Every finding on record at Cottage Grove Post Acute

Based on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain. Findings include: 1. Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact. Resident 39 received scheduled pain medication and PRN pain medications. Resident 39 had frequent pain, which occasionally affected her/his sleep and ADLs. On 4/23/25 Resident 39 was admitted to hospice. On 6/23/25 at 11:25 AM, and 6/27/25 at 9:15 AM, Resident 39 stated two weeks ago, the facility ran out of her/his prescribed morphine. Resident 39 reported being informed by multiple staff members her/his medication had not been reordered. As a result, she/he went several days without receiving her/his pain medication. Resident 39 stated she/he had been taking morphine for an extended period of time and believed she/he should have been gradually titrated off the medication, rather than cut off. Resident 39 reported experiencing nausea, vomiting, and diarrhea, which led to her/him being sent to the hospital. When asked about her/his pain level when the medication was not available she/he stated The pain I can take, it was the diarrhea that I could not tolerate. The resident indicated her/his pain was unmanaged and she/he was also concerned about her/his blood sugars being all over the place. A 4/23/25 Hospice Physician Order instructed staff to administer morphine sulfate (narcotic pain medication) 0.75 ml three times a day for pain and give 0.75 ml every hour PRN for pain and shortness of breath. Review of a 6/8/25 Progress Note indicated Resident 39 experienced symptoms of opiod withdrawl including: elevated blood pressure, nausea, diarrhea, general malaise, cold sweats, and dizziness. Staff reported the facility ran out of Resident 39's prescribed morphine on 6/7/25 in the morning and were unable to administer the resident's pain medication. Resident 39 experienced symptoms consistent with opioid withdrawal. Staff called the on-call provider to request a medication refill, but they did not respond. Resident 39 was transferred to the hospital for further evaluation and treatment. A 6/2025 MAR revealed the following: -morphine was not administered on 6/7/25 at 3:00 PM and 11:00 PM. -morphine was not administered on 6/8/25 at 700 AM, 3:00 PM, and 11:00 PM. -hydralazine 25 mg was administered on 6/8/25 for elevated blood pressure. -morphine was not administered on 6/9/20 at 7:00 AM, and 3:00 PM. A 6/8/25 Emergency Department Provider Note indicated Resident 39 admitted to the emergency department with fatigue, nausea, vomiting, diarrhea, cold chills and sweats. Resident 39 stated her/his symptoms had been ongoing for the last 24 hours. Resident 39 stated she/he took morphine due to pain related to lower extremity amputations. The resident stated the nursing facility ran out of her/his morphine two days ago. Resident 39's nurse called and confirmed the situation. It appeared completely feasible that the resident was experiencing opioid withdrawals since the last dose was approximately 48 hours prior. Resident 39 was provided an order for oxycodone 5 mg because the facility did not have morphine available. A 6/8/25 Progress Note indicated Resident 39 returned from the hospital with an order for oxycodone 5 mg to be administered every four hours PRN for pain. Resident 39's Pain Level Summary indicated the following on 6/9/25: -12:55 AM, pain level 8/10. -9:45 AM, pain level 8/10. -12:13 PM, pain level 6/10. -3:56 PM, pain level 9/10. -11:22 PM, pain level 3/10. On 6/24/25 at 3:50 PM, Staff 20 (LPN) stated the facility ran out of resident 39's morphine on 6/7/25. She informed the oncoming nurse and assumed the refill would be requested. The next day, she noticed the medication was not reordered and believed the resident was experiencing opioid withdrawal symptoms, including cold sweats, elevated blood pressure, and elevated blood sugar levels. Staff 20 reported leaving three messages for the on-call provider, but did not receive a response. She stated it was typical for the on-call provider not to respond to messages. Staff 20 stated the morphine was typically stocked in the back up medication stock, but administration required approval, which she described as difficult to obtain. Staff 20 added that on 6/8/25 she contacted the hospital, informed them the facility was out of Resident 39's morphine and asked if they could write a short-term prescription. On 6/24/25 at 4:13 PM, Staff 22 (LPN) stated 6/6/25, was when she first noticed Resident 39 was running low on her/his morphine. She reported that no specific staff member was designated to re-order medications and the facility frequently ran out of medications over the weekend. On 6/7/25 during shift change Staff 22 was informed Resident 39 experienced symptoms consistent with opioid withdrawal and was transferred to the hospital. Upon the resident's return, Staff 22 noted the resident was prescribed oxycodone, but not morphine. She stated Resident 39 appeared withdrawn and was not at her/his baseline. Staff 22 further stated the resident's medication was not refilled in a timely manner and acknowledged that it just fell through the cracks. On 6/25/25 at 2:45 PM, Staff 25 (Prescribing Technician) confirmed the facility called the pharmacy on 6/8/25 to request a refill of Resident 39's morphine prescription. On 6/25/25 at 3:18 PM, Staff 23 (Prescribing Technician) and Staff 21 (Pharmacist) stated on 6/9/25 at 8:17 AM, the facility requested a refill for Resident 39's morphine and the medication was delivered to the facility the evening of 6/9/25. On 6/26/25 at 1:20 PM, Staff 2 (DNS) and Staff 24 (Regional Nurse Consultant) reviewed Resident 39's 6/2025 MAR and narcotic log. Staff 2 and Staff 24 confirmed the facility failed to administer seven doses of resident 39's morphine. Documentation indicated the medication was unavailable or not administered. Staff 2 stated the facility's expectation was for nurses to follow the established medication reordering process. Staff 2 acknowledged multiple staff failed to reorder Resident 39's medication in a timely manner. Staff 2 acknowledged Resident 39's hospitalization could have been avoided if the facility had provided timely pain management. Staff 2 confirmed the facility had ongoing issues with communication from the on-call provider and this caused a delay in residents obtaining medication refills. 2. Resident 33 was admitted to the facility in 11/2023 with diagnoses including polyosteoarthritis (osteoarthritis that affects five or more joints in the body simultaneously). A public complaint was received on 3/25/25 which alleged Resident 33 did not receive her/his scheduled pain medication from 3/21/25 through 3/23/25. A review of Physician Orders revealed a 2/22/24 order for Lyrica (a pain medication) twice a day in the morning and in the evening. The 2/2025 MAR revealed Resident 33 did not receive Lyrica starting 3/21/25 evening dose through 3/24/25 morning dose. Medication Administration Notes from 3/21/25 through 3/24/25 revealed Resident 33 was out of Lyrica. A 3/23/25 Progress Note revealed Resident 33 needed a new script for Lyrica and an order refill request was placed in the provider's binder on 3/23/25. A review of the pain monitor from 3/21/25 through 3/24/25 revealed Resident 33's pain level varied from 0/10 to 10/10. A review of the 3/2025 CNA Pain Task documentation revealed Resident 33 experienced pain from 3/21/25 through 3/24/25 which was unchanged with non-pharmacological interventions. On 6/23/25 at 8:23 AM, Resident 33 stated she/he had constant pain in her/his shoulders and lower back. Resident 33 stated the facility ran out of her/his medications often and she/he would go without pain medications until the pharmacy delivered the pain medications. Resident 33 stated without pain medications, her/his pain level gets to 10/10. On 6/25/25 at 1:39 PM, Staff 17 (LPN) stated medications should be ordered when there was a week left so the resident did not run out of medications. Staff 17 stated the facility did not always have an effective system for ordering medications. On 6/26/25 at 10:51 AM, Staff 2 (DNS) stated Resident 33's Lyrica was not available starting the evening dose on 3/21/25 through the morning dose on 3/24/25. Staff 2 stated during this time Resident 33's pain level got up to 9-10/10 but no new orders for pain control were obtained and Resident 33's as needed Tylenol was not administered. Staff 2 stated the CNA task documentation showed non-pharmacological pain control interventions were tried including distraction, repositioning, and rest, but the non-pharmacological pain interventions were not effective. Staff 2 stated her expectation would be the nurse should call the provider for a temporary order in the interim until the Lyrica arrived.

Based on interview and record review it was determined the facility failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, and 33) reviewed for MDS and unnecessary medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 20 was admitted to the facility in 1/2025 with diagnoses including reduced mobility and muscle wasting. A review of Resident 20's clinical record revealed her/his Discharge Return Not Anticipated MDS assessment was in progress and overdue by nine days on 6/24/25. On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 20's MDS was late. On 6/27/25 at 7:15 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for staff was to have the MDSs completed timely. 2. Resident 21 was admitted to the facility in 7/2020 with diagnoses including kidney disease and heart failure. A review of Resident 21's clinical record revealed her/his Annual MDS assessment was in progress and overdue by 13 days on 6/26/25. On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 21's MDS was late. On 6/27/25 at 7:15 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for staff was to have the MDSs completed timely. 3. Resident 32 was admitted to the facility in 12/2024 with diagnoses including Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). A review of Resident 32's clinical record revealed an 4/5/25 Quarterly MDS completed on 4/21/25. On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 32's 4/5/25 Quarterly MDS was completed on 4/21/25. Staff 5 acknowledged the 4/5/25 Quarterly MDS was completed late and should have been completed by 4/18/25. 4. Resident 33 was admitted to the facility in 2/2023 with diagnoses including schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, similar to schizophrenia, and mood disorder symptoms, like mania or depression). a. A review of Resident 33's clinical record revealed a 2/20/25 Annual MDS completed on 3/24/25. On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 33's 2/20/25 Annual MDS was completed on 3/24/25. Staff 5 acknowledged the 2/20/25 Annual MDS was completed late and should have been completed by 3/5/25. b. A review of Resident 33's clinical record revealed a 5/23/25 Quarterly MDS completed on 6/9/25. On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 33's 5/23/25 Quarterly MDS was completed on 6/9/25. Staff 5 acknowledged the 5/23/25 Quarterly MDS was completed late and should have been completed on 6/5/25.

