Every finding on record at Corinth Rehabilitation Suites on the Parkway

Based on observation, interview and record review, the facility failed to provide a resident or family group with private space for residents monthly council meeting for 11 of 11 confidential residents reviewed for resident council. The facility failed to ensure residents were provided a private space for resident council meetings without being interrupted or disturbed by staff or visitors who were not invited to participate. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings Included: During a confidential resident group interview at an undisclosed date and time, held in the activity room, 11 residents stated the resident council meeting was always held in the Activity Room. The residents stated they did not have a private room since some of the offices were attached to the Activity Room, including the Activity Director, Salon, Social Worker, and Staffing Coordinator. Two residents stated during resident council meetings were frequently interrupted by staff walking through to an office or additional residents coming in late. The residents explained that the Activity Director attended their Resident Council Meetings and was aware of the interruptions. Observations made during confidential resident group interview at an undisclosed time and date revealed the Director of Maintenance walked in from an outside door and through the activity room, the hairstylist walked out of the salon on two occasions and then walked back in a third time with a family member talking very loudly. The door to be shut to the salon in order to conduct the confidential resident group interview. One resident's wife came and got him out of the meeting for a visit, an additional resident joined the meeting late. the Activity Director left her office and walked through the Activity Room during the meeting. Observation on 07/28/2026 at 2:10 PM revealed there was no sign on the outside of the Activity Room to indicate a meeting was in progress and not to disturb. During an interview on 07/28/2026 at 2:10 PM, the Activity Director stated resident council meetings were held monthly in the Activity Room. The Activity Director stated when the meetings occurred the salon was not open and the Social Worker was new to the facility and that office had been previously unoccupied, so no distractions. The Activity Director stated there were times when people came into the Activity Room or residents came late to the meeting. The Activity Director stated she normally posted a sign on the door letting everyone know not to interrupt and she did not post a meeting on this date. The Activity Director stated having interruptions during the Resident Council Meeting could cause there to be concerns of the residents not having a private meeting which could cause them to feel they could not speak freely about their concerns. During an interview on 07/29/2026 at 10:45 AM, the Administrator said the Resident Council Meetings should be held monthly and should be held where there is privacy allowing the residents to be able to voice concerns and feel safe to speak. He said minutes should be taken at the meeting, of any grievances should be made regarding any concerns that came from the meeting, and the information was to be shared at the morning meeting. The Administrator said he was not aware the Resident Council Meeting routinely experienced interruptions. Review of Activity Policies and Procedures dated 11/04/2024 revealed SUBJECT: PATIENT/RESIDENT COUNCIL OR GROUP POLICY: The Facility will ensure a Resident Council or Group is organized and facilitated, upon request and residents of the Facility.PROCEDURES: .2. If a Resident Council or Group is requested, the Activity/Recreation Department will arrange a private meeting space.

Based on observation, interviews and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed. -Out of 100 windows across the front of the facility 26 window screens were frayed, torn, cut, or had holes.-Six windows across the front of the facility, looking out of the vestibule to the [NAME]-cochere were foggy making it difficult to see out.-room [ROOM NUMBER] had a dirty/foggy window.-Ten glass doors leading to the outside of the facility, throughout the facility were foggy making it difficult to see out. This failure could place residents at risk of living in an uncomfortable environment and diminished quality of life.Findings included: During a confidential resident group interview with 11 residents from 1:30 PM to 2:10 PM on 07/28/2026 revealed one of the residents stated the facility had many windows and doors which were foggy and cloudy causing them to be difficult to see out. The resident explained that being in the facility 24 hours per day 7 days a week was not like home and as a person who likes to look outside the foggy glass caused them to be depressed. The resident stated they understood it may be expensive to fix but it would make the facility not look bad. The resident stated they love to look outside when they can't be outside. Observations on 07/29/2026 from 12:20 PM to 12:30 PM revealed the following:-the Human Resource/Payroll (per the Floor Plan) was noted to have a bent screen frame.-room [ROOM NUMBER] had a hole in one of the two screens.-room [ROOM NUMBER] had two window screens that were frayed and torn about 2-4 inches from the bottom, leaving open space.-room [ROOM NUMBER] had a hole in one of the two screens. -room [ROOM NUMBER] had a bent-up screen frame on one of the two screens.-room [ROOM NUMBER]A had a hole in the corner of one of the two screens.-Therapy Room had three sets of two windows on the front of the building that had screens that were frayed and torn 2-4 inches of area on the bottoms of the screens.-room [ROOM NUMBER] had two window screens that were frayed and torn about 2-4 inches from the bottom, leaving open space.-room [ROOM NUMBER] had two window screens that were frayed and torn about 2-4 inches from the bottom, leaving open space.-400 Hall Dining room had 12 windows. Four of six windows on the front of the building for frayed and one had a square cut out of the middle of the screen. Two of the windows on the side of the building had holes in the screens.-room [ROOM NUMBER] had holes in the two screens. Observations on 07/29/2026 from 12:31 PM to 12: 45 PM revealed the following:-Therapy Gym had one door leading to the outside that was noted to be foggy.-Door outside of MDS office leading to the outside was noted to be foggy.-Door at the end of 400 hall leading to the outside was noted to be foggy.-400 Hall Dayroom had one door leading to the outside was noted to be foggy.-Door at the end of 300 hall leading to the outside was noted to be foggy.-300 Hall Activities Dayroom had two doors that lead outside. Both were noted to be foggy.-Main Dining Room had two doors that lead outside. Both were noted to be foggy.-room [ROOM NUMBER] room was difficult to see out. The window appeared to be dirty on the outside and appeared to be foggy and difficult to see out. During observations on 07/29/2025 at 12:40 PM, the Rehabilitation Director stopped Surveyor and stated oh there is a resident who has expressed concerns during therapy about the condition of the windows being dirty and hard to see out. During an interview on 07/29/2026 at 12:54 PM, the Activity Director stated during one of the resident council meetings one of the residents' expressed concerns about the windows/doors being dirty and difficult to see out. The Activity Director stated she reported the concern in the stand-up meeting to either Housekeeping or Maintenance. During an interview on 07/29/2026 at 12:56 PM, the Housekeeping Director stated she received a report from the Resident Council Meeting regarding the windows being dirty. The Housekeeping Director stated the housekeepers cleaned the windows on the inside, but she was not sure who cleaned the outside of the building. During an interview on 07/29/2026 at 1:03 PM, the Director of Maintenance stated the facility had double paned windows. He stated the seal had broken down causing them to be foggy. The Director of Maintenance stated there was no way to clean the windows. He said the facility would have to have the door company remove the glass, replace the glass, and reseal the windows. The Director of Maintenance stated he had noticed the torn and frayed window screen. The Director of Maintenance stated he had just started the process of getting bids to replace some of the screens, but he did not have any current bids for review. The Director of Maintenance stated the frayed, damaged screens could cause bugs to get in the building if a resident wanted their window open. During an interview on 07/29/2026 at 1:35 PM, the Administrator stated she had been informed by another staff member about the screens being damaged and foggy windows/doors. The Administrator stated the screens on the doors were to keep the residents safe and keep bugs out of the facility. The Administrator stated the windows/doors being foggy caused the residents to have difficulty seeing outside and not being able to ensure the bird feeds, and bird baths. The Administrator stated it diminishes the homelike environment. Review of Maintenance/Housekeeping Policies and Procedures, undated, revealed .Windows: Check windows for cracks, fogging and damaged caulking and repair, as necessary. Operate window. Ensure that limiters are in place as required. Replace damaged window screens. Lock window when finished.

Based on interview and record review, the facility failed to obtain from hospice the most recent plan of care specific to each patient, hospice election form, physician certification of the terminal illness specific to each resident, hospice physician orders specific to each resident and the hospice medication information specific to each patient for two (Residents #22 and # 82) of three residents reviewed for hospice services. 1. The facility failed to obtain Resident #22's most recent hospice plan of care, hospice election form, physician certification of the terminal illness, hospice physician orders, and the hospice medication information from Hospice Agency H. 2. The facility failed to obtain Resident #82's current hospice election form, physician certification of the terminal illness and a current Hospice plan of care from Hospice Agency M. These failures could result in residents' services and treatments not being coordinated and those services not being provided as needed.Findings included: 1. Review of Resident #22's Face Sheet, dated 07/28/26, reflected an [AGE] year-old-male with an admission date of 06/21/24. Record review of Resident #22's MDS Significant Change assessment dated [DATE] reflected a BIMs of 1 which indicated he was severely cognitively impaired. He was dependent for all ADLs and was receiving hospice services. Diagnoses included heart failure and infection and inflammation to a cardiac and vascular device (pacemaker-helps regulate heart rate) Review of Resident #22's Order Summary Report as of 07/28/26, reflected, Refer to [Hospice Agency H] to evaluate and treat as indicated, with a start date of 07/01/26 Review of Resident #22's hospice binder from Hospice Agency H revealed no hospice election form, no current physician plan of care, no physician certification of terminal illness, and no hospice aide care plan. Record review of Resident #22's Electronic record reflected no hospice election form, no current physician plan of care, no physician certification of terminal illness, and no hospice aide care plan. During an interview on 07/28/26 at 10:55 a.m., Resident #22's Responsible Party stated she had asked for the hospice aides to come in at least 3x weeks. She stated she was not sure if they were coming or not. During an interview on 07/28/2026 at 12:50 p.m. with the Social Woker she stated she had been in her role for 3 weeks. She stated she was responsible for the grievances. She stated she had not spoken with Resident #22 spouse about any concerns about his hospice services but stated she would reach out and follow up with her. During an interview on 07/28/26 at 1:00 p.m., RN K stated she would see hospice staff in the building every day except weekends and she was not sure how often the hospice aides were coming to see Resident #22. During an interview on 07/28/26 at 2:45 p.m., Hospice RN D stated she had just brought in all of the hospice documents. She stated she thought she brought the hospice documents in when they admitted Resident #22 on 07/02/26 and had no idea what had happened to them. She stated she was not sure who the hospice coordinator was in the facility. She stated they were not always notified when there was treatment changes. She stated she comes 1 x week, and another nurse comes 1 x week, and the aide come 5 x week. She stated she had spoken with the Responsible Party and communicated the care plan with them. During an interview on 07/29/26 at 8:30 a.m., ADON A stated they communicate with staff on the 24-hour report and the hospice agency should be listed on the report. She stated the hospice aids are supposed to let the charge nurse know when they are here and report any concerns before leaving the facility. She stated she was not sure if that was happening or not. She stated they were informed yesterday (07/28/26) that the Social Worker would be the hospice coordinator going forward and they would be meeting with each hospice agency to communicate the process. 2. Record review of Resident #82's Face Sheet dated 07/28/26 revealed Resident #82 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #82 was diagnosed with Chronic Pain (pain lasting longer than 3 to 12 months, frequently associated with arthritis, back problems, and nerve damage), and Severe Dementia with Anxiety (final stage of cognitive decline with constant sense of worry). Record review of Care Plan for #82 dated 07/25/26 revealed Baseline Care Plan OBJECTIVE: [Resident #82] is a new admission. He admitted from home for respite care. Record review revealed there was not an MDS Assessment completed due to the length of time Resident #82 had been in the facility. The MDS Assessment was not due. Record review of Physician's Orders for Resident #82 dated July 2026 revealed there was a physician's order for hospice services through [Hospice Agency M]. Record review of Medication Administration Record for Resident #82 dated July 2026 revealed there was a physician's order for Notify [Hospice Agency M] if ineffective pain regime or difficulty breathing start date was 07/26/26. Record Review of Hospice Service Agreement for Resident #82 dated 07/28/26 revealed an agreement was signed between the facility and facility on 07/28/26. During an interview on 07/28/26 at 10:40 a.m. Resident #82's family members revealed Resident #82 had a change in condition on 07/26/26 when he stopped communicating and lost the ability to swallow his pills. The family members stated the hospice nurse came and gave the facility comfort care physician orders to address pain. The family members expressed concern that they had called the hospice company 7 times on 07/27/2026 and were not able to get anywhere with updating the schedule for pain medications. The family members expressed concern that Resident #82 was restless and not calm. During an interview on 07/28/26 at 10:45 a.m. with ADON A revealed [Hospice Agency M] had not left a hospice binder. There was no paperwork for Resident #82 on how to contact the hospice company, no care plan to coordinate care between the facility and hospice or the certification of terminal illness. ADON A stated she had called [Hospice Agency M] in order to update the medication regime. During an interview on 07/28/26 at 11:08 a.m., the Admissions Coordinator revealed she worked on the admission for Resident #82. She stated Resident #82 was admitted from home and Hospice Agency M was covering a 5-day respite stay. She said Resident #82 was now private pay as his condition did not deteriorate as quickly as expected. The Admissions Coordinator stated she worked directly with Hospice Agency M to get pre-admission paperwork for Resident #82. She said the pre-admission paperwork was uploaded into the electronic health record. The Admissions Coordinator said she did not know if the paperwork included a care plan or a certification of terminal illness. The Admissions Coordinator reviewed the uploaded paperwork and stated that Hospice Agency M sent case notes and a medication list. During an interview on 07/28/26 at 2:37 PM, ADON A revealed she spoke with the Social Worker for Hospice Agency M and was told the hospice did not provide a hospice binder including the care plan or certification of terminal illness when a resident was admitted under respite care. She said the hospice binder and information would be brought to the facility now that Resident #82 was private pay. During an interview on 07/28/26 at 3:18 p.m., the Interim DON stated he was not aware if the nurse, family, or ADON were working on getting information from Hospice Agency M regarding the coordination of care between the facility and the hospice. During an interview on 07/29/26 at 1:20 p.m., the Social Worker stated she was informed on 07/28/26 she would be responsible for ensuring the hospice documentation was present and incorporated into the resident's clinical record and the comprehensive care plan. She stated she would be coordinating any equipment's needs, set up monthly care plan meetings with the hospice agencies, and make sure the contact information was on the record which should improve the overall quality of care provided to the residents who were receiving hospice services. During an interview on 07/29/26 at 3:05 p.m., the Interim DON revealed it was important for there to be coordination of care between the facility and hospice to ensure timely and accurate treatment for the residents. He stated failing to coordinate the plan of care could cause delays in activities of daily living also because neither party would know who was to complete what task. The Interim DON stated that regardless of if the resident was admitted to the facility for respite care or long-term care, the Hospice plan of care of was needed as well as the certification of terminal illness, hospice medication list, and hospice physician orders. During an interview on 07/29/26 at 3:49 p.m., the Administrator stated she and the Interdisciplinary team were going to be focusing on having individual meetings with the hospice companies to ensure there was continuity of care for residents. The Administrator stated the importance of the coordination of care and even if a resident came in under respite care the facility needed the same information to ensure the residents were cared for appropriately. The Administrator stated moving forward the Social Worker would coordinate care with the hospice companies to ensure there was a clear line of communication. She stated If a resident came in for respite care, she would expect all needed information like the plan of care and certification of terminal illness would be in the facility at the time of admission if not before. The Administrator stated the plan of care was used to paint a picture for the care that was to be provided to the residents by both the hospice company and facility. Review of the facility's policy, Hospice Care, dated May 2023, reflected, . To provide continuity of care, the hospice, nursing home, and resident/representative must collaborate in the development of a coordinated care plan which includes, but is not limited to, the following:A. Resident/representative choices regarding care.B. The hospice philosophy of care and all services necessary for the palliation andmanagement of terminal illness and related conditions.C. Measurable goals and interventions based on comprehensive and ongoingassessments.D. Interventions that address, as appropriate, the identification of timely, pertinent nonpharmacologic and pharmacological interventions to manage pain and other symptoms of discomfort.E. The hospice portion that governs the actions of the hospice and describes theservices that are needed to care for the resident;F. Identification of the services the nursing home will continue to provide; andG. The identification of the provider responsible for performing specificservices/functions that have been agreed upon.5. The Facility will designate in the resident's medical record the name and number of the hospice provider and update the care plan to reflect on the medications and services which will be provided by the hospice service.To address communication regarding the resident's care between the nursing home and the hospice, the nursing facility will designate a staff person to participate in the ongoing communication and include the resident representative in decision-making. The nursing facility will provide the name of the designated staff member/or designee to the resident/representative for ongoing communication regarding care or concerns.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #75, Resident #10, and Resident #25) of eight residents reviewed for infection control. 1. The facility failed to ensure LVN E set up a clean field for the glucometer and testing supplies during the fingerstick blood sugar for Resident # 75; failed to perform hand hygiene after obtaining a fingerstick blood sugar for Resident #75; and failed to adequately disinfect the glucometer and bottle of test strips after the completion of the fingerstick blood sugar for Resident #75 on 07/28/26. 2. The facility failed to ensure RN A C removed her gloves, sanitized the blood pressure cuff after taking Resident # 10's blood pressure and then failed to ensure she prepared Resident #10's medication without cross contaminating the medications when she popped the medications directly into her gloved hand on 07/27/26. 3. The facility failed to ensure Agency CNA F performed hand hygiene during incontinence care for Resident #10 on 07/29/26. 4. The facility failed to ensure Resident #25's urinary drainage tubing was kept from touching the floor while up in her wheelchair on 07/27/26 and 07/28/26. These failures could place residents at risk for infection and cross contamination.Findings included: 1. Record review of Resident #75's, Face sheet, dated 07/28/26 reflected a [AGE] year-old female with an admission date of 04/24/26. Resident #75 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). During an observation on 07/28/26 at 12:00 p.m. LVN E was at the medication cart preparing supplies to obtain Resident #75's fingerstick blood sugar. LVN E put on gloves without performing hand hygiene, pulled a glucometer from the top of the medication cart, lancets, a bottle of test strips, alcohol wipes and a gauze pad and entered Resident #75's room to check her blood sugar. LVN E place the glucometer, the bottle of test strips and remaining supplies on the residents over the bed table without cleaning the table or placing a barrier down for the supplies. LVN E then opened the test strips and pulled one from the bottle and placed it into the glucometer. She then wiped the residents' finger with an alcohol pad and laid the used alcohol pad on the overbed table. She then pricked the resident's finger and wiped the first drop of blood with the gauze pad and laid the used lancet and gauze pad on the overbed table. LVN E then picked up the glucometer and obtained a blood sugar reading of 185. LVN E gathered the lancet, test strips, gauze, and alcohol pad and disposed of them in the sharp's container by the resident's door. LVN E then removed her gloves, picked up the glucometer and bottle of test strips and while in route to the medication cart, dropped the bottle of test strips on the floor. LVN E picked up the bottle, placed it and the dirty glucometer on top of the medication cart and without performing hand hygiene, opened the drawer of the medication cart and retrieved a bottle of Sani cloth disinfectant that had a disinfectant time of 2 minutes. She put on gloves and wiped the glucometer and then wiped the bottle of strips with the same Sani-cloth wipe and immediately placed both back in the top of medication cart. LVN E then removed her gloves and without performing hand hygiene retrieved the resident's insulin pen, dialed in 2 units. LVN E then put on gloves without performing hand hygiene, entered Resident #75's room and administered the insulin. LVN E returned to medication cart, removed her gloves and without performing hand hygiene placed the insulin pen back in the top of the medication cart. During an interview 07/28/26 at 12:10 p.m. LVN E stated she was supposed to perform hand hygiene every time she changed her gloves and stated she realized she had failed to do that. She stated she knew she was supposed to disinfect the glucometer between each resident use but stated she was not sure what the contact time was for the germicidal wipe she had used. LVN E retrieved the germicidal wipe and verified the contact time for disinfecting was 2 minutes. She stated she had not waited for the full amount of time needed to ensure the glucometer was properly disinfected. She stated she should not have carried the whole bottle of test strips into the room and was not aware she needed to set up a barrier for her supplies. She stated the risk of these failures was the spread of infections and blood borne pathogens. 2. Record review of Resident #10's face sheet, dated 07/28/26, reflected a [AGE] year-old female with an admission date of 06/05/26.Record review of Resident #10's 5-day MDS Assessment, dated 06/22/26, reflected she had BIMS score of 14, which indicated she was cognitively intact. Diagnoses included dysphagia (swallowing difficulties) and cerebrovascular accident (stroke). Resident #10 received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach).During a medication observation and interview on 07/28/26 at 7:13 p.m. revealed RN C at the medication cart in front of Resident #10's room. RN C put on a gown and gloves, opened the medication cart and pulled out a blood pressure cuff and entered Resident #10's room and checked her blood pressure. RN C returned to the medication cart, still wearing gown and gloves and opened the medication cart and placed the blood pressure cuff back in the cart without sanitizing it first. RN C then opened the Medication Profile for Resident #10 and pulled blister packs of metformin 500 mg, methocarbamol 750 mg tablet, apixaban 5 mg tablet, carvedilol 6.25 mg tablet and popped the pills in her gloved hand. After the first 4 pills, RN C could not locate the resident's Atorvastatin. She stated the blister pack was empty. She stated she was going to check the other cart to see if it was placed on the wrong cart. RN C then removed her gown and gloves, performed hand hygiene and went to the nurse's station, opened up the other medication cart, and looked through the cart. RN C then returned with a medication cup containing 1 pill of Atorvastatin and then retrieved a bottle of phenytoin 125 mg/5 ml, poured the required amount of medication, and crushed the pills in preparation for the mediation administration. RN C then entered Resident #10's room with the medications, performed hand hygiene, put on gown and gloves, and administered the medications through the resident's g-tube. During an interview on 07/27/26 at 7:45 p.m. with RN C she stated she did not realize she had not removed her gloves and performed hand hygiene before she started pulling the medications. She stated she should have sanitized the blood pressure cuff before returning it to the medication cart. She stated she was not aware she could not punch the pills into her gloved hand. She stated failing to follow the infection control protocols could place residents at risk of transmission of germs. 3. During an observation on 07/29/26 at 09:50 a.m. Agency CNA F and CNA G entered Resident #10's room to provide incontinence care. Both staff performed hand hygiene and put on gloves and gowns and unfastened the residents' brief. Agency CNA F wiped front to back changing the wipes with each wipe. Both staff then rolled resident onto her side. Agency CNA F then wiped front to back, cleaning moderate amount of bowel movement. Agency CNA F then placed clean brief under the resident without changing gloves or performing hand hygiene. Agency CNA F then stated she forgot the barrier cream. Agency CNA F removed her gloves and without performing hand hygiene searched through the residents' chest of drawers and retrieved the barrier cream. Agency CNA F put on gloves without performing hand hygiene and applied the barrier cream to the resident's inner thighs and groin area. Agency CNA F and CNA G then assisted with rolling resident back onto her back without first changing her gloves and performing hand hygiene. Both staff adjusted the brief, the sheets, repositioned her in bed all while Agency CNA F was wearing the gloves used to apply the barrier cream. After completion of care both staff removed gloves and gowns and performed hand hygiene. During an interview on 07/29/26 at 09:50 a.m. Agency CNA F stated they were to do hand hygiene before care and after. Agency CNA F then stated she should have performed hand hygiene when they went from dirty to clean. She stated not doing hand hygiene properly could spread infection. 4. Record review of Resident Face Sheet for Resident #25 dated 07/29/26 revealed Resident #25 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 was diagnosed with Wedge Compression Fracture of Fourth Thoracic Vertebra (a collapse of the front part of the upper-mid back bone into a wedge shape, commonly caused by osteoporosis or physical trauma), Obstructive and Reflux Uropathy (a condition where blocked urine flow causes a backward pressure surge, forcing urine to reflux into the kidneys and leading to swelling, tissue injury, and potential kidney failure), and Chronic Kidney Disease (a long-term condition where the kidneys slowly lose their ability to filter blood and waste). Record review of MDS Assessment for Resident #25 dated 07/14/26 revealed Resident #25 scored a 08 on the Brief Interview for Mental Status (BIMS) indicating Resident #25 had moderate cognitive impairment. Under Section H for Bladder and Bowel Resident #25 was noted to have an indwelling catheter. Observation on 07/27/26 at 6:43 p.m. revealed Resident #25 sitting up in her wheelchair completing a word find puzzle. Resident #25 was observed to have a catheter bag hanging under her wheelchair. Resident #25's catheter bag and tubing were sitting directly on the floor. Sediment was observed in the tubing. Observation on 07/28/26 at 9:29 a.m. revealed Resident #25 sitting up in her wheelchair in front of a table putting together a puzzle. Resident #25's catheter bag was hung under her wheelchair, touching the floor. Observation on 07/28/26 at 12:42 p.m. revealed Resident #25 sitting up in her wheelchair having lunch in the dining room. Resident #25's catheter bag was hung under her wheelchair, touching the floor. During an interview on 07/28/2026 at 4:27 p.m., RN K stated catheter bags should be hung underneath a wheelchair but not touching the floor. RN K stated there would be concern of the catheter tubing or catheter bag being punctured and touching the ground could introduce bacteria into the urinary tract. RN K stated she made rounds and checked on catheters. RN K stated she had looked at Resident #25's catheter during the shift but stated she had not observed it directly touching the floor. Observation on 07/28/2026 at 4:29 p.m. with RN K revealed Resident #25's catheter bag under her wheelchair and touching the floor. RN K then began to adjust the back and tubing to position off of the floor. During an interview with ADON B on 07/29/26 at 10:40 a.m. she stated she was the infection preventionist for the facility. She stated she had done numerous trainings with the staff on hand hygiene, enhanced barrier precautions, and they performed skills checks with the staff upon hire and anytime they witness deficient practice. She stated agency staff was provided with an orientation packet which included the facilities protocols for infection control. She stated hand hygiene was expected to be performed any time the staff changed their gloves. She stated staff was to clean the surface of the table and place a barrier down for any type of supplies to be used on the residents, test strips, wound care, etc. She stated staff were to sanitize the blood pressure cuff after each resident use, and staff were never to touch a resident's medications with their hands. She stated glove changes and hand hygiene were required when going from dirty to clean during incontinent care. ADON B stated catheter bags were to be hung on wheelchairs ensuring the catheter bag and catheter tubing were not touching the floor. ADON B stated if the catheter bag or tubing was on the floor it could cause an infection like a urinary tract infection. She stated all of the infection control procedures were to prevent infections and the spread of germs and blood borne pathogens. During an interview with the Interim DON on 07/29/26 at 2:40 p.m. he stated the staff should be trained on the proper sanitizing of glucometers and when to perform hand hygiene during glucose monitoring upon hire and during skills checks. He stated the staff were to use the EPA approved Sani-wipes to clean the glucometers and ensure they were to wait at the required contact time to ensure the glucometer was disinfected. He stated staff were to always perform hand hygiene after any procedure, before moving to the next procedure. He stated staff were never to touch a resident's medications with gloved hands or bare hands. He stated the risk of not following the proper procedures were cross contamination and potential for the spread of blood borne pathogens. He stated staff were to change their gloves and perform hand hygiene after they performed incontinence care and before applying the clean brief and always before going from dirty to clean. He stated by not following proper hand hygiene it placed residents at risk of urinary tract infections. He stated he and the ADONs would continue to train and make rounds to ensure the staff were following the correct procedures. Record review of the facility's policy titled, Hand Hygiene/Hand Washing, dated May 2023, reflected, .Hand Hygiene/Hand washing is the most important component for preventing the spread of infection.Hand Hygiene/hand washing is done: .Before patient/resident contact.After.contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.After patient/resident contact.After removal of medical/surgical or utility gloves.Contact with patient's/resident's intact skin (e.g. taking a pulse or blood pressure.). Record review of the facility's policy titled, Medication Management Program, dated January 2005, reflected, The Facility implements a Medication Management program to meet the pharmaceutical need of patients and residents, according to established standards of practice and regulatory requirements.Stethoscope and blood pressure cuff are.cleaned after each use. Administering the Medication Pass.Perform hand hygiene. Do not touch the medication when opening a bottle or unit dose package.If a medication which is not in a protective container is dropped, it should be discarded according to policy. Record review of the facility's policy titled, Disinfection of Patient/Resident Care Equipment: Blood Glucose Meters, dated May 2023, reflected, .Blood glucose meters and point of care testing devices are at high risk of becoming contaminated with bloodborne pathogens.The facility uses a two-step cleaning and disinfecting procedure between every patient/resident use.Use an EPA disinfectant wipe.to remove any visible contaminants, soil or other debris.Use a second EPA wipe disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.Contact time is the total time needed for the disinfectant solution to remain wet on the surface to achieve disinfection of all the stated efficacy kill claims. The contact time requirements can be located on the product label. Record review of the facilities undated policy titled, Indwelling Urinary Catheter Care and Removal, revealed .Keep the catheter drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases risk of CAUTI [catheter-associated urinary tract infection]. Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI.

Based on, interview and record review the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider for two of four residents (Resident #1 and Resident #78) reviewed for discharge. 1. The facility failed to ensure discharge summary was completed for Resident #1's discharge on [DATE]. 2. The facility failed to document reason for transfer to hospital for Resident #78's, notify physician of resident going to the hospital and give report to receiving hospital on [DATE] for Resident #78. This failure could place residents at risk of discharge services being uncoordinated at time of discharge, not receiving the proper treatment at the hospital and continuity of care issues.Findings included: 1. Record review of Resident Progress Notes for Resident #1 dated 07/08/26 revealed Resident discharged home with meds [medications] and belongings. Family here to p/u [pick up] AOX3 [alert and oriented to person, place, and time. 0 distress 0 discomfort. Record review of Resident #1 electronic record revealed no discharge summary was completed. Record review of Functional Assessment for Resident #1 dated 07/08/26 revealed Resident #1 was planned to discharge on [DATE] home with her son. Resident #1 was noted to be independent with activities of daily activities and had finished her antibiotic prior to discharge. During an interview on 07/29/26 at 9:09 a.m., the Social Worker revealed as the Social Worker she was responsible for issuing the Notice of Medicare Non-Coverage (NOMNC) but if she was unavailable then the Rehab Director or Business Office Manager (BOM) would assist. She stated the signed NOMNC would be uploaded into documents in the electronic health record. The Social Worker stated her first day was 07/08/26 so she was not aware of Resident #1 and her discharge. During an interview on 07/29/26 at 9:26 a.m., the Rehab Director stated Resident #1 was covered by insurance. Rehab Director stated there was a belief the insurance was going to be issuing a NOMNC and when this information was communicated with Resident #1 she decided she would discharge home the following day, 07/08/26. The Rehab Director stated that the Social Worker normally would communicate the NOMNC information and get the form signed but she and the BOM stepped in to assist when needed. She stated the Social Worker was not in place when Resident #1 discharged . She stated the admissions Coordinator was assisting with setting up home health and any equipment needed for discharging residents at that time. She stated she was unable to document the because she did not have access to progress notes or the Discharge Summary. During an interview on 07/29/26 at 9:29 a.m., the Admissions Coordinator stated she had set up home health for Resident #1 on 07/08/26. The Admissions Coordinator stated she was not able to document setting up home health for Resident #1 because she did not have access to progress notes. During an interview on 07/29/26 at 9:32 a.m., the BOM stated she was on vacation when Resident #1 discharged . She stated Resident #1 was covered by a commercial insurance policy which did not provide NOMNC because it was not a Medicare plan. The BOM stated she had noted in her files that Resident #1 already had needed equipment at home and the Admissions Coordinator had made the referral to the home health agency. During an interview on 07/29/26 at 3:21 p.m., the Interim DON stated if a discharge summary was not initiated prior to discharge, nursing should have initiated the process. The Interim DON stated he could not provide information on Resident #1 because he was not in the facility at the time of the discharge. The discharge summary provided a recapitulation of the resident's time in the facility, communicated any needed services or equipment and medications a resident was on. The Interim DON stated it was important to ensure continuity of the resident's care. 2. Record Review of Resident #78's face sheet undated reflected Resident #78 was admitted on [DATE] with diagnoses including urinary tract infection and congestive heart failure. Resident #78 was discharged on 07/14/26 to local hospital. Record Review of Resident #78's MDS assessment dated [DATE] reflected Resident #28 was an unplanned and discharged - return anticipated to a short-term general hospital. Record Review of Resident #78's progress notes for July 2026 reflected no nursing documentation of discharge or transfer to hospital on [DATE]. Record Review of Resident #78's clinical record revealed no hospital transfer form or discharge summary for Resident #78 being sent to hospital on [DATE]. Interview on 07/29/2026 at 9:58 AM, RN O stated Resident #78 was sent to hospital after her shift on 07/14/26 and was on 200 hall. She stated she did not know the specifics of why Resident #78 was sent to the hospital. She stated the charge nurse assigned to Resident #78 was responsible to document the hospital transfer. Interview on 07/29/2026 at 10:12 AM, RN P stated she worked the day shift on 07/14/26 on the 200 hall but Resident #78 stayed on 100 hall. She stated she did not know the specifics why Resident #78 was sent to the hospital since she was not assigned to her. RN P was not sure when the resident was sent to the hospital. She stated the charge nurse should document the specifics including transfer to hospital in progress notes, assess the resident and complete a change of condition assessment. She stated the physician, responsible party and DON should be notified of resident being sent out to hospital. Interview on 07/29/26 at 10:35 AM, Agency LVN Q stated she was assigned the 100 hall on 07/14/26 on the day shift. She stated Resident #78 complained of her back hurting her and did not want to take pain medication and was concerned about her feet swelling. She stated she and ADON A assessed Resident #78 and vitals were within normal limits. Agency LVN Q stated was not sure why she did not document Resident #78's concerns. She stated Resident #78 was sent out to local hospital after shift change at 6 pm on 07/14/26. She stated she did not document Resident #78's transfer to the hospital and/or notify the physician and receiving hospital since Resident #78 did not transfer to hospital on her shift. She stated the nurse at time of discharge should contact the receiving hospital to give them report of Resident #78 and ensure resident has their face sheet, medication list, and the last vitals of the resident. Interview on 07/29/26 at 11:09 AM, the NP stated she was on vacation on 07/14/26 and the facility nurse would have contact the on-call number to notify about a resident's change of condition and/or transfer to the hospital. She stated it was important to be notified when a resident is sent to the hospital. Interview on 07/29/2026 at 11:22 AM, Agency LVN R stated she did not recall Resident #78 and her being sent out to the hospital on [DATE]. She stated she did not notify physician or receiving hospital for Resident #78 since she did not send any residents to the hospital that she could recall on her shift on 07/14/26. She stated the facility did provide her access to electronic record so she could document on the residents assigned to her. Interview on 07/29/2026 at 1:46 PM, ADON A stated Resident #78 was her own responsible party. She stated on 07/14/26 Resident #78 complained of back pain and her legs being more swollen on day shift. She stated Resident #78 wanted to go to hospital for further evaluation per her request and was sent out nonemergency transport on 07/14/26. She stated the charge nurse on 07/14/26 assigned to Resident #78 should have documented Resident #78's condition at the time she wanted to go to the hospital that included vitals, notification of physician, and contacted the receiving hospital to give report on resident's condition. She stated day shift nurse on 07/14/26 would have been the one who called to set up nonemergency transportation to hospital for Resident #78 and it should be documented in resident clinical record. She stated it was important to document and notify physician of Resident #78's transfer to hospital for coordination of care. She stated she will look at 24-hour report to see if anything is documented about Resident #78 being sent to hospital on [DATE]. ADON A stated she could not find a hospital transfer form for Resident #78. Interview on 07/29/2026 at 3:20 PM, the Interim DON revealed he started on 07/27/26. He stated he expected Resident #78's transfer to the hospital documentation to be documented in resident's clinical record on 07/14/26 including resident's condition at time of transfer, reason for transfer to hospital and notifying of physician and receiving hospital. The Interim DON stated it was important for transfer to hospital documentation and notification to physician and receiving hospital to occur for residents for the coordination of care and for residents to receive the proper treatment needed at the hospital. The facility did not provide the 24-hour report for Resident #78 prior to exit on 07/29/26. Review of facility's policy Discharge/Transfer last revised 10/23/19 reflected The patient/resident will be discharged /transferred (home/another entity) by order of his/her attending physician. Facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/resident's individual needs.3. Types of discharges: A. Planned discharge to the patient's/resident's home/private residence or assisted living facility: 1) Obtain an order for discharge/transfer from the patient's/resident's physician 2) Arrange community resources identified by the interdisciplinary team/patient/resident and/or family. 3) Provide written Discharge Instructions for care to the patient/resident and/or family when discharging the patient home or to a community setting such as assisted living. 4) Complete the Discharge Summary, documenting the resident's assessment at time of discharge and a summation of the patient's/resident's stay. 5)Place a copy of completed forms in the patient's/resident's stay.C. Planned Resident-Initiated Discharge to Another Healthcare Facility: 1) Complete the Resident Transfer Form when the patient/resident is discharged to another health care agency such as a hospital or nursing facility. 2) Send copies of the patient's face sheet, advance directives, copies of physician orders, MAR and TAR, and any state specific records in accordance with state regulations. 3) Maintain copies of all discharge/transfer rooms in patient's/resident's permanent medical record. 4) Refer to Social Service Policy on Discharge Planning. Review of facility's policy Documentation - Licensed Nurse last revised 02/02/2026 reflected The nursing staff will be responsible for recording care and treatment, observations and assessments and other appropriate entries in the patient/resident clinical record.Nursing Progress Notes/Other A. Significant Change: A significant change in condition is noted in the nursing progress notes as soon as possible after observation of the patient/resident. Notifications of the physician/family member and or responsible party of such occurrences are also noted in the medical record. B. If the condition of the patient/resident calls for the transfer of the patient/resident to an acute care facility, the date, time of transfer, name of the facility, the mode of transportation surrounding the transfer is documented in the final progress note (see Discharge Policy and Procedure). An order for transfer to the acute care facility must be written. C. The final nursing progress note describes the condition of the patient/resident at the time of discharge and addresses destination, mode of transportation, those who accompanied the patient/resident and what time the patient/resident left the facility.

