Every finding on record at Country Manor Healthcare and Rehab Center

Based on interview and document review, the facility failed to identify an outbreak of gastrointestinal (GI) illness, implement corrective action to reduce the spread of illness and infections in the facility and report the outbreak to the State Agency (SA). This had the potential to affect all 124 residents in the facility and facility staff. Findings include: The facility's infection/tracking and monitoring spreadsheet tracked unit name, resident name, room number, admitted , existing infection from previous month(s), infection type, body system of infection, surveillance definition met, symptom(s), onset date, and date symptoms resolved. Review of the spreadsheet from December 1, 2024, through January 21, 2025, revealed the following: Nine residents in the month of December were identified with GI concerns: -8 residents were identified to reside on the Pioneer Village unit with an infection type of gastroenteritis. The date of first onset was 12/3/24 and the date of last symptoms resolved was 12/17/24. Symptoms included emesis, loose stools, and nausea. -1 resident was identified to reside on the Rapid Recovery 2 unit with an infection type of gastroenteritis. The date of first onset was 12/12/24 and the date of last symptoms resolved was 12/17/24. Symptoms included emesis, nausea. Four residents in the month of January were identified with GI concerns: -2 residents were identified to reside on the Garden Cottage unit with an infection type of gastroenteritis. The date of first onset was 1/12/25 and the date of last symptoms resolved was 1/19/25. Symptoms included loose stools and nausea. -2 residents were identified to reside on the Rapid Response 1 unit with an infection type of gastroenteritis. The date of first onset was 1/17/25 and the date of last symptoms resolved was blank. Symptoms included loose stools and vomiting. The spreadsheet lacked identification of precautions or interventions implemented in response to the identified infections. A document titled Infection Control dated December 2024, which included analysis of facility infections, identified nine GI nososcomial (facility acquired) infections for the month of December. The section for conclusion/actions was blank. An Infection Control Analysis document was not provided for January 2025. The facility's Employee Illness Log dated December 2024 identified symptoms tracked to include vomiting only, diarrhea only, Cold or Respiratory infection, Influenza/COVID symptoms, positive for influenza, positive for COVID-19, C-Diff (Clostridiodes difficile, a bacterial infection that causes diarrhea and inflammation of the colon), pink eye, GI, skin issues, strep throat, mono (Mononucleosis-a contagious viral illness), other medical, ill child/family, and personal. The number of infections were tracked by unit or department which included Pioneer Village, Garden Cottage, Rapid Recovery 1, Rapid Recovery 2, Activities, Therapy, Dietary, Social Service, Housekeeping & Laundry, Maintenance, and On-call/Support Staff. Review of the log revealed the following: Twenty-eight staff were identified with GI concerns in the month of December: -1 staff member from Pioneer Village and 1 staff member from the Activity department were identified with diarrhea only. -11 staff from Pioneer Village, 7 staff from Garden Cottage, 6 staff from Rapid Recovery 1, 6 staff from Rapid Recovery 2, 1 staff from Housekeeping & Laundry and 2 on-call/support staff were identified with GI concerns. The Employee Illness Log for the month of January was requested but not provided. The log lacked identification of dates of illness, resolution of employee symptoms, return to work criteria met or any precautions or interventions implemented to reduce the spread of infections in the facility. Review of the Weekly Quality Council Minutes dated December 31, 2024, January 7, 2025, and January 14, 2025, indicated infection trends/patterns were reviewed and discussed and revealed the following: -12/31/24: identified eight residents with GI symptoms with 8 residing on one wing. -1/7/25: indicated GI cases stabilized. -1/14/25: nososcomial infections/rates-increase in GI infection in December. The minutes did not address employee illnesses or identify actions taken by the facility to address the outbreak or concerns. During interview on 1/23/24 at 12:00 p.m., the infection preventionist (IP) stated she obtained information for infection control surveillance from the nursing staff, case managers, and resident chart documentation to identify potential infections and look for patterns. IP reviewed the facility infection control surveillance logs and verified the resident and employee infections as listed above. She stated infection prevention information was reviewed daily at the interdisciplinary team meeting, weekly on Tuesdays during Quality council meetings and monthly during Quality Assurance and Performance Improvement meetings. She denied any recent outbreaks in the facility, however, confirmed there had been a pattern of eight residents on the Pioneer Village unit with GI symptoms beginning in December. She logged the information on her spreadsheet, made sure the residents were on droplet and contact precautions and indicated the precautions could be discontinued after the resident was asymptomatic for 72 hours. She had been concerned about the potential the GI symptoms were norovirus (a group of viruses that can cause gastroenteritis, an inflammation of the stomach and intestines) and spoke with the facility nurse practitioner regarding testing. However, the nurse practitioner (NP) had told her she didn't think the local hospital performed the test. She did not contact the hospital herself to confirm testing availability. She denied any outbreak of food-borne illness in the facility but stated food-borne illness went hand in hand with a GI outbreak. If an outbreak occurred, she would look to see if there was something in common the residents ate and talk with the dietary manager regarding dietary employee GI illness. However, she had not spoken to any of the dietary staff in December regarding GI illness and was only aware of three staff with respiratory illness. After this discussion she stated she would consider eight residents on one unit an outbreak. She denied any action was taken to prevent the spread of GI illness to other units of the facility or to employees, outside of placing the symptomatic residents under droplet and contact precautions. No testing of the resident for the infectious organism occurred, no education to staff was provided and the outbreak was not reported the state agency. During interview on 1/23/25 at 1:38 p.m., nurse practitioner (NP) stated she was aware of multiple residents and staff with reported GI symptoms in the month of December. NP stated she considered 8 residents residing on the same unit, with the same reported symptoms, as an outbreak. She was unsure of how many staff were affected with GI symptoms but that would be taken into consideration as well. Residents were placed in contact/droplet precaution and NP denied further action regarding the GI illness in the facility. During interview on 1/23/25 at 12:35 p.m., the director of nursing was unaware of the pattern of GI illness in the facility but stated eight residents on one unit would and could be looked at as an outbreak. Her expectations were for the IP to address the outbreak per the facility policy to include placing the residents in the appropriate precautions, the use of isolation bins, signs alerting staff and visitors, hand hygiene, the affected residents eating in their room and reporting the outbreak to the SA, if appropriate. She would have expected the IP follow up with the laboratory to have testing due to the potential type of infection. If the outbreak was contagious, it would be important to identify what it is to help stop the spread and determine a treatment. As well as protect the health of the other residents and make sure we are following current guidelines. The Management of Gastrointestinal Illness/Outbreak policy last reviewed 6/24, directed it was policy of this facility that once loose, watery stools have been evaluated, prevention and outbreak management measures must be followed. The policy defined Gastroenteritis as inflammation of the stomach and small and large intestines. Viral gastroenteritis (norovirus) is an infection caused by a variety of viruses that result in vomiting or diarrhea. It is often called the 'stomach flu'. The policy further defined an outbreak as three or more cases of diarrhea on one specific unit, and directed staff to discontinue group activities where sick and well residents would be together, group activities should be kept to a minimum or postponed until outbreak is over; minimize the flow of staff between sick and well residents; staff should be assigned to work with either well or sick residents, but not care for both groups; a sign will be posted at the entrances of the facility explaining to visitors/friends that the facility's residents are experiencing GI symptoms; the infection preventionist/designee will inform the medical director and request orders for cultures on 2-3 residents who are experiencing symptoms; the infection preventionist/designee will call the Department of Health and inform them of the suspected outbreak and do updates as necessary; the clinical managers/supervisors, under the direction of the director of nursing and the infection preventionist/designee, will assist with in-servicing the staff on the criteria, guidelines, and recommendations; the infection preventionist/designee will report resolution to appropriate public health agencies and gather collected data for final narrative report.

Based on observation, interview and document review, the facility failed to monitor 1 of 2 residents (R97) reviewed for wound care. Findings include: R97's quarterly Minimum Data Set (MDS) dated [DATE], included R97 had moderate cognitive impairment. R97 had a diagnosis of dementia. R97's encounter summary dated 12/20/24 from Central MN Foot & Ankle included Staff at Country Manor are to clean the right great toe with warm water and gentle soap; gently pat dry, then apply a thin layer of triple antibiotic ointments followed by a band-aid until healed. R97's interdisciplinary notes dated 12/20/24, included right great toe bandage changed. Mild bleeding noted. Cleaned and applied abx ointments. Interdisciplinary notes failed to include additional entries describing skin impairment or treatment. During interview on 1/22/25 at 4:56 p.m., registered nurse (RN)-A stated she was unsure if R97 had a skin impairment to her right great toe. RN-A confirmed R97's electronic medical record (EMR) lacked monitoring and documentation on a skin impairment to the right great toe. RN-A confirmed there was a daily wound care order for R97 which was being documented on daily as being completed. During interview on 1/23/25 at 9:34 a.m., director of nursing (DON) stated there should be monitoring set up when a resident has a skin impairment. The DON stated wound documentation including appearance, size and drainage should have been completed at a minimum weekly. The DON confirmed there was an order for daily wound care to R97's right great toe. The DON confirmed R97's EMR failed to include any documentation of a skin impairment to R97's right great toe since 12/20/24. The DON stated it was important to have monitoring and documentation to watch for progress or changes to the skin impairment. Undated facility document titled Skin Condition Review included all nursing staff are responsible for monitoring the effectiveness of implemented interventions and in making necessary changes.

Based on interview and observation the facility failed to ensure timely necessary dental services were received for 1 of 1 resident (R54) reviewed for dental care. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 was cognitively intact and had diagnoses of heart failure, diabetes and below knee amputation. R54's care plan identified R54 had poor dentation with missing and broken teeth. The care plan instructed staff to provide set-up and assistance with oral hygiene two times a day, assess condition of oral cavity, offer dental exam yearly and as needed, and assist with setting up appointment as needed. The Treatment Record for 11/30/23 did not include assessment of R54's teeth. The MDS Oral/Dental Section L. completed on 9/25/23, indicated R54 had missing and broken teeth and indicated R54's last dental appointment had been in August 2023. No additional section L. assessments were provided for the requested time frame between 12/2022 and 11/30/23. Centrasota Oral Surgeons document signed by the Dr. [NAME] on 8/10/23, identified 15 teeth for extraction. NURSE NOTES: 8/11/23, entry reported R54 had been at the dentist on 8/10/23 for a broken tooth and needed oral surgery. Clindamycin 300 mg [milligrams] three times a day was ordered. 8/22/2023 entry reported a message was left with Centrasota Surgeons for teeth extractions. 8/30/23 Centrasota Oral Surgeons to send release of information to proceed with referral. 11/30/23 10:20 a.m., note by registered nurse (RN-A): writer had received notice on 11/27/23 that Centrasota dental could not accommodate R54, and R54 agreed with referral to in-house dental service because R54 just wanted to get their teeth out so they could get their dentures. During an interview on 11/27/23 at 2:26 p.m., R54 stated they had needed to have all their teeth pulled since August, but nothing had been done to get her an appointment. During an interview on 11/30/23 at 9:12 a.m., registered nurse RN-A stated R54 had broken and bad teeth. The facility was working on getting R54 an appointment with the in-house dentist because the outside dentist did not have the ability to accommodate R54's mobility needs. RN-A stated she would have to look to see when R54's referral was initiated, and stated she could not say what was considered a reasonable amount of time to pass for a resident waiting for dental services. During an interview on 11/30/23 at 9:42 a.m., LPN-A stated she scheduled dental appointments. They had regular non-emergent dental services at the facility every three months. The dental team was last at the facility on 11/7/23. LPN-A confirmed R54 had an outside referral sent in August for dental services. LPN-A stated the dental place had never got back to her. However, she had talked to them, and was told they had sent her 3 or 4 faxes. LPN-A stated she never received the faxes. The dental office also said they could not accommodate R54's mobility needs. LPN-A stated she talked to R54's case manager and they said R54 should be scheduled with the inhouse dentist. LPN-A stated they had just sent the needed forms for the inhouse dentist upstairs at 9:15 a.m. LPN-A stated she had not scheduled very many extractions, so she didn't know what a reasonable amount of time would be for a resident to wait to have their teeth extracted. During an interview on 11/30/23 at 11:15 a.m., R54 stated their teeth were bad when they arrived, and were getting worse. They hurt all the time. R54 stated they had wanted to get their teeth removed since August and had never refused dental care. They had even prepaid $5000 dollars into a denture fund for their dentures, so all they needed was their teeth pulled. R54 stated the nurse had been down earlier and said they were working on a new dental appointment. During an interview on 11/30/23 at 11:46 a.m., the executive clinical director confirmed the facility had in house dental services that came about every three months. The executive clinical director and the director of nursing both indicated they had not been made aware R54 needed their teeth extracted and indicated it was possible something had been canceled or R54 had refused services. It was the case manager's [nurse manager] responsibility to track resident dental needs and ensure needed treatments were received. If R54 needed to have teeth pulled back in August, dental care should have been addressed. The following documents were requested and not received: All triggered Section V - Care Area Assessment (CAA) Summary number 15. Dental Care that triggered betwen 12/2022, to present. Dental Care policies and procedures. Care conference notes. Provider progress notes related to R54's dental status.

