Every finding on record at Hathaway Manor Extended Care

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who upon admission had both upper and lower dentures, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing assessments did not include or identify he/she had dentures in place and there was no other nursing department documentation related to oral care provided to him/her associated with having dentures. Findings Include:Review of the Facility's Policy tilted Documentation-Clinical, dated as revised 12/29/2025, indicated the following: -the purpose is to ensure accuracy and completeness of clinical documentation.-facility must make a comprehensive assessment of a resident's needs, strengths, areas of risk, goals, life history and preferences using the resident assessment instrument (RAI) and further assessments.- the assessment process must include direct observation and communication with the resident as well as communication with licensed and non-licensed staff members on all shifts.-admission nursing note includes any information not addressed in the nursing admission assessment to describe the resident's condition at the time of admission. Resident #1 was admitted to the Facility in May 2024, diagnoses included dementia, aphasia (inability to comprehend or formulate language from damage to specific regions of the brain), rheumatoid arthritis, normal pressure hydrocephalus (excessive fluid buildup in the brain), hypertension, anxiety, and cognitive communication deficit.During an interview on 08/06/26 at 9:00 A.M., Family Member #1 said Resident #1 was admitted to the Facility in May 2024, that he/she had upper and lower partial dentures in place at that time, and that he/she had them since he (Family Member #1) was young. Review of Resident #1's Nursing admission Assessment, dated 05/23/2024, indicated that he/she did not wear dentures.Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated January 2026 through June 2026, the functional abilities-oral hygiene section indicated that oral hygiene is the ability to use suitable items to clean teeth; dentures (if applicable): is the ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment. Further review of Resident #1's CNA Documentation Records did not specify if he/she had dentures. Review of Resident #1's Medical Record, indicated there was no documentation to support that Resident #1 had partial upper and lower dentures.During an interview on 08/05/26 at 2:36 P.M., the Unit Manager said she was not aware that Resident #1 had partial dentures. The Unit Manager said upon a resident's admission the nurses' complete head-to-toe assessments of the residents' which includes checking their oral cavity and whether they have dentures or not. The Unit Manager said if a resident has dentures the nurse must document it in their medical record.During an interview on 08/05/26 at 4:09 P.M., the Assistant Director of Nursing (ADON) said she was not aware that Resident #1 had partial dentures. The ADON said that the nurses are responsible for completing oral assessments on residents' annually and quarterly. The ADON said she reviewed Resident #1's admission Nursing Assessment (dated 05/23/24) and his/her Initial Nutritional Assessment (dated 05/29/24) and that both assessments indicated he/she had no dentures. The ADON said it is the Facility's expectation that nurses are accurately assessing residents' and documenting in their medical records.During a telephone interview on 08/10/26 at 2:07 P.M., and a subsequent telephone interview on 08/18/26 at 10:53 A.M., the Director of Nursing (DON) said she was not aware Resident #1 had partial dentures and that she had not reviewed his/her medical record. The DON said that nurses' complete admission assessment on all residents (head-to-toe) including assessing their oral cavity by looking at and inspecting the inside of the resident's mouth. The DON said the nurses are responsible for determining and assessing if a resident has dentures, their own teeth or no teeth and that it is documented in their medical record. The DON said it was her expectation that all nurses are accurately assessing residents and that their medical records are accurate.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had upper and lower partial dentures and required staff assistance with oral hygiene, the Facility failed to ensure that he/she received care and treatment that meet professional standards of practice related to his/her oral care needs.Findings Include:Review of the Facility's Policy, Standards of Routine Resident Care, dated as revised March 20, 2009, indicated the following:-it is the policy of the facility that each resident shall receive at least certain basic nursing care in the Nursing Facility. -these tasks are associated with the resident's personal cleanliness and routine activities of daily living.-provide oral care to each resident at least twice daily, unless specified by the resident's Care Plan.-Oral care shall be given to residents as part of morning and bedtime care.-residents with dentures shall have these removed at bedtime to soak overnight unless the resident's routine or preference indicates other care measures.Resident #1 was admitted to the Facility in May 2024, diagnoses included dementia, aphasia (inability to comprehend or formulate language from damage to specific regions of the brain), rheumatoid arthritis, normal pressure hydrocephalus (excessive fluid buildup in the brain), hypertension, anxiety, and cognitive communication deficit.Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 03 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact) and he/she required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity) with oral hygiene (ability to use suitable items to clean teeth, dentures (if applicable) the ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment. During an interview on 08/06/26 at 9:00 A.M., Family Member #1 said Resident #1 was admitted to the Facility in May 2024, that he/she had both upper and lower partial dentures when admitted , and that he/she had dentures since he (Family Member #1) was young. Family Member #1 said that staff were not removing and cleaning Resident #1's partial dentures while he/she was at the Facility.Review of Resident #1's admission Facility Assessments from May 2024, indicated there was no documentation to support that nursing identified he/she had partial dentures at the time of admission.Review of Resident #1's Certified Nurse Aide (CNA) Documentation Record (ADL Flow Sheets), dated January 2026 through June 2026, indicated that although CNAs documented that they provided assistance with Resident #1's oral hygiene care, there was no documentation to support he/she was assisted with denture care.During an interview on 08/05/26 at 1:29 P.M., Certified Nurse Aide (CNA) #2 said Resident #1 had his/her own teeth and only required supervision with mouth care. CNA #2 said she was unaware that Resident #1 had dentures. CNA #2 said if she had known Resident #1 had partial dentures, she would have supervised him/her with removing them from his/her mouth and put them into a denture cup with a denture tablet overnight to clean them.During an interview on 08/05/26 at 1:16 P.M., with CNA #1 and at 3:03 P.M. with CNA #4, they said they were aware Resident #1 had partial dentures, and that he/she required supervision with oral hygiene/care. CNA #1 and CNA #4 both said that when they assisted Resident #1 with morning mouth care his/her partial dentures were already in his/her mouth. CNA #1 and CNA #4 said that Resident #1 had a denture cup in his/her room and that the CNAs on the 3:00 P.M. to 11:00 P.M. shift were supposed to remove resident's dentures and place them in a denture cup with a denture tablet to soak overnight.During an interview on 08/05/26 at 3:33 P.M., CNA #5 said she works the 3:00 P.M. to 11:00 P.M. shift and that she was assigned to Resident #1 on her scheduled workdays. CNA #5 said she assisted Resident #1 with mouth care (brushing and rinsing teeth) before he/she went to bed. CNA #5 said that she did not know Resident #1 had upper and lower partial dentures because his/her teeth did not look like dentures. CNA #5 said Resident #1 did not have a denture cup in his/her bathroom.Review of Resident #1's Medical Record, indicated there were no nursing assessments or documentation to support Resident #1 had partial upper and lower dentures or that nursing staff removed, cleaned and soaked his/her dentures overnight.During an interview on 08/05/26 at 2:36 P.M., the Unit Manager said she was not aware that Resident #1 had partial dentures. The Unit Manager said if a resident has full or partial dentures the CNAs that work the 3:00 P.M. to 11:00 P.M. shift should be removing and cleaning the resident's dentures then placing them into denture cup with a denture tablet to soak overnight. The Unit Manager said that the CNAs should be making sure that resident's dentures are being properly cleaned.During an interview on 08/05/26 at 4:09 P.M., the Assistant Director of Nursing (ADON) said she was not aware that Resident #1 had partial dentures. The ADON said that the nurses are responsible for completing oral assessments on residents' annually and quarterly. The ADON said she reviewed Resident #1's admission Nursing Assessment (dated 05/23/24) and his/her Initial Nutritional Assessment (dated 05/29/24) and said that both assessments did not indicate he/she had dentures. The ADON said it is the Facility's expectation that nurses are accurately assessing residents' and documenting in their medical records.During a telephone interview on 08/10/26 at 2:07 P.M., and a subsequent telephone interview on 08/18/26 at 10:53 A.M., the Director of Nursing (DON) said she was not aware Resident #1 had partial dentures and that she had not reviewed his/her medical record. The DON said that nurses' complete admission assessment on all residents (head-to-toe) including assessing their oral cavity by looking at and inspecting the inside of the resident's mouth. The DON said the nurses are responsible for determining and assessing if a resident has dentures, their own teeth or no teeth and ensuring that resident assessments are accurate.The DON said if a resident has dentures nursing staff should be providing denture care in the morning and evening. The DON said the 3:00 P.M. to 11:00 P.M. shift nursing staff should be removing, cleaning, and soaking resident's dentures overnight. The DON said it was her expectation that all nursing staff are providing proper denture care to all residents with dentures.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission to the Facility had partial upper and lower dentures, the Facility failed to ensure they developed and implemented a comprehensive person-centered care plan with interventions, goals and outcomes that addressed his/her individual oral care needs, which at a minimum included daily removal and cleaning of his/her dentures.Findings include:Review of the Facility's Policy, titled Care Planning, dated as revised 02/15/25, indicated the following:-the facility will develop and implement a comprehensive person-centered car plan for each resident, consistent with the resident rights that include measurable objectives and time frames to meet a resident's medical and nursing needs.-the purpose is to provide effective and person-centered care to the resident.- the standardized care plans must be individualized for the resident by adding Care needs/preferences, interventions and resident specific strategies based on the assessment of a resident's needs, strengths, goals, life history, and preferences.Resident #1 was admitted to the Facility in May 2024, diagnoses included dementia, aphasia (inability to comprehend or formulate language from damage to specific regions of the brain), rheumatoid arthritis, normal pressure hydrocephalus (excessive fluid buildup in the brain), hypertension, anxiety, and cognitive communication deficit. During an interview on 08/06/26 at 9:00 A.M., Family Member #1 said Resident #1 was admitted to the Facility in May 2024 and that he/she had upper and lower partial dentures. Family Member #1 said Resident #1 has had dentures since he (Family Member #1) was young. Review of Resident #1's admission Care Plans related to Activities of Daily Living (ADL), dated 05/24/24, and his/her Care Plans dated as reviewed and renewed with his/her February 2026 Quarterly Minimum Data Set Assessment (MDS) indicated that he/she required staff assistance with oral hygiene and encourage oral care with morning (A.M.) and evening (P.M.) care.However, Resident #1's ADL Care Plans did not indicate that he/she had upper and lower partial dentures and did not include interventions related to the need for daily denture care.Review of Resident #1's CNA Care Kardex, (used as a reference guide by CNA's, provides direct care staff with a brief overview of each resident's care), (reviewed in conjunction with his/her care plan), indicated it did not identify that he/she had upper and lower partial dentures with the need for daily denture care.During an interview on 08/05/26 at 12:46 P.M., the MDS Coordinator said she could not recall if Resident #1 had partial or full dentures but knew that he/she needed assistance with oral hygiene. The MDS Coordinator said that the Unit Manager and nurses are responsible for developing and updating resident's care plans annually and quarterly.During an interview on 08/05/26 at 1:16 P.M., with Certified Nurse Aide (CNA) #1 and at 3:04 P.M. with CNA #4, they said were aware that Resident #1 had partial dentures, and that he/she required supervision with oral hygiene/care. CNA #1 and CNA #4 both said they could not recall if Resident #1's CNA Care Kardex indicated that he/she had partial dentures.During an interview on 08/05/26 at 4:09 P.M., the Assistant Director of Nursing (ADON) said if a resident has dentures (full or partial), it should be documented on their Care Plan and CNA Care Kardex. The ADON said she reviewed Resident #1's Care Plan and CNA Care Kardex and said that they did not indicate he/she had dentures.During a telephone interview on 08/10/26 at 2:07 P.M., and a subsequent telephone interview on 08/18/26 at 10:53 A.M., the Director of Nursing (DON) said she was not aware Resident #1 had partial dentures and that she had not reviewed his/her medical record. The DON said that nurses are responsible for developing residents' Care Plans and that if a resident has dentures, it should be documented on their Care Plan and Care Kardex. The DON said it was her expectation that nurses ensure all residents' Care Plans are accurate and include their individual care needs.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was severely cognitively impaired, unable to make their needs known and was dependent on staff for bed mobility, the Facility failed to ensure Resident #1 was free from the use of physical restraints when, on 5/27/26 during the overnight shift, Certified Nurse Aide #1 observed and reported to Nurse #1, that Resident #1, who was in bed, had each corner of the bed sheet that was on top of him/her, tied to the straps emanating (originating) from the beds air mattress, that was beneath him/her. Resident #1 was unable to untie and remove the bed sheet, which was therefore restraining him/her from getting up, if desired.Findings include:Review of the Facility Policy titled Resident Abuse Prevention, most recently revised 10/17/22, indicated that it was the policy of the Facility to ensure an environment free of abuse, which included freedom from physical restraints not medically required to treat the resident's condition.Review of Resident #1's clinical record indicated he/she was admitted to the Facility during January 2024 and his/her diagnoses included Alzheimer's Disease.Review of Resident #1's most recent Minimum Data Set Assessment, dated 4/21/26, indicated his/her cognitive patterns were severely impaired and he/she was dependent on staff members when transferring between surfaces and for bed mobility.Resident #1's Care Plan related to alteration in ability to provide self-care, dated as initiated 4/29/26, indicated it included a goal that Resident #1 would maintain dignity, comfort and cleanliness. Additional interventions, dated as initiated 4/29/26, indicated that Resident #1 was fully dependent on staff for activities of daily living.Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 5/27/26, indicated that a staff member (later identified as Certified Nurse Aide #1) found Resident #1 in bed on 5/27/26 during the 11:00 P.M. to 7:00 A.M. shift, with his/her top sheet (at each corner) tied to the air mattress straps and reported this observation to a staff member (later identified to be Nurse #1.)Review of Certified Nurse Aide (CNA) #1's Statement, dated 5/27/26, indicated that at 3:30 A.M. on 5/27/26, she found Resident #1 in bed with his/her top sheet tied to the mattress strings at each corner of the bed and reported her observation to Nurse #1.Review of Nurse #1's Statement, dated 5/27/26, indicated that on 5/27/26 at [sometime] around 5:00 A.M. or 5:30 A.M., CNA #1 told her that Resident #1's top sheet was tied in knots to the straps of his/her air mattress and tucked in where they were not easily visible.The Surveyor was unable to interview CNA #1 or Nurse #1 as they did not respond to the Department of Public Health's letter or telephone requests for an interview.During a telephone interview on 6/25/26 at 3:10 P.M., CNA #2 said that she cared for Resident #1 during the 3:00 P.M. to 11:00 P.M. shift on 5/26/26. CNA #2 said that Resident #1 followed his/her typically routine and she changed him/her into pajamas before dinner and fed him/her dinner. CNA #2 said that she last saw Resident #1 in bed when she provided incontinence care to Resident #1 sometime after dinner. CNA #2 said that because Resident #1 required two care givers, CNA #3 assisted her.CNA #2 said that Resident #1's bed sheet was not tied to the air mattress when she provided care to him/her and said that Resident #1 was unable to tie it him/herself.During an interview on 6/16/26 at 1:45 P.M. the Director of Nurses said that on 5/27/26, Nurse #1 told the Unit Manager that Resident #1's top sheet had been tied to the straps of the air mattress beneath him/her during the previous 11:00 P.M. to 7:00 A.M. shift.The Facility's Internal Investigation indicated that although staff members denied tying Resident #1's bed sheet to his/her air mattress straps, thereby restricting his/her movement, Resident #1 was totally dependent on staff for care and physically incapable of doing it him/herself.On 6/16/24 the Facility was found to be in past non-compliance with an effective date of 6/05/26 and provided the Surveyor with a plan of correction which addressed the concern area as evidenced by:A. On 5/27/26, skin and pain assessments were completed by the Unit Manager for Resident #1 without findings of injury related to the alleged incident.B. Resident #1 was also assessed and monitored for emotional or behavioral changes with none noted. Resident #1 will be provided with support as needed.C. On 5/27/26, the Administrator/Director of Nursing suspended CNAs #1 and #2 and Nurses #1 and #2 pending their investigation.D. Between 5/27/26 and 6/03/26, all Facility staff were trained on the Facility Patient Abuse Policy, prohibition on restraint use and Abuse reporting.E. On 6/04/26 the Facility initiated rounding on all units by Unit Managers observing for the absence of devices that could be considered a restraint.F. Results of the Internal Investigation and observations made during rounds will be reviewed during the June 2026 QAPI Meeting, and ongoing as needed.G. The Administrator/designee are responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had been observed by two staff members restrained in bed when the bed sheet that was on top of him/her was tied (secured) to his/her mattress at each corner, the Facility failed to ensure staff consistently implemented and followed the Facility Abuse Policy, when the staff members did not immediately report the allegations to their shift supervisor or the Administrator/Designee, as required. Findings include:Review of the Facility Policy titled Resident Abuse Prevention, most recently revised 10/17/22, indicated that it was the policy of the Facility for all individuals to identify and report immediately to their supervisor any allegation of abuse. The Policy indicated that unreasonable confinement or restraint is considered physical abuse.Review of Resident #1's clinical record indicated he/she was admitted to the Facility during January 2024 and his/her diagnoses included Alzheimer's Disease.Review of Resident #1's most recent Minimum Data Set Assessment, dated 4/21/26, indicated his/her cognitive patterns were severely impaired and he/she was dependent on staff members when transferring between surfaces and for bed mobility.Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 5/27/26, indicated that a staff member (later identified as Certified Nurse Aide #1) found Resident #1 in bed with the top sheet tied to the air mattress straps and reported this observation to a staff member (later identified as Nurse #1).Review of Certified Nurse Aide (CNA) #1's Statement, dated 5/27/26, indicated that at 3:30 A.M. on 5/27/26, she found Resident #1 in bed with the top sheet (that was over him/her) tied to the mattress strings at each corner of the bed and reported her observation to Nurse #1.Review of Nurse #1's Statement, dated 5/27/26, indicated that on 5/27/26 (sometime) around 5:00 A.M. or 5:30 A.M. [more than an hour after finding Resident #1 restrained by his/her bed sheet] CNA #1 told her that Resident #1's top sheet was tied in knots to the straps of his/her air mattress and tucked in where they were not easily visible.The Surveyor was unable to interview Nurse #1 or CNA #1 as they did not respond to the Department of Public Health's letter or telephone requests for an interview. During an interview on 6/16/26 at 1:45 P.M. the Director of Nurses said that on 5/27/26 at 11:00 A.M. [six hours after being made aware of the restraint], Nurse #1 told the Unit Manager that Resident #1's top sheet had been tied to the straps of the air mattress beneath him/her.The Director of Nursing said that on 5/27/26, during an interview, CNA #1 told her that she had also found Resident #1's bed sheet tied to the air mattress on a prior occasion and said that she had reported that observation to Nurse #2.During a telephone interview on 6/26/26 at 11:00 A.M. Nurse #2 said that [prior to the incident on 5/27/26] on 5/23/26, CNA #1 had told him that Resident #1's bed sheet was tied to his/her bed. Nurse #2 said that he checked Resident #1's bed and did not see that the bed sheet was tied. Nurse #2 said that he did not understand CNA #1's statement as an indication of abuse and thought she was sharing a concern about how the bed had been made. Nurse #2 said that he did not report CNA #1's statements at that time (5/23/26) to his/her supervisor.The DON said that Nurse #1 and Nurse #2 had not immediately informed her or the Administrator of the allegations made by CNA #1 on 5/23/26 and 5/27/26, in accordance with the Facility Policy.On 6/16/24 the Facility was found to be in past non-compliance with an effective date of 6/05/26 and provided the Surveyor with a plan of correction which addressed the concern as evidenced by:A. On 5/27/26, the Facility initiated an investigation of the allegation that Resident #1 had been restrained by a bed sheet.B. On 5/27/26, the Administrator/Director of Nursing suspended CNAs #1 and #2 and Nurses #1 and #2 pending investigation.C. Between 5/27/26 and 6/03/26, all Facility staff were trained on the Facility Patient Abuse Policy, prohibitions on restraint and Abuse reporting.D. Starting 5/28/26 and on-going, the Facility initiated review of the timeliness of reporting for all incident reports by the Director of Nurses/designee.E. Results of the Internal Investigation and incident report review will be reported during the June 2026 QAPI Meeting, and ongoing as needed.F. The Administrator/designee are responsible for overall compliance.

Based on observation, interview, and record review, the facility failed to ensure a person-centered individualized comprehensive care plan was developed and implemented for two Residents (#90 and #80), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #90, to develop a care plan for a cervical (upper neck) fracture; and2. For Resident #80, to develop a care plan for smoking. Findings include: Review of the facility's policy titled Care Planning, dated as last revised 2/15/25, indicated but was not limited to the following: -The facility will develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -The standardized care plans must be individualized for the resident by adding care needs/preferences, interventions, and resident specific strategies based on the assessment of a resident's needs, strengths, goals, life history, and preferences. 1. Resident #90 was admitted to the facility in March 2025 with diagnoses which included dementia, arthritis, failure to thrive, and history of falling. Review of the Minimum Data Set (MDS) Assessment, dated 3/27/26, indicated Resident #90 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating he/she had severe cognitive impairment. Review of the MDS assessment, dated 12/29/25, indicated he/she had sustained a fall with a major injury since the previous assessment. Review of the medical record including nursing progress notes, fall risk assessments, change in condition assessments, and hospital discharge documents indicated but were not limited to the following: -On 12/9/25 at 1:50 A.M, Resident #90 returned from the emergency room. The nursing progress note indicated he/she sustained a cervical fracture, and no surgical or invasive interventions would be performed due to his/her inability to tolerate the use of a cervical collar. -On 12/11/25 a Fall Risk Assessment indicated he/she had a fall on 12/7/25 and a fracture related to the fall. -On 12/29/25 a significant change MDS was completed due to a decline, weight loss, and recent cervical fracture. -The Hospital After Visit Summary, dated 12/8/25, indicated on page one, Resident #90 was seen in the emergency department because of a fall and had evidence of a possible fracture in their neck and they suspect it was an old finding. -The Hospital Transfer Summary, dated 12/8/25, indicated on page four and five, Resident #90 had a Computed Tomography Scan (CT Scan-imaging of the body using a combination of X-Rays and computer technology) of the cervical spine and head, the CT scan was compared to a previous CT scan from 3/20/25 and the impression/findings were an Acute non-displaced type II odontoid process fracture (sudden crack/incomplete break at the base of C2 Vertebrae, usually caused by falls and often managed with a hard collar for 6-12 weeks). Review of the Comprehensive Care Plan failed to indicate Resident #90 had a cervical fracture, if said cervical fracture was acute or chronic/old or if Resident #90 required any precautions/restrictions/interventions related to the cervical fracture. During an interview on 4/16/26 at 11:02 A.M, Nurse #3 said the fracture should have been documented whether acute or chronic in the medical record and it should have been care planned with orders, restrictions, and interventions and it was not. During an interview on 4/16/26 at 11:15 A.M., MDS Nurse #1 said she doesn't do the care plans only the MDS Assessments, but a care plan for the fracture should have been developed and it was not. During an interview on 4/16/26 at 11:25 A.M., the Director of Nurses (DON) said they should have developed a care plan for the cervical fracture and any recommendations/interventions needed to care for Resident #90. During an interview on 4/16/26 at 11:40 A.M., Consulting Staff #1 said a care plan should have been developed for the fracture. 2. Review of the facility's policy titled Resident Smoking Policy, dated as last revised 12/30/2025, indicated but was not limited to the following: -Residents who choose to smoke will be assessed to determine what level of supervision is required. -All cigarettes and smoking ignition materials, including matches and lighters, will be held and secured by facility staff in a designated location. -Determine the resident's independence and/or dependence with functional mobility outdoors, smoking ability, and the need for protective gear upon admission, quarterly, annually, with a significant change in resident's condition, and as needed as identified by Interdisciplinary Team. -Residents' care plan/Kardex will be kept updated, and interventions will be communicated to staff including assistance level needed, protective gear required, and any other resident specific interventions. Resident #80 was admitted to the facility in March 2025 with diagnoses including Alzheimer's disease and heart failure. Review of Resident #80's MDS assessment, dated 3/17/26, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. Additionally, the MDS indicated Resident #80 currently used tobacco. During an interview on 4/14/26 at 9:00 A.M., Resident #80 said he/she is an independent smoker. Resident #80 said he/she gets their smoking supplies from the nurses' station prior to going outside. Resident #80 said there are designated smoking times throughout the day. On 4/16/26 at 9:40 A.M. and 4/17/26 at 9:39 A.M., the surveyor observed Resident #80 return inside the facility after smoking and proceed to walk back towards his/her room with their rollator. On both occasions, the surveyor observed staff stop Resident #80 to remind him/her to turn in their smoking supplies at the nurses' station. Review of Smoking Assessments for Resident #80, dated 4/5/25, 9/5/25, 12/5/25, and 3/26/26, indicated the Resident did wish to smoke, and that he/she did not require supervision or a smoking apron. Review of the comprehensive care plans for Resident #80 failed to indicate a smoking care plan was developed or implemented. During an interview on 4/15/26 at 2:20 P.M., Nurse #1 said the process for smoking is that residents have designated times that they can go outside. Nurse #1 said the residents must stop at the nurses' station to retrieve their smoking supplies and to be let outside. Nurse #1 said all smoking supplies are kept at the nurses' station and no smoking supplies should be in resident rooms. Nurse #1 said Resident #80 does not always turn in their smoking supplies, and staff will have to remind Resident #80 to turn the smoking supplies in at the nurses' station. Nurse #1 said residents are assessed periodically to determine if they are safe to smoke independently. Nurse #1 said she is not sure if there is a place in the resident's chart other than the assessment to see a resident's smoking status. On 4/16/26 at 11:28 A.M., Certified Nursing Assistant (CNA) #1 said sometimes Resident #80 gets distracted after returning inside the facility from smoking and will need a reminder to turn in his/her smoking supplies. On 4/16/26 at 11:31 A.M., Nurse Manager #2 said the process for smoking is there are designated smoking times, and the residents who choose to smoke must go to the nurses' station to gather their supplies and be let outside. Nurse Manager #2 said when the residents return inside, they must stop at the nurses' station to return their smoking supplies. Nurse Manager #2 said Resident #80 does need reminders to turn in his/her smoking supplies at times. Nurse Manager #2 said she would expect a care plan to be developed and implemented for Resident #80 regarding his/her smoking status and that there should be an intervention specific to Resident #80 needing periodic reminders to turn in his/her smoking supplies. On 4/16/26 at 4:18 P.M., the DON said if a resident wishes to smoke, they are assessed to determine if they can smoke independently or needed supervision. The DON said she would expect a resident who is an independent smoker to have an individualized care plan in place. The DON said Resident #80 should have a care plan related to his/her smoking status.

