Every finding on record at Cordele Health and Rehabilitation

Based on observations, staff interviews, and review of the facility policy, Pureed Diet Preparation and Services, the facility failed to ensure pureed foods were prepared according to standardized recipes and professional food service standards for residents requiring texture-modified diets. This deficient practice had the potential to affect seven residents who received pureed diets and could increase the risk that residents would receive food with an inconsistent texture that did not meet their prescribed dietary needs. Findings Include:Review of the facility policy titled, Pureed Diet Preparation and services, documented under the section, Standardized Recipe Requirements section, all pureed diet items shall: Be based on standardized, dietitian- approved recipes. Include ingredient lists, preparation instructions, and yield information. It was revealed under Standardized Recipe Requirements All puree diet items shall.: Be based on standardized dietitian-approved recipes. It was revealed under the Documentation Requirements section the facility shall maintain: Standardized pureed recipes. Observation and interview on 06/13/2026 at 11:45 AM revealed the Dietary Manager prepared pureed beans and pureed spaghetti without using standardized recipes. The Dietary Manager used beans and bean liquid to prepare pureed beans. For pureed spaghetti, tomato paste was used as a thinning agent. Measuring tools were not used to measure ingredients during the preparation process. The Dietary Manager confirmed she does not use recipes when preparing pureed foods.Interview with the Administrator on 06/13/2026 at 12:43 PM revealed she was unaware that dietary staff were not using standardized recipes for pureed food preparation. The Administrator stated her expectation is that all dietary staff use standardized recipes when preparing meals, including pureed diets, to ensure residents receive appropriate nutritional balance.

Based on observations, staff interviews, and review of the facility policy titled Safe Food Handling, the facility failed to ensure food was properly labeled, dated, and maintained in sanitary conditions to prevent foodborne illness. This deficient practice had the potential to affect 61 residents.Findings include:Review of the facility's policy titled, Safe Food Handling with a review date of 04/18/2026, documented under Section C. Food Storage, Number 5, All food items shall be labeled and dated.A tour with the Dietary Manager (DM) on 06/12/2026 at 9:30AM revealed the following concerns:Observation of the walk-in cooler revealed a box of raw bacon that was not labeled or dated correctly, a gallon of water that was not dated or labeled, and a pan of chicken salad with an expiration date of 06/10/2026. The DM confirmed the findings at the time of the observation.During an interview conducted at the time of the observation, the DM stated she was responsible for ensuring food items were labeled with open dates and use by dates to promote food safety. The DM stated she would provide education to dietary staff regarding proper labeling and dating of food items and the disposal of expired food products.

Based on observations, staff interviews, record review and review of the facility's policy titled Dignity Policy for Long-Term Care, the facility failed to respect the dignity of one of 32 sampled residents (R) R1. This deficient practice had the potential to cause loss of self-worth and diminished quality of life.Findings include:Review of the facility's policy titled Dignity Policy for Long-Term Care undated, documented, Purpose: To promote and protect the dignity, rights, and individuality of all residents receiving long-term care. Policy Statement: All residents have the right to be treated with dignity and respect regardless of age, disability, health condition, culture, religion, gender, sexual orientation, or personal beliefs. Staff Responsibilities: Uphold residents' dignity in all interactions.Review of the facility's electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnosis included but not limited to pressure ulcer of sacrum.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 07 which indicated R1 had severely impaired cognition, section M (Skin Conditions) R1 had one unhealed pressure ulcer.Review of care plan dated 05/06/2026 documented R1 had a stage four pressure ulcer with an intervention to clean sacrum.Review of a Physician's Order dated 06/09/2026 documented to cleanse sacrum with normal saline (NS) solution. Pat dry. Apply Mesalt to wound bed and cover with a dry dressing every other day and as needed. Every day shift every other day for Wound Care Treatment and as needed for soiled or loose dressing. Observation and interview on 06/12/2026 at 04:35 PM during wound care revealed Registered Nurse/Wound Care Nurse (RN/WCN) AA informed R1 that she and a Certified Nursing Assistant (CNA) were going to assist the resident to turn onto her side and put on a diaper. RN/WCN AA confirmed she used the term diaper when referring to the resident's brief. RN/WCN AA stated the product packaging identified the items as diaper and that was the term she used. RN/WCN AA further stated that babies wear diapers and acknowledged that referring to a resident's brief as a diaper could cause the resident to feel inferior.Interview on 06/13/2026 at 05:02 PM with Licensed Practical Nurse Supervisor (LPNS) BB revealed staff should refer to residents' incontinence products as briefs rather than diapers. LPNS BB stated diapers are associated with babies and referring to a resident's brief as a diaper could affect the resident's dignity. LPNS BB further stated residents may feel embarrassed or as though they are being treated like children when staff use the term diaper.Interview on 06/14/2026 at 8:45 AM with the Director of Nursing (DON) revealed her expectations was for staff to refer to the residents' incontinence products as briefs. The DON stated that referring to briefs as diapers was a dignity concern. The DON further stated that use of the term diaper could cause residents to feel ashamed, become upset, or experience feelings of depression.

Based on observations, resident and staff interviews, record review and review of the facility policy titled, Resident Call Light Response Policy, the facility failed to provide reasonable accommodation of needs by not placing call lights within reach of two of 32 sampled residents (R) R18 and R39. This deficient practice had the potential to cause delayed assistance, potential for falls and unmet needs.Findings include:Review of the facility's policy titled, Resident Call Light Response Policy, reviewed 04/28/2026, documented, Purpose: To ensure that all residents receive timely assistance, maintain dignity and safety, and have continuous access to staff through the facility's call light system. Policy Statement: The facility shall maintain a functioning call light system that is available to residents at all times. Procedures: 1. Call Light Accessibility: Residents shall have access to a functioning call light device at all times while in bed, seated in a chair, or in the bathroom. Staff shall verify call light accessibility during each shift and after every resident transfer or repositioning. 1.Review of the facility's electronic medical record (EMR) documented R18 was admitted to the facility on [DATE] with diagnoses included but not limited to malaise (generalized unwellness) and hypoxemia (lack of oxygen).Review of the 5 Day Medicare Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognition) Brief Interview for Mental Status (BIMS) of 12 which indicated R18 had moderately impaired cognition, section GG (Functional Abilities) R18 is dependent on staff for Activities of Daily Living (ADL) care.Review of the care plan dated 04/02/2026 documented R18 had risk for falls related to (r/t) impaired physical mobility with interventions to provide a working and reachable call light.Observation on 06/12/2026 at 9:41 AM revealed R18 lying in bed, call light was observed hanging on the back of the bed rail and not accessible to R18.Observation on 06/12/2026 at 2:52 PM revealed R18 lying in bed, call light was observed hanging on the back of the bed rail and not accessible to R18.Observation on 06/13/2026 at 8:15 AM revealed R18 lying in bed, call light was observed hanging on the back of the bed rail and not accessible to R18.Observation on 06/13/2026 at 9:26 AM revealed R18 lying in bed, call light was observed hanging on the back of the bed rail and not accessible to R18.Interview on 06/13/2026 at 9:28 AM with R18 revealed she stated she did not know where the call light was and she could not reach it.2. Review of the facility's electronic medical record (EMR) documented R39 was admitted to the facility on [DATE] with diagnoses included but not limited to hemiplegia and hemiparesis following nontraumatic subarachnoid and hemorrhage affecting right dominant side.Review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 15 which indicated R39 had intact cognition, section GG (Functional Abilities) R39 was dependent on staff for toileting.Review of care plan dated 04/16/2026 documented R39 was at risk for falls related to (r/t) impaired physical mobility with intervention to provide a working and reachable call light.Observation on 06/12/2026 at 09:13 AM revealed R39 lying in bed, call light was observed hanging on R39's roommate's bed and out of reach of R39.Observation on 06/12/2026 at 01:20 PM revealed R39 lying in bed, call light was observed hanging on R39's roommate's bed and out of reach of R39.Observation on 06/13/2026 at 08:30 AM revealed R39 lying in bed, the call light was observed hanging on R39's roommate's bed and out of reach of R39.Observation on 06/13/2026 at 09:35 AM revealed R39 lying in bed, the call light was observed hanging on R39's roommate's bed and out of reach of R39. The call light was out of reach of R39.Interview on 06/13/2026 at 9:40 AM with Certified Nursing Assistant (CNA) CC revealed she confirmed Resident (R) 18's call light was hanging on the back of the bed rail and was not within the resident's reach. At the time of the interview, CNA CC asked R18 to demonstrate use of the call light. R18 attempted multiple times to reach the call light by extending her arm but was unable to do so and stated she could not reach it. CNA CC confirmed R18 was unable to access the call light. CNA CC also confirmed R39's call light was hanging on the roommate's bed and was not accessible to R39. CNA CC stated R39's roommate had access to her own call light and that R39's call light was also located on the roommate's bed, out of R39's reach. CNA CC stated that if call lights were not accessible, residents might be unable to summon staff assistance when needed, which could increase the risk of adverse events, including falls and unmet care needs.Interview on 06/13/2026 at 5:05 PM with the Licensed Practical Nurse Supervisor (LPNS) BB revealed call lights were expected to be kept within residents' reach at all times and secured to residents' bed linens or clothing. LPNS BB stated if call lights were not within reach, residents could be at risk for adverse outcomes, including falls or injury if attempting to reach the call light. LPNS BB further stated that in emergency situations, particularly for residents without a roommate, delayed access to assistance could result in death.Interview on 06/13/2026 at 8:45AM with the Director of Nursing (DON) revealed her expectations were that call lights should be within reach of the residents at all times and be on the residents' beds. She stated the residents were to be checked at least every two hours when staff did rounds. The DON further stated if call light were not accessible to the residents, their needs would not be met, and it could cause delay in care.

Based on record review and staff interviews the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) System for one of four resident (R) R22 reviewed for resident assessments.Findings include:Review of the electronic medical record (EMR) on 06/13/2026 documented R22 was discharged from the facility on 03/05/2026. Review of R22's MDS discharge assessment documented it was completed on 06/13/2026.During an interview on 06/13/2026 at 4:23 PM, MDS Care Plan Coordinator stated R22's MDS discharge assessment was not completed and was not entered into the system. The MDS Care Plan Coordinator stated discharge assessments typically appeared in the system; however this assessment was not present or completed.

Based on observations, staff and family interviews, record review, and review of the facility policy titled, LTC MDS and Care plan, the facility failed to develop a comprehensive, person-centered care plan for one of 33 sampled residents (R) (R47). This deficient practice had the potential to place R47 at risk of unmet needs, medical complications, and a diminished quality of life. Findings includeReview of the facility policy titled, LTC MDS and Care Plans, revised December 2023, documented under the section, Policy and Procedure subject, Care Plan, It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Review of R47's quarterly Minimum Data Set (MDS) dated [DATE] in the electronic health record (EHR) documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and in Section O (Special Treatments, Procedures, and Programs) CPAP (continuous positive airway pressure).Review of a physician order for R47 dated 05/28/2026, CPAP: Change face or nasal mask for CPAP every 3 months. Change water chamber on CPAP every 6 months. CPAP settings at 13. Review of the care plan dated 12/30/2023 for R47 revealed that it did not include CPAP care as part of his care plan.In an interview on 06/14/2026 at 11:30 AM with the MDS Coordinator verified that R47's CPAP needs were not included in the care plan until 06/13/2026. The MDS Coordinator confirmed that the use of CPAP should have been assessed and implemented into the care plan. Interview on 06/14/2026 at 1:43 PM with the Director of Nursing (DON) confirmed that a resident's CPAP should be part of that resident's care plan. She stated that she expected staff to review care plans to determine interventions.