Based on observation, interview, and record review the facility failed to ensure resident and family requested preferences were honored for 1 of 2 residents (R460) reviewed for choices. Findings include: R460 was admitted to the facility on [DATE], with diagnoses of fracture of unspecified thoracic vertebra, fracture of first lumbar vertebra, chronic respiratory failure, and pneumonia. A Minimum Data Set nursing note entry on 11/27/23, indicated R460 was cognitively intact. R460's care plan identified mouth sores, instructed oral hygiene three times a day, and to administer medications as ordered. The chart assessment Self-Administration of Respiratory Inhalants dated 11/24/23, concluded R460 was safe to administer inhalants after setup. The treatment record dated 11/2023, indicated a new entry on 11/30/23, that instructed staff to offer magic mouthwash after meals and nebulizers four times a day. The document Physician Orders For 11/30/2023, included medications ordered on: 11/24/23, Magic mouthwash swish and spit 5 ml [milliliters] by mouth every four hours prn [ as needed] for mouth sores. The order was discontinued on 11/28/23. 11/28/23, magic mouthwash swish and spit 15 ml every 4 hours prn for mouth sores. 11/28/23, Magic mouth wash swish and spit 15 ml three times a day after meals for mouth sores. Nebulizer medication orders: 11/24/34, formoterol fumarate 20 mcg [micrograms]/2 ml solution for nebulization (neb) two times a day. 11/27/23, Budesonide 1mg / 2 ml suspension for nebulization twice a day. During an interview on 11/27/23 at 1:24 p.m., R460 stated they wanted their magic mouth wash at the same time as their nebulizer treatment so they could rinse their mouth right after the it was done just like their doctor had instructed them to do when they were at home. R460 stated they had told the facility that was their preference when they arrived. Family also tried to straighten it out, but nothing had changed. During an interview on 11/28/23 12:53 p.m., R460's family member (FM-A) stated the family had communicated right away to the facility that R460 needed to have magic mouth wash after each nebulizer treatment because the treatments caused lesions and pain in R460's mouth. We had thought that was all straightened out and that she was getting the magic mouth wash with the nebulizer treatment intead of having to ask for it. During an interview on 11/29/23 at 12:02 p.m., R460 stated they had asked for their mouth wash this morning when the nurse started the nebulizer treatment, but never received it. R460 stated they needed the mouth wash to rinse right away because the nebulzer medicine caused mouth pain. R460 stated it was painful to eat, so they also needed magic mouthwash after meals. R460 stated at the care conference the day prior, they had told staff they wanted to get the magic mouthwash at the same time as the nebulizer treatment and meals, but nothing had changed. During an interview on 11/29/23 at 2:36 p.m., registered nurse (RN-B) stated the doctor ordered R460's magic mouthwash as prn [as needed] which meant R460 needed to ask for it. Reminders were in place for staff to also ask R460 if they wanted the magic mouth wash. The magic mouth wash was changed to scheduled because R460 was not remembering to ask for it each time. Further, RN-B stated during the discharge planning meeting the day prior, R460 said they had wanted the magic mouth wash scheduled. RN-B stated she had not heard this before, but they had contacted the provider and obtained an order for the magic mouth wash to be scheduled three times a day. During an interview on 11/30/23 at 12:08 p.m., the executive clinical director stated it was reasonable for a resident to request, and receive magic mouth wash with each nebulizer treatment and indicated the order had been changed to scheduled three times a day to try and accommodate R460's preferences. To ensure the new order met R460's preference of rinsing right after meals and neb treatments the nurse could have requested the provider to change R460's order to give magic mouth wash with nebulizer treatments and with meals so R460 would not have to wait or ask for the medication. The director of nursing expressed agreement.

Based on interview and document review, the facility failed to ensure beta-blocker medication (used to control heart rhythm, treat [CONDITION(S)], and reduce high blood pressure) was administered in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's PPS 5-day minimum data set (MDS) dated [DATE], identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional directions were to hold the medication if R1's systolic blood pressure was less than 110 or R1's heart rate was less than 55. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional directions were to hold the medication if R1's heart rate was less than 55. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A clarification dated 5/6/21, identified to hold the medication if R1's systolic blood pressure was less than 110 or R1's heart rate was less than 55. R1's May 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - On 6/5/22 at 8:00 p.m., R1 was administered [MEDICATION(S)] 50 mg even though her pulse was 52. - On 6/6/21 at 8:00 p.m., R1 was administered [MEDICATION(S)] 50 mg even though her pulse was 54. R1's June 2022 EMAR identified on 6/10/22 at 8:00 p.m., R1 was administered [MEDICATION(S)] 50 mg even though her pulse was 65. The EMAR additionally identified the reason for holding was the medication was hold if pulse is above 50. Pulse was 65. R1's Pharmacist Recommendations to Nursing dated 11/9/21, identified R1 currently had an order to 'hold [MEDICATION(S)] for systolic blood pressure less than 110 or pulse rate less than 55.' On evening shifts, [MEDICATION(S)] does not appear to be held per order on 10/1/21, 10/9/21, and 10/10/21. Please educate staff and complete med error documentation. The form identified education had been provided on 11/14/21. During a phone interview on 6/7/22, at 9:58 a.m. the consultant pharmacist stated obtaining a pulse is the most important part when administering a beta blocker because [MEDICATION(S)] can play a role in [CONDITION(S)] (slow heart rate). The consultant pharmacist stated there was a medication error because the facility staff did not follow the physician's parameters as indicated by the medication order. Additionally, the consultant pharmacist stated errors of this type were previously identified and had been part of her reports to the facility. During a telephone interview on 6/7/22, at 10:42 a.m. trained medication aide (TMA)-A who administered R1's [MEDICATION(S)] stated she reviewed all orders in the EMAR prior to administering and, by this, she would know what to do. For example, sometimes a pulse or blood pressure would need to be collected before a medication could be given. TMA-A stated if the pulse was too low, she would not give the medication. She would let the nurse know at the end of her shift which medications were not given and why. TMA-A had never been told she had ever had a medication error. During an interview with the director of nursing (DON) and the director of quality (DOQ) on 6/7/22, at 12:12 p.m. the DON stated they conducted a chart review on 6/7/22, which included R1's medication administrations. The medication errors were identified at that time. The DON then educated the staff involved on the medication errors, how to conduct medication administration and how to prevent it from happening in the future. The DON stated the education was conducted over the phone on 6/7/22, after survey entrance and the facility had not conducted a systemic review of the medication errors. During a telephone interview on 6/7/22, at 12:51 p.m. R1's physician stated she would expect staff to follow medication orders as written and hold the [MEDICATION(S)] when parameters were not met. The facility policy Preventing and Detecting Adverse Consequences and Medication Errors reviewed 6/21, identified the facility interdisciplinary team reviewed the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. The quality assurance committee then conducted a root cause analysis of the medication administration errors to determine the source of errors, implemented process improvement steps, and compared results over time to determine that system improvements were effective in reducing errors.

Based on observation, interview, and document review, the facility failed to ensure voiced concerns about care were acted upon, assessed, and resolved to satisfaction for 1 of 1 resident (R1) who had complaints of rough treatment during transfers in and out of bed. Findings include: A provided Formal Grievances policy, undated, identified the facility recognized grievances may arise from residents and their families, and it listed an intent of dealing with such concerns effectively so all such situations could be addressed and resolved. The policy directed any grievance was to be brought to the department manager, or designee, and/or the Vice President of long-term care (LTC) and RR/AC. If unable to be resolved at that time, then the appropriate department supervisor was to be notified and a Country Manor Concern Intake Form completed with the nature of the grievance(s), any action(s) taken, and the initiator of any action(s) completed. This form and completed documentation were then to be presented to the administrator who may or may not take further action. Further, the policy directed the facility would respond to formal grievances as soon as possible but not longer than seven (7) days. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required extensive assistance for bed mobility and transfer. Further, the MDS recorded R1 as having depression and demonstrating no pain. R1's care plan, dated 8/02/12, identified R1 needed extensive assist of two with turning and repositioning and transferred with assistance of two with a EZ stand (mechanical device to transfer). On 9/9/21, at 9:47 a.m. R1 was observed seated in his wheelchair in his room with oxygen on. R1 was interviewed at this time, and he explained he had just recently moved to his current room from the Pinecone Unit. However, R1 explained when he resided on the Pinecone Unit there had been a big black man who was rough when he transferred him into bed. R1 described it, He would just plop me in bed and it hurt so bad when he would turn me! R1 expressed he reported these concerns about the man to his family member (FM)-A several times, who then reported it to a nurse which resulted in a meeting being held between FM-A and the facility to discuss the concerns. R1 reiterated he did not like or want the man providing care to him because of the way he interacted with him in the past. In a additional interview at 9:55 a.m. R1 did state he felt the man really did not mean to hurt me and maybe did not know his own strength. In addition, R1 stated he did not feel he was abused. On 9/9/21, at 10:50 a.m. FM-A was interviewed. FM-A explained R1 had contacted her several times back in July 2021 and was upset with the way a male staff member, who R1 described as a bigger black male, was transferring him into bed and repositioning him. These repeatedly voiced concerns caused her to ask for a meeting with the facility on 8/2/21. At the meeting, FM-A provided the registered nurse manager (RN)-A and social worker (SW)-A with a list of her concerns including R1's concerns about potentially rough transfers and repositioning by this male staff member. FM-A expressed frustration with the facility's lack of follow-up to the concern and added, I had to provide my issues in writing [to them] since I felt this was the only way they would respond to my concerns since I had so many [concerns] in the past with no response. During subsequent interview with FM-A, at 11:26 a.m., FM-A reiterated RN-A and SW-A attended the meeting on 8/2/21, and she voiced she no longer wanted the male staff member to work with R1. FM-A added, I honestly thought the worker quit since I [hadn't] seen him but no one got back me about this at all. I don't even know if he has worked with [R1] after I made my complaint. A requested list of grievances from the facility for R1 indicated the following: On 8/30/21, a Concern Tracking Form was made that indicated FM-A had concerns on care areas including 1. O2 tubing and placement-alleges on the floor. 2. Use of mechanical lift device for mobility (EZ stand to EZ Lift) 3. Missing T-shirts 4. Missing sock for brace x1 and did report she had to move resident to room due to closure of unit. The concern form did not indicate any concern of rough transfers of cares for R1. When interviewed on 9/9/21, at 1:40 p.m. RN-A recalled and verified she had been made aware of concerns with potentially rough cares and transfers by a male staff member from R1 and FM-A at a meeting with them on 8/2/21. RN-A explained they were able to identify the staff member as nursing assistant (NA)-A, and NA-A had typically been regarded as a good NA and did not suspect NA acted willfully to harm to injure R1 while caring for him. RN-A stated she spoke with R1 about the concern, and she felt him to be kind of wavering in his story and concern; however, RN-A verified he did report potential concerns with rough transfers and treatment. RN-A expressed a grievance should have been completed for R1 and FM-A's concern(s) and added she believed SW-A did this and completed any needed follow-up to ensure it was resolved. R1's medical record was reviewed and lacked evidence the voiced grievance and concern about potentially rough cares was documented, acted upon or resolved through means in accordance with their policy and procedures for grievances. During interview on 9/9/21, at 2:02 p.m. the director of nursing (DON) stated she was aware R1 had expressed concerns of potentially rough treatment by NA-A; however, she had not been informed by RN-A or SW-A that the concern involved rough transfers. The only incident or concern she had knowledge of resulted from visiting with R1 on 8/10/21, when R1 had voiced NA-A put socks on his (R1's) feet which caused his feet to hurt. A provided document, dated 8/10/21, indicated the DON visited with R1 who voiced, It was a weekend, did not know time of the year. He had surgery on his feet in the 50's and the black man pulled on his socks too fast and caused pain in his feet. He was not able to specify when this happened. He had not worked with [R1] since this incident, he did not mention abuse or mistreatment, only that his feet hurt when the man pulled on his socks. When interviewed on 9/9/21, at 3:11 p.m. SW-A stated she recalled being present at the meeting held with R1 and FM-A on 8/2/21, and she verified FM-A expressed concerns about rough treatment adding R1 voiced the male staff member probably just didn't know his own strength. SW-A stated she did not recall who the specific staff member was, nor any subsequent actions taken to address the concern adding the nurse manager (RN-A) no longer worked at the nursing home. During interview 9/9/21, at 3/15/21 p.m. she felt there was no reason to fill out a grievance/concern tracking form since SW-A addressed the issues at the meeting they had on 8/2/2021.