Based on observations, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #75 and Resident #10) reviewed for pharmacy services. 1. The facility failed to ensure LVN E followed the manufacturer's instructions to prime the Novolog pen (Insulin aspart) (Hormone) prior to dialing in the required amount of Insulin to be administered to Resident #75 on 07/28/26. 2. The facility failed to ensure facility staff re-order Resident #10's Atorvastatin 40 mg (used to lower cholesterol) in a timely manner for Resident #10 which resulted in RN C borrowing the medication from Resident #29 on 07/27/26. These failures placed residents at risk of not receiving the full dosage of medication, missed doses of medication, wrong medication and drug interactions.Findings included: 1. Record review of Resident #75's, Face sheet, dated 07/28/26 reflected a [AGE] year-old female with an admission date of 04/24/26. Diagnosis included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #75's Physician's Order for July 2026, reflected, Novolog FlexPen U-100 Insulin (insulin aspartu-100) insulin pen; 100 unit/mL (3 mL); amt: Per Sliding Scale; If Blood Sugar is 150 to 200, give 2 Units.subcutaneous Before Meals 06:30, 11:30, 16:30.with a start date of 06/06/26. An observation on 07/28/26 at 12:00 p.m. revealed LVN E performed hand hygiene, put on gloves, and entered Resident #75's room to obtain a fingerstick blood sugar. The blood sugar reading was 189. LVN E returned to the medication cart and checked the computer to determine the amount of insulin needed per sliding scale, 2 units of Novolog insulin was needed per sliding scale. LVN E retrieved the insulin pen from the medication cart and attached a needle and dialed in 1 unit to [NAME] the pen (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly). There was no drop of insulin visualized at the tip of the pen. LVN E then dialed in the 2 units of insulin, put on gloves and entered Resident #75's room and administered the insulin to Resident #37, holding the pen to the resident's skin for at least 10 seconds. During an interview on 07/28/2026 at 12:10 p.m., LVN E stated she was not aware she had to prime the Insulin pen with 2 units of insulin. She stated she had not read the manufacturer's instructions on administration but stated she had been taught by one of the nurses at the facility to [NAME] the pens with 1 unit. She stated she thought that was not enough but stated she thought that was the facilities protocol. She stated she understood the purpose of priming the pen was to ensure there was no air in the needle. She stated she did not see any insulin at the end of the pen with just one unit. She stated going forward she would prime the pen with 2 units each time or until the insulin was visible at the end of the pen. 2. Record review of Resident #10's face sheet, dated 07/28/26, reflected a [AGE] year-old female with an admission date of 06/05/26. Record review of Resident #10's 5-day MDS Assessment, dated 06/22/26, reflected she had BIMS score of 14, which indicated she was cognitively intact. Diagnoses included dysphagia (swallowing difficulties) and cerebrovascular accident (stroke). Resident #10 received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach). During a medication observation and interview on 07/28/26 at 7:13 p.m. revealed RN C at the medication cart in front of Resident #10's room. RN C pulled up the Medication Profile for Resident #10 and pulled blister packs of metformin 500 mg, methocarbamol 750 mg tablet, apixaban 5 mg tablet, carvedilol 6.25 mg tablet and a bottle of phenytoin 125 mg/5 ml She looked in the medication cart to obtain the residents atorvastatin 40 mg tablet and stated the blister pack was empty and stated the previous nurse must not had re-ordered the medication. RN C clicked the button to re-order the medication. She stated she was going to check the other cart to see if it was placed on the wrong cart. RN C went to the nurse's station, opened up the other medication cart, and looked through the cart. She then pulled Resident #29's blister pack of atorvastatin 40 mg tablet and punched 1 pill into a medication cup. RN C returned to the medication cart with the tablet, punched the other medications into a separate medication cup, crushed each tablet and poured the required amount of the liquid medication and entered Resident #10's room and administered the medication through the resident's g-tube. During an interview on 07/27/26 at 7:45 p.m., RN C stated it was her first night back and the previous nurse had not reordered Resident #10's atorvastatin. She stated the facility had an E-Kit, but it took so much time to go to the E-Kit. She stated since the resident did not have her medication she thought it would be ok to borrow from someone else. In an interview with the Interim DON on 07/29/26 at 2:40 p.m., the DON stated it was never acceptable to borrow a medication from another resident, and the staff member had been counseled. He stated there was no excuse for this since they had an E-Kit that had most of the common medications the residents took. He stated the re-ordering process was a very simple process and the staff all knew they were to re-order when a resident had a 5-day supply on hand. He stated the staff were responsible for following up with the pharmacy in the event the medication was not delivered. He stated there was no excuse for this. He stated the facility's' procedure was to prime the insulin pen with 2 units of insulin and repeat if insulin was not present at the end of pen to ensure the air had been removed. He stated the LVN would be re-educated on the correct procedure. He stated the risk of borrowing medications was that the staff member was not following the five rights of medication administration, right resident, right dose, right medication, right time, and right route. He stated failing to prime the insulin pen could result in giving an air shot and the resident not receiving correct amount of insulin required. Record review of the manufacture instructions for (Novolog) Aspart obtained from https://www.novolog.com/ searched on 07/30/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps. Record review of the facility's policy titled, Medication Management Program, dated January 2025, reflected, The Facility implements a Medication Management program to meet the pharmaceutical need of patients and residents, according to established standards of practice and regulatory requirements.Medication supplied for an individual patient/resident are not administered to another patient/resident.If a medication is unavailable, contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws and regulations, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of one (Facilities only medication room) and failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for one of four residents (Resident #82) for storage of drugs and biologicals. 1. The facility failed to ensure a vial of Tuberculin Purified protein derivative in the medication room refrigerator that had been opened, was dated with the date it was opened on 07/29/2026. 2. The facility failed to ensure Resident # 82 did not have unsecured prescription medication in their room when a blister pack of ciprofloxacin was observed sitting on a shelf in the resident room on 07/27/26. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications and risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries. The findings include: During an observation on 07/29/26 at 8:05 a.m. of the facility's only medication room refrigerator with ADON B revealed an undated opened vial of Tuberculin Purified protein derivative (substance used for skin test for tuberculosis). During an interview with the ADON B on 07/29/26 at 08:10 a.m., she stated the Tuberculin Purified protein derivative had to be dated when opened. She stated once it was opened it would only be good for 30 days. She stated the risk of not dating it once opened was the potential for false positive or an inaccurate test, which could lead to a missed infection. She stated all the nurses performed the Tuberculin skin test on any new admission and whoever opened the vial was responsible for dating and stated the nurses were always supposed to check the date before using any medication. 2. Record review of Resident Face Sheet for Resident #82 dated 07/28/26 revealed Resident #82 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #82 was diagnosed with Chronic Pain (pain lasting longer than 3 to 12 months, frequently associated with arthritis, back problems, and nerve damage), and Severe Dementia with Anxiety (final stage of cognitive decline with constant sense of worry). Record review of Care Plan for #82 dated 07/25/26 revealed Baseline Care Plan OBJECTIVE: [Resident #82] is a new admission. He admitted from home for respite care. The MDS Assessment was not reviewed due to it had not been completed due to the length of time Resident #82 had been in the facility Record review of Physician's Orders for Resident #82 dated July 2026 revealed there was no physician's order for Cipro.Record review of Medication Administration Record for Resident #82 dated July 2026 revealed there was no physician's order for Cipro. Record review of Medication Profile for Resident #82 from Hospice, dated 07/23/26 revealed Resident #82 was on Cipro 500mg oral tablet every 12 hours for 10 hours from 07/08/26-07/17/26. The Cipro order was no longer an active order. During an observation on 07/27/26 at 6:14 p.m., revealed Resident #82 was lying in bed sleeping soundly. A bubble pack of medications which contained Ciprofloxacin (Cipro) was observed sitting on top of a box, sitting on a shelf in the resident's room. During an observation and interview on 07/28/26 at 10:40 a.m. with family members, it was revealed when they arrived in the morning of 07/28/26, the box that had been sitting on the shelf was removed. The family member stated the hospice company told them to bring the medication to the facility when he was admitted last week. The medication had remained in the room until they arrived 07/28/26 and they noticed the box and the bubble pack of medication had been removed. The family members stated they did not know where the medication was, but they did not take it home. During an interview on 07/28/26 at 3:19 p.m., the Interim DON stated medications should be stored in resident rooms unless there was a proper evaluation with a physician's order that the resident was appropriate and safe to administer their own medications. The Interim DON stated this would all be in the residents' file if this was the case. The Interim DON stated he was not aware of any resident's self-administering medications in the facility. The Interim DON stated that all medications should be kept locked up in the medication room or medication cart to ensure safe keeping. During an interview on 07/28/26 at 4:12 p.m. with RN K stated she was part of Resident #82's initial admission. RN K stated she was not aware of a physician's order for Cipro. RN K stated she was not aware a bubble pack of Cipro had been brought to the facility but stated some of the medications were left at home and a family member had to bring it back. RN K stated medications should not be in a resident room for safety reasons and if she saw medication in a resident room, she would remove it from the room and lock it in the medication cart. RN K stated she did not see any medications in Resident #82's room. During an observation on 07/28/26 at 4:15 p.m., the Interim DON and RN K stated there was no Cipro for Resident #82 that had been placed in the medication cart for the nurse or the medication aide from Resident #82's room. During an interview on 07/29/26 at 9:45 a.m., the Interim DON stated he spoke with the MDS Coordinator L who was the Guardian Angel for Resident #82 and during rounds she removed the Cipro from the room. The medication was secured and the family was to be notified in order for them to pick it up. During an interview on 07/29/26 at 9:53 a.m., MDS Coordinator L stated during rounds on Tuesday (07/28/2026) morning she noticed a bubble pack of medications for Resident #82. MDS Coordinator L stated she removed the medication from the room and gave it to ADON B. MDS Coordinator L stated she was the Guardian Angel for Resident #82 and had made rounds in his room but only noticed he had a box of supplies and other belongings but did not go through his personal belongings. She stated 07/28/26 was the first and only time she saw the medication and removed it. During an interview on 07/29/26 at 9:59 a.m. with ADON B stated MDS Coordinator L brought her medication that was found in Resident #82's room. ADON B stated she placed the medication in pharmacy destruction in the medication room. ADON B stated medications should not be stored in a resident's room for the safety of the residents. Record review of the facility's policy titled Medication Storage, dated April 2024, reflected .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products.with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident received adequate supervision for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility did not implement interventions per the Speech Therapist and the Nurse Practitioner when they did not provide recommendations of occasional supervision, upright posture during meals and upright posture for greater than 30 minutes after meals for Resident #1 on 3/7/26 after a choking incident. The facility failed to implement the interventions of occasional supervision, upright posture during meals and upright posture for greater than 30 minutes after meals recommended by the speech therapy to help prevent choking episodes for Resident #1 after she was discharged from speech therapy. These failures could put residents at risk of frequent accidents and decline in health.Record review of Resident #1's face sheet date 4/28/26 reflected an admission date of 4/6/25. Resident #1 was a [AGE] year-old female with the following pertinent diagnoses: Chronic obstructive pulmonary disease (a disease causing restricted airflow and breathing problems), mild protein-calorie malnutrition, Pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, dysphagia (a condition that makes it difficult to communicate), food in larynx causing asphyxiation (a deficient supply of oxygen to the brain caused by an inability to breath), gastro-esophageal reflux disease (when stomach acid frequently comes up into the esophagus), cognitive communication deficit and Type 2 Diabetes (a disease that causes the body to not use insulin correctly and sugar builds up in the blood). Record review of Resident #1's MDS assessment, dated 4/9/26, reflected her cognition was intact with a BIMS of 15. Resident #1's diet was mechanically altered and therapeutic. Resident #1 needed setup or clean up assistance for eating. Record review of Resident #1's Care Plan revised on 3/16/26 reflected .Problem Start Date: 03/13/2026 Resident #1 with documented episode of choking while eating. Edited: 03/16/2026 Long Term Goal Target Date: 06/27/2026Resident #1 will safely consume meals without choking through next review. Created: 03/16/2026 Approach Start Date: 03/13/2026 Chest Xray as ordered Created: 03/16/2026 Approach Start Date: 03/13/2026 Down grade diet to mechanical soft Created: 03/16/2026 Approach Start Date: 03/13/2026 Ensure resident is in proper positioning prior to meals. Created: 03/16/2026 Approach Start Date: 03/13/2026 Speech Therapy to assess and treat as indicated Created: 03/16/2026. Further review revealed the care plan did not address the choking incident on 3/7/26 and was not revised to include discharge recommendations of occasional supervision, upright posture during meals and upright posture for greater than 30 minutes after meals by Speech Therapy. Record review of Resident #1's orders as of 4/28/26 reflected an active order dated 4/7/25 Dining Room Preference: In room, active order dated 3/12/26 for EATING with assist x 1; SET UP ASSISTANCE and active order dated 3/13/26 Consistent Carb, Mechanical Soft Special Instructions: NAS, double protein. Further review revealed the orders did not include Resident #1's need for occasional supervision, upright posture during meals and upright posture for greater than 30 minutes after meals. Record review of Resident #1's progress note written by Agency LVN G dated 3/7/26 reflected During lunch time was called to the resident's room that she was choking, arrived in the room to see the resident was sitting upright, face red to color with no cyanosis nor loss of oxygen. Oxygen saturations 97 percent on right arm, pulse equals 01. No respiratory distress noted. Resident able to cough and clear her airway well. Resident is alert and responsive times 4. After some time with this resident, told her would like to change her diet to mechanical soft. Her response was I would like to keep my diet the same, this happened because I was talking to my roommate while eating. Resident's total lung field check and is clear bilaterally. Resident's Nurse Practitioner made aware. X-ray was done to resident's knee that she earlier complaint of. Nebulizer treatment given times 1. After 20 minutes pulse equals 77 and peripheral oxygen saturation equals 97percent , Continuing to monitor status Record review of Resident #1's progress note written by ADON H dated 3/13/26 reflected This nurse was on the hallway at approximate 12:40pm when a visitor from room XXX called out stating the resident in YYY was choking. This nurse immediately responded and entered the room. Upon arrival, resident was noted to be sitting upright at 30 degree angle in bed with facial flushing and signs of distress. Resident was awake, responsive and nodding head appropriately when asked if she was choking. Audible vocalization present. Resident appeared to have food lodged in throat and was attempting to cough. Head of bed was at once elevated to approximately 50 degrees and resident was encouraged to cough. Within approximately 30 secs resident was able to expel a piece of food measuring approximately a half dollar size piece of food, identified as cauliflower. Resident denied further difficulty breathing or choking at that time. No immediate respiratory distress noted. Charge nurse on hall was notified immediately notified and was instructed to respond to the room to perform a full nursing assessment and obtain vital signs. Speech therapist was notified at once of choking at bedside and responded to room as well. After consultation with Speech therapist and residents nurse practitioner residents diet was downgraded to mech soft pending further evaluation by speech therapist. A new meal tray of downgraded diet was taken to patients room with speech therapist at bedside. This nurse notified the Nurse Practitioner and Nurse Practitioner has ordered chest x-ray to rule out possible aspiration. Nurse Practitioner additionally instructed that is resident is to eat meals in dining room for closer supervision during meals. Representative notified via phone, message left, awaiting call back at this time. Resident remained awake and responsive following event and was left in the care of the assigned charge nurse for continued monitoring and assessment. This nurse returned to room [ROOM NUMBER] additional times in 20 min and patient verbally responsive, alert and oriented X 4 and no symptoms/signs of pain or distress at this time. Able to make needs and wants known to staff. Bed placed in lowest position, call light within reach and door to room left open. Record review of Resident of Resident #1's Speech Therapy Discharge Summary date 4/21/26 reflected discharge recommendations .Diet recommendations - Solids = Mechanical Soft textures; diet recommendations - liquids = all liquids; comprehensive strategies/positions: to facilitate safety and efficiently, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions and alternations of liquids/solids upright posture during meals and upright posture for greater than 30 minutes after meals; Supervision for oral intake = occasional supervision; Discharge recommendations: to facilitate optimal cognitive-communicative performance, the following strategies are recommended: eliminate background noise. An interview with Resident #1 on 4/28/26 at 9:26am revealed she had been at the facility for over a year. Resident #1 reported she had two incidents in which she choked on food while eating in her room. Resident #1 was unable to provide the dates of the incidents but stated they had occurred in 2026. Resident #1 stated because of the 2nd incident her diet was changed to mechanical soft. Resident #1 stated mechanical soft food was working well for her and she had no other incidents of choking. Resident #1 stated they also provided her speech therapy, and the speech therapist watched her eat several times. Resident #1 reported no other staff had watched her eat. Resident #1 stated she prefers to eat in her room and had told staff she did not want to eat in the dining room. An interview with Resident #1's Roommate on 4/28/26 at 9:32am revealed she heard Resident #1 choking twice and both times she yelled for help. Resident #1's roommate stated she had seen the speech therapist in the room several times but had not observed any other staff in the room while Resident #1 at her meals. An interview with CNA A on 4/28/26 at 10:51am revealed she would assist Resident #1 with meal setup. CNA A reported Resident #1 did not want to get out of bed to go to the dining room and therefore she ate in her room daily. CNA A stated she has never supervised Resident #1 during mealtime, she stated no one told her she had to be supervised. An interview with CNA B on 4/28/26 at 11:20am revealed when she worked with Resident #1 she would set up her tray and chop her food up. CNA B stated Resident #1 preferred to eat in her bed. CNA B stated she had never provided Resident #1 supervision during her meals and stated Resident #1 was not on the feeding/supervision list. An interview with CNA C on 4/28/26 at 11:13am revealed she delivered Resident #1's meal and would set her tray up. CNA C stated she would ask Resident #1 if she needed any help with her meal and Resident #1 always stated no. CNA C stated she was unaware of any place in Resident #1's record that indicated she needed to supervise her and if she needed to supervise Resident #1 the nurse would have notified her. An observation of lunch meal tray delivery for Resident #1 on 4/28/26 at 12:30pm revealed Resident #1 received her meal tray at 12:35pm. The unknown staff delivered the tray to her room and setup her tray. The unknown staff was heard telling Resident #1 what was on her tray. The unknown staff was in Resident #1's room for about 2 minutes. Surveyor then entered the room. Resident #1 had a tray of mechanical soft food which matched her food ticket. There was no staff observed supervising Resident #1. An interview with the Speech Therapist on 4/28/26 at 1:05pm revealed Resident #1 was re-referred to him on 3/13/26 but Resident #1 had been on speech therapy from 1/13/26 to 3/12/26. The Speech Therapist stated they had been working on cognition and she had not had any swallowing issues that he was aware of. The Speech Therapist stated Resident #1 was re-referred to him on 3/13/26 for a choking episode and he initiated services the same day. The Speech Therapist stated he immediately downgraded Resident #1 to a mechanical soft diet. The Speech Therapist stated he observed Resident #1 eating the mechanical soft diet 17 times. The Speech Therapist stated he had not been informed of any other choking incidents and was only aware of the incident that happened on 3/13/26. The Speech Therapist stated he had already discharged Resident #1 from speech therapy and recommended upright posture for at least 30 minutes and occasional supervision. The Speech Therapist stated he provided his discharge summary to the Director of Rehab and she would let nursing staff know about the recommendations. The Speech Therapist stated it was the nursing staff responsibility to provide the occasional supervision. The Speech Therapist stated the occasional supervision was to make sure Resident #1 had not declined. The Speech Therapist stated the risk to the resident of not having gotten the occasional supervision was the resident could have a repeated episode of choking. An interview with LVN D on 4/28/26 at 1:11pm revealed she had only been working with Resident #1 since March 2026 and Resident #1 has never needed supervision during her meals. LVN D stated she had not heard of Resident #1 having had choking incidents nor had she observed Resident #1 choking. LVN D stated the resident would be at risk of choking if she had not been informed of the resident's choking risk. An interview with the Restorative Aide on 4/28/26 at 1:41pm revealed she was not assigned to Resident #1 for eating supervision or services. The Restorative Aide stated therapy recommended supervision for a resident during mealtimes then the resident is usually assigned to her. The Restorative Aide stated she had not had any resident that needed supervision recently. An interview with the ADON on 4/29/26 at 10:40am revealed she was familiar with Resident #1 but had not heard about the resident having had choking incidents. The ADON stated the steps that should have been taken when a resident has a choking incident were as follows: staff notify nurse, notify the doctor and ensure any orders made are entered, request a speech evaluation and complete an incident report with all necessary assessments. The ADON was unable to explain how recommendations and intervention from therapy for residents were communicated to her and the nursing staff to make sure interventions are implemented. The ADON then got clarification on the process and stated therapy would enter any necessary orders and they would discuss it during morning meeting, then the information was verbally told to the CNAs. The ADON was unable to state what occasional supervision meant and stated she would have gotten clarification on it from therapy, had she known about the recommendation. The ADON stated the risk of not having the appropriate interventions in place upon discharge from therapy would be a possible choking incident. An interview with the Director of Rehab on 4/29/26 at 1:39pm revealed occasional supervision on a discharge summary meant someone would check on the residents during meals. The Director of Rehab stated it would have been nursing staffs' responsibility to supervise the resident if the resident chose to be in her room during mealtimes. The Director of Nursing stated the nurses and CNAs should have been popping in occasionally to make sure Resident #1 had no issues eating her food. The Director of Rehab stated any discharge recommendations from therapy would have been talked about in morning meetings, rehab staff would inform nursing staff of a resident's discharge from therapy and any recommendations made. The Director of Rehab stated it was the responsibility of the ADON or DON to convey any discharge recommendations to the nurses and CNAs. The Director of Nursing stated she was only informed of one incident with Resident #1 choking and had not been informed of the incident on 3/7/26. The Director of Rehab stated that risk to the resident of staff not following the discharge instructions for Resident #1 could have resulted in her choking again. An interview with Interim DON E on 4/30/26 at 11:58 am revealed she had no knowledge of Resident #1 being at risk for choking. Interim DON E stated the expectation of staff if a resident had a potential of choking would be they encourage the resident to eat in the dining room, request a swallow study and ensure interventions were in place to prevent anymore choking incidents. Interim DON E stated if a resident refused to go to the dining room to eat she would have staff supervise them in their room. Interim DON E stated if a resident was discharged from therapy with recommendations for occasional supervision, she would have an in-service on the resident's needs to educate the CNAs about the resident needs and would ensure the supervision needs were documented on the 24 hour report for nurses. Interim DON E stated the risk of not providing the appropriate interventions and supervision for a resident who had a history of choking would be they could have another incident of choking. An interview with Interim DON F on 4/30/26 at 12:31pm revealed the expectation for a choking incident would be the nurse help dislodge the item and once they were stable, they would assess the resident, notify the physician and family and complete an incident report. Interim DON F stated the nurse should also refer the resident to speech therapy for an evaluation. Interim DON F stated once therapy had recommendations for the resident, they would provide them to nursing staff, put them on the 24-hour report and ensure all staff were aware of the recommendations. Interim DON F stated because staff did not know about the recommendations for therapy for Resident #1 she would conduct an in-service with the nurses and CNAs about the supervision needs for the resident. Interim DON F stated the risk to the resident of staff not knowing they had to check on the resident during mealtime would be adverse reactions to the resident such as choking. Interim DON F stated staff should have completed an incident report and referral to speech therapy after the first incident with Resident #1. An interview with the Interim Administrator on 4/30/26 at 1:03pm revealed a resident choking incident should have prompted staff to report it to therapy so the resident could have gotten evaluated. The Interim Administrator stated when therapy made recommendations for a resident they would ensure nursing staff knew and would add cues in the room so that new staff would be aware of the recommendations. The Interim Administrator stated the recommendations for Resident # 1 from therapy should have been relayed to nursing staff or the resident should have been referred to the Restorative Aide to ensure the resident's safety. The Interim Administrator stated the risk to the resident of staff not appropriately following therapy's recommendation would be the resident could choke or they could have a decline in health affecting their weight and food intake. Record review of the facility's policy Accident/Incident Reporting - Patient/Resident revised 11/1/17 reflected .An incident is any adverse outcome associated as a direct consequence of treatment or care (example: medication and treatment errors). An accident is an unexpected, unintended event that can result in bodily injury. PROCEDURES:1. All incidents and accidents involving patients/residents are immediately reported to the departmental or unit supervisor or in his/her absence, the house supervisor. In addition, all serious incidents such as those outlined in guideline #10 are immediately reported to the Administrator and Director of Nursing. 7. Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician and promptly reported to the family or legal representative. 8. For 3 days following an incident/accident the nurse documents the condition of thepatient/resident in the medical record every shift.

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 centralized staff work area reviewed for resident call system.The facility failed to ensure they had a working call light system that was audible at the centralized staff work area (nurses' station).This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.During an observation and interview on 04/16/26 at 8:05 a.m., Resident # 6 was heard yelling I need help to get up, I need help. The call light was illuminated but no audible sound was heard. LVN L was observed walking down the hallway and entered Resident #6's room and asked him to stop yelling. Resident #6 stated he was sorry but stated he had been waiting for 45 minutes for someone to come and help him. LVN L stated it had not been 45 minutes. LVN L assisted the resident from his bed to his wheelchair into the bathroom and told him to call when he was finished. LVN L then checked the bed and determined it was not raising up to chair level which was why Resident #6 was unable to get out of bed. She stated she would notify maintenance to see what was wrong with the bed. During an interview with RN B on 04/16/26 at 8:30 a.m., he stated he will answer call lights when he noticed them on. He stated it would be very helpful if they were audible. He stated the lights only illuminate and do not ring so they might go unnoticed for a while. He stated sometimes the lights were audible and other times they were not. He stated he was not sure why they were not audible. RN B was not able to state how long the call light system had not be audible.During an observation and interview on 04/16/2026 at 11:07 AM, the call light notification center (phone with screen identifying the room numbers of residents who requested assistance) was located at the nurses' station directly looking down Hall 200. The Administrator stated the call light system should be sounding as she pointed down Hall 200 at call lights illuminating above resident doors, but no audible sound could be heard. When the Administrator and this Investigator walked up to the call light notification center there was a cord plugging in the phone, the cord was not pushed all the way into the phone, once the phone was plugged in it began to be heard audibly and show the room numbers. The Administrator explained that the staff could not answer the call lights at the nurse's station but had to walk to the residents' rooms, respond, then reset the call lights in the resident rooms. The Administrator stated she was not aware the call light notification center had been unplugged previously.During an interview with the Maintenance Director on 04/16/2026 at 11:15 AM, he said the call light system was obsolete, and was no longer able to purchase parts to keep the call light system fully operational. The Maintenance Director stated he was in the process of getting bids turned into corporate for approval to have the call light system replaced. The Maintenance Director stated there was a supply of cow bells available to pass out to residents in the event the call light system went completely down. He stated it was not uncommon to find the call light system unplugged. The Maintenance Director stated he went to the former DON several times about this concern, he stated that the call light system shows error messages and continually beeps audibly requiring the staff to pick up the phone and set it back down to reset the light, which was why he thought the staff would unplug the phone.During an interview with the CSD on 04/16/2026 at 12:28 PM, it was revealed the call light system was functioning again where the lights were able to be seen and heard audibly. The CSD stated the Administrator was going around doing a one-on-one in-service education with the staff. The CSD stated the unplugging of the call light system was previously an issue around February 2026 and education was conducted at that time. The CSD denied receiving additional complaints. Observation on 04/16/2026 at 12:37 PM, revealed two call lights sounding at the call light notification center but there were no actual light illuminating and the message at the notification center showed failed.During an interview on 04/17/26 at 8:00 a.m., Resident #6 stated he was thankful for the assistance on 04/16/26. He stated he usually was able to get out of the bed by himself but stated he could not get his bed to rise up where he could slide over into his wheelchair. He stated he does not have to call for help very often, but when he did call for help it would take the staff a while to answer his light. He stated it was not always, but sometimes it was over an hour for them to come. Observation on 04/17/2026 at 8:15 AM, revealed a call light on 200 hall was illuminated both red and white lights were flashing. The call light notification center showed call lights on 100 hall and 300 halls but no information regarding 200 hall.During an interview with CSD on 04/17/2026 at 4:06 PM, it was revealed that the call light system should be maintained and in working order. The CSD stated this meant the call lights should be able to be seen illuminated when looking down the hallway as well as audible at the nurses' station at the call light notification center. Any issues with the call light system should be reported to the Maintenance Director to address and fix any malfunction. The CSD stated that management should be making rounds in the facility at varying times to ensure the call light system was working during rounds. The CSD stated the call light system was utilized to notify staff of a resident needing assistance. The call light system not working could cause a delay in assistance to the residents.Review of Call Lights Policy dated 05/05/2023 revealed .POLICY: The staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. PROCEDURES: 1. Respond to call lights and requests for assistance as quickly as practicable. 3. Staff respond to emergency light immediately.4. Staff will cancel the call light to notify others that the residents is being assisted. 5. If unable to complete the requested task, inform the patient/resident/family and notify the appropriate discipline. Call lights should not be canceled until the resident's need has been addressed.

Based on observation, interview, and record review the facility failed to have Physician Orders for the resident's immediate care for one of two (Resident #1) reviewed for resident assessments. The facility failed to have Physician orders for the care and treatment for Resident #1's foley catheter, colostomy, and wound care orders upon his readmission to the facility on [DATE]. This failure could place resident at risk for not receiving appropriate care and treatment services. Findings included: Record review of Resident #1's undated Face Sheet reflected a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected a BIMS of 15 which indicated he was cognitively intact, had a urinary catheter, colostomy (surgical procedure that creates an opening in the abdomen to the colon) and abscess (collection of pus and dead tissue) to the groin (junction area between the lower abdomen and inner thigh) and perineum (area between the anus and the genitals) Record review of Resident #1's care plan completed on 03/19/26 reflected the resident was a new admission post sepsis. Goals were to identify the residents' immediate health and safety needs. Approaches included Catheter use for wound management. Turn and reposition. Treatments- see Physician orders. The colostomy was not identified. Record Review of Resident #1's hospital discharge orders dated 04/09/26 did not contain orders for wound care, foley catheter or colostomy care. Instructions indicated, Please send detailed wound care instructions with the patient. Continue wound vac in the skilled nursing facility. Recommend frequent repositioning and pressure offloading to prevent pressure ulcer in the back . Record review of Resident #1's Physician Order Summary for April 2026 reflected no orders for the urinary catheter or colostomy care. Wound care orders were added on 04/15/26 and reflected, Daily wound treatment: Cleanse peri/medial lower buttock with Dakin's (antiseptic) solution, pat dry, apply calcium alginate (absorbent dressing with particles of silver) with silver, top with abdominal pads (absorbent dressing) and secure with mesh underwear daily. Sacrum: continue wound vac to sacrum 125 mmhg (pressure) continuous medium negative pressure. To be changed Monday-Wednesday-Friday. Record review of Resident #1's progress note by RN B on 04/10/26 at 5:49 p.m. reflected, Resident returned from hospital admission at this time. He was accompanied by his [Family member] and two transport personnel who transferred him to bed via manual lift. Diagnosis: Perineal Abscess wound complication. He is alert and oriented x 4, on a regular diet and requires assistance with ambulation.NP [name] was notified of patient's arrival. His wound vac (negative pressures wound therapy device) was assembled and connected to the machine and power source was plugged. Suction pressure was set to intermittent 125 mmHg of pressure. The skin and all system assessment was deferred at this time. Record review of Resident #1's progress note by RN D on 04/10/26 at 10:00 p.m. reflected, The skin assessment done- Surgical wound site to coccyx (base of spine) area. Another wound noted on perineum and scrotum, Wound vac noted.skin grafted site on right upper leg- Reddened area noted. Suture marking on both upper legs on inner aspects of thigh.Last foley changed on 04/09/26. Last colostomy bag changed on 04/09/26. Record review of Resident #1' progress note by RN B on 4/12/26 at 3:46 p.m. reflected, Resident informed this RN at this time that he wishes to defer wound care treatment until 4/13.The bandage were clean, dry and intact at this time upon assessment. Colostomy is also intact, indwelling catheter intact, no kinking and urine color is pale yellow. Record review of Resident #1 progress noted dated 04/13/26 at 4:51 p.m. by the Treatment nurse (recorded as Late entry on 04/15/26 5:00 p.m.) reflected, Writer rounded on resident today for weekly wound care rounds. Wound vac in place to sacrum. Currently set to 125 mmhg. Suctioning noted. MD also assessed peri/groin incisions intact. No open areas noted lower extremities. MD to reinstate previous orders. During an interview and observation on 04/15/26 at 2:40 p.m., Resident #1 and his family member revealed he had returned to the facility late on 04/10/26 after a short stay in the hospital for re-evaluation of his wounds. Resident was observed with a urinary catheter and a wound vac at the bedside set to 125 mmhg. Resident #1's family member stated all of this started with the Resident #1 having the flu back in January 2026. She stated he ended up with a severe infection that was diagnosed as gangrene to his buttocks. She stated he had multiple surgeries and skin grafts, and they had to do a reversable colostomy to help with the healing of the wounds as well as the urinary catheter. She stated the hospital sent him to this facility around the middle of March 2026 but did not send him here with any antibiotics. Resident #1 stated he was getting wound care daily, but started to have increased drainage and they sent him out to the hospital for evaluation. He stated he did not have a wound vac prior to going to the hospital. Resident #1's family member stated since his return, he had been receiving wound care, but the facility contacted her and asked if the hospital had sent any wound care orders with her, and she stated she got the same copy the facility got. She stated she had brought her copy of his discharge orders yesterday (04/14/26). She stated his wound vac dressing was changed last Friday (04/10/26) at the hospital and stated it was changed twice a week at the hospital. Resident #1 and his family member did not have concerns about his wound care. During an interview on 04/15/26 at 3:32 p.m. with the Treatment Nurse, she stated Resident #1 re-admitted to the facility on the evening of 04/10/26 and the hospital had not sent any wound care orders. She stated she had obtained wound care orders on Monday 04/13/26 from the facility's wound care physician which was to resume the previous wound care orders, with the exception of the wound vac and she was still trying to verify with the hospital the orders. She stated she obtained the orders for the wound vac on 04/14/26. She stated she should had restarted the orders she had on 04/13/26 and then added the wound vac orders. She stated the nurse doing the admission should have reached out to the hospital, or herself, and she could have reached out to the wound care physician for the facility, or the weekend supervisor could had reached out as well. She stated Resident #1 did get wound care on 04/13/26 and 04/14/26, it just was not documented. She stated the risk of not having orders upon admission were wounds could not receive treatment and could decline and become worse or infected or colotomy care and urinary catheter care could be missed which increased the risk of infections. During an interview on 04/15/26 at 3:36 p.m. RN B revealed he started Resident #1's re-admission to the facility. He stated Resident #1 did not come with any wound care orders from the hospital. He stated he did not think to call the MD and ask if he could re-start the previous wound care orders, urinary catheter orders, or colostomy care orders. He stated he was not sure who the wound care physician was since their most recent wound care physician had passed away. He stated he did not think about calling the Treatment Nurse, and stated that was what he should have done, or attempted to contact the hospital to obtain the orders. He stated RN D completed the skin assessment and dressing change on 04/11/26, and the resident declined to have wound care on 04/12/26. He stated it was the admitting nurse's responsibility to input the admission orders, and the DON and the ADONs would review the orders the next day or on Monday if it was a weekend admission. He stated they had to have orders to meet the needs of the resident. During an interview on 04/16/26 at 10:50 a.m. with the Clinical Service Director she stated the previous DON had been gone since the end of March 2026 and both the ADONs were new to their roles. She stated it was the expectation any resident admitted to the facility had to have orders to provide the necessary care the resident needed, which would include wound care orders, urinary catheter care orders and colostomy care orders. She stated new admissions would be reviewed in the morning clinical meetings, but the DON and ADON would be responsible for reviewing hospital discharge orders to ensure all the orders were captured. She stated if the hospital discharge orders did not have wound care orders, they had to clarify it with the physician to determine the treatment needed. She stated daily orders would need to be clarified immediately in order to provide the residents with the necessary care they needed. She stated not having admission orders could delay resident treatments which could result in a decline in the residents' overall well-being and recovery. She stated they identified the facility had documentation issues and had a mobile DON who was to start on 04/20/26 along with Cooperate support for training needs. Record review of the facility's policy Physician Orders, dated May 2023, reflected, .The qualified licensed nurse completed an admission medication regimen review from the transfer record from an acute care hospital, home, or other entity.A call is placed to the physician to confirm the orders and request any additional orders as needed.Upon admission, the Facility has physician orders for the resident's immediate care to include not limited to.Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan.Facilities with paper medical records will transcribe the order on the Medication Administration record (MAR) or Treatment Record as appropriate. Initial and date the entry on the MAR/Treatment Record. Medication Administration or Treatment Records are generated electronically in facilities with electronic medical records.