Based on record review and interview, the facility's Consultant Pharmacist failed to identify irregularities during the monthly Medication Regimen Review (MRR) related to the administration of an antidepressant medication for one Resident (#11), out of a total sample of 26 residents. Findings include:Review of the facility's policy titled Drug Regimen Review/Medication Regimen Review, last revised 10/6/22, indicated but was not limited to:-In accordance with State and Federal Regulations, the Consultant Pharmacists will review each resident's clinical chart monthly, or more frequently depending on the resident's condition and the risks for adverse consequences related to current medications.-This review of the clinical chart shall be comprehensive, and findings shall be documented on the Consultant Pharmacist Review/Signature sheet in the chart (or in the electronic medical record (EMR) if applicable).-Apparent irregularities including, but not limited to, the use of any drug that meets criteria for an unnecessary drug will be reported in writing to the Director of Nursing, Medical Director, Attending Physician, and Administrator.-Purpose: To ensure drug and medication regimen reviews are completed, received, and reviewed by appropriate personnel in a timely manner to promote positive patient outcomes and to prevent or minimize adverse consequences related to medication therapy, to the extent possible.-A Consultant Pharmacist employs a systemic approach to medication management which includes consideration of: -Duration-Consultant Pharmacist-identified irregularities may include, but not limited to one or more of the following: -Unnecessary drugs, which may include: -Excessive duration-Psychotropic drugs are given pursuant to a PRN (as needed) order for greater than 14 days, and the prescribed duration for the PRN order and/or rationale for this duration is not documented in the clinical record. Review of the facility's policy titled Psychotropic Medications, last revised 9/18/24, indicated but was not limited to:-Psychotropic medications can affect mood and behavior and include, but are not limited to, the following classes of medications: antidepressants. -As with all medications, psychotropics shall only be administered following an order by a physician or other person lawfully authorized to prescribe medications (the prescriber). -As needed (PRN) medications will require a 14-day order. -For psychotropic medications other than antipsychotics, for use beyond the initial PRN 14-day order, a prescriber must document the rationale for continuance, and the anticipated duration. Resident #11 was admitted to the facility in March 2023 with diagnoses including generalized anxiety disorder, Alzheimer's disease, and dementia with mood disturbance. Review of the Minimum Data Set (MDS) assessment, dated 3/27/26, indicated Resident #11 had a severe cognitive deficit as evidenced by staff interview and had received antidepressant medications. Review of Resident #11's current Physician's Orders indicated but was not limited to:-Trazodone (antidepressant) 50 milligram (mg) tablet, give one tablet daily by mouth daily as needed for agitation daily, order date 6/29/25 Further review of Resident #11's Physician's Orders failed to indicate the as needed Trazodone order had a stop date or a date to re-evaluate the continued use. Review of Resident #11's Nursing Notes, dated 1/12/26, indicated but not limited to: - As needed Trazodone reviewed with the provider, continue current order for 30 days as Resident utilized it related to increased anxiety and agitation with effect. Further review of Resident #11's Nursing Notes failed to indicate the Trazodone order had been reviewed with the prescribing Provider after 1/12/26. Review of the Physician visit notes, dated 1/16/26 and 3/20/26, provided to the surveyor failed to indicate Resident #11's as need Trazodone had been re-evaluated by the prescriber. Review of Resident #11's January Medication Administration Record (MAR) indicated as needed Trazodone was administered one time on 1/25/26. Review of Resident #11's February MAR indicated as needed Trazodone was administered four times on 2/8/26, 2/13/26, 2/16/26, and 2/22/26. Review of Resident #11's March MAR indicated as needed Trazodone was administered one time on 3/28/26. Review of Resident #11's April MAR, 4/1/26 to 4/21/26, indicated as needed Trazodone was administered five times on 4/5/26, 4/15/26, 4/16/26, 4/17/26, and 4/19/26. Review of the Consultant Pharmacist's Medication Review Assessments, dated 2/13/26, 3/12/26, and 4/12/26, indicated but was not limited to:-Type of Review: Monthly -Were any medication irregularities found or any medication recommendations made for provider review: No-Nursing/Provider Response: Not Applicable-Signed by the Consultant Pharmacists During an interview on 4/21/26 at 11:21 A.M., Nurse #2 said as needed psychotropic medications should have an order to re-evaluate the medication as indicated by the Physician. She said after the discussion with the provider there needed to be an order written with the providers orders and nurses note to document the conversation and Physician. During a telephonic interview on 4/21/26 at 12:07 P.M., the Consultant Pharmacist said as needed psychotropic medications needed to be re-evaluated by the provider periodically. He said he reviews every resident's chart monthly to check for irregularities. He said when he does a record review he checks for correct dose, duration, and appropriate use. He said if he notices an as needed psychotropic medication without a stop date, he will make a recommendation for the provider to continue to re-evaluate the medication and document the rationale to continue it. He said his process is if the provider does not address the recommendation, then he will make the recommendation again, and if it is not addressed for a third month then he would make a recommendation to continue to re-evaluate the medication and document the rationale to continue to use the medication periodically. He reviewed the MRRs for Resident #11 and said he has not made any recommendations for Resident #11 since October 2025 when had recommended for the provider to re-evaluate the as needed Trazodone and document why it should or should not be continued. He said he believes if he makes a recommendation twice in one year then he does not have to make them again for another year. During a telephonic interview on 4/21/26 at 12:54 P.M., the Physician said Resident #11 required as needed Trazodone to help with their behaviors. He said as needed psychotropic medications need to be reviewed every 14 days after initially being prescribed then to every 30 days. He said he relies on the Consultant Pharmacist's MRRs to catch any missed documentation or re-evaluations. He said the Pharmacist should have been his back-up in case something was missed. During an interview on 4/21/26 at 1:22 P.M, Unit Manager #1 said any psychotropic medications given on an as needed basis needed to be re-evaluated 14 days after the initial order then per the physician's order. She reviewed Resident #11's medical record and said the last time his/her as needed Trazodone order was re-evaluated by the physician was 1/12/26 and he/she had MRRs on 2/13/26, 3/12/26, and 4/12/26 with no recommendations. She said the Consultant Pharmacist would put recommendations in for an as needed psychotropic medication when he noticed they had not been re-evaluated and did not have an order to re-evaluate the medication. During an interview on 4/21/26 at 1:22 P.M., the Assistant Director of Nursing said the Consultant Pharmacist would make recommendations for psychotropic medications given on an as needed basis that had not been re-evaluated and documented with a rationale to continue it. She said this was not done.

Based on record review and interview, the facility failed to ensure for one Resident (#11), out of a total sample of 26 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure a physician's order for an as needed Trazodone (antidepressant) medication contained a duration of use and failed to ensure the prescriber reassessed the Resident's condition and documented a clinical rationale for the continued use of as needed Trazodone medication as required.Findings include:Review of the facility's policy titled Psychotropic Medications, last revised 9/18/24, indicated but was not limited to:-Psychotropic medications can affect mood and behavior and include, but are not limited to, the following classes of medications: antidepressants. -As with all medications, psychotropics shall only be administered following an order by a physician or other person lawfully authorized to prescribe medications (the prescriber). -As needed (PRN) medications will require a 14-day order. -For psychotropic medications other than antipsychotics, for use beyond the initial PRN 14-day order, a prescriber must document the rationale for continuance, and the anticipated duration.Resident #11 was admitted to the facility in March 2023 with diagnoses including generalized anxiety disorder, Alzheimer's disease, and dementia with mood disturbance.Review of the Minimum Data Set (MDS) assessment, dated 3/27/26, indicated Resident #11 had a severe cognitive deficit as evidenced by staff interview and had received antidepressant medications.Review of Resident #11's current Physician's Orders indicated but was not limited to:-Trazodone 50 milligram (mg) tablet, give one tablet daily by mouth daily as needed for agitation daily, order date 6/29/25Further review of Resident #11's Physician's Orders failed to indicate the as needed Trazodone order had a stop date or a date to re-evaluate the continued use.Review of Resident #11's Nursing Notes, dated 1/12/26, indicated but was not limited to: - As needed Trazodone reviewed with the provider, continue current order for 30 days as Resident utilized it related to increased anxiety and agitation with effect.Further review of Resident #11's Nursing Notes failed to indicate the Trazodone had been reviewed with the prescribing Provider after 1/12/26.Review of the Physician's visit notes, dated 1/16/26 and 3/20/26, failed to indicate Resident #11's as needed Trazodone had been re-evaluated by the prescriber.Review of Resident #11's January Medication Administration Record (MAR) indicated as needed Trazodone was administered one time on 1/25/26.Review of Resident #11's February MAR indicated as needed Trazodone was administered four times on 2/8/26, 2/13/26, 2/16/26, and 2/22/26.Review of Resident #11's March MAR indicated as needed Trazodone was administered one time on 3/28/26.Review of Resident #11's April MAR, 4/1/26 through 4/21/26, indicated as needed Trazodone was administered five times on 4/5/26, 4/15/26, 4/16/26, 4/17/26, and 4/19/26.During an interview on 4/21/26 at 11:21 A.M., Nurse #2 said as needed psychotropic medications should have an order to re-evaluate the medication as indicated by the Physician. She said after the discussion with the provider there needed to be an order written with the provider's orders and a nurse's note to document the conversation with the Physician.During a telephonic interview on 4/21/26 at 12:54 P.M., the Physician said Resident #11 required as needed Trazodone to help with their behaviors related to their diagnoses. He said the facility protocol was for as needed psychotropic to be reviewed 14 days after initially being prescribed then every 30 days. He said something must have been missed.During an interview on 4/21/26 at 1:22 P.M, Unit Manager #1 said any psychotropic medications given on an as needed basis needed to be re-evaluated 14 days after the initial order then per the physician's order. She reviewed Resident #11's medical record and said the last time his/her as needed Trazodone order was re-evaluated by the physician was 1/12/26 and she did not see any further documented Trazodone reviews.During an interview on 4/21/26 at 1:38 P.M., Nurse #4 said an order would pop up in the Electronic Medical Record indicating a resident needed a medication reviewed with the provider. She said she would then speak to the provider and review the medication, then write an order to either continue the medication for a specified duration or discontinue, and document it in a nursing note and the provider would document the rationale in their note.During an interview on 4/21/26 at 2:57 P.M., the Assistant Director of Nursing said she reviewed Resident #11's chart. She said the last time Resident #11's as needed Trazodone was re-evaluated by the prescriber was on 1/12/26. She said an order was put in the Resident's medical record to re-evaluate the as needed dose of Trazodone in 30 days from 1/12/26, but that was not done as it should have been. Refer to F756

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for two Residents (#90 and #8), out of a total sample of 26 residents. Specifically, the facility failed to ensure:1. For Resident #90, a cervical fracture diagnosis was accurately documented; and2. For Resident #8, accurate COVID-19 test results were scanned into the medical record. Findings include:Review of the facility's policy titled Documentation-Clinical, dated as last revised 12/29/25, indicated but was not limited to the following:-Resident status, including change in condition, nursing or other services provided and resident response or progress will be documented as warranted.-Purpose is to ensure accuracy and completeness of clinical records. 1. Resident #90 was admitted to the facility in March 2025 with diagnoses which included dementia, arthritis, failure to thrive, and history of falling. Review of the Minimum Data Set (MDS) Assessment, dated 12/29/25, indicated Resident #90 had sustained a fall with a major injury since the previous assessment. Review of the Hospital After Visit Summary, dated 12/8/25, indicated on page one, Resident #90 was seen in the emergency department because of a fall and had evidence of a possible fracture in their neck and they suspect it was an old finding. Review of the Hospital Transfer Summary, dated 12/8/25, indicated on pages four and five, Resident #90 had a Computed Tomography Scan (CT Scan-imaging of the body using a combination of X-Rays and computer technology) of the cervical spine and head. The CT scan was compared to a previous CT scan from 3/20/25 and the impression/findings were an Acute non-displaced type II odontoid process fracture (sudden crack/incomplete break at the base of C2 Vertebrae, usually caused by falls and often managed with a hard collar for 6-12 weeks). Review of the physician progress notes, care plans, and diagnosis list from 12/8/25 through 4/16/26 failed to indicate Resident #90 had a cervical fracture or if said cervical fracture was acute or chronic/old. During an interview on 4/16/26 at 11:02 A.M, Nurse #3 said the hospital documents are not clear. She said the first page says the fracture might be old, but the CT scans clearly say the fracture is acute. She said there were not any additional notes or documents related to the fracture in the record. She said the fracture should be documented whether acute or chronic in the medical record and it was not. During an interview 4/16/26 at 11:15 A.M., MDS Nurse #1 said the MDS Assessment was coded as a fall with major injury because the CT scans indicated an acute fracture, but the conflicting information on the paperwork should have been clarified to ensure they had an accurate diagnosis to care for him/her. During an interview on 4/16/26 at 11:25 A.M., the Director of Nurses (DON) said they should have obtained clarifying documentation of the cervical fracture to ensure they had an accurate diagnosis to care for Resident #90 and that should have been documented in the medical record and it was not. During an interview on 4/16/26 at 11:35 A.M., the Administrator said the fracture diagnosis should have been clarified because the hospital paperwork had discrepancies whether the fracture was new or old and they would have to investigate it. During an interview on 4/16/26 at 11:40 A.M., Consulting Staff #1 said the diagnosis should have been clarified and at the very least documented in a progress note and it was not. She said there was nothing else related to the fracture scanned into the medical record. 2. Resident #8 was admitted to the facility in October 2025 with diagnoses which included Parkinson's disease, sepsis, and COVID-19. Review of the MDS Assessment, dated 4/1/26, indicated Resident #8 had been readmitted to the facility on [DATE]. Review of the medical record including physician and nursing progress notes, test results, and hospital discharge summary indicated but were not limited to the following:-On 3/16/26 Resident #8 was transferred to the hospital and returned on 3/26/26.-On 3/17/26 Resident #8 tested positive for COVID-19 and was on isolation precautions at the hospital.-A BINAXNOW COVID-19 Test scanned into his/her medical record, dated 3/20/26, indicated Resident #8 was asymptomatic and had a negative test result. During an interview on 4/16/26 at 11:02 A.M., Nurse #3 said she was unsure why that test result was scanned into the medical record because he/she was at the hospital on 3/20/26. During an interview on 4/16/26 at 3:34 P.M., the Assistant Director of Nursing (ADON) said that test dated 3/20/26 was not accurate, he/she was not in the building, so it was not possible the test was done. During an interview on 4/21/26 at 2:17 P.M., the Administrator said that test was not accurate, as Resident #8 was not in the building on 3/20/26.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate medical record when nursing documentation in Resident #1's Electronic Medication Administration Record (MAR) and the Controlled Substance Register was found to be incomplete and did not accurately reflect what medications were or were not administered.Findings include:Review of the Facility's Policy titled, Administration Procedure for all Medications, dated 09/20/13, indicated the following:- Check the MAR for order;-after administration, return to cart, and document administration in the MAR.Review of the Facility's Policy titled, Clinical Documentation, revised 12/29/25, indicated the following:-the licensed nurse notes the time and date of all medications administered in the MAR;- the nurse who administers the medications must document it in the resident's record;-if a scheduled medication is withheld or not given as ordered, the nurse documents this and lists the reason for the resident not receiving the medication;Resident #1 was admitted to the facility in December 2023, diagnoses included Parkinson's disease, atherosclerotic heart disease, hypercholesterolemia, hypertension, dysphagia, rheumatic aortic insufficiency, malignant neoplasm of the breast and thyroid disorder.Review of Resident #1's Physician's Active Orders Report, for February 2026, indicated his/her orders included the following:- Amlodipine besylate (an antihypertensive medication), give 5 milligrams (mg) tablet by mouth daily at 9:00 A.M. - Aspirin (an anti-inflammatory medication), give 81 mg tablet by mouth daily at 9:00 A.M. - Carbidopa-Levodopa (anti-parkinsonism medication) give 25 mg -100 mg tablet by mouth three times a day.- Letrozole (aromatase inhibitor - used for breast cancer) give 2.5 mg tablet by mouth daily at 9:00 A.M. - Losartan Potassium (anti-hypertensive medication) 25 mg tablet give three tablets (75 mg) by mouth daily at 9:00 A.M. - Hyoscyamine Sulphate (anti-cholinergic medication used for excessive saliva) solution 0.125 mg/1 milliliter (ml) by mouth three times a day.- Miralax (laxative) 17 grams (gm) powder for solution, mix 17 gm with liquid by mouth daily at 8:00 A.M. - Senna 8.6 mg (used for constipation) give one tablet by mouth twice a day.- Colace (stool softener) 100 mg capsule give one capsule by mouth daily at 9:00 A.M.-Atropine Sulfate (anti-cholinergic medication used for excessive saliva) 1% solution give two drops sublingual (under tongue) before meals.- Lexapro (antidepressant medication) 10 mg give one tablet by mouth daily at 8:00 A.M. - Albuterol Sulfate (bronchodilator) 0.083% solution give one unit dose inhalation once daily at 9:00 A.M. - Morphine Sulfate (opioid analgesic) solution 20 mg/ml give 0.25 ml = 5 mg by mouth twice daily.Review of Resident #1's February 2026 MAR indicated that on 02/09/26, the administration times for the following medications were coded as (H), held due to the previous shift nurse not having documented administration: 7:30 A.M. medications:-Atropine Sulfate 1% solution;8:00 A.M. medications:-Hyoscyamine Sulphate solution 0.125 mg/1 milliliter (ml);-Miralax 17 grams powder for solution;-Lexapro 10 mg;-Morphine Sulfate solution 20 mg/ml;9:00 A.M. medications- Amlodipine besylate 5 mg;- Aspirin 81 mg;- Carbidopa-Levodopa 25 mg -100 mg;- Letrozole 2.5 mg;- Losartan Potassium 25 mg;- Senna 8.6 mg;- Colace 100 mg;- Albuterol Sulfate 0.083% solution;Review of the Controlled Substances Register for Resident #1 indicated that his/her Morphine Sulfate solution was signed off as being administered on 02/09/26 at 8:00 A.M. This was inconsistent with the documentation in the Electronic MAR.During an interview on 03/17/26 at 1:50 P.M., the Assistant Director of Nurses (ADON) said that on 02/09/26 she relieved Nurse #4 and took over the care of Nurse #4's residents at approximately 11:30 A.M. (which included Resident #1). The ADON said that she noticed that Resident #1's morning medications had not been signed off as being administered by Nurse #4 in the Electronic MAR.The ADON said that she asked Nurse #4 if she administered Resident #1's morning medications to him/her and said that Nurse #4 said she had administered his/her morning medications. The ADON also said that Nurse #4 said she had not signed off that she had administered Resident #1's medications in the Electronic MAR, but did not explain why she had not signed them off in the Electronic MAR.The ADON said when a nurse administers a medication to a resident, they are required to document it in Electronic MAR immediately after administration. The ADON said that on 2/09/26, Nurse #4 went home without signing off that she had administered Resident #1's morning medications in the Electronic MAR. During an interview on 3/17/26 at 2:50 P.M., Nurse #5 said on 02/09/26 she worked the 3:00 P.M. through 11:00 P.M. shift. Nurse #5 said that when she went to administer medications to her residents, the Electronic MAR was in RED for Resident #1's morning medications. Nurse #5 said that when the Electronic MAR is in RED, it means that medications were not signed off as being administered and the Electronic MAR will remain in RED until the medications are signed off as being given, held or not given.Nurse #5 said that in order for the Electronic MAR not to be in RED, there has to be documentation to indicate what the status is of the medications. Nurse #5 said that she documented in Resident #1's Electronic MAR that his/her morning medications were held (H) due to the previous nurse not having completed the documentation. Nurse #5 said that after she documented that reason in the Electronic MAR, it was no longer RED and she was able to document that she administered the medications that were due for all of the Residents on her assigned shift.During a telephone interview on 03/18/26 at 10:50 A.M., Nurse #4 said that she worked on 02/09/26 from 7:00 A.M. through 11:30 A.M., (only the first half of the day shift). Nurse #4 said that she administered Resident #1's morning medications but did not sign them off in the Electronic MAR. Nurse #4 said that it was facility policy to sign off medications in the Electronic MAR immediately after administering them but said that day, she was very busy and just administered her residents morning medications without signing them off in the Electronic MAR.Nurse #4 said that after she administered all of her residents' medications, she went to the nurse's station to document in the Electronic MAR that she had administered the scheduled morning medications to all of her residents and was informed that she had to go home. Nurse #4 said that she went home without signing off in the Electronic MAR that she had administered Resident #1's morning medications.During a telephone interview on 03/18/26 at 11:35 A.M., the Director of Nurses (DON) said that on 02/09/26, Nurse #4 went home without signing off in the Electronic MAR that she had administered Resident #1's morning medications. The DON said that it was her expectation that nurses sign off in the Electronic MAR that medications were administered immediately after administering medications to their residents. The DON said that Nurse #4 did not follow the facility's policy for medication administration.

Based on interviews and record reviewed, for one Resident (#50) of 26 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #50, the facility failed to initiate replacement of lost/missing dentures timely. Findings include: Review of the facility's policy titled Dental Services, dated 10/19/2017, indicated but was not limited to the following: -Within 3 days following confirmation of lost or damaged dentures social services or their designee must make a referral for appropriate dental services for repair and/or replacement. -Social Services or their designee will maintain contact with dental services, the resident and/or representative if applicable until the problem is resolved and the dentures are replaced and repaired. Review of the Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that Resident #50 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Review of the progress note, dated 5/22/24, completed by the Registered Dietitian, indicated Resident #50 needed a dental referral for new dentures and nursing was aware. Review of Resident #50's medical record indicated his/her Health Care Proxy signed a consent for dental services on 9/4/24 and a referral was initiated on 9/11/24 (112 days after the Registered Dietitian acknowledged the need for new dentures). Review of a 2023 Grievance form (month/day not indicated on form) indicated the dentist was contacted for consult for denture replacement due to Health Care Proxy request for replacement. Further review of the Grievance form indicated the outcome included a scheduled (date not specified) dental consult for denture replacement. Review of the dental consult, dated 11/5/24, indicated it was completed in response to the 9/11/24 request. During an interview on 1/13/25 at 2:17 PM., Resident #50's Health Care Proxy said the Resident's upper and lower dentures were reported missing over nine months ago and there was still no resolution. She said she has asked at every care conference she has attended and knows a grievance form was initiated, and she isn't sure when, if at all, the Resident will receive replacement dentures. She said when she brought it up at the September care conference the facility staff had her sign a consent form for dental services that should have been completed when the dentures first went missing. She said the process has been delayed because of changes in staff. During an interview on 1/14/25 at 4:02 P.M., Social Worker #1 said she was aware of this longstanding issue. She said she started working for the facility in April 2024 and can recall the missing dentures being brought up by family at this time. She said it was brought up again in June and isn't sure what happened. She said she had the Health Care Proxy sign a consent for dental services in September. She said the grievance form is from 2023 and was completed prior to her working at the building. She said she isn't sure why there has been a delay in having the resident referred to and seen by the dentist. During an interview on 1/15/25 at 11:10 A.M., Unit Manager #2 said she had no additional information to explain why the consult didn't happen earlier than September. She said there was supposed to be a consult in July but was unclear why it didn't occur; she said she did not follow up. During an interview on 1/15/25 at 2:15 P.M., the Administrator said she cannot speak to what was done prior to her employment (began in November 2024) but she was aware that Resident #50 had a consult in November 2024. She said she didn't realize this had been a longstanding issue but knows there have been changes in facility staff which could explain the delay. She said there should have been follow up through the entire process to ensure the Resident received replacement dentures.

Based on records reviewed and interviews for one Resident (#122) out of 26 sampled residents, who had a court appointed legal guardian due to incapacitation (the inability to make his/her own health care decisions), the facility failed to ensure that his/her Legal Guardian was fully informed in advance and given information including the risk and benefits of psychotropic medications (medications that can affect mood and behavior) prior to their use. Findings include: Review of the facility's policy titled Psychotropic Medications, dated 5/3/2005, indicated but was not limited to the following: -Each of the following elements: purpose of administering the psychotropic medication, prescribed dosage, route of administration, known benefits and side effects of medication of the informed consents documents must be discussed with the prescriber, and the resident or the resident's legal representative. -In a case where a legal guardian is assigned, the guardian has the authority to consent to the use of psychotropic medications except antipsychotic medications. Resident #122 was admitted to the facility in October 2023 with diagnoses which included Alzheimer's disease with late onset, major depressive disorder, and dementia. Review of Resident #122's record indicated that an appointment for guardianship was filed on 10/11/23. Review of Resident #122's current Physician's Orders indicated but were not limited to: -Sertraline (antidepressant) 25 milligrams (mg) daily, 9/2/24 Review of the Psychotropic Consent form, dated 9/2/24, indicated that Resident #122 signed the form acknowledging he/she understood the listed risks and benefits for Sertraline 25 mg daily. Review of Resident #122's October 2024 through January 2025 Medication Administration Records (MAR) indicated he/she received Sertraline as ordered. During an interview on 1/14/25 at 3:10 P.M., Unit Manager #2 said the only situation when a person would not sign their own consents is if the health care proxy is activated. She said she believes the resident can sign their own paperwork because the Resident appears to be oriented. She said she would have to talk to social services because they inform the nurses if anyone cannot sign for themselves. She said she can see that the Resident signed their own consent for Sertraline on 9/2/24. During an interview on 1/14/25 at 3:16 P.M., Social Worker #2 said it was a tricky situation because the Resident seemed alert and oriented but has a court appointed legal guardian. She said she didn't know who should sign the psychotropic consent in this case and would need to find out the answer. During an interview on 1/14/25 at 3:29 P.M., Social Worker #1 said the Resident received an emergency guardian in 2023 and has had a court appointed legal guardian to make healthcare decisions for them since 2023. She said the Resident is not capable of signing consents and the legal guardian is the only person who can consent for healthcare related needs. During an interview on 1/14/25 at 3:50 P.M., the Administrator said the consent form should have been reviewed and signed by the legal guardian prior to administering the medication.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in three of three kitchenettes. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 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 FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 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. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. Review of the facility's policy titled Dietary: Sanitary Conditions, revised 9/21/22, indicated but was not limited to: Policy: [the facility] will procure food from sources approved or considered satisfactory by Federal, State, or local authorities; and store, prepare, distribute and serve food under sanitary conditions. Intent: Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. Prevention of Foodborne Illness: -Proper food preparation, storage, and handling practices are essential in preventing foodborne illness; -Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microorganisms; -Practices to maintain safe refrigerated storage include: Labeling, use by dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (when applicable) or discarded; -Temperature control and freedom from contamination are also important when ready-to-eat or prepared food items for snack are sent to the unit and are held for deliver; or stored at the nursing station, in a unit refrigerator or in unit cupboards; -Food handling risks associated with food stored on the units may include but are not limited to: Food left in refrigerators beyond safe use by dates (including, but not limited to foods that have been opened but were not labeled, etc.). Review of the facility's policy titled Dietary Department Guidelines, revised May 2018, indicated but was not limited to: -All items stored in the refrigerator will be covered and use by date labeled; -Stock items will be monitored for expiration dates and used or discarded as needed. On 1/14/25 at 10:49 A.M., the surveyor observed three opened containers of thickened liquids in the Unit 1 kitchenette refrigerator. Two of the containers were not labeled with the date they were opened. One container was dated 1/5/25. Manufacturer's instructions on the containers stated: After opening, may be kept up to 7 days under refrigeration. On 1/14/25 at 10:58 A.M., the surveyor observed four opened containers of thickened liquids in the Unit 3 kitchenette refrigerator. The surveyor observed all four containers were not labeled with the date they were opened. On 1/15/25 at 4:15 P.M., the surveyor observed four opened containers of thickened liquids in the Unit 1 kitchenette refrigerator. The surveyor observed three containers were not labeled with the date they were opened, and one container was dated 1/5/25. On 1/15/25 at 4:30 P.M., the surveyor observed two opened containers of thickened liquids in the Unit 2 kitchenette refrigerator. Both containers were not labeled with the date they were opened. During an interview on 1/15/25 at 4:30 P.M., Certified Nursing Assistant (CNA) #2 said the kitchen labels the thickened liquid containers with the expiration date. CNA #2 said they only use containers the kitchen has dated; if a container has no date, CNA #2 said they will open a new container of thickened liquid. CNA #2 and the surveyor observed an unopened bottle of thickened juice that was dated 1/25. CNA #2 said 1/25 was the expiration date written by the kitchen and the thickened juice could be used until 1/25. During an interview on 1/15/25 at 4:40 P.M., the Food Service Director (FSD) said the kitchen handwrites dates on each thickened liquid container with the date it was received to help with product rotation in the main kitchen's dry storage room. The FSD said the containers labeled 1/25 were labeled by the kitchen staff to indicate the facility received the thickened liquid containers in January 2025. The FSD said 1/25 did not indicate an expiration or use by date for opened containers. The FSD said when a new container of thickened liquids is opened, the container is to be dated with the opened date. The FSD said the thickened liquids were good for seven days after opening, per the manufacturer's instructions. During an interview on 1/16/25 at 10:45 A.M., the Administrator said staff was to label all open food and beverages with the date opened. The Administrator said staff should be labeling and dating food and beverages, per the facility's food storage policies, to ensure food and beverages served to residents comply with safe food practices.

Based on interview and record review, the facility failed to ensure one Resident (#42), in a sample of 26 residents, had been seen by a physician every 60 days. Findings include: Resident #42 was admitted to the facility in August 2020. Review of the Physician's Progress Notes indicated Resident #42 was seen by the MD (Doctor of Medicine) on 6/7/24. The next visit conducted by a physician was 11/1/24, 147 days later. During an interview on 1/15/25 at 11:44 A.M., the Director of Nurses (DON) said there were no additional physician visits for Resident #42 between June 2024 and November 2024. She said the Resident's primary physician had not been coming in to see residents timely and a termination notice was issued and the Resident was provided a new physician at the end of October 2024. She said it was not acceptable for a Resident to go from June to November without seeing a physician.