Based on observation, interview, and document review, the facility failed to quarantine a resident (R213) who was readmitted and not vaccinated for COVID-19. The facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to the proper utilization of personal protective equipment (PPE) for 1 of 4 resident (R213) reviewed for transmission based precautions (TBP). In addition, the facility failed to ensure isolation gowns were not reused for 1 of 4 residents (R311) reviewed for infection control practices. Further, the facility failed to ensure a catheter drainage bag was kept off the floor to prevent contamination for 1 of 3 residents (R5) who utilized indwelling urinary catheters. Findings include: Current CDC guidance dated 2/10/21, directed health care workers who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. CMS COVID-19 Long Term Care Facility Guidance, dated 4/2/20, directed nursing homes to immediately ensure they were complying with all Centers for Medicare & Medicaid Services (CMS) and CDC guidance related to infection control which included the use of standard, contact and droplet precautions. R213's Detailed Summary dated 8/16/21, indicated R213 was readmitted to the facility on [DATE], and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R213's admission Minimum Data Set (MDS) dated [DATE], indicated R213 had severe cognitive impairment, and required extensive assist with bed mobility, transfers, dressing, toileting, one assist with eating and personal hygiene. R213's MDS further indicated falls prior to admission, in the last 2-6 months prior to admission w/fracture and 2 falls since admission R213's updated care plan dated 8/10/21, indicated R213 was at risk for falls, on the falling star program, and was to be in his doorway or at the nurses desk to maintain close observation. R213's care plan further indicated R213 was not vaccinated for COVID-19 and was at risk for COVID-19. R13's care plan directed was to wear a cloth face mask if tolerated when staff was providing care or within six feet for R213 or when R213 was outside of R213's room. R213's care plan directed Therapeutic Recreation would provide in room leisure activities. R213's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/21, at 2:21 p.m. signage was observed on R213's door, which indicated R213 was on droplet and contact precautions, and required an isolation gown, mask, eye protection, and gloves before entering R213's room. R213 was not observed in room at that time. On 8/9/21, at 5:10 p.m. R213 sat at the nurse's station on the Rapid Recovery unit., and R213's mask did not cover R213's nose or mouth but was down around R213's chin. Staff and residents were observed to walk by R213 less than six from R213. R213 while R213 sat in the main pathway by the nurses desk. On 8/9/21, at 7:05 p.m. registered nurse (RN)-G stated R213 was on quarantine for 14 days because R213 was readmitted from the hospital and had not received the COVID 19 vaccine. RN-G stated before entering R213's room PPE needed was a gown, N95 mask, gloves, and eye protection. On 8/9/21, at 7:09 p.m. R213 sat outside of the threshold of his room and ate supper on the tray table. During supper meal, nursing assistant (NA)-F was observed to stand less than six feet from R213 outside of R213's doorway and assisted R213 with supper by handing R213 his fork. NA-F wore eye protection and a surgical mask; but did not wear a gown, gloves, or N95 respirator. RN-D approached NA-F and instructed NA-F to put an isolation gown and gloves on when working with R213. On 8/9/21, at 7:10 p.m. NA-F verified she should have donned an isolation gown and gloves while assisting R213 with supper. On 8/9/21, at 7:11 p.m. RN-D stated R213 was on a 14-day quarantine and droplet precautions because R213 was readmitted from the hospital and had not received the COVID-19 vaccine. RN-D stated staff should wear an isolation gown, gloves, eye protection, and a mask when working with residents on quarantine. RN-D verified she instructed NA-F to put on an isolation gown and gloves while supervising R213 during supper. On 8/10/21, at 8:36 a.m. NA-G sat with R213 outside of the threshold of R213's doorway while R213 ate breakfast in arm's reach of R213. NA-G did not wear a gown, gloves or N95 mask. On 8/10/21, at 5:44 p.m. R213 sat at the nurses station on the Rapid Recovery unit, and R213's mask did not cover R213's nose or mouth but was down around R213's chin. On 8/11/21, at 12:17 p.m. R213 sat in his wheelchair in the threshold of his room and ate lunch while speech therapist (ST)-A sat next to him. ST-A wore a clear face shield, surgical mask, and gown. On 8/11/21, at 3:38 p.m. R213 sat at the Rapid Recovery unit nurses' station, and listened to country music, and wore a surgical mask around his mouth and nose. LPN-B only wore a surgical mask, and eye protection, and knelt next to R213 and sang to R213. On 8/12/21, at 8:41 a.m. R213 sat in his wheelchair outside the threshold of his doorway, wore a clear face shield without a mask. On 8/12/21, at 9:34 a.m. RN-E stated not all staff had been fit tested for N95 respirators and the facility tried to catch staff as they could. RN-E stated if staff were not N-95 fit tested , staff should not enter isolation rooms. RN-E stated she did not have a current plan to ensure staff were fit tested for use of an N95 respirator. On 8/12/21, at 9:44 a.m. NA-D and NA-E were observed to wear face shields, gowns, gloves, and surgical masks as they escorted R213 to his room from the Rapid Recovery nurses' station. They entered the room and closed the door. On 8/12/21, at 9:48 a.m. NA-D and NA-E exited R213's room and wore surgical masks and face shields. On 8/12/21, at 9:50 a.m. NA-D stated she assisted R213 with a transfer into bed. NA-D stated she did not wear an N95 when she assisted R213 into bed and should have worn one. NA-D stated she had been fit tested for N95. Review of facility documentation however, indicated NA-D had not been N95 fit tested . On 8/12/21, at 9:59 a.m. NA-E stated she had assisted R213 into bed and verified she did not wear an N95 mask, and only wore a surgical mask when she assisted R213 into bed. NA-E stated she had not been fit tested to wear an N95 respirator. On 8/12/21, at 11:56 a.m. physical therapist (PT)-A was observed being fit tested for an N95 respirator in the education room. At 8/12/21, at 11:57 a.m. PT-A exited the education room and stated he was just fit tested for a N95 respirator and was informed about the testing that day. PT-A stated he had worked with residents in quarantine rooms, and prior to that had not been N95 fit tested . On 8/12/21, at 12:29 p.m. RN-E provided list of employees and indicated the ones who were not N95 fit tested . The facilities staff scheduled was reviewed and compared to the list of employees who were not N95 fit tested , revealed on the night shift for 8/9/21 and 8/11/21, none of the 12 staff who worked, had been fit tested for use of an N95 mask. On 8/12/21, at 2:29 p.m. DON stated it was the expectation staff who worked with residents on quarantine to be N95 fit tested and wear an N95 respirator. The DON further stated if staff were not fit tested for an N95 respirator or had medical exclusions to wear an N95 respirator, staff should not enter any rooms on quarantine. On 8/13/21, at 11:44 a.m. RN-F stated R213 was on Falling Stars due to R213's impulsiveness, poor judgement, and subsequent falls and required to be in line of sight. RN-F stated R213 was on quarantine because R213 was a readmission, was unvaccinated and required a 14-day quarantine. RN-F stated R213 was allowed out of his room because R213 needed to be in line of sight of staff because R213 would get out of his wheelchair and attempt to stand. RN-F stated there were no designated staff assigned to R213 for one on ones, and staff would just tag team. RN-F stated sometimes RN-F would sit at the nurse's station and other times R213 sat in his doorway so staff could see R213. The facility policy Management of Suspected or Confirmed Corona Virus (COVID-19) revised 8/13/21, directed to quarantine all admitted and readmitted residents regardless of diagnosis, fall risk, and/or cognition in their rooms for 14 days unless they are fully vaccinated. The policy was updated to also include, the facility would also be doing fit testing for employees on the use of N95 respirators upon hire if that employee will be in direct contact with residents or will have the need to enter a quarantine room. R311's Profile Face Sheet indicated R311 was admitted on [DATE]. R311's Resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R311's care plan initiated on 8/5/21, directed R311 would remain on a 14 day room restriction upon admission or readmission to the facility during the pandemic. On 8/9/21, at 6:27 p.m. the dinner tray service to rooms was observed on the Pinecone Lodge unit. Nursing assistant (NA)-A was observed donning personal protective equipment (PPE) prior to bringing R311 a meal tray. Registered nurse (RN)-B could be heard talking to NA-A from inside R311's room. RN-B stated she was going to hang her isolation gown in the room to use the next time she needed to enter R311's room. When RN-B exited the room she was interviewed, RN-B verified she was unsure if re-using an isolation gown was acceptable practice but had been in/out of the room at least four times already. RN-B verified she was re-using her isolation gown, she verified the facility did not have a shortage on isolation gowns. On 8/9/21, at 6:36 p.m. RN-B verified it was not acceptable practice to hang isolation gowns in the quarantine room and continue to use them. On 8/13/21, at 11:34 a.m. the director of nursing (DON) verified it was not acceptable practice for staff to re-use isolation gowns. The facility policy titled Personal Protective Equipment for Resident with Confirmed or Suspected COVID-19 directed staff to discard the isolation gown in a waste container or hamper after removing. R5's Detailed Summary Sheet printed 8/12/21, indicated R5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 had a severe cognitive impairment, had an indwelling catheter, had a urinary tract infection ([CONDITION(S)]) in the past 30 days and [CONDITION(S)]. R5 required extensive assist with toileting cares. R5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Change specified catheter monthly for retention of urine -Do not irrigate Foley catheter, change as needed for leaking or decreased urinary output using similar sized catheter. Change catheter and tubing prior to obtaining a urinalysis/urine culture sample. May attach leg bag when out of bed then re-attach to straight drainage when in bed. Flush only when instructed by urology, then use a regular flush when indicated. -Foley catheter cares every shift R5's care plan initiated 6/9/21, identified R5's risk of infections related to the catheter, and directed catheter cares and changes, and for catheter bag to be hung below level of bladder at all times, but lacked directives to ensure catheter drainage bag was kept off the floor. R5's nursing assistant (NA) worksheet/communication dated 8/11/21, directed NA's to provide catheter cares every shift and as needed, but lacked directives for positioning of catheter and to ensure R5's catheter drainage bag was kept off the floor. R5's Interdisciplinary Notes dated 8/11/21, for care conference on 8/10/21, indicated R5 had been hospitalized from 6/6/21, through 6/9/21, with a [CONDITION(S)] and [CONDITION(S)]. On 8/9/21, at 3:12 p.m. R5 was observed lying in bed with his catheter drainage bag sitting on the privacy bag which was on the floor. On 8/12/21, at 8:20 a.m. R5 was observed to be lying in bed, with his catheter drainage bag hanging from the bottom right side of his bed, in a cloth privacy bag, touching the floor. On 8/12/21, at 8:34 a.m. NA-C entered R5's room to do morning cares, including catheter cares. NA-C verified R5's catheter drainage bag and cloth privacy bag were sitting on the floor and should have been hung to keep off the floor. NA-C stated the catheter privacy bag was wet and needed to be changed. NA-C washed up R5, provided catheter cares using proper infection control practices, and dressed R5. NA-C stated it appeared that R5's catheter was getting clogged, as it had some sediment in the tubing, so would tell the nurse. NA-C transferred R5 into the wheelchair and hung the catheter drainage bag under the wheelchair, off the floor. NA-C went to inform licensed practical nurse (LPN)-A that R5's catheter drainage bag had been on the floor and to get a privacy bag to cover R5's catheter drainage bag. On 8/12/21, at 9:20 a.m. LPN-A changed R5's catheter drainage bag, placed it in a clean privacy bag, and hung it under R5's wheelchair. LPN-A verified R5's catheter tubing had sediment in it and stated she did not like that, so would talk to R5's case manager. LPN-A verified the catheter drainage bags, even when in a privacy bag, should not be hanging so it touched the floor due to risk of infection. On 8/12/21, at 10:27 am. registered nurse (RN)-C verified catheter drainage bag and privacy bag should not be touching the floor. On 8/12/21, at 2:44 p.m. director of nursing (DON) verified catheter drainage bags should be kept off the floor to prevent cross-contamination and risk of infection. The facility policy and procedure for Urinary Catheter Care reviewed 6/21, lacked directives to ensure the catheter drainage bag and tubing were hung so they were not touching the floor or contaminated surface.

Based on interview and document review, the facility failed to ensure a baseline care plan was provided in writing for 2 of 5 residents and/or their representatives (R87, R96) reviewed for care plans. Findings include: R87's Detailed Summary report printed on 8/13/21, indicated R87's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R87's admission Minimum Data Set (MDS) dated [DATE], identified R87 had severely impaired cognition, and was totally dependent for all activities of daily living (ADL). In addition R87 was dependent on tube feeding for nutrition. R87's care plan started on 7/16/21, addressed the minumum required elements for effective and person-centered care. On 8/10/21, at 11:28 a.m. family member (FM)-A and FM-B were interviewed. FM-A and FM-B stated they could not recall attending any care conference or being offered a copy of the baseline care plan in the first couple of days after R87's admission. FM-A could not recall any staff asking him anything about R87's daily preferences. During an interview on 8/13/21, at 9:08 a.m. the director of social services (SW)-A stated there should have been a progress note about the initial care conference and care plan in R87's progress notes. SW-A reviewed the progress notes but could not find any notes on the care conference and baseline care plan. SW-A stated they do not offer residents and resident representatives a copy of the baseline care plan but the resident and/or resident representative could ask for copies of anything they want. During an interview with registered nurse (RN)-A on 8/13/21, at 9:58 a.m. RN-A stated she did not document that she provided a written care plan to R87 and/or their representative. R96's Detailed Summary report printed on 8/13/21, identified R96's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R96's care plan started 5/4/21, addressed the minumum required elements for effective and person-centered care. R96's quarterly MDS dated [DATE], indicated R96 was moderately cognitively intact and required extensive assistance with ADLs. In an interview with R96 on 8/10/21, at 10:53 a.m. R96 stated she could not recall receiving any written care plan. During an interview with SW-A on 8/13/21, at 9:01 a.m. SW-A reviewed R96's progress notes but could not find documentation that the care conference was completed and that a copy of the baseline care plan was provided to the resident and/or the resident representative. -at 9:43 a.m. the director of nursing (DON) stated nursing always gives the baseline care plan to the resident and their families. -at 11:16 a.m. the DON verified it was her expectation that staff would enter a progress note and include that the base line care plan was offered to the resident and/or their representative in writing. The facility policy Baseline Care Plan review date 6/21, directed staff would develop a baseline care plan within 48 hours of admission. Along with the baseline care plan is a summary of the care plan that is provided to the resident and representative in language that can be understood. The policy directed staff would document in the clinical record that the baseline care plan was given to the the resident and representative.