Based on observations, staff interviews and review of the facility's policy titled, Accident Hazards at Bedside Policy (Long- Term Care), the facility failed to ensure the environment was free of accident hazards by having one pair of scissors on one of four medication carts unattended. This deficient practice had the potential to cause severe injury to the residents.Findings include:Review of the facility's policy titled, Accident Hazards at Bedside Policy (Long- Term Care), undated, documented, under the section, Policy: The facility will maintain a safe bedside environment by identifying and correcting accident hazards to reduce the risk of falls, injuries, and equipment-related incidents. Safety interventions will be individualized based on each resident's assessed needs and care plan.Observation on 06/13/2026 at 8:10 AM revealed one medication cart on the 200 hallway with one pair of scissors on the medication cart which was unattended. There was no nurse at the medication cart and residents were observed ambulating along the hallway. Observation on 06/13/2026 at 9:15 AM revealed one medication cart on the 200 hallway with one pair of scissors on the medication cart which was unattended. There was no nurse at the medication cart and residents were observed ambulating along the hallway. Observation on 06/13/2026 at 10:16 AM revealed one medication cart on the 200 hallway with one pair of scissors on the medication cart which was unattended. There was no nurse at the medication cart and residents were observed ambulating along the hallway. Interview on 06/13/2026 at 10:20 AM with Licensed Practical Nurse (LPN) DD confirmed the pair of scissors was on the medication cart and the cart was left unattended. She confirmed she left the cart to get items for medication administration, and the scissors were left on top of the cart. She confirmed the medication cart was out of her view and she could not see the cart. She also confirmed residents were ambulating along the hallway and they could take the scissors. LPN DD stated the scissors should not be on top of the medication cart, they should be locked in the cart because residents could take the scissors and cut themselves or another resident. Interview on 06/13/2026 at 5:02 PM with Licensed Practical Nurse Supervisor (LPNS) BB confirmed scissors should not be left on top of the medication cart, they should be locked in the cart and secured. She stated that when scissors were left unattended on top of the medication cart, a resident could take the scissors and hurt themselves or another resident or others. Interview on 06/13/2026 at 8:45AM with the Director of Nursing (DON) revealed her expectations were for scissors not to be on the medication carts because it was a safety issue. She stated that when scissors were left unattended on the medication carts, a resident could take the scissors and harm themselves and another resident.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, LTC Oxygen, the facility failed to maintain respiratory equipment consistent with professional standards for one of two sampled residents (R) (R47). Specifically, the facility failed to bag a continuous positive airway pressure(CPAP) mask when not in use. The deficient practice had the potential to cause infection.Findings include:Review of the facility policy titled, Respiratory care equipment storage and respiratory supply bag policy, documented under Policy statement: The facility shall provide respiratory care services in a manner that promotes resident safety infection prevention and equipment integrity all respiratory equipment supplies, oxygen delivery devices, and respiratory supply equipment shall be stored, maintained, cleaned, and transported according to manufacturer recommendations infection prevention standards and facility policies. Documented under Requirements: Respiratory supply bag shall: be cleanable and in good repair, remain closed when not in use, be used only for respiratory care supplies and equipment, and be clearly identified if designated for a specific resident.Review of R47's quarterly Minimum Data Set (MDS) dated [DATE] in the electronic health record (EHR) documented in Section C ( Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and in Section O - (Special Treatments, Procedures, and Programs) CPAP.Review of a physician order for R47, dated 05/28/2026, CPAP: Change face or nasal mask for CPAP every 3 months. Change water chamber on CPAP every 6 months. CPAP settings at 13.Observation on 06/12/2026 at 10:49 AM revealed R47's CPAP mask was not bagged. Observation on 06/13/2026 at 12:03 PM revealed R47's CPAP mask was not bagged.Observation on 06/13/2026 at 2:51 PM revealed R47's CPAP mask was not bagged. Interview on 06/13/2026 at 2:56 PM with Licensed Practical Nurse (LPN) EE confirmed that R47's CPAP mask was not bagged. She revealed that R47's CPAP mask should be cleaned and bagged after every use. Interview on 06/14/2026 at 1:43 PM with the Director of Nursing (DON) confirmed that when CPAP masks are stored, they should be clean and bagged.Interview on 06/14/2026 at 11:43 AM with the administrator from the sister facility, confirmed that when CPAP masks are stored, they should be clean and bagged. She stated that her expectation is for staff to bag and date all respiratory masks to prevent infection. She stated that the negative outcome from not covering respiratory equipment can lead to dust irritants than can lead to respiratory infections.

Based on observations, staff interviews, record review, and review of the facility policies titled, Cleaning Glucometer and Disinfecting, Medication Administration, F/C care/Peri-care, Infection Control - Standard and Transmission-based Precautions and Infection Control Hand Hygiene, the facility failed to implement infection control practices. Specifically, staff were observed touching a tablet with bare hands during resident care, failing to disinfect a glucometer between resident use, and failing to sanitize bedside tables after catheter care for two of 32 sampled residents (R) R50, R87. This deficient practice had the potential to increase the risk of infection and adversely affect residents' health and safety.Findings include:Review of the facility's policy titled, Cleaning Glucometer and Disinfecting dated June 2023, documented To establish a standardized process for cleaning and disinfecting glucometers to prevent the transmission of bloodborne pathogens and healthcare-associated infections among residents, staff, and visitors. Policy: All glucometers used within the facility shall be cleaned and disinfected after each resident use in accordance with the manufacturer's instructions, CDC (Center for Disease Control) infection prevention guidelines, and facility infection control policies. Glucometers shall not be shared between residents unless they have been properly cleaned and disinfected. Scope: This policy applies to all nursing personnel, medication aides, and other healthcare personnel responsible for blood glucose monitoring. Review of the facility's policy titled, Medication Administration dated 05/2028 documented 1. The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident.Review of the facility's policy titled F/C care/Peri-care undated documented Proper Foley catheter care involves daily cleaning, maintaining a closed drainage system, regular bag changes, hydration, and monitoring for signs of infection or complications.Review of the facility's policy titled Infection Control - Standard and Transmission-based Precautions, dated 03/2023 documented, Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines.Review of the facility's policy titled, Infection Control Hand Hygiene, dated March 2023, documented Purpose: 2. Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.1.Review of the facility's electronic medical record (EMR) revealed R50 was admitted to the facility on [DATE] with diagnoses included but not limited to obstructive and reflux uropathy.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 08 which indicated R50 had severely impaired cognition, section H (Bowel and Bladder) R50 had indwelling catheter.Review of care plan dated 04/15/2026 documented R50 has bowel and bladder incontinence and is at risk of complications. On 01/02/2025 R50 returned from hospital with a urinary catheter diagnosis of obstructive and reflux uropathy. Observation and interview on 06/12/2026 at 3:58 PM revealed Certified Nursing Assistant (CNA) CC provided catheter care to R50. At the completion of the procedure, CNA CC removed the supplies from the overbed table but did not clean or disinfect the table. CNA CC stated the table should have been cleaned and disinfected because the wash basin and towel used during the procedure were placed on the table, which could result in contamination of the surface. CNA CC further stated residents' meal trays are placed on the overbed table and failure to clean and disinfect the surface could increase the risk of infection.2. Review of the facility's electronic medical record (EMR) documented R87 was admitted to the facility on [DATE] with diagnosis included but not limited to essential hypertension.Review of the Initial admission Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 15 which indicated R87 had intact cognition.Review of care plan dated 06/02/2026 documented R87 had . congested heart failure (CHF) with intervention to give medications as ordered by physician.Review of physician's orders dated 06/02/2026 documented to give carvedilol tablet 6.25 milligrams (mg). Give 1 tablet by mouth two times a day for Hypertension.Observation and interview on 06/13/2026 at 8:36 AM during medication administration revealed Licensed Practical Nurse (LPN) EE was preparing medications for R87 when one carvedilol 6.25 mg tab fell onto the bare surface of the medication cart. LPN EE used her bare hands and picked up the tablet and placed it in the medication cup with the other medications to administer to the resident. LPN EE confirmed she handled the medication tablet with her bare hands. LPN EE stated she should have used gloves or another appropriate method to handle the tablet rather than touching it directly with her hands. LPN EE stated that direct contact with the medication could increase the risk of transferring bacteria to the resident. LPN EE further stated she should not have picked up the tablet directly from the medication cart before administering it to the resident because contaminated surfaces may contribute to the transmission of bacteria and increase the risk of infection.Observation and interview on 06/13/2026 at 9:17 AM revealed Licensed Practical Nurse (LPN) DD removed a blood glucose meter from a resident's bed in room [ROOM NUMBER]. Upon exiting the room, LPN DD placed the blood glucose meter directly onto the surface of the medication cart without first cleaning or disinfecting the device. During an interview immediately following the observation, LPN DD confirmed she did not clean or disinfect the blood glucose meter before placing it on the medication cart. LPN DD further confirmed she did not routinely clean or disinfect the blood glucose meter between resident uses and stated she cleaned the device only at the end of each shift. LPN DD stated the blood glucose meter should be cleaned and disinfected between resident uses and after each use. She further stated placing an uncleaned device on the medication cart could result in the transfer of microorganisms from contaminated surfaces to the medication cart and potentially to other residents during medication preparation and administration. LPN DD stated failure to clean and disinfect the blood glucose meter between resident uses could increase the risk of infection transmission.Interview on 06/13/2026 at 5:02 PM with Licensed Practical Nurse Supervisor (LPNS) BB revealed blood glucose meters were required to be cleaned and disinfected between resident uses with Sani-Wipes and allowed to remain wet for the manufacturer's recommended contact time before use with another resident. LPNS BB stated failure to clean and disinfect a blood glucose meter after resident use and between residents could result in cross-contamination and increase the risk of infection transmission, particularly because the device is used during blood glucose monitoring. LPNS BB further stated staff should not handle medication tablets with bare hands. She stated direct contact with medication tablets could result in cross-contamination and increase the risk of transmitting microorganisms to residents, which could adversely affect their health and potentially require additional medical treatment or hospitalization. Interview on 06/14/2026 at 8:19 AM with the Registered Nurse/Interim Infection Preventionist (RN/IIP) revealed blood glucose meters were required to be cleaned and disinfected between each resident use and placed on a protective barrier to prevent cross-contamination. RN/IIP stated placing an uncleaned blood glucose meter directly on the surface of a medication cart could result in cross-contamination and increase the risk of infection transmission to residents. RN/IIP further stated staff should not handle medication tablets with bare hands and should use gloves or another appropriate method when handling medications. RN/IIP stated direct contact with medication tablets could result in cross-contamination and increase the risk of transmitting microorganisms to residents, potentially adversely affecting their health.Interview on 06/14/2026 at 8:45 AM with the Director of Nursing (DON) revealed her expectation was that blood glucose meters be cleaned and disinfected between resident uses. The DON stated failure to clean and disinfect blood glucose meters between resident uses could result in cross-contamination and increase the risk of infection transmission to residents. The DON further stated medication tablets should not be handled with bare hands. She stated tablets that fall onto the medication cart should be discarded and replaced with a new tablet obtained through the appropriate medication distribution process. The DON stated handling medication tablets with bare hands could result in cross-contamination and increase the risk of transmitting bacteria to residents. The DON also stated staff should remove supplies and clean and disinfect the bedside table after providing catheter care. The DON stated failure to clean and disinfect the bedside table after catheter care could result in cross-contamination and increase the risk of infection transmission.

Based on observations, staff interviews, and review of the facility policy titled, Dietary Cleaning, the facility failed to ensure that the walk-in refrigerator, the oven, and the fryer were kept clean and sanitary, in a manner that prevents foodborne illness to the residents. This deficient practice had the potential to affect 56 of 62 residents who receive food from the kitchen. Findings include: A review of the facility policy titled Dietary Cleaning revealed: Creating a kitchen cleaning policy for a long-term care facility is essential to maintaining food safety, hygiene, and overall health. Under objective: The objective of this policy is to establish clear guidelines for maintaining a clean, sanitary kitchen environment to prevent food borne illness and ensure the health and safety of residents, staff, and visitors. Under General Guideline: All kitchen surfaces, utensils, equipment, and food storage areas must be kept clean and sanitized. During an initial walk through the kitchen on 4/1/2025 at 9:00 am with the Dietary Manager (DM) the following observations were made: Both ovens had burnt food stains, the fryer had debris, and the oil was dark colored. The side of the stove by the fryer had built up dirt and greasy substance. The walk-in fridge was very dirty with food debris, the floor was unkept with debris and the shelving was rusted. The DM acknowledged that the oven and the fryer were dirty as well as the walk-in fridge. A follow up walk through on 4/2/2025 at 9:10 am of the main kitchen revealed all previous observations remained, including stains built-up by the stove. All observations were confirmed with the DM during the walk through. Interview on 4/2/2025 at 9:40 am with the DM regarding her expectation of dietary staff maintaining a clean, sanitary environment in the kitchen. She stated that she expected staff to clean the refrigerator daily and deep clean it once a week and clean the oven daily and deep clean it once a week. She also stated that the fryer should be kept clean as well. Interview on 4/3/2025 at 12:50 pm with the facility Administrator regarding her expectations of staff when it came to maintaining a clean and sanitary environment with food storage, she revealed that the kitchen staff had a cleaning schedule, and she expected staff to wipe down everything at end of the day. She stated that she expected them to follow the cleaning schedule. She stated that the walk-in refrigerator should be cleaned on a monthly rotation and if staff walked in and observed something that needed immediate attention, that it should be addressed right away.