Based on observation, interview, and record review it was determined the facility failed to provide palatable food to 1 of 1 kitchen and 2 of 4 (#s 4 and 33) residents reviewed for food and kitchen tasks. This placed residents at risk for weight loss and reduced quality of life. Findings include: 1. A review of the 6/25/25 lunch menu revealed the facility was to provide: spaghetti with meatballs, herb green beans, and garlic bread sticks. On 6/25/25 at 11:44 AM kitchen meal service was observed. Pasta, meat sauce, garlic bread sticks, and green beans were observed to be served from the steam table. Pasta was observed to be served with tongs, appeared overcooked, and broke apart as it was served. A test tray was requested. On 6/25/25 at 12:22 PM, the test tray was sampled: -herb green beans tasted metallic and were bland. -garlic bread stick was doughy with no garlic flavor. -spaghetti noodles were mushy, soft, and overcooked. -meat sauce was flavorful but the meatball had no flavor. On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like anything, the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table. On 6/25/25 at 2:33 PM, Staff 1 (Administrator) stated she would not want to have overcooked pasta to be an everyday occurrence but she has eaten the pasta and generally liked it. Staff 1 stated she expected herb green beans to be herb, would expect the garlic bread to have garlic on it. 2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including quadriplegia (paralysis of all four limbs). On 6/23/25 at 9:09 AM, Resident 4 stated she/he did not care for the food; the vegetables were overcooked and bland with no flavor. On 6/25/25 at 12:22 PM, the test tray was sampled: -herb green beans tasted metallic and were bland. -garlic bread stick was doughy with no garlic flavor. -spaghetti noodles were mushy, soft, and overcooked. -meat sauce was flavorful but the meatball had no flavor. On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like anything, the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table. 3. Resident 33 was admitted to the facility in 2/2023 with diagnoses including depression. On 6/23/25 at 8:17 AM, and 6/26/25 at 9:44 AM, Resident 33 stated the food was terrible, cold, and sometimes the meat was too tough. Resident 33 stated she/he had the spaghetti for lunch on 6/25/25. Resident 33 stated the spaghetti, and the meatball did not taste good, were bland, and needed onions or some seasoning added. On 6/25/25 at 12:22 PM, the test tray was sampled: -herb green beans tasted metallic and were bland. -garlic bread stick was doughy with no garlic flavor. -spaghetti noodles were mushy, soft, and overcooked. -meat sauce was flavorful but the meatball had no flavor. On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like anything, the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 3 halls (West Hall) and 1 of 1 sampled resident (#28) during random observations. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. On 6/24/25 at 10:19 AM, Resident 44 was observed touching multiple items in the PPE cart located outside room [ROOM NUMBER] for approximately five minutes. The resident opened multiple drawers and made contact with a facemask, N95 mask, and a stethoscope. Staff 28 (CNA) was standing behind the resident during this time and did not redirect the resident or sanitize the PPE cart following the interaction. On 6/24/25 at 10:26 AM, Staff 14 (LPN) asked Staff 28 to not let Resident 44 touch items in the PPE supplies. Staff 28 then re-directed Resident 44 away from the PPE cart. Staff 14 acknowledged the incident did not align with infection control protocol. On 6/26/25 at 11:43 AM, Staff 26 (RN/Infection Preventionist) acknowledged Resident 44 touching items in PPE cart and staff not sanitizing the carts afterwards was not in alignment with infection control best practice. 2. On 6/24/25 at 10:33 AM, an ice chest and water pitcher were observed on a cart on the [NAME] Hall, positioned near a room under enhanced barrier precautions. The ice scoop was sitting in an uncovered container. On the lower shelf of the cart, there were two boxes of gloves, a box of straws, and an empty cup containing a white liquid substance. On 6/24/25 at 10:38 AM, Staff 27 (CNA) stated many residents pass by the water pitcher cart and it was difficult to ensure they did not place dirty items on the cart. Staff 27 acknowledged the presence of a soiled cup on the water pitcher cart and the uncovered ice scoop. Staff 27 stated it was a challenge to ensure residents did not place items on the cart throughout the day. On 6/25/25 at 9:02 AM, a water pitcher with an uncovered ice scoop was observed on a cart on the [NAME] Hall, positioned near a room under EBP. On 6/26/25 at 11:43 AM, Staff 26 (RN/Infection Preventionist) acknowledged the presence of dirty items sitting next to a clean water pitcher used to serve residents were not in alignment with infection control best practice. 3. Resident 28 was admitted to the facility in 5/2022 with diagnoses including heart failure and kidney disease. A 5/29/25 Physician order instructed staff to clean Resident 28's right heel and cover with foam dressing daily. A 6/9/25 Physician order instructed staff to provide wound care twice a day to Resident 28's buttocks. On 6/24/25 at 10:40 AM, No PPE signage was observed outside Resident 28's room. Multiple staff were observed to enter Resident 28's room to provide personal care without donning PPE. On 6/24/25 at 10:40 AM, Staff 12 (Agency LPN) confirmed Resident 28 had open wounds and she had just completed her/his wound care. Staff 29 (CNA) and Staff 30 (CNA) assisted her with Resident 28's dressing change. Staff 12 stated she was not aware the resident was supposed to be on EBP(enhanced barrier precautions). Staff 12 confirmed no signage was posted outside the resident's door. Staff 12 further added any nurse could post EBP signage. On 6/24/25 at 11:03 AM, Staff 29 stated she was not really sure when a resident should be on precautions because the facility did not always update resident care plans. Staff 29 stated the facility did not always post signage to indicate what kind of precautions residents were on. Staff 29 confirmed she did not wear PPE when assisting with wound care. On 6/24/25 at 11:06 AM, Staff 26 (RN/Infection Preventionist) observed Staff 12, Staff 29, and Staff 30 exiting Resident 28's room. Staff 26 stated Resident 28 should have enhanced barrier precautions signage posted due to Resident 28 having open wounds, but the signage was not posted. Staff 26 also observed Staff 12, Staff 29, and Staff 30 exiting Resident 28's room and confirmed they were not wearing PPE during wound care. Staff 26 acknowledged infection control measures were not followed. On 6/25/25 at 8:51 AM, Staff 12 stated she was not aware she needed to wear PPE before providing direct care to residents on enhanced barrier precautions.

Based on interview and record review it was determined the facility failed to notify the physician of the resident's discharge to the hospital for 1 of 1 sampled resident (#39)reviewed for hospitalizations. This placed residents at risk for delayed treatment. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness. A review of Resident 39's clinical record revealed no indication the resident's physician was notified. On 6/25/25 at 11:44 AM, Staff 19 (Nurse Practitioner) stated she was not informed Resident 39 was sent to the hospital on 6/8/25. On 6/26/25 at 1:20 PM, Staff 2 (DNS) acknowledged Resident 39's physician was not notified when the resident was sent to the hospital.

Based on observation, interview and record review it was determined the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 2 sampled residents (#38) reviewed for personal property. This placed residents at risk of loss or theft of property. Findings include: Resident 38 was admitted to the facility in 2/2025 with diagnoses including anxiety and reduced mobility. A 2/13/25 admission MDS revealed Resident 38 was cognitively intact. A 3/9/25 Grievance Concern Problem Identification and Follow-Up form indicated Resident 38 reported a concern with six packs of cigarettes missing. Steps taken revealed social services reviewed and discussed options for tracking cigarettes which came into the facility. Resident 38 did not want to store her/his cigarettes at the nurse's station because many of the locks can be opened with any key. There was no evidence of the cigarettes, so the facility would not refund or replace the cigarettes for Resident 38. Social services would place an order for maintenance to investigate the lock issue. Administration review revealed there was no evidence of Resident 38's cigarettes existence. On 6/23/25 at 9:06 AM, Resident 38 stated the facility's rule was to store residents' smoking materials in a locked box at the nurses' station. Residents kept a key, and staff opened the box when she/he wanted to smoke. Resident 38 stated the keys distributed to residents would open all the locked boxes. Resident 38 stated in 3/2025 she/he had six packs of cigarettes missing out of the locked boxes. On 6/25/25 at 11:31 AM, Staff 13 (CNA) stated Resident 38 reported to her she/he was missing six packs of cigarettes from the lock box. Staff 13 assisted Resident 38 with the grievance form. On 6/25/25 at 11:46 AM, Staff 14 (Social Services Assistant) stated the facility did not allow unsupervised smokers to keep their smoking materials in a lock box in their rooms. Residents were to bring their key to the nurses' station, and a staff member opened the lock box and gave residents their smoking materials and when they were done residents return their smoking materials to the nurses' station. On 6/25/25 at 11:44 AM, and 12:06 PM, The drawer at the nurses' station was observed to have a lock on it. Staff 5 (MDS Coordinator) opened the drawer, which was not locked. A clear box with multiple sections was observed to have locks which opened upward. A key was in the drawer on top of the clear box. The key opened multiple boxes. Staff 1 (Administrator) stated the key was a master key if needed. On 6/27/25 at 7:21 AM, Staff 1 (Administrator) stated she would expect for staff to keep the drawer locked where the cigarettes are stored. Staff 1 stated the facility continued to work on fixing the cigarette storage as it does not work.

Based on interview and record review it was determined the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider prior to a resident being transferred to the hospital for 1 of 1 sampled resident (#39) reviewed for hospitalization. This placed the resident at risk for unassessed needs. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness. No evidence was found in Resident 39's clinical record to indicate the facility provided the following prior to Resident 39 being transferred to the hospital: -Contact information of the practitioner who was responsible for the care of the resident. -Advance directive information. -Medications (including when last received). On 6/27/25 at 10:19 AM, Staff 2 (DNS) stated but she was unable to provide documentation to confirm the facility provided appropriate information to the receiving health care institution or provider prior to Resident 39's transport to the emergency department on 6/8/25.

Based on interview and record review it was determined the facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a determination of a significant change of condition of a resident for 1 of 1 sampled resident (#39) reviewed for hospitalizations. This placed residents at risk for unassessed care needs. Findings include: Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact and was on hospice. On 6/25/25 at 10:11 AM, Staff 5 (LPN/MDS Coordinator) confirmed Resident 39 graduated from hospice on 5/30/25. Staff 5 stated she did not discuss this with Resident 39 and acknowledged she did not complete a SCSA. On 6/26/25 at 1:20 PM, Staff 2 (DNS) confirmed Resident 39 was discharged from hospice on 5/30/25 and acknowledged the facility failed to complete a SCSA for Resident 39.

Based on observation, interview, and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 1 sampled resident (#32) reviewed for pressure ulcers. This placed residents at risk for unmet wound care needs. Findings include: Resident 32 was admitted to the facility in 12/2024 with diagnoses including Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). A review of a 1/1/25 Skin & Wound Evaluation revealed Resident 32 was admitted with a Stage 3 pressure ulcer wound (a full-thickness skin loss, where the wound extends through the skin and into the fat tissue). A 6/24/25 review of Resident 32's care plan revealed no evidence of a baseline care plan for her/his Stage 3 pressure ulcer wound. On 6/24/25 at 2:38 PM, an observation of Resident 32's wound revealed a wound consistent with a Stage 3 pressure ulcer wound. On 6/26/25 at 12:43 PM, Staff 3 (LPN Care Manager) stated when a resident was admitted with a pressure ulcer wound, a care plan focused on current wound(s), with a goal and interventions geared towards wound care and healing must be initiated upon admission. Staff 3 stated Resident 32 was admitted with a Stage 3 pressure ulcer wound and she acknowledged Resident 32 did not have a baseline care plan for her/his pressure ulcer wound. On 6/27/25 at 8:34 AM, Staff 2 (DNS) stated MDS assessments must be completed timely.

2. Resident 38 was admitted to the facility in 2/2025 with a diagnoses including hypertensive heart disease with heart failure (a condition where the heart cannot pump blood effectively). Physician orders with a start date of 3/15/25 instructed staff to obtain Resident 38's weight every day shift on Saturdays for weight monitoring. A review of Resident 38's weights report revealed from 3/29/25 through 6/2/25, Resident 38's weight was documented on the report as obtained out of 12 times physician ordered. The 5/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring with a start date of 3/15/25. The TAR was documented as NA three times, a weight of 172 one time, and a code six one time. There was no legend for what NA was defined as. Code six was indicated as glucose. Physician orders with a start date 6/20/25 instructed staff to obtain Resident 38's weight every day shift for cardiac monitoring. The 6/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring. The TAR was documented as NA three times and a weight of 171 one time. The 6/2025 TAR instructed staff to obtain daily weights every day shift for cardiac monitoring with a start date of 6/20/25. From 6/20/25 through 6/24/25, there were checks documented three times with no weights documented and the code of two documented twice, which indicated Resident 38 refused to have her/his weight obtained. A 6/23/25 Progress Note revealed to obtain a daily weight every day shift for cardiac monitoring. No documentation of Resident 38's weight was recorded on the note. On 6/26/25 at 8:39 AM, Staff 12 (Agency LPN) stated she documented weights on the TAR or under vitals in resident's clinical record. Staff 12 stated she did not recall that she documented NA on the TAR for Resident 38's weights. If a resident refused to have weight obtained, she would typically not document NA. On 6/27/25 at 7:20 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation of staff would be to complete physician ordered weights and document weights or refusals of weights in the resident's clinical record. Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 33 and 38) reviewed for medication and pain medications. This placed residents at risk for adverse side effects and unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2/2023 with diagnoses including schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, similar to schizophrenia, and mood disorder symptoms, like mania or depression). Review of Resident 33's Physician Orders revealed an 4/5/25 order for Austedo 12 mg twice a day prescribed to treat drug induced dyskinesia (a movement disorder characterized by involuntary, repetitive, and sometimes jerky or writhing movements, often triggered by certain medications). The 5/2025 MAR revealed Resident 33 did not receive Austedo on the following days: -5/12/25 AM dose. -5/13/24 AM and PM doses. -5/14/25 AM and PM doses. -5/15/25 AM dose. Review of Medication Administration Notes between 5/12/25 and 5/15/25 revealed Resident 33 was out of Austedo, and the pharmacy was contacted on 5/14/25. A 6/25/25 review of the 6/2025 MAR revealed Resident 33 did not receive Austedo on the following days: -6/14/25 PM dose. -6/15/25 PM dose. -6/16/25 PM dose. -6/17/25 AM dose. -6/18/25 through 6/24/25 AM and PM doses. A review of Medication Administration Notes between 6/14/25 and 6/24/25 revealed Resident 33 was out of Austedo, and the pharmacy was contacted on 6/17/25. A 6/17/25 Medication Administration Note revealed Resident 33 stated she/he could feel the effects of not taking the Austedo. A 6/20/25 Medication Administration Note revealed Resident 33's PCP was notified of the missing doses of Austedo. A 6/25/25 Progress Note revealed Resident 33's PCP was informed of the missing doses of Austedo, and the orders were received to hold the Austedo until the medication was delivered from the pharmacy. On 6/26/25 at 10:51 AM, Staff 2 (DNS) stated Resident 33's medication Austedo was not available from 5/12/25 until the PM dose on 5/15/25 and there was no documentation the PCP was notified. Staff 2 stated Resident 33's Austedo was not available from 6/14/25 until 6/25/25 and stated the PCP was notified on 6/20/25. Staff 2 stated her expectation was to order medications a week prior to running out of the medication so residents did not run out of medication. Staff 2 stated the PCP should be notified as soon as Resident 33's medication was not available.

