Every finding on record at Deerings Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to complete and a two-person gait belt transfer when CNA A and CNA B hooked their arms underneath Resident #1's arms and picked her up from the floor. The facility failed to notify LVN C when CNA A and CNA B found Resident #1 on the floor. This failure could place residents at risk of inadequate supervision and preventable injuries. Findings included: Record review of Resident #1's admission Record, dated 6/24/26, revealed s a [AGE] year-old male, admitted [DATE], with diagnoses including stroke, depression, anxiety, and aphasia (difficulty communicating). Record review of Resident #1's Significant Change MDS Assessment, dated 6/10/26, revealed:He had a BIMS score of 6 of 15 (indicating severe cognitive impairment).He needed substantial assistance with transfers.There were no documented falls on the MDS. Record review of Resident #1's Care Plan Report, last updated 1/16/26, revealed:Problem: Resident is at risk for falls related to cognitive deficit, poor safety awareness. Goal: Resident will not sustain serious injury through the review date. Interventions included: anticipate and meet the resident's needs; may have anti-rollback device on wheelchair; may have non-slip grip to wheelchair seat. There was no indication of how to transfer Resident #1. During an observation on 6/24/26 at 11:29 a.m., Resident #1 was sitting on the floor in the doorway of his room. CNA A asked why Resident #1 was on the floor and he said he needed to get something. CNA A said this was why he needed to use the call light. CNA A and CNA B then stood on either side of Resident #1, hooked their (CNA A and CNA B) arms under Resident #1's arms, pulled Resident #1 up, and then placed Resident #1 in the wheelchair. During an interview on 6/24/26 at 11:45 a.m., the DON said when a resident fell, she expected staff to do an incident/accident report. The DON stated if an aide found a resident on the ground, she expected the aide to get the nurse, make sure the resident was safe until the nurse assessed for vital signs, pain, or injuries. The DON said she expected the staff to ask the resident why, and how, they fell, if they remembered. They DON said she expected staff to notify her, the resident's doctor, and start Neurological checks (a rapid, focused evaluation used by healthcare providers to assess a patient's nervous system functioning and monitor for changes in brain or nerve activity) if necessary. The DON stated Resident #1 had a history of stroke and was very impulsive and needed a lot of help with ADLs and he had no safety awareness. The DON said Resident #1 wanted to do a lot of things by himself and needed a lot of redirection. The DON stated Resident #1's last fall had been a while. The DON stated a fall would be from the wheelchair to the floor. The DON stated Resident #1 had a low bed with a mat because he would put himself on the floor and crawl around. The DON said if Resident #1 was found on the floor she expected the staff to use a gait belt to assist in getting Resident #1 off the floor. During an interview on 6/24/26 at 12:32 p.m., LVN C stated that when a resident fell, she assessed the vital signs and looked for injuries. LVN C said she looked for skin tears or bones protruding. LVN C said she asked for soreness or complaints of hurting and then she would get orders for an x-ray. LVN C said she liked to help the aides get the residents off the floor if they fell. LVN C said she transferred residents from the floor to the wheelchair and then the bed so she could do a full assessment. Then she would notify the doctor, the DON, the Responsible Party, and hospice if necessary. LVN C said after assessments and notifications, she was looking to see if fall mat was in place. LVN C stated most of the falls on her hall were the residents trying to get into the chair or get something out of the closet and leaned too far forward. LVN C said she got residents off the floor by hooking her arms under the resident's arms and transferred them. LVN C stated no one told her Resident #1 fell 6/24/26 in her room. LVN C stated she expected the aides to tell her when a resident fell and she had two aides. LVN C left to do an assessment on Resident #1. During an interview and observation on 6/24/26 at 12:45 p.m., Resident #1 in his wheelchair holding his arm out. LVN C sprayed disinfectant on his arm and Resident #1 yelled. LVN C stated she monitored for falls by making sure fall prevention measures were in place. LVN C said the staff tried to keep their eye on the high-risk residents and if the staff saw the high-risk residents going into their room, the staff tried to follow them and transfer the high-risk resident to bed. LVN C said Resident #1 liked to crawl out of bed a lot. LVN C said if the wheelchair was immediately behind Resident #1 it was a fall. During an interview on 6/25/26 at 1:48 p.m., PT D stated the correct way to pick up a resident was to first let the nurse know to assess; have two people; place a gait belt on the person; stand side-by-side to pick up the resident. PT D said the staff could do front and back or side to side. PT D said hooking under the arms could cause shoulder dislocation. PT D said she did help with in-services on transfers approximately quarterly. PT D said staff should know how to do a two-person transfer. PT D said she saw some of the staff with gait belts. PT D said she did not monitor the back halls very much. PT D said she monitored the front halls for gait belts. PT D said most of the residents who needed gait belts were on the back two halls. During an interview on 6/25/26 at 1:26 p.m., the DON stated the expectation was for the staff put the gait belt under the resident's chest, put their arm under the resident's arms and grab the back of the gait belt. The DON stated the staff could grab one-handed if it was two-person transfer, as long as there were two hands on the gait belt it was ok. The DON said she did expect gait belts to be used. The DON stated she monitored for gait belt use because she was out on the floor. The DON said she expected the aides to have a gait belt on their person. The DON said aides had a yearly evaluation on transfers. After being informed of the 6/24/26 observation, the DON and Administrator both said the transfer was not completed correctly and the fall was not handled correctly. The DON said she did not know of any incident where Resident #1 went from the wheelchair to the floor purposely. The Administrator stated consequences of an improper transfer could be dislocation or injury and the gait belt really there for support. Record review of the facility's undated policy and procedure titled, Moving a Resident Bed to Chair/Chair to Bed, indicated, : The purpose of this procedure is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps: Note: this procedure may require two (2) persons.Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires two persons (one on each side) grasp the gait belt and gently stand and turn the resident and sit him or her in the chair. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. Record review of the undated CNA Proficiency check list documented one-person and two-person transfers were both transfers that were expected to be done satisfactorily. Record review of the facility's undated policy and procedure titled, Fall Policy revealed: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. In instances where fall risk measures do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. Record review of in-service, dated 4/20/26, revealed: If you find a resident on the floor, they a nurse assessment before being picked up off the floor. Neither CNA A nor CNA B attended the in-service.

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 9 (Rooms 301, 303, 307, 308, 312, 404, 405, 410 and 411) of 48 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy for Rooms 301, 303, 307, 308, 312, 404, 405, 410 and 411. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: Observation on 05/21/2026 at 2:35 PM of resident rooms in 301, 303, 307, 308, 312, 404, 405, 410 and 411 on halls 3 and 4 revealed that each room had dual occupancy with an A and B bed in each. There was one side curtain that would provide full visual to just one of the beds but not the other one. The side curtain had a gap of four feet and was unable to allow both beds to have total visual privacy. Interview on 05/21/2026 at 3:08 PM the Administrator said it was expected for the residents to be able to have full visual privacy. The Administrator said if the resident rooms did not have a full visual privacy then the resident may not receive privacy and dignity as wanted. Record review of the facility's undated policy titled Resident rights indicated in part: Privacy and confidentiality. The resident has a right to personal privacy. Personal privacy includes accommodation and medical treatment. The facility must respect the residents' right to personal privacy .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for kitchen sanitation.The facility failed to ensure stored foods were properly stored, labeled, and dated.The facility failed to ensure items past the Use by Date (UBD) were discarded. The facility failed to ensure prepared food was discarded after 7 days, according to the facility policy.The facility failed to ensure Dietary Staff wore hair nets correctly when in the kitchen.This failure could affect residents by placing them at risk of food contamination and food-borne illnesses.Findings include: During the initial tour of the kitchen conducted on 05/19/2026 between 9:05 AM and 10:00 AM, the following were observed:Dry Storagea bag of cornstarch was opened and not sealed,two large plastic bins containing white powder was not labeled or dated,a bag of instant mashed potatoes was opened and not sealed, and did not have a received or opened date,a bag of taco seasoning was opened and not sealed,a bag of refried beans was opened and not sealed,a plastic bin labeled bacon bits had 1 date of 02/04/2026 that did not specify if it was the received, opened, or UBD, a plastic bin of powdered cheesecake was opened and not sealed and had 1 date 05/19 that did not specify if it was the received, opened, or UBD,a box of dried pinto beans was opened and not sealed,a plastic bin labeled powdered milk had 1 date of 03/04/2026 that did not specify if it was the received, opened, or UBD,a zippered bag was not sealed and contained 3 opened packages (powdered creamer, powdered mocha creamer, and pink sugar substitute) and had 1 date of 04/20/2026 that did not specify if it was the received, opened, or UBD,a bag of bowtie pasta was opened and not sealed, and had 1 date of 05/13/2026 that did not specify if it was the received, opened, or UBD,a bag of potato chips was opened and not sealed, and was not dated,a bag of granola was opened and not sealed, and had 1 date of 04/06/2026 that did not specify if it was the received, opened, or UBD,a bag of candy pieces was opened and not sealed, and was not dated,a bag of peppered gravy mix was opened and not sealed, and had 1 date of 05/13/2026 that did not specify if it was the received, opened, or UBD,a box of graham cracker crusts was opened and not sealed,a bottle of sesame seeds had a UBD of 06/11/2025,a bottle of oregano had a UBD of 05/30/2025,a bottle of ground mustard had a UBD of 09/06/2025,a bottle of ground ginger had a UBD of 04/09/2025,two plastic tubs filled with resident water pitchers were faced up and not covered,pans and bowls were faced up and not covered. Walk-In Refrigeratora plastic container labeled apple sauce had a UBD of 05/16/2026,a plastic container of olives had 1 date of 05/08/2026 that did not specify if it was the received, opened, or UBD,a tray held condiment cups filled with brown, orange, red and white substances, neither the tray nor the cups were labeled or dated,a tray held 2 covered beverage glasses, the label was smeared and unreadable,a bag of guacamole had 1 date of 03/25 that did not specify if it was the received, opened, or UBD,a box of sausage patties was opened and not sealed, and was not labeled with a received or opened date,a plastic tube of raw ground beef was opened, wrapped in plastic wrap, had a red liquid seeping out of the plastic wrap, was not dated, and was on a shelf above a tray that contained covered beverage cups,a plastic container of sliced jalapenos was not dated,a zippered bag of sliced turkey had 1 date of 05/18/2026 that did not specify if it was the received, opened, or UBD,a bag of tortillas was not dated,a plastic bin of grated cheese was not dated,3 plastic bags of cake were not dated. Spice Rack Above Blendera bottle of rosemary had a UBD of 08/22/2019,a bottle of paprika had a UBD of 04/12/2026,a bottle of basil leaves had a UBD of 03/24/2025. Other3 large plastic bins on a shelf held cooking/serving utensils and were not covered,coffee filters on the juice machine were faced up and not covered. Observation of the dining room on 05/19/2026 at 10:05 AM, revealed 4 cereal dispensers filled with different cereals were not dated and 2 drink dispensers filled with liquid were not labeled or dated. A follow-up visit to the kitchen on 05/20/2026 between 11:42 AM and 12:30 PM, the following was observed:The Dietary Manager (DM)'s hair net did not cover the front and sides of her hair. In an interview with the DM on 05/20/2026 at 4:00 PM, she said her expectations for labeling were the name, received date, opened date, and UBD to be placed on each food item. She said items opened and leftovers in the refrigerator were good for 6 days before they had to be disposed of. She said items in the dry storage were good until the UBD and if there was not a UBD, they were good for 1 year after the received date. The DM said that spoiled items may cause residents to get sick. The DM said all items should be resealed after opened to prevent pests and keep items fresh. The DM said she struggled with covering all her hair and used 2 hairnets (1 for front and 1 for back). The DM said she will look for extra-large hairnets to order. The DM said she has previously trained her staff on these things and will repeat the training starting today. The DM said cross-contamination can make the residents sick and/or not want to eat meals from the kitchen. Review of the facility's policy Label, Dating, and Receiving, dated 2012, revealed in part:Labeling and dating food items:If food is removed from its original container, it must be labeled to include the name of the food item.Date all food items with the date it was received.All dates must include the month, the day, and the year.If a food item does not have an expiration date designated by the manufacturer, then add an expiration date to the food item of one year from the current date.Dry food storage practices:Dry bulk foods such as flour and sugar should be stored in covered containers and labeled, and the containers should be cleaned regularly.Once a food item in the dry storage is opened, it should be resealed, using either a container with a lid, or a closed zippered bag, and should be dated as to when opened.Cold food storage practices:Raw foods should be stored below any cooked or ready to eat foods.Meats should be placed on the bottom shelf of the refrigerator.Once any food item in refrigerators or freezers has been opened, it should be resealed completely using either a container with a lid, or a closed zippered bag and dated to when opened.Storage of leftovers or opened foods:Perishable leftovers or opened foods should be dated with an expiration date of 7 days from the date opened.Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately.Review of the facility's policy Dietary Food Service Personnel Policy and Procedures, dated 2012, revealed in part: Sanitation and Food Handling:Hair nets or hats covering the hairline are worn at all times.All paper goods and other disposables must be kept covered to prevent contamination.Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observations, interviews and record review it was determined the facility failed to provide pharmaceutical services that ensured the accurate administering of drugs for 2 of 2 nurse medication carts (hall 3 cart and hall 4 cart ) and 3 of 4 residents (#15, #24 and #56) observed for medications stored and properly labeled. The hall 3 nurse medication cart had one insulin pen that belonged to Resident #15 that that had expired. The hall 4 nurse medication cart had one insulin pen that belonged to Resident #24 and #56 that had expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Review of Resident #15's admission record dated 05/20/2026 revealed she was admitted to the facility on [DATE] with diagnosis of type 2 diabetes. She was [AGE] years of age. (Type 2 diabetes is a chronic condition where the body cannot use insulin properly, leading to high blood sugar levels, which can be managed but not cured. Insulin is an essential hormone. It helps your body turn food into energy and manages your blood sugar levels). Review of Resident #15's physician orders dated 05/20/2026 indicated in part: Merilog SoloStar subcutaneous solution pen-injector. Inject as per sliding scale. Subcutaneously before meals and at bedtime related to type 2 diabetes. (Subcutaneous means under or beneath the skin). Review of Resident #24's admission record dated 05/20/2026 revealed he was admitted to the facility on [DATE] with diagnosis of type 2 diabetes. He was [AGE] years of age. Review of the current care plan for Resident #24, last reviewed/revised: 09/19/2025, revealed in part: The resident has diabetes. The resident will have no complications related to diabetes through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #24's physician orders dated 05/20/2026 indicated in part: Humalog injection solution. Inject as per sliding scale, subcutaneously before meals and at bedtime for diabetes. Review of Resident #56's admission record dated 05/20/2026 revealed he was admitted to the facility on [DATE] with diagnosis of type 2 diabetes. He was [AGE] years of age. Review of Resident #56's physician orders dated 05/20/2026 indicated in part: Fiasp FlexTouch Subcutaneous Solution Pen-injector. Inject as per sliding scale: subcutaneously before meals and at bedtime related to diabetes. Review of the current care plan for Resident #56, last reviewed/revised: 02/27/2026, revealed in part: The resident has diabetes. The resident will have no complications related to diabetes through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Observation and interview on 05/19/2026 at 9:10 AM revealed the nurse medication cart for hall 4 was inspected with RN A present. The cart was locked so the nurse unlocked it, and on the top drawer of the cart were several insulin pens. One of the insulin pens had an open date of 04/10/26 that belonged to Resident #15. The RN said the insulin pen had expired and she had not noticed it until just now. RN A said that she did mostly treatments but at times worked as a charge nurse as well. The RN said if an expired insulin was administered then that could possibly lead to the medication not causing the desired effect or even an adverse effect. Observation and interview on 05/19/2026 at 9:16 AM revealed the nurse medication cart for hall 3 was inspected with LVN B present. The cart was locked so the nurse unlocked it, and on the top drawer of the cart were several insulin pens. There were 2 insulin pens that had expired as they had been opened longer than 28 days. One of the pens had an open date of 04/10/26 that belonged to Resident #24 and the other pen that belonged to Resident #56 was dated 04/14/26. LVN B said that it was each nurse's responsibility to make sure all the insulin pens were still good and not expired whenever they took over the medication cart. The LVN said that she had not noticed that the insulin pens had expired. LVN B said that if any expired insulins were administered there was a possibility that the medication might not be as effective and the resident's blood sugar might not go down as indicated. Interview on 05/21/2026 at 1:50 PM the DON said it was expected for each nurse to take responsibility for their cart once they took over them. The DON said that it was expected for the expired insulins to be removed from the cart. The DON said that if an expired insulin was administered then it could possibly lead to a possible side effect and also not be as effective. Interview on 05/21/2026 3:02 PM with the Administrator said it was expected for the nurses to remove any expired insulin pens from the medication carts. The Administrator said that if a resident was administered an expired insulin there was a possibility that it might not be as effective. Record review of the facility's document titled Insulin pen use and dated 4/1/15 indicated in part: Storage instructions. Once you take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time, it can be safely kept at room temperature up to 86 degrees Fahrenheit. Do not use it after this time.

Based on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (Resident #7) of two residents reviewed for pressure ulcers. The facility failed to ensure that dressing changes were completed for Resident #7's pressure ulcers to left heel and right elbow on 5/10/2026, 5/14/2026, 5/16/2026, 5/17/2026, 5/18/2026, and 5/20/2026. This failure could place residents with pressure ulcers at risk for infection, pain, and worsening of the wound.Findings included: A record review of Resident #7 face sheet dated 5/21/2026, revealed Resident #7 was a [AGE] year old female initially admitted to facility on 11/8/2024 with diagnoses of chronic venous hypertension with other complications of bilateral lower extremity (a condition of elevated blood pressure in the leg veins caused by malfunctioning vein valves or blockages), peripheral vascular disease (progressive circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside of the heart or brain), unspecified protein calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands. The diagnoses of pressure ulcer of right elbow, stage IV (severe, full thickness skin and tissue loss) was added on 4/8/2026, delirium (a sudden change in thinking and awareness that can lead to confusion, memory problems or hallucinations was added on 4/1/2026, delusions (a fixed, false belief that an individual holds despite objective evidence) was added on 4/1/2026, pressure ulcer other site, stage III (a full-thickness skin loss extending to the subcutaneous fat) was added 12/2/2025. A record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Section E behaviors physical, verbal, or other behaviors all occurred from 1 to 3 days. Section E also revealed rejection of care and wandering occurred from 1 to 3 days. Section M skin conditions revealed Resident #7 had presence of a pressure ulcer. Section M0300 current number of unhealed pressure ulcers/injuries at each stage revealed Resident #7 had 1 unstageable pressure ulcer (a full thickness skin wound where the true depth and severity of the tissue damage cannot be assessed) that was not present on admission/reentry. A record review of Resident #7's Care Plan reflected a Problem Area stating, Focus: Resident has Stage III pressure wound to left heel initiated on 05/6/2026. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings as needed. Focus: Resident #7 has a stage IV pressure ulcer to right elbow revised on 3/30/2026. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings as needed. A record review of Resident #7's orders dated 5/21/2026 revealed, TX: Stage III Pressure wound of the Left Heel: Cleanse with wound cleanser/Normal Saline, pat dry with 4x4 gauze, apply calcium alginate with silver, skin prep peri wound, wrap with gauze roll and secure with tape once a day/PRN with a start date of 4/28/2026. TX: Stage IV Pressure Ulcer to right elbow: Cleanse with wound cleanser/Normal Saline, pat dry with 4x4 gauze, apply Collagen Sheet, apply calcium alginate with silver, skin prep peri (around) wound, wrap with gauze roll and secure with tape once a day/PRN. A record review of Resident #7's Wound Care Progress note completed by Wound Care MD, dated 5/19/2026 revealed Resident #7 had Stage IV pressure wound to right elbow present for greater than 118 days, Wound progress: Improved evidenced by decreased surface area, Infection Assessment: No sign of infection. Stage III pressure wound to left heel was present for greater than 17 days, Wound progress: Improved evidenced by decreased surface area, Infection Assessment: No sign of infection. A record review of Resident #7's TAR revealed there was no treatment recorded for Stage III pressure wound to left heel or Stage IV to right elbow on 5/10/2026, 5/14/2026, 5/16/2026, 5/17/2026, 5/18/2026, and 5/20/2026. In an interview and observation of Resident #7 on 5/21/2026 at 8:00 AM, revealed dressing was not present on Resident #7's right elbow. Resident #7 had socks on her feet so not able to observe dressing to heel. Resident #7 stated that RN A would replace the dressing to her elbow when she arrived at work. Resident #7 stated RN A was a good nurse and she trusted her. Resident #7 denied pain to the wound and stated the dressing must have come off while she was sleeping. Resident #7 stated that her wound was improving and was smaller than it was. An interview and observation of Resident #7 on 5/21/2026 at 2:13 PM, revealed dressing was not present on Resident #7's right elbow. Resident # 7 stated that the nurses have not covered it yet. Resident #7 denied pain to the wound. In an interview on 5/21/2026 at 2:30PM with RN A, she said that she was the Treatment Nurse for the facility. RN A stated once she completed a treatment, she signed off the treatment in the TAR. RN A stated when she was not in the facility the Charge Nurses completed the treatments. RN A stated she was not responsible for monitoring if the nurses were signing the treatments out in the TAR but sometimes, she noticed they didn't and would report it to the DON. RN A stated if a dressing became dislodged the nurses would let her know and she would replace it or Charge Nurses could also utilize a PRN order and replace the dressing. RN A stated Resident #7's wound was healing and she had no negative outcome due to treatments not being completed. RN A stated the risk of treatments not being completed could be infection or deterioration of the wound. In an interview on 5/21/2026 at 2:45 PM with RN M, she stated she was a Charge Nurse at the facility. RN M stated in the Treatment Nurse's absence they would perform the treatments. RN M stated they performed the treatment and signed it off in the TAR. RN M stated if a dressing was dislodged it needed to be replaced as soon as possible. The charge nurses or the treatment nurse, either one could replace it. RN M stated the treatment nurse was present and she was not responsible for her treatment on this day. RN M stated it had not been reported to her that the dressing had become dislodged. In an interview on 05/21/2026 at 03:37PM with DON, she stated that it was her expectation that staff document wound care. She stated that wound care should be performed per the orders. She stated if it wasn't documented, then it shows it wasn't complete. She stated that if staff are unable to finish a scheduled task on their shift it should be passed on to the next shift, to herself, or the ADON, so that it can be completed. She stated that refusals of care should be documented after several attempts and reported to the MD, herself, and the Responsible Party. She stated the impact to the resident of not receiving care that was ordered could contribute to the worsening of the wound. DON stated Resident #7's wounds were improving and had no negative outcome from wound care not being completed. DON stated it was her responsibility to monitor the TAR and ensure that treatments were provided. In an interview with the Administrator on 05/21/2026 at 04:00PM, she stated that she expected that dressing changes be performed per the physician orders and per policy. She stated if it wasn't signed out on the TAR then it looks like it wasn't completed. She stated that the potential impact to the resident of not doing wound care per the orders and policy standards could lead to worsening of the wound. A review of the facility's policy revised 5/5/2025 for Pressure Injury: Prevention, Assessment, and Treatment failed to include guidance for facility expectations regarding following wound care orders.

Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Resident #7) whose records were reviewed for assessments. The facility failed to complete a Significant Change in Status MDS for Resident #7 after pressure ulcers were identified and a change in behavior. This failure placed residents at risk for not having interventions in place to meet their needs for care assistance and treatments.Findings include: A record review of Resident #7's face sheet dated 5/21/2026, revealed Resident #7 was a [AGE] year old female initially admitted to facility on 11/8/2024 with diagnoses of chronic venous hypertension with other complications of bilateral lower extremity (a condition of elevated blood pressure in the leg veins caused by malfunctioning vein valves or blockages), peripheral vascular disease (progressive circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside of the heart or brain), unspecified protein calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands). The diagnosis of pressure ulcer of right elbow, stage IV (severe, full thickness skin and tissue loss) was added on 4/8/2026, delirium (a sudden change in thinking and awareness that can lead to confusion, memory problems or hallucinations) was added on 4/1/2026, delusions (a fixed, false belief that an individual holds despite objective evidence) was added on 4/1/2026, pressure ulcer other site, stage III (a full-thickness skin loss extending to the subcutaneous fat) was added 12/2/2025. A record review of Resident #7's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. Section E behaviors indicated physical, verbal, or other behaviors did not occur. Section E also revealed rejection of care and wandering did not occur. Section M skin conditions revealed Resident #7 was coded 0 on unhealed pressure ulcers indicating pressure ulcers were not present. A record review of Resident #7's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment. Section E behaviors indicated physical, verbal, or other behaviors all occurred from 1 to 3 days. Section E also revealed rejection of care and wandering occurred from 1 to 3 days. Section M skin conditions revealed Resident #7 had presence of a pressure ulcer. Section M0300 current number of unhealed pressure ulcers/injuries at each stage revealed Resident #7 had 1 unstageable pressure ulcer (a full thickness skin wound where the true depth and severity of the tissue damage cannot be assessed) that was not present on admission/reentry. A record review of Resident #7's Wound Care Progress note completed by Wound Care MD, dated 5/19/2026, revealed Resident #7 had a Stage IV pressure wound to right elbow present for greater than 118 days, Stage III pressure wound of right posterior thigh was resolved on 5/19/2026, Stage 3 pressure wound to left heel was present for greater than 17 days. A record review of Resident #7's Order Summary dated 5/21/2026, revealed treatment orders for Stage IV pressure ulcer to right elbow with a start date of 3/25/2026. Treatment orders for Stage III Pressure wound of the left heel with a start date of 4/28/2026. Treatment orders for Stage III to right posterior (back) of thigh with a start date of 5/15/2026. In an interview on 05/21/2026 at 2:00 PM, with the DON she stated that the MDS Coordinator was responsible for completing the Significant Change in Status MDS after the Interdisciplinary team identifies the significant change. DON stated she did not realize pressure ulcers or a change in behavior were a cause for a Significant Change in status MDS to be completed. DON stated the pressure ulcers to Resident #7's left heel and thigh were chronic and had a history of opening and closing. In an interview on 05/21/2026 at 3:00 PM, with the MDS Coordinator she stated Resident #7 had pressure ulcers. She stated her behaviors come and go in severity. She was not aware that a Significant Change MDS needed to be completed. She stated that this failure could cause the resident to miss care areas such as the wound care or other care areas that were not being identified and/or a comprehensive care plan being completed. She stated she would schedule a Significant Change in Status MDS to be completed for Resident #7. In an interview on 5/21/2026 at 3:23PM with the Regional Reimbursement Nurse she said the facility follows the RAI (Resident Assessment Instrument) manual when determining whether residents have significant change. Failure to complete as required could lead to decreased quality of care. In an interview on 5/21/2026 at 3:30PM with the Administrator, she stated that the MDS Coordinator along with the Interdisciplinary team was responsible for identifying changes in a resident's condition that requires a Significant Change Status Assessment. Administrator stated the risk of not correctly identifying changes in residents' status could lead to a decrease in quality of care. Administrator stated Resident #7 has not had a negative outcome due to the assessment not being complete. A Record Review of the RAI Manual revised October 2025 revealed: A significant change is a major decline or improvement in a resident's status that:Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limitingImpacts more than one area of the resident's health status; andRequires interdisciplinary review and/or revision of the care plan. Decline in two or more of the following:-Presence of a resident mood item not previously reported by the resident or staff and/or increase in the symptom frequency, increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for the items in Section E-Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status.

Based on record review and interviews the facility failed to ensure that 1 (Resident #1) of 5 residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician for a safe and effective transition of care. The facility discharged Resident #1 on 07/25/2025 without conducting a safe discharge as indicated in the facility's policy and provide an effective transition of care. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness.The findings included: Record review of Resident #1's admission record dated 10/07/2025 revealed he was admitted to the facility on [DATE] with diagnoses of alcohol dependence with withdrawal, depression and weakness. He was [AGE] years of age and was his own responsible party. Record review of the current care plan for Resident #1, last reviewed/revised: 06/13/2025, revealed The resident has a behavior problem r/t cognitive deficit as evidence by he was smoking in his room, resident is buying alcohol beverages thru door dash and drinking alcohol (consumption) in the building that could interfere with his medication and create health problems such as falls with fractures including fall resulting death. Resident will not smoke in his room x 90 days. Resident will not consume alcohol beverages in the building x 90 days. Educate resident on health consequences of alcohol consumption. Notify MD/FNP of resident's alcohol consumption. Offer AA services to resident. Sign a negotiated agreement with resident. Record review of Resident #1's discharge MDS assessment dated [DATE] revealed: BIMS totaled 6 indicating resident had severe impairment. Urinary continence was occasionally incontinent and bowel continence was always continent. Mobility - used manual wheelchair. Review of Resident #1's progress notes dated 05/06/2025 revealed Resident reported not being happy at the nursing home but understands why he needs to be here. D/C plan to be discussed with the interdisciplinary team. Review of Resident #1's progress notes dated 06/28/2025 revealed Doctor with resident. Instructed to stop drinking alcohol. Asked if he experiences anxiety. Resident stated yes. New order received. Review of Resident #1's progress notes dated 07/25/2025 at 2:41 am revealed: Resident previous Administrator here and resident [1] loaded into car with belongings. All medications and instructions sent with [previous] Administrator. Now out of the building. Author: LVN A. During a telephone interview on 11/07/2025 at 2:08 pm, the previous Administrator said Resident #1 was being non-compliant with the rules of him not listening to stop bringing in alcohol into the building, said the resident continued to do that and placed other resident's at risk in case they got a hold of the alcohol. The Previous Administrator said there had been a 30-day discharge given to Resident #1 but did not recall if they had made the Ombudsman aware. He said there should be evidence of that letter somewhere in his record. He said Resident #1 agreed to go to the other facility which was a type of group home and the resident's family member was also okay with that. The Previous Administrator said they had not just given the resident 2 hours to get ready and then taken him out of the facility. He said they had not had a meeting regarding the discharge. During a telephone interview on 11/07/2025 at 3:15pm - Attempted to reach Resident #1 via his phone on several occasions and there was no answer. The resident's phone was not set up to leave messages. During a telephone interview on 11/07/2025 at 3:20pm with Resident #1's family member, she said that she was not sure if the facility was able to do that, meaning to discharge him. The family member said she felt she had no say regarding that since Resident #1 was his own responsible party. The family member said she was not sure if the facility could just discharge someone. The family member was made aware of surveyor reaching out to Resident #1 but he did not answer his phone. The family member said the resident was very deaf and for surveyor to consider texting him. The family member said she knew Resident #1 had been discharged to a facility out of town, knew what facility it was and also was aware that Resident #1 was currently residing there. During a telephone interview on 11/07/2025 at 3:40 pm Resident #1's doctor stated that he recalled having a talk with Resident #1 regarding him drinking alcohol and it being mixed with his medications. The doctor said apparently the resident would continue to be non-compliant. The doctor said if Resident #1 continued to mix the alcohol with his medication that could lead to a bad effect. The doctor said he did not recall signing a discharge notice or letter regarding the resident's discharge from the facility. The physician said he did not recall having some kind of meeting regarding Resident #1's discharge plans. During an interview on 11/07/2025 at 3:52 pm with t he facility he said he did not recall them issuing Resident #1 a 30-day notice or notifying the Ombudsman regarding the discharge. The RCN said he would have been aware if they had issued one because that meant they would have had a discharge plan meeting. During an interview on 11/07/2025 at 3:54pm the ADON said she did not recall them notifying the Ombudsman regarding Resident's #1 discharge nor that they conducted a discharge plan. During an interview on 11/07/2025 at 3:56 pm with MDS coordinator said the previous Administrator had found Resident #1 another place to move to and that he had agreed to go because that way he could do as he wanted to including keeping alcohol as they were not as strict. The MDS coordinator said when they discharge a resident they first have a care plan meeting to see what the resident needs are, if any other options they can have and, also consists of a discharge care plan. During a telephone interview on 11/07/2025 and on 11/08/2025 at different times of the day attempted to reach out to Resident #1 but resident did not answer his phone. Resident was then texted and he replied to the texts as follows. 11/07/2025 at 4:46 pm resident was asked if had agreed to move to another facility. Resident replied he had but once he got there the conditions were horrible. 11/07/2025 at 4:49 pm resident was asked if he was given an option to stay at this facility and he replied Yes. 11/08/2025 at 2:24 pm resident was asked if they had had a discharge meeting prior to being discharged from the facility and he replied no. During a telephone interview on 11/10/2025 at 9:50 am with the previous Administrator stated he had contacted Resident #1's family member and she was in agreement with the resident moving to another facility. The previous Administrator said that he had even offered to send the resident to another state but the family member had refused as she was unable to provide care for him. The previous Administrator said the previous DON had assisted with the discharge and they had a file in her office but he would not know where it would be located as he no longer worked at the facility. The previous Administrator said Resident #1 had signed himself out as he was his own RP. The previous Administrator said Resident #1 had signed a document indicating he was in agreement to leave the facility on his own will and that it should have been filed by the facility but he would not know where it was. The previous Administrator said there had not being any discharge plan meeting as far as he knew. During an interview on 11/10/2025 at 10:50 am with the RCN, he said they had searched for any documentation regarding Resident 1's discharge plans and there were none found. The RCN said whenever there was a discharge it had to be signed by the doctor and none of that was found. The RCN said he believed that Resident #1 might have left the faciity on his own will and was not necessarily discharged by the facility so no 30-day notice was issued but that they should have still contacted the Ombudsman. During a telephone interview on 11/10/2025 at 11:15 am the previous DON said there had not been a 30-day discharge done for Resident #1 that she could recall before he discharged from the facility. She said that the previous Administrator knew about a facility in Houston Texas and had contacted them and they had accepted Resident #1. The previous DON said that she was present in the previous Administrators office when he had told Resident #1 if he would like to move to another facility. She said that the resident had agreed to go on his own will thus reason there was no 30-day notice given. The previous DON said she did not recall if the Ombudsman was notified of the discharge. The previous DON said they had not had a discharge plan meeting before the resident was discharged . During a telephone interview on 11/10/2025 at 3:00pm LVN A said that Resident #1 willingly left the facility and that he was happy to leave the facility and start in a new place. LVN A said as far as he knew there was no 30-day discharge notice given probably because the resident willingly left the facility. LVN A said that he did not recall if Resident #1 had signed a discharge document. LVN A said he did remember the resident signing a form but it could have been the list of medications he was taking with him. LVN A said as far as he knew the only thing that was done was that they contacted Resident 1's family member about the move to which at first she was kind of not sure but then later she was okay with the move. LVN A said as far as he knew that was the only discharge plan that was done. During an interview on 11/10/2025 at 4:52 pm the interim Administrator said she did not know much regarding Resident #1's discharge as she was not at the facility when it occurred. The interim Administrator said the facility should have followed their policy on how to perform a safe discharge so that the resident could receive the best care when discharged to another facility. Review of the facility undated policy titled Discharge planning process policy revealed in part: Nursing facility must complete discharge planning when discharge is anticipated to a private residence, assisted living, another nursing facility or another type of residential location. Assess the residents continuing care needs including consideration of the residents and family/caregivers preferences for care, include regular re-evaluations of the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated as needed to reflect these changes. Develop an interdisciplinary team discharge plan designed to ensure that the residents needs will be met after discharge from the facility including resident and family/caregiver education needs. Initiate and maintain collaboration between the nursing facility and the local contact agency to support the residents transition to community living as applicable includes making referrals to the local agency under the process established by the state and assisting the resident and family./caregivers in locating and coordinating post discharge services. Discharge summary must include, a recapitulation of the residents stay that includes but is not limited to, diagnoses course of illness/treatment or therapy and pertinent labs, radiology and consultation result. A post discharge plan of care. A post discharge plan of care will help the resident adjust to their new living environment. The final discharge summary will be filed in the residents medical record.