Based on observations and staff interviews, the facility failed to maintain a clean, sanitary, and comfortable environment for three of 13 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed. Specifically, the PTAC (Packaged Terminal Air Conditioner) vents were dirty. This deficient practice had the potential to compromise the health and safety of residents and staff by increasing the risk of respiratory and allergy symptoms due to inadequate air filtration and reduced fresh air circulation. Findings include: Review of the undated facility- provided document titled PTAC Preventative Maintenance Guide under the Three-Monthly PTAC Air Cleaning Tasks section revealed, 1. Air Filter Clean the filter with a vacuum or running water. 2. Vent Screen Clean or replace the vent screen. Remove the front grille and clean it with a dampened cloth Review of the undated facility-provided document titled HVAC (heating, ventilation, and air conditioning): Clean Air Filters details the following steps, At a minimum, air filters are to be replaced or thoroughly cleaned depending on the type of filter every month. Clean evaporator coils if lint build up is present. Observations on 4/1/2025 between 9:00 am and 10:00 am of the facility's PTAC air filters in resident room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] revealed that the PTAC units in these rooms had heavily soiled air filters with a thick accumulation of dust, dirt, and debris. Originally white, the air filters appeared dark gray due to trapped contaminants. When lifted for inspection, they released visible dust clouds and were clogged with a dense layer of grime. During an interview on 3/19/2025 at 9:35 am with Housekeeper II and Housekeeper JJ, they revealed that they did not clean the air filters. However, they did clean the grills, wiping them daily when they cleaned the rooms. During an interview on 4/3/2025 at 10:50 am with the Director of Housekeeping and the Director of Maintenance, they confirmed during a facility tour that maintenance was responsible for cleaning the air filters in the PTAC units. The maintenance staff cleaned the grills on the air filter covers as needed.

Based on staff interviews, record review, and review of the facility policy titled, (Long Term Care [NAME] Data Set) LTC MDS and Care Plan, the facility failed to follow the care plan for one of eight residents (R) (R168) and failed to include a care plan for O2 use with interventions for one of eight R (R37) who receive (O2) therapy. The deficient practice had the potential for R168 and R37's oxygen needs to go unmet. Findings include: Review of the facility policy titled LTC MDS and Care Plan with a revision date of December 2023 revealed under the Care Plan section: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment services, and interventions. 1. Review of the Care Plan dated 3/17/2025 for R168 revealed a focus diagnoses of emphysema/chronic obstructive pulmonary disease related to smoking. An intervention for oxygen setting revealed oxygen settings as ordered. Review of the Medication Administration order revealed the physician's order for Continuous oxygen @ (at) 2L/M Liters (L), minute (M), (Nurse is responsible for checking and maintaining Treatment Administration Record (TAR) every shift (QS). Administration Record (TAR) every shift (QS). She said she did not check the care plan, nor follow it as stated. An interview with the Director of Nursing (DON) on 4/3/2025 at 11:00 am revealed her expectations of the nurses following Doctor's orders and regulating O2 or any medication, she expected the nurses to access the Provider, change the settings when ordered, and alter the Care Plan to address those changes so that it flowed with the doctor's orders. 52213 2. An observation on 4/1/2025 at 9:30 AM revealed and unsecured oxygen tank in Resident (R) (37), room [ROOM NUMBER]. The oxygen cylinder was noted to be in front of R 37's dresser drawers standing upright. No nasal cannula or nebulizer was attached the cylinder. A review of the physician's orders for R37 confirmed an O2 order. Review of the care plan for R37 revealed no care plan was in place for the resident's O2. An interview on 4/3/2025 at 1:40 pm with the MDS Director revealed that R37 was care planned for O2 at 3 LPM. The intervention states that on 7/5/2024, the resident was admitted to the hospital: Low O2 on 3 liters via nasal cannula (81%) admitted to room number DX: Dyspnea/COPD without exacerbation with low saturation. She verified that the resident was ordered for O2 at 2 liters. It was her expectation that care plans contained the correct information that was resident centered.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medical Gas Cylinder Storage, the facility failed to ensure an oxygen (O2) tank was properly secured for one of five residents (R) (R37) reviewed for O2 storage. The deficient practice had the potential to result in harm or injury to the facility's residents. Findings include: Review of the facility policy titled Medical Gas Cylinder Storage dated February 2025 revealed under 2.0 General Requirements: All freestanding oxygen cylinders shall be in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them. Review of the electronic medical record (EMR) revealed that R37 was admitted to the facility with diagnoses of, but not limited to dependence on supplemental oxygen, dyspnea (shortness of breath), pneumonia (recurrent), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, dementia, unspecified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R37 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Status) revealed need for supervision to partial assistance for ADLs (activities of daily living). An observation on 4/1/2025 at 9:30 am revealed an unsecured O2 tank/cylinder in R37's room, room [ROOM NUMBER]. The O2 tank was noted to be in front of R37's dresser drawers standing upright, unsecured. No nasal cannula or nebulizer were attached to the O2 cylinder. During an interview on 4/3/2025 at 11:50 am with Certified Nurse Aide (CNA BB), she stated all O2 cylinders/tanks should be secured to the chairs or stored in the supply room. She stated, When a cylinder gets empty, we take it and replace it. She confirmed there should not be an extra cylinder in resident rooms and cylinders should be stored in a rack or attached to a resident's wheelchair. She confirmed O2 cylinders were not to be stored in resident rooms. During an interview on 4/3/2025 at 1:30 pm with the Director of Nursing (DON), she stated it was her expectation for O2 cylinders to be stored in the supply room if not secured when in use by a resident.

Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, Oxygen (O2) Concentrator and LTC (long term care)-Oxygen, the facility failed to ensure that residents received O2 as ordered for two of eight residents (R) (R29 and R168) receiving O2 therapy; and failed to ensure that the O2 concentrator (machine that supplies O2) was clean, sanitary, and free of sediment build-up for one of eight R (R33) receiving O2 therapy. The deficient practice had the potential to put the residents at risk for medical complications such as hypoxia, respiratory depression, and infection. Findings include: Review of the facility's policy titled Oxygen Concentrator last revised 3/5/2024 documented under Policy Explanation and Compliance Guidelines: Oxygen is administered under orders of the attending physician. Care of the Concentrator: Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device, external filters will be cleaned weekly. Only trained individuals, such as the Maintenance Director or supplier, shall service the device. The Housekeeping Department Responsibilities: Clean the outside casing of the concentrator and nebulizer units during routine room cleaning with an EPA- (Environmental Protection Agency) registered disinfectant in accordance with label instructions. Review of the facility's policy titled LTC-Oxygen dated April 2025 revealed under Policy Subject: Oxygen: . 1. There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered. Review of the electronic medical record (EMR) revealed R29 was admitted with diagnoses of, but not limited to anemia, heart failure, hypertension, diabetes mellitus, multiple sclerosis (MS). Review of the Minimum Data Set (MDS) revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Abilities and Goals) revealed R29 required substantial/maximal assistance with shower/bath and tub/shower transfers, Section J (MDS) revealed shortness of breath (SOB) with exertion, sitting and lying flat. Resident is on oxygen (O2) therapy. 1. Interview/observation on 4/1/2025 at 10:45 am with R29 revealed that his O2 should be set at 3 liters per minute (LPM), and he did not change it. He went on to reveal that the staff changed his O2 tubing every Sunday, as well as the water for the humidifier. R29's O2 was observed to be set at 3 LPM, the water bottle for the humidifier was dated 3/31/2025, and there was no label/date on the tubing showing when it had been changed. Observation on 4/1/2025 at 12:15 pm, R29's O2 was set at 3 LPM, the tubing was still unlabeled. Observation on 4/3/2025 at 11:15 am revealed R29's O2 was set at 2 LPM. The O2 tubing had been changed. Interview on 4/2/2025 at 4:15 pm with the Director of Nursing (DON) revealed that it was her expectation that the physician orders be followed and if there needed to be a change, they should contact the physician to inform them if a change was needed. 52213 2. Review of the EMR for R33 revealed that the resident was admitted to the facility with diagnoses that included but were not limited to paroxysmal atrial fibrillation, anemia, deep vein thrombosis (DVT), hypertension, ulcerative colitis, thyroid disorder, anxiety, depression, obstructive sleep apnea, and a multiple drug resistant organism in a wound, presence of a cardiac pacemaker, congestive heart failure, herpes zoster keratitis, Parkinsonism, chronic obstructive pulmonary disease (COPD) and insomnia. Review of the annual MDS dated [DATE] for R33 revealed in Section C (Cognitive Patterns), a BIMS score of 15, indicating intact cognition. Section J (MDS): Received as needed medication, shortness of breath (SOB) with exertion, sitting and lying flat. Resident is on oxygen (O2) therapy. Oxygen settings: O2 via nasal canula (NC) at 3 liters per minute (LPM). Observation on 4/1/2025 at 9:30 am revealed R33 lying in bed with O2 tubing on. The O2 concentrator was noted to be on and running with fluffy, brown/gray/white substance covering the filter area and the entire machine. Observation on 4/2/2025 at 8:55 am revealed R33 lying in bed with the O2 concentrator running with fluffy brown/gray/white substance covering machine and filter area. Observation on 4/3/2025 at 11:15 am revealed R33 lying in bad using the O2 concentrator, with the O2 concentrator filter covered with fluffy, light-brown and white substance. Interview on 4/3/2025 at 10:55 am with the Maintenance Director revealed the facility's policy was that housekeeping was to clean O2 concentrators weekly when O2 was in use. He also stated that the O2 provider was responsible for maintaining and changing the filter on each concentrator. He stated that his expectation was for the O2 provider to come in and complete regular cleaning and maintenance. 48338 3. Review of the EMR for R168 revealed he was admitted with diagnoses including but not limited to diabetes mellitus, sepsis, hypertension, and chronic obstructive pulmonary disease (COPD). Review of the Admission MDS dated [DATE] for R168 revealed in Section C (Cognitive Patterns) a BIMS score was not coded; section GG indicated eating/oral hygiene was independent; shower/bath dependent; toileting hygiene, upper/lower body dressing, and personal hygiene, required assistance. Review of the care plan dated 3/17/2025 revealed a focus area where R168 removes nasal cannula and changes the oxygen setting. The interventions revealed the oxygen setting was oxygen as ordered by the physician. Review of the physician's orders for R168 revealed on 4/2/2025 at 8:50 am during medication observation with Licensed Practical Nurse (LPN) AA, the order read, Continuous oxygen @ 2L/M (liters/minute), (Nurse is responsible for checking and maintaining Treatment Administration Record (TAR) every shift (QS). LPN AA said she did not follow the care plan as ordered. When asked what she would do going forward, she said she would notify the MD (medical doctor) to get an order to cover the titration when he removed his O2 and follow the care plan. An observation of the Medication Administration Record (MAR) revealed an order on the resident's list of medication that read, Continuous oxygen 3L-4L/NC. Observe that the resident is wearing nasal cannula (NC) every 2 hours. Document oxygen saturation. The start date and time was 4/2/2025 at 12:00. The second order read, May increase oxygen to 4L if R168 has desaturation-stat episode, as needed for Shortness of Breath (SOB). The start date was 4/2/2025 (at) 12:15 PM. An observation on 4/2/2025 at 9:10 am revealed the nurse placed her meds on the overbed table and helped R168 in the bathroom. She also took an O2 tank and tubing to the bathroom because the resident was not wearing it in the bathroom. The rate was set at 3.5 LPM and she said when R168's O2 saturation dropped, they bumped it up to 4 LPM. At 9:12 am, the O2 rate was increased to 4 LPM on the concentrator. The O2 rate remained at 4 LPM on the concentrator. Review of the physician's orders for R168 revealed an order that read, Continuous oxygen 3L-4L/NC. Observe that the resident is wearing NC every 2 hours. Document oxygen saturation (O2 sat) percentage. The start date and time was 4/2/2025 at 12:00. The second order read, May increase oxygen to 4L if resident has had a desaturation stat-episode, as needed for Shortness of Breath (SOB). The start date was 4/2/2025 @ 12:15 PM. An interview on 4/3/2025 at 11:00 am with the DON revealed her expectations of the nurses following Doctor's orders and administering medications as prescribed. She said the nurses were to ensure what the resident was on exactly what was ordered. She said she expected the tubing to be labeled and dated for O2 and the humidification bottle to be labeled as well. She said she expected the used tubing to be labeled and bagged for disposal. She said if there was an issue with regulating O2 or any medication, she expected the nurse to access the Provider and change the settings when ordered.

