dumpster doors and not to overfill the dumpsters. Dietary Manager stated she did not know the risk of having the dumpster fence/door(s) open even though it had a sign to have them closed at all times. Interview on 03/27/2025 at 8:30 a.m., the Administrator stated it was not appropriate to have trash on the concrete by the dumpsters or trash hanging from the top of the dumpster. Administrator stated it was because it was an infection control issue and would invite pests to the building. Administrator stated the risk to the residents was minimal since the dumpsters were outside but depending on the trash, if it is a major trash, which can be hazardous to the residents. Administrator stated the dumpster lids and fence/door(s) need to be closed. Administrator further stated, the facility does not have a particular policy for the dumpsters.

Based on interviews, and record reviews, the facility failed to develop and implement abuse, neglect policies that addresses screening of a potential employee's license which resulted in an employee being allowed to work as a nurse with no license or education check for 1 (Staff Member G) of 24 staff . The facility failed to screen Staff Member G to ensure she was licensed to practice as a GVN through the TX-BON. As a result Staff Member G was allowed to provide care and services to residents outside of her scope that included administration of medications that included PICC line normal saline flushes, short, long, sliding scale insulins and narcotics, wound care for stage III (3) wounds, monitoring of dialysis ports, PICC lines, and catheters with no direct supervision and providing supervision to certified nurse aides and medication aides. Staff Member G worked at the facility in the capacity of a GVN without legal authority from 11/24/24 to 01/31/24. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. While the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for minimum harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure could place residents at risk of receiving inappropriate care, abuse or neglect. Findings included: Record review of facility policy labeled Abuse Investigations undated revealed: Preventing Abuse. Employee Background Checks. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff .Screening. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum. Protocols for conducting employment background checks . Background Criminal Investigations and Pre-employment Testing. Screenings. State and Federal law mandates that certain persons with convicted of certain crimes or otherwise legally excluded, may not be employed in most facilities and agencies providing care to the aged and disabled . The organization also cheeks the C.N.A. Registry, The Misconduct Registry, the EPLS (Excluded Parties List System) and the OIC (Dept. of Health & Human Services Office of Inspector General List of Excluded Individuals/Entities per chapter 93 of the Texas Admin.Code and Chapter 253 of the Texas Health and Safety Code) on all individuals . For certain positions, this organization may conduct an extensive investigation of applicant's background, with written approval, including but not limited to: personal employment references/records, . and educational records, as well as other background information as deemed appropriate. In an interview on 01/31/24 10:12 PM with the DON and Staff Member G, Staff Member G said she had attended nursing school in New York state. She said she was waiting on her transcript from her school to get a date to test in TX. She said she assumed she was good to work in TX because she was hired as a GVN. The DON said it would be the ADON and HR responsibility to check for current valid licensure. In an interview on 2/1/24 at 12:18 PM the DON said that STAFF MEMBER G would be responsible for the number of residents in the high twenties each shift. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. Record review of Staff Member G's personnel file revealed: Application dated 11/21/23-Position applied for GVN/LVN with previous experience as an LPN from 062023 to current (11/21/23) reason for leaving-relocating. Another previous experience was as a Student Nurse from 06/2021 to 06/23. Interview Questions by ADON A, dated 11/21/23- What experience do you have working in (nursing, laundry, housekeeping, food service, etc)? I previously worked w/pts in their homes assisting with ADL's, nursing school clinicals and as an LPN in a pediatric office . Additional notes and comments. I am eligible to work with a graduate nurse permit until I pass my NCLEX in Texas. Employment Acknowledgement dated 11/21/23- Signed by both Staff Member G and ADON A revealed a position of GVN and a date of hire 11/24/23. Position Description Job Title: Licensed Vocational Nurse last revised 11/2019-Signed by Staff Member G 11/27/23. TXBON NCLEX PN Application dated 11/03/23 revealed: Applicants must submit the following items for their file to be considered complete & ready for an ATT review: 1.NCLEX-PN Application and $75 fee. 2.Fingerprint submission for a criminal background check (CBC) completed through IdentoGo. You will receive an email from IdentoGo with instructions on how to complete your fingerprints. The email will not be sent until we've received your NCLEX Application. Most applicants won't need to complete this step if they previously submitted fingerprints as a student or on a previous application. You will receive an email from IdentoGo if Board staff confirms that you are required to re- fingerprint 3.Completion of the Nursing Jurisprudence Exam (NJE). You do not need to retake the NJE if you completed it during a previous licensure application. 4. Registration with Pearson [NAME]. The name on your ID must match exactly the name you provided person view when you registered. If your name doesn't match, you will not be allowed to test and you will be required to reapply to receive a new ATT. 5. Affidavit of graduation parentheses (AOG) parentheses submitted by your program Dean [NAME] slash director after graduation. Texas graduates: your program dean\/director will submit the AOG electronically through the AOG portal. Your information will only appear in the AOG portal if you provided the correct school code and graduation date on your influx application. Out of state graduates: your program Dean/director will need to complete and submit the paper affidavit of graduation. *Keep in mind that additional application requirements may be added at any time during the review process An incomplete application and/or failure to complete pending items could delay the issuance of an ATT, Graduate Vocational Nurse (GVN) permit, if eligible, and permanent licensure . 10. I certify by entering my name below, I am the person applying for licensure with Texas Board of Nursing and meet the qualifications required by Texas law and regulations. Further, I certify the information provided in this application has been personally provided and reviewed by me and that the statements, documentation, and information submitted via the online application through an Internet interface are true, accurate, and complete, in every respect. I have not used a false or fictitious name in said application. I read and understand the questions and statements in the application and will abide by all current state and federal laws and regulations affecting nursing licensure. I understand that providing false or misleading information, as well as omitting pertinent or material information in connection with this application, is grounds for negative licensure consequences, which may include licensure denial or revocation and may subject me to civil or criminal penalties. I consent to the release of confidential information to the Texas Board of Nursing and further au1horizc the Board to use and lo release said information as needed for the evaluation and disposition of my application. Further, I understand that If l have any questions regarding this affidavit, I may contact an attorney. Signed 0926/23 . Payment date 11/03/23 . NOTE: This document is a copy of the electronic license application for the person named above and does NOT constitute a verification of license or represent a copy of the individual's license. There was no verification of license to practice as a GVN from the TX BON in Staff Member G's personnel file. Record review of Daily Assignment Sheets from 11/01/23 to 02/15/24 revealed: Staff Member G worked on 11/24/23 2-10p shift with LVN F on the 400 halls. 11/27/23 2-10p with LVN [NAME] the 400 hall. 11/28/23 2p-10p with LVN J on the 400 hall. 11/29/23 2p-10p with LVN K on 400 hall. 11/30/23 2p-10p with no other nurse on 400 hall, 3 other nurses on the shift. Total of 4 days with another nurse after hire date of 11/24. Total of 1 day in November of 2023 with no other nurse on the hall with Staff Member G. 12/01/23 2p-10p with no other nurse on 400 hall. 12/04/23 2p-10p with no other nurse on 400 hall. 12/05/23 2p-10p with no other nurse on 400 hall. 12/06/23 2p-10p with no other nurse on 400 hall. 12/07/23 2p-10p with no other nurse on 400 hall. 12/11/23 2p-10p with no other nurse on 400 hall. 12/12/23 2p-10p with no other nurse on 400 hall. 12/18/23 2p-10p with no other nurse on 400 hall. 12/19/23 2p-10p with no other nurse on 400 hall. 12/20/23 2p-10p with no other nurse on 400 hall. 12/21/23 2p-10p with no other nurse on 400 hall. 12/22/23 2p-10p with no other nurse on 400 hall. 12/25/23 2p-10p with no other nurse on 400 hall. 12/26/23 2p-10p with no other nurse on 400 hall. 12/27/23 2p-10p with no other nurse on 400 hall. 12/28/23 2p-10p with no other nurse on 400 hall. 12/29/23 2p-10p with no other nurse on 400 hall. 17 days in December of 2023 with no supervision on hall 400. 01/01/2024 2p-10p with no other nurse on 400 hall. 01/02/24 2p-10p with no other nurse on 400 hall. 01/03/24 2p-10p with no other nurse on 400 hall. 01/04/24 2p-10p with no other nurse on 400 hall. 01/08/24 2p-10p with no other nurse on 400 hall. 01/09/24 2p-10p with no other nurse on 400 hall. 01/10/24 2p-10p with no other nurse on 400 hall. 01/11/24 2p-10p with no other nurse on 400 hall. 01/15/24 2p-10p with no other nurse on 400 hall. 01/16/24 2p-10p with no other nurse on 400 hall. 01/17/24 2p-10p with no other nurse on 400 hall. 01/18/24 2p-10p with LVN K on 400 hall. 01/22/24 2p-10p with no other nurse on 400 hall. 01/23/24 2p-10p with no other nurse on 400 hall. 01/24/24 2p-10p with no other nurse on 400 hall. 01/30/24 2p-10p with no other nurse on 400 hall. 16 days in January 2024 with 15 of those days with no supervision on hall 400. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. During an interview on 02/15/24 at 4:55PM, the ADM said he did not have a license screening policy, but he would try to look for something. During a telephone interview on 02/16/24 at 10:01 AM with New York (NY) state Nursing college, the Registrar verified that Staff Member G completed the Vocational/Practical Nursing program and graduated 06/15/2023. The Registrar said that Staff Member G's name was not released to the state of NY [NAME] due to nonpayment. She said a person's name was sent to NY [NAME] after they had graduated the nursing program and paid their balance due to the school so they could register to take the NCLEX. The Registrar said record still showed a balance due. She said their system updated daily so if Staff Member G paid her balance due that day, then she could have her name released and be eligible to sit for the NCLEX. During a telephone interview on 02/16/24 at 02:20 PM NY [NAME] said, Staff Member G would not be eligible to use the GPN status. Her completion of the practical nursing program had been submitted to the NY [NAME] however Staff Member G never went further and tested . He said in the state of New York a person could practice as a GPN from the date of graduation to 90 days later without the need to apply. However, he said it was only valid for 90 days which would have run out on 09/15/23 for graduate nursing status. He said that would be the time to test and pass the NCLEX, but if a person had not passed the test or scheduled to test within those 90 days, then they would have to stop practicing as a GPN after the 90 days. NY [NAME] said Staff Member G did not have any status with New York. He said she never applied in any way in NY state. During a telephone interview on 02/16/24 at 03:13 PM with TXBON, she told me Staff Member G had only paid for her NCLEX and applied to take the exam. She said Staff Member G had not submitted an affidavit from her nursing school, graduation confirmation, or scheduled and submitted her fingerprints. She said Staff Member G had to schedule for her fingerprints with a specific approved TX BON approved company as it was federal, and it would tie in with her background check. TX BON said it would only be after Staff Member G had provided all the previous mentioned items, that Staff Member G could get an ATT. It would only be after any person was given the ATT in the state of Texas, that they could then apply with the TX BON for a nursing permit. Only after all these steps were completed, could any person legally represent themselves as a GVN in the state of TX. TX BON said that Staff Member G education had been verified and she was educated, but nothing further. TXBON said Staff Member G had not completed all the steps required in TX to legally practice as a GVN. During an interview on 02/16/24 at 05:31PM PM with HR, she said it was her responsibility to obtain a completed application from an individual. She said it was her responsibility screen the application and direct the person and their application to the proper department. She said if it was a nurse, being a GVN, GN, LVN or RN and a nurse aide or medication aide, then she sent the person and their application to the ADON A for interview. After ADON A had interview and would want to go with that person then she would discuss the pay, verify their license, do the reference checks, and background checks. She said that as a GVN or GN a nurse would not show up under the TXBON because there is not a section for GVN or GN status only LVN or RN status and because they were neither she would not be able to look on the TXBON. So, she said that she made the potential employee show them that they graduated from a nursing school and/or transcript that showed they completed a vocational nursing or registered nursing program at a college. HR said with the graduation she thought that automatically made them a GVN or GN. She said that Staff Member G had made her aware that she paid to test when she was hired, and that it was from NY and that the TXBON was just waiting for her transcripts to schedule a test for the NCLEX nursing exam. HR was aware that if Staff Member G did not pass the test, then she would not be allowed to work as a GVN any longer. HR said she spoke to Staff Member G sometime in the first part of January about her test and Staff Member G told her that she was still waiting to hear back from TXBON and had not heard anything. HR said that she just did not like hiring anyone that was not already licensed as a nurse in the state of Texas or in a compact state with Texas. She said it was just too hard to verify that information and she did not realize that there were several steps beyond graduating from nursing school to use the title of GVN or GN. This was determined to be an Immediate Jeopardy on 02/16/24. The ADM was provided the Immediate Jeopardy template on 02/16/24 at 8:55PM and a Plan of removal was requested. The following Plan of Removal submitted by the facility and accepted on 02/18/24 at 2:00PM Facility has no practicing GVN in the building. Staff member G was terminated on 1/31/2024. Facility will not hire GVN's or GN's as of 1/31/2024. DON audited all residents that could have suffered from Staff Member G providing nursing services 2/1/2024. No notable adverse effects were found during audit on 2/1/2024. DON/ designee will Audit residents using 24 nursing report starting 2/2/2024, that could have suffered from Staff Member G providing care, weekly-X4. CorpHR/Designee immediately in-serviced Administrator, HR, and Nursing Administration staff Including DON and ADON's on the facility's abuse and neglect policies starting 2/18/2024 11AM. Facility updated and implemented a written screening process on 2/17/2024, to include that any applicant with GVN/GN status will immediately stop the hiring process, and to ensure all professional staff are licensed, certified, or registered in accordance with applicable State laws to include Candidate applies in person at the facility. The hiring manager interviews the candidate. Candidate completes the background release forms and submits to HR at the conclusion of a successful interview. HR processes all required background and reference checks per company and state regulations. a. Texas Department of Public Safety b. Misconduct registry (EMR) c. Texas OIG d. Texas OIG exclusion e. C.N. A/ Med Aide Registry f. Texas BON Licensure Verification g. Sanctions Search h. SAM i. EVerify If a candidate has been prohibited from employment due to offenses listed under the Texas Health and Safety code or the Texas BON, HR will notify the candidate of this information and will not be employed by the facility. If a candidate has successfully completed the background checks an offer will be made and an invitation for new hire orientation will be scheduled. Corp.HR/Designee will be responsible for monitoring of the screening process starting 2/18/2024, WeeklyX4, monthlyX2, and quarterlyX3. Corp.HR/Designee will review new hire packets daily, or as needed with each new hire. All future new-hire licensed professional staff will have completed competencies prior to floor orientation. DON/designee will be responsible for competency training, with licensed professionals being able to provide return demonstration of skills. All current licensed professionals have been verified for current licensure as of 2/14/2024. Medical Director notified 2/16/2024 of IJ. IJ processes completed on 2/17/2024 will be brought to ADHOC QA meeting 2/18/2024 with Corp.HR/Designee and will continue with monthly QA X3 months, and quarterly X3 thereafter, to include Corp.HR/Designee. Monitoring of the facility's POR began on 02/18/24 at 2:00PM Record review of Staff Member G HR employee status effective date 1/31/24 revealed: Voluntary Termination. Rehire Eligability- Not Eligible for Rehire. Record review of Resident Roster for 400 Hall dated 02/01/24 revealed no adverse events for any resident. Record review of Resident Roster for 400 Hall dated 02/08/24 revealed no adverse events for any resident. Record review of Resident Roster for 400 Hall dated 02/15/24 revealed no adverse events for any resident. Record review of Inservice labeled Abuse/Neglect/Hiring GVN/GN screening process dated 02/18/24 by Corporate Nurse Consultant/HR designee 1Facility will conduct employment background checks, reference checks, criminal conviction investigations and licensing determination for all professional staff. 2. No GVN or GN's will be hired Any questions regarding licensing and or background checks will be referred to corporate HR. Brief evaluation of the participants responses to the inservice Question and Answer All hiring managers verbalized understanding of the hiring process to include screening of all applicants. Inservice staff included via signature of attendance ADM, DON, ADON A, ADON B, HR, Record review Abuse Investigation Policy dated Preventing Abuse-Employee Background Checks. Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual Screening-Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern as a minimum. Inservice dated 2/16/24 Abuse/Neglect- by DON and ADON B Definition of Abuse Post test on abuse by all above mentioned staff on 2/17/24 as well as 3 agency staff. Record review of LVN/RN licensure verifications dated 02/14/24 revealed: 3 RNs licensed to practice as a Nurse 16 LVN's all nurses at the facility were licensed to practice as a LVN or RN. Record review of facility policy labeled Personnel-Hiring and Employment - Background Screening Investigations undated revealed: Our facility conducts background screening checks reference checks and criminal conviction investigation checks on individuals making application for employment with our facility For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's' license. Record review of Employee Interview Questions undated revealed Question 1. 1. Do you have a current Texas nursing license? 2. If multi state, are you making Texas your permanent address? Record review of Employee Hiring Checklist undated revealed a section labeled Start Hiring Process that required initials and included https://txbn.boardof for the TXBON nursing license verification and nursing.org/licenselookup/?o=a3sKM1JioWd3avR7gp56JIFyka2AHSC7QzdAW9VmtM%3D to assist a [NAME] search for other state's nursing verifications. Nursing Proficiency Record review of QAPI meeting dated 02/18/24 revealed: Area: Hiring a Non licensed professional (GVN) Standard: All professional staff will be licensed, certified, or registered. The facility will not hire GVN or GN Observation: An out of state graduate nurse was hired without a proper permit from the state of Texas Implementation: 1. The Hiring Manager will conduct employment background check, reference checks, and criminal conviction checks on persons making application for employment within the facility. 2. Any licensed professional applying for a position that may involve direct contact with residents, his\ her licensing board will be contacted to determine if any sanctions have been assigned against the applicant's license, if his\ her license is valid in the state of Texas, and or if the out of state license is in the process of being reviewed by the Texas State board of nursing and application fee has been paid. During an interview on 02/18/24 at 4:00PM with HR, she said that the new system was that when someone filled out an application, they would give it to her and she only asked what position they were applying for, then would take the person and their application to the appropriate department managers. She said any floor nurse would be interviewed by the ADON's. She said they had a new interview questionnaire that the nurses had to go through that asked if the nurses were licensed or just GVN/GN. HR said if the person was a GVN or GN then the facility could not hire them. After the person had their interview with the department managers, then they were brought back to her to do the background checks and licensure verifications. A new item that was added as well was a new hiring checklist. It included what needed to be done with the initials to the side after completion. The checklist included the TXBON. If they are from out of State, the DON will have already been notified, but she will direct the person's verification to her again. HR said if she was ever in doubt about anything she was to call her Corporate HR manager for clarification. During an interview on 02/18/24 at 4:30PM with ADON A and ADON B, they both said that the facility began a new set of interview questions with the top question for nurses being if they were currently licensed in TX as a nurse and if the person said they were a GVN or GN, then they were supposed to stop the interview right there, because the facility no longer hired a GVN or GN. If they have a license to practice in another state then the interview also stops and that person will go to the DON for an interview, because there are times when there is only a certain amount of time they can work in TX. ADON B said that both the ADON's would do the competency skills check-off for any new LVN, and the DON would do the competency check for any new RN prior to the new employee's first day of work on the floor with the residents. They both said that they were not part of the monitoring of the new hire packet reviews. During an interview on 02/18/24 at 4:50PM with DON and ADM. They both said the facility no longer hired GVN's or GN's at the facility. They had to already have a license to practice as an LVN or RN in the state of TX. The DON said any person that was to be interviewed that had a license from a different state was directed to her because some are only granted a short window of time that they could practice in Texas and she would have to verify those dates as well as if they were legal to practice in Texas as some states did not offer a compact status and were only for each individual state. Both ADM and DON said they had never been a part of the verification of professional licenses in the past and always left it to HR. It had not been until survey team asked the question regarding Staff Member G's license that they realized it had never been checked. The DON said after it was brought to their attention, they terminated Staff Member G. ADM said they had a meeting earlier in the day and had been developing the new hiring checklist that included all the different websites that had to be checked to also include the TXBON. The DON said they revamped their employment interview questions as well to include the license status as the first question. She said that would save time in the beginning because the first question asked if a person was a GVN or GN and that would stop the interview. She said it would then be directed to the person that the facility did not hire GVN or GN, so they would need to wait until they got full LVN or RN license before they could come back and reapply. The ADM said the Corporate HR, himself, and DON would review any future hiring packets as they were completed to ensure everything had been covered. The DON said she took a resident roster for the 400 hall and reviewed through all their nurses' notes, lab orders, MAR's, TAR's, and the 24-hour report sheets during the time Staff Member G had been on duty and had not noted any adverse events during those times. She said she continued to monitor the residents weekly reviewing the 24-hr report sheets since Staff Member G was terminated. The ADM said he notified the Medical Director 02/16/24 after the IJ was presented to him. The DON said HR verified all the current nurses' licenses on 2/14/24. The ADM was informed the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interviews, and record reviews, the facility failed to ensure professional staff was licensed in accordance with applicable State laws for 1 (Staff Member G) of 24 personnel reviewed for licensed nursing. The facility failed to verify if Staff Member G was licensed to practice as a GVN through the TX-BON. As a result, Staff Member G was allowed to provide care/services/treatment to residents including PICC line normal saline flushes, short, long and sliding scale insulins, narcotics administration, stage 3 wound care, monitoring of dialysis ports and catheters for 26 of 92 residents on 400 hall. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. While the Immediate Jeopardy was lowered on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated with a severity level of no actual harm with a potential for minimum harm due to the facilities need to evaluate the effectiveness of the corrective actions. These failures could place residents at risk of being provided care by staff who are not qualified per state law. Findings included: In an interview on 01/31/24 at 10:12 PM with DON and Staff Member G, Staff Member G said she had attended nursing school in New York state. She said she was waiting on her transcript from her school to get a date to test in TX. She said she assumed she was good to work in TX because she was hired as a GVN. the DON said it would be the ADON and HR responsibility to check for current valid licensure. In an interview on 2/1/24 at 12:18 PM the DON said that STAFF MEMBER G would be responsible for the number of residents in the high twenties each shift. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. Record review of Staff Member G's personnel file on 02/15/24 revealed: Application dated 11/21/23-Position applied for GVN/LVN with previous experience as an LPN from 062023 to current (11/21/23) reason for leaving-relocating. Another previous experience was as a Student Nurse from 06/2021 to 06/23. Interview Questions by ADON A, dated 11/21/23- What experience do you have working in (nursing, laundry, housekeeping, food service, etc)? I previously worked w/pts in their homes assisting with ADL's, nursing school clinicals and as an LPN in a pediatric office . Additional notes and comments. I am eligible to work with a graduate nurse permit until I pass my NCLEX in Texas. Employment Acknowledgement dated 11/21/23- Signed by both Staff Member G and ADON A revealed a position of GVN and a date of hire 11/24/23. Position Description Job Title: Licensed Vocational Nurse last revised 11/2019-Signed by Staff Member G 11/27/23. TXBON NCLEX PN Application dated 11/03/23 revealed: Applicants must submit the following items for their file to be considered complete & ready for an ATT review: 1 .5. Affidavit of graduation parentheses (AOG) parentheses submitted by your program Dean [NAME] slash director after graduation. Texas graduates: your program dean\/director will submit the AOG electronically through the AOG portal. Your information will only appear in the AOG portal if you provided the correct school code and graduation date on your influx application. Out of state graduates: your program Dean/director will need to complete and submit the paper affidavit of graduation. *Keep in mind that additional application requirements may be added at any time during the review process An incomplete application and/or failure to complete pending items could delay the issuance of an ATT, Graduate Vocational Nurse (GVN) permit, if eligible, and permanent licensure . 10. I certify by entering my name below, I am the person applying for licensure with Texas Board of Nursing and meet the qualifications required by Texas law and regulations. Further, I certify the information provided in this application has been personally provided and reviewed by me and that the statements, documentation, and information submitted via the online application through an Internet interface are true, accurate, and complete, in every respect. I have not used a false or fictitious name in said application. I read and understand the questions and statements in the application and will abide by all current state and federal laws and regulations affecting nursing licensure. I understand that providing false or misleading information, as well as omitting pertinent or material information in connection with this application, is grounds for negative licensure consequences, which may include licensure denial or revocation and may subject me to civil or criminal penalties. I consent to the release of confidential information to the Texas Board of Nursing and further au1horizc the Board to use and lo release said information as needed for the evaluation and disposition of my application. Further, I understand that If l have any questions regarding this affidavit, I may contact an attorney. Signed 0926/23 . Payment date 11/03/23 . NOTE: This document is a copy of the electronic license application for the person named above and does NOT constitute a verification of license or represent a copy of the individual's license. There was no verification of license to practice as a GVN from the TX BON in Staff Member G's personnel file. Record review of Daily Assignment Sheets from 11/01/23 to 02/15/24 revealed: Staff Member G worked on 11/24/23 2-10p shift with LVN F on the 400 halls. 11/27/23 2-10p with LVN [NAME] the 400 hall. 11/28/23 2p-10p with LVN J on the 400 hall. 11/29/23 2p-10p with LVN K on 400 hall. 11/30/23 2p-10p on 400 hall, 12/01/23 2p-10p with no other nurse on 400 hall. 12/04/23 2p-10p with no other nurse on 400 hall. 12/05/23 2p-10p with no other nurse on 400 hall. 12/06/23 2p-10p with no other nurse on 400 hall. 12/07/23 2p-10p with no other nurse on 400 hall. 12/11/23 2p-10p with no other nurse on 400 hall. 12/12/23 2p-10p with no other nurse on 400 hall. 12/18/23 2p-10p with no other nurse on 400 hall. 12/19/23 2p-10p with no other nurse on 400 hall. 12/20/23 2p-10p with no other nurse on 400 hall. 12/21/23 2p-10p with no other nurse on 400 hall. 12/22/23 2p-10p with no other nurse on 400 hall. 12/25/23 2p-10p with no other nurse on 400 hall. 12/26/23 2p-10p with no other nurse on 400 hall. 12/27/23 2p-10p with no other nurse on 400 hall. 12/28/23 2p-10p with no other nurse on 400 hall. 12/29/23 2p-10p with no other nurse on 400 hall. 17 days in December of 2023 with no supervision on hall 400. 01/01/2024 2p-10p with no other nurse on 400 hall. 01/02/24 2p-10p with no other nurse on 400 hall. 01/03/24 2p-10p with no other nurse on 400 hall. 01/04/24 2p-10p with no other nurse on 400 hall. 01/08/24 2p-10p with no other nurse on 400 hall. 01/09/24 2p-10p with no other nurse on 400 hall. 01/10/24 2p-10p with no other nurse on 400 hall. 01/11/24 2p-10p with no other nurse on 400 hall. 01/15/24 2p-10p with no other nurse on 400 hall. 01/16/24 2p-10p with no other nurse on 400 hall. 01/17/24 2p-10p with no other nurse on 400 hall. 01/18/24 2p-10p with LVN K on 400 hall. 01/22/24 2p-10p with no other nurse on 400 hall. 01/23/24 2p-10p with no other nurse on 400 hall. 01/24/24 2p-10p with no other nurse on 400 hall. 01/30/24 2p-10p with no other nurse on 400 hall. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. During an interview on 02/15/24 at 4:55PM, the ADM said he did not have a license screening policy, but he would try to look for something. During a telephone interview on 02/16/24 at 10:01 AM with New York (NY) state Nursing college, the Registrar verified that Staff Member G completed the Vocational/Practical Nursing program and graduated 06/15/2023. The Registrar said that Staff Member G's name was not released to the state of NY [NAME] due to nonpayment. She said a person's name was sent to NY [NAME] after they had graduated the nursing program and paid their balance due to the school so they could register to take the NCLEX. The Registrar said record still showed a balance due. She said their system updated daily so if Staff Member G paid her balance due that day, then she could have her name released and be eligible to sit for the NCLEX. During a telephone interview on 02/16/24 at 02:20 PM with NY [NAME], said, Staff Member G would not be eligible to use the GPN status. Her completion of the practical nursing program had been submitted to the NY [NAME] however Staff Member G never went further and tested . He said in the state of New York a person could practice as a GPN from the date of graduation to 90 days later without the need to apply. However, he said it was only valid for 90 days which would have run out on 09/15/23 for graduate nursing status. He said that would be the time to test and pass the NCLEX, but if a person had not passed the test or scheduled to test within those 90 days, then they would have to stop practicing as a GPN after the 90 days. NY [NAME] said Staff Member G did not have any status with New York. He said she never applied in any way in NY state. During a telephone interview on 02/16/24 at 03:13 PM with TXBON, she told me Staff Member G had only paid for her NCLEX and applied to take the exam. She said Staff Member G had not submitted an affidavit from her nursing school, graduation confirmation, or scheduled and submitted her fingerprints. She said Staff Member G had to schedule for her fingerprints with a specific approved TX BON approved company as it was federal, and it would tie in with her background check. TX BON said it would only be after Staff Member G had provided all the previous mentioned items, that Staff Member G could get an ATT. It would only be after any person was given the ATT in the state of Texas, that they could then apply with the TX BON for a nursing permit. Only after all these steps were completed, could any person legally represent themselves as a GVN in the state of TX. TX BON said that Staff Member G education had been verified and she was educated, but nothing further. TXBON said Staff Member G had not completed all the steps required in TX to legally practice as a GVN. During an interview on 02/16/24 at 05:31PM PM with HR, she said it was her responsibility to obtain a completed application from an individual. She said it was her responsibility screen the application and direct the person and their application to the proper department. She said if it was a nurse, being a GVN, GN, LVN or RN and a nurse aide or medication aide, then she sent the person and their application to the ADON A for interview. After ADON A had interview and would want to go with that person then she would discuss the pay, verify their license, do the reference checks, and background checks. She said that as a GVN or GN a nurse would not show up under the TXBON because there was not a section for GVN or GN status only LVN or RN status and because they were neither she would not be able to look on the TXBON. So, she said that she made the potential employee show them that they graduated from a nursing school and/or transcript that showed they completed a vocational nursing or registered nursing program at a college. HR said with the graduation she thought that automatically made them a GVN or GN. She said that Staff Member G had made her aware that she paid to test when she was hired, and that it was from NY and that the TXBON was just waiting for her transcripts to schedule a test for the NCLEX nursing exam. HR was aware that if Staff Member G did not pass the test, then she would not be allowed to work as a GVN any longer. HR said she spoke to Staff Member G sometime in the first part of January about her test and Staff Member G told her that she was still waiting to hear back from TXBON and had not heard anything. HR said that she just did not like hiring anyone that was not already licensed as a nurse in the state of Texas or in a compact state with Texas. She said it was just too hard to verify that information and she did not realize that there were several steps beyond graduating from nursing school to use the title of GVN or GN. Record review of TXBON regarding 15.15 Board's Jursidiction Over a Nurse's Practice in Any Role and Use of the Nursing Title accessed at Texas Board of Nursing - Practice - Nursing Practice on 02/28/24 revealed Use of any protected nursing title by an individual who is not licensed to practice either licensed vocational nursing or professional nursing in accordance with the licensing requirements in Texas, or who does not hold a valid compact license to practice nursing poses a potential threat to public safety related to this act of deception and misrepresentation to the public who may be seeking the services of a licensed nurse. In the opinion of the Board, the expressed or implied use of the title LVN, or RN, or any other title that implies nursing licensure requires compliance with the NPA and Board Rules. As stated in Rule 217.11(1)(A), the nurse is accountable to adhere to any state, local, or federal laws impacting the nurse's area of practice. This was determined to be an Immediate Jeopardy on 02/16/24. The ADM was provided the Immediate Jeopardy template on 02/16/24 at 8:55PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility and accepted on 02/18/24 at 2:00PM. Facility has no practicing GVN in the building. Staff member G was terminated on 1/31/2024. Facility will not hire GVN's or GN's as of 1/31/2024. DON audited all residents that could have suffered from Staff Member G providing nursing services 2/1/2024. No notable adverse effects were found during audit on 2/1/2024. DON/ designee will Audit residents using 24 nursing report starting 2/2/2024, that could have suffered from Staff Member G providing care, weekly-X4. Facility updated and implemented a written screening process on 2/17/2024, to include that any applicant with GVN/GN status will immediately stop the hiring process, and to ensure all professional staff are licensed, certified, or registered in accordance with applicable State laws to include: Candidate applies in person at the facility. The hiring manager interviews the candidate. Candidate completes the background release forms and submits to HR at the conclusion of a successful interview. HR processes all required background and reference checks per company and state regulations. a. Texas Department of Public Safety b. Misconduct registry (EMR) c. Texas OIG d. Texas OIG exclusion e. C.N. A/ Med Aide Registry f. Texas BON Licensure Verification g. Sanctions Search h. SAM i. EVerify h If a candidate has successfully completed the background checks an offer will be made and an invitation for new hire orientation will be scheduled. Corp./Designee in-serviced Admin, HR, DON, and ADON's on updated/revised screening process 2/18/2024, staff verbalized understanding. Corp.HR/Designee will be responsible for monitoring of the screening process starting 2/18/2024, WeeklyX4, monthlyX2, and quarterlyX3. Corp.HR/Designee will review new hire packets daily, or as needed with each new hire. All future new-hire licensed professional staff will have completed competencies prior to floor orientation. DON/designee will be responsible for competency training, with licensed professionals being able to provide return demonstration of skills. All current licensed professionals have been verified for current licensure as of 2/14/2024. Medical Director notified 2/16/2024 of IJ. IJ processes completed on 2/17/2024 will be brought to ADHOC QA meeting 2/18/2024with Corp.HR/Designee and will continue with monthly QA X3 months, and quarterly X3 thereafter, to include Corp.HR/Designee. Monitoring of the facility's POR began on 02/18/24 at 2:00PM Record review of Staff Member G HR employee status effective date 1/31/24- Voluntary Termination. Rehire Eligibility- Not Eligible for Rehire. Record review of Inservice labeled Abuse/Neglect/Hiring GVN/GN screening process dated 02/18/24 by Corporate Nurse Consultant/HR designee 1Facility will conduct employment background checks, reference checks, criminal conviction investigations and licensing determination for all professional staff. 2. No GVN or GN's will be hired Any questions regarding licensing and or background checks will be referred to corporate HR. Brief evaluation of the participants responses to the inservice Question and Answer All hiring managers verbalized understanding of the hiring process to include screening of all applicants. Inservice staff included via signature of attendance ADM, DON, ADON A, ADON B, HR, Record review of LVN/RN licensure verifications dated 02/14/24 revealed 3 RNs licensed to practice as a Nurse 16 LVN's all nurses at the facility were licensed to practice as a LVN or RN. Record review of facility policy labeled Personnel-Hiring and Employment - Background Screening Investigations undated revealed: Our facility conducts background screening checks reference checks and criminal conviction investigation checks on individuals making application for employment with our facility For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicants' license. Record review of Employee Interview Questions undated revealed Question 1. 1. Do you have a current Texas nursing license? 2. If multi state, are you making Texas your permanent address? Record review of Employee Hiring Checklist undated revealed a section labeled Start Hiring Process that required initials and included https://txbn.boardof for the TXBON nursing license verification and nursing.org/licenselookup/?o=a3sKM1JioWd3avR7gp56JIFyka2AHSC7QzdAW9VmtM%3D to assist a [NAME] search for other state's nursing verifications. Nursing Proficiency Record review of QAPI meeting dated 02/18/24 revealed: Area: Hiring a Non licensed professional (GVN) Standard: All professional staff will be licensed, certified, or registered. The facility will not hire GVN or GN Observation: An out of state graduate nurse was hired without a proper permit from the state of Texas Implementation: 3. The Hiring Manager will conduct employment background check, reference checks, and criminal conviction checks on persons making application for employment within the facility. 4. Any licensed professional applying for a position that may involve direct contact with residents, his\ her licensing board will be contacted to determine if any sanctions have been assigned against the applicant's license, if his\ her license is valid in the state of Texas, and or if the out of state license is in the process of being reviewed by the Texas State board of nursing and application fee has been paid. During an interview on 02/18/24 at 4:00PM with HR, she said that the new system was that someone filled out an application and would give to her and she only asked what position they were applying for, then would take the person and their application to the appropriate department managers. She said any floor nurse would be interviewed by the ADON's. She said they had a new interview questionnaire that the nurses had to go through that asked if the nurses were licensed or just GVN/GN. HR said if the person was a GVN or GN then the facility could not hire them. After the person had their interview with the department managers, then they were brought back to her to do the background checks and licensure verifications. A new item that was added as well was a new hiring checklist. It included what needed to be done with the initials to the side after completion. The checklist included the TXBON. If they are from out of State, DON will have already been notified, but she will direct the person's verification to her again. HR said if she was ever in doubt about anything she was to call her Corporate HR manager for clarification. During an interview on 02/18/24 at 4:30PM with ADON A and ADON B, they both said that the facility began a new set of interview questions with the top question for nurses being if they were currently licensed in TX as a nurse and if the person said they were a GVN or GN, then they were supposed to stop the interview right there, because the facility no longer hired a GVN or GN. If they have a license to practice in another state then the interview also stops and that person will go to the DON for an interview, because there are times when there is only a certain amount of time they can work in TX. ADON B said that both the ADON's would do the competency skills check-off for any new LVN, and the DON would do the competency check for any new RN prior to the new employee's first day of work on the floor with the residents. They both said that they were not part of the monitoring of the new hire packet reviews. During an interview on 02/18/24 at 4:50PM with DON and ADM. They both said the facility no longer hired GVN's or GN's at the facility. They had to already have a license to practice as an LVN or RN in the state of TX. DON said any person that was to be interviewed that had a license from a different state was directed to her because some are only granted a short window of time that they could practice in Texas and she would have to verify those dates as well as if they were legal to practice in Texas as some states did not offer a compact status and were only for each individual state. Both ADM and DON said they had never been a part of the verification of professional licenses in the past and always left it to HR. It had not been until survey team asked the question regarding Staff Member G's license that they realized it had never been checked. DON said after it was brought to their attention, they terminated Staff Member G. ADM said they had a meeting earlier in the day and had been developing the new hiring checklist that included all the different websites that had to be checked to also include the TXBON. DON said they revamped their employment interview questions as well to include the license status as the first question. She said that would save time in the beginning because the first question asked if a person was a GVN or GN and that would stop the interview. She said it would then be directed to the person that the facility did not hire GVN or GN, so they would need to wait until they got full LVN or RN license before they could come back and reapply. ADM said the Corporate HR, himself, and DON would review any further hiring packets as they were completed to ensure everything had been covered. DON said she took a resident roster for the 400 hall and reviewed through all their nurses' notes, lab orders, MAR's, TAR's, and the 24-hour report sheets during the time Staff Member G had been on duty and had not noted any adverse events during those times. She said she continued to monitor the residents weekly reviewing the 24-hr report sheets since Staff Member G was terminated. ADM said he notified the Medical Director 02/16/24 after the IJ was presented to him. DON said HR verified all the current nurses' licenses on 2/14/24. The ADM was informed the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated with a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review, the facility failed to evaluate and maintain and effective Quality Assurance and Performance Improvement program that focused on indicators of the outcomes of care and quality of life. The facility's QAPI plan had not been reviewed annually for need revisions. This failure placed the residents at risk for a decreased quality of care and decreased quality of life within their living environment. The findings included: Review of the facility's QAPI Committee Plan revealed it was established November 2017 and had been reviewed during 12/2017 and 12/2018. The plan specified [in part]: Evaluation The key elements of this program will be reviewed to assure that they are occurring, that the program is efficient, it is accessible to the community members and that the results are communicated to the appropriate audience . This plan will be reviewed minimally on an annual basis. Substantial changes to the plan will be identified and documented. The most current version will be available for review in the notebook with facility postings in the front entry sitting area . In an interview on 1/31/24 at 4:57 PM, the Administrator stated QA meetings were held monthly. He stated the monthly meetings were attended by the Medical Director, Administrator, DON, ADONs, MDS nurses, Business Office Manager, Activity Director, Social Services, and Maintenance Director. He stated the committee discussed quality measures, wounds, falls, active infections, and Resident Council Meeting Minutes. The Administrator stated he started employment in the facility 6 months ago. He stated no PIPS had been developed during the past 6 months since he had been in facility. He stated no concern areas had triggered that would result in the development of a PIP. He stated if the staff members identify a concern, they tell their department supervisor who presents the concern during the QA meeting or the morning meeting. The Administrator stated he had not reviewed the facility's QAPI plan.