Based on interview and record review, the facility failed to monitor and provide treatment per facility protocol for bowel regimen related to constipation for 1 of 6 residents (R1) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. Further review of MDS, indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 11/13/20, indicated R1 was a potential in alteration for toileting related to needing increased assistance due to recent left-sided [CONDITION(S)] (CVA) with right sided weakness and dementia. Further the care plan directed staff to monitor and record frequency and characteristics of stool, and Country Manor Bowel Program as needed (PRN) protocol to prevent constipation. The Bowel protocol directed Day 1: prune juice or apricot nectar, Day 2: MOM (Milk of Magnesia-used as a laxative) 30 cc or Senna (laxative) 1 tab, Day 3: [MEDICATION(S)] (laxative) suppository, and Day 4: fleets enema (saline laxative). R1's daily charting for bowel and bladder dated 12/21/20, indicated the following: 11/3/20, on second shift, small incontinent bowel movement (BM), 11/4/20 through 11/10/20 indicated no BM and on 11/11/20 on second shift, small BM. The facility printed and provided a BM Graph for R1. The graph indicated R1 had a small bowel movement on 11/3/20 and 11/11/20 consistent with the daily charting bowel and bladder. On the bottom of the printed graph, there was a hand written note that indicated staff reported R1 had a BM on 11/7/20, however, facility failed to provide evidence as to where they found the documentation, and which staff member reported the BM when asked. Review of R1's progress notes for 11/7/20 lacked documentation of a reported BM. R1's telemedicine visit note dated 11/9/20, indicated nursing staff updated nurse practitioner (NP) that R1's speech was a little better and R1 has not been cooperating in therapy. However, there was no mention of concern with lack of bowel movement. A review of R1's progress notes indicated the following: -Progress note dated 11/10/20, indicated R1 did not have a bowel movement for several days so [MEDICATION(S)] 5 mg suppository administered. Patient has not had a bowel movement yet. -Progress note dated 11/11/20, indicated R1 refused a.m. and p.m. medication, in addition to breakfast, lunch, and supper tray. The progress note did not indicate R1 had a bowel movement. -Progress note dated 11/12/20, indicated R1 had not been eating meals, and again refused supper and medications. The progress note did not indicate R1 had a bowel movement. -Progress note dated 11/13/20, family was updated on R1's status and behaviors and R1 again refused medications and meal trays. The progress note did not indicate R1 had a bowel movement. -Progress note dated 11/14/20, indicated R1 was admitted to the hospital for an evaluation related to being lethargic and abnormal vital signs. R1's medication record dated 12/21/20, indicated R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . While the progress note from 11/10/20, indicated 1 dose of [MEDICATION(S)] 5 mg had been administered, the medication record did not reflect that this medication was administered. Further review of medication record, indicated R1 was not given any PRN medication for lack of bowel movement as directed per BM protocol (milk of magnesia, suppository, and enema) from the time of her admission through the date of discharge. R1's hospital summary dated 11/17/20, indicated R1 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/21/20, at 12:35 p.m. registered nurse (RN)-A indicated R1 would have behaviors and refuse a lot of things, like toileting, R1 would be resistive. Further, RN-A stated, We can only do so much but re-approaching R1 was successful. On 12/21/20, at 4:11 p.m. director of nursing (DON) indicated staff should follow the facility's BM protocol. Further, DON stated if staff administer milk of magnesia (MOM), a suppository, or an enema, it should be documented in the medication record. DON confirmed there was no documentation that R1 had a bowel movement from 11/3/20 through 11/11/20. On 12/22/20, at 9:15 a.m. when asked about R1's bowel protocol, RN-B indicated the night shift nurse will make a list of residents who did not have a BM and then the morning nurse would be expected to follow the BM protocol (prune juice, milk of magnesia, suppository, and enema) and it would be documented in the resident's record. Further, RN-B stated she does not recall R1 and stated, I don't have a way to look up any of the information. On 12/22/20, at 10:30 a.m. DON indicated she was unable to provide any additional documentation or details regarding the hand written note on the BM log or which staff member reported that R1 had a BM on 11/7/20. In addition, DON stated staff counted R1's small BM that was documented on 11/3/20 and 11/11/20 as having a BM, due to R1 not eating much, however, typically staff would not count a small BM. On 12/22/20, at 12:13 p.m. nurse practitioner (NP) indicated R1 would frequently refuse care and refuse medications but NP did not have any notes from visits on 11/6/20 and 11/9/20 NP visit regarding any constipation concerns brought to her attention by the facility staff. The NP declined to answer questions from investigator related to R1's hospitalization and stated, I think she had a lot of medical issues. Facility policy titled, Country Manor Bowel Program, reviewed 6/19, indicated to prevent constipation nursing staff will use the following interventions as needed per standing orders. Residents may also have individualized prescribed medications for constipation. Day 1: prune juice or apricot nectar Day 2: MOM 30 cc or Senna 1 tab Day 3: [MEDICATION(S)] suppository and Day 4: fleets enema.

Based on observation, interview, and document review, the facility failed to ensure all staff received education regarding infection control practices, including following precautions and using personal protective equipment (PPE) during [MEDICAL CONDITION] (COVID-19) outbreak, in accordance with Centers for Disease Control (CDC) guidelines, for 1 of 2 residents (R1) reviewed, in contact and droplet precautions. This had the potential to affect all 152 residents residing in the facility. Findings include: R1 was admitted to the facility on [DATE] following hospitalization for pneumonia with an unspecified organism and acute [MEDICAL CONDITION]. During the entrance conference on 4/7/20 at 9:45 a.m. registered nurse (RN)-A reported, due to R1's discharge from a hospital and diagnosis, and due to the current COVID 19 pandemic, R1 was placed in contact (wearing gloves and gown when entering room) and droplet (wearing mask and eye protection when entering room) precautions upon admission to the facility. During an observation on 4/7/20, at 11:46 a.m. R1's room door was open, and on the door, was a small dark sign, directing, Before entering resident's room, please check with the nurse. A plastic bin, with three drawers, had been placed beside R1's door and contained PPE. A sign on top of the bin directed anyone entering the room, to don PPE, with pictures to show what PPE was required and how to put it on. Information technology (IT)-A, wearing a mask, approached R1's room, knocked on the open door, announced he needed to check something in the bathroom, and without donning PPE, entered R1's room. R1 stated, What? three times, and then asked IT-A to come closer because she couldn't hear him. IT-A walked to within two feet of R1, and bent down with his face close to her ear, and again stated he was there to check something in the bathroom. IT-A walked to the closed bathroom door, turned the handle with an ungloved hand, and entered R1's bathroom. The bathroom door closed and after a few moments, IT-A opened the bathroom door by the handle, and walked to exit R1's room into the hallway. IT-A was immediately stopped by surveyor and RN-A was summoned. On 4/7/20, at 11:50 a.m. IT-A stated he did not notice the sign on the door and was not aware that he shouldn't have entered R1's room without donning PPE. During an interview on 4/7/20, at 11:52 a.m. RN-A stated all staff should have completed mandatory training and staff should not enter rooms of residents that have precautions without donning PPE as directed. RN-A stated she did not know if IT-A completed the training. During a telephone interview on 4/8/20, at 11:21 a.m. RN-A, the director of nursing, and the vice president, indicated IT-A did not attend the mandatory training offered 3/10/20, however, has now completed the training. Review of the facility's undated policy, Management of Suspected or Confirmed [MEDICAL CONDITION] (COVID-19), included, All healthcare personnel will be correctly trained and capable of implementing infection control procedures and adhere to requirements.

Based on interview and document review, the facility failed to provide the estimated daily cost of stay on the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for 5 of 5 (R44, R62, R83, R389, R390) residents whose Medicare A coverage ended and the residents remained in the facility. This has the potential to affect all residents residing in the facility who are eligible for Medicare coverage. Findings include: R44's SNFABN form was reviewed, the SNFABN form was given and signed 2/4/19 with Medicare A coverage ending 2/7/19. The estimated daily cost box indicated a cost estimate was unavailable at this time. R62's SNFABN 5 form was reviewed, the SNFABN form was given and signed 2/15/19 with Medicare A coverage ending 2/19/19. The estimated daily cost box indicated a cost estimate was unavailable at this time. R83's SNFABN form was reviewed, the form was given and signed 2/22/19 with Medicare A coverage ending 2/25/19. The estimated daily cost box indicated a cost estimate was unavailable at this time. R389's SNFABN form was reviewed, the form was given and signed 12/27/18 with Medicare A coverage ending 12/30/18. The estimated daily cost box indicated a cost estimate was unavailable at this time. R390's SNFABN form was reviewed, the form was given and signed 1/1/19 with Medicare A coverage ending 1/4/19. The estimated daily cost box indicated a cost estimate was unavailable at this time. When interviewed on 3/28/19, at 12:15 p.m. director of nursing (DON) stated she was not familiar with the SNFABN form. DON stated the registered nurse (RN) case managers complete these forms and you should check with one of them. When interviewed on 3/28/19, at 12:29 p.m. assistant director of nursing (ADON) stated she was covering for one of the RN case managers currently, but did not know anything about the estimated cost portion. ADON stated to try speaking to a RN case manager in the short stay unit. When interviewed on 3/28/19, at 12:50 p.m. RN-F stated therapy will give the RN case managers notice when therapy is ending that is when we complete the form. RN-F stated she was directed to put in no cost available at this time because they would not know the cost estimate until minimal data set (MDS) is processed. RN-F stated if the resident would want to know about the estimated daily cost she thought the business office might be able to help them. RN-F stated the nursing case managers have discussed how they need to come up with an estimated daily cost, but that is as far as they have gotten. A facility policy was requested and was not received as the DON stated they did not have a policy for this.