Based on observations, staff interviews, and review of the facility's policy titled, Hand Hygiene and Policy Procedure, the facility failed to ensure the infection control process was followed for two residents (R) (R48 and R168) during medication observation. The deficient practice had the potential to spread infection to other residents, staff and visitors. Findings include: Review of the facility policy titled Hand Hygiene dated 8/4/2011 revealed under Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Section 2: Waterless Handwashing Products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under Handwashing. Review of the facility policy titled Policy Procedure dated 3/2023 revealed under Procedure: . 3. The facility will provide personal protective equipment (PPE) to support compliance with standard and transmission-based precautions and ensure that it is readily available for staff use. Staff are required to adhere to standard precautions and use PPE according to standard precautions. An observation on 4/2/2025 at 8:42 am revealed Licensed Practical Nurse (LPN) AA drew up the heparin for R48 and cleansed the top of the vial, dialed the 2U (units) for waste in the Insulin Pen and extracted it, then dialed 5U of Lantus insulin via pen. She then pulled and set up her medication using the same gloves she drew heparin and dialed the insulin pen. An observation on 4/2/2025 at 9:10 am revealed LPN AA placed medications on the overbed table and helped R168 in the bathroom. She also took an O2 tank and tubing to the bathroom because the resident was not wearing it in the bathroom. She assisted R168 back to bed with the same gloves and gave him the fluticasone nasal spray one puff in each nostril. She then gave R168 a Spiriva inhaler one spray by mouth using the same gloves. She placed the mask for the albuterol inhaler over the nasal cannula (NC) for O2 and turned it on for 15 minutes. She then removed her gloves and sanitized her hands. An interview on 4/2/2025 at 9:30 am with LPN AA, she revealed she should have sanitized her hands and changed her gloves after she drew the injections, and before she set up her pills to avoid contamination with R48. She also said that she should have doffed (taken off) her gloves and washed her hands once she finished assisting R168 in the bathroom and before she gave her oral medication. An interview on 4/3/2025 at 11:00 am with the Director of Nursing (DON), she stated prior to the nurse giving the medication, she expected them to sanitize and/or wash their hands when taking care of residents and then giving medications. She said she expected them to change gloves between routes of medication and/or wash their hands to avoid cross-contamination.

Based on resident and staff interviews, record review, and review of the facility's policies titled, Non-Pressure Ulcers, and Treatment Administration Record (TAR), the facility failed to ensure that wound care was provided as ordered by the physician, for one of three residents (R) (RA) with venous ulcers. The deficit practice caused RA not to receive medical treatments as needed, and placed RA at risk for adverse consequences. Findings included: Review of the facility's policy titled, Non-Pressure Ulcers, dated 6/21/2021, revealed under Procedures: 3. Treatment and Management: Wound Care: A structured wound care protocol should be followed, including cleaning . dressing changes 4. Documentation: All non-pressure ulcers must be documented in the resident's medical record including the . treatments provided Review of the facility's policy titled, Treatment Administration Record (TAR), dated 6/21/2021 revealed under, 2. Recording and Documentation: All treatments must be recorded on the TAR with the exact date and time they were administered. Review of the clinical record revealed RA was admitted to the facility with diagnoses of but not limited to paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, and hypertension. Review of physician's orders and TAR's revealed that RA had a treatment order with a start date of 10/31/2024, to clean the areas to the bilateral lower legs with acetic acid-soaked gauze for approximately five minutes, pat dry, apply gentamycin ointment to the wound bed, and apply a dry dressing every shift. An additional order with a start date of 1/2/2025 documented when applying gentamycin to the wounds on the bilateral lower extremities, apply [Brand name] (non-adherent dressing) to the site, then the bordered/dry dressing every shift. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that RA was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating little to no cognitive impairment. The MDS assessment also included that RA had two venous or arterial ulcers. Review of the facility's wound report revealed that RA had a venous ulcer to the right lower leg (with onset date of 2/8/2024) and a venous ulcer to the left lower leg (with onset date of 7/16/2024). Review of the Medication Administration Records (MAR's) revealed an order entry with a start date of 3/29/2024, that documented the nurse was responsible for checking and maintaining the TAR every shift. Review of the TAR's revealed the wound treatments to the bilateral lower legs were scheduled to be provided every day, on both the day shift and the night shift. However, further review of RA's clinical record, including the TAR's, revealed no evidence that wound treatments were documented as provided as ordered and scheduled daily. Review of the TAR's revealed wound care was provided eight times in December 2024, eleven times in January 2025, and seven times in February 2025 as follows: Review of the TAR for December 2024 revealed there was no evidence that wound treatments were provided to RA's bilateral lower leg venous ulcers on the day shift on 12/24/2024, 12/29/2024 and 12/31/2024, or on the night shift on 12/3/2024, 12/5/2024, 12/8/2024, and 12/22/2024. Review of the TAR for January 2025 revealed there was no evidence that wound treatments were provided on the day shift on 1/1/2025, 1/7/2025, 1/10/2025, 1/11/2025, 1/15/2025, 1/16/2025, 1/17/2025, 1/18/2025 and 1/31/2025, or on the night shift on 1/10/2025 and 1/15/2025. Review of the TAR for February 2025 revealed there was no evidence that wound treatments were provided on the on the day shift on 2/15/2025 or on the night shift on 2/2/2025, 2/5/2025, 2/6/2025, 2/13/2025, 2/14/2025, and 2/15/2025. During an interview on 2/18/2025 at 11:30 am with the Wound Care Licensed Practical Nurse (LPN) confirmed RA had non-pressure ulcers to the bilateral legs. During an interview on 2/19/2025 at 2:05 pm with RA revealed that the wound care nurse provided wound care to her lower extremities on the day shift, but on weekends and nights it depended on who was working, if the treatments were provided. During an interview on 2/18/2025 at 2:35 pm with the Director of Nursing (DON) revealed that on weekends the Registered Nurse (RN) supervisor or medication nurse was responsible for wound care treatments. During an additional interview on 2/19/2025 at 3:15 pm with the DON revealed that wound care treatments ordered on the night shift, the nurse assigned to the resident was responsible for completing the treatment.

Based on observations, record review and staff interviews, the facility failed to follow physician orders for one of eight residents (R) #49. Specifically, the facility failed to ensure intravenous (IV) access site was removed from resident as ordered by physician after antibiotic regime was completed. The deficient practice had the potential to increase the probability of infection to occur at the IV insertion site. Findings: Review of the electronic medical record revealed that resident (R# 49) was admitted to the facility with diagnoses that included but were not limited to cardiovascular accident, hemiplegia of left hand, hypertension, neurogenic bladder, urinary retention, foley catheter and history of recurrent urinary tract infections (UTI). Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed that resident has a Brief Interview for Mental Status (BIMS) score of 15, which means the resident is cognitively intact. Section H (Bladder and Bowel) revealed that resident was utilizing an indwelling catheter during the seven day look back period of assessment. Review of the care plan dated 4/17/2023 revealed that resident had urinary incontinence/ indwelling catheter for diagnosis of neurogenic bladder, and recurrent UTIs. Review of the nurses' notes revealed that resident # 49 received IV antibiotics, between 4/14/2023 and 4/20/2023. The orders were as follows: 4/13/2023, new orders noted per the urologist, DX: multi resistant UTI. Insert IV and instill I gram of meropenem IV every 8 hours for seven days. At the completion of the treatment, discontinue the IV and restart the alternating antibiotic treatment. Obtain urine culture 3 to 5 days after the completion of the IV antibiotic treatment. Interview on 4/25/2023 at 11:31 a.m. with R#49 revealed that resident stated that he had a urinary tract infection and had received antibiotics for it. Continued interview also revealed that the antibiotics were completed, and the resident was unsure of the last dose received. Observation on 4/26/2023 at 9:15 a.m. revealed that R#49 IV was intact in the right upper arm. Interview on 4/26/2023 at 4:19 p.m. with facility Nurse Practitioner revealed that IV and the IV antibiotics were ordered by the urologist. The Practitioner stated that she would evaluate R #49 to determine continued use of the IV access. Interview on 4/26/2023 at 4:20 p.m. with Licensed Practical Nurse (LPN) AA revealed that she had not administered any IV medications during her shift and was not aware the resident had an IV. There was no notification from the off going nurse of any IV antibiotics that should be administered to R #49. Interview on 4/26/2023 at 4:35 p.m. with the MDS Coordinator revealed that the urologist for the facility had been ordering four different antibiotics to alternate weekly for the residents that have Foley catheters and that also have chronic UTIs. She stated that if an IV was placed, it was for the resident to have meropenem IV for seven days because he had drug resistant infection in his urine. Interview on 4/27/2023 at 12:30 p.m. with LPN BB revealed when a resident has an IV, flushing and maintenance of the IV would be ordered and should be on the task list for nurses to complete. Review of the task list for R #49 did not reveal IV maintenance orders. Interview on 4/27/2023 at 2:00 p.m. with Director of Nursing (DON) revealed that IVs are flushed per the MD orders. She stated that it is done before and after administrating IV medications. Dressing changes are completed per doctors' orders.

Based on observations, record review, and staff interviews the facility failed to ensure that oxygen (02) tubing and respiratory equipment were properly stored for two (2) of 15 residents (R) R#32 and R#35. Specifically, the facility failed to ensure that the 02 tubing for R#32 was changed weekly as ordered, the facility also failed to ensure R#35 C-PAP (Continuous Positive Airway Pressure) (ventilation in which a constant level of pressure is continuously applied to the upper respiratory tract of a person) mask was properly stored when not in use. Findings: Review of the electronic medical record (EHR) for resident R #32 revealed that the resident was admitted to the facility with diagnoses that included but are not limited to peripheral vascular disease, chronic obstructive pulmonary disease, and right upper lobe pneumonia. Review of the Physicians' orders revealed that oxygen therapy is to be routine, as needed to keep oxygen stats more than or equal to 90%. Review of the Minimum Data set (MDS) Annual assessment dated [DATE] Section C (Cognitive Patterns) revealed resident had a Brief Interview of Mental Status (BIMS) score of 15 indicating resident had no cognitive impairment. Review of care plan for R#32 initiated on 5/4/2022 revealed that resident had interventions in place for her respiratory plan of care that included evaluate the effectiveness of oxygen and respiratory therapy. Observation on 4/25/2023 at 11:00 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation on 4/26/2023 at 11:55 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation on 4/27/2023 at 10:00 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation was confirmed by Licensed Practical Nurse (LPN) BB. Review of the policy titled oxygen administration had no instructions for tubing and mask maintenance. Review of EHR for R # 35 revealed that he was admitted to the facility with diagnoses that include but are not limited to multiple sclerosis, chronic kidney disease, neurogenic bladder, obstructive sleep apnea, and anxiety. Review of the Quarterly MDS assessment dated [DATE] revealed in Section C0500 BIMS score of 15 indicating resident had no cognitive impairment. Review of the care plan for R# 35 revealed that resident has respiratory problem that includes obstructive sleep apnea that requires the use of a C-pap. Interview on 4/25/2023 at 10:45 a.m. with R #35 revealed that the c-pap machine is used at night and the staff assists him with applying and removing the c-pap mask. Further interview also revealed that resident could not recall when the staff had cleaned his c-pap mask after use. Observation on 4/26/2023 at 11:50 a.m. revealed R#35 C-pap mask was not stored and labeled properly. Interview on 4/26/2023 at 11:47 a.m. with LPN AA, revealed that the tubing for oxygen is changed by the night shift charge nurse every week on Sunday nights. Further interview also revealed that LPN AA was unsure if the respiratory equipment should be dated. Interview on 4/27/2023 at 9:50 a.m. with LPN CC revealed that oxygen tubing, nebulizer mask, and humidifier bottles are changed on Sunday nights. She stated that they are to be dated and have a bag for when they are not in use. Interview on 4/27/2023 at 1:30 p.m. with the Director of Nursing (DON) revealed that it is her expectation that oxygen tubing is changed during the night shift on Sunday evenings. The 02 tubing and the humidifier bottle should be changed and dated, and a bag should be available to place the 02 tubing in when it is not in use. Further interview also revealed that the c-pap masks are to be cleaned when they are visibly soiled and should be properly stored when not in use as well.