Based on observation, interview, and record review the facility failed treat each resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of five residents (Residents #5 and #7) reviewed for treatment with respect and dignity. CNA A and HA B stood while feeding Residents # 5 and #7. RN C was on her phone while monitoring the dining room with residents present. HA B was texting while feeding Resident #5. This failure placed residents at risk of feeling embarrassed, infantilized, dehumanized, or stigmatized due to their need for assisted dining. Findings included: Record review of Resident #5's admission Record, dated 6/13/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (progressive neurological disorder causing tremors, stiffness, and slow movement). Record review of Resident #5's Annual MDS Assessment, dated 3/27/25, revealed: (the updated MDS was in progress) He had a mental status score of 3 of 15 (indicating severe cognitive impairment), He needed supervision while eating. Record review of Resident #7's admission Record, dated 6/13/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a progressive central nervous system disease affecting the brain and spinal cord causing muscle weakness, balance issues and cognitive issues). Record review of Resident #7's Quarterly MDS Assessment, dated 4/10/25, revealed: He had a mental status score of 10 of 15 (indicating moderate cognitive impairment) He needed substantial or maximal assistance with eating. Record review of Resident #7's care plan, updated 2/15/24, revealed: Resident #7 had an ADL Self Care Performance Deficit. Identified interventions included: The resident required to be fed. Observation on 6/12/25 at beginning at 12:07 p.m. of the lunch meal revealed: there were 27 residents present. At 12:08 p.m. Resident #7 was served a meal of a sandwich; CNA A fed him standing up. There was a chair immediately behind CNA A, she kicked the chair out of way when CNA walked around Resident #7 to get extra napkins. At 12:23 p.m., HA B stood while feeding Resident #5. HA B had no interaction with Resident #5. She held a roll up to Resident #5's mouth while Resident #5 took bite after continuous bite. Eventually the Administrator promoted HA B to sit. After sitting, HA B's phone went off and she held it under the table while answering it. HA B got up and walked away from Resident #5 to answer the phone without saying a word to him and returned. An observation at 12:44 p.m. on 6/12/25 revealed RN C stood to the side of the room scrolling on her phone while she was supposed to be monitoring the dining room. Interview on 6/12/25 at 1:09 p.m. CNA A stated she worked at the facility off and on for three years, but this was her second day back. CNA A stated she was trained to sit while feeding residents and talk to them at eye level and talk to them so you could if there were any choking issues instead of standing like I was and it's more comfortable for the residents. CNA A stated she usually sat while feeding residents but she just wanted to stand on 6/12/25. Observation on 6/12/25 at 3:23 p.m. revealed RN C behind the nurse's station scrolling on social media. Interview on 6/12/25 at 5:01 p.m. HA B stated she was trained to feed residents sitting down. HA B did not know the reason. HA B said the reason she stood was because it was more work to sit to feed Resident #5. HA B said she did not talk to Resident #5 because her English was very limited. Interview on 6/12/25 at 5:58 p.m. the DON stated her expectation for feeding residents was that aides sat down at eye level because it was patient centered care. The DON said the staff were not to have phones out, staff were to have all their attention on the resident. The DON stated she monitored for that when she was in the dining room. The DON stated she told CNA A to sit down at lunch. The DON said she felt the aides were not giving the residents the attention they needed when they were not sitting. The DON stated giving unrestricted bites while the staff was on the phone was not ok because residents needed to be taking one bite at a time. The DON stated nurses were responsible for monitoring for cell phone use while in the dining room. The DON stated she had in-serviced staff on phone use and every time she caught staff on phones she did an in-service. The DON said she did not notice RN C on the phone during lunch and said she was not doing a good job of monitoring if she was on the phone. The DON stated nurses were allowed to be on the phone if they were trying to get a hold of the doctor. The DON stated they were not supposed to be on social media because that took away from their job. Interview on 6/12/25 at 6:39 p.m. the Regional RN stated the corporate expectation was staff sit down and assist residents who needed help eating. The Regional RN said this was supposed to be monitored by the charge nurse and administrative staff routinely. The Regional RN stated routinely meant any time they passed by, there was no set number of times the staff needed to check. The Regional RN said it was in the employee handbook to not be on the phone. The Regional RN stated they told staff to step outside if they needed to take a phone call and it was not ok to be at the table and on the phone at the same time because it sent the message the phone was more important. The Regional RN said he would be upset if he was the resident. Interview on 6/13/25 at 1:11 p.m. a random resident interview stated they were the only person who noticed staff were on their phones all the time. The resident said they were afraid to approach staff when staff were on their phone because they did not want to interrupt the staff and ask for what the resident needed. Record review of the facility's Guidelines for Dining Room Etiquette, undated, revealed: Do not carry on conversations with coworkers that do not pertain to residents and their dining experience, do not shout across the dining room or elevate your voice. Do not use a cell phone while assisting residents in the dining room. Try to keep the dining room [NAME] and minimize noise. If you assist residents by feeding them, make sure that you are sitting at eye level with them, not standing over them. Record review of the Employee Handbook, undated, revealed: Personal Communication devices: use of personal communication devices during scheduled work hours is not permitted at the facility. Record review of the facility's policy and procedure on Resident's Rights, revised 11/28/16, revealed. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility, including: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or maintenance or enhancement of his or her quality of life, recognizing each member's individuality.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #57 and Resident #214) of 16 residents reviewed for infection prevention and control. The ADON failed to wear PPE when performing wound care for Resident #57 who was on EBP for an indwelling catheter and a Stage 3 pressure ulcer on his coccyx (area at the base of the spine). CNA A and NA B failed to wear PPE when providing incontinent care for Resident #214 who required EBP for a Stage 4 pressure ulcer to her sacrum (lower back between the hip bones). These failures could put residents at risk of acquiring infections, secondary infections, and communicable diseases. Findings include: Record review of Resident #57's facility face sheet, dated 3/19/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His medical diagnoses included obstructive and reflux uropathy (condition where urine flow is blocked leading to backflow of urine into the kidneys) and stage 3 pressure ulcer to the coccyx. Record review of Resident #57's Admission MDS Assessment, dated 2/13/25, revealed one stage 3 pressure ulcer that was present on admission to the facility and the presence of an indwelling urinary catheter. Record review of Resident #57's care plan, initiated 2/11/25 and revised 3/18/25, revealed a focus that Resident #57 was on Enhanced Barrier Precautions (EBP) related to an open wound and indwelling catheter. During observation on 3/19/25 at 2:45 pm, the ADON failed to apply all required PPE - he only wore gloves - while performing wound care to the wound on Resident #57's coccyx in compliance with the facility's EBP policy. Record review of Resident #214's facility face sheet, dated 3/20/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her medical diagnoses included hepatic encephalopathy (brain dysfunction caused by liver dysfunction), hypertension (High blood pressure), pressure ulcer of sacral region stage 4, functional quadriplegia (complete immobility due to severe disability), Record review of Resident #214's admission MDS assessment, dated 3/7/25, revealed resident was dependent with incontinent care. Record review of Resident #214's care plan, dated 3/5/25, revealed a focus that Resident #214 was on enhanced barrier precautions related to open wound. During observation on 3/18/25 at 4:23 PM of incontinent care for Resident #214 revealed CNA A and NA B did not apply the required personal protective equipment (PPE) - they wore gloves only - to comply with enhanced barrier precautions (EBP) as ordered. In an interview on 3/18/25 at 4:40 PM with CNA A and NA B both stated that they did not realize the resident had a wound and they were unaware they needed the EBP. In an interview on 3/19/25 at 3:00 pm the ADON stated that he was aware that Resident #57 was on EBP, and he forgot to apply PPE. He stated he had no excuse as the facility's infection preventionist and the person responsible for ensuring EBP was done properly, and that he just overlooked the PPE cart at the bedside. In an interview on 3/20/25 at 02:30 PM with the DON stated that EBP should be worn during high contact activities including incontinent care for residents who have wounds, extra lines, tubes or catheters. She stated that the ADON should have worn gloves and a gown during Resident #57's wound care and that CNA A and NA B should have worn gloves and gown during incontinent care. The DON stated that staff should hand sanitize or wash hands between glove changes. The DON stated that the staff should change gloves between clean and dirty tasks. Review of facility policy Enhanced Barrier Precautions dated 4/1/24 revealed, in part: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing. EBP are indicated for residents with any of the following .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Record review of the facility's policy titled Infection Control Plan dated 2019 indicated in part: Infection control - the facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection control program - the facility will establish an infection control program under which it - investigates controls and prevents infections in the facility. At least annually and on an as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain an efficient and up to date infection control program. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Implement hand hygiene (Hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Record review of the facility's policy titled Fundamentals of infection control precautions dated 3/2023 indicated in part: A variety of infection control measure are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care, before and after changing a dressing, upon and after coming in contact with a resident's intact skin, after handling soiled or used dressings, after removing gloves. Gloving - gloves are worn for three important reasons- to provide protective barrier and prevent cross contamination of the hands when touching blood, body fluids, secretions, excretion, mucous membranes and nonintact skin. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use and hands can become contaminated during removal of gloves, failure to change gloves between resident contacts is an infection control hazard. 48593 Resident #214 Bladder and Bowel Incontinence

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the facility's only dry storage were dated and sealed appropriately. 2. The facility failed to ensure food items in the facility's only walk in freezer were dated and stored appropriately. 3. The facility failed to ensure food items in the facility's only walk in refrigerator were thrown out after use by date, and ensure items were labeled and dated appropriately. 4. The facility failed to ensure personal food items were not stored in the facility's only walk in refrigerator. 5. The facility failed to ensure items were not stored on the ground of the dry food storage. 6. The facility failed to check temperatures of food items prior to serving food. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observations of the facility's kitchen's only dry storage on 03/18/25 at 10:22 AM revealed the following items were not sealed or dated, items found stored on the floord of the dry food storage: - A stack of four tin containers which each had what appeared to be pie crust in them open and undated. - One box of thermal cups was found stored between two food racks on the ground. Observations of the facility's kitchen's only walk in fridge on 03/18/25 at 10:30AM revealed the following items were not dated or passed the use by date: - One bottle of sparkling water with no resident label. Staff was later seen drinking this drink. - A container labeled Potato Salad with a use by date of 03/16/2025 - A container labeled apple jelly: with a use by date of 03/16/2025 - A container with no label or date contained a bag with what appeared to be a red sauce. - A container with a label of strawberries with no use by date but an open date of 1/30/2025. Observations of the facility's kitchen's only walk in freezer on 03/18/25 at 10:40AM revealed the following items were not labeled, dated, or properly covered: - Three uncovered single serve containers of an orange frozen substance next to a container of Orange Flavored Sorbet Observation of lunch meal service on 3/18/2025 and 3/19/2025 revealed no temperatures were taken prior to serving meals. During an interview on 3/19/2025 at 12:30 pm with [NAME] G stated that she was unaware that she needed to take temperatures prior to serving food. [NAME] G stated that she checks the temperatures when cooking to ensure the food items were cooked to safe temperatures. During an interview on 03/20/25 at 1:31 PM with the DM, she stated she was unaware of the items not being stored properly in the dry food storage or refrigerator. The DM stated that she did remove the Orange Sorbet from the freezer when she saw that they were not covered. The DM stated she has tried to teach the staff that the walk-in fridge was not for personal use but the previous manager allowed it so it has been hard to break the habit. The DM stated the staff should be labeling everything that was opened with an open date and use by date. The DM stated that every item that was opened should be placed into a sealable container. The DM stated that the previous manager did not have the staff take temperatures prior to serving meals only when the items were cooked to ensure that items reached safe temperatures. Record review of the facility policy titled storage refrigerators dated 2012 stated in part 5. Food must be covered when stored, with a date label identifying what is in the container. Record review of the facility policy titled Dry storage and Supplies dated 2012 stated in part b. all food and supplies are to be stored six (6) inches above the flood on surfaces which facilitate thorough cleaning. And 4. Open packages of food are stored in closed container with tight covers and dated as to when opened. Record review of the facility policy titled Daily food temperature control dated 2012 stated in part We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the temperature log.

Based on observation, interview and record review the facility failed to ensure each resident was provided food prepared in a form designed to meet individual needs for 1 of 1 resident (Residents #213) reviewed for pureed diets. The facility failed to prepare the pureed diet to the consistency required for Resident #213. This failure could place residents at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings include: Record review of Resident #213's facility face sheet, dated March 20, 2025 revealed Resident #213 was a [AGE] year-old female admitted to the facility on [DATE]. Her Medical diagnoses included cerebral infarction (lack of blood flow to an area of the brain, leading to brain cell death), dementia, type II diabetes mellitus. Record review of Resident #213's admission MDS (Minimum Data Set) assessment, dated March 8, 2025, revealed resident was to have a mechanically altered diet. Resident's Brief Interview for Mental Status was not conducted as the resident is rarely or never understood. Record review of Resident #213's care plan, dated March 5, 2025, revealed an intervention of offer a diet as ordered by the physician. Record review of Resident #213's physician order summary report, dated March 20, 2025 revealed a diet order of regular diet with pureed texture and nectar consistency fluids. Ordered initiated 03/19/2025. During an observation on 03/18/2025 at 11:50 am and 03/19/2025 at 11:45 am the puree tray was observed to be runny and water-like, and not a smooth, pudding-like consistency. During an interview with [NAME] G, who prepared the pureed tray, on 03 /19/25 at 12:00 PM she stated that she was trained by videos for puree texture. She stated that the food needs to be smooth. [NAME] G did not know the puree should have been thicker. During an interview with the Dietitian on 3/20/2025 at 11:10 am she stated that the puree dishes should have a smooth pudding like consistency and should stay on the spoon when scooped and turned over. She stated that the kitchen can make the consistency thinner if it was ordered by a doctor, but it should not be runny or a water-like consistency. During an interview with the DM on 03/20/25 at 1:31 PM revealed that she was not checking the consistency of the puree but did have a communication sheet from the nursing staff to make the resident's puree thinner. The DM was unable to produce communication sheet. Record review of the facility's policy titled Consistency Modification dated 2012 revealed in part, 3. The desired consistency for blended foods is that of applesauce to mashed potatoes.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Residents #1, #2, #3) reviewed for resident abuse. This was determined to be past noncompliance due to the facility having implementedsctions that corrected the non compliance to the beginning of the inspection. The facility failed to prevent verbal abuse against Resident #3 by LVN B. The facility failed to prevent verbal abuse against Resident #1 by the dietary manager. The facility failed to prevent verbal abuse against Resident #2 by CNA A. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non compliance to the beginning of the inspection. The findings were: Review of Resident #3's Admission Record dated 2/14/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety disorder, Intermittent explosive disorder ( a mental and behavioral disorder characterized by explosive outbursts of anger or violence, often to the point of rage that are disproportionate to the situation at hand), bipolar disorder ( mood swings of highs and lows), and chronic pain syndrome. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he scored an 8 on his mental status exam (indicating moderate cognitive impairment), he had verbal behaviors directed toward others and behaviors not directed toward others on a daily basis, he usually understood others and his vision was highly impaired. He used a walker and a wheelchair for mobility, and he required moderate assistance with personal hygiene and was able to toilet himself. Record review of Resident #3's care plan reflected: Resident has potential to demonstrate verbally abusive behaviors. r/t intermittent explosive behaviors. Goal: Resident will verbalize understanding of need to control, verbally abusive behavior through the review date. Date Initiated: 09/06/2024 revision on: 09/18/2024 Interventions included: Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document date Initiated: 09/06/2024, flu with psych services as indicated date Initiated 01/07/2025, Give resident as many choices as possible about care and activities date Initiated: 09/06/2024, Notify the charge nurse of any abusive behaviors Date Initiated: 09/06/2024. When the resident becomes agitated Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation. During an interview on 2/11/25 at 6:07 PM to 6:26 PM, The visitor stated while she was at the facility on January 13, 2025, she witnessed LVN B verbally abuse Resident #3. Resident #3 was standing at the back of nurse's station when LVN B rose from her chair. She came from behind the nurse's station yelling at the resident and told him not to talk to the staff that way. The visitor stated she was sitting across from the nurse's station on the couch against the west wall. She stated she did not hear Resident #3 say anything, but she could tell he had spoken to the staff. She stated she could hear LVN B very clearly when she yelled at him that he had been to the bathroom earlier and pointed her finger in his face and told him to go down the hall to the bathroom where he been earlier. The visitor stated she heard Resident #3 say he could not remember where he had gone to the bathroom. He stated he needed to go to the bathroom again. The visitor stated LVN continued to scold him as she walked him to the shower room. The resident was apologetic and hanging his head down and told her he just needed to go to the bathroom, and he could not go in his room because the toilet was leaking. She took him in to the shower room and immediately returned to the nurse's station. The visitor stated she heard someone tell the resident that they were going to move him to another room because the toilet in his room was not working. She stated she approached the nurse's station and told LVN B that she had spoken to Resident #3 in an abusive manner. She stated LVN B stated, I was redirecting him, and it was not abuse. Go ahead and report me if you want to. The visitor stated she reported the incident to the Interim administrator the next day and filed a report with the HHSC complaint hotline . In an interview with CNA C at 5:00 PM on 2/11/25 she stated she had been inserviced on abuse and neglect. She stated she had not witnessed any staff member treat a resident in an abusive manner. She stated she loved the residents and would report abuse immediately to the administrator. She stated abuse could be verbal, physical, or mental. In an interview with CNA D on 2/13/25 at 4:00 PM she stated she did not hear an altercation between LVN B and Resident #3 on 1/13/25. She stated she had never heard seen any staff member speak to a resident in an abusive manner. She stated she was last inserviced on abuse and neglect on 1/23/25 . She stated abuse could be verbal, physical, or mental. Interview with CNA E at 12:00 PM on 2/13/25 she stated she knew that abuse could be verbal, physical, or mental. She stated abuse could be withholding care from a resident. She stated she had never witnessed a coworker be abusive toward a resident and that she would report immediately to the administrator or DON. During an interview on 02/14/25 at 10:00 AM, Resident #3 stated he did not remember any staff member speaking to him in an abusive manner. He stated he felt safe in the facility and kept repeating he did not want to get anyone in trouble. During an interview on 02/13/25 at 4:45 PM, the Administrator who was also the facility abuse coordinator stated LVN B was terminated at the conclusion of her investigation due to violating resident rights and unbecoming conduct for a company employee. She stated she felt the 3 incidents of alleged abuse had occurred because the facility several different administrators in the past year and staff were not trained properly. She stated the Administrator, the DON and the Human Resource manager were responsible for training employees on abuse and neglect. During an interview on 2/14/25 at 1:00 PM the Corporate Regional manager of the facility stated she monitors the facility closely to ensure residents are free from abuse and neglect. She said her monitoring includes reviewing all incidents that were reported by the facility, visiting with the ombudsman and residents of the facility and conduct onsite visits with the facility staff to ensure that the residents were protected from abuse and neglect. Record review of Resident #1's Face Sheet (Admission Record) dated 2/14/25 indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's medical history included adult-onset diabetes ( a condition in which there is too much sugar in the blood), end stage renal disease (a condition in which the kidneys cannot filter wastes from the blood), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), dependence on renal dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so), protein calorie malnutrition ( a nutritional state in which reduced availability of nutrients leads to changes in body composition and describes a condition that results in mild to severe undernutrition). Record review of Resident #1's Optional State MDS assessment dated [DATE] reflected the resident had a BIMS score of 15 which indicated she was cognitively intact. The MDS assessment indicated Resident #1 displayed no behaviors. The assessment also indicated Resident #1 used a wheelchair for mobility, was independent with transfers and bed mobility, eating and did not have significant wt loss. Record review of Resident # 1's care plan reflected a problem which was initiated on 1/24/25. It stated that Resident #1 had a history of making false accusations. Interventions included were: Have a witness Present when giving resident money and remind resident in a calm manner. There were no other interventions listed and both were initiated on 1/24/25. During an interview on 2/13/25 at 10:58 AM, the Activity Director stated she was in the dining room on 1/23/25 at 2:00 PM when Resident #1 had returned from dialysis. She stated Resident #1 was upset and angry because her lunch tray had not been saved for her until she returned from dialysis. She stated Resident #1 was cursing and the Dietary Manager confronted Resident #1 in the Activity Directors doorway of her office and asked Resident #1 What the F-K is your problem screaming at my staff? The Activity Director stated the Dietary manager also told Resident #1 she knew Resident #1 had thrown the staff under the bus by complaining to the Ombudsman about the dietary staff. The Activity Director stated Resident #1 immediately said: I'm sorry, I'm sorry to the Dietary Manager, and the Dietary manager told the Resident that she needed to apologize to her staff. During an interview on 2/14/25 at 11:00 AM, Resident #1 stated she vaguely remembered the incident with the Dietary Manager. Resident #1 said she remembered that her and the Dietary Manager were both angry, but she stated sometimes she did not remember things well because of her dialysis and kidney disease. She stated she remembered she was so upset because the dietary staff did not save her anything to eat. He stated that the dietary manager had been terminated due to the incident and she felt safe in the facility at the time of the interview. She stated if she had concerns with abuse to herself or other residents, she would report it to the administrator or the DON. Attempted to interview the Dietary Manager by phone on 2/14/25 at 11:30 AM but was unable to reach her by phone or leave a message. During an interview on 2/13/25 at 3:45 PM the administrator stated the Activity Director did not report to witnessing abuse or had suspicions of abuse toward Resident #1 by the Dietary Manager when she witnessed the confrontation between the Dietary Manage and Resident #1. She stated her expectation was any suspicion of abuse or allegations of abuse be reported to her immediately. She stated an Inservice on abuse and neglect was given to all staff on 1/23/25 and again on 1/24/25. All staff attended. Review of Resident #2's Admission Record dated 2/13/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder recurrent ( a common condition and serious mental health condition that is characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life ), psychotic disorder (a mental illness characterized by a disconnection from reality), dementia with behavioral disorder ( a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough with daily life and inappropriate social interactions) , and pain in unspecified joint. Review of Resident #2's Annual MDS assessment dated [DATE] revealed he scored a 3 on his mental status exam (indicating severe cognitive impairment), he had verbal behaviors directed toward others 1-3 days during the 14 days look back period, moderate assistance with eating, was dependent with adl's, and used a wheelchair for mobility. Record review of Resident # 2's care plan reflected a problem: Resident #2 yells out, cursing at staff. He takes medication for intermittent explosive disorder. Goal resident #2 will have less than 20 episodes a day of yelling out. Interventions included: Resident #2 will be redirected when yelling, Resident #2 o Resident has been noted with yelling out 'help, help'. When doing so please provide resident with polite encouragement on using call-light appropriately to not disturb other residents. Dated revised 2/15/24 and initiated on 2/15/24. A record review of inservices reflected an inservice on 1/13/25 on the facility's abuse and neglect policy and procedure and was attended by CNA A. An inservice on abuse and neglect was also held on 1/15/25 after the incident with CNA A and attended by 35 facility staff including CNA's, Nurses, Dietary staff, H/R Manager, housekeeping staff, Business Office Manager and the Activity director. Record review of the facility investigation 5-day report revealed the incident occurred on 1/15/25 at 5:00 PM and was reported to HHSC at 9:15 PM on 1/15/25. The perpetrator was immediately suspended and terminated at the conclusion of the investigation. During an interview on 2/13/25 at 2:30 PM, the HR Manager said on 1/15/25 at 5:30 PM, she was in her office and heard someone yelling at Resident # 2 to Shut up! She stated she heard it a second time as she was getting up from her desk to see what was going on. She stated she saw CNA A in the hallway and heard her scream loudly at Resident #2. She stated she immediately reported it to the AIT who reported it to the interim administrator. During an interview on 2/13/25 at 3:45 PM, the administrator stated she had zero tolerance for abuse. She stated an Inservice on abuse and neglect was completed on 1/15/25 with all staff and CNA A was terminated. She stated the dietary manager was suspended immediately when the allegation of abuse was reported, and she was fired at the completion of her investigation which revealed the dietary manager did confront the resident and speak to her in a disrespectful manner and violated the corporate code of conduct. Review of the facility policy titled Abuse/Neglect dated 3/29/18, revealed, in part: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

Based on interview, and record review the facility failed to ensure all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 of 6 residents (Resident #1) reviewed for abuse. 1. The Activity director failed to immediately report her suspicions of abuse when she heard the Dietary Manager use profanity directed toward Resident # 1. This failure could affect any resident and contribute to further abuse or neglect This was determined to be past noncompliance due to the facility having implemented actions that corrected the non compliance to the beginning of the inspection. Findings included: Review of facility policy titled Abuse/Neglect dated revised 9/9/24, revealed, in part: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Record review of Resident #1's Face Sheet (Admission Record) dated 2/14/25 indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's medical history included adult-onset diabetes ( a condition in which there is too much sugar in the blood), end stage renal disease (a condition in which the kidneys cannot filter wastes from the blood), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), dependence on renal dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so), protein calorie malnutrition ( a nutritional state in which reduced availability of nutrients leads to changes in body composition and describes a condition that results in mild to severe undernutrition). Record review of Resident #1's Optional State MDS assessment dated [DATE] reflected the resident had a BIMS score of 15 which indicated she was cognitively intact. The MDS assessment indicated Resident #1 displayed no behaviors. The assessment also indicated Resident #1 used a wheelchair for mobility, was independent with transfers and bed mobility, eating and did not have significant wt loss. Record review of Resident # 1's care plan reflected a problem which was initiated on 1/24/25. It stated that Resident #1 had a history of making false accusations. Interventions included were: Have a witness Present when giving resident money and remind resident in a calm manner. There were no other interventions listed and both were initiated on 1/24/25. Record review of the facility's investigation worksheet dated received on 1/24/25 and the provider 5-day and investigation report dated 1/30/25 documented the incident occurred on 1/22/25 at 2:00 PM and was reported to regulatory services by the Regional Nurse on 1/23/25. During an interview on 2/13/25 at 10:58 AM, the Activity Director stated she was in the dining room on 1/23/25 at 2:00 PM. She stated resident #1 had returned from dialysis and had come into the dining room. She stated Resident #1 was upset and angry because her lunch tray had not been saved for her until she returned from dialysis. She stated Resident #1 was cursing. The Dietary Manager confronted Resident #1 in the Activity Directors office doorway and asked her: What the F-K is your problem screaming at my staff? The Activity Director stated the Dietary manager told Resident #1 she knew Resident # 1 had thrown the staff under the bus by complaining to the Ombudsman about them not doing their jobs. The Activity Director stated Resident #1 immediately said: I'm sorry, I'm sorry to the Dietary Manager, The Dietary manager told Resident #1 that she needed to apologize to her staff for cursing. The Activity Director stated she did not report it to the Administrator until 1/24/25. She stated she stated she did not realize she should have reported the incident immediately. She stated she started in July of 2024, and she had an in-service on abuse during orientation, but she did not remember anything about how soon it should be reported. She stated she had been inserviced and counseled after the incident by the interim administrator. During an interview on 2/14/25 at 11:00 AM, Resident #1 stated she vaguely remembered the incident with the Dietary Manager. Resident #1 said she remembered that she and the Dietary Manager were both angry, but she stated sometimes she did not remember things well because of her dialysis and kidney disease. She stated she remembered she was so upset because the dietary staff did not save her anything to eat. She stated that the dietary manager had been terminated due to the incident and she felt safe in the facility at the time of the interview. She stated she stated if she had concerns with abuse to herself or other residents, she would report it to the administrator or the DON. Attempted to interview the Dietary Manager by phone on 2/14/25 at 11:30 AM but was unable to reach her by phone or leave a message. During an interview on 2/13/24 at 3:45 PM, the administrator stated the Activity Director did not report witnessing abuse or had suspicions of abuse toward Resident #1 by the Dietary Manager when she witnessed the confrontation between the Dietary Manage and Resident #1. She stated her expectation was that suspicion of abuse or allegations of abuse be reported to her immediately. She stated an Inservice on abuse and neglect, and Resident Rights had been started on 1/23/25 and 1/24/25 and completed by all staff on immediate reporting of allegations of suspected abuse or neglect and resident rights. She stated it was her responsibility to monitor complaints and concerns by residents and ensure the facility was doing all that was within their control to prevent occurrences of abuse and neglect. She stated the dietary manager was suspended immediately when she when the allegation of abuse was reported, and she was fired at the completion of her investigation which revealed the dietary manager did confront the resident and speak to her in a disrespectful manner and violated the corporate code of conduct.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired foods were discarded. This failure could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on [DATE] at 09:45 AM, of the dry storage pantry revealed: ,d+[DATE]-ounce bottle of lemon juice expired [DATE]. ,d+[DATE]-ounce bottle of enchilada sauce expired [DATE]. ,d+[DATE]-ounce bag of powdered orange drink mixes expired [DATE]. ,d+[DATE] ounce opened bag of vanilla wafers expired [DATE]. In an interview and observation on [DATE] at 09:45 AM, the Dietary Manager was informed of the expired food items found during the initial inspection of the kitchen. The Dietary Manager took the items to discard them. The Dietary Manager stated kitchen staff was responsible for discarding expired items. The Dietary Manager stated that she was ultimately responsible for ensuring expired foods are discarded. Review of facility policy dated ,d+[DATE] titled Food Storage, revealed in part: All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of foods. .c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded. .f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #6 and Resident #25) reviewed for infection control. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Residents #6 and #25. CNA A failed to wash or sanitize her hands prior to putting on gloves and after removing them during incontinent care while assisting Residents #6 and #25 This failure could place resident's at risk for cross contamination and the spread of infection. Finding include: RESIDENT #6 Record review of Resident #6's admission record dated 02/14/24 indicated she was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain problems resulting in memory loss and confusion), dementia (memory loss and judgement impairment), absence of right and left leg, Diabetes mellitus 2, and chronic kidney disease (kidney damage that affects filtering of blood). She was [AGE] years of age. Record review of Resident #6's care plan revised date 12/20/23 indicated in part: Focus: The resident has bladder incontinence. Goals: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Staff will apply barrier cream after each incontinent episode. Incontinent care as indicated and apply moisture barrier after each episode. Provide pericare after each incontinent episode. Record review of Resident #6's MDS dated [DATE] indicated in part: Urinary and Bowel continence = Always incontinent. During an observation on 02/14/24 at 10:15 AM revealed CNA A performed incontinent care for Resident #6. CNA A entered the room and put on some gloves without first washing her hands and proceeded to perform the incontinent care. CNA A used the bed control to place the resident on a flat position. CNA A pulled Resident #6's brief down from the front and the resident was noted to be wet from urine. CNA A wiped the peri area from dirty to clean (back to front) with wet wipes instead of clean to dirty (front to back ). Resident #6 rolled herself to her right side and CNA A wiped the residents bottom with wet wipes. CNA A removed the wet brief, opened a container of ointment, and applied the ointment to the residents bottom while still wearing the same gloves. While still wearing the same gloves, CNA A fastened a clean brief to Resident #6 and then removed her soiled gloves. CNA A then left the resident's room without sanitizing or washing her hands. RESIDENT #25 Record review of Resident #25's admission record dated 02/15/24 indicated she was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to right and left hand. She was [AGE] years of age. Record review of Resident #25's care plan revised date 02/13/24 indicated in part: Focus: Resident has bladder incontinence. Resident has bowel incontinence. Goals: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: INCONTINENT care as indicated and apply moisture barrier after each episode. Provide pericare after each incontinent episode. Record review of Resident #25's MDS dated [DATE] indicated in part: Urinary and Bowel continence = Always incontinent. During an observation 02/14/24 at 09:34 AM revealed CNA A performed incontinent care for Resident #25. CNA A put some gloves on and proceeded to undo the resident's brief. The resident's brief was noted to be wet from urine. CNA A then took some wet wipes and wiped the resident's vagina from front to back. CNA A then turned the resident on her right side and wiped the resident buttocks and rectal area with a back to front motion going towards the vaginal area. While still wearing the same gloves, CNA A took a container of cream and applied it to the residents peri-area. While still wearing the same gloves CNA A grabbed the bed rail and then fastened the new brief on Resident #25. CNA A then removed her gloves and put on a new pair of gloves without washing her hands or applying hand sanitizer. CNA A then proceeded to help dress the resident and transferred the resident from her bed to her wheelchair with a mechanical lift. During an interview on 02/15/24 at 02:00 PM CNA A said she had worked at the facility for approximately one and a half years as a CNA. CNA A said whenever she performed incontinent care, she would clean from front to back. CNA A said she was supposed to wipe from front to back during the incontinent care but that she had messed up and wiped back to front when she had cleaned Residents #6 and #25. CNA A said she should have washed her hands or used hand sanitizer prior to putting on clean gloves. CNA A said she should have changed her gloves before she applied the new brief on the residents. CNA A said if she wiped from back to front it could lead to infections such as UTI's or cross contamination. CNA A said she had gotten nervous and forgot to wash her hands and wipe from front to back during the incontinent care. CNA A said she had received training on incontinent care as indicated on the CNA proficiency audit. During an interview on 02/15/24 at 02:40 PM the DON said the expectation was for staff to wipe from front to back during incontinent care so that they did not containment the clean area or vagina as it could lead to an infection. The DON said staff were expected to change their gloves when going from dirty to clean to prevent contamination of the clean areas. The DON said staff were supposed to use hand sanitizer or wash their hands in between glove changes. The DON said a CNA proficiency was done upon hire and on a yearly basis. The DON said the proficiency was done by the ADON or herself but the ADON was not here today. The DON said the failure probably occurred because the CNA got nervous and forgot the correct steps during the incontinent care. During an interview on 02/15/24 at 03:14 PM the Administrator said it was expected for CNAs to wipe from front to back during incontinent care. The Administrator said the CNA's were expected to wash or use hand sanitizer prior to putting on clean gloves on in between glove change. The Administrator said staff were expected to change their gloves once they became contaminated to prevent cross contamination. The Administrator said he believed the failure occurred because the staff got nervous and felt the pressure of being observed by the state surveyor and forgot the correct steps. Record review of the facility's document titled Phase 2 competencies for aides-Perineal care/incontinent care female undated indicated in part: Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area. Emphasizing clean to dirty. Beginning steps - wash hands - wear gloves and follow standard precautions. Put on clean gloves before washing perineal area. Obtain a disposable wipe. Wash genital area, start at the inside of the vagina and work outward moving from front to back and using a clean wipe for each stroke. Dry genital area moving from front to back with towel. After washing genital area turn to side then wipe rectal area moving from front to back using a clean area of washcloth for each stroke. Dispose of used wipes and brief in the plastic trash bag. Avoid contact between your clothing and used items. After disposing of used linen and placing used equipment in designated storage area, remove and dispose of gloves (without contaminating self) into waste container and wash hands. Record review of the facility document titled Fundamentals of infection control precautions dated 03/2023 indicated in part: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamental of infection control precautions. Gloves are worn for three important reasons, to provide protective barrier and prevent gross contamination of the hand when touching blood, body fluids, secretions, excretions, mucous membranes and non-intact skin. The wearing of gloves in specified circumstances will reduce the risk of exposure to bloodborne pathogens and is mandatory for all employees. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident, in this situation, gloves must be changed between resident contact, and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have a small inapparent defects or be torn during use and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard. 45399

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 2 of 9 Residents (Resident #42, Resident #25) inspected for medication reconciliation and failed to ensure medications were documented when given. LVN B did not document the administration of a controlled medication on the individual controlled medication records after administering medication for Resident #42 and Resident #25. This failure could place residents at risk of under dose, overdose, and drug diversion. The findings were : During an observation and record review on 02/13/2024 at 02:20 PM the medication cart was inspected with the LVN B. The controlled medication count was incorrect for two residents (Residents #42 and #25). Resident #42's blister pack of APAP/ Codeine 300-60 MG contained 12 pills and the corresponding medication sheet indicated there were 13 pills left. Resident #25's blister pack of APAP/ Codeine 300-60 MG contained 18 pills and the corresponding medication sheet indicated there were 19 pills left . During an interview with LVN B on 02/13/2024 at 02:30 PM, LVN B stated he wasn't sure why the narcotic sheet was incorrect and must have forgotten to sign out the medications. LVN B stated the process of giving medications included signing out the narcotics if they were popped out of the blister pack. LVN B stated there was a medication reconciliation at the end of the shift with the oncoming nurse. LVN B stated that he had not had his count be wrong before . Interview with the DON on 02/15/24 at 10:32 am revealed if a nurse is giving a PRN narcotic medication the narcotic should be signed out of the narcotic sign out sheet if the medication is taken out of the blister pack. The DON stated there were no issues with narcotic counts in the past. Record review of the facility's policy titled Storage and Documentation of Schedule II Controlled Medications , reflected in part, Disposition of controlled substances is maintained on the sheet supplied by the pharmacy with each Schedule II controlled substance and the controlled substances in scheduled III and IV provided by in counters. Entries are to be made in pen each time a controlled substance is used. The nurse administering the medication will record the following information: Date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug.