Based on interview and documentation review the facility failed to adequately respond to a grievance when 1 of 1 residents (R108) reported she did not want a specific nursing assistant (NA) to provide care. In addition, the facility failed to maintain evidence of grievances filed for the last 3 years. This practice had the potential to affect all residents that reside at the facility. Findings Include: R108's Annual Minimum Data Sets ((MDS) dated [DATE] indicates intact cognition. A Quarterly MDS dated [DATE] indicated R108 was dependent for all cares including bed mobility and transfers and requires assist of two, was frequently incontinent of urine and required being checked and changed with assist of two. [DIAGNOSES REDACTED]. Care Area Assessment (CAA) indicated R108 required assistance with transfers with EZ mechanical lift, bed mobility, toileting, dressing, grooming, bathing, and wheeling. R108's care plan dated 12/5/18 indicated R108 is non ambulatory and required extensive to total assist with all of her activities of daily living including assist of 2 staff for transfers with a mechanical lift. R108 required assist with repositioning, bed mobility and assist with incontinent briefs. During interview on 3/26/19, at 8:16 a.m. R108 stated she has had some unhappy experiences with an aide. Stated nursing assistant (NA)-A causes her pain when she changes her depends, soaker pad and repositioned her. R108 stated she requires staff assist of two to change her depends and reposition her, and while most of the staff are very good, she does not feel NA-A gives her good care and does not want her in her room. R108 stated this has been reported to the facility, however does not know whom it was reported to. During interview on 3/27/19, at 12:16 p.m. R108 stated the two aides that helped with activities of daily living (ADL's) and changing of her depends and soaker pad, R108 stated aides were very competent and all went smooth in the morning. R108 stated she talked to the social worker (SW) this morning, name unknown, and told SW she is worried to talk about NA-A and worried about talking to the state surveyors as she fears she could be kicked out of the facility. R108 stated she told NA-A not to come in her room anymore after NA-A refused to help her adjust her depends when it pinched her skin. NA-A came back to help R108 with adjustments of depends and soaker pad when R108 stated she sent NA-A out of her room and told NA-A not to come in her room again. R108 does not know the date this instance took place, however believes it took place a couple months ago. R108 stated she told registered nurse (RN)-A about NA-A and the history of this aide refusing cares when R108 is in pain with the pinching of depends and wrinkles in her soaker pad and needing readjustments. R108 stated the last time NA-A was in her room was about two months ago and has several concerns regarding NA-A. R108 feels NA-A does not want to help her and went on to state that NA-A states that R108's soaker pad is fine when it needs to be straightened, same with her depends when it is not put on right. R108 stated she feels like a burden when NA-A cares for her. R108 stated all she wants is her depends and soaker pad comfortable. R108 stated she feels safe in facility. R108 stated she told the SW on Monday (MONTH) 25th she was going to talk to state surveyor about NA-A and tell them she is scheduled to work on the unit where R108 resides. R108 stated she looked at the schedule each day to ensure NA-A is not on her wing. During interview on 3/28/19, at 9:10 a.m. NA-C stated R108 requires repositioning after changing her depends and soaker pad as R108 does not like the depends tight and soaker pad needs to be wrinkle and lump free. NA-C stated she relayed information regarding R108 request not to have NA-A in her room to RN-A. NA-C stated she is not sure what was done about it, however she has not seen NA-A working on the unit where R108 resides for a couple months. During interview on 3/28/19, at 9:55 a.m. RN-B stated nothing of concern has been brought to her attention and she does not know of any concerns with staff. During interview on 3/28/19, at 10:08 a.m. RN-C stated R108 has issues with her attends, pad and have made several attempts to address her concerns, keeping the tabs open at night and keeping the same staff as much as possible for continuity of care. RN-C stated she is not aware of any particular staff that R108 does not want in her room. During interview on 3/28/19, at 10:29 a.m. DON stated she is not aware of any particular NA that R108 does not want taking care of her. DON stated R108 is particular with her brief placement and it needs to be readjusted quite frequently through out the day. DON stated staff were educated in November, (YEAR) on how to place the brief correctly as not to cause R108 pain. During interview on 3/28/19, at 12:44 p.m. RN-A stated there was an evening about two months ago R108 requested not to have NA-A care for her or go into her room any longer. RN-A stated she reported this to the supervisor RN-D. RN-A stated she did nothing further to follow up except for advising NA-A not to go in R108's room or care for her. During interview on 3/28/19, at 12:58 p.m. RN-D stated he recalls an evening where R108 requested NA-A not go in her room any longer, RN-D believed it was a personality issue and does not recall why R108 had concerns with NA-A. RN-D stated he advised NA-A not to go in R108's room or care for her. RN-D stated his responsibility ended after advising NA-A not to go in R108's room. RN-D stated he did not realize there were any issues with this situation until surveyors interview. RN-D stated RN-A should have filled out a concern report and given it to the case manager to look into. During interview on 3/28/19, at 1:17 p.m. DON stated any nurse a concern is voiced to, can fill out a concern form. DON stated in this case she would have expected RN-A to fill out a concern report for the case manager. DON stated the case manager could have ensured 108's request for NA-A not going in her room was followed up on had she known. DON stated if we knew about this situation we would have gotten more details, investigated an taken it seriously. During interview on 3/28/19, at 3:17 p.m. DON stated she is going to interview R108 and other staff members who worked with NA-A and R108. DON stated she will have NA-A suspended until she has this investigation closed. DON stated all employees receive abuse prevention education which includes screening, training, identification, investigation, protection, and reporting. Grievance Policy: On 3/27/19 the facility's Formal Grievance Policy was reviewed and indicated the process was to be carried out without thread of discharge or reprisal against the resident or person filing the grievance, may be filed orally, written, and/or anonymously. Further, the policy directed to respond to formal grievances ASAP but no longer than seven days and the resident has a right to a written decision of their grievance. There was no indication how long grievances would be maintained for later review. Grievances for the last three years was requested. A manila folder with Country Manor Concern Intake Forms was provided. Upon review, the provided forms dated back to the (MONTH) 1, 2019. A request was made for three years of grievances. Another stack of concern forms was provided. Upon review, there were no concern forms provided that had been dated prior to the last survey of 4/12/18. When interviewed on 3/28/19, at 8:15 a.m. the registered nurse (RN)-E in charge of quality and regulatory management stated the concern forms are kept from survey to survey and that there were no formal grievances since she took her position in 2014. When questioned about what happens to the concern forms, RN-E was unsure if they were shredded or stored someplace off site. RN-E stated concern forms are kept for one survey year. When the survey is over we start the new ones. The Country Manor Health Care & Rehabilitation Center Concern Intake Policy was reviewed and indicated a process for documentation, investigation, response, and review of all concerns. There was no direction on the policy for the maintenance of the results of all grievances for three years.

Based on observation, interview and documentation review, the facility failed to ensure an assessment was completed to determine safe medication administration for 1 of 1 residents (R64) observed to have a medication cup on his bed side stand with four medications in the cup. Findings include: R64's primary [DIAGNOSES REDACTED]. R64's Self Administration of Medication Assessment, dated 11/6/16, indicated R64 would like licensed nursing to administer all medications. R64's Annual Self- Administration of Medication form on 11/03/17, indicated R64 continues to request staff to administer all medications. On 4/12/2018, at 8:10 a.m. R64 had a medication cup containing four pills sitting on his bedside table with no staff present. The medication cup had the following: 1. Aspirin 81 milligrams (mg), 2. [MEDICATION NAME] 500 mg for diabetes. 3. [MEDICATION NAME] 2, one capsule for vision, 4. Senna one capsule for constipation. There was no medical doctor's orders for self administration or an assessment indicating self administration. On 4/12/18, at 8:46 a.m. assistant director of nursing (ADON) stated the nurses are to be administering R64's medications to him, and typically they should not be leaving the pills on the bed side stand for him to take. On 4/12/18, at 1:26 p.m. nursing assistant (NA)-C stated R64 takes his medications from the cup when he wakes up and sits up sometime in the morning. NA-C stated the nurses normally leave his medications sitting on his bedside stand. A facility policy, Self Administration of Medications revised 1/18 indicated If a resident requests to self- administer medications, the interdisciplinary team (IDT) will assess the resident to determine if it is clinically appropriate to honor the resident's choice in order to maintain the residents highest practicable level of functioning. The resident has the right to defer the responsibility to the facility. A resident may only self administered medications after the IDT has determined which medications , may be safely administered.

Based on interview and record review the facility failed to assure identified preference for bathing frequency for 1 of 4 residents (R25) reviewed for choices. Findings include: R25's significant change Minimum Data Set ((MDS) dated [DATE], identified R25 had moderate cognitive impairment and required supervision with bathing. The MDS indicated choices were important to R25. R25's medical [DIAGNOSES REDACTED]. During interview on 4/11/18, at 1:16 p.m. R25 stated he received a bath weekly but had previously taken a shower daily prior to his admission. R25 stated he had informed staff he would like to receive showers more frequently than once a week but the frequency had not increased. R25's care plan, initiated 9/27/17, indicated R25 had a self care deficit with bathing related to [MEDICAL CONDITION]. The care plan directed staff to provide assist of one to transfer for safety and assist with bathing. Staff were directed to encourage R25 to participate with bathing. On 4/11/18, at 2:06 p.m. registered nurse (RN)-B stated residents are asked upon entrance to the facility what they would prefer for bathing and this information is documented on the Country Manor Health Care Rehab Center 24 Hour Nursing Assessment. The assessment does not specifically address frequency of bathing desired. During document review, a form titled Country Manor Health Care Rehab Center 24 Hour Nursing Assessment, dated 8/17, identified the resident preferred a shower, however, did not identify the frequency desired. The section labeled comments remained blank. On the same form, dated 10/20/17, the indication of shower was noted, with no information recorded under the comments section. This was also noted on the 24 Hour Nursing Assessments dated 12/19/17, and 1/17/18. During interview on 4/12/18, at 1:19 p.m. the assistant director of nursing (ADON) stated residents are asked their preference for bathing upon admission and this is reviewed quarterly. The ADON stated satisfaction with frequency is not specifically reviewed or documented. A facility policy revised 12/17, titled Country Manor Health Care & Rehab Center Bath-Shower or Tub identified a resident would be asked upon admission and PRN (as needed ) bathing preferences of bath or shower. The policy did not identify a choice for frequency of bathing.

Based on observation, interview and documentation review the facility failed to provide hand splint/palm protector according to the functional maintenance program for 1 of 2 residents (R64) who had limited range of motion. Findings include: R64's annual Minimum Data Set ((MDS) dated [DATE], indicated R64 was cognitively intact, independent with transfers, bed mobility, dressing, eating, toileting and locomotion. The MDS further indicated R64 had limitation on one side of lower extremity and no impairment on upper extremity. The MDS did not identify R64's upper extremity limitation to upper right hand. R64's care plan dated 8/3/17, indicated he had tightness to right hand, 3-5th fingers. R64's Rehabilitation Services occupational therapy Functional Maintenance Program Guidelines dated 8/21/17, indicated R64 was to wear his right palm protector seven nights a week. An interdisciplinary note dated 3/21/18, indicated R64 wore palm protector at night time and received restorative nursing. On 4/11/18, at 1:38 p.m. nursing assistant (NA)-B stated R64 is supposed to wear his right hand palm protector at night, but he usually takes it off himself. NA-B stated night shift puts palm protector on and NA-B was not aware that R64 was taking palm protector off at night. NA-B stated it was the usual process to let the licence practical nurse (LPN) or registered nurse (RN) on duty know when the residents are not following the restorative nursing program and the nurse's would then notify therapy. During observation on 4/11/18, at 1:42 p.m. R64 was observed to be in bed with no palm protector on his right hand, the last three digits on the right hand were closed to the palm and could not open those fingers. R64's palm protector was on top of the refrigerator. R64 stated he does not wear his right hand splint any longer, because it does not do him any good, and it has not helped for a long time. R64 then stated he has not worn his hand splint for approximately two months. R64's Nursing Rehabilitation/Restorative Care Record dated (MONTH) of (YEAR) recorded 17 nights of R64 wearing his palm protector and 11 nights not wearing palm protector. In (MONTH) (YEAR), the Nursing Rehabilitation/Restorative Care record, recorded 18 nights wearing palm protector and 7 nights with no documentation. In (MONTH) (YEAR), R64's Nursing Reanimation/Restorative Care Record recorded 25 nights of refusal of wearing the palm protector, four nights with no documentation and two nights wearing the palm protector. The (MONTH) Nursing Rehabilitation/Restorative Care Record dated (MONTH) (YEAR), recorded seven nights wearing palm protector, and four nights not wearing palm protector through (MONTH) 12th, (YEAR). Although the Interdisciplinary Note indicated he wore the palm protector at night, the Nursing Rehabilitation/Restorative Care Record in (MONTH) (YEAR) indicated he refused the palm protector 25 times. On 4/12/18, at 9:23 a.m. director of rehabilitation (DR) stated R64 was first seen by rehabilitation therapy services starting (MONTH) 8, (YEAR), for contractures of his right hand of digits three through five. DR stated R64 should still be wearing his right hand palm protector at night per his functional maintenance program that was implemented (MONTH) 21st, (YEAR). DR stated she would expect nursing to let therapy know if they noticed a change, pain, or someone who is refusing their functional maintenance program. DR stated she would have a screening done for him. On 4/12/18, at 10:41 a.m. Occupational Therapist (OT)-A accompanied by DR made a visit with R64 in his room. OT-A manipulated each joint of R64's digits on right hand and stated he had no decline in his range of motion of his hand. OT-A then stated she will talk to his physician about splints or other options for R64. A policy was requested but not received.

Based on observation, interview, and document review the facility failed to ensure grooming needs for facial hair removal was provided for 1 of 3 residents (R39) reviewed who was dependent upon staff assistance with activities of daily living (ADL). Findings include: R39's [DIAGNOSES REDACTED]. R39's admission Minimum Data Set, dated dated [DATE], indicated R39 was moderately cognitively impaired. R39's Care Area Assessment (CAA) dated 1/28/18, indicated R39 had self-care deficits due to weakness, pain, decreased mobility with increased reliance on staff for cares. The CAA indicated R39 required staff assistance with grooming. The CAA also indicated R39 was blind in the left eye, had poor vision in the right eye, and was only able to see objects and R39 was not able to read. R39 was observed on 4/10/18, at 10:13 a.m. in R39's room with glasses on and several, approximately half inch long, white hairs on the chin. R39 was observed on 4/11/18, at 9:03 a.m. in R39's room washing up in the bathroom with glasses on and several, approximately half inch long, white hairs on the chin. R39 stated it does bother me to have long chin hairs and I cannot do it by myself. R39 stated I had a shower yesterday. R39 was observed on 4/12/48, at 8:59 a.m. in the hallway in a wheelchair with several, approximately half inch long, white hairs on the chin. During an interview on 4/12/18, at 9:01 a.m. nursing assistant (NA)-A stated we do not have tweezers or razors for residents to use. NA-A stated the residents need to have their own razors. NA-A stated if the resident asked me to get rid of the chin hairs I would then help them if they had their own razor. During an interview on 4/12/18, at 9:33 a.m. registered nurse (RN)-A stated residents need to provide a razor or something to shave the chin hairs. RN-A stated we provide assistance with shaving if the resident would ask us. RN-A stated we should ask the residents if the chin hairs bother them. RN-A stated the staff should notice the chin hair length and ask if they would like the chin hair removed. That same day, at 9:44 a.m. RN-A agreed R39's chin hairs were approximately a half inch in length and white. RN-A stated the staff should ask if ladies would like the chin hairs removed. RN-A stated R39 was the assist of one staff for dressing and grooming. The facility policy Shaving-Electric Razor dated 2/10, indicated nursing staff to offer to shave residents daily and as need.