Based on interview and record review it was determined the facility failed to ensure resident pain medication was not misappropriated for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain. Findings include: Resident 3 was admitted [DATE] with diagnoses including a leg fracture. Review of a facility's policy Ordering and Receiving Controlled Medications dated 1/2023 revealed the facility must document and verify the quantity of controlled substances received. Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility including medication for Resident 3. The receipt was initialed by Staff 3 (LPN). Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified. Review of the Facility Reportable Incident (investigation) form dated 9/27/24 revealed on 9/26/24 between 10 PM and 10:30 PM the facility received narcotic medication for several residents including Resident 3 all in one package. The medications were received by Staff 4 (LPN) who did not check the contents of the package. At 2:45 AM Staff 3 notified the administrator Resident 3's pain medication card of 14 tablets of oxycodone was missing. The investigation also indicated the medications were not located in the building and the facility could not substantiate or unsubstantiated misappropriation at the time. In an interview on 10/15/24 at 7:30 AM Staff 4 said on 9/26/24 pharmacy delivered some narcotic medications around 10-10:30 PM. Staff 4 said the facility received three cards of narcotics and one card was for Resident 3. Staff 4 said she double checked the package to make sure all the medications were there and placed the package behind the nursing station visible to anyone. Staff 4 said Staff 3 was administering medications to residents that night and Staff 3 was on break when the medications arrived. Staff 4 said she did not have direct observation of the package of medications from the time they arrived to 2:45 AM. Staff 4 said she told Staff 3 pain medications were delivered around 2:45 AM, and said Staff 3 had informed her Resident 3's pain medications were missing. In an interview on 10/15/24 at 9:50 AM Staff 3 said on 9/26/24 the pharmacy delivered a package of narcotic medications while she was on break from 11:00 PM to 11:20 PM. Some time between 11:30 PM and 12 AM, Staff 3 noticed a package of medications on a computer at the nurse's station. Staff 3 said she checked the medications and found Resident 3's card of oxycodone was missing. Staff 3 said no one had told her the medications were delivered. In an interview on 10/16/24 9:00 AM Staff 1 acknowledged facility policy was not followed by staff regarding Resident 3's medication and the medication was misappropriated. On 9/27/24, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was misappropriation of pain medications. The Plan of Correction included: 1. Staff educated on policy and procedures of pharmaceutical receipt, documentation and storage, 2. Auditing procedure and verification processes by DON and Administrator, and 3. Monthly review of receipt and storage of medications and audits to be performed daily for three weeks, weekly for three weeks and then monthly.

Based on interview and record review it was determined the facility failed to store narcotic pain medications in a safe manner. This placed residents at risk for misappropriation of medications. Findings include: Review of the facility's Controlled Medication Storage policy dated 1/2024 revealed narcotic pain medication must be maintained in separately locked permanently affixed compartments. Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility and receipt was initialed by Staff 3 (LPN). Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified. Review of the Facility Reportable Incident (investigation) form dated 9/27/24 revealed on 9/26/24 between 10 PM and 10:30 PM the facility received narcotic medication for several residents all in one package. The medications were received by Staff 4 (LPN) who did not check the contents of the package and placed the package behind the nursing station. At 2:45 AM Staff 3 notified the administrator Resident 3's pain medication card of 14 tablets of oxycodone was missing. In an interview on 10/15/24 at 7:30 AM Staff 4 said on 9/26/24 pharmacy delivered some narcotic medications around 10-10:30 PM. Staff 4 said the facility received three cards of narcotics. Staff 4 said she double checked the package to make sure all the medications were there and placed the package behind the nursing station visible to anyone. Staff 4 said she did not have direct observation of the package of medications from the time they arrived at 2:45 AM. In an interview on 10/15/24 at 9:50 AM Staff 3 said on 9/26/24 the pharmacy delivered a package of narcotic medications while she was on break from 11:00 PM to 11:20 PM. Some time between 11:30 PM and 12 AM Staff 3 noticed a package of medications sitting on a computer at the nurse's station. In an interview on 10/16/24 9:00 AM Staff 1 acknowledged facility policy was not followed by staff regarding safe storage of narcotic medications. On 9/27/24, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was improper storage of narcotic pain medications. The Plan of Correction included: 1. Staff educated on policy and procedures of pharmaceutical receipt, documentation and storage, 2. Auditing procedure and verification processes by DON and Administrator, and 3. Monthly review of receipt and storage of medications and audits to be performed daily for three weeks, weekly for three weeks and then monthly.

Based on interview and record review it was determine the facility failed to ensure the dietary manager had current certification for 1 of 1 kitchen reviewed. This placed residents at risk for unmet dietary needs. Finding include: On [DATE] at 10:23 AM and 3:09 PM Staff 26 (Dietary Manager) was requested to produce her Dietary Manager certification. Staff 26 stated she believed her certification as a Dietary Manager expired in ,d+[DATE] and she was unable to located her certificate. On [DATE] at 8:30 AM Staff 1 (Administrator) acknowledged Staff 26's certification was expired.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 17, 18, 19, 20, and 21) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 12/6/22 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 17 (Former CNA), Staff 18 (CNA), Staff 19 (CNA), Staff 20 (CNA), and Staff 21 (CNA), which revealed the following: - Staff 17 was hired on 12/16/04; the facility was unable to provide a performance review. - Staff 18 was hired on 1/25/16; the facility was unable to provide a performance review but stated it was completed in 2020. - Staff 19 was hired on 2/6/17; the facility was unable to provide a performance review. - Staff 20 was hired on 3/2/23; the facility was unable to provide a performance review. - Staff 21 was hired on 2/1/21; the facility was unable to provide a performance review. On 3/7/24 at 11:08 AM Staff 1 (Administrator) acknowledged the performance evaluations were not completed annually for Staff 17, Staff 18, Staff 19, Staff 20, and Staff 21.

Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet needs. Findings include: Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep). The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent. A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day. The 2/23/24 baseline care plan had no information related to Resident 253's respiratory needs or equipment. On 3/6/24 at 3:23 PM Staff 27 (LPN) stated after the initial nursing assessment was completed a unit manager was to ensure the care plan was accurate. On 3/6/24 at 4:00 PM Staff 16 (LPN-Resident Care Manager) stated she was not aware Resident 253 required continuous oxygen. Staff 16 acknowledged the information related to the needed respiratory care and equipment for Resident 253 was not included in her/his baseline care plan.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received assistance with nail care for 2 of 5 sampled residents (#s 15 and 18) reviewed for ADLs. This placed residents at risk for poor hygiene and unmet needs. Findings include: 1. Resident 18 admitted 2022 with diagnoses including diabetes and depression. A physician's order dated 2/7/23 directed licensed nurses to check the resident's finger and toe nails once a week on bath days and trim as needed every Tuesday evening. Staff were to document a + if nails were trimmed and a - if nails were not trimmed. Resident 18's Comprehensive Care Plan revised 2/28/24 indicated the resident often declined nail care and staff were to encourage the resident to receive nail care. According to Resident 18's 2/2024 LN Task Report she/he was scheduled for nail care on 2/6/24, 2/13/24, 2/20/24, and 2/27/24. There was no documentation on any of these days to indicate nail care was completed or refused. On 3/4/24 at 1:54 PM Resident 18 was observed to have very long finger nails on both hands. Resident 18 stated she/he had not asked staff to trim them. The resident was scheduled for a bath/shower on 3/5/24. On 3/6/24 at 11:37 AM Staff 11 (CNA) stated Resident 18 was diabetic so only licensed nurses trimmed Resident 18's nails on the resident's bath days. Staff 11 stated the resident refused a shower on 3/5/24 but allowed a partial bed bath. Staff 11 stated the resident was in need of a nail trim and confirmed nail care was not provided by the nurse. On 3/7/24 at 9:21 AM Staff 27 (LPN) confirmed she did not provide nail care to Resident 18. On 3/7/24 at 12:56 PM Staff 15 (RNCM) and Staff 16 (LPN Resident Care Manager) confirmed Resident 18 needed nail care and there were no recent documented refusals. 35855 2. Resident 15 admitted to the facility in 2022 with diagnoses including dementia. An 4/24/23 care plan indicated Resident 15 had an ADL self-care performance deficit, and staff were to check nail length and clean on bath days and as necessary. A 12/23/23 Annual MDS indicated Resident 15 was dependent for personal hygiene. A 3/2024 Documentation Survey Report revealed Resident 15 was bathed on 3/1/24 and 3/5/24. On 3/4/24 at 1:26 PM and 3/7/24 at 8:56 AM Resident 15's thumb nails were both approximately an inch long and other nails on her/his hands approximately half inch long with brown debris under the right ring finger and both left and right index fingers. On 3/7/24 Resident 15 also had a reddish tinge on top of multiple fingers around the fingernails. On 3/7/24 at 8:52 AM Staff 1 (Administrator) indicated she would review and provide additional information. On 3/7/24 at 10:17 AM Staff 3 (CNA) stated when bathing Resident 15 she cleaned under her/his toenails and fingernails but did not trim Resident 15's nails because she/he was diabetic and the nurses were required to trim diabetic residents' nails. No diagnosis of diabetes was found in Resident 15's clinical record. No additional information was provided.

Based on interview and record review it was determined the facility failed to follow a physician's order for daily weights for 1 of 2 residents (#14) reviewed for respiratory care. This placed residents at risk for delay in treatment. Findings include: Resident 14 admitted to the facility in 2021 with diagnoses including congestive heart failure (CHF), chronic respiratory failure and chronic obstructive pulmonary disease (COPD). According to the resident's medical record she/he was hospitalized for respiratory problems and/or CHF on 11/19/23, 12/7/23, 1/16/24, and 2/21/24. Re-admission orders dated 2/25/24 directed the facility to obtain daily weights x 4 weeks for CHF. The order did not include parameters for physician notification, however the facility had standing orders from the medical director indicating if daily weights were obtained related to a diagnosis of CHF the physician was to be notified for weight gain greater than two pounds in 24 hours, three pounds in 72 hours or greater than five pounds in one week. There was no documented evidence the order was clarified to determine if the parameters for notification should be added. Review of the resident's weight records revealed the following documented weights: 3/7/2024 11:09 200.0 Lbs Mechanical Lift 3/6/2024 07:37 195.0 Lbs Mechanical Lift 3/5/2024 08:58 208.0 Lbs Mechanical Lift 3/3/2024 13:38 198.0 Lbs Mechanical Lift 3/2/2024 16:57 201.0 Lbs Mechanical Lift 2/27/2024 13:34 202.0 Lbs Mechanical Lift 2/25/2024 17:51 203.0 Lbs Mechanical Lift The directive for daily weights was on the TAR for licensed nurse acknowledgment. The resident's 2/2024 and 3/2024 TAR indicated to see progress notes for 2/26/24, 2/29/24, 3/3/24, and 3/4/24, however no corresponding progress notes were found in the record for those dates. The weight record was blank for 2/28/24 and 3/1/24. On 3/6/24 at 2:46 PM Staff 29 (CNA) stated CNAs referred to POC (Point of Care, part of the electronic health record) for a list of residents who needed weighed and how often. Staff 29 referred to the POC record and demonstrated Resident 14 was listed as one who required weekly and/or PRN weight, not daily weights. On 3/6/24 at 3:03 PM Staff 12 (LPN) confirmed the order for daily weights was not entered into the record for the direct care staff to know to obtain the weights daily, but it was entered under Licensed Nurse Tasks. On 3/7/24 at 12:02 PM Staff 15 (RNCM) and Staff 16 (LPN Resident Care Manager) confirmed the order was not entered correctly and licensed staff did not follow up until 3/7/24 with the resident's primary provider to report weight variance or to clarify the order.

Based on observation, interview, and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep). The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent. The Oxygen Sats (saturation) Summary for Resident 253 indicated her/his oxygen level on 2/22/23 was at 91 percent and no oxygen levels were monitored from 2/27/24 through 3/1/24. A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day and the administration record was referenced. The 2/2024 TAR had no documentation of Resident 253's oxygen order or instructions related to the monitoring of her/his oxygen equipment. On 3/4/24 at 3:09 PM and 3/6/24 at 8:28 AM Resident 253 was observed in bed with continuous oxygen in use at two liters per minute through a nasal cannula. On 3/6/24 at 3:11 PM Staff 24 (CNA) stated she only reported issues with Resident 253's oxygen levels if oxygen levels were below 90 percent. On 3/6/24 at 3:41 PM Staff 22 (LPN) stated she recalled Resident 253 was admitted to the facility with supplemental oxygen. Staff 22 acknowledged orders for Resident 253's oxygen were not transcribed to the TAR and she did not verify or enter the oxygen order when Resident 253 admitted to the facility. On 3/6/24 at 4:00 PM Staff 16 (LPN-Resident Care Manager) stated she was not aware Resident 253 required continuous oxygen and her/his oxygen order was not entered into the system.

Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer. Findings include: Resident 35 was admitted to the facility in 10/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 10/17/22 Significant Change CAA indicated Resident 35 was at risk for pressure ulcers related to incontinence of bowel and bladder and needed assistance with ADLs. Resident 35 had a Stage 3 (full thickness skin loss) pressure ulcer. The 10/5/22 care plan indicated the resident had bladder incontinence. The resident will remain free from skin breakdown due to incontinence and brief use A Progress Note dated 10/7/22 indicated Resident 35 had an unblanchable area to her/his coccyx (tailbone). This was not identified as a Stage 1 pressure ulcer (unblanchable area). A Skin and Wound Assessment sheet dated 10/31/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage, description, measurements or if the physician was notified. A Skin and Wound Assessment sheet dated 11/15/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage or description of the pressure ulcer. A Skin and Wound Assessment sheet dated 11/17/22 indicated the resident had an unstageable pressure ulcer. A review of Resident 35's 10/5/22 through 11/14/22 electronic record revealed no indication staff educated the resident regarding the risks and benefits of repositioning while in bed or the resident's non-compliance with repositioning prior to the development of the unstageable pressure ulcer. Random observations from 11/14/22 through 11/18/22 on day and evening shifts revealed Resident 35 lying flat on her/his back. On 11/15/22 at 4:53 Staff 6 (CNA) stated Resident 35 refused to change positions while in bed. On 11/16/22 at 12:30 PM Staff 25 (CNA) stated Resident 35 refused to reposition while in bed and staff reported this to nursing. On 11/16/22 at 12:40 PM Staff 26 (CNA) stated Resident 35 refused to reposition while in bed and nursing was aware. On 11/16/22 at 2:47 PM Staff 15 (LPN/RCM) stated she was aware the resident refused to reposition while in bed but this was not documented in the electronic record. Staff 15 stated she provided staff education multiple times on the importance of repositioning residents every two hours to avoid pressure ulcers and to document refusals but they did not comply. Staff 15 stated Resident 35 refused repositioning and acknowledged staff did not document the resident's refusals to reposition while in bed. On 11/17/22 at 1:31 PM Staff 2 (DNS) acknowledged on 10/7/22 Resident 35 had a Stage 1 pressure ulcer and a skin sheet should have been completed. Staff 2 further stated Resident 35's pressure ulcer worsened to a Stage 3 and was now unstageable. Staff 2 acknowledged the Skin and Wound Assessment sheets were inaccurate and incomplete and Resident 35's care plan did not have information related to the resident's pressure ulcer.

Based on observation and interview it was determined the facility failed to provide a clean and well maintained environment for 5 of 30 resident room floors and 1 of 3 carpeted halls. This placed residents at risk for lack of a clean and homelike environment. Findings include: Observations made during the week of 11/14/22 through 11/18/22 revealed an area in the hallway in front of resident room eleven with carpet frayed and lifted at the seam. The carpet throughout the hall had multiple areas with dark stains and irregular shaped areas of discoloration. On 11/15/22 12:35 PM the floor in resident room 9 was observed with black and sticky areas between the bed and the window and at the foot of each bed. The areas near the dresser had large sticky yellow stains. On 11/16/22 at 12:40 PM Staff 14 (Housekeeper) stated the floors in resident rooms six, nine, 23, 28 and 29 were all difficult to clean and remained sticky because the facility no longer obtain special floor cleaning supplies. On 11/16/22 at 1:01 PM Staff 13 (Housekeeping Supervisor) confirmed the special floor cleaning supplies were no longer available. Staff 13 stated the floors were cleaned daily but did not appear clean because of the condition of the floors in many rooms. On 11/17/22 at 11:00 AM the floor in resident rooms six, nine, 23, 28 and 29 and the carpet in the south hall were observed with Staff 1 (Administrator). Staff 1 acknowledged the carpet should be replaced, the floors in the rooms observed did not appear in the best condition and specific plans to address the flooring were not available.

Based on interview and record review it was determined the facility failed to obtain physician's orders and properly manage a wound for 1 of 3 sampled residents (#4) reviewed for wound care. This resulted in Resident 4 requiring surgical intervention to address the facility's failure to appropriately care for a wound. Findings include: Resident 4 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. The 4/14/19 Nursing Admission Database indicated the resident admitted with a wound vac (a machine which performs vacuum-assisted closure and healing of a wound) located on her/his right flank. The 4/14/19 admission orders [REDACTED]. A hand written note in the admission orders [REDACTED]. No information related to the frequency of wound vac changes or type of dressing was found. A review of the 4/2019 TAR did not reveal an entry for any care related to the wound vac until 4/29/19, 15 days after admission. The 4/29/19 entry for the wound vac dressing change was documented as completed by Staff 3 (LPN) during N[NAME] shift on 4/30/19. Staff 3's progress note for the 4/30/19 N[NAME] shift revealed the wound vac was intact. The note did not indicate Staff 3 changed the wound vac dressing. Attempts to reach Staff 3 regarding the wound vac documentation was unsuccessful. A 5/1/19 progress note indicated Resident 4 was sent to the emergency room for a dislodged nephrostomy tube (a drainage tube inserted into the kidney). The 5/2/19 hospital admission documentation revealed a portion of the wound vac foam dressing in the right flank wound was firmly embedded into the tissues. The wound care nurse was unable to remove the dressing due to pain and bleeding. Resident 4 required surgical debridement to remove the retained wound vac foam. On 11/20/19 at 6:28 PM Staff 12 (LPN) reported the resident did not come with wound vac orders and she was unable to obtain orders from the hospital. She stated she would have left the admission documentation for the RNCM to follow up on the following morning. Staff 12 reported she did not recall ever changing Resident 4's wound vac dressing. On 11/26/19 at 12:51 PM Staff 18 (LPN) recalled there were no orders to change the resident's wound vac dressing. She stated she was not sure how long there was nothing on the TAR related to the wound vac. Staff 18 stated the normal process was to change wound vac dressings every three days. She further reported she would not have been prompted to provide wound care if it was not on the TAR. On 11/26/19 at 1:04 PM Staff 17 (CNA) stated Resident 4 had a wound vac however he would not have done anything with it because only nurses handled [DEVICE]. He did not recall anything related to nurses changing the wound vac. On 11/26/19 at 1:15 PM Staff 5 (CNA) stated she could not recall if the resident had a wound vac. She reported the only thing she would have done with a wound vac would be report to the nurse if it had low batteries. She stated the nurses handled all of the care related to [DEVICE]. On 11/26/19 at 1:25 PM Staff 10 (RN) could not recall why the wound vac treatment was entered on the TAR on 4/29/19. She stated she would not have known a resident required wound treatments if they were not on the TAR. On 11/27/19 at 1:22 PM Staff 2 (Director of Nursing) acknowledged it was unlikely Staff 3 changed the wound vac dressing on the night of 4/29/19 considering the dressing was found to be embedded into the wound on 5/2/19. She stated the ball was dropped when the admission orders [REDACTED]. Staff 2 did not speak to the lack of documentation to indicate if the wound vac dressing was ever changed prior to the hospitalization on [DATE]. Additional time was given to provide additional documentation and none was provided.

Based on interview and record review it was determined the facility failed to ensure staff adhered to standards of nursing practice for 11 of 13 licensed nurses (#s 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) related to high blood sugar. This failure, determined to be an immediate jeopardy situation, resulted in Resident 18 developing uncontrolled diabetes and required intravenous insulin administration at the hospital. Resident 33 became unresponsive requiring transfer to the emergency department. Residents 6, 9, 24 and 40 were placed at risk for complications related to high blood sugar. Findings include: A review of the facility's 12 insulin dependent diabetic residents CBG records from 6/1/18 through 7/18/18 revealed six residents (#s 6, 9,18, 24, 33 and 40) with CBGs over 400 (normal is 70 to 100). A review of the resident's clinical records revealed, with few exceptions, the licensed nurse staff who obtained the elevated CBGs failed to notify the physician, monitor or assess the resident for [MEDICAL CONDITION]. On 7/18/18 at 10:59 AM Staff 8 (LPN) was asked about CBGs of 600 he documented for Resident 18 and what actions he took. He stated he did not notify the physician of Resident 18's high blood sugar because there were no parameters to do so. On 7/18/18 at 4:34 PM Staff 7 (LPN) stated Staff 21 (Facility Medical Director), who was also the attending physician for 43 of the 45 current residents, did not want to be notified of high CBGs unless the resident was symptomatic. She stated at other facilities she would notify the physician for CBGs over 400. She stated she would call Staff 21 for CBGs over 500. She stated Staff 21 told her to stop calling unless the resident was symptomatic. On 7/18/18 at 1:20 PM Staff 2 (DNS) stated her expectation related to standard of practice for residents with an elevated CBG was for licensed nurses to administer insulin as ordered and recheck the CBG. Staff 2 stated if there were no physician ordered parameters for CBGs over 400 then the physician should be notified. She expected the licensed nurses to assess residents for [MEDICAL CONDITION] and document those assessments. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence Residents 6, 9,18, 24, 33 and 40 were assessed and monitored for [MEDICAL CONDITION], or the resident's physician was promptly notified of the resident's high blood sugars. Refer to F-684