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 3 residents (Residents #17 and #55) whose records were reviewed for baseline care plans following admission to the facility, in that: 1. Resident #17 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following her admission to the facility. 2. Resident #55 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following his admission to the facility. This failure placed the residents at risk for not receiving care and services to meet their needs and to promote physical and mental health and well-being within their new living environment. The findings included: 1. Resident #17 Review of Resident #17's Admission Record, dated 2/01/2024 revealed a [AGE] year-old female admitted to the facility on ,d+[DATE] with diagnoses including dementia, hypertension (high blood pressure), anxiety disorder, pain, and gastro-esophageal reflux disease (back-up of stomach acid into the esophagus). Review of Resident #17's electronic health record revealed no documented evidence a baseline care plan had been completed. 2. Resident #55 Review of Resident #55's Admission Record, dated 2/01/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia with mood disturbance, schizoaffective disorder (mental illness characterized by psychosis and mood swings), type 2 diabetes mellitus (abnormal blood sugar levels), depression, anxiety disorder, gastro-esophageal reflux disease (back-up of stomach acid into the esophagus), insomnia, acute kidney failure, and cerebral infarction (stroke). Review of Resident #55's electronic health record revealed no documented evidence a baseline care plan had been completed. In an interview on 2/01/24 at 2:45 PM, MDS Coordinator D stated the admitting nurse started the care plan by completing the interim plan of care. She stated the IDT went over all the new admissions in the morning meeting, completed baseline care plans, went over it with resident and/or responsible party and then scanned it into the electronic health record. She reviewed the electronic records for Resident #17 and Resident #55 and stated a baseline care plan was not completed for either resident. In an interview and record review on 2/01/24 at 2:48 PM, the RN Corporate Director of Clinical Reimbursement reviewed Resident #55's electronic health record and stated she did not see where a baseline care plan had been completed for him. She stated the Interim Plan of Care was not a baseline care plan. In an interview on 2/01/24 at 3:19 PM, the RN Corporate Director of Clinical Reimbursement stated the staff had known to complete the baseline care plans for 4 months. She stated Resident #55's was missed. She stated there was a glitch in the system during updates in the program used for electronic medical records. She provided a copy of the facility policy and procedure for base line care plans for review. Review of the facility policy and procedure for Baseline Care Plans, not dated, revealed the following [in part]: Baseline care plans will be implemented beginning November 28, 2017. (1) The facility must develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must - (i) Be developed within 48 hours of a resident's admission.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, 1 of 8 residents (Resident #40) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan that included her weight bearing status for Resident #40 or that she should wear a knee brace. This failure could place the resident at risk for injury and providers not having the most current information for the Resident's plan of care. Findings included: Record review of Resident #40's Annual MDS assessment dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE], with the following diagnoses: displaced fracture of lateral malleus of right femur . Her BIMS score was 15. Record review of Resident 40's physician orders dated 02/01/24 revealed she did not have an order for weight bearing status or an order for her right knee brace. Record review of Resident #40's electronic health record revealed the most recent comprehensive care plan dated 01/04/24 did not contain the resident's weight bearing status or interventions for her right leg brace . Review of hospital discharge instructions revealed the resident was to be weight bearing as tolerated and wear a right knee immobilizer for transfers. In an interview on 0/1/07/23 at 3:32 PM the DON revealed it would be her expectation that the care plan should include the resident's weight bearing status and an intervention for the right leg brace. She stated the care plan should be updated by the DON. She stated failure to update the care plan could result in the resident not receiving the care he needs. She stated it was her responsibility to update the care plans and ensure the care plan meetings were held. She stated the failure occurred because there was no order at the time of admission. She stated the MDS LVNS completed all the facility MDS's. Review of the facility's undated policy titled: Care Plans, Comprehensive Person Centered revealed the following [in part]: It is developed by an interdisciplinary team within 7 days of completing the MDS. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and psychosocial and functional needs is developed and implemented for each resident and describes the services to be provided to maintain the highest practicable physical, mental, and psychosocial wellbeing.

Based on observations, interviews, and record review, the facility failed to ensure a resident who is incontinent receives appropriate treatment and services to prevent urinary tract infections for one 1 of 2 residents (Resident #67) reviewed for infection control practices. CNA H failed to clean bedside table before setting supplies up for incontinent care. CNA H failed to change gloves between clean and dirty brief change during incontinence care. CNA H failed to wipe from front to back during cleansing peri area including not cleansing from labia folds thru urethral opening. This failure could affect the 24 residents on hall 400 who were occasionally or frequently incontinent of bladder and bowel by placing them at risk for the spread of infection. Findings included: Review of Resident #67 face sheet dated 2/1/23 revealed an [AGE] year-old female admitted to facility on 3/18/22 with diagnoses including dementia, age-related physical debility, muscle weakness, difficulty in walking, and cognitive communication deficit. Observation of incontinence care on 1/31/24 at 7:40 PM revealed CNA H placed items on Resident #67's bedside table before cleaning the top. CNA H then took resident's brief obviously soiled with urine and folded between resident's legs. CNA H then wiped left groin and right groin. Missed wiping front to back over vaginal and urethral area. Had the resident help turn and pulled dirty brief from under resident then placed clean brief on bed and no glove change or hand hygiene performed. She stepped into the restroom at this time and grabbed a second pair of gloves without performing hand hygiene and fastened the brief without cleaning vaginal or urethral area during peri care. Then walked away to get a trash bag for dirty brief and wipes. In an interview on 1/31/24 at 07:45 PM with CNA H, when questioned what steps she may have missed that could be a cross contamination issue, she stated she forgot to change her gloves. When reviewing her steps of incontinent care, she said she forgot to wipe down the middle and front to back. She said there was no other steps she could think of she had missed. (Note the bedside table was not wiped following incontinent care.) In an interview on 1/31/24 at 07:48 PM with Resident #67, when asked how she thought peri care was performed she said me. In an interview on 2/1/24 at 09:30 AM with ADON A regarding CNA expectations for peri-care, she revealed she did performance checks upon hire. She said she had a binder of employees. She revealed there had been an increased rate of urinary tract infections and overall infections. In a record review on 2/1/24 at 09:35 AM with HR it is revealed that CNA H first date of hire was 12/08/23, but she had worked in the facility prior to hire date with the staffing agency. In an interview on 2/1/24 at 09:42 PM the DON stated her expectations would be to have staff trained for competency after their date of hire. In a record review of CAN H had Training/Skill competency sheets signed by ADON A, the facility's Infection Preventionist. On CNA H Proficiency Check Off: Perineal Care; CNA H was signed off on 12/01/23. All boxes checked Met. Under Task #7 [in part]: Washes/cleanses genital area moving front to back. (Female - separate labia with one hands and cleanse the area with downward stroke). Record review of the facility policy titled Perineal Care (revision date February 2018), revealed the following [in part]: Steps in the procedure 8. For female resident: b. Wash perineal area, wiping from front to back. (1) Sperate labia and wash area downward from front to back. 15. Clean the bedside stand. Record review of the facility policy titled Handwashing/Hand Hygiene, not dated, revealed the following [in part]: Policy statement: This facility considers hand hygiene the primary means to prevent spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. Record review of the Infection Prevention Manual for Long Term Care HEALTHCARE ASSOCIATED INFECTION SUMMARY REPORT BY RESIDENT DAYS Month/ Year January 2024 Tracking Log (in-part) URINARY TRACT INFECTIONS Without indwelling catheter for Hall 400 has a total #4. Under specific Trends [in-part]: Overall increase in total infection rate from previous month. Specific increase in skin infections and Urinary Tract Infections

Based on observations, interviews, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with currently accepted professional principles for 1 of 1 Medication rooms. 1. Discontinued medications were stored in an unsecured plastic box beneath the desk of ADON A. This failure placed the residents at risk for potential harm from access to medications that were controlled drugs and were not prescribed for their medical conditions. The findings included: In and observation and interview on 1/31/23 at 11:30 AM the ADON A had plastic unlocked box underneath her desk on the floor in her office. The box contained the following narcotics: Alprazolam 0.25 mg 4 tablets, APAP/Codeine 300/30 mg 8 tablets, APAP/Codeine 300/60 mg 4 tablets, Lorazepam 0.5mg 4 tablets, Pregabalin 25 mg 4 tablets, Temazepam 15 mg 4 tablets, Tramadol 50 mg 8 tablets, and Zolpidem 5 mg 4 tablets. She stated the box was given to her by another nurse a few days ago to return to the DON and she had forgotten it was there. She stated she should have given it to the DON who would call the pharmacy to pick the medications up. She stated the failure could have resulted in a drug diversion. In an interview on 01/31/24 at 12:50 PM the DON stated the medications had been under ADON A's desk because she did not follow the proper process and send the discontinued medications to her for disposal or pick up by the pharmacy. She stated failure to follow the proper process for narcotic storage could result in a drug diversion. Record review of the facility policy Medication Labeling and Storage, not dated, revealed the following [in part]: Controlled medications (listed as schedule 2 through 5 of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on interview and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 8 residents (Resident # 43) reviewed for resident records. The facility failed to ensure physician orders were written for Resident #40. This failure could place residents at risk of having errors in care and treatment. Findings included: Record review of Resident #40's Annual MDS dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE], with the following diagnoses: displaced fracture of lateral malleus of right femur. She had a BIMS score of 15 which meant she was cognitively intact. Record review of Resident 40's physician orders dated 02/01/24 revealed she did not have an order for weight bearing status or an order for her right knee brace. Review of hospital discharge instructions revealed the resident was to be weight bearing as tolerated and wear a right knee immobilizer for transfers. In an observation and interview on 01/30/24 at 11:03 AM Resident #40 had a knee brace on her right leg. Resident # 40 stated her knee brace did not fit correctly. She stated it was applied by therapy or the CNAs. In an interview on 1/31/24 at 7:30 AM the Therapy Director stated Resident #40 had had the knee brace since admission. She stated she measured the resident for the knee brace. She thought the order was on the resident's chart. During an interview on 01/30/23 at 1:56 PM, the DON stated Resident #40 should have an order for the right knee brace and for weight bearing status. She stated the admitting nurse should have transcribed the information from the discharge instructions to the physician orders on admission. She stated any questions the nurse had should have been clarified at that time. The DON stated the omission could result in the resident not receiving needed treatment or services. The DON stated she was responsible for monitoring resident charts for accuracy. Review of the facility policy titled, Medication and Treatment Orders dated July 2016, revealed it did not specifically specify transcription of orders but revealed the following [in part]: Verbal orders should be immediately recorded in the resident's chart by the person receiving the order.

45437 Based on interview and record review, the facility failed to ensure a care plan was developed within seven days after completion of the comprehensive MDS assessment, for three residents of six residents (Residents #1, #48 and #79) reviewed for comprehensive care plans. 1) The facility failed to develop a comprehensive care plan for Resident #1 after completion of the comprehensive MDS assessment. 2) The facility failed to develop a comprehensive care plan for Resident #48 within seven days after completion of the comprehensive MDS assessment. 3) The facility failed to develop a comprehensive care plan for Resident #79 after completion of the comprehensive MDS assessment. These failures could place residents at risk for not receiving the required care. The findings were: 1) Record review of Resident #1's Admission Record, dated 11/10/2022, revealed Resident #1 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #1's had diagnoses which included Acute Respiratory Failure (fluid builds up in the sacs in your lungs), Congestive Heart Failure (heart does not pump blood as well as it should), Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flow and make it difficult to breathe), and Major Depressive Disorder (clinical depression that last more than 2 weeks). Record review of Resident #1's Significant Change MDS Assessment (MDS), dated [DATE], revealed Resident #1 was initiated due to a recent hospital stay resulting which resulted in IV medications in and out of the hospital. Section V (CAAS ) Care Assessment Summary showed completion on 09/16/2022. Section Z, Assessment Administration showed completion on 09/16/2022. Record review of Resident #1's care plan conference sign in sheet showed a care plan meeting was conducted on 09/15/2022 before the completion of the Significant Change MDS. There was not a RN in attendance for this care plan meeting. 2) Record review of Resident #48's Admission Record revealed Resident #48 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included, Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flow and make it difficult to breathe), Gastrointestinal Hemorrhage (blood in your digestive tract), and Major Depressive Disorder (clinical depression that last more than 2 weeks). Record review of Resident #48's Annual MDS Assessment (MDS) revealed it was done on 07/08/2022 . Record review of Resident #48's care plan conference sign in sheet showed a care plan meeting was conducted on 06/09/2022 and 09/29/2022. There was not a comprehensive care plan meeting completed for the comprehensive Annual assessment on 07/08/2022 .There was a care plan in the resident's file. 3) Record review of Resident #79's Admission Record, dated 11/10/2022, revealed Resident #79 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #79's had diagnoses which included Mild Intellectual Disabilities (deficits in intellectual functions), Schizoaffective Disorder (mental disorder characterized by marked schizophrenia symptoms and behaviors), and hypertension (high blood pressure). Record review of Resident #79's Annual (MDS) assessment, dated 07/20/2022, revealed Resident #79 was recently admitted to the facility on [DATE]. Section V (CAAS) Care Assessment Summary showed completion on 07/27/2022. Section Z, Assessment Administration showed completion on 07/27/2022. Record review of Resident #79's care plan conference sign in sheet showed a care plan meeting was conducted on 07/20/2022 before the completion of the Annual MDS . There was a care plan in the resident's file that was completed after the MDS assessment was completed. In an interview on 11/09/2022 at 2:48 a.m., MDS Coordinator 1 and MDS Coordinator 2 both said they did not schedule the care plan meetings and the care plan meetings should be conducted after the MDS was completed and signed. They were unsure why they were done before the MDS was signed. They were also unsure why they were not completed after every assessment within 7 days after the completion of the MDS. They both said it was the LBSW responsibility to conduct the care plan meetings . The MDS coordinators were not asked to do the scheduling for care plans. In an interview on 11/10/2022 at 9:27 a.m., LBSW said she was the one responsible for the care plan meetings and the care plan schedule. She said she was given the MDS list by dates and they were done every 90 days. She did not realize they were supposed to be completed after the MDS assessment was done, which reflected the care areas that were triggered in section V. She said that she realized it was important to complete the care plan meeting after the MDS assessment was complete so that the care plan would show an accurate picture of what was going on with the resident. She also did not realize there was a difference between a comprehensive care plan meeting and quarterly care plan meetings. Record review of the facilities Comprehensive Care plans policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 6 residents (Resident #246) reviewed for activities of daily living. The facility failed to shave and assist Resident #246 with personal care. This failure could place residents at risk for loss of dignity, risk for infections, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #246's face sheet, dated 11/10/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: urinary tract infection, low potassium level, muscle weakness, major depressive disorder recurrent. Record review of the Admission Minimum Data Set (MDS) for Resident #246, dated 11/3/22, reflected a BIMS score of 15, which indicated the resident was cognitively intact. Resident #246 was assessed to require extensive assistance of two with transfers, limited assistance of one with personal hygiene and bathing. In an observation and interview on 11/08/22 at 10:30 AM Resident #244 stated he needed a shave. His face had a growth of beard approximately 1/4 in in length and his hair was not combed. He was in a hospital gown. He stated he asked the aide yesterday for a shave when he was bathed, but they did not shave him. In an observation and interview on 11/9/22 9:00 AM, Resident #246 stated he should get a bath today and the aide was supposed to shave men on their bath days. Resident #246 stated he had a bath on Tuesday, Thursday, and Saturday. He stated he would like a shave today. Resident #246's hair was not combed and his face was not shaved. In an observation and interview on 11/10/22 at 09:41 AM revealed Resident #246 had not been shaved. He stated he asked for a shave yesterday and the aide said he would do it later; but he never came back. Resident #246 was wearing sweats that he had on during an observation on 11/9/22. Hospitality Aide B was the aide on his hall and the aide he asked to shave him. Resident #246's hair was not combed. Resident #246 stated he did not like going without his face shaved and he was not accustomed to wearing a beard. He stated he didn't feel clean when he did not shave. In an interview on 11/10/22 at 10:00 AM, the ADON said it was her expectation for resident's to be shaved daily if they wished to do so. She stated it was the responsibility of the aides to shave the residents when needed. She stated she would see that Resident #246 was shaved today. She stated the resident was not shaved because the aide failed to properly carry out his job duties. She stated another factor was the resident had transferred to another hallway and the resident was not on the bath schedule for that hall. She stated Hospitality Aide B was assigned to the resident's hall yesterday, and this aide was no longer employed by the facility. She stated he should have informed the charge nurse of the duties he had not completed before leaving the facility, but he did not. She stated it was the nurses responsibility to monitor the residents to ensure the aides performed their job duties . Record Review of the facility policy Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed the following in part: .Policy Statement Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting).