Based on record review and interviews, the facility failed to ensure the total program of care was reviewed by a physician for one Resident (#42), out of a total sample of 26 residents. Specifically, the facility failed to ensure the Resident's former primary physician and new primary physician evaluated the significant weight loss of Resident #42. Findings include: Resident #42 was admitted to the facility in August 2020 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/15/24, indicated Resident #42 had a weight loss of 5% or more in one month or 10% or more in six months. Review of the care plans indicated Resident #42 was at a nutritional risk related to dementia, anxiety, depression, hypertension and a history of variable intake with unintentional weight loss. Review of the interventions included but were not limited to: weekly weights, notify physician and dietitian of persistent weight loss, provide fortified foods (cereal at breakfast, potatoes at lunch/dinner), provide nutritional supplements (Magic Cup ice cream and Boost Breeze daily). Review of the weights for Resident #42 included but were not limited to the following: 7/2/24: 128.2 pounds (lbs.) 7/18/24: 128.2 lbs. 8/8/24: 121.2 lbs.; loss of 5.46% in 3 weeks 8/19/24: 122.6 lbs.; loss of 6.69% in one month 9/4/24: 117.80 lbs. 9/16/24: 114.4 lbs. 9/23/24: 109.8 lbs.; loss of 10.6% in one month 10/23/24: 110.60 lbs. 11/12/24: 111.2 lbs. 11/25/24: 111.60 lbs. 12/2/24: 107.0 lbs. 12/6/24: 104.6 lbs. 12/9/24: 105.4 lbs.; loss of 5.22 % in one month 12/17/24: 108.6 lbs. 12/23/24: 111.4 lbs. 12/30/24: 113.8 lbs.; loss of 11.23% in six months Review of the Physician's Progress Notes indicated Resident #42 was seen by the MD (Doctor of Medicine) on 6/7/24. The next visit conducted by a physician was 11/1/24. During an interview on 1/14/25 at 3:30 P.M., the Assistant Director of Nurses said Resident #42 had a primary physician who was no longer coming to the facility and switched primary physicians in October 2024, with the first visit with the new physician being 11/1/24. Review of the Physician's Progress Notes from 11/1/24, 12/2/24, and 1/3/25 failed to indicate the Resident's significant weight loss had been addressed by the physician. During an interview on 1/15/25 at 12:53 P.M., the Director of Nurses (DON) said the facility started having issues with the previous physician conducting visits timely. She said the facility had terminated the contract with the previous physician and the Resident was assigned to the Medical Director as the new primary physician. She said the previous physician did not have a Nurse Practitioner and there were no other physicians or physician extenders who would have seen the Resident for the physician between June 2024 and November 2024. She said she had reached out to the office of the previous physician and no physician visits after 6/7/24 had been received. She said the process was for the Unit Manager or the Registered Dietitian to notify the physician to evaluate a resident with significant weight loss. She said the Unit Manager for Resident #42 was not available for interview. During an interview on 1/15/25 at 1:10 P.M., the Registered Dietitian said she did not have any conversations with the previous or current physician regarding the significant weight loss for Resident #42 and the Unit Manager was responsible for speaking with the physicians. During an interview on 1/16/25 at 9:00 A.M., the Medical Director said the previous physician was terminated and the initial visit with Resident #42 was on 11/1/24. He said he was not aware of the significant weight loss for the Resident and it was probably overlooked. He said neither he nor the Nurse Practitioner had evaluated the weight loss. He said in reviewing his progress notes the weight loss may be related to the diagnosis of dementia, but it would have to be reviewed and he would need to run some baseline labs (blood work).

Based on observation, record review, and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#38) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 26 sampled residents. Specifically, Resident #38 did not receive the physician ordered amount of tube feeding, staff administering tube feedings were not signing off administration, and there were no physician's orders on how much water to administer with and between medications. Findings include: Review of the facility's policy titled Clinical Enteral Feeding- Documentation, revised in September 2010, indicated the following: -Physician's order: record the physician's order for the enteral feeding on the MAR (medication administration record); document the order is being carried out; document the amount of formula and water on the Input/Output Record (I&O) -Water flush: record the amount of hydration flush on the I&O record; record the amount of the pre- and post-medication flush, maintain and record the total water intake every 8 hours and calculate the 24-hour total -Changing the spike set: change the syringe and feeding set according to the manufacturer's recommendations. Do not change the spike delivery set with a closed system until the bottle is empty. Resident #38 was admitted to the facility in April 2024 with a diagnoses of status post cerebral infarction (stroke) and dysphagia, with a new G-tube. Review of the Minimum Data Set (MDS) assessment, dated 11/8/24, indicated Resident #38 had a feeding tube and the portion of the total calories the Resident received through a feeding tube was 51% or more. Review of the care plans indicated Resident #38 was dependent on the G-tube with the following interventions: -hold feeding if greater than 30 cc (cubic centimeters; equal to 30 milliliters (ml)) aspirate [sic] -administer tube feed: Jevity 1.5, 1380 ml, frequency 60 {ml/hour} -free water as ordered, assure total intake is 900 cc's every 24 hours -document tube feed and water intake every shift -administer medications per physician order Review of the Physician's Orders indicated Resident #38 had the following orders related to the feeding tube: -Jevity 1.5 1000 ml; rate of 60 ml/hour; total formula volume (rate x 23 hours)= 1380 ml (11/21/24) -free water 150 ml every 4 hours (11/21/24) -routine site care, day shift and as needed; cleanse with normal saline or soap and water, apply drainage sponge (6/2/24) -replace feeding syringe every 24 hours (5/4/24) -Diet: NPO (nothing by mouth) (11/11/24) Review of the physician's orders failed to indicate if/when residuals (fluid/contents that remain in the stomach) should be checked, at what amount of residual the feeding should be held, how much water would be used prior, during, and after the administration of medications. On 1/13/25 at 8:38 A.M., the surveyor observed Resident #38 in bed with the head of bed elevated. The feeding tube pump was observed set at 60 ml/hour and flush 150 ml/4 hours. The 1 liter (1000 ml) bottle of Jevity 1.5 was dated 1/13/25 at midnight (8 hours and 38 minutes prior) with 800 ml left in the bottle (indicating the Resident had received 200 ml since midnight. According to the physician's orders, Resident #38 should have received 510 ml by 8:30 A.M. (60 ml x 8.5 hours= 510 ml total), a difference of 310 ml. Review of the nursing progress note, dated 1/13/25 at 2:10 A.M., indicated Resident #38 was currently on an antibiotic for pneumonia. The nursing progress note indicated Nurse #3 held the tube feeding at midnight due to Resident #38 having 60 ml of residual. The nurse indicated the following re-checks: 12:25 A.M. 30 ml, 1:05 A.M. less than 5 ml. The nurse indicated the tube feeding was restarted at 1:05 A.M. at 60 ml per hour with 150 ml flush every 4 hours. The nursing progress note indicated the tube feeding was held for a little over an hour, which would equate to a loss of 65 ml (not 310 ml as observed). On 1/14/25 at 8:47 A.M., the surveyor observed Resident #38 in bed with the head of the bed elevated. The feeding tube pump was observed set at 60 ml/hour and flush 150 ml/4 hours. The 1-liter bottle of Jevity 1.5 was dated 1/14/25 at midnight (8 hours and 47 minutes prior) with 700 ml left in the bottle (indicating the Resident had received 300 ml since midnight.) According to the physician's orders, Resident #38 should have received 510 ml by 8:30 A.M. (60 ml x 8.5 hours= 510 ml total), a difference of 210 ml. Review of the nursing progress notes failed to indicate the tube feeding which was started on 1/14/25 at midnight was held for any reason. On 1/15/25 at 8:55 A.M., the surveyor observed Resident #38 in bed with the head of the bed elevated. The feeding tube pump was observed set at 60 ml/hour and flush 150 ml/4 hours. The 1-liter bottle of Jevity 1.5 was dated 1/15/25 at midnight (8 hours and 55 minutes prior) with 650 ml left in the bottle (indicating the Resident had received 350 ml since midnight. According to the physician's orders, Resident #38 should have received 540 ml by 8:30 A.M. (60 ml x 9 hours= 540 ml total), a difference of 190 ml. Review of the nursing progress notes failed to indicate the tube feeding which was started on 1/15/25 at midnight was held for any reason. During an interview on 1/15/25 at 7:15 P.M., Nurse #3 said the bottles for the feeding tube get changed whenever they were almost empty, below 100 ml left and that it happened to be changed at midnight for a couple of nights. Nurse #3 said he checked the residual anytime he provided care related to the G-tube (giving medications, checking placement, changing the bottle). He said he was not sure if it was written down, but he holds the tube feed if the residual was over 45 ml because he was familiar with the Resident who normally had a residual of less than 10 and he had been worried about aspiration related to the most recent diagnosis of pneumonia. He said he normally only administers one medication to the Resident, and he will flush with 5 ml of water before administering the medication, put 5 ml of water in with the medication and flush with 5 ml of water after giving the medication. Review of the January 2025 MAR indicated the order for the tube feeding was only signed off by the day shift every day. The orders were not signed off by the nurse who started a new bottle. Review of the MAR and TAR failed to indicate the amount of intake for Resident #38. During an interview on 1/15/25 at 9:20 A.M., Nurse #2 said Resident #38 was on a continuous feeding so the bottle would get changed whenever it was empty and not on a set schedule. She said I&O's were kept in a separate binder. Nurse #2 reviewed the I&O binder and said there were no recordings of intake for Resident #38. On 1/15/25 at 11:57 A.M., the surveyor observed Resident #38 connected to the feeding tube which was running at 60 ml/hour. At 2:44 P.M. the surveyor observed the tube feed pump beeping with a message that read hold error? The tube feed pump was not administering the Jevity 1.5 at this time and there was 400 ml left in the bottle, 100 ml less than the previous observation almost three hours prior. The surveyor did not observe any staff entering the Resident's room between 2:44 P.M. and 3:09 P.M. During an observation with interview on 1/15/25 at 3:09 P.M., the surveyor observed Nurse #4 enter the room of Resident #38 and hit the continue button on the tube feed pump. Nurse #4 said the machine was beeping when she came into the room and she pressed the button to start the machine again. She said she did not know why it was on hold or how long it had been on hold. She said she didn't normally calculate how much a resident on a feeding tube was getting. During an interview on 1/15/25 at 3:24 P.M., Nurse #4 said she had done the calculations and Resident #38 should have had 900 ml by this point (60 ml x 15 hours) but that she would factor in holding the tube feed for care, holding for medications and possibly holding for activities would all contribute the remaining 400 ml in the bottle. Nurse #4 said when administering medications to Resident #38 she puts each medication in with 5 ml of water and flushes with 5 ml of water between the medications. During an interview on 1/15/25 at 3:40 P.M., Nurse #2 said she had been the assigned nurse for Resident #38 on the 7:00 A.M. to 3:00 P.M. shift. She said the Resident had not gotten out of bed today and the tube feed was only held for care for about 10 minutes. During an interview on 1/15/25 at 3:52 P.M., the Registered Dietitian said there was a 72-hour report that was available on the tube feed pump. She said she had just run the report which indicated Resident #38 had received 3707 ml of nutritional feed (433 less than the ordered amount of 1380 per day for three days for a total of 4140) and 2100 of water (600 less than the ordered amount of 900 per day for three days for a total of 2700). She said the calculated nutritional feed for Resident #38 was for 60 ml per hour for 23 hours per day and the additional hour of the feed being held was for care, for a total of 1380 ml every 24 hours. She said according to the physician's orders Resident #38 should complete a 1000 ml bottle of Jevity in 17 hours and the bottles should not last 24 hours. During an interview on 1/15/25 at 4:05 P.M., the Assistant Director of Nurses said she reviewed the medical record and there was not an order for checking the residual or what amount to hold the tube feed related to the residual. She said there should be an order in place, so the nurses know how much water to use with the medications and to flush with before and after medications. She said unless the physician gives orders to monitor the intake or there was a change in weight, it would not be the process to record intake. She said the tube feed for Resident #38 was being held for care and for administration of medications and it was not possible for the tube feed to have only been held for 10 minutes on the day shift on this day. During an interview on 1/16/25 at 10:20 A.M., the Director of Nurses said the order for the administration of the feeding tube should allow each nurse to sign off, not just the day shift. She said the orders needed to be clarified to include flushes and holding time as the hold time was probably longer in a 24-hour period related to care and medication administration and this should be included in the calculations. She said there should be orders for how much water to mix with medications and how much to flush with between medications.