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of four (Residents #4) reviewed for pharmacy services. 1.The facility failed to ensure Resident #4 was free from abuse when ADON E knowingly placed the following medications on hold without a physician's order: Resident #4's Latanoprost 0.005% eye drops prescribed for once per day, on hold from [DATE] until [DATE], 25 doses were missed.2. Resident #4's Dorzolamide 2% eye drops prescribed for two time a day, on hold from [DATE] until [DATE], 47 doses were missed. 3.The facility failed to ensure MA H cleared Resident #4's nasal passages before the administration of Fluticasone Nasal Spray. This failure placed residents at risk of not receiving therapeutic dosage of medication. Findings included: 1. Review of a Face Sheet for Resident #4 dated [DATE] revealed Resident #4 was an [AGE] year-old female who was admitted to the facility originally on [DATE] and readmitted on [DATE]. Resident #4 was diagnosed with Bilateral Primary Open-Angle Glaucoma (chronic, progressive eye disease-and the most common form of glaucoma-characterized by slow, asymptomatic damage to the optic nerve, often associated with high eye pressure. It causes irreversible peripheral vision loss, leading to blindness if untreated), multiple sclerosis (autoimmune disease of the central nervous system) and allergic rhinitis (inflammation of the mucous membranes of the nose).Review of Resident #4's MDS dated [DATE] revealed Resident #4 was coded to have moderately impaired vision .limited vision; not able to see newspaper headlines but can identify objects. Resident #4 wears corrective lenses .contacts, glasses, or magnifying glasses. Resident #4 was noted to score an 11 on the BIMS indicating Resident #4 had moderate cognitive impairment.Section I-Active Diagnoses.Other.Additional active diagnoses.B. Unspecified open-angle glaucoma, stage unspecified. Review of Resident #4's Care Plan dated [DATE] revealed Problem.Problem Start Date: [DATE] Category: Visual Function [Resident #4] has impaired vision related to Glaucoma.Goal.Pain will be relieved or minimized related to ocular pressure through next review.Approach.Administer drugs as ordered at appropriate times and in appropriate order.If more than one type of eye drops are ordered at same time, wait 5 minutes between administering each type of eye drop.Keep eye appointment as scheduled.Plan activities that do not place straining on the eyes.Teach resident to avoid activities that may increase intraocular pressure (URIs, emotional upset-worry, fear, anger). Record review of Resident #4's Active Physician Order for [DATE] reflected, Dorzolamide drops: 2% amt: 1 drop.each eye twice a day.latanoprost drops:0.005%; amt 1 drop.each eye once a day.with a start date of [DATE] .Fluticasone propionate spray suspension; 50 mcg (corticosteroids to treat allergies); amt: 1 spray; nasal twice a day . with a start date of [DATE]. There was no order indicating when the Dorzolamide and Latanoprost eye drops were placed on hold or restarted. Review of Medication Administration Record for Resident #4 dated [DATE] revealed Resident #4 was prescribed Dorzolamide ophthalmic drops 2% two times per day. Resident #4's Dorzolamide was on hold from [DATE] until the evening dose on [DATE]. Resident #4 missed a total of 47 doses of Dorzolamide. Resident #4 was prescribed Latanoprost ophthalmic drops 0.005% one-time per day. Resident #4's Latanoprost was put on hold from [DATE]-[DATE]. Resident #4 missed 25 total doses of Latanoprost.Review of Resident #4's Progress Notes by ADON E dated [DATE] revealed .XXX[DATE] at 22:33 [10:33 PM] .Patients eye drops out of date. Hospice RN CM contacted to refill: Lantaprost [sic] gtts and Dorzolamide HCL gtts. Medication placed [sic] on hold until arrival. Charge nurse to reactivate order and take off hold when arrives from hospice pharmacy.signed by [ADON E] .Review of Resident #4's Progress Notes by LVN Q dated [DATE] at 13:39 [1:39 p.m.] .During this shift, it was identified 2 prescribed ophthalmic medication ( [sic] eye drops); Latanoprost 0.005%, and Dorzolamide 2% had been placed on hold by another nurse without notification to family, or follow-up with hospice or pharmacy. The resident's family contacted the facility requesting clarification regarding the reason for holding the medications and expressed concern about the lack of communication. This nurse reviewed the patient's chart and confirmed the absence of follow up with either hospice or facility pharmacy after documented the reason for hold was awaiting for delivery. [Hospice Agency] were contacted and verified that the prescribed glaucoma eye- [sic] drops are not covered under the hospice. [NP] was notified of the situation, including the medication hold, Dx: B/L open-angle glaucoma, and family concerns, new order to resume both Latanoprost 0.005%, and Dorzolamide2% [sic] as previously prescribed. Pharmacy was contacted promptly to process and dispense medications. confirmation was received to ensure timely delivery and continuation of therapy. The resident's family was called back, and was updated regarding the situation, including the reason for the interruption, action taken to resolve the issue, and plan to resume treatment. The family reports lack of communication between facility staff, hospice services and them.signed by LVN Q.Review of Resident #4's Progress Notes by ADON E dated [DATE] by ADON E at 9:45 a.m.Pharmacy contacted regarding status of Latanoprost 0.005%, and Dorzolamide 2% eye gtts, as orders taken off hold per EMAR. Pharmacy confirmed Dorzolamide gtts were delivered at 1800 (6pm) on [DATE]. Pharmacy also stated that Lantaprost [sic] eye gtts had not been requested for refill since [DATE]. Refill request for Lantanoprost [sic] completed both verbally with pharmacy and electronic EMAR request at this time. Ongoing follow up completed to ensure availability of medications and continuity of care. Awaiting call back from nursing to confirm that Dorzolamide gtts are on medication cart .signed by ADON E.XXX[DATE] at 10:18 AM. Dorzolamide gtts verified present on medication cart.signed ADON E.XXX[DATE] 10:20 AM.Lantaprost gtt [sic] hold order continues until delivery of medication by pharmacy.signed ADON E.XXX[DATE] at 10:37 AM.[NP] notified that Lantaprost [sic] eye gtts are awaiting pharmacy delivery. Medication was placed back on hold until delivery. Pharmacy states ETA for medication will be on PM med run.signed by ADON E.Review of Resident #4's Progress Notes by ADON F [DATE] at 18:31 [6:31 p.m.] .nurse called [Family Member] to inquire if the family would like to family to set up an appointment for the eye doctor, [family member] declined facility setting up appointment stated that she would follow up with personal eye doctor.signed by ADON F.Review of Resident#4's Progress Notes revealed there was no documentation or follow-up by ADON E documented from [DATE] until [DATE].Review of a Pharmacy Manifest dated [DATE] revealed Resident #4's Dorzolamide Ophthalmic Solution was delivered to the facility on [DATE].Review of a Pharmacy Manifest dated [DATE] at 8:18 PM, revealed Resident #4's Latanoprost Ophthalmic Solution was delivered to the facility on [DATE].Review of Investigation Statements documented by Administrator dated [DATE] revealed On [DATE] [ADON E] and [Resident #4's Family Member] came to admin office. [ADON E] began to explain that the {Family Member] is upset she was not notified of [Resident #4's] eye drops being placed on hold. Admin stated that it is regarding clinical matters and she needed to be a part of it. [Interim DON] arrived shortly afterwards, and [Family Member] expressed her concerns again. At this time [ADON E] admit that she was the one the placed the orders on hold and told the nurses to follow up. Admin reported this allegation to HHSC on 4.13.26 [Interim DON] & HR Suspended [ADON E] pending investigation Notified Physician, Medical Director, Family, Ombudsman. Abuse & Neglect Inservice. Admin reached out to [ADON] to further interview, but the calf [sic]was not answered. [ADON F] Reached out to the [Family Member] to schedule an ophthalmologist appointment. [Family Member] declined and stated she has an outside one and can schedule one if she needs too but she has had glaucoma for years and is not sure she needs an appointment. Review of an Investigation Statement with LVN R dated [DATE] revealed On 4.14.26 Admin spoke with [LVN R].[LVN R] stated that on that night [ADON E] was doing an Audit she found the expired medication and she told [LVN R] that she had put it on hold that I just had to put it on the 24hr report that the nurse is to take it off hold once received from the pharmacy. I was not directed to do anything else and for me I did not think to follow up on the medication because it is not given at night, so I am not triggered to remember. As a nurse when you put a medication on hold you have to get doctors' orders first, so I assumed she had done that since she told me she had already put it on hold. Additionally, I want to state that when I get orders to put a medication on hold, I get a time frame from the physician like 3-7 days that way triggers me to review. [ADON E] put it in as an open-ended hold. Review of an Investigation Statement with LVN Q dated [DATE] revealed On 4.14.26 Admin spoke with LVN Q. [LVN Q] stated that on 3.19.26 [LVN R] reported to her on her oncoming shift that the medication was put on hold and when it comes in to take if off hold, that was all that was directed to me. It did not arrive on my shift, so I did not take the medication off hold. We nurse usually call the Doctor/Family/Hospice before we put the medication on hold because we have to get orders to do that in the first place, so I thought it was done because it had been put on hold during the previous shift. On 4.11.26 the [Family Member] had taken [Resident #4] to the park and called me while they were down there and had asked when the last time was, she had received her eye drops, so I looked in the chart and gave her the dates, and the [Family Member] said that no one had notified her so I told her that I would look into this. So, I called hospice and they said they did not do that medication, then I called the pharmacy to see if they had it, next I called [NP] and told her what was going on and that the pharmacy had the med and asked if it was ok to take it off hold and order, [NP] told me it was ok so I did that and I documented in the chart. [ADON E] was on call and aware.Review of an Investigation Statement with RN C dated [DATE] revealed [DATE] 1:45 p.m.Interview with RN C] .I asked this employee what her knowledge was of the eye drops for [Resident #4]. [RN C] stated last weekend she heard the charge nurse talking about [Resident #4's] eye drops being on hold and not in the facility. [LVN Q] said they had been ordered but were not in the facility. [RN C] stated she contacted the person on call which was [ADON E]. [ADON E] informed her she had placed the med on hold and ordered the medication. [RN C] stated she had looked for it, and it was not in the facility. [RN C] then stated she initiated an incident report that she then passed onto [LVN Q] to complete as she was the nurse who identified the issue. The report was then placed under the administrator's door. [RN C] went on to say all parties were notified including the physician, family, Administrator, [Interim DON]. Finally, [RN C] confirmed with [ADON E] that the med had been ordered. She said because she only works weekends she was not aware when the med arrived.During an interview with the Administrator on [DATE] at 8:53 a.m., it was revealed that ADON E was suspended as a result of a self-report the facility called in. During the investigation it was learned ADON E placed Resident #4's eye drops on hold for almost a month so Resident #4 went without her eye drops for almost a month. ADON E admitted to placing Resident #4's eye drops on hold and did not get a physician's order to do so. During an interview with the Interim DON on [DATE] at 8:53 a.m., it was revealed an assessment was conducted on Resident #4 and the physician and family were notified about the medication being placed on hold. Interim DON stated ADON E removed the eye drops from the medication cart while ADON E was doing an audit on a medication cart. ADON E discarded the medication and decided to put the medication on hold and told the nurse to not restart the medication until the medication was back in the building. Interim DON stated ADON E failed to get a physician's order and/or notify the physician. ADON E failed to follow through with ensuring the medication was properly reordered or obtained from a pharmacy. Interim DON stated that ADON E practiced outside the scope of nursing by placing Resident #4's eye drops on hold and giving directions to nurses without a physician's order.During an interview with a Family Member on [DATE] at 10:45 a.m., it was revealed she was mostly upset with ADON E and stated ADON E blamed the nurses on the floor for not following up on the eye drops. Family Member stated ADON E needed to be held accountable as she was the supervisor who stopped the eye drops for Resident #4 and placed them on hold. Family Member stated she was not contacted by ADON E regarding the eye drops being placed on hold.During an interview with the MD on [DATE] at 11:40 a.m., it was revealed she learned approximately a week ago that Resident #4 had not been receiving her glaucoma medications (eye drops). MD stated she was not notified about the eye drops being place on hold. MD stated a resident failing to receive prescribed eye drops for glaucoma could cause a worsening condition, but the condition varies per patient. MD stated no changes had been reported to her regarding Resident #4. MD stated there was confusion with Resident #4 being on hospice and whether hospice would cover the cost of the medication. MD stated hospice did not cover eye drops or order those medications ordinarily as they did not pertain to the admitting diagnosis. During an interview with ADON E on [DATE] at 2:12 p.m., it was revealed she was hired as an ADON in [DATE] but had been PRN since [DATE]. ADON E explained she was not currently active in the building and did not confirm she was suspended pending investigation. ADON E stated she was doing a medication audit on the night shift when she noted Resident #4's eye drops expired. ADON E stated she removed the eye drops from the medication cart. ADON E stated she documented the information, communicated with the oncoming charge nurse, and reported it to the DON. ADON E stated she attempted to contact the hospice but only got a busy signal so she communicated with the oncoming charge nurse, and a note was left in the hospice binder. ADON E stated she asked the oncoming to communicate the medications being placed on hold and to the hospice nurse. ADON E was asked if she followed up on the eye drops being on hold and ADON E stated she documented the issues, communicated to the staff and the DON. When ADON E was asked if she communicated with the NP or the physician she stated, I'm pretty sure the doctor was aware. ADON E explained the workflow for medications not available were to place them on hold. ADON E stated she did not specifically call the physician at 3:00 AM when she was working but stated she thought she would have talked with the physician. ADON E stated in stand up during the clinical meeting she followed up and stated the eye drops for Resident #4 were discussed. ADON E stated she communicated the eye drops being on hold and stated she requested clarification. ADON E stated she sent emails to the previous DON and Administrator. ADON E stated the eye drops expired were identified as ADON and ADON E stated her job was to make sure the need for the medication was addressed and that appropriate steps were taken to get the needed medication in the building. ADON E stated she was only hearing that the medication had not been delivered by the hospice and that hospice was working on it. When asked what she could have done as ADON, ADON E stated she identified the eye drops were expired, documented the information, reported it to the Administrator and DON and followed up on what information she was receiving from the charge nurses which was that the medication was still on hold. ADON E stated she did not call the hospice again after calling on [DATE] and the phone was busy. ADON E stated she did not call Resident #4's physician, she only spoke with the administration and charge nurses. ADON E stated she did not call Resident #4's family. When asked what could have been done differently on part of her job as an ADON, ADON E repeated she identified the eye drops were expired, documented the information, reported it to the Administrator and DON. ADON E stated Resident #4 not receiving eye drops could lead to increased pressure and progression of glaucoma including loss of vision over time.During an interview with Administrator on [DATE] at 2:39 p.m., revealed in the morning clinical meeting the nurses would go over each resident, anything new coming up, behaviors, any resident appointments, IVs, and if a resident had not had a BM in 72 hours. The Administrator stated she did not remember hearing that Resident #4 was without her eye drops or that the eye drops were on hold except one time when ADON E said something. The Administrator the eye drops being on hold did not come up in the clinical meeting daily. The Administrator stated there was information from the charge nurse reports a few times that they had not received the medication from the pharmacy or hospice. The Administrator stated that ADON E was assigned the task of ensuring follow-up was conducted regarding any pharmacy issues like medications not being available or received from the pharmacy. The Administrator stated she had not seen a medication stay on hold for a long period of time. The Administrator stated as the ADON/Supervisor it was up to ADON E to address problems that she may see, follow up and find out how to fix the issues. ADONs were to help the nurses on the floor with guiding and assisting and ensuring clinical issues were being addressed. During an interview with ADON F on [DATE] at 3:41 p.m., revealed she started as an ADON on [DATE]. ADON F stated when she started, she was assigned to the infection control system and ADON E was over the pharmacy systems. ADON F stated that she did not recall Resident #4's medications being brought up in the clinical meeting. ADON F stated she knew it was not discussed daily. ADON F stated she found out there was a concern with Resident #4's eye drops on Monday, [DATE] when the hospice nurse came to her about the family calling her upset about ADON E putting the eye drops for Resident #4 being placed on hold. ADON F stated the hospice nurse went ahead and ordered the eye drops because the family was upset.During an interview with Interim DON on [DATE] at 3:45 p.m., revealed ADON E was assigned to the pharmacy system meaning anything regarding medication, physician's orders, entering and auditing physician's orders and making sure medications were in the building with physician's being notified and Responsible Parties being notified. Interim DON heard on Monday, [DATE] when Resident #4's family complained. ADON E reported the medication was on hold. Interim DON stated she understood the nurses were going directly to ADON E because she placed the eye drops for Resident #4 on hold, originally. Interim DON stated as ADON, ADON E should have followed up to see what was going on with getting the eye drops but instead ADON E delegated everything to other people and never followed up. During an interview with Administrator on [DATE] at 8:50 a.m., it was revealed she did not remember any calls related to Resident #4's eye drops over the weekend. The Administrator stated she found out about the medication error on Monday, [DATE]. The Administrator stated ADON E was the on-call nurse over the weekend and was suspended pending investigation on the afternoon of [DATE]. The Administrator stated Resident #4's family member came to see her on the afternoon of [DATE] regarding the concerns with the eye drops and some other concerns.An attempt was made to interview the former DON on [DATE] at 9:08 a.m A message was left for a return call.During an interview with the Pharmacy Consultant on [DATE] at 9:09 a.m., revealed Latanoprost and Dorzolamide are used to treat glaucoma. The Pharmacy Consultant explained that a resident not receiving the eye drops could cause the eye pressure to increase but would not cause physical pain. The Pharmacy Consultant stated she did not know if the resident's vision could get blurry. The Pharmacy Consultant stated that glaucoma was silent and did not have a lot of symptoms but over years could cause the vision of a resident to lessen due to the eye not being able to take in much light. The Pharmacy Consultant stated glaucoma was a slow progression. The Pharmacy Consultant stated the most important thing for Resident #4 was to ensure the medication was restarted as soon as possible.During an interview with LVN Q on [DATE] at 9:20 a.m., revealed stated that he had been working at the facility as an LVN for two years. LVN Q explained that Resident #4's eye drops were placed on hold on the night shift on [DATE]. LVN Q stated she worked the following day and was told they were waiting on the eye drops to arrive from the pharmacy. LVN Q stated on Saturday, [DATE] the family called about Resident #4's eye drops. LVN Q stated when she worked since [DATE] she would report in the morning meeting that the eye drops had not been received. ADON E was giving her the information that the medications were still on hold. LVN Q stated she was not able to unhold a medication because she did not receive the physician's order to take the medication off hold. LVN Q stated normally when a medication was placed on hold there was a stop date for when the medication was to be restarted. LVN Q stated she was not able to take an order from ADON E because she was a nurse and not a physician. LVN Q explained ADON E was the nurse to put the medication on hold. LVN Q reported to the former DON and ADON E and she would only get the response that the eye drops were still on hold. LVN Q stated she did not call hospice nor the pharmacy as a follow up. LVN Q stated ADON E should have taken care of the eye drops, called pharmacy and hospice because she executed the order. LVN Q stated there was no physician's order associated with this medication being put on hold. LVN Q stated physician's orders that were not actually physician's orders could not be passed along. An attempt was made to interview LVN R on [DATE] at 9:28 a.m A message was left for a return call.An attempt was made to interview LVN S on [DATE] at 9:38 a.m. A message was left for a return call.During an interview with Resident #4 on [DATE] at 9:50 a.m., revealed she was diagnosed with glaucoma some time in her 30's. Resident #4 stated she was put on eye drops twice per day, Latanoprost and Dorzolamide. Resident #4 denied experiencing vision loss, blurry vision or pain because of the glaucoma. Resident #4 stated she utilized two separate pairs of glasses for her near- and far-sighted vision. Resident #4 stated she recently went without her eye drops for a period, so she reported to her Family Member. Resident #4 stated she complained to her Family Member the eye drops had been restarted. Resident #4 stated that while she knew she was not getting the eye drops she stated she could not think of any side effects she experienced.During an interview with MA T on [DATE] at 10:25 a.m., revealed Resident #4 was previously receiving eye drops (latanoprost and dorzolamide) and then they were stopped because the eye drops were put on hold. MA T stated she would ask the nurse depending on who worked. If it was agency they could not have assisted her because the agency nurses were not familiar with the residents. MA T reported to her charge nurses when the eye drops were originally placed on hold. MA T stated she did not have the ability to get the eye drops or fix the order. MA T stated she would ask about the eye drops she was only told the eye drops were on hold. MA T stated she was told ADON E put them on hold. MA T stated when medications were placed on hold, they usually had a stop date, but the eye drops did not.During an interview with Clinical Services Director (CSD) on [DATE] at 10:39 a.m., it was revealed that ADONs were expected to report to the DON and act in the place of a DON if there was no DON or if the DON was not in the building. ADONs were to be involved in the daily clinical meeting including going over charting from the day before, admissions, reviewing physician's orders, reviewing incident/accidents amongst other things. CSD stated the Latanoprost and Dorzolamide being on hold for almost a month was not reported to her. CSD stated these medications being placed on hold should have been discussed in the morning clinical meeting. CSD stated any medication that needed to be placed on hold a nurse should be getting physician's order and usually the physician would provide a stop and start date for the hold time. CSD stated when she became aware of the eye drops being on hold when she reviewed ADON E had not put a stop date and there was no information about the physician being contacted. CSD stated she was informed of the medication error on Monday [DATE]. CSD stated ADON E was the clinical management on call over the past weekend. CSD stated if ADON E and/or Weekend Supervisor learned of Resident #4's family's concern over the weekend the Interim DON and Administrator should have been contacted. CSD stated she would consider this a form of neglect. CSD stated ADON E was new in her position. ADON E was described by CSD as someone who was very heightened about everything that came up as a concern, but ADON E lacked the ability to follow up and fix concerns. ADON E could identify concern but no accountability to fix issues.During an interview with Ophthalmologist Assistant on [DATE] at 11:54 a.m., revealed Resident #4 was diagnosed with Severe Stage Bilateral Glaucoma. Ophthalmologist Assistant explained glaucoma caused high pressure in the eye that would damage the optic nerve resulting in permanent blindness. The eye drops (Latanoprost and Dorzolamide) were prescribed to keep eye pressure down and prevent further damage. Ophthalmologist Assistant stated Resident #4 would not feel pain as a person could not feel the eye pressure increasing which was why it was important for a patient to be followed by an Ophthalmologist. Once there was vision loss it was permanent and could not be reversed. Ophthalmologist Assistant stated it was very important to continue the eye drops and if needed the eye drops could be sent to the facility. Ophthalmologist Assistant stated they had not seen Resident #4 since August so she could not speak to whether going for almost a month without the eye drops caused further damage to Resident #4's eyes.During an interview with Administrator on [DATE] at 12:38 a.m., revealed on Monday afternoon, [DATE], Resident #4's Family Member came in and notified her and ADON E of a complaint, part of which was the concern of Latanoprost and Dorzolamide eye drops being withheld for almost a month, and no one told Family Member. Due to the concerns Interim DON was brought in to hear Family Member concerns. As a result, ADON E reported that she in fact placed the eye drops on hold in March without a physician order. ADON E was placed on suspension pending investigation on [DATE] around 3:00 PM. ADON E did not report calling the physician but there were no physician's orders in the EHR. Administrator explained that the investigation started, safe surveys were started, Abuse Neglect Exploitation in-service was started, a skin and pain assessment were conducted with Resident #4 due to Family Member's other complaints. Family Member, Medical Director and Ombudsman were all notified and then a report was made to HHSC. Administrator stated she spoke with LVN R who reported she was working the night ADON E was completing the medication cart audits. ADON E reported to LVN R the Latanoprost and Dorzolamide were expired and that she put them on hold. ADON E asked LVN R to report to the oncoming nurse that they were on hold until the medications came from the pharmacy. Administrator to place a medication on hold she understood there should have been a call to the physician to receive a physician's order first. Administrator stated she spoke with LVN Q who stated LVN R reported to her the medication was on hold and LVN Q needed to take the medication off hold when the medications arrived from the pharmacy. Both LVN Q and LVN R thought everything was taken care of because ADON E was the one who placed the eye drops on hold. Administrator denied every hearing LVN Q bring up Resident #4's eye drops being unavailable and/or on hold. During an interview with the Interim DON on [DATE] at 1:00 p.m., it was revealed she had only been supporting the facility for just over a week. Interim DON explained that ADON and DON should be running a report before the clinical meeting to determine if there are unavailable medications or on hold medications. Then the ADON and DON should be discussing the medications and follow up for any clarification, making sure the physician, family and residents are notified. Interim DON stated it was important to ensure medications that were unavailable or on hold should be trouble shot to get a root cause and then ensure that no harm occurred because of the resident not having the medication. Interim DON stated the significance of a resident not receiving glaucoma medications was dependent on the individual resident as each person responded differently but glaucoma was a slowing moving illness. Glaucoma caused eye pressure to build up in the eye and eventually lead to blindness if left untreated. Interim DON stated she was not familiar with Resident #4 and what stage her glaucoma was. Interim DON denied receiving a call about the medication error involving Resident #4's eye drops. Interim DON stated she felt she and Administrator should have received a call in Saturday when the family complained due to the length of the medication error. Interim DON stated ADON E acted outside her scope as a LVN by telling nurses to not restart the Latanoprost and Dorzolamide eye drops for Resident #4. During an interview with Hospice Nurse on [DATE] at 1:19 p.m., it was revealed she had received a call around 6:00 AM from Family Member of Resident #4 regarding Resident #4's Latanoprost and Dorzolamide being discontinued. Hospice Nurse stated she had not previously been notified of a change with these medications. Hospice Nurse stated hospice did not cover the cost of glaucoma medications and did not order the medications as it was not part of the admitting diagnosis to hospice. Hospice Nurse the glaucoma medications would be ordered through the facility's pharmacy. Hospice Nurse due to their concern about Resident #4 going without the Latanoprost and Dorzolamide Hospice Nurse wrote a telephone order for the Latanoprost and Dorzolamide eye drops because they were included in the original list of medications at the time Resident #4 admitted to hospice, so the facility had an active prescription to be able to obtain the medications from the pharmacy. Hospice Nurse stated ADON E told her the eye drops had been removed from their original box with label and expiration date, so ADON E placed the eye drops on hold and stated she forgot to follow-up. Therefore, Resident #4 went without her Latano