Based on observations, interview and record review the facility failed to residents who are incontinent of bladder received appropriate treatment to prevent urinary tract infections for 2 of 3 residents (Residents #6 and #25) by 1 of 3 nurse aide staff (NA A) reviewed for incontinence care. NA A failed to change her gloves after they became contaminated during incontinent care while assisting Residents #6 and #25. NA A failed to wash or sanitize her hands prior to putting on gloves and after removing them during incontinent care while assisting Residents #6 and #25 These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. Finding include: RESIDENT #6 Record review of Resident #6's admission record dated 02/14/24 indicated she was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain problems resulting in memory loss and confusion), dementia (memory loss and judgement impairment), absence of right and left leg, Diabetes mellitus 2, and chronic kidney disease (kidney damage that affects filtering of blood). She was [AGE] years of age. Record review of Resident #6's care plan revised date 12/20/23 indicated in part: Focus: The resident has bladder incontinence. Goals: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Staff will apply barrier cream after each incontinent episode. Incontinent care as indicated and apply moisture barrier after each episode. Provide pericare after each incontinent episode. Record review of Resident #6's MDS dated [DATE] indicated in part: Urinary and Bowel continence = Always incontinent. During an observation on 02/14/24 at 10:15 AM NA A performed incontinent care for Resident #6. NA A entered the room and put on some gloves without first washing her hands and proceeded to perform the incontinent care. NA A used the bed control to place the resident on a flat position. NA A pulled Resident #6's brief down from the front and the resident was noted to be wet from urine. NA A wiped the peri area from dirty to clean (back to front) with wet wipes instead of clean to dirty (front to back ). Resident #6 rolled herself to her right side and NA A wiped the residents bottom with wet wipes. NA A removed the wet brief, opened a container of ointment, and applied the ointment to the residents bottom while still wearing the same gloves. While still wearing the same gloves, NA A fastened a clean brief to Resident #6 and then removed her soiled gloves. NA A then left the resident's room without sanitizing or washing her hands. RESIDENT #25 Record review of Resident #25's admission record dated 02/15/24 indicated she was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis, contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to right and left hand. She was [AGE] years of age. Record review of Resident #25's care plan revised date 02/13/24 indicated in part: Focus: Resident has bladder incontinence. Resident has bowel incontinence. Goals: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: INCONTINENT care as indicated and apply moisture barrier after each episode. Provide pericare after each incontinent episode. Record review of Resident #25's MDS dated [DATE] indicated in part: Urinary and Bowel continence = Always incontinent. During an observation 02/14/24 at 09:34 AM revealed NA A performed incontinent care for Resident #25. NA A put some gloves on and proceeded to undo the resident's brief. The resident's brief was noted to be wet from urine. NA A then took some wet wipes and wiped the resident's vagina from front to back. NA A then turned the resident on her right side and wiped the resident buttocks and rectal area with a back to front motion going towards the vaginal area. While still wearing the same gloves, NA A took a container of cream and applied it to the residents peri-area. While still wearing the same gloves NA A grabbed the bed rail and then fastened the new brief on Resident #25. NA A then removed her gloves and put on a new pair of gloves without washing her hands or applying hand sanitizer. NA A then proceeded to help dress the resident and transferred the resident from her bed to her wheelchair with a mechanical lift. During an interview on 02/15/24 at 02:00 PM NA A said she had worked at the facility for approximately one and a half years as a NA. NA A said whenever she performed incontinent care, she would clean from front to back. NA A said she was supposed to wipe from front to back during the incontinent care but that she had messed up and wiped back to front when she had cleaned Residents #6 and #25. NA A said she should have washed her hands or used hand sanitizer prior to putting on clean gloves. NA A said she should have changed her gloves before she applied the new brief on the residents. NA A said if she wiped from back to front it could lead to infections such as UTI's or cross contamination. NA A said she had gotten nervous and forgot to wash her hands and wipe from front to back during the incontinent care. NA A said she had received training on incontinent care as indicated on the NA proficiency audit. During an interview on 02/15/24 at 02:40 PM the DON said the expectation was for staff to wipe from front to back during incontinent care so that they did not containment the clean area or vagina as it could lead to an infection. The DON said staff were expected to change their gloves when going from dirty to clean to prevent contamination of the clean areas. The DON said staff were supposed to use hand sanitizer or wash their hands in between glove changes. The DON said a NA proficiency was done upon hire and on a yearly basis. The DON said the proficiency was done by the ADON or herself but the ADON was not here today. The DON said the failure probably occurred because the NA got nervous and forgot the correct steps during the incontinent care. During an interview on 02/15/24 at 03:14 PM the Administrator said it was expected for NAs to wipe from front to back during incontinent care. The Administrator said the NA's were expected to wash or use hand sanitizer prior to putting on clean gloves on in between glove change. The Administrator said staff were expected to change their gloves once they became contaminated to prevent cross contamination. The Administrator said he believed the failure occurred because the staff got nervous and felt the pressure of being observed by the state surveyor and forgot the correct steps. Record review of NA A's NA proficiency audit dated 09/18/2023 indicated in part: Skills hand washing = S, Perineal care: female = S. Infection control awareness = S. (S = Satisfactory). Conducted by ADON on 09/18/23. Record review of the facility's document titled Phase 2 competencies for aides-Perineal care/incontinent care female undated indicated in part: Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area. Emphasizing clean to dirty. Beginning steps - wash hands - wear gloves and follow standard precautions. Put on clean gloves before washing perineal area. Obtain a disposable wipe. Wash genital area, start at the inside of the vagina and work outward moving from front to back and using a clean wipe for each stroke. Dry genital area moving from front to back with towel. After washing genital area turn to side then wipe rectal area moving from front to back using a clean area of washcloth for each stroke. Dispose of used wipes and brief in the plastic trash bag. Avoid contact between your clothing and used items. After disposing of used linen and placing used equipment in designated storage area, remove and dispose of gloves (without contaminating self) into waste container and wash hands.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 2 medication rooms (Med room [ROOM NUMBER]) reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure controlled drugs were stored and separately locked and in permanently affixed compartments. These failures could place the residents at risk of drug diversion and access to medications. Findings included: Observation of the facility Med room [ROOM NUMBER] with LVN B on 02/13/2024 at 02:20 pm revealed a narcotic lock box in the unlocked medication refrigerator. The narcotic lock box was not secured to the fridge and was unlocked. The box contained three boxes of lorazepam 2mg/ml. With one box of lorazepam 2mg/mL in the fridge outside of the unlocked box. An interview with LVN B on 02/13/2024 at 02:25 pm, he stated he was unsure why the lock box was not secured and locked. He agreed the controlled drugs needed to be in a permanently affixed compartment and locked to prevent drug diversion . The box did have a chain affixed to the box but was not attached to the refrigerator. An interview with the DON on 02/15/24 at 10:32 am, the DON stated that the narcotic box should be permanently affixed and locked to prevent controlled drug diversion. The DON had no reason the lock box would not be properly locked or affixed. A review of the facility policy titled Storage and Documentation of Schedule II Controlled Medications , reflected in part, All Schedule II controlled medications will be stored under double lock and checked for accountability at each change of shift .

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #31 and #48) reviewed for resident abuse. The facility failed to prevent verbal abuse against Resident #31 and Resident #48 by CNA C. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings were: Review of Resident #31's Admission Record revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes with diabetic retinopathy (damage to the blood vessels in the tissue at the back of the eye) and macular edema (swelling in part of the retina caused by excess fluid from damaged blood vessels), end stage renal disease (condition in which a person's kidneys cease functioning on a permanent basis) with dependence on renal dialysis, high blood pressure, major depressive disorder, and anxiety disorder. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed he had severely impaired vision, he scored a 15 on his mental status exam (indicating no cognitive impairment), he had no reported behaviors, required only supervision for ADLs, used a wheelchair or walker for mobility, received dialysis, and was a smoker. Review of Resident #31's Care Plan revision date 02/14/24 revealed: Focus - Resident has a history of making false accusations about staff and other residents. Family states he had a history of false accusations at home. (Date initiated 12/20/23, revision 02/14/24). Goal - Resident will have reduced or absence of false accusation over the next 90 days (Date initiated 12/20/23). Interventions - Evaluate the resident's ability to understand behavior and the consequences of that behavior; Listen/talk to the resident - see if they will tell you why they do the behavior; Staff will investigate all accusations foe verification of truth (Date initiated 12/20/23). Review of Resident #48's Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cardiomyopathy (enlargement of the heart muscle), chronic kidney disease, chronic obstructive pulmonary disease, and mild cognitive impairment. Review of Resident #48's Quarterly MDS assessment dated [DATE] revealed she scored a 9 on her mental status exam (indicating moderate cognitive impairment), she had no reported behaviors, she required only supervision for all ADLs, and used a wheelchair for mobility. In a resident council interview on 02/13/24 at 2:13 PM Resident #31 stated that CNA C frequently came to work smelling like marijuana. Ten of the twelve residents present (including Resident #48 who was sitting next to Residnet #31) for the meeting agreed with Resident #31. In an interview on 02/14/24 at 8:08 AM Resident #31, stated that he had gone to speak with the Activity Director that morning about an issue he had regarding retaliation from CNA C and was told by the Activity Director that CNA C was caught listening to the resident council meeting held by the surveyor the previous day (02/13/24). Resident #31 stated that in the dining room last night (02/13/24) he and Resident #48 both witnessed CNA C make comments like he doesn't care if he gets fired and he hates being around all these snitches and then stated that he was going to come to work smelling like marijuana on Friday (02/16/24) and see who rats him out. The comments were made last night after CNA C slammed Resident #31's meal tray on the table. He stated he did not feel comfortable eating his food after that because he was worried that CNA C might have spit in the food or something, so he did not have dinner. In an interview on 02/14/24 at 10:11 AM the Activity Director confirmed that she did catch CNA C listening at the door during the surveyor-led resident council meeting yesterday (02/13/24) and had to ask him to leave the area because the meeting was confidential for the residents. She also stated that the residents had complained to her about CNA C in the past and that the Administrator had been doing coaching with him. She stated that Resident #31 told her that morning that CNA C had retaliated against him (Resident #31) and Resident #48 because of what had been said at the meeting with the surveyor, when he slammed dinner trays and made comments about people ratting on him and that he (CNA C) did not like snitches. In an interview on 02/14/24 at 2:00 PM CNA C came into the conference room and stated he wanted to clear himself of some allegations that had been said about him. CNA C stated he had started working at the facility since April 2023 but had been terminated for a little while due to something against policy but had been re-hired within a week or so. CNA C stated that one of the residents present during the resident council meeting told him that Resident #31 had made false allegations such as him smelling like marijuana when coming to the facility which was not true. CNA C stated he had just talked to the Administrator and the DON, and they had suspended him because of the allegations. CNA C denied he had ever mentioned that he better not hear the resident's snitching on him or any type of snitching in general. CNA C stated he did look through the dining room door yesterday (02/13/24) while the resident council was going on, but he was not sure what was going on. CNA C stated he was not standing at the dining room door listening in to hear what was being discussed at the resident council meeting, he said that he was just checking in on the residents. In an interview on 02/15/24 at 9:15 AM the Activity Director stated that she had personally witnessed CNA C arrive at work smelling like marijuana as well as returning from break smelling like it . She stated she had not reported CNA C to the Administrator but she did plan to. She stated several residents had complained to her about it, but none had reported it to the Administrator or filed a grievance until Resident #31. She stated that she told the residents to immediately go to the DON or Administrator to report their concerns so that the issues could be investigated right then. She stated that when Resident #31 told her that CNA C had been slamming the dinner trays and making comments about snitches, she immediately took him to the Administrator to report his concerns. In an interview on 02/15/24 at 9:39 AM Resident #48 stated that at dinner on 2/13/24, CNA C came into the dining room and was slamming the dinner trays on the table she shared with Resident #31 and saying that he did not want to be around all these snitches . She confirmed that Resident #31 refused to eat his meal that night because he was afraid that CNA C had spit in the food. She admitted to being startled by the trays being slammed on the table and the way CNA C was speaking about snitches. In an interview on 2/15/24 at 5:11 PM the Social Worker stated that on 2/14/24, the Administrator asked her to speak to Resident #31 to get a statement about CNA C retaliating for what was said during about him the resident council meeting. She stated that Resident #31 told her that at dinner the previous night (2/13/24) CNA C slammed his (Resident #31) tray down on the table and said something about how are you going to rat a cuz out. Resident #31 also told the Social Worker that the Activity Director caught CNA C listening at the door during the resident council and that during dinner while he made comments about snitches CNA C had repeated things word for word that Resident #31 had said during the meeting. Resident #31 told the Social Worker that he was afraid to eat his meal that night because he thought CNA C might have spit in it. Resident #31 told her that CNA C always talks all big and bad and that he felt like if he came back up to the facility, he would come looking for him. She stated there had been complaints about CNA C before, but for him being lazy or speaking too informally to the residents. She stated that Resident #31 had brought his concerns about CNA C coming to work smelling like marijuana to the administration last week and they had started looking into it but he had not filed a grievance on it. She stated she had never received a complaint of a resident feeling threatened or afraid of CNA C before. In an interview on 2/15/24 at 5:46 PM the DON stated that she would consider retaliation going after someone that said something about you or told on you for something. She stated that it was abuse. The DON stated that there was no facility in-service specifically regarding retaliation that she was aware of but she believed there might be training on the online learning platform the facility used and in the employee handbook. She stated she was made aware of the situation regarding Resident #31 and CNA C by the Administrator, and they immediately asked the Social Worker to speak with Resident #31. She stated that she and the Administrator spoke to CNA C and he denied slamming the dinner trays on the table and making any comments about snitches to or around Resident #31 and Resident #48. The DON stated CNA C was immediately suspended on 2/14/24, pending an investigation of the retaliation allegation and had been terminated earlier that afternoon (2/15/24). In an interview on 02/15/24 at 6:26 PM the Administrator stated that retaliation was getting back at someone for reporting an event that was considered an infraction. He stated that for the residents of the facility, retaliation was a violation of resident rights and a form of abuse. He stated he believed that the facility handled the situation with CNA C according to the facility's policy and procedures as the employee in question was terminated and placed on the no rehire list. When asked why he believed CNA C would have felt comfortable acting in a retaliatory manor towards a resident he stated that he felt CNA C was trying to scare the resident into not saying anything about his actions and that the facility would not do anything because they had invested money into him by sending him to CNA school. Review of facility policy titled Abuse/Neglect dated 3/29/18, revealed, in part: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

Based on interview and record review, the facility failed to inform the resident/RP of a significant change in the resident's physical status or a need to alter treatment for one (Resident #5) of 10 residents reviewed for resident and RP rights. The facility failed to notify Resident #5's RP of coccyx pressure wound worsened post hospital visit. This failure could place residents at risk for health information not being communicated in order for treatment decisions to be made. Findings include: Record review of Resident #5's face sheet dated 12/15/23 revealed a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone) unstageable (one cannot determine the extent of injury as the whole wound bed cannot be visualized because it is fully or al partially covered with slough or eschar) and type 2 diabetes mellitus (the body either doesn't produce enough insulin, or it resists insulin) with hyperglycemia(high blood sugar), and unspecified protein- calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS of 03, she was severely cognitive impaired and had an unstageable pressure ulcer. Record review of Resident #5's weekly ulcer assessment dated [DATE] revealed a coccyx (a triangular arrangement of bone that makes up the final segment of the vertebral column and represents the vestigial tail) unstageable pressure ulcer that measured 6.5 cm in length, 6.5 cm in width, and 0.1 in depth. Eschar, black, brown or tan adhered to the wound. Record review of Resident #5's progress note dated 09/08/23 revealed [Resident #5] was transferred to a hospital on 09/08/2023 10:30 PM related to Family wants to revoke palliative care and send to ER for hospital admittance. Record review of Resident #5's readmission nurses note dated 09/21/23 revealed reason for visit request from family, revoked palliative care and DNR . Resident #5 arrived to facility via EMS and was accompanied by family. Record review of Resident #5's weekly ulcer assessment dated [DATE] revealed a coccyx unstageable pressure ulcer that measured 7.5 cm in length, 12.5 cm in width, and 0 for depth. Reason for no depth was marked as superficial. Eschar, black, brown or tan adhered to the wound. During interview on 12/15/23 at 9:57 am, Resident #5's RP stated she was not aware of Resident #5 coccyx wound had gotten significantly bigger. Resident #5's RP stated she was made aware of Resident #5 coccyx wound on 12/08/23 by a family member who had gone to visit Resident #5 at the hospital. Resident #5 RP stated she had called the DON asking questions and was told Resident #5's coccyx wound had gotten bigger after her return from the previous hospitalization . During interview on 12/15/32 at 11:11 am, the DON stated Resident #5 had a hospitalization in September per family request to revoke palliative care services. The DON stated when Resident #5 returned from that hospitalization in 9/21/23 her coccyx wound had gotten bigger, and the charge nurse should had reported that to the Resident #5's RP. The DON stated family had accompanied Resident #5 when she returned on 09/21/23 to the facility but was not sure if Resident #5's RP had been notified of the worsening coccyx pressure ulcer. The DON stated the charge nurses were responsible of notifying residents' RP of any changes to the resident. During an interview on 12/15/23 at 11:49 am, RN A stated she had worked the day Resident #5 returned from her last hospitalization and had seen her coccyx pressure ulcer had gotten bigger. RN A stated family was present upon Resident #5 readmission and they had seen her coccyx wound at bedside. RN A stated she did not document that in Resident #5 electronic records and had no documentation to show Resident #5's RP was made aware of Resident #5's coccyx wound worsening post hospitalization . Record review of Family Notification policy dated 2003 revealed in part Objective: To keep families informed. Procedure: The family will be notified of any resident change, i.e., health problem, new interest through: telephone call, verbal exchange when family member is in the facility, or regular report. Record review of Resident Rights policy undated revealed in part A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Exercise of rights: 3. In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative; b. The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law; 4. The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. Planning and implementing care: 3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- a. Facilitate the inclusion of the resident and/or resident representative; b. Include an assessment of the resident's strengths and needs; c. Incorporate the president's personal and cultural preferences in developing goals of care.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 4 of 7 residents (Resident #30, Resident #41, Resident #52, and Resident #73) reviewed for monitoring of [MEDICAL CONDITION] medication. The facility failed to monitor residents' anti-[MEDICAL CONDITION] medications for therapeutic levels: Resident #41 had a history of [REDACTED]. The facility failed to obtain and monitor laboratory levels for the three anti-[MEDICAL CONDITION] medications she was prescribed ([MEDICATION NAME] Acid, and [MEDICATION NAME]). Resident #41 had [MEDICAL CONDITION] on 3/4/19 resulting in intubation and hospitalization with laboratory levels subtherapeutic (low) for two of three anti-[MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME] Acid). On 3/8/19 she returned to the facility. The facility failed to obtain physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 3/15/19. While the IJ was removed on 3/15/19, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. Non Immediate Jeopardy findings: - The facility did not adequately monitor Resident #30 and Resident #73 for [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) levels. -The facility did not adequately monitor Resident # 52 for [MEDICATION NAME] ([MEDICATION NAME]) levels. These failures could place residents taking anti-[MEDICAL CONDITION] medication at risk for nontherapeutic levels of their anti-[MEDICAL CONDITION] medications, [MEDICAL CONDITION], and death. Findings include: Resident #41 Record review of Resident #41's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she was a [AGE] year-old-female admitted to the facility 4/19/16, readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #41 Care Plan effective on 02/07/19 revealed she had a [MEDICAL CONDITION] disorder and was at risk for injury due to [MEDICAL CONDITION] disorder. Interventions include: Obtain labs as ordered to monitor levels of medications to maintain therapeutic levels and avoid toxicity. Review of Resident #41's local hospital record dated 3/4/19 revealed in part: [AGE] year-old female with past medical history of [REDACTED]. During an observation on 03/10/19 at 11:39 AM, Resident #41 was laying in bed with Oxygen at 3 Liters per minute per nasal cannula. Record review of Resident #41's Start-Up Orders dated 12/31/18 revealed the following anti-[MEDICAL CONDITION] medications and laboratory orders: - [MEDICATION NAME] (Levetiracetam) 100 mg/ml (milligrams/milliliters); give 12.5 ml (=1250 mg) by mouth twice a day. - [MEDICATION NAME] ([MEDICATION NAME]) 100 mg; give 1 tablet by mouth three times a day. - [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) 250 mg/5 ml; give 20 ml (=1000 mg) by mouth twice times a day. - [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) level every Monday. According to Drugs.com, accessed on 03/27/19, [MEDICATION NAME] is an anti-epileptic drug used to treat [MEDICAL CONDITION]. With [MEDICATION NAME], one's kidney function needs to be tested often .overdose symptoms may include extreme drowsiness, agitation, aggression, shallow breathing, weakness, or [MEDICAL CONDITION]. [MEDICATION NAME] is an anti-epileptic drug that slows down impulses in the brain that cause [MEDICAL CONDITION]. An overdose of [MEDICATION NAME] can be fatal .overdose symptoms may include twitching eye movements, slurred speech, loss of balance, tremor, muscle stiffness or weakness, nausea, vomiting, feeling light-headed, [MEDICAL CONDITION], and slow or shallow breathing. [MEDICATION NAME] acid is used to treat [MEDICAL CONDITION] disorders and is sometimes used together with other [MEDICAL CONDITION] medications. [MEDICATION NAME] acid can cause liver failure that may be fatal. One may need frequent blood tests when taking medications [MEDICATION NAME] and [MEDICATION NAME] Acid. Review of Resident #41's Physician's telephone order dated 12/31/18 revealed the following laboratory orders: - [MEDICATION NAME] Acid , [MEDICATION NAME] to be drawn 1/2/19 and every Monday following. Review of Resident #41's Medication Administration Record [REDACTED] - [MEDICATION NAME] 100 mg/ml; give 12.5 ml=1250 mg by mouth twice a day - [MEDICATION NAME] 125 mg/5 ml; give 4 ml=100 mg by mouth three times a day - [MEDICATION NAME] Acid 250 mg/5 ml; give 10 ml=500 mg by mouth twice a day Review of Resident #41's Laboratory results: 1/8/19 [MEDICATION NAME] Acid 38 (low) (range 50-120) [MEDICATION NAME] 18.9 (range 12.0-46.0) [MEDICATION NAME] 6.6 (low) (range 10-20) 1/14/19 [MEDICATION NAME] Acid 41 (low) [MEDICATION NAME] 18.3 [MEDICATION NAME] 5.8 (low) 1/21/19 [MEDICATION NAME] Acid 23 (low) [MEDICATION NAME] 6.8 (low) [MEDICATION NAME] 4.1 (low) Review of Resident #41's Physician's Telephone Orders dated 1/25/19 revealed: - Continue current anti-[MEDICAL CONDITION] meds (medications) - [MEDICATION NAME] Acid, [MEDICATION NAME] , and [MEDICATION NAME] serum level (no frequency) specified - F/U (Follow up) in 6 months During an interview on 3/15/19 at 8:59 a.m. the Director of Nurses (DON) said her understanding of the 1/25/19 telephone order was the laboratory orders were changed to every six months. She said I would have had to clarify that order. During an interview on 3/15/19 at 9:54 a.m. the Medical Director (MD) confirmed Resident #41 had been in the hospital several times for [MEDICAL CONDITION]. He said the nurses or his Nurse Practitioners should have caught the [MEDICAL CONDITION] medications were not being monitored. He agreed the telephone order dated 1/25/19 for 6 months follow up misinterpreted and Resident #41 needed ongoing monitoring. He said they would not have put a follow up on [MEDICAL CONDITION] medications every 6 months because the resident was in a Nursing Home. The Medical Director looked at the telephone order and said there was nothing about changing the lab orders. The Medical Director said I agree, that should have been clarified. It's not an order from us. The Medical Director was informed when Resident #41 returned on 3/8/19 the [MEDICATION NAME] & [MEDICATION NAME] had monitoring labs ordered but there were no orders for [MEDICATION NAME] Acid. He was informed the [MEDICATION NAME] was still pending. He acknowledged the order should have been clarified. He instructed the DON to clarify at that time. *Note: On 1/25/19 the laboratory was changed to every 6 months for [MEDICATION NAME] Acid, [MEDICATION NAME], and [MEDICATION NAME] levels. Review of Resident #41's MAR indicated [REDACTED] - [MEDICATION NAME] 100 mg/ml; give 12.5 ml-1250 mg by mouth twice a day - [MEDICATION NAME] 125 mg/5 ml; give 4 ml=100 mg by mouth three times a day - [MEDICATION NAME] Acid 250 mg/5 ml; give 10 ml=500 mg by mouth twice a day Review of Resident #41's Physician's Telephone order dated 2/20/19 revealed: - Draw [MEDICATION NAME] and [MEDICATION NAME] level every week starting 2/21/19. *Note: There was no clarification order for [MEDICATION NAME] Acid level. Review of Resident #41's Laboratory results reported 2/21/19: - [MEDICATION NAME] (12-46) 57.1 (High) - [MEDICATION NAME] (10-20) 14.3 Review of Resident #41's Lab results collected 2/27/19 and reported 3/3/19: [MEDICATION NAME] (12-46) 15.5 [MEDICATION NAME] (10-20) no lab results During an interview on 3/14/19 at 12:25 PM with LVN B regarding the [MEDICATION NAME] level for 2/27/19 not being in Resident #41's chart, LVN B called the contacted laboratory and said the laboratory told her that they had an order for [REDACTED]. During an interview on 3/14/19 at 3:15 pm with RN (Registered Nurse) H regarding Resident #41's [MEDICATION NAME] results for 2/27/19, RN H said she was told by LVN B during that the contract laboratory computers were down and they were unable to look up any lab results or the lab requisition dated 2/21/19. RN H attempted to call the contract laboratory at 3:20 PM and reached a recording to leave a voice mail. Review of Resident #41's Nurses Notes dated 3/4/19 revealed the following: - at 07:55 AM, LVN D had notified LVN B Resident was twitching and wasn't herself. LVN D then brought Resident where LVN B noticed she was seizing and was very stiff. LVN B noticed the Resident was [MEDICAL CONDITION]. - 08:00 AM LVN B stayed with Resident while LVN D called 911. 08:08 AM Resident continued to seize. Paramedics arrived. 08:09 AM Resident and Paramedics left facility in route to a local ER. 08:10 AM Report was given to RN at the local ER. 08:14 AM LVN B notified daughter of Resident. Review of Resident #41's SBAR Communication Form (Situation, Background, Assessment, Recommendation) dated 3/4/19: revealed: -at 07:30 AM LVN B was notified that resident was twitching and very stiff. Resident continues to seize. - 08:00 AM LVN D called 911. 08:08 AM resident continued with [MEDICAL CONDITION]. Paramedics arrived. Resident pulse is [MEDICAL CONDITION]. -08:09 AM Resident left the facility with paramedics in route to a local hospital. 08:10 AM report given to Registered Nurse (RN) at the local ER (emergency room ), - 08:14 AM Notified daughter that Resident was sent to the hospital ER for [MEDICAL CONDITION]. Review of Resident #41's physician's orders [REDACTED]. - Send to local hospital to evaluate and treat Review of Resident #41's local hospital record dated 3/4/19 revealed in part: Upon arrival to emergency room (ER) the patient continued to [MEDICAL CONDITION]. The patient was given 2 liters of fluids bolus, [MEDICATION NAME] 500 mg, [MEDICATION NAME] (Levetiracetam) 1000 mg, [MEDICATION NAME] 8 mg, and a push of Propofol 75 mg. The patient was intubated for airway protection and started on Propofol drip after which the [MEDICAL CONDITION] stopped. The patient's anti-[MEDICAL CONDITION] medication levels were found to be subtherapeutic with [MEDICATION NAME] ([MEDICATION NAME]) levels of 8 (low) and [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) level of 12.6 (low). Record review of Resident #41's Admission/Readmission Data Summary indicated she returned to the facility on [DATE] at 4:30 PM. Review of Resident #41's Start-Up Orders dated 3/8/19 revealed: - Levetiracetam ([MEDICATION NAME]) 100 mg/ml; give 10 ml=1,000 mg by mouth twice a day - [MEDICATION NAME] ([MEDICATION NAME]) 150 mg; give 1 tablet by mouth three times a day - [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) 250 mg/5 ml; give 15 ml=750 mg by mouth twice a day Review of Resident's # 41 MAR indicated [REDACTED] - Levetiracetam ([MEDICATION NAME]) 100 mg/ml; give 10 ml=1000 mg by mouth twice a day - [MEDICATION NAME] ([MEDICATION NAME]) 150 mg; give 1 tablet by mouth three times a day; - [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) 250 mg/5 ml; give 15 ml=750 mg by mouth twice a day Review of Resident #41's Laboratory results collected on 3/11/19 and reported on 3/12/19: [MEDICATION NAME] (Levetiracetam) (12-46) (pending) [MEDICATION NAME] ([MEDICATION NAME]) (10-20) 16.2 *Note: There continued to be no clarification for lab monitoring for the [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) level. Review of Resident #41's physician's orders [REDACTED]. Clarification on [MEDICATION NAME] ([MEDICATION NAME]): [MEDICATION NAME] ([MEDICATION NAME]) 125 mg/ml: 4 ml=100 mg give by mouth three times a day. Note: this is a dosage decrease from 450 mg daily total to 300 mg daily total despite the lab level being in therapeutic range. During an interview on 3/14/19 at 3:47 PM with the DON, she said Resident #41 went to the hospital on [DATE] and returned 3/8/19. The DON said she was not employed at the facility prior to the resident's hospitalization and did not know if she was getting her anti-[MEDICAL CONDITION] medications prior to the hospitalization . The DON said she started to work at the facility on 3/4/19. During an interview on 3/14/19 at 4:17 PM LVN E said the contract laboratory did not draw a [MEDICATION NAME] ([MEDICATION NAME]) level on Resident #41 on 2/27/19. LVN E said the laboratory requisition dated 2/21/19 was for [MEDICATION NAME] (Levetiracetam) and [MEDICATION NAME] ([MEDICATION NAME]) levels weekly. LVN E said she did not see an order for [REDACTED]. LVN E said she was unaware the labs were not drawn until it was brought to her attention. LVN E said LVN B told her Resident #41's laboratory work had been drawn today and the results were not back yet. LVN E said she called the contract laboratory and was told they had not received the blood yet (the contract laboratory was in Arlington and the blood specimens were drawn from a company from Lubbock). LVN E said when Resident #41 returned to the facility from the hospital, the new orders canceled out the previous orders. During an interview on 3/14/19 at 5:54 PM the Administrator was made aware of laboratory results not being in Resident #41's record. During an interview on 3/15/19 at 11:41 AM the Administrator said the former DON was terminated earlier this year. She said the ADON and the Interim DON (RN G) took over the DON responsibilities. The Administrator said no one specific was appointed in charge of labs. She said the facility monitored labs in their clinical meetings. She said we know if someone has labs, we make sure labs are being done, and follow up the next day. She said she did not have access to the laboratory website to get lab results. The Administrator said the ADON and Interim DON (RN G) worked it out among themselves in the morning meetings. The Administrator said the nurses would either go to the ADON or the Interim DON for any problems. The Administrator said the ADON had access on the computer to get lab results. During an interview on 3/15/19 at 11:50 AM RN G (Interim DON prior to the hiring of the current DON) said she did not have anything to do with the labs. She said the contract laboratory the facility was using was going to close and the facility was going to use a local laboratory service. She said she thought the nurses would write fax on the lab result paper when they were faxed to the doctor. She said if the doctor made any changes, the doctor would write it on the lab result paper, fax the paper back to the facility and the nurses would transcribe any new orders to the physician order [REDACTED]. During an interview on 3/15/19 at 12:29 PM with the ADON by telephone, she said she was designated for the labs. She said the Administrator and herself had been trying to fill in when the previous DON was terminated. She said the contract laboratory were sending incomplete lab results. She said she would try to call the laboratory at 10:00 AM, 1:00 PM, and/or 4:00 PM to try and get the lab results. She said she has heard that either this Thursday or Friday (3/14/19 or 3/15/19) the contract laboratory would no longer be doing the facility's lab work. She said the Administrator was working with a local hospital to do the facility's lab work. During an interview on 3/15/19 at 1:15 PM with the Family Nurse Practitioner (FNP), she said the [MEDICAL CONDITION] medication labs are usually done every week and then could be done monthly if stable. During an interview on 3/15/19 at 2:35 PM, RN H said the FNP had ordered stat labs for [MEDICATION NAME] (Levetiracetam) , [MEDICATION NAME] ([MEDICATION NAME]) , and [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) today, they would be drawn at the facility and taken to a local hospital. She said the facility would no longer use the contracted laboratory. She said the ADON would get the discharge paperwork from the hospital and write the re-admit orders. She said the nurses should clarify any orders as needed. Review of the facility's Policy and Procedure titled Lab Orders revised 3/2012 documented, in part: Policy: It is the policy of this home to provide or obtain laboratory services to meet the needs of its residents. The home is responsible for the timeliness of the services. The home must notify the attending physician of the lab results. Procedure: Lab orders will be printed on the MAR indicated [REDACTED] The DON/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician. The DON/designee will be responsible to notify the lab when a lab result is not received in a timely manner. The attending physician will be notified promptly of lab results. Review of the facility's Policy and Procedure dated 11/2017 on Medication Management documented, in part: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug without adequate monitoring Medication Management is based in the care process and includes recognition of, identification of the problem/need, assessment, diagnoses/cause identification, management/ treatment, monitoring, and revising interventions, as warranted, as well as documenting medication management steps. The attending physician plays a key leadership role in medication management by developing. monitoring, and modifying the medication regimen. The facility's medication management supports and promotes: The monitoring of medications for efficacy and adverse consequences. Procedures: The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis and with consideration of resident preferences. The consultant pharmacist or member of the Interdisciplinary team complies, analyzes, and presents findings regarding the proper monitoring of medication therapy to appropriate healthcare disciplines. The following conditions are satisfied prior to initiation and/or continuation of therapy: The need for and response to therapy are monitored and documented in the resident's medical record. Documentation that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine that the regimen in question is not the cause. The resident's medication regimen is evaluated when there is significant negative change from baseline. During an interview on 3/15/19 at 4:12 PM the Administrator, DON, Regional Corporate Consultant and Regional RN Consultant were informed of the Immediate Jeopardy (IJ). The facility was informed of the need of a Plan of Removal. During an interview on 3/15/19 at 5:37 PM the Regional Corporate Compliance Office said he made it to the facility about once a month and did not know how the lab process did not work. The Regional RN Consultant said he thought turnover and inadequate training contributed to the failure. Record review of the facility's Plan of Removal dated 3/15/19 documented: 1. The Medical Director was notified of the Immediate Jeopardy by the Administrator at 5:00 p.m. on 3/15/19. 2. Stat labs were drawn and sent to hospital for Resident #41. 3. Audit has been completed to ensure that all residents on anti-convulsants have lab results and that results have been reported to the physician. There were 12 residents. 4. Facility's practice related to pharmacy services related to inadequate lab monitoring and neglect related to physician clarification of lab orders. a. It is the facility's Administrator and DON/Designee's responsibility to ensure the policy on lab monitoring and following lab related physician orders [REDACTED]. Lab monitoring tool has been initiated and will be used going forward in the clinical stand up process. b. It is the responsibility of the nurses to notify the physician and lab services when necessary and appropriate. This will include critical lab values to be reported immediately to the physician. Also, lab results related to infections will be reported to the physician immediately. All other non-immediate labs will be faxed to physician's office and inserted into medical records for physician's review upon monthly visits. c. Licensed staff currently working have been in-serviced on pharmacy services and lab orders related to anti-convulsants. Other licensed staff will be in-serviced prior to working the floor. d. It is the responsibility of the Director of Nurses/Assistant Director of Nurses to ensure that all new telephone orders for labs as well as residents who are admitted and or readmitted are written correctly and this will be monitored daily by the DON/ADON or designee on the weekend or non-business days. This will be monitored during a daily meeting with a flip chart utilized. All pending labs will be followed up on in the time frame called for according to the type of lab ordered. 3. In-services a. The DON in-serviced the nursing staff on the policy and procedure related to pharmacy services related to inadequate lab monitoring and neglect related to physician clarification of lab orders. The clinical consultant has provided in-service with return demonstration of understanding. The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by return demonstration of understanding. The in-service will continue each shift to ensure all staff has the training and validate return demonstration of understanding. The licensed staff verbalize understanding of policy and procedure related to lab system. a. Physician orders [REDACTED].>b. Telephone order written c. Lab requisition completed in lab notebook d. Lab notification of all stat orders. e. All new labs documented on 24 hour report for follow up f. Labs reported to physician timely as indicated. During an interview on 3/15/19 at 5:43 PM with LVN J. She said she had been employed at the facility for 3 days. She said she was oriented to Hall 400 the previous day and this was her first shift by herself. She said she didn't know which residents were receiving therapeutic medications since she does not pass medications. During an interview on 3/15/19 at 5:52 PM RN H said she thought the IJ was because there was no way to track labs. She said there was no book or board in the med room or anything. RN H said she did not know what was ordered so they could not know what was coming in and then could not follow up on it. RN H said the only person who had a password to the Laboratory Service was the Assistant Director of Nurses. She said the current DON had not been at the facility long enough to put anything in place and the previous DON wasn't exactly open to suggestions. When asked why RN H did not bring the concerns to the Administrator, she said the Administrator is worried about other things than labs. During an interview on 3/15/19 at 5:52 PM, Medication Aide (MA) I said that Resident #30 was on [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) for behavioral problems and Resident #41 was on [MEDICATION NAME] (Levetiracetam), [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]), and [MEDICATION NAME] ([MEDICATION NAME]) for [MEDICAL CONDITION]. During an interview on 3/15/19 at 6:32 PM the Regional RN Consultant said the Medical Director okayed the facility getting stat labs on everyone so we can just start the calendar all over again. During an interview on 3/15/19 at 7:06 PM RN H said she was the Charge Nurse on halls 100 and 200. She confirmed she did receive an in-service on 3/15/19. She said the in-service covered lab orders, how we take the order, get the requisition, get it on 24 hour report, original goes in lab book, call family, and document it in the Nurse's Notes. During an interview on 3/15/19 at 7:25 PM Medication Aide (MA) F said while the facility was between DON's they had the Minimum Data Set RN stand in. MA F said she never knew anything and just dumped more and more on the ADON. During an interview on 03/15/19 at 07:37 PM with LVN J. She said they had an In-service on writing lab orders/protocols for any resident this evening. She said she understood the protocol. She said she will call the MD for clarification and call the DON for any other questions. She said the DON and MD telephone numbers are posted at nurse's station. During an interview on 3/15/19 at 7:54 PM the Administrator, Regional Corporate Consultant and Regional RN consultant was informed immediacy removed but the facility still remained out of compliance at a level of harm due to the lack of time to monitor their Plan of Removal. Resident #30 Record review of Resident #30's recent MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident # 30's Care Plan dated 1/24/19 documented a care plan for monitoring of [MEDICAL CONDITION] and lab values for therapeutic ranges. Review of Resident #30's consolidated Physician order [REDACTED]. - [MEDICATION NAME] ([MEDICATION NAME]) 250 mg 1 tablet po TID for Mood/[MEDICAL CONDITION] - [MEDICATION NAME] acid ([MEDICATION NAME]/[MEDICATION NAME]) lab monthly. Review of Resident #30's lab section: no results for (MONTH) or (MONTH) 2019. RESIDENT #73 Review of Resident #73's Resident Face Sheet (undated) documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #73's quarterly MDS assessment dated [DATE] documented in part: She had [DIAGNOSES REDACTED]. Review of Resident #73's Care Plan updated 1/24/19 documented no care plan for monitoring for [MEDICAL CONDITION] and/or medication monitoring. Review of Resident #73's Physician order [REDACTED]. - 3/18/16 for Valporic Acid ([MEDICATION NAME]/[MEDICATION NAME]) ([MEDICATION NAME]) tablet 250 mg three times a day - 5/30/18 [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) level one time a month. Review of Resident #73's lab section documented the last [MEDICATION NAME] Acid ([MEDICATION NAME]/[MEDICATION NAME]) level available was 8/3/18 and it was 15 (Low). RESIDENT #52 Review of Resident #52's Resident Face Sheet (undated) documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #52's quarterly MDS assessment dated [DATE] documented, in part: She had a [DIAGNOSES REDACTED].>She received hospice services. Review of Resident #52's Care Plan dated 1/1/18 documented she received an anti-convulsant medication. The Goal was: minimize the risk of [MEDICAL CONDITION] activity. Identified approaches included: monitor lab values for therapeutic ranges as ordered by my physician. Review of Resident #52's Physician order [REDACTED]. There were no lab orders for monitoring. Review of Resident #52's labs showed documented her last [MEDICATION NAME] ([MEDICATION NAME]) lab was dated 3/28/18 with a result of 5.0 (low). There were no new orders.