1. Based on interview and record review it was determined the facility failed to assess, monitor and intervene related to high blood sugar values for 6 of 12 sampled residents (#s 6, 9, 18, 24, 33 and 40) reviewed for diabetic management. This failure, determined to be an immediate jeopardy situation, resulted in Resident 18 developing uncontrolled diabetes and required intravenous insulin administration at the hospital. Resident 33 became unresponsive and the physician provided orders for the resident to transfer to the emergency department. Residents 6, 9, 24 and 40 were placed at risk for complications related to high blood sugar. Findings include: On 7/18/18 at 3:28 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed that the failure to ensure residents with elevated blood sugar were assessed, monitored and provided with any appropriate interventions constituted a situation of immediate jeopardy to the health and welfare of residents. Surveyors requested the development and implementation of a plan to ensure resident safety. On 7/18/18 at 5:54 PM a plan to ensure resident safety was accepted from the facility and at 6:10 PM the plan was verified as implemented and the immediate jeopardy situation was removed. The plan for removal of the immediate jeopardy included: - Current residents with a [DIAGNOSES REDACTED]. - Current residents with a [DIAGNOSES REDACTED]. - Physician order [REDACTED]. Hypo/[MEDICAL CONDITION] signs and symptoms will be entered into the electronic record. - Diabetic residents will be placed on Alert Charting to monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and CBG results. - Licensed Nurses will be reeducated on signs and symptoms of hypo/[MEDICAL CONDITION], notification of MD if CBGs are outside parameters, assessment of resident when CBG is outside of parameters and documentation of resident assessment and MD/family notifications. Licensed Nurses currently working have been re-educated. Remaining Licensed Nurses will be re-educated prior to their next shift. - Licensed Nurses will complete CBG and PRN Physician Notification competencies prior to working their next scheduled shift. - The facility will create a policy and procedure for monitoring signs and symptoms of hypo/[MEDICAL CONDITION]. - Ongoing monitoring of CBG results will be done in the morning MACC (Monitoring of Acute Change) meeting by the DNS and RNCMs. a. Resident 18 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 18's diabetic care plan with a start date of 5/24/17 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] and the resident's diabetes would be managed. Staff were to notify the physician of CBG results per order and monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. A review of Resident 18's (MONTH) (YEAR) Physician order [REDACTED]. If the resident's CBG was greater than 300 then seven units of Humalog (insulin) were to be administered. A handwritten note pad page dated 2/15, not found in Resident 18's clinical record, provided by Staff 5 (Social Services) on 7/19/18 indicated Witnesses 1, 2 and 3 were concerned Resident 18 had a UTI and the nursing department was to monitor for UTI. The witnesses were also concerned about the resident's blood sugar. A Progress Note dated 6/24/18 indicated Resident 18's CBG continued to run high with general malaise noted (a potential symptom of high blood sugar) and the physician was notified. The note failed to indicate how long the resident's blood sugar was high (normal range is generally considered 70 to 100), how high the blood sugar was, what specifically the physician was notified of and what the physician's response was. Resident 18's CBG record revealed the following CBG readings over 400: 462 on 6/26/18 at 4:15 PM 600 on 6/27/18 at 6:41 AM 600 on 6/27/18 at 11:32 AM 600 on 6/27/18 at 4:05 PM with a comment of Off scale: High 483 on 6/27/18 at 8:43 PM 406 on 6/28/18 at 6:58 AM 491 on 6/29/18 at 4:50 PM Off scale: High on 7/2/18 at 4:13 PM 501 on 7/2/18 at 8:37 PM with a comment of Off scale: High 410 on 7/15/18 at 3:35 PM 410 on 7/15/18 at 3:52 PM Resident 18's CBG record revealed between 6/22/18 and 7/2/18 there were eight CBG readings between 200-299 and 12 readings between 300-399. A NAR (nutrition at risk) meeting Progress Note dated 6/26/18 failed to address Resident 18's high blood sugar. A review of Resident 18's clinical record revealed no indication the resident was assessed and monitored for [MEDICAL CONDITION] or any interventions implemented. The record failed to indicate the physician was notified of the resident's continuing very high blood sugars after 6/24/18. A Progress Note dated 7/2/18 indicated Resident 18 complained of chest pain and shortness of breath. Interventions were not successful and the resident was sent to the emergency department by ambulance. A hospital History and Physical dated 7/3/18 indicated Resident 18 had [MEDICAL CONDITION] and uncontrolled diabetes which may have progressed to a hyperosmolar state (a potentially fatal complication of high blood sugar). The resident was placed on IV (intravenous) insulin (injectable medication to treat high blood sugar). On 7/18/18 at 10:59 AM Staff 8 (LPN) stated he did not notify the physician of Resident 18's high blood sugar because there were no parameters to do so. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence Resident 18 was assessed and monitored for [MEDICAL CONDITION], or the resident's physician was promptly notified of the resident's high blood sugars. b. Resident 33 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 33's diabetic care plan with a start date of 6/17/15 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] and staff were to monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. A Physician's Telephone Orders dated 7/3/18 indicated if Resident 33's CBG was greater than 250 to administer 12 units of Humalog (insulin). The physician did not want to be called for elevated blood sugars and wanted a list of CBGs greater than 450 on Tuesday (7/10/18). A review of Resident 33's clinical record revealed no rationale for the physician not wanting to be notified immediately of elevated CBGs unless they were greater than 450. There was no evidence the facility attempted to clarify the order with the physician. Resident 33's CBG record revealed a CBG of 442 on 7/16/18 at 4:23 PM. A review of Resident 33's clinical record revealed no evidence the resident's physician was notified for treatment orders to address the resident's high CBG or the resident was assessed and monitored for [MEDICAL CONDITION]. A Progress Note dated 7/17/18 at 5:54 AM indicated Resident 33 had increased confusion, did not know where she/he was or what year it was, was sweating profusely and was having difficulty with her/his oxygen tubing. The resident's CBG was 354. The resident was administered a breathing treatment and the resident's confusion seemed to get better. The resident was observed opening sugar packets to eat the sugar. The resident stated the sugar made him feel better. The resident was educated regarding the risks of eating sugar with an already elevated CBG. The note failed to indicate the physician was notified for treatment orders to address the resident's high CBG or that the resident was assessed and monitored for [MEDICAL CONDITION]. Resident 33's CBG record revealed a CBG of 451 on 7/17/18 at 7:14 AM and 485 on 7/17/18 at 11:26 AM. A review of Resident 33's clinical record revealed no evidence the resident's physician was notified for treatment orders to address the resident's high CBG or the resident was assessed and monitored for [MEDICAL CONDITION]. Resident 33's CBG record revealed a CBG of 473 on 7/17/18 at 4:14 PM A Progress Note dated 7/17/18 at 4:30 PM revealed Resident 33's CBG was 473 before dinner. The resident did not wake up or respond when the resident's blood sugar was checked or when the resident received an insulin injection. The resident was asked to provide a urine sample earlier in the shift and was sleeping ever since. The physician was notified and gave orders to send the resident to the emergency department. On checking the resident's vital signs the resident woke up, was angry and refused to go to the hospital. The resident continued to sleep most of the shift. A Progress Note dated 7/18/18 at 1:30 AM revealed Resident 33 continued to show progressed confusion as she/he had for the last couple of days. The resident had labored breathing, was pale in color and complained of chest pain. The resident's CBG was 445. The resident asked to be transferred to the hospital, 911 was called and the resident left the facility at 12:55 AM. A hospital Emergency Department Encounter dated 7/18/18 indicated Resident 33's urine glucose level was greater than 1000 (normal is 0 to 0.8) and blood glucose level was 343. The resident was administered IV antibiotics for a UTI and was administered 10 units of regular insulin which resulted in a lower CBG of 246. The resident was discharged back to the facility. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence Resident 33 was assessed and monitored for [MEDICAL CONDITION], or the resident's physician was promptly notified of the resident's high blood sugars. c. Resident 9 was admitted in 4/2018 with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED].>- [MEDICATION NAME] U-100 insulin pen, 20 units at bedtime - [MEDICATION NAME]pen, 10 units before meals - CBG check before meals and at bedtime There were no parameters for CBG levels found in the medical record to direct staff when to contact the physician or treatment options for critically high or low blood sugars. The 6/2018 MAR identified the resident's blood sugars generally ran in the 200-300 range before dinner and bedtime. On four occasions, the CBG testing read over 400: - On 6/12/18 at 5:18 PM, the CBG level was 406 - On 6/13/18 at 5:01 PM, the CBG level was 473 - On 6/14/18 at 4:27 PM, the CBG level was 470 - On 6/16/18 at 8:21 PM, the CBG level was 591 Progress notes and MAR documentation did not reflect notification of the physician, monitoring of the resident or treatment of [REDACTED]. In a 7/18/18 interview at 4:57 PM, Staff 9 (LPN) stated if a blood sugar reading was under 70 or over 400 she would notify the physician and ask for further treatment orders. Upon review of the 6/2018 MAR, Staff 9 confirmed she did not notify the physician of high blood sugars or request additional treatment orders. d. Resident 6 admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Resident 6's current care plan for diabetes, updated 5/29/18, indicated the resident was at risk for low and high blood sugar. The care plan indicated the physician was to be notified of any CBG levels less than 70 or greater than 400. In addition, staff were to monitor the resident and the resident's CBG levels until the resident stabilized. A Vitals Report from 6/1/18 through 7/18/18 indicated the following CBG levels: 6/27/18 - 415 6/29/18 - 435 6/30/18 - 540 7/4/18 - 564 7/8/18 - 402 7/9/18 - 503 (11:31 AM) 7/9/18 - 407 (4:23 PM) 7/10/18 - 417 (11:24 AM) 7/10/18 - 461 (4:36 PM) 7/11/18 - 442 (9:04 AM) 7/11/18 - 522 (12:17 PM) 7/11/18 - 519 (4:41 PM) 7/12/18 - 421 7/13/18 - 471 7/14/18 - 418 7/16/18 - 415 7/18/18 - 446 A 7/4/18 progress note indicated the physician was contacted regarding the 7/4/18 CBG result and new orders were obtained. No evidence was found to indicate the physician was contacted or the resident was assessed and monitored regarding the elevated CBG levels on the remaining dates. On 7/18/18 at 1:18 PM Staff 15 (LPN) acknowledged she measured Resident 6's CBG on 7/13/18 when it measured 471. Staff 15 stated she typically notified the physician of abnormal CBG levels but acknowledged there was no indication the resident's physician was contacted. Staff 15 stated she was not familiar with the resident's care plan. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence to indicate staff contacted a physician, assessed and monitored Resident 6's elevated CBG levels. e. Resident 40 admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) (YEAR) Vitals Report revealed Resident 40 had high CBG results on the following dates: -On 6/17/18 at 11:59 AM CBG of 527 and at 4:15 PM a CBG of 512. -On 6/18/18 at 4:23 PM a CBG of 442 and at 7:43 PM a CBG of 460. -On 6/19/18 at 4:45 PM a CBG of 405. -On 6/20/18 at 7:14 AM a CBG of 403. -On 6/24/18 at 5:11 PM a CBG of 414. -On 6/26/18 at 8:44 PM a CBG of 428. -On 6/27/18 at 4:22 PM a CBG of 454. -On 7/9/18 at 9:49 AM a CBG of 401. -On 7/9/18 at 11:30 AM CBG of 487. -On 7/10/18 at 11:22 AM a CBG of 440. A review of the clinical record from 6/1/18 through 7/18/18 revealed no information regarding whether Resident 40 was assessed, monitored or had symptoms of high blood sugar. On 7/8/18 at 4:34 PM Staff 7 (LPN) stated Resident 40 was insulin dependent, required CBG checks twice per shift and was administered a set amount of insulin one time per shift. She indicated Resident 40 at times had high blood sugars from eating candy. Staff 7 indicated she documented the high blood sugars and any signs or symptoms of high blood sugar. On 7/19/18 at 8:31 AM Staff 2 (DNS) stated she found no evidence to indicate Resident 40 was assessed or monitored related to the resident's high blood sugars. f. Resident 24 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. - Humalog Insulin - Basaglar KwikPen (insulin) - CBG check before meals and as needed. The 6/2018 MAR indicated the amount for the sliding scale Humalog Insulin at: - CBG less than 70, call MD - CBG from 0 to 99, give 0 units - CBG from 100 to 300, give 8 units Resident 24's diabetic care plan with a start date of 3/14/18 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] (high blood sugar) and staff were to monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. The 6/2018 MAR and 7/1/18 through 7/19/18 MAR identified Resident 24's blood sugars generally ran in the 200-300 range before meals and bedtime. On nine occasions, the CBG testing read over 400: - On 6/25/18 at 11:54 AM, the CBG was 434 - On 6/27/18 at 4:24 PM, the CBG was 418, at 6:08 PM, the CBG was 418 and at 10:54 PM, the CBG was 426 - On 7/3/18 at 11:34 AM and at 11:54 AM, the CBG was 441 - On 7/6/18 at 5:14 PM, the CBG was 406 - On 7/13/18 at 11:07 PM, the CBG was 424 - On 7/14/18 at 11:33 AM, the CBG was 421 Medical record review for Resident 24 revealed no evidence staff notified the physician or monitored for [MEDICAL CONDITION] with the high blood sugar readings. In an interview on 7/18/18 at 4:57 PM, Staff 9 (LPN) stated if a blood sugar reading was under 70 or over 400 she notified the physician and asked for further treatment orders. On 7/19/18 08:31 AM, Staff 2 (DNS) confirmed there was no evidence Resident 24's physician was notified of the elevated CBGs or was monitored for signs and symptoms of [MEDICAL CONDITION]. 2. Based on observation, interview and record review it was determined the facility failed to ensure a palm protector was consistently in place for 1 of 1 sampled resident (#42) reviewed for ADLs. This placed residents at risk for skin breakdown. Findings include: Resident 42 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. The resident's 6/29/18 In Room Care Plan indicated the resident was to have the left hand and arm washed daily and a sheep skin palm protector applied to the left hand. The palm protector was to be on in the morning and off at HS as the resident would allow. The In Room Care Plan further indicated staff were to wash and dry the resident's left hand with warm soapy water when removing the palm protector. An observation on 7/16/18 at 2:07 PM revealed the resident did not have a palm protector in her/his left hand. An observation on 7/17/18 at 12:54 PM revealed the resident did not have a palm protector in her/his left hand. An observation on 7/18/18 at 8:45 AM revealed the resident did not have a palm protector in her/his left hand. An observation on 7/19/18 at 9:37 AM revealed the resident did not have a palm protector in her/his left hand. In an interview on 7/18/18 at 8:45 AM Resident 42 stated the staff did not place a sheep skin palm protector to her/his left hand but occasionally placed a cloth wedge (in the shape of a carrot) in the left hand. The resident further stated it was a long time since a palm protector was placed in the resident's left hand. In an interview on 7/18/18 at 10:08 AM Staff 18 (CNA) stated staff were to put the cloth wedge and not a sheep skin palm protector in the resident's left hand. Staff 18 acknowledged the resident did not have a palm protector in the left hand but it was supposed to be in place. In an interview on 7/19/18 at 10:04 AM Staff 3 (RNCM) acknowledged the 6/29/18 In Room Care Plan indicated the resident was to have a sheep skin palm protector in her/his left hand. Staff 3 further acknowledged the resident was to have a cloth wedge instead of the palm protector. Staff 3 further acknowledged the In Room Care Plan was not revised or updated for the resident to indicate the cloth wedge instead of the sheepskin palm protector.