Based on record review and staff interview, for one Resident (#138), of two closed records reviewed, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment. Findings include: Review of the facility's policy titled Care Planning, revised 10/28/22, indicated but was not limited to the following: 2. Once discharge is planned, process will be as follows utilizing Discharge Checklist: -Day/night prior to discharge a. initiate post-acute Discharge Transition Summary Form b. Complete Discharge Medication List form and place in packet c. Copy MOLST and place original in packet/copy in chart d. Copy most recent lab/diagnostic testing and place in packet e. Complete medication reconciliation -Day of Discharge a. Review discharge packet and medication list b. Gather medications/treatments c. Review packet/medications/treatments with resident and/or responsible party d. Obtain resident and/or responsible party sign [sic] packet and medication list/s e. Nurse signs packet and medication list(s) f. Fax discharge documents to PCP office (include physician discharge summary) g. Fax discharge documents to home care agency (include physician discharge summary) Resident #138 was admitted to the facility in October 2024 for a brief stay for respite care. Review of the medical record indicated Resident #138 was discharged home on 10/20/24. During an interview on 1/15/25 at 9:14 A.M., Resident Representative #1 said Resident #138 was admitted to the facility for a respite stay in October 2024 while his/her home caregivers were on vacation. Resident Representative #1 said the Resident's home care services and equipment were in place already and his/her discharge home was uneventful with no concerns identified. Review of the closed medical record failed to indicate a recapitulation of the Resident's stay was completed by the Attending Physician. During an interview on 1/15/25 at 1:47 P.M., the Director of Nursing (DON) said that all discharged residents, even those at the facility for respite, should have a discharge summary with a recapitulation of the Resident's stay completed when discharged . During an interview on 1/15/25 at 1:57 P.M., the DON said she reviewed the Resident's closed medical record and could not find that a discharge summary or recapitulation of the Resident's stay had been completed.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was confused and unable to make his/her needs known, the Facility failed to ensure Resident #1 was free from physical and verbal abuse when, on 1/21/24 around 7:00 P.M., Nurse #1 was witnessed by other staff members treating Resident #1 in a verbally and physically abusive manner. Findings include: Review of the Facility Resident Abuse Prevention, Investigation and Reporting Policy, last revised 10/17/22, indicated that it was the policy of the Facility to ensure an environment free of abuse. Review of Resident #1's clinical record indicated that he/she was admitted to the Facility during March 2023 and his/her diagnoses included dementia, major depressive disorder, schizoaffective disorder, schizophrenia and anxiety disorder. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, completed 1/24/24, indicated that his/her short and long term memory skills were impaired; he/she sometimes understood others and he/she exhibited physically and verbally abusive behavioral symptoms. The MDS indicated Resident #1 was nonambulatory and was dependent on staff members for wheelchair mobility and transferring between surfaces. Review of Resident #1's Care Plan related to behavioral symptoms, dated as initiated 6/20/23, reviewed and renewed with his/her January 2024 Quarterly MDS, indicated he/she yelled out, was combative and refused care at times due to dementia. The Care Plan identified interventions which included speaking slowly and directly, anticipating and assisting with all needs and, when Resident #1 was agitated, leaving him/her in a safe situation and reproaching at later times. An additional intervention, dated as initiated 10/10/23, indicated Resident #1 used a reclining wheelchair for comfort. Review of Resident #1's Care Plan related to comfort, dated as initiated 3/06/23, reviewed and renewed with his/her January 2024 Quarterly MDS, indicated that Resident #1 had the potential to experience pain due to arthritis. The Care Plan indicated a goal was for Resident #1 to experience decreased pain and interventions indicated staff were to identify, assess and document the presence of pain and observe for behaviors, such as irritability and restlessness, as possible indicators of pain. Review of Resident #1's Care Plan related to end of life, dated as initiated 11/06/23, indicated Resident #1 was admitted to hospice care on 10/25/23. During in person interviews on: - 2/21/24 at 10:58 A.M. with Nurse #2, - 2/21/24 at 12:50 P.M. with Certified Nursing Assistant (CNA) #3, and telephone interviews on - 2/28/24 at 2:10 P.M. with Nurse #3, and, - 2/29/24 at 3:15 P.M. with CNA #5, they said the following: They observed Nurse #1 interacting with Resident #1 around 7:00 P.M. on 1/21/24. Nurse #2, CNA #3 and CNA #5 said that Nurse #1 yelled at Resident #1 and pointed or wagged one of her fingers in Resident #1's face. Nurse #2 and CNA #5 said that they heard Nurse #1 tell Resident #1 what are you going to do about it in an angry, aggressive and threatening tone of voice. CNA #3 and CNA #5 said Nurse #1 told Resident #1 you don't tell me to shut up or you shut up too. Nurse #3 said that although he was in and out of resident rooms and did not observe the entire interaction between Nurse #1 and Resident #1, and said he heard Nurse #1 speaking to Resident #1 in a high-pitched tone of voice, similar to the way someone might speak to a child. Nurse #2 and CNA #5 said that at one point, Resident #1 kicked his/her leg toward Nurse #1 and that Nurse #1 grabbed Resident #1's leg in response. Nurse #2 and CNA #5 said Nurse #1 pulled on Resident #1's leg. Nurse #2 said Nurse #1 pulled Resident #1's leg with sufficient force to move him/her forward in the reclining wheelchair. Nurse #2 said that when Nurse #1 walked away from Resident #1, Nurse #1 stated that Resident #1 needed to learn how to talk to people. CNA #3 said that Nurse #1 did not seem to understand that Resident #1 was confused. CNA #3 and CNA #5 said Resident #1 became more agitated by the interaction with Nurse #1 and said Nurse #1 bothered Resident #1. Although Resident #1's communication and cognition deficits limited his/her ability to articulate his/her feelings about the alleged incident, an unimpaired individual would experience physical pain and mental anguish when verbally and physical abused by a caregiver. On 2/21/24 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) On 1/21/24, skin and pain assessments were completed by nursing for Resident #1 without findings of injury related to the alleged incident. Staff continue to assess Resident #1's pain and skin daily per the care plan and to provide frequent checks of his/her wheelchair positioning due to fall risk and confusion. B) On 1/21/24, Nurse #1 was immediately escorted from the Facility, the Facility notified the Agency which employed Nurse #1 of the allegation and the Facility informed the Agency that Nurse #1 was not to return to the Facility. C) On 1/22/24, the Facility Social Worker met with Resident #1 and his/her family member to offer on-going support. D) On 1/25/24, Resident #1 was examined by the Nurse Practitioner and his/her care plan reviewed. E) Between 1/21/24 and 1/31/24, the Facility posted additional information on all units and public areas with regard to abuse identification and prevention. F) Training on Abuse, Resident Rights, Ethics and the Facility Code of Conduct was provided to all staff during December 2023 and January 2024 and continues to be provided to new staff and as needed in response to concerns. G) The Facility initiated Shift to Shift huddles on 12/18/23 which continue daily to ensure reporting of resident condition changes and care plan development across all shifts and documentation from the huddles is reviewed daily by Facility Leadership and Interdisciplinary Team Members in Morning Meeting. H) The Facility initiated a daily Resident Interview Program on 12/18/23 during which residents are asked about safety and concerns and observed for cleanliness, comfort and freedom from pain. Documentation from the Resident Interview documentation is reviewed daily by Facility Leadership and Interdisciplinary Team Members in Morning Meeting. I) The Quality Assurance Committee met 2/02/24 to review the on-going Abuse Prevention and Response plans and will meet again in February 2024. J) The Administrator and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had undergone a right total hip arthroplasty, had a history of arthritis of the hip and required pain management, the Facility failed to ensure nursing adequately assessed and effectively helped manage his/her complaints of increased pain. On 12/10/23, at approximately 8:30 A.M., Resident #2 complained of increased right hip pain after being repositioned in bed, and had requested pain medication, however Nurse #2 did not administer pain medication to Resident #2 until two and half hours after his/her initial complaints of increased right hip pain. An x-ray was obtained of Resident #2's right hip and he/she was found to have mild soft tissue swelling and an acute periprosthetic fracture of his/her right hip. Finding include: The Facility's Policy, titled Pain Management, dated as revised 6/16/2022, indicated the following: - the Facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals, quality of life, functionality and preferences; - resident's will be assessed for the presence of pain, and individualized pain management interventions will be implemented through their care plan and the effectiveness will be evaluated on an ongoing basis; - maintain the highest possible level of comfort for all residents by providing a system to identify, assess, treat, and evaluate pain; - design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with resident directed goals; - every shift, resident's will be screened for the presence of pain by making an inquiry of the resident or by observing for signs of pain; - the screen will be documented on the Electronic Medical Record (eMAR); - all staff will report any observation or communication of pain to the nurse responsible for that resident; - the nurse will assess the resident's pain based on resident interview and/or observations of signs and symptoms; - residents receiving treatment for pain will be monitored and re-assessed for the treatment's effectiveness in providing pain relief; - the date and time of each dose of pain medication administered, both routine (scheduled) and as needed (PRN), will be documented in the eMAR; - the effectiveness of PRN medication interventions will be documented in the eMAR; - the treatment plan will be evaluated for effectiveness, and changed as indicated, until satisfactory balance of side effects and pain relief is achieved; Resident #2 was admitted to the Facility in December 2023, diagnoses included: presence of right artificial hip joint, orthopedic aftercare, fracture of unspecified part of neck of right femur - subsequent encounter for closed fracture with routine healing, osteoarthritis of the hip, vertigo, post-traumatic stress disorder and major depressive disorder. Review of Resident #2's Care Plan related to Pain, dated 12/03/23, indicated goals included he/she will experience a decrease in pain after pain reducing measures are implemented and will verbalize an acceptable level of pain following individualized pain management. Interventions included to identify, assess and document presence of pain, medicate per physician's orders, observe effectiveness of pain medication and adjust as indicated, and to encourage resident to report occurrences of pain at onset and monitor for changes in signs and symptoms of pain. Review of Resident #2's Admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #2, was cognitively intact, required moderate assistance of staff with transfers, ambulation, dressing, hygiene, bathing and toileting. The MDS indicated Resident #2's frequency of pain was almost constantly, with a pain severity rating of 5 (numerical rating scale 0 indicating no pain, to 10 indicating severe pain). Review of the Facility's Internal Investigation, dated 12/10/23, indicated that at approximately 8:30 A.M. Resident #2 reported to the nurse (later identified as Nurse #4) that a Certified Nurse Aide (CNA) came into his/her room to answer the call light and was rough and caused him/her pain during repositioning. The Investigation indicated that Resident #2 reported that the CNA grabbed him/her and put him/her into bed, and he/she complained of increased pain. The Investigation indicated that that Resident #2 had been receiving PRN medication of Tylenol (analgesic, pain reliever) and Tramadol (an opioid analgesic used for moderate to moderately severe pain) and his/her pain levels varied from 0 (none) to 10 (severe). The Investigation indicated that the Physician was notified, ordered an x-ray of Resident #2's right hip which revealed an acute periprosthetic fracture and he/she was transferred to the Hospital for further evaluation and treatment. Review of Resident #2's right hip and pelvis x-ray Report, dated 12/10/23, indicated there was an acute periprosthetic fracture of the right hip and mild tissue swelling. Review of Nurse #4's (the nurse who Resident #2 complained to) Written Witness Statement, dated 12/10/23, indicated that Resident #2 reported to her that at 8:30 A.M. (on 12/10/23), he/she put his/her call light on, a CNA came in and repositioned him/her, that he/her told the CNA that he/she was in pain and the CNA just left him/her that way. The Statement indicated that Resident #2 stated that the CNA was rough with him/her and hurt his/her legs during the repositioning. During an interview on 12/27/23 at 3:20 P.M., Nurse #4 said she was working as a CNA on 12/10/23 during the 7:00 A.M. to 3:00 P.M. shift. Nurse #4 said that at approximately 8:30 A.M., she delivered Resident #2's breakfast tray and he/she was lying in bed and his/her facial expression looked uncomfortable. Nurse #4 said Resident #2 told her that a CNA came into his/her room, repositioned him/her, hurt him/her during the repositioning, that he/she was uncomfortable, and that the CNA just left him/her that way and never came back. Nurse #4 said she reported this to the DON and Nurse #2 (who was the nurse assigned to care for and treat Resident #2 during that shift). Review of Nurse #2's Written Witness Statement, dated 12/10/23, indicated that she went into Resident #2's room and he/she told her that he/she was thrown into bed like a bag of potatoes by a CNA. The Statement indicated that Resident #2 said that the CNA grabbed him/her, put him/her in the bed and that Resident #2 complained of increased right hip pain. The Statement indicated that she notified the DON and the Physician, and the Physician ordered an x-ray of his/her right hip to rule out any injury. During a telephone interview on 1/03/24 at 4:30 P.M., Nurse #2 said Resident #2 had received his/her scheduled medications between 7:00 A.M. and 7:30 A.M. on 12/10/23 and that included Gabapentin (anticonvulsant also used for nerve pain). Nurse #2 said that Resident #2 told her that his/her usual right hip pain was not like the increased pain he/she experienced when the CNA threw him/her in bed like a sack of potatoes and repositioned him/her in bed that morning around 8:30 A.M. Nurse #2 said Resident #2 said that he/she had worked with therapy the day before and said his/her hip did not hurt as bad as it did when the CNA repositioned him/her in bed that morning. Nurse #2 said she could not recall if she medicated Resident #2 after he/she complained of increased pain after the CNA repositioned him/her in bed. Nurse #2 said she should have re-assessed Resident #2's pain and medicated him/her with the PRN Tramadol (opioid pain medication used for moderate to severe pain). Nurse #2 said that she should have written a nurse's note in Resident #2's medical record and said she believed she had re-assessed Resident #2's pain, medicated him/her with the PRN medication and wrote a nurses note. Review of Resident #2's Physician's Orders, dated 12/02/23, indicated he/she had an order for Tylenol 650 milligrams (mg) (Analgesic, treats mild to moderate pain) as needed, not to exceed 3 grams in 24 hours. Review of Resident #2's Physician's Orders, dated 12/04/23, indicated he/she had an order for Tramadol 50 mg every six hours as needed for pain, (Moderate 4-7) to (Severe 8-10). Review of Resident #2's Narcotic Administration Record, dated 12/10/23, indicated that at 11:00 A.M., he/she was administered Tramadol 50 mg, however that was two and a half hours after he/she complained to Nurse #2 about having increased hip pain. However, review of Resident #2's Medication Administration Record (MAR), for the month of December 2023, indicated that on 12/10/23, there was no documentation to support that Resident #2 received any PRN medication for complaints of increased pain. Review of Resident #2's Nurse Progress Notes, dated 12/10/23, indicated there was no documentation to support that Nurse #2 documented his/her change in condition, that she effectively monitored changes in his/her pain intensity, or effectiveness of the pain medication she administered to him/her as required per facility policies. During a telephone interview on 1/08/24 at 11:43 A.M., the Director of Nursing (DON) said she expected that Nurse #2 should have re-assessed Resident #2's increased pain, medicated him/her with PRN pain medication, re-assessed the effectiveness of the PRN pain medication and documented Resident #2's assessment and change of condition in the progress notes. The DON said Nurse #2 did not follow the Facility's Pain Management Policy. Review of Resident #2's Hospital Emergency Department After Visit Summary, dated 12/11/23, indicated Resident #2 was seen for complaints of right hip pain. The Summary indicated that Resident #2 received hydromorphone (opioid used for severe pain) 1 mg for pain and an x-ray of his/her right hip and pelvis was obtained and revealed a subtrochanteric (a break in the proximal femur bone within five centimeters of the lesser trochanter) fracture of the right hip with edema in the soft tissues which may be due to recent trauma or recent postoperative state versus a combination of these. The Summary indicated to follow up with an orthopedic surgeon. Review of Resident #2's Orthopedic Surgeon Consult, dated 12/14/23, indicated that he/she had a fracture which was non-operative, to continue with physical therapy and weight bearing as tolerated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, required physical assistance from staff for transfers and mobility, and who had been administered medication by nursing to treat an acute episode of hypoglycemia (low blood sugar), the Facility failed to ensure he/she was provided adequate supervision by nursing in an effort to maintain his/her safety to prevent an incident/accident resulting in an injury. On 11/29/23, Nurse #1 administered glucose gel to Resident #1 to treat his/her low blood sugar, however Nurse #1 failed to recheck his/her blood glucose level, left him/her unattended in his/her bed and later found Resident #1 lying on the bathroom floor crying out in pain when range of motion was attempted to his/her right leg. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation of his/her injury, was diagnosed with hypoglycemia, acute right pubic bone fractures and was admitted to the Hospital. Findings include: Review of the Facility Policy titled, Falls Management Program Practice Guidelines, undated, indicated the following: -four most common risk factors are: impaired cognition - some practitioners cite dementia as the top risk factor for falls, medications-affect balance, orientation, gait and mobility, medical conditions-affect vision, balance, strength, gait and mobility, and urinary incontinence-urine on the floor, attempting to get to the bathroom without assistance due to urgency; Review of the Facility Policy titled, Falls Risk Reduction, dated as revised 11/02/23, indicated the following: -all residents will be assessed for falls risk factors; -those determined to have risk factors will receive individualized interventions based on risk factors in order to reduce risk for falls and minimize the actual occurrence of falls; -ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents; -complete Fall Risk Assessment; -identify resident's specific risk factors to determine which risk factors need further assessment and/or require intervention. Review of the Facility's Policy titled, Hypoglycemia Protocol, undated, indicated the following: -hypoglycemia is defined as a blood glucose of less than 70 mg (milligrams)/dl (deciliter) with or without symptoms; -assess for signs and symptoms of hypoglycemia which could include the following: sweating, facial pallor, shakiness, tremors, increased appetite, nausea, dizziness or light-headedness, sleepiness, tingling around the mouth and tongue, change in level of consciousness ranging from confusion to coma, weakness, rapid heart rate, headache, seizures; -repeat blood glucose every 15 minutes until two blood glucose levels above 70 and no symptoms; Resident #1 was admitted to the Facility in January 2023, diagnoses spinal stenosis of lumbar region, hypertensive urgency, acute kidney failure, weakness, hypoglycemia, major depressive disorder, dementia and diabetes mellitus with ketoacidosis. Review of Resident #1's Fall Risk Assessment, dated 10/30/23, indicated that he/she was at increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 required maximum assistance from staff with transfers and moderate assistance from staff with ambulation, hygiene and toileting. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated 11/06/23, indicated he/she required the physical assistance of one staff member with ambulation, mobility, transfers, and toileting. Review of Resident #1's Urinary Incontinence Care Plan, dated 11/07/23, indicated he/she had chronic and intractable urinary incontinence related to dementia and could not perform personal hygiene or manage clothing, interventions included to toilet resident during their individual morning and evening care, before and after meals, before going back to bed, if resident appears restless or if requested. Review of Resident #1's Certified Nurse Aide (CNA) Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #1 required the physical assistance of one staff member with transfers, ambulation, dressing, toileting, bathing and hygiene and was incontinent of bladder. Review of a Fall Incident and Root Cause Analysis Report, dated 11/29/23, indicated that at 10:00 A.M., Resident #1 was found on his/her buttocks on the bathroom floor and urine was noted on the floor. The Report indicated Resident #1 was unable to recall incidents leading up to the fall, was confused and forgetful. The Report indicated Resident #1's blood sugar was 39 mg/dl at 8:00 A.M. The Report indicated that Resident #1 sustained an injury to his/her right leg/hip area. Review of the Facility's Internal Investigation, dated 11/29/23, indicated that at approximately 8:00 A.M. Resident #1 had a low blood glucose level of 39 mg/dl, was confused, unable to answer questions appropriately and was given glucose gel 15 grams. The Investigation indicated that Nurse #1 waited a bit (exact duration of time unknown) for his/her condition to improve, he/she became more alert, was forming words, so she left Resident #1 in bed and checked in on him/her 15 minutes later. The Investigation indicated Resident #1 was improving and was able to answer questions. The Investigation indicated that 20 minutes later, (at approximately 10:00 A.M.) Nurse #1 went to check in on Resident #1 and found him/her on the floor in the bathroom with his/her pants halfway down with urine and feces on the floor. The Investigation indicated Resident #1 was crying and complaining of pain in his/her right hip and leg and Nurse #1 was unable to perform Range of Motion to his/her right leg due to pain. The Investigation indicated that Resident #1 was transferred to the Hospital ED. Review of Resident #1's Nurse Progress Note, dated 11/29/23 at 2:41 P.M., (written by Nurse #1), indicated that Resident #1 had a CBG (capillary blood glucose) level of 39 mg/ml this morning, speech unremarkable, confused, unable to answer questions accurately, orange juice was attempted but he/she was unable to sit up properly and swallow thin liquids. The Note indicated that glucose gel 15 gm (gram) was given, waited for his/her status to change and he/she started to form words. The Note indicated that 15 minutes later, Resident #1 was able to answer questions accurately, form words and 20 minutes later, Resident #1 was found on the floor in his/her bathroom with pants down and urine and feces noted on the floor. The Note indicated that Resident #1 was crying, unable to perform Range of Motion (ROM) to his/her right leg and cried out in pain when he/she tried to move his/her right leg. The Note indicated that Resident #1 was transferred to the Hospital ED. During a telephone interview on 1/04/24 at 12:30 P.M., Nurse #1 said that she obtained Resident #1's CBG between 7:45 A.M. and 7:50 A.M. on 11/29/23 and it was 39 mg/dl. Nurse #1 said she attempted to give Resident #1 orange juice, but he/she was confused, not making any sense, was unable to sit up or swallow and did not eat anything that morning. Nurse #1 said she gave Resident #1 one packet of glucose gel (15 gm) and after a few minutes, she checked in on him/her, he/she was still confused and not making any sense. Nurse #1 said that a few minutes later, she checked in on Resident #1, he/she formed words and was more alert. Nurse #1 said that when she went to check on Resident #1 again, which was approximately at 10:00 A.M., she found him/her on the floor in the bathroom complaining of right leg pain. Nurse #1 said she never rechecked Resident #1's blood glucose level after she administered the packet of glucose gel but should have. Nurse #1 said Resident #1 was transferred to the Hospital ED for evaluation. Based on Nurse #1's Progress Note and interview, regarding the sequence of events on 11/29/23 related to Resident #1 hypoglycemic episode, there was no documentation to support Nurse #1 rechecked his/her blood glucose level every 15 minutes until he/she had two blood glucose levels of 70 mg/dl and had no symptoms, therefore leaving him/her unattended and at risk for falls. During an interview on 12/27/23 at 4:10 P.M., Certified Nurse Aide (CNA) #2 said that on 11/29/23 at approximately 8:00 A.M., she went to give Resident #1 his/her breakfast tray and the Nurse told her not to give Resident #1 his/her breakfast tray because his/her blood sugar was low. CNA #2 said that Resident #1 was talking to him/herself, was out of it and was not making any sense. CNA #2 said that she went back in to check on Resident #1 between 8:30 A.M. and 8:45 A.M., and Resident #1 was still out of it, not making any sense, and was not him/herself. CNA #2 said that she never gave Resident #1 his/her breakfast tray that morning because he/she was not alert enough to feed him/herself or be fed by staff. During an interview on 12/28/23 at 11:05 A.M., Unit Manager #1 said that at approximately 9:15 A.M. on 11/29/23, she went into Resident #1's room to obtain a COVID sample and said Resident #1 was not his/her usual self and his/her behavior was not at his/her baseline. Unit Manager #1 said that approximately 20 minutes later, Nurse #1 informed her that Resident #1 was on the bathroom floor in his/her room. Unit Manager #1 said that she went into Resident #1's room, he/she was sitting on the bathroom floor crying and pointed to his/her right hip area and said that it hurt. Unit Manager #1 said that she called 911 and when Emergency Medical Services (EMS) arrived, she heard Nurse #1 tell EMS that Resident #1's blood sugar was low, heard EMS ask Nurse #1 if she rechecked Resident #1's CBG and that Nurse #1 had stated no to EMS. Review of Resident #1's Hospital Discharge Summary, dated 11/29/23, indicated that Resident #1 presented to the Hospital ED after an episode of hypoglycemia and an unwitnessed fall at the Nursing Home. The Summary indicated that Resident #1 was found to have a blood sugar of 38 mg/dl this morning at the Nursing Home and upon arrival at the ED, Resident #1 was found to be hypoglycemic with a blood sugar of 43 mg/dl. The Summary indicated that Resident #1 was given D 10 bolus (dextrose used to treat severe hypoglycemia) 100 milliliters (ml) intravenously. The Summary indicated that Resident #1's blood sugar was rechecked and was 29 mg/dl and he/she was given D 50 25 ml (used for rebound hypoglycemia) intravenously and D 5 in Ringers lactate solution (crystalloid isotonic intravenous fluid of balanced electrolytes) at 125 ml/hr. intravenously. The Summary indicated that a CT scan of Resident #1's right hip revealed acute right pubic (pelvic) bone fractures and that the fall probably due to hypoglycemia. The Summary indicated that Resident #1 was admitted to the Hospital for hypoglycemia and acute right pubic bone fractures. During an interview on 12/28/23 at 11:40 A.M., the Director of Nurses (DON) said it was her expectation that nursing stay with Resident #1 until his/her blood sugar levels were 70 mg/dl or above. The DON said it was her expectation that Nurse #1 recheck Resident #1's blood sugar level every 15 minutes until they were 70 or above and said Nurse #1 did not recheck Resident #1's blood sugar level. The DON said that Resident #1's low blood sugar level, change in condition and transferring him/herself to the bathroom contributed to his/her fall. On 12/28/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 11/29/23, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment of hypoglycemia and injury as a result of an unwitnessed fall. B) 11/29/23, Nurse #1 was immediately educated by the Director of Nurses (DON) to follow the Facility's hypoglycemia protocol and to ensure re-testing and re-assessment of resident's who are hypoglycemic. C) 12/06/23 and 12/07/23, Nursing Staff were in-serviced on the Facility's Diabetic Management Policy and Hypoglycemia Protocol by the Staff Development Coordinator (SDC) and the Director of Nurses (DON). D) 12/07/23, Nursing Staff were in-serviced on the Facility's Falls Management Policy by the Staff Development Coordinator (SDC). E) 12/13/23 - 12/15/23, A Facility wide audit of all diabetic resident's blood glucose results was completed by the Regional Director of Clinical Services. F) 12/15/23, Unit Manager #1 and Nurse #1 were in-serviced on the proper policy and procedure of their positions and compliance with standards of practice by the SDC. G) DON and Unit Managers will conduct daily audits of all diabetic resident's blood glucose results to ensure the Hypoglycemic Protocol and Diabetic Management Policy were followed. H) Audits will be conducted daily for three weeks, then weekly for three months or until substantial compliance is achieved. I) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. J) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a Diabetic, had experienced an acute episode of hypoglycemia (low blood sugar) and required administration of glucose gel for treatment, the Facility failed to ensure Resident #1 was provided nursing care and treatment in accordance with professional standards of practice, when on 11/29/23, after Nurse #1 administered the glucose gel, she failed to recheck Resident #1's blood glucose level, left him/her unattended in his/her bed and later found Resident #1 (who was unable to transfer or ambulate without the physical assistance from staff) lying on the bathroom floor. Resident #1 was later diagnosed with hypoglycemia, acute right pubic bone fractures and was admitted to the Hospital. Findings include: Review of the Facility Policy titled, Diabetic Management Protocol, dated as revised April 6, 2018, indicated the following: -residents who have diabetes will receive care according to accepted standards of care focused on maintaining blood glucose control and preventing both acute and chronic complications; -upon admission, initiate diabetic management physician order set; -perform fingerstick blood glucose monitoring as ordered; -administer insulin/oral hypoglycemic medication as ordered; -assess for and respond to any change in condition; -treat hypoglycemic episode according to hypoglycemic protocol; Review of the Facility's Policy titled, Hypoglycemia Protocol, undated, indicated the following: -hypoglycemia is defined as a blood glucose of less than 70 mg (milligrams)/dl (deciliter) with or without symptoms; -assess for signs and symptoms of hypoglycemia which could include the following: sweating, facial pallor, shakiness, tremors, increased appetite, nausea, dizziness or light-headedness, sleepiness, tingling around the mouth and tongue, change in level of consciousness ranging from confusion to coma, weakness, rapid heart rate, headache, seizures; -Treatment of blood sugar (BS) 50 mg/dl or less, conscious, able to swallow, able to take food by mouth, remain with patient if symptomatic and provide 30 grams of carbohydrates; 8 ounces of juice or soda (regular, not sugar free or diet) or; 1 cup of applesauce or; 12 saltines or; 2 tablespoons of sugar, jelly, honey or; 16 ounce cup of milk -skim, low-fat or whole; or provide 30 grams of glucose gel (two tubes), and retest blood glucose in 15 minutes, -if blood glucose less than 70, provide another 15 grams of carbohydrates; -repeat blood glucose every 15 minutes until two blood glucose levels above 70 and no symptoms; -add order to check blood glucose level one time at 2:00 A.M., in addition to any other MD orders for blood glucose check; -notify MD per Physician Notification Pamphlet of hypoglycemic event, using Situation Background Assessment Recommendation (SBAR) include vitals, symptoms, time of last food intake, time/dose of diabetic meds, response to therapy, and ask for change in regime if appropriate; -document on SBAR: event, times of glucose checks, signs and symptoms of hypoglycemia, treatment, resolution, assessment, correspondence with MD/NP prior to administering the next insulin or oral diabetes agent for medication and glucose monitoring orders; -post hypoglycemic event: review insulin regime with MD/NP within 24 hours of event. Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 defined Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in January 2023, diagnoses spinal stenosis of lumbar region, hypertensive urgency, acute kidney failure, weakness, hypoglycemia, major depressive disorder, dementia and diabetes mellitus with ketoacidosis. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 required maximum assistance from staff with transfers and moderate assistance from staff with ambulation. Review of the Facility's Internal Investigation, dated 11/29/23, indicated that at approximately 8:00 A.M. Resident #1 had a low blood glucose level of 39 mg/dl, was confused, unable to answer questions appropriately and was given glucose gel 15 grams. The Investigation indicated that Nurse #1 waited a bit (exact amount of time unknown) for his/her condition to improve, he/she became more alert, was forming words, so she left Resident #1 in bed and checked in on him/her 15 minutes later. The Investigation indicated Resident #1 was improving and was able to answer questions. The Investigation indicated that 20 minutes later, Nurse #1 went to check in on Resident #1 and found him/her on the floor in the bathroom with his/her pants halfway down with urine and feces on the floor. The Investigation indicated Resident #1 was crying and complaining of pain in his/her right hip and leg and Nurse #1 was unable to perform Range of Motion to his/her right leg due to pain. The Investigation indicated that Resident #1 was transferred to the Hospital ED. Review of Resident #1's Physician Order, dated 1/27/23, indicated he/she had a Physician's order for the following: -check blood glucose level before meals and at bedtime, notify MD/NP/PA when blood glucose is less than 70 mg/dl and greater than 350 mg/dl and -the orders included parameters in the event of a low blood sugar, for nursing to administer one from the following for blood glucose less than 51 mg/dl: - 30 gm glucose gel (2 tubes); - 8 ounces of juice or soda; - 1 cup of apple sauce; - 12 saltines; - 2 tablespoons of sugar or jelly. -remain with resident if symptomatic; -repeat above every 15 minutes until two blood glucose levels above 70 mg/dl and asymptomatic. Review of Resident #1's Nurse Progress Note, dated 11/29/23 at 2:41 P.M., (written by Nurse #1), indicated that Resident #1 had a CBG (capillary blood glucose) level of 39 mg/ml this morning, speech unremarkable, confused, unable to answer questions accurately, orange juice was attempted but he/she was unable to sit up properly and swallow thin liquids. The Note indicated that glucose gel 15 gm (gram) was given, waited for his/her status to change and he/she started to form words. However, Resident #1's Physicians orders indicated to administer 30 gm of glucose gel for a CBG less than 51 mg/dl, (not 15 gm, as documented by Nurse #1). The Progress Note further indicated that 15 minutes later, Resident #1 was able to answer questions accurately, form words and 20 minutes later, Resident #1 was found on the floor in his/her bathroom with his/her pants down and urine and feces noted on the floor. The Note indicated that Resident #1 was crying, unable to perform Range of Motion (ROM) to his/her right leg and cried out in pain when he/she tried to move his/her right leg. The Note indicated that Resident #1 was transferred to the Hospital ED. During a telephone interview on 1/04/24 at 12:30 P.M., Nurse #1 said that she obtained Resident #1's CBG between 7:45 A.M. and 7:50 A.M. on 11/29/23 and it was 39 mg/dl. Nurse #1 said she attempted to give Resident #1 orange juice, but he/she was confused, not making any sense, was unable to sit up or swallow and did not eat anything that morning. Nurse #1 said she gave Resident #1 one packet of glucose gel (15 gm) and after a few minutes she checked in on him/her, he/she was still confused and not making any sense. Nurse #1 said that a few minutes later, she checked in on Resident #1 and he/she was able to form words and was more alert. Nurse #1 said around 10:00 A.M., she went to check on Resident #1 again and found him/her on the floor in the bathroom complaining of right leg pain. Nurse #1 said Resident #1 was transferred to the Hospital ED. Nurse #1 said that she did not check Resident #1's Physician orders, but said she should have. Nurse #1 said she was not aware that Resident #1 had specific Physician orders with parameters in the event of a hypoglycemic incident. Nurse #1 said she administered just one packet of glucose gel (for a total of 15 gm, not 30 gm per physician's orders). Nurse #1 said she never rechecked Resident #1's blood sugar after she administered the packet of glucose gel, but said she should have. Nurse #1 said that she did not follow Resident #1's Physician Orders or facility policy for the treatment of Resident #1's hypoglycemia. During an interview on 12/27/23 at 4:10 P.M., Certified Nurse Aide (CNA) #2 said that on 11/29/23 at approximately 8:00 A.M., she went to give Resident #1 his/her breakfast tray and the Nurse told her not to give Resident #1 his/her breakfast tray because his/her blood sugar was low. CNA #2 said that Resident #1 was talking to him/herself, was out of it and was not making any sense. CNA #2 said that she went back in to check on Resident #1 sometime between 8:30 A.M. and 8:45 A.M., and that Resident #1 was still out of it, was not making any sense, and was not him/herself. During an interview on 12/28/23 at 11:05 A.M., Unit Manager #1 said that at approximately 9:15 A.M. on 11/29/23, she went into Resident #1's room to obtain a COVID sample and said Resident #1 was not his/her usual self and his/her behavior was not at his/her baseline. Unit Manager #1 said that Resident #1 required emergent transfer to the Hospital Emergency Department for evaluation that day and when Emergency Medical Services (EMS) arrived (exact time unknown), she heard Nurse #1 tell EMS that Resident #1's blood sugar was low and heard EMS ask Nurse #1 if she rechecked Resident #1's blood sugar and that Nurse #1 had stated no to EMS. Unit Manager #1 said that Nurse #1 did not inform her that Resident #1 had a hypoglycemic episode that morning. Unit Manager #1 said that it was her expectation that nurses notify her of any change in a resident's condition. Review of Resident #1's Hospital Discharge Summary, dated 11/29/23, indicated that Resident #1 presented to the Hospital ED after an episode of hypoglycemia and an unwitnessed fall at the Nursing Home. The Summary indicated that Resident #1 was found to have a blood sugar of 38 mg/dl this morning at the Nursing Home and upon arrival at the ED, Resident #1 was found to be hypoglycemic with a blood sugar of 43 mg/dl. The Summary indicated that Resident #1 was given D 10 bolus (dextrose used to treat severe hypoglycemia) 100 milliliters (ml) intravenously. The Summary indicated that Resident #1's blood sugar was rechecked and was 29 mg/dl and he/she was given D 50 25 ml (used for rebound hypoglycemia) intravenously and D 5 in Ringers lactate solution (crystalloid isotonic intravenous fluid of balanced electrolytes) at 125 ml/hr. intravenously. The Summary indicated that a CT scan of Resident #1's right hip revealed acute right pubic (pelvic) bone fractures and that the fall was probably due to hypoglycemia. During an interview on 12/28/23 at 11:40 A.M., the Director of Nurses (DON) said it was her expectation that nursing stay with Resident #1 until his/her blood sugar levels were 70 mg/dl or above. The DON said it was her expectation that Nurse #1 checked Resident #1's blood sugar level every 15 minutes until they were 70 mg/dl or above. The DON said Nurse #1 did not recheck Resident #1's blood sugar level and did not follow Resident #1's Physician orders or the Facility's Policy related to Hypoglycemic Protocol. On 12/28/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 11/29/23, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment of hypoglycemia and injury as a result of an unwitnessed fall. B) 11/29/23, Nurse #1 was immediately educated by the Director of Nurses (DON) to follow the Facility's hypoglycemia protocol and to ensure re-testing and re-assessment of resident's who are hypoglycemic. C) 12/06/23 and 12/07/23, Nursing Staff were in-serviced on the Facility's Diabetic Management Policy and Hypoglycemia Protocol by the Staff Development Coordinator (SDC) and the Director of Nurses (DON). D) 12/07/23, Nursing Staff were in-serviced on the Facility's Falls Management Policy by the Staff Development Coordinator (SDC). E) 12/13/23 - 12/15/23, A Facility wide audit of all diabetic resident's blood glucose results was completed by the Regional Director of Clinical Services. F) 12/15/23, Unit Manager #1 and Nurse #1 were in-serviced on the proper policy and procedure of their positions and compliance with standards of practice by the SDC. G) DON and Unit Managers will conduct daily audits of all diabetic resident's blood glucose results to ensure the Hypoglycemic Protocol and Diabetic Management Policy were followed. H) Audits will be conducted daily for three weeks, then weekly for three months or until substantial compliance is achieved. I) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. J) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure he/she was free from verbal and mental abuse from a staff member when on 10/28/23, Certified Nurse Aide (CNA) #1 responded to Resident #1's call light and request for assistance with care, and per Resident #1, CNA #1 was rude, angry, abrupt, and intimidated him/her. Resident #1 became distressed, was tearful when recounting the incident with other staff members, and reported that he/she was afraid of CNA #1. Although CNA #2 said she witnessed CNA #1 verbally abuse Resident #1, she also said she did not intervene or attempt to stop the abuse, but instead stood in the doorway and watched to protect the resident. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 10/1722, indicated the following: - Verbal abuse includes, but is not limited to, threats of harm and/or making statements to frighten resident, - Mental abuse includes humiliation, harassment, threats of punishment or deprivation, and - It is the policy of the Facility and the responsibility of all covered individuals to ensure an environment free of abuse, neglect, mistreatments, misappropriation of resident property, and exploitation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 10/31/23, indicated that on 10/31/23 at approximately 3:30 P.M. Resident #1 reported to Social Worker (SW) #1 that on 10/28/23, a CNA #1 yelled at him/her. Review of a Police Report, dated 10/31/23, indicated that Resident #1 said CNA #1 yelled at him/her which frightened him/her enough to report it. The Report indicated that Resident #1 said that he/she had urinated in his/her bed and CNA #1 yelled at him/her saying, get out of bed, you've been here long enough. The Report indicated that Resident #1 said he/she frantically tried to get out of bed and slipped. The Report indicated that Resident #1 said CNA #1 had not physically abused him/her, but had been verbally abusive to him/her. Resident #1 was admitted to the Facility in August 2023, diagnoses included lumbar radiculopathy (pinched nerve), anxiety, urinary tract infection, post laminectomy (surgery to remove part of a vertebrae or vertebra in order relieve pressure on nerves) syndrome, and post traumatic stress disorder. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/16/23, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), and required supervision to minimal assistance from staff to meet his/her care needs. During a telephone interview on 11/29/23 at 11:40 A.M., Resident #1 said that on 10/28/23 he/she asked CNA #1 to change him/her before he/she stood up from the bed because he/she had already urinated in his/her brief. Resident #1 said he/she had a urinary tract infection at the time (back in October 2023), which caused him/her to urinate frequently. Resident #1 said CNA #1 responded back to him/her in a demanding tone of voice and said get into the wheelchair now! Resident #1 said CNA #1 was angry and yelled at him/her. Resident #1 said CNA #1 made him/her very nervous, so he/she just did whatever CNA #1 told him/her to do. Resident #1 said that when he/she attempted to stand up to get into the wheelchair, he/she slid to the floor onto his/her hands and knees because the floor was wet with urine. Resident #1 said he/she may need rehabilitation again in the future, but was afraid to return to the Facility if CNA #1 was still employed there. Review of the Facility's Investigation Summary Report, dated 10/31/23, indicated that SW #1 received a message that Resident #1 wanted to speak with her, and that SW #1 met with him/her. The Report indicated that Resident #1 was very upset about an incident that occurred on 10/28/23. The Report indicated that Resident #1 used his/her call light because he/she was incontinent, and CNA #1 responded and entered his/her room. The Report indicated Resident #1 that told SW #1 that CNA #1 told him/her that he/she needed to use the bathroom and that was why he/she (Resident #1) was still at the Facility. The Report indicated that Resident #1 said CNA #1 was very rude and almost yelling at him/her and insisted he/she get into the wheelchair to use the bathroom. The Report indicated that Resident #1 said he/she went to put his/her feet on the floor and fell forward onto his/her hands and knees because the floor was wet from him/her being incontinent. The Report indicated that Resident #1 was crying and very upset, and said he/she was fearful of CNA #1 and that he/she did not deserve that type of treatment. The Report indicated that Resident #1 was very tearful when he/she discussed the alleged incident with SW #1. During an in-person interview on 11/29/23 at 10:40 A.M., a telephone interview on 12/06/23 at 10:33 A.M., and review of CNA #2's Written Witness Statement, dated 11/01/23, CNA #2 said on 10/28/23, she told CNA #1 that Resident #1 needed help washing and changing, and that CNA #1 responded back to her and said Resident #1 could do it him/herself. CNA #2 said she followed CNA #1 to Resident #1's room and then stayed close by (stood in the doorway to Resident #1's room) to watch because she knew CNA #1 was frustrated and she (CNA #2) wanted to be there for Resident #1. CNA #2 said that CNA #1 walked into Resident #1's room and told Resident #1 that he/she could do it him/herself. CNA #2 said she heard Resident #1 say he/she wanted to stay in bed to get washed and changed, but CNA #1 insisted Resident #1 get up out of bed and to go into the bathroom. CNA #2 said she watched as Resident #1 tried to stand up but he/she ended up going down and both knees hit the floor, but was able to get up by him/herself. CNA #2 said CNA #1 did not seem concerned that Resident #1 had fallen, and said CNA #1 did not say anything to Resident #1 when he/she fell . CNA #2 said after Resident #1 fell to the floor, he/she got up and CNA #1 walked with him/her to the bathroom. CNA #2 said that CNA #1 was very rude to Resident #1 and had rushed him/her to get to the bathroom. CNA #2 said she stayed in the doorway to Resident #1's room and had not intervened to protect Resident #1. CNA #2 said that later in the day Resident #1 was in the bathroom crying and needed to be consoled because of how he/she had been treated by CNA #1. Although CNA #2 said she felt that CNA #1 was frustrated that day, and took it upon herself to go and stand in Resident #1's doorway to support him/her while CNA #1 provided care, despite witnessing what she (CNA #2) believed was rude, angry, and intimidating treatment of Resident #1, and witnessing CNA #1 stand back and offer no assistance to Resident #1 after he/she fell , CNA #1 did not intervene, did not go get help from nursing, and did not report the incident as required, all of which placed Resident #1 at potential risk for continued abuse. During a telephone interview on 11/29/23 at 11:37 A.M., Non-sampled Resident A (Resident #1's roommate at the time the allegation was made), said on 10/28/23 he/she did not hear any yelling or the conversation between CNA #1 and Resident #1 because he/she was watching a movie and had his/her ear buds in, which blocked out external sound. NS Resident A said he/she did, however, see CNA #1 in their room and saw Resident #1 on the floor crying. NS Resident A said that after CNA #1 left their room, Resident #1 was still crying and said that he/she was so scared because he/she had never been spoken to like that before. During telephone interviews on 11/29/23 at 2:28 P.M., and 12/06/23 at 1:29 P.M., Social Worker #1 (SW) said she received a general voicemail on 10/30/23 from Unit Secretary #1 that Resident #1 wanted to speak with her. SW #1 said she spoke with Resident #1 on 10/31/23 and he/she told her that CNA #1 yelled at him/her about going to the bathroom. SW #1 said Resident #1 told her that he/she fell because there was urine on the floor. SW #1 said Resident #1 was tearful when he/she talked to her. SW #1 said Resident #1 said he/she was concerned that CNA #1 would return. SW #1 said she reported the allegation to the Director of Nurses (DON) immediately. SW #1 said that once she told Resident #1 that the Police had been called, that the allegation would be investigated by the Facility, and that CNA #1 had been removed from the Facility, Resident #1 said he/she felt safe. During an interview on 11/29/23 at 1:17 P.M., the Director of Nurses (DON) said Social Worker (SW) #1 notified her on 10/31/23 in the afternoon that Resident #1 alleged that on 10/28/23, CNA #1 was rude and almost yelling at him/her about using the bathroom, and that she immediately began an investigation in to the allegation. The DON said both CNA #1 and CNA #2 were facility employees and had received abuse training. The DON said the Facility did not substantiate the allegation of abuse but did terminate CNA #1's employment.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and required supervision to minimal assistance to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 10/28/23, after an alleged incident of verbal abuse and mental abuse of Resident #1 by Certified Nurse Aide (CNA ) #1 that occurred during the provision of care, was witnessed by one staff member (CNA #2), and Resident #1 who was emotionally distressed by how he/she had been treated by CNA #1 also reported the incident of alleged abuse to three other staff members (CNA #3, CNA #4 and Unit Secretary #1), however none of them immediately reported the abuse to their supervisor as required, and as a result CNA #1 continued to work in the Facility for several days placing Resident #1 and other residents at risk for abuse. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 10/1722, indicated the following: - When a covered individual believes that he or she has reasonable cause to believe that a resident has been abused, neglected, mistreated, exploited, or has had property misappropriated, the covered individual has the responsibility to report to his/her supervisor, and - The preliminary investigator shall promptly remove the accused in order to prevent further potential harm to the resident. Review of the Facility's Investigation Summary Report, dated 10/31/23, indicated that Social Worker #1 received a message that Resident #1 wanted to speak with her, and that SW #1 met with him/her on 10/31/23. The Report indicated that Resident #1 was very upset about an incident that occurred on 10/28/23. The Report indicated that Resident #1 used his/her call light because he/she was incontinent, and CNA #1 responded and entered his/her room. The Report indicated that Resident #1 said CNA #1 told him/her that he/she needed to use the bathroom and that was why he/she (Resident #1) was still at the Facility. The Report indicated that Resident #1 said CNA #1 was very rude and almost yelling at him/her and insisted he/she get into the wheelchair to use the bathroom. The Report indicated that Resident #1 said he/she went to put his/her feet on the floor and fell forward onto his/her hands and knees, because the floor was wet from him/her being incontinent. The Report indicated that Resident #1 was crying and very upset and said he/she was fearful of CNA #1 and that he/she did not deserve that type of treatment. The Report indicated that Resident #1 was very tearful when he/she discussed this with SW #1. Resident #1 was admitted to the Facility in August 2023, diagnoses included lumbar radiculopathy (pinched nerve), anxiety, urinary tract infection, post laminectomy (surgery to remove part of a vertebrae or vertebra in order relieve pressure on nerves) syndrome, and post-traumatic stress disorder. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/16/23, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), and required supervision to minimal assistance from staff to meet his/her care needs. During a telephone interview on 11/29/23 at 11:40 A.M., Resident #1 said in October 2023, he/she had a urinary tract infection which caused him/her to urinate frequently. Resident #1 said he/she asked CNA #1 to change him/her before he/she stood up from the bed because he/she had already urinated in his/her brief. Resident #1 said CNA #1 responded to him/her in a demanding voice and said, get into the wheelchair now! Resident #1 said CNA #1 was angry at him/her and yelled at him/her. Resident #1 said CNA #1 made him/her very nervous, so he/she did whatever CNA #1 told him/her to do. Resident #1 said that when he/she attempted to stand to get into the wheelchair, he/she slid to the floor onto his/her hands and knees because the floor was wet with urine. Resident #1 said Nurse #1 and CNA # #3 came into his/her room right after it happened to console him/her because he/she was so afraid. Resident #1 said he/she may need rehabilitation again in the future but said he/she was afraid to return to the Facility if CNA #1 was still employed there. During an in-person interview on 11/29/23 at 10:40 A.M., a telephone interview on 12/06/23 at 10:33 A.M., and review of CNA #2's Written Witness Statement, dated 11/01/23, CNA #2 said on 10/28/23 at approximately 2:00 P.M., she told CNA #1 that Resident #1 needed help washing and changing, and said CNA #1's response to her was that Resident #1 could do it him/herself. CNA #2 said she followed CNA #1 to Resident #1's room and then stayed close (stood on the doorway to Resident #1's room) to watch because she knew CNA #1 was frustrated and she wanted to be there for Resident #1. CNA #2 said that CNA #1 walked into Resident #1's room and she heard CNA #1 tell Resident #1 that he/she could do it him/herself. CNA #2 said she heard Resident #1 say he/she wanted to stay in bed to get washed and changed, but that CNA #1 insisted Resident #1 to go into the bathroom. CNA #2 said Resident #1 tried to stand and he/she ended up going down and both knees hit the floor, but he/she was able to get up by him/herself. CNA #2 said CNA #1 did not seem concerned that Resident #1 had fallen and said CNA #1 did not say anything to Resident #1 when he/she fell . CNA #2 said after Resident #1 fell to the floor, he/she got up by him/herself and CNA #1 walked with him/her to the bathroom. CNA #2 said that CNA #1 was very rude to Resident #1 and had rushed him/her. CNA #2 said she stayed in the doorway to Resident #1's room but had not intervened verbally or physically to protect Resident #1. CNA #2 said that at approximately 2:50 P.M., Resident #1 was in the bathroom crying and needed to be consoled because of how he/she had been treated by CNA #1. CNA #2 said she did not report this, but that she just tried to console Resident #1. Although CNA #2 said she felt that CNA #1 was frustrated that day, and took it upon herself to go and stand in Resident #1's doorway to support him/her while CNA #1 provided care, despite witnessing what she (CNA #2) believed was rude, angry, and intimidating treatment of Resident #1, and witnessing CNA #1 stand back and offer no assistance to Resident #1 after he/she fell , CNA #1 did not intervene, did not go get help from nursing, and did not report the incident as required, all of which placed Resident #1 at risk for continued abuse. Review of CNA #3's Written Witness Statement, dated 11/01/23, indicated that on 10/28/23 sometime in the afternoon, he had been checking on residents when he noticed Resident #1 was upset. The Statement indicated that he asked Resident #1 if he/she was okay, and Resident #1 told him that CNA #1 is rude, rushes him/her, and has an attitude toward him/her. The Statement indicated that Resident #1 told him (CNA #3) that CNA #1 has it out for him/her. The Statement indicated that CNA #3 tried to comfort Resident #1, but he/she continued to cry because of how he/she was treated by CNA #1. The Statement indicated that Resident #1 told him (CNA #3) that he/she did not want CNA #1 to be his/her aide or to assist him/her in anything. The Statement indicated that CNA #3 told Resident #1 not to worry and that it would not happen again. The Statement indicated that CNA #3 had not reported the allegation as required, because he had to leave the Facility emergently that day and did not have time. The Surveyor was unable to interview CNA #3 as he did not respond to the Department of Public Health's telephone call or letter request for an interview. During an interview on 12/15/23 at 12:00 P.M., and review of CNA #4's Written Witness Statement, undated, CNA #4 said that Resident #1 told her that on 10/28/23, that CNA #1 yelled at him/her for being wet and that he/she should go into the bathroom. CNA #4 said that Resident #1 told her that when he/she stood up, he/she slipped and fell because the floor was wet. CNA #4 said she was not entirely sure, but said she thought she notified the evening nursing supervisor (later identified as Nursing Supervisor #1) about what Resident #1 had told her, CNA #4 and said the nursing supervisor told her that she already knew about an incident involving Resident #1 and CNA #1 that had happened on the weekend. During an interview on 12/15/23 at 1:09 P.M., Nursing Supervisor #1 said she works 12:00 P.M. to 4:00 P.M. on weekdays. Nursing Supervisor #1 said CNA #4 had reported to her on 10/30/23, sometime in the evening, that Resident #1 wanted to speak with her, so she went into Resident #1's room and he/she talked about how he/she was going to stay at the Facility longer because he/she needed more Physical Therapy. Nursing Supervisor #1 said Resident #1 never mentioned anything about a CNA yelling at him/her. Nursing Supervisor #1 said CNA #4 had not reported to her any allegations of abuse involving Resident #1. Nursing Supervisor #1 said she first heard of Resident #1's allegation of abuse on 10/31/23 after facility administration had already been made aware. During an interview on 11/29/23 at 11:06 A.M., and review of Unit Secretary #1's Written Witness Statement, dated 10/31/23, Unit Secretary #1 said she is also a CNA and had worked as a CNA on 10/29/23 during the 3:00 P.M. to 11:00 P.M. shift. Unit Secretary #1 said she answered Resident #1's call light at approximately 9:30 P.M., and said Resident #1 asked her if she heard about what had happened to him/her the day before. Unit Secretary #1 said Resident #1 told her that CNA #1 had yelled at him/her and scared her. Unit Secretary #1 said Resident #1 told her that he/she fell to his/her knees because the floor was wet. Unit Secretary #1 said Resident #1 was crying when he/she told her about the alleged incident and kept saying how scared he/she was. Unit Secretary said she left a voice message for Social Worker #1 that indicated Resident #1 wanted to speak with her. During telephone interviews on 11/29/23 at 2:28 P.M., and 12/06/23 at 1:29 P.M., Social Worker #1 (SW) said she received a general voice message on 10/30/23 from Unit Secretary #1 that Resident #1 wanted to speak with her. Social Worker (SW) #1 said Resident #1 told her that on 10/28/23 CNA #1 yelled at him/her about going to the bathroom. SW #1 said Resident #1 told her that he/she fell because there was urine on the floor. SW #1 said Resident #1 was tearful when he/she talked to her. SW #1 said Resident #1 said he/she was concerned that CNA #1 would return. Review of CNA #1's time card indicated, that after the alleged incident of verbal abuse involving Resident #1, she worked at the facility on the following shifts: -10/29/23 6:37 A.M. to 3:13 P.M. -10/31/23 6:40 A.M. to 3:09 P.M. During an interview on 12/15/23 at 12:55 P.M. the Staff Development Coordinator (SDC) said if a CNA is notified of an allegation of abuse or suspects abuse, they are required to report it their direct supervisor, and that for CNA's, that would be he nurse on the unit. The SDC said if the nurse is not on the unit for any reason, then the CNA should report the abuse to the supervisor if there is one on duty or to the Director of Nurses (DON). The SDC said CNA #1, CNA #2, CNA #3, CNA #4 and the Unit Secretary were all employees of the facility, and had received training on the facility abuse policy. During an interview on 11/29/23 at 1:17 P.M., the Director of Nurses (DON) said Social Worker #1 notified her on 10/31/23 in the afternoon that Resident #1 alleged that on 10/28/23, CNA #1 was rude and almost yelling at him/her about using the bathroom. The DON said several staff members had been made aware of the allegation on 10/28/23 involving CNA #1, but had not reported it to her or the Administrator. The DON said Nurse #1 told her during the investigation that Resident #1 felt uncomfortable with CNA #1 on 10/28/23 to the point where Nurse #1 took over his/her care. The DON said staff are required to report to any allegation of abuse to administration immediately, but had not, and therefore CNA #1 was not suspended until after she was made aware of the allegation on 10/31/23. The DON said CNA #1 worked two shifts after staff were aware of the allegation of verbal abuse and had not reported it.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose elected code status and had a Physician's Order for a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation if a patients breathing stops or if patients heart stops beating) the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. On [DATE], at approximately 4:40 A.M., Resident #1, who was seated in his/her wheelchair near the nursing station, slumped over, he/she was assessed by nursing as being unresponsive to verbal and tactile stimuli, was noted to be without a pulse, respirations or a blood pressure, nursing staff immediately intervened and initiated life saving measures in an attempt to resuscitate him/her, including administering Cardiopulmonary Resuscitation (CPR), utilizing the Automated External Defibrillator (AED), and activating the 911 Emergency Medical Services (EMS), without checking his/her code status. After Resident #1 was resuscitated by the nurses, they (nursing staff) then determined he/she was a DNR. Resident #1 complained of pain and was transferred to the Hospital Emergency Department by EMS for evaluation, and was diagnosed with multiple rib fractures, left anterior chest wall hematoma, and a [CONDITION(S)]. Resident #1 was admitted to the Hospital, placed on Comfort Care measures, and died in the Hospital three days later. Findings include: Review of the Facility Policy titled Advance Directives/Do Not Resuscitate Orders, dated as last revised [DATE], indicated the Facility is to respect each resident's right to participate in and/or make his/her treatment decisions. Review of the Facility Policy titled Residents' Rights, dated as last revised [DATE], indicated a resident has the right to and the Facility must promote and facilitate resident self-determination through the support of the resident's choices. Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Activation of Health Care Proxy (HCP) Determination Form, dated [DATE], indicated his/her HCP was activated. Review of Resident #1's Medical Order for Life-Sustaining Treatment (MOLST) Form, dated [DATE], and signed by his/her Health Care Proxy, indicated Resident #1 was a DNR, Do Not Intubate (DNI), and Do Not Ventilate (DNV). Review of Resident #1's Care Plan titled, Advanced Directives, dated [DATE], indicated he/she had chosen to be a DNR. The Care Plan also indicated his/her decisions regarding Advanced Directives will be respected. Review of Resident #1's Physician Orders, dated [DATE], indicated he/she was a DNR. During an interview on [DATE] at 2:29 P.M., Family Member #1 said Resident #1 was a DNR and said she does not know why the nurse started CPR without checking his/her chart first to determine his/her code status. Family Member #1 said it was heart wrenching to see Resident #1 suffer the next few days on Comfort Care before he/she did finally died . Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that on [DATE] at approximately 4:40 A.M., Resident #1 was noted to be unresponsive in his/her wheelchair, without pulse or respirations, nursing was unable to obtain a blood pressure. A Code Blue was called, CPR was initiated, and almost simultaneously, Resident #1 had a pulse. The Report indicated it was only at that time (after he/she was resuscitated) that was it determined by nursing that Resident #1 was a DNR. Review of Resident #1's Nursing Progress Note (written by Nurse #1), dated [DATE], indicated that at 4:40 A.M., Resident #1 was noted to be unresponsive. After completing an initial assessment, CPR was initiated, AED pads were applied, ambu bag (used to provide ventilation) was in place with 15 liters of oxygen, no shock was advised according to AED, CPR was continued, and at 4:43 A.M. code status was received, (Nurse #1 was informed that resident was a DNR) and CPR was terminated. At 4:48 A.M. EMS arrived on scene, Resident #1 was noted with pulse present and able to identify pain. During an interview on [DATE] at 8:07 A.M., Nurse #1 said, on [DATE], at approximately 4:40 A.M., Resident #1 was noted to be slumped over in his/her wheelchair in front of the nurses station. Nurse #1 said he/she was unresponsive to both verbal and tactile stimuli. Nurse #1 said, with the help from Certified Nurse Aide (CNA) #1, they got Resident #1 to the floor and assessed him/her to be without a pulse, without respirations, and she was unable to obtain a blood pressure. Nurse #1 said at that point she knew the situation was the real thing and that Resident #1 was coding. Nurse #1 said she yelled to CNA #1 to retrieve the code cart and AED. Nurse #1 said she then began to administer chest compressions. Nurse #1 said she instructed Nurse #2 to call 911 and CNA #2 to call a Code Blue over the intercom system. Nurse #1 said once the AED pads were placed on Resident #1, no shocked was advised, so she continued administering CPR. Nurse #1 said Nurse #3 arrived from another unit and assisted by providing rescue breaths via an ambu bag and supplemental oxygen. Nurse #1 said shortly after a few rescue breaths were given, Resident #1 had a pulse and became responsive. Nurse #1 said that is when Nurse #2 announced that Resident #1 was a DNR. During an interview on [DATE] at 8:51 A.M., Nurse #2 said she was sitting behind the nurses station at the computer when she heard Nurse #1 yell to her to call 911. Nurse #2 said she called 911 and then she retrieved Resident #1's chart to determine his/her code status. Nurse #2 said she noted that Resident #1 was a DNR and yelled to Nurse #1 and Nurse #3 to stop CPR. Nurse #2 said Resident #1 was responsive before she informed Nurse #1 and Nurse #3 that he/she was a DNR. During an interview on [DATE] at 9:22 A.M., Certified Nurse Aide (CNA) #1 said she noticed that Resident #1 (who was seated in his/her wheelchair in front of the nurses station) had become quiet, so she tried to get his/her attention but he/she did not respond, so she told Nurse #1. CNA #1 said Nurse #1 performed a sternal rub on Resident #1 with no response. CNA #1 said Nurse #1 announced Resident #1 was a full code, and Nurse #2 called 911 and CNA #2 called Code Blue over the intercom. CNA #1 said Resident #1 was already breathing on his/her own, when she heard Nurse #2 announce that Resident #1 was a DNR. During an interview on [DATE] at 4:17 P.M., the Staff Development Coordinator (SDC) said, it is the Facility's Policy that the first nurse that identifies an unresponsive resident is to initiate CPR and the second responding nurse is to act as the code leader and the first thing would be to check the residents MOLST form for his/her code status. During an interview on [DATE] at 4:27 P.M., the Director of Nurses (DON) said, the first nurse to find a resident down without a pulse or respirations would assess and call a code blue if needed. The DON said the second nurse on the scene would act as the code leader and give team direction. The DON said the second nurse would check the resident's chart for the MOLST form, and would then direct the first nurse to continue CPR or stop CPR. However, statements made by the Director of Nursing and the SDC regarding nursing to start CPR and then once code status is determined, nursing would either continue with CPR or stop CPR, was inconsistent with Resident #1's right to self determination and his/her choice to be a DNR, and therefore he/she should not have be administered CPR. Review of Resident #1's Hospital Discharge Summary, dated [DATE], indicated he/she sustained multiple bilateral rib fractures, left anterior chest wall hematoma, acute hypoxic respiratory failure, and a right hip fracture. The Summary indicated Resident #1 was placed on Comfort Care measures and died three days later.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Orders indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation if a patients breathing stops or if patients heart stops beating), the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when nursing initiated life saving measure before determining the residents code status. On [DATE], at approximately 4:40 A.M., Resident #1, who was seated in a wheelchair near the nursing station, slumped over, was noted to be unresponsive to verbal and tactile stimuli, and upon assessment by nursing was found to be without a pulse, respirations, and a blood pressure. However, despite Resident's Physicians Orders and written Advanced Directives that clearly indicated his/her code status was a DNR, nursing immediately started cardiopulmonary resuscitation (CPR), called a Code Blue, applied and use the Automated External Defibrillator (AED) and call 911. Resident #1 was resuscitated by nursing staff, who then determined he/she was a DNR. Resident #1 complained of pain, was transferred the Hospital Emergency Department, where it was determined he/she had multiple rib fractures, left anterior chest wall hematoma, and a [CONDITION(S)]. Resident #1 was admitted , placed on Comfort Care measures, and died in the Hospital three days later. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Titled Nursing Practice and Cardiopulmonary Resuscitation, dated as revised ,d+[DATE], indicated that as a Standard of Nursing Practice, the nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's position that these standards, in the context of practice in all settings where health care is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L. c. 46, S 9, except when the patient has a current, valid Do Not Resuscitate order/status. It further indicated, that for the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences, the nurses role in obtaining accurate information about the DNR status of all assigned patients. Review of the Facility Policy titled Emergency/Code Blue Response, dated as last revised [DATE], indicated when a staff member observes an individual experiencing a medical emergency, the following response will be activated: -The staff member that finds the victim in distress will call loudly Code Blue to signal for help -Activate the call bell system if the system can be reached -Do Not Leave the victim unless there is no alternative -The staff member who responds to the call for help will be responsible for overhead paging of Code Blue with location of emergency three times The First Nurse responding to the emergency will: -Assess the resident -Begin treatment appropriate to the medical emergency, including whether to start Cardiopulmonary Resuscitation (CPR) The Second Nurse responding to the emergency will: -Coordinate the care for the victim and act as the Code Leader -He/she will immediately determine the pre-existing resuscitation wishes of the victim by reviewing the signed Medical Orders for Life-Sustaining Treatment (MOLST) and Physician's order for resuscitation status -Direct to continue or stop CPR based on the Physician's order -Activate the Automatic External Defibrillator (AED) protocols for [CONDITION(S)] -Assess whether to contact community Emergency Medical Services (EMS/911) Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Health Care Proxy (HCP) Determination Form, dated [DATE], indicated his/her HCP was activated. Review of Resident #1's MOLST Form, dated [DATE], indicated Resident #1 was a DNR, Do Not Intubate (DNI), and Do Not Ventilate (DNV). Review of Resident #1's Care Plan titled, Advanced Directives, dated [DATE], indicated he/she had chosen to be a DNR. The Care Plan also indicated his/her decisions regarding Advanced Directives will be respected. Review of Resident #1's Physician Orders, dated [DATE], indicated he/she was a DNR. During an interview on [DATE] at 2:29 P.M., Family Member #1 said Resident #1 was a DNR and said she does not know why the nurses would start CPR without checking his/her chart first to determine his/her code status. Family Member #1 said even though Resident #1 was put on Comfort Care measures in the Hospital, said it was heart wrenching to watch Resident #1 suffer until he/she finally died . Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that on [DATE] at approximately 4:40 A.M., Resident #1 was noted to be unresponsive in his/her wheelchair, without pulse or respirations, nursing was unable to obtain a blood pressure. A Code Blue was called, CPR was initiated, and almost simultaneously, Resident #1 had a pulse. The Report indicated it was only at that time (after he/she was resuscitated) that was it determined by nursing that Resident #1 was a DNR. Review of Resident #1's Nursing Progress Note (written by Nurse #1), dated [DATE], indicated that at 4:40 A.M., Resident #1 was noted to be unresponsive. After completing an initial assessment, CPR was initiated, AED pads were applied, ambu bag (used to provide ventilation) was in place with 15 liters of oxygen, no shock was advised according to AED, CPR was continued, and at 4:43 A.M. code status was received, (Nurse #1 was informed that resident was a DNR) and CPR was terminated. At 4:48 A.M. EMS arrived on scene, Resident #1 was noted with pulse present and able to identify pain. During an interview on [DATE] at 8:07 A.M., Nurse #1 said, on [DATE], at approximately 4:40 A.M., Resident #1 was noted to be slumped over in his/her wheelchair in front of the nurses station. Nurse #1 said Resident #1 was unresponsive to both verbal and tactile stimuli. Nurse #1 said with help from CNA #1, they got Resident #1 to the floor and she assessed him/her to be without a pulse, without respirations, and she was unable to obtain a blood pressure. Nurse #1 said at that point she knew the situation was the real thing and that Resident #1 was coding. Nurse #1 said she yelled to CNA #1 to retrieve the code cart and AED, she instructed Nurse #2 to call 911, and told CNA #2 to call Code Blue over the intercom system. Nurse #1 and said she began to administer chest compressions to Resident #1. Nurse #1 said CNA #1 returned with the Code Cart and the AED, the AED pads were placed on Resident #1, but no shocked was advised, so she continued to administer CPR. Nurse #1 said Nurse #3 arrived from another unit and assisted by providing rescue breaths via an ambu bag and supplemental oxygen. Nurse #1 said shortly after a few rescue breaths were given, Resident #1 had a pulse and became responsive. Nurse #1 said after Resident #1 became responsive, that was when Nurse #2 announced that Resident #1 was a DNR. During an interview on [DATE] at 8:51 A.M., Nurse #2 said she was sitting behind the Nurses Station when she heard Nurse #1 yell to her to call 911. Nurse #2 said she called 911 and then she grabbed Resident #1's chart to check his/her code status. Nurse #2 said she noticed Resident #1 was a DNR and yelled to Nurse #1 and Nurse #3 to stop CPR. Nurse #2 said Resident #1 was responsive before she announced he/she was a DNR. During an interview on [DATE] at 9:22 A.M., Certified Nurse Aide (CNA) #1 said when Nurse #1 announced Resident #1 was a Full Code, she went and retrieved the code cart and AED as instructed. CNA #1 said when she placed the AED pads onto Resident #1's chest, Nurse #1 had already started administering CPR. CNA #1 said by the time Resident #1 was breathing on his/her own, Nurse #2 then announced Resident #1 was a DNR. During an interview on [DATE] at 4:17 P.M., the Staff Development Coordinator (SDC) said, it is the Facility's Policy for the first nurse to identify an unresponsive resident, is to initiate CPR. The SDC said the second nurse responding is to act as the code leader and the first thing the second nurse needed to do would be to check the residents MOLST form for his/her code status. During an interview on [DATE] at 4:27 P.M., the Director of Nurses said, the first nurse to find a resident down would assess the resident and call a code blue if needed. The DON said the second nurse on the scene would act as the code leader, give team direction, and the second nurse would check the resident's chart for the MOLST form. However, statements made by the Director of Nursing and the SDC regarding nursing to start CPR and then once code status is determined nursing would either continue with CPR or stop CPR, was inconsistent with professional standards of practice, that for a resident who has a medical order written by a physician for a DNR, it instructs health care providers not to do CPR if they stop breathing or if their heart stops beating. Review of Resident #1's Hospital Discharge Summary, dated [DATE], indicated he/she sustained multiple bilateral rib fractures, left anterior chest wall hematoma, acute hypoxic respiratory failure, and a right [CONDITION(S)]. The Summary indicated Resident #1 was placed on Comfort Care measures and died three days later.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Comprehensive Person Centered Plan of Care indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation if a patients breathing stops or if the patients heart stops beating), the Facility failed to ensure the staff implemented and followed interventions identified in his/her plan of care related to his/her Advanced Directives. On [DATE] at approximately 4:40 A.M., Resident #1, who was seated in his/her wheelchair near the nursing station, slumped over, became unresponsive, was assessed by nursing to be without a pulse, respirations, and a blood pressure, however despite Resident #1's plan of care related to Advanced Directives that indicated he/she was a DNR, nursing staff immediately initiated life saving measures including administering cardiopulmonary resuscitation (CPR) and Resident #1 was resuscitated. Resident #1 was subsequently transferred to the Hospital Emergency Department, where he/she was diagnosed with multiple rib fractures, left anterior chest wall hematoma, a [CONDITION(S)], and was admitted . Resident #1 was placed on Comfort Care measures and died in the Hospital three days later. Findings include: Review of the Facility Policy titled Care Planning, dated as revised [DATE], indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframe's to meet a resident medical, nursing, mental, and psychosocial needs and to provide effective and person-centered care to each resident. Review of the Facility Policy titled Advance Directives/Do Not Resuscitate Orders, dated as last revised [DATE], indicated the Facility is to respect each resident's right to participate in and/or make his/her treatment decisions. Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Health Care Proxy (HCP) Determination Form, dated [DATE], indicated his/her HCP was activated. Review of Resident #1's Medical Orders for Life-Sustaining Treatment (MOLST) Form, dated [DATE], indicated Resident #1 was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Ventilate (DNV). Review of Resident #1's Care Plan titled, Advanced Directives, dated [DATE], indicated he/she had chosen to be a DNR. The Care Plan also indicated his/her decisions regarding Advanced Directives will be respected. During an interview on [DATE] at 11:32 A.M., the Director of Social Services said the last Care Plan meeting for Resident #1 was held on [DATE] with Resident #1's Family Member. The Director said care plans were reviewed at that time with Resident #1's Family Member and his/her care plan remained accurate and current. Review of Resident #1's Physician Orders, dated [DATE], indicated he/she was a DNR. Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated [DATE], indicated that on [DATE] at approximately 4:40 A.M., Resident #1 was noted to be unresponsive in his/her wheelchair, without pulse or respirations, nursing was unable to obtain a blood pressure. A Code Blue was called, CPR was initiated, and almost simultaneously, Resident #1 had a pulse. The Report indicated it was only at that time (after he/she was resuscitated) that was it determined by nursing that Resident #1 was a DNR. Review of Resident #1's Nursing Progress Note (written by Nurse #1), dated [DATE], indicated that at 4:40 A.M., Resident #1 was noted to be unresponsive. After completing an initial assessment, CPR was initiated, Automated External Defibrillator (AED) pads were applied, ambu bag (used to provide ventilation) was in place with 15 liters of oxygen, no shock was advised according to AED, CPR was continued, and at 4:43 A.M. code status was received, (Nurse #1 was informed that resident was a DNR) and CPR was terminated. At 4:48 A.M. EMS arrived on scene, Resident #1 was noted with pulse present and able to identify pain. During an interview on [DATE] at 8:07 A.M., Nurse #1 said, on [DATE], at approximately 4:40 A.M., Resident #1 was found slumped over in his/her wheelchair in front of the nurses station. Nurse #1 said Resident #1 was unresponsive to both verbal and tactile stimuli. Nurse #1 said, with help from CNA #1, they got Resident #1 to the floor and she assessed him/her to be without a pulse, without respirations, and she was unable to obtain a blood pressure. Nurse #1 said at that point she knew the situation was the real thing and that Resident #1 was coding. Nurse #1 said she yelled to CNA #1 to retrieve the code cart and AED, and she then began to administer chest compressions. Nurse #1 said she instructed Nurse #2 to call 911 and CNA #2 to call a Code Blue over the intercom system. Nurse #1 said once the AED pads were placed on Resident #1, no shocked was advised, so she continued to administer CPR. Nurse #1 said Nurse #3 arrived from another unit and assisted by providing rescue breaths via the ambu bag and supplemental oxygen. Nurse #1 said shortly after a few rescue breaths were given, Resident #1 had a pulse and became responsive. Nurse #1 said that was when Nurse #2 announced that Resident #1 was a DNR. During an interview on [DATE] at 8:51 A.M., Nurse #2 said she was sitting behind the Nurses Station at the computer when she heard Nurse #1 yell to her to call 911, which she did, and then she retrieved Resident #1's chart to determine his/her code status. Nurse #2 said she saw that Resident #1 was a DNR and yelled to Nurse #1 and Nurse #3 to stop CPR, however Resident #1 was already noted to be responsive. During an interview on [DATE] at 9:22 A.M., Certified Nurse Aide (CNA) #1 said she noticed that Resident #1, who was seated in his/her wheelchair in front of the nurses station, had become quiet, said she tried to get his/her attention but he/she did not respond, so she notified Nurse #1. CNA #1 said Nurse #1 performed a sternal rub on Resident #1, but he/she did not respond. CNA #1 said Nurse #1 announced that Resident #1 was a Full Code, then Nurse #1 started CPR, Nurse #2 called 911, CNA #2 called Code Blue over the intercom, and she retrieved the code cart and the AED. CNA #1 said during the second round of CPR, Resident #1 became responsive and had a pulse. CNA #1 said by the time Nurse #2 announced that Resident #1 was a DNR, Resident #1 was breathing on his/her own. During an interview on [DATE] at 4:17 P.M., the Staff Development Coordinator (SDC) said, it is the Facility's Policy that the first nurse that identifies an unresponsive resident is to initiate CPR and the second responding nurse is to act as the code leader and the first thing the second nurse was supposed to do was to check the residents MOLST form for his/her code status. During an interview on [DATE] at 4:27 P.M., the Director of Nurses (DON) said, the first nurse to find a resident down without a pulse or respirations would assess and call a code blue if needed. The DON said the second nurse on the scene would act as the code leader and give team direction. The DON said the second nurse would check the resident's chart for the MOLST form, and would then direct the first nurse to continue CPR or stop CPR. However, statements made by the Director of Nursing and the SDC regarding nursing to start CPR and then once code status is determined, nursing would either continue with CPR or stop CPR, was inconsistent with Resident #1's plan of care which indicated should he/she experience cardiac or respiratory arrest, he/she did not want to be resuscitated, as his/her code status was a DNR and therefore should not have been administered CPR. Review of Resident #1's Hospital Discharge Summary, dated [DATE], indicated he/she sustained multiple bilateral rib fractures, left anterior chest wall hematoma, acute hypoxic respiratory failure, and a right hip fracture. The Summary indicated Resident #1 was placed on Comfort Care measures and died three days later.