Based on observation, interview and document review, the facility failed to provide nail care in accordance with the written plan of care, for 1 of 1 residents (R19) reviewed for activities of daily living (ADLs) who was dependent upon staff for assistance. Findings include: R19's plan of care updated 2/8/17, identified R19 was totally dependent on staff to meet all needs and was unable to participate. The plan of care also identified R19 had potential for altered skin integrity related to, BUE (bilateral upper extremity) hands & feet contractures r/t (related to) mycotic aneurysm & [MEDICAL CONDITION]. The plan of care directed weekly nail care on bath day and as needed, and to Keep nails cut as to avoid hang nails-nurse to trim with baths. Review of the R19's undated nursing assistant (NA) care sheet, Group A Days, directed staff, make sure to check fingernails with cares and update nurse if nails need trimming . During an observation on 3/6/17, at 7:31 p.m. R19 was lying in bed and both hands were observed clenched in a fist like position. A small carrot shaped cushion was placed inside of R19's left hand, with nothing in the right hand, however, a small carrot shaped cushion was lying on the bed next to R19. R19's fingernails on both hands were long and jagged. During observations on 3/8/17, at 3:14 p.m. and again on 3/9/17, at 9:56 a.m. R19 was lying in bed with hands clenched in a fist like position, with the carrot shaped cushion in the left hand, and nothing in the right. A carrot shaped cushion was lying on the bed next to R19. During both observations, R19's fingernails remained long and jagged. When interviewed on 3/9/17, at 11:02 a.m. nursing assistant (NA)-A stated R19's nail care was to be completed by a nurse. NA-A stated she had given R19 a bath on Tuesday morning (3/7/17) before 6:00 a.m. so she had told the night nurse R19's nails needed to be trimmed. When interviewed on 3/9/17, at 11:16 a.m. licensed practical nurse (LPN)-A stated R19's nails were to be checked with every bath, and that either the nurse or the NA's could trim his nails, adding, We both try to keep up on them. R19's nails and skin on the palm of each hand were observed with LPN-A. LPN-A stated R19's nails were pretty hard to get at, due to the clenched fingers. LPN-A gently opened R19's hands to assess the skin on the palm of each hand and indicated the skin was intact. LPN-A stated, Yeah, they (nails) need to be trimmed. They're pretty jagged. We'll take care of that. During an interview on 3/9/17, at 11:38 a.m. registered nurse (RN)-A stated a nurse should be looking at R19's nails when assessing his skin on bath days and nails were to be trimmed by a nurse, with baths, as directed on R19's plan of care. RN-A added, The expectation is, staff will follow policies and procedures set in place.

Based on observation, interview, and document review, the facility failed to provide nail care for 1 of 1 resident (R19) reviewed for activities of daily living (ADLs), who was dependent on staff to meet grooming needs. Findings include: R19's facility form titled, Resident [DIAGNOSES REDACTED]. R19's Care Area Assessment (CAA) dated 11/28/16, indicated R19 required total assist with all ADLs and mobility, and was dependent on staff to anticipate and meet all needs and cares. R19's plan of care updated 2/8/17, directed weekly nail care on bath day and as needed, and to Keep nails cut as to avoid hang nails-nurse to trim with baths. Review of the R19's undated nursing assistant (NA) care sheet, Group A Days, directed staff, make sure to check fingernails with cares and update nurse if nails need trimming . Review of the bath schedule for Garden Cottage unit, included R19 received baths on Tuesday and Friday morning each week. During observation on 3/6/17, at 7:31 p.m. R19 was lying in bed and both hands were observed clenched in a fist like position. A small carrot shaped cushion was placed inside of R19's left hand, with nothing in the right hand, however, a small carrot shaped cushion was lying on the bed next to R19. R19's fingernails on both hands were long and jagged. When interviewed on 3/7/17, at 10:44 a.m. family member (FM)-A stated, (R19's) nails aren't always trimmed like they should be. During observations on 3/8/17, at 3:14 p.m. and again on 3/9/17, at 9:56 a.m. R19 was lying in bed with hands clenched in a fist like position, with the carrot shaped cushion in the left hand, and nothing in the right. A carrot shaped cushion was lying on the bed next to R19. During both observations, R19's fingernails remained long and jagged. When interviewed on 3/9/17, at 11:02 a.m. nursing assistant (NA)-A stated R19's nail care was to be completed by a nurse. NA-A stated she had given R19 a bath on Tuesday morning (3/7/17) before 6:00 a.m. so she had told the night nurse R19's nails needed to be trimmed. When interviewed on 3/9/17, at 11:16 a.m. licensed practical nurse (LPN)-A stated R19's nails were to be checked with every bath, and that either the nurse or the NA's could trim his nails, adding, We both try to keep up on them. R19's nails and skin on the palm of each hand were observed with LPN-A. LPN-A stated R19's nails were pretty hard to get at, due to the clenched fingers. LPN-A gently opened R19's hands to assess the skin on the palm of each hand and indicated the skin was intact. LPN-A stated, Yeah, they (nails) need to be trimmed. They're pretty jagged. We'll take care of that. During interview on 3/9/17, at 11:38 a.m. registered nurse (RN)-A stated a nurse should be looking at R19's nails when assessing his skin on bath days and nails were to be trimmed by a nurse, with baths, as directed on R19's plan of care. RN-A added, The expectation is, staff will follow policies and procedures set in place. Facility policy, Fingernails-Cleaning and Trimming, updated 1/17, directed nursing staff to provide nail care necessary to the residents, to promote cleanliness and to prevent infection. The policy also included, Nail care should be provided in conjunction with the resident's bath whenever possible.

Based on interview and document review, the facility failed to ensure laboratory results were provided to 1 of 1 residents (R102) who expressed he was not notified of them on a consistent and timely basis. Findings include: R102's quarterly Minimum Data Set ((MDS) dated [DATE], identified R102 had intact cognition, and received a daily anticoagulant medication. During interview on 2/21/16, at 3:19 p.m. R102 stated he did not feel included in decisions about his medical care because staff do not tell him the results of his frequent laboratory blood tests. R102 stated he was only informed of the results if he asked for them, and stated he would like to be told about the results of his laboratory tests when the facility received them. R102's medical record indicated the resident had a Chemistry 8 Panel (electrolyte panel) collected on 2/18/16, and a magnesium level test collected on 2/16/16, with staff initials on the bottom of the lab results identifying the physician had been updated on the results. However, there was no indication R102 had been updated on the results of his completed laboratory tests. When interviewed on 2/23/16, at 11:51 a.m. licensed practical nurse (LPN)-A stated she was the person who received R102's laboratory test results on 2/16/16 and 2/18/16, but had not notified R102 of the results. R102 had come to her before wanting to know his lab results, however, she did not notify him, Unless something changes, or if, He would come up and ask. During interview on 2/24/16, at 9:06 a.m. registered nurse (RN)-B stated residents at the facility were involved in their care by keeping them, Updated with any changes, including labs. Residents were told of their lab results if something was abnormal, non-routine, or, If the patient asks about them, but otherwise the nursing staff did not routinely notify residents of their laboratory results. When interviewed on 2/24/16, at 11:03 a.m. the assistant director of nursing (ADON) stated the nursing staff or physician were responsible to make sure residents were notified of their laboratory results. A facility Laboratory Services policy dated 12/2015, identified laboratory tests were used, For purposes of providing information for the diagnosis, prevention, or treatment of [REDACTED]. Further, the policy identified staff would update the resident or family with abnormal results, however did not identify who or how residents would be notified of non-abnormal results to ensure they were informed of their health status.

Based on observation, interview, and document review, the facility failed to ensure the required posting of nursing hours was accurately displayed to include the current date and facility census. This had potential to affect all 159 residents, staff and visitors who wished to review the information. Findings include: During the initial tour of the facility on 2/21/16, at 11:34 a.m. the Nurse Staffing of Country Manor posting was displayed on a bulletin board next to the reception desk by the main entrance. There was a total of three days posted which were dated 2/13/16, 2/14/16, and 2/15/16. Further, each day had a space to write the facility census in, however this space was left blank on each posting. When interviewed on 2/21/16, at 11:36 a.m. receptionist (RCP)-A stated the postings listed were not current, and she was not sure why, (I'm) not entirely sure why they're from a week ago. During interview on 2/21/16, at 5:40 p.m. the director of nursing (DON) stated the postings displayed by the main entrance were the only area of the building the hours are posted for the public and residents to view, and the registered nurse (RN) supervisors were responsible to change them on the weekends. The DON reviewed the incorrect postings and stated the dates were inaccurate, and the facility census should have been identified on the postings. A facility Nursing Hours policy dated 4/2015, identified the posting was used to, Communicate with residents and family that the (facility) has sufficient staff to meet the resident's needs. The policy identified a procedure which included to post the hours on a daily basis and include the resident census.