Based on record review and interview, the facility failed to inform the physician for 1 of 10 residents (Residents #1) reviewed for delay in care when there was a possible need for physician intervention. · The facility received an order for [REDACTED]. · Resident #1 was sent to the hospital on [DATE] and had a [DIAGNOSES REDACTED]. This failure resulted in a delay in medical treatment for [REDACTED]. This failure could affect any resident who received orders for lab work, to include, urinalysis and could result in delayed medical care. Findings included: Record review of Resident #1's undated admission and discharge summary documented she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1's MDS (Minimum Data Set) dated 08/20/16 indicated in part: · BIMS (Brief Interview Mental Status) = 09, indicating resident was moderately impaired. · [MEDICAL CONDITION]=Behavior not present. · Transfer = 3 (extensive assistance) and 2 (one person physical assist). · Personal hygiene = 3 (extensive assistance) and 2 (one person physical assist). · Functional limitation in range of motion = upper extremity impairment on one side; lower extremity impairment on one side. · Bowel and urinary continence = Always continent. · Active [DIAGNOSES REDACTED]. Record review of Resident #1's nurse's notes indicated in part: · 08/23/16: 7:00 pm., Resident noted with increased confusion; Doctor notified and ordered CBC, CMP and UA. Family here, made aware. Signed by LVN A. (2p-10p shift). (LVN=Licensed Vocational Nurse, CBC=complete blood count, CMP=chemistry profile) · 08/24/26: 1:00 am., Resting quietly in bed with eyes closed, respirations even, unlabored. No signs/symptoms of acute distress, incontinent care after each episode-continue to monitor. Signed by LVN B. (10p-6a shift). · 08/24/16: 3:00 pm., Upon report CNA (Certified Nurse Aide) and nurse had attempted to have resident urinate on bed side commode. Resident was unsuccessful and not following requests due to increased confusion. Resident was rendered with bed pan to see if she would urinate in the bed pan. Resident had BM (bowel movement) and urine specimen contaminated. Care rendered will try to get UA again. Signed by LVN C. (2p-10p shift). · 08/24/16: 9:00 pm., Attempted in and out straight cath with sterile technique with no urine return, left cath in for a few minutes with no urine return. Signed by LVN C. (2p-10p shift). · 08/25/16: 1:00 am., resting quietly in bed with eyes closed, will attempt to cath for UA. Signed by LVN B. (10p-6a shift). · 08/25/16: 9:00 am., Encouraging fluid and bedside commode to urinate with no urine output. Attempted in and out straight catheter again with no urine output. Signed by LVN C. (6a-2p shift). · 08/25/16: 3:00 pm., Family here informed family if she would sit in room with resident on bedside commode and encourage fluids to get UA, family agreed. Signed by LVN C. (2p-10p shift). · 08/25/16: 4:00 pm., Successful with urine sample put in ice, UA to be sent to lab in AM. Signed by LVN C. (2p-10p shift). · 08/26/16: (no time listed) UA results received, waiting new order per MD (Medical Doctor). Signed by LVN C. · 08/26/16: (no time listed) MD ordered [MEDICATION NAME] 1gm IM with [MEDICATION NAME] to be given until culture received. Signed by LVN C. ([MEDICATION NAME]= antibiotic, gm=gram, IM=intramuscular, [MEDICATION NAME]=numbing medication). · 08/26/16: 1:45 pm., Resident family request resident be sent to ER for further evaluation. MD ordered/aware. Ambulance transferred via stretcher to hospital. Signed by LVN C. Record review of Resident #1's facility's urinalysis report dated 08/26/16 indicated in part: · Blood= 3+++. Reference range (negative). See below for explanation. · Leukocytes = Large. Reference range (negative-trace). See below for explanation. · RBC's = 64+++. Reference range (0-5). See below for explanation. · WBC's = 598+++. Reference range (0-5). See below for explanation. · Bacteria = Many. Reference range (negative-few). See below for explanation. · MD notified 08/26/16 at 11:30am; [MEDICATION NAME] IM 1gm with [MEDICATION NAME] till culture report received. Red or white blood cells. Blood cells aren't found in urine normally. Inflammation disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine. Strenuous exercise, such as running a marathon, can also cause blood in the urine. White blood cells may be a sign of infection or kidney disease. Leukocyte esterase (WBC esterase). Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is present. Bacteria, yeast cells, or parasites. There are no bacteria, yeast cells, or parasites in urine normally. If these are present, it can mean you have an infection. Reference: www.webmd.com/a-to-z-guides/urine-test <http://www.webmd.com/a-to-z-guides/urine-test> Reviewed 09/23/16. Record review of Resident #1's facility's urine culture report dated 08/26/16 indicated in part: · Preliminary report: Gram negative bacilli isolated at >100,000 cfu/ml. ID and sensitivity to follow. (>=more than, cfu/ml= colony-forming units per milliliter, ID=identity). (Note: Gram negative bacilli is the name of the organsim detected in the urine). Record review of Resident #1's physician's telephone orders indicated in part: · 08/23/16: 7:00 pm. CBC, CMP and UA for confusion. (CBC=complete blood count, CMP=chemistry profile, UA=urinalysis). · 08/26/16: 1:45 pm May send to ER (emergency room ) for further evaluation. Record review of Resident #1's nurse to nurse report indicated in part: · 08/23/16: 2-10 shift= CBC, CMP, UA in AM. · 08/24/16: 10-6 shift= CBC, CMP, UA-need UA; 6-2 shift=need urine; 2-10 shift=needs UA. Record review of Resident #1's hospital records dated 08/26/16 indicated in part: · Time seen 2:39 pm. Chief complaint= decreased mental status-[MEDICAL CONDITION] (loss of ability to understand or express speech). Onset/duration = days ago. · Character of altered mental status: Decreased responsiveness-not speaking. · Baseline: Alert but disoriented to time. · 2:54 pm Urine obtained by catheterization. Indwelling catheter placed for acute urine output measurement in a critically ill patient. Difficult procedure requiring multiple attempts with several different sized catheters before successful urinary catheterization. Other complication: urethra to the right. · 3:15pm 3 liters IVF NS + [MEDICATION NAME] and [MEDICATION NAME] given. (IVF = intravenous fluid, NS= normal saline, [MEDICATION NAME] and [MEDICATION NAME] are antibiotics). 4:10pm temperature 99.0 F, patient aphasic; 4:35pm Patient with 101.0 F temperature; 5:35pm temperature 102.0 F, rectal Tylenol given; 6:00pm 103.0 F temperature. · Disposition: admitted -ICU (intensive care unit), condition when patient left department- critical. · Nursing notes: 3:00 pm Patient more drowsy lethargic; 5:00 pm Vital signs deteriorating HR [MEDICAL CONDITION] 120's, temperature increasing-patient having muscle tremors. · Labs: UA (urinalysis), WBC > 165 (white blood cells more than 165), RBC 10 (red blood cells 10), Positive [MEDICATION NAME], leukocytes 500. (normal ranges for WBC is 0-4, RBC is 0-3, [MEDICATION NAME] should be negative and leukocytes should be negative according to the hospital UA lab sheet). · Lab: CMP (comprehensive metabolic panel) [MEDICATION NAME] = 2.67 at 3:15 pm and 2.78 at 5:07 pm. (Normal range 0.5-2.2 mmoL/L according to hospital CMP lab sheet- mmoL/L = millimoles per litre). · Primary Diagnosis: [REDACTED]. · discharge date : 08/30/16- discharge [DIAGNOSES REDACTED]. 2. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], urinary tract infection resolved. 3. Urinary tract infection most likely bacterial [MEDICATION NAME]. 4. Acute kidney injury prerenal secondary to [MEDICAL CONDITION] resolved. During an interview on 09/12/16 at 3:29 p.m. LVN F said she was familiar with Resident #1. LVN F said Resident #1 was able to make her needs known. LVN F said Resident #1 could tell them if she needed to go to the restroom and could feed herself. LVN F said she came to work on 08/26/16 and Resident #1 told her she was not feeling well. LVN F said she remembered placing a hat in her bedside commode to catch the urine. LVN F said when she later checked the hat there was urine in the hat but disposed of it because she did not know how long the urine had been left in the hat. LVN F said throughout the day the resident got worse. (Hat=device placed in toilet to catch urine sample). During an interview on 09/13/16 at 2:45 p.m. LVN C said she attempted to straight-cath Resident #1 but could not get a urine return. LVN C said on 08/25/16 the resident was a little confused so she called the doctor and told him they still had not obtained a urine sample. LVN C said the doctor told her to encourage liquids and try to get the urine sample again. LVN C said on 08/26/16 Resident #1's daughter was at the facility and she asked the daughter if she could help with obtaining the urine sample. LVN C said she asked the daughter if she could sit with the resident while the resident sat on the bedside commode. LVN C said when she returned to check on them; the resident had urinated in the hat and the sample was collected then. LVN C said shortly after that she administered the antibiotic [MEDICATION NAME]. LVN C said the daughter then requested the resident be sent out to the hospital that same day 08/26/16 at 1:45 pm due to the resident's change in condition. LVN C said they sent the resident to the hospital and the daughter accompanied the resident in the ambulance. During an interview on 09/13/16 at 4:48 p.m. LVN G said they had attempted several ways to obtain a urine sample from Resident #1. LVN G said they tried by having her stand up but the urine would dribble down her leg, tried the bed pan but that did not work, tried the bedside commode and also no luck. LVN G said Resident #1 had refused to be straight-cathed when she had asked her. During an interview on 09/14/16 at 2:12 p.m. the ADON (Assistant Director of Nurses) said she assisted LVN H with attempting to straight-cath Resident #1 like 2 days later after the order was received. The ADON said they had not been successful in obtaining the urine sample. The ADON said it seemed the resident's uterus was like tilted making difficult to insert the catheter. The ADON said Resident #1 was alert and awake X3 (X3 indicates resident was alert to person, place and time). The ADON said Resident #1 knew her by name but on the last day she was at the facility on 08/26/16 the resident was confused and did not even remember her name. During a telephone interview on 09/15/16 at 11:00 p.m. LVN B said she had straight-cathed Resident #1 on 08/23/16 and 08/24/16 during the night shift but had not being able to obtain a urine sample due to no urine return. LVN B said she thought she had documented the attempts on the nurse's notes. During a telephone interview on 09/16/16 at 9:05 a.m. the DON (Director of Nurses) said on 09/15/16 she discussed with the doctor what his thoughts were on whether or not to send Resident #1 to the hospital due to her vital signs being stable. The DON said the doctor said from his point of view he did not believe that it required for the resident to be sent out if her vital signs were normal. During a telephone interview on 09/16/16 at 10:10 a.m. the facility doctor said since Resident #1 did not have an elevated temperature he did not believe the facility had to send the resident to the hospital. The doctor said if the facility could not obtain a urine sample and the resident was getting worse then maybe they should have sent her to the hospital. During an interview on 09/16/16 at 2:37 p.m. LVN A said on 08/23/16 he went to administer Resident #1's medication. LVN A said the resident's daughter was at bedside. LVN A said the daughter told him the resident was not being herself and did not even recognize her when she usually did. LVN A said he then also noticed the resident was having increased confusion so he called the doctor. LVN A said the doctor ordered some lab work including a UA. LVN A said he did not have time to attempt to get a UA at that time. Record review of the facility's policy and procedure dated 03/2012 indicated in part: · It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following. · A significant change in the resident's physical, mental or psychosocial status such as a deterioration in health, mental psychosocial status, in life threatening conditions or clinical complications; a decision to transfer or discharge the resident from the home. · After resident changes in condition including but not limited to falls, injuries, change in health and psychosocial status conduct a thorough assessment and compare against baseline. · The attending physician should be notified as soon as possible if immediate attention required or as soon as feasible if the resident is stable. · If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. Record review of the facility's room roster provided on 09/20/16 indicated there were 85 residents at the facility.

Based on interview and record review, the facility failed to ensure each resident received and was provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for 1 (Resident #1) of 10 residents reviewed for quality of care. · The facility failed to monitor Resident #1 ' s bowel movements despite a problem with constipation. Resident #1 was sent to the emergency roiagnom on [DATE] due to a change in condition and was diagnosed with [REDACTED]. · The facility received an order to obtain a UA (urinalysis) from Resident #1 on 08/23/16 at 7:00 p.m. but the facility did not obtain the UA until 08/25/16 at 4:00 p.m., 45 hours later. This deficient practice affected Resident #1 and could place 53 residents that had a [DIAGNOSES REDACTED]. Findings included: Record review of Resident #1's undated admission and discharge summary documented she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1's MDS (Minimum Data Set) dated 08/20/16 indicated in part: · BIMS (Brief Interview Mental Status) = 09, indicating resident was moderately impaired. · [MEDICAL CONDITION]=Behavior not present. · Transfer = 3 (extensive assistance) and 2 (one person physical assist). · Personal hygiene = 3 (extensive assistance) and 2 (one person physical assist). · Functional limitation in range of motion = upper extremity impairment on one side; lower extremity impairment on one side. · Bowel and urinary continence = Always continent. · Active [DIAGNOSES REDACTED]. Record review of Resident #1's facility's start up orders dated 08/08/16 indicated in part: · [MEDICATION NAME] 5mg by mouth daily. Hour- PRN. DX: Constipation. ([MEDICATION NAME]=stimulant laxative, mg=milligram, Dx=diagnosis, PRN=as needed). From 08/08/16 through 08/26/16 there was no documentation found indicating the medication had been administered. · MOM 30ml by mouth every HS. Hour-PRN if no BM X 2days. Dx: constipation. (MOM=milk of magnesia, ml=milliliter, HS=hour of sleep, BM=bowel movement). From 08/08/16 through 08/26/16 it was documented this medication was administered once on 08/10/16 but there were no documentation/results found indicating if the medication had been effective. · Fleets enema per rectally if MOM ineffective. Hour- PRN. From 08/08/16 through 08/26/16 there was no documentation found indicating the medication had been administered. Record review of Resident #1's nurse to nurse report indicated in part on 08/12/16: - 6-2 shift= monitor BM states hasn't had since last week/bomb given; - 2-10 shift=used bathroom several times. During an interview on 09/20/16 at 10:49 a.m. LVN J said she was the author of the note on the nurse to nurse report dated 08/12/16 where it indicated monitor BM states hasn't had since last week/bomb given. LVN J said that day Resident #1's daughter had called the facility and told her the resident had not had a bowel movement since last week. LVN J said she went and asked the resident when was the last time she had a bowel movement. LVN J said Resident #1 told her she did not remember when she last had a bowel movement and that she had not been regular. LVN J said she told the CMA to administer the bomb. LVN J said the bomb consisted of prune juice, [MEDICATION NAME] and MOM. LVN J said she did not remember if she had asked the CNA's if she had regular bowel movements after that. LVN J said she would tell the CNA's if the residents were having loose stools or if resident's complained of not having bowel movements in 2 or 3 days to notify her. During an interview on 09/16/16 at 2:37 p.m. LVN A said he was the nurse that documented used bathroom several times regarding Resident #1 on the nurse to nurse notes dated 08/12/16. LVN A said he did not personally observe the resident's bowel movements but that he documented that based on what the CNAs told him. LVN A said he did not recall which CNA told him that. Record review of Resident #1's care plan conference summary dated 08/18/16 indicated in part: Summary of care plan conference discussion: Family concerned with constipation- MD notified- medication given- will monitor for BM. (resident's daughter was present at meeting). Record review of Resident #1's physician's telephone orders dated 08/18/16 at 8:30 am, Senna 2 tabs PO QHS Dx: Constipation. (Senna=laxative, PO=by mouth, QHS=every hour of sleep, Dx=diagnosis). Record review of Resident #1's nurses notes dated 08/23/16 at 7:00 pm documented Resident noted with increased confusion, Doctor notified and ordered CBC, CMP and UA. Family here made aware. Signed by LVN A. (2p-10p shift). (LVN=Licensed Vocational Nurse, CBC=complete blood count, CMP=chemistry profile) During an interview on 09/16/16 at 2:37 p.m. LVN A said on 08/23/16 he went to administer Resident #1's medication. LVN A said the resident's daughter was at bedside. LVN A said the daughter told him the resident was not being herself and did not even recognize her when she usually did. LVN A said he then also noticed the resident was having increased confusion so he called the doctor. LVN A said the doctor ordered some lab work including a UA. LVN A said he did not have time to attempt to get a UA at that time. Resident #1's physician's telephone orders dated 08/23/16 at 7:00pm - CBC, CMP and UA for confusion. (CBC=complete blood count, CMP=chemistry profile, UA=urinalysis). Record review of Resident #1's nurse to nurse report indicated in part: · 08/23/16: 2-10 shift= CBC, CMP, UA in AM. · 08/24/16: 10-6 shift= CBC, CMP, UA-need UA; 6-2 shift=need urine; 2-10 shift= needs UA. Resident #1's nurses notes dated 08/24/26 at 1:00 am documented Resting quietly in bed with eyes closed, respirations even, unlabored. No signs/symptoms of acute distress, incontinent care after each episode-continue to monitor. Signed by LVN B. (10p-6a shift). During a telephone interview on 09/15/16 at 11:00 p.m. LVN B said she had straight-cathed Resident #1 on 08/23/16 and 08/24/16 during the night shift and had not being able to obtain a urine sample due to no urine return. LVN B said she thought she had documented the attempts on the nurse's notes. Resident #1's nurses notes dated 08/24/26 at 3:00 pm Upon report CNA (Certified Nurse Aide) and nurse had attempted to have resident urinate on bed side commode. Resident was unsuccessful and not following requests due to increased confusion. Resident was rendered with bed pan to see if she would urinate in the bed pan. Resident had BM (bowel movement) and urinated specimen contaminated. Care rendered will try to get UA again. Signed by LVN C. (2p-10p shift). Resident #1's nurses notes dated 08/24/26 at 9:00 pm, Attempted in and out straight cath with sterile technique with no urine return, left cath in for a few minutes with no urine return. Signed by LVN C. (2p-10p shift). (6 hours after the last documented time Resident #1 urinated) Review of Resident #1 ' s nurses notes indicated: · 08/25/16: 1:00 am., resting quietly in bed with eyes closed, will attempt to cath for UA. Signed by LVN B. (10p-6a shift). · 08/25/16: 9:00 am., Encouraging fluid and bedside commode to urinate with no urine output. Attempted in and out straight catheter again with no urine output. Signed by LVN C. (6a-2p shift). (18 hours after the last documented time Resident #1 urinated) · 08/25/16: 3:00 pm., Family here informed family if she would sit in room with resident on bedside commode and encourage fluids to get UA, family agreed. Signed by LVN C. (2p-10p shift). (24 hours after the last documented time Resident #1 urinated) · 08/25/16: 4:00 pm., Successful with urine sample put in ice, UA to be sent to lab in AM. Signed by LVN C. (2p-10p shift). · 08/26/16: (no time listed) UA results received, waiting new order per MD (Medical Doctor). Signed by LVN C. · 08/26/16: (no time listed) MD ordered [MEDICATION NAME] 1gm IM with [MEDICATION NAME] to be given until culture received. Signed by LVN C. ([MEDICATION NAME]= antibiotic, gm=gram, IM=intramuscular, [MEDICATION NAME]=numbing medication). · 08/26/16: 1:45 pm., Resident family request resident be sent to ER for further evaluation. MD ordered/aware. Ambulance transferred via stretcher to hospital. Signed by LVN C. Record review of Resident # 1's facility's urinalysis report dated 08/26/16 indicated in part: · Blood= 3+++. Reference range (negative). See below for explanation. · Leukocytes = Large. Reference range (negative-trace). See below for explanation. · RBC's = 64+++. Reference range (0-5). See below for explanation. · WBC's = 598+++. Reference range (0-5). See below for explanation. · Bacteria = Many. Reference range (negative-few). See below for explanation. · MD notified 08/26/16 at 11:30am, [MEDICATION NAME] IM 1gm with [MEDICATION NAME] till culture received. According to www.webmd.com/a-to-z-guides/urine-test <http://www.webmd.com/a-to-z-guides/urine-test> (Reviewed 09/23/16), - Red or white blood cells. Blood cells aren't found in urine normally. Inflammation disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine .White blood cells may be a sign of infection or kidney disease. -Leukocyte esterase (WBC esterase). Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is present. - Bacteria, yeast cells, or parasites. There are no bacteria, yeast cells, or parasites in urine normally. If these are present, it can mean you have an infection. Record review of Resident #1's facility's urine culture report dated 08/26/16 indicated in part: · Preliminary report: Gram negative bacilli isolated at >100,000 cfu/ml. ID and sensitivity to follow. (>=more than, cfu/ml= colony-forming units per milliliter, ID=identity). (Note: Gram negative bacilli is the name of the organism detected in the urine). Record review of Resident #1's physician's telephone orders dated 08/26/16 at 1:45pm - May send to ER (emergency room ) for further evaluation. Resident #1's ADL tracking log dated August 2016 indicated there was no documentation indicating if resident was having bowel movements. In the Bowel section, the 1st shift, 2nd shift and 3rd shift slots from 08/08/16 through 08/26/16 were blank. During an interview on 09/15/16 at 4:23 p.m. the DON (Director of Nurses) said the CNA's probably did not document Resident #1's bowel movements because that was the only ADL flow sheet for that resident. Record review of Resident #1's hospital records dated 08/26/16 indicated in part: · Time seen 2:39 pm. Chief complaint= decreased mental status-[MEDICAL CONDITION] (loss of ability to understand or express speech). Onset/duration = days ago. · Character of altered mental status: decreased responsiveness-not speaking. · Baseline: Alert but disoriented to time. · 2:54pm Urine obtained catheterization indwelling catheter placed for acute urine output measurement in a critically ill patient. Difficult procedure requiring multiple attempts with several different sized catheters before successful urinary catheterization. Other complication: urethra to the right. · 3:15pm 3 liters IVF NS + [MEDICATION NAME] and [MEDICATION NAME] given. (IVF = intravenous fluid, NS= normal saline, [MEDICATION NAME] and [MEDICATION NAME] are antibiotics). 4:10pm temperature 99.0 F, patient aphasic.; 4:35pm Patient with 101.0 F temperature; 5:35pm temperature 102.0 F, rectal Tylenol given; 6:00pm 103.0 F temperature. · Disposition: admitted - ICU (intensive care unit), condition when patient left department- critical. · Nursing notes: 3:00 pm Patient more drowsy lethargic; 5:00 pm Vital signs deteriorating HR [MEDICAL CONDITION] 120's, temperature increasing-patient having muscle tremors; 7:58 pm disimpacted with PA about 240cc's. (PA=Physician Assistant, cc=cubic centimeters). · Procedure: CT abdomen/pelvis with intravenous contrast. Stomach and bowel: Significant fecal retention in the rectosigmoid colon. Increased fecal retention. · Labs: UA (urinalysis), WBC > 165 (white blood cells more than 165), RBC 10 (red blood cells 10), Positive [MEDICATION NAME], leukocytes 500. (normal ranges for WBC is 0-4, RBC is 0-3, [MEDICATION NAME] should be negative and leukocytes should be negative according to the hospital UA lab sheet). · Lab: CMP (comprehensive metabolic panel) [MEDICATION NAME] = 2.67 at 3:15pm and 2.78 at 5:07pm. (Normal range 0.5-2.2 mmoL/L according to hospital CMP lab sheet- mmoL/L = millimoles per litre). · Primary Diagnosis: [REDACTED]. · discharge date : 08/30/16- discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], urinary tract infection resolved; 3. Urinary tract infection most likely bacterial [MEDICATION NAME].; 4. Acute kidney injury prerenal secondary to [MEDICAL CONDITION] resolved. During an interview on 09/12/16 at 1:50 p.m. HA (Hospitality Aide) E said she recalled providing care for Resident #1 when she was at the facility. HA E said she could not recall if the resident was having regular bowel movements nor recalled documenting them on the bowel movement ADL sheet. During an interview on 09/12/16 at 3:29 p.m. LVN F said she was familiar with Resident #1. LVN F said Resident #1 was able to make her needs known. LVN F said Resident #1 could tell them if she needed to go to the restroom and could feed herself. LVN F said she came to work on 08/26/16 and Resident #1 had told her she was not feeling well. LVN F said she remembered placing a hat in her bedside commode to catch the urine. LVN F said when she later checked the hat there was urine in the hat but disposed of it because she did not know how long the urine had been left in the hat. LVN F said throughout the day the resident got worse. (Hat=device placed in toilet to catch urine sample). During an interview on 09/13/16 at 2:45 p.m. LVN C said she had attempted to straight-cath Resident #1 but could not get a urine return. LVN C said on 08/25/16 the resident was a little confused so she called the doctor and told him they still had not obtained a urine sample. LVN C said the doctor told her to encourage liquids and try to get the urine sample again. LVN C said on 08/26/16 Resident #1's daughter was at the facility so she asked the daughter if she could help with obtaining the urine sample. LVN C said she asked the daughter if she could sit with the resident while the resident sat on the bedside commode. LVN C said when she returned to check on them; the resident had urinated in the hat and the sample was collected then. LVN C said shortly after that she administered the antibiotic [MEDICATION NAME]. LVN C said the daughter then requested the resident be sent out to the hospital that same day 08/26/16 at 1:45pm due to the resident's change in condition. LVN C said they sent the resident to the hospital and the daughter accompanied the resident in the ambulance. During an interview on 09/13/16 at 4:48 p.m. LVN G said they had attempted several ways to obtain a urine sample from Resident #1. LVN G said they tried by having her stand up but the urine would dribble down her leg, tried the bed pan but that did not work, tried the bedside commode and also no luck. LVN G said Resident #1 had refused to be straight-cathed when she had asked her. During an interview on 09/14/16 at 2:12 p.m. the ADON (Assistant Director of Nurses) said she assisted LVN H with attempting to straight-cath Resident #1 2 days later after the order was received. The ADON said they had not been successful in obtaining the urine sample. The ADON said it seemed the resident's uterus was like tilted making difficult to insert the catheter. The ADON said Resident #1 was alert and awake X3 (X3 indicates resident was alert to person, place and time). The ADON said Resident #1 knew her by name but on the last day she was at the facility on 08/26/16 the resident was confused and did not even remember her name. During a telephone interview on 09/16/16 at 10:10 a.m. the facility doctor said because Resident #1 did not have an elevated temperature he did not believe the facility had to send the resident to the hospital. The doctor said if the facility could not obtain a urine sample and the resident was getting worse then maybe they should have sent her to the hospital. During an interview on 09/16/16 at 2:42 p.m. CNA I said he remembered working the hall where Resident #1 resided on 08/12/16. CNA I said he remembered assisting Resident #1 to the restroom but could not recall if she was having regular bowel movements. During an interview on 09/16/16 at 5:30 p.m. the hospital ER-PA (emergency room -Physician Assistant) said Resident #1's abdomen was very distended so she ordered an x-ray of her abdomen. The PA said the x-ray indicated the resident had a significant amount of fecal retention or fecal impaction which was the same thing. The PA said she disimpacted-removed some of the stool which provided some comfort to the resident. During an interview on 09/19/16 at 4:00 p.m. the DON said she could not locate a specific policy on bowel monitoring. The DON said they had done an in-service in regards to that but at the time could not locate it. The DON said the CNA was to report to the nurse if the resident had not had a bowel movement in 2 or 3 days. The DON said the nurse was to then administer PRN laxative medication if the resident had an order for [REDACTED]. Record review of the facility's policy and procedure dated 03/2012 indicated in part: · It is the policy of this home to Inform the resident, the residents physician and if indicated the residents responsible party of the following. · A significant change in the resident's physical, mental or psychosocial status such as deterioration in health, mental psychosocial status, in life threatening conditions or clinical complications; a decision to transfer or discharge the resident from the home. · After resident changes in condition including but not limited to falls, injuries, change in health and psychosocial status conduct a thorough assessment and compare against baseline. · The attending physician should be notified as soon as possible if immediate attention required or as soon as feasible if the resident is stable. · If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. Record review of the facility's room roster provided on 09/20/16 indicated there were 53 residents with a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 9 sampled residents (Resident #5, and #9) reviewed for falls. a) Resident #5 fell on [DATE] which resulted in a femur (leg) fracture. CNA A failed to properly transfer the resident from the commode to her wheelchair. After the fall, CNA A proceeded to transfer the Resident from the floor to the wheelchair and then from the wheelchair to her bed, prior to alerting the nurse so an assessment could be performed prior to moving the resident. b) Resident #9 fell backward in his bed on 5/14/16, hitting his right shoulder and upper back. CNA A failed to use the physician ordered mechanical lift while transferring the resident from his wheelchair to his bed. This deficient practice placed 3 residents reviewed who required use of a mechanical lift with transfers and 6 residents reviewed who had fallen at risk for additional falls with injuries. Findings include: RESIDENT #5 The undated face sheet indicated Resident #5 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set significant change (MDS) assessment dated [DATE] revealed she had severely impaired cognition. The resident's functional status for transfers was listed as requiring extensive assistance with one person physical assistance. Review of Resident #5's Plan of Care dated 1/27/16 revealed the resident to be at risk for falls related to cognitive and mobility impairment with approaches/interventions including Give resident verbal reminders not to ambulate/transfer without assistance and Resident safe to go to restroom unassisted. Encourage to use call light if assistance needed. Review of Resident #5's fall risk assessment dated [DATE] revealed the resident to have a score of 26; anything greater than a score of 10 is considered high risk. Review of the provider investigation report dated 5/17/16 reflected that on 5/14/16 at 8:55 p.m., CNA A assisted Resident #5 with transferring from the commode to her wheelchair. When the resident stood up, CNA A began to pull up the resident's pants and began to transfer the resident to the left where her wheelchair was. The resident got out of balance and could not move her legs. CNA A held onto the resident but both lost their balance as CNA A was behind the resident instead of in front. The resident fell face forward to the floor, hitting her forehead. The resident's feet were bent and she complained of pain instantly. CNA A proceeded to transfer the resident from the floor to the wheelchair and then onto bed. It was after CNA A put the resident to bed that she then informed her charge nurse, LVN B of the incident. LVN B assessed Resident #5 to have a contusion to her head, pain to her right elbow, right knee, right leg and to her head. Resident #5 was sent to the hospital via 911. The report showed the facility suspended CNA A pending the outcome of their investigation. The provider investigation report had written statements attached. CNA A wrote in her statement: On the afternoon of 5/14/16, I went on break. During the break another aide looked after the residents on the hall (hall 400). The other aide took Resident #5 to the rest room. The resident stayed in the rest room a few minutes. Then I came off break at 8:25 p.m. and saw Resident #5's call light on so I went to go help her off the toilet. I went to the left side of the toilet, held the right and left side of her pants and began to raise her to transfer to the left which is where the wheel chair was. During this, Resident #5 got out of balance; she couldn't move her legs. I held onto her as tightly as I could but had lost balance as I was standing from behind her back. Then she fell face forward to the floor on her forehead, feet were bent and she was aching from pain. I went on to transfer from floor to wheel chair and then from wheel chair to bed. After I put blankets on her the other aide walked into the room. We both walked out and I told her Resident #5 fell in the restroom and I helped her off the toilet to bed. I went to nurse's station and let LVN B know the resident needed help. LVN B wrote in her statement, CNA A reported to me that she had an emergency with a resident and I should go assess her. Upon arrival to the room the resident was lying on her bed with a contusion to her head. Resident #5 said she had pain to her right elbow, right leg and knee and to her head. 911 was initiated and the resident was taken to the hospital via ambulance. The physician, Director of Nurses (DON), and family were notified. Review of the X-ray completed on 5/14/16 showed fracturing of the distal right femur above the knee joint. In an interview on 5/24/16 at 9:00 a.m. (at the new facility her family transferred her to), Resident #5 was in bed with her right leg brace on. With an interpreter (facility administrator) the resident said she did not remember the incident. She did say she hurt, and pointed to her right leg. The administrator said the resident is no longer able to bear weight on her leg, does not go to the restroom anymore, has in indwelling catheter and is incontinent of bowel. The administrator said the resident was on two pain medications, Tramadol 50 milligrams every 6 hours as needed and Norco 5/325 milligrams three times a day. In an interview on 5/18/16 at 4:30 p.m., the administrator and DON said CNA A was suspended then terminated as a result of the incident involving Resident #5. The Administrator said, Well there was more to her being fired than just this resident. The administrator said CNA A had another issue regarding transfers with another resident this same day. The administrator and DON said CNA A failed to use the mechanical lift to transfer Resident #9 and he fell back in his bed, her falling on him. They both said they were not aware of this incident until 3 days later 5/17/16, when Resident #9 told his charge nurse, LVN C. The DON added, CNA A knew to use the mechanical lift and she had another aide in the room to help, but she attempted to transfer him by herself. All aides have the resident's care plans on the back of their rest room door so at any time any aide knows what the resident requires. RESIDENT #9 The undated face sheet indicated Resident #9 was a [AGE] year old Hispanic male admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #9's quarterly MDS assessment dated [DATE] revealed he was alert and oriented. Resident #9 was total assist of one staff for all activities of daily living and he was a total assist that required two staff for transfers. Review of Resident #9's Admission Plan of Care dated 9/14/15 revealed the resident required maximum assist with a mechanical lift for all transfers. The resident was considered high risk for falls due to the stroke and left sided weakness. The care plan was updated on 5/14/16 and revealed, Hoyar lift for all transfers. Aide failed to use the lift and transferred him by one person and he landed on bed, her on top. Resident bruised his right upper side and complained of right sided pain. X-ray done and negative. Staff education complete and refer to restorative. Review of Resident #9's current physician monthly orders dated 3/1/16 - 4/30/16 and good for 90 days showed an order for [REDACTED]. The order was originally dated 9/17/15. Review of the provider investigation report dated 5/20/16 reflected that on 5/14/16 during the 2/10 shift, during a two person transfer the resident became stiff, the Hoyar was not used and 2 aides fell on resident as he fell on to his bed. CNA A was terminated (was currently on suspension for the incident involving Resident #3), staff were inserviced regarding proper transfer using a lift and the resident was started on restorative therapy. The provider investigation report had written statements attached. HA (hospitality aide) D wrote in her statement: CNA A asked me to assist her in transferring Resident #9 from his wheel chair to his bed. After entering his room I took off his shoes then she asked me to step back and that's when she transferred him by herself to his bed. All of this occurred Saturday the 14th of May. She did not fall or injure the resident in any way. Review of nurse's notes showed: - 5/17/16 at 10:45 a.m., LVN C wrote, CNA reported that resident complains of back pain and it had been reported to her that on 5/14/16 during a transfer to the bed 2 CNA's (Certified Nurse Aides) stated they did not use the Hoyar lift and resident became stiff during transfer and they fell on top of him as he fell to the bed. This nurse assessed the resident at this time from head to toe and noted to have swelling and tender to his right mid back. Notified the doctor and received order for X-ray and Tylenol #3 one tablet every 6 hours. Attempted to call family but no answer. (The family was reached at 1:00 p.m. this same day). - 5/17/16 at 7:00 p.m. showed no acute findings from the X-ray. In an interview on 5/23/16 at 2:00 p.m., Resident #9 was in his bed resting. LVN C accompanied the surveyor and interpreted the conversation in Spanish to assure the resident understood. Resident #9 said it was only CNA A who attempted to transfer him and she did not use the lift. Resident #9 said HA D was in the room with CNA A but did not help CNA A transfer him. He said he hit his right upper back and shoulder on his side rail and pointed to the rail and his back. He said his back still hurt somewhat. LVN C said at this time, You always use two staff to work the lift. LVN C added that she did not learn of the incident until 3 days after it happened. In a telephone interview on 5/23/16 at 2:45 p.m., CNA A said she had been a CNA for two years and had worked at the facility since February 2016. CNA A spoke of the incident involving Resident #3. She said, Her call light was going off so I went to help her. the building was short staffed and I was in a bit of a rush. The resident was in her restroom and wanted off the toilet immediately. The red light was flashing and this means a hurry and do something so I transferred her but the resident wanted to use the sink first to wash her hands. The resident lost her balance in all of this. The restroom is very crowded. The resident changed her footing and tripped over herself and I went down with her. Staff were all busy playing around instead of working so I got her off the floor and in bed because she kept telling me get me up. CNA A was then asked about the incident regarding Resident #9. CNA A said HA D was not helping; instead she kept saying how she hated the job and was going to quit. I had no help at all and HA D was no help. They train us to have two people for the lifts but HA D would not help so I decided to just do the transfer myself. I didn't want to make him suffer staying in his wheelchair and he wanted in his bed so I tried to put him there but he became stiff and fell in the bed and I fell on him. Review of the facility's policy and procedure dated 1/2008 and revised 3/2012 titled 'Mechanical Lift documented, in part: It is the policy of this home to utilize Hoyar lifts when it is necessary to safely transfer a resident due to body weight or physical condition. Review of the facility's policy and procedure dated 1/2008 and revised 3/2014 titled 'Abuse- Reportable Events documented, in part: It is the policy of this home to prohibit resident abuse or neglect in any form. Under the section titled Training: It is the responsibility of every employee to report immediately anything that could affect the health and welfare of any resident. Failure to immediately report any such occurrence will result in disciplinary action, and may include termination of employment. On 5/24/16 at 10:30 a.m., the Administrator provided a list of 38 residents identified as requiring transfer assistance of some degree from facility staff. The list include there were 11 residents who required a mechanical lift for transfers.