Based on observation and staff interviews. The facility failed to ensure the kitchen was maintained in a clean and sanitary condition. The deficient practice had the potential to affect 58 of 62 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 4/25/2023 at 9:00 a.m. the floor and walls were observed to have brown/black/and yellow stains throughout the kitchen. The main kitchen had four air condition units with dirty vents, and spider webs noted between the unit space and the window. Continued observation revealed of the window unit located in the rear of the kitchen had a white blanket positioned underneath the unit that was wet with brown stains noted. Observation on 4/25/2023 at 9:02 a.m. of the dishwasher room revealed the floor under the single compartment sink had missing and lose tile noted from the wall to the middle of the floor. The walls under the dishwashing sink had a thick black substance that was noted on the wall and around the drainage pipe that was attached to the wall. Interview on 4/25/2023 at 12:08 p.m. with the Dietary Manager revealed it is the responsibility of the kitchen staff to ensure that the main kitchen and appliances are clean and in good working order. The continued interview also revealed that it is her responsibility to ensure that the cleaning schedule is followed and completed daily. All areas of concern during the initial tour were confirmed by the dietary manager. Interview on 4/27/2023 at 11:01 a.m. with the facility maintenance director revealed he was aware of all areas of concern but did not have work orders submitted at this time.

Based on observation, record review, and review of the facility policies titled, LTC-Pressure Ulcers and Hand Hygiene. The facility failed to ensure that proper hand hygiene was conducted during wound care treatment for one of 10 residents (R#31). The deficient practice had the potential to increase the probability of infection risks for the resident. Findings include: Review of the facility policy titled, Hand Hygiene effective date 5/2022 revealed under: Indications for Hand Washing and Hand Antisepsis; If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before and after patient contact. Under: Use of Gloves; Gloves should always be worn when contact with blood, body fluids, or other potentially infectious material, mucous membranes and non-intact skin could occur. Gloves do not provide complete protection and glove integrity may be compromised by long or poorly groomed nails. Review of the facility policy titled, LTC-Pressure Ulcers effective date 11/2021 revealed under Policy subject: Pressure Ulcers 4. The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Record review for R#31 revealed resident was admitted to the facility with diagnoses of atrial fibrillation, Cardiomegaly, Diabetes Mellitus, cellulitis of left lower limb, Chronic non-pressure ulcer, fracture of left fibula. Continued record review revealed Admission Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) C0500 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating resident had minimal cognitive impairment. Wound Care observation on 4/26/2023 at 10:00 a.m. revealed Wound care nurse gathered supplies and proceeded to residents' room to complete wound care. A barrier was placed on the residents' bedside table and wound care supplies were placed on the barrier. The nurse applied gloves and removed the old bandage and placed it in the trash bag. New gloves were applied without washing or sanitizing hands in between. This process continued throughout the wound care procedure for R#31, the resident had four different areas for treatments to be completed. Interview on 4/26/2023 at 10:30 a.m. with Wound care nurse revealed that the proper procedure for wound care treatment is when gloves are removed the nurse is to sanitize or wash hands with soap and water between each glove change. Further interview also revealed that Wound care nurse confirmed that sanitizer was not used between glove changes. Interview on 4/26/2023 at 3:02 p.m. with the Director of Nursing (DON) revealed that the Wound Care Nurse should have sanitized her hands between glove changes while completing wound care. Further interview also revealed that the expectation is that when conducting any care for residents that gloves are to be worn and hands should be sanitized and or cleaned with soap and water between glove changes.