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one (Resident #4) of 13 residents reviewed for significant medication errors. The facility failed to ensure Resident #4 was free from significant medication errors when the following were placed on hold:-Latanoprost 0.005% eye drops prescribed for once per day on hold without physician's order on [DATE] until [DATE], 25 doses were missed.-Dorzolamide 2% eye drops prescribed for two times a day on hold without physician's order on [DATE] until [DATE], 47 doses were missed. This failure had the potential to place residents at risk for not receiving the therapeutic benefits from their medication.Findings Included:Review of a Face Sheet for Resident #4 dated [DATE] revealed Resident #4 was an [AGE] year-old female who was admitted to the facility originally on [DATE] and readmitted on [DATE]. Resident #4 was diagnosed with Bilateral Primary Open-Angle Glaucoma (chronic, progressive eye disease-and the most common form of glaucoma-characterized by slow, asymptomatic damage to the optic nerve, often associated with high eye pressure. It causes irreversible peripheral vision loss, leading to blindness if untreated.)Review of Resident #4's MDS dated [DATE] revealed Resident #4 was coded to have moderately impaired vision .limited vision; not able to see newspaper headlines but can identify objects. Resident #4 wears corrective lenses .contacts, glasses, or magnifying glasses. Resident #4 was noted to score an 11 on the BIMS indicating Resident #4 had moderate cognitive impairment.Section I-Active Diagnoses.Other.Additional active diagnoses.B. Unspecified open-angle glaucoma, stage unspecified.Review of Resident #4's Care Plan dated [DATE] revealed Problem.Problem Start Date: [DATE] Category: Visual Function [Resident #4] has impaired vision related to Glaucoma.Goal.Pain will be relieved or minimized related to ocular pressure through next review.Approach.Administer drugs as ordered at appropriate times and in appropriate order.If more than one type of eye drops are ordered at same time, wait 5 minutes between administering each type of eye drop.Keep eye appointment as scheduled.Plan activities that do not place straining on the eyes.Teach resident to avoid activities that may increase intraocular pressure (URIs, emotional upset-worry, fear, anger).Review of Medication Administration Record for Resident #4 dated [DATE] revealed Resident #4 was prescribed Dorzolamide ophthalmic drops 2% two times per day. Resident #4's Dorzolamide was on hold from [DATE] until the evening dose on [DATE]. Resident #4 missed a total of 47 doses of Dorzolamide. Resident #4 was prescribed Latanoprost ophthalmic drops 0.005% one-time per day. Resident #4's Latanoprost was put on hold from [DATE]-[DATE]. Resident #4 missed 25 total doses of Latanoprost.Review of Resident #4's Progress Notes by ADON E dated [DATE] revealed .XXX[DATE] at 22:33 [10:33 PM].Patients eye drops out of date. Hospice RN CM contacted to refill: Lantaprost [sic] gtts and Dorzolamide HCL gtts. Medication placed [sic] on hold until arrival. Charge nurse to reactivate order and take off hold when arrives from hospice pharmacy.esigned by [ADON E].Review of Resident #4's Progress Notes by LVN Q dated [DATE] at 13:39 [1:39 PM].During this shift, it was identified 2 prescribed ophthalmic medication ( [sic] eye drops); Latanoprost 0.005%, and Dorzolamide 2% had been placed on hold by another nurse without notification to family, or follow-up with hospice or pharmacy. The resident's family contacted the facility requesting clarification regarding the reason for holding the medications and expressed concern about the lack of communication. This nurse reviewed the patient's chart and confirmed the absence of follow up with either hospice or facility pharmacy after documented the reason for hold was awaiting for delivery. [Hospice Agency] were contacted and verified that the prescribed glaucoma eye- [sic] drops are not covered under the hospice. [NP] was notified of the situation, including the medication hold, Dx: B/L open-angle glaucoma, and family concerns, new order to resume both Latanoprost 0.005%, and Dorzolamide2% [sic] as previously prescribed. Pharmacy was contacted promptly to process and dispense medications. confirmation was received to ensure timely delivery and continuation of therapy. The resident's family was called back, and was updated regarding the situation, including the reason for the interruption, action taken to resolve the issue, and plan to resume treatment. The family reports lack of communication between facility staff, hospice services and them.esigned by LVN Q.Review of Resident #4's Progress Notes by ADON E dated [DATE] by ADON E at 9:45 AM.Pharmacy contacted regarding status of Latanoprost 0.005%, and Dorzolamide 2% eye gtts, as orders taken off hold per EMAR. Pharmacy confirmed Dorzolamide gtts were delivered at 1800 (6pm) on [DATE]. Pharmacy also stated that Lantaprost [sic] eye gtts had not been requested for refill since [DATE]. Refill request for Lantanoprost [sic] completed both verbally with pharmacy and electronic EMAR request at this time. Ongoing follow up completed to ensure availability of medications and continuity of care. Awaiting call back from nursing to confirm that Dorzolamide gtts are on medication cart .esigned by ADON E.XXX[DATE] at 10:18 AM. Dorzolamide gtts verified present on medication cart.esigned ADON E.XXX[DATE] 10:20 AM.Lantaprost gtt [sic] hold order continues until delivery of medication by pharmacy.esigned ADON E.XXX[DATE] at 10:37 AM.[NP] notified that Lantaprost [sic] eye gtts are awaiting pharmacy delivery. Medication placed back on hold until delivery. Pharmacy states ETA for medication will be on PM med run.esigned by ADON E.Review of Resident #4's Progress Notes by ADON F [DATE] at 18:31 [6:31 PM].nurse called [Family Member] to inquire if the family would like to family to set up an appointment for the eye doctor, [family member] declined facility setting up appointment stated that she would follow up with personal eye doctor.esigned by ADON F.Review of Resident#4's Progress Notes revealed there was no documentation or follow-up by ADON E documented from [DATE] until [DATE].Review of a Pharmacy Manifest dated [DATE] revealed Resident #4's Dorzolamide Ophthalmic Solution was delivered to the facility on [DATE].Review of a Pharmacy Manifest dated [DATE] at 8:18 PM, revealed Resident #4's Latanoprost Ophthalmic Solution was delivered to the facility on [DATE].Review of Investigation Statements documented by Administrator dated [DATE] revealed On [DATE] [ADON E] and [Resident #4's Family Member] came to admin office. [ADON E] began to explain that the {Family Member] is upset she was not notified of [Resident #4's] eye drops being placed on hold. Admin stated that it is regarding clinical matters and she needed to be a part of it. [Interim DON] arrived shortly afterwards and [Family Member] expressed her concerns again. At this time [ADON E] admit that she was the one the placed the orders on hold and told the nurses to follow up. Admin reported this allegation to HHSC on 4.13.26 [Interim DON] & HR Suspended [ADON E] pending investigation Notified Physician, Medical Director, Family, Ombudsman. Abuse & Neglect Inservice. Admin reached out to [ADON] to further interview but the calf [sic]was not answered. [ADON F] Reached out to the [Family Member] to schedule an ophthalmologist appointment. [Family Member] declined and stated she has an outside one and can schedule one if she needs too but she has had glaucoma for years and is not sure she needs an appointment. Review of an Investigation Statement with LVN R dated [DATE] revealed On 4.14.26 Admin spoke with [LVN R].[LVN R] stated that on that night [ADON E] was doing an Audit she found the expired medication and she told [LVN R] that she had put it on hold that I just had to put it on the 24hr report that the nurse is to take it off hold once received from the pharmacy. I was not directed to do anything else and for me I did not think to follow up on the medication because it is not given at night so I am not triggered to remember. As a nurse when you put a medication on hold you have to get doctors' orders first, so I assumed she had done that since she told me she had already put it on hold. Additionally, I want to state that when I get orders to put a medication on hold, I get a time frame from the physician like 3-7 days that way it triggers me to review. [ADON E] put it in as an open-ended hold. Review of an Investigation Statement with LVN Q dated [DATE] revealed On 4.14.26 Admin spoke with LVN Q.[LVN Q] stated that on 3.19.26 [LVN R] reported to her on her oncoming shift that the medication was put on hold and when it comes in to take if off hold, that was all that was directed to me. It did not arrive on my shift so I did not take the medication off hold. We nurse usually call the Doctor/Family/Hospice before we put the medication on hold because we have to get orders to do that in the first place so I thought it was done because it had been put on hold during the previous shift. On 4.11.26 the [Family Member] had taken [Resident #4] to the park and called me while they were down there and had asked when was the last time, she had received her eye drops, so I looked in the chart and gave her the dates and the [Family Member] said that no one had notified her so I told her that I would look into this. So, I called hospice and they said they did not do that medication, then I called the pharmacy to see if they had it, next I called [NP] and told her what was going on and that the pharmacy had the med and asked if it was ok to take it off hold and order, [NP] told me it was ok so I did that and I documented in the chart. [ADON E] was on call and aware.Review of an Investigation Statement with RN C dated [DATE] revealed [DATE] 1:45 PM.Interview with RN C].I asked this employee what her knowledge was of the eye drops for [Resident #4]. [RN C] stated last weekend she heard the charge nurse talking about [Resident #4's] eye drops being on hold and not in the facility. [LVN Q] said they had been ordered but were not in the facility. [RN C] stated she contacted the person on call which was [ADON E]. [ADON E] informed her she had placed the med on hold and ordered the medication. [RN C] stated she had looked for it and it was not in the facility. [RN C] then stated she initiated an incident report that she then passed onto [LVN Q] to complete as she was the nurse who identified the issue. The report was then placed under the administrator's door. [RN C] went on to say all parties were notified including the physician, family, Administrator, [Interim DON]. Finally, [RN C] confirmed with [ADON E] that the med had been ordered. She said because she only works weekends she was not aware when the med arrived.During an interview with the Administrator on [DATE] at 8:53 AM, it was revealed that ADON E was suspended as a result of a self-report the facility called in. During the investigation it was learned ADON E placed Resident #4's eye drops on hold for almost a month so Resident #4 went without her eye drops for almost a month. ADON E admitted to placing Resident #4's eye drops on hold and did not get a physician's order to do so. During an interview with the Interim DON on [DATE] at 8:53 AM, it was revealed an assessment was conducted on Resident #4 and the physician and family were notified about the medication being placed on hold. Interim DON stated ADON E removed the eye drops from the medication cart while ADON E was doing an audit on a medication cart. ADON E discarded the medication and decided to put the medication on hold and told the nurse to not restart the medication until the medication was back in the building. Interim DON stated ADON E failed to get a physician's order and/or notify the physician. ADON E failed to follow through with ensuring the medication was properly reordered or obtained from a pharmacy. Interim DON stated that ADON E practiced outside the scope of nursing by placing Resident #4's eye drops on hold and giving directions to nurses without a physician's order.During an interview with a Family Member on [DATE] at 10:45 AM, it was revealed she was mostly upset with ADON E and stated ADON E blamed the nurses on the floor for not following up on the eye drops. Family Member stated ADON E needed to be held accountable as she was the supervisor who stopped the eye drops for Resident #4 and placed them on hold. Family Member stated she was not contacted by ADON E regarding the eye drops being placed on hold.During an interview with the MD on [DATE] at 11:40 AM, it was revealed she learned approximately a week ago that Resident #4 had not been receiving her glaucoma medications (eye drops). MD stated she was not notified about the eye drops being place on hold. MD stated a resident failing to receive prescribed eye drops for glaucoma could cause a worsening condition, but the condition varies per patient. MD stated no changes had been reported to her regarding Resident #4. MD stated there was confusion with Resident #4 being on hospice and whether hospice would cover the cost of the medication. MD stated hospice did not cover eye drops or order those medications ordinarily as they did not pertain to the admitting diagnosis. During an interview with ADON E on [DATE] at 2:12 PM, it was revealed she was hired as an ADON in [DATE] but had been PRN since [DATE]. ADON E explained she was not currently active in the building and did not confirm she was suspended pending investigation. ADON E stated she was doing a medication audit on the night shift when she noted Resident #4's eye drops expired. ADON E stated she removed the eye drops from the medication cart. ADON E stated she documented the information, communicated with the oncoming charge nurse, and reported it to the DON. ADON E stated she attempted to contact the hospice but only got a busy signal so she communicated with the oncoming charge nurse, and a note was left in the hospice binder. ADON E stated she asked the oncoming to communicate the medications being placed on hold and to the hospice nurse. ADON E was asked if she followed up on the eye drops being on hold and ADON E stated she documented the issues, communicated to the staff and the DON. When ADON E was asked if she communicated with the NP or the physician she stated, I'm pretty sure the doctor was aware. ADON E explained the workflow for medications not available were to place them on hold. ADON E stated she did not specifically call the physician at 3:00 AM when she was working but stated she thought she would have talked with the physician. ADON E stated in stand up during the clinical meeting she followed up and stated the eye drops for Resident #4 were discussed. ADON E stated she communicated the eye drops being on hold and stated she requested clarification. ADON E stated she sent emails to the previous DON and Administrator. ADON E stated the eye drops expired were identified as ADON and ADON E stated her job was to make sure the need for the medication was addressed and that appropriate steps were taken to get the needed medication in the building. ADON E stated she was only hearing that the medication had not been delivered by the hospice and that hospice was working on it. When asked what she could have done as ADON, ADON E stated she identified the eye drops were expired, documented the information, reported it to the Administrator and DON and followed up on what information she was receiving from the charge nurses which was that the medication was still on hold. ADON E stated she did not call the hospice again after calling on [DATE] and the phone was busy. ADON E stated she did not call Resident #4's physician, she only spoke with the administration and charge nurses. ADON E stated she did not call Resident #4's family. When asked what could have been done differently on part of her job as an ADON, ADON E repeated she identified the eye drops were expired, documented the information, reported it to the Administrator and DON. ADON E stated Resident #4 not receiving eye drops could lead to increased pressure and progression of glaucoma including loss of vision over time.During an interview with Administrator on [DATE] at 2:39 PM, revealed in the morning clinical meeting the nurses would go over each resident, anything new coming up, behaviors, any resident appointments, IVs, and if a resident had not had a BM in 72 hours. The Administrator stated she did not remember hearing that Resident #4 was without her eye drops or that the eye drops were on hold except one time when ADON E said something. The Administrator the eye drops being on hold did not come up in the clinical meeting daily. The Administrator stated there was information from the charge nurse reports a few times that they had not received the medication from the pharmacy or hospice. The Administrator stated that ADON E was assigned the task of ensuring follow-up was conducted regarding any pharmacy issues like medications not being available or received from the pharmacy. The Administrator stated she had not seen a medication stay on hold for a long period of time. The Administrator stated as the ADON/Supervisor it was up to ADON E to address problems that she may see, follow-up and find out how to fix the issues. ADONs were to help the nurses on the floor with guiding and assisting and ensuring clinical issues were being addressed. During an interview with ADON F on [DATE] at 3:41 PM, revealed she started as an ADON on [DATE]. ADON F stated when she started, she was assigned to the infection control system and ADON E was over the pharmacy systems. ADON F stated that she did not recall Resident #4's medications being brought up in the clinical meeting. ADON F stated she knew it was not discussed daily. ADON F stated she found out there was a concern with Resident #4's eye drops on Monday, [DATE] when the hospice nurse came to her about the family calling her upset about ADON E putting the eye drops for Resident #4 being placed on hold. ADON F stated the hospice nurse went ahead and ordered the eye drops because the family was upset.During an interview with Interim DON on [DATE] at 3:45 PM, revealed ADON E was assigned the pharmacy system meaning anything regarding medication, physician's orders, entering and auditing physician's orders and making sure medications were in the building with physician's being notified and Responsible Parties being notified. Interim DON heard on Monday, [DATE] when Resident #4's family complained. ADON E reported the medication was on hold. Interim DON stated she understood the nurses were going directly to ADON E because she placed the eye drops for Resident #4 on hold, originally. Interim DON stated as ADON, ADON E should have followed up to see what was going on with getting the eye drops but instead ADON E delegated everything to other people and never followed up. During an interview with Administrator on [DATE] at 8:50 AM, it was revealed she did not remember any calls related to Resident #4's eye drops over the weekend. The Administrator stated she found out about the medication error on Monday, [DATE]. The Administrator stated ADON E was the on-call nurse over the weekend and was suspended pending investigation on the afternoon of [DATE]. The Administrator stated Resident #4's family member came to see her on the afternoon of [DATE] regarding the concerns with the eye drops and some other concerns.An attempt was made to interview the former DON on [DATE] at 9:08 AM. A message was left for a return call.During an interview with the Pharmacy Consultant on [DATE] at 9:09 AM, revealed Latanoprost and Dorzolamide are used to treat glaucoma. The Pharmacy Consultant explained that a resident not receiving the eye drops could cause the eye pressure to increase but would not cause physical pain. The Pharmacy Consultant stated she did not know if the resident's vision could get blurry. The Pharmacy Consultant stated that glaucoma was silent and did not have a lot of symptoms but over years could cause the vision of a resident to lessen due to the eye not being able to take in much light. The Pharmacy Consultant stated glaucoma was a slow progression. The Pharmacy Consultant stated the most important thing for Resident #4 was to ensure the medication was restarted as soon as possible.During an interview with LVN Q on [DATE] at 9:20 AM, revealed stated that he had been working at the facility as an LVN for two years. LVN Q explained that Resident #4's eye drops were placed on hold on the night shift on [DATE]. LVN Q stated she worked the following day and was told they were waiting on the eye drops to arrive from the pharmacy. LVN Q stated on Saturday, [DATE] the family called about Resident #4's eye drops. LVN Q stated when she worked since [DATE] she would report in the morning meeting that the eye drops had not been received. ADON E was giving her the information that the medications were still on hold. LVN Q stated she was not able to unhold a medication because she did not receive the physician's order to take the medication off hold. LVN Q stated normally when a medication was placed on hold there was a stop date for when the medication was to be restarted. LVN Q stated she was not able to take an order from ADON E because she was a nurse and not a physician. LVN Q explained ADON E was the nurse to put the medication on hold. LVN Q reported to the former DON and ADON E and she would only get the response that the eye drops were still on hold. LVN Q stated she did not call hospice nor the pharmacy as a follow up. LVN Q stated ADON E should have taken care of the eye drops, called pharmacy and hospice because she executed the order. LVN Q stated there was no physician's order associated with this medication being put on hold. LVN Q stated physician's orders that were not actually physician's orders could not be passed along. An attempt was made to interview LVN R on [DATE] at 9:28 AM. A message was left for a return call.An attempt was made to interview LVN S on [DATE] at 9:38 AM. A message was left for a return call.During an interview with Resident #4 on [DATE] at 9:50 AM, revealed she was diagnosed with glaucoma some time in her 30's. Resident #4 stated she was put on eye drops twice per day, Latanoprost and Dorzolamide. Resident #4 denied experiencing vision loss, blurry vision or pain because of the glaucoma. Resident #4 stated she utilized two separate pairs of glasses for her near- and far-sighted vision. Resident #4 stated she recently went without her eye drops for a period, so she reported to her Family Member. Resident #4 stated she complained to her Family Member the eye drops had been restarted. Resident #4 stated that while she knew she was not getting the eye drops she stated she could not think of any side effects she experienced.During an interview with MA T on [DATE] at 10:25 AM, revealed Resident #4 was previously receiving eye drops (latanoprost and dorzolamide) and then they were stopped because the eye drops were put on hold. MA T stated she would ask the nurse depending on who worked. If it was agency they could not have assisted her because the agency nurses were not familiar with the residents. MA T reported to her charge nurses when the eye drops were originally placed on hold. MA T stated she did not have the ability to get the eye drops or fix the order. MA T stated she would ask about the eye drops she was only told the eye drops were on hold. MA T stated she was told ADON E put them on hold. MA T stated when medications were placed on hold, they usually had a stop date, but the eye drops did not.During an interview with Clinical Services Director (CSD) on [DATE] at 10:39 AM, it was revealed that ADONs were expected to report to the DON and act in the place of a DON if there was no DON or if the DON was not in the building. ADONs were to be involved in the daily clinical meeting including going over charting from the day before, admissions, reviewing physician's orders, reviewing incident/accidents amongst other things. CSD stated the Latanoprost and Dorzolamide being on hold for almost a month was not reported to her. CSD stated these medications being placed on hold should have been discussed in the morning clinical meeting. CSD stated any medication that needed to be placed on hold a nurse should be getting physician's order and usually the physician would provide a stop and start date for the hold time. CSD stated when she became aware of the eye drops being on hold when she reviewed ADON E had not put a stop date and there was no information about the physician being contacted. CSD stated she was informed of the medication error on Monday [DATE]. CSD stated ADON E was the clinical management on call over the past weekend. CSD stated if ADON E and/or Weekend Supervisor learned of Resident #4's family's concern over the weekend the Interim DON and Administrator should have been contacted. CSD stated she would consider this a form of neglect. CSD stated ADON E was new in her position. ADON E was described by CSD as someone who was very heightened about everything that came up as a concern, but ADON E lacked the ability to follow up and fix concerns. ADON E could identify concern but no accountability to fix issues.During an interview with Ophthalmologist Assistant on [DATE] at 11:54 AM, revealed Resident #4 was diagnosed with Severe Stage Bilateral Glaucoma. Ophthalmologist Assistant explained glaucoma caused high pressure in the eye that would damage the optic nerve resulting in permanent blindness. The eye drops (Latanoprost and Dorzolamide) were prescribed to keep eye pressure down and prevent further damage. Ophthalmologist Assistant stated Resident #4 would not feel pain as a person could not feel the eye pressure increasing which was why it was important for a patient to be followed by an Ophthalmologist. Once there was vision loss it was permanent and could not be reversed. Ophthalmologist Assistant stated it was very important to continue the eye drops and if needed the eye drops could be sent to the facility. Ophthalmologist Assistant stated they had not seen Resident #4 since August so she could not speak to whether going for almost a month without the eye drops caused further damage to Resident #4's eyes.During an interview with Administrator on [DATE] at 12:38 PM, revealed on Monday afternoon, [DATE], Resident #4's Family Member came in and notified her and ADON E of a complaint, part of which was the concern of Latanoprost and Dorzolamide eye drops being withheld for almost a month, and no one told Family Member. Due to the concerns Interim DON was brought in to hear Family Member concerns. As a result, ADON E reported that she in fact placed the eye drops on hold in March without a physician order. ADON E was placed on suspension pending investigation on [DATE] around 3:00 PM. ADON E did not report calling the physician but there were no physician's orders in the EHR. Administrator explained that the investigation started, safe surveys were started, Abuse Neglect Exploitation in-service was started, a skin and pain assessment were conducted with Resident #4 due to Family Member's other complaints. Family Member, Medical Director and Ombudsman were all notified and then a report was made to HHSC. Administrator stated she spoke with LVN R who reported she was working the night ADON E was completing the medication cart audits. ADON E reported to LVN R the Latanoprost and Dorzolamide were expired and that she put them on hold. ADON E asked LVN R to report to the oncoming nurse that they were on hold until the medications came from the pharmacy. Administrator to place a medication on hold she understood there should have been a call to the physician to receive a physician's order first. Administrator stated she spoke with LVN Q who stated LVN R reported to her the medication was on hold and LVN Q needed to take the medication off hold when the medications arrived from the pharmacy. Both LVN Q and LVN R thought everything was taken care of because ADON E was the one who placed the eye drops on hold. Administrator denied every hearing LVN Q bring up Resident #4's eye drops being unavailable and/or on hold. During an interview with the Interim DON on [DATE] at 1:00 PM, it was revealed she had only been supporting the facility for just over a week. Interim DON explained that ADON and DON should be running a report before the clinical meeting to determine if there are unavailable medications or on hold medications. Then the ADON and DON should be discussing the medications and follow up for any clarification, making sure the physician, family and residents are notified. Interim DON stated it was important to ensure medications that were unavailable or on hold should be trouble shot to get a root cause and then ensure that no harm occurred because of the resident not having the medication. Interim DON stated the significance of a resident not receiving glaucoma medications was dependent on the individual resident as each person responded differently but glaucoma was a slowing moving illness. Glaucoma caused eye pressure to build up in the eye and eventually lead to blindness if left untreated. Interim DON stated she was not familiar with Resident #4 and what stage her glaucoma was. Interim DON denied receiving a call about the medication error involving Resident #4's eye drops. Interim DON stated she felt she and Administrator should have received a call in Saturday when the family complained due to the length of the medication error. Interim DON stated ADON E acted outside her scope as a LVN by telling nurses to not restart the Latanoprost and Dorzolamide eye drops for Resident #4. During an interview with Hospice Nurse on [DATE] at 1:19 PM, it was revealed she had received a call around 6:00 AM from Family Member of Resident #4 regarding Resident #4's Latanoprost and Dorzolamide being discontinued. Hospice Nurse stated she had not previously been notified of a change with these medications. Hospice Nurse stated hospice did not cover the cost of glaucoma medications and did not order the medications as it was not part of the admitting diagnosis to hospice. Hospice Nurse the glaucoma medications would be ordered through the facility's pharmacy. Hospice Nurse due to their concern about Resident #4 going without the Latanoprost and Dorzolamide Hospice Nurse wrote a telephone order for the Latanoprost and Dorzolamide eye drops because they were included in the original list of medications at the time Resident #4 admitted to hospice, so the facility had an active prescription to be able to obtain the medications from the pharmacy. Hospice Nurse stated ADON E told her the eye drops had been removed from their original box with label and expiration date, so ADON E placed the eye drops on hold and stated she forgot to follow-up. Therefore, Resident #4 went without her Latanoprost and Dorzolamide eye drops for a period.During an interview with Administrator and CSD on [DATE] at 2:30 PM, it revealed ADON E was terminated from the facility effective [DATE]. ADON E was not excepting any calls from the facility or Administrator at the time, but Human Resources would be mailing her termination notice through certified mail.During an interview with RN C on [DATE] at 3:14 PM, revealed she was the Weekend RN Supervisor. RN C stated over the weekend it was brought to her attention Resident #4 had not had her Latanoprost or Dorzolamide in almost a month. LVN Q stated both were put on hold. RN C stated she checked the medication cart and medication refrigerator and could not locate the eye drops for Resident #4. RN C stated she called the on call clinical manager who was ADON E. ADON E confirmed the Latanoprost and Dorzolamide were on hold and explained they were both expired. RN

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of seven (Resident #5 and Resident #6) residents observed for infection control. 1. The facility failed to ensure the Treatment Nurse performed hand hygiene during wound care for Resident #5 on 04/15/26. 2. The facility failed to ensure LVN L utilized Enhanced Barrier Precautions while transferring Resident #6 from bed to wheelchair and wheelchair to toilet on 04/16/26 and failed to perform hand hygiene before leaving the room. These failures could place residents at risk for infection and cross contamination.Findings included:1. Record review of Resident #5's undated face sheet reflected a [AGE] year-old female admitted [DATE], diagnosis included acute embolism and thrombosis of right tibial vein (blood clot lower leg).During an interview on 04/15/26 at 10:30 a.m., Resident #5 stated she had been admitted to the facility with bruises on her abdomen from the lovenox injections (anticoagulant) she was receiving due to a blood clot in her leg. Resident #5 stated she was glad they had recently stopped the lovenox, stating she was tired of getting stuck so much. Resident #5 stated she had a wound on the back of her right leg which the facility was treating every day. During an observation and interview on 04/15/26 at 10:55 a.m., the Treatment Nurse was observed at the treatment cart preparing wound care supplies for Resident #5. The Treatment Nurse stated Resident #5 had a small lesion on the back of her right calf the doctor thinks might be skin cancer. The Treatment Nurse gathered her supplies, performed hand hygiene, put on a gown and then put on 3 pairs of gloves one on top of the other, on both hands. The Treatment Nurse entered Resident #5's room and removed the old dressing from the wound. The wound had moderate amount of blood-tinged drainage. The Treatment Nurse then removed the top pair of gloves and proceed to clean the wound with normal saline. The Treatment Nurse then removed the second pair of gloves and applied a small piece of calcium alginate (absorbent type of dressing) to the wound and covered with a dry dressing. The Treatment Nurse then removed the final pair of gloves, her gown and performed hand hygiene. During an interview with the Treatment Nurse on 04/15/26 at 11:10 a.m., she stated she was supposed to perform hand hygiene before and after wound care. She stated she had put on 3 pairs of gloves as convivence for her. She stated she was supposed to perform hand hygiene after gloves changes and stated she should not had triple gloved. She stated the risk to the resident was spread of infection. 2. Record review of Resident #6's undated face sheet reflected a [AGE] year-old male, admitted [DATE]. Diagnoses included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production), chronic viral hepatis C (virus that cause liver inflammation) and hemiparesis unspecified side (weakness affecting one side of the body).During an observation and interview on 04/16/26 at 8:05 a.m., Resident #6 was heard yelling I need help to get up, I need help. The call light was illuminated but no audible sound was heard. An Enhanced Barrier sign was posted outside of Resident #6's room and a cart containing gloves and gowns were also outside of the door. LVN L was observed walking down the hallway and entered Resident #6's room. LVN L then proceeded to transfer Resident #6 from his bed to his wheelchair without putting on gloves or gown. Resident #6 was observed with a dressing on his lower left leg. LVN L then pushed Resident #6 into the bathroom and assisted him to the toilet and told him to call when he was finished. LVN L then checked the bed and determined it was not raising up to chair level which was why Resident #6 was unable to get out of bed. She stated she would notify maintenance to see what was wrong with the bed. LVN L then left the room without performing hand hygiene, walked down the hall and used the hand sanitizer from the hall dispenser. During an interview with LVN L on 04/16/26 at 8:10 a.m., LVN L stated she was not sure if Resident # 6 was on Enhanced Barrier precautions, but stated she guessed he would be since had had a bandage on his leg. She stated she knew when a resident was on enhanced barrier precautions they were to wear gloves during direct care but stated she was not sure about the gown. She stated Enhanced Barrier precautions was new to her and stated she guessed she needed some more training related to what to wear and when to wear it. She stated she used the hand sanitizer in the hallway and thought that was acceptable. During an interview on 04/17/26 at 8:00 a.m., Resident #6 stated he was usually able to get out of the bed by himself but stated yesterday (04/16/26) he could not get his bed to rise up where he could slide over into his wheelchair. Resident #6 stated he had asked the staff why they were wearing gowns when they helped him and they told him it was to protect him. He stated not all of the staff wore the gowns. He stated he did have a wound on his leg the staff was treating every day. During an interview on 04/17/26 at 4:06 p.m., the Clinical Service Director stated staff were to change their gloves and perform hand hygiene during wound care. She stated they were to remove their gloves after removing the dressing and cleaning the wound, prior to applying the treatment for the wound. She stated they were never taught to double or triple glove. She stated by not following proper glove changes and hand hygiene it placed residents at risk of cross contamination. She stated they had done extensive in-services with the staff on infection control, especially hand hygiene and the use of Enhanced barrier precautions. She stated any resident with a wound, a catheter, or a G-tube required the use of gown and gloves during any high contact care. Record review of the facility's undated policy titled, Performing A Dressing Change, reflected, .Wash hands before and after donning gloves.Don gloves.Remove old dressing.change gloves.Cleanse the wound of drainage, debris, or dressing/filler residue.change gloves.Apply a cover dressing-date and initial cover dressing.remove gloves. Record review of the facility's policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, dated May 2023, reflected, Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP will be implemented for All resident with the following.Wounds and/or indwelling medical devices (urinary catheter, feeding tube.)regardless of MDRO colonization status.EBP will be implemented during the following high-contact resident care activities.Transferring.Providing hygiene.changing briefs or assisting with toilet.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two of six (Residents #1 and #2) reviewed for comprehensive care plans. 1. The facility failed to include, in the care plan for Resident #1 created on 03/18/26, and revised on 04/15/26, the colostomy and the necessary care and interventions. 2. The facility failed to include, in the care plan for Resident #2 last revised on 04/06/26, the midline catheter inserted on 03/27/26, and the necessary care and interventions. These failures could place residents at risk of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of Resident #1's undated Face Sheet reflected a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated his cognition was intact, he had a urinary catheter, colostomy (surgical procedure that creates an opening in the abdomen to the colon) and abscess (collection of pus and dead tissue) to the groin (junction area between the lower abdomen and inner thigh) and perineum (area between the anus and the genitals) Record review of Resident #1's care plan completed on 03/19/26 reflected the resident was a new admission post sepsis. Goals were to identify the residents' immediate health and safety needs. Approaches included Catheter use for wound management. Turn and reposition. Treatments- see Physician orders. There was no care plan addressing Resident #1's colostomy, goals, or interventions. Record review of Resident #1' progress note on 03/18/26 at 2:59 a.m. by Agency LVN K, reflected, Resident admitted to facility from [hospital name] .Resident has a colostomy that is intact and draining semi solid waste material.Foley catheter put in today at hospital with about 500 ml clear amber urine output.Had a number of surgeries in the hospital including colostomy. During an interview and observation on 04/15/26 at 2:40 p.m., Resident #1 and his family member revealed he had returned to the facility late on 04/10/26 after a short stay in the hospital for re-evaluation of his wounds. Resident was observed with a urinary catheter and a wound vac at the bedside set to 125 mmhg (pressure). Resident #1's family member stated he had multiple surgeries and skin grafts, and they had to do a reversable colostomy to help with the healing of the wounds as well as the urinary catheter. She stated the hospital sent him to this facility around the middle of March 2026. Resident #1's family member stated since his return, he had been receiving colostomy care and catheter care. 2. Record review of Resident #2's undated Face sheet reflected a [AGE] year-old-femle admitted [DATE]. Diagnosis included encephalopathy (disturbance of brain function) cellulitis (bacterial infection of the skin), urinary tract infection, and pressure ulcers. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderately impaired cognition. She had a foley catheter, was always incontinent of bowel, and had not received intravenous therapy while a resident. Record review of Resident #2's Physician order history report from 03/21/26 through 04/17/26 reflected: 3/27-26-OK to start midline (8-12 cm peripheral venous access device inserted into upper arm veins) for long term IV fluids infusion . No discontinuation date noted 03/27/26-Sodium chloride 0.9% parenteral solution- amt: 3 liters at 80 ml/hr. continuous- Discontinued on 03/31/26. 03/27/26-when Peripheral line catheter not in use: flush every 12 hours with 10 ml NS.start date 03/27/26 and discontinued date of 04/07/26. Scheduled at 12 midnight and 12 noon each day. 04/10/26- OK to start PICC/midline for intravenous infusion- one time orderRecord review of Resident #2's Care plan date 4/15/26 did not address the resident's mid-line catheter. An interview with RN B on 04/15/26 at 3:36 p.m. revealed he worked 12-hour shifts from 6 a.m. to 6 pm. He stated he and RN D, who worked the 6 p.m. to 6 a.m. shift, worked the same rotation. He stated Resident #2 was admitted to the facility with very poor nutrition, failure to thrive, and wounds. He stated her oral intake was poor and the NP ordered a midline catheter to be placed and for Resident #2 to receive 3 liters of normal saline. He stated they were to leave the midline in after completion of the fluids and flush every 12 hours to keep it patent (open) in case she needed some additional fluids. He stated his last shift on 04/03/26, Resident #2's midline was patent and flushing well. He stated when he returned to work on 04/06/26, he was told by RN D when she came to work for the 6 p.m. to 6 a.m. shift (which begins on 04/05/26 and ended 04/06/26) the midline was not present. He stated they had re-inserted another midline on 04/10/26 for additional fluids and he was waiting for orders to discontinue the midline. During an observation and interview on 04/16/26 2:25 p.m. with Resident #2, she stated she was trying her best to eat and drink more. Resident #2 was observed with a midline in place in her right upper left arm. Dressing was intact, clean and dry. During an interview with MDS Nurse G on 04/17/26 at 2:39 p.m., She stated that she and MDS Nurse P were responsible for completing and updating the comprehensive care plans when they completed the initial, quarterly, significant change assessment and annual assessments. She stated the DON and ADONs updated the care plans when there were changes. She stated the nurses, and usually the ADONs, did the baseline care plan upon admission of a resident, and would need to keep it updated until the comprehensive care plan was completed. She stated urinary catheters, midline catheters, colostomies all should be care planned to ensure they addressed the interventions, and needs of the resident. She stated the care plan was the tool that provided an overall plan as to the needs and wishes of the resident. An Interview on 04/17/26 at 4:10 p.m. with the Clinical Service Director revealed the MDS Coordinators, the DON, and the ADONs were all responsible for updating the care plans. She stated the floor nurses were responsible for starting the care plan upon admission and should include all aspects of the resident's immediate care needs, which would include, colostomies, catheters and midline catheters. She stated the care plan was a comprehensive look at all the residents' needs and what the facility was doing to address those needs. She stated failing to have the care plan completed and updated could result in unmet needs. Record review of the facility's policy, Care Plan Process, Person-Centered Care, revised May 2023, reflected, The facility will develop and implement a .comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality.

Based on interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for one of two residents (Resident #2) reviewed for peripheral intravenous care. 1. The facility failed to ensure Agency LVN K obtained physician's orders for the removal of Resident #2's midline intravenous catheter on 04/04/26. 2. The facility failed to document the removal of Resident #2's midline catheter on 04/04/26. These failures placed the resident at risk of ensuring the midline was removed properly and intact which could lead to infection and embolism, and communicated with oncoming staff for further monitoring.Findings included: Record review of Resident #2's undated Face sheet reflected a [AGE] year-old-femle admitted [DATE]. Diagnosis included encephalopathy (disturbance of brain function) cellulitis (bacterial infection of the skin), urinary tract infection, and pressure ulcers. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 12 indicating resident was moderately cognitively impaired. She had a foley catheter, was always incontinent of bowel, and had not received intravenous therapy while a resident. Record review of Resident #2's Physician order history report from 03/21/26 through 04/17/26 reflected: 3/27-26-OK to start midline (8-12 cm peripheral venous access device inserted into upper arm veins) for long term IV fluids infusion .No discontinuation date noted 03/27/26-Sodium chloride 0.9% parenteral solution- amt: 3 liters at 80 ml/hr. continuous Discontinued on 03/31/26. 03/27/26- when Peripheral line catheter not in use: flush every 12 hours with 10 ml NS.start date 03/27/26 and discontinued date of 04/07/26. Scheduled at 12 midnight and 12 noon each day. Record review of Resident #2's April 2026 MAR/TAR revealed the midline was flushed every 12 hours from 04/01/26 through 12 noon 04/03/26 by RN B 6 a.m.-6 p.m. shift, and by RN D 6p.m. to 6 a.m. shift. On 04/04/26, Agency LVN K signed off the midline was flushed at 7:13 a.m. (for the midnight flush time). Record review of Nursing progress notes for Resident #2 reflected: 04/04/26 6:21 a.m. recorded as Late Entry on 04/05/26 at 6:23 a.m. by Agency LVN M-No midline is noted 04/06/26 at 3:42 p.m. by RN B reflected.Midline to Right upper arm is no longer present.She [Resident #2] completed her course of ABT (antibiotics) on 04/03.NP was contacted for notification of condition and who ordered DC (discontinuation) of midline. No further orders at this time. 04/07/26-10:17 a.m. by RN B reflected Resident is eating better today.dark amber urine with noted sedimentation.NP was notified and this RN inquired whether she wants to order IV fluids for resident.No IV fluids midline ordered at this time . An interview with RN B on 04/15/26 at 3:36 p.m. revealed he worked 12-hour shifts on 6 a.m. to 6 pm. He stated he and RN D, who worked the 6 p.m. to 6 a.m. shift worked the same rotation. He stated Resident #2 was admitted to the facility with very poor nutrition, failure to thrive and wounds. He stated her oral intake was poor and the NP ordered a midline catheter to be placed for Resident #2 to receive 3 liters of normal saline. He stated they were to leave the midline in after completion of the fluids and flush every 12 hours to keep it patent (open), in case she needed some additional fluids. He stated his last shift on 04/03/26, Resident #2's midline was patent and flushing well. He stated when he returned to work on 04/06/26, he was told by Agency LVN N, when she came to work for the 6 p.m. to 6 a.m. shift (which begins on 04/05/26 and ended 04/06/26), the midline was not present. He stated he notified the Interim DON and the NP who declined to have another midline placed at that time, but she later re-ordered another midline on 04/10/26 for additional round of IV fluids. He stated he thought they determined it was Agency LVN K who possibly had discontinued the midline on 04/04/26, but he could not be sure. He stated they were required to have a physician's order to discontinue a midline catheter, and they had to document the procedure, which included if the catheter came out intact, or showed any signs of damage. He stated in addition they had to assess the insertion site for signs of infection, and cover the insertion site with a dressing to prevent risk of infection. He stated he was currently waiting for orders to discontinue the midline. During an interview on 04/16/26 2:25 p.m. with Resident #2, she stated she did not remember what happened to her midline catheter in her right arm. She stated she was so out of it, at that time, she did not remember if someone took it out, or if it came out. She stated she was feeling a little better, but she still did not have an appetite. She stated she was trying her best to eat and drink more. During an interview on 04/16/26 at 7:12 p.m. with RN D she stated when she returned to work, on her 6 p.m. to 6 a.m. shift on 04/06/26, she received report from RN B that someone had discontinued the midline catheter on Resident #2, and he was following up with the doctor to determine if they needed to have it re-inserted. She stated she was unable to locate an order to have the midline discontinued. She stated they had to have an order to discontinue a midline catheter and had to document the procedure, describe the condition of the catheter and the insertion site. Attempts were made to reach Agency LVN K on 04/17/26 at 12:50 p.m. with no answer and no return call. An interview on 04/17/26 at 4:10 p.m. with the Clinical Service Director revealed her expectation was for the nurses to check the midlines every shift and follow physician orders for flushing, and document once the procedure had been completed. She stated they had to have a physician order to discontinue a midline, and the staff should be documenting the procedure and documenting the condition of the line upon removal and assessing the insertion site and how the resident tolerated the procedure. She stated they needed an overall re-education for the nurses on documentation requirement. She stated they had a book of protocol and procedures at the nursing station for the Agency staff as well. She stated failure to obtain an order could result in a midline being removed when it shouldn't and failing to document the removal the oncoming staff would not know what to assess for if there had been complications during the removal. Record review of the facility's undated procedure, Removing PICC, reflected, .Verify the practitioners orders to discontinue catheter.After successful removal of the catheter, apply manual pressure to the site and just above the site with a sterile gauze pad for a minimum of 30 seconds or until hemostasis is achieved. Cover the site with a petroleum-based ointment and sterile dressing for at least 24 hours.Assess the integrity of the removed catheter. Compare the length of the catheter with the original insertion length.If you note any damage, notify the practitioner immediately.Document the procedure.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 5 (100 Hall nurse medication cart) medication carts reviewed for medication storage:The facility failed to ensure all medication including insulin pen were not left unsecure and unattended on the 100 hall nurse medication cart. This failure could place residents at risk of having access to unauthorized medications and/or lead to adverse drug reactions or drug diversions. Findings included:During an observation on 04/15/2026 at 12:02 PM, the Hall 100 nurses medication cart was observed to have an insulin pen, lancets and glucometer strips sitting out on top of the medication cart. The medication cart was locked and there was no nurse or staff member at the medication cart, four different staff members were observed to walk past the medication cart . During an observation and interview on 04/15/2026 at 12:09 PM, revealed RN B was walking from down the hallway from a resident room. RN B walked up to the 100 Hall nurse medication cart, unlocked the medication cart and placed the insulin pen, lancets and glucometer strips in the top drawer. RN B stated it was the facility policy to make sure the medication cart was locked and secured 100% of the time when he walked away. RN B stated he never left medications out on top of the cart. Investigator pointed out the insulin and RN B stated he neglected to place the insulin pen back in the medication cart. RN B stated failing to put away medications could result in someone having access to the medication. During an interview with the CSD on 04/16/2026 at 10:39 AM, it was revealed that it was the policy of the facility for all medications to be locked inside of a medication cart or in the medication room when it was unattended. The CSD stated no medication should be left out on the top of the medication cart due to concerns for resident, visitor, and staff safety if the medication was to be picked up by someone. The CSD stated it was up to nursing management to do walking rounds to ensure medications were secured at all times.Review of Medication Storage policy dated 04/17/2024 revealed .POLICY: 1. Medication and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State Federal laws, the facility store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. PROCEDURES: 1. The LTC Pharmacy Provider dispenses medication and biologics in packaging/containers that meet regulatory requirements. Medications and biologicals shall be kept and stored in these packages/containers. Transfer of medications and biologicals from one container to another is not permitted, except by a licensed pharmacist. 2. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented and systematically organized for two of four (Resident #1 and Resident #2) reviewed for clinical documentation. 1. The facility failed to ensure staff documented Resident # 1's wound care on the MAR/TAR, that was provided or declined, from 04/11/26 through 04/14/26.2. The facility failed to ensure Resident #2's foley catheter physician order reflected the foley catheter size, the amount required for the [NAME], and the rationale for its use. This failure could place residents at risk of not receiving treatments as ordered which could impact the residents' health and recovery. Findings included:Record review of Resident #1's undated Face Sheet reflected a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected a BIMS of 15 which indicated he was cognitively intact, had a urinary catheter, colostomy (surgical procedure that creates an opening in the abdomen to the colon) and abscess (collection of pus and dead tissue) to the groin (junction area between the lower abdomen and inner thigh) and perineum (area between the anus and the genitals) Record review of Resident #1's care plan completed on 03/19/26 and revised on 04/15/26 did not address Resident #1's colostomy. Record review of Resident #1 progress note by RN B on 04/10/26 at 5:49 p.m. reflected, Resident returned from hospital admission at this time. He was accompanied by his [family member] and two transport personnel who transferred him to bed via manual lift. Diagnosis: Perineal (area between genitals and rectum) Abscess wound complication. He is alert and oriented x 4, on a regular diet and requires assistance with ambulation. NP [name] was notified of patient's arrival. His wound vac (negative pressure wound therapy device) was assembled and connected to the machine and power source was plugged. Suction pressure was set to intermittent 125 mmHg of pressure. The skin and all system assessment was deferred at this time. Record review of Resident #1's progress note by RN D on 04/10/26 at 10:00 p.m. reflected, The skin assessment done- Surgical wound site to coccyx (base of the spine) area. Another wound noted on perineum and scrotum, Wound vac noted.skin grafted site on right upper leg- Reddened area noted. Suture marking on both upper legs on inner aspects of thigh.Last foley changed on 04/09/26. Last colostomy bag changed on 04/09/26. There was no documentation to reflect what treatment to the wounds was provided. Record review of Resident #1's Electronic Record reflected no evidence that wound care was provided or declined on 04/11/26. Record review of Resident #1' progress note by RN B on 4/12/26 at 3:46 p.m. reflected, Resident informed this RN at this time that he wishes to defer wound care treatment until 4/13. Record review of Resident #1 progress noted dated 04/13/26 at 4:51 p.m. by the Treatment nurse (recorded as Late entry on 04/15/26 5:00 p.m.) reflected, Writer rounded on resident today for weekly wound care rounds. Wound vac in place to sacrum. Currently set to 125 mmhg. Suctioning noted. MD also assessed peri/groin incisions intact. No open areas noted lower extremities. MD to reinstate previous orders. Record review of Resident #1's Electronic Record reflected no evidence that wound care was provided or declined on 04/14/26. During an interview and observation on 04/15/26 at 2:40 p.m., Resident #1 was observed in bed with a wound vac in place and a urinary catheter. Interview with Resident #1 and his family member revealed he had returned to the facility late on 04/10/26 after a short stay in the hospital for re-evaluation of his wounds. Resident #1 stated he was getting wound care daily but had started to have increased drainage and they sent him out to the hospital for evaluation on 04/06/26. He stated he did not have a wound vac prior to going to the hospital. Resident #1's family member stated since his return on 04/10/26 he had been receiving wound care. During an interview on 04/15/26 at 3:32 p.m. with the Treatment Nurse she stated Resident #1 re-admitted to the facility on the evening of 04/10/26 and the hospital had not sent any wound care orders. She stated she had obtained wound care orders on Monday 04/13/26 from the facility's wound care physician which was to resume the previous wound care orders, with the exception of the wound vac and she was still trying to verify with the hospital the orders. She stated she obtained the orders for the wound vac on 04/14/26. She stated she should had restarted the orders she had on 04/13/26 and then added the wound vac orders. She stated the nurse doing the admission should had reached out to the hospital, or herself and she could had reached out to the wound care physician for the facility or the weekend supervisor could had reached out as well. She stated she provided Resident #1 wound care on 04/13/26 and 04/14/26, it just was not documented. She stated the risk of not having orders upon admission were wounds could not receive treatment and could decline and become worse or infected. She stated it was the expectation any treatment provided needed to be documented on the MAR/TAR, so it was clear what treatment were provided and by whom. During an interview on 04/15/26 at 3:36 p.m. RN B revealed he had started Resident #1's re-admission to the facility. He stated Resident #1 did not come from the hospital with wound care orders. He stated RN D completed the skin assessment and dressing change on 04/11/26 and the resident declined to have wound care on 04/12/26. He stated it was the admitting nurse's responsibility to input the admission orders, and the DON and the ADONs would review the orders the next day or on Monday if it was a weekend admission. He stated they had to have orders to meet the needs of the resident. He stated it was the expectation to document any treatment provided on the MAR/TAR to show a treatment was completed or if it was declined. He stated he documented in the progress note about the Resident's refusal but stated there was nothing on the MAR/TAR since no orders had been put in the system. 2. Record review of Resident #2's undated Face sheet reflected a [AGE] year-old-femle admitted [DATE]. Diagnosis included encephalopathy (disturbance of brain function) cellulitis (bacterial infection of the skin), urinary tract infection, and pressure ulcers. Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 12 indicating resident was moderately cognitively impaired. She had a foley catheter, was always incontinent of bowel, and had not received intravenous therapy while a resident. Record Review of Resident #2's care plan initiated on 04/02/26 reflected, [Resident #2] requires an indwelling urinary catheter related to urinary retention and urinary tract infections.Interventions.Change catheter per MD order. Record review of Resident #2's Physician order history report from 03/21/26 through 04/17/26 reflected: Indwelling foley catheter ___Fr (unit of measurement), ____cc's for______ Diagnosis____ continuous, with a start date 03/16/26. No size of the catheter, the bulb size or rationale for use was identified May change foley catheter for obstruction or dislodging as needed, with a start date of 03/16/26 During an observation and interview on 04/16/26 2:25 p.m., Resident #2 was observed to have a urinary catheter. Resident #2 stated she was not sure how long she had the catheter and was not certain why she had it. She stated she did have a wound on her bottom, the facility was treating. During an interview on 04/16/26 at 10:50 a.m. with the Clinical Service Director, she stated the previous DON had been gone since the end of March 2026, and both the ADONs were new to their roles. She stated it was the expectation, any resident admitted to the facility, had to have orders to provide the necessary care the resident needed, which would include wound care orders, urinary catheter care orders, and depicting the size of the catheter and bulb size. She stated daily orders would need to be clarified immediately in order to provide the residents with the necessary care they needed. She stated any treatment provided was expected to be documented on the MAR/TAR, and reflect what treatment was provided. She stated not having a clear and concise clinical record could delay resident treatments which could result in a decline in the residents' overall well-being and recovery. She stated they identified the facility had documentation issues and had a mobile DON who was to start on 04/20/26 along with corporate support for training needs. Review of the facility's policy, Documentation guidelines dated January 2024, reflected, Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the patient's/resident record. A complete health pictures of the patient/resident must be available to all disciplines contributing to patient/resident care. Documentation in the electronic medical record (EMR) and paper versions comply with professional standards.