Based on observation, interview, and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care for 2 (Resident #5 and #9) of 9 residents reviewed for falls. A) CNA A failed to properly transfer Resident #5 from the commode to the wheelchair and the resident fell , sustaining injury. CNA A then proceeded to transfer Resident #5 from the floor to the wheelchair and then from the wheelchair to the bed without notifying the charge nurse so a physical assessment could be performed prior to moving the resident; B) CNA A failed to use a physician ordered mechanical lift to transfer Resident #9 from his wheelchair to his bed and the resident fell backward in to his bed hitting his right upper back and shoulder on the side rail. CNA A did not report the incident. This deficient practice placed 3 residents reviewed who required use of a mechanical lift with transfers and 6 residents reviewed who had fallen at risk for additional falls with injuries. Findings included: RESIDENT #5 The undated face sheet indicated Resident #5 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set significant change (MDS) assessment dated [DATE] revealed she had severely impaired cognition. The resident's functional status for transfers was listed as requiring extensive assistance with one person physical assistance. Review of Resident #5's Plan of Care dated 1/27/16 revealed the resident to be at risk for falls related to cognitive and mobility impairment with approaches/interventions including Give resident verbal reminders not to ambulate/transfer without assistance and Resident safe to go to restroom unassisted. Encourage to use call light if assistance needed. Review of Resident #5's fall risk assessment dated [DATE] revealed the resident to have a score of 26; anything greater than a score of 10 is considered high risk. Review of the provider investigation report dated 5/17/16 reflected that on 5/14/16 at 8:55 p.m., CNA A assisted Resident #5 with transferring from the commode to her wheelchair. When the resident stood up, CNA A began to pull up the resident's pants and began to transfer the resident to the left where her wheelchair was. The resident got out of balance and could not move her legs. CNA A held onto the resident but both lost their balance as CNA A was behind the resident instead of in front. The resident fell face forward to the floor, hitting her forehead. The resident's feet were bent and she complained of pain instantly. CNA A proceeded to transfer the resident from the floor to the wheelchair and then onto bed. It was after CNA A put the resident to bed she then informed her charge nurse, LVN B of the incident. LVN B assessed Resident #5 to have a contusion to her head, pain to her right elbow, right knee, right leg and to her head. Resident #5 was sent to the hospital via 911. The report showed the facility suspended CNA A pending the outcome of their investigation. The provider investigation report dated 5/17/16 also had written statements attached. CNA A wrote in her statement: On the afternoon of 5/14/16, I went on break. During the break another aide looked after the residents on the hall (hall 400). The other aide took Resident #5 to the rest room. The resident stayed in the rest room a few minutes. Then I came off break at 8:25 p.m. and saw Resident #5's call light on so I went to go help her off the toilet. I went to the left side of the toilet, held the right and left side of her pants and began to raise her to transfer to the left which is where the wheel chair was. During this, Resident #5 got out of balance; she couldn't move her legs. I held onto her as tightly as I could but had lost balance as I was standing from behind her back. Then she fell face forward to the floor on her forehead, feet were bent and she was aching from pain. I went on to transfer from floor to wheel chair and then from wheel chair to bed. After I put blankets on her the other aide walked into the room. We both walked out and I told her Resident #5 fell in the restroom and I helped her off the toilet to bed. I went to nurse's station and let LVN B know the resident needed help. LVN B wrote in her statement, CNA A reported to me that she had an emergency with a resident and I should go assess her. Upon arrival to the room the resident was lying on her bed with a contusion to her head. Resident #5 said she had pain to her right elbow, right leg and knee and to her head. 911 was initiated and the resident was taken to the hospital via ambulance. The physician, Director of Nurses (DON), and family were notified. Review of the X-ray completed on 5/14/16 showed fracturing of the distal right femur above the knee joint. In an interview on 5/24/16 at 9:00 a.m. (at the new facility her family transferred her to), Resident #5 was in bed with her right leg brace on. With an interpreter (facility administrator) the resident said she did not remember the incident. She did say she hurt, and pointed to her right leg. The administrator said the resident is no longer able to bear weight on her leg, does not go to the restroom anymore, has in indwelling catheter and is incontinent of bowel. The administrator said the resident was on two pain medications, [MEDICATION NAME] 50 milligrams every 6 hours as needed and [MEDICATION NAME] 5/325 milligrams three times a day. In an interview on 5/18/16 at 4:30 p.m., the administrator and DON said CNA A was suspended then terminated on 5/20/16 as a result of the incident involving Resident #5. The Administrator said, Well there was more to her being fired than just this resident. The administrator said CNA A had another issue regarding transfers with another resident this same day. The administrator and DON said CNA A failed to use the mechanical lift to transfer Resident #9 and he fell back in his bed, her falling on him. They both said they were not aware of this incident until 3 days later 5/17/16, when Resident #9 told his charge nurse, LVN C. The DON added, CNA A knew to use the mechanical lift and she had another aide in the room to help, but she attempted to transfer him by herself. All aides have the resident's care plans on the back of their rest room door so at any time any aide knows what the resident requires. RESIDENT #9 The undated face sheet indicated Resident #9 was a [AGE] year old Hispanic male admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #9's quarterly MDS assessment dated [DATE] revealed he was alert and oriented. Resident #9 was total assist of one staff for all activities of daily living and he was a total assist that required two staff for transfers. Review of Resident #9's Admission Plan of Care dated 9/14/15 revealed the resident required maximum assist with a mechanical lift for all transfers. The resident was considered high risk for falls due to the stroke and left sided weakness. The care plan was updated on 5/14/16 and revealed, Hoyar lift for all transfers. Aide failed to use the lift and transferred him by one person and he landed on bed, her on top. Resident bruised his right upper side and complained of right sided pain. X-ray done and negative. Staff education complete and refer to restorative. Review of Resident #9's current physician monthly orders dated 3/1/16 - 4/30/16 and good for 90 days showed an order for [REDACTED]. Review of the provider investigation report dated 5/20/16 reflected that on 5/14/16 during the 2/10 shift, during a two person transfer the resident became stiff, the Hoyar was not used and 2 aides fell on resident as he fell on to his bed. CNA A was terminated (was currently on suspension for the incident involving Resident #3), staff were inserviced regarding proper transfer using a lift and the resident was started on restorative therapy. The provider investigation report had written statements attached. HA (hospitality aide) D wrote in her statement: CNA A asked me to assist her in transferring Resident #9 from his wheel chair to his bed. After entering his room I took off his shoes then she asked me to step back and that's when she transferred him by herself to his bed. All of this occurred Saturday the 14th of May. She did not fall or injure the resident in any way. Review of nurse's notes showed: - 5/17/16 at 10:45 a.m., LVN C wrote, CNA reported that resident complains of back pain and it had been reported to her that on 5/14/16 during a transfer to the bed 2 CNA's (Certified Nurse Aides) stated they did not use the Hoyar lift and resident became stiff during transfer and they fell on top of him as he fell to the bed. This nurse assessed the resident at this time from head to toe and noted to have swelling and tender to his right mid back. Notified the doctor and received order for X-ray and Tylenol #3 one tablet every 6 hours. Attempted to call family but no answer. (The family was reached at 1:00 p.m. this same day). - 5/17/16 at 7:00 p.m. showed no acute findings from the X-ray. In an interview on 5/23/16 at 2:00 p.m., Resident #9 was in his bed resting. LVN C accompanied the surveyor and interpreted the conversation in Spanish to assure the resident understood. Resident #9 said it was only CNA A who attempted to transfer him and she did not use the lift. Resident #9 said HA D was in his room and removed his shoes but did not help CNA A transfer him. He said he hit his right upper back and shoulder on his side rail and pointed to the rail and his back. He said his back still hurt somewhat. LVN C said at this time, You always use two staff to work the lift. LVN C added that she did not learn of the incident until 3 days after it happened. In a telephone interview on 5/23/16 at 2:45 p.m., CNA A said she had been a CNA for two years and had worked at the facility since February 2016. CNA A said she had been trained to use a mechanical lift and felt comfortable using one. CNA A spoke of the incident involving Resident #3. She said, Her call light was going off so I went to help her. the building was short staffed and I was in a bit of a rush. The resident was in her restroom and wanted off the toilet immediately. The red light was flashing and this means a hurry and do something so I transferred her but the resident wanted to use the sink first to wash her hands. The resident lost her balance in all of this. The restroom is very crowded. The resident changed her footing and tripped over herself and I went down with her. Staff were all busy playing around instead of working so I got her off the floor and in bed because she kept telling me get me up. CNA A was then asked about the incident regarding Resident #9. CNA A said HA D was not helping her; instead, HA D kept saying how she hated the job and was going to quit. CNA A said HA D had been trained and checked off (skills competency checklist) to be able to safely use the lift. CNA A continued, I had no help at all and HA D was no help. They train us to have two people for the lifts but HA D would not help so I decided to just do the transfer myself. I didn't want to make him suffer staying in his wheelchair and he wanted in his bed so I tried to put him there but he became stiff and fell in the bed and I fell on him. Review of the facility's policy and procedure dated 1/2008 and revised 3/2012 titled 'Mechanical Lift documented, in part: It is the policy of this home to utilize Hoyar lifts when it is necessary to safely transfer a resident due to body weight or physical condition. Review of the facility's policy and procedure dated 1/2008 and revised 3/2014 titled 'Abuse- Reportable Events documented, in part: It is the policy of this home to prohibit resident abuse or neglect in any form. Under the section titled Training: It is the responsibility of every employee to report immediately anything that could affect the health and welfare of any resident. Failure to immediately report any such occurrence will result in disciplinary action, and may include termination of employment. On 5/24/16 at 10:30 a.m., the Administrator provided a list of 38 residents identified as requiring transfer assistance of some degree from facility staff. The list include there were 11 residents who required a mechanical lift for transfers.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care for 1 of 9 residents reviewed for a significant change of condition (Resident #1) as evidenced by failure of Licensed Vocational Nurse A, Licensed Vocational Nurse B, and Registered Nurse C to thoroughly assess and treat Resident #1's pain throughout the weekend of February 6 and 7, 2016 after Resident #1 complained of severe pain and was unable to get out of bed following a fall that resulted in multiple fractures. This deficient practice resulted in severe pain over a two day period for Resident #1 and could result in discomfort, pain, and depression for the 42 residents who had conditions that required pain management. Findings included: 1. An undated Resident Admission Record documented Resident #1 was an [AGE] year-old male admitted to the facility 7/24/15 with [MEDICAL CONDITION], ischemic [MEDICAL CONDITION], hypertension, chronic [MEDICAL CONDITION] embolism, acute embolism lower extremity, [MEDICAL CONDITIONS], and shortness of breath. A 7/28/15 history and physical also documented Resident #1 had [MEDICAL CONDITION]. 2. A Minimum Data Set (MDS) Assessment for Resident #1 dated 1/14/16 documented he had a Brief Interview for Mental Status (BIMS) score of 14 indicating he was not cognitively impaired; he required limited assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygeine, and he utilized a wheelchair for mobility. He was frequently incontinent of bowel and bladder. The MDS documented that Resident #1 was prescribed pain medication on an as-needed basis and he reported he had not had any pain in the previous five days. The MDS documented no falls since admission. 3. physician's orders [REDACTED]. (milligrams) every 6 hours prn (as needed) for pain, unspecified. 4. A January 2016 PRN (As needed) Medications Flowsheet for Resident #1 documented that in January, Resident #1 received a total of 9 doses of [MEDICATION NAME] during the month. 5. A Comprehensive Pain Assessment Form for Resident #1, dated 1/23/15 (most recent on file) documented Resident #1 did not have pain in the past 5 days and rarely had pain. When he did have pain, his pain was an aching pain that was completely relieved with medication. 6. A nurse's note dated 2/8/16 at 0845 (8:45 a.m.) documented that Resident #1 was being sent to the hospital due to all-over pain. The writer documented that Resident # 1 said he had fallen while transferring himself. The note documented Resident #1 was guarded with every limb and stated that his hip, back, arms, and legs hurt. 7. Multiple Hospital Imaging Reports for Resident #1 dated 2/8/16 included the following findings: Multifocal (arising from two or more places) right posterolateral (on the side and toward the back of the body) rib fractures; Mildly displaced fractures of the right fourth, fifth, sixth, seventh, eighth, and ninth posterolateral ribs; Severe L1 (first lumbar vertebrae) compression fracture has progressed as compared to previous examination suggestive of a possible acute or chronic time course; and Suspicion of a [MEDICAL CONDITION] scapula (shoulder blade) below the glenoid (the cavity in the shoulder blade into which the head of the upper arm bone fits). 8. During an interview on 2/16/16 at 4:00 p.m., Resident #1 was alert and oriented to person, place, and time. When asked if he had a recent fall, Resident #1 said that he had gotten up out of bed during the night and lost his balance. He said he fell on his bottom. He said he did not know how he broke his ribs because at the time of the fall he just felt immediate, intense pain in his bottom. He said it felt like a thousand needles, and that is what he told the nurse that was on duty. When asked if the nurse looked at his bottom after he fell , he said, Not until three days later! Resident #1 said, I told them something was broken. I was in a lot of pain. I didn't know what to do! All day, I told them I was in pain, I said, I got a lot of pain, you gotta do something! and they (staff) kept saying, 'We can't do anything right now, we'll give you a pain killer'. Resident #1 said, I told them but they ignored me. You don't know, I went through hell! I told them to do something, you know those ribs really hurt. I couldn't sit and I couldn't get up. Resident #1 said, I had to fight with 'em, I know how I feel! I said, please, please, please help me! The pain was enormous! When asked about the nurse's note on Sunday (February 7) that documented he was up, smiling and cheerful, and waving his arms and torso around denying pain, Resident #1 said that was not true. Resident #1 said that after he got the stronger pain medication, he had a lot of relief and could get up and move around now. 9. A Facility Provider Investigation Report dated 2/8/16 documented that on 2/8/16, Resident #1 was complaining of pain to his back, legs, arms, and hips, stating he had fallen on 2/6/15 at 1:00 a.m. The report documented that Resident #1 got up on his own when he fell and had put himself back to bed, but the charge nurse was aware of the fall. Resident #1 was noted to have a skin tear to his right wrist and an abrasion to his left shin. He was sent to the emergency room for evaluation (2/8/16) and was determined to have multiple acute rib fractures and a right scapular (shoulder blade) fracture. The facility documented that they conducted in-services to the staff on falls and abuse, and put a low bed and floor mats in place for the resident. The facility attached an inservice titled Falls dated 2/9/16. The Summary of the meeting said See Attached. Attached was the facility's fall policy and procedure. The facility also attached an in-service titled Abuse dated 2/9/16 and the facility's policy on Abuse was attached. 10. The following nurse's notes were attached to the Investigation Report (and also filed under nurse's notes in Resident #1's record). LVN (Licensed Vocational Nurse) D: 2/11/16: On 2/8/16 at 0800 (8:00 a.m.) the CMA (certified medication aide) informed me that Resident #1 was complaining of pain. When I got to his room he was complaining of all over pain, stating that he had fallen on the floor while self-transferring. He stated that he had gotten himself back into bed. After I assessed him, I asked the charge nurse that worked the weekend if he had fell . She told me that he had fallen on Saturday 2/6/16 in the early morning during the 10-6 shift. I notified the Dr. (Doctor) and sent him to (hospital) ER (emergency room ) to be evaluated . LVN B: 2/6/16 0645 (6:45 a.m.) Charge Nurse reported to this nurse that rsd (resident) had a fall at 0100 (1:00 a.m.). CNA (Certified Nurse's aide) reported that this time that rsd c/o (complaining of) pain et (and) wants to stay in bed for breakfast. CMA notified to administer pain medication at this time. Rsd tray brought to his room. Effective results noted. Rsd up for lunch in wheelchair without further c/o (complaints of) pain/discomfort. In pleasant mood. No guarding or grimacing noted. A statement dated 2/11/16 by CMA E documented that on Saturday 2/6/15, LVN A told her that Resident #1 had fallen that night. CMA E documented that Resident #1 complained of pain at 10:00 a.m. and LVN B authorized administration of [MEDICATION NAME] 50 mg. (milligrams). CMA E documented that on Sunday February 7, Resident #1 remained in bed and refused to get up. She documented he verbalized pain and she gave him [MEDICATION NAME]. She documented on Monday February 8, Resident #1 told her he was feeling much worse and he cried out when she lifted his head, so she notified LVN D. 11. Nurse's notes in Resident #1's record included the notes (above) that were attached to the investigation report and in addition, included the following: 2/6/16 at 0100: Sitting in floor with back up against bed stated, feet just sliped (sp) from under him. non-skid socks on. V/S (vital signs) 97.6-78-19, 136/74. Denies hitting head. Noted 0.5 cm (centimeter) ST (skin Tear) to R (right) wrist. Cleaned with NS (normal saline) and band aide applied. Has abrasion to L shin (leg). Hand grasp equal. PERL (pupils equal and reactive to light), moves all extremities. Nurse aide and myself assisted up to bed. (Written by LVN A) 2/6/16 at 0220 (2:20 a.m.) C/O (Complaining of achayness (sp) medicated with [MEDICATION NAME] 50 mg po (by mouth) per orders. (Written by LVN A) 2/6/16 0330 (3:30 a.m.) Resting in bed. Eyes closed. Resp (respiration) even and non labored. No noted distress at this time. (Written by LVN A) 2/7/16 2100 (9:00 p.m.) Resident denies any discomfort after fall. waving arms and twisting torso to demonstrate no discomfort. smiling and cheerful. (Written by Registered Nurse C). Undated Note by CNA F: Saturday the 6th of February at about 6:45 a.m. I went to Resident #1's room to get him dressed for breakfast. As I was turning him in bed to get his brief on, he was complaining of pain in his chest and back. I asked him what happened and he explained that he had fallen that night and wanted to stay in bed. I finished changing him and went to tell my nurse (LVN B). She simply said, Just ask the med aid for pain medicine for him. Then I told her and after breakfast I went to check on Resident #1 once again and he said the pain went down and he felt better. Before lunch I went to change and get Resident #1 up so that he could eat, but he said he just wanted to stay in bed. After that I told my nurse and she said, Ok that was fine. When lunch was over, I did my last round and Resident #1 told me he was hurting again and I told my nurse that he was in pain. 12. A facility Incident/Accident Report dated 2/8/16 at 8:30 a.m. documented that Resident #1 reported that he fell while transferring himself on 2/6/15. An assessment of Resident #1 was documented as a skin tear to his right wrist and an abrasion to his left shin. The incident report documented that the physician was notified on 2/8/16 at 8:00 a.m. and Resident #1 was sent to the emergency room for evaluation. 13. During an interview on 2/16/16 at 1:50 p.m., the DON (Director of Nurses) said that LVN A was terminated because she did not complete the required paperwork following Resident #1's fall, and she did not notify the physician. She said LVN A did not write a nurse's note or an incident report. She said, There was nothing. She said that the three nurse's notes that were on record for 2/6/16 were late entries that LVN A wrote on Monday, February 8, when the DON asked her to write what occurred. When asked whether LVN B and RN C treated Resident #1's pain or called the physician, the DON said that LVN B and RN C thought LVN A notified the physician. When asked who told her that, since there were no nurse's notes regarding physician contact or physician's orders [REDACTED]. When discussing that Resident #1 was complaining about pain multiple on Saturday, could not get out of bed to eat or use the restroom, and LVN B and RN C still did not call the physician and report the fall and pain, the DON first said she thought that was fine if the [MEDICATION NAME] he already had was effective. When discussing whether the chest and back pain Resident #1 complained about on Saturday was his usual pain the DON acknowledged it was not and that it was new pain. She then said the physician should have been called. 14. During an interview on 2/16/16 at 12:00 noon, LVN A said that she was working with Resident #1 the night he fell . She said she was new and this was her first night to work alone. She said the nurse aide alerted her Resident #1 was on the floor. She said she assessed Resident #1 and he said his bottom hurt. She said he had an abrasion on his shin and a skin tear on his wrist. She said she assisted the nurse aide to put him back to bed. She said she gave him a pain pill about 2:00 a.m. or 2:20 a.m. She said it was a busy night and she had another fall in the building that she had to send to the emergency room . She said she worked with Resident #1 again the second night and thought she gave him pain medication that night. She said she was giving him pain medication off of an existing order for [MEDICATION NAME] for general pain. She said the facility's policy was that she was supposed to have notified the resident's physician before her shift ended the night of the fall, but she didn't. She said she told the oncoming nurse (LVN B) who led her to believe that she would notify the physician. LVN A said the facility terminated her for not calling the physician and not completing an incident report. 15. During an interview on 2/16/16 at 3:40 p.m., CNA G said she was on duty with LVN A the night Resident #1 fell and that she also worked the following night (Saturday night) with LVN A. CNA G said that she found Resident #1 on the floor when making rounds. He told her that he fell when he got up to use his urinal. She said that she and LVN A put Resident #1 back to bed. CNA G said that the next night when she went in to care for him she asked him to turn over and he told her he could not turn because of pain in his chest. CNA G said Resident #1 usually used a urinal but he could not use the urinal and went to the bathroom in his brief that night. CNA G said she knew that she reported Resident #1's pain to LVN A at least twice that night, but could not say whether LVN A ever went into the room to assess Resident #1 and she did not know if Resident #1 got any pain medication. 16. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident#1 for the Month of February documented that for night shift on February 6, 2016 (the night Resident #1 fell ), Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time. The pain management flowsheet only documented that the post-pain rating at 4:00 a.m. was 0. On the night of 2/7/16, LVN A documented one dose of [MEDICATION NAME] 50 mg. at an unidentified time and stated the medication was effective at 6:10 a.m. 17. During interviews on 2/16/15 at 11:10 a.m. and 2/22/16 at 1:40 p.m., CNA F said that she worked the day (6:00 a.m. to 2:00 p.m.) shifts with LVN B on 2/6/16 and 2/7/16. CNA F said that on Saturday 2/6/16, Resident #1 was moaning in pain when she turned him, which was unusual for him. CNA F said she told LVN B and LVN B told her to tell the medication aide. CNA F said she did not have to move him again until after lunch, and Resident #1 again moaned in pain at being moved. She said that she told LVN B again that Resident #1 was in pain. CNA F said that on last rounds Resident #1 was moaning in pain again, though she waiting until she had finished her hall before she went to tell LVN B again. She said it would have been about shift change time the last time she told LVN B. CNA F said she did not know if LVN B went in to assess Resident #1 after she reported the pain each time. CNA F said Resident #1 never got out of bed on her shift. When discussing how the resident was on Sunday, [DATE], CNA F said she really could not remember, but thought it was about the same as Saturday, and if he complained about pain she would have told the nurse. 18. During interviews on 2/16/16 at 10:45 a.m. and a telephone interview on 2/17/16 at 3:35 p.m., LVN B first stated in both interviews that she wrote the note dated 2/6/16 at 0645 (6:45 a.m.) on that date and time. LVN B later acknowledged during the interview on 2/17/16 that when she was contacted by the Director of Nurses on Monday 2/8/16 regarding events of the weekend for Resident #1, there were no notes from her. She said she had written one but it was gone. She said the note that was currently in the record with the date of 2/16/16 at 0645 was actually written on 2/18/16. LVN B said that on Saturday, February 6, 2016 in the morning, Resident #1 complained to her that he had pain all over. She said she did not call the doctor because he already had an order for [REDACTED]. When asked about CNA F's report that she had told LVN B three times that Resident #1 was in pain on Saturday, LVN B said that she medicated him with [MEDICATION NAME] after the first two complaints, but the third complaint was reported to her when she was leaving for the day so she just told the evening shift nurse about it, and the evening nurse indicated she would check on him. When asked how Resident #1 was on Sunday, LVN B said he was about the same as Saturday. She said he was hurting and did not want to get out of bed and that she gave him [MEDICATION NAME]. When discussing that there were no nursing notes from her at all on Sunday, she said she just missed it. 19. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident#1 for the Month of February documented that for day shift on February 6, 2016, Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time. The pain management flowsheet only documented that his post-pain rating at 11:00 a.m. was 0. The Medication sheets did not document any [MEDICATION NAME] administered on 2/7/16 on the day shift. 20. During interviews 2/16/16 at 4:30 p.m. and 2/22/16 at 5:05 p.m., RN (Registered Nurse) C said she was the charge nurse on Resident #1's hall on the evening shifts (2:00 p.m. to 10:00 p.m.) Saturday, February 6 and Sunday, February 7, 2016. She said she did not write any nurse's notes on Saturday February 6 regarding Resident #1. She said, I'm not even sure I knew he had fallen on Saturday. When discussing that LVN B said in her interview that she had discussed Resident #1's fall and his pain with RN C at shift change on Saturday, RN C said that what LVN B said was not true. She said they did not have any such conversation. RN C said she could not say why she did not assess Resident #1 on her shift on 2/6/16, except that she probably did not know she needed to. When discussing the nurse's note that RN C wrote on Sunday February 7, 2016, at 9:00 p.m., RN C said in her first interview that she assessed the resident at shift change on 2/7/16 (2:00 p.m.) and then wrote the nurse's note that evening at 9:00 p.m. During the second interview when she was asked about the discrepancy of her note following LVN A's note that was not written until 2/8/16, RN C then acknowledged that she did not write the note dated 2/7/16 until 2/8/16 when asked to write a note by the Director of Nurses. RN C said, But the note was true. He wasn't in pain or I would have sent him out. 21. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident #1 for the Month of February documented that for evening shift on February 6, 2016, Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time for c/o (complaint of) pain and was assessed that the medication was effective at 4:00 p.m. On 2/7/16 one dose of [MEDICATION NAME] was administered for c/o pain and determined effective at 5:00 p.m. 22. A physician's telephone order dated 2/9/16 documented an order for [REDACTED]. 23. The PRN Medication Flowsheet and Pain Management Flowsheet for Resident #1 documented his first dose of [MEDICATION NAME] 5/325 mg. for pain was administered on 2/9/16 at 11:00 p.m. 24. The In-services for Falls and Abuse on 2/9/16 were not attended by LVN B and RN C according to the signature pages. 25. During interviews on 2/22/16 at 10:30 a.m., 4:00 p.m., and 5:00 p.m., and 2/23/16 at 9:45 a.m. the RN Consultant for the facility stated the DON was not available for follow up interviews the last two days of this investigation due to a family emergency. He said that he was aware of Resident #1's injuries and the facility's investigation that took place. The RN Consultant said that if Resident #1 was cognitively intact and said that he suffered pain all weekend, then he would tend to believe him. He said that the nurses involved over the weekend should all have been disciplined and in-serviced on pain management and physician notification, and he had initiated those actions following the surveyor's inquiries. 26. During an interview on 2/17/16 at 3:25 p.m., Resident #1's physician said he was not notified regarding Resident #1's fall, reports of pain, or injuries until 2/8/16. The physician said there was not much to do for the fractures in the way of treatment, except treat the pain. He said he should have been notified when Resident #1 complained of chest and back pain Saturday morning. 27. The facility's policy and procedure titled, Falls-Evaluation and Prevention revised on 9/2014 included the following: Under, Following a fall, the following steps should be undertaken: .Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of an injury . 28. The facility's policy and procedure titled, Pain Management Revised 11/2013 included the following: 1. Each resident's pain will be assessed using the Comprehensive Pain Assessment upon admission, re-admission, the onset or an increase in pain, quarterly, and whenever there is a significant change in condition that may cause an increase in pain. .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is . .11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non pharmacological measures.\ 29. On 2/23/16 the Assistant Director of Nursing reported that there were 42 residents in the facility that were taking pain medications.