Based on interview and record review it was determined the facility failed to notify the physician of elevated CBG results for 6 of 12 sampled residents (#s 6, 9, 18, 24, 33 and 40) reviewed for insulin administration. This failure, determined to be an immediate jeopardy situation, resulted in Resident 18 developing uncontrolled diabetes and requiring intravenous insulin administration at the hospital. Resident 33 became unresponsive and the physician provided orders for the resident to transfer to the emergency department. Residents 6, 9, 24 and 40 were placed at risk for complications related to high blood sugar. Findings include: 1. Resident 18 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 18's diabetic care plan with a start date of 5/24/17 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] (high blood sugar) and the resident's diabetes would be managed. Staff were to notify the physician of CBG results per order and monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. A review of Resident 18's (MONTH) (YEAR) Physician order [REDACTED]. If the resident's CBG was greater than 300 then seven units of Humalog (insulin) were to be administered. A Progress Note dated 6/24/18 indicated Resident 18's CBG continued to run high with general malaise noted (a potential symptom of high blood sugar) and the physician was notified. The note failed to indicate how long the resident's blood sugar was high (normal range is generally considered 70 to 100), how high the blood sugar was, what specifically the physician was notified of and what the physician's response was. Resident 18's CBG record revealed the following CBG readings over 400: 462 on 6/26/18 at 4:15 PM 600 on 6/27/18 at 6:41 AM 600 on 6/27/18 at 11:32 AM 600 on 6/27/18 at 4:05 PM with a comment of Off scale: High 483 on 6/27/18 at 8:43 PM 406 on 6/28/18 at 6:58 AM 491 on 6/29/18 at 4:50 PM Off scale: High on 7/2/18 at 4:13 PM 501 on 7/2/18 at 8:37 PM with a comment of Off scale: High 410 on 7/15/18 at 3:35 PM 410 on 7/15/18 at 3:52 PM Resident 18's CBG record revealed between 6/22/18 and 7/2/18 there were eight CBG readings between 200-299 and 12 readings between 300-399. A review of Resident 18's clinical record revealed no indication the physician was notified of the resident's continuing very high blood sugars after 6/24/18. A Progress Note dated 7/2/18 indicated Resident 18 complained of chest pain and shortness of breath. Interventions were not successful and the resident was sent to the emergency department by ambulance. A hospital History and Physical dated 7/3/18 indicated Resident 18 had [MEDICAL CONDITION] and uncontrolled diabetes which may have progressed to a hyperosmolar state (a potentially fatal complication of high blood sugar). The resident was placed on IV (intravenous) insulin (injectable medication to treat high blood sugar). On 7/18/18 at 10:59 AM Staff 8 (LPN) stated he did not notify the physician of Resident 18's high blood sugar because there were no parameters to do so. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence Resident 18 was assessed and monitored for [MEDICAL CONDITION], or the resident's physician was promptly notified of the resident's high blood sugars. 2. Resident 33 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 33's diabetic care plan with a start date of 6/17/15 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] and staff were to monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. A Physician's Telephone Orders dated 7/3/18 indicated if Resident 33's CBG was greater than 250 to administer 12 units of Humalog (insulin). The physician did not want to be called for elevated blood sugars and wanted a list of CBGs greater than 450 on Tuesday (7/10/18). A review of Resident 33's clinical record revealed no rationale for the physician not wanting to be notified immediately of elevated CBGs unless they were greater than 450. There was no evidence the facility attempted to clarify the order with the physician. Resident 33's CBG record revealed a CBG of 442 on 7/16/18 at 4:23 PM. A review of Resident 33's clinical record revealed no evidence the resident's physician was notified for treatment orders to address the resident's high CBG or the resident was assessed and monitored for [MEDICAL CONDITION]. A Progress Note dated 7/17/18 at 5:54 AM indicated Resident 33 had increased confusion, did not know where she/he was or what year it was, was sweating profusely and was having difficulty with her/his oxygen tubing. The resident's CBG was 354. The resident was administered a breathing treatment and the resident's confusion seemed to get better. The resident was observed opening sugar packets to eat the sugar. The resident stated the sugar made him feel better. The resident was educated regarding the risks of eating sugar with an already elevated CBG. The note failed to indicate the physician was notified for treatment orders to address the resident's high CBG or that the resident was assessed and monitored for [MEDICAL CONDITION]. Resident 33's CBG record revealed a CBG of 451 on 7/17/18 at 7:14 AM and 485 on 7/17/18 at 11:26 AM. A review of Resident 33's clinical record revealed no evidence the resident's physician was notified for treatment orders to address the resident's high CBG or the resident was assessed and monitored for [MEDICAL CONDITION]. Resident 33's CBG record revealed a CBG of 473 on 7/17/18 at 4:14 PM A Progress Note dated 7/17/18 at 4:30 PM revealed Resident 33's CBG was 473 before dinner. The resident did not wake up or respond when the resident's blood sugar was checked or when the resident received an insulin injection. The resident was asked to provide a urine sample earlier in the shift and was sleeping ever since. The physician was notified and gave orders to send the resident to the emergency department. On checking the resident's vital signs the resident woke up, was angry and refused to go to the hospital. The resident continued to sleep most of the shift. A Progress Note dated 7/18/18 at 1:30 AM revealed Resident 33 continued to show progressed confusion as she/he had for the last couple of days. The resident had labored breathing, was pale in color and complained of chest pain. The resident's CBG was 445. The resident asked to be transferred to the hospital, 911 was called and the resident left the facility at 12:55 AM. A hospital Emergency Department Encounter dated 7/18/18 indicated Resident 33's urine glucose level was greater than 1000 (normal is 0 to 0.8) and blood glucose level was 343. The resident was administered IV antibiotics for a UTI and was administered 10 units of regular insulin which resulted in a lower CBG of 246. The resident was discharged back to the facility. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence the resident's physician was promptly notified of the resident's high blood sugars. 3. Resident 9 was admitted in 4/2018 with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED]. The 6/2018 MAR identified the resident's blood sugars generally ran in the 200-300 range before dinner and bedtime. On four occasions, the CBG testing read over 400: - On 6/12/18 at 5:18 PM, the CBG level was 406 - On 6/13/18 at 5:01 PM, the CBG level was 473 - On 6/14/18 at 4:27 PM, the CBG level was 470 - On 6/16/18 at 8:21 PM, the CBG level was 591 Progress notes and MAR documentation did not reflect staff notified the physician of the abnormal CBG values. In a 7/18/18 interview at 4:57 PM, Staff 9 (LPN) stated if a blood sugar reading was under 70 or over 400 she notified the physician and asked for further treatment orders. Upon review of the 6/2018 MAR, Staff 9 confirmed she did not notify the physician of high blood sugars. On 7/19/18 at 8:31 AM, Staff 2 (DNS) confirmed there was no evidence the physician was notified of the elevated CBGs. 4. Resident 6 admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Resident 6's current care plan for diabetes, updated 5/29/18, indicated the resident was at risk for hypo/[MEDICAL CONDITION]. The care plan indicated the physician was to be notified of any CBGs less than 70 or greater than 400. In addition, staff were to monitor the resident and the resident's CBGs until the resident stabilized. A 6/1/18-7/18/18 Vitals Report indicated the following CBGs: 6/27/18 - 415 6/29/18 - 435 6/30/18 - 540 7/4/18 - 564 7/8/18 - 402 7/9/18 - 503 (11:31 AM) 7/9/18 - 407 (4:23 PM) 7/10/18 - 417 (11:24 AM) 7/10/18 - 461 (4:36 PM) 7/11/18 - 442 (9:04 AM) 7/11/18 - 522 (12:17 PM) 7/11/18 - 519 (4:41 PM) 7/12/18 - 421 7/13/18 - 471 7/14/18 - 418 7/16/18 - 415 7/18/18 - 446 A 7/4/18 progress note indicated the physician was contacted regarding the 7/4/18 CBG result and new orders were obtained. No evidence was found to indicate the physician was contacted regarding the elevated CBGs on the remaining dates. On 7/18/18 at 1:18 PM Staff 15 (LPN) acknowledged she measured Resident 6's CBG on 7/13/18 when it measured 471. Staff 15 stated she typically notified the physician of abnormal CBGs but acknowledged there was no indication the resident's physician was contacted. Staff 15 stated she was not familiar with the resident's care plan. On 7/19/18 at 8:31 AM Staff 2 (DNS) acknowledged there was no evidence to indicate staff contacted a physician regarding Resident 6's elevated CBGs. 5. Resident 40 admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) (YEAR) Vitals Report revealed Resident 40 had high CBG levels on the following dates: -On 6/17/18 at 11:59 AM CBG of 527 and at 4:15 PM a CBG of 512. -On 6/18/18 at 4:23 PM a CBG of 442 and at 7:43 PM a CBG of 460. -On 6/19/18 at 4:45 PM a CBG of 405. -On 6/20/18 at 7:14 AM a CBG of 403. -On 6/24/18 at 5:11 PM a CBG of 414. -On 6/26/18 at 8:44 PM a CBG of 428. -On 6/27/18 at 4:22 PM a CBG of 454. -On 7/9/18 at 9:49 AM a CBG of 401. -On 7/9/18 at 11:30 AM CBG of 487. -On 7/10/18 at 11:22 AM a CBG of 440. A review of the clinical record from 6/1/18 through 7/18/18 revealed no information regarding whether Resident 40's physician was notified of the high blood sugars. On 7/8/18 at 4:34 PM Staff 7 (LPN) stated Resident 40 was insulin dependent, required CBG checks twice per shift and was administered a set amount of insulin one time per shift. She indicated Resident 40 at times had high blood sugars from eating candy. Staff 7 indicated she documented the high blood sugars and any signs or symptoms of high blood sugar. Staff 7 further indicated she typically called the physician if the resident's blood sugar was greater than 400 but was directed by Staff 21 (Medical Director) to not call unless Resident 40 was symptomatic. On 7/19/18 at 8:31 AM Staff 2 (DNS) stated she found no evidence to indicate Resident 40's physician was notified of the elevated CBGs. 6. Resident 24 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Resident 24's diabetic care plan with a start date of 3/14/18 indicated a goal including the resident would have no undetected signs or symptoms of [MEDICAL CONDITION] (high blood sugar) and staff were to monitor the resident for signs and symptoms of [MEDICAL CONDITION] with blood sugar greater than 140. The 6/2018 MAR and 7/1/18 to 7/19/18 MAR identified the resident's blood sugars generally ran in the 200-300 range before meals and bedtime. On nine occasions, the CBG testing read over 400: - On 6/25/18 at 11:54 AM, the CBG was 434 - On 6/27/18 at 4:24 PM, the CBG was 418, at 6:08 PM, the CBG was 418 and at 10:54 PM, the CBG was 426 - On 7/3/18 at 11:34 AM and at 11:54 AM, the CBG was 441 - On 7/6/18 at 5:14 PM, the CBG was 406 - On 7/13/18 at 11:07 PM, the CBG was 424 - On 7/14/18 at 11:33 AM, the CBG was 421 Progress notes and MAR documentation did not reflect staff notified the physician of the abnormal CBG values. On 7/19/18 at 8:31 AM, Staff 2 (DNS) confirmed there was no evidence the physician was notified of Resident 24's elevated CBGs. Refer to F684.