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart Hall 100) of 4 medication carts reviewed for pharmacy services.The facility failed to ensure Licensed Vocational Nurse A counted controlled drugs every change of shift and signed the medication sheet form after the count while she was responsible for the Medication Cart on Hall 100.The failure could place residents at risk of not having the medication available due to possible drug diversion.Findings Included:Record review of the Medication Cart on Hall 100's medication count sheet on 02/26/26 at 10:16 AM revealed missing signatures for shift change counts for Off duty and On duty for 02/03/26, 02/06/26, 02/08/26, and 02/12/26.Interview on 02/26/26 at 2:15 PM, Director of Nursing B stated the staff were trained by a nurse to perform counts at the beginning and end of their shift on the medication cart that they were assigned to during their shift. She stated the person either not signing on or not signing off was not doing a good job at protecting their nursing license if something were to be discovered later. She stated that she would be unable to prove that the staff successfully counted if they did not sign on or sign off on the count sheet. She stated that she expected the nurses to sign the medication count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse.Interview on 02/26/26 at 2:30 PM, Licensed Vocational Nurse A stated she wished that the medication count sheet was easier to understand and on one line. She stated that she got confused when she must sign on the right side of the sheet when signing onto her shift but then she must go down to the next line and sign on the left side of the sheet when she was signing off from her shift. She stated that she knew that she should have signed the medication sheet after counting the medications on 02/03/26, 02/06/26, 02/08/26, and 02/12/26. She stated that she understood the importance of signing the count sheet because it was proof that she counted with the other nurse. She stated that she did perform the counts as required. She stated she was trained to sign the sheet right after counting.Review of facility policy dated 01/15/25 and titled Medication Management Program reflected the following: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements.Security and Safety Guidelines: 9. Controlled substances are accounted for each patient/resident on a Controlled Substance Record (obtained from the contract pharmacy). A. Substances are counted by the authorized staff members at each change of shift.

Based on interview, and record review, the facility failed to administer medications according to physician's orders for 1 of 4 residents (Resident #1) reviewed for medications. The facility failed to follow Physician D's order by applying a second Lidocaine patch by accident to Resident #1. This failure could place residents at risk of harm by not receiving their medication as instructed by physician. Findings included: Review of the Care Plan dated 02/09/2026 for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included HIV (Human Immunodeficiency Virus is a virus that attacks the body's immune system which can lead to AIDS (Acquired Immunodeficiency Syndrome), Seizures, Hypokalemia (Low potassium levels), Cellulitis (Bacterial skin infection), Anxiety (Excessive worry or unease), Vitamin deficiency, Muscle Weakness, Neuralgia (Intense sudden and sever facial pain), Neuritis (Nerve or inflammation of the nervous system), Candidal balantis (Inflammation of the penis), Constipation (Difficulty passing hard stools), Neuromuscular dysfunction (impair the communication between nerves and muscles, leading to muscle weakness, atrophy, and impaired movement), Paraplegia (Paralysis that affects the lower half of the body), Depression (Persistent feelings of sadness or loss of interest), Nausea with vomiting (mild digestive issues to more serious illnesses), Insomnia (Difficulty falling asleep, staying asleep, or waking up to early), Hyperosmolality and hypernatremia (Cellular dehydration from water loss or sodium gain), Hypertension (High blood pressure), Atopic dermatitis (Dry, itchy, or inflamed skin, Scabies (Skin infestation caused by mites). Review of the BIMS (Brief Interview for Mental Status) dated 01/23/2025 for Resident #1 revealed that he received a score of 15, indicating his cognition was intact. Review of the physician's orders for Resident #1 reflected an order was written on 01/04/26 for Lidoderm (Lidocaine) adhesive patch, medicated 5%; amount to administer: 1; topical. The order was for 9:00 AM to be put on the left hip and to be removed at 9:00 PM. Review of the MAR (Medication Administration Record) dated 01/16/2026 for Resident #1 revealed that Medication Aide B administered the Lidocaine patch as scheduled at 9:00 AM. Review of the Progress Note dated 01/16/2026 entered at 2:39 PM revealed that Licensed Vocational Nurse A administered a lidocaine patch on the left lower hip area of Resident #1 and did not notice the other lidocaine patch that was located higher up on the left hip area that was being covered by Resident #1's briefs. Once the situation was discovered, Licensed Vocational Nurse A removed the additional Lidocaine patch. During an interview on 02/11/2026 at 1:25 PM, Director of Nursing C stated the Lidocaine patch incident happened, was found, and was corrected within 30 minutes. The resident told them directly that the staff applied an additional Lidocaine patch without taking the first one off. During an interview on 02/11/2026 at 1:30 PM, Administrator E stated Resident #1 was saying the staff was double dosing him with the lidocaine patch. She stated that she asked Resident #1 who gave him the additional Lidocaine patch. She stated that he said Licensed Vocational Nurse B. She stated that she personally looked. Resident #1 did have two Lidocaine patches on. It was an over-the-counter lidocaine patch. The second Lidocaine patch was removed. The physician was notified and said there was no risk. The physician said just to monitor but that there was no adverse reaction. During an interview on 02/11/2026 at 2:04 PM, Medication Aide B stated that Resident #1 received a Lidocaine patch at 9:00 AM and had it removed at 9:00 PM. She stated that on 01/16/2026 she did give Resident #1 a Lidocaine patch at 9:00 AM. She stated that when she gave him the Lidocaine patch he did not already have one on him. She stated that Licensed Vocational Nurse A applied a second Lidocaine patch shortly after her. During an interview on 02/11/2026 at 2:34 PM, Licensed Vocational Nurse A stated that she did administer an additional Lidocaine patch to Resident #1. She stated it was by accident. She stated that she was passing medications to Resident #1. She stated Resident #1 also was scheduled to receive a Lidocaine patch at the same time. She stated that she gave him his medication and left to go get the Lidocaine patch. When she returned, she stated that she did not see the Lidocaine patch that must have been given in the time period in between from when she left to get the Lidocaine patch and when she returned with the additional Lidocaine patch. She stated that Resident #1 was verbal and could have communicated to her that he had just been given a Lidocaine patch but instead he did not tell her that Medication Aide B had just came into the room and gave him a Lidocaine patch. She stated that he was verbal and even told her where he would like to have the Lidocaine patch applied. She stated that Resident #1 had called for Director of Nursing C and told her about the additional Lidocaine patch that was put on by Licensed Vocational Nurse A. She stated that Director of Nursing C asked her about the additional Lidocaine patch and she stated that she did not see a Lidocaine patch on Resident #1 at the time that she gave him the Lidocaine patch at 9:12 AM. She stated that she went back to Resident #1's room and looked for the Lidocaine patch and discovered that it was higher up on his left hip area than where she applied hers. She stated that Resident #1 must have moved the patch on his own or it could have moved on its own from Resident #1 repositioning in the bed. She stated that normally Medication Aide B would be the one to apply the Lidocaine patch but on that day he was complaining about wanting a nurse to apply the patch so that was why she did it. During an interview on 02/18/26 at 12:20 PM, Nurse Practitioner F stated that the risk of injury from an additional Lidocaine patch for 20 minutes to Resident #1 would be very low. Review of facility policy dated 01/15/2025 and titled Medication Management Program reflected the following: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Preparing for the Medication Pass4. Authorized staff must understand: D. The 8 Rights for administering medication: 1) The Right Patient/Resident 2) The Right Drug 3) The Right Dose 4) The Right Time 5) The Right Route 6) The Right Charting 7) The Right Results 8) The Right Reason 5. The same person authorized medical or licensed person prepares, administers,and records the medications.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 9 residents reviewed for ADLs. The facility failed to ensure Resident #1 had facial hair on her chin removed on 01/07/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.Findings include: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included non-Alzheimer's dementia (types of cognitive decline not caused by Alzheimer's disease), and hypertension (elevated blood pressure). Resident #1's BIMS score was a 13, which indicated Resident #1's cognition was intact. The MDS assessment indicated Resident #1 partial/moderate assistance with shower/bathe self. Record review of Resident #1's Care Plan revised 12/10/25, reflected the following: Problem: [Resident #1] requires assistance with ADL's R/T visual impairment, weakness, impaired cognition. Goal: Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Approach: . bathing: extensive to total one person assistance. An observation on 01/07/26 at 11:21 AM revealed Resident #1 was sitting at the edge of the bed. Resident #1 had scattered chin hair that was long approximately 3/4 inch in length. Resident #1 stated she got showers regularly according to her schedule in the week Mondays-Wednesdays-Fridays, and she had been asking the staff to shave her chin hair, but they kept telling her that, per facility policy, they did not have razors in the facility. Resident #1 stated she felt embarrassed and did not like to get out of her room. She stated she ate in her room and did not like to go to the dining room because of the facial hair. An interview on 01/07/26 at 2:42 PM with LVN B revealed CNAs were responsible for residents' showers and grooming; including facial hair removal/shaving for female residents. She added Resident #1's facial hair should be inspected weekly during shower days and trimmed/shaved according to the resident's liking. LVN B stated it was the responsibility of the charge nurses for each Hall to make sure residents received appropriate and consistent daily care. LVN B stated the risk to Resident #1 was infection, loss of dignity, and self-isolation. In an interview on 01/07/26 at 3:35 PM, CNA A stated that CNAs were responsible for shaving/removing facial hair for female residents on shower days and as needed. CNA A stated the facility had disposable razors designed for shaving residents in the facility. CNA A stated that the first time he was assigned to Resident #1's care, and did not know who told her that the facility did not have razors. He stated long facial hair could cause certain female residents embarrassment and loss of dignity. An interview with the DON on 01/07/26 at 3:47 PM revealed the CNAs were supposed to shave/remove female residents' facial hair during the shower days or as desired by the residents. She stated the facility had razors as part of residents' grooming supplies. The DON stated charge nurses were expected to ensure residents were showered and groomed as needed by the resident's preference. She stated she had not been notified by anyone that Resident #1 had facial hair and would like to be shaved. She stated that lack of proper grooming could lead to skin problems and overall dignity issues. Record review of the facility's policy Activities of Daily Living, Optimal Function, revised 05/05/23, reflected the following: . The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene .

40316 Based on observation , interview, and record review, the facility failed to ensure each resident was free from neglect when the facility failed to provide care and services for treatment of diabetes for one resident (Resident #5) of 24 residents reviewed for neglect. Resident # 5 did not receive oral medications and insulin for treatment of diabetes from 01/27/23 to 02/28/23. The facility failed to have a system in place to ensure: 1) Physician orders were in place for medications to control blood sugar for more than one month (1/27/23 2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2) Treatment was provided for elevated blood sugars equal to or greater than 300 mg/dL on multiple occasions for Resident #5. 3) Their policy of notifying the physician for elevated blood sugars equal to or greater than 300 mg/dL for Resident #5. 4) Treatment was provided when Resident #5 showed signs and symptoms of hyperglycemia. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. This failure could place residents of the facility at risk for neglect and could lead to serious injury, serious impairment, pain, mental anguish and death. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. According to the National Library of Medicine (https://www.ncbi.nlm.nih.gov/books/NBK482142/), Hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. This problem is most commonly seen in type 2 diabetes. HHS is a serious and potentially fatal complication of type 2 diabetes . The mortality rate in HHS can be as high as 20%, which is about 10 times higher than the mortality seen in diabetic ketoacidosis. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on 01/27/23. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not recieve any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervison. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed the following goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the resident's normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident wasn't on insulin. In an interview on 03/02/23 at 12:10 PM with MD T , the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD T. I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD 2, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON said that the staff had been trained on neglect but was unable to say when the last training was. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. The DON said that the staff had been trained on neglect but was unable to say when the last training was. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. The administrator said he was not sure when the staff had last been trained on neglect. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. In an interview on 03/04/23 at 02:46 PM LVN N said she wasn't sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON , she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. The Interim DON was able to explain what neglect was but was unsure when the nursing staff had last been trained on neglect. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report neglect to the appropriate authorities. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review of the facility policy titled Abuse, Neglect, Exploitation or Mistreatment (dated 10/01/2020) revealed the following statement, Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of facility's In-service Abuse and Neglect/Falls dated 01/31/23 by DON reflected staff were in-serviced on abuse and neglect. It reflected that LVN E, LVN I, LVN O, LVN P, LVN S, ADON, Wound Care Nurse M and RN U were all in-serviced on abuse/neglect policy. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR reflected the following : Resident #5 is not currently in the facility. The allegation of neglect has been reported to the state agency and is being thoroughly investigated. Appropriate actions will be taken as the investigation is conducted. The results of the investigation will be submitted to the state agency in 5 days. The administrator will be re-educated by the Regional [NAME] President of Operations or the Clinical Consultant on timely reporting and investigation of allegations of abuse and neglect. This will be completed on 3/4/23. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE], to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. Admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: Admission policy including the requirement that orders are to be entered into matrix completely and accurately. Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction Residents displaying a change of condition should be assessed to identify the signs and symptoms of hyper and hypoglycemia and notify the physician for further direction The physician should be notified of blood sugars out of the range of ordered parameters or above 300 per policy. Any blood glucose monitoring when nursing management not in facility will be reviewed by 2nd nurse and signed as validated that it is within range or out of ordered parameters or above 300 and that physician is notified. Notification of responsible party for acute change in condition Abuse Neglect and Misappropriation training. This re-education will be initiated on 3/3/23 by the Interim Director of Nursing/designee. Any licensed nurse including Agency Nurses not receiving this education by the end 3/7/23 will receive prior to next scheduled shift. An employee roster will be utilized to track education compliance. Scheduled agency personnel will receive this re-education prior to working scheduled shift. This will also be presented in new hire orientation. Licensed Nurses including agency Nurses will not work until training completed. Agency nurse training will be tracked by the Mobile Director of Nursing or Interim Director of Nursing to validate that the agency nurse scheduled to work has had the training and education and if not, training and education will be arranged or completed by the Mobile Director of Nursing or Interim Director of Nursing. The next 6 shift changes a member of nursing management (Nurse Assessment Coordinator, RN Supervisor, Interim Director of Nursing, Mobile Director of Nursing, Assistant Director of Nurs [TRUNCATED]

40316 Based on observation, interview, and record review, the facility failed to notify the resident's physician when there was a significant change in the physical status, and when a decision for transfer of the resident from the facility was made for one (Resident #5) of 24 residents reviewed for notification of changes and transfer of the resident from facility to hospital. 1. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2. The facility failed to notify the physician of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 3. The facility failed to notify the physician when Resident #5 showed signs and symptoms of hyperglycemia. 4. The facility failed to notify the physician when Resident #5 was transferred to the hospital with a blood sugar of 537 mg/dL (normal range is 70-110 mg/dL). 5.The facility failed to follow their policy of physician notification of elevated blood sugars greater than 300 mg/dL. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar of 537 mg/dL on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on 01/27/23. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not recieve any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervison. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the resident's normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of the hospital discharge orders dated 1/27/23 (resident was admitted [DATE]) indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital on 2/28/23 because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. LVN R stated that she did not notify MD T of Resident #5's high blood sugars. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated, I don't know why she [Resident #5] wasn't on insulin. When asked if she knew what the facility policy was during the interview, LVN R stated No. In an interview on 03/02/23 at 12:10 PM MD T was unaware of the decline that led to Resident #5's hospitalization . MD T said, I think her sugars are usually well-controlled? I think she was on metformin or something I think that was discontinued in the hospital . I remember that her metformin was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023. The progress notes that I write are received by medical records . I was under the impression that the orders I gave were put into the chart. When asked about the high blood sugars that led to Resident #5's hospitalization , MD T said that she knew that Resident #5 had been having high blood sugars and did not know that Resident #5 had been sent to the hospital. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar on 2/28/23. I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, and it was 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD 2. She stated, I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD T, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility. He stated, .I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. In an interview on 03/04/23 at 02:46 PM LVN N said she was not sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but could not remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, Interim DON said, There's a possibility they could go into diabetic ketoacidosis [a life-threatening condition]. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in either checking blood glucose or reporting change in condition. The personnel files of 2 nurses (Wound Care Nurse M and LVN BB) contained a skills check off form regarding checking blood glucose, but the form was not signed by either nurse. One nurse's personnel file (LVN CC) had skills check off forms for checking blood glucose and reporting a change in condition to the physician. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report a resident's change in condition to the resident's physician. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. Review of facility's policy Physician and Other Communication/Change in Condition revised 10/16/17 reflected to improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .3. Notify the physician of the change in medical condition (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 4. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the resident's/patient's condition .6. Patient's/residents family member/legal representative will be notified of any change in condition required an emergent transfer to the hospital. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. Admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: Admission policy including the requirement that orders are to be entered into matrix completely and accurately Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction Residents displaying a change of condition should be assessed to identify the signs and symptoms of hyper and hypoglycemia and notify the physician for further direction The physician should be notified of blood sugars out of the range of ordered parameters or above 300 per policy Any blood glucose monitoring when nursing management not in facility will be reviewed by 2nd nurse and signed as validated that it is within range or out of ordered parameters or above 300 and that physician is notified. Notification of responsible party for acute change in condition Abuse Neglect and Misappropriation training This re-education will be initiated on 3/3/23 by the Interim Director of Nursing/designee. Any licensed nurse including Agency Nurses not receiving this education by the end 3/7/23 will receive prior to next scheduled shift. An employee roster will be utilized to track education compliance. Scheduled agency personnel will receive this re-education prior to

Based on observations, interviews and record review, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan for one (Resident #5) of 24 residents reviewed for quality of care. 1. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2. The facility failed to notify the physician of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 3. The facility failed to notify the physician when Resident #5 showed signs and symptoms of hyperglycemia. 4. The facility failed to notify the physician when Resident #5 was transferred to the hospital with a blood sugar of 537 mg/dL (normal range is 70-110 mg/dL). 5. The facility failed to follow their policy of physician notification of elevated blood sugars great than 300 mg/dL. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place all residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on 01/27/23. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not receive any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervision. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the residents normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of the January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, Blood Sugar less than 70, call MD. Blood Sugar is 70 to 150, give 0 Units. Blood Sugar is 151 to 200, give 2 Units. Blood Sugar is 201 to 250, give 4 Units. Blood Sugar is 251 to 300, give 6 Units. Blood Sugar is 301 to 350, give 8 Units. Blood Sugar is 351 to 400, give 10 Units. Blood Sugar is greater than 400, call MD. Review of the hospital discharge orders dated 1/27/23 (resident was admitted [DATE]) indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477 mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP AA] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident wasn't on insulin. LVN R stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 12:10 PM with MD T, the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD T. I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD 2, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN 7] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN 7] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. LVN O stated he didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. DON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. ADM stated he didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. RN Q stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 02:46 PM LVN N said she wasn't sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. LVN N stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. Interim DON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. LVN BB stated she didn't know the facility policy on notifying the MD for elevated blood sugars. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in either checking blood glucose or reporting change in condition to the physician. The personnel files of 2 nurses (Wound Care Nurse M and LVN BB) contained a skills check off form regarding checking blood glucose, but the form was not signed by either nurse. One nurse's personnel file (LVN CC) had skills check off forms for checking blood glucose and reporting a change in condition to the physician. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report a resident's change in condition to the resident's physician. Review of facility In-service Admission Compliance dated 12/09/22 reflected LVN I, LVN P, LVN S, Wound Care Nurse M were in-serviced with a total of seven nurses that received this facility in-service. The in-service reflected under Admissions Instructions about a new resident to Alert the DON and physician that a pt [patient] is here and send med list to the physician. Physician may have changes to the med orders, or additional labs they want ordered, so be ready to make notes. 2. Input the med orders - if not done by 8 pm that day, meds will not arrive at midnight, and will be delayed until the next day . [patients] generally aren't too pleased about missed meds either Under medication orders it reflected about readmitted patients that prior physician orders have to be discontinued and would have medication list in admittance/hospital pack that needed to be confirmed with the attending physician. It reflected all medications must be entered into electronic record and included instructions on how to input orders into the electronic record. Review of facility in-service Train the trainer dated 12/12/22 by Regional Nurse reflected 2. All nurses must complete training prior to next scheduled shift including agency. 3. Instructed on Audit tools and Admission process and follow up. 4. ADONs will audit new admits within 24 hours Monday through Friday. Weekend Supervisor/Designees will audit Sat/Sunday. Management and Weekend will address concerns and provide education redirection of clinical if necessary. 5. ADON will validate using clinical meeting from M - F. Weekend Supervisor or Designee will validate using clinical meeting form assigned by DON. It reflected Staffing Coordinator (Previous ADON) and DON were in-serviced on 12/13/22. Review of facility In-service Admissions dated 12/12/22 by DON reflected Please follow the attached guidelines when new admission arrives. Assessment completed immediately All medication should be put in system before end of shift. Licensed Nurse will be re-educated on the admission process including the expectation that orders are to be transcribed and implemented as ordered. Licensed Nurse will utilize admission check list for guidance on completion and will have admission orders verified and validated by another nurse on the shift. This in-service reflected a sign-in sheet which included ADON, Wound Care Nurse M, LVN I, LVN P and LVN S. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. Review of facility's policy Physician and Other Communication/Change in Condition revised 10/16/17 reflected to improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .3. Notify the physician of the change in medical condition (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 4. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the resident's/patient's condition .6. Patient's/residents family member/legal representative will be notified of any change in condition required an emergent transfer to the hospital. Review of facility's policy Physician Orders last revised 10/27/17 reflected The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .Admission: 1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed .3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. Under Telephone and Verbal section it reflected 2. Record the actual order received from the physician. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR for quality of care reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely

40316 Based on observation, interview and record review, the facility failed to ensure residents had admission physician orders for their immediate care for two residents (Resident #5 and Resident #173) of 24 residents reviewed for admitting physician orders. 1. The facility failed to reconcile hospital discharge orders for diabetes medication (insulin sliding scale) upon Resident #5's readmission to the facility from the hospital on 1/27/23. 2. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 3. The facility failed to have physician orders for treatment of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 4. The facility failed to physician orders when Resident #5 showed signs and symptoms of hyperglycemia. This failure resulted in Resident #5 having no orders for diabetes medication, and no orders for the physician notification in the case of very high blood sugar for one month (1/27/23-2/28/23). This failure resulted in Resident #5 having frequent high blood sugars, which were not treated by staff and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). 5. The facility failed to ensure Resident #173 had admitting physician orders for wound care for her pressure ulcer when she was admitted on [DATE] from the hospital. These failures could place all residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: 1. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on 01/27/23. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not receive any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervision. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the residents normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lisper high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of the January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, Blood Sugar less than 70, call MD. Blood Sugar is 70 to 150, give 0 Units. Blood Sugar is 151 to 200, give 2 Units. Blood Sugar is 201 to 250, give 4 Units. Blood Sugar is 251 to 300, give 6 Units. Blood Sugar is 301 to 350, give 8 Units. Blood Sugar is 351 to 400, give 10 Units. Blood Sugar is greater than 400, call MD. Review of the physician orders revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. (Normal range is 70-110 mg/dL) Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM documented a blood sugar of 397 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. (Normal range is 70-110 mg/dL). Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses, who documented Resident #5's high blood sugar, reported these high blood sugars to MD T. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . [NP AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review revealed the physician was not notified of the elevated blood sugar of 477. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident was not on insulin. LVN R was unsure of the facility policy for admission orders and was not sure if she had been trained by administration on physician order entry. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. LVN O said he hadn't received training from administration on physician order entry. In an interview on 03/02/23 at 12:10 PM with MD T, the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD 2 usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P said she had not received training from administration on physician order entry. In an interview on 03/02/23 at 01:01 PM, LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD 2. I didn't know I had to. I asked another nurse [LVN R] what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E said she had not received training from administration on physician order entry. In an interview on 03/02/23 at 01:05 PM, the ADON denied reporting Resident #5's high blood sugars to MD T, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow . The ADON said she was not sure if staff had received training from administration on physician order entry. The ADON was unable to state what MD T's parameters were. The ADON chose not to answer the question, What would you consider a high blood sugar level? In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. The DON said she was not sure if staff had received training from administration on physician order entry. In an interview on 03/02/23 at 02:11 PM, the ADM said, Best practice? Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. ADM said he was not sure if staff had received training from administration on physician order entry. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. RN Q said she had not received training from administration on physician order entry. In an interview on 03/04/23 at 02:46 PM, LVN N said she was not sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident did not receive any orders for diabetes medication I would think that it would be life-threatening. LVN N said she had not received training from administration on physician order entry. In an interview on 03/04/23 at 3:00 PM, MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with the Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident does not receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. Interim DON said she was not sure if staff had received training from administration on physician order entry. In an interview on 3/06/23 at 4:51 PM, LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when a resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall got admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happened late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes did not get diabetes medication, Well, eventually they would die. LVN BB said she hadn't received training from administration on physician order entry. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in order reconciliation or entry of physician orders. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to enter physician orders. Review of facility In-service Admission Compliance dated 12/09/22 reflected LVN I, LVN P, LVN S, Wound Care Nurse M were in-serviced with a total of seven nurses that received this facility in-service. The in-service reflected under Admissions Instructions about a new resident to Alert the DON and physician that a pt [patient] is here and send med list to the physician. Physician may have changes to the med orders, or additional labs they want ordered, so be ready to make notes. 2. Input the med orders - if not done by 8 pm that day, meds will not arrive at midnight, and will be delayed until the next day . [patients] generally aren't too pleased about missed meds either Under medication orders it reflected about readmitted patients that prior physician orders have to be discontinued and would have medication list in admittance/hospital pack that needed to be confirmed with the attending physician. It reflected all medications must be entered into electronic record and included instructions on how to input orders into the electronic record. Review of facility in-service Train the trainer dated 12/12/22 by Regional Nurse reflected 2. All nurses must complete training prior to next scheduled shift including agency. 3. Instructed on Audit tools and Admission process and follow up. 4. ADONs will audit new admits within 24 hours Monday through Friday. Weekend Supervisor/Designees will audit Sat/Sunday. Management and Weekend will address concerns and provide education redirection of clinical if necessary. 5. ADON will validate using clinical meeting from M - F. Weekend Supervisor or Designee will validate using clinical meeting form assigned by DON. It reflected Staffing Coordinator (Previous ADON) and DON were in-serviced on 12/13/22. Review of facility In-service Admissions dated 12/12/22 by DON reflected Please follow the attached guidelines when new admission arrives. Assessment completed immediately All medication should be put in system before end of shift. Licensed Nurse will be re-educated on the admission process including the expectation that orders are to be transcribed and implemented as ordered. Licensed Nurse will utilize admission check list for guidance on completion and will have admission orders verified and validated by another nurse on the shift. This in-service reflected a sign-in sheet which included ADON, Wound Care Nurse M, LVN I, LVN P and LVN S. Review of facility's policy Physician Orders last revised 10/27/17 reflected The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .Admission: 1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed .3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. Under Telephone and Verbal section it reflected 2. Record the actual order received from the physician. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested . The POR was accepted on 03/04/23 at 4pm. The accepted POR for admission physician orders reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. Admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: Admission policy including the requirement that orders are to be entered into matrix completely and accurately Admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction Residents displaying a change of condition should be assessed to identify the signs and symptoms of hyper and hypoglycemia and notify the physician for further direction The physician should be notified of blood sugars out of the range of ordered parameters or above 300 per policy Any blood glucose monitoring when nursing management not in facility will be reviewed by 2nd nurse and signed as validated that it is within range or out of ordered parameters or above 300 and that physician is notified. Notification of responsible party for acute change in condition Abuse Neglect and Misappropriation training This re-education will be initiated on 3/3/23 by the Interim Director of Nursing/designee. Any licensed nurse including Agency Nurses not receiving this education by the end 3/7/23 will receive prior to next scheduled shift. An employee roster will be utilized to track education compliance. Scheduled agency personnel will receive this re-education prior to working scheduled shift. This will also be presented in new hire orientation. Licensed Nurses including agency Nurses will not work until training completed. Agency nurse training will be tracked by the Mobile Director of Nursing or Interim Director of Nursing to validate that the agency nurse scheduled to work has had the training and education and if not, training and education will be arranged or completed by the Mobile Director of Nursing or Interim Director of Nursing The next 6 shift changes a member of nursing management (Nurse Assessment Coordinator, RN Supervisor, Interim Director of Nursing, Mobile Director of Nursing, Assistant Director of Nursing) will attend shift to shift report to validate that any resident that has had a change of condition has been assessed appropriately, physician notified and orders implemented promptly. Blood sugars ordered and monitored during the shift will be reviewed to validate that 2nd nurse validated that results were within parameters or below 300 or physician notified if out of parameters or above 300. This will begin on 3/3/23 at 11PM and end on Sunday 3/5/23 3pm shift. After this will be done as monitoring in clinical morning meeting and on weekends by charge nurse. The Director of Nursing/Designee and/or Manager on Duty will review the 24-hour report and the facility activity report to identify any documentation regarding a change of condition and validate that the resident has been assessed appropriately, physician notified, RP/Family notified and orders implemented promptly. This includes signs and symptoms of hyper and hypoglycemia. This will be completed Monday -Friday in the Clinical Meeting and Charge Nurse on weekends. When a change of condition is identified the medical record will be reviewed by the clinical management team for any [NAME] [TRUNCATED]