Based on record review, and interviews with staff and a physician, it was determined that the facility failed to implement interventions to monitor residents' status during hypo/hyperglycemic episodes and/or to notify the physicians of four residents (#13, #36, #73 and #8) with blood sugar levels less than 60 and greater then 451 in a sample of eight insulin dependent diabetic residents from a total sample of 32 residents. That failure to monitor and implement interventions for continued [DIAGNOSES REDACTED] resulted in a loss of consciousness for resident #13 and the likelihood of serious harm for the other diabetic residents in the sample. Therefore it was determined that an immediate and serious threat to resident health and safety existed on 4/6/12 through 6/7/12 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: According to the American Medical Director's Association's "Managing Diabetes in the Long-Term Care Setting" Clinical Practice Guideline, if [DIAGNOSES REDACTED] is not promptly recognized and treated it can result in long-term disability, particularly in cognitively impaired individuals. Without adequate documentation, it is difficult to know whether treatment goals are being achieved or whether modification of the care plan is appropriate. It is important to document the reason(s) for treatment decisions, including decisions not to treat or to choose one treatment approach over another. According to the 'Merck Manual of Medical Information,' blood sugar levels are normally between 70 and 110 milligrams per deciliter (mg/dl). Over time, elevated blood sugar levels damage blood vessels, nerves, and other internal structures. Poorly controlled blood sugar levels also tend to cause the blood levels of fatty substances to rise, resulting in accelerated [MEDICAL CONDITION]. When blood sugar levels are too low, the first organ affected is the brain. [DIAGNOSES REDACTED] must be treated quickly because within minutes it can become severe, leading to increasing confusion, coma, and permanent [MEDICAL CONDITION]. Monitoring blood sugar levels is an essential part of diabetes care. The facility's Diabetic Patient Management Protocol instructed nursing staff that for a blood sugar less than 60, give four ounces of juice, non diet cola, eight ounces of skim milk, two ounces of Med Pass or glucose gel. Repeat the blood sugar level check in 15 to 20 minutes as long as patient is alert. If a resident's blood sugar level was less than 60 and the patient was unresponsive, give [MEDICATION NAME] 1 mg and call the physician. Call EMS if indicated. Notify the physician of blood sugar levels less than 60 or greater than 450. During an interview on 6/07/12 at 2:15 p.m., registered nurse "M" stated that nursing staff were to follow the specific physicians' orders for a resident regarding when to notify the physician about abnormal blood sugar levels. If the physician did not specify parameters for when to be notified, then licensed nurses were to supposed to follow the facility's policy, which had been approved by all of the physicians. However, the nursing staff failed to consistently implement interventions, to monitor residents during hypo/hyperglycemic episodes and/or to notify the physicians for blood sugar levels less than 60 and greater than 451 for four residents (#13, #36, #73 and #8) in a sample of eight insulin dependent diabetic residents. That failure to implement interventions for continued [DIAGNOSES REDACTED] resulted in a loss of consciousness for resident #13 and the likelihood of serious harm for the other diabetic residents in the sample who had repeated hypo/hyperglycemic episodes. 1. Resident #13 had a [DIAGNOSES REDACTED]. The resident #13 had a care plan dated 4/3/12 to address the resident's risk for hypo/[MEDICAL CONDITION] related to his/her [DIAGNOSES REDACTED]. There were interventions for nursing staff to give medications as ordered, to obtain accuchecks as ordered, to observe for signs and symptoms of [DIAGNOSES REDACTED] such as shaking, sweating, anxiousness, dizziness, increased hunger, headache, weakness and impaired vision, to observe for signs and symptoms of [MEDICAL CONDITION] such as increased thirst, frequent urination, dry skin, drowsiness, nausea, and increased hunger, to obtain lab work as ordered and to report to the physician as indicated/ordered. There was a physician's orders [REDACTED]. - 400; 12 units for levels from 401 - 450 and; 15 units for blood sugar levels of 451 or greater. If the blood sugar level was greater than 451, then the nurse was to notify the physician. Review of the resident's April and May 2012 Medication Administration Record [REDACTED] 24 on 4/12/12 at 6:30 a.m.; 21 on 4/13/12 the blood sugar level at 6:30 a.m. and 28 at 4:30 p.m.; 22 on 4/14/12 at 6:30 a.m.; 59 on 4/17/12 at 6:30 a.m. and; 25 on 4/19/12 at 6:30 a.m. and "LO" at 4:30 p.m. However , there was no evidence that nursing staff had followed the facility's diabetic management protocol or notified the physician, and monitored the resident during those hypoglycemic episodes on 4/6/12, 4/13/12 at 4:30 p.m., and 4/19/12. The 4/13/12 nurse's notes documented that the resident's blood sugar level was 34 around breakfast time. The nurse noted that she had given the resident Med Pass supplement and the resident's blood sugar level rose to 45. although the facility's policy was to repeat monitoring the resident's blood sugar level in 15 to 20 minutes, there was no evidence of continued monitoring of the resident's blood sugar level or of the provision of any other interventions. According to the 4/13/12 nurses's note, the resident #13 was later taken to lunch and then the CNA summoned the nurse because the resident was unresponsive. The resident was returned to his/her room and a registered nurse gave [MEDICATION NAME] to his/her. After having given [MEDICATION NAME] to the resident, the nurse re-checked the resident's blood sugar level which had risen to 60. According to the facility's for Diabetic Patient Management, nursing staff was supposed to notify the resident's physician if the resident's blood sugar level was below 60 but nursing staff did not notify the resident's physician about the abnormal blood sugar level. During an interview on 6/07/12 at 2:30 p.m., Assistant Director of Nursing (ADON), "C" stated that on 4/13/12 when she noted the resident's blood sugar level was 34 at breakfast time, she gave the Med Pass supplement to the resident and rechecked the resident's blood sugar level which was 45. However, ADON "C" was unable to provide evidence of providing any interventions or continued monitoring of the resident's blood sugar level until the resident lost consciousness at lunch in the dining room. She said, at that time, she gave the [MEDICATION NAME] to the resident and rechecked the blood sugar level which was 60. However, there was no documentation that the physician had been notified about those abnormal low blood sugar levels. During an interview on 6/07/12 at 1:15 p.m., the resident's physician stated that he expected the nurses to call him if a resident's blood sugar level less than 60 and greater than 400 for adjustments to possibly be made to the resident's insulin coverage. He said that he did not remember the nursing staff calling him in April when the resident's blood sugar levels were in the twenties. He stated if somebody had repetitive blood sugar levels in the twenties then that would stick out in his mind. He said that the resident had more of a history of high blood sugar levels than low blood sugar levels. He stated that he would instruct nursing staff to give juice to the resident if the resident was conscious and to recheck the resident's blood sugar level in 30 minutes. He said that if the resident was unconscious then he would order the nurse to give [MEDICATION NAME] and call 911 if needed. The physician said that if nothing was done for a resident with an extremely low blood sugar level then, that resident could possibly slip into unconsciousness and "plummet." The nursing staff recorded the following blood sugar levels for the resident: 476 on 4/27/12 at 9:00 p.m.; 491 on 4/28/12 at 9:00 p.m.; 478 on 5/7/12 at 9:00 p.m.; 466 on 5/13/12 at 9:00 p.m. However, there was no evidence that nursing staff had monitored the resident's blood sugar levels according to the facility's policy or notified the physician as ordered. 2. Resident #73 had a [DIAGNOSES REDACTED]. levels from 400 - 449; and 15 units for levels from 401 - 450 and; 15 units for blood sugar levels of 451 or greater. In addition, if the resident's blood sugar level was greater than 451, then the resident's blood sugar level was supposed to be repeated in two hours and; if the resident's blood sugar level was still greater than 400, then the physician was to be notified. Review of the resident's April 2012 MAR indicated [REDACTED]. On 4/13/12, a licensed nursing staff documented on the resident's MAR indicated [REDACTED]. 3. Resident #36 had [DIAGNOSES REDACTED]. The resident had a care plan since 12/20/11 to address being an insulin dependent diabetic with a need to maintain balance between food intake and insulin intake. There were interventions for nursing staff to administer medications and obtain blood sugar levels as ordered. The resident also had a care plan since 12/20/11 to address the need for a therapeutic diet due to the resident's [DIAGNOSES REDACTED]. There were interventions for nursing staff to monitor the resident for hypo/[MEDICAL CONDITION]. There was a physician's orders [REDACTED].#36 four times a day at 6:30 a.m., 11:30 a.m., 4:30 p.m. and at 9:00 p.m. The nurse was supposed to give 2 units of insulin for blood sugar levels from 60-100; 3 units for levels from 101-120; 4 units for levels from 121-150; 5 units for levels from 151-200; 6 units for levels from 201-300; 8 units for levels 301-400, and 9 units for levels great than or equal to 400. The order also included that due to non-numeric readouts on blood sugar level testing equipment an entry by nursing staff of 999 on the resident's MAR indicated [REDACTED]"low" blood sugar level on the meter. Review of the resident's April and May 2012 MARs revealed nursing staff had recorded the following blood sugar levels for him/her: exceeded 450 on 4/1, 4/8, 4/12, 4/16, 4/17, 4/19, 4/21, 4/29, and 4/30/12; 457 at 11:30 a.m. and 521 at 4:30 p.m. on 4/1/12; 999 ( code for a "high" reading on the glucometer) at 11:30 a.m. on 4/8/12; 500 at 11:30 a.m. on 4/12; 492 at 11:30 a.m. on 4/16; 501 at 11:30 a.m. on 4/17; 507 at 11:30 a.m. on 4/19; 493 at 11:30 a.m. on 4/21; 498 at 9 p.m. on 4/29 and; 463 at 11:30 a.m. on 4/30/12. Licensed nursing staff documented that 9 units of [MEDICATION NAME] had been administered as ordered with each reading above 400. However, there was no evidence in the clinical record that nursing staff had monitored the resident during those times when his/her blood sugar level was above 400 for any symptoms of [MEDICAL CONDITION] or that the resident's physician was notified of those blood sugar levels. Nursing staff recorded that the resident's blood sugar level was below 60 on 4/1, 4/3, 4/5, 4/6, 4/10, 4/11, 4/14, 4/15, 4/20, 4/22, 4/23/12, and 4/25/12. Nursing staff recorded the resident's blood sugar level was below 60 as follows: 47 at 9 p.m. on 4/1/12; 55 at 9 p.m. on 4/3; 49 at 6:30 a.m. on 4/5; 52 at 6:30 a.m. on 4/6; 44 at 6:30 a.m. at 4/10; 52 at 6:30 a.m. on 4/11; 39 at 9 p.m. on 4/14; 32 at 9 p.m. on 4/15; 34 at 9 p.m. on 4/20; 32 at 9 p.m. on 4/22; 59 at 4:30 p.m. on 4/23 and; 47 at 6:30 a.m. on 4/25/12. However, there was no evidence in the clinical record that licensed nursing staff had implemented interventions for low blood sugar levels according to the facility's protocol or notified the physician, and monitored the resident for symptoms of [DIAGNOSES REDACTED]. Nursing staff recorded that the resident's blood sugar level exceeded 450 on 5/10, 5/12, 5/15, 5/16, 5/18, 5/20, 5/21, 5/22, 5/27 and 5/30/12. Nursing staff recorded the resident's blood sugar levels as follows: 485 at 11:30 a.m. on 5/10/12; 999 (coded for a "high" reading on the glucometer) at 11:30 a.m. on 5/12/12; 455 at 11:30 a.m., 500 at 4:30 p.m. and "999" again at 9 p.m. on 5/15/12; 483 at 9 p.m. on 5/16; 500 at 9 p.m. on 5/18; 457 at 11:30 a.m. on 5/20; 516 at 11:30 a.m. on 5/21; 508 at 11:30 a.m. on 5/22; 471 at 4:30 p.m. on 5/27 and; 523 at 11:30 a.m. on 5/30/12. Licensed nursing staff documented that 9 units of [MEDICATION NAME] was administered to the resident as ordered for blood sugar levels equal to or greater than 400. However, there was no evidence in the clinical record that nursing staff monitored the resident during those times for any symptoms of [MEDICAL CONDITION] or notified his/her physician. The resident's physician stated during an interview on 6/7/12 at 5:20 p.m. that he would have expected licensed nursing staff to notify him when any blood sugar level for a resident was less than 60 or greater than 400. The physician confirmed that he had not been notified when the resident's blood sugar level had been abnormally high or low in April and May. 4. Resident #8 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The resident had a care plan in the clinical record (printed 5/22/12) to address a problem of a need to maintain balance between food intake and insulin intake since the resident was non-compliant with his/her therapeutic regimen at times. There were interventions for nursing staff to administer medications according to the physician's orders [REDACTED]. There was a physician's orders [REDACTED]. of skim milk or 2 oz. of Med Pass or Glucose agent and then repeat the resident's FSBS in 15 - 20 minutes. If the resident was unresponsive, then the nurse was to give him/her 1 mg. of [MEDICATION NAME] and call the physician. If the resident's blood glucose was less than 60 or greater than 450 on consecutive occasions, then his/her attending physician was supposed to have been called. There was a physician's orders [REDACTED]. The nurse was to give 2 units of insulin for blood sugar levels from 201 - 250; 4 units for levels from 251 - 300; 6 units for levels from 301 - 350; 8 units for levels from 351 - 400; 10 units for levels from 401 - 450 and; 15 units for blood sugar levels of 451 or greater. A review of nursing staff's documentation in the clinical record and on the resident's April and May, 2012 Medication Administration Records (MARs) revealed the following FSBS levels for resident #8: 25 at 6:30 a.m. and 32 at 9 p.m. on 5/01/12 ; 491 at 6:30 a.m. and 37 at 11:30 a.m. on 5/07;482 at 11:30 a.m. on 5/08; 484 at 4:30 p.m. and 52 at 9 p.m. on 5/15; 46 at 6:30 a.m. on 5/17; 36 at 9 p.m. on 5/20; "0" at 4:30 p.m. and 38 at 9 p.m. on 5/25; 453 at 11:30 p.m. on 5/29 and; 32 at 4:30 p.m. on 5/30/12. Although the resident's FSBS level was recorded as having been above 60 on 5/25/12 at 10:43 a.m., nursing staff documented that 1 mg of [MEDICATION NAME] had been given. Nursing staff recorded the resident's blood sugar level on 5/25/12 as 151 at 6:30 a.m. and 320 at 11:30 a.m. Although there was a nursing note at 2:05 p.m. on 5/25/12 that the physician had seen the resident, there was no documentation to indicate whether or not they had made him aware of the resident's [DIAGNOSES REDACTED] at 6:30 a.m. that day. There was no evidence that nursing staff monitored the resident or implemented any interventions during the hypo/hyperglycemic episodes. There was no evidence that nursing staff stayed with the resident until his/her blood sugar level had stabilized. There was no evidence that the resident's FSBS level was rechecked on any of the above dates and times. Nursing staff recorded that the resident's FSBS level as follows: 514 at 4:30 p.m. on 4/02/12; 54 at 4:30 p.m. on 4/06; "0" at 4:30 p.m. on 4/08; 44 at 6:30 a.m. on 4/11; "0" at 11:30 a.m. on 4/16; 464 at 4:30 p.m. on 4/19; 53 at 11:30 a.m. on 4/23; 28 at 6:30 a.m. on 4/24; "0" at 11:30 a.m. and 508 at 4:30 p.m. on 4/25; 500 at 11:30 a.m. on 4/26 and; 54 at 4:30 p.m. on 4/20/12. However, there was no evidence that nursing staff monitored the resident or implemented interventions as ordered during those hypo/hyperglycemic episodes. There was no evidence that nursing staff stayed with the resident until the blood sugar level stabilized. There was no evidence that the resident's FSBS level was rechecked on any of the above dates and times. Therefore, it was determined that a likelihood of serious harm for resident #8 existed during April and May, 2012. Repeated attempts to contact the resident's physician were unsuccessful. Although messages were left for the physician regarding the resident and his/her FSBS levels, he did not return the surveyor's calls made on 6/07/12 and 6/08/12. Although the facility provided internal nursing staff communication information (24 hour nursing service reports that were not part of a resident's clinical record) which included documented entries about some rechecks of blood sugar levels for residents, those entries were not signed or dated by nursing staff and had not been incorporated into individual residents' clinical records. The immediate and serious threat to resident health and safety was determined to have been removed on 6/08/12 but, the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining fingerstick blood sugar levels as ordered, implementing interventions for hypo/[MEDICAL CONDITION], monitoring residents, notifying physicians and documenting those actions in the clinical record; reviewing and revising care plans as necessary; monitoring by supervisory nursing staff for the results of fingerstick blood sugar levels and any interventions if needed; notifying physicians promptly about abnormal blood sugar levels as ordered and per facility policy; supervising by supervisory nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; evaluation by the Quality Assurance committee for the implementation and effectiveness of the facility's interventions to ensure that fingerstick blood sugar levels are done as ordered, that interventions are implemented and residents monitored for hypo/[MEDICAL CONDITION], that episodes of hyper/[DIAGNOSES REDACTED] are communicated to the physicians promptly and that revisions to the plans of care are done as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility conducted a 100% chart audit of all diabetic residents. An audit was conducted to identify all residents with sliding scale insulin orders. Physicians were notified by the facility about any irregular blood sugar levels that occurred outside the parameters established by the facility's protocol that were identified during the audit. Completed 6/7/12. 2. All residents who were identified with irregular blood sugar level findings were reviewed by the pharmacist and recommendations made to the physicians as indicated for optimal diabetic management. Completed 6/8/12. 3. Each resident's diabetic care plan was reviewed and revised as necessary by the facility. Completed 6/7/12. 4. The facility educated all licensed staff (on duty) regarding the facility's diabetic management program and new forms for fingerstick blood sugar level documentation. Fingerstick Blood Sugar and Fingerstick Blood Sugar Follow-up forms were implemented with the Medication Administration Records (MARs) on 6/8/12. Licensed staff not on duty will be educated before being allowed to return to work . 6. The facility implemented a plan on 6/07/12 and clarified on 6/08/12 for the specific day assignments for the Director of Nursing (during the week) and RN Supervisor (on weekends) to audit blood sugar level readings daily to ensure compliance for 30 days and weekly thereafter. 7. The Administrator will review the audits and report the information to the QA committee. Implemented 6/8/12. 8. The facility notified the Medical Director of the concerns identified regarding blood sugar management. Completed 6/7/12.

Based on record review and staff interview, the facility failed to ensure that the physicians' orders for the administration of insulin were followed for two (2) residents (#1 and #2) from a survey sample of five (5) residents. Findings include: 1. Record review for Resident #1 revealed the July 2012 physician's orders [REDACTED]. However, further record review, to include review of the July 2012 Medication record for this resident, revealed no evidence to indicate that the [MEDICATION NAME] 10 unit doses had been administered to this resident as ordered on [DATE] and 07/06/2012 at 8:00 a.m., and on 07/08/2012 at 8:00 a.m., 12:00 p.m., and 5:00 pm, as ordered. The above was acknowledged during interview with the Director of Nursing conducted at 5:30 p.m. on 07/20/2012. 2. Record review for Resident #2 revealed the July 2012 physician's orders [REDACTED]. This physician's orders [REDACTED]. A Physician's Interim Orders sheet dated 07/03/2012 specified to discontinued to [MEDICATION NAME] 2 unit, twice daily order, and to start [MEDICATION NAME] 3 units, twice daily, and to discontinue the [MEDICATION NAME] 22 unit, twice daily order, and to start [MEDICATION NAME] 24 units twice daily. There was no reference to modify or discontinue the 3 unit [MEDICATION NAME] R dosage to be given at bedtime. However, further record review, to include review of the July 2012 Medication Record, revealed no evidence to indicate that Resident #2 administered the ordered bedtime 3 unit doses of routine [MEDICATION NAME]from 07/04/2012 through 07/19/2012.