Based on observation, interview, and record review the facility failed to ensure that 2 of 2 resident's (ID #'s 244 and 84 ) of reviewed for indwelling catheters received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The facility failed to ensure that the indwelling catheter remained secure for resident #84 to reduce friction and movement at the insertion site. The facility failed to ensure that the indwelling catheter of resident # 244 remained secure and was positioned properly off the floor. These failures placed residents with indwelling catheters at risk for injury, suffering pain, and/or infection. The findings included: Resident #84 Record review of the Admission Record for resident #84 dated 11/8/22, documented he was an [AGE] year-old male with an initial admitted [DATE]. The following diagnoses were documented: acute kidney failure, hypertension, retention of urine, sepsis, acute pyelonephritis (infection in the kidney) Review of Resident #84's Admission MDS (Minimum Data Set) dated 10/26/22 revealed the resident had a BIMS of 13 which indicated mild cognitive impairment and he required extensive assistance of two people with bed mobility and transfers, dressing, and personal hygiene; total assistance of two persons with transfers; total assistance of two people with toileting and bathing, the resident had an Indwelling catheter, and was occasionally incontinent of bowel. Review of Resident #84's Care Plan, which was last revised on 10/21/22 documented in part: Resident has a urinary catheter and is at risk for urinary tract infections and injury. Approaches: Position catheter bag and tubing below the level of the bladder. Review of the Admission Physician Orders dated 11/8/22 for resident #84 documented in part: Foley catheter for diagnoses urinary retention ; Foley Care every shift; Change catheter and drainage bag as needed for leakage or obstruction. Observation on 11/9/22 at 7:00AM revealed Resident #84 had catheter bag hanging on the rail of his bed with the head of his bed elevated 90 degrees. The resident's wife was sitting at his bedside. An observation and interview on 11/9/22 at 11:30 AM that the catheter tubing had no urine in it and the catheter tubing was hanging down on the right side of the bed. The head of the resident's bed remained elevated. The Surveyor asked resident #84 if he had a leg strap to keep the catheter securely in place and he stated no. The surveyor asked who positioned the catheter on the side of he bed and Resident #84's wife replied that Hospitality Aide B hung the catheter bag on the bed rail above the resident's bladder. Interview and observation on 11/9/22at 11:40 AM, LVN A stated she was responsible for monitoring to see that foley catheters bags were positioned correctly on the resident's beds. She stated catheters should be secured to the resident's leg to prevent trauma to the resident and the catheter should be placed below the level of the bladder. She stated Hospitality aide B was currently on break and should have checked the catheter bag before leaving his hall. LVN A accompanied the surveyor to Resident #84's room and observed the catheter bag hanging on the bed rail above the resident's bladder and stated it was not positioned correctly and stated she would have the Hospitality Aide B report to her before returning to duty on the floor. Resident #244 Record review of the Admission Record for resident #244 dated 11/9/22, documented he was an [AGE] year-old male with an initial admitted [DATE]. The following diagnoses were documented: urinary tract infection, hypertension, retention of urine, acute kidney failure, and prostate enlargement with lower urinary tract symptoms. Review of Resident #244's Admission MDS (Minimum Data Set) dated 11/4/22 revealed the resident had a BIMS of 12 which indicated moderate cognitive impairment and he required minimal assist of one person with bed mobility and transfers, dressing, and personal hygiene; total assistance of two persons with transfers; assistance to stabilize with toileting and, the resident had an Indwelling catheter, and was continent of bowel. Review of Care Plan last reviewed on 10/21/22 for resident #84 documented in part: Resident has a urinary catheter and is has a urinary tract infection and trauma. Approaches: Position catheter bag and tubing below the level of the bladder, secure catheter bag with a leg strap, may use a leg bag when up. Review of the Admission Physician Orders dated 11/8/22 for resident #84 documented in part: Foley catheter for diagnoses urinary retention ; Foley Care every shift; Change catheter and drainage bag as needed for leakage or obstruction. Secure catheter with a leg strap to prevent pulling. An observation and interview on 11/9/22 at 11:45:M by the surveyor and LVN A revealed Resident #244 had his catheter laying on the floor approximately 2 feet from his bedside with his bedside table sitting on top of the catheter bag. The tubing was attached to the bag and was pulled taut while the resident lay in his bed. The resident stated he transferred himself from his wheelchair to his bed. In an interview on 11/9/22 at 11:45 AM, LVN A stated she was responsible for monitoring to see that foley catheters bags were positioned correctly on the resident's beds. She stated catheters should be secured to the resident's leg to prevent trauma and/or infection to the resident and the catheter should be placed below the level of the bladder. She stated Hospitality Aide B was currently on break and should have checked the resident and his catheter bag before leaving his hall. LVN A had accompanied the surveyor to Resident #244's room and observed the catheter bag laying on the floor underneath the wheel of the resident's bedside table. She stated it was not positioned correctly and stated she would have the Hospitality Aide B report to her before returning to duty on the floor. Hospitality aide B had left the facility and was not available for an interview after his lunch break. Review of Hospitality Aide B's employee file revealed that he had been competency checked on foley catheter care with satisfactory performance documented by the ADON. In an interview on 11/9/22 at 12:00 PM the DON stated her expectation was that aides should check their residents frequently and always before leaving the floor on breaks and at the end of their shift. She stated the failure occurred because the Hospitality aide did not perform his job duties as he had been trained to do. Review of the facility's Policy & Procedure on Foley Catheter Guidelines revised on 9/2014 provided by DON on 11/10/22 documented in part: Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The urinary bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the bladder. Be sure the catheter tubing and drainage bag are kept off the floor. Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Catheter tubing should be strapped to the resident's inner thigh.

Based on observation, interview and record review the facility failed to ensure food was stored in accordance with professional standards for 1 of 3 refrigerators reviewed for food storage. One refrigerator contained expired one-half gallon buttermilk. This failure by the facility could have caused residents who ate food prepared with outdated product to acquire foodborne illnesses. Findings include: Observation on [DATE] at 11:40 AM revealed an open container approximately one-third full of low-fat cultured buttermilk in the two-door refrigerator next to the serving line was observed to have a use by date of [DATE]. In an interview on [DATE] at 11:45 AM the Dietary Manager (DM) said that somebody probably missed the expired buttermilk during their routine inspections and that it should not have been there. In an interview on [DATE] at 10:35 AM the Dietitian said TCS food per facility policy should be discarded no later than three days beyond the expiration date and said the staff must have missed the expired buttermilk when they were doing their routine sweep. [DATE] 3:30 PM Record review of a facility policy titled Policy & Procedure Manual, Food Storage dated ,d+[DATE] revealed in part: Procedure: .7. c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold or discarded.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 (Resident #50) reviewed for PASARR. Resident #50 with diagnoses of mental illness, did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Record Review of Resident #50's Face Sheet, dated 11/10/22, revealed he was a [AGE] year-old male, admitted to the facility on [DATE], with the following diagnoses: anxiety disorder with an onset date of 09/02/22, schizophrenia disorder (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior) with an onset date of 09/20/20, schizoaffective disorder ( a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), depressive type with an onset date of 09/27/22, and dementia with an onset date of 09/02/22. Record Review of the significant change MDS assessment, dated 10/07/22, revealed Resident #50, (Section I - Active Diagnoses), Psychiatric/Mood Disorder diagnosis had active diagnosis for anxiety disorder and schizophrenia. Record Review of Resident #50's PASARR Level I Screening (PL1), dated 09/02/22, was negative for (MI) mental illness. There was no documentation that Resident #50 had a PASARR Level II Screening (PE) after the diagnosis of schizophrenia disorder with an onset date of 09/20/20. Record Review of Resident #50's Summary Order Report, dated 11/10/22, revealed an order for Seroquel (start date 10/06/22) for the diagnosis of schizophrenia and lorazepam for anxiety disorder. In an interview, on 11/09/22 at 3:25 PM, the MDS Coordinator 1 said she was responsible for PASARR screening and updating them. She said the PASARR Level 1 screening was completed at the hospital before Resident #50 was admitted to the facility and was negative for mental illness. She said she doesn't update a PASARR when they come from the hospital until she does an audit of the resident's chart and catches it. She said she conducts an audit every time a MDS is updated. When asked why it wasn't updated with the latest MDS update, as the resident was admitted on [DATE], she said she did not know. The MDS Coordinator 1 said a PASSAR Level II screening had not been completed for Resident #50. She said a 1012 form (a form that eliminates the need for a PASRR Level II Screening (PE) due to the resident having a primary DX of Dementia or Alzheimer's) had also not been completed either. In an interview, on 11/10/22 at 9:04 AM, the DON said it was the responsibly of the MDS Coordinator to review the diagnosis of a resident when admitted to the facility and complete/update a PASSAR Level I or II if warranted. The DON said a resident might not receive PASARR services if they are eligible if this is not done. There was no facility policy regarding PASARR.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #'s 1 and 2) of 5 residents reviewed for ADLs. The facility failed to provide showers consistently for Residents #1 and #2 per the facility bathing schedule. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. Findings included: Review of Resident #1's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was cognitively intact with a BIMS score of 12 (a score of 12 indicated mild cognitive impairment). She was totally dependent in the bathing activity from 2 staff. Review of Resident #1's Care Plan initiated on 09/06/21 revealed she had ADL self-care deficits and required moderate assistance from one staff for bathing. There was no documentation in the Care Plan For refusal of baths. Review of Resident #1's November 2020 ADL Documentation Report revealed the resident did not receive 14 out of 17 baths. She did not get a bath from 11/06/21 thru 11/30/21/ ( 24 days). Resident #1's December 2021 ADL Documentation Report revealed the resident did not receive 11 out of 12 baths in December 2021. She did not get a bath from 12/2/21 until 12/9/21 that was documented as given per the resident's son's request in the nurse's progress notes. She had not received another bath before she was transferred to the hospital on 12/22/21 (13 days) with complaints of SOB, Nausea and vomiting, and a rapid heartbeat. Record review revealed Resident #1 was in the hospital and unavailable for interview at the time of the investigation. Interview with Resident #1's family member (responsible party on 12/23/21 at 2:00 PM revealed that the family member did not feel that the resident was bathed at the facility. He stated that she often had an odor when he visited, and he had to ask the facility to bath her during a recent visit due to her body odor. Review of Resident #2's MDS dated [DATE] revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was cognitively intact with a BIMS score of 12 (a score of 12 indicated mild cognitive impairment). Bathing was coded an 8 which indicated the activity did not occur. Review of Resident #2's Care Plan initiated on 09/22/21 revealed she had ADL self- care deficits and required moderate assistance with bathing from 1 staff. There was no documentation of refusal of care in the resident's care plan Review of Resident #2's November 2021 ADL Documentation Report revealed the resident did not get 9 out of 12 baths. She did not get a bath from 11/04/21 through 11/18/21 (14 days) and 11/19/21 through 11/29/21 (10days). Resident #2's December 2021 ADL Documentation Report revealed the resident did not receive 8 out of 8 baths in December 2021. She did not get a bath from 12/1/21 through 12/22/21 (21 days). In an interview and observation on 12/23/20 at 3:43 PM Resident #2 was in her room. She was well groomed and had no odor. She said she did not always get her showers. She stated that she had not had a shower this week and hoped she got one tomorrow. She stated she did not remember when she had her last shower. She stated she did not get her showers like she should at the facility. In an interview on 07/23/20 at 3:30 PM CNA A stated she does her showers unless she is the only aide assigned to the hall and this does not happen very often. In an interview on 12/23/20 at 4:00 PM the ADON said the facility used a lot of agency staff and they were not always reliable. She verified some of the showers had been missed and were not documented as refused in the electronic record. She stated that it was the ADON's responsibility to monitor the documentation in the electronic records and the shower sheets and shower sheets to ensure the residents were receiving their baths. She stated there were usually 2 ADON's, but she had been the only ADON until recently and she had not recently been monitoring on a regular basis. She stated the new ADON would assist her when she was trained. In an interview on 12/23/20 at 3:27 PM CNA B said the showers do not get always done but it does not happen very often. She stated she would tell the nurse if the resident refused a bath. In an interview on 12/23/20 at 3:58 PM CNA C said staff were not always able to get all the residents' showers done but they try unless they are shorthanded. She stated that does not happen as often lately. She stated she tells the nurse if residents refuse and she always documents her baths on the ADL Documentation record electronically. Review of the facility's un-dated Quality of Care Policy for Activities of Daily living revealed the facility provides the necessary care and services to ensure that each resident attains or maintains the highest practicable physical, mental and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care.

Based on interview, and record review, the facility failed to ensure [CONDITION(S)] drugs were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #) reviewed for unnecessary [CONDITION(S)] medications. A. Resident #87 was administered [MEDICATION(S)], an antipsychotic medication, without a diagnosis for justification of use. The facility's failure could affect residents receiving [CONDITION(S)] medications, placing them at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms. The findings included: Review of Resident #87's Resident Face Sheet, dated 10/01/2021, revealed resident was a [AGE] year-old female who had been admitted to the facility on [DATE]. The resident had diagnoses of generalized anxiety disorder, major depressive disorder recurrent, Restlessness and agitation, and Generalized anxiety disorder. Review of Resident #87's Physician Order Report, dated 10/01/2021, revealed an order for [MEDICATION(S)] 25 mg, every 24 hours, administer at bedtime as needed for agitation, with a start date of 09/04/2021. Review of the medication [MEDICATION(S)], on Web MD, accessed on 10/07/21 revealed the therapeutic class of [MEDICATION(S)] was an antipsychotic that can be used to treat certain mental mood conditions (such as [CONDITION(S)], [CONDITION(S)] disorder, and sudden episodes of [CONDITION(S)] or depression associated with [CONDITION(S)] disorder). Record review of the most recent MDS, an admission MDS dated [DATE], documented there was no diagnosis indicating Resident #21 suffered from a mental or mood condition requiring the use of an antipsychotic medication. Record review of documentation of Pharmacy reviews by the consultant Pharmacist revealed that Resident ID # 87's meds were reviewed 0n 09/08/2021. The reports do consultant documented that the resident's medications were reviewed and there was a recommendation to obtain a stop date for use of the prn [MEDICATION(S)]. The pharmacy consultant also noted that there was no informed consent for use of the antipsychotic signed by the resident or their legal representative in the resident record. During an interview on 10/01/2021 at 5:08 PM, the DON agreed there was not a proper diagnosis for the use of the medication [MEDICATION(S)]. She stated the Pharmacy Consultant completed the reviews on the 8th and the facility had received the recommendations on 09/15/21. She stated the ADON was responsible for placing the pharmacy recommendations in the physicians folders to be signed, which lets the physician know that the pharmacy consultant has made a recommendation. The physicians usually visit weekly and check their folders and act on the recommendations by writing an order . The DON Checked the physicians folder and confirmed that the recommendation was not in his folder. ADON hire date of 11/7/2012, stated she was responsible for getting the pharmacy consultants report into the physicians folder to be signed. She acknowleged that agitation is not a proper diagnosis for [MEDICATION(S)]. Review of the facility's policy for Antipsychotic Medication Use, dated as revised March 2015, revealed the following [in part]: Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 7. Antipsychotic medications shall on be given for the following conditions: [CONDITION(S)], schizoid-affective disorder, mood disorders with psychotic features, and treatment refractory major delusional disorder, delusional disorder, delusional disorder, mood disorder, [CONDITION(S)] in the disorder of dementia . 11. Antipsychotic meds will not be given for wandering, poor self-care, restlessness, mild anxiety, restlessness, or nervousness.

Based on observation, interview, and record review, the facility failed to ensure a resident provided respiratory care received the care consistent with professional standards of practice for 1 of 3 residents (Resident #86) reviewed for oxygen administration. Resident #86 was observed using supplemental oxygen via nasal cannula, and did not have a physician's order for oxygen administration. The facility's failure could place residents at risk for compromised health status from receiving treatments and procedures not ordered by a physician. The findings included: Review of the Admission Record, printed 10/01/21, revealed Resident #86 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. The form documented the resident had been hospitalized from 11/30/20 to 12/08/20 and had readmission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/29/21 at 9:46 AM revealed Resident #86 was resting in bed with her eyes closed. An oxygen concentrator positioned at the side of the head of the bed was running and was set at a volume of 3 liters per minute. The resident was not using the oxygen. The nasal cannula tubing was lying on the floor at the side of the bed. A wheelchair with a portable oxygen tank in a bag mounted on the back of the chair was observed at the foot of the bed. Observation on 9/30/21 at 2:26 PM revealed Resident #86 was sitting up in bed. The oxygen concentrator was running and was set at 2.5 liters per minute. The resident had the nasal cannula on the top of her head. She stated she had been eating a snack. Review of the physician orders, dated 10/01/21, revealed Resident #86 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #86's quarterly MDS Assessment, dated 9/08/21, revealed oxygen therapy had not been selected. Review of Resident #86's comprehensive care plan, dated as reviewed/revised on 9/13/21, revealed it did not address shortness of breath or supplemental oxygen use. During an interview and record review on 10/01/21 at 5:05 PM, the DON stated the nurse who received a physician order entered the order into the electronic health record. She stated a licensed nurse could start oxygen per nursing judgment and then get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the nursing progress notes and did not find evidence of when the oxygen use was started or by whom. She stated the nursing notes occasionally documented oxygen use between December 2020 and February 2021. She stated the last time oxygen was documented as being used was on 2/12/2021. The DON stated she would find a facility policy and procedure for oxygen administration and physician orders. Observation on 10/01/21 at 5:15 PM revealed Resident #86 was resting in bed. She was using the oxygen at 2.5 liters per minute via nasal cannula. The oxygen tubing and humidifier bottle were dated 10/03/21 and initialed. The initials were not legible. In an interview on 10/01/21 at 5:20 PM, the DON stated the oxygen tubing and humidifier bottle should be dated the day it was changed, and not the date it would next be changed. She stated 10/03/21 would be Sunday, the date it would be changed. Review of the facility's policy and procedure for Oxygen Administration, dated as revised October 2010, revealed the following [in part]: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed . Documentation After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for prn [as needed] administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure .

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 3 (Resident #5, #11, and #12) of 13 residents reviewed for ADLs. The facility failed to provide showers consistently for Residents per the facility bathing schedule. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life. Findings included: Review of Resident #5's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was cognitively intact with a BIMS score of 13 (a score of 13-15 indicated cognitively intact). She required physical help in part of the bathing activity from one staff. Review of Resident #5's Care Plan initiated on 05/15/20 revealed she had ADL self-care deficits and required moderate assistance from one staff for bathing. Review of Resident #5's July 2020 ADL Documentation Report revealed the resident did not receive 9 out of 12 baths. She did not get a bath from 07/02/20 thru 07/08/20 (8 days) and from 07/12/20 thru 07/24/20 (14 days). In an interview and observation on 07/21/20 at 12:35 PM Resident #5 was sitting in her room in her wheelchair. She was dressed but her hair was not combed, and she did not appear to be properly groomed. She said she was not pleased with her care and had not received a shower. Review of Resident #11's MDS dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was cognitively intact with a BIMS score of 14 (a score of 13-15 indicated cognitively intact). She required physical help in part of the bathing activity from one staff. Review of Resident #11's Care Plan initiated on 05/15/18 revealed she had ADL self- care deficits and required extensive assistance with bathing from two staff. Review of Resident #11's July 2020 ADL Documentation Report revealed the resident did not get 4 out of 12 baths. She did not get a bath from 07/19/20 through 07/27/20 (9 days). In an interview and observation on 07/21/20 at 12:44 PM Resident #11 was in bed, her hair appeared disheveled and she was wearing a hospital gown. She said she was not happy with her care. She said she had not had a shower for the last two weeks. Review of Resident #12 MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). Review of Resident #12's Care Plan initiated on 05/01/20 revealed she had ADL self-care deficits and required moderate assistance from one staff for bathing. Review of Resident #12's July 2020 ADL Documentation Report revealed the resident did not get 7 out of 12 baths. She did not get a bath from 07/01/20 thru 07/07/20 (7 days) or from 07/22/20 thru 07/27/20 (6 days). In an interview and observation on 07/28/20 at 3:43 PM Resident #12 was in her room. She was well groomed. She said she was upset because she was not receiving assistance with her showers. She said she had to shower herself, but it was difficult for her and she should receive assistance from staff. In an interview on 07/23/20 at 3:30 PM CNA A said staff tried to the get the residents showers done but were not always able to get all of them done. In an interview on 07/24/20 at 4:30 PM the Administrator said the facility had 16 staff out with COVID-19. He said some of the showers may have been missed. He said the facility had contracted with agency staff, but they were not always reliable. In an interview on 07/28/20 at 11:27 AM CNA B said all the showers do not get done but it does not happen very often. In an interview on 07/28/20 at 2:58 PM CNA C said staff were not able to get all the residents' showers done but they try. Review of the facility's un-dated Quality of Care Policy for Activities of Daily living revealed the facility provides the necessary care and services to ensure that each resident attains or maintains the highest practicable physical, mental and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care.

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of eleven residents reviewed for neglect. The facility failed to have an RN available to supervise RN A, as ordered by the Board of Nursing, who could have intervened and provided emergency care to Resident #1. As a result of this failure, RN A failed to contact the physician, stay with Resident #1, and contact EMS when the resident's blood sugar level was critically low, her condition did not respond to the [MEDICATION NAME] (emergency medication used to increase a person's blood sugar) and the resident was unresponsive. Forty minutes after Resident #1 was found she was transferred to the hospital on [DATE]. She remained unresponsive and was placed on life support. Resident #1 did not become responsive again and expired on [DATE] after being taken off life support. An Immediate Jeopardy was identified on [DATE] as beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed the 25 diabetic residents on Halls 100, 200, and 300 where RN A worked at risk of serious physical harm, injury, and/or death. Findings included: Review of Resident #1's closed record revealed an MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of two people for activities of daily living. Review of her Care Plan dated [DATE] reflected there was not a care plan regarding her diabetes. Review of Resident #1's (MONTH) physician's orders [REDACTED]. [DATE]: Inject 20 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 30 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 40 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Give 500 mg of [MEDICATION NAME] (medication used to help control and lower blood sugars) twice a day by mouth. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #1's nurse's note documented by RN A on [DATE] at 3:14 a.m. reflected Resident #1 became unresponsive to stimuli. Skin was cool to touch and clammy. Resident #1 had frothy secretions coming out of her mouth. Head was repositioned to prevent aspiration. FSBS (Finger Stick Blood Sugar) was taken and was noted to be 21 mg/dl. Resident #1's vital signs were noted to be the following: 95.8 temperature, 79 heart rate, 20 respirations per minute, and her blood pressure was ,[DATE]. Continue to monitor closely. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of Resident #1's MAR for (MONTH) (YEAR) reflected the following order: Inject 1 mg of [MEDICATION NAME] intramuscularly as needed for low blood sugar (if blood sugar is less than 60 and resident is unresponsive) which had a start date of [DATE] at 3:10 a.m. and had been put on the MAR by RN A. There was not a signed physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of [MEDICATION NAME]'s Information page for physicians accessed at http://uspl.lilly.com/[MEDICATION NAME]/[MEDICATION NAME].html#pi on [DATE] at 12:49 p.m. reflected the following: [MEDICATION NAME] is indicated as a treatment for [REDACTED]. If the response is delayed .emergency aid should be sought so that [MEDICATION NAME] (route other than oral which is usually either intramuscularly, subcutaneous, or intravenous) glucose can be given. Review of Resident #1's nurse's note documented by RN A on [DATE] at 4:40 a.m. reflected Resident #1 remained unresponsive to stimuli, and her eyes appeared to be rolled back after being given [MEDICATION NAME] at 3:15 a.m. FSBS rechecked at 3:25 a.m. and noted to be at 40 and at 3:45 a.m. at 59. Resident #1 did not arouse to sternum rub. EMS (Emergency Medical Services) was notified at 3:55 a.m. When paramedics arrived to facility, IV was started in left arm and [MEDICATION NAME] at 10% hung and infused. Resident #1 was transferred to the stretcher and taken to ambulance at 4:30 a.m. to be transported to the ER. The notes also reflected the RN was unable to contact the resident's family. No additional vital signs were recorded. Review of Resident #1's Emergency Department Admission reflected her date of admission was [DATE]. The record reflected Resident #1 arrived to the emergency roiagnom on [DATE] at 4:48 a.m. Resident #1 presented with decreased responsiveness and possible cause was listed as low blood sugar. Resident #1 was intubated on [DATE] at 5:08 a.m. and was put on a ventilator to assist with breathing and was admitted to the ICU. Review of the Hospital's Physician Notes reflected that on [DATE], Resident #1 was still on the ventilator and had been off sedation for 24 hours but remained unresponsive and the family requested terminal extubation (The withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support.) Resident #1 was discharged from the hospital on [DATE] with hospice services. Resident #1 remained unresponsive and her prognosis was poor. Interview with Resident #1's family on [DATE] at 10:30 a.m. revealed Resident #1 expired on [DATE]. He stated she never woke up after the low blood sugar incident, so he made the difficult decision to take her off life support and take her home. He stated Resident #1's blood sugar went low every once in a while, but it had never gotten as low as 21. Interview with RN A on [DATE] at 11:43 a.m. revealed on [DATE] around 3:15 a.m CNA B told her Resident #1 was not acting right. She stated she went down to Resident #1's room and found her unresponsive and cold and clammy. She stated she took Resident #1's vital signs and knew she was a diabetic so she took her blood sugar. Resident #1's blood sugar was 21. She stated she realized the resident was hypoglycemic (when a resident has low blood sugar). She stated she knew the resident had an order for [REDACTED].#1's room at that time, even though the resident was still unresponsive. RN A stated she came back about ten minutes later and rechecked her blood sugar and it was 40. She stated she left the room at that time and Resident #1 was still unresponsive at that time. She stated she came back about 20 minutes later and took her blood sugar again and it was 59. She stated the resident was still unresponsive so she decided at that point she should send Resident #1 to the hospital. RN A revealed she called 911 and went back to the room and stayed with the resident until the paramedics arrived. She stated the resident remained unresponsive and when EMS arrived, the paramedics started an IV but Resident #1 was still completely unresponsive. RN A stated EMS transferred Resident #1 to the stretcher and the resident started to groan, but other than that she was still out of it. RN A stated she never called the physician during the 45 minutes between finding the resident unresponsive and sending her to the hospital. RN A stated she left a message for the doctor after Resident #1 was sent to the hospital. She stated she did not remember notifying the DON or any administrative staff about the incident, but she did record the incident on the 24 hour report for the upcoming shift. RN A stated if she could go back and change things, she would have given the [MEDICATION NAME] and after a few minutes when it had not worked, she would have called 911. She stated she also would have called the doctor sooner to see what he wanted her to do. She stated she did not know why she waited so long to call 911, but she cannot go back and change it. Interview with CNA B on [DATE] at 10:30 p.m. revealed she was RN A's aide the night of the incident on [DATE]. She revealed she came into work around 10:00 p.m. and started her initial rounds. She said she remembered Resident #1's family was still there and Resident #1 was alert and talking. She stated Resident #1's family left a little after midnight. When she began her second round around 1:30 a.m. she noticed Resident #1 was very pale and had some white stuff coming from her mouth. CNA B stated she went to get RN A and asked her to go assess Resident #1 because something was not right. RN A told her she would go look at Resident #1 in a minute. CNA B continued on her rounds with other residents and went back to check on Resident #1 around 2:00 a.m. CNA B stated Resident #1 was still very pale and appeared to be unconscious because she was not waking up. She asked RN A to go look at Resident #1 again and RN A went down to Resident #1's room and looked at the resident but did not take vital signs or anything. RN A told her she had the situation handled, so she went back to care for other residents. CNA B went back to check on Resident #1 again around 2:30 a.m. and noticed Resident #1 was still pale and was not waking up. CNA B asked RN A what was going on with the resident and RN A told her that Resident #1 was going to be okay but to just keep an eye on her. At that point, she went and got CNA C to go look at Resident #1 with her. CNA B stated the time was probably around 3:00 a.m. CNA B and CNA C went down to check on the resident and she was still the same way. Resident #1 was unresponsive, pale, and still frothing at the mouth. CNA B revealed they asked LVN D to come and look at the resident, because RN A was not helping. At that point, RN A got up with them and went down to look at the resident. RN A told LVN D to not go into the room. RN A took Resident #1's vital signs and said her blood sugar was really low. RN A told her (CNA B) she had it handled, so she finished her rounds. CNA B revealed after a while, probably close to 4:00 a.m., she finally saw the paramedics arrive. She stated Resident #1 looked exactly the same. She was still unresponsive and finally around 4:30ish, the paramedics told RN A that it was just better if they took Resident #1 to the hospital. Attempt to interview LVN D was made on [DATE] at 10:44 a.m. but LVN D's phone number was not working. Interview with LVN E on [DATE] at 11:40 a.m. revealed she was one of the other nurses the night of the incident. She revealed LVN D told her CNA B had asked her to go look at Resident #1 because she was looking bad and RN A told her she had it handled. LVN E stated she remembered CNA B coming up to the desk, a little after midnight, a few times throughout the night asking RN A to go look at Resident #1. LVN E stated RN A never let them know what was going on with her residents and ignored aides' concerns regularly. Interview with the DON on [DATE] at 11:43 a.m. revealed she knew Resident #1 had been sent to the hospital, but did not remember why. Once she reviewed RN A's nurse's notes, she stated RN A should not have waited so long to call emergency services. She stated RN A should have called 911 when she found Resident #1 completely unresponsive. The DON stated she did not investigate the incident or ask RN A what happened. She revealed they had not done any in-services with staff regarding changes in conditions or blood sugar checks since the incident. Interview with ADON F on [DATE] at 1:15 p.m. revealed the ADON over RN A's hall that night was no longer employed with the facility, but ADON F did remember the other ADONs and the DON discussed the reason for discharge of Resident #1 the next day during morning meeting. Review of RN A's license on the Board of Nursing website on [DATE] at 12:45 p.m. reflected RN A's nursing license was on probation. Review of the Agreed Order from the Texas Board of Nursing reflected on or about [DATE], while employed at the same facility, she failed to initiate cardio-pulmonary resuscitation (CPR) after finding a resident unresponsive with no respirations or pulse and instead went to check his code status. RN A's conduct resulted in an unnecessary delay in care and was likely to injure the resident, including possible demise from lack of timely interventions and appropriate nursing care. Review of the Agreed Order from the Texas Board of Nursing reflected RN A was to be supervised by another RN who is on the premises. The supervising RN was not required to be on the same unit or ward, but should be on facility grounds and readily available to provide assistance and intervention if necessary. Review of RN A's employee file reflected a Notification of Employment dated [DATE] and signed by the Corporate Director of Clinical Services which stated the following: I have received a complete copy of the Order of the Board and am aware of the stipulations placed on this license by the Texas Board of Nursing. I agree to notify the Board's office and provide information to the Board regarding this nurse's resignation or termination. Review of the staff schedule and sign in sheet since [DATE] reflected RN A worked 24 10pm-6am shifts, including [DATE], without another RN in the building and readily available for supervision. Further review of the sign in sheets revealed RN A had worked on Halls 100, 200, and 300. Review of RN A's job description signed on [DATE] by RN A reflected the following: Initiates emergency support measures . Emergency situations are recognized and appropriate action is instituted. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they were aware RN A was on probation and was to be under the supervision of another RN. The Administrator stated he was the Administrator of the building during the prior incident with RN A when she did not perform CPR on another resident. He stated he was willing to give her a second chance. The DON stated RN A could always call her for advice but she was not on facility grounds as her supervision the night of the incident. Interview with the Administrator on [DATE] at 11:20 a.m. revealed RN A had originally been on the 2pm-10pm shift when they had learned of her probation in (MONTH) (YEAR). He stated RN A then switched to the night shift in December. He stated he was under the impression RN A would be on the same 4 on 2 off schedule (work four days and they are off for two days) as the other RN on night shift, so she could provide supervision. He stated because of their mistake, RN A worked over 20 night shifts since (MONTH) without another RN supervising her according to her probation terms. Review of the facility's Change in Resident's Condition or Status Policy revised in (MONTH) (YEAR) reflected the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident .d. A significant change in the resident's physical/emotional/mental conditions . A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of the facility's undated Abuse/Neglect policy reflected the following: Definition of 'Neglect' 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of/Actual Neglect . 6. Inadequate provision of care . 9. Leaving someone unattended who need supervision.An Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator and DON were informed of the IJ on [DATE] at 1:40 p.