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED].#1) of four residents reviewed for CPR. The facility failed to ensure CPR was provided to Resident #1 who was a full code. On [DATE] CPR was not initiated by facility staff for 13 minutes after Resident #1 was found not breathing, without a pulse, and unresponsive. Resident #1 was pronounced deceased at the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk of not receiving necessary life-saving measures, decline in health, and even death. Findings included: Review of Resident #1's physician orders, dated [DATE], revealed the resident was a [AGE] year-old female readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's physician orders [REDACTED]. Review of Resident #1's care plan, initiated [DATE] and edited [DATE], revealed Resident #1 had a full code status and approaches included, Resident has completed the following advanced directives: .(X) Full code. In an interview on [DATE] at 11:15 a.m. the PT said he went to work with Resident #1 for her therapy at about 10:38 a.m. He said the resident was on isolation due to readmission so he enter the resident's room after donning PPE. He said Resident #1 was not responding to him calling out her name. He said her eyes were closed and her mouth was open. He said he shook her leg and called out her name and she still did not respond. He said he shook her shoulder and she still did not respond or move. He said he checked her pulse and was not able to feel one. He said he then put his ear up to her mouth and did not feel any breath coming from her. He said he was trained in CPR but had been instructed in the nursing home to notify the charge nurse and not initiate CPR without establishment of a resident's code status. He said he immediately went to find LVN A and reported his observations. He said LVN A went to the resident's room and he stayed outside. In an interview on [DATE] at 2:46 p.m. LVN A said the PT came to tell him Resident #1 was unresponsive. He said he did not check her code status before he went to check her. He said Resident #1's skin was warm to touch when he checked her pulse at her neck and wrist. He said she had no pulse. He said he checked for her breathing and she was not breathing. He said he went to get an RN to have them check the resident and pronounce her. He said he did not check the code status at the time. He said he was trained in CPR and AED and understood CPR was performed on a person who still had a pulse. Review of Resident #1's Nurse Notes, dated [DATE], revealed the following entries on Resident #1: 11:22 a.m., LVN A documented, The resident was found unresponsive at 10:50 a.m., upon which I called an RN to check on the resident and she found she was unresponsive too. This nurse got the crash cart at 10:55 a.m. and CPR was started at 10:58 a.m. The AED was brought by another nurse at 11:05 a.m. and activated. EMS arrived at 11:12 a.m. and took over. 11:45 a.m. the ADON documented, This nurse was notified after a care plan meeting that the resident was found unresponsive with no pulse and no respirations. This nurse helped initiate CPR with primary nurse and continued until EMS responders arrived on scene and took over. 1:34 p.m. the ADON documented, 11:36 a.m.-EMS x 4 left with resident to transport to hospital. 3:59 p.m. the ADON documented, Staff was notified by clinical liaison that CPR had continued in the ambulance during transport and then for an additional 30 minutes at the hospital before time of death was called. Interview on [DATE] at 11:50 a.m. RN B said on [DATE] at approximately 10:50 a.m. LVN A asked her to assess Resident #1 for him and determine if the resident needed to be pronounced. She said she thought LVN A had already determined Resident #1 was a DNR but did not ask him. She said she thought Resident #1 was a DNR. She said at 10:51 a.m. she assessed the resident and confirmed she was unresponsive and had no pulse or respirations. She said she did not pronounce the resident as she thought she could not pronounce. She said she thought LVN A would contact the physician or NP to pronounce. She said at approximately 10:58 a.m. the ADON said Resident #1 was a full code and CPR was initiated. In an interview on [DATE] at 10:40 a.m. the Administrator said Resident #1 had been assessed on [DATE] at 9:01 a.m. and she was alert, oriented, and had no issues. She said at 10:45 a.m. Resident #1 was unresponsive when the PT went to work with the resident. She said at 10:48 a.m. the PT reported to LVN A Resident #1 was unresponsive, had no pulse and no respirations and LVN A assessed Resident #1 without checking her code status. She at 10:50 a.m. LVN A asked her who could pronounce a resident. She said RN B could. She said at 10:51 a.m. RN B assessed Resident #1 and confirmed she had no pulse, no respirations, and was unresponsive but RN B said the physician needed to be notified. She said at 10:58 a.m. the ADON said Resident #1 was a full code and CPR was initiated as well as 911 called. She said she expected staff to check a resident's code status to determine if CPR/AED needed to be initiated or not. Interview on [DATE] at 11:25 a.m. the DON said she was not at the facility on [DATE]. She said Resident #1's code status should have been checked by LVN A and RN B to determine if she was a full code or DNR. Review of the facility's Emergency-911 policy and procedure, revised [DATE], revealed, Policy: The staff will call 911 for emergency situations. This policy only applies to residents who have been determined to be a full code Procedures: 1. Qualified staff initiates the appropriate procedures, i.e., oxygen, suction, CPR (with or without automatic external defibrillation (AED)), as appropriate, etc. in accordance with patient/resident Advanced Directives The administrator and DON were notified on [DATE] 01:40 p.m., that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on [DATE] at 01:41 p.m. The facility's Plan of Removal was accepted on [DATE] 4:55 p.m., and included the following interventions: 1.LVN A and RN B were suspended on [DATE]; 2. Residents with full code status have the potential to be affected by the alleged deficient practice. The Social Service director had completed an audit of code status to verify accuracy. This was completed [DATE]; 3. Licensed Nurses and Certified Nursing Assistants including agency/contract will be re-educated by the Director of Nursing/designee regarding the following: Person finding resident unresponsive will not leave the resident unattended but will call for help immediately. At the beginning of each shift the staff will be assigned duties in case of the need to initiate CPR, who will validate code, who will call 911, who will gather equipment and who will be the scribe. A notebook can be found at the nurse's station with code status which is kept current by the social service department. Licensed nurses will respond immediately to the emergency and evaluate resident and begin CPR if full code status Nurse will direct Certified Nursing Assistants or other staff to gather equipment (crash cart) and bring to the resident room. Staff will call 911 and will assist nurse Once resuscitation is initiated it must continue until Emergency Medical Services arrives and takes over, or resident's spontaneous efforts have returned and are adequate Any staff not receiving this information by [DATE] will receive prior to their next scheduled shift, this will include any staff on FMLA , sick days, or vacation. This information will also be presented to agency staff before reporting to assigned area. 4. Licensed nurses will be interviewed daily for 5 days on each shift then weekly for 2 weeks by members of nursing management to validate that the transfer of learning regarding the expectation that a resident found unresponsive that is a full code has CPR initiated immediately upon discovery. Code status will be reviewed quarterly and with significant change to validate that code status remains accurate as part of the care planning process. The Director of Nursing/designee will randomly interview licensed nurses weekly for 3 months to validate that nurses understand the expectation that Cardiopulmonary Resuscitation is to be initiated on a resident found unresponsive that is a full code. An ad hoc Quality Assurance Performance Improvement Committee meeting was held on [DATE] and the medical director was notified of the immediate jeopardy and the contents of this plan. 5. The data will be presented by the Director of Nursing or Administrator to the Quality Assurance Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at the time of discovery. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 10 staff (DON, Administrator, 2 RNs, and 6 LVNs) they were able to appropriately define full code status and DNR status, identify the location of the resident code status, provided the procedure for a resident found unresponsive with no vital signs that was a full code, provided a procedure for change of condition, accurately assess/ document/ and report a significant change of condition. Chart reviews were completed and reflected code status. Resident care plans included their code status. Observation on [DATE] at 5:00pm revealed a Code Status binder was located at the nursing station with the face sheets of all current residents with the code status in alphabetical order. On [DATE] at 5:39 p.m., the Administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to continue to monitor the effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of fifteen residents reviewed who required assistance with meals. The facility failed to provide Resident #1 adequate supervision on 03/08/18 to prevent the resident from sustaining a hot liquid burn. Resident #1, who had contractures of both biceps that limited his elbow extension and needed assistance with meals spilled hot coffee on himself and sustained a second-degree burn to his abdomen. An Immediate Jeopardy (IJ) at the past non compliance level (PNC) existed from 03/08/18 to 03/12/18. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation on 03/27/18. This failure could affect the fifteen residents who needed assistance with meals by placing them at risk for serious injury, or harm of hot liquid burns. Findings included: Review of Resident #1's Face Sheet dated 03/14/18, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the baseline care plan dated 03/07/18 reflected Resident #1 required assistance with eating and was receiving nectar thickened liquids. Resident #1 was to receive skilled therapy services. Review of CNA Point of Care History for Resident #1 eating support reflected from 03/05/18 - 03/08/18 he needed one person physical assist, limited assistance, and supervision were documented as level of care. Review of Observation Detail Report dated 04/12/18 revealed the Admission/Readmission Nursing Data Collection Tool was completed on date 03/05/18. The Admission/Readmission Nursing Data Collection Tool reflected Resident #1 had swallowing disorder, stroke, his cognitive status was modified independent, eating is one person assist, impairment on both sides, coughing or choking during meals or when swallowing medications. Review of the occupational therapy plan of care dated 03/06/18 reflected the Occupational Therapist evaluated Resident #1 determined contractures on both biceps that limits elbow extension. He required assistance with meals and had limited range of motion of both arms limited elbow extension. Occupational Therapy goals included working with the resident to increase the resident's level of independence with meals. The Occupational Therapist documented on 03/06/18 that Resident #1 was alert and oriented to time, person and place, dependent 100% assist with feeding. Interview with Occupational Therapist (OT) on 04/13/18 at 11:19 AM revealed when Resident #1 admitted she conducted an assessment and documented level of assistance needed was total assist for eating since he was unable to grasp very well. She informed CNAs and nurses verbally about residents' level assistance required. OT said that Resident #1 could hold a cup but would need assistance lifting it to his mouth. OT demonstrated lifting a cup with her elbows bent and a lifting motion up to her mouth. Review of speech therapy treatment notes dated 03/07/08 revealed that Resident #1 was oriented times four and communicates wants/needs with no issue. Educated CNA for Resident #1 need to have assistance during intake due to self-feeding issues. Review of facility's Incident/Accident Report dated 03/08/18 revealed on 03/08/18 at 8:30 AM, CNA C came to assist resident with breakfast and noted an area on side of his lower abdomen and called the nurse. Lower abdomen was red and blistered. Removed all clothing and sheets that had coffee on it. Applied cold compress to area. Medical doctor was notified and family called. Medical doctor ordered to send resident to emergency room for evaluation. Findings, Resident #1 states he asked CNA A for coffee and she gave him coffee. Sign in room stated patient needs to be fed meals. Follow-up to prevent reoccurrence is staff will assist/supervise Resident #1 with all meals and drinks. Care plan updated. Review of the hospital Emergency Provider Report dated 03/08/18 revealed Resident #1 was cognitively intact and appeared well-being and well-developed, abdomen had mild [DIAGNOSES REDACTED] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.) under 2nd degree burn <1% BSA (Accurate estimation of body surface area (BSA) in small and patchy burns, the patient's hand is used to estimate percentage of burn which is traditionally considered as 1 %) of right lateral lower abdomen. Small amount of translucent yellow fluid in dressing. TTP ([MEDICAL CONDITIONS] purpura (blood disorder causes blood clots to form in small blood vessels) around this area. Burn appears to be older than 2 hours. discharged [DATE] back to facility with Silvadine cream (medication for treatment of [REDACTED]. Review of the U.S. National Library of Medicine revealed second-degree burns: affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial [MEDICAL CONDITION] third-degree burns: affect the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. https://medlineplus.gov/ency/article/ 0.htm (accessed on 04/02/18). Review of the facility's Investigation report for (Resident #1), dated 03/15/18, the Administrator revealed that CNA A set up a cup of lemonade for Resident #1 and placed it in his hand prior to the coffee incident. Resident #1 asked CNA A for a cup of coffee on 03/08/18 and CNA A informed the resident that she needed to thicken it. CNA A went to the kitchen and obtained nectar thickener, instant coffee, and mixed it with hot water from the coffee brewing station. CNA A gave the resident the coffee with the lid on it with a straw. CNA A repositioned the resident to a 90-degree angle and placed the beverage in the resident's hand. CNA A left the room to assist others. Resident reported that he had taken the lid off the beverage just before it spilled on him. Nurse assessed resident and determined to send resident to hospital. Physician was notified, family notified, and EMS (Emergency Medical Services) was notified. Resident stated that he was able to eat without assistance. Family reported after the incident that they prefer staff to assist resident with his meals even if he tells staff that he does not need assistance. Review of the coffee brewing and hot water delivery system coming out of the brewing system is just below 200 degrees (Fahrenheit) per manufacturer optimal brewing temperature. Interview with Resident # 1 on 03/29/18 at 8:12 AM revealed he remembered spilling coffee. He could not remember if there was a lid on the coffee cup. He stated staff provided assistance with meals. Interview with CNA A, an agency CNA, on 04/13/18 at 10:55 AM revealed she knew that the resident needed help eating. She stated that on the morning of the incident she observed Resident #1 drinking lemonade using a Styrofoam cup with a straw. She said that Resident #1 was able to drink alone without any trouble. Resident #1 asked CNA A for a cup of coffee who asked Medication Aide D if Resident #1 could have coffee. Medication Aide D told her to go to the kitchen to get the coffee. CNA A made the coffee where the thickener was located next to the brew station. CNA A said that the coffee cooled as she was stirring in the thickener. She said that she did not fill the cup to the top, placed a lid on and straw. She said that the cup was warm but not hot. CNA A stated that she placed the cup in Resident #1's hand and asked if he was okay, and he replied that he was okay. CNA A left the room to assist with other residents' feedings. She did not see on the computer where it said to assist with feeding for Resident #1. CNA A said that she knew she could ask a nurse about resident assistance. Interview with Medication Aide D on 04/13/18 at 11:51 AM revealed that she was unsure of Resident #1's level of supervision since she only gave medications. She said she supervised him with medications and did not observe difficulty swallowing. There was a sign in Resident #1's room that said assist with feeding. On the day of the incident an aide came to her and asked if she could get Resident #1 coffee. Medication Aide D told her to go ask a nurse and the two never spoke afterwards. Later another aide asked her to look at Resident #1. Medication Aide D saw that Resident #1 had red blister on his abdomen. Interview with CNA C on 04/13/18 at 10:22 AM revealed that on the day of the incident she walked into Resident #1's room and noticed his shirt and linens were wet. She thought it may have been urine. When she removed the linens, and lifted his shirt she saw that he was blistered and it was beginning to bubble but he never complained of pain. She called for the nurse to come who applied a cold compress. Resident #1 said an aide gave him coffee. Resident #1 was able to communicate fine and was able to bring food and drink to his mouth. CNA C said that PT (Physical Therapy) told nursing that Resident #1 needed help with eating, which also included drinking. Before she gets coffee, she will ask a nurse to make sure it is okay, and only can get coffee from the pot not from the brewer. CNA C stated that when she started working at the facility she was given an orientation and the DON reviewed how to access resident records on the computer. CNA C said that it has information about the residents including their level of care. She also knew if she has questions to talk to a nurse. In addition, CNA C said that another aide would go down the hall and familiarize them with residents and their care needs. For Resident #1 the computer said to assist with meals. This means positioning, thickening, and supervision. Supervision means he could not be left alone with food or drinks. Interview with LVN E on 04/13/18 at 11:08 AM revealed that she did look at Resident #1's wound on 03/08/18 after 8:00 AM. LVN E stated Resident # 1 said he spilled coffee on himself. She could not recall the exact time, but she said that it was red, closed blisters about the size of a ten-inch circle. She called for the DON and ADON to come to the room. While the DON and ADON attended to Resident #1 she called the family and doctor who gave the order to send Resident #1 to the hospital. When Resident #1 returned from the hospital that day they did a skin assessment and saw no change in the wound. She stated there were no new wounds or burns. Interview with the DON on 03/28/18 at 2:38 PM revealed that CNA A was asked by Resident #1 to bring him coffee. She said that CNA A did not follow resident care with needing assistance with eating. When she was alerted to the incident they noticed his skin was blistering, a cold compress was applied and 911 called. The resident never alerted them of any pain and refused pain medications offered. Follow-up interview conducted on 04/12/18 at 2:46 PM revealed that when agency staff are hired they must be in-serviced about facility policy and procedures. There is a binder that staff must review, and sign off regarding abuse/neglect, falls, resident care requirements, and how to access the information. The DON stated the she or a charge nurse conduct the training. Outgoing staff and oncoming staff will review a shift to shift report that details information about residents. When CNAs start their shift, they are expected to review the patient profile on the computer that has the resident's level of care such as special equipment needed, transfers, and diet requirements including supervision of meals. Interview with the former Administrator on 03/29/18 at 12:35 PM revealed that CNA A had earlier given the resident a cold beverage and he was able to manipulate the cup. The resident then asked for a cup of coffee. She went to the dining area got the coffee and thickened it and gave the resident the cup and left since he had no problems drinking the cold beverage earlier. He believed that the resident tried to take the lid off the cup and that was how he spilled it. When another CNA came in to assist with feeding the resident she noticed the spill. The CNA called the nurse and first aid was applied, 911 was called, the family was called, and the doctor was called. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed that on the day of the incident with Resident #1, CNA A was able to get the coffee on her own and take it to the resident. He said that prior to the incident the hot beverage temperatures were 225 degrees Fahrenheit which was the optimal temperature set by the manufacturer. Review facility abuse, neglect, exploitation, or mistreatment policy and procedure dated 09/12/17 revealed: .Section III: .6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An Immediate Jeopardy (IJ) was identified to have occurred from 03/08/18 through 03/12/18. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the noncompliance prior to the start of the investigation: The facility's Provider Investigation Report, dated 03/08/18, reflected that the vendor for the coffee brewer was contacted who lowered the temperature of the brewing system. An email sent by vendor dated 03/08/18, detailed that the technician lowered the water temperature down to 185 degrees Fahrenheit. Facility restricted access to hot beverage area by placing a physical barrier at the entry to keep non-dietary staff and residents away from the brew system. In addition, all staff were in-serviced that only dietary staff were allowed in the brew area. Facility created a policy that only dietary staff could thicken the hot beverages. A sign at the brew system was placed with directions detailing all hot drinks made at the dispenser must place two ice cubes in cup and stir and take temperature to make sure it is lower than 165 degrees Fahrenheit. On 03/09/18, therapy helped identify all residents who required assistance with hot beverages and care plans were revised. The facility had the DON and ADON monitor the 24-hour report daily for any hot beverage issues. The Dietary director had to monitor coffee and hot water dispenser temperatures for three times a week. CNA A's employment was terminated. Every morning during stand up the facility reviews therapy notes, get notes form nurses, and CNAs and update the resident's profile. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed since the day of the incident with Resident #1 the temperature of the hot coffee was lowered to 165 degrees Fahrenheit. Observation on 03/29/18 of the dining room revealed a barrier to prevent non-related kitchen staff and residents from entering the area where the hot beverages are located. Next to the hot beverage dispenser was a sign posted that instructed staff how to fill the cups, and the temperature of the liquid that should be lower than 165 degrees Fahrenheit, and place two ice cubes in the cup to lower the temperature lower than 165 degrees Fahrenheit. A hot beverage log was located next to the dispenser reflecting temperature documentation showing the hottest temperature was 165 degrees Fahrenheit. The Food Service Director poured a cup of coffee from the dispenser and took the temperature. The temperature reading was 142 degrees Fahrenheit. Review of coffee temperature log located in the dining room next to the brewing station dated (MONTH) (YEAR) revealed temperatures taken daily for breakfast 1, breakfast 2, lunch, and dinner revealed temperatures at or below 165 degrees Fahrenheit. Observation on 03/27/18 - 03/29/18 revealed no residents had access to the hot beverage area. On 03/29/18 at 5:15 PM observation of the evening meal revealed that residents in the assisted dining room were assisted and supervised by staff. No one was left alone with hot beverages. Also, staff were always present in the dining room supervising and assisting. Additionally, residents who ate in their rooms had assistance. No concerns were observed. Observation on 03/29/18 at 8:19 AM revealed Resident #1 was in his room with staff who was assisting him with feeding and drinking. The coffee had a lid and was not accessible to the resident. At no time was the resident left alone with food or drink accessible. Review of staff in-service training on 03/09/18 titled Serving Hot Beverages conducted for all staff detailed that serving areas to be supervised to ensure changes are implemented, residents who require assistance with meals will be supervised, hot beverages are served in Styrofoam cups with lids and filled no more than ¾ full or one inch from top of cup, two ice chips must be added and stirred to make temperature below 165 degrees Fahrenheit. An in-service dated 03/12/18 titled Abuse & Neglect was conducted for all staff. Individual interviews conducted on 04/12/18 and 04/13/18 across all shifts with CNAs C, E, F, G, H, I, J, K, L, M, N, and O revealed that staff had access to resident care information, and knew how to access the information on the computer. They also said that they could ask a nurse, about a residents' care. Some information on the computer is the care needs and level of care. CNAs C, E, F, G, H, I, J, K, L, M, N, and O) said that when the resident profile reflects that they are assist with meals then it means that they cannot leave residents alone. On 04/13/18 from 3:45 PM- 4:06 PM, individual interviews were conducted with dietary aides P and Q, and dietary manager assistant R revealed that after the incident they received an in-service on hot beverages. They stated that dietary staff can only make the thicken liquids beverages. They stated that comes out at 165 degrees Fahrenheit. They are required to place coffee in the urns 30 minutes prior to meals being served. If staff want to get coffee, they must ring the bell and dietary staff will get what they need. There are two people who like coffee at night so they will temp the coffee down to 155 degrees Fahrenheit. The residents will get the coffee around 9:00 PM an hour after the coffee was made. Hot beverages are placed in Styrofoam cups with a lid. Observation conducted on 04/12/18 revealed that CNAs demonstrated on the hall computer how they access resident information and what information was available to them. Information available was resident care needs such as dressing, bathing, transfers by type and person, and assistance level for meals. Observation on 04/13/18 at 12:38 PM of CNA O's ability to have computer access for two newly admitted residents' who required feeding assistance was observed. CNA O was able to access the newly admitted residents' profiles and show all care requirements including care level. Observation on 04/13/18 at 5:22 PM of the evening meal was conducted. Residents who required assistance with meals were observed in the dining room and in their rooms. All cups had lids. Residents who required supervision were supervised and assisted to their level of care needs. No concerns were noted. An undated feeding report provided by the Administrator reflected fifteen residents who required feeding assistance.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for one (Resident #1) of fifteen residents reviewed who required assistance with meals. The facility failed to provide Resident #1 adequate supervision on 03/08/18 to prevent the resident from sustaining a hot liquid burn. Resident #1, who had contractures of both biceps that limited his elbow extension and needed assistance with meals spilled hot coffee on himself and sustained a second-degree burn to his abdomen. An Immediate Jeopardy (IJ) at the past non compliance level existed from 03/08/18 to 03/12/18. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation on 03/27/18. This failure could affect the fifteen residents who needed assistance with meals by placing them at risk for serious injury, or harm of hot liquid burns. Findings included: Review of Resident #1's Face Sheet dated 03/14/18, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the baseline care plan dated 03/07/18 reflected Resident #1 required assistance with eating and was receiving nectar thickened liquids. Resident #1 was to receive skilled therapy services. Review of CNA Point of Care History for Resident #1 eating support reflected from 03/05/18 - 03/08/18 he needed one person physical assist, limited assistance, and supervision were documented as level of care. Review of Observation Detail Report dated 04/12/18 revealed the Admission/Readmission Nursing Data Collection Tool was completed on date 03/05/18. The Admission/Readmission Nursing Data Collection Tool reflected Resident #1 had swallowing disorder, stroke, his cognitive status was modified independent, eating is one person assist, impairment on both sides, coughing or choking during meals or when swallowing medications. Review of the occupational therapy plan of care dated 03/06/18 reflected the Occupational Therapist evaluated Resident #1 determined contractures on both biceps that limits elbow extension. He required assistance with meals and had limited range of motion of both arms limited elbow extension. Occupational Therapy goals included working with the resident to increase the resident's level of independence with meals. The Occupational Therapist documented on 03/06/18 that Resident #1 was alert and oriented to time, person and place, dependent 100% assist with feeding. Interview with Occupational Therapist (OT) on 04/13/18 at 11:19 AM revealed when Resident #1 admitted she conducted an assessment and documented level of assistance needed was total assist for eating since he was unable to grasp very well. She informed CNAs and nurses verbally about residents' level assistance required. OT said that Resident #1 could hold a cup but would need assistance lifting it to his mouth. OT demonstrated lifting a cup with her elbows bent and a lifting motion up to her mouth. Review of speech therapy treatment notes dated 03/07/08 revealed that Resident #1 was oriented times four and communicates wants/needs with no issue. Educated CNA for Resident #1 need to have assistance during intake due to self-feeding issues. Review of facility's Incident/Accident Report dated 03/08/18 revealed on 03/08/18 at 8:30 AM, CNA C came to assist resident with breakfast and noted an area on side of his lower abdomen and called the nurse. Lower abdomen was red and blistered. Removed all clothing and sheets that had coffee on it. Applied cold compress to area. Medical doctor was notified and family called. Medical doctor ordered to send resident to emergency room for evaluation. Findings, Resident #1 states he asked CNA A for coffee and she gave him coffee. Sign in room stated patient needs to be fed meals. Follow-up to prevent reoccurrence is staff will assist/supervise Resident #1 with all meals and drinks. Care plan updated. Review of the hospital Emergency Provider Report dated 03/08/18 revealed Resident #1 was cognitively intact and appeared well-being and well-developed, abdomen had mild [DIAGNOSES REDACTED] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.) under 2nd degree burn <1% BSA (Accurate estimation of body surface area (BSA) in small and patchy burns, the patient's hand is used to estimate percentage of burn which is traditionally considered as 1 %) of right lateral lower abdomen. Small amount of translucent yellow fluid in dressing. TTP ([MEDICAL CONDITIONS] purpura (blood disorder causes blood clots to form in small blood vessels) around this area. Burn appears to be older than 2 hours. discharged [DATE] back to facility with Silvadine cream (medication for treatment of [REDACTED]. Review of the U.S. National Library of Medicine revealed second-degree burns: affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial [MEDICAL CONDITION] third-degree burns: affect the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. https://medlineplus.gov/ency/article/ 0.htm (accessed on 04/02/18). Review of the facility's Investigation report for (Resident #1), dated 03/15/18, the Administrator revealed that CNA A set up a cup of lemonade for Resident #1 and placed it in his hand prior to the coffee incident. Resident #1 asked CNA A for a cup of coffee on 03/08/18 and CNA A informed the resident that she needed to thicken it. CNA A went to the kitchen and obtained nectar thickener, instant coffee, and mixed it with hot water from the coffee brewing station. CNA A gave the resident the coffee with the lid on it with a straw. CNA A repositioned the resident to a 90-degree angle and placed the beverage in the resident's hand. CNA A left the room to assist others. Resident reported that he had taken the lid off the beverage just before it spilled on him. Nurse assessed resident and determined to send resident to hospital. Physician was notified, family notified, and EMS (Emergency Medical Services) was notified. Resident stated that he was able to eat without assistance. Family reported after the incident that they prefer staff to assist resident with his meals even if he tells staff that he does not need assistance. Review of the coffee brewing and hot water delivery system coming out of the brewing system is just below 200 degrees (Fahrenheit) per manufacturer optimal brewing temperature. Interview with Resident # 1 on 03/29/18 at 8:12 AM revealed he remembered spilling coffee. He could not remember if there was a lid on the coffee cup. He stated staff provided assistance with meals. Interview with CNA A, an agency CNA, on 04/13/18 at 10:55 AM revealed she knew that the resident needed help eating. She stated that on the morning of the incident she observed Resident #1 drinking lemonade using a Styrofoam cup with a straw. She said that Resident #1 was able to drink alone without any trouble. Resident #1 asked CNA A for a cup of coffee who asked Medication Aide D if Resident #1 could have coffee. Medication Aide D told her to go to the kitchen to get the coffee. CNA A made the coffee where the thickener was located next to the brew station. CNA A said that the coffee cooled as she was stirring in the thickener. She said that she did not fill the cup to the top, placed a lid on and straw. She said that the cup was warm but not hot. CNA A stated that she placed the cup in Resident #1's hand and asked if he was okay, and he replied that he was okay. CNA A left the room to assist with other residents' feedings. She did not see on the computer where it said to assist with feeding for Resident #1. CNA A said that she knew she could ask a nurse about resident assistance. Interview with Medication Aide D on 04/13/18 at 11:51 AM revealed that she was unsure of Resident #1's level of supervision since she only gave medications. She said she supervised him with medications and did not observe difficulty swallowing. There was a sign in Resident #1's room that said assist with feeding. On the day of the incident an aide came to her and asked if she could get Resident #1 coffee. Medication Aide D told her to go ask a nurse and the two never spoke afterwards. Later another aide asked her to look at Resident #1. Medication Aide D saw that Resident #1 had red blister on his abdomen. Interview with CNA C on 04/13/18 at 10:22 AM revealed that on the day of the incident she walked into Resident #1's room and noticed his shirt and linens were wet. She thought it may have been urine. When she removed the linens, and lifted his shirt she saw that he was blistered and it was beginning to bubble but he never complained of pain. She called for the nurse to come who applied a cold compress. Resident #1 said an aide gave him coffee. Resident #1 was able to communicate fine and was able to bring food and drink to his mouth. CNA C said that PT (Physical Therapy) told nursing that Resident #1 needed help with eating, which also included drinking. Before she gets coffee, she will ask a nurse to make sure it is okay, and only can get coffee from the pot not from the brewer. CNA C stated that when she started working at the facility she was given an orientation and the DON reviewed how to access resident records on the computer. CNA C said that it has information about the residents including their level of care. She also knew if she has questions to talk to a nurse. In addition, CNA C said that another aide would go down the hall and familiarize them with residents and their care needs. For Resident #1 the computer said to assist with meals. This means positioning, thickening, and supervision. Supervision means he could not be left alone with food or drinks. Interview with LVN E on 04/13/18 at 11:08 AM revealed that she did look at Resident #1's wound on 03/08/18 after 8:00 AM. LVN E stated Resident # 1 said he spilled coffee on himself. She could not recall the exact time, but she said that it was red, closed blisters about the size of a ten-inch circle. She called for the DON and ADON to come to the room. While the DON and ADON attended to Resident #1 she called the family and doctor who gave the order to send Resident #1 to the hospital. When Resident #1 returned from the hospital that day they did a skin assessment and saw no change in the wound. She stated there were no new wounds or burns. Interview with the DON on 03/28/18 at 2:38 PM revealed that CNA A was asked by Resident #1 to bring him coffee. She said that CNA A did not follow resident care with needing assistance with eating. When she was alerted to the incident they noticed his skin was blistering, a cold compress was applied and 911 called. The resident never alerted them of any pain and refused pain medications offered. Follow-up interview conducted on 04/12/18 at 2:46 PM revealed that when agency staff are hired they must be in-serviced about facility policy and procedures. There is a binder that staff must review, and sign off regarding abuse/neglect, falls, resident care requirements, and how to access the information. The DON stated the she or a charge nurse conduct the training. Outgoing staff and oncoming staff will review a shift to shift report that details information about residents. When CNAs start their shift, they are expected to review the patient profile on the computer that has the resident's level of care such as special equipment needed, transfers, and diet requirements including supervision of meals. Interview with the former Administrator on 03/29/18 at 12:35 PM revealed that CNA A had earlier given the resident a cold beverage and he was able to manipulate the cup. The resident then asked for a cup of coffee. She went to the dining area got the coffee and thickened it and gave the resident the cup and left since he had no problems drinking the cold beverage earlier. He believed that the resident tried to take the lid off the cup and that was how he spilled it. When another CNA came in to assist with feeding the resident she noticed the spill. The CNA called the nurse and first aid was applied, 911 was called, the family was called, and the doctor was called. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed that on the day of the incident with Resident #1, CNA A was able to get the coffee on her own and take it to the resident. He said that prior to the incident the hot beverage temperatures were 225 degrees Fahrenheit which was the optimal temperature set by the manufacturer. Review facility abuse, neglect, exploitation, or mistreatment policy and procedure dated 09/12/17 revealed: .Section III: .6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An Immediate Jeopardy (IJ) was identified to have occurred from 03/08/18 through 03/12/18. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the noncompliance prior to the start of the investigation: The facility's Provider Investigation Report, dated 03/08/18, reflected that the vendor for the coffee brewer was contacted who lowered the temperature of the brewing system. An email sent by vendor dated 03/08/18, detailed that the technician lowered the water temperature down to 185 degrees Fahrenheit. Facility restricted access to hot beverage area by placing a physical barrier at the entry to keep non-dietary staff and residents away from the brew system. In addition, all staff were in-serviced that only dietary staff were allowed in the brew area. Facility created a policy that only dietary staff could thicken the hot beverages. A sign at the brew system was placed with directions detailing all hot drinks made at the dispenser must place two ice cubes in cup and stir and take temperature to make sure it is lower than 165 degrees Fahrenheit. On 03/09/18, therapy helped identify all residents who required assistance with hot beverages and care plans were revised. The facility had the DON and ADON monitor the 24-hour report daily for any hot beverage issues. The Dietary director had to monitor coffee and hot water dispenser temperatures for three times a week. CNA A's employment was terminated. Every morning during stand up the facility reviews therapy notes, get notes form nurses, and CNAs and update the resident's profile. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed since the day of the incident with Resident #1 the temperature of the hot coffee was lowered to 165 degrees Fahrenheit. Observation on 03/29/18 of the dining room revealed a barrier to prevent non-related kitchen staff and residents from entering the area where the hot beverages are located. Next to the hot beverage dispenser was a sign posted that instructed staff how to fill the cups, and the temperature of the liquid that should be lower than 165 degrees Fahrenheit, and place two ice cubes in the cup to lower the temperature lower than 165 degrees Fahrenheit. A hot beverage log was located next to the dispenser reflecting temperature documentation showing the hottest temperature was 165 degrees Fahrenheit. The Food Service Director poured a cup of coffee from the dispenser and took the temperature. The temperature reading was 142 degrees Fahrenheit. Review of coffee temperature log located in the dining room next to the brewing station dated (MONTH) (YEAR) revealed temperatures taken daily for breakfast 1, breakfast 2, lunch, and dinner revealed temperatures at or below 165 degrees Fahrenheit. Observation on 03/27/18 - 03/29/18 revealed no residents had access to the hot beverage area. On 03/29/18 at 5:15 PM observation of the evening meal revealed that residents in the assisted dining room were assisted and supervised by staff. No one was left alone with hot beverages. Also, staff were always present in the dining room supervising and assisting. Additionally, residents who ate in their rooms had assistance. No concerns were observed. Observation on 03/29/18 at 8:19 AM revealed Resident #1 was in his room with staff who was assisting him with feeding and drinking. The coffee had a lid and was not accessible to the resident. At no time was the resident left alone with food or drink accessible. Review of staff in-service training on 03/09/18 titled Serving Hot Beverages conducted for all staff detailed that serving areas to be supervised to ensure changes are implemented, residents who require assistance with meals will be supervised, hot beverages are served in Styrofoam cups with lids and filled no more than ¾ full or one inch from top of cup, two ice chips must be added and stirred to make temperature below 165 degrees Fahrenheit. An in-service dated 03/12/18 titled Abuse & Neglect was conducted for all staff. Individual interviews conducted on 04/12/18 and 04/13/18 across all shifts with CNAs C, E, F, G, H, I, J, K, L, M, N, and O revealed that staff had access to resident care information, and knew how to access the information on the computer. They also said that they could ask a nurse, about a residents' care. Some information on the computer is the care needs and level of care. CNAs C, E, F, G, H, I, J, K, L, M, N, and O) said that when the resident profile reflects that they are assist with meals then it means that they cannot leave residents alone. On 04/13/18 from 3:45 PM- 4:06 PM, individual interviews were conducted with dietary aides P and Q, and dietary manager assistant R revealed that after the incident they received an in-service on hot beverages. They stated that dietary staff can only make the thicken liquids beverages. They stated that comes out at 165 degrees Fahrenheit. They are required to place coffee in the urns 30 minutes prior to meals being served. If staff want to get coffee, they must ring the bell and dietary staff will get what they need. There are two people who like coffee at night so they will temp the coffee down to 155 degrees Fahrenheit. The residents will get the coffee around 9:00 PM an hour after the coffee was made. Hot beverages are placed in Styrofoam cups with a lid. Observation conducted on 04/12/18 revealed that CNAs demonstrated on the hall computer how they access resident information and what information was available to them. Information available was resident care needs such as dressing, bathing, transfers by type and person, and assistance level for meals. Observation on 04/13/18 at 12:38 PM of CNA O's ability to have computer access for two newly admitted residents' who required feeding assistance was observed. CNA O was able to access the newly admitted residents' profiles and show all care requirements including care level. Observation on 04/13/18 at 5:22 PM of the evening meal was conducted. Residents who required assistance with meals were observed in the dining room and in their rooms. All cups had lids. Residents who required supervision were supervised and assisted to their level of care needs. No concerns were noted. An undated feeding report provided by the Administrator reflected fifteen residents who required feeding assistance.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit and prevent neglect for one (Resident #1) of fifteen residents reviewed who required assistance with meals. The facility failed to provide Resident #1 adequate supervision on 03/08/18 to prevent the resident from sustaining a hot liquid burn. Resident #1, who had contractures of both biceps that limited his elbow extension and needed assistance with meals spilled hot coffee on himself and sustained a second-degree burn to his abdomen. An Immediate Jeopardy (IJ) at the past non compliance level (PNC) existed from 03/08/18 to 03/12/18. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation on 03/27/18. This failure could affect the fifteen residents who needed assistance with meals by placing them at risk for serious injury, or harm of hot liquid burns. Findings included: Review of the policy, Abuse, Neglect, Exploitation, or Mistreatment, dated 09/12/17 revealed . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoids physical harm . Review of Resident #1's Face Sheet dated 03/14/18, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the baseline care plan dated 03/07/18 reflected Resident #1 required assistance with eating and was receiving nectar thickened liquids. Resident #1 was to receive skilled therapy services. Review of CNA Point of Care History for Resident #1 eating support reflected from 03/05/18 - 03/08/18 he needed one person physical assist, limited assistance, and supervision were documented as level of care. Review of Observation Detail Report dated 04/12/18 revealed the Admission/Readmission Nursing Data Collection Tool was completed on date 03/05/18. The Admission/Readmission Nursing Data Collection Tool reflected Resident #1 had swallowing disorder, stroke, his cognitive status was modified independent, eating is one person assist, impairment on both sides, coughing or choking during meals or when swallowing medications. Review of the occupational therapy plan of care dated 03/06/18 reflected the Occupational Therapist evaluated Resident #1 determined contractures on both biceps that limits elbow extension. He required assistance with meals and had limited range of motion of both arms limited elbow extension. Occupational Therapy goals included working with the resident to increase the resident's level of independence with meals. The Occupational Therapist documented on 03/06/18 that Resident #1 was alert and oriented to time, person and place, dependent 100% assist with feeding. Interview with Occupational Therapist (OT) on 04/13/18 at 11:19 AM revealed when Resident #1 admitted she conducted an assessment and documented level of assistance needed was total assist for eating since he was unable to grasp very well. She informed CNAs and nurses verbally about residents' level assistance required. OT said that Resident #1 could hold a cup but would need assistance lifting it to his mouth. OT demonstrated lifting a cup with her elbows bent and a lifting motion up to her mouth. Review of speech therapy treatment notes dated 03/07/08 revealed that Resident #1 was oriented times four and communicates wants/needs with no issue. Educated CNA for Resident #1 need to have assistance during intake due to self-feeding issues. Review of facility's Incident/Accident Report dated 03/08/18 revealed on 03/08/18 at 8:30 AM, CNA C came to assist resident with breakfast and noted an area on side of his lower abdomen and called the nurse. Lower abdomen was red and blistered. Removed all clothing and sheets that had coffee on it. Applied cold compress to area. Medical doctor was notified and family called. Medical doctor ordered to send resident to emergency room for evaluation. Findings, Resident #1 states he asked CNA A for coffee and she gave him coffee. Sign in room stated patient needs to be fed meals. Follow-up to prevent reoccurrence is staff will assist/supervise Resident #1 with all meals and drinks. Care plan updated. Review of the hospital Emergency Provider Report dated 03/08/18 revealed Resident #1 was cognitively intact and appeared well-being and well-developed, abdomen had mild [DIAGNOSES REDACTED] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.) under 2nd degree burn <1% BSA (Accurate estimation of body surface area (BSA) in small and patchy burns, the patient's hand is used to estimate percentage of burn which is traditionally considered as 1 %) of right lateral lower abdomen. Small amount of translucent yellow fluid in dressing. TTP ([MEDICAL CONDITIONS] purpura (blood disorder causes blood clots to form in small blood vessels) around this area. Burn appears to be older than 2 hours. discharged [DATE] back to facility with Silvadine cream (medication for treatment of [REDACTED]. Review of the U.S. National Library of Medicine revealed second-degree burns: affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial [MEDICAL CONDITION] third-degree burns: affect the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. https://medlineplus.gov/ency/article/ 0.htm (accessed on 04/02/18). Review of the facility's Investigation report for (Resident #1), dated 03/15/18, the Administrator revealed that CNA A set up a cup of lemonade for Resident #1 and placed it in his hand prior to the coffee incident. Resident #1 asked CNA A for a cup of coffee on 03/08/18 and CNA A informed the resident that she needed to thicken it. CNA A went to the kitchen and obtained nectar thickener, instant coffee, and mixed it with hot water from the coffee brewing station. CNA A gave the resident the coffee with the lid on it with a straw. CNA A repositioned the resident to a 90-degree angle and placed the beverage in the resident's hand. CNA A left the room to assist others. Resident reported that he had taken the lid off the beverage just before it spilled on him. Nurse assessed resident and determined to send resident to hospital. Physician was notified, family notified, and EMS (Emergency Medical Services) was notified. Resident stated that he was able to eat without assistance. Family reported after the incident that they prefer staff to assist resident with his meals even if he tells staff that he does not need assistance. Review of the coffee brewing and hot water delivery system coming out of the brewing system is just below 200 degrees (Fahrenheit) per manufacturer optimal brewing temperature. Interview with Resident # 1 on 03/29/18 at 8:12 AM revealed he remembered spilling coffee. He could not remember if there was a lid on the coffee cup. He stated staff provided assistance with meals. Interview with CNA A, an agency CNA, on 04/13/18 at 10:55 AM revealed she knew that the resident needed help eating. She stated that on the morning of the incident she observed Resident #1 drinking lemonade using a Styrofoam cup with a straw. She said that Resident #1 was able to drink alone without any trouble. Resident #1 asked CNA A for a cup of coffee who asked Medication Aide D if Resident #1 could have coffee. Medication Aide D told her to go to the kitchen to get the coffee. CNA A made the coffee where the thickener was located next to the brew station. CNA A said that the coffee cooled as she was stirring in the thickener. She said that she did not fill the cup to the top, placed a lid on and straw. She said that the cup was warm but not hot. CNA A stated that she placed the cup in Resident #1's hand and asked if he was okay, and he replied that he was okay. CNA A left the room to assist with other residents' feedings. She did not see on the computer where it said to assist with feeding for Resident #1. CNA A said that she knew she could ask a nurse about resident assistance. Interview with Medication Aide D on 04/13/18 at 11:51 AM revealed that she was unsure of Resident #1's level of supervision since she only gave medications. She said she supervised him with medications and did not observe difficulty swallowing. There was a sign in Resident #1's room that said assist with feeding. On the day of the incident an aide came to her and asked if she could get Resident #1 coffee. Medication Aide D told her to go ask a nurse and the two never spoke afterwards. Later another aide asked her to look at Resident #1. Medication Aide D saw that Resident #1 had red blister on his abdomen. Interview with CNA C on 04/13/18 at 10:22 AM revealed that on the day of the incident she walked into Resident #1's room and noticed his shirt and linens were wet. She thought it may have been urine. When she removed the linens, and lifted his shirt she saw that he was blistered and it was beginning to bubble but he never complained of pain. She called for the nurse to come who applied a cold compress. Resident #1 said an aide gave him coffee. Resident #1 was able to communicate fine and was able to bring food and drink to his mouth. CNA C said that PT (Physical Therapy) told nursing that Resident #1 needed help with eating, which also included drinking. Before she gets coffee, she will ask a nurse to make sure it is okay, and only can get coffee from the pot not from the brewer. CNA C stated that when she started working at the facility she was given an orientation and the DON reviewed how to access resident records on the computer. CNA C said that it has information about the residents including their level of care. She also knew if she has questions to talk to a nurse. In addition, CNA C said that another aide would go down the hall and familiarize them with residents and their care needs. For Resident #1 the computer said to assist with meals. This means positioning, thickening, and supervision. Supervision means he could not be left alone with food or drinks. Interview with LVN E on 04/13/18 at 11:08 AM revealed that she did look at Resident #1's wound on 03/08/18 after 8:00 AM. LVN E stated Resident # 1 said he spilled coffee on himself. She could not recall the exact time, but she said that it was red, closed blisters about the size of a ten-inch circle. She called for the DON and ADON to come to the room. While the DON and ADON attended to Resident #1 she called the family and doctor who gave the order to send Resident #1 to the hospital. When Resident #1 returned from the hospital that day they did a skin assessment and saw no change in the wound. She stated there were no new wounds or burns. Interview with the DON on 03/28/18 at 2:38 PM revealed that CNA A was asked by Resident #1 to bring him coffee. She said that CNA A did not follow resident care with needing assistance with eating. When she was alerted to the incident they noticed his skin was blistering, a cold compress was applied and 911 called. The resident never alerted them of any pain and refused pain medications offered. Follow-up interview conducted on 04/12/18 at 2:46 PM revealed that when agency staff are hired they must be in-serviced about facility policy and procedures. There is a binder that staff must review, and sign off regarding abuse/neglect, falls, resident care requirements, and how to access the information. The DON stated the she or a charge nurse conduct the training. Outgoing staff and oncoming staff will review a shift to shift report that details information about residents. When CNAs start their shift, they are expected to review the patient profile on the computer that has the resident's level of care such as special equipment needed, transfers, and diet requirements including supervision of meals. Interview with the former Administrator on 03/29/18 at 12:35 PM revealed that CNA A had earlier given the resident a cold beverage and he was able to manipulate the cup. The resident then asked for a cup of coffee. She went to the dining area got the coffee and thickened it and gave the resident the cup and left since he had no problems drinking the cold beverage earlier. He believed that the resident tried to take the lid off the cup and that was how he spilled it. When another CNA came in to assist with feeding the resident she noticed the spill. The CNA called the nurse and first aid was applied, 911 was called, the family was called, and the doctor was called. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed that on the day of the incident with Resident #1, CNA A was able to get the coffee on her own and take it to the resident. He said that prior to the incident the hot beverage temperatures were 225 degrees Fahrenheit which was the optimal temperature set by the manufacturer. An Immediate Jeopardy (IJ) was identified to have occurred from 03/08/18 through 03/12/18. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the noncompliance prior to the start of the investigation: The facility's Provider Investigation Report, dated 03/08/18, reflected that the vendor for the coffee brewer was contacted who lowered the temperature of the brewing system. An email sent by vendor dated 03/08/18, detailed that the technician lowered the water temperature down to 185 degrees Fahrenheit. Facility restricted access to hot beverage area by placing a physical barrier at the entry to keep non-dietary staff and residents away from the brew system. In addition, all staff were in-serviced that only dietary staff were allowed in the brew area. Facility created a policy that only dietary staff could thicken the hot beverages. A sign at the brew system was placed with directions detailing all hot drinks made at the dispenser must place two ice cubes in cup and stir and take temperature to make sure it is lower than 165 degrees Fahrenheit. On 03/09/18, therapy helped identify all residents who required assistance with hot beverages and care plans were revised. The facility had the DON and ADON monitor the 24-hour report daily for any hot beverage issues. The Dietary director had to monitor coffee and hot water dispenser temperatures for three times a week. CNA A's employment was terminated. Every morning during stand up the facility reviews therapy notes, get notes form nurses, and CNAs and update the resident's profile. Interview with the Food Service Director on 03/29/18 at 10:38 AM revealed since the day of the incident with Resident #1 the temperature of the hot coffee was lowered to 165 degrees Fahrenheit. Observation on 03/29/18 of the dining room revealed a barrier to prevent non-related kitchen staff and residents from entering the area where the hot beverages are located. Next to the hot beverage dispenser was a sign posted that instructed staff how to fill the cups, and the temperature of the liquid that should be lower than 165 degrees Fahrenheit, and place two ice cubes in the cup to lower the temperature lower than 165 degrees Fahrenheit. A hot beverage log was located next to the dispenser reflecting temperature documentation showing the hottest temperature was 165 degrees Fahrenheit. The Food Service Director poured a cup of coffee from the dispenser and took the temperature. The temperature reading was 142 degrees Fahrenheit. Review of coffee temperature log located in the dining room next to the brewing station dated (MONTH) (YEAR) revealed temperatures taken daily for breakfast 1, breakfast 2, lunch, and dinner revealed temperatures at or below 165 degrees Fahrenheit. Observation on 03/27/18 - 03/29/18 revealed no residents had access to the hot beverage area. On 03/29/18 at 5:15 PM observation of the evening meal revealed that residents in the assisted dining room were assisted and supervised by staff. No one was left alone with hot beverages. Also, staff were always present in the dining room supervising and assisting. Additionally, residents who ate in their rooms had assistance. No concerns were observed. Observation on 03/29/18 at 8:19 AM revealed Resident #1 was in his room with staff who was assisting him with feeding and drinking. The coffee had a lid and was not accessible to the resident. At no time was the resident left alone with food or drink accessible. Review of staff in-service training on 03/09/18 titled Serving Hot Beverages conducted for all staff detailed that serving areas to be supervised to ensure changes are implemented, residents who require assistance with meals will be supervised, hot beverages are served in Styrofoam cups with lids and filled no more than ¾ full or one inch from top of cup, two ice chips must be added and stirred to make temperature below 165 degrees Fahrenheit. An in-service dated 03/12/18 titled Abuse & Neglect was conducted for all staff. Individual interviews conducted on 04/12/18 and 04/13/18 across all shifts with CNAs C, E, F, G, H, I, J, K, L, M, N, and O revealed that staff had access to resident care information, and knew how to access the information on the computer. They also said that they could ask a nurse, about a residents' care. Some information on the computer is the care needs and level of care. CNAs C, E, F, G, H, I, J, K, L, M, N, and O) said that when the resident profile reflects that they are assist with meals then it means that they cannot leave residents alone. On 04/13/18 from 3:45 PM- 4:06 PM, individual interviews were conducted with dietary aides P and Q, and dietary manager assistant R revealed that after the incident they received an in-service on hot beverages. They stated that dietary staff can only make the thicken liquids beverages. They stated that comes out at 165 degrees Fahrenheit. They are required to place coffee in the urns 30 minutes prior to meals being served. If staff want to get coffee, they must ring the bell and dietary staff will get what they need. There are two people who like coffee at night so they will temp the coffee down to 155 degrees Fahrenheit. The residents will get the coffee around 9:00 PM an hour after the coffee was made. Hot beverages are placed in Styrofoam cups with a lid. Observation conducted on 04/12/18 revealed that CNAs demonstrated on the hall computer how they access resident information and what information was available to them. Information available was resident care needs such as dressing, bathing, transfers by type and person, and assistance level for meals. Observation on 04/13/18 at 12:38 PM of CNA O's ability to have computer access for two newly admitted residents' who required feeding assistance was observed. CNA O was able to access the newly admitted residents' profiles and show all care requirements including care level. Observation on 04/13/18 at 5:22 PM of the evening meal was conducted. Residents who required assistance with meals were observed in the dining room and in their rooms. All cups had lids. Residents who required supervision were supervised and assisted to their level of care needs. No concerns were noted. An undated feeding report provided by the Administrator reflected fifteen residents who required feeding assistance.