1. Based on observation, interview and record review it was determined the facility failed to follow physician orders [REDACTED].#s 9, 64, 69, 98 and 101) reviewed for medications and pain. Residents 64 and 69 experienced severe pain and Resident 69 experienced increased muscle spasms and anxiety. This also placed residents at risk for increased symptoms. Findings include: a. Resident 69 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The Pain CAA dated 5/6/16 indicated Resident 69 had chronic pain and she/he reported pain which made it difficult to sleep at night and limited her/his daily activities. Resident 69's current care plan stated Resident 69 had chronic pain and included an intervention to administer medications per physician's orders [REDACTED]. The December 2016 MAR indicated [REDACTED]. Resident 69 was administered [MEDICATION NAME] medication at least twice daily every day in December except for 12/23/17 through 12/26/17. The April 2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 4/17/17 at 2:46 pm Resident 69 was observed with a pained facial expression on her/his face. Resident 69 stated she/he had not received her/his [MEDICATION NAME] pain medication and indicated she/he was in severe pain. On 4/18/17 at 9:56 am Resident 69 stated 4/17/17 was not the only day she/he had not received her/his [MEDICATION NAME] medication. Resident 69 stated she/he suffered from pain and without the [MEDICATION NAME] pain medication she/he felt like she/he wanted to die. On 4/20/17 at 10:14 am Staff 15 (LPN) stated Resident 69 went without [MEDICATION NAME] pain medication for several days in December 2016. On 4/21/17 at 12:57 pm Staff 11 (pharmacist) stated regarding the December 2016 unavailability of [MEDICATION NAME] the facility faxed in a request to refill Resident 69's [MEDICATION NAME] medication on 12/18/17 which the pharmacy missed processing. Staff 11 stated the facility contacted the pharmacy again on 12/27/17 to request a refill of [MEDICATION NAME] and there was no contact with the pharmacy between 12/18/17 and 12/27/17. Staff 11 further stated regarding the April 2017 unavailability of the [MEDICATION NAME] medication the pharmacy contacted the facility initially on 4/5/17 and notified the facility of a need for a prior authorization for [MEDICATION NAME] medication. A review of Resident 69's medical record did not contain documentation the pharmacy or physician was contacted regarding the status of Resident 69's [MEDICATION NAME] medication from 12/18/17 to 12/27/17 and from 4/5/17 to 4/16/17. On 4/21/17 at 1:46 pm Staff 5 (RNCM) acknowledged Resident 69's [MEDICATION NAME] medication had been changed from PRN to scheduled in April of 2017 as prior to this Resident 69 was requesting this medication every four hours very consistantly. She further acknowledged Resident 69 had requested her/his PRN [MEDICATION NAME] December 23rd through December 26th and it was not available to her/him. better monitoring of the status of Resident 69's [MEDICATION NAME] refill should have been completed to ensure Resident 69 did not run out of her/his medication in December 2016 or April 2017. b. Resident 98 admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 98's physician orders [REDACTED]. Resident 98's April 2017 MAR indicated [REDACTED]. On 4/19/17 at 1:06 pm Staff 6 (LPN) acknowledged she administered Resident 98 [MEDICATION NAME] late within the last month and stated when administered late Resident 98 experienced increased shakiness. On 4/21/17 at 11:31 am Staff 4 (RNCM) acknowledged the late administrations of Resident 98's [MEDICATION NAME] medication and the time sensitive nature of the medication. c. Resident 101 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. The 4/2017 MAR indicated [REDACTED] -[MEDICATION NAME] 25 mg twice per day for hypertension -[MEDICATION NAME] 25-100 mg twice per day for extrapyramidal movements disorder -Duloxetine 60 mg twice per day for major [MEDICAL CONDITION] -Ropinirole 3 mg at bedtime for restless leg syndrome -Aripiprazole 5 mg once per day for [MEDICAL CONDITION] disorder -[MEDICATION NAME] 40 mg once per day in the evening for [MEDICAL CONDITION] -[MEDICATION NAME] 100 units/ml 60-80 units twice per day for diabetes. Additionally the following medications were not given as ordered: -Humalog 100 units/ml 30 units before meals and bedtime for diabetes. This medication was not administered until 8:00 pm on 4/4/17. Resident 101 missed five doses of insulin. -Novilin 100 units/ml administer 60 units twice per day before breakfast and at night. This medication was not administered until 8:00 pm on 4/4/17. Resident 101 missed two doses of insulin. Review of the EKIT (emergency medication supply) inventory revealed the following medications were stocked in the facility's EKIT: * [MEDICATION NAME] * [MEDICATION NAME] * [MEDICATION NAME] * Humalog 100 /units/ml 30 units before meals and bedtime = In EKIT * [MEDICATION NAME] 100 units/ml 60-80 units twice per day. * Novilin 100 units/ml administer 60 units twice per day On 4/21/17 at 8:02 am the resident was observed laying in bed and was asked about her/his medications. Resident 101 recalled that she/he missed a medication for her/his restless leg syndrome one night but the facility administered the medication the next night. On 4/21/17 at 7:41 am and 1:40 pm Staff 6 (LPN) indicated she was on duty when Resident 101 was admitted . The pharmacy delivery times were 12:00 am and 2:00 am. Staff 6 indicated she did not ask the pharmacy to satellite the medications nor did she access the EKIT and was unsure why. On 4/21/17 at 1:44 pm Staff 4 (RNCM) indicated Staff 6 was a newer nurse and she did not access the EKIT for medications. d. Resident 9 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. On 4/19/17 at 6:55 pm Resident 9 stated a concern regarding waiting for a pain medication. Resident 9 stated she/he requested a pain pill at 6:00 pm and Staff 12 (LPN) brought it at 6:50 pm. The resident stated it was not unusual to wait for a pain medication and worried the pain would get out of control if the medication was not administered timely. Resident 9 stated after requesting pain medication, if the wait was longer than an hour she/he had to look for the nurse. On 4/19/17 at 7:08 pm Staff 12 stated she had forgotten to give Resident 9 her/his pain medication. e. Resident 64 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] indicated Resident 64's pain was moderate and became severe when her/his pain medication was not administered timely. The March 2017 physician's orders [REDACTED]. The March 2017 MAR indicated [REDACTED]. The April 2017 MAR indicated [REDACTED]. On 4/20/17 at 9:33 am Resident 64 stated her/his pain became severe when she/he did not receive her/his medication timely. On 4/20/17 at 2:51 pm Staff 8 (CNA) stated Resident 64 sometimes had increased pain. On 4/21/17 at 2:04 pm Staff 4 (RNCM) confirmed Resident 64 received [MEDICATION NAME] multiple times late. f. Resident 64 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The March 2017 physician's orders [REDACTED]. The March 2017 MAR indicated [REDACTED] -[MEDICATION NAME] was not administered from 3/22/17 through 3/27/17. -[MEDICATION NAME] was not administered 3/2/17, 3/3/17 and from 3/18/17 through 3/20/17. -[MEDICATION NAME] sulfate was not administered 3/24/17 and 3/25/17. On 4/20/17 at 7:21 am Staff 9 (CNA) stated Resident 64 had additional muscle spasms in her/his back a few weeks ago. On 4/20/17 at 9:33 am Resident 64 stated she/he remembered she/he did not receive her/his medications and experienced additional muscle spasms and anxiety. On 4/20/17 at 2:51 am Staff 8 (CNA) stated Resident 64 had complained of additional back pain around the end of March. On 4/21/17 at 2:04 pm Staff 4 (RNCM) confirmed Resident 64 did not receive the previously noted doses of [MEDICATION NAME], and [MEDICATION NAME] sulfate. 2. Based on interview and record review it was determined the facility failed to initiate a temporary plan of care for 1 of 3 sampled residents (# 63) reviewed for urinary catheter. This placed residents at risk for unmet catheter needs. Findings include: Resident 63 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A History and Physical dated 10/20/16 revealed Resident 63 had a UTI associated with catheterization and had a history of [REDACTED]. Physicians order dated 10/28/16 contained an order for [REDACTED].>Resident 63's In Room Care Plan dated 11/11/16 revealed the resident was continent of bladder. The Preliminary Care Plan dated 11/11/16 failed to include information regarding Resident 63's Foley catheter. On 4/21/17 at 12:08 pm Staff 4 (RNCM) confirmed the care plan was incorrect.

Based on interview and record review it was determined the facility failed to administer medications as ordered for 3 of 3 sampled residents (#s 1, 2 and 4). Resident 1 reported chest pain to facility staff and [MEDICATION NAME] (medication used to alleviate chest pain) was not administered. Several hours later Resident 1 was diagnosed with [REDACTED]. Findings include: 1. Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Resident Progress Notes dated 12/23/15 written by Staff 3 (LPN) documented the resident complained of chest wall pain most of this day and the resident verbalized the scheduled pain medication was effective. The resident's MAR dated 12/23/15 indicated the resident received [MEDICATION NAME] twice and [MEDICATION NAME]. There was no indication [MEDICATION NAME] was given for chest pain. The facility's Investigation dated 12/28/15 revealed the resident reported left-sided chest pain to Staff 3 (LPN) at 7:00 am on 12/23/15. The investigation indicated the chest pain radiated to left arm, was stabbing in nature and beyond a 10 on 1-10 pain scale. Staff 3 did not administer [MEDICATION NAME] to the resident. The form indicated Staff 3 requested non-emergent transportation for the resident to go to the hospital for an evaluation of an elevated creatinine (laboratory test used to assess kidney function). Staff 2 documented when the paramedics arrived they were surprised to learn the resident had been having chest pain. The hospital's History and Physical dated 12/23/15 documented the resident reported chest pain for most of the day while at the facility, the resident went to the hospital and an anterior [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) was diagnosed . A Corrective Action form dated 12/31/15 documented the facility reported the results of the investigation to the State Board of Nursing. On 11/1/16 at 9:30 am Staff 2 (DNS) indicated her investigation concluded the resident had [MEDICATION NAME] ordered and the facility should have given it after the resident reported chest pain. She reported the investigation results to the State Board of Nursing. On 11/1/16 at 10:20 am Witness 2 (Physician) stated when facility staff called to report a resident had chest pain, she asked if their [MEDICATION NAME] was effective. She did not recall Resident 1. On 11/2/16 at 2:10 pm Staff 3 (LPN) indicated on 12/23/15 the resident had chest wall pain, she gave pain and anti-anxiety medications; and they were effective. Staff 3 stated the resident was going to be transported non-emergently by the paramedics for an evaluation of abnormal lab results and the resident reported she/he had been having chest pain when the paramedics were at the resident's bedside. Staff 3 stated she still thought non-emergent transport was all that was needed that day and the resident did not have actual chest pain. On 11/7/16 at 12:00 pm Witness 3 (Family) indicated on 12/23/15 the resident telephoned and reported the facility had been doing nothing for the resident's chest pain. Witness 3 stated she/he called the facility to report the chest pain, she/he came to the facility as soon as possible, the paramedics were at the resident's bedside and the resident reported chest pain. She voiced concern the resident endured chest pain without adequate treatment for [REDACTED]. 2. Resident 2 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] indicated the resident's cognition was intact. The physician's orders [REDACTED]. On 11/2/16 at 12:00 pm Staff 2 (DNS) stated on 9/30/15 the resident reported her/his morning blood pressure medication fell off a bedside table and into the trash. She indicated Staff 3 (LPN) admitted she did not see Resident 2 take the medication before she left the room. On 11/2/16 at 2:10 pm Staff 3 (LPN) stated she left the resident's medication on the bedside table and went to check on a resident in another room. Staff 3 stated after she was told the resident's medication fell off the table, she got medication from the medication cart and watched the resident take the medication. She stated it was a rare occurrence for her not to observe a resident take their medication. 3. Resident 4 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A Physician's Progress Note dated 12/17/15 documented the resident's venous ultrasound showed chronic venous thrombus . Aspirin 81 mg daily (QOD ok as well) was recommended. The (MONTH) (YEAR) MAR indicated on 12/17/15 Aspirin 325 mg QD was discontinued and Aspirin 81 mg po QD was begun on 12/18/15. A fax dated 12/30/15 indicated Staff 4 (RNCM) requested a clarification of the resident's aspirin orders. The physician's orders [REDACTED]. On 11/1/16 at 3:55 pm Staff 4 (RNCM) stated she was doing the monthly recaps of the resident's orders at the end of (MONTH) (YEAR) when she discovered the aspirin dose written on the MAR did not match the orders. She stated there was no order on 12/17/15 for the resident's ASA 325 mg to be discontinued and there was no order to start ASA 81 mg. She indicated on 12/31/15 they received an order from Witness 2 (Physician), the resident's aspirin dose was ASA 81 mg daily and the ASA 325 mg order was discontinued. On 11/1/16 at 4:00 pm Witness 2 (Physician) was shown her order dated 12/31/15 for the resident's aspirin orders. Witness 2 stated she did not recall the specifics and must have evaluated the resident's need for only aspirin 81 mg daily at that time. On 11/2/16 at 2:10 pm Staff 3 (LPN) indicated the resident had a specialist who wrote a recommendation for the dose of Aspirin and she wrote it as an order on the MAR. She stated she took the 325 mg dose of Aspirin off the resident's MAR and wrote in Aspirin 81 mg po QD.