Based on record review, observation, policy review and interview, the facility failed to ensure that for two Residents (#212 and #97), out of a total sample of 26 residents, accidents were minimized, interventions were implemented to prevent falls/injury, and supervision was provided to prevent accident and injury to the residents. Findings include: 1. For Resident #212, the staff failed to implement interventions to prevent falls/ injury to the Resident. Resident #212 was admitted to the facility in February 2021 after being hospitalized following a fall at home, secondary to the progression of his/her [CONDITION(S)] (disease that affects the central nervous system) as well as a urinary tract infection. Review of Resident #212's Plan of Care for falls, dated 8/8/20 (from a prior admission), indicated that the Resident was at risk for falls due to a change in mobility/gait, fell in the past year, and had unstable balance and vision problems. The goal was, Resident will be free from injury related to falls. Interventions to prevent falls/injury included: -Fall Risk Assessment upon admission, re-admission, significant change in condition -Include resident/family in assessment process to determine strategies for fall prevention -Educate resident/family on fall prevention strategies -Provide well lit, uncluttered environment -Place items resident uses frequently in reach to prevent bending or reaching -Gait belt for all transfers -Encourage participation in diversional activities -Individualize care plan to meet resident's assessed needs -Keep call bell within reach -Rehab services as needed -3/7/21: Educate patient to use call bell to call for assistance with transfers. Review of the social services' note, late entry dated 2/22/21, indicated Resident #212 presented as alert and oriented with some forgetfulness at baseline; the Resident would complete short term rehab with a plan to discharge home with services. Review of the Minimum Data Set (MDS) assessment, dated 2/22/21, indicated Resident #212 was assessed to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Further review of the MDS, under Section G, Functional Status, indicated Resident #212 was coded as requiring extensive assistance with bed mobility, transfers, walking in the room and corridor, locomotion, both on and off the unit, dressing, and toilet use. The MDS indicated that the Resident had a chronic urinary catheter and was occasionally incontinent of bowel. The MDS also indicated that the Resident had experienced a fall in the last month prior to admission, had fallen in the last 2-6 months prior to admission, and had not had a fracture related to a fall in the six months prior to admission/entry or reentry. Review of Resident #212's medical record indicated that on 3/6/21, the Resident had an unwitnessed fall at 12:00 P.M., while self-toileting. The Resident was found in the bathroom face down and denied hitting his/her head. The nurse's note indicated the walker was in the bathroom beside the Resident. The Resident was reportedly yelling, Help, I broke my ankle! The note indicated that there were no visible injuries, EMS was contacted, and the Resident was transported to the Emergency Department (ED) for evaluation for a suspected broken ankle. Review of the medical record indicated Resident #212 returned from the hospital on 3/6/21 at 9:00 P.M., with a diagnosis of closed left ankle fracture. The ankle was placed in a splint; the Resident was to be non-weight bearing, and to follow up with orthopedics. Review of the facility Incident/Accident Report completed for this fall indicated that the Resident was using the rest room without assistance, lost his/her balance, and was found on the floor by the nurse. Review of the Fall Risk Assessment completed following Resident #212's fall on 3/6/21 indicated that the Resident scored 6 out of 10, indicating that the Resident was at High Risk for falls. Review of Resident #212's care plan for falls indicated immediate actions taken to prevent further falls (Care Plan Adjustments) included: Call for assistance for help using restroom and or other tasks. No other interventions were identified, or implemented in the plan of care, to prevent further falls and injury. Review of the medical record indicated that on 4/15/21 at 3:00 P.M., Resident #212 experienced a second unwitnessed fall. Review of the Incident/Accident Report completed at the time of the fall, indicated Resident #212 attempted to get out of the wheelchair unassisted and fell . The Resident was described as being confused with impaired memory. The nurse who completed the post fall investigation indicated that, Resident is confused and did not say where he/she was going. The Resident's roommate told the nurse completing the post fall investigation that, He/She just tried to get up by himself/herself. Review of the nurse's note written by the nurse caring for Resident #212 at the time of the fall indicated that, Around 1500 (3:00 P.M.) this shift this nurse hears someone call for help. Went into [Resident #212's room] noted resident laying face first on the floor. Resident had attempted to get out of chair unassisted. Immediately noted that resident was lying in blood. Called for help. Moved surrounding object away. Attempted to reposition resident to determine where the blood was coming from but maintained C-spine. Resident laid on his/her back. Noted that resident was profusely bleeding from his/her forehead. Directed nursing to apply pressure to resident's left forehead. Area also noted to left hand from fall. Nursing was able to slow bleeding. EMS arrived quickly and resident was sent to [hospital] for eval [evaluation]. Review of Resident #212's care plan indicated immediate actions to prevent further falls (Care Plan Adjustments) indicated on 4/16/21 a medication review. On 5/6/21 at 11:40 A.M., the surveyor observed Resident #212 in his/her room. The Resident was alert, pleasant, and talkative. Resident #212 said that things were going well and acknowledged his/her past falls and the cast on his/her left foot from the 3/6/21 fall. The Resident had a bandage covering a wound on the left forehead, sustained during the fall on 4/15/21. The Resident was seated in a wheelchair adjacent to the left side of the bed with a hard cast on the left foot elevated on the footrest of the wheelchair. The Resident's call light was observed out of the Resident's reach. The call light was observed on the opposite side of the bed from where the Resident was sitting, tucked underneath a pillow. During an interview on 5/6/21 at 11:47 A.M., Unit Manager (UM) #2 said that the Resident would use his/her call light to alert staff if he/she needed anything. The surveyor asked UM#2 to come to the Resident's room to observe the placement of the Resident's call light. UM#2 said that the call light was not accessible to the Resident at that time due to it being under the pillow on the opposite side of the bed from where the Resident was sitting. Review of the Fall Risk Assessment completed following Resident #212's 4/15/21 fall indicated a score of 5 out of a possible 10 that inaccurately determined that the Resident was at Low Risk for falls. The assessment also indicated that the Resident had experienced a fracture related to a fall in the past six months (fractured ankle on 3/6/21), and that the Resident was confused or forgetful. Further record review indicated that no additional interventions to prevent further falls and injury were implemented for the Resident. During an interview on 5/12/21 at 3:59 P.M., the Director of Nursing (DON) said after reviewing the Plan of Care, that there were no additional interventions implemented to ensure the Resident's safety and prevent further falls for Resident #212 who continued to demonstrate unsafe behaviors by attempting to get up unassisted from the wheelchair without warning. 2. For Resident #97, the staff failed to complete a falls risk assessment and a pain assessment and implement meaningful and timely interventions per facility policy to prevent additional falls. Findings include: Review of the facility's policy titled Falls Management: Post Fall 5 Whys Pilot, revised 11/28/18, indicated the following: 4. Remove any causes of fall and implement preventive measures to prevent reoccurrence. 5. Update care plan to reflect new interventions. 6. List resident on the 24-hour report 9. Conduct interdisciplinary falls team meeting at the subsequent clinical morning meeting 9.1. Review the 5 Whys analysis 9.2. Determine need for additional actions/interventions based on team evaluation and root cause 9.3. Communicate information to staff and care planning team Resident #97 was admitted to the facility with a diagnosis of dementia with behavioral disturbances. Review of the Resident's record indicated that Resident #97 has had a recent pathological hip fracture and a recent fall out of bed. Review of the Minimum Data Set (MDS) assessment, dated 3/13/21, indicated that Resident #97 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating the Resident had severe cognitive impairment. Review of Occupational Therapy Treatment Encounter notes indicated: 5/08/21-No fall interventions referenced in the note 5/10/21-No fall interventions referenced in the note. Patient complained of increased left hip pain with standing and weight bearing; nursing supervisor made aware. Review of Physical Therapy Treatment Encounter note, dated 5/11/21, indicated: -No interventions recommended status post fall 5/8 or 5/10. Review of Resident #97's current care plan did not have any interventions to minimize Resident #97's risk from falling out of the wheelchair. During an interview on 05/11/21 at 04:15 P.M., Unit Manager (UM) #1 said Resident #97 had two recent falls, one on 5/8/21 and the second on 5/10/21. UM #1 said the investigations are not complete and the only intervention put into place was for Rehab Services to evaluate the Resident. UM #1 said no other interventions had been put in place because the falls investigation had not been completed. Review of the facility incident checklist for Resident #97's fall on 5/8/21 indicated: -Incident report, dated 5/8/21, indicated Resident #97 observed sitting on buttocks in day room near wheelchair. Plan rehab screen for positioning. -Skin Tear, Laceration, Bruise investigation of unknown origin completed- No skin issues - One witness statement, dated 5/8/21, indicated Resident #97 found sitting on buttocks on the day room floor. No rotation of hips/legs. Resident denies pain; no open areas or bump on head. -Rehabilitation referral for positioning and cushion. -No Fall Risk or Pain Assessment performed. Review of the facility incident checklist for Resident #97's fall on 5/10/21 indicated: -Incident report, dated 5/10/21, indicated the nurse was on the phone and all three aides were attending to other residents. The nurse heard a loud bang and walked around the nurse's station and saw Resident #97 on the floor. -Post fall investigation: Resident #97 was resting, found on floor (unwitnessed), loss of balance, loss of strength/weakness, getting up from wheelchair, confused, no alarms, no injuries -Communication In-service: blank -Witness statement: blank -Fall Risk Assessment completed- Resident scored 6 out of 10- High risk for falls -Pain assessment completed- Resident denies pain During an interview on 05/11/21 at 05:00 P.M., UM #1 said the weekend staff did not complete the pain assessment or fall assessment for the fall that occurred on 5/8/21. UM #1 said agency staff is part of the problem, because they don't always know what forms they have to complete. UM #1 said there have been no interventions put into place or updates to the care plans because the investigations have not been completed. During an interview on 05/12/21 at 04:06 P.M., Rehab Staff #1 said she was aware Resident #97 had fallen over the weekend and said Resident #97 requires supervision at all times and should be at the nursing station when in his/her wheelchair. During an interview on 05/12/21 at 04:13 P.M., the Director of Rehabilitation (Rehab) said she was aware Resident #97 fell this weekend, but was not aware he/she had a second fall on 5/10/21 and the Rehab Department had not received a rehab referral to evaluate Resident #97 for either fall out of his/her wheelchair. The Rehab Director said the staff typically has a falls meeting each morning and that's when rehab receives the referrals for post falls evaluations, but there had not been a meeting since last week.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that after becoming aware of Resident #1's burns, that nursing notified the Physician and his/her activated Health Care Proxy (HCP). On 2/18/21, Resident #1 reported to Nurse #2 that he/she had spilled hot tea on his/her left upper thigh and hip. Resident #1 sustained second-[MEDICAL CONDITION](burn that affects both the outer and underlying layer of skin, causing pain, redness, swelling and blistering), however, Nurse #2 did not notify the Physician or the HCP about the incident. Resident #1'[MEDICAL CONDITION] not reported to the Physician and HCP until four days later, on 02/22/21, at which point orders were obtain from the physician. Findings include: The Facility's Policy, titled Physician Notification, dated as revised September 2011, indicated that upon identification of a resident who has clinical changes or a change in condition, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician. The Policy indicated to document: - Findings related to change in condition on Situation Background Appearance Review and Notify (SBAR) - Physician notification and response - 24 Hour Change of Status Report - Family notification - Interventions and resident disposition The Facility's Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised 12/29/11, indicated that all accidents or incidents involving residents must be investigated and reported to the Administrator. The Policy indicated the licensed nurse shall examine all accident/incident victims and notify the victim's physician of the accident or incident. Resident #1 was admitted to the Facility in August 2019, [DIAGNOSES REDACTED]. Review of the Advance Directive Care Plan, dated 12/24/20, indicated that Resident #1 had an activated HCP. Review of Resident #1's Incident/Accident Report, written by Nurse #1, dated 02/18/21 (please note that this Incident Report was written by Nurse #1 on 02/22/21, as a late entry for 02/18/21), indicated that Resident #1 reported to her that he/she sustained a burn on Thursday night (02/18/21) during dinner when he/she spilled hot tea on him/herself and said that it really hurt. The Report indicated Nurse #1 assessed the area and noted a large burn with multiple fluid filled blisters on his/her left thigh and hip. The Report indicated that the HCP and the Physician were notified on 02/22/21 and that the Physician ordered [MEDICATION NAME] cream (used to prevent and treat wound infections in patients with second- and third-degree burns) treatment to the affected areas daily for seven days. Review of Resident #1's Nurse Progress Note, written by Nurse #1, dated 02/23/21, (but noted as a late entry for 02/22/21), indicated that in addition to the information provided in the Incident/Accident, Nurse #1 ensured Management was immediately made aware, and that the Physician was notified. The Note indicated that Resident #1 requested that ice be applied to the burn area, the Physician was notified and ordered ice to be applied to burn areas for 10 minutes every four hours, as needed for discomfort, for seven days with frequent monitoring of areas. During an interview on 03/15/21 at 1:40 P.M., Nurse #1 said that on Monday, 02/22/21, Resident #1 reported to her that he/she had a bad burn on his/her left leg and said that the burn happened on Thursday (02/18/21) night at dinner time after he/she spilled tea on his/her left thigh and hip area. Nurse #1 said she assessed the burn area and noted a large red burned area with multiple fluid filled blisters on his/her left thigh and hip area. Nurse #1 said she notified the Unit Manager, the Director of Nurses and called the Physician. Nurse #1 said the Physician told her that he was not aware that Resident #1 had sustained a burn on Thursday 02/18/21 and said this was the first time he was notified of the burn. During an interview on 03/15/21 at 2:40 P.M., the Unit Manager said that she was unaware that Resident #1 had sustained a burn on 02/18/21 and said she was first notified of Resident #1's burn on 02/22/21 when Nurse #1 notified her. The Unit Manager said that she did not have an Accident/Incident Report for Resident #1's burn and said that she asked Nurse #1 to complete the Report and notify the Physician and HCP of the burn. Review of a second Incident/Accident Report and Investigation, related to Resident #1's burn, written by Nurse #2, dated 02/18/21, (please note that this Incident Report was written by Nurse #2 on 02/22/21 as a late entry for 02/18/21), indicated that Resident #1 knocked his/her cup of tea over and the tea spilled onto his/her left thigh and that it burned him/her. The Report and Investigation indicated that Resident #1's HCP and his/her Physician were notified on 02/18/21. However, during an interview with the Surveyor on 03/16/21 at 7:36 A.M., Nurse #2 said she did not notify Resident #1's HCP or the Physician of the burn on 02/18/21 and said she did not complete an Incident Report about the 02/18/21 incident, until she came in for her shift on 02/22/21 at 10:30 P.M. Review of Resident #1's Nurse Progress Note, written by Nurse #2 dated 02/23/21, (noted as a late entry for 02/18/21), indicated that at 8:15 P.M. Resident #1 came out to the nurse's station and stated that he/she knocked a cup of tea over and it fell on to his/her left upper thigh and burned him/her. The Note indicated that she (Nurse #2) assessed the burn and noted a large pink blotchy area to his/her left upper thigh. The Note indicated that cool compresses were applied to the affected area, that the evening Nursing Supervisor was notified and told Nurse #2 to just monitor the site. During an interview on 03/16/21 at 7:36 A.M., Nurse #2 said that on Thursday (02/18/21) at approximately 8:30 P.M., Resident #1 notified her that he/she knocked his/her tea over and it fell on to his/her left leg. Nurse #2 said she looked at the burn area and noted a pink blotchy area to Resident #1's left upper thigh and said she asked Certified Nurse Aide (CNA) #1 to apply a cold wet facecloth to the area. Nurse #2 said that she notified the evening Nursing Supervisor of the burn and said the Nursing Supervisor told her to just monitor the area. Nurse #2 said she did not notify the Physician or his/her HCP and said she did not write a nurse progress note or complete an Accident/Incident Report. Review of Resident #1's medical record indicated, there was no documentation to support that Nurse #2 notified Resident #1's Physician or his/her activated HCP on 02/18/21 that Resident #1 had sustained a burn to his/her left leg. During an interview on 03/16/21 at 3:15 P.M., the Director of Nurses (DON) said that Resident #1 sustained a burn on his/her left inner thigh area on 02/18/21 and said that Nurse #2 did not follow the Facility policy and did not notify him (DON) or the Physician of Resident #1's burn on 02/18/21. The DON said that he and the Physician were not notified of the burn until 02/22/21.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who sustained second [MEDICAL CONDITION](burn that affects both the outer and underlying layer of skin- causing pain, redness, swelling and blistering), after spilling a hot beverage on him/herself, the Facility failed to ensure nursing staff provided care and services to him/her that met professional standards of practice. On 2/18/21, after Resident #1 reported to Nurse #2 that he/she spilled a cup of hot tea onto him/herself, she failed to document her assessment of the injury, failed to notify the Physician to obtain appropriate treatment orders for the burn areas, failed to monitor the injury after it was reported to her, and then delegated a nursing task (application of cool compress) related to Resident #1's burns, to a non-licensed staff member. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility's Policy, titled Physician Notification, dated as revised September 2011, indicated that upon identification of a resident who has clinical changes or a change in condition, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician. The Facility's Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised 12/29/11, indicated that all accidents or incidents involving residents must be investigated and reported to the Administrator. The Policy indicated: - Regardless of how minor an accident or incident may be, report the accident/incident to the department supervisor as soon as such accident/incident is discovered - Complete an Incident Report for all reported accidents or incidents - The licensed nurse shall examine all accident/incident victims and notify the victim's physician of the accident or incident The Facility's Policy, titled Documentation - Clinical, dated as revised 1/30/2017, indicated: - For a change in condition/Incidents: complete documentation for change in resident condition or incidents, interventions and resident response - Continue documentation as often as the resident condition warrants and at a minimum every shift for 72 hours or until the condition stabilizes or resolves Resident #1 was admitted to the Facility in August 2019, [DIAGNOSES REDACTED]. Review of Resident #1's Incident/Accident Report, written by Nurse #1, dated 02/18/21 (please note that this Incident Report was written by Nurse #1 on 02/22/21 as a late entry for 02/18/21), indicated that Resident #1 reported to her that he/she sustained a burn on Thursday night (02/18/21) during dinner when he/she spilled hot tea on him/herself and said that it really hurt. The Report indicated Nurse #1 assessed the area and noted a large burn with multiple fluid filled blisters on his/her left thigh and hip. The Report indicated that his/her activated Health Care Proxy (HCP) and the Physician was notified on 02/22/21 and that the Physician ordered [MEDICATION NAME] cream (used to prevent and treat wound infections in patients with second- and third-degree burns) as a treatment for [REDACTED]. Review of second Incident/Accident Report and Investigation, related to Resident #1's burn, written by Nurse #2, dated 02/18/21 (please note that this Incident Report was written by Nurse #2 on 02/22/21 as a late entry for 02/18/21), indicated that Resident #1 knocked his/her cup of tea over and the tea split on his/her left thigh and that it burned him/her. The Report and Investigation indicated that Resident #1's HCP and Physician were notified on 02/18/21. However, during an interview with the Surveyor on 03/16/21 at 7:36 A.M., Nurse #2 said she did not notify Resident #1's HCP or the Physician of the burn on 02/18/21 and said she did not complete an Incident Report about the 02/18/21 incident, until she came in for her shift on 02/22/21 at 10:30 P.M. Review of Resident #1's medical record indicated, there was no documentation to support that on 02/18/21, Nurse #2 assessed Resident #1's burns, monitored, or provided treatment to the areas. Review of Resident #1's medical record indicated, there was no documentation to support that on 02/18/21, Nurse #2 reported Resident #1's incident to the oncoming shift nursing staff, so his/her nurse could monitor the areas, or provide treatment. Review of Resident #1's medical record indicated, there was no documentation from 02/18/21 through 02/21/21, to support that nursing staff assessed, monitored or provided treatment to the second [MEDICAL CONDITION] Resident #1's left thigh and hip area. Review of Resident #1's Weekly Skin Check, dated 02/22/21, completed by Nurse #1, indicated that Resident #1 had a large red burn with multiple fluid filled blisters noted to the left upper anterior thigh and left hip and that the Physician was made aware and a treatment was initiated. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Nurse Progress Note, written by Nurse #1, dated 02/23/21, (noted as a late entry for 02/22/21), indicated that Resident #1 reported to her that he/she sustained a burn on Thursday (02/18/21) evening during dinner when he/she accidentally spilled tea on his/her lap and that it really hurts. The Note indicated that upon assessment, a large red burn was noted to his/her left upper anterior thigh and left hip with multiple fluid filled blisters. The Note indicated that Management was immediately made aware, the Physician was notified, and a new order was obtained for [MEDICATION NAME] cream to be applied to the affected area daily for seven days. The Note indicated that Resident #1 asked if ice could be put on the burn areas, the Physician was notified and ordered ice be applied to burn areas for 10 minutes every four hours, as needed, for discomfort for seven days, with frequent monitoring of areas. Review of Resident #1's Nurse Progress Note, written by Nurse #2 dated 02/23/21, (but noted as a late entry for 02/18/21), indicated that at 8:15 P.M. (on 02/18/21) Resident #1 came out to the nurse's station and stated that he/she knocked a cup of tea over and it fell on to his/her left upper thigh and burned him/her. The Note indicated that Nurse #2 assessed the burn and noted a large pink blotchy area to his/her left upper thigh. The Note indicated that cool compresses were applied to the affected area, that the evening Nursing Supervisor was notified and told her (Nurse #2) to just monitor the site. During an interview on 03/15/21 at 1:40 P.M., Nurse #1 said that on Monday, 02/22/21, Resident #1 reported to her that he/she had a bad burn on his/her left leg and said that the burn happened on Thursday (02/18/21) night at dinner time after he/she spilled tea on his/her left thigh and hip area. Nurse #1 said she assessed the burn area and noted a large red burned area with multiple fluid filled blisters on his/her left thigh and hip area. Nurse #1 said she notified the Unit Manager, the Director of Nurses and called the Physician. Nurse #1 said the Physician told her that he was not aware that Resident #1 had sustained a burn on Thursday 02/18/21 and said this was the first time he was notified of the burn. Nurse #1 said the Physician ordered [MEDICATION NAME] cream to the affected areas daily for seven days. Review of Resident #1's physician progress notes [REDACTED].#1 sustained a second degree burn to his/her left upper thigh on 02/18/21 when he/she transferred hot water from one cup to another and spilled it onto his/her left upper thigh. The Note indicated that physical exam revealed Resident #1 had a burn noted to his/her left thigh and to apply [MEDICATION NAME] cream topically to the burn, cover with Xeroform (non-adherent dressing with [MEDICATION NAME] to cover and protect wounds from burns) and change the dressing twice a day. During an interview on 03/15/21 at 2:40 P.M., the Unit Manager said that she was unaware that Resident #1 had sustained a burn on 02/18/21 and said she was first notified of Resident #1's burn on 02/22/21 when Nurse #1 notified her. The Unit Manager said that she did not have an Accident/Incident Report for Resident #1's burn. The Unit Manager said there was no documentation in Resident #1's record to indicate he/she sustained a burn on 02/18/21 and said there was no assessment or treatment in place for Resident #1's burn. The Unit Manager said there was no documentation to support that Nurse #2 notified the Physician or the HCP on 02/18/21, and said they were not notified of the incident until 02/22/21, when she directed Nurse #1 to make the calls. During an interview on 03/16/21 at 7:36 A.M., Nurse #2 said that on Thursday (02/18/21) at approximately 8:30 P.M., Resident #1 notified her that he/she knocked his/her tea over and it fell on to his/her left leg. Nurse #2 said she looked at the burn area and noted a pink blotchy area to Resident #1's left upper thigh and said she asked Certified Nurse Aide (CNA) #1 to apply a cold wet facecloth to the area. Nurse #2 said that she notified the evening Nursing Supervisor of the burn and said the Nursing Supervisor told her to just monitor the area. Nurse #2 said she did not notify the Physician or his/her HCP and said she did not write a nurse progress note or complete an Accident/Incident Report. Review of Certified Nurse Aide (CNA) #1's Witness Statement, dated 02/18/21, indicated that at 8:00 P.M. Resident #1 asked CNA #1 for a cup of tea and that when he came back to the nurse's station, sometime later, Resident #1 said that he/she had spilled the tea on his/her left upper thigh. The Statement indicated CNA #1 walked Resident #1 to his/her room and applied a cold compress to the area. During an interview on 03/15/21 at 4:00 P.M., Certified Nurse Aide (CNA) #1 said that on 02/18/21, he gave Resident #1 a cup of hot tea, from the hot water dispenser in the unit kitchenette, at approximately 8:00 P.M., and then went to care for his other residents. CNA #1 said that at approximately 8:30 P.M., he saw Resident #1 at the nurse's station speaking to Nurse #2 and said that Resident #1 was saying he/she spilled the tea on his/her left upper thigh. CNA #1 said that Nurse #2 asked him to apply cold compresses to Resident #1's burn area and said that he applied cold compresses to Resident #1's burn several times during the remainder of evening shift. During an interview on 03/16/21 at 3:15 P.M., the Director of Nurses (DON) said that Resident #1 sustained a burn on his/her left inner thigh area on 02/18/21 and said that Nurse #2 did not follow the Facility policy and did not notify him or the Physician of Resident #1's burn on 02/18/21. The DON said that he and the Physician were not notified of the burn until 02/22/21. The DON said there was no documentation that he could find in Resident #1's medical record and that there was no Incident Report completed from 02/18/21 through 02/21/21 to indicate that he/she sustained a burn on 02/18/21.

Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who required supervision with eating, the Facility failed to ensure staff provided an environment free of accidents and hazards, when Resident #1 was served a cup of hot tea with hot water that was obtained from the hot water dispenser located inside the unit's kitchenette. Staff failed to take the temperature of the hot tea prior to serving it to Resident #1 and he/she spilled the hot cup of tea onto him/herself and sustained second [MEDICAL CONDITION](burn that affects both the outer and underlying layer of skin- causing pain, redness, swelling and blistering) to his/her left upper thigh and hip, which required treatment with [MEDICATION NAME] cream topically to the burns, cover with Xeroform (non-adherent dressing with [MEDICATION NAME] to cover and protect wounds from burns) dressing and to change the dressing twice a day. Findings include: The Facility's Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised 12/29/11, indicated that all accidents or incidents involving residents must be investigated and reported to the Administrator. The Policy indicated: - Regardless of how minor an accident or incident may be, report the accident/incident to the department supervisor as soon as such accident/incident is discovered - Complete an Incident Report for all reported accidents or incidents - The licensed nurse shall examine all accident/incident victims and notify the victim's physician of the accident or incident. - The nurse supervisor/charge nurse must conduct an immediate investigation of the accident or incident. - The nurse supervisor/charge nurse shall complete an Incident/Accident Report prior to the end of shift and submit it to the Director of Nursing Services promptly. The Burn Foundation's Fact Sheet, published in 2017 and titled Safety Facts on [MEDICAL CONDITION]: the two highest risk populations for [MEDICAL CONDITION] children under the age of 5 and adults over 65; hot liquids can cause life-threatening burn injuries; coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury and when tap water reaches 131 degrees Fahrenheit and it can cause a second degree (partial thickness) burn in five seconds. Resident #1 was admitted to the Facility in August 2019 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 11/26/20, indicated that Resident #1 required supervision with eating. Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated 02/22/21, indicated that on 02/18/21 at 6:00 P.M., Resident #1 reported to the nurse that he/she spilled hot tea on his/her left upper inner thigh. The Report indicated that a staff member served Resident #1 a cup of hot water from the instant hot water dispenser. The Report indicated that Resident #1 transferred the water from one cup to another cup and that is when he/she spill the hot water. During an interview on 03/16/21 at 3:15 P.M., the Director of Nurses (DON) said that Resident #1 sustained a burn on his/her left inner thigh area on 02/18/21 from a cup of tea that was served to him/her from the hot water dispenser in the unit kitchenette. The DON said that he was unaware there were hot water dispensers in the unit kitchenettes and said he asked the maintenance department to shut down the hot water dispensers in all of the unit kitchenettes after Resident #1's incident occurred. The DON said the Facility did not have a policy on dispensing water from the hot water dispensers in the unit kitchenettes, said that the Facility did not have a policy on serving hot beverages. The DON said the Facility would have followed manufacturer instructions for use of the InSinkErator Instant Hot Water Dispensers. Review of the InSinkErator Instant Hot Water Dispenser (identified by the Facility as the hot water dispenser used at the time of Resident #1's incident) Owner's Manual, undated, indicated the factory temperature pre-set is 190 degrees Fahrenheit. During an interview on 03/15/21 at 1:20 P.M., the Maintenance Assistant said that all 3 Units had InSinkErator instant hot water dispensers and said all the InSinkErator hot water dispensers were turned off and unplugged so they could no longer work or be accessed to dispense hot water by staff. During an Observation on 03/15/21 at 1:15 P.M., in the Kitchenette on the unit where Resident #1 resided, Unit #2, the Surveyor observed there was an InSinkErator Instant Hot Water Dispenser. The Instant Hot Water Dispenser was plugged into the electrical outlet, was functioning and the temperature reading of the water dispensed and tested , by the Maintenance Assistant, read 177 degrees Fahrenheit. During an Observation on 03/15/21 at 1:20 P.M., in the Kitchenette on Unit #3, the Surveyor observed there was an InSinkErator Instant Hot Water Dispenser. The Instant Hot Water Dispenser was plugged into the electrical outlet, was functioning and the temperature reading of the water dispensed and tested , by the Maintenance Assistant, read 177 degrees Fahrenheit. The DON said he could not explain why the InSinkerator Instant hot water dispensers were still working in the Unit #2 and Unit #3 kitchenettes and said he thought the hot water dispensers were disabled after the incident. The Maintenance Assistant said he could not explain why the InSinkErator hot water dispensers were functioning on Unit #2 and Unit #3's kitchenettes. During an interview on 03/15/21 at 4:00 P.M., Certified Nurse Aide (CNA) #1 said that on 02/18/21, he gave Resident #1 a cup of hot tea, from the hot water dispenser in the unit kitchenette, at approximately 8:00 P.M., then went to care for his other residents. CNA #1 said he did not take the temperature of the hot water dispenser when he made tea for Resident #1, said that he was never taught to obtain the temperature of the water from the hot water dispenser in the unit kitchenette prior to serving it to the residents. CNA #1 said there were no thermometers available to test the hot water coming from the hot water dispenser in the unit kitchenette. Review of Resident #1's Incident/Accident Report, dated 02/18/21 (please note that this Incident Report was written by Nurse #1 as a late entry on 02/22/21 for 02/18/21), indicated that Resident #1 reported to her that he/she sustained a burn on Thursday night (02/18/21) during dinner when he/she spilled hot tea on him/herself and said that it really hurt. The Report indicated Nurse #1 assessed the area and noted a large burn with multiple fluid filled blisters on his/her left thigh and hip. The Report indicated that the activated HCP and the Physician was notified on 02/22/21 and that the Physician ordered [MEDICATION NAME] cream (used to prevent and treat wound infections in patients with second- and third-degree burns) to be applied to the affected areas daily for seven days. During an interview on 03/15/21 at 1:40 P.M., Nurse #1 said that on Monday, 02/22/21, Resident #1 reported to her that he/she had a bad burn on his left leg and said that the burn happened on Thursday (02/18/21) night at dinner time after he/she spilled tea on his/her left thigh and hip area. Nurse #1 said she assessed the burn area and noted a large red burned area with multiple fluid filled blisters on his/her left thigh and hip area. Nurse #1 said she notified the Unit Manager, the Director of Nurses and called the Physician. Nurse #1 said the Physician told her that he was not aware that Resident #1 had sustained a burn on Thursday 02/18/21 and said this was the first time he was notified of the burn. Nurse #1 said the Physician ordered [MEDICATION NAME] cream to the affected areas daily for seven days. Review of second Incident/Accident Report and Investigation, dated 02/18/21 (please note that this Incident/Accident Report and Investigation was written by Nurse #2 on 02/22/21 as a late entry for 02/18/21), indicated that Resident #1 knocked his/her cup of tea over and the tea spilled onto his/her left thigh and that it burned him/her. The Report and Investigation indicated that Resident #1's HCP and Physician were notified on 02/18/21 of the incident. However, during an interview with the surveyor on 03/16/21 at 7:36 A.M., Nurse #2 said she did not notify Resident #1's HCP or the Physician of the burn on 02/18/21 and said she did not complete the Incident Report until she came in for her shift on 02/22/21 at 10:30 P.M. Nurse #2 said she looked at the burn area and noted a pink blotchy area to Resident #1's left upper thigh and said she asked the Certified Nurse Aide (CNA) to apply a cold wet facecloth to the area. Nurse #2 said that CNA #1 used the hot water dispenser in the unit kitchenette to make tea for Resident #1. Nurse #2 said that she notified the evening Nursing Supervisor of the burn and said the Nursing Supervisor told her to just monitor the area. Nurse #2 said she did not write a nurse progress note or complete an Accident/Incident Report. The Surveyor attempted to interview the Nursing Supervisor; however, the Nursing Supervisor did not respond to the Surveyors requests to be interviewed. Review of Resident #1's medical record indicated, there was no documentation to support and the Facility was unable to provide documentation to support that Nurse #2 had made the Nursing Supervisor aware of the incident. During an interview on 03/15/21 at 2:40 P.M., the Unit Manager said that she was unaware that Resident #1 had sustained a burn on 02/18/21 and said she was first notified of Resident #1's burn on 02/22/21. The Unit Manager said she did not have an Accident/Incident Report for Resident #1's burn incident on 2/18/21. The Unit Manager said, prior to 02/22/21, there was no documentation in Resident #1's record to indicate he/she sustained a burn on 02/18/21, including no nursing assessment or physician's orders [REDACTED].#1's burn. Review of Resident #1's physician progress notes [REDACTED].#1 sustained a second degree burn to his/her left upper thigh on 02/18/21 when he/she transferred hot water from one cup to another and spilled it onto his/her left upper thigh. The Note indicated that physical exam revealed Resident #1 had a burn noted to his/her left thigh and to apply [MEDICATION NAME] cream topically to the burn, cover with Xeroform (non-adherent dressing with [MEDICATION NAME] to cover and protect wounds from burns) and change the dressing twice a day.