Based on interview and record review, the facility failed to consult with the resident's physician when there was an accident that resulted in injury and had the potential for requiring physician intervention and a need to alter treatment for 1 of 9 residents reviewed for a significant change of condition (Resident #1) as evidenced by failure of Licensed Vocational Nurse A, Licensed Vocational Nurse B, and Registered Nurse C to notify Resident #1's physician throughout the weekend of February 6 and 7, 2016 after Resident #1 fell and complained of severe pain. On February 8, Resident #1 was diagnosed with [REDACTED]. This deficient practice resulted in a delay of physician intervention and effective pain relief for Resident #1 for two days and could result in discomfort, pain, and depression for the 42 residents who had conditions that required pain management and who could experience a significant change in their condition. Findings included: 1. An undated Resident Admission Record documented Resident #1 was an [AGE] year-old male admitted to the facility 7/24/15 with [MEDICAL CONDITION], ischemic [MEDICAL CONDITION], hypertension, chronic [MEDICAL CONDITION] embolism, acute embolism lower extremity, [MEDICAL CONDITIONS], and shortness of breath. A 7/28/15 history and physical also documented Resident #1 had [MEDICAL CONDITION]. 2. A Minimum Data Set (MDS) Assessment for Resident #1 dated 1/14/16 documented he had a Brief Interview for Mental Status (BIMS) score of 14 indicating he was not cognitively impaired; he required limited assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygeine, and he utilized a wheelchair for mobility. He was frequently incontinent of bowel and bladder. The MDS documented that Resident #1 was prescribed pain medication on an as-needed basis and he reported he had not had any pain in the previous five days. The MDS documented no falls since admission. 3. physician's orders [REDACTED]. (milligrams) every 6 hours prn (as needed) for pain, unspecified. 4. A January 2016 PRN (As needed) Medications Flowsheet for Resident #1 documented that in January, Resident #1 received a total of 9 doses of [MEDICATION NAME] during the month. 5. A Comprehensive Pain Assessment Form for Resident #1, dated 1/23/15 (most recent on file) documented Resident #1 did not have pain in the past 5 days and rarely had pain. When he did have pain, his pain was an aching pain that was completely relieved with medication. 6. A nurse's note dated 2/8/16 at 0845 (8:45 a.m.) documented that Resident #1 was being sent to the hospital due to all-over pain. The writer documented that Resident # 1 said he had fallenwhile transferring himself. The note documented Resident #1 was guarded with every limb and stated that his hip, back, arms, and legs hurt. 7. Multiple Hospital Imaging Reports for Resident #1 dated 2/8/16 included the following findings: Multifocal (arising from two or more places) right posterolateral (on the side and toward the back of the body) rib fractures; Mildly displaced fractures of the right fourth, fifth, sixth, seventh, eighth, and ninth posterolateral ribs; Severe L1 (first lumbar vertebrae) compression fracture has progressed as compared to previous examination suggestive of a possible acute or chronic time course; and Suspicion of a [MEDICAL CONDITION] scapula (shoulder blade) below the glenoid (the cavity in the shoulder blade into which the head of the upper arm bone fits). 8. During an interview on 2/16/16 at 4:00 p.m., Resident #1 was alert and oriented to person, place, and time. When asked if he had a recent fall, Resident #1 said that he had gotten up out of bed during the night and lost his balance. He said he fell on his bottom. He said he did not know how he broke his ribs because at the time of the fall he just felt immediate, intense pain in his bottom. He said it felt like a thousand needles, and that is what he told the nurse that was on duty. When asked if the nurse looked at his bottom after he fell , he said, Not until three days later! Resident #1 said, I told them something was broken. I was in a lot of pain. I didn't know what to do! All day, I told them I was in pain, I said, I got a lot of pain, you gotta do something! and they (staff) kept saying, 'We can't do anything right now, we'll give you a pain killer'. Resident #1 said, I told them but they ignored me. You don't know, I went through hell! I told them to do something, you know those ribs really hurt. I couldn't sit and I couldn't get up. Resident #1 said, I had to fight with 'em, I know how I feel! I said, please, please, please help me! The pain was enormous! When asked about the nurse's note on Sunday (February 7) that documented he was up, smiling and cheerful, and waving his arms and torso around denying pain, Resident #1 said that was not true. Resident #1 said that after he got the stronger pain medication, he had a lot of relief and could get up and move around now. 9. The following nurse's notes were attached to the Investigation Report (and also filed under nurse's notes in Resident #1's record). LVN (Licensed Vocational Nurse) D: 2/11/16: On 2/8/16 at 0800 (8:00 a.m.) the CMA (certified medication aide) informed me that Resident #1 was complaining of pain. When I got to his room he was complaining of all over pain, stating that he had fallen on the floor while self-transferring. He stated that he had gotten himself back into bed. After I assessed him, I asked the charge nurse that worked the weekend if he had fell . She told me that he had fallen on Saturday 2/6/16 in the early morning during the 10-6 shift. I notified the Dr. (Doctor) and sent him to (hospital) ER (emergency room ) to be evaluated . LVN B: 2/6/16 0645 (6:45 a.m.) Charge Nurse reported to this nurse that rsd (resident) had a fall at 0100 (1:00 a.m.). CNA (Certified Nurse's aide) reported that this time that rsd c/o (complaining of) pain et (and) wants to stay in bed for breakfast. CMA notified to administer pain medication at this time. Rsd tray brought to his room. Effective results noted. Rsd up for lunch in wheelchair without further c/o (complaints of) pain/discomfort. In pleasant mood. No guarding or grimacing noted. A statement dated 2/11/16 by CMA E documented that on Saturday 2/6/15, LVN A told her that Resident #1 had fallen that night. CMA E documented that Resident #1 complained of pain at 10:00 a.m. and LVN B authorized administration of [MEDICATION NAME] 50 mg. (milligrams). CMA E documented that on Sunday February 7, Resident #1 remained in bed and refused to get up. She documented he verbalized pain and she gave him [MEDICATION NAME]. She documented on Monday February 8, Resident #1 told her he was feeling much worse and he cried out when she lifted his head, so she notified LVN D. 10. Nurse's notes in Resident #1's record included the notes (above) that were attached to the investigation report and in addition, included the following: 2/6/16 at 0100: Sitting in floor with back up against bed stated, feet just sliped (sp) from under him. non-skid socks on. V/S (vital signs) 97.6-78-19, 136/74. Denies hitting head. Noted 0.5 cm (centimeter) ST (skin Tear) to R (right) wrist. Cleaned with NS (normal saline) and band aide applied. Has abrasion to L shin (leg). Hand grasp equal. PERL (pupils equal and reactive to light), moves all extremities. Nurse aide and myself assisted up to bed. (Written by LVN A) 2/6/16 at 0220 (2:20 a.m.) C/O (Complaining of achayness (sp) medicated with [MEDICATION NAME] 50 mg po (by mouth) per orders. (Written by LVN A) 2/6/16 0330 (3:30 a.m.) Resting in bed. Eyes closed. Resp (respiration) even and non labored. No noted distress at this time. (Written by LVN A) 2/7/16 2100 (9:00 p.m.) Resident denies any discomfort after fall. waving arms and twisting torso to demonstrate no discomfort. smiling and cheerful. (Written by Registered Nurse C). Undated Note by CNA F: Saturday the 6th of February at about 6:45 a.m. I went to Resident #1's room to get him dressed for breakfast. As I was turning him in bed to get his brief on, he was complaining of pain in his chest and back. I asked him what happened and he explained that he had fallen that night and wanted to stay in bed. I finished changing him and went to tell my nurse (LVN B). She simply said, Just ask the med aid for pain medicine for him. Then I told her and after breakfast I went to check on Resident #1 once again and he said the pain went down and he felt better. Before lunch I went to change and get Resident #1 up so that he could eat, but he said he just wanted to stay in bed. After that I told my nurse and she said, Ok that was fine. When lunch was over, I did my last round and Resident #1 told me he was hurting again and I told my nurse that he was in pain. 10. A facility Incident/Accident Report dated 2/8/16 at 8:30 a.m. documented that Resident #1 reported that he fell while transferring himself on 2/6/15. An assessment of Resident #1 was documented as a skin tear to his right wrist and an abrasion to his left shin. The incident report documented that the physician was notified on 2/8/16 at 8:00 a.m. and Resident #1 was sent to the emergency room for evaluation. 11. During an interview on 2/16/16 at 1:50 p.m., the DON (Director of Nurses) said that LVN A was terminated because she did not complete the required paperwork following Resident #1's fall, and she did not notify the physician. When asked whether LVN B and RN C called the physician, the DON said that LVN B and RN C thought LVN A notified the physician. When asked who told her that, since there were no nurse's notes regarding physician contact or physician's orders [REDACTED]. When discussing that Resident #1 was complaining about pain multiple times on Saturday, could not get out of bed to eat or use the restroom, and LVN B and RN C still did not call the physician and report the fall and pain, the DON first said she thought that was fine if the [MEDICATION NAME] he already had was effective. When discussing whether the chest and back pain Resident #1 complained about on Saturday was his usual pain the DON acknowledged it was not and that it was new pain. She then said the physician should have been called. 12. During an interview on 2/16/16 at 12:00 noon, LVN A said that she was working with Resident #1 the night he fell . She said she was new and this was her first night to work alone. She said the nurse aide alerted her Resident #1 was on the floor. She said she assessed Resident #1 and he said his bottom hurt. She said he had an abrasion on his shin and a skin tear on his wrist. She said she assisted the nurse aide to put him back to bed. She said she gave him a pain pill about 2:00 a.m. or 2:20 a.m. She said it was a busy night and she had another fall in the building that she had to send to the emergency room . She said the facility's policy was that she was supposed to have notified the resident's physician before her shift ended the night of the fall, but she didn't. She said she told the oncoming nurse (LVN B) who led her to believe that she would notify the physician. LVN A said the facility terminated her for not calling the physician. 13. During an interview on 2/16/16 at 3:40 p.m., CNA G said she was on duty with LVN A the night Resident #1 fell and that she also worked the following night (Saturday night) with LVN A. CNA G said that she found Resident #1 on the floor when making rounds. He told her that he fell when he got up to use his urinal. She said that she and LVN A put Resident #1 back to bed. CNA G said that the next night when she went in to care for him she asked him to turn over and he told her he could not turn because of pain in his chest. CNA G said Resident #1 usually used a urinal but he could not use the urinal and went to the bathroom in his brief that night. 14. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident#1 for the Month of February documented that for night shift on February 6, 2016 (the night Resident #1 fell ), Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time. The pain management flowsheet only documented that the post-pain rating at 4:00 a.m. was 0. On the night of 2/7/16, LVN A documented one dose of [MEDICATION NAME] 50 mg. at an unidentified time and stated the medication was effective at 6:10 a.m. 15. During interviews on 2/16/15 at 11:10 a.m. and 2/22/16 at 1:40 p.m., CNA F said that she worked the day (6:00 a.m. to 2:00 p.m.) shifts with LVN B on 2/6/16 and 2/7/16. CNA F said that on Saturday 2/6/16, Resident #1 was moaning in pain when she turned him, which was unusual for him. CNA F said she told LVN B and LVN B told her to tell the medication aide. CNA F said she did not have to move him again until after lunch, and Resident #1 again moaned in pain at being moved. She said that she told LVN B again that Resident #1 was in pain. CNA F said that on last rounds Resident #1 was moaning in pain again, though she waiting until she had finished her hall before she went to tell LVN B again. She said it would have been about shift change time the last time she told LVN B that Resident #1 was moaning in pain. When discussing how the resident was on Sunday, [DATE], CNA F said she really could not remember, but thought it was about the same as Saturday, and if he complained about pain she would have told the nurse. 16. During interviews on 2/16/16 at 10:45 a.m. and a telephone interview on 2/17/16 at 3:35 p.m., LVN B said that on Saturday, February 6, 2016 in the morning, Resident #1 complained to her that he had pain all over. She said she did not call the doctor because he already had an order for [REDACTED]. When asked about CNA F's report that she had told LVN B multiple times that Resident #1 was in pain on Saturday, LVN B said that she medicated him with [MEDICATION NAME] after the first two complaints, but the third complaint was reported to her when she was leaving for the day so she just told the evening shift nurse about it, and the evening nurse indicated she would check on him. When asked how Resident #1 was on Sunday, LVN B said he was about the same as Saturday. She said he was hurting and did not want to get out of bed and that she gave him [MEDICATION NAME]. LVN B said she did not call the doctor on Saturday or Sunday. 17. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident #1 for the Month of February documented that for day shift on February 6, 2016, Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time. The pain management flowsheet only documented that his post-pain rating at 11:00 a.m. was 0. The Medication sheets did not document any [MEDICATION NAME] administered on 2/7/16 on the day shift. 18. During interviews 2/16/16 at 4:30 p.m. and 2/22/16 at 5:05 p.m., RN (Registered Nurse) C said she was the charge nurse on Resident #1's hall on the evening shifts (2:00 p.m. to 10:00 p.m.) Saturday, February 6 and Sunday, February 7, 2016. She said, I'm not even sure I knew he had fallen on Saturday. When discussing that LVN B said in her interview that she had discussed Resident #1's fall and his pain with RN C at shift change on Saturday, RN C said that what LVN B said was not true. She said they did not have any such conversation. RN C said she could not say why she did not assess Resident #1 on her shift on 2/6/16, except that she probably did not know she needed to. When discussing the nurse's note that RN C wrote on Sunday February 7, 2016, at 9:00 p.m., RN C said in her first interview that she assessed the resident at shift change on 2/7/16 (2:00 p.m.) and then wrote the nurse's note that evening at 9:00 p.m. During the second interview when she was asked about the discrepancy of her note following LVN A's note that was not written until 2/8/16, RN C then acknowledged that she did not write the note dated 2/7/16 until 2/8/16 when asked to write a note by the Director of Nurses. RN C said, But the note was true. He wasn't in pain or I would have sent him out. 19. A PRN Medication Flowsheet and Pain Management Flow Sheet for Resident #1 for the Month of February documented that for evening shift on February 6, 2016, Resident #1 received one dose of [MEDICATION NAME] 50 mg. at an unidentified time for c/o (complaint of) pain and was assessed that the medication was effective at 4:00 p.m. On 2/7/16 one dose of [MEDICATION NAME] was administered for c/o pain and determined effective at 5:00 p.m. 20. A physician's telephone order dated 2/9/16 documented an order for [REDACTED]. 21. The PRN Medication Flowsheet and Pain Management Flowsheet for Resident #1 documented his first dose of [MEDICATION NAME] 5/325 mg. for pain was administered on 2/9/16 at 11:00 p.m. 22. During interviews on 2/22/16 at 10:30 a.m., 4:00 p.m., and 5:00 p.m., and 2/23/16 at 9:45 a.m. the RN Consultant for the facility stated the DON was not available for follow up interviews the last two days of this investigation due to a family emergency. He said that he was aware of Resident #1's injuries and the facility's investigation that took place. The RN Consultant said that if Resident #1 was cognitively intact and said that he suffered pain all weekend, then he would tend to believe him. He said that the nurses involved over the weekend should all have been disciplined and in-serviced on pain management and physician notification, and he had initiated those actions following the surveyor's inquiries. 23. During an interview on 2/17/16 at 3:25 p.m., Resident #1's physician said he was not notified regarding Resident #1's fall, reports of pain, or injuries until 2/8/16. The physician said there was not much to do for the fractures in the way of treatment, except treat the pain. He said he should have been notified when Resident #1 complained of chest and back pain Saturday morning. 24. The facility's policy titled Change of Condition-Observing, Reporting, and Recording revised on 3/2012 and provided by the Assistant Director of Nursing on 2/23/16 included the following: It is the policy of this home to inform the resident, the resident's physician and if indicated, the resident's responsible party of the following: 1. An accident or incident involving the resident, which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications . .4. A need to alter treatment significantly . 25. On 2/23/16 the Assistant Director of Nursing reported that there were 42 residents in the facility that required pain management/received pain medications.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 5 of 8 residents reviewed for wandering. The facility failed to provide adequate supervision for Resident #20 who eloped from the facility on 9/14/14 some time after 7:30 p.m. The staff did not discover he was gone until 9/15/15 at 9 a.m. - over 13 hours. The facility staff failed to monitor the resident's location every two hours as required by his care plan. The facility was located on a four lane street with a 40 miles per hour speed limit. The facility failed to consistently inform direct care staff (aides) of the wander-guards status of each resident on a wander-guard. (Resident #20, #22, #23, #24, and #26) An Immediate Jeopardy (IJ) was identified on 10/14/14. The IJ was removed on 10/16/14 but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. These failures could affect any of the 20 residents identified by the facility with dementia who had wandering behaviors by leaving them at risk of leaving the facility without being seen by staff in situations that might lead to serious injury or death. Findings include: RESIDENT #20 Review of Resident #20's undated Admission and Discharge Summary documented he was a [AGE] year old male admitted to the facility on [DATE]. Review of his 9/01/14 - 10/31/14 Physician order [REDACTED]. Review of Resident #20's 5/21/14 and 6/03/14 Wandering /Elopement Risk assessment tool documented he had a history of [REDACTED]. Review of Resident #20's 9/01/14 - 10/31/14 Physician order [REDACTED]." Review of Resident #20's 7/05/14 quarterly MDS (Minimum Data Set) assessment documented he scored a 6 of 15 on the mental status exam (indicating severe cognitive impairment), with inattention and disorganized thinking. He did not exhibit any wandering behavior in the seven days prior to the assessment. He ambulated independently and did not use any devices (walker, wheelchair). Review of Resident #20's 7/25/14 care plan documented Resident #20 required a wander-guard device due to wandering in an unsafe environment. The approaches included "monitor and document wander-guards device for placement q (each) shift" and "monitor residents location every 2 hours" both to be done by nursing. Review of Resident #20's 5/21/14 CNA Care Plan documented Resident #20 needed a wander-guard. His cognitive ability was not filled in. Review of the 9/2014 Treatment Flow Sheet documented the nurses checked Resident #20's wander guard during the day shift every day, and the evening shift on 9/01/14 - 9/03/14 and 9/05/14 - 9/13/14. 9/14/14 was blank (indicating it was not checked). The nurses on the night shift checked the wander-guards to ensure it worked properly on 9/1/14 - 9/12/14. 9/13/14 and 9/14/14 were blank (indicating it was not checked). Review of Resident #20's 9/15/14 Nurse's Notes documented: - 9:15 a.m. nurse for hall 300 notified staff of unknown whereabouts of resident. All staff began searching the facility inside and outside. Staff also began driving around to locate resident. - 9:30 a.m. notified daughter of unknown whereabouts of resident. Daughter stated, "he's at my aunt's house, he's been there since 9:00 p.m. last night. We don't know how he got there but someone dropped him off." - 9:40 a.m. alerted staff of whereabouts of resident, notified doctor, orders to discharge resident home with medications. Notified daughter of situation due to resident's at high risk of elopement and not wanting to stay in facility. Review of the Nurse's Notes and the Incident/Accident Report showed no other elopement attempts by Resident #20. Review of Resident #20's 9/15/14 Discharge Summary documented he was discharged home with medications. Review of the facility's 9/17/14 Provider Investigation Report documented "Resident has been talking about leaving, so wander-guard was affixed to his ankle. He removed the wander-guard and left the building about 2100 on 9/14 arriving at his aunt's house at 2120. Administrator was made aware of his absence at 0915 on 9/15. Staff launched a search of the surrounding area while the DON called family members. Once we made contact with his daughter, we informed her that we could not insure his safety and he was being discharged to her care immediately." The facility did not identify any adverse effects. The Provider Response included: "Charge nurses from 2 - 10, 10-6, and 6 - 2 are being disciplined for failure to make thorough walking rounds and insure all residents were present. " The Post-Investigation Actions included: "staff in-service done 9/15 regarding the need for on-coming nurses to make the mandatory walking rounds with off-going nurse every shift change." Review of the facility's 9/15/14 incident investigation action plan documented that Resident #20 "eloped at about 2100 9/14." Administration alerted to his absence at about 0915 on 9/15/14, so Charge Nurses 2 p.m.- 10 p.m. and 10 p.m. - 6 a.m. last night and 6 a.m. - 2 p.m. this morning did not do walking rounds to ensure all residents were here. The facility documented they disciplined the Charge Nurses. The facility in-serviced the nursing staff at 1400 on 9/15/14 regarding completing walking rounds at each shift change. The facility documented Certified Medication Aides and Certified Nurse's Aides (CNA) were to ask Charge Nurses to physically check wander-guards each shift and document. During an interview on 10/12/14 at 8 p.m. Certified Medication Aide (CMA) O said she remembered talking to Resident #20 and giving him his medication between 7 and 7:30 p.m. on 9/14/14 She said Resident #20 must have left some time after that. She said Resident #20 got an over the counter medication and something else that she did not remember. She said she had to "hunt him down" in the front television room. CMA O said Resident #20 was always in the front television room. She said she did not know how Resident #20 got out the door. CMA O said she did not understand why Resident #20 was in the facility, that he was independent with activities of daily living (ADLs), he walked independently without a cane. CMA O said the night he got out was a regular night and there was nothing unusual going on. She said "we were so used to him being the library (front television room) I guess they assumed he'd stay there." During an interview on 10/12/14 at 8:05 p.m. Hospitality Aide (HA) P said Resident #20 got around ok and physically seemed ok. She said he seemed strong and was continent. HA P said Resident #20 would sit in the front TV room. HA P said she did not work the night Resident #20 got out. During an interview on 10/12/14 at 8:10 p.m. HA Q said she worked the 2 p.m. - 10 p.m. shift. She said she remembered Resident #20 but was not working the night he left. HA Q said Resident #20 wandered a lot. She said Resident #20 was independent and did everything for himself. She said she thought he knew where he was. HA Q said Resident #20 knew he could not leave and would try to leave with people. During an interview on 10/12/14 at 8:30 a.m. the DON said residents with wander-guards got green bracelets on 10/09/14 and they put the wander-guard list in the CNA ADL book. She added the facility put the list in the beginning of the MARs and Treatment Administration Records. This was verified with the DON present. Observation of the surroundings of the facility on 10/12/14 at 8:40 p.m. (a Sunday night, the same day of the week he got out) showed the facility was on five lane road with a speed limit of 40 miles per hour. The traffic was moderate. There were sidewalks around the facility. Interview on 10/13/14 at 9:30 a.m. CMA R said she was supposed to give Resident #20 medication in the morning on 9/15/14. (Resident #20 was supposed to have Aspirin 81 milligrams (mg), digoxin 125 mcg, spironolactone 25mg, imipramine 50 mg, carvedilol 25 mg, and enalapril maleate 20mg at 7 a.m.) She said one of the other aides asked her where he was. CMA R said Resident #20 was "one of those" who was never in his room. She said it was not uncommon for him to be up front and not in his room or his bed. CMA R confirmed she did not go looking for him. She said she did not think anything about it. She said the aide checked the rooms and outside and then told the Charge Nurse. CMA R said the Charge Nurse reported it to the DON. She said Resident #20 was for the most part quiet. She said he spent a lot of time outside in the courtyard. She said she believed he was continent. CMA R said he walked independently and well. CMA R said she was not aware of any falls. CMA R said she believed Resident #20 was in his right mind, he was not absentminded and she did not think he had dementia. Interview on 10/13/14 at 9:55 a.m. CNA S said Resident #20 walked independently and never asked the staff for anything. She said he was continent. She said he was never in the hall or in his room and he liked to be watch television in another resident's room. She said she worked the 6 - 2 shift 9/14/14 and he showed his usual behavior - he did not seem mad or upset or anything. During an interview on 10/13/14 at 10:07 a.m. LVN T said she was an agency nurse and had not worked at the facility before. She said she was on duty the morning they discovered he was gone (9/15/14). LVN T said one of the aides asked her where "resident so-and-so" was and she went looking all over the place for him. She said the DON called the resident's family. She said she did rounds that morning and was told he was never in his room. She said she was told he went to therapy and and watched television up front a lot so if she looked in his room he would never be there. She said there was nothing unusual about that day. LVN T said one of the aides - she did not remember which one - noticed he had not touched his breakfast which is why they started looking for him. During an interview on 10/13/14 at 10:30 a.m. LVN L said she worked the 10 p.m. - 6 a.m. shift beginning 9/14/14. Resident #20 roamed a lot and was not in his bed when she got to work that night. She said she did not have a second chance to check on him since she had four other residents who needed immediate attention. She said Resident #20 frequently went to bed around 2 or 3 in the morning and usually stayed up front in the television room. She acknowledged she did not realize he was gone for her entire shift. She said Resident #20 was independently ambulatory and would complain about having a roommate so he would not sleep in his room. She said he would sleep in the front library/television area or outside on the back patio. LVN L said Resident #20 did not want to be in the facility. She said Resident #20 knew about his medications and was "pretty cognitive." She said Resident #20 wore a brief but she did not understand why. LVN L said Resident #20 was all over the place - the smoking area, up front watching television. She said when she checked the hall she took it for granted that he would be up front. She said the night he got out she was too busy and did not have a chance to check to see if he went to bed. During an interview on 10/13/14 at 11:00 a.m. Resident #20's daughter (responsible party) said the facility did not call her until the next morning around 10 a.m. (9/15/14) She said her aunt called her around 8 or 9 p.m. on 9/14/14 to say that he was there. She said he did not know how he got out of the facility and he was supposed to have a wander-guard on. The daughter reported Resident #20 used to live "a few blocks away." The daughter said he walked to where he used to live and a neighbor gave him a ride to her aunt's house. She said Resident #20 was currently "ok." The daughter did not feel Resident #20 was capable of making decisions for himself. During a telephone interview on 10/13/14 at 11:25 a.m. Resident #20's sister in law said he had arrived at her house at around 9:00 p.m. approximately a month ago. The sister in law said Resident #20 used to live in that area. The sister in law said Resident #20 had a bracelet on and later found it in her shop. The sister in law said he appeared dirty and that he does not like to shower. The sister in law said Resident #20 had told her that he had jumped over a wall to get out of the nursing home. The sister in law said she did not know who dropped him off at her house. The sister in law said Resident #20 was staying in her shop in the backyard and he did not like sleeping indoors. The sister in law said she did not think about calling the police that instead she called Resident #20's daughter. The sister in law said Resident #20's daughter told her to please watch him and she would come over tomorrow. The sister in law said the next day was when the nursing home called the daughter to notify her about Resident #20 missing. The sister in law said the nursing home had told the daughter that they were not going to re-admit Resident #20 back. Observation on 9/25/14 at 10:20 a.m. showed the wander-guard alarm worked at the front door. Observation on 9/26/14 at 3:30 p.m. showed Resident #20's room was on the back two halls. It was 15 steps from Resident #20's room to the back door that had a wander-guard system. The room was within sight of the nurse's station. During an interview on 9/29/14 at 9:55 a.m. the Director of Nurses (DON) said the family did not call the facility to notify them that Resident #20 was out of the facility. She said the Charge Nurse alerted the management staff at around 9:00 a.m. that they could not find Resident #20. The DON said they searched inside and outside of the facility and she called the daughter. She said the daughter reported Resident #20 showed up at an aunt's house at 9:00 p.m. the night before and the daughter did not know how he got there. The DON said Resident #20 did not believe he needed to be at the facility and he wanted to leave. She said Resident #20 stayed in the front television area or around physical therapy. She said the facility wrote all the involved staff up from the three shifts - the nurses and the aides. She said the Friday before (9/12/14) she verified he had the wander-guard on his ankle. The DON said upon investigation the shower aide noticed it was not on his ankle on Saturday morning (9/13/14) but he had it on his hat. The DON said the shower aide notified the Charge Nurse. The DON said she interviewed the Charge Nurse who verified the shower aide reported the detached wander-guard but the Charge Nurse got busy and forgot about checking on it. She said he had cut the wander-guard off one time before the elopement. She said the nurses were supposed to be checking each shift to make sure it was working properly. She said they signed of that it was in place. The DON said she made a list of all Residents on a wander-guard and placed it in the active charting notebook. She said maintenance checked to make sure the system worked properly. The DON confirmed the time line: 9/14/14 between 8:00 p.m. and 9:00 p.m. Resident #20 got out of the facility (2 - 10 shift). There was one Charge Nurse and 2 aides responsible for overseeing that hall. 9/14/14 10:00 p.m. shift change and the nurses were supposed to be doing walking rounds. She said there was nothing unusual that happened that night that she was aware of. The DON said the 10:00 p.m. - 6:00 a.m. shift was one Charge Nurse for 2 halls and 2 aides that did not notice Resident #20 was missing. 9/15/13 6:00 a.m. shift changed and there was one Charge Nurse for Resident #20's hall and a minimum of 2 aides who did not notice Resident #20's absence for three hours. During an interview on 9/29/14 at 10:30 a.m. the Administrator said they were having a morning meeting on 9/15/14 and the Charge Nurse reported they could not find Resident #20 so the staff fanned out and checked the streets. He said the DON contacted the family who informed her that Resident #20 showed up at his aunt's house at 9:20 p.m. He said they disciplined all the Charge Nurses involved and the DON/Assistant Director of Nurses (ADON) disciplined all the aides because they should have notified the nurse but he did not "know the particulars." He said there was a previous episode of Resident #20 taking off his wander-guard. He said the wander-guard should not have been off for very long because the 2 - 10 shift documented they checked it. He was informed Resident #20 was without his wander-guard since Saturday morning. During an interview on 9/29/14 at 11:10 a.m. the ADON acknowledged there were 3 shifts of staff who should have noticed Resident #20 was missing. She said the wander-guard should be on resident's CNA care plans. Observation on 9/29/14 at 2 p.m. showed the wander-guard alarm sounding and the door locked while the alarm was sounding. Observation on 10/12/14 at 8:35 p.m. showed a resident with a wander-guard on their ankle and a green bracelet around their wrist. During an interview on 10/14/14 at 1:49 p.m. the Administrator was informed of the IJ based off lack of supervision on 9/14/14 through 9/15/15. He said there was no good reason for the lack of supervision, that was why the facility called in the incident. Observation on 10/14/14 at 2:00 p.m. with the Maintenance Director showed the wander-guard system at the back door worked. All emergency exits had ear-splitting alarms on them and they were all functional. The alarms sounded once the door was opened until someone with a key to the alarm manually turned if off. Observation on 10/15/14 at 8:30 a.m. showed Resident #20's former residence was less than half a mile from the facility (0.4 miles) but Resident #20 did have to cross the four-lane road to get to it. (Resident #20 was cognitive enough to recognize where he was and identify how to get to his former house from the facility. During an interview on 9/29/14 at 11:10 a.m. the ADON said the wander-guard should be on Resident's CNA care plans. Surveyor and the ADON checked Resident #22's CNA care plan posted on the back of his door. The wander-guard was not listed on the documented. The ADON acknowledged this. The ADON and surveyor checked Resident #12's CNA care plan on the back of the resident's door and the wander-guard was not listed. The ADON said it should be on the care plan as she wrote it on Resident #12's care plan. She said the only other way the aides had to know about the wander-guards were through in-services and the Charge Nurse. She said the Charge Nurse should be alerting the aides who had positioning devices and wander-guards. The ADON said the wander-guard should be on Resident's CNA care plans. She said the only other way the aides had to know about the wander-guards were through in-services and the Charge Nurse. She said the Charge Nurse should be alerting the aides who had positioning devices and wander-guards During an interview on 9/29/14 at 11:40 a.m. Resident #23's CNA care plan was checked. There was no CNA care plan posted and the wander-guard device was not listed. During an interview on 9/29/14 at 11:50 a.m. the Administrator was informed the facility did not have a consistent process for informing direct care staff who did and did not have a wander-guard. He said residents could cut off the wander-guards frequently. RESIDENT #12 Review of Resident #12's undated Admission and Discharge Summary documented he was a [AGE] year old male admitted to the facility on [DATE]. Review of the 9/01/14 - 10/31/14 Physician order [REDACTED]. Review of Resident #12's 9/01/14 - 10/31/14 Physician order [REDACTED]. Review of Resident #12's Nursing Assistant Care Plan showed the wander-guard was not listed. During a 9/29/14 interview beginning at 11:10 a.m. the ADON said the wander-guard should be on the care plan as she wrote it on Resident #12's care plan. RESIDENT #22 Review of Resident #22's undated Admission and Discharge Summary documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's 8/01/14 - 9/30/14 Physician order [REDACTED]. During a 9/29/14 interview beginning at 11:10 a.m. the ADON acknowledged Resident #22's Nursing Assistant Care Plan did not address Resident #22's wander-guards as she wrote it in. RESIDENT #23 Review of Resident #23's undated Admission and Discharge Summary documented she was an [AGE] year old female admitted to the facility on [DATE]. Review of her 9/01/14 - 10/31/14 Physician order [REDACTED]. Review of the 9/01/14 - 10/31/14 Physician order [REDACTED]. Resident #23's 9/2014 CNA Care Plan documented she wandered and had exit-seeking behaviors. During an interview on 9/29/14 at 11:40 a.m. the DON acknowledged the wander-guard was not listed. RESIDENT #24 Review of Resident #24's 9/23/14 face sheet documented he was a [AGE] year old male admitted to the facility originally on 2/10/14 and readmitted [DATE]. He had [DIAGNOSES REDACTED]. Review of Resident #24's 9/01/14 - 10/31/14 Physician order [REDACTED]. Resident #24's CNA Care Plan was checked and it was not present and it did not list the wander-guard device. The DON was informed of this during an interview on 9/29/14 at 11:35 a.m. Review of the facility's 3/2012 policy and procedure on Wandering Resident documented, in part: it is the policy of this home that residents at risk for wandering will be identified and monitored for safety. During an interview on 10/16/14 at 2:24 p.m. the Administrator, the ADON, the DON, and the Corporate RN Consultant was informed the Plan of Removal was accepted and the IJ for lack of supervision was lifted. Review of the facility's 10/14/14 Action Plan/Plan of Removal documented: 1. Medical Director notified by DON at 1600 by DON. 2. All Residents must be observed by their assigned CNAs every 2 hours through each day to validate they are still in facility or on facility grounds. This will be done during routine incontinence and positioning checks. 3. Monitoring of residents when they cannot be located- a. It is the responsibility of the charge nurses to routinely monitor the residents in their section of the facility while those residents are residing in the facility. If any resident cannot be located then the Administrator, Director of Nurses or Designee will be notified. Completion Date: 10/14/14. b. All staff will be retrained on the definition of elopement and their responsibility will be to immediately communicated by telephone to the Administrator/ DON/ ADON. Completion Date: 10/14/14. c. Nursing staff will also be retrained to search entire facility including immediate grounds when a resident cannot be immediately located and to continue to follow the directions of Adm/DON/ADON. Completion Date: 10/14/14. d. The training will also include the notification of the local law enforcement is required when a resident cannot be located in facility or on the immediate grounds. Completion Date: 10/14/14. e. The Licensed Nurse/ DON/ ADON or Administrator will also contact family/ responsible party of elopement. Completion Date: 10/14/14. f. Any identified issues/concerns regarding checking of residents will be addressed immediately upon being identified by either performing more training or counseling as needed to ensure compliance with monitoring of residents. Completion date: 10/14/14. g. In addition to charge nurse responsibilities, facility on-call nurses will be monitoring night shift by personal visits to the facility on weekends through November. Completion Date: 10/14/14. h. The reference source and primary charting for nurses is the Wander Risk check sheet in the skilled charting book which has photos of residents. In the nurse's MAR books, charting of the verification of operating Wander-guard Transmitters is found. The reference source for CNAs will be the ADL flow sheet books where documentation of residents with wander-guards will be kept up-to-date. As a fall-back to be sure CNAs are able to identify those residents who have wander-guards, each of these residents will have a green wristband (some of these may additionally be connected to obvious places on the resident's wheelchair, if necessary). 4. In-Services a. The DON/ Regional Nurse Consultant/ ADON/. Adm in-serviced the nursing staff on checking of residents every 2 hours while admitted to the facility. For staff that are not currently scheduled. they will be in-serviced on this process prior to being allowed to work. Completion Date: 10/14/14. b. Training related to the monitoring of residents is incorporated into the facility's orientation process. Completion Date: 10/14/14. c. Random staff interviews have been done by the Administrator, DON, ADON to assure appropriate understanding of the information regarding residents at risk of wandering and the need to contact Adm/ DON/ ADON as well as family in case a resident cannot be located. Completion Date: 10/14/14. d. Agency staff will be oriented to this process through notification of the employing agency. They will be required to have their nurses orient with our On-Call Nurse prior to their first shift working at Deerings. The On-Call nurse will turn said documentation of orientation into the DON or Adm as soon as expedient after completion. Completion Date: 10/14/14. 5. Quality Assurance The Administrator will ensure monthly review of residents being monitored during monthly Quality Assurance for monthly oversight and direction included with the Medical Director for 3 Consecutive months. Completion Date 10/29/14 (next scheduled meeting - Medical Director currently out of town). Review of the 10/14/14 Addendum (things the facility did prior to the IJ being called) documented: - Immediately after learning Resident #20 was safe with family at 0920 on 9/15, all residents with orders for wander-guards were checked to assure placement and working order. 100% of facility residents were accounted for at the same time. (Completed 9/15/14.) - In-servicing began before change of shift at 1400 on 9/15 to remind all nurses of the requirement to do walking rounds at shift change. In-services were also started to remind nurses of proper way to check wander-guards each shift and documented same on medication administration record. (Completed 9/15/14) - A list of residents with wander-guards and photographic identification was placed with the active charting books, Nurse MAR's and CNA ADL books. (The list was placed in the Active Charting notebook on 9/15/14. The list was placed in the CNA ADL books on 9/23/14. Photographic evidence was placed in books on 10/14/14) - 10 -6 shift nurses checking wander-guards will also utilize the transmitter testing device to insure the devices are operable. (Completed 9/15/14) - Testing of doors equipped with wander-guard receivers revealed a slight possibility that a transmitter might not activate the door if it were at an odd elevation. Additional sensors were ordered to make this more foolproof (completed 9/15/14.) Ongoing Actions: a. The DON is checking all wander-guards daily, Monday - Friday, for placement and reviewing nurse's documentation on MARs. To insure monitoring on weekends, as well, staff nurses who are in special positions of responsibility and currently On-Call will be checking these issues on the weekends. This rigid weekend monitoring will be conducted through November. b. Extended receivers received and installed on the wander-guard system on 9/18/14. c. Doors were already programmed to lock down automatically during the night. Maintenance personnel adjusted these times to Front door 1900 - 0530, Rear Door 1900 - 0530, therapy access door - 1800 - 0700. Regardless of whether someone has a wander-guard or not, during these hours, use of a keypad code is necessary to open the doors. d. Maintenance personnel are also checking the wander-guard system daily and documenting the working order of these doors. Prior to this incident, they were checking all doors weekly. e. Of the three charge nurses involved, one was an agency nurse and she has been barred from further work here. The 2 - 10 nurse was disciplined and continues in our employ. The 10 - 6 nurse who failed to notice Resident #20 missing her whole shift did not take her discipline well, offered her resignation and it was accepted. f. On 9/23, after further discussion with surveyors, it was decided that additional identification of wanderers was needed. Green bracelets were ordered to identify these people in the way yellow bracelets identify those with swallowing issues. On 10/09/14 these bracelets were received and placed on residents and/or their wheelchairs. g. 10/12 - 10/14 in-services were conducted to remind staff of the use of the green bracelets and also repeat emphasis on checking wander-guard bracelets and door receivers. Above actions completed 10/14. h. Weekly Resident Risk Meetings will include reviewed the residents with Wander-guards beginning on 10/15/14. Follow- Up Outcomes : a. DON will documented in weekly Resident At Risk Meetings, the efficacy of programs in place above. b Administrator will document progress in quarterly Quality Assurance Meetings through the remainder of 2014. Review of the Resident Monitoring System Notebook at the nurse's station on 9/26/14 (prior to the IJ) verified the Maintenance Director checked all wander-guard sensors as working on 9/10/14 and 9/08/14. (The facility was checking the wander-guard system.) Review of the Active Charting notebook at the nurse's station on 9/26/14 (prior to the IJ) at 10 a.m. verified there was a list of residents with a wander-guard posted in both the front and the back nurse's station. A list provided by the facility on 9/29/14 documented there were 20 residents with wander-guards in the facility.