Based on interview and document review, the facility failed to ensure changes in clinical status including significantly elevated blood sugars and/or results that were a change of condition were promptly reported to the physician for 2 of 28 residents (R300 and R355) with diabetes. Findings include: R300 was admitted to the facility on [DATE], after a hospitalization for acute [MEDICAL CONDITION], diabetic ketoacidosis (a life-threatening complication when the body does not produce enough insulin), and a [MEDICAL CONDITION] with ventriculoperitoneal shunt (used to take excess fluid from brain, and "shunt" or divert it to the abdomen for absorption) placement. While hospitalized , R300 had blood sugars greater than 1,100 milligrams per deciliter (mg/dL) which required a continuous insulin drip to return to normal levels. R300's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) completed on [DATE], identified R300's cognitive skills for decision making were severely impaired, did not speak, and a brief interview for mental status (BIMS) was not completed because R300 was rarely understood. R300's physician orders [REDACTED]. ? [MEDICATION NAME] (a quick acting insulin) One unit per carbohydrate consumed with each meal ? [MEDICATION NAME] sliding scale insulin with all meals per blood sugar results ? [MEDICATION NAME] (a long acting insulin) 20 units with breakfast and a bedtime ? Glucometer (blood sugar) checks four times a day ? Ensure Clear 120 milliliters (mL) four times a day ? [MEDICATION NAME] 1.5 mL/hour for nine hours at night via enteral feeding tube ([DEVICE]) Review of R300's glucometer record for ,[DATE] included the following blood sugars: ? From [DATE] to [DATE] the results ranged from ,[DATE] with one reading of 409. ? On [DATE], at 7:00 a.m. the blood sugar was 392. At 11:00 a.m. it was 525. At 8:00 p.m. the machine could not give a number and only read as "HI". ? On [DATE] at 0010 (12:10 a.m.) the blood sugar was 515. ? On [DATE], at 7:00 a.m., the final recorded blood sugar for R300 was 524. Review of the interdisciplinary notes included the following: ? A note written by registered nurse (RN)-E on [DATE], at 12:39 a.m. identified R300 had a blood glucose level of "HI" reading on [DATE], at 8:00 p.m. A call was placed to the on-call physician and orders were given to administer eight units of [MEDICATION NAME] and fax the primary physician in the morning to obtain sliding scale parameters for R300's 8:00 p.m. blood sugars. ? A note written by licensed practical nurse (LPN)-C on [DATE], at 10:44 a.m. indicated R300 had been nauseous and was dry heaving that day with a temperature of 100.2. ? A note written by LPN-C on [DATE], at 2:01 p.m. indicated staff had entered R300's room at 11:00 a.m. for therapy, when R300 was found unresponsive. Nursing staff lowered R300 to the ground, cardiopulmonary resuscitation (CPR) was initiated at 11:04 a.m. and continued until paramedics arrived. Per the time line that was provided by the facility, on the morning of [DATE], R300 awoke at her normal time, was alert and responding to staff by nodding yes or no. Blood sugar was checked at 0700 and was 524. Resident was given eight units of [MEDICATION NAME] per insulin sliding scale and 20 units of [MEDICATION NAME]. R300 went to breakfast and ate bites of toast and cereal. She was given two units of [MEDICATION NAME] per carbohydrate counting orders. R300 participated in therapy from 9:30 to 9:55 a.m. and was brought back to her room. Per the nursing note written on [DATE], at 10:44 a.m., R300 was nauseated and dry heaving. R300 was left in her room and in her wheelchair. The desk nurse called the primary physician at 10:45 for a second attempt to follow up from the morning fax. A message was left with the primary's nurse. At 11:00 R300 was found unresponsive in her wheelchair. Staff began CPR and the desk nurse called 911 and then the primary physician was called again and was not available. A message was left again with the primary physician's nurse. Review of R300's code blue record (no date), revealed CPR was discontinued by the paramedics at 11:24 a.m. after a shock was administered and a pulse was found. The paramedics inserted a breathing tube and set up an external pacemaker and at 11:34 a.m. R300 was transported to the emergency room . R300 passed away in the emergency roiagnom on [DATE], at 12:55 p.m. Review of the facility's glucometer (Assure 4) manufacturer's manual dated ,[DATE] revealed a reading of "HI" meant the blood sugar test result was greater than 550 mg/dL and recommended seeking immediate medical assistance. An interview with LPN-F on [DATE], at 11:35 a.m. indicated that each resident had their own glucometer and LPN-F was not sure how high the machine reads. LPN-F also indicated that each resident had their own specific guidelines under the sliding scale order on when to call the physician. LPN-F was not sure of any facility policy of when to call the physician when the blood sugar was high. During interview on [DATE], at 12:04 p.m., RN-D indicated the facility supplied individual glucometers for residents when they were admitted which were all the same model. RN-D stated if a resident's blood sugar usually ran in the ,[DATE]'s and then was having readings in the ,[DATE] range, the staff would call the physician because that would be a change for the resident. RN-D also stated if the glucometer reading was too high to register on the machine a call would also be placed to the physician. RN-D further described how the physician would usually give an order for [REDACTED]. During interview on [DATE], at 10:10 a.m., the director of nursing (DON) indicated she had completed an internal quality investigation of R300's incident days following the incident. However, DON stated she wasn't sure if the information gathered had been brought to the quality assurance meetings or not. DON revealed that the staff were not educated by the facility on specific parameters on when to call the physician related to blood sugar readings and felt the staff didn't need to call R300's physician when her readings were in the 500's because, "That was her baseline." DON also indicated no reeducation or changes of policy were completed after the investigation because it was felt the staff acted appropriately. On [DATE], at approximately 3:10 p.m., the DON verified there was no physician involvement in the internal quality investigation. R300's medical record lacked evidence of physician notification or involvement from 8:00 p.m. on [DATE], until the day shift of [DATE], despite her blood sugars having remained elevated (based on a blood sugar reading of 515 on [DATE], at 12:10 a.m. post administration of fast acting insulin). The medical record lacked evidence of on-going blood sugar testing throughout the overnight hours to ensure it returned to a safe level and lacked evidence considering the impact of R300's continuous tube feeding on her elevated blood sugars. The medical record also lacked evidence to support R300's baseline blood sugars were near 500 mg/dl. During interview on [DATE], at 1:03 p.m., licensed practical nurse (LPN)-C recalled caring for R300 during the morning [DATE], when she passed away. LPN-C stated R300's blood sugar had been high that morning and a fax was sent to the primary physician around 7:30 or 8:00 a.m., but she knew that the physician only worked a couple days a week and would be difficult to get a hold of. LPN-C indicated R300 had gone for therapy after breakfast, so no blood sugar recheck was completed. LPN-C was not aware of any facility policy which gave guidance on when to call a physician related to blood sugar results. During interview on [DATE], at 1:18 p.m., medical doctor (MD)-A stated the expectation was that nurses would use their judgment on when to call a physician for high or low blood sugars. Further, MD-A indicated the nurses should recheck blood sugars to make sure they were responding and coming down and contacting a primary physician as soon as possible. However, if they couldn't get a hold of the physician, they could always send a resident to the hospital. During interview on [DATE], at 8:11 a.m., MD-B stated it was his opinion that blood sugar readings greater than 500 were bad no matter what. MD-B indicated it was expected that if a resident had a blood sugar that high (greater than 500), the on-call physician should have been notified and an order for [REDACTED]. MD-B stated type one diabetics are at risk for decay and going into an acidotic state with blood sugars reading over 500. MD-B was unable to recall R300's specific baseline but stated that less than 200 would have been normal and acceptable. MD-B added that a person would be in danger with blood sugars greater than 500 even if they didn't have any symptoms and that leaving someone with blood sugars that high can make it very difficult to get them normalized again, "It is a slippery slope." During interview on [DATE], at 2:16 p.m., RN-E recalled being the nurse assigned to care for R300 on the night shift from [DATE]-[DATE]. RN-E stated she would give the nursing assistants (NA) who she was working with a verbal report of anything pertinent about the residents. RN-E remembered that R300 had unstable blood sugars and had been on an insulin drip while hospitalized . RN-E also stated R300 was receiving tube feedings during the night which affected blood sugar readings, so the nurses had to take that into consideration when taking blood sugars and administering insulin. RN-E indicated R300's blood sugar had read "HI" on the evening of [DATE], so she called the on-call physician who gave instructions to administer the eight units of insulin for a blood sugar greater than 400 per R300's orders and to contact the primary physician in the morning to get parameters for the bedtime sliding scale. RN-E stated she then watched for symptoms of [MEDICAL CONDITION] (high blood sugar), and rechecked R300's blood sugar at on [DATE], at 12:10 a.m., per her nursing judgment. R300's blood sugar was 515. RN-E indicated she was aware 515 was an elevated result for R300 but did not think she needed to contact the on-call physician again because R300 did not have any symptoms of [MEDICAL CONDITION]. RN-E confirmed R300 had received her continuous tube feeding that night from 6:00 p.m. to 6:00 a.m. Review of R300's vital sign record revealed the last set of vital signs checked were on [DATE] at 8:00 p.m. The abnormal vitals included a temperature of 99.2 and a rapid pulse at 116. No vital signs were checked again until R300 was found unresponsive. During interview on [DATE], at 11:26 a.m., NA-B didn't think the nurses usually passed on information to the nursing assistants about a resident having high blood sugars, that information was usually just between the nurses, but the nurses would tell them to be aware of the signs of high or low blood sugars. NA-B recalled working the night shift on [DATE]-[DATE] with R300 and stated the nurse had not passed on any specific information to be aware of, such as monitoring for signs of [MEDICAL CONDITION] when caring for R300 that night. During interview on [DATE], at 8:21 a.m., MD-C stated it was expected that the nurses recheck a blood sugar after administration of short acting insulin and call the on call physician again if the blood sugar remained elevated. MD-C indicated elevated was considered when the machine read "HI" for sure, but also greater than 400. MD-C didn't think anyone would not call if the level stayed elevated as it was normal nursing judgment to call again and they wouldn't want that liability. MD-C confirmed a reading greater than 500 on a recheck warranted physician notification for sure and potential dangers for type one diabetics with blood sugars that high included decay which was the most obvious. Review of the facility's policy titled, treatment for [REDACTED]. Review of the facility's policy titled, Change in Condition which was last reviewed in ,[DATE] revealed licensed staff would obtain necessary data for a complete assessment and notify the physician of the change. The policy further gave direction that if unable to contact the physician after ,[DATE] to four hours, depending on the significance of change, to contact the medical director. Also, follow up by the licensed staff of the change in condition should continue for a minimum of 48 hours following the onset of the change which is to include at a minimum a full set of vital signs every four hours for the first 24 hours. A policy specifically related to the treatment of [REDACTED]. R355 experienced a change of condition related to atypical blood glucose levels; however, the facility failed to notify his physician of the change. R355's History and Physical dated [DATE], revealed evidence of mild acute kidney injury with a creatinine level of 1.36 mg/dL (with a baseline of 1.16 mg/dL). The report also noted a blood glucose of 117 mg/dL (with a normal range of 70 to 100 mg/dL), with a plan to hold [MEDICATION NAME] (an oral agent used to manage blood sugars) due to concerns of [MEDICAL CONDITION]. Review of the hospital medication administration report dated [DATE] through [DATE], revealed R355 received insulin to manage his blood sugars while hospitalized . R355 received the following: ? [MEDICATION NAME] 100 units/ milliliter (U/mL) insulin pen, correction scale, daily at bedtime, starting [DATE], through discharge from the hospital on [DATE]. ? [MEDICATION NAME] 100 U/mL insulin pen, correction scale, three times daily, starting [DATE], through discharge from the hospital on [DATE]. The Safe Transitions of Care Transfer Form dated [DATE], identified R355 with controlled type-two diabetes, alert/oriented mental status, and hospitalization post right ankle sprain with discharge goals of continuing rehabilitation. R355's Orders Discharge Report dated [DATE], included a diabetic and cardiac diet, with [MEDICATION NAME] 500 mg noted as ON HOLD until his creatinine levels returned to baseline. The orders identified R355's usual dose of [MEDICATION NAME] was 500 mg, three times daily. The orders did not include insulin as was administered during his hospital stay. The orders lacked an individualized goal range for blood sugars, or parameters for when his physician was to be notified. Subsequent physician orders [REDACTED]. ? On [DATE], at 4:00 a.m. an order from the nurse practitioner was received for glucometer checks, twice daily at alternate times, lab draw for hemoglobin A1C (a lab test used to gauge how well blood sugars were controlled over time), and [MEDICATION NAME] to remain on hold until R355's creatinine and A1C results were completed. ? On [DATE], a faxed request for physician orders [REDACTED]. The physician's response was to continue with [MEDICATION NAME] on hold, re-check creatinine levels in one month and re-check hemoglobin A1C levels in one month. Review of Interdisciplinary Notes for R355 from [DATE] through [DATE], revealed the following: ? On [DATE], at 3:52 p.m. licensed practical nurse (LPN)-D noted that R355 was to have labs drawn the following day to determine whether [MEDICATION NAME] was to be restarted. ? On [DATE], at 12:47 p.m. LPN-D noted R355's labs were reviewed by the nurse practitioner and [MEDICATION NAME] was to continue to be on hold, with a redraw of his hemoglobin A1C in one month. Review of Glucometer Record dated [DATE] through [DATE], revealed blood sugar readings ranging from 116 to 364 mg/dL. The 8:00 p.m. blood sugar readings revealed a progressive increase, including readings of 246, 270, 268, 290, 249, 292, 306, and 364. R355 had three readings above 300, including a reading of 349 on [DATE], at 11:00 a.m. (prior to eating lunch), with the following reading of 306 at 8:00 p.m., and a reading of 364 on [DATE], at 8:00 p.m. R355's medical record revealed physician visits took place on [DATE], and as recently as [DATE], but lacked evidence to indicate his blood sugars were addressed and/or reviewed during these visits. During interview on [DATE], at 10:10 a.m. R355 reported he was unsure of the signs and symptoms his body tended to present when his blood sugars were high. R355 stated that prior to his hospitalization he lived alone at home, with well controlled blood sugars which ran between 90 to 110 mg/dL. R355 denied any symptoms of [MEDICAL CONDITION]. During interview on [DATE], at 7:52 a.m. LPN-E stated she would have notified a resident's physician for blood sugars outside of the physician ordered parameters. She stated that if no parameters were identified, she would still notify the physician if the blood sugar was outside of the resident's typical range. During interview on [DATE], at 1:50 p.m. registered nurse (RN)-C stated she would monitor a resident for signs or symptoms of [MEDICAL CONDITION] and review the resident's diet if she noticed a gradual increase of blood sugars at a specified time of day. When asked specifically about R355's progressive increase of his 8:00 p.m. blood sugars, RN-C stated that the facility staff were paying attention to R355's blood sugars and were looking at his diet. She added, R355 felt fine and was asymptomatic. RN-C stated that R355's doctor rounded in the facility on a daily basis and concerns such as this were noted for them to review during rounds. She reported that the physician was notified of R355's increasing blood sugars during rounds on the afternoon of [DATE], and the [MEDICATION NAME] was ordered to be restarted in response. RN-C stated that if his blood sugars had "jumped" higher and he was symptomatic, the change of condition would have been handled with more urgency.