Based on interview and record review it was determined the facility failed to implement additional interventions after a fall with injury for 1 of 2 sampled residents (#2) who had a fall with fracture. The resident a second fall and sustained an additional fracture. Findings include: Resident 2 was admitted to the facility on [DATE] after a fall and fracture at home. The resident's [DIAGNOSES REDACTED]. On 5/1/15 a CAA (care area assessment) Summary Report indicated Resident 2 was at risk for falls due to a history of falls, use of antidepressant, and forgetfulness related to a [DIAGNOSES REDACTED]. On 5/7/15 a Falls Care Plan identified the resident was at risk for falls due to a history of falls, [DIAGNOSES REDACTED]s, and dementia. The facility's interventions included assess for risk factors and physical and occupational therapies, and to see In Room plan of care. The In Room Care Plan identified Resident 2 required minimal assistance with one person for transfer and for showering An Incident Investigation and facility Fall Investigation indicated Resident 2 was found on the floor lying flat on her/his back on 5/10/15 at 7:30 am. The investigation identified, according to the resident, she/he had transferred from the bed to the wheelchair and then pulled her/himself out of the wheelchair and fell . The resident was assisted back to bed and reminded to use the call light. Later, the resident complained of hip pain, medication was given, the Physician was notified and an X-ray obtained. An Incident Investigation and facility Fall Investigation identified Resident 2 fell on ,[DATE] at 6:45 pm during a shower. The investigation indicated the resident slipped in the shower room while being given a shower by Staff 4, CNA. The CNA assisted the resident to stand so she could wash her/his back and buttock and the resident lost balance. The resident landed on her/his right elbow and a clavicle injury was suspected. The investigative determination indicated the resident had a fall on the prior shift with increased hip pain and decreased ability to tolerate standing in shower room resulting in resident slipping and landing on (her/his) elbow injuring (her/his) clavicle. The facility determined the root cause of the fall was the recent fall and hip pain and possible injury. The shower was slippery and the resident lost balance while being assisted to stand and be washed. On 5/10/15 a Witness Report written by Staff 4, CNA, indicated she helped the resident to stand and the resident lost balance and slipped. The soap and water were too slippery to safely assist the resident to the floor when she/he slipped. The report identified the resident stated her/his shoulder, hip and leg hurt. A Discharge Summary/Recapitulation of Stay indicated Resident 2 experienced a fall and while the x-ray result was pending, had another fall with possible injury to the shoulder. The Physician was notified and the resident was transported to the hospital per orders. An un-dated or timed Diagnostic Laboratory results identified a portable x-ray was taken of Resident 2's right hip and pelvis on 5/10/10 at 1:38 pm. The results indicated the resident has an acute fracture of the right subcapital hip (hip fracture). The hospital's History and Physical identified the resident was admitted after a ground level fall but it was somewhat unclear as to how the fall exactly happened. Radiographs revealed a right femoral neck fracture (hip fracture) with displacement and a clavicle shaft fracture. In interview on 7/28/15 at 11:25 am Staff 4, CNA, reported Resident 2 was weaker than usually on 5/10/15 but didn't complain of pain. She stated the resident transferred into the shower chair fine but when she stood her/him up to wash her/his backside, the resident was weak and slipped. Staff 4 reported she did not know the resident had a possible hip fracture when she showered her/him or she would not have showered her/him. In interview on 8/3/15 at 10:14 am Staff 5, CNA, reported she worked during the day on 5/10/15 when she heard Resident 2 fall at 7:30 am. Staff 5 stated after the resident fell , she/he didn't complain of pain, however, approximately 20 minutes later the resident reported pain and the resident stated she/he thought she/he broke a hip. The nurse was alerted. Staff 5 stated she reported Resident 2's fall to Staff 4, the evening CNA, and stated she/he had a possible hip injury. In interview on 8/3/15 at 3:14 pm Staff 3, LPN, reported Resident 2 fell on [DATE] at 7:30 am and he assessed the resident after the fall. He stated the resident experienced usual pain after the fall but then had increased pain so he asked for an x-ray to rule out an injury. Staff 3 reported he told Staff 4, the evening CNA, the resident had a fall and they were waiting on x-ray results to rule out injury and stated the resident might need more assistance. Staff 3 stated he assumed Staff 4 would take an additional person to assist with the resident's shower and assumed Staff 4 would know not to stand the resident due to a possible hip injury. However, he confirmed he did not instruct the CNA to take those precautions. In interview on 8/5/15 at 1:32 pm Staff 9, LPN, reported if a resident fell and had a suspected hip injury it was the nurse's responsibly to pass the information to the CNAs and instruct them on any changes to the plan of care pending the x-ray result. Staff 9 stated she would ask the CNA not to transfer or stand the resident until the results came back. In interview on 8/13/15 at 10:20 am Staff 10, RNCM, reported she did not work on 5/10/15, however, she would have instructed staff to keep Resident 2 seated until an injury was ruled out. In interview on 8/14/15 at 1:05 pm Staff 2, DNS, stated Resident 2 should not have been stood for a shower with a suspected hip fracture.

Based on observation, interview and record review it was determined the facility failed to follow the physician's orders for 1 of 3 (#1) sampled residents. On 11/3/11 at 7:00 am Resident 1's CBG (fingerstick blood sugar) was 103, the physician's orders signified insulin was not needed for this CBG result and the facility nurse administered 50 units of Humalog (fast-acting regular insulin) to Resident 1. The resident became hypoglycemic (CBG below 70), was hospitalized and then discharged from the hospital on [DATE]. Findings include: A review of Oregon State Board of Nursing Scope of Practice Standards [PHONE NUMBER] for all Licensed Practical Nurses revealed (2)(A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling; (3)(g) Ensures unsafe nursing practices are reported to the Board of Nursing and unsafe practice conditions to the appropriate regulatory agency(s) and (6)(f) Has the authority and responsibility to question any order or recommendation which is not clear, perceived as unsafe, contraindicated for the client or inconsistent with the plan of care. Resident 1 was admitted to the facility in October, 2011 with [DIAGNOSES REDACTED]. The Physician's Orders dated 10/22/11 indicated [MEDICATION NAME](Humalog; a rapid-acting regular insulin) was to be given according to the results of Resident 1's CBGs taken before meals. The Physician's Orders were written as: "Insulin [MEDICATION NAME] 100 unit/ml sub-Q (subcutaneous injection); Inject 1-12 units subcutaneous three times a day before meals (7:30 am, 11:30 am and 5:00 pm). CBG less than 150 no insulin..." The November, 2011 Diabetic Flowsheet indicated when Resident 1's CBG results were less than 150, Humalog insulin was not needed. The flowsheet dated 11/3/11 revealed the resident's CBG was 103 and the resident received an injection of Humalog. The amount of Humalog administered was not recorded on the flowsheet. The Resident Progress Notes dated 11/3/11 revealed at 7:05 am Resident 1's CBG was 103, Staff 2 (LPN) gave the resident 50 units of Humalog insulin in error and Staff 4 (RN) was informed. The notes indicated the resident's physician ordered Resident 1's transfer to the hospital. Despite the resident's consumption of sugar-laden food and fluids, the resident's CBG was 64. The notes indicated the paramedics arrived at 7:47 am and transported the resident to the local emergency room . The Emergency Department (ER) Note dated 11/3/11 indicated Resident 1's CBG dropped to 41, intravenous (IV) glucose was administered and an hour later, the resident's CBG was 58. The resident was hospitalized for [REDACTED]. The hospital's Discharge Summary dated 11/4/11 indicated the resident did not experience further hypoglycemic events while hospitalized and the resident chose to be discharged home. On 12/8/11 at 9:45 am Staff 2 (LPN) stated she saw the resident's CBG of 103 written on the Diabetic Flowsheet and misread the order for Humalog insulin 100 units/ml. Staff 2 stated she thought she was to administer a "maintenance dosage of 100 units of Humalog insulin." Staff 2 stated she drew up 50 units of Humalog, as that was as much solution as the insulin syringe could hold. She stated she gave the 50 units of Humalog insulin to the resident and planned to return and give another 50 units, making the dosage 100 units Humalog insulin. Staff 2 stated she realized her mistake, did not draw up the additional 50 units of Humalog she had intended to and informed Staff 4 (RN). Staff 2 stated she did not ask another nurse to double check her when she drew up Resident 1's Humalog insulin on 11/3/11. Staff 2 stated the facility staff gave the resident some food, orange juice and extra sugar. Staff 2 stated ever since her medication error on 11/3/11, another nurse double checked her when she drew up insulin. Staff 2 stated the State Board of Nursing was aware of the significant error. On 12/8/11 at 10:05 am Staff 1 (DNS) stated all insulins drawn up by Staff 2 (LPN) have been double checked by another nurse since the significant insulin error on 11/3/11. On 12/8/11 at 11:30 am Staff 2 (LPN) reviewed Diabetic Flowsheets with the surveyor and correctly identified the type and amount of insulin scheduled to be given. On 12/12/11 at 10:00 am Staff 1 (DNS) stated she has re-educated Staff 2 regarding insulin administration since the significant insulin error occurred. Refer to F333

Based on observation, interview and record review the facility failed to prevent a significant insulin medication error for 1 of 3 (#1) sampled residents who received insulin. On 11/3/11 Resident 1's CBG was 103, the physician's orders [REDACTED]. The resident became hypoglycemic (CBG below 70) and the resident was hospitalized . Resident 1 was admitted to the facility in October, 2011 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders indicated "Insulin [MEDICATION NAME] unit/ml sub-Q (subcutaneous injection); inject 1-12 units subcutaneous three times a day before meals (7:30 am, 11:30 am and 5:00 PM). CBG less than 150 no insulin..." The November, 2011 Diabetic Flowsheet revealed the resident's CBG was 103 at 7:00 am on 11/3/11. The flowsheet indicated the Humalog insulin was not to be given when the resident's CBG was less than 150. The flowsheet revealed Humalog insulin was administered to the resident on 11/3/11. The specific amount of Humalog was not documented. The Resident Progress Notes dated 11/3/11 indicated at 7:00 am the resident's CBG was 103, the resident was given 50 units of Humalog insulin, Staff 2 (LPN) realized she made a significant insulin error and alerted Staff 4 (RN). The notes indicated the resident consumed food and fluids with a high sugar content. The resident's CBG dropped to 64, paramedics arrived and transported the resident to the local hospital. The Emergency Department (ER) Note dated 11/3/11 documented an hour after the resident arrived to the ER, the resident's CBG dropped to 41, intravenous (IV) glucose was given and the resident's CBG was 58 an hour later. The ER note revealed the resident was hosptalized on [DATE] for unstable [DIAGNOSES REDACTED] and overnight observation. The facility's Medication Error report dated 11/3/11 revealed Resident 1's CBG was 103 at 7:00 am and an injection of 50 units of Humalog insulin was given to the resident. The report indicated Staff 2's medication administration re-education was provided by the facility DNS after Staff 2's significant medication error occurred. The report revealed the DNS planned to closely supervise Staff 2's insulin administration for at least one month and another nurse was observe Staff 2 when she drew up insulin doses. On 12/8/11 at 9:45 am Staff 2 (LPN) stated she was aware Resident 1's CBG was 103 and she misread the insulin order on the resident's Diabetic Flowsheet on 11/3/11. Staff 2 stated she thought the Humalog 100/ units/ml solution written on the resident's Diabetic Flowsheet meant to give 100 units of Humalog. She stated the syringe was full when she drew up 50 units of Humalog insulin, she injected 50 units of Humalog to Resident 1, realized her mistake and notified Staff 4 (RN). Staff 2 stated she did not ask another nurse to double check when she drew up the resident's insulin syringe. Staff 2 stated since the morning of 11/3/11, another nurse checked all the insulins she drew up and she reported the medication error to the Oregon State Board of Nursing. On 12/8/11 at 10:05 am Staff 1 (DNS) stated all insulins drawn up by Staff 2 (LPN) have been double checked by another nurse since Staff 2 made the significant insulin error. On 12/8/11 at 11:30 am Staff 2 (LPN) reviewed Diabetic Flowsheets with the surveyor and correctly identified the type and amount of insulin scheduled to be given. Staff 2 stated since the significant insulin medication error she made on 11/3/11, another nurse double checked her when she drew up insulin. 12/12/11 at 10:35 am Staff 4 (RN) stated "I remember when (Staff 2) told me she gave 50 units of regular insulin. I knew that amount of a short-acting insulin was not right. I looked at the MAR and had her call the physician." On 12/12/11 at 10:00 am Staff 1 (DNS) stated she provided re-education related to insulin administration to Staff 2 after the significant insulin error occurred.