Based on observations, interviews and record review the facility failed to provide pharmaceutical services that ensured the blood glucose monitor (glucometer) accurately monitored blood glucose levels to meet the needs of each resident for 2 of 4 halls in the facility. The facility failed in that: ? Blood Glucose Meter Control Records from January 2014 to current showed the calibration readings were, at times, outside the range and no action was taken to correct the problem or to ensure the blood glucose meters were working correctly. These failures resulted in an Immediate Jeopardy (IJ) was identified on 10/16/14. While the IJ was removed on 10/17/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. This failure could placed 18 diabetic residents (Hall 1 and 2) at risk of poor blood glucose control and inaccurate administration of medication. The facility failed to provide pharmaceutical services, including procedures to ensure the accurate receiving, dispensing, administering and documentation of all drugs/biological to meet the needs of residents for pharmaceutical services for two of 21 residents (Resident #6 and #11) reviewed for medications. a) Resident #6 was not administered Aspirin as ordered by the physician for 24 days. This failure could place 26 residents with physician ordered Aspirin at risk for a blood clot, heart attack or stroke. c) Resident #11 was not administered her B-12 injection the physician ordered on the 21st of each month. This failure could place 5 residents on B-12 injections at risk of pernicious anemia. The IJ Findings included: BLOOD GLUCOSE METER During observation on 9/22/14 at 11:00 a.m., the glucometer control logs were reviewed for the front and the back halls: January 2014 UNIT 1A - (glucometer serial #1415) The normal control result was out of range for 3 of the 31 days and had 5 days that were blank. The high control result was also out of range for 26 of 27 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A- (glucometer serial #6687) The normal control result was out of range for 4 of the 31 days and had 4 days that were blank. The high control result was also out of range for 26 of 27 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. February 2014 UNIT 1A - (glucometer serial #1415) The normal control result was out of range for 19 of the 28 days and had 5 days that were blank. The high control result was also out of range for 13 of 28 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - (glucometer serial #6687) The normal control result was out of range for 19 of the 28 days, had one day where the reading was LO and had 5 days that were blank. The high control result was also out of range for 17 of 28 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. March 2014 UNIT 1A - (glucometer serial #1415) The normal control result was out of range for 17 of the 31 days and had 7 days that were blank. The high control result was also out of range for 16 of 31 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - (glucometer serial #6687) The normal control result was out of range for 15 of the 31 days and had 4 days that were blank. The high control result was also out of range for 21 of 31 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. April 2014 UNIT 1A - (glucometer serial #1415) The normal control result was out of range for 16 of the 30 days (all the days that were tested ) and had 14 days that were blank (7 days in a row). The high control result was also out of range for 6 of 30 days and 14 days were blank (7 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - (glucometer serial #6687) The normal control result was out of range for 17 of the 30 days and had 7 days that were blank. The high control result was also out of range for 7 of 30 days and 7 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. May 2014 There were four glucometers listed for May 2014. UNIT 1A - (glucometer serial #1415) The normal control result was out of range for 5 of the 31 days and had 16 days that were blank. The high control result was also out of range for 14 of 31 days (all days that were tested ) and 17 days were blank (9 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - (glucometer serial #6687) The normal control result was out of range (96-120) for 4 of the 31 days and had 21 days that were blank (21 days in a row). The high control result was also out of range for all 10 days that were tested and 21 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - (This is a different glucometer with last four serial #5565 used for units 1A and 2A) The days started with the 13th- The normal control result was out of range for 5 of the 19 remaining days and had 9 days that were blank (9 days in a row). The high control result was also out of range for all 10 days that were tested and 9 days were blank (9 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - (This is a different glucometer with last four serial #703F used for units 1A and 2A) The days started with the 23rd - The normal control result was out of range for 2 of the remaining 9 days. The high control result was all blank (nothing filled in). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. June 2014 There were three glucometers listed for June 2014. UNIT A - (This is a different glucometer with last four serial #703F used for units 1A and 2A) The normal control result was out of range for 4 of the 15 days that were tested . The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - (This is a different glucometer with last four serial #2321 used for units 1A and 2A) The normal control result was out of range for 10 of the 14 days that were tested ; three of these days the reading was LO. There was one day that was blank (no calibration check performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - (This is a different glucometer with last four serial #1686 used for units 1A and 2A) The normal control result was out of range for 8 of the 14 days that were tested ; three of these days the reading was LO. There was one day that was blank (no calibration check performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. July 2014 There were six glucometers listed for July 2014. UNIT A - (This is a different glucometer with last four serial #2321 used for units 1A and 2A) The normal control result was not out of range for the 3 days listed (July 1-3 only) but July 1 was blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 1A - (This is a different glucometer with last four serial #5565 used for units 1A and 2A) The days started with the 3rd- The normal control result was out of range for 15 of the 19 days that were tested (7/3/14 - 7/21/14) and had 1 day that was blank. The high control result was also out of range for all 18 days that were tested and 1 day was blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #1415 used for units 1A and 2A) The days started with the 3rd- The normal control result was out of range for 16 of the 19 days that were tested ( 7/3/14 - 7/21/14) and had 2 days that were blank. The high control result was also out of range for all 18 days that were tested and 1 day was blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #1686 used for units 1A and 2A) The normal control result was 107-145 for the 1 day listed (July 22) but no result was documented. The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #2321 used for units 1A and 2A) The days started with the 22nd- The normal control result was 107-145 but no results were documented for the 9 of 10 10 days. There were 5 days that were blank. The high control result was totally blank. On 7/24/14 was written, "Machine not working." The next 4 days were blank (no calibration performed). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #9862 used for units 1A and 2A) The normal control result was 107-145 for the 2 days listed (July 29-30) but 1 of the days was blank (no calibration result documented). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. August 2014 There were four glucometers listed for August 2014. No unit listed - (This is a different glucometer with last four serial #9862 used for units 1A and 2A) The normal control result was out of range for 8 of the 14 days listed (August 1-14 only) and 4 days were blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - (This is a different glucometer with last four serial #2321 used for units 1A and 2A) The normal control result was out of range for 10 of the 14 days listed (August 1-14 only) and 3 days were blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #5565 used for units 1A and 2A) The days started with the 15th- The normal control result was out of range for 7 of the 17 days that were tested ( 8/15/14 - 8/31/14). The high control result was also out of range for 13 of the 17 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- (This is a different glucometer with last four serial #1415 used for units 1A and 2A) The days started with the 15th- The normal control result was out of range for 3 of the 17 days that were tested ( 8/15/14 - 8/31/14). The high control result was also out of range for 13 of the 17 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. September 2014 There were three glucometers listed for September 2014. UNIT A - (This is a different glucometer with last four serial #5565 used for units 1A and 2A) The normal control result was out of range for 19 of the 21 days that were tested ( 9/1/14 - 9/21/14). The high control result was also out of range for 13 of the 21 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - (This is a different glucometer with last four serial #2801 used for units 1A and 2A) The normal control result was out of range for 6 of 6 days that were tested ( 9/16/14 - 9/21/14). The high control result was also out of range for 5 of the 6 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - (This is a different glucometer with last four serial #4200 used for units 1A and 2A) tested on e day only, 9/13/14 - The normal control range was 98-122 but no result was documented. The high control range was 250-312 but no result was documented. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - (This is a different glucometer with last four serial #1415 used for units 1A and 2A) The normal control result was out of range for 8 of the 12 days that were tested ( 9/1/14 - 9/12/14). The high control result was also out of range for 10 of the 12 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. Review of the pharmacy consultant report for September 2014 noted, "Glucometer Calibration Log has holes in it- Station A." Review of package insert of True Control Glucose Control (used to test and calibrate glucometers) noted, in part, " If test result displayed in meter falls within range of control values given on test strip vial label, testing technique and system performance are acceptable. Control results must be within result range printed on test strip vial label. If a control test result is outside control range, do not use test strips or meter for blood glucose testing. Check to see if control or test strips have expired and open new bottle if necessary. Repeat test. WARNING! Do not use test strips or meter for blood glucose testing if control results are not within control range." An interview on 9/22/14 at 2:30p.m. with the Assistant Director of Nurses (ADON) Staff A and the Unit Manager staff B was held. The ADON acknowledged the control readings were not within the parameters. She said the staff "should recheck the glucometer or get another one that works but don't use the one that won't test accurately." An interview on 9/22/14 at 2:50p.m. with the Director of Nurses (DON) C she also acknowledged the glucometer readings were outside the normal range and were not safe to use. She said the pharmacist "caught this a couple of weeks ago and suspects when staff opened a new bottle of strips they are not holding down the button on the glucometer to clear it." Surveyor showed the DON the readings were still outside the acceptable range as of 9/21/14 and asked if staff had been inserviced on the concern. The DON said she could not remember if there had been an inservice regarding the issue but would look. An interview on 9/22/14 at 3:30p.m. with the Registered Nurse (RN) Nurse Consultant also acknowledged if the glucometer reading was outside the range staff should retest but do not use a glucometer that did not work accurately. These failures resulted in the identification of an IJ on 10/16/14 at 2:24 p.m. While the IJ was removed on 10/17/14 at 10:28 a.m., the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. Review of the 10/16/14 Plan of Removal for Monitoring and Treating Residents with Diabetes documented: Medical Director has been notified of the IJ by the DON at 12:35 p.m. on 10/16/14. The initial part of this problem was brought to our attention on 9/22/14 by the survey team. IJ notification was 2:00 p.m. on 10/16/14. Actions Taken 1. On 9/22/14, the DON personally checked each glucometer for proper calibration and operation. There was some question on two meters, so we purchased six new meters from (a local drug store) and test strips/control solution to go with them. This was to avoid any confusion with the old meters/strips that were ordered from a supplier that could not provide replacements immediately. Completed 9/22/14. Additional supplies were bought locally in the next few weeks. 2. The DON and ADON presented in-services to all nurses available, following up with nurses as they came to work in days following. These in-services were on how to check glucometers' HI/LO parameters. Completed 9/22/14. 3. Nurses were in-services as in 2 above regarding documentation on Medication Administration Record [REDACTED]. Completed 9/24/14. 4. On 9/22/14, Medical Director initiated a standard sliding scale for administration of insulin with parameters of when to notify the physician. By 10/06/14, Medical Director had consensus with other attending physicians on the standard parameters. Orders were written on 10/07/14 and 10/08/14 for each diabetic resident that this applied to. Some diabetics do not need Capillary Blood Glucose (CBGs) done; their physicians have chosen to go with periodic HBA1C tests (A blood test that provides an average of your blood sugar control over the past 2 to 3 months). Completed 10/10/14. 5. On 10/03/14, we received the standard Assure Platinum Glucometers that we normally order through (a medical supply company). Those were put in service and nurses were reminded how to use them with documentation starting on 10/03/14. The glucometers purchased locally at a cost of about $920, were stored in the DON's office as back up units, should we experience sudden failure of units in the future. Completed 10/03/14. 6. The DON is monitoring the blood sugar and glucometer testing each morning when she comes to work Monday - Friday. Completed 9/23/14 Actions Planned/ Monitoring 1. In addition to the weekday monitoring by the DON, the On-Call Nurses will be monitoring glucometer testing/ calibration/ operation as well as administration of insulin and withholding of insulin/ notification of physician on weekends when they come to the facility to monitor shift change rounds and other activities (schedule attached). Completions 10/16/14. 2. Specific training for Agency nurses will be accomplished by giving agencies notice that their nurses must expect to receive training prior to working their first shift at the facility. They will be required to have their nurses orientate with our On-Call Nurse prior to their first shift working at the facility. The On Call Nurse will turn in said documentation of training regarding diabetic treatment and glucometers in to the DON or Administrator as soon as practical. Schedule of On-Call Nurses is attached. Completion 10/16/14. 3. Quality Assurance - The Administrator, will ensure monthly review of diabetic resident treatment/ glucometer calibrating and testing to be monitored during the monthly Quality Assurance Committee Meeting. This meeting will include the Medical Director for the next three consecutive months. Completions 10/29/14. Review of the attached documentation with the 10/16/14 Plan of Removal documented: - 9/22/14 receipts for Glucometers and with testing supplies. - Inservice dated 9/22/14 on Glucometers with return demonstration held by the DON. Fifteen nurses attended. - Inservice dated 9/24/14 on Insulin Documentation to include Physician Notification. 14 Nurses attended. - Receipt on 10/01/14 for 4 Blood Glucose Meters. - On call Rotation Schedule for the Month of October. During an interview on 10/14/14 at 2:08 p.m. Licensed Vocational Nurse (LVN) U said she knew how to calibrate the glucometers. LVN U said if the glucometer was out of range she would use a different glucometer that was in range to do blood sugar checks. LVN U said if a resident had a blood sugar of 40 she would notify the doctor if the resident did not have any standing orders. LVN U said that was what a nursing judgment would mean to her. During an interview on 10/14/14 at 2:56 p.m. Staff coordinator LVN G said she would at times work the floor if they could not find coverage. Staff coordinator LVN G said if a resident had a blood sugar of 40 she would notify the doctor on what to do next. During an interview on 10/14/14 at 3:05 p.m. Agency LVN X said if she got a blood sugar reading of 40 she would check the physician orders [REDACTED]. Agency LVN X said if the resident did not have a particular order regarding low blood sugar she would call the doctor. During an interview on 10/14/14 at 3:12 p.m. RN Y said if she got a blood sugar reading of 40 she would notify the doctor to see if they wanted to give a glucagon injection. RN Y said if the resident did not have any particular orders for low or hi blood sugars she would still first call the doctor. During an interview on 10/14/14 at 3:27 p.m. LVN F said that if a resident had a blood sugar of 40 he would call the doctor for further directions. LVN F said if the glucometer was out of range he would re-test it with the solution if still out of range use another meter. During an interview on 10/14/14 at 4:07 p.m. the DON stated that when she said for the nurse to use nursing judgment she meant that they should call the doctor if a resident had a hi or low blood sugar. During an interview on 10/14/14 at 4:26 p.m. RN N acknowledged that it was her initials on the glucometer logs which had the out of range readings. RN N said she did not remember being trained on calibrating the glucometers. RN N said she had read the instructions on the glucometer strips regarding the calibration range but still did not understand it. RN N said she never thought there was something wrong with the low or high readings as long as they were under the low number and above the high number. RN N said she now knew how to correctly calibrate the glucometers since she had been trained. During an interview on 10/15/14 at 9:38 a.m. LVN Z said she was a new employee and today was her fifth day at work. LVN Z said if she got a blood sugar reading of 40 she would notify the doctor on what they wanted to do next. During an observation on 10/17/14 at 9:30 a.m. LVN V calibrated the glucometer used on hall 100. LVN V did the test as explained in the manual and the results were within range. LVN V said she would check the glucometer log to make sure the glucometer she was using was in range prior to using it everyday. During an observation on 10/17/14 at 9:40 a.m. LVN U calibrated the glucometer used on hall 400. LVN U did the test as explained in the manual and the results were within range. LVN U said she would check the glucometer log to make sure the meter was in range prior to using it. During an observation on 10/17/14 at 10:00 a.m. LVN W calibrated the glucometer used on hall 300. LVN W did the test as explained in the manual and the results were within range. LVN W said she was aware of making sure the meter had been calibrated and was within range prior to using it. LVN W said if the meter was out of range she would re-test it and if it still was out of range she would use a different meter. LVN W said she would then report the defective meter to the DON. The IJ was removed on 10/17/14 at 10:28 a.m., the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. A list provided by the facility on 09/22/14 indicated there were 18 residents on Halls 1 and 2 (the front halls) that get their blood sugar checked by the facility's blood glucose meters. MEDICATIONS RESIDENT #6 Review of Resident #6's undated Admission Record indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively impaired, required extensive assistance with bed mobility, transfers, dressing, hygiene and bathing. Review of Resident #6's re-admission orders [REDACTED] Review of Resident #6's Medications Flowsheet dated 8/1/2014 - 8/31/2014 indicated on 8/19/14 the Aspirin 81 mg, delayed release was marked out and Aspirin 81 mg, chewable was written on another flowsheet. There was documentation Resident #6 was administered the Aspirin for the rest of August 2014. Review of Resident #6's Medication Flowsheet dated 9/1/2014 - 9/30/2014 indicated the Aspirin 81 mg, delayed release was highlighted in yellow through the month on September 2014. There was no documentation Aspirin 81 mg, chewable was administered since 9/1/14. During an interview on 9/25/14 at 12:20 p.m. the ADON was informed of Resident #6 not getting the physician ordered Aspirin since 9/01/14. The ADON acknowledged the Aspirin 81 mg, chewable was not caught when the September Medication Flowsheets were reviewed and put out. The ADON said at the first of the month a new Medication Flowsheet book is switched out. The ADON said "multiple people looking at that and no one caught it." RESIDENT #11 Review of Resident #11's Record of admitted d 12/03/11 indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #11's quarterly MDS assessment dated [DATE] indicated she was cognitively intact. Required supervision/set-up help only with transfer, ambulation, dressing, eating, hygiene and bathing. Review of Resident #11's consolidated Physician order [REDACTED]. Review of Resident #11's Medication Flowsheet dated 9/1/2014 - 9/30/2014 indicated the same above Cyanocobalamin order to be given on the 21st of the month. There was no documentation the B-12 injection was given on 9/21/14. During an interview on 9/25/14 at 12:20 p.m. the ADON was informed Resident #11's B-12 injection ordered on [DATE] was not documented as given. The ADON was informed surveyor was going to interview Resident #11. The ADON said "let me know if she didn't get it." During an interview on 9/25/14 at 12:35 p.m. Resident #11 was sitting in a chair in the dining room. She had just finished eating her lunch. When asked if she had received her B-12 injection on Sunday 9/21/14 she said "no, I didn't get it." Review of the facility's Nursing policy and Procedure "Medication - Administration" dated 06/2012 documented in part: Policy - It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure Medications are prepared, administered and recorded only by licensed nursing, cerified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR (medication administration record) is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration. Lists provided by the facility on 9/29/14 indicated there were 26 residents on Aspirin and 5 residents on B-12 injections.

Based on observation, interview and record review the facility failed to provide care and services to maintain the highest practicable well-being in accordance with the comprehensive assessment for 16 of 17 diabetic residents that required Capillary Blood Glucose (CBG) blood sugar monitoring and insulin administration (Residents' #5, #9, #10, #16, #17, #18, #19, #24, #29, #30, #32, #33, #34, #35, #36 and #37) reviewed for quality of care. a) Resident #17 had physician orders [REDACTED]. Resident #17 did not have CBG results documented twice in August 2014. Resident #17's scheduled insulin was not documented for 6 days in August 2014. Resident #17 did not have parameters of when to notify the doctor. Resident #17 had a CBG reading of "39" on 8/24/14 (less than 60 was considered low). b) Resident #19 had physician orders [REDACTED]. April 2014 there was one time insulin was not documented and three times blood sugars were not documented. Resident #19 did not have parameters of when to notify the physician. Resident #19 experienced low CBG results with increased vomiting and confusion. c) Resident #29 had physician orders [REDACTED]. Resident #29's scheduled insulin was not documented two times in October 2014. Resident #29's scheduled insulin was not documented four times in September 2014. Resident #29's sliding scale insulin was not documented once in September 2014. Resident #29's CBG results were not documented twice in September 2014. Resident #29's scheduled insulin was not documented seven times in August 2014. Resident #29's CBG results and/or sliding scale insulin administration were not documented three times in August 2014. d) Resident #30 had physician orders [REDACTED]. Resident #30 did not have documented CBG results one time in October 2014. Resident #30's scheduled insulin was held one time without doctor's orders in October 2014. Resident #30 did not have documented CBG results six times in September 2014. Resident #30 did not have documented scheduled insulin four times in September 2014. Resident #30 did not have documented CBG results and/or sliding scale insulin documented 21 times in August 2014. Resident #30 did not have documented scheduled insulin 12 times in August 2014. e) Resident #5 had physician orders [REDACTED]. September 2014 - there was one time the scheduled insulin was not documented. f) Resident #9 had physician orders [REDACTED]. September 2014 Resident #9's 2 CBG results were not documented and five scheduled insulin administrations were not documented. August 2014 Resident #9's scheduled insulin was not documented two times. August 2014 CBG results were not documented two times. g) Resident #10 had physician orders [REDACTED]. Resident #10's CBGs were not documented three times in September 2014. Resident #10 had a CBG result but no insulin administration documented once in September 2014. Resident #10 did not have his scheduled insulin documented once in September. Resident #10 had two undocumented CBG results in August 2014. h) Resident #16 had physician orders [REDACTED]. Resident #16's CBGs were not documented twice in September 2014. Resident #16 had 7 CBG results not documented. Resident #16 had three times when insulin administration was not documented. i) Resident #18 had physician orders [REDACTED]. September 2014 - there was one time the blood sugar and the scheduled insulin was not documented. j) Resident #24 had physician orders [REDACTED]. August 2014 - there were 4 times the blood sugar checks and two times the scheduled insulin was not documented. September 2014 - there was one time the blood sugar check was not documented. k) Resident #32 had physician orders [REDACTED]. Resident #32 had one undocumented CBG or sliding scale result for September 2014. Resident #32 had undocumented CBG and/or sliding scale insulin four times in August 2014. l) Resident #33 had physician orders [REDACTED]. August 2014 - there was one time the blood sugar and two times the scheduled insulin was not documented. m) Resident #34 had physician orders [REDACTED]. August 2014 - there was one time the blood sugar and three times the scheduled insulin was not documented. September 2014 - there were two times the blood sugar and two times the scheduled insulin was not documented. n) Resident #35 had physician orders [REDACTED]. August 2014 - there were two times the blood sugar and two times the scheduled insulin was not documented. September 2014 - there were four times the blood sugars were not documented. o) Resident #36 had physician orders [REDACTED]. August 2014 - there was one time the blood sugar check was not documented. September 2014 - there was one time the blood sugar check was not documented. p) Resident #37 had physician orders [REDACTED]. August 2014 - there were 7 times the blood sugar checks and one time the scheduled insulin was not documented. September 2014 - there was one time the blood sugar check and one time the scheduled insulin were not documented. q) Blood Glucose Meter Control Records from January 2014 to current showed the calibration readings were, at times, outside the range and no action was taken to correct the problem or to ensure the blood glucose meters were working correctly. These failures resulted in the identification of an IJ (Immediate Jeopardy) on 10/16/14. While the IJ was removed prior to exit on 10/17/14, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern." This deficient practice could place 26 residents with diabetes at risk of not receiving timely medical evaluation and treatment resulting in complications secondary to [DIAGNOSES REDACTED]/[MEDICAL CONDITION] such as coma and death. The facility failed to ensure staff assessed and monitored care for one (Resident #16) of two residents who received [MEDICAL TREATMENT]. r) Resident #16's [MEDICAL TREATMENT] shunt was not assessed upon returning from [MEDICAL TREATMENT]. This deficient practice could place 2 residents who received [MEDICAL TREATMENT] at risk of infection and [MEDICAL TREATMENT] complications. The IJ findings included: DIABETIC MONITORING RESIDENT #17 Review of Resident #17's undated Admission and Discharge Summary (face sheet) documented Resident #17 was an [AGE] year old male admitted to the facility on [DATE]. Review of Resident #17's September Diabetic flow sheets documented he had [DIAGNOSES REDACTED]. Review of Resident #17's 8/30/14 30 day MDS assessment documented he was diabetic and had injections of insulin the 7 of 7 days prior to the assessment. Review of Resident #17's 8/20/14 Start up orders documented an order for [REDACTED]. Review of Resident #17's Start up orders Diabetic monitoring form documented: 8/13/14- 6:30 a.m. no CBG results documented. 8/23/14- 6:30 a.m. CBG of 52 with "OJ" (orange juice) beneath it. There was no documentation the doctor was notified. 8/24/14- 6:30 a.m. CBG of 39 with a line and then 79. There was no documentation the doctor was notified. 8/25/14- 8:00 p.m. no results documented. According to the American Diabetes Association, [DIAGNOSES REDACTED] (low blood sugar) is a condition characterized by abnormally low blood glucose. The sugar, the food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar. (blood sugar: 1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose. 3) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. In the United States, blood glucose test results are reported as mg/dL. Medical journals and other countries use millimoles per liter (mmol/L). To convert to mg/dL from mmol/L, multiply mmol/L by 18. Example: 10 mmol/L ??A zA? 18 = 180 mg/dL. The only sure way to know whether you are experiencing [DIAGNOSES REDACTED] is to check your blood glucose, if possible. Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma sleep-like state in which a person is not conscious. May be caused by [MEDICAL CONDITION] (high blood glucose) or [DIAGNOSES REDACTED] (low blood glucose) in people with diabetes., and death. If left untreated, [DIAGNOSES REDACTED] may lead to a [MEDICAL CONDITION] or unconsciousness (passing out, a coma). In this case, someone else must take over. ? Signs and symptoms of [DIAGNOSES REDACTED] are shakiness, nervousness or anxiety, sweating, chills and clamminess. Irritability or impatience, confusion, including [MEDICAL CONDITION], rapid/fast heartbeat, lightheadedness or dizziness. Hunger and nausea, sleepiness, blurred/impaired vision, tingling or numbness in the lips or tongue. Headaches, weakness or fatigue. Anger, stubbornness, or sadness. Lack of coordination, nightmares or crying out during sleep, [MEDICAL CONDITION] and unconsciousness. ? Last Reviewed: July 12, 2013 ? Last Edited: September 16, 2014 ? Reference: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html There were no documentation that Resident #17 received his [MEDICATION NAME] on 8/21/14, 8/25/14, 8/26/14, 8/28/14, 8/29/14, and 8/30/14. Review of Resident #17's September Diabetic Flow Sheet documented, in part: 9/03/14- 6:30 a.m. CBG of 58. No insulin given. 9/11/14- 6:30 a.m. CBG of 52. 9/15/14- 8 p.m. CBG of 51. 9/17/14- 6:30 a.m. CBG of 53. 9/19/14- 6:30 a.m. CBG of 51. 9/20/14- 6:30 a.m. CBG of 53. 9/21/14- 6:30 a.m. CBG of 50. There was no documentation on the Diabetic Flow Sheets or the Nurse's Notes that the doctor was notified. During an interview on 9/26/14 at 1:55 p.m. the DON was shown Resident #17's diabetic flow sheets. She compared the flow sheets to the nurse's notes and the 24 hour report. The flow sheet dated 8/24/14 showed a CBG result of 39, it was rechecked at 49, and checked a third time to 79. The DON read the note that the resident was awake and alert and was given orange juice with sugar twice and the nurse held his [MEDICATION NAME] but there was no documentation the doctor or his nurse' practitioner were notified. The DON acknowledged the flow sheet (dated 8/25/14) had no findings documented in the nurse's notes or the 24 hour report. She said if it was not signed there was no way to tell what insulin Resident #17 did or did not get. During a follow up interview on 9/26/14 at 2:40 p.m. the DON said she followed up with the nurse who did not call the doctor because there were no parameters to notify the doctor. She said the nurse used "nursing judgement." She said Resident #17's doctor varied his high parameters but usually it was notify him if the CBG was below 60. She said she reviewed all of the physician's orders [REDACTED]. She said [MEDICATION NAME] was long acting and she would have given it. She said the nurse should have rechecked the blood sugars. The DON said there was nothing on the 24 hour report. The September 2014 flow sheets were also reviewed during this interview (9/26/14 at 2:40 p.m.) with the DON: -9/11/14 the DON said the CBG results looked like a 52 on the original. She confirmed there was nothing in the nurse's notes or in the 24 hour report about the CBG result or the physician being notified. -9/15/14 the DON said the CBG looked like a 51 and there was nothing in the 24 hour report or the nurse's notes about the CBG of the physician being notified. -9/17/14 the DON said the CBG looked like a 53 or 33 and there was nothing in the 24 hour report or the nurse's notes about the CBG of the physician being notified. -9/19/14 the DON said the CBG result was a 51 and there was nothing in the nurse's notes or 24 hour report about the CBG or the physician being notified. -9/20/13 the DON said the CBG result was a 53 and there was nothing in the nurse's notes or the 24 hour report about the CBG or the physician being notified. -9/21/14 the DON said the CBG result was 50 and there was nothing in the nurse's notes about the CBG. She said the 2 - 10 nurse documented that Resident #17's blood sugar was "low" and "that was it." There was nothing about the physician being notified. During an interview on 9/26/14 at 3:05 p.m. Licensed Vocational Nurse (LVN) F said Resident #17's blood sugars fluctuated between the 50's and the 200's. He said Resident #17's doctor usually wanted to be notified if the blood sugar was below 60 but the upper parameter changed from resident to resident. LVN F said there were no parameters for Resident #17. RESIDENT #19 Review of Resident #19's undated Admission and Discharge Summary Face Sheet noted the resident was admitted on [DATE]. He was a [AGE] year old male. His [DIAGNOSES REDACTED]. Review of the MDS assessments dated 4/19/14 and 7/18/14 reflected the resident was diabetic. Review of nurse's notes dated 3/22/14 at 9:30 p.m., "Patient confused and vomiting, could not tell his name or where he was. He was diaphoretic. Fingerstick is 46. Glucose gel administered, rechecked after 10 minutes and is 116. Patient still confused, sandwich given but continues with problems swallowing. Rechecked at 94. EMT (Emergency Medical Technician) called. Patient was alert and oriented times 2 by the time EMT arrived. MD notified." Review of physician orders [REDACTED].#19 returned to the facility) noted, "Please check CBG regularly and titrate dose of Glimeperide according to CBG readings since patient is having hypoglycemic episodes." There were no parameters on the physician orders [REDACTED]. Additional nurse's notes dated 3/26/14 at 8:00 a.m., "CBG 110- therapy reports notable right side facial drooping and dragging slightly of left leg. Called Dr and DON- received order to transport to hospital via ambulance." Review of physician orders [REDACTED].#19 returned to the facility) noted, sliding scale insulin orders but no parameters as to when to notify the physician of low or high blood sugar readings. Review of the start up orders/treatment administration record for April 2014 noted: Humalog R per sliding scale <100 - 0 units 101-150 - 2 units 151-200 - 4 units 201-250 - 6 units 251-300 - 8 units >301 - 10 units CBG's AC and HS (before meals and night time) 4/12/14 at 9:00 p.m. - CBG was 316. The staff initialed "rt" (for right) but did not document how much insulin was given. There was no documentation the physician was contacted for a blood sugar greater than 301. 4/13/14 - the CBG at 11:15 a.m., 4:15 p.m. and 9:00 p.m. was blank (not done). 4/14/14 - Written on the treatment sheet was, "d/c (discontinue) s/s insulin and continue accu checks AC & HS." Again, no parameters were documented. During an interview on 9/26/14 at 4:10 p.m., the DON confirmed there was no insulin documented as given on the aforementioned days. She said "different doctors had different parameters but there were no set parameters; just a nursing judgement as to when to call the physician." RESIDENT #29 Review of Resident #29's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's 8/14/14 Quarterly MDS Assessment documented she was diabetic and had received insulin injections 7 of 7 days prior to the assessment. Review of her 10/01/14 through 11/30/14 Physician order [REDACTED]. [MEDICATION NAME] R sliding scale: 201 - 250 = 2 units 251 - 300 = 4 units 301 - 351 = 6 units 351 - 400 = 8 units If blood sugar is less than 60 or greater than 400 call doctor. [MEDICATION NAME] 24 units at 7 a.m. (long acting insulin) [MEDICATION NAME] 10 units at 4:30 p.m. [MEDICATION NAME] 6 units at 11:30 a.m. Review of Resident #29's 10/01/14 through 10/14/14 Diabetic Flow sheet documented: [MEDICATION NAME] 6 units at 11:30 a.m.: 10/01/14 no documentation of the insulin being administered. 10/05/14 no documentation of the insulin being administered. Review of Resident #29's 09/01/14 - 09/30/14 Diabetic Flow Sheet documented: 9/03/14 [MEDICATION NAME] 24 units at 7 a.m. No documentation of the insulin being administered. 9/03/14 [MEDICATION NAME] 6 units at 11:30 a.m. No documentation of the insulin being administered. 9/08/14 11:30 a.m. no CBG or insulin administration was documented. 9/09/14 7 a.m. CBG was 214. There was no insulin administration documented. (Resident #29 should have received 2 units of [MEDICATION NAME]) 9/09/14 11:30 a.m. CBG was 413. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/10/14 [MEDICATION NAME] 6 units at 11:30 a.m. No documentation of the insulin being administered. 9/10/14 at 11:30 a.m. CBG was 421. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/11/14 at 11:30 a.m. CBG was 541. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/17/14 at 5 p.m. CBG was 407. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/17/14 at 8 p.m. CBG was 473. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/18/14 at 5 p.m. CBG of 405. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. 9/23/14 at 7 a.m. [MEDICATION NAME] 24 units. No documentation the insulin was administered. 9/25/14 at 5 p.m. No CBG or insulin administration documented. 9/25/14 at 8 p.m. No CBG or insulin administration was documented. Review of the 8/01/14 - 8/31/14 Diabetic Flow Sheet documented: 8/08/14 [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. 8/10/14 [MEDICATION NAME] 10 units at 4:30 p.m. There was no documentation the insulin was administered. 8/16/14 at 11:30 a.m. CBG of 397. There was no documentation of what (if any) insulin was given. 8/16/14 8 p.m.. CBG 464. The nurse gave 8 units of insulin. There was no documentation the doctor was notified. 8/21/14 [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. 8/25/14 [MEDICATION NAME] 24 units at 7 a.m. There was no documentation the insulin was administered. 8/25/14 [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. 8/25/14 [MEDICATION NAME] 10 units at 4:30 p.m. There was no documentation the insulin was administered. 8/25/14 5 p.m. No CBG or insulin administration recorded. 8/25/14 at 8 p.m. No CBG or insulin administration recorded. 8/28/14 [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. During an interview on 10/16/14 at 5:40 p.m. the DON compared the nurse's notes and the 24-hour report to the above dates. She said there was no reason documented for the blanks (i.e. out on pass etc.). She said she had no idea why the [MEDICATION NAME] or the [MEDICATION NAME] Insulin was not given, there was nothing documented. She said it was unknown if Resident #29 got any insulin on 8/16/14 at 11:30 a.m. RESIDENT #30 Review of Resident #30's undated Admission and Discharge Summary documented she was a [AGE] year old female admitted to the facility on [DATE]. Review of Resident #30's 9/01/14 through 10/31/14 Physician order [REDACTED]. Review of Resident #30's 9/20/14 quarterly MDS documented she was diabetic, received [MEDICAL TREATMENT] and received insulin injections 7 of 7 days prior to the assessment. Review of Resident #30's 10/01/14 - 10/31/14 Physician order [REDACTED]. [MEDICATION NAME] N 10 units at 7 a.m. (long acting insulin) [MEDICATION NAME] R per sliding scale 120 - 180 = 2 units 181 - 240 = 4 units 241 - 300 = 6 units 301 - 400 = 8 units. Greater than 401 = 10 units and notify doctor. Call MD if CBG lower than 60 or greater than 400. CBG before meals and at bedtime. Review of Resident #30's October 2014 Diabetic Flowsheets documented: 10/05/14 7 a.m. No CBG or sliding scale insulin administration documented (Resident #30 did get the [MEDICATION NAME] N). 10/10/14 [MEDICATION NAME] N 10 units 7 a.m. held. (7 a.m. CBG results 69) Review of Resident #30's September 2014 Diabetic Flowsheet documented: 9/01/14 at 10 a.m. No CBG or insulin administration documented 9/02/14 7 a.m. There was no documentation that the [MEDICATION NAME] N 10 units was administered. (CBG results 133, Resident #30 got 2 units of [MEDICATION NAME] insulin) 9/03/14 at 10 am. No CBG or insulin administration documented. 9/03/14 7 a.m. There was no documentation the [MEDICATION NAME] N 10 units was administered. 9/05/14 10 a.m. no CBG or insulin administration documented. 9/06/14 11:30 a.m. No CBG or insulin administration documented. 9/08/14 7 a.m. There was no documentation that the [MEDICATION NAME] N 10 units was administered 9/08/14 at 10 a.m. No CBG or insulin administration documented. 9/10/14 at 10 a.m. No CBG or insulin administration documented. 9/11/14 7 a.m. There was no documentation the [MEDICATION NAME] N 10 units was administered. Review of Resident #30's August 2014 Diabetic Flow sheet documented: 8/04/14 5 p.m. No CBG or insulin administration documented 8/07/14 at 7 a.m. There was no documentatin the [MEDICATION NAME] N 10 units was administered. (CBG was 78) 8/08/14 at 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/09/14 7 a.m. CBG 100. The nurse documented she held Resident #30's [MEDICATION NAME] N 10 units. (No telephone order was found to indicate the doctor wanted this done) 8/10/14 at 7 a.m. the nurse initialed it was done, but not what the CBG were results or any insulin (if necessary). 8/10/14 at 8 p.m. No CBG or insulin administration documented. 8/11/14 at 7 am. No CBG or insulin administration documented. 8/13/14 at 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/13/14 10 a.m. No CBG or insulin administration documented 8/14/14 at 11:30 am. No CBG or insulin administration documented. 8/15/14 at 7 am. No CBG or insulin administration documented. 8/16/14 at 11:30 a.m. No CBG or insulin administration documented. 8/19/14 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/20/14 at 7 am. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/20/14 10 a.m. No CBG or insulin administration documented. 8/20/14 8 p.m. No CBG or insulin administration documented. 8/21/14 7 a.m. No CBG or insulin administration documented. There was no documentation the [MEDICATION NAME] N 10 units was administered. 8/24/14 at 11:30 am. No CBG or insulin administration documented. 8/25/14 at 7 am. No CBG or insulin administration documented. 8/25/14 10 a.m. No CBG or insulin administration documented. 8/25/14 5 p.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/26/14 7 a.m. There was no documentation Resident #30 received [MEDICATION NAME] N 10 units. 8/29/14 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received [MEDICATION NAME] N 10 units. 8/30/14 7 a.m. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/31/14 7 a.m. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. 8/31/14 at 11:30 am. CBG of 165. No insulin administration documented. During an interview on 10/17/14 at 9:25 am. the ADON said Resident #30 had [MEDICAL TREATMENT] on Monday -Wednesdays- and Fridays but she should be back by 5 p.m., but if Resident #30 was not back by 5 p.m. she expected the staff to do the CBG as soon as she did get back. The ADON said Resident #30 left for [MEDICAL TREATMENT] at 10 a.m. and there was no reason why the staff should miss the 7 a.m. CBG. The ADON compared the above dates to the 24 hour report and the nurse's notes. She said on 8/08/14 Resident #30 returned to the facility at 5:45 p.m. She said if it was not documented there was no way to tell what Resident #30's blood sugar was or if she got any insulin. The ADON said Resident #30's [MEDICATION NAME] N was a long acting and there was no order to hold the insulin. RESIDENT #5 Review of Resident #5's undated Admission Record indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a [DIAGNOSES REDACTED]. Review of Resident #5's consolidated Physician order [REDACTED]. [MEDICATION NAME] sliding scale 140-200 = 2 units 201-250 = 3 units 251-300 = 4 units If FSBS (fasting blood sugar) less than 60 or greater than 300 notify MD (medical doctor) (Blood Sugar Check) AC (before meals) & HS(hour of sleep) - Before meals and at bedtime; 0700 a.m., 11:30 a.m., 5:00 p.m., 8:00 p.m. ([MEDICATION NAME] is a fast-acting insulin) [MEDICATION NAME] 20 units; subcutaneous once a day; 07:00 a.m. ([MEDICATION NAME] is a once a day long-acting insulin that should be given at the same time each day). Review of Resident #5's Diabetic Flow Sheet dated 9/1/2014 - 9/30/2014 indicated: - 9/07/14 at 7:00 a.m. her blood sugar was 88. There was no documentation [MEDICATION NAME] 20 units was administered. There was no explanation on the flow sheet if the insulin was given or not given. Review of Resident #5's nurse's notes for 9/07/14 did not indicate the [MEDICATION NAME] 20 units was given or not given. During an interview on 9/24/14 at 10:15 a.m. the Registered Nurse (RN) Consultant verified there was no explanation why Resident #5's [MEDICATION NAME] 20 units was not given on 9/07/14. RESIDENT #9 Review of Resident #9's undated Admission and Discharge Summary (face sheet) documented she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's 6/24/14 quarterly MDS Assessment documented she was diabetic and had insulin injections 7 of 7 days prior to the assessment. Review of Resident #9's 8/01/14 - 9/30/14 Physician order [REDACTED]. Humalog Insulin, subcutaneous 201 - 250 = 2 units 251 - 300 = 4 units 301 - 350 = 6 units 351 - 400 = 8 units If less than 60 or greater than 400 notify the doctor. CBG to be checked at 7:00 a.m. on Monday and Thursday. CBG to be checked at 12:20 p.m. on Tuesday and Wednesday. [MEDICATION NAME]pen 18 units before bedtime (7:00 p.m.) [MEDICATION NAME]pen 24 units in the morning. Review of Resident #9's September 2014 Diabetic Flow Sheet documented: 9/08/14 at 8:00 a.m. CBG results was blank. There was no way to determine what her CBG result was or any insulin administration. 9/09/14 at 12:30 p.m. CBG results was blank. There was no way to determine what her CBG result was or any insulin administration. 24 units at 7:00 a.m. [MEDICATION NAME] Insulin was blank on 9/03/14, 9/08/14, 9/09/14. (No documentation to establish if the insulin had been given) 18 units at 7:00 p.m. [MEDICATION NAME] 18 units was blank on 9/04/14, 9/15/14. (No documentation to establish if the insulin had been given.) Review of Resident #9's August Diabetic Flow Sheet documented: 8/01/14 7 a.m. There was no documentation Resident #9 received [MEDICATION NAME] 24 units. 8/14/14- 7:00 a.m. CBG results was blank. There was no way to determine what her CBG result was or any insulin administration. 8/12/14- 12:30 p.m. CBG and insulin administration (if needed) was blank. (Resident #9 did get her [MEDICATION NAME]that morning) 8/20/14- 9:00 p.m. There was no documentation Resident #9 received [MEDICATION NAME] 18 units at night. During an interview on 9/25/14 at 11:45 a.m. the Corporate RN said if there was a nurse's note there was no way to prove if she got it or not. The ADON said she was sure Resident #9 got the insulin because she would tell the staff if they missed anything. She said she did not know why the CBG results or the insulin was not documented. She said the facility was using a lot of agency nurses. RESIDENT #10 Review of Resident #10's undated Admission and Discharge Summary (face sheet) documented he was a [AGE] year old male admitted to the facility on [DATE]. Review of his 8/01/14 - 9/30/14 Physician order [REDACTED]. Review of Resident #10's 7/28/14 quarterly MDS Assessment documented he was diabetic. He received 7 days of insulin injections for the 7 days prior to the assessment. Review of his 8/22/14 care plan documented he was diabetic. The facility identified the short-term goal of "Resident will adhere to diabetic diet as evidenced by blood glucose levels within normal limits and [DIAGNOSES REDACTED]/ [MEDICAL CONDITION]." Review of Resident 8/01/14 through 9/30/14 Physician order [REDACTED]. CBG before meals and before bed. [MEDICATION NAME] R sliding scale 201-251 = 6 units 251 - 300 = 8 units 301 - 350 = 10 units 351 - 400 = 12 units 401 - 450 = 15 units 451 - 500 = 20 units If blood sugar less than 60 or above 500 call doctor. [MEDICATION NAME] 20 units at bed time Review of Resident #10's September 2014 Diabetic Flow Sheet documented: 9/07/14- 11:30 a.m. CBG was blank. There was no way to determine what the results were and if insulin administration was necessary. 9/08/14- 11:30 a.m. had the nurse's initials but no CBG results or insulin administration (if needed) documented. 9/12/14- 5:00 p.m. CBG results of 219. No sliding scale insulin documented as given (per sliding scale order. Res