Based on interview and document review, the facility failed to ensure changes in clinical status, including significantly elevated blood sugar levels, were clinically monitored and promptly reported to the physician for 2 of 28 residents (R300, R355) with diabetes. Findings include: R300 was admitted to the facility on [DATE], after a hospitalization for acute [MEDICAL CONDITION], diabetic ketoacidosis (a life-threatening complication when the body does not produce enough insulin), and a [MEDICAL CONDITION] with ventriculoperitoneal shunt (used to take excess fluid from brain, and "shunt" or divert it to the abdomen for absorption) placement. While hospitalized , R300 had blood sugars greater than 1,100 milligrams per deciliter (mg/dL) which required a continuous insulin drip to return to normal levels. R300 [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) completed on [DATE] identified R300's cognitive skills for decision making were severely impaired, that the resident did not speak, and that a brief interview for mental status (BIMS) was not completed because R300 was rarely understood. R300's physician orders [REDACTED]. ? [MEDICATION NAME] (a quick acting insulin) one unit per carbohydrate consumed with each meal ? [MEDICATION NAME] sliding scale insulin with all meals per blood sugar results ? [MEDICATION NAME] (a long acting insulin) 20 units with breakfast and at bedtime ? Glucometer (blood sugar) checks four times a day ? Ensure Clear (a nutritional supplement) 120 milliliters (mL) four times a day ? [MEDICATION NAME] (liquid nutrition) 1.5 mL/hour for nine hours at night via enteral tube (feeding tube) Review of R300's [DATE] glucometer records included the following the following documented blood sugars (BS): ? From [DATE], to [DATE], the BS results ranged from ,[DATE] with one reading of 409. ? On [DATE], at 7:00 a.m., the blood sugar was 392. At 11:00 a.m. it was 525. At 8:00 p.m. the BS reading recorded as "HI". ? On [DATE] at 0010 (12:10 a.m.) the blood sugar was 515. ? On [DATE], at 7:00 a.m., the final recorded blood sugar for R300 was 524. Review of the interdisciplinary notes included the following: ? A note written by registered nurse (RN)-E on [DATE], at 12:39 a.m. identified R300 had a blood glucose level of "HI" on [DATE], at 8:00 p.m. A call was placed to the on-call physician and orders were given to administer eight units of [MEDICATION NAME] and fax the primary physician in the morning to obtain sliding scale parameters for R300's 8:00 p.m. blood sugars. ? A note written by licensed practical nurse (LPN)-C on [DATE], at 10:44 a.m. indicated R300 had been nauseated and was dry heaving that day with a temperature of 100.2? Fahrenheit(F) and a call was placed to the primary medical physician and message was left with the physician's nurse. ? A note written by LPN-C on [DATE], at 2:01 p.m. indicated staff had entered R300's room at 11:00 a.m. for therapy, when R300 was found unresponsive. Nursing staff lowered R300 to the ground, cardiopulmonary resuscitation (CPR) was initiated at 11:04 a.m. and continued until paramedics arrived. Per the time line that was provided by the facility, on the morning of [DATE], R300 awoke at her normal time, was alert and responding to staff by nodding yes or no. Blood sugar was checked at 0700 and was 524. Resident was given eight units of [MEDICATION NAME] per insulin sliding scale and 20 units of [MEDICATION NAME]. R300 went to breakfast and ate bites of toast and cereal. She was given two units of [MEDICATION NAME] per carbohydrate counting orders. R300 participated in therapy from 9:30 to 9:55 a.m. and was brought back to her room. Per the nursing note written on [DATE] at 10:44 a.m., R300 was nauseated and dry heaving. R300 was left in her room and in her wheelchair. The desk nurse called the primary physician at 10:45 a.m. for a second attempt to follow up from the morning fax. A message was left with the primary's nurse. At 11:00 a.m. R300 was found unresponsive in her wheelchair. Staff began CPR and the desk nurse called 911 and then the primary physician was called again but was not available. A message was left again with the primary physician's nurse. Review of R300's code blue record (no date), revealed CPR was discontinued by the paramedics at 11:24 a.m. after a shock was administered and a pulse was found. The paramedics inserted a breathing tube and set up an external pacemaker and at 11:34 a.m. R300 was transported to the emergency room . R300 passed away in the emergency roiagnom on [DATE], at 12:55 p.m. Review of the facility's glucometer (Assure 4) manufacturer's manual dated ,[DATE] revealed a reading of "HI" meant the blood sugar test result was greater than 550 mg/dL and recommended seeking immediate medical assistance. An interview with LPN-F on [DATE], at 11:35 a.m. indicated that each resident had their own glucometer and LPN-F was not sure how high the machine read. LPN-F also indicated that each resident had their own specific guidelines under a sliding scale order on when to call the physician. LPN-F was not sure of any facility policy of when to call the physician when a resident's blood sugar was high. During interview on [DATE], at 12:04 p.m., RN-D indicated the facility supplied individual glucometers for residents when they were admitted which were all the same model. RN-D stated if a resident's blood sugar usually ran in the ,[DATE]'s and then was having readings in the ,[DATE] range, the staff would call the physician because that would be a change for the resident. RN-D also stated if the glucometer reading was too high to register on the machine a call would also be placed to the physician. RN-D further described how the physician would usually give an order for [REDACTED]. During interview on [DATE], at 10:10 a.m., the DON indicated she had completed an internal quality investigation of R300's incident days following the incident. However, DON stated she wasn't sure if the information gathered had been brought to the quality assurance meetings or not. The DON stated the staff were not educated by the facility on specific parameters on when to call the physician related to blood sugar readings and felt the staff didn't need to call R300's physician when her readings were in the 500's because, "That was her baseline." The DON also indicated no reeducation or changes of policy were completed after the investigation because it was felt the staff had acted appropriately. On [DATE], at approximately 3:10 p.m., the DON verified there had been no physician involvement in the internal quality investigation. R300's medical record lacked evidence of physician notification or involvement from 8:00 p.m. on [DATE], until the day shift of [DATE], despite her blood sugars having remained elevated (based on a blood sugar reading of 515 on [DATE], at 12:10 a.m. post administration of fast acting insulin). The medical record lacked evidence of on-going blood sugar testing throughout the overnight hours to ensure it returned to a safe level and lacked evidence considering the impact of R300's continuous tube feeding on her elevated blood sugars. The medical record also lacked evidence to support R300's baseline blood sugars having been near 500 mg/dl. During interview on [DATE], at 1:03 p.m., licensed practical nurse (LPN)-C recalled caring for R300 during the morning [DATE], when R300 passed away. LPN-C stated R300's blood sugar had been high that morning and a fax had been sent to the primary physician around 7:30 or 8:00 a.m., but she knew that the physician only worked a couple days a week and would be difficult to get a hold of. LPN-C indicated R300 had gone for therapy after breakfast, so no blood sugar recheck had been completed. R300 returned from therapy and was brought back to her room because she had nausea. Staff left R300 up in her wheelchair because of the nausea. Staff found R300 in her room at 11:00 a.m. unresponsive. LPN-C was not aware of any facility policy which gave guidance on when to call a physician related to blood sugar results. During interview on [DATE], at 1:18 p.m., medical doctor (MD)-A stated the expectation was that nurses would use their judgment on when to call a physician for high or low blood sugars. Further, MD-A indicated the nurses should recheck blood sugars to make sure they were responding and coming down and contacting a primary physician as soon as possible. However, if they couldn't get a hold of the physician, they could always send a resident to the hospital. During interview on [DATE], at 8:11 a.m., MD-B stated it was his opinion that blood sugar readings greater than 500 were bad no matter what. MD-B stated it was expected that if a resident had a blood sugar that high (greater than 500), the on-call physician should have been notified and an order for [REDACTED]. MD-B stated type one diabetics are at risk for decay and going into an acidotic state with blood sugars reading over 500. MD-B was unable to recall R300's specific baseline but stated that less than 200 would have been normal and acceptable. MD-B added that a person would be in danger with blood sugars greater than 500 even if they didn't have any symptoms and that leaving someone with blood sugars that high can make it very difficult to get them normalized again stating, "It is a slippery slope." During interview on [DATE], at 2:16 p.m., RN-E recalled being the nurse assigned to care for R300 on the night shift from [DATE]-[DATE]. RN-E stated she would give the nursing assistants (NA) who she was working with a verbal report of anything pertinent about the residents. RN-E remembered that R300 had unstable blood sugars and had been on an insulin drip while hospitalized . RN-E also stated R300 was receiving tube feedings during the night which affected blood sugar readings, so the nurses had to take that into consideration when taking blood sugars and administering insulin. RN-E indicated R300's blood sugar had read "HI" on the evening of [DATE], so she had called the on-call physician who had given instructions to administer eight units of insulin for a blood sugar greater than 400 per R300's orders, and to contact the primary physician in the morning to get parameters for the bedtime sliding scale. RN-E stated she then watched for symptoms of [MEDICAL CONDITION] (high blood sugar), and rechecked R300's blood sugar on [DATE], at 12:10 a.m., per her nursing judgment. At that time R300's blood sugar was 515. RN-E indicated she was aware 515 was an elevated result for R300 but did not think she needed to contact the on-call physician again because R300 did not have any symptoms of [MEDICAL CONDITION]. RN-E confirmed R300 had received her continuous tube feeding that night from 6:00 p.m. to 6:00 a.m. Review of R300's vital sign record revealed the last set of vital signs checked were on [DATE] at 8:00 p.m. At that time R300 had abnormal vital signs including a temperature of 99.2?F and a rapid pulse at 116. No vital signs had been checked again until R300 was found unresponsive the following morning. During interview on [DATE], at 11:26 a.m., NA-B stated she didn't think the nurses usually passed on information to the nursing assistants about a resident having high blood sugars, and stated that information was usually just between the nurses, but the nurses would tell them to be aware of the signs of high or low blood sugars. NA-B recalled working the night shift on [DATE], through [DATE], with R300 and stated the nurse had not passed on any specific information to be aware of, such as monitoring for signs of [MEDICAL CONDITION] when caring for R300 that night. During interview on [DATE], at 8:21 a.m., MD-C stated it was expected that the nurses recheck a blood sugar after administration of short acting insulin and call the on call physician again if the blood sugar remained elevated. MD-C indicated elevated was considered when the machine read "HI" for sure, but also greater than 400. MD-C didn't think anyone would not call if the level stayed elevated as it was normal nursing judgment to call again and they wouldn't want that liability. MD-C confirmed a reading greater than 500 on a recheck warranted physician notification for sure and potential dangers for type one diabetics with blood sugars that high included decay which was the most obvious. Review of the facility's policy titled, treatment for [REDACTED]. Review of the facility's policy titled, Change in Condition last reviewed ,[DATE], revealed licensed staff were to obtain necessary data for a complete assessment and notify the physician of the change. The policy further gave direction that if unable to contact the physician after ,[DATE] to four hours, depending on the significance of change, to contact the medical director. Also, follow up by the licensed staff of the change in condition should continue for a minimum of 48 hours following the onset of the change which is to include at a minimum a full set of vital signs every four hours for the first 24 hours. A policy specifically related to the treatment of [REDACTED]. R355's medical record lacked identification of rising blood glucose levels and/or evidence of physician notification of blood sugars outside of his typical range. The record also lacked evidence to support R355's diet was addressed in relation to his increased blood glucose levels. R355's History and Physical dated [DATE], revealed evidence of mild acute kidney injury with a creatinine level of 1.36 mg/dL (with a baseline of 1.16 mg/dL). The report also noted a blood glucose of 117 mg/dL (with a normal range of 70 to 100 mg/dL), with a plan to hold [MEDICATION NAME] (an oral agent used to manage blood sugars) due to concerns of [MEDICAL CONDITION]. Review of the hospital medication administration report dated [DATE] through [DATE], revealed R355 received insulin to manage his blood sugars while hospitalized . R355 received the following: ? [MEDICATION NAME] 100 units/ milliliter (U/mL) insulin pen, correction scale, daily at bedtime, starting [DATE], through discharge from the hospital on [DATE]. ? [MEDICATION NAME] 100 U/mL insulin pen, correction scale, three times daily, starting [DATE], through discharge from the hospital on [DATE]. The Safe Transitions of Care Transfer Form dated [DATE], identified R355 with controlled type-two diabetes, alert/oriented mental status, and hospitalization post right ankle sprain with discharge goals of continuing rehabilitation. R355's Orders Discharge Report dated [DATE], included a diabetic and cardiac diet, with [MEDICATION NAME] 500 mg noted as ON HOLD until his creatinine levels returned to baseline. The orders identified R355's usual dose of [MEDICATION NAME] was 500 mg, three times daily. The orders did not include insulin as was administered during his hospital stay. The orders lacked an individualized goal range for blood sugars, or parameters for when his physician was to be notified. Subsequent physician orders [REDACTED]. ? On [DATE], at 4:00 a.m. an order from the nurse practitioner was received for glucometer checks, twice daily at alternate times, lab draw for hemoglobin A1C (a lab test used to gauge how well blood sugars were controlled over time), and [MEDICATION NAME] to remain on hold until R355's creatinine and A1C results were completed. ? On [DATE], a faxed request for physician orders [REDACTED]. The physician's response was to continue with [MEDICATION NAME] on hold, re-check creatinine levels in one month and re-check hemoglobin A1C levels in one month. Review of Interdisciplinary Notes for R355 from [DATE] through [DATE], revealed the following: ? On [DATE], at 3:52 p.m. licensed practical nurse (LPN)-D noted that R355 was to have labs drawn the following day to determine whether [MEDICATION NAME] was to be restarted. ? On [DATE], at 12:47 p.m. LPN-D noted R355's labs were reviewed by the nurse practitioner and [MEDICATION NAME] was to continue to be on hold, with a redraw of his hemoglobin A1C in one month. Review of Glucometer Record dated [DATE] through [DATE], revealed blood sugar readings ranging from 116 to 364 mg/dL. The 8:00 p.m. blood sugar readings revealed a progressive increase, including readings of 246, 270, 268, 290, 249, 292, 306, and 364. R355 had three readings above 300, including a reading of 349 on [DATE], at 11:00 a.m. (prior to eating lunch), with the following reading of 306 at 8:00 p.m., and a reading of 364 on [DATE], at 8:00 p.m. R355's medical record revealed physician visits took place on [DATE], and as recently as [DATE], but lacked evidence to indicate his blood sugars were addressed and/or reviewed during these visits. During interview on [DATE], at 10:10 a.m. R355 reported he was unsure of the signs and symptoms his body tended to present when his blood sugars were high. R355 stated that prior to his hospitalization he lived alone at home, with well controlled blood sugars which ran between 90 to 110 mg/dL. R355 denied any symptoms of [MEDICAL CONDITION]. During interview on [DATE], at 7:52 a.m. LPN-E stated she would have notified a resident's physician for blood sugars outside of the physician ordered parameters. She stated that if no parameters were identified, she would still notify the physician if the blood sugar was outside of the resident's typical range. During interview on [DATE], at 1:50 p.m. registered nurse (RN)-C stated she would have monitored a resident for signs or symptoms of [MEDICAL CONDITION] and reviewed the resident's diet if she noticed a gradual increase of blood sugars at a specified time of day. When asked specifically about R355's progressive increase of his 8:00 p.m. blood sugars, RN-C stated that the facility staff were paying attention to R355's blood sugars and were looking at his diet. She added, R355 felt fine and was asymptomatic. RN-C stated that R355's doctor rounded in the facility on a daily basis and concerns such as this were noted for them to review during rounds. She reported that the physician was notified of R355's increasing blood sugars during rounds on the afternoon of [DATE], and the [MEDICATION NAME] was ordered to be restarted in response. RN-C stated that if his blood sugars had "jumped" higher and he was symptomatic, the change of condition would have been handled with more urgency.