Based on record review, it was determined that the consultant pharmacist failed to identify and report to the attending physician and the director of nursing the occurrences of hypo/hyperglycemic episodes for four insulin dependent diabetic residents (#13, #73, #36 and #8) without indications of adequate monitoring by nursing staff, of rechecks of blood sugar levels and/or of the implementation of the facility's protocol or physician notification in a total sample of 32 residents. The failure to identify and report the irregularities resulted in the continuation of inconsistent diabetic management by the nursing staff for those residents which had the likelihood of serious harm to diabetic residents. Findings include: 1. A review of the clinical record and Medication Administration Records (MARs) for resident #13 revealed that the resident had hypo/hyperglycemic episodes nine times in April 2012 and once in May 2012 prior to the consultant pharmacist doing the resident's monthly drug regimen review. The consultant pharmacist reviewed the resident's drug regimen on 4/10/12 and 5/8/12. However, the pharmacist failed to identify and report the failure of nursing staff to monitor the resident during those episodes and to recheck the resident's fingerstick blood sugar levels when his/her readings were less than 60 and greater than 451. See F309 for additional information regarding resident #13. 2. A review of the clinical record and Medication Administration Records (MARs) for resident #73 revealed that the resident had hypo/hyperglycemic episodes on 2/6/12 and 3/10/12 and a hyperglycemic episode on 4/13/12. The consultant pharmacist reviewed the resident's drug regimen on 2/15/12, 3/13/12, 4/11/12, and 5/9/12. However, the pharmacist failed to identify and report the failure of nursing staff to monitor the resident during those episodes and to recheck his/her fingerstick blood sugar levels following blood sugar level readings of less than 60 and greater than 451. See F309 for additional information regarding resident #73 3. A review of the clinical record and Medication Administration Records (MARs) for resident #36 revealed that the resident had hypo/hyperglycemic episodes 15 times in April 2012 and 12 times in May 2012 prior to the consultant pharmacist's drug regimen review. The consultant pharmacist reviewed the resident's drug regimen on 4/11/12 and 5/9/12. However, the pharmacist failed to identify and report nursing staff failure to monitor the resident during those episodes and to recheck fingerstick blood sugar levels following blood sugar level readings of less than 60 and greater than 451. See F309 for additional information regarding resident #36. 4. A review of the clinical record and Medication Administration Records for resident #8 revealed that the resident had hypo/hyperglycemic episodes nine times in April and nine times in May, 2012 prior to the drug regimen review. The consultant pharmacist reviewed the resident's drug regimen on 4/10/12 and 5/08/12. However, the pharmacist failed to identify and report the failure of nursing staff to monitor the resident during those episodes and to recheck fingerstick blood sugar (FSBS) levels following blood sugar level readings recorded at less than 60 or greater than 451. See F309 for additional information regarding resident #8. The immediate and serious threat to resident health and safety was determined to have been removed on 6/08/12 but, the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining fingerstick blood sugar levels as ordered, implementing interventions for hypo/hyperglycemia, monitoring residents, notifying physicians and documenting those actions in the clinical record; reviewing and revising care plans as necessary; monitoring by supervisory nursing staff for the results of fingerstick blood sugar levels and any interventions if needed; notifying physicians promptly about abnormal blood sugar levels as ordered and per facility policy; supervising by supervisory nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; evaluation by the Quality Assurance committee for the implementation and effectiveness of the facility's interventions to ensure that fingerstick blood sugar levels are done as ordered, that interventions are implemented and residents monitored for hypo/hyperglycemia, that episodes of hyper/[DIAGNOSES REDACTED] are communicated to the physicians promptly and that revisions to the plans of care are done as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility conducted a 100% chart audit of all diabetic residents. An audit was conducted to identify all residents with sliding scale insulin orders. Physicians were notified by the facility about any irregular blood sugar levels that occurred outside the parameters established by the facility's protocol that were identified during the audit. Completed 6/7/12. 2. All residents who were identified with irregular blood sugar level findings were reviewed by the pharmacist and recommendations made to the physicians as indicated for optimal diabetic management. Completed 6/8/12. 3. Each resident's diabetic care plan was reviewed and revised as necessary by the facility. Completed 6/7/12. 4. The facility educated all licensed staff (on duty) regarding the facility's diabetic management program and new forms for fingerstick blood sugar level documentation. Fingerstick Blood Sugar and Fingerstick Blood Sugar Follow-up forms were implemented with the Medication Administration Records (MARs) on 6/8/12. Licensed staff not on duty will be educated before being allowed to return to work . 6. The facility implemented a plan on 6/07/12 and clarified for specific day assignments on 6/08/12 for the Director of Nursing (during the week) and RN Supervisor (on weekends) to audit blood sugar level readings daily to ensure compliance for 30 days and weekly thereafter. 7. The Administrator will review the audits and report the information to the QA committee. Implemented 6/8/12. 8. The facility notified the Medical Director of the concerns identified regarding blood sugar management. Completed 6/7/12.

Based on interview with administrative staff, it was determined that the facility failed to maintain a quality assessment and assurance committee that identified a problem with four insulin dependent diabetic residents who had orders for fingerstick blood sugar levels and recurrences of abnormal blood sugar levels with no evidence of physician notification and/or implementation of the facility's protocol and/or rechecks of the blood sugar levels and monitoring of those residents. This failure resulted in the committee not developing and implementing appropriate corrective action plans to prevent recurrences and the likelihood of a serious threat to the health of diabetic residents. Therefore, it was determined that an immediate jeopardy existed on 4/06/12 through 6/07/12 when the facility implemented a plan to remove the jeopardy on 6/08/12. Findings include: During an interview on 6/7/12 at 2 p.m., administrative staff "S" stated that the facility's QA&A committee met quarterly with the Medical Director present. She stated that the interdisciplinary team met weekly without the Medical Director. Administrative staff "S" said that most identification of issues for the QA&A committee to address comes from yearly family satisfaction surveys, the Resident Council meeting minutes and the facility's grievance file. Although she described quality issues that had been identified and action plans implemented, there was no information or evidence that the committee had identified the problem regarding abnormal fingerstick blood sugar levels and the lack of evidence to ensure that physicians were notified, that monitoring was done and/or that the facility's protocol had been implemented for four of eight insulin dependent diabetic residents in the sample. Resident #13 had a hypoglycemic episode and lost consciousness. Therefore, it was determined that an immediate and serious threat of harm existed from 4/6/12 through 6/7/12 when the facility implemented a plan on 6/08/12 to correct the problems and prevent recurrences. See F309 for additional information regarding residents #13, #36, #73 and #8. The immediate and serious threat to resident health and safety was determined to have been removed on 6/08/12 but, the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining fingerstick blood sugar levels as ordered, implementing interventions for hypo/[MEDICAL CONDITION], monitoring residents, notifying physicians and documenting those actions in the clinical record; reviewing and revising care plans as necessary; monitoring by supervisory nursing staff for the results of fingerstick blood sugar levels and any interventions if needed; notifying physicians promptly about abnormal blood sugar levels as ordered and per facility policy; supervising by supervisory nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; evaluation by the Quality Assurance committee for the implementation and effectiveness of the facility's interventions to ensure that fingerstick blood sugar levels are done as ordered, that interventions are implemented and residents monitored for hypo/[MEDICAL CONDITION], that episodes of hyper/[DIAGNOSES REDACTED] are communicated to the physicians promptly and that revisions to the plans of care are done as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility conducted a 100% chart audit of all diabetic residents. An audit was conducted to identify all residents with sliding scale insulin orders. Physicians were notified by the facility about any irregular blood sugar levels that occurred outside the parameters established by the facility's protocol that were identified during the audit. Completed 6/7/12. 2. All residents who were identified with irregular blood sugar level findings were reviewed by the pharmacist and recommendations made to the physicians as indicated for optimal diabetic management. Completed 6/8/12. 3. Each resident's diabetic care plan was reviewed and revised as necessary by the facility. Completed 6/7/12. 4. The facility educated all licensed staff (on duty) regarding the facility's diabetic management program and new forms for fingerstick blood sugar level documentation. Fingerstick Blood Sugar and Fingerstick Blood Sugar Follow-up forms were implemented with the Medication Administration Records (MARs) on 6/8/12. Licensed staff not on duty will be educated before being allowed to return to work . 6. The facility implemented a plan on 6/07/12 and clarified for specific day assignments on 6/08/12 for the Director of Nursing (during the week) and RN Supervisor (on weekends) to audit blood sugar level readings daily to ensure compliance for 30 days and weekly thereafter. 7. The Administrator will review the audits and report the information to the QA committee. Implemented 6/8/12. 8. The facility notified the Medical Director of the concerns identified regarding blood sugar management. Completed 6/7/12.