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on [DATE] reflected: Staff will be in-serviced by Corporate Director of Clinical Operations on [DATE] on neglect policy, and to never leave a resident unattended during an emergency. Current staff will be in-serviced today, both day and evening. Night, weekend, and PRN staff will be in-serviced prior to shift. No one will work without having received information. The Plan of Removal will be used for in-service. One hundred percent audit was completed on [DATE] on all residents requiring blood glucose monitoring. Orders were reviewed for high/low parameters and notification of MD Clinical staff were in-serviced by Corporate Director of Clinical Operations on [DATE] on change in resident's condition or status policy. If a resident is found in distress, the charge nurse will notify the resident's attending physician and DON. The nurse will make detailed observations and gather pertinent information utilizing the SBAR assessment. Corporate Director of Clinical Operations in-serviced nursing staff on [DATE] on best nursing practice of using [MEDICATION NAME] injection. If resident continues to be unresponsive after 15 minutes of injection, EMS will be called for additional intervention. Competency checks will be performed on staff for the above in-services on [DATE] and [DATE]. Change in condition policy will be included in all orientations going forward, with included post-test. DON will monitor SBAR assessments that are written for a resident change in condition. Nurse who demonstrated poor judgment during the episode in question was suspended and terminated on [DATE]. Monitoring the Plan of Removal: Interviews with CNA G, LVN H, and CNA B on [DATE] at 10:05 p.m. through 10:30 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in conditions and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interviews with LVN J, LVN K, LVN L, CNA M, CNA N, CNA O, and CNA P on [DATE] between 1:00 p.m. through 2:00 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in condition and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they believed the immediate jeopardy occurred because RN A left a resident alone who was unresponsive and in a state of emergency and did not notify the physician. RN A did not call 911 when the [MEDICATION NAME] did not work. The Administrator stated they should have caught the situation but RN A had not documented the incident correctly. When asked what they would do differently to prevent another IJ, the Administrator stated they would no longer hire nurses who were on probation with the board of nursing. The DON stated they started doing SBAR forms (forms used by nurses when a change in condition is noted) and she would review them all. They both revealed they had been in-serviced over the abuse/neglect policy and reportable events. On [DATE], the Immediate Jeopardy (IJ) was removed. On [DATE] at 4:15 p.m., DON and the Corporate Director of Operations were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 25 diabetic residents who resided on Halls 100, 200, and 300 where RN A worked.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent neglect for one (Resident #1) of 11 residents reviewed for neglect. 1. The facility failed to have an RN available to supervise RN A, as ordered by the Board of Nursing, who could have intervened and provided emergency care to Resident #1. As a result of this failure, RN A failed to contact the physician, stay with Resident #1, and contact EMS when the resident's blood sugar level was critically low, her condition did not respond to the [MEDICATION NAME] (emergency medication used to increase a person's blood sugar) and the resident was unresponsive. Forty minutes after Resident #1 was found she was transferred to the hospital on [DATE]. She remained unresponsive and was placed on life support. Resident #1 did not become responsive again and expired on [DATE] after being taken off life support. 2. The Administrator and DON failed to identify the neglect by RN A and failed to investigate and report to the State Agency when Resident #1 experienced a significant change in condition related to her blood sugar and level of consciousness. An Immediate Jeopardy was identified on [DATE] as beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed the 25 diabetic residents on Halls 100, 200, and 300 where RN A worked at risk of serious physical harm, injury, and/or death. Findings included: Review of the facility's Change in Resident's Condition or Status Policy revised in (MONTH) (YEAR) reflected the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident .d. A significant change in the resident's physical/emotional/mental conditions . A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of the facility's undated Abuse/Neglect policy reflected the following: Definition of 'Neglect' 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of/Actual Neglect . 6. Inadequate provision of care . 9. Leaving someone unattended who need supervision. Review of Resident #1's closed record revealed an MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of two people for activities of daily living. Review of her Care Plan dated [DATE] reflected there was not a care plan regarding her diabetes. Review of Resident #1's (MONTH) physician's orders [REDACTED]. [DATE]: Inject 20 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 30 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 40 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Give 500 mg of [MEDICATION NAME] (medication used to help control and lower blood sugars) twice a day by mouth. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #1's nurse's note documented by RN A on [DATE] at 3:14 a.m. reflected Resident #1 became unresponsive to stimuli. Skin was cool to touch and clammy. Resident #1 had frothy secretions coming out of her mouth. Head was repositioned to prevent aspiration. FSBS (Finger Stick Blood Sugar) was taken and was noted to be 21 mg/dl. Resident #1's vital signs were noted to be the following: 95.8 temperature, 79 heart rate, 20 respirations per minute, and her blood pressure was ,[DATE]. Continue to monitor closely. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of Resident #1's MAR for (MONTH) (YEAR) reflected the following order: Inject 1 mg of [MEDICATION NAME] intramuscularly as needed for low blood sugar (if blood sugar is less than 60 and resident is unresponsive) which had a start date of [DATE] at 3:10 a.m. and had been put on the MAR by RN A. There was not a signed physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of [MEDICATION NAME]'s Information page for physicians accessed at http://uspl.lilly.com/[MEDICATION NAME]/[MEDICATION NAME].html#pi on [DATE] at 12:49 p.m. reflected the following: [MEDICATION NAME] is indicated as a treatment for [REDACTED]. If the response is delayed .emergency aid should be sought so that [MEDICATION NAME] (route other than oral which is usually either intramuscularly, subcutaneous, or intravenous) glucose can be given. Review of Resident #1's nurse's note documented by RN A on [DATE] at 4:40 a.m. reflected Resident #1 remained unresponsive to stimuli, and her eyes appeared to be rolled back after being given [MEDICATION NAME] at 3:15 a.m. FSBS rechecked at 3:25 a.m. and noted to be at 40 and at 3:45 a.m. at 59. Resident #1 did not arouse to sternum rub. EMS (Emergency Medical Services) was notified at 3:55 a.m. When paramedics arrived to facility, IV was started in left arm and [MEDICATION NAME] at 10% hung and infused. Resident #1 was transferred to the stretcher and taken to ambulance at 4:30 a.m. to be transported to the ER. The notes also reflected the RN was unable to contact the resident's family. No additional vital signs were recorded. Review of Resident #1's Emergency Department Admission reflected her date of admission was [DATE]. The record reflected Resident #1 arrived to the emergency roiagnom on [DATE] at 4:48 a.m. Resident #1 presented with decreased responsiveness and possible cause was listed as low blood sugar. Resident #1 was intubated on [DATE] at 5:08 a.m. and was put on a ventilator to assist with breathing and was admitted to the ICU. Review of the Hospital's Physician Notes reflected that on [DATE], Resident #1 was still on the ventilator and had been off sedation for 24 hours but remained unresponsive and the family requested terminal extubation (The withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support.) Resident #1 was discharged from the hospital on [DATE] with hospice services. Resident #1 remained unresponsive and her prognosis was poor. Interview with Resident #1's family on [DATE] at 10:30 a.m. revealed Resident #1 expired on [DATE]. He stated she never woke up after the low blood sugar incident, so he made the difficult decision to take her off life support and take her home. He stated Resident #1's blood sugar went low every once in a while, but it had never gotten as low as 21. Interview with RN A on [DATE] at 11:43 a.m. revealed on [DATE] around 3:15 a.m CNA B told her Resident #1 was not acting right. She stated she went down to Resident #1's room and found her unresponsive and cold and clammy. She stated she took Resident #1's vital signs and knew she was a diabetic so she took her blood sugar. Resident #1's blood sugar was 21. She stated she realized the resident was hypoglycemic (when a resident has low blood sugar). She stated she knew the resident had an order for [REDACTED].#1's room at that time, even though the resident was still unresponsive. RN A stated she came back about ten minutes later and rechecked her blood sugar and it was 40. She stated she left the room at that time and Resident #1 was still unresponsive at that time. She stated she came back about 20 minutes later and took her blood sugar again and it was 59. She stated the resident was still unresponsive so she decided at that point she should send Resident #1 to the hospital. RN A revealed she called 911 and went back to the room and stayed with the resident until the paramedics arrived. She stated the resident remained unresponsive and when EMS arrived, the paramedics started an IV but Resident #1 was still completely unresponsive. RN A stated EMS transferred Resident #1 to the stretcher and the resident started to groan, but other than that she was still out of it. RN A stated she never called the physician during the 45 minutes between finding the resident unresponsive and sending her to the hospital. RN A stated she left a message for the doctor after Resident #1 was sent to the hospital. She stated she did not remember notifying the DON or any administrative staff about the incident, but she did record the incident on the 24 hour report for the upcoming shift. RN A stated if she could go back and change things, she would have given the [MEDICATION NAME] and after a few minutes when it had not worked, she would have called 911. She stated she also would have called the doctor sooner to see what he wanted her to do. She stated she did not know why she waited so long to call 911, but she cannot go back and change it. Interview with CNA B on [DATE] at 10:30 p.m. revealed she was RN A's aide the night of the incident on [DATE]. She revealed she came into work around 10:00 p.m. and started her initial rounds. She said she remembered Resident #1's family was still there and Resident #1 was alert and talking. She stated Resident #1's family left a little after midnight. When she began her second round around 1:30 a.m. she noticed Resident #1 was very pale and had some white stuff coming from her mouth. CNA B stated she went to get RN A and asked her to go assess Resident #1 because something was not right. RN A told her she would go look at Resident #1 in a minute. CNA B continued on her rounds with other residents and went back to check on Resident #1 around 2:00 a.m. CNA B stated Resident #1 was still very pale and appeared to be unconscious because she was not waking up. She asked RN A to go look at Resident #1 again and RN A went down to Resident #1's room and looked at the resident but did not take vital signs or anything. RN A told her she had the situation handled, so she went back to care for other residents. CNA B went back to check on Resident #1 again around 2:30 a.m. and noticed Resident #1 was still pale and was not waking up. CNA B asked RN A what was going on with the resident and RN A told her that Resident #1 was going to be okay but to just keep an eye on her. At that point, she went and got CNA C to go look at Resident #1 with her. CNA B stated the time was probably around 3:00 a.m. CNA B and CNA C went down to check on the resident and she was still the same way. Resident #1 was unresponsive, pale, and still frothing at the mouth. CNA B revealed they asked LVN D to come and look at the resident, because RN A was not helping. At that point, RN A got up with them and went down to look at the resident. RN A told LVN D to not go into the room. RN A took Resident #1's vital signs and said her blood sugar was really low. RN A told her (CNA B) she had it handled, so she finished her rounds. CNA B revealed after a while, probably close to 4:00 a.m., she finally saw the paramedics arrive. She stated Resident #1 looked exactly the same. She was still unresponsive and finally around 4:30ish, the paramedics told RN A that it was just better if they took Resident #1 to the hospital. Attempt to interview LVN D was made on [DATE] at 10:44 a.m. but LVN D's phone number was not working. Interview with LVN E on [DATE] at 11:40 a.m. revealed she was one of the other nurses the night of the incident. She revealed LVN D told her CNA B had asked her to go look at Resident #1 because she was looking bad and RN A told her she had it handled. LVN E stated she remembered CNA B coming up to the desk, a little after midnight, a few times throughout the night asking RN A to go look at Resident #1. LVN E stated RN A never let them know what was going on with her residents and ignored aides' concerns regularly. Interview with the DON on [DATE] at 11:43 a.m. revealed she knew Resident #1 had been sent to the hospital, but did not remember why. Once she reviewed RN A's nurse's notes, she stated RN A should not have waited so long to call emergency services. She stated RN A should have called 911 when she found Resident #1 completely unresponsive. The DON stated she did not investigate the incident or ask RN A what happened. She revealed they had not done any in-services with staff regarding changes in conditions or blood sugar checks since the incident. Interview with ADON F on [DATE] at 1:15 p.m. revealed the ADON over RN A's hall that night was no longer employed with the facility, but ADON F did remember the other ADONs and the DON discussed the reason for discharge of Resident #1 the next day during morning meeting. Review of RN A's license on the Board of Nursing website on [DATE] at 12:45 p.m. reflected RN A's nursing license was on probation. Review of the Agreed Order from the Texas Board of Nursing reflected on or about [DATE], while employed at the same facility, she failed to initiate cardio-pulmonary resuscitation (CPR) after finding a resident unresponsive with no respirations or pulse and instead went to check his code status. RN A's conduct resulted in an unnecessary delay in care and was likely to injure the resident, including possible demise from lack of timely interventions and appropriate nursing care. Review of the Agreed Order from the Texas Board of Nursing reflected RN A was to be supervised by another RN who is on the premises. The supervising RN was not required to be on the same unit or ward, but should be on facility grounds and readily available to provide assistance and intervention if necessary. Review of RN A's employee file reflected a Notification of Employment dated [DATE] and signed by the Corporate Director of Clinical Services which stated the following: I have received a complete copy of the Order of the Board and am aware of the stipulations placed on this license by the Texas Board of Nursing. I agree to notify the Board's office and provide information to the Board regarding this nurse's resignation or termination. Review of the staff schedule and sign in sheet since [DATE] reflected RN A worked 24 10pm-6am shifts, including [DATE], without another RN in the building and readily available for supervision. Further review of the sign in sheets revealed RN A had worked on Halls 100, 200, and 300. Review of RN A's job description signed on [DATE] by RN A reflected the following: Initiates emergency support measures . Emergency situations are recognized and appropriate action is instituted. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they were aware RN A was on probation and was to be under the supervision of another RN. The Administrator stated he was the Administrator of the building during the prior incident with RN A when she did not perform CPR on another resident. He stated he was willing to give her a second chance. The DON stated RN A could always call her for advice but she was not on facility grounds as her supervision the night of the incident. Interview with the Administrator on [DATE] at 11:20 a.m. revealed RN A had originally been on the 2pm-10pm shift when they had learned of her probation in (MONTH) (YEAR). He stated RN A then switched to the night shift in December. He stated he was under the impression RN A would be on the same 4 on 2 off schedule (work four days and they are off for two days) as the other RN on night shift, so she could provide supervision. He stated because of their mistake, RN A worked over 20 night shifts since (MONTH) without another RN supervising her according to her probation terms. An Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator and DON were informed of the IJ on [DATE] at 1:40 p.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on [DATE] reflected: Staff will be in-serviced by Corporate Director of Clinical Operations on [DATE] on neglect policy, and to never leave a resident unattended during an emergency. Current staff will be in-serviced today, both day and evening. Night, weekend, and PRN staff will be in-serviced prior to shift. No one will work without having received information. The Plan of Removal will be used for in-service. One hundred percent audit was completed on [DATE] on all residents requiring blood glucose monitoring. Orders were reviewed for high/low parameters and notification of MD Clinical staff were in-serviced by Corporate Director of Clinical Operations on [DATE] on change in resident's condition or status policy. If a resident is found in distress, the charge nurse will notify the resident's attending physician and DON. The nurse will make detailed observations and gather pertinent information utilizing the SBAR assessment. Corporate Director of Clinical Operations in-serviced nursing staff on [DATE] on best nursing practice of using [MEDICATION NAME] injection. If resident continues to be unresponsive after 15 minutes of injection, EMS will be called for additional intervention. Competency checks will be performed on staff for the above in-services on [DATE] and [DATE]. Change in condition policy will be included in all orientations going forward, with included post-test. DON will monitor SBAR assessments that are written for a resident change in condition. Nurse who demonstrated poor judgment during the episode in question was suspended and terminated on [DATE]. Monitoring the Plan of Removal: Interviews with CNA G, LVN H, and CNA B on [DATE] at 10:05 p.m. through 10:30 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in conditions and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interviews with LVN J, LVN K, LVN L, CNA M, CNA N, CNA O, and CNA P on [DATE] between 1:00 p.m. through 2:00 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in condition and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they believed the immediate jeopardy occurred because RN A left a resident alone who was unresponsive and in a state of emergency and did not notify the physician. RN A did not call 911 when the [MEDICATION NAME] did not work. The Administrator stated they should have caught the situation but RN A had not documented the incident correctly. When asked what they would do differently to prevent another IJ, the Administrator stated they would no longer hire nurses who were on probation with the board of nursing. The DON stated they started doing SBAR forms (forms used by nurses when a change in condition is noted) and she would review them all. They both revealed they had been in-serviced over the abuse/neglect policy and reportable events. On [DATE], the Immediate Jeopardy (IJ) was removed. On [DATE] at 4:15 p.m., DON and the Corporate Director of Operations were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 25 diabetic residents who resided on Halls 100, 200, and 300 where RN A worked.