Based on records reviewed and interviews for one of three sampled residents, (Resident #1), the Facility failed to ensure staff delivered oxygen via an appropriate delivery source; and failed to administer appropriate liters of oxygen when, on [DATE], Resident #1 experienced an acute change in condition, became severely hypoxemic (below-normal level of oxygen in blood), had an oxygen saturation level (percentage of oxygen in the bloodstream) of 70% (Normal Range: ,[DATE]%) on room air, staff administered oxygen via a face mask at 3 Liters (L) per minute with little effect and, Resident #1 became unresponsive, required cardiopulmonary resuscitation (CPR), was transferred to the hospital and died . Findings include: The Mayo Clinic Letter, dated [DATE], indicated that hypoxemia is a below-normal level of oxygen in your blood. Hypoxemia is a sign of a problem related to breathing or circulation. Hypoxemia can be estimated by measuring the oxygen saturation of your blood using a pulse oximeter (a small device that clips to your finger for monitoring a person's oxygen saturation). Normal blood oxygen saturation levels are considered ,[DATE] percent. If the level is below 90 percent, it is considered low, resulting in hypoxemia. The American National Red Cross Guidelines, dated 2011, indicated oxygen saturation levels below 85% indicate severe [MEDICAL CONDITION] and require oxygen to be delivered via a non-rebreather mask (face mask with an attached oxygen reservoir bag and one-way valve between the mask and bag in which patient inhales oxygen from the bag and exhaled air escapes through flutter valves on the side of the mask) at ,[DATE] Liters per minute. The Journal of Nursing Education and Practice, dated ,[DATE], indicated nurses should be able to assess for hypoxemia/[MEDICAL CONDITION] and administer appropriate oxygen therapy for individuals with all levels of dyspnea (shortness of breath). Individuals experience an increase in the work of breathing and this may cause difficulty in maintaining adequate oxygenation. When treating acute or unstable dyspnea, usual treatment should include appropriate controlled oxygen therapy via a high flow system to maintain oxygen saturation greater than or equal to ,[DATE]%. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated [DATE], indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation and transfer to hospital. The Plan of Care, titled Advanced Directives, dated [DATE], indicated Resident #1 was a Full Code (in the event of cardiac or respiratory arrest, all attempts of resuscitation will be made). The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 was cognitively impaired. The Nursing Home to Hospital Transfer Form, dated [DATE], indicated Resident #1 was in respiratory distress with oxygen saturation levels in the 70's, placed in oxygen which was titrated up to 3 L per minute with minimal results. The Policy titled, Oxygen Administration, dated [DATE], indicated to document the date and time oxygen started, method of administration and Liter flow needed. A Nurse Progress Note, dated [DATE], indicated at 10:40 A.M., Nurse #1 noted Resident #1 was pale with slight shortness of breath, respiratory rate of 26 (normal ,[DATE]), a dry cough with an oxygen saturation level between ,[DATE]% on room air. The Note indicated Nurse #1 notified the Physician Assistant who ordered that Resident #1 be transferred to the emergency room and an ambulance was called. The Nursing Note indicated Nurse #1 placed Resident #1 in oxygen (the method of administration was not documented) and titrated (increased) the flow rate (flow rate was not documented), with minimal effect. Although the Note indicated Resident #1's oxygen administration was changed to a face mask and his/her oxygen saturation level increased to ,[DATE]%, which remained below normal levels, the oxygen flow rate was not documented. This was not consistent with the Facility's Oxygen Administration Policy. The Nursing Note indicated Emergency Medical Systems Responders (EMS) arrived and a few minutes later, Resident #1 became unresponsive, a Code Blue and 911 was called, CPR was initiated and the automated external defibrillator (AED) was applied. The Nursing Note indicated CPR continued until firefighters and the 911 EMS responders arrived, took charge and transferred Resident #1 to the hospital. The Surveyor interviewed Paramedic #1 at 1:13 P.M. on [DATE]. Paramedic #1 said when she arrived at the Facility, Resident #1 was in respiratory distress with oxygen saturation rate in the 70's, was on oxygen via a nasal cannula at 3 L/minute and his/her oxygen saturation levels were in the 70's. Paramedic #1 said she placed Resident #1 on oxygen at 15 L/minute using a non-rebreather mask. Paramedic #1 said when a resident has a low oxygen saturation rate, the appropriate oxygen delivery method is to give high flow oxygen via a non-rebreather mask at 15 L/minute. Paramedic #1 said she informed her partner, who was an EMT (Emergency Medical Technician), to call 911 for backup as she was unable to transport Resident #1 because Resident #1 was a Priority One (Critically ill or injured person requiring immediate attention; unstable patients with potentially life-threatening injury or illness) which required two paramedics for transport to the hospital. A Medical Emergency/Code Blue Flow Sheet, dated [DATE], indicated: 11:05 A.M., the ambulance EMS Responders were on scene at Facility. 11:11 A.M., Resident #1 became unresponsive. 11:12 A.M., Code Blue and 911 was called. 11:13 A.M., Compressions began, AMBU (hand-held device used to provide positive pressure ventilation to patients who are not breathing) and AED applied. 11:17 A.M., No shock advised. 11:18 A.M., No pulse, compressions continue. 11:21 A.M., No pulse, compressions continue. 11:22 A.M., No shock advised. 11:32 A.M., EMS (NB) arrived on scene. 11:35 A.M., EMS continue CPR and treatment. 11:40 A.M., No shock advised. 11:42 A.M., Patient on stretcher, transported to hospital. The Surveyor interviewed Charge Nurse #1 at 1:02 P.M. on [DATE]. Charge Nurse #1 said she didn't know what Resident #1's oxygen saturation level was when she notified the Physician Assistant (PA) and called the ambulance for transport. Charge Nurse #1 said if a resident had an oxygen saturation level in the 70's, she would start oxygen at 2 L/minute via nasal cannula and if the resident's oxygen saturation level didn't improve, she would apply an oxygen mask at a higher Liter flow of ,[DATE] L/minute and possibly a non-rebreather mask at ,[DATE] L/minute. Charge Nurse #1 said that at the time she called for an ambulance transport, Resident #1 did not require a 911 (emergency assistance) transport because he/she was still breathing and could wait for the ambulance to arrive, or words to that effect. The Surveyor interviewed Nurse #1 at 1:56 P.M. on [DATE]. Nurse #1 said Resident #1 didn't look right, or words to that effect, she obtained Resident #1's oxygen saturation level which was in the 70's, and informed Charge Nurse #1. Charge Nurse #1 informed the PA who ordered that Resident #1 be transferred to the hospital. Nurse #1 said she applied oxygen at 2 Liters/minute by nasal cannula to Resident #1, noticed Resident #1 was mouth breathing, applied an oxygen face mask and titrated the oxygen liter flow rate. Nurse #1 said she could not recall Liter flow rate of oxygen, but said Resident #1's oxygen saturation levels increased to the the low 80's. Nurse #1 said Resident #1 did not warrant a 911 transport because he/she was responsive with no respiratory distress and oxygen saturation levels were responding to the oxygen. Nurse #1 said when Resident #1 became unresponsive, he/she then required a 911 transport, a Code Blue (emergency situation announced in an institution in which a resident is in cardiopulmonary arrest, requiring a team of providers to rush to the specific location and begin immediate resuscitative efforts) was called and CPR (cardiopulmonary resuscitation) was started. The Surveyor interviewed Unit Manager #1 at 2:52 P.M. on [DATE]. Unit Manager #1 said she responded to Resident #1's Code Blue and documented the event on the code blue flow sheet. Unit Manager #1 said she wasn't sure if Resident #1 was on oxygen. Unit Manager #1 said if a resident had a low oxygen saturation level, she would apply oxygen at 5 or 10 Liters/minute via a non-rebreather, but could not remember if the oxygen level for a non-rebreather was 5 or 10 Liters/minute because the non-rebreather masks were already set up on the code cart, or words to that effect. The Surveyor interviewed Nurse #2 at 3:56 P.M. on [DATE]. Nurse #2 said she responded to Resident #1's Code Blue and assisted in the CPR of Resident #1. Nurse #2 said she did not know what Resident #1's oxygen saturation levels were before he/she required CPR. Nurse #2 said if a resident was alert and responsive with poor oxygen saturation levels, she would call the ambulance instead of calling 911, because the resident was stable if they were responsive. Nurse #2 said if a resident's oxygen saturation level was poor, oxygen is not harmful. Nurse #2 was unsure about how much oxygen to apply or which delivery method to use. Nurse #2 said she didn't remember the specifics of when to use a non-rebreather mask because they don't use them on a regular basis here, or words to that effect. The Surveyor interviewed Supervisor #1 at 4:35 P.M. on [DATE]. Supervisor #1 said Resident #1 developed labored breathing and had critically low oxygen saturation levels and should have been immediately placed on oxygen at 10 L/minute via a non-rebreather mask. The Surveyor interviewed the Director of Nurses at 5:15 P.M. on [DATE]. The Director of Nurses said Resident #1 was sitting up and responsive when staff made their first assessment and the ambulance was called. The Director of Nurses said Resident #1 was not at a 911 level when he/she was initially assessed by staff and when he/she became unresponsive, staff appropriately called 911, called a Code Blue and began CPR. The Director of Nurses said he was unaware of any specific policy regarding when to call for an ambulance or call 911. The Director of Nurses said it is a case by case situation based on the resident's clinical condition. The Director of Nurses said staff did everything appropriately.

Based on records reviewed and interviews, the facility failed to ensure 3 of 3 staff immediately reported an allegation of abuse. On 11/7/16 at 6:00 P.M., CNA #1, CNA #2 said Nurse #3 yelled out to Resident #1, [***] you and flipped him/her off with her middle finger and the Nursing Supervisor was informed on 11/8/16 at 6:30 A.M. and didn't report the allegation. Findings include: The Facility's Resident Abuse Prevention, Investigation and Reporting Policy, dated February 2010 indicated, when an employee has reasonable cause that a resident has been abused, he/she shall immediately report that suspicion to his/her supervisor. Upon receiving an allegation of abuse, supervisors will take necessary steps to protect all residents and then immediately notify the Administrator. An employee punch detail form, dated 11/7/16, indicated Nurse #3 punched in at 2:38 P.M. and punched out at 11:51 P.M. A witness statement, dated 11/8/16, indicated on 11/7/16 between 4:30 P.M. and 5:00 P.M., Nurse #2 witnessed Nurse #3 swear the F word and flip her finger at Resident #1. The witness statement indicated Nursing Supervisor #1 was on the unit during part of this altercation. A witness statement, dated 11/11/16, indicated on 11/7/16 on the 3-11 shift, CNA #2 heard Nurse #3 yell out [***] you and stick up her middle finger at Resident #1. The witness statement indicated CNA #2 informed Nursing Supervisor #1 she needed to speak to him and then CNA #2 overheard Nurse #2 talk to Nursing Supervisor #1 at the nurses' station about what had happened. A Department of Public Health Incident Report Form, dated 11/17/16, indicated on 11/7/16 at 7:00 P.M., Nurse #3 became upset with Resident #1, stated to Resident #1 mind your [***] ing business and flipped her middle finger at Resident #1. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 3:11 P.M. on 12/30/16. CNA #1 said on 11/7/16 at approximately 6:00 P.M., she heard Nurse #3 yell [***] you and throw her middle finger up at Resident #1. CNA #1 said Nurse #3 continued to work her 3-11 shift on 11/7/16 and did not leave the facility. CNA #1 said she did not report the verbal abuse to the supervisor and should have reported the abuse to the supervisor. The Surveyor interviewed the Director of Nurses at 4:00 P.M. on 12/30/16. The Director of Nurses said CNA #1 and CNA #2 should have immediately reported the allegation of abuse to Nursing Supervisor #1, an investigation should have begun immediately, Nurse #3 should have been suspended pending outcome of the investigation and he should have been notified. The Surveyor interviewed Nursing Supervisor #1 at 9:21 A.M. on 1/4/17. Nursing Supervisor #1 said on 11/7/16, he was unaware Nurse #3 had sworn at Resident #1. Nursing Supervisor #1 said on 11/8/16 at approximately 6:30 A.M., CNA #2 informed him Nurse #3 had sworn [***] you and flipped her middle finger at Resident #1 on 11/7/16 during the 3-11 shift. Nursing Supervisor #1 said he left the facility and did not report the abuse allegation to the Director of Nurses on 11/8/16 when he first became aware of the allegation of abuse. Nursing Supervisor #1 said he should have notified the Director of Nurses and an investigation should have begun per facility policy. Nursing Supervisor #1 said Nurse #2, CNA #1 and CNA #2 should have immediately reported the verbal abuse to him on 11/7/16. The Surveyor interviewed CNA #2 at 11:40 A.M. on 1/9/17. CNA #2 said on 11/7/16 at supper time on the 3-11 shift, she heard Nurse #3 say [***] you, I quit to Resident #1 and then put her hand up in the air with the middle finger pointed at Resident #1. CNA #2 said later on that evening, she told Nursing Supervisor #1 she needed to speak to him. CNA #2 said she did not report the verbal abuse to Nursing Supervisor #1 until approximately 6:30 A.M. on 11/8/16. CNA #2 said she should have immediately reported the verbal abuse to Nursing Supervisor #1 after it occurred on 11/7/16. Nurse #2 and Nurse #3 did not respond to the Surveyor's requests for interview made by telephone or by letter sent to the address of record at the Facility.

Based on records reviewed and interviews, the facility failed to ensure for 1 of 3 sampled residents (Resident #1) was free from verbal abuse. Resident #1 was subject to verbal abuse when Nurse #3 addressed him/her using vulgar and gestured language. Findings include: The Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired and had [DIAGNOSES REDACTED]. The Facility's Resident Abuse Prevention, Investigation and Reporting Policy, dated February 2010, indicated it is the policy of the facility and responsibility of all staff to assure an environment free of abuse. Verbal abuse is the use of oral, written or gestured language to residents. The Facility's Observing Resident's Rights Everyday Policy, undated, indicated, resident's have the right to be free from verbal abuse and be treated at all times with courtesy and respect. A Resident/Family Concern form, dated 11/8/16, indicated Nurse Manager #1 answered Resident #1's call light at approximately 7:45 A.M. The note indicated Resident #1 was upset and started crying and said the nurse who was working last night with blonde and pink hair, told Resident #1 to [***] off and flipped him/her off with her middle finger. A Resident/Family Concern Form, dated 11/8/16, indicated Social Worker #1 interviewed Resident #1. The note indicated Resident #1 stated he/she was at nurses' station close to 7:00 P.M. on 11/7/16 when a nurse told Resident #1 to mind your [***] ing business and then flipped him/her off with her middle finger. An Incident/Accident Report, undated indicated, Resident #1 reported a nurse had used foul language with him/her and pointed her middle finger up at him/her. An employee punch detail form, dated 11/7/16, indicated Nurse #3 punched in at 2:38 P.M. and punched out at 11:51 P.M. A witness statement, dated 11/8/16, indicated on 11/7/16 between 4:30 P.M. and 5:00 P.M., Nurse #2 witnessed Nurse #3 swear the F word and flip her finger at Resident #1. The witness statement indicated Nursing Supervisor #1 was on the unit during part of this altercation. A witness statement, dated 11/11/16, indicated on 11/7/16 on the 3-11 shift, CNA #2 heard Nurse #3 yell out [***] you and stick up her middle finger at Resident #1. The witness statement indicated CNA #2 informed Nursing Supervisor #1 she needed to speak to him and then CNA #2 overheard Nurse #2 talk to Nursing Supervisor #1 at the nurses station about what had happened. A Department of Public Health Incident Report Form, dated 11/17/16, indicated on 11/7/16 at 7:00 P.M., Nurse #3 became upset with Resident #1, stated to Resident #1 mind your [***] ing business and flipped her middle finger at Resident #1. The Surveyor interviewed Unit Manager #1 at 2:50 P.M. on 12/30/16. Unit Manager #1 said she answered Resident #1's call light on 11/8/16 at 7:45 A.M. Resident #1 informed her that a nurse who worked last night told him/her to [***] off and flipped her the middle finger. Unit Manager #1 said it was facility policy that staff immediately report to their supervisor any allegation of abuse, the alleged abuser is suspended, an investigation is started by management and the Director of Nurses or Administrator is notified of the allegation. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 3:11 P.M. on 12/30/16. CNA #1 said on 11/7/16 at approximately 6:00 P.M., she heard Nurse #3 yell [***] you and throw her middle finger up at Resident #1. CNA #1 said Nurse #3 continued to work her 3-11 shift on 11/7/16 and did not leave the facility. Nurse #2 and Nurse #3 did not respond to the Surveyor's requests for interview made by telephone or by letter sent to the address of record at the Facility.