Based on interview and record review, it was determined the facility failed to consult with the resident's physician when a resident had a change in physical status for five(Residents #16, #17, #19, #29, and #32)of 17 residents reviewed sliding scale insulin coverage. A. Resident #16 had high (greater than 350)capillary blood glucose (CBG) levels once in September 2014, two times in July 2014, and once in June 2014. B. Resident #17 had no diabetic parameters to indicate to the nurses when to notify the physician. Resident #17 had low CBG results (less than 60)twice in August 2014 and seven times in September 2014. C. Resident #19 had no diabetic parameters to indicate to the nurses when to notify the physician. Resident #17 had one high CBG (above 300)in April 2014. D. Resident #29 had six high (above 400)CBG readings in September 2014 and one in August 2014. E. Resident #32 had one high (above 401)CBG reading in September 2014. An Immediate Jeopardy (IJ) was identified on 10/16/14 at 2:24 p.m. While the IJ was removed on 10/17/14 at 10:28 a.m., the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 24 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. The findings included: RESIDENT #16 Review of Resident #16's undated Admission and Discharge Summary (face sheet) documented he was an [AGE] year old male admitted to the facility on [DATE]. Review of Resident #16's 9/01/14 - 10/31/14 Physician order [REDACTED]. Resident #16's 9/20/14 quarterly MDS assessment documented he was diabetic and on [MEDICAL TREATMENT]. He had insulin injections 7 of 7 days prior to the assessment. Review of Resident #16's 09/01/14 - 10/31/14 Physician order [REDACTED]. [MEDICATION NAME] (a long acting insulin) 15 units in the morning. [MEDICATION NAME] Insulin (short acting insulin) per sliding scale (s/s): If blood sugar is less than 60 call doctor. If blood sugar is 141 to 200 give 2 units. If blood sugar is 201 to 250 give 4 units. If blood sugar is 251 to 300 give 6 units. If blood sugar is 301 to 350 give 9 units. If blood sugar is greater than 350 give 10 units. If blood sugar is greater than 351 call doctor. Before meals and at bedtime (7 a.m., 11:30 a.m., 5 p.m., 8 p.m.) Review of Resident #16's September 2014 Diabetic Flow sheet documented: 9/20/14 at 11:30 a.m. CBG of 359. The nurse administered 10 units of insulin. There was no documentation the physician had been notified. Review of Resident #16's July 2014 Diabetic Flow sheet documented: 7/12/14 - 8:00 p.m. CBG result of 371. There was no documentation the doctor was notified. 7/13/14 - 8:00 p.m. CBG result of 466. There was no documentation the doctor was notified. Review of Resident #16's June 2014 Diabetic Flow sheet documented: 6/04/14 - 8:00 p.m. CBG result of 419. The nurse gave 2 units. There was no documentation the doctor was notified. During an interview on 9/26/14 at 3:45 p.m. the Director of Nurses (DON) confirmed the readings. She read the 7/12/14 entry and remarked the nurse gave 9 units of insulin which "made no sense." She acknowledged the parameters were above 351. The DON read the nurses notes and the 24 hour report and could find no documentation the doctor was notified of the elevated blood sugar. She said she could find no documentation the physician was notified of the 7/13/14 blood sugar either. The DON said the 6/04/14 CBG result was 419 and the nurse gave 2 units; she had no idea why. She could not find documentation the doctor was notified in the nurse's notes or the 24 hour report. RESIDENT #17 Review of Resident #17's undated Admission and Discharge Summary (face sheet) documented Resident #17 was an [AGE] year old male admitted to he facility on 7/28/14. Review of Resident #17's September Diabetic flow sheets documented he had [DIAGNOSES REDACTED]. Review of Resident #17's 8/30/14 30 day MDS assessment documented he was diabetic and had injections of insulin the 7 of 7 days prior to the assessment. Review of Resident #17's 8/20/14 Start-up orders documented an order for [REDACTED]. Review of Resident #17's Start-up orders Diabetic monitoring form documented: 8/23/14- 6:30 a.m. CBG of 52 with "OJ" (orange juice) beneath it. 8/24/14- 6:30 a.m. CBG of 39 with a line and then 79. Review of Resident #17's September Diabetic Flow Sheet documented, in part: 9/03/14- 6:30 a.m. CBG of 58. No insulin given. 9/11/14- 6:30 a.m. CBG of 52. 9/15/14- 8:00 p.m. CBG of 51. 9/17/14- 6:30 a.m. CBG of 53. 9/19/14- 6:30 a.m. CBG of 51. 9/20/14- 6:30 a.m. CBG of 53. 9/21/14- 6:30 a.m. CBG of 50. There was no documentation on the Diabetic Flow Sheet or the Nurse's Notes that the doctor was notified of these blood sugars. During an interview on 9/26/14 at 1:55 p.m. the DON was shown Resident #17's diabetic flow sheets. She compared the flow sheets to the nurse's notes and the 24 hour report. She said 8/23/14 showed a CBG result of 39, it was rechecked at 49, and checked a third time to 79. The DON read the note that the resident was awake and alert and was given orange juice with sugar twice and the nurse held his [MEDICATION NAME] but there was no documentation the doctor or his nurse practitioner was notified. She said, "I'm sure they were." During a follow up interview on 9/26/14 at 2:40 p.m. the DON said she followed up with the nurse who did not call the doctor because there were no parameters to notify the doctor. She said the nurse used "nursing judgement." She said Resident #17's doctor varied his high parameters but usually it was to notify the doctor if the CBG was below 60. She said she reviewed the physician's orders [REDACTED]. She said [MEDICATION NAME] was long acting and she would have given it. She said the nurse should have rechecked. The DON said there was nothing on the 24 hour report about Resident #17's blood sugars. The DON acknowledged the following readings: - 9/11/14 the DON said the CBG results looked like a 52 on the original. She confirmed there was nothing in the nurse's notes or in the 24 hour report about the CBG or if the doctor was notified. - 9/15/14 the DON said the CBG looked like a 51 and there was nothing in the 24 hour report or the nurse's notes about the CBG or if the doctor was notified. - 9/17/14 the DON said the CBG looked like a 53 or 33 and there was nothing in the 24 hour report or the nurse's notes about the CBG or if the doctor was notified. - 9/19/14 the DON said the CBG result was a 51 and there was nothing in the nurse's notes or 24 hour report about the CBG or if the doctor was notified. - 9/20/13 the DON said the CBG result was a 53 and there was nothing in the nurse's notes or the 24 hour report about the CBG or if the doctor was notified. - 9/21/14 the DON said the CBG result was 50 and there was nothing in the nurse's notes about the CBG. She said the 2 - 10 nurse documented on the 24 hour report that Resident #17's blood sugar was "low" and that was it. She said there was no documentation the doctor was notified. During an interview on 9/26/14 at 3:05 p.m. Licensed Vocational Nurse (LVN) F said Resident #17's blood sugars fluctuated between the 50's and the 200's. He said Resident #17's doctor usually wanted to be notified if the blood sugar was below 60 but the upper parameter changed from resident to resident. LVN F said there were no parameters for Resident #17. RESIDENT #19 Review of Resident #19 's undated Admission and Discharge Summary Face Sheet noted the resident was admitted on [DATE]. He was a [AGE] year old male. His [DIAGNOSES REDACTED]. Review of the MDS assessments dated 4/19/14 and 7/18/14 reflected the resident was diabetic. Review of nurse's notes dated 3/22/14 at 9:30 p.m., "Patient confused and vomiting, could not tell his name or where he was. He was diaphoretic. Fingerstick is 46. Glucose gel administered, rechecked after 10 minutes and is 116. Patient still confused, sandwich given but continues with problems swallowing. Rechecked at 94. EMT (Emergency Medical Technician) called. Patient was alert and oriented times 2 by the time EMT arrived. MD notified." Review of physician orders [REDACTED].#19 returned to the facility) noted, "Please check CBG regularly and titrate dose of Glimeperide according to CBG readings since patient is having hypoglycemic episodes." There were no parameters on the physician orders [REDACTED]. Additional nurse's notes dated 3/26/14 at 8:00 a.m., "CBG 110- therapy reports notable right side facial drooping and dragging slightly of left leg. Called Dr and DON- received order to transport to hospital via ambulance." Review of physician orders [REDACTED].#19 returned to the facility) noted, sliding scale insulin orders but no parameters as to when to notify the physician of low or high blood sugar readings. Review of the start up orders/treatment administration record for April 2014 noted: Humalog R per sliding scale <100 - 0 units 101-150 - 2 units 151-200 - 4 units 201-250 - 6 units 251-300 - 8 units >301 - 10 units CBG's AC and HS (before meals and night time) 4/12/14 at 9:00 p.m. - CBG was 316. The staff initialed "rt" (for right) but did not document how much insulin was given. There was no documentation the physician was contacted for a blood sugar greater than 301. 4/13/14 - the CBG at 11:15 a.m., 4:15 p.m. and 9:00 p.m. was blank (not done). 4/14/14 - Written on the treatment sheet was, "d/c (discontinue) s/s insulin and continue accu checks AC & HS." Again, no parameters were documented. During an interview on 9/26/14 at 4:10 p.m., the DON confirmed there was no insulin documented as given on the aforementioned days. She said "different doctors had different parameters but there were no set parameters; just a nursing judgement as to when to call the physician." RESIDENT #29 Review of Resident #29's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's 8/14/14 Quarterly MDS Assessment documented she was diabetic and had received insulin injections 7 of 7 days prior to the assessment. Review of her 10/01/14 through 11/30/14 Consolidated Physician order [REDACTED]. Order Dated 3/29/13 [MEDICATION NAME] R (fast acting insulin) sliding scale: 201 - 250 = 2 units 251 - 300 = 4 units 301 - 351 = 6 units 351 - 400 = 8 units If blood sugar is less than 60 or greater than 400 call doctor. 7/17/14 [MEDICATION NAME] 24 units at 7 a.m. 7/21/14 [MEDICATION NAME] 10 units at 4:30 p.m. 7/21/14 [MEDICATION NAME] 6 units at 11:30 a.m. Review of Resident #29's 9/01/14 through 9/30/14 Diabetic Flow sheet documented: 9/09/14 11:30 a.m. CBG was 413. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. 9/10/14 at 11:30 a.m. CBG was 421. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. 9/11/14 at 11:30 a.m. CBG was 541. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. 9/17/14 at 5 p.m. CBG was 407. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. 9/17/14 at 8 p.m. CBG was 473. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. 9/18/14 at 5 p.m. CBG of 405. The nurse gave 8 units of insulin. There was no documentation the doctor had been notified. Review of the 8/01/14 - 8/31/14 Diabetic Flow Sheet documented: 8/16/14 8 p.m. CBG 464. The nurse gave 8 units of insulin. There was no documentation the doctor was notified. During an interview on 10/16/14 at 5:50 p.m. the DON compared the above dates to Resident #29's Nurse's Notes and the corresponding 24-hour report. She acknowledged she was unable to to find any documentation the doctor was notified. RESIDENT #32 Review of Resident #32's 11/05/11 Record of Admission documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's 7/07/14 quarterly MDS assessment documented she was diabetic and had insulin injections 7 of 7 days prior to the assessment. Review of Resident #32's 10/01/14 - 11/30/14 Consolidated Physician order [REDACTED]. Order Dated 11/15/13 CBG's before meals and at bedtime. Humalog Sliding Scale: 201- 250 = 4 units 251 - 300 = 6 units 301 - 350 =8 units 351 - 400 = 10 units notify doctor if below 60 or above 401. Review of Resident #32's Diabetic Flowsheet documented on 9/12/14 at 11:30 a.m. she had a CBG of 451. The nurse gave 10 units of insulin. There was no documentation the doctor had been notified. During an interview on 10/16/14 at 5 p.m. the DON compared the above dates with Resident #32's nurse's notes and the 24 hour report. She said she could not find any documentation the nurse contacted the doctor. During an interview on 10/17/14 at 10:45 a.m. the ADON said if it was not on the MARs, the TARs, the nurse's notes, or the 24 hour report, it was not there. Review of the facility's 3/2012 Policy and Procedure on Diabetes Mellitus Resident - Nursing care of documented, in part: "It is the policy of this home to assure that residents with diabetes will receive adequate assessments and treatments to prevent complications related to diabetes. Procedure: the physician should specify high and low parameters for diabetic residents. Notify the Physician: finger stick blood sugar is greater than 300 or blood glucose is greater than 250 despite additional insulin per sliding scale or blood glucose is less than 70 unless the physician ordered specific parameters for the individual resident. Review of the facility's 3/2012 policy and procedure on Change of Condition - Observing, Reporting, and Recording documented, in part: "It is the policy of this home to inform the resident, the resident's physician, and if indicated the residents responsible party of the following: A significant change in the resident's physical, mental, or psychosocial status such as deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change in condition is resolved such as a fall without injury or head trauma). If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician), or the emergency room physician. Document the Date, time condition change was identified; Pertinent assessment findings; Who was notified and when. Communication: 1. The change in condition and interventions related to the change will be documented on the 24 hour report from on the shift that the change occurred. 2. The licensed nurse(s) and nursing assistant will communicate to the oncoming shift orally and through the 24-hour report, the change in condition and interventions. During an interview on 10/16/14 at 2:24 p.m. the Administrator and DON were informed of the IJ and the need for a Plan of Removal. Review of the 10/16/14 Plan of Removal for Monitoring and Treating Residents with Diabetes documented: Medical Director has been notified of the Immediate Jeopardy by the DON at 1235 on 10/16/14. The initial part of this problem was brought to our attention on 9/22/14 by the survey team. Immediate Jeopardy notification was 1400 on 10/16/14. Actions Taken 1. On 9/22/14, the DON personally checked each glucometer for proper calibration and operation. There was some question on two meters, so we purchased six new meters from (a local pharmacy) and test strips/control solution to go with them. This was to avoid any confusion with the old meters/ strips there were ordered from a supplier that could not provide replacements immediately. Completed 9/22/14. Additional supplies were bought locally in the next few weeks. (Receipts Provided 10/16/14) 2. The DON and ADON presented in-services to all nurses available, following up with nurses as they came to work in days following. These in-services were on how to check glucometers ' HI/LO parameters. Completed 9/22/14. 3. Nurses were in-services as in 2 above regarding documentation on Medication Administration Record [REDACTED]. Completed 9/24/14. 4. On 9/22/14, Medical Director initiated a standard sliding scale for administration of insulin with parameters of when to notify the physician. By 10/06/14, Medical Director had consensus with other attending physicians on the standard parameters. Orders were written on 10/07/14 and 10/08/14 for each diabetic resident that this applied to. Some diabetics do not need CBGs done; their physicians have chosen to go with periodic HBA1C tests. Completed 10/10/14. 5. On 10/03/14, we received the standard Assure Platinum Glucometers that we normally order through (a medical supply company). Those were put in service and nurses were reminded how to use them with documentation starting on 10/03/14. The glucometers purchased locally at a cost of about $920, were stored in the DON's office as back up units, should we experience sudden failure of units in the future. Completed 10/03/14. 6. The DON is monitoring the blood sugar and glucometer testing each morning when she comes to work Monday - Friday. Completed 9/23/14 Actions Planned/ Monitoring 1. In addition to the weekday monitoring by the DON, the On-Call Nurses will be monitoring glucometer testing/ calibration/ operation as well as administration of insulin and withholding of insulin/ notification of physician on weekends when they come to the facility to monitor shift change rounds and other activities (schedule attached). Completions 10/16/14. 2. Specific training for Agency nurses will be accomplished by giving agencies notice that their nurses must expect to receive training prior to working their first shift at the facility. The will be required to have their nurses orient with our On-Call Nurse prior to their first shift working at the facility. The On Call Nurse will turn said documentation of training regarding diabetic treatment and glucometers in to the DON or Administrator as soon as practical. Schedule of On-Call Nurses is attached. Completion 10/16/14. 3. Quality Assurance - The Administrator, will ensure monthly review of diabetic resident treatment/ glucometer calibrating and testing to be monitored during the monthly Quality Assurance Committee Meeting. This meeting will include the Medical Director for the next three consecutive months. Completions 10/29/14. During an interview on 10/17/14 at 10:28 a.m. the Administrator and DON were informed the IJ was lifted but the facility remained out of compliance due to the lack of monitoring. During an interview on 10/14/14 at 2:08 p.m. LVN U said if a resident had a blood sugar of 40 she would notify the doctor if the resident did not have any standing orders. LVN U said that was what a nursing judgment would mean to her. During an interview on 10/14/14 at 3:27 p.m. LVN F said that if a resident had a blood sugar of 40 he would call the doctor for further directions. During an interview on 10/14/14 at 4:07 p.m. the DON stated that when she said for the nurse to use nursing judgment she meant that they should call the doctor if a resident had a hi or low blood sugar. Review of the attached documentation with the 10/16/14 Plan of Removal documented: - 9/22/14 receipts for Glucometers and with testing supplies. - In-service dated 9/22/14 on Glucometers with return demonstration held by the DON. Fifteen nurses attended. - In-service dated 9/24/14 on Insulin Documentation to include Physician Notification. 14 Nurses attended. - Receipt on 10/01/14 for 4 Blood Glucose Meters. - On call Rotation Schedule for the Month of October. A list provided by the facility on 9/25/14 documented there were 24 residents who were on some form of CBG testing.

Based on observation, interview and record review it was determined the Administrator and DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 16 of 17 residents (Resident #5, #9, #10, #16, #17, #18, #19, #24, #29, #30, #32, #33, #35, #36, and #37) reviewed for glucose monitoring and 1 of 8 wandering residents (Resident #20). 1) The DON failed to ensure the facility staff was fully trained in the use of the blood sugar glucometers and to provide supervision of staff to ensure the staff was knowledgeable of what procedures to use when they received a result which was out of range. 2) The Administrator failed to supervise the Director of Nurses (DON) to ensure she monitored nursing staff for compliance with assessing diabetic residents regarding accurate quality monitoring checks of their daily blood sugars; and that staff was knowledgeable in what procedures to follow when one of the results was out of range such as notifying the physician per orders or administering insulin as ordered. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:24 p.m. While the IJ was removed on [DATE] at 10:28 a.m., the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures to ensure the glucometers were providing the correct results of blood sugar levels and not troubleshooting to determine whether the glucometers were working placed the facility's 26 diabetics at risk for: developing abnormal blood sugar levels without being identified and/or not receiving the appropriate dosage of insulin as ordered by the physician. This could result in a decline in their health and well-being without recognizing hyper/[DIAGNOSES REDACTED] and being treated accordingly, which could then result in coma, brain damage and death. 3) The Administrator and Director of Nurses (DON) failed to ensure staff were following the faciltiy's policy and procedure in supervising wandering residents. Resident #20 eloped from the facility some time after 7:30 p.m. on Sunday night [DATE]. The night shift (10 p.m. - 6 a.m.) did not notice Resident #20 was missing for the entire shift. The day shift (6 a.m. - 2 p.m.) did not notice Resident #20 was missing until three (3) hours into their shift. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:49 p.m. The IJ was removed on [DATE] at 2:24 p.m. but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. Failure to ensure staff were properly checking on residents placed the facility's 20 wandering residents at risk for unsupervised elopement on a busy four land road. Findings included: DIABETIC RESIDENTS - GLUCOMETER TESTING BLOOD GLUCOSE METER During observation on [DATE] at 11:00 a.m., the glucometer control logs were reviewed for the front and the back halls: [DATE] UNIT 1A - The normal control result was out of range for 3 of the 31 days and had 5 days that were blank. The high control result was also out of range for 26 of 27 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A- The normal control result was out of range for 4 of the 31 days and had 4 days that were blank. The high control result was also out of range for 26 of 27 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. February 2014 UNIT 1A - The normal control result was out of range for 19 of the 28 days and had 5 days that were blank. The high control result was also out of range for 13 of 28 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - The normal control result was out of range for 19 of the 28 days, had one day where the reading was LO and had 5 days that were blank. The high control result was also out of range for 17 of 28 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] UNIT 1A - The normal control result was out of range for 17 of the 31 days and had 7 days that were blank. The high control result was also out of range for 16 of 31 days and 5 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - The normal control result was out of range for 15 of the 31 days and had 4 days that were blank. The high control result was also out of range for 21 of 31 days and 4 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] UNIT 1A - The normal control result was out of range for 16 of the 30 days (all the days that were tested ) and had 14 days that were blank (7 days in a row). The high control result was also out of range for 6 of 30 days and 14 days were blank (7 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - The normal control result was out of range for 17 of the 30 days and had 7 days that were blank. The high control result was also out of range for 7 of 30 days and 7 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] There were four glucometers listed for [DATE]. UNIT 1A - The normal control result was out of range for 5 of the 31 days and had 16 days that were blank. The high control result was also out of range for 14 of 31 days (all days that were tested ) and 17 days were blank (9 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 2A - The normal control result was out of range for 4 of the 31 days and had 21 days that were blank (21 days in a row). The high control result was also out of range for all 10 days that were tested and 21 days were blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - The days started with the 13th- The normal control result was out of range for 5 of the 19 remaining days and had 9 days that were blank (9 days in a row). The high control result was also out of range for all 10 days that were tested and 9 days were blank (9 days in a row). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A (different serial number and the days started with the 23rd) - The normal control result was out of range for 2 of the remaining 9 days. The high control result was all blank (nothing filled in). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] There were three glucometers listed for [DATE]. UNIT A - The normal control result was out of range for 4 of the 15 days that were tested . The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - The normal control result was out of range for 10 of the 14 days that were tested ; three of these days the reading was LO. There was one day that was blank (no calibration check performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - The normal control result was out of range for 8 of the 14 days that were tested ; three of these days the reading was LO. There was one day that was blank (no calibration check performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] There were six glucometers listed for [DATE]. UNIT A - The normal control result was not out of range for the 3 days listed ([DATE]-3 only) but [DATE] was blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT 1A - The days started with the 3rd- The normal control result was out of range for 15 of the 19 days that were tested ( [DATE] - [DATE]) and had 1 day that was blank. The high control result was also out of range for all 18 days that were tested and 1 day was blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The days started with the 3rd- The normal control result was out of range for 16 of the 19 days that were tested ( [DATE] - [DATE]) and had 2 days that were blank. The high control result was also out of range for all 18 days that were tested and 1 day was blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The normal control result was ,[DATE] for the 1 day listed ([DATE]) but no result was documented. The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The days started with the 22nd- The normal control result was ,[DATE] but no results were documented for the 9 of 10 10 days. There were 5 days that were blank. The high control result was totally blank. On [DATE] was written, "Machine not working." The next 4 days were blank (no calibration performed). Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The normal control result was ,[DATE] for the 2 days listed ([DATE]-30) but 1 of the days was blank (no calibration result documented). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] There were four glucometers listed for [DATE]. No unit listed - The normal control result was out of range for 8 of the 14 days listed ([DATE]-14 only) and 4 days were blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - The normal control result was out of range for 10 of the 14 days listed ([DATE]-14 only) and 3 days were blank (no calibration performed). The high control result was totally blank. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The days started with the 15th- The normal control result was out of range for 7 of the 17 days that were tested ( [DATE] - [DATE]). The high control result was also out of range for 13 of the 17 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed- The days started with the 15th- The normal control result was out of range for 3 of the 17 days that were tested ( [DATE] - [DATE]). The high control result was also out of range for 13 of the 17 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. [DATE] There were three glucometers listed for [DATE]. UNIT A - The normal control result was out of range for 19 of the 21 days that were tested ( [DATE] - [DATE]). The high control result was also out of range for 13 of the 21 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - The normal control result was out of range for 6 of 6 days that were tested ( [DATE] - [DATE]). The high control result was also out of range for 5 of the 6 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. No unit listed - tested on e day only, [DATE] - The normal control range was ,[DATE] but no result was documented. The high control range was ,[DATE] but no result was documented. Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. UNIT A - The normal control result was out of range for 8 of the 12 days that were tested ( [DATE] - [DATE]). The high control result was also out of range for 10 of the 12 days that were tested . Under the column, Corrective Action was a circle with a line through it to indicate no action was taken. An interview on [DATE] at 2:30p.m. with the Assistant Director of Nurses (ADON) Staff A and the Unit Manager staff B was held. The ADON acknowledged the control readings were not within the parameters. She said the staff "should recheck the glucometer or get another one that works but don't use the one that won't test accurately." An interview on [DATE] at 2:50p.m. with the Director of Nurses (DON) staff C she also acknowledged the glucometer readings were outside the normal range and were not safe to use. She said the pharmacist "caught this a couple of weeks ago and suspects when staff opened a new bottle of strips they are not holding down the button on the glucometer to clear it." Surveyor showed the DON the readings were still outside the acceptable range as of [DATE] and asked if staff had been inserviced on the concern. The DON said she could not remember if there had been an inservice regarding the issue but would look. An interview on [DATE] at 3:30p.m. with the Registered Nurse (RN) Nurse Consultant also acknowledged if the glucometer reading was outside the range staff should retest but do not use a glucometer that did not work accurately. Review of the pharmacy consultant report for [DATE] noted, "Glucometer Calibration Log has holes in it- Station A." Review of package insert of True Control Glucose Control (used to test and calibrate glucometers) noted, in part, " If test result displayed in meter falls within range of control values given on test strip vial label, testing technique and system performance are acceptable. Control results must be within result range printed on test strip vial label. If a control test result is outside control range, do not use test strips or meter for blood glucose testing. Check to see if control or test strips have expired and open new bottle if necessary. Repeat test. WARNING! Do not use test strips or meter for blood glucose testing if control results are not within control range." DIABETIC RESIDENTS - PARAMETERS, INSULIN ADMINISTRATION, AND NOTIFICATION OF DOCTOR DIABETIC MONITORING RESIDENT #17 Review of Resident #17's undated Admission and Discharge Summary (face sheet) documented Resident #17 was an [AGE] year old male admitted to the facility on [DATE]. Review of Resident #17's September Diabetic flow sheets documented he had [DIAGNOSES REDACTED]. Review of Resident #17's [DATE] 30 day MDS assessment documented he was diabetic and had injections of insulin the 7 of 7 days prior to the assessment. Review of Resident #17's [DATE] Start up orders documented an order for [REDACTED]. Review of Resident #17's Start up orders Diabetic monitoring form documented: [DATE]- 6:30 a.m. no CBG results documented. [DATE]- 6:30 a.m. CBG of 52 with "OJ" (orange juice) beneath it. There was no documentation the doctor was notified. [DATE]- 6:30 a.m. CBG of 39 with a line and then 79. There was no documentation the doctor was notified. [DATE]- 8:00 p.m. no results documented. According to the American Diabetes Association, [DIAGNOSES REDACTED] (low blood sugar) is a condition characterized by abnormally low blood glucose. The sugar, the food you eat gets digested and broken down into a sugar your body's cells can use. This is glucose, one of the simplest forms of sugar. (blood sugar: 1. A class of carbohydrates with a sweet taste, including glucose, fructose and sucrose. 2. A term used to refer to blood glucose. 3) levels, usually less than 70 mg/dlmilligrams (MILL-ih-grams) per deciliter (DESS-ih-lee-tur), a unit of measure that shows the concentration of a substance in a specific amount of fluid. In the United States, blood glucose test results are reported as mg/dL. Medical journals and other countries use millimoles per liter (mmol/L). To convert to mg/dL from mmol/L, multiply mmol/L by 18. Example: 10 mmol/L ??A zA? 18 = 180 mg/dL. The only sure way to know whether you are experiencing [DIAGNOSES REDACTED] is to check your blood glucose, if possible. Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma sleep-like state in which a person is not conscious. May be caused by [MEDICAL CONDITION] (high blood glucose) or [DIAGNOSES REDACTED] (low blood glucose) in people with diabetes., and death. If left untreated, [DIAGNOSES REDACTED] may lead to a [MEDICAL CONDITION] or unconsciousness (passing out, a coma). In this case, someone else must take over. ? Signs and symptoms of [DIAGNOSES REDACTED] are shakiness, nervousness or anxiety, sweating, chills and clamminess. Irritability or impatience, confusion, including [MEDICAL CONDITION], rapid/fast heartbeat, lightheadedness or dizziness. Hunger and nausea, sleepiness, blurred/impaired vision, tingling or numbness in the lips or tongue. Headaches, weakness or fatigue. Anger, stubbornness, or sadness. Lack of coordination, nightmares or crying out during sleep, [MEDICAL CONDITION] and unconsciousness. ? Last Reviewed: [DATE] ? Last Edited: [DATE] ? Reference: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html There were no documentation that Resident #17 received his [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #17's September Diabetic Flow Sheet documented, in part: [DATE]- 6:30 a.m. CBG of 58. No insulin given. [DATE]- 6:30 a.m. CBG of 52. [DATE]- 8 p.m. CBG of 51. [DATE]- 6:30 a.m. CBG of 53. [DATE]- 6:30 a.m. CBG of 51. [DATE]- 6:30 a.m. CBG of 53. [DATE]- 6:30 a.m. CBG of 50. There was no documentation on the Diabetic Flow Sheets or the Nurse's Notes that the doctor was notified. During an interview on [DATE] at 1:55 p.m. the DON was shown Resident #17's diabetic flow sheets. She compared the flow sheets to the nurse's notes and the 24 hour report. The flow sheet dated [DATE] showed a CBG result of 39, it was rechecked at 49, and checked a third time to 79. The DON read the note that the resident was awake and alert and was given orange juice with sugar twice and the nurse held his [MEDICATION NAME] but there was no documentation the doctor or his nurse' practitioner were notified. The DON acknowledged the flow sheet (dated [DATE]) had no findings documented in the nurse's notes or the 24 hour report. She said if it was not signed there was no way to tell what insulin Resident #17 did or did not get. During a follow up interview on [DATE] at 2:40 p.m. the DON said she followed up with the nurse who did not call the doctor because there were no parameters to notify the doctor. She said the nurse used "nursing judgement." She said Resident #17's doctor varied his high parameters but usually it was notify him if the CBG was below 60. She said she reviewed all of the physician's orders [REDACTED]. She said [MEDICATION NAME] was long acting and she would have given it. She said the nurse should have rechecked the blood sugars. The DON said there was nothing on the 24 hour report. The [DATE] flow sheets were also reviewed during this interview ([DATE] at 2:40 p.m.) with the DON: -[DATE] the DON said the CBG results looked like a 52 on the original. She confirmed there was nothing in the nurse's notes or in the 24 hour report about the CBG result or the physician being notified. -[DATE] the DON said the CBG looked like a 51 and there was nothing in the 24 hour report or the nurse's notes about the CBG of the physician being notified. -[DATE] the DON said the CBG looked like a 53 or 33 and there was nothing in the 24 hour report or the nurse's notes about the CBG of the physician being notified. -[DATE] the DON said the CBG result was a 51 and there was nothing in the nurse's notes or 24 hour report about the CBG or the physician being notified. -[DATE] the DON said the CBG result was a 53 and there was nothing in the nurse's notes or the 24 hour report about the CBG or the physician being notified. -[DATE] the DON said the CBG result was 50 and there was nothing in the nurse's notes about the CBG. She said the 2 - 10 nurse documented that Resident #17's blood sugar was "low" and "that was it." There was nothing about the physician being notified. During an interview on [DATE] at 3:05 p.m. Licensed Vocational Nurse (LVN) F said Resident #17's blood sugars fluctuated between the 50's and the 200's. He said Resident #17's doctor usually wanted to be notified if the blood sugar was below 60 but the upper parameter changed from resident to resident. LVN F said there were no parameters for Resident #17. RESIDENT #19 Review of Resident #19's undated Admission and Discharge Summary Face Sheet noted the resident was admitted on [DATE]. He was a [AGE] year old male. His [DIAGNOSES REDACTED]. Review of the MDS assessments dated [DATE] and [DATE] reflected the resident was diabetic. Review of nurse's notes dated [DATE] at 9:30 p.m., "Patient confused and vomiting, could not tell his name or where he was. He was diaphoretic. Fingerstick is 46. Glucose gel administered, rechecked after 10 minutes and is 116. Patient still confused, sandwich given but continues with problems swallowing. Rechecked at 94. EMT (Emergency Medical Technician) called. Patient was alert and oriented times 2 by the time EMT arrived. MD notified." Review of physician orders [REDACTED].#19 returned to the facility) noted, "Please check CBG regularly and titrate dose of Glimeperide according to CBG readings since patient is having hypoglycemic episodes." There were no parameters on the physician orders [REDACTED]. Additional nurse's notes dated [DATE] at 8:00 a.m., "CBG 110- therapy reports notable right side facial drooping and dragging slightly of left leg. Called Dr and DON- received order to transport to hospital via ambulance." Review of physician orders [REDACTED].#19 returned to the facility) noted, sliding scale insulin orders but no parameters as to when to notify the physician of low or high blood sugar readings. Review of the start up orders/treatment administration record for [DATE] noted: Humalog R per sliding scale <100 - 0 units ,[DATE] - 2 units ,[DATE] - 4 units ,[DATE] - 6 units ,[DATE] - 8 units >301 - 10 units CBG's AC and HS (before meals and night time) [DATE] at 9:00 p.m. - CBG was 316. The staff initialed "rt" (for right) but did not document how much insulin was given. There was no documentation the physician was contacted for a blood sugar greater than 301. [DATE] - the CBG at 11:15 a.m., 4:15 p.m. and 9:00 p.m. was blank (not done). [DATE] - Written on the treatment sheet was, "d/c (discontinue) s/s insulin and continue accu checks AC & HS." Again, no parameters were documented. During an interview on [DATE] at 4:10 p.m., the DON confirmed there was no insulin documented as given on the aforementioned days. She said "different doctors had different parameters but there were no set parameters; just a nursing judgement as to when to call the physician." RESIDENT #29 Review of Resident #29's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's [DATE] Quarterly MDS Assessment documented she was diabetic and had received insulin injections 7 of 7 days prior to the assessment. Review of her [DATE] through [DATE] Physician order [REDACTED]. [MEDICATION NAME] R sliding scale: 201 - 250 = 2 units 251 - 300 = 4 units 301 - 351 = 6 units 351 - 400 = 8 units If blood sugar is less than 60 or greater than 400 call doctor. [MEDICATION NAME] 24 units at 7 a.m. (long acting insulin) [MEDICATION NAME] 10 units at 4:30 p.m. [MEDICATION NAME] 6 units at 11:30 a.m. Review of Resident #29's [DATE] through [DATE] Diabetic Flow sheet documented: [MEDICATION NAME] 6 units at 11:30 a.m.: [DATE] no documentation of the insulin being administered. [DATE] no documentation of the insulin being administered. Review of Resident #29's [DATE] - [DATE] Diabetic Flow Sheet documented: [DATE] [MEDICATION NAME] 24 units at 7 a.m. No documentation of the insulin being administered. [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. No documentation of the insulin being administered. [DATE] 11:30 a.m. no CBG or insulin administration was documented. [DATE] 7 a.m. CBG was 214. There was no insulin administration documented. (Resident #29 should have received 2 units of [MEDICATION NAME]) [DATE] 11:30 a.m. CBG was 413. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. No documentation of the insulin being administered. [DATE] at 11:30 a.m. CBG was 421. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] at 11:30 a.m. CBG was 541. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] at 5 p.m. CBG was 407. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] at 8 p.m. CBG was 473. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] at 5 p.m. CBG of 405. The nurse gave 8 units of insulin (the highest dose ordered per the sliding scale). There was no documentation the doctor had been notified. [DATE] at 7 a.m. [MEDICATION NAME] 24 units. No documentation the insulin was administered. [DATE] at 5 p.m. No CBG or insulin administration documented. [DATE] at 8 p.m. No CBG or insulin administration was documented. Review of the [DATE] - [DATE] Diabetic Flow Sheet documented: [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. [DATE] [MEDICATION NAME] 10 units at 4:30 p.m. There was no documentation the insulin was administered. [DATE] at 11:30 a.m. CBG of 397. There was no documentation of what (if any) insulin was given. [DATE] 8 p.m.. CBG 464. The nurse gave 8 units of insulin. There was no documentation the doctor was notified. [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. [DATE] [MEDICATION NAME] 24 units at 7 a.m. There was no documentation the insulin was administered. [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. [DATE] [MEDICATION NAME] 10 units at 4:30 p.m. There was no documentation the insulin was administered. [DATE] 5 p.m. No CBG or insulin administration recorded. [DATE] at 8 p.m. No CBG or insulin administration recorded. [DATE] [MEDICATION NAME] 6 units at 11:30 a.m. There was no documentation the insulin was administered. During an interview on [DATE] at 5:40 p.m. the DON compared the nurse's notes and the 24-hour report to the above dates. She said there was no reason documented for the blanks (i.e. out on pass etc.). She said she had no idea why the [MEDICATION NAME] or the [MEDICATION NAME] Insulin was not given, there was nothing documented. She said it was unknown if Resident #29 got any insulin on [DATE] at 11:30 a.m. RESIDENT #30 Review of Resident #30's undated Admission and Discharge Summary documented she was a [AGE] year old female admitted to the facility on [DATE]. Review of Resident #30's [DATE] through [DATE] Physician order [REDACTED]. Review of Resident #30's [DATE] quarterly MDS documented she was diabetic, received [MEDICAL TREATMENT] and received insulin injections 7 of 7 days prior to the assessment. Review of Resident #30's [DATE] - [DATE] Physician order [REDACTED]. [MEDICATION NAME] N 10 units at 7 a.m. (long acting insulin) [MEDICATION NAME] R per sliding scale 120 - 180 = 2 units 181 - 240 = 4 units 241 - 300 = 6 units 301 - 400 = 8 units. Greater than 401 = 10 units and notify doctor. Call MD if CBG lower than 60 or greater than 400. CBG before meals and at bedtime. Review of Resident #30's [DATE] Diabetic Flowsheets documented: [DATE] 7 a.m. No CBG or sliding scale insulin administration documented (Resident #30 did get the [MEDICATION NAME] N). [DATE] [MEDICATION NAME] N 10 units 7 a.m. held. (7 a.m. CBG results 69) Review of Resident #30's [DATE] Diabetic Flowsheet documented: [DATE] at 10 a.m. No CBG or insulin administration documented [DATE] 7 a.m. There was no documentation that the [MEDICATION NAME] N 10 units was administered. (CBG results 133, Resident #30 got 2 units of [MEDICATION NAME] insulin) [DATE] at 10 am. No CBG or insulin administration documented. [DATE] 7 a.m. There was no documentation the [MEDICATION NAME] N 10 units was administered. [DATE] 10 a.m. no CBG or insulin administration documented. [DATE] 11:30 a.m. No CBG or insulin administration documented. [DATE] 7 a.m. There was no documentation that the [MEDICATION NAME] N 10 units was administered [DATE] at 10 a.m. No CBG or insulin administration documented. [DATE] at 10 a.m. No CBG or insulin administration documented. [DATE] 7 a.m. There was no documentation the [MEDICATION NAME] N 10 units was administered. Review of Resident #30's [DATE] Diabetic Flow sheet documented: [DATE] 5 p.m. No CBG or insulin administration documented [DATE] at 7 a.m. There was no documentatin the [MEDICATION NAME] N 10 units was administered. (CBG was 78) [DATE] at 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. [DATE] 7 a.m. CBG 100. The nurse documented she held Resident #30's [MEDICATION NAME] N 10 units. (No telephone order was found to indicate the doctor wanted this done) [DATE] at 7 a.m. the nurse initialed it was done, but not what the CBG were results or any insulin (if necessary). [DATE] at 8 p.m. No CBG or insulin administration documented. [DATE] at 7 am. No CBG or insulin administration documented. [DATE] at 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. [DATE] 10 a.m. No CBG or insulin administration documented [DATE] at 11:30 am. No CBG or insulin administration documented. [DATE] at 7 am. No CBG or insulin administration documented. [DATE] at 11:30 a.m. No CBG or insulin administration documented. [DATE] 7 a.m. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. [DATE] at 7 am. No CBG or insulin administration documented. There was no documentation Resident #30 received the [MEDICATION NAME] N 10 units. [DATE] 10 a.m. No CBG or insulin administration documented. [DATE] 8 p.m. No CBG or insulin administration documented. [DATE] 7 a.m. No CBG or insulin administration documented. There was no documentat