Based on interview and record review, the facility failed to have evidence that all alleged neglect violations were investigated thoroughly and residents were protected from further abuse during the investigation for one (Residents #1) of 11 residents reviewed for abuse and neglect. 1. The facility failed to have an RN available to supervise RN A, as ordered by the Board of Nursing, who could have intervened and provided emergency care to Resident #1. As a result of this failure, RN A failed to contact the physician, stay with Resident #1, and contact EMS when the resident's blood sugar level was critically low, her condition did not respond to the [MEDICATION NAME] (emergency medication used to increase a person's blood sugar) and the resident was unresponsive. Forty minutes after Resident #1 was found she was transferred to the hospital on [DATE]. She remained unresponsive and was placed on life support. Resident #1 did not become responsive again and expired on [DATE] after being taken off life support. 2. The Administrator and DON failed to identify the neglect by RN A and failed to investigate and report to the State Agency when Resident #1 experienced a significant change in condition related to her blood sugar and level of consciousness. An Immediate Jeopardy was identified on [DATE] as beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed the 25 diabetic residents on Halls 100, 200, and 300 where RN A worked at risk of serious physical harm, injury, and/or death. Findings included: Review of Resident #1's closed record revealed an MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of two people for activities of daily living. Review of her Care Plan dated [DATE] reflected there was not a care plan regarding her diabetes. Review of Resident #1's (MONTH) physician's orders [REDACTED]. [DATE]: Inject 20 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 30 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 40 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Give 500 mg of [MEDICATION NAME] (medication used to help control and lower blood sugars) twice a day by mouth. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #1's nurse's note documented by RN A on [DATE] at 3:14 a.m. reflected Resident #1 became unresponsive to stimuli. Skin was cool to touch and clammy. Resident #1 had frothy secretions coming out of her mouth. Head was repositioned to prevent aspiration. FSBS (Finger Stick Blood Sugar) was taken and was noted to be 21 mg/dl. Resident #1's vital signs were noted to be the following: 95.8 temperature, 79 heart rate, 20 respirations per minute, and her blood pressure was ,[DATE]. Continue to monitor closely. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of Resident #1's MAR for (MONTH) (YEAR) reflected the following order: Inject 1 mg of [MEDICATION NAME] intramuscularly as needed for low blood sugar (if blood sugar is less than 60 and resident is unresponsive) which had a start date of [DATE] at 3:10 a.m. and had been put on the MAR by RN A. There was not a signed physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of [MEDICATION NAME]'s Information page for physicians accessed at http://uspl.lilly.com/[MEDICATION NAME]/[MEDICATION NAME].html#pi on [DATE] at 12:49 p.m. reflected the following: [MEDICATION NAME] is indicated as a treatment for [REDACTED]. If the response is delayed .emergency aid should be sought so that [MEDICATION NAME] (route other than oral which is usually either intramuscularly, subcutaneous, or intravenous) glucose can be given. Review of Resident #1's nurse's note documented by RN A on [DATE] at 4:40 a.m. reflected Resident #1 remained unresponsive to stimuli, and her eyes appeared to be rolled back after being given [MEDICATION NAME] at 3:15 a.m. FSBS rechecked at 3:25 a.m. and noted to be at 40 and at 3:45 a.m. at 59. Resident #1 did not arouse to sternum rub. EMS (Emergency Medical Services) was notified at 3:55 a.m. When paramedics arrived to facility, IV was started in left arm and [MEDICATION NAME] at 10% hung and infused. Resident #1 was transferred to the stretcher and taken to ambulance at 4:30 a.m. to be transported to the ER. The notes also reflected the RN was unable to contact the resident's family. No additional vital signs were recorded. Review of Resident #1's Emergency Department Admission reflected her date of admission was [DATE]. The record reflected Resident #1 arrived to the emergency roiagnom on [DATE] at 4:48 a.m. Resident #1 presented with decreased responsiveness and possible cause was listed as low blood sugar. Resident #1 was intubated on [DATE] at 5:08 a.m. and was put on a ventilator to assist with breathing and was admitted to the ICU. Review of the Hospital's Physician Notes reflected that on [DATE], Resident #1 was still on the ventilator and had been off sedation for 24 hours but remained unresponsive and the family requested terminal extubation (The withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support.) Resident #1 was discharged from the hospital on [DATE] with hospice services. Resident #1 remained unresponsive and her prognosis was poor. Interview with Resident #1's family on [DATE] at 10:30 a.m. revealed Resident #1 expired on [DATE]. He stated she never woke up after the low blood sugar incident, so he made the difficult decision to take her off life support and take her home. He stated Resident #1's blood sugar went low every once in a while, but it had never gotten as low as 21. Interview with RN A on [DATE] at 11:43 a.m. revealed on [DATE] around 3:15 a.m CNA B told her Resident #1 was not acting right. She stated she went down to Resident #1's room and found her unresponsive and cold and clammy. She stated she took Resident #1's vital signs and knew she was a diabetic so she took her blood sugar. Resident #1's blood sugar was 21. She stated she realized the resident was hypoglycemic (when a resident has low blood sugar). She stated she knew the resident had an order for [REDACTED].#1's room at that time, even though the resident was still unresponsive. RN A stated she came back about ten minutes later and rechecked her blood sugar and it was 40. She stated she left the room at that time and Resident #1 was still unresponsive at that time. She stated she came back about 20 minutes later and took her blood sugar again and it was 59. She stated the resident was still unresponsive so she decided at that point she should send Resident #1 to the hospital. RN A revealed she called 911 and went back to the room and stayed with the resident until the paramedics arrived. She stated the resident remained unresponsive and when EMS arrived, the paramedics started an IV but Resident #1 was still completely unresponsive. RN A stated EMS transferred Resident #1 to the stretcher and the resident started to groan, but other than that she was still out of it. RN A stated she never called the physician during the 45 minutes between finding the resident unresponsive and sending her to the hospital. RN A stated she left a message for the doctor after Resident #1 was sent to the hospital. She stated she did not remember notifying the DON or any administrative staff about the incident, but she did record the incident on the 24 hour report for the upcoming shift. RN A stated if she could go back and change things, she would have given the [MEDICATION NAME] and after a few minutes when it had not worked, she would have called 911. She stated she also would have called the doctor sooner to see what he wanted her to do. She stated she did not know why she waited so long to call 911, but she cannot go back and change it. Interview with CNA B on [DATE] at 10:30 p.m. revealed she was RN A's aide the night of the incident on [DATE]. She revealed she came into work around 10:00 p.m. and started her initial rounds. She said she remembered Resident #1's family was still there and Resident #1 was alert and talking. She stated Resident #1's family left a little after midnight. When she began her second round around 1:30 a.m. she noticed Resident #1 was very pale and had some white stuff coming from her mouth. CNA B stated she went to get RN A and asked her to go assess Resident #1 because something was not right. RN A told her she would go look at Resident #1 in a minute. CNA B continued on her rounds with other residents and went back to check on Resident #1 around 2:00 a.m. CNA B stated Resident #1 was still very pale and appeared to be unconscious because she was not waking up. She asked RN A to go look at Resident #1 again and RN A went down to Resident #1's room and looked at the resident but did not take vital signs or anything. RN A told her she had the situation handled, so she went back to care for other residents. CNA B went back to check on Resident #1 again around 2:30 a.m. and noticed Resident #1 was still pale and was not waking up. CNA B asked RN A what was going on with the resident and RN A told her that Resident #1 was going to be okay but to just keep an eye on her. At that point, she went and got CNA C to go look at Resident #1 with her. CNA B stated the time was probably around 3:00 a.m. CNA B and CNA C went down to check on the resident and she was still the same way. Resident #1 was unresponsive, pale, and still frothing at the mouth. CNA B revealed they asked LVN D to come and look at the resident, because RN A was not helping. At that point, RN A got up with them and went down to look at the resident. RN A told LVN D to not go into the room. RN A took Resident #1's vital signs and said her blood sugar was really low. RN A told her (CNA B) she had it handled, so she finished her rounds. CNA B revealed after a while, probably close to 4:00 a.m., she finally saw the paramedics arrive. She stated Resident #1 looked exactly the same. She was still unresponsive and finally around 4:30ish, the paramedics told RN A that it was just better if they took Resident #1 to the hospital. Attempt to interview LVN D was made on [DATE] at 10:44 a.m. but LVN D's phone number was not working. Interview with LVN E on [DATE] at 11:40 a.m. revealed she was one of the other nurses the night of the incident. She revealed LVN D told her CNA B had asked her to go look at Resident #1 because she was looking bad and RN A told her she had it handled. LVN E stated she remembered CNA B coming up to the desk, a little after midnight, a few times throughout the night asking RN A to go look at Resident #1. LVN E stated RN A never let them know what was going on with her residents and ignored aides' concerns regularly. Interview with the DON on [DATE] at 11:43 a.m. revealed she knew Resident #1 had been sent to the hospital, but did not remember why. Once she reviewed RN A's nurse's notes, she stated RN A should not have waited so long to call emergency services. She stated RN A should have called 911 when she found Resident #1 completely unresponsive. The DON stated she did not investigate the incident or ask RN A what happened. She revealed they had not done any in-services with staff regarding changes in conditions or blood sugar checks since the incident. Interview with ADON F on [DATE] at 1:15 p.m. revealed the ADON over RN A's hall that night was no longer employed with the facility, but ADON F did remember the other ADONs and the DON discussed the reason for discharge of Resident #1 the next day during morning meeting. Review of RN A's license on the Board of Nursing website on [DATE] at 12:45 p.m. reflected RN A's nursing license was on probation. Review of the Agreed Order from the Texas Board of Nursing reflected on or about [DATE], while employed at the same facility, she failed to initiate cardio-pulmonary resuscitation (CPR) after finding a resident unresponsive with no respirations or pulse and instead went to check his code status. RN A's conduct resulted in an unnecessary delay in care and was likely to injure the resident, including possible demise from lack of timely interventions and appropriate nursing care. Review of the Agreed Order from the Texas Board of Nursing reflected RN A was to be supervised by another RN who is on the premises. The supervising RN was not required to be on the same unit or ward, but should be on facility grounds and readily available to provide assistance and intervention if necessary. Review of RN A's employee file reflected a Notification of Employment dated [DATE] and signed by the Corporate Director of Clinical Services which stated the following: I have received a complete copy of the Order of the Board and am aware of the stipulations placed on this license by the Texas Board of Nursing. I agree to notify the Board's office and provide information to the Board regarding this nurse's resignation or termination. Review of the staff schedule and sign in sheet since [DATE] reflected RN A worked 24 10pm-6am shifts, including [DATE], without another RN in the building and readily available for supervision. Further review of the sign in sheets revealed RN A had worked on Halls 100, 200, and 300. Review of RN A's job description signed on [DATE] by RN A reflected the following: Initiates emergency support measures . Emergency situations are recognized and appropriate action is instituted. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they were aware RN A was on probation and was to be under the supervision of another RN. The Administrator stated he was the Administrator of the building during the prior incident with RN A when she did not perform CPR on another resident. He stated he was willing to give her a second chance. The DON stated RN A could always call her for advice but she was not on facility grounds as her supervision the night of the incident. Interview with the Administrator on [DATE] at 11:20 a.m. revealed RN A had originally been on the 2pm-10pm shift when they had learned of her probation in (MONTH) (YEAR). He stated RN A then switched to the night shift in December. He stated he was under the impression RN A would be on the same 4 on 2 off schedule (work four days and they are off for two days) as the other RN on night shift, so she could provide supervision. He stated because of their mistake, RN A worked over 20 night shifts since (MONTH) without another RN supervising her according to her probation terms. Review of the facility's Change in Resident's Condition or Status Policy revised in (MONTH) (YEAR) reflected the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident .d. A significant change in the resident's physical/emotional/mental conditions . A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of the facility's undated Abuse/Neglect policy reflected the following: Definition of 'Neglect' 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of/Actual Neglect . 6. Inadequate provision of care . 9. Leaving someone unattended who need supervision. An Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator and DON were informed of the IJ on [DATE] at 1:40 p.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on [DATE] reflected: Staff will be in-serviced by Corporate Director of Clinical Operations on [DATE] on neglect policy, and to never leave a resident unattended during an emergency. Current staff will be in-serviced today, both day and evening. Night, weekend, and PRN staff will be in-serviced prior to shift. No one will work without having received information. The Plan of Removal will be used for in-service. One hundred percent audit was completed on [DATE] on all residents requiring blood glucose monitoring. Orders were reviewed for high/low parameters and notification of MD Clinical staff were in-serviced by Corporate Director of Clinical Operations on [DATE] on change in resident's condition or status policy. If a resident is found in distress, the charge nurse will notify the resident's attending physician and DON. The nurse will make detailed observations and gather pertinent information utilizing the SBAR assessment. Corporate Director of Clinical Operations in-serviced nursing staff on [DATE] on best nursing practice of using [MEDICATION NAME] injection. If resident continues to be unresponsive after 15 minutes of injection, EMS will be called for additional intervention. Competency checks will be performed on staff for the above in-services on [DATE] and [DATE]. Change in condition policy will be included in all orientations going forward, with included post-test. DON will monitor SBAR assessments that are written for a resident change in condition. Nurse who demonstrated poor judgment during the episode in question was suspended and terminated on [DATE]. Monitoring the Plan of Removal: Interviews with CNA G, LVN H, and CNA B on [DATE] at 10:05 p.m. through 10:30 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in conditions and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interviews with LVN J, LVN K, LVN L, CNA M, CNA N, CNA O, and CNA P on [DATE] between 1:00 p.m. through 2:00 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in condition and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they believed the immediate jeopardy occurred because RN A left a resident alone who was unresponsive and in a state of emergency and did not notify the physician. RN A did not call 911 when the [MEDICATION NAME] did not work. The Administrator stated they should have caught the situation but RN A had not documented the incident correctly. When asked what they would do differently to prevent another IJ, the Administrator stated they would no longer hire nurses who were on probation with the board of nursing. The DON stated they started doing SBAR forms (forms used by nurses when a change in condition is noted) and she would review them all. They both revealed they had been in-serviced over the abuse/neglect policy and reportable events. On [DATE], the Immediate Jeopardy (IJ) was removed. On [DATE] at 4:15 p.m., DON and the Corporate Director of Operations were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 25 diabetic residents who resided on Halls 100, 200, and 300 where RN A worked. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 30 diabetic residents.

Based on interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one (Resident #1) of 11 residents reviewed for quality of care. RN A failed to contact the physician, stay with Resident #1, and contact EMS when the resident's blood sugar level was critically low, the resident's condition did not respond to [MEDICATION NAME] (medication to help raise a person's blood sugar) and the resident was unresponsive. Forty minutes after Resident #1 was found she was transferred to the hospital on [DATE]. She remained unresponsive and was placed on life support. Resident #1 did not become responsive again and expired on [DATE] after being taken off life support. An Immediate Jeopardy was identified on [DATE] as beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed the 25 diabetic residents who resided on Hall 100, 200, and 300 where RN A worked at risk of serious physical harm, injury, and/or death. Findings included: Review of Resident #1's closed record revealed an MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of two people for activities of daily living. Review of her Care Plan dated [DATE] reflected there was not a care plan regarding her diabetes. Review of Resident #1's (MONTH) physician's orders [REDACTED]. [DATE]: Inject 20 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 30 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 40 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Give 500 mg of [MEDICATION NAME] (medication used to help control and lower blood sugars) twice a day by mouth. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #1's nurse's note documented by RN A on [DATE] at 3:14 a.m. reflected Resident #1 became unresponsive to stimuli. Skin was cool to touch and clammy. Resident #1 had frothy secretions coming out of her mouth. Head was repositioned to prevent aspiration. FSBS (Finger Stick Blood Sugar) was taken and was noted to be 21 mg/dl. Resident #1's vital signs were noted to be the following: 95.8 temperature, 79 heart rate, 20 respirations per minute, and her blood pressure was ,[DATE]. Continue to monitor closely. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of Resident #1's MAR for (MONTH) (YEAR) reflected the following order: Inject 1 mg of [MEDICATION NAME] intramuscularly as needed for low blood sugar (if blood sugar is less than 60 and resident is unresponsive) which had a start date of [DATE] at 3:10 a.m. and had been put on the MAR by RN A. There was not a signed physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of [MEDICATION NAME]'s Information page for physicians accessed at http://uspl.lilly.com/[MEDICATION NAME]/[MEDICATION NAME].html#pi on [DATE] at 12:49 p.m. reflected the following: [MEDICATION NAME] is indicated as a treatment for [REDACTED]. If the response is delayed .emergency aid should be sought so that [MEDICATION NAME] (route other than oral which is usually either intramuscularly, subcutaneous, or intravenous) glucose can be given. Review of Resident #1's nurse's note documented by RN A on [DATE] at 4:40 a.m. reflected Resident #1 remained unresponsive to stimuli, and her eyes appeared to be rolled back after being given [MEDICATION NAME] at 3:15 a.m. FSBS rechecked at 3:25 a.m. and noted to be at 40 and at 3:45 a.m. at 59. Resident #1 did not arouse to sternum rub. EMS (Emergency Medical Services) was notified at 3:55 a.m. When paramedics arrived to facility, IV was started in left arm and [MEDICATION NAME] at 10% hung and infused. Resident #1 was transferred to the stretcher and taken to ambulance at 4:30 a.m. to be transported to the ER. The notes also reflected the RN was unable to contact the resident's family. No additional vital signs were recorded. Review of Resident #1's Emergency Department Admission reflected her date of admission was [DATE]. The record reflected Resident #1 arrived to the emergency roiagnom on [DATE] at 4:48 a.m. Resident #1 presented with decreased responsiveness and possible cause was listed as low blood sugar. Resident #1 was intubated on [DATE] at 5:08 a.m. and was put on a ventilator to assist with breathing and was admitted to the ICU. Review of the Hospital's Physician Notes reflected that on [DATE], Resident #1 was still on the ventilator and had been off sedation for 24 hours but remained unresponsive and the family requested terminal extubation (The withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support.) Resident #1 was discharged from the hospital on [DATE] with hospice services. Resident #1 remained unresponsive and her prognosis was poor. Interview with Resident #1's family on [DATE] at 10:30 a.m. revealed Resident #1 expired on [DATE]. He stated she never woke up after the low blood sugar incident, so he made the difficult decision to take her off life support and take her home. He stated Resident #1's blood sugar went low every once in a while, but it had never gotten as low as 21. Interview with RN A on [DATE] at 11:43 a.m. revealed on [DATE] around 3:15 a.m CNA B told her Resident #1 was not acting right. She stated she went down to Resident #1's room and found her unresponsive and cold and clammy. She stated she took Resident #1's vital signs and knew she was a diabetic so she took her blood sugar. Resident #1's blood sugar was 21. She stated she realized the resident was hypoglycemic (when a resident has low blood sugar). She stated she knew the resident had an order for [REDACTED].#1's room at that time, even though the resident was still unresponsive. RN A stated she came back about ten minutes later and rechecked her blood sugar and it was 40. She stated she left the room at that time and Resident #1 was still unresponsive at that time. She stated she came back about 20 minutes later and took her blood sugar again and it was 59. She stated the resident was still unresponsive so she decided at that point she should send Resident #1 to the hospital. RN A revealed she called 911 and went back to the room and stayed with the resident until the paramedics arrived. She stated the resident remained unresponsive and when EMS arrived, the paramedics started an IV but Resident #1 was still completely unresponsive. RN A stated EMS transferred Resident #1 to the stretcher and the resident started to groan, but other than that she was still out of it. RN A stated she never called the physician during the 45 minutes between finding the resident unresponsive and sending her to the hospital. RN A stated she left a message for the doctor after Resident #1 was sent to the hospital. She stated she did not remember notifying the DON or any administrative staff about the incident, but she did record the incident on the 24 hour report for the upcoming shift. RN A stated if she could go back and change things, she would have given the [MEDICATION NAME] and after a few minutes when it had not worked, she would have called 911. She stated she also would have called the doctor sooner to see what he wanted her to do. She stated she did not know why she waited so long to call 911, but she cannot go back and change it. Interview with CNA B on [DATE] at 10:30 p.m. revealed she was RN A's aide the night of the incident on [DATE]. She revealed she came into work around 10:00 p.m. and started her initial rounds. She said she remembered Resident #1's family was still there and Resident #1 was alert and talking. She stated Resident #1's family left a little after midnight. When she began her second round around 1:30 a.m. she noticed Resident #1 was very pale and had some white stuff coming from her mouth. CNA B stated she went to get RN A and asked her to go assess Resident #1 because something was not right. RN A told her she would go look at Resident #1 in a minute. CNA B continued on her rounds with other residents and went back to check on Resident #1 around 2:00 a.m. CNA B stated Resident #1 was still very pale and appeared to be unconscious because she was not waking up. She asked RN A to go look at Resident #1 again and RN A went down to Resident #1's room and looked at the resident but did not take vital signs or anything. RN A told her she had the situation handled, so she went back to care for other residents. CNA B went back to check on Resident #1 again around 2:30 a.m. and noticed Resident #1 was still pale and was not waking up. CNA B asked RN A what was going on with the resident and RN A told her that Resident #1 was going to be okay but to just keep an eye on her. At that point, she went and got CNA C to go look at Resident #1 with her. CNA B stated the time was probably around 3:00 a.m. CNA B and CNA C went down to check on the resident and she was still the same way. Resident #1 was unresponsive, pale, and still frothing at the mouth. CNA B revealed they asked LVN D to come and look at the resident, because RN A was not helping. At that point, RN A got up with them and went down to look at the resident. RN A told LVN D to not go into the room. RN A took Resident #1's vital signs and said her blood sugar was really low. RN A told her (CNA B) she had it handled, so she finished her rounds. CNA B revealed after a while, probably close to 4:00 a.m., she finally saw the paramedics arrive. She stated Resident #1 looked exactly the same. She was still unresponsive and finally around 4:30ish, the paramedics told RN A that it was just better if they took Resident #1 to the hospital. Attempt to interview LVN D was made on [DATE] at 10:44 a.m. but LVN D's phone number was not working. Interview with LVN E on [DATE] at 11:40 a.m. revealed she was one of the other nurses the night of the incident. She revealed LVN D told her CNA B had asked her to go look at Resident #1 because she was looking bad and RN A told her she had it handled. LVN E stated she remembered CNA B coming up to the desk, a little after midnight, a few times throughout the night asking RN A to go look at Resident #1. LVN E stated RN A never let them know what was going on with her residents and ignored aides' concerns regularly. Interview with the DON on [DATE] at 11:43 a.m. revealed she knew Resident #1 had been sent to the hospital, but did not remember why. Once she reviewed RN A's nurse's notes, she stated RN A should not have waited so long to call emergency services. She stated RN A should have called 911 when she found Resident #1 completely unresponsive. The DON stated she did not investigate the incident or ask RN A what happened. She revealed they had not done any in-services with staff regarding changes in conditions or blood sugar checks since the incident. Interview with ADON F on [DATE] at 1:15 p.m. revealed the ADON over RN A's hall that night was no longer employed with the facility, but ADON F did remember the other ADONs and the DON discussed the reason for discharge of Resident #1 the next day during morning meeting. Review of RN A's license on the Board of Nursing website on [DATE] at 12:45 p.m. reflected RN A's nursing license was on probation. Review of the Agreed Order from the Texas Board of Nursing reflected RN A was to be supervised by another RN who is on the premises. The supervising RN was not required to be on the same unit or ward, but should be on facility grounds and readily available to provide assistance and intervention if necessary. Review of RN A's employee file reflected a Notification of Employment dated [DATE] and signed by the Corporate Director of Clinical Services which stated the following: I have received a complete copy of the Order of the Board and am aware of the stipulations placed on this license by the Texas Board of Nursing. I agree to notify the Board's office and provide information to the Board regarding this nurse's resignation or termination. Review of the staff schedule and sign in sheet since [DATE] reflected RN A worked 24 10pm-6am shifts, including [DATE], without another RN in the building and readily available for supervision. Further review of the sign in sheets revealed RN A had worked on Halls 100, 200, and 300. Review of RN A's job description signed on [DATE] by RN A reflected the following: Initiates emergency support measures . Emergency situations are recognized and appropriate action is instituted. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they were aware RN A was on probation and was to be under the supervision of another RN. The Administrator stated he was the Administrator of the building during the prior incident with RN A when she did not perform CPR on another resident. He stated he was willing to give her a second chance. The DON stated RN A could always call her for advice but she was not on facility grounds as her supervision the night of the incident. Interview with the Administrator on [DATE] at 11:20 a.m. revealed RN A had originally been on the 2pm-10pm shift when they had learned of her probation in (MONTH) (YEAR). He stated RN A then switched to the night shift in December. He stated he was under the impression RN A would be on the same 4 on 2 off schedule (work four days and they are off for two days) as the other RN on night shift, so she could provide supervision. He stated because of their mistake, RN A worked over 20 night shifts since (MONTH) without another RN supervising her according to her probation terms. Review of the facility's Change in Resident's Condition or Status Policy revised in (MONTH) (YEAR) reflected the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident .d. A significant change in the resident's physical/emotional/mental conditions . A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of the facility's undated Abuse/Neglect policy reflected the following: Definition of 'Neglect' 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of/Actual Neglect . 6. Inadequate provision of care . 9. Leaving someone unattended who need supervision. An Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator and DON were informed of the IJ on [DATE] at 1:40 p.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on [DATE] reflected: Staff will be in-serviced by Corporate Director of Clinical Operations on [DATE] on neglect policy, and to never leave a resident unattended during an emergency. Current staff will be in-serviced today, both day and evening. Night, weekend, and PRN staff will be in-serviced prior to shift. No one will work without having received information. The Plan of Removal will be used for in-service. One hundred percent audit was completed on [DATE] on all residents requiring blood glucose monitoring. Orders were reviewed for high/low parameters and notification of MD Clinical staff were in-serviced by Corporate Director of Clinical Operations on [DATE] on change in resident's condition or status policy. If a resident is found in distress, the charge nurse will notify the resident's attending physician and DON. The nurse will make detailed observations and gather pertinent information utilizing the SBAR assessment. Corporate Director of Clinical Operations in-serviced nursing staff on [DATE] on best nursing practice of using [MEDICATION NAME] injection. If resident continues to be unresponsive after 15 minutes of injection, EMS will be called for additional intervention. Competency checks will be performed on staff for the above in-services on [DATE] and [DATE]. Change in condition policy will be included in all orientations going forward, with included post-test. DON will monitor SBAR assessments that are written for a resident change in condition. Nurse who demonstrated poor judgment during the episode in question was suspended and terminated on [DATE]. Monitoring the Plan of Removal: Interviews with CNA G, LVN H, and CNA B on [DATE] at 10:05 p.m. through 10:30 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident is was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in conditions and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interviews with LVN J, LVN K, LVN L, CNA M, CNA N, CNA O, and CNA P on [DATE] between 1:00 p.m. through 2:00 p.m. revealed they had been in-serviced before their shift regarding change in conditions, what to do when a resident was unresponsive and abuse/neglect. They all revealed they had to complete a quiz regarding the in-services. They all revealed they were to contact the Administrator immediately with any allegation of abuse or neglect. They were able to give examples of changes in condition and what to do if they recognized a change in condition. They also were able to state they would not leave an unresponsive resident and to treat it as an emergency. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they believed the immediate jeopardy occurred because RN A left a resident alone who was unresponsive and in a state of emergency and did not notify the physician. RN A did not call 911 when the [MEDICATION NAME] did not work. The Administrator stated they should have caught the situation but RN A had not documented the incident correctly. When asked what they would do differently to prevent another IJ, the Administrator stated they would no longer hire nurses who were on probation with the board of nursing. The DON stated they started doing SBAR forms (forms used by nurses when a change in condition is noted) and she would review them all. They both revealed they had been in-serviced over the abuse/neglect policy and reportable events. On [DATE], the Immediate Jeopardy (IJ) was removed. On [DATE] at 4:15 p.m., DON and the Corporate Director of Operations were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 25 diabetic residents on Halls 100, 200, and 300 where RN A had worked.

Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #1) of 11 residents reviewed neglect. 1. The Administrator and DON failed to provide an RN to supervise RN A, as ordered by the Board of Nursing, who could have intervened and provided emergency care to Resident #1. On one of the shifts when she was not supervised by another RN, RN A failed to carry out her duties as described in her job description when she failed to initiate emergency support measures as appropriate and protect residents from harm and failed to recognize an emergency situation and take appropriate action. RN A failed to contact the physician, stay with Resident #1 or contact EMS when the resident's blood sugar was low, and the resident did not respond to [MEDICATION NAME] and was unresponsive. Forty minutes after Resident #1 was found she was transferred to the hospital on [DATE]. She remained unresponsive and was placed on life support. Resident #1 did not become responsive again and expired on [DATE] after being taken off life support. 2. The Administrator and DON failed to implement the Abuse/Neglect policy and Change in Condition Policy when they failed to identify neglect by RN A and failed to investigate when Resident #1 experienced a significant change in condition related to her blood sugar and level of consciousness. The incident was recorded on the 24 hour report and was discussed in the morning meeting, which was attended by the DON and Administrator. An Immediate Jeopardy was identified on [DATE] as beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed the 25 diabetic residents who resided on Hall 100, 200, and 300 where RN A worked at risk of serious physical harm, injury, and/or death. Findings included: Review of RN A's license on the Board of Nursing website on [DATE] at 12:45 p.m. reflected RN A's nursing license was on probation. Review of the Agreed Order from the Texas Board of Nursing reflected on or about [DATE], while employed at the same facility, she failed to initiate cardio-pulmonary resuscitation (CPR) after finding a resident unresponsive with no respirations or pulse and instead went to check his code status. RN A's conduct resulted in an unnecessary delay in care and was likely to injure the resident, including possible demise from lack of timely interventions and appropriate nursing care. Review of the Agreed Order from the Texas Board of Nursing reflected RN A was to be supervised by another RN who is on the premises. The supervising RN was not required to be on the same unit or ward, but should be on facility grounds and readily available to provide assistance and intervention if necessary. Review of RN A's employee file reflected a Notification of Employment dated [DATE] and signed by the Corporate Director of Clinical Services which stated the following: I have received a complete copy of the Order of the Board and am aware of the stipulations placed on this license by the Texas Board of Nursing. I agree to notify the Board's office and provide information to the Board regarding this nurse's resignation or termination. Review of the staff schedule and sign in sheet since [DATE] reflected RN A worked 24 10pm-6am shifts, including [DATE], without another RN in the building and readily available for supervision. Further review of the sign in sheets revealed RN A had worked on Halls 100, 200, and 300. Review of RN A's job description signed on [DATE] by RN A reflected the following: Initiates emergency support measures . Emergency situations are recognized and appropriate action is instituted. Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they were aware RN A was on probation and was to be under the supervision of another RN. The Administrator stated he was the Administrator of the building during the prior incident with RN A when she did not perform CPR on another resident. He stated he was willing to give her a second chance. The DON stated RN A could always call her for advice but she was not on facility grounds as her supervision the night of the incident. Interview with the Administrator on [DATE] at 11:20 a.m. revealed RN A had originally been on the 2pm-10pm shift when they had learned of her probation in (MONTH) (YEAR). He stated RN A then switched to the night shift in December. He stated he was under the impression RN A would be on the same 4 on 2 off schedule (work four days and they are off for two days) as the other RN on night shift, so she could provide supervision. He stated because of their mistake, RN A worked over 20 night shifts since (MONTH) without another RN supervising her according to her probation terms. Review of Resident #1's closed record revealed an MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of two people for activities of daily living. Review of her Care Plan dated [DATE] reflected there was not a care plan regarding her diabetes. Review of Resident #1's (MONTH) physician's orders [REDACTED]. [DATE]: Inject 20 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 30 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Inject 40 units of [MEDICATION NAME] ,[DATE] insulin subcutaneously once a day. [DATE]: Give 500 mg of [MEDICATION NAME] (medication used to help control and lower blood sugars) twice a day by mouth. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #1's nurse's note documented by RN A on [DATE] at 3:14 a.m. reflected Resident #1 became unresponsive to stimuli. Skin was cool to touch and clammy. Resident #1 had frothy secretions coming out of her mouth. Head was repositioned to prevent aspiration. FSBS (Finger Stick Blood Sugar) was taken and was noted to be 21 mg/dl. Resident #1's vital signs were noted to be the following: 95.8 temperature, 79 heart rate, 20 respirations per minute, and her blood pressure was ,[DATE]. Continue to monitor closely. According to https://medlineplus.gov/ency/article/ 6.htm, obtained on [DATE], Low blood sugar is a condition that occurs when the body's blood sugar (glucose) decreases and is too low. Blood sugar below 70 mg/dL (3.9 mmol/L) is considered low. Blood sugar at or below this level can be harmful. Review of Resident #1's MAR for (MONTH) (YEAR) reflected the following order: Inject 1 mg of [MEDICATION NAME] intramuscularly as needed for low blood sugar (if blood sugar is less than 60 and resident is unresponsive) which had a start date of [DATE] at 3:10 a.m. and had been put on the MAR by RN A. There was not a signed physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of [MEDICATION NAME]'s Information page for physicians accessed at http://uspl.lilly.com/[MEDICATION NAME]/[MEDICATION NAME].html#pi on [DATE] at 12:49 p.m. reflected the following: [MEDICATION NAME] is indicated as a treatment for [REDACTED]. If the response is delayed .emergency aid should be sought so that [MEDICATION NAME] (route other than oral which is usually either intramuscularly, subcutaneous, or intravenous) glucose can be given. Review of Resident #1's nurse's note documented by RN A on [DATE] at 4:40 a.m. reflected Resident #1 remained unresponsive to stimuli, and her eyes appeared to be rolled back after being given [MEDICATION NAME] at 3:15 a.m. FSBS rechecked at 3:25 a.m. and noted to be at 40 and at 3:45 a.m. at 59. Resident #1 did not arouse to sternum rub. EMS (Emergency Medical Services) was notified at 3:55 a.m. When paramedics arrived to facility, IV was started in left arm and [MEDICATION NAME] at 10% hung and infused. Resident #1 was transferred to the stretcher and taken to ambulance at 4:30 a.m. to be transported to the ER. The notes also reflected the RN was unable to contact the resident's family. No additional vital signs were recorded. Review of Resident #1's Emergency Department Admission reflected her date of admission was [DATE]. The record reflected Resident #1 arrived to the emergency roiagnom on [DATE] at 4:48 a.m. Resident #1 presented with decreased responsiveness and possible cause was listed as low blood sugar. Resident #1 was intubated on [DATE] at 5:08 a.m. and was put on a ventilator to assist with breathing and was admitted to the ICU. Review of the Hospital's Physician Notes reflected that on [DATE], Resident #1 was still on the ventilator and had been off sedation for 24 hours but remained unresponsive and the family requested terminal extubation (The withdrawal of mechanical ventilation from critically ill patients who are not expected to survive without respiratory support.) Resident #1 was discharged from the hospital on [DATE] with hospice services. Resident #1 remained unresponsive and her prognosis was poor. Interview with Resident #1's family on [DATE] at 10:30 a.m. revealed Resident #1 expired on [DATE]. He stated she never woke up after the low blood sugar incident, so he made the difficult decision to take her off life support and take her home. He stated Resident #1's blood sugar went low every once in a while, but it had never gotten as low as 21. Interview with RN A on [DATE] at 11:43 a.m. revealed on [DATE] around 3:15 a.m CNA B told her Resident #1 was not acting right. She stated she went down to Resident #1's room and found her unresponsive and cold and clammy. She stated she took Resident #1's vital signs and knew she was a diabetic so she took her blood sugar. Resident #1's blood sugar was 21. She stated she realized the resident was hypoglycemic (when a resident has low blood sugar). She stated she knew the resident had an order for [REDACTED].#1's room at that time, even though the resident was still unresponsive. RN A stated she came back about ten minutes later and rechecked her blood sugar and it was 40. She stated she left the room at that time and Resident #1 was still unresponsive at that time. She stated she came back about 20 minutes later and took her blood sugar again and it was 59. She stated the resident was still unresponsive so she decided at that point she should send Resident #1 to the hospital. RN A revealed she called 911 and went back to the room and stayed with the resident until the paramedics arrived. She stated the resident remained unresponsive and when EMS arrived, the paramedics started an IV but Resident #1 was still completely unresponsive. RN A stated EMS transferred Resident #1 to the stretcher and the resident started to groan, but other than that she was still out of it. RN A stated she never called the physician during the 45 minutes between finding the resident unresponsive and sending her to the hospital. RN A stated she left a message for the doctor after Resident #1 was sent to the hospital. She stated she did not remember notifying the DON or any administrative staff about the incident, but she did record the incident on the 24 hour report for the upcoming shift. RN A stated if she could go back and change things, she would have given the [MEDICATION NAME] and after a few minutes when it had not worked, she would have called 911. She stated she also would have called the doctor sooner to see what he wanted her to do. She stated she did not know why she waited so long to call 911, but she cannot go back and change it. Interview with CNA B on [DATE] at 10:30 p.m. revealed she was RN A's aide the night of the incident on [DATE]. She revealed she came into work around 10:00 p.m. and started her initial rounds. She said she remembered Resident #1's family was still there and Resident #1 was alert and talking. She stated Resident #1's family left a little after midnight. When she began her second round around 1:30 a.m. she noticed Resident #1 was very pale and had some white stuff coming from her mouth. CNA B stated she went to get RN A and asked her to go assess Resident #1 because something was not right. RN A told her she would go look at Resident #1 in a minute. CNA B continued on her rounds with other residents and went back to check on Resident #1 around 2:00 a.m. CNA B stated Resident #1 was still very pale and appeared to be unconscious because she was not waking up. She asked RN A to go look at Resident #1 again and RN A went down to Resident #1's room and looked at the resident but did not take vital signs or anything. RN A told her she had the situation handled, so she went back to care for other residents. CNA B went back to check on Resident #1 again around 2:30 a.m. and noticed Resident #1 was still pale and was not waking up. CNA B asked RN A what was going on with the resident and RN A told her that Resident #1 was going to be okay but to just keep an eye on her. At that point, she went and got CNA C to go look at Resident #1 with her. CNA B stated the time was probably around 3:00 a.m. CNA B and CNA C went down to check on the resident and she was still the same way. Resident #1 was unresponsive, pale, and still frothing at the mouth. CNA B revealed they asked LVN D to come and look at the resident, because RN A was not helping. At that point, RN A got up with them and went down to look at the resident. RN A told LVN D to not go into the room. RN A took Resident #1's vital signs and said her blood sugar was really low. RN A told her (CNA B) she had it handled, so she finished her rounds. CNA B revealed after a while, probably close to 4:00 a.m., she finally saw the paramedics arrive. She stated Resident #1 looked exactly the same. She was still unresponsive and finally around 4:30ish, the paramedics told RN A that it was just better if they took Resident #1 to the hospital. Attempt to interview LVN D was made on [DATE] at 10:44 a.m. but LVN D's phone number was not working. Interview with LVN E on [DATE] at 11:40 a.m. revealed she was one of the other nurses the night of the incident. She revealed LVN D told her CNA B had asked her to go look at Resident #1 because she was looking bad and RN A told her she had it handled. LVN E stated she remembered CNA B coming up to the desk, a little after midnight, a few times throughout the night asking RN A to go look at Resident #1. LVN E stated RN A never let them know what was going on with her residents and ignored aides' concerns regularly. Interview with the DON on [DATE] at 11:43 a.m. revealed she knew Resident #1 had been sent to the hospital, but did not remember why. Once she reviewed RN A's nurse's notes, she stated RN A should not have waited so long to call emergency services. She stated RN A should have called 911 when she found Resident #1 completely unresponsive. The DON stated she did not investigate the incident or ask RN A what happened. She revealed they had not done any in-services with staff regarding changes in conditions or blood sugar checks since the incident. Interview with ADON F on [DATE] at 1:15 p.m. revealed the ADON over RN A's hall that night was no longer employed with the facility, but ADON F did remember the other ADONs and the DON discussed the reason for discharge of Resident #1 the next day during morning meeting. An Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator and DON were informed of the IJ on [DATE] at 1:40 p.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal accepted on [DATE] reflected: Administration staff were in-serviced on proper reporting guidelines on [DATE] by Corporate Director of Clinical Operations. One hundred percent audit was completed on [DATE] on all residents requiring blood glucose monitoring. Orders were reviewed for high/low parameters and notification of MD. Nurse who demonstrated poor judgment during the episode in question was suspended and terminated on [DATE]. Monitoring the Plan of Removal: Interview with the Administrator and DON on [DATE] at 2:45 p.m. revealed they believed the immediate jeopardy occurred because RN A left a resident alone who was unresponsive and in a state of emergency and did not notify the physician. RN A did not call 911 when the [MEDICATION NAME] did not work. The Administrator stated they should have caught the situation but RN A had not documented the incident correctly. When asked what they would do differently to prevent another IJ, the Administrator stated they would no longer hire nurses who were on probation with the board of nursing and they no longer had any nurses on probation. The DON stated they started doing SBAR forms (forms used by nurses when a change in condition is noted) and she would review them all. They both revealed they had been in-serviced over the abuse/neglect policy and reportable events. Review of the DON, LVN D, LVN E, and LVN Q's employee files revealed they were not on probation with the board of nursing. On [DATE], the Immediate Jeopardy (IJ) was removed. On [DATE] at 4:15 p.m., DON and the Corporate Director of Operations were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. Review of the list of diabetic residents from the DON and dated [DATE] reflected there were 25 diabetic residents who resided on Hall 100, 200, and 300.