Based on interviews and record reviews, the facility failed to ensure residents right to be free from neglect for one (Resident #1) of 7 residents reviewed for neglect. LVN A and LVN B failed to take vitals, perform neuro check, determine if the resident had a pulse or respirations or activate emergency response system immediately by calling 911 when informed Resident #1 was on the floor, bleeding and unresponsive on [DATE] at 3:34 p.m. LVN A and LVN B failed to call 911 for 20 minutes after the resident was discovered on the floor. The facility made a telephone call to Emergency Response System 911 on [DATE] at 3:54 p.m., 20 minutes after the after the resident was first observed to be lying on the floor, and she sustained the following injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE] rib fractures, contusion, and [MEDICAL CONDITION]. As a result of her injuries, the resident expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect all 105 residents by placing them at risk for not receiving emergency care and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. The resident was coded to have had two or more falls since admission. Her cognition skills were coded as severely impaired and she required extensive assistance with transfers, bed mobility, and toilet use. The resident required limited assistance with walking in room and the corridor, and had a wandering behaviors, and mobility device was coded wheelchair. Review of Nurse Note dated [DATE] at 3:34 p.m. by LVN A reflected, Called to room by can (sic) noted resident lying on side on floor, noted urine on floor from bed to where resident is laying in front of bathroom floor, moaning, responds at first to name requested a smoke, approx. a about (sic) a minute later, while assessing resident noted fresh blood from mouth small amt. resident now unresponsive to verbal or tacticle (sic) stimuli, 911 called at this time, assesses resident vs ,[DATE] 71 95% ra (room air) non responsive. 3:41 p.m. 911 into facility report given copy of records also. Review of Resident #1's Falls Investigation Worksheet, dated [DATE], by LVN A indicated the fall time as 3:34 p.m., and reflected, .resident had a change in mental status in the last 90 days, increased confusion, unwitnessed fall, bleeding from mouth unresponsive. Recommendation/Interventions All interventions in place. Continue to re-direct . Review of the Fire Department's 911 timeline on [DATE], revealed a 911 call was made from the facility at 3:54 p.m., ( the call was made 20 minutes after the fall), the paramedics arrived in Resident #1's room at 3:58 p.m. Resident # 1 was transferred out of the facility. Review of the Hospital Report Status, dated [DATE] at 6:44 p.m., reflected, ASSESSMENT: Injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE]th rib fractures, contusion .PLAN: Acute and Active Problems: [MEDICAL CONDITION], rib fractures, contusion in setting of [MEDICAL CONDITION] with coagulopathy .The wishes of this patient and care plan were discussed immediately with the patient's POA and her brother .They were updated as her (resident) imaging results came back, and were made aware that delaying treatment like correction of [MEDICAL CONDITION] and elevated INR would make things worse, should they decide to pursue full care .After extensive discussion, the decision was made that she (resident) would be admitted to the hospital, but continue on comfort care . Review of the Hospital discharge summary dated [DATE], reflected, .Date of admission: [DATE] .Admission Diagnosis: [REDACTED].discharge to: expired. An interview with LVN F (ADON) on [DATE] at 1:00 p.m. revealed on [DATE], she was informed of a second fall at around 3:30 p.m. by the Admissions Coordinator when she was coming out of a care plan meeting. She revealed on her way to Resident #1's room, she met LVN A, who was assigned to Resident # 1 in the hallway. She revealed LVN A informed her that she had already notified hospice about the fall. She revealed when she tried to enter Resident #1's room, the resident's body was laying diagonally in the passageway blocking the main door. She revealed she squeezed herself inside the resident's room, and observed 2 agency CNAs, one facility staff CNA, and LVN B standing in the resident's room. She revealed she observed a moderate pool of bright red blood coming from somewhere and the pool was around the resident's head, and the resident was unresponsive. She revealed she requested for someone to get a blood pressure cuff so that she could take the resident's vitals. She revealed LVN B got out of the room to get a blood pressure cuff. She revealed she took the vitals, but the resident remained unresponsive. She revealed she asked for somebody to call 911. She revealed she then asked LVN B why she found her standing in the resident's room with 3 CNAs and doing nothing. She revealed she asked LVN A why she did not stay with the resident while the resident was on the floor. She revealed she then told both LVNs A and B, just because she is on hospice we do not stop rendering aid. She revealed she was very upset and informed the Administrator of LVN A's lack of care towards Resident #1 immediately when the resident was enroute to the hospital. An interview with LVN B on [DATE] at 1:20 p.m. revealed on [DATE] she was in DON D's office when the Admissions Coordinator informed DON D that Resident #1 was on the floor in her room. She revealed on her way to the resident's room, she saw the assigned nurse, LVN A, at the nurses' station and informed her that the resident was on the floor. She revealed LVN A informed her she was aware that the resident was on the floor, and had already been in the resident's room, and was trying to call hospice. She revealed she had to squeeze herself into the resident's room because the resident's body was blocking the door. LVN B said she observed 2 agency CNAs and one staff CNA standing in the room. She revealed the resident appeared unresponsive with her eyes closed, and there was a large pool of blood near the resident's head. She denied observing blood from the resident's mouth. She revealed she did not know where the blood was coming from because she never attempted to move the resident. She revealed she never attempted to take the resident's vitals or complete neurological checks because she had no blood pressure cuff to perform vitals. When asked why she did not ask one of the CNAs in the room to get her the equipment she needed, she had no answer. When asked why she did not call 911 immediately when she observed the resident was unresponsive, she had no answer. An interview with CNA M on [DATE] at 1:45 p.m. revealed on [DATE], he heard a thud coming out of Resident #1's room while he was next door caring for another resident. He revealed he left what he was doing and went to find out what had caused the sound. He revealed as he tried to enter Resident #1's room, the resident was on the floor, and he yelled for LVN A in the hallway to call 911 because the resident was bleeding. He revealed LVN A told him to stay with the resident. He revealed two agency CNAs came to the resident's room. He revealed LVN A came to the resident's room and stood by the door and asked if the resident was bleeding, and told him together with the other 2 agency CNAs not to lift the resident off the floor, as she was going to look for LVN F (ADON). CNA M revealed the resident had her eyes closed and was not talking. CNA M revealed he then asked the two agency CNAs to stay with the resident while he went next door to finish the care which he was providing before Resident #1 fell . He revealed upon return to Resident #1's room, there were no nurses in the room, except for the 2 agency CNAs. He revealed the resident may have stayed on the floor for approximately 15 to 20 minutes. He revealed LVN B later came into the Resident's room and did nothing. An interview with the Admissions Coordinator on [DATE] at 2:30 p.m. revealed on [DATE], she was informed by the Receptionist to look for LVN F (ADON) because she (Receptionist) saw Resident #1 in her room on the floor with CNAs in the room. She revealed while she was looking for LVN F (ADON) she met RN C (Staff Development) in the hallway by the bathroom. She revealed she informed her that Resident #1 was on the floor, and had been asked to find LVN F (ADON), but could not find her. She revealed RN C (Staff Development) told her to find the assigned nurse to Resident #1, and she (RN C) went into the bathroom. She revealed she then went to the DON's office and found DON D together with LVN B, and told them that Resident #1 was on the floor. She revealed DON D and LVN B did not respond, but continued to talk about a piece of paper that was in front of them. She revealed she then saw the assigned nurse, LVN A, standing at the nurses' station, and she informed her that Resident #1 was on the floor in her room. She revealed the nurse informed her that she was aware of it and was trying to call hospice. An interview with the Receptionist on [DATE] at 10:00 a.m. revealed on [DATE] she saw Resident #1 on the floor with CNA M standing near the resident, and an agency CNA standing by the doorway. She revealed she asked the two CNAs if LVN A was aware of the fall. She revealed the agency CNA stated that was the second time the resident had fallen since shift change. She revealed she then spoke with LVN A, who was at the nurses' station, who informed her that she was trying to get LVN F (ADON). She revealed she then offered to look for LVN F (ADON). She revealed she also informed the Administrator that Resident #1 was on the floor. She said the Administrator thanked her for the information. An interview with agency CNA N on [DATE] at 4:00 p.m. revealed on [DATE] she was in the facility and began her shift at 2:00 p.m. She revealed approximately at 3:00 p.m., she heard CNA M yelling out that the resident was on the floor, bleeding, and to call 911. She revealed she rushed to the room and found the resident on the floor with a lot of blood around her head, and the resident was unresponsive. She revealed while she was in the resident's room together with CNA M, LVN A came and stood by the door and told them not to lift the resident off the floor because she was going to call LVN F (ADON). She revealed LVN B came into the room and stood by. She revealed LVN F (ADON) finally came into the room, and tried to rouse the resident without success. She revealed LVN F (ADON) then asked for someone to get a blood pressure cuff. She revealed LVN B stepped out of the room and brought the blood pressure cuff. She revealed LVN F (ADON) asked for someone to call 911 after taking vitals. She revealed she heard LVN F (ADON) asking where LVN A was, and why she was not in the room with the resident. An interview with LVN A on [DATE] at 3:30 p.m. revealed on [DATE] at approximately 3:00 p.m., she was informed by CNA M that the resident was on the floor. She revealed when she went to the resident's room, she stood by the door and told CNA M and CNA R to leave the resident on the floor while she went to DON D's office. She revealed she informed DON D that she needed to call 911 because Resident #1 was on the floor. She revealed DON D told her No. She revealed she then went back to the resident's room and stood by the door and asked the CNAs in the room if the resident was bleeding. She revealed she was told by the CNAs that the resident was bleeding and was not responding. She revealed she went to the nurses' station to call the hospice nurse. She revealed she returned to the resident's room later and found LVN F (ADON) performing vitals, and LVN B and three CNAs were in the resident's room. She stated she left the room to go call 911 when LVN F (ADON) asked for someone to call 911. She revealed she did not provide immediate care to the resident because the resident had a DNR order and was on hospice. When asked why she did not go inside the resident's room to assess the resident's bleeding and the level of consciousness, perform vitals, and complete neurological checks, she revealed, I did not give as much care as I would have done with other residents whom I expect to live longer. I did not give diligent care because she was hospice. In an interview with LVN A on [DATE] at 12:00 p.m., when asked why her nurse's notes dated [DATE] at 3:34 p.m. differed with the events she verbally reported had occurred during the second fall at 3:34 p.m. on [DATE], she responded that she was sorry and was embarrassed. An interview with the Interim DON on [DATE] at 12:35 p.m. revealed she had no idea of what occurred on [DATE] when Resident #1 fell and ended up in hospital. She revealed she began her duties as an Interim DON in the facility on [DATE]. When asked about documentation on neurological checks, she stated they were not available. She revealed every fall should be followed by a fall assessment, neurological checks, and a care plan update. An interview with the Interim Administrator on [DATE] at 10:00 a.m. he revealed he did not know all the details about Resident #1's falls that occurred on [DATE]. He revealed he assumed his post as an Interim Administrator on [DATE]. He stated both DON D and the Administrator were terminated for failure to report abuse, neglect, and failure to follow appropriate policies and procedures. Review of the facility's Physician and Other Communication/Change in Condition policy, dated (YEAR), reflected, .8. In the event of a life-threatening event - contact 911 immediately. Review of the facility's Neurological Checks (Neuro Checks) policy, dated (YEAR), reflected, The licensed nurse will perform neurological checks following any type of actual or suspected head injury or for changes in level of consciousness. Review of the facility's Fall Management policy, dated (YEAR), reflected, .5. Any unwitnessed fall will have neuro checks completed per policy regardless of the resident's cognitive status at the time of the incident. Review of the facility's Abuse, Neglect, Exploitation or Mistreatment policy, dated (YEAR), reflected, .1. The facility's Leadership prohibits neglect .Definitions .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm .4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: C. Ignoring the patient's/resident's needs, requests, etc . The Interim Administrator was notified on [DATE] at 4:25 p.m. that an Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 1:48 p.m. and included: The facility failed to timely assess resident after a fall and provide an appropriate response The facility failed to follow Fall Policy. Resident identified in the Immediate Jeopardy no longer resides in the facility. The Administrator and Director of Nursing in place on [DATE] were terminated on [DATE]. The nurse assigned to the identified resident was terminated on [DATE]. Current residents, including hospice residents, who were admitted during the last 30 days will have a Fall Risk Evaluation completed by licensed nurses. The nursing management team will review and validate accuracy of the evaluation. Care Plans will be updated as needed for appropriate resident specific intervention based on identified risk factors from their Fall Risk Evaluation. Interventions will be communicated to line staff through the Resident Profile in (the computer system). This will be completed by [DATE]. Current residents, including hospice residents, who have sustained a fall in the last 30 days will be audited for appropriate interventions on their care plan. This will be completed by [DATE]. ADON, MDS Coordinator, and Staff Development Coordinator will receive one-on-one re-education on evaluating a resident for injury after a fall, notifying the physician of a change in condition and responding appropriately to an emergency situation this education will be completed by 1:00 pm on [DATE]. Licensed Nurses including ADON's, MDS Coordinators, and Staff Development Coordinator will be re-educated by Clinical Services Director on by 4:00 pm on [DATE]: Evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation, including a resident receiving hospice services. The Physician Communication/Notification of a Change in Condition Policy. Any licensed nurse not receiving this education by 4:00 pm on [DATE] will not be scheduled to work until receiving this education. All agency staff will receive this education one on one using an Agency Quick Start (Specified Education material grouped together) with signature list of who has had the training and will be located in an agency binder. Any agency staff who has not received the education will not be allowed to provide patient care. In an interview with the Interim Administrator and the Clinical Services Director on [DATE] at 1:36 p.m., they revealed an IJ was called because of the facility's failure to self-report the incident to the State, and failure to investigate the incident. They revealed there was a systematic failure that led to the nurses not responding to the incident properly. They revealed there was a breakdown in the leadership that led to facility staff not following policy. Interviews on [DATE] from 8:00 a.m. through 1:00 p.m. revealed six of six nurses (LVNs B, F, P, L; RNs H and C from 6:54 a.m. to 7::15 p.m. shift) revealed they had received in-service training and understood how to evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation; how to complete an accurate Fall Risk Evaluation after each fall, and update the care plan to include appropriate resident specific intervention based on the root cause of the fall and risk factors identified in the Fall Risk Evaluation. An interview on [DATE] at 7:30 a.m. with the Interim Administrator and the Clinical Services Director revealed the remainder of the facility staff and agency staff who had not completed the in-service training would not be allowed to clock in until they completed the in-service training. Individual interviews with facility staff (LVNs B, F, P, L; RNs H and C, CNAs I, J, K, O, and Q, and Staffing Coordinator) between 8:00 a.m. and 1:00 p.m. on [DATE] revealed they had received in-service training regarding identifying signs of neglect and reporting immediately to their supervisor and the abuse coordinator. Review of LVN A's personnel records revealed she was terminated on [DATE]. Review of LVN B was issued with a Final written Warning on [DATE]. On [DATE] at 1:00 p.m., the Administrator and Corporate Nurse Consultant were notified the IJ was removed. The facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. CMS Form 672, Resident Census and Condition of Residents, signed and dated by the MDS Coordinator on [DATE], reflected a census of 105 residents.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibited neglect for one (Resident #1) of 7 residents reviewed for neglect. 1. LVN A failed to implement resident care policies to prevent neglect when she did not take vitals, perform neuro checks, or activate emergency response system immediately by calling 911 when she was informed Resident #1 was on the floor, bleeding and unresponsive on [DATE] at 3:34 p.m. 2. LVN B failed to implement resident care policies to prevent neglect when she did not take vitals, perform neuro checks to determine if Resident #1's neurological functions were intact, and determine if the resident had a pulse or respirations and contact 911 when she went to the resident's room and found the resident on the floor, bleeding, and unresponsive. The facility made a telephone call to Emergency Response System 911 on [DATE] at 3:54 p.m., 20 minutes after the after the resident was first observed to be lying on the floor, and she sustained the following injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE] rib fractures, contusion, and [MEDICAL CONDITION]. As a result of her injuries, the resident expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal These failures could affect all 105 residents by placing them at risk for not receiving emergency care and further life-saving treatments as desired, which could result in death. Findings included: Review of the facility's Abuse, Neglect, Exploitation or Mistreatment policy, dated (YEAR), reflected, .1. The facility's Leadership prohibits neglect .Definitions .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm .4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: C. Ignoring the patient's/resident's needs, requests, etc . 1. All alleged violation concerning abuse, neglect, .are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law .1. The facility maintains that all allegations of abuse, neglect, .are thoroughly investigated and appropriate actions are taken. Review of the facility's Physician and Other Communication/Change in Condition policy, dated (YEAR), reflected, .8. In the event of a life-threatening event - contact 911 immediately. Review of the facility's Neurological Checks (Neuro Checks) policy, dated (YEAR), reflected, The licensed nurse will perform neurological checks following any type of actual or suspected head injury or for changes in level of consciousness. Review of the facility's Fall Management policy, dated (YEAR), reflected, .5. Any unwitnessed fall will have neuro checks completed per policy regardless of the resident's cognitive status at the time of the incident. Review of Resident #1's Admission Nurse's Note dated [DATE] at 3:56 p.m. by LVN E reflected, resident was alert and oriented x 3 (meaning aware of self, time, and place) able to make needs known .Pt requires assist x1 with Adls and transfers, pt noted to be walking and was going into other pats (sic) rooms and was redirected. Continent of bowel and bladder .Pt was oriented on basic (Facility) routine . Review of Resident #1's Consolidated Physician Orders, dated [DATE] through [DATE], reflected, Admit to (Hospice) for Dx liver [MEDICAL CONDITION]: ascites hep c with a start date [DATE]; [MEDICATION NAME] (diuretic) 40mg 1 tab; oral (Dx unspecified [MEDICAL CONDITION] of liver) with a start date [DATE]; [MEDICATION NAME] (anxiolytic - benzodiazepine) 0.25 m1 - 1ml oral (Dx: Other specified anxiety disorder) every 2 hours PRN with a start date [DATE]. Review of Resident #1's Baseline Care Plan, dated [DATE], reflected, .Services and Treatments to be provided by facility: hospice, behavior management, medical management, and skilled nursing services .Fall risk: Minimize falls, encourage use of call light, orient to room. Review of Resident #1's Falls - Fall Risk (Acuity) Assessment, dated [DATE] at 1:27 a.m. by LVN E reflected, the resident was coded: has intermittent confusion, poor recall, judgement, safety awareness; required use of assistive devices e.g. cane, walker, wheelchair; ambulated independently and was continent; was on diuretics; has no history of falls; had decline in cognitive skills. On the assessment's medication use section, only diuretics were checked as being in use, and anxiolytics, and benzodiazepines boxes (which the resident was receiving) were left unchecked. The resident was coded as not at risk for falls. Review of Resident #1's MDS assessment dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. The resident was coded to have had two or more falls since admission. Her cognition skills were coded as severely impaired and she required extensive assistance with transfers, bed mobility, and toilet use. The resident required limited assistance with walking in room and the corridor, and had a wandering behaviors, and mobility device was coded wheelchair. Review of Resident #1's Care plan dated [DATE] at 12:00 p.m., reflected, .Resident #1 have (sic) episodes of sitting on floor non-compliant with call light for assistance. Cognition fluctuates during the day with dx of [MEDICAL CONDITION] of liver. She have (sic) had multiple falls ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE] .Approach Start Date: [DATE]: Staff will assist with toileting and transfers. Encouraging resident to use call light at all times. Keep call light in reach. An interview with LVN G on [DATE] at 11:00 a.m. revealed she care planned Resident #1 for falls on [DATE], when the resident was already in the hospital. She revealed she wrote the care plan because the facility anticipated the resident's return to the facility after hospitalization . When asked why she did not write the care plan on any of the following dates [DATE], [DATE], [DATE], [DATE] and [DATE], when the resident had actual falls in the facility, she had no answer. Review of Resident's #1's Nurse's Note dated [DATE] revealed at 1:45 p.m. the resident was found on the floor in her room, and the resident informed the nurse she fell when she attempted to go use the rest room. A wheelchair was delivered to the facility by hospice that same day at 7:57 p.m. Review of Resident #1's Nurse's Note dated [DATE], reflected, .Patient falls to the floor and lays down when she does not want to do something .Patient is a danger to herself, she will not use her wheelchair or walker and stagers (sic) around like she is going to fall. Review of Resident #1's Nurse's Note dated [DATE], by LVN F (ADON) reflected, It was reported to myself that pt had a fall in the spa room causing her to bite down on her tounge, (sic) upon assessment pt in w/c in room ., noted pt to have small amount of blood to mouth, when awakened pt does respond to my voice, v/s ,[DATE] 133 oxygen sat 93% ra no resp distress noted . Review of Resident #1's Nurse's Note dated [DATE], reflected, Patient came out of her room naked and went to the spa and sat on the floor .This nurse and 3 other aides helped her to feet (sic) since she couldn't walk herself back to the room. Review of Resident #1's Nurse's Note dated [DATE] at 1:04 a.m., reflected, Patient got up from her bed removed her brief and walked to 201 door and slept on the floor moaning and groaning, tried to wake her up but patient was in deep sleep. Covered patient up and stayed with her since is (sic) a danger to herself and to other patients until she woke up. At 1:53 a.m. the nurse wrote, Patient woke up tried to get up but remains very weak to walk by herself, she is currently a high fall risk. Helped her with 3 other aides from the floor to wheelchair . Review of Resident #1's Nurse's Note, dated [DATE] at 2:09 p.m. by LVN A, reflected, Had incident incontinent and sitting on floor vs 97.2 ,[DATE] 88 18 98% ra assisted up cleaned up given seven up to drink, denies any pain, alert, confused. Spoke with hospice nurse this am in regards to resident non compliant. Review of Resident #1's Patient/Resident Incident/Accidents Investigation Worksheet dated [DATE] at 2:09 p.m. by LVN A, reflected, Noted resident standing in room naked urine on floor as going into room, noted resident bump against wall fell landed on bottom confused asking for a cigarette. Attempted to re orient. Toileted, dressed adult brief placed on taken to bed. Given .lime soda to drink. On [DATE], DON D wrote on the same Investigation Worksheet dated [DATE] as follows: Continue to re-direct, no apparent injuries. Review of Nurse Note dated [DATE] at 3:34 p.m. by LVN A reflected, Called to room by can (sic) noted resident lying on side on floor, noted urine on floor from bed to where resident is laying in front of bathroom floor, moaning, responds at first to name requested a smoke, approx. a about (sic) a minute later, while assessing resident noted fresh blood from mouth small amt. resident now unresponsive to verbal or tacticle (sic) stimuli, 911 called at this time, assesses resident vs ,[DATE] 71 95% ra non responsive. 3:41 p.m. 911 into facility report given copy of records also. The Note revealed a telephone call was made to Emergency Response System 911 on [DATE] at 3:54 p.m., 20 minutes after the resident was first observed to be lying on the floor, bleeding and unresponsive. Review of Resident #1 clinical records revealed no documentation of neurological checks on Resident #1's unwitnessed falls that occurred on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's Falls Investigation Worksheet, dated [DATE], by LVN A indicated the fall time as 3:34 p.m., and reflected, .resident had a change in mental status in the last 90 days, increased confusion, unwitnessed fall, bleeding from mouth unresponsive. Recommendation/Interventions All interventions in place. Continue to re-direct . Review of the Fire Department's 911 timeline on [DATE], revealed a 911 call was made from the facility at 3:54 p.m., the paramedics arrived in Resident #1's room at 3:58 p.m. Review of the Hospital Report Status, dated [DATE] at 6:44 p.m., reflected, ASSESSMENT: multiple ground level falls .Injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE]th rib fractures, contusion .PLAN: Acute and Active Problems: [MEDICAL CONDITION], rib fractures, contusion in setting of [MEDICAL CONDITION] with coagulopathy .The wishes of this patient and care plan were discussed immediately with the patient's POA and her brother .They were updated as her (resident) imaging results came back, and were made aware that delaying treatment like correction of [MEDICAL CONDITION] and elevated INR would make things worse, should they decide to pursue full care .After extensive discussion, the decision was made that she (resident) would be admitted to the hospital, but continue on comfort care . Review of the Hospital discharge summary dated [DATE], reflected, .Date of admission: [DATE] .Admission Diagnosis: [REDACTED].discharge to: expired. Review of the State Intake Database on [DATE] reflected a self-report regarding Resident #1's fall was received from the facility on [DATE]. The investigation report was received from the facility on [DATE]. The investigation report reflected, prior to discharge to the hospital, Resident #1 received a physical assessment from the charge nurse and was determined to require transfer to the hospital due to altered mental status and blood coming from the lip. Interviews with RN A, LVNs L and P (ADON), CNAs I, J, K, O, Q and Staffing Coordinator on [DATE] between 11:15 a.m. and 2:00 p.m. revealed Resident #1 always wandered in hallways with an unsteady gait. They all did not know what fall interventions were in place for the resident. Review of Resident #1's clinical records including the care plan did not indicate what fall interventions and supervision were required for the resident. An interview with LVN F (ADON) on [DATE] at 1:00 p.m. revealed Resident #1 had an unsteady gait when ambulating. She revealed the resident fell twice on [DATE]. She revealed the first fall occurred around 2:00 p.m., and she was informed of the second fall at around 3:30 p.m. by the Admissions Coordinator when she was coming out of a care plan meeting. She revealed on her way to Resident #1's room, she met LVN A who was assigned to the resident in the hallway. She revealed LVN A informed her that she had already notified hospice about the fall. She revealed when she tried to enter Resident #1's room, the resident's body was laying diagonally in the passageway blocking the main door. She revealed she squeezed herself inside the resident's room, and observed 2 agency CNAs, one facility staff CNA, and LVN B standing in the resident's room. She revealed she observed a moderate pool of bright red blood coming from somewhere and the pool was around the resident's head, and the resident was unresponsive. She revealed she requested for someone to get a blood pressure cuff so that she could take the resident's vitals. She revealed LVN B got out of the room to get a blood pressure cuff. She revealed she took the vitals, and the resident remained unresponsive. She revealed she asked for somebody to call 911. She revealed she then asked LVN B why she found her standing in the resident's room with 3 CNAs and doing nothing. She revealed she asked LVN A why she did not stay with the resident while the resident was on the floor. She revealed she then told both LVNs A and B, just because she is on hospice we do not stop rendering aid. She revealed she was very upset and informed the Administrator of LVN A's lack of care towards Resident #1 immediately after the resident was enroute to the hospital. An interview with LVN B on [DATE] at 1:20 p.m. revealed on [DATE] she was in DON D's office when the Admissions Coordinator informed DON D that Resident #1 was on the floor in her room. She revealed on her way to the resident's room, she saw the assigned nurse, LVN A, at the nurses' station and informed her that the resident was on the floor. She revealed LVN A informed her she was aware that the resident was on the floor, and had already been in the resident's room, and was trying to call hospice. She revealed she had to squeeze herself into the resident's room because the resident's body was blocking the door. LVN B said she observed 2 agency CNAs and one staff CNA standing in the room. She revealed the resident appeared unresponsive with her eyes closed, and there was a large pool of blood near the resident's head. She denied observing blood from the resident's mouth. She revealed she did not know where the blood was coming from because she never attempted to move the resident. She revealed she never attempted to take the resident's vitals or complete neurological checks because she had no blood pressure cuff to perform vitals. When asked why she did not ask one of the CNAs in the room to get her the equipment she needed, she had no answer. When asked why she did not call 911 immediately when she observed the resident was unresponsive, she had no answer. An interview with CNA M on [DATE] at 1:45 p.m. revealed the resident had multiple falls in the facility. He revealed he heard a thud coming out of Resident #1's room while he was next door caring for another resident. He revealed he left what he was doing and went to find out what had caused the sound. He revealed as he tried to enter Resident #1's room, the resident was on the floor, and he yelled for LVN A in the hallway to call 911 because the resident was bleeding. He revealed LVN A told him to stay with the resident. He revealed two agency CNAs came to the resident's room. He revealed LVN A came to the resident's room and stood by the door and asked if the resident was bleeding, and told him together with the other 2 agency CNAs not to lift the resident off the floor, as she was going to look for LVN F (ADON). CNA M revealed the resident had her eyes closed and was not talking. CNA M revealed he then asked the two agency CNAs to stay with the resident while he went next door to finish the care which he was providing before Resident #1 fell . He revealed upon return to Resident #1's room, there were no nurses in the room, except for the 2 agency CNAs. He revealed the resident may have stayed on the floor for approximately 15 to 20 minutes. He revealed LVN B later came into the Resident's room and did nothing. An interview with the Admissions Coordinator on [DATE] at 2:30 p.m. revealed she was informed by the Receptionist to look for LVN F (ADON) because she (Receptionist) saw Resident #1 in her room on the floor with CNAs in the room. She revealed while she was looking for LVN F (ADON) she met RN C (Staff Development) in the hallway by the bathroom. She revealed she informed her that Resident #1 was on the floor, and had been asked to find LVN F (ADON), but could not find her. She revealed RN C (Staff Development) told her to find the assigned nurse to Resident #1, and she (RN C) went into the bathroom. She revealed she then went to the DON's office and found DON D together with LVN B, and told them that Resident #1 was on the floor. She revealed DON D and LVN B did not respond, but continued to talk about a piece of paper that was in front of them. She revealed she then saw the assigned nurse, LVN A, standing at the nurses' station, and she informed her that Resident #1 was on the floor in her room. She revealed the nurse informed her that she was aware of it and was trying to call hospice. An interview with the Receptionist on [DATE] at 10:00 a.m. revealed on [DATE] she saw Resident #1 on the floor with CNA M standing near the resident, and an agency CNA standing by the doorway. She revealed she asked the two CNAs if LVN A was aware of the fall. She revealed the agency CNA stated that was the second time the resident had fallen since shift change. She revealed she then spoke with LVN A, who was at the nurses' station, who informed her that she was trying to get LVN F (ADON). She revealed she then offered to look for LVN F (ADON). She revealed she also informed the Administrator that Resident #1 was on the floor. She said the Administrator thanked her for the information. An interview with agency CNA N on [DATE] at 4:00 p.m. revealed on [DATE] she was in the facility and began her shift at 2:00 p.m. She revealed while doing her initial rounds at 2:00 p.m., she found Resident #1 on the floor. She revealed she did not know how long the resident had been lying on the floor. She revealed at that time, the resident was conscious. She revealed she informed LVN A whom she stated, did not react fast enough. She revealed LVN A lacked a sense of urgency. She revealed another nurse came into the room and helped her (CNA N) to lift the resident off the floor and laid her in bed. She revealed approximately an hour later, she heard CNA M calling stating that the resident was on the floor, bleeding, and to call 911. She revealed she rushed to the room and found the resident on the floor with a lot of blood around her head area, and the resident was unresponsive. She revealed while she was in the resident's room together with CNA M, LVN A came and stood by the door and told them not to lift the resident off the floor because she was going to call LVN F (ADON). She revealed LVN B came into the room and stood by. She revealed LVN F (ADON) finally came into the room, and tried to rouse the resident without success. She revealed LVN F (ADON) then asked for someone to get a blood pressure cuff. She revealed LVN B stepped out of the room and brought the blood pressure cuff. She revealed LVN F (ADON) asked for someone to call 911 after taking vitals. She revealed she heard LVN F (ADON) asking where LVN A was, and why she was not in the room with the resident. An interview with LVN A on [DATE] at 3:30 p.m. revealed Resident #1 had quite a few falls. She revealed the resident ambulated on her own and her gait was unsteady. She revealed the resident did not use a wheelchair or walker. She revealed she talked to the hospice nurse about the resident needed one-on-one care. She revealed the resident was not referred to physical therapy for gait evaluation. She revealed on [DATE] after the first fall, she told the Administrator that, staff cannot watch the resident ,[DATE]. She revealed the Administrator responded, We have to work with what we got. She revealed at around 2:00 p.m. on [DATE], she was called by an agency CNA who informed her that she found the resident on the floor. She revealed there was urine on the floor, and the resident asked for a cigarette while she laid on the floor. She revealed the resident's speech was slurred. She revealed she left the resident on the floor because she was going to look for help to get the resident off the floor. She revealed she did not return to get the resident up, but another nurse together with the agency CNA lifted the resident off the floor. She revealed the agency CNA cleaned the resident and laid her in bed. She revealed she then offered the resident a soda drink. When asked if she performed any vitals or neurological checks, she said she did not. She revealed after approximately an hour, she was informed by CNA M that the resident was again on the floor. She revealed when she went to the resident's room, she stood by the door and told CNA M and CNA R to leave the resident on the floor while she went to DON D's office. She revealed she informed DON D that she needed to call 911 because Resident #1 was on the floor. She revealed DON D told her No. She revealed she then went back to the resident's room and stood by the door and asked the CNAs in the room if the resident was bleeding. She revealed she was told by the CNAs that the resident was bleeding and was not responding. She revealed she went to the nurses' station to call the hospice nurse. She revealed she returned to the resident's room later and found LVN F (ADON) performing vitals, and LVN B and three CNAs were in the resident's room. She stated she left the room to go call 911 when LVN F (ADON) asked for someone to call 911. She revealed she did not provide immediate care to the resident because the resident had a DNR order and was on hospice. When asked why she did not go inside the resident's room to assess the resident's bleeding and the level of consciousness, perform vitals, and complete neurological checks, she revealed, I did not give as much care as I would have done with other residents whom I expect to live longer. I did not give diligent care because she was hospice. In an interview with LVN A on [DATE] at 12:00 p.m., when asked why her nurse's notes dated [DATE] at 3:34 p.m. differed with the events she verbally reported had occurred during the second fall at 3:34 p.m. on [DATE], she responded that she was sorry and was embarrassed. An interview with the Interim DON on [DATE] at 12:35 p.m. revealed she had no idea of what occurred on [DATE] when Resident #1 fell and ended up in hospital. She revealed she began her duties as an Interim DON in the facility on [DATE]. When asked about documentation on neurological checks, she stated they were not available. She revealed every fall should have been followed by a fall assessment, neurological checks, and a care plan update. Review of the In-service Records reflected staff were in-serviced by RN C on falls management, and abuse/neglect on [DATE]. An interview with the Interim Administrator on [DATE] at 10:00 a.m. he revealed he did not know all the details about Resident #1's falls that occurred on [DATE]. He revealed he assumed his post as an Interim Administrator on [DATE]. He revealed he was under instruction from the facility's legal department not to make available to the State Survey Agency the full Provider Investigation Report. The Interim Administrator produced Form 3613A, Provider Investigation Report, dated [DATE], with the incident date of [DATE] at 3:35 p.m. No other additional information on how the investigation was carried out was made available. He stated both DON D and the Administrator were terminated for failure to report abuse, neglect, and failure to follow appropriate policies and procedures. The Interim Administrator was notified on [DATE] at 4:25 p.m. that an Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 1:48 p.m. and included: The facility failed to timely assess resident after a fall and provide an appropriate response. The facility failed to follow Fall Policy. Resident identified in the Immediate Jeopardy no longer resides in the facility. The Administrator and Director of Nursing in place on [DATE] were terminated on [DATE]. The nurse assigned to the identified resident was terminated on [DATE]. Current residents who were admitted during the last 30 days will have a Fall Risk Evaluation completed by licensed nurses. The nursing management team will review and validate accuracy of the evaluation. Care Plans will be updated as needed for appropriate resident specific intervention based on identified risk factors from their Fall Risk Evaluation. Interventions will be communicated to line staff through the Resident Profile in (the computer system). This will be completed by [DATE]. Current residents who have sustained a fall in the last 30 days will have a Fall Risk Evaluation completed by licensed nurses. The nursing management team will review and validate accuracy of the evaluation. Residents identified to be at risk will have their care plan reviewed and updated as needed for appropriate resident specific intervention based on identified risk factors from their Fall Risk Evaluation. Interventions will be communicated to line staff through the Resident Profile in (the computer system). This will be completed by [DATE]. Current residents who have sustained a fall in the last 30 days will be audited for appropriate interventions on their care plan. This will be completed by [DATE]. The remaining current residents will then have a Fall Risk Evaluation completed. Any resident at risk will have their care plan reviewed and updated as needed for appropriate resident specific intervention based on identified risk factors from their Fall Risk Evaluation. Interventions will be communicated to line staff through the Resident Profile in (the computer system). This will be completed by [DATE]. ADON, MDS Coordinator, and Staff Development Coordinator will receive one-on-one re-education on evaluating a resident for injury after a fall, notifying the physician of a change in condition and responding appropriately to an emergency situation this education will be completed by 1:00 pm on [DATE]. Licensed Nurses including ADON's, MDS Coordinators, and Staff Development Coordinator will be re-educated by Clinical Services Director on by 4:00 pm on [DATE]: Evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation. How to complete an accurate Fall Risk Evaluation Fall Risk Evaluation must be completed after each fall and the care plan updated to include appropriate resident specific intervention based on the root cause of the fall and the identified risk factors identified in the Fall Risk Evaluation. The Physician Communication/Notification of a Change in Condition Policy. Any licensed nurse not receiving this education by 4:00 pm on [DATE] will not be scheduled to work until receiving this education. All agency staff will receive this education one on one using an Agency Quick Start (Specified Education material grouped together) with signature list of who has had the training and will be located in an agency binder. Any agency staff who has not received the education will not be allowed to provide patient care. Certified Nursing Assistants will be re-educated by Clinical Services Director on Fall Prevention and Resident Profile by 4pm on [DATE]. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. All agency staff will receive this education one on one using an Agency Quick Start (Specified Education material grouped together) with signature list of who has had the training and will be located in an agency binder. Any agency staff who has not received the education will not be allowed to provide patient care. The orientation process for all new hire and agency nurses will be monitored by Administrator. An interview with the Interim Administrator and the Clinical Services Director on [DATE] at 1:36 p.m., they revealed an IJ was called because of the facility's failure to self-report the incident to the State, and failure to investigate the incident. They revealed there was a systematic failure that led to the nurses not responding to the incident properly. They revealed there was a breakdown in the leadership that led to facility staff not following policy. Interviews on [DATE] from 8:00 a.m. through 1:00 p.m. revealed six of six nurses (LVNs B, F, P, L; RNs H and C from 6:54 a.m. to 7::15 p.m. shift) revealed they had received in-service training and understood how to evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation; how to complete an accurate Fall Risk Evaluation after each fall, and update the care plan to include appropriate resident specific intervention based on the root cause of the fall and risk factors identified in the Fall Risk Evaluation. An interview on [DATE] at 7:30 a.m. with the Interim Administrator and the Clinical Services Director revealed the remainder of the facility staff and agency staff who had not completed the in-service training would not be allowed to clock in until they completed the in-service training. Individual interviews with facility staff (LVNs B, F, P, L; RNs H and C, CNAs I, J, K, O, and Q, and Staffing Coordinator) between 8:00 a.m. and 1:00 p.m. on [DATE] revealed they had received in-service training regarding identifying signs of neglect and reporting immediately to their supervisor and the abuse coordinator. Review of LVN A's personnel records revealed she was terminated on [DATE]. Review of LVN B was issued with a Final written Warning on [DATE]. On [DATE] at 1:00 p.m., the Administrator and Corporate Nurse Consultant were notified the IJ was removed. The facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. CMS Form 672, Resident Census and Condition of Residents, signed and dated by the MDS Coordinator on [DATE], reflected a census of 105 residents.