Based on record review, and interviews with staff and a physician, it was determined that the facility failed to notify physicians about hypo/hyperglycemic episodes of two of four residents (#13, and #36) with blood sugar levels less than 60 and greater then 451 in a sample of eight insulin dependent diabetic residents from a total sample of 32 residents. That failure to notify the physician resulted in continued [DIAGNOSES REDACTED] for resident #13 and a loss of consciousness, and the likelihood of serious harm for the other diabetic residents in the sample. Therefore it was determined that an immediate and serious threat to resident health and safety existed on 4/6/12 through 6/7/12 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: The facility's Diabetic Patient Management Protocol instructed nursing staff that if a resident's blood sugar level was less than 60, give four ounces of juice, non diet cola, eight ounces of skim milk, two ounces of Med Pass or glucose gel. Repeat the blood sugar level check in 15 to 20 minutes as long as resident was alert. If a resident's blood sugar level was less than 60 and the patient was unresponsive, then give [MEDICATION NAME] 1 mg and call the physician. Call EMS if indicated. Notify the physician of resident's blood sugar levels of less than 60 or greater than 450. During an interview on 6/07/12 at 2:15 p.m., registered nurse "M" stated that nursing staff were supposed to follow the specific physicians' orders for a resident regarding when to notify the physician about abnormal blood sugar levels. If the physician did not specify parameters for when to be notified, then licensed nurses were to supposed to follow the facility's policy, which had been approved by all of the physicians. However, the nursing staff failed to consistently notify the physician about blood sugar levels less than 60 and greater than 451 for two insulin dependent diabetic residents (#13, and #36). That failure resulted in continued [DIAGNOSES REDACTED] and loss of consciousness for resident #13 and the likelihood of serious harm for the other diabetic residents in the sample who had repeated hypo/hyperglycemic episodes. 1. Review of resident #13's April and May 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 24 on 4/12/12 at 6:30 a.m.; 21 on 4/13/12 the blood sugar level at 6:30 a.m. and 28 at 4:30 p.m.; 22 on 4/14/12 at 6:30 a.m.; 59 on 4/17/12 at 6:30 a.m. and; 25 on 4/19/12 at 6:30 a.m. and "LO" at 4:30 p.m. However , there was no evidence that nursing staff had followed the facility's diabetic management protocol or notified the physician, and monitored the resident during those hypoglycemic episodes on 4/6/12, 4/13/12 at 4:30 p.m., and 4/19/12. The 4/13/12 nurse's notes documented that the resident's blood sugar level was 34 around breakfast time. The nurse noted that she had given the resident Med Pass supplement and the resident's blood sugar level rose to 45. although the facility's policy was to repeat monitoring the resident's blood sugar level in 15 to 20 minutes, there was no evidence of notification of the physician. According to the 4/13/12 nurses's note, the resident #13 was later taken to lunch and then the CNA summoned the nurse because the resident was unresponsive. The resident was returned to his/her room and a registered nurse gave [MEDICATION NAME] to his/her. After having given [MEDICATION NAME] to the resident, the nurse re-checked the resident's blood sugar level which had risen to 60. According to the facility's for Diabetic Patient Management, nursing staff was supposed to notify the resident's physician if the resident's blood sugar level was below 60 but nursing staff did not notify the resident's physician about the abnormal blood sugar level. During an interview on 6/07/12 at 2:30 p.m., Assistant Director of Nursing (ADON), "C" stated that on 4/13/12 when she noted the resident's blood sugar level was 34 at breakfast time, she gave the Med Pass supplement to the resident and rechecked the resident's blood sugar level which was 45. However, there was no documentation that the physician had been notified about those abnormal low blood sugar levels. During an interview on 6/07/12 at 1:15 p.m., the resident's physician stated that he expected the nurses to call him if a resident's blood sugar level less than 60 and greater than 400 for adjustments to possibly be made to the resident's insulin coverage. He said that he did not remember the nursing staff calling him in April when the resident's blood sugar levels were in the twenties. He stated if somebody had repetitive blood sugar levels in the twenties then that would stick out in his mind. He said that the resident had more of a history of high blood sugar levels than low blood sugar levels. He stated that he would instruct nursing staff to give juice to the resident if the resident was conscious and to recheck the resident's blood sugar level in 30 minutes. He said that if the resident was unconscious then he would order the nurse to give [MEDICATION NAME] and call 911 if needed. The physician said that if nothing was done for a resident with an extremely low blood sugar level then, that resident could possibly slip into unconsciousness and "plummet." See F309 for additional information regarding resident #13. 2. Review of the resident #36's April and May 2012 MARs revealed nursing staff had recorded the following blood sugar levels for him/her: exceeded 450 on 4/1, 4/8, 4/12, 4/16, 4/17, 4/19, 4/21, 4/29, and 4/30/12; 457 at 11:30 a.m. and 521 at 4:30 p.m. on 4/1/12; 999 ( code for a "high" reading on the glucometer) at 11:30 a.m. on 4/8/12; 500 at 11:30 a.m. on 4/12; 492 at 11:30 a.m. on 4/16; 501 at 11:30 a.m. on 4/17; 507 at 11:30 a.m. on 4/19; 493 at 11:30 a.m. on 4/21; 498 at 9 p.m. on 4/29 and; 463 at 11:30 a.m. on 4/30/12. Licensed nursing staff documented that 9 units of [MEDICATION NAME] had been administered as ordered with each reading above 400. However, there was no evidence that the resident's physician was notified of those blood sugar levels. Nursing staff recorded that the resident's blood sugar level was below 60 on 4/1, 4/3, 4/5, 4/6, 4/10, 4/11, 4/14, 4/15, 4/20, 4/22, 4/23/12, and 4/25/12. Nursing staff recorded the resident's blood sugar level was below 60 as follows: 47 at 9 p.m. on 4/1/12; 55 at 9 p.m. on 4/3; 49 at 6:30 a.m. on 4/5; 52 at 6:30 a.m. on 4/6; 44 at 6:30 a.m. at 4/10; 52 at 6:30 a.m. on 4/11; 39 at 9 p.m. on 4/14; 32 at 9 p.m. on 4/15; 34 at 9 p.m. on 4/20; 32 at 9 p.m. on 4/22; 59 at 4:30 p.m. on 4/23 and; 47 at 6:30 a.m. on 4/25/12. However, there was no evidence in the clinical record that licensed nursing staff had notified the physician. Nursing staff recorded that the resident's blood sugar level exceeded 450 on 5/10, 5/12, 5/15, 5/16, 5/18, 5/20, 5/21, 5/22, 5/27 and 5/30/12. Nursing staff recorded the resident's blood sugar levels as follows: 485 at 11:30 a.m. on 5/10/12; 999 (coded for a "high" reading on the glucometer) at 11:30 a.m. on 5/12/12; 455 at 11:30 a.m., 500 at 4:30 p.m. and "999" again at 9 p.m. on 5/15/12; 483 at 9 p.m. on 5/16; 500 at 9 p.m. on 5/18; 457 at 11:30 a.m. on 5/20; 516 at 11:30 a.m. on 5/21; 508 at 11:30 a.m. on 5/22; 471 at 4:30 p.m. on 5/27 and; 523 at 11:30 a.m. on 5/30/12. Licensed nursing staff documented that 9 units of [MEDICATION NAME] was administered to the resident as ordered for blood sugar levels equal to or greater than 400. However, there was no evidence in the clinical record that nursing staff notified his/her physician. The resident's physician stated during an interview on 6/7/12 at 5:20 p.m. that he would have expected licensed nursing staff to notify him when any blood sugar level for a resident was less than 60 or greater than 400. The physician confirmed that he had not been notified when the resident's blood sugar level had been abnormally high or low in April and May. See F309 for additional information regarding resident #36. The immediate and serious threat to resident health and safety was determined to have been removed on 6/08/12 but, the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining fingerstick blood sugar levels as ordered, implementing interventions for hypo/[MEDICAL CONDITION], monitoring residents, notifying physicians and documenting those actions in the clinical record; reviewing and revising care plans as necessary; monitoring by supervisory nursing staff for the results of fingerstick blood sugar levels and any interventions if needed; notifying physicians promptly about abnormal blood sugar levels as ordered and per facility policy; supervising by supervisory nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; evaluation by the Quality Assurance committee for the implementation and effectiveness of the facility's interventions to ensure that fingerstick blood sugar levels are done as ordered, that interventions are implemented and residents monitored for hypo/[MEDICAL CONDITION], that episodes of hyper/[DIAGNOSES REDACTED] are communicated to the physicians promptly and that revisions to the plans of care are done as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'J' to an 'D' level when the facility implemented the following plan of correction: 1. The facility conducted a 100% chart audit of all diabetic residents. An audit was conducted to identify all residents with sliding scale insulin orders. Physicians were notified by the facility about any irregular blood sugar levels that occurred outside the parameters established by the facility's protocol that were identified during the audit. Completed 6/07/12. 2. All residents who were identified with irregular blood sugar level findings were reviewed by the pharmacist and recommendations made to the physicians as indicated for optimal diabetic management. Completed 6/08/12. 3. Each resident's diabetic care plan was reviewed and revised as necessary by the facility. Completed 6/07/12. 4. The facility educated all licensed staff (on duty) regarding the facility's diabetic management program and new forms for fingerstick blood sugar level documentation. Fingerstick Blood Sugar and Fingerstick Blood Sugar Follow-up forms were implemented with the Medication Administration Records (MARs) on 6/08/12. Licensed staff not on duty will be educated before being allowed to return to work . 6. The facility implemented a plan on 6/07/12 and clarified for specific day assignments on 6/08/12 for the Director of Nursing (during the week) and RN Supervisor (on weekends) to audit blood sugar level readings daily to ensure compliance for 30 days and weekly thereafter. 7. The Administrator will review the audits and report the information to the QA committee. Implemented 6/08/12. 8. The facility notified the Medical Director of the concerns identified regarding blood sugar management. Completed 6/07/12.

Based on record reviews, and staff and physician interviews, it was determined that the facility failed to implement care plan interventions for three insulin dependent diabetic residents (#13, #36, and #8) in a sample of eight insulin dependent diabetic residents, who experienced hypo/hyperglycemic episodes (blood sugar levels less than 60 and greater than 450), from a total sample of 32 residents. The failure to implement planned interventions resulted in a continuing hypoglycemic episode and loss of consciousness for resident #13 and the likelihood of serious harm for the other insulin dependent diabetic residents in the sample. Findings include: 1. Resident #13 had a care plan dated 4/03/12 to address the resident's risk for hypo/[MEDICAL CONDITION] related to the [DIAGNOSES REDACTED]. There were interventions for nursing staff to administer medications as ordered; to perform accu-checks as ordered; to observe for signs and symptoms of [DIAGNOSES REDACTED] such as shaking, sweating, anxiousness,dizziness,increased hunger, headache, weakness and impaired vision; to observe for signs and symptoms of [MEDICAL CONDITION] such as increased thirst, frequent urination, dry skin, drowsiness, nausea, and increased hunger; to obtain lab work as ordered and; to report to the physician as indicated/ordered. However, nursing staff failed to consistently implement planned interventions when the resident's blood sugar levels were less than 60 and more than 451 nine times in April and two times in May, 2012. On 4/13/12, the resident had [DIAGNOSES REDACTED] with a blood sugar level of 34. Although nursing staff gave the resident Med Pass supplement, a blood sugar level of 45 (continued [DIAGNOSES REDACTED]) was recorded on the recheck. There was no evidence of any interventions implemented or monitoring of the resident's status done prior to the resident having been taken to lunch where the resident became unresponsive. See F309 for additional information regarding resident #13. 2. Resident #36 had [DIAGNOSES REDACTED]. There was a care plan since 12/20/11 to address the resident's insulin dependent diabetic status with a need to maintain balance between food intake and insulin intake. There were interventions that included nursing staff to administer medications and obtain blood sugar levels as ordered. The resident also had a plan since 12/20/11 to address the need for a therapeutic diet due to the [DIAGNOSES REDACTED]. However, nursing staff failed to consistently implement planned interventions when the resident's blood sugar levels were less than 60 and more than 451 for 18 times in April and 12 times in May, 2012. There was no evidence that facility staff consistently monitored the resident or that the physician was notified as planned when the resident had hypo/hyperglycemic episodes on those days. See F309 for additional information regarding resident #36. 3. Resident #8 had a [DIAGNOSES REDACTED]. There was a care plan problem (reprinted on 5/22/12) to address the resident's IDDM and "need to maintain a balance between food intake and insulin intake/noncompliant with therapeutic regimens at times". There were interventions for nursing staff to give medications as ordered, to obtain fingerstick blood sugar levels (FSBS) and sliding scale insulin as ordered, to monitor for signs and symptoms of hypo/[MEDICAL CONDITION], to check the FSBS as needed for symptoms or resident complaints, and if hypoglycemic, to stay with the resident to ensure safety until the resident's blood sugar level stabilized. However, nursing staff failed to consistently implement planned interventions when the resident's blood sugar levels were less than 60 and more than 451 for 12 times in April and 13 times in May, 2012. There was no evidence that the nursing staff consistently rechecked FSBS levels, monitored the resident and stayed with the resident during hypoglycemic episodes as planned. See F309 for additional information regarding resident #8. The immediate and serious threat to resident health and safety was determined to have been removed on 6/08/12 but, the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining fingerstick blood sugar levels as ordered, implementing interventions for hypo/[MEDICAL CONDITION], monitoring residents, notifying physicians and documenting those actions in the clinical record; reviewing and revising care plans as necessary; monitoring by supervisory nursing staff for the results of fingerstick blood sugar levels and any interventions if needed; notifying physicians promptly about abnormal blood sugar levels as ordered and per facility policy; supervising by supervisory nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; evaluation by the Quality Assurance committee for the implementation and effectiveness of the facility's interventions to ensure that fingerstick blood sugar levels are done as ordered, that interventions are implemented and residents monitored for hypo/[MEDICAL CONDITION], that episodes of hyper/[DIAGNOSES REDACTED] are communicated to the physicians promptly and that revisions to the plans of care are done as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'J' to a 'D' level when the facility implemented the following plan of correction: 1. The facility conducted a 100% chart audit of all diabetic residents. An audit was conducted to identify all residents with sliding scale insulin orders. Physicians were notified by the facility about any irregular blood sugar levels that occurred outside the parameters established by the facility's protocol that were identified during the audit. Completed 6/07/12. 2. All residents who were identified with irregular blood sugar level findings were reviewed by the pharmacist and recommendations made to the physicians as indicated for optimal diabetic management. Completed 6/08/12. 3. Each resident's diabetic care plan was reviewed and revised as necessary by the facility. Completed 6/07/12. 4. The facility educated all licensed staff (on duty) regarding the facility's diabetic management program and new forms for fingerstick blood sugar level documentation. Fingerstick Blood Sugar and Fingerstick Blood Sugar Follow-up forms were implemented with the Medication Administration Records (MARs) on 6/08/12. Licensed staff not on duty will be educated before being allowed to return to work . 6. The facility implemented a plan on 6/07/12 and clarified for specific day assignments on 6/08/12 for the Director of Nursing (during the week) and RN Supervisor (on weekends) to audit blood sugar level readings daily to ensure compliance for 30 days and weekly thereafter. 7. The Administrator will review the audits and report the information to the QA committee. Implemented 6/08/12. 8. The facility notified the Medical Director of the concerns identified regarding blood sugar management. Completed 6/07/12.