Based on interview and record review, in response to allegations of neglect, the facility failed to have evidence that all alleged violations were thoroughly investigated to prevent further incidents of neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to thoroughly investigate an incident of LVN A and LVN B failing to take vitals, perform neuro check, determine if Resident #1 had a pulse or respirations or activate emergency response system immediately by calling 911 when informed Resident #1 was on the floor, bleeding and unresponsive on [DATE] at 3:34 p.m. LVN A and LVN B failed to call 911 for 20 minutes after the resident was discovered on the floor. Resident #1 was transferred to a hospital on [DATE] and determined to have a subdural hematoma, extra-axial hemorrhage, left ,[DATE] rib fractures contusion, and [MEDICAL CONDITION]. The resident expired in the hospital two days later, on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. This failure resulted in LVN A and LVN B continuing to work at the facility with no re-education and monitoring to ensure they provided timely response a resident with a change of condition, including residents receiving hospice services. Therefore, placing all 105 residents at risk of delayed care and possible resulting serious injury, harm or death. Findings include: Review of Resident #1's MDS assessment dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. The resident was coded to have had two or more falls since admission. Her cognition skills were coded as severely impaired and she required extensive assistance with transfers, bed mobility, and toilet use. The resident required limited assistance with walking in room and the corridor, and had a wandering behaviors, and mobility device was coded wheelchair. Review of Resident #1's Baseline Care Plan, dated [DATE], reflected, .Services and Treatments to be provided by facility: hospice, behavior management, medical management, and skilled nursing services .Fall risk: Minimize falls, encourage use of call light, orient to room. Review of Resident #1's Care plan dated [DATE] at 12:00 p.m., reflected, .Resident #1 have (sic) episodes of sitting on floor non-compliant with call light for assistance. Cognition fluctuates during the day with dx of [MEDICAL CONDITION] of liver. She have (sic) had multiple falls ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE] .Approach Start Date: [DATE]: Staff will assist with toileting and transfers. Encouraging resident to use call light at all times. Keep call light in reach. Review of Resident #1's Nurse's Note dated [DATE] at 1:04 a.m., reflected, Patient got up from her bed removed her brief and walked to 201 door and slept on the floor moaning and groaning, tried to wake her up but patient was in deep sleep. Covered patient up and stayed with her since is (sic) a danger to herself and to other patients until she woke up. At 1:53 a.m. the nurse wrote, Patient woke up tried to get up but remains very weak to walk by herself, she is currently a high fall risk. Helped her with 3 other aides from the floor to wheelchair . Review of Resident #1's Nurse's Note, dated [DATE] at 2:09 p.m. by LVN A, reflected, Had incident incontinent and sitting on floor vs 97.2 ,[DATE] 88 18 98% ra assisted up cleaned up given seven up to drink, denies any pain, alert, confused. Spoke with hospice nurse this am in regards to resident non compliant. Review of Resident #1's Patient/Resident Incident/Accidents Investigation Worksheet dated [DATE] at 2:09 p.m. by LVN A, reflected, Noted resident standing in room naked urine on floor as going into room, noted resident bump against wall fell landed on bottom confused asking for a cigarette. Attempted to re orient. Toileted, dressed adult brief placed on taken to bed. Given .lime soda to drink. On [DATE], DON D wrote on the same Investigation Worksheet dated [DATE] as follows: Continue to re-direct, no apparent injuries. Review of Nurse Note dated [DATE] at 3:34 p.m. by LVN A reflected, Called to room by can (sic) noted resident lying on side on floor, noted urine on floor from bed to where resident is laying in front of bathroom floor, moaning, responds at first to name requested a smoke, approx. a about (sic) a minute later, while assessing resident noted fresh blood from mouth small amt. resident now unresponsive to verbal or tacticle (sic) stimuli, 911 called at this time, assesses resident vs ,[DATE] 71 95% ra non responsive. 3:41 p.m. 911 into facility report given copy of records also. Review of Resident #1 clinical records revealed no documentation of neurological checks on Resident #1's unwitnessed falls that occurred on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's Falls Investigation Worksheet, dated [DATE], by LVN A indicated the fall time as 3:34 p.m., and reflected, .resident had a change in mental status in the last 90 days, increased confusion, unwitnessed fall, bleeding from mouth unresponsive. Recommendation/Interventions All interventions in place. Continue to re-direct . Review of the Fire Department's 911 timeline on [DATE], revealed a 911 call was made from the facility at 3:54 p.m., the paramedics arrived in Resident #1's room at 3:58 p.m. An interview with the Interim Administrator on [DATE] at 10:00 a.m. he revealed he did not know all the details about Resident #1's falls that occurred on [DATE]. He revealed he assumed his post as an Interim Administrator on [DATE]. He revealed he was under instruction from the facility's legal department not to make available to the State Survey Agency the full Provider Investigation Report. The Interim Administrator produced Form 3613A, Provider Investigation Report, dated [DATE], with the incident date of [DATE] at 3:35 p.m. No other additional information showing that an investigation was carried out was made available. The information on Form 3613A did not reveal any evidence that an investigation was carried out following the incident. He stated both DON D and the Administrator were terminated for failure to report abuse, neglect, and failure to follow appropriate policies and procedures. An interview with LVN F (ADON) on [DATE] at 1:00 p.m. revealed Resident #1 had an unsteady gait when ambulating. She revealed the resident fell twice on [DATE]. She revealed the first fall occurred around 2:00 p.m., and she was informed of the second fall at around 3:30 p.m. by the Admissions Coordinator when she was coming out of a care plan meeting. She revealed on her way to Resident #1's room, she met LVN A who was assigned to the resident in the hallway. She revealed LVN A informed her that she had already notified hospice about the fall. She revealed when she tried to enter Resident #1's room, the resident's body was laying diagonally in the passageway blocking the main door. She revealed she squeezed herself inside the resident's room, and observed 2 agency CNAs, one facility staff CNA, and LVN B standing in the resident's room. She revealed she observed a moderate pool of bright red blood coming from somewhere and the pool was around the resident's head, and the resident was unresponsive. She revealed she requested for someone to get a blood pressure cuff so that she could take the resident's vitals. She revealed LVN B got out of the room to get a blood pressure cuff. She revealed she took the vitals, and the resident remained unresponsive. She revealed she asked for somebody to call 911. She revealed she then asked LVN B why she found her standing in the resident's room with 3 CNAs and doing nothing. She revealed she asked LVN A why she did not stay with the resident while the resident was on the floor. She revealed she then told both LVNs A and B, just because she is on hospice we do not stop rendering aid. She revealed she was very upset and informed the Administrator of LVN A's lack of care towards Resident #1 immediately after the resident was enroute to the hospital. An interview with the Receptionist on [DATE] at 10:00 a.m. revealed on [DATE] she was coming from the activities room when she saw Resident #1 on the floor with CNA M standing near the resident, and an agency CNA standing by the doorway. She revealed she asked the two CNAs if LVN A was aware of the fall. She revealed the agency CNA stated that was the second time the resident had fallen since that change of shift. She revealed she then spoke with LVN A who was at the nurses' station who informed her that she was trying to get LVN F (ADON). She revealed she then offered to look for LVN F (ADON). She revealed she also informed the Administrator of that the resident on the floor and he responded by thanking her for the information. An interview with LVN A on [DATE] at 3:30 p.m. revealed Resident #1 had quite a few falls. She revealed the resident ambulated on her own and her gait was unsteady. She revealed the resident did not use a wheelchair or walker. She revealed she talked to the hospice nurse about the resident needing one-on-one 1:1 care. She revealed the resident was not referred to physical therapy for gait evaluation. She revealed on [DATE] after the first fall, she told the Administrator that, staff cannot watch the resident ,[DATE]. She revealed the Administrator responded, we have to work with what we got. She revealed at around 2:00 p.m. on [DATE], she was called by an agency CNA who informed her that she found the resident on the floor. She revealed there was urine on the floor, and the resident asked for a cigarette while she laid on the floor. She revealed the resident's speech was slurred. She revealed she left the resident on the floor because she was going to look for help to get the resident off the floor. She revealed she did not return to get the resident up, but another nurse together with the agency CNA lifted the resident off the floor. She revealed the agency CNA cleaned the resident and laid her in bed. She revealed she then offered the resident a soda drink. When asked if she performed any vitals or neuro checks, she said she did not. She revealed after approximately an hour, she was informed by CNA M that the resident was again on the floor. She revealed when she went to the resident's room, she stood by the door and told CNA M and CNA N to leave the resident on the floor while she went to the DON's office. She revealed she informed the DON that she needed to call 911 because Resident #1 was on the floor. She revealed the DON told her No. She revealed she then went back to the resident's room and stood by the door and asked the CNAs in the room if the resident was bleeding. She revealed she was told by the CNAs that the resident was bleeding and was not responding. She revealed she went to the nurses' station to call the hospice nurse. She revealed she returned to the resident's room later and found LVN F (ADON) performing vitals, and LVN B, and three CNAs were in the resident's room. She stated she left the room to go call 911 when LVN F (ADON) asked for someone to call 911. She revealed she did not provide immediate care to the resident because the resident had a DNR order and was on hospice. When asked why she did not go inside the resident's room to assess the resident's bleeding and the level of consciousness, perform vitals, and neuro checks, she revealed, I did not give as much care as I would have done with other residents whom I expect to live longer. I did not give diligent care because she was hospice. Review of the facility's Suspension Pending Investigation dated [DATE], for the Administrator reflected, Reason for Suspension .Failure to report abuse (neglect). Failure to follow appropriate policies and procedure. Employee Comments: Only remember when it was reported to me on [DATE] that there was a potential self-reportable via phone call in my office by DON when .the conference room. Review of the facility's Suspension Pending Investigation dated [DATE], for DON D, reflected, Reason for Suspension .Failure to report abuse (neglect). Failure to follow appropriate policies and procedure. Review of the facility's Abuse, Neglect and Misappropriation of Property policy, dated (YEAR), reflected .2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source ., are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours in the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides the jurisdiction in long-term care facilities) in accordance with State law through established procedures. 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect . Review of the facility's Abuse, Neglect and Misappropriation of Property policy, dated (YEAR), reflected .2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source ., are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours in the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides the jurisdiction in long-term care facilities) in accordance with State law through established procedures. 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect . On [DATE] at 1:00 p.m., the Administrator and Corporate Nurse Consultant were notified the IJ was removed. The facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. Form CMS-672, Resident Census and Condition of Residents, signed and dated by the MDS Coordinator on [DATE] reflected a census of 105 residents

Based on interviews and record reviews, the facility failed to ensure residents right to be free from neglect for one (Resident #1) of 7 residents reviewed for neglect. LVN A and LVN B failed to take vitals, perform neuro check, determine if the resident had a pulse or respirations or activate emergency response system immediately by calling 911 when informed Resident #1 was on the floor, bleeding and unresponsive on [DATE] at 3:34 p.m. LVN A and LVN B failed to call 911 for 20 minutes after the resident was discovered on the floor. The facility made a telephone call to Emergency Response System 911 on [DATE] at 3:54 p.m., 20 minutes after the after the resident was first observed to be lying on the floor, and she sustained the following injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE] rib fractures, contusion, and [MEDICAL CONDITION]. As a result of her injuries, the resident expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect all 105 residents by placing them at risk for not receiving emergency care and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. The resident was coded to have had two or more falls since admission. Her cognition skills were coded as severely impaired and she required extensive assistance with transfers, bed mobility, and toilet use. The resident required limited assistance with walking in room and the corridor, and had a wandering behaviors, and mobility device was coded wheelchair. Review of Nurse Note dated [DATE] at 3:34 p.m. by LVN A reflected, Called to room by can (sic) noted resident lying on side on floor, noted urine on floor from bed to where resident is laying in front of bathroom floor, moaning, responds at first to name requested a smoke, approx. a about (sic) a minute later, while assessing resident noted fresh blood from mouth small amt. resident now unresponsive to verbal or tacticle (sic) stimuli, 911 called at this time, assesses resident vs ,[DATE] 71 95% ra (room air) non responsive. 3:41 p.m. 911 into facility report given copy of records also. Review of Resident #1's Falls Investigation Worksheet, dated [DATE], by LVN A indicated the fall time as 3:34 p.m., and reflected, .resident had a change in mental status in the last 90 days, increased confusion, unwitnessed fall, bleeding from mouth unresponsive. Recommendation/Interventions All interventions in place. Continue to re-direct . Review of the Fire Department's 911 timeline on [DATE], revealed a 911 call was made from the facility at 3:54 p.m., ( the call was made 20 minutes after the fall), the paramedics arrived in Resident #1's room at 3:58 p.m. Resident # 1 was transferred out of the facility. Review of the Hospital Report Status, dated [DATE] at 6:44 p.m., reflected, ASSESSMENT: Injuries: subdural hematoma, extra-axial hemorrhage, left ,[DATE]th rib fractures, contusion .PLAN: Acute and Active Problems: [MEDICAL CONDITION], rib fractures, contusion in setting of [MEDICAL CONDITION] with coagulopathy .The wishes of this patient and care plan were discussed immediately with the patient's POA and her brother .They were updated as her (resident) imaging results came back, and were made aware that delaying treatment like correction of [MEDICAL CONDITION] and elevated INR would make things worse, should they decide to pursue full care .After extensive discussion, the decision was made that she (resident) would be admitted to the hospital, but continue on comfort care . Review of the Hospital discharge summary dated [DATE], reflected, .Date of admission: [DATE] .Admission Diagnosis: [REDACTED].discharge to: expired. An interview with LVN F (ADON) on [DATE] at 1:00 p.m. revealed on [DATE], she was informed of A second fall at around 3:30 p.m. by the Admissions Coordinator when she was coming out of a care plan meeting. She revealed on her way to Resident #1's room, she met LVN A, who was assigned to Resident # 1 in the hallway. She revealed LVN A informed her that she had already notified hospice about the fall. She revealed when she tried to enter Resident #1's room, the resident's body was laying diagonally in the passageway blocking the main door. She revealed she squeezed herself inside the resident's room, and observed 2 agency CNAs, one facility staff CNA, and LVN B standing in the resident's room. She revealed she observed a moderate pool of bright red blood coming from somewhere and the pool was around the resident's head, and the resident was unresponsive. She revealed she requested for someone to get a blood pressure cuff so that she could take the resident's vitals. She revealed LVN B got out of the room to get a blood pressure cuff. She revealed she took the vitals, and the resident remained unresponsive. She revealed she asked for somebody to call 911. She revealed she then asked LVN B why she found her standing in the resident's room with 3 CNAs and doing nothing. She revealed she asked LVN A why she did not stay with the resident while the resident was on the floor. She revealed she then told both LVNs A and B, just because she is on hospice we do not stop rendering aid. She revealed she was very upset and informed the Administrator of LVN A's lack of care towards Resident #1 immediately after the resident was enroute to the hospital. An interview with LVN B on [DATE] at 1:20 p.m. revealed on [DATE] she was in DON D's office when the Admissions Coordinator informed DON D that Resident #1 was on the floor in her room. She revealed on her way to the resident's room, she saw the assigned nurse, LVN A, at the nurses' station and informed her that the resident was on the floor. She revealed LVN A informed her she was aware that the resident was on the floor, and had already been in the resident's room, and was trying to call hospice. She revealed she had to squeeze herself into the resident's room because the resident's body was blocking the door. LVN B said she observed 2 agency CNAs and one staff CNA standing in the room. She revealed the resident appeared unresponsive with her eyes closed, and there was a large pool of blood near the resident's head. She denied observing blood from the resident's mouth. She revealed she did not know where the blood was coming from because she never attempted to move the resident. She revealed she never attempted to take the resident's vitals or complete neurological checks because she had no blood pressure cuff to perform vitals. When asked why she did not ask one of the CNAs in the room to get her the equipment she needed, she had no answer. When asked why she did not call 911 immediately when she observed the resident was unresponsive, she had no answer. An interview with CNA M on [DATE] at 1:45 p.m. revealed on [DATE] he heard a thud coming out of Resident #1's room while he was next door caring for another resident. He revealed he left what he was doing and went to find out what had caused the sound. He revealed as he tried to enter Resident #1's room, the resident was on the floor, and he yelled for LVN A in the hallway to call 911 because the resident was bleeding. He revealed LVN A told him to stay with the resident. He revealed two agency CNAs came to the resident's room. He revealed LVN A came to the resident's room and stood by the door and asked if the resident was bleeding, and told him together with the other 2 agency CNAs not to lift the resident off the floor, as she was going to look for LVN F (ADON). CNA M revealed the resident had her eyes closed and was not talking. CNA M revealed he then asked the two agency CNAs to stay with the resident while he went next door to finish the care which he was providing before Resident #1 fell . He revealed upon return to Resident #1's room, there were no nurses in the room, except for the 2 agency CNAs. He revealed the resident may have stayed on the floor for approximately 15 to 20 minutes. He revealed LVN B later came into the Resident's room and did nothing. An interview with the Admissions Coordinator on [DATE] at 2:30 p.m. revealed on [DATE], she was informed by the Receptionist to look for LVN F (ADON) because she (Receptionist) saw Resident #1 in her room on the floor with CNAs in the room. She revealed while she was looking for LVN F (ADON) she met RN C (Staff Development) in the hallway by the bathroom. She revealed she informed her that Resident #1 was on the floor, and had been asked to find LVN F (ADON), but could not find her. She revealed RN C (Staff Development) told her to find the assigned nurse to Resident #1, and she (RN C) went into the bathroom. She revealed she then went to the DON's office and found DON D together with LVN B, and told them that Resident #1 was on the floor. She revealed DON D and LVN B did not respond, but continued to talk about a piece of paper that was in front of them. She revealed she then saw the assigned nurse, LVN A, standing at the nurses' station, and she informed her that Resident #1 was on the floor in her room. She revealed the nurse informed her that she was aware of it and was trying to call hospice. An interview with the Receptionist on [DATE] at 10:00 a.m. revealed on [DATE] she saw Resident #1 on the floor with CNA M standing near the resident, and an agency CNA standing by the doorway. She revealed she asked the two CNAs if LVN A was aware of the fall. She revealed the agency CNA stated that was the second time the resident had fallen since shift change. She revealed she then spoke with LVN A, who was at the nurses' station, who informed her that she was trying to get LVN F (ADON). She revealed she then offered to look for LVN F (ADON). She revealed she also informed the Administrator that Resident #1 was on the floor. She said the Administrator thanked her for the information. An interview with agency CNA N on [DATE] at 4:00 p.m. revealed on [DATE] she was in the facility and began her shift at 2:00 p.m. She revealed approximately at 3:00 PM, she heard CNA M yelling out that the resident was on the floor, bleeding, and to call 911. She revealed she rushed to the room and found the resident on the floor with a lot of blood around her head, and the resident was unresponsive. She revealed while she was in the resident's room together with CNA M, LVN A came and stood by the door and told them not to lift the resident off the floor because she was going to call LVN F (ADON). She revealed LVN B came into the room and stood by. She revealed LVN F (ADON) finally came into the room, and tried to rouse the resident without success. She revealed LVN F (ADON) then asked for someone to get a blood pressure cuff. She revealed LVN B stepped out of the room and brought the blood pressure cuff. She revealed LVN F (ADON) asked for someone to call 911 after taking vitals. She revealed she heard LVN F (ADON) asking where LVN A was, and why she was not in the room with the resident. An interview with LVN A on [DATE] at 3:30 p.m. revealed at approximately 3:00 PM, she was informed by CNA M that the resident was on the floor. She revealed when she went to the resident's room, she stood by the door and told CNA M and CNA R to leave the resident on the floor while she went to DON D's office. She revealed she informed DON D that she needed to call 911 because Resident #1 was on the floor. She revealed DON D told her No. She revealed she then went back to the resident's room and stood by the door and asked the CNAs in the room if the resident was bleeding. She revealed she was told by the CNAs that the resident was bleeding and was not responding. She revealed she went to the nurses' station to call the hospice nurse. She revealed she returned to the resident's room later and found LVN F (ADON) performing vitals, and LVN B and three CNAs were in the resident's room. She stated she left the room to go call 911 when LVN F (ADON) asked for someone to call 911. She revealed she did not provide immediate care to the resident because the resident had a DNR order and was on hospice. When asked why she did not go inside the resident's room to assess the resident's bleeding and the level of consciousness, perform vitals, and complete neurological checks, she revealed, I did not give as much care as I would have done with other residents whom I expect to live longer. I did not give diligent care because she was hospice. In an interview with LVN A on [DATE] at 12:00 p.m., when asked why her nurse's notes dated [DATE] at 3:34 p.m. differed with the events she verbally reported had occurred during the second fall at 3:34 p.m. on [DATE], she responded that she was sorry and was embarrassed. An interview with the Interim DON on [DATE] at 12:35 p.m. revealed she had no idea of what occurred on [DATE] when Resident #1 fell and ended up in hospital. She revealed she began her duties as an Interim DON in the facility on [DATE]. When asked about documentation on neurological checks, she stated they were not available. She revealed every fall should be followed by a fall assessment, neurological checks, and a care plan update. An interview with the Interim Administrator on [DATE] at 10:00 a.m. he revealed he did not know all the details about Resident #1's falls that occurred on [DATE]. He revealed he assumed his post as an Interim Administrator on [DATE]. He stated both DON D and the Administrator were terminated for failure to report abuse, neglect, and failure to follow appropriate policies and procedures. Review of the facility's Physician and Other Communication/Change in Condition policy, dated (YEAR), reflected, .8. In the event of a life-threatening event - contact 911 immediately. Review of the facility's Neurological Checks (Neuro Checks) policy, dated (YEAR), reflected, The licensed nurse will perform neurological checks following any type of actual or suspected head injury or for changes in level of consciousness. Review of the facility's Fall Management policy, dated (YEAR), reflected, .5. Any unwitnessed fall will have neuro checks completed per policy regardless of the resident's cognitive status at the time of the incident. The Interim Administrator was notified on [DATE] at 4:25 p.m. that an Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 1:48 p.m. and included: The facility failed to timely assess resident after a fall and provide an appropriate response The facility failed to follow Fall Policy. Resident identified in the Immediate Jeopardy no longer resides in the facility. The Administrator and Director of Nursing in place on [DATE] were terminated on [DATE]. The nurse assigned to the identified resident was terminated on [DATE]. Current residents, including hospice residents, who were admitted during the last 30 days will have a Fall Risk Evaluation completed by licensed nurses. The nursing management team will review and validate accuracy of the evaluation. Care Plans will be updated as needed for appropriate resident specific intervention based on identified risk factors from their Fall Risk Evaluation. Interventions will be communicated to line staff through the Resident Profile in (the computer system). This will be completed by [DATE]. Current residents, including hospice residents, who have sustained a fall in the last 30 days will be audited for appropriate interventions on their care plan. This will be completed by [DATE]. ADON, MDS Coordinator, and Staff Development Coordinator will receive one-on-one re-education on evaluating a resident for injury after a fall, notifying the physician of a change in condition and responding appropriately to an emergency situation this education will be completed by 1:00 pm on [DATE]. Licensed Nurses including ADON's, MDS Coordinators, and Staff Development Coordinator will be re-educated by Clinical Services Director on by 4:00 pm on [DATE]: Evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation, including a resident receiving hospice services. The Physician Communication/Notification of a Change in Condition Policy. Any licensed nurse not receiving this education by 4:00 pm on [DATE] will not be scheduled to work until receiving this education. All agency staff will receive this education one on one using an Agency Quick Start (Specified Education material grouped together) with signature list of who has had the training and will be located in an agency binder. Any agency staff who has not received the education will not be allowed to provide patient care. In an interview with the Interim Administrator and the Clinical Services Director on [DATE] at 1:36 p.m., they revealed an IJ was called because of the facility's failure to self-report the incident to the State, and failure to investigate the incident. They revealed there was a systematic failure that led to the nurses not responding to the incident properly. They revealed there was a breakdown in the leadership that led to facility staff not following policy. Interviews on [DATE] from 8:00 a.m. through 1:00 p.m. revealed six of six nurses (LVNs B, F, P, L; RNs H and C from 6:54 a.m. to 7::15 p.m. shift) revealed they had received in-service training and understood how to evaluating a resident for injury after a fall and notifying the physician and responding appropriately to an emergency situation; how to complete an accurate Fall Risk Evaluation after each fall, and update the care plan to include appropriate resident specific intervention based on the root cause of the fall and risk factors identified in the Fall Risk Evaluation. An interview on [DATE] at 7:30 a.m. with the Interim Administrator and the Clinical Services Director revealed the remainder of the facility staff and agency staff who had not completed the in-service training would not be allowed to clock in until they completed the in-service training. Individual interviews with facility staff (LVNs B, F, P, L; RNs H and C, CNAs I, J, K, O, and Q, and Staffing Coordinator) between 8:00 a.m. and 1:00 p.m. on [DATE] revealed they had received in-service training regarding identifying signs of neglect and reporting immediately to their supervisor and the abuse coordinator. Review of LVN A's personnel records revealed she was terminated on [DATE]. Review of LVN B was issued with a Final written Warning on [DATE]. On [DATE] at 1:00 p.m., the Administrator and Corporate Nurse Consultant were notified the IJ was removed. The facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. CMS Form 672, Resident Census and Condition of Residents, signed and dated by the MDS Coordinator on [DATE], reflected a census of 105 residents.