Based on record and document review, observation, interview with staff, interview with residents and families, the facility failed to provide pharmaceutical services that ensured 1) the accuracy of insulin, 2) identify an inaccurate physician order [REDACTED].#20 and #21) in a total sample of 27 residents. Findings include: 1. For Resident #20, the facility failed to identify that the pharmacy-generated label on the vial of Levemir insulin was incorrect. The pharmacy label indicated the dose was ten times the actual dose ordered by the physician, with the potential for serious harm for the resident.. On 9/4/13 at 5:45 A.M. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 25 taken by Nurse #1 (normal range 70-120). The resident expired at the facility at 6:20 A.M. Resident #20 had [DIAGNOSES REDACTED]. The resident was receiving Levemir insulin 12 units daily every morning since 2011. Review of the telephone order sheets revealed that on 7/15/13 the physician added a new order for Levemir insulin 8 units daily at 4:30 P.M. Review of the August Medication Administration Record (MAR) revealed that this new order was handwritten on the MAR. Review of the September MAR revealed a printed entry reading Levemir 80 units daily at 4:30 P.M. Further review of the September 2013 MAR revealed that three different nursing staff had signed that they administered 80 units of Levemir at 4:30 P.M. on 9/1/13, 9/2/13 and 9/3/13. There was no documentation on the MARs or in the nurses' notes that any of the three nurses questioned the order for 80 mg of Levemir. A review of the facility's policy and procedure for medication ordering and receiving from the pharmacy indicated that medications were received on a timely basis and the facility was to maintain accurate records of medication orders and receipts. A drug reorder book would serve as the facility's permanent record of medication procurement and will be located at each wing. A review of the drug re-ordering and receiving medication orders for Unit 2 and interview with Unit Manager #2 on 9/9/13 at 9:10 A.M., the Unit Manager #2 said "we used to have a book but I haven't seen one this year." The manager then pulled some drug reorder receipts scattered all over the unit. The facility's nurse consultant went with the surveyor to Unit 2 at 9:40 A.M.and searched the unit for the drug re-order book and said, "the facility has to have one on that unit." The nurse consultant was observed to open every drawer at the nurses' station, looked on all the shelves, in between books/folders and in the cabinets of the unit and found no re-ordering drug book. The nurse consultant also found some drug re-order receipts from the pharmacy scattered all over the unit and said there was no pharmacy book. A review of the facility's policy and procedure for monthly physician orders [REDACTED]. The policy indicated that two designated licensed nurses will review the new printed monthly physician order [REDACTED]. An investigation by the Pharmacy Manager, following inquiry by the surveyor, indicated that the pharmacy did not receive the physician's telephone order slip for Levemir insulin for the 7/15/13 physician's orders [REDACTED]. In addition, the pharmacy investigation determined that the Levemir insulin was dispensed to the facility based on the hand-written entry on the August MAR and the signatures of the two nurses who indicated they had edited that MAR. During interview on 9/9/13 at 10:30 A.M., the Pharmacy Director reviewed the pharmacy's investigation completed for Resident #20. The investigation report reviewed how the resident receiving Levemir insulin received the erroneous dosage of 80 units. The Pharmacy Director said the facility received a telephone order from the resident's doctor on 7/15/13 for insulin Levemir 8 units at 4:30 P.M., for Resident #20. The Pharmacy Director said the pharmacy did not receive the telephone order in July 2013 and had no record of the 8 units of Levemir. The Pharmacy Director said the pharmacy received the August monthly edit for Resident #20 and noted the hand written entry for Levemir insulin 8 units at 4:30 P.M. The investigation report indicated the pharmacy's consulting pharmacist read the August edit record and entered in the pharmacy computer Levemir 12 units everyday and 80 units every day at 1630 (4:30 P.M.) The report indicated the pharmacist entry of 80 units was apparently due to mis-reading the "U" in units as a "O". The facility submitted a refill request using the refill sticker for the insulin and on 8/21/13 the pharmacy filled the prescription using the Levemir 12 units daily and 80 units at 1630. This was packed by a technician and verified with another pharmacist. The report had no information of how the pharmacist verified the original insulin order of 8 units of Levemir insulin and no verification of a physician's orders [REDACTED]. According to the pharmacy order sheet, which had a printed date of 8/21/13, provided by the pharmacy upon surveyor request, for Resident #20, the facility received one vial of Levemir insulin 100 units per milliliter (ml), quantity 10 (i.e. 10 ml). On 9/9/13, two vials of Levemir insulin, labeled with Resident #20's name, were brought to the surveyor, both of which were printed as filled on 8/22/13. The label on each vial had the same instructions, "Inject 12 units subcutaneously daily and inject 80 units subcutaneously at 4:30 P.M." These instructions, compared to the physician order, were incorrect for the 4:30 P.M. dose of Levemir insulin. Resident #20 should have received only 8 units of Levemir insulin as the physician had ordered. 2. For Resident #21, the facility failed to recognize a discrepancy between the physician's orders [REDACTED]. The physician ordered that the resident receive the medication once daily for seven days. The pharmacy dispensed 30 tablets with 6 available refills. The medication label did not reflect the physician order [REDACTED]. A review of the facility's policy and procedure for medication ordering and receiving from the pharmacy indicated that medications were received on a timely basis and the facility was to maintain accurate records of medication orders and receipts. A drug order book would serve as the facility's permanent record of medication procurement and will be located at each wing. A review of the drug re-ordering and receiving medication orders for Unit 2 on 9/9/13 at 9:10 A.M., the Unit Manager #2 said "we used to have a book but I haven't seen one this year." The manager then pulled some drug reorder receipts scattered all over the unit. The facility's nurse consultant went with the surveyor to Unit 2 at 9:40 A.M.and searched the unit for the drug re-order book and said, "the facility has to have one on that unit." The nurse consultant was observed to open every drawer at the nurses' station, looked on all the shelves, in between books/folders and in the cabinets of the unit and found no re-ordering drug book. The nurse consultant also found some drug re-order receipts from the pharmacy scattered all over the unit and said there was no pharmacy book. Resident #21 had lived at the facility for several months and had [DIAGNOSES REDACTED]. Review of the resident's record revealed that on 7/16/13, the physician gave an interim order for the resident to receive Flexeril, a muscle relaxant, 5 mg at bedtime for one week. Review of the Medication Administration Record (MAR) for July 2013 revealed that the order was transcribed onto the MAR incorrectly, noting that the drug was to be administered at 6:00 A.M. The nurses signed that the resident received Flexeril on 6 consecutive days at 6:00 A.M. The last nurse signature was circled, indicating that the last dose was not given, according to interview with the Director of Nursing on 9/13/13 at 11:00 A.M. The Director of Nursing provided a copy of a Medication Error Report, dated 7/23/13, which identified the error in timing of administration, i.e. that the order indicated the drug was to be given at bedtime and the order was transcribed onto the MAR to be given at 6:00 A.M. The outcome was written that no effect was noted for the resident. Measures taken to prevent recurrence were noted as education provided on 24 hour checks and telephone order transcription. Attached to the Medication Error Report was a copy of the drug blister pack sent to the facility with the Flexeril. The label on the blister pack had the resident's name and date of 7/16/13. The order printed on the label read cyclobenzaprine (generic name of Flexeril) 5 mg tablet, give 1 tablet by mouth at bedtime, and the quantity was noted as 30 tablets, with 6 refills available. The copy of the blister pack showed that 10 pills had been popped from the blister pack and 20 pills remained. Review of this copy of the blister pack revealed a discrepancy with documentation in the resident's record. The physician order [REDACTED]. The pharmacy label did not note that it was only for 7 days and 30 pills had been in the blister pack, and indicated there were were 6 refills for this prescription. During interview on 9/12/13 at 2:50 P.M., the above information was discussed with the Director of Nursing, and a request was made for more information to clarify the identified discrepancies. The Director of Nursing had no immediate explanation or clarification of the issues. On 9/13/13 at 3:50 P.M., the Director of Nursing said that the pharmacy had been called but they could not provide any clarification on the identified discrepancy or any documentation related to the drug order. The pharmacy staff had advised the Director of Nursing that they would initiate an investigation. The Director of Nursing said no documentation or evidence of the physician order [REDACTED].

Based on record review and staff interview, the facility failed to provide services which met professional standards of quality for medication administration, including accurate transcription, editing, reconciliation and administration, for 10 residents (#1, #2, #4, #5, #9, #11, #12, #20, #21 and #27) in a sample of 27 Residents. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice". Please refer to the "Nursing 2013 Drug Handbook" for accepted standards in regards to proper medication administration along with nursing considerations of drug administration issues. 1. For Resident #20, the facility failed to ensure the medication ordered by the physician was documented correctly on the Medication Administration Record (MAR) and administered as ordered. Staff failed to recognize and clarify the medication administration record for three days and documented that the wrong dose of medication was administered. Two nurses said they did not administer 80 units of [MEDICATION NAME]but gave 8 units, and did not take action to correct the MAR or clarify the physician orders to prevent potential dosage errors. The resident died at the facility the following morning. Resident #20's medical record was reviewed by the surveyor on [DATE] at 1:45 P.M. and initial review indicated a potential medication error. Documentation on the [DATE] MAR indicated that 80 units (10 times the original ordered amount) of [MEDICATION NAME]had been administered on [DATE], [DATE] and [DATE] at 4:30 P.M. The medical record indicated on [DATE], the physician had ordered [MEDICATION NAME]8 units daily at 4:30 P.M. (not 80 units). The July and [DATE] MARs indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M.. During an interview on [DATE] at 1:50 P.M., Unit Manager #2 said the resident had died on [DATE]. The Manager said he/she and the physician were surprised when informed of the resident's death. He/she said the resident had been at his/her baseline the day before and his/her death was not anticipated or expected. On [DATE] at 2:50 P.M., a subsequent interview was conducted with the Director of Nurses and Unit Manager #2. Prior to discussion the medical record indicated the resident had been administered a 10 times higher dose of [MEDICATION NAME]then ordered. The Unit Manager #2 said that the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) had told him/her that he/she had gone into the resident's room to obtain the morning blood sugar and got a blood sugar of 25. The manager said the nurse administered the [MEDICATION NAME] (anti-hypoglycemic) and oxygen, but that the resident died and he/she made the RN Nurse Pronouncement. Review of the MAR for [DATE] indicated the resident received scheduled insulin of [MEDICATION NAME] and [MEDICATION NAME] sliding scale insulin. The physician's order sheet for [DATE] for insulin indicated the following: [MEDICATION NAME]12 units at 6:30 A.M. and [MEDICATION NAME]80 units at 4:30 P.M., [MEDICATION NAME]based on blood sugars obtained at 6:30 A.M. and 4:30 P.M. The 4:30 P.M. dose of [MEDICATION NAME] at 80 units was incorrect on both the physician orders and the MAR. Upon further inquiry with the Director of Nurses and Unit Manager #2, the dose of the [MEDICATION NAME]was discussed. Both agreed that the [DATE] MAR and physician order incorrectly indicated the dose of [MEDICATION NAME]was for 80 units to be administered at 4:30 P.M. The Director of Nurses and Unit Manager #2 said that three different nurses signed the incorrect MAR indicating that they administered 80 units to the resident. The insulin that was originally ordered on [DATE] as 8 units was not documented correctly on the MAR, and three nurses signed that the incorrect dose was administered for three days. Staff took no action to correct the error to prevent future medication errors. Please refer to F309, F425, F428. 2. a) For Resident #12, the facility failed to properly edit the monthly physician order sheets to ensure that multiple orders to administer Tylenol both scheduled and as needed did not exceed the ordered parameter of 3000 mg per day. Resident #12 had lived at the facility for several years and had [DIAGNOSES REDACTED]. Review of the monthly physician order sheets in the resident's record revealed that, since [DATE], the resident had an order for [REDACTED]. On [DATE] the resident started on Tylenol, pain reliever, 650 mg scheduled twice daily at 8 A.M. and 8:00 P.M. On [DATE], the Tylenol order for twice daily was discontinued and a new order was obtained for Tylenol extra strength 1000 mg three times per day scheduled at 6:00 A.M., 2:00 P.M. and 10:00 P.M., with a parameter not to exceed 3000 mg in 24 hours. During interview on [DATE] at 8:35 A.M., Unit Manager #3 said that the parameter not to exceed 3000 mg per day applied to a total of any/all Tylenol administered to the resident in a 24 hour period. The surveyor reviewed the two current Tylenol orders, scheduled and as needed, with Unit Manager #3, who said that he/she recognized that the scheduled Tylenol reached the limit of 3000 mg in 24 hours, and that any additional Tylenol given as needed would exceed the parameter of 3000 mg. Unit Manager #3 said the physician would be contacted for clarification. Review of the Medication Administration Records for June, July, August and [DATE] revealed that no additional Tylenol in excess of the scheduled 3000 mg had been administered to the resident during that time period. b) For Resident #12, the facility failed to ensure that multiple doses of [MEDICATION NAME]based on the sliding scale ordered by the physician were accurately administered, from [DATE] through the time of survey review on [DATE]. Review of the physician orders revealed that as of [DATE], the resident had the following additional orders related to diabetes management: - Capillary Blood Glucose (CBG) four times daily (6:30 A.M., 10:00 A.M., 2:00 P.M., 8:00 P.M.), - Hold sliding scale insulin unless CBG is over 400, and - do not cover bedtime CBG Review of the physician orders for [DATE] revealed that the resident had an order for [REDACTED]. CBG ,[DATE], 8 units CBG of 450 or greater, 10 units and notify the physician Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, revealed the following errors: [DATE] - at 8:00 P.M. (the bedtime dose), the resident was given 3 units of [MEDICATION NAME]for a CBG of 267, when the physician order stipulated no insulin was to be given at bedtime and coverage should not have been given for CBG less than 400 [DATE] - at 10:00 A.M., CBG of 419 and 10 units administered, which should have been 8 units according to the sliding scale [DATE] - at 10:00 A.M., CBG of 411 and 10 units administered, which should have been 8 units according to the sliding scale [DATE] - at 8:00 P.M., the resident was given 8 units of [MEDICATION NAME]for a CBG of 476, when the physician order stipulated no insulin was to be given at bedtime [DATE] - at 8:00 P.M., the resident was given 10 units of [MEDICATION NAME]for a CBG of 510, when the physician order stipulated no insulin was to be given at bedtime [DATE] - at 8:00 P.M., the resident was given 8 units of [MEDICATION NAME]for a CBG of 402, when the physician order stipulated no insulin was to be given at bedtime [DATE] - at 2:00 P.M., no CBG result was recorded [DATE] - at 2:00 P.M., no CBG result was recorded [DATE] - at 8:00 P.M., no CBG result was recorded [DATE], [DATE], [DATE], [DATE], [DATE] - at 10:00 A.M., the resident was given [MEDICATION NAME]according to the sliding scale even though coverage should not have been given for CBG less than 400 [DATE], [DATE], [DATE] - at 2:00 P.M., the resident was given [MEDICATION NAME]according to the sliding scale even though coverage should not have been given for CBG less than 400 [DATE] and [DATE] - at 2:00 P.M., no CBG result recorded [DATE] - at 8:00 P.M., no CBG result recorded Record review revealed that on [DATE], the physician changed the CBG and sliding scale orders, with no change to the sliding scale dosing, as follows: - Check the CBG level twice daily at 11:30 A.M. and 8:00 P.M., and - Give sliding scale [MEDICATION NAME]coverage only if the CBG was over 400 Sliding scale insulin administration errors, after [DATE], were identified as follows: [DATE], 8:00 P.M., the CBG was 408 but no insulin was given [DATE], 8:00 P.M., the CBG was 445 but no insulin was given [DATE], 8:00 P.M., the CBG was 446 but no insulin was given [DATE], 8:00 P.M., the CBG was 421 but no insulin was given [DATE], 8:00 P.M., the CBG was 432 but no insulin was given [DATE], 8:00 P.M., the CBG was 270 and it was documented that 4 units of insulin was given On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised that there were multiple insulin errors as noted above. 3. For Resident #2, the facility failed to ensure that the medication administration records (MAR) were accurate and that the resident received the medications as ordered by the physician. The physician's orders was for the resident to receive lactobacillus (a [MEDICATION NAME]) and [MEDICATION NAME] (anti reflux drug) daily. However, the resident was administered extra strength acidophilus ([MEDICATION NAME]) instead of the ordered lactobacillus, and for 5 days did not receive the [MEDICATION NAME]. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The most recent significant change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was independent with set up for eating. The MDS assessment also indicated the resident had significant change in status for ability to make needs known and required extensive assistance from staff for activities of daily living. Review of the medical record indicated the resident was hospitalized and readmitted to the facility on [DATE]. The readmission physician orders indicated the resident was to receive [MEDICATION NAME] 20 mg daily and lactobacillus 1 capsule daily. Review of the Medication Administration Record (MAR) for [DATE] indicated the nursing staff consistently administered both medications. Review of the [DATE] MAR indicated that the [MEDICATION NAME] had not been transcribed onto the MAR and next to the lactobacillus the letters "ES" was added. According to the clinical record the [MEDICATION NAME] was not discontinued and there was no evidence the physician had altered the order for lactobacillus. The documentation indicated that the resident did not received the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE] and [DATE] and received lactobacillus "ES" daily. During interview on [DATE] at 11:00 A.M., with Nurse #3, the surveyor inquired about the "ES" documented on the MAR next to the lactobacillus. Nurse #3 said that the it stood for extra strength. The nurse opened the medication cart and took out a bottle of extra strength acidophilus. The Nurse was asked if the bottle he/she was showing the surveyor was the medication administered to the resident as lactobacillus and the nurse said yes. The MAR was reviewed with Nurse #3 and confirmed that this was not the medication ordered by the physician. During interview on [DATE] at 11:30 A.M. the Unit Manager #2 and the Charge Nurse, he/she said that the [MEDICATION NAME] had not been transcribed from the August to September orders. The charge nurse said he/she would call the physician. On [DATE] at 1:00 P.M., information related to the administration of these two medications was discussed with the Director of Nurses. On [DATE], the Director of Nurses provided a Medication Error Investigation form and the investigation indicated that the medication [MEDICATION NAME] was omitted from the September MAR, but that it was an editing problem. However, the investigation form did not address the interchange of [MEDICATION NAME] medication and that the resident had not received 5 doses of the [MEDICATION NAME]. 4. For Resident #1, the facility staff failed to ensure that multiple scheduled and PRN (as needed) medications appeared correctly and as ordered on the monthly medication administration records (MAR). Resident #1, a long term care resident who had [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had short and long term memory loss, and required extensive assistance from staff for transfer, dressing and hygiene. Review of the [DATE] monthly physician orders and MAR (medication administration record) indicated the resident received vitamin D 2 50,000 international units, 1 capsule daily on Mondays and Fridays. Review of the July, August and [DATE] MARs indicated the resident was not administered the Vitamin D2 as ordered because he MARs indicated that the medication was discontinued on [DATE]. However, review of the [DATE] monthly physician orders failed to locate any order to discontinue the Vitamin D2and it should not have been discontinued. Further review of the [DATE] MAR indicated the following medications were to be administered to the resident as needed (PRN). - [MEDICATION NAME], 10 mg (milligram) suppository, PRN - Milk of Magnesia (MOM), 30 cc, PRN - [MEDICATION NAME] HCL, 25 mg, 4 times a day/PRN. - Robitussion 10 ml, every 4 hours/PRN. Review of the August and [DATE] physician orders and MAR indicated that these medications were no longer included on the MAR and therefore were not available to the resident. There was no physician order discontinuing any of the PRN medications. In addition, on [DATE] the physician ordered vitamin B 12, 50,000 international units/milliliters, 1 capsule daily on Mondays and Fridays. On [DATE], this order was discontinued and changed to vitamin B 12 ([MEDICATION NAME]) injection 1000 mcg (micrograms) monthly. However, the nurse documented the order as 1000 units not micrograms. Review of the August MAR, physician orders and actual medication indicated the pharmacy had labeled it correctly. During interview on [DATE] at 10:50 A.M., the surveyor reviewed the medication concerns with Unit Manager #2. Unit Manager #2 said he/she could not explain the medication concerns but would look into the matter. On [DATE] at approximately 10:00 A.M., the Director of Nurses provided two medication error reports dated [DATE]. Review of the reports confirmed that the nursing staff had not properly edited the MARs and had failed to ensure that the physician's orders were in place in accordance with the plan of care. In addition, the investigation identified that the nursing staff documented an incorrect dose and that the resident did not receive some of the medications. The investigation indicated that the correct medications were added to the MAR. On [DATE] at 11:30 A.M., the physician orders and September MAR was reviewed. The nursing staff obtained physician orders on [DATE] for [MEDICATION NAME], 10 mg (milligram) suppository, PRN, Milk of Magnesia (MOM), 30 cc, PRN, [MEDICATION NAME] HCL, 25 mg, 4 times a day/PRN, robitussion 10 ml, every 4 hours/PRN and for vitamin D 2 50,000 international units, 1 capsule daily on Mondays and Fridays. However, according to the [DATE] MAR, the vitamin D 2 was not documented to be administered. The Director of Nurses was advised and he/she stated he/she would take care of it. On [DATE] at 1:00 P.M., Unit Manager #2 said he/she was unaware that the vitamin D 2 was not transcribed on the MAR. He/she said she must of forgot. 5. For Resident #5, the facility failed to accurately edit the physician orders by having two separate physician orders for skin treatments that the resident did not have, and the treatments were not being done. Resident #5 was a long term care resident with multiple [DIAGNOSES REDACTED]. The medical record was reviewed [DATE]. A review of the last quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had short and long term memory problems and was totally dependent on staff for all activity's of daily. The assessment indicated the resident was at risk for pressure ulcers and had no pressure areas. A review of the monthly physician orders for [DATE] indicted the resident had two physician's orders for skin treatments for pressure ulcers. The first physician order dated [DATE] indicated to cleanse the resident's small of back with normal saline and apply [MEDICATION NAME] powder and followed by an allevyn dressing and to do a daily dressing change. The second physician's order dated [DATE] indicated the resident had a Stage II area on the coccyx and the treatment was for a saline spray and apply a [MEDICATION NAME] dressing and change the dressing every 3 days. A review of the [DATE] and [DATE] treatment records and nursing documentation indicated the resident had no pressure areas. The surveyor observed on [DATE] at 10:20 A.M., with the Unit Manager #3, the resident's skin was clear of pressure areas. Interview with the Unit Manager #3 after the observation of the residents skin, the manager reviewed the orders and said he/she said the physician's order needed to be reviewed and the old skin treatments needed to be removed from the orders. 6. For Resident #9, the facility failed to follow the physician's orders for the administration of an antilipemic medication, from admission to the facility on [DATE] to the date of medical record review on [DATE]. The facility was not aware the nursing staff were not following the physician's orders. Resident #9 was admitted for long term care placement following a hospitalization for gait instability and was diagnosed with [REDACTED]. The hospital discharge physician's orders on [DATE] indicated the resident was to receive [MEDICATION NAME] (an antilipemic) 40 mg. every other day. The facility's admission physician's orders for [DATE] also noted the medication [MEDICATION NAME] was to be given every other day. A review of the medication administration records from admission [DATE] - [DATE] indicated the nurses' administered the medication to the resident every day and did not follow the physician's order for every other day. Refer to F329. 7. a) For Resident #21, the facility failed to ensure that the physician interim orders were accurately transcribed and edited for the time of administration of [MEDICATION NAME]. Staff failed to follow the facility's policies and procedures for editing and transcribing medication orders, as well as documentation and recording upon receipt of medications from the pharmacy. Resident #21 had [DIAGNOSES REDACTED]. Review of the resident's record revealed that on [DATE] the physician gave an interim order for the resident to receive [MEDICATION NAME], a muscle relaxant, 5 mg at bedtime for one week. Review of the Medication Administration Record (MAR) for [DATE] revealed that the order was transcribed onto the MAR incorrectly, noting that the drug was to be administered at 6:00 A.M. The nurses signed that the resident received [MEDICATION NAME] on 6 consecutive days at 6:00 A.M. The last nurse signature was circled on [DATE] with no documentation why the signature was circled. According to interview with the Director of Nursing on [DATE] at 11:00 A.M., the circled signature indicated that the last dose was not given, The Director of Nursing provided a copy of a Medication Error Report, dated [DATE], which identified the error in timing of administration, i.e. that the order indicated the drug was to be given at bedtime and the order was transcribed onto the MAR to be given at 6:00 A.M. The outcome was written that no effect was noted for the resident. Measures taken to prevent recurrence were noted as education provided on 24 hour checks and telephone order transcription. Review of this copy of the blister pack revealed that the pharmacy label did not note that the drug was only for 7 days. There were 30 pills in the blister pack. On [DATE] at 11:00 A.M., the Director of Nursing said that no documentation by the nurse who had circled the last dose as not given had been found. The Director of Nursing said that there should have been a note by the nurse, with an explanation why it was not administered to the resident. The Director of Nursing said she thought it might have been because the nurse noticed the timing discrepancy, but had no explanation why the nurse did not then correct the error on the MAR so the last dose could be given at bedtime as ordered. The Director of Nursing had no explanation why the pharmacy label was different from the facility's physician interim order or why this discrepancy was not identified upon reconciliation when the medication was delivered by the pharmacy. A review of the facility's policy and procedure for medication ordering and receiving from the pharmacy included that medications were received on a timely basis and the facility was to maintain accurate records of medication orders and receipts. A drug order book would serve as the facility's permanent record of medication procurement and would be located at each wing. During interview on [DATE] at 9:10 A.M., the Unit Manager #2 said the facility did not use a drug order book, and there was no drug order book on the unit. A review of the facility's policy and procedure for monthly physician orders editing indicated the new order sheets and MARs printed at the end of month would be reviewed and edited by licensed nursing staff for the following month. The policy indicated that two designated licensed nurses would review the new computer-generated physician order sheets for the upcoming month and compare them to the current physician's sheets in the clinical records. Review of the MAR for [DATE], which included the admnistration record for [MEDICATION NAME], revealed that only one nurse's signature that the editing of the MAR had been done. b) Additionally, for Resident #21, the facility failed to administer an accurate dose of [MEDICATION NAME]based on the sliding scale ordered by the physician since at least [DATE]. The resident had a physician order for [REDACTED]. CBG ,[DATE], no coverage CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. Multiple errors were found in several months, as follows: [DATE], 8:00 P.M., CBG 338, no insulin documented as given, should have received 8 units [DATE], 11:30 P.M., CBG 170, no insulin documented as given, should have received 2 units [DATE], 8:00 P.M., CBG 325, given 10 units, should have received 8 units [DATE], 4:30 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 4:30 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., CBG 179, no insulin given, should have received 2 units [DATE], 4:30 P.M., CBG 321, no insulin documented as given, should have received 8 units [DATE], 8:00 P.M., CBG 193, no insulin documented as given, should have received 2 units [DATE], 8:00 P.M., CBG 247, given 6 units, should have received 4 units [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., CBG 180, no insulin documented as given, should have received 2 units [DATE], 11:30 A.M., CBG 279, given 8 units, should have received 6 units [DATE], 8:00 P.M., CBG 317, given 4 units, should have received 8 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 6:30 A.M., CBG 154, no insulin given, should have received 2 units [DATE], 8:00 P.M., CBG 216, no insulin documented as given, should have received 4 units [DATE], 4:30 P.M., CBG 205, no insulin documented as given, should have received 4 units [DATE], 8:00 P.M., CBG 202, no insulin documented as given, should have received 4 units [DATE], 6:30 A.M., CBG 175, no insulin documented as given, should have received 2 units [DATE], 4:30 P.M., CBG 209, no insulin documented as given, should have received 4 units [DATE], 6:30 A.M., CBG 160, no insulin given, should have received 2 units [DATE], 4:00 P.M., CBG 168, no insulin documented as given, should have received 2 units [DATE], 4:30 P.M., CBG 235, no insulin documented as given, should have received 4 units [DATE], 8:00 P.M., CBG 242, no insulin documented as given, should have received 4 units [DATE], 8:00 P.M., CBG 250, given 4 units, should have received 6 units [DATE], 11:30 A.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., CBG 250, given 4 units, should have received 6 units [DATE], 4:30 P.M., CBG 298, given 5 units, should have received 6 units [DATE], 6:30 A.M., CBG 180, no insulin given, should have received 2 units [DATE], 11:30 A.M., no CBG recorded, no insulin documented as given [DATE], 11:30 A.M., CBG 270, given 2 units, should have received 4 units [DATE], 4:30 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., CBG 176, given 4 units, should have received 2 units [DATE], 11:30 A.M., no CBG recorded, no insulin documented as given [DATE], 11:30 A.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., CBG 170, no insulin given, should have received 2 units [DATE], 4:30 P.M., CBG 245, given 6 units, should have received 4 units [DATE], 6:30 A.M., CBG 167, no insulin given, should have received 2 units [DATE], 4:30 P.M., CBG 202, given 2 units, should have received 4 units [DATE], 4:30 P.M., CBG 264, given 4 units, should have received 6 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 8. a) For Resident #4, the facility failed to ensure that staff did not administer insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on [DATE], the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. There was no evidence that the physician was contacted to clarify the timing of the CBG and the sliding scale. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer sliding scale insulin, contrary to the physician's order, at 6:30 A.M. from the time of the change in order on [DATE] through the date of survey review on [DATE], as follows: [DATE], CBG 276, received 6 units of insulin [DATE], CBG 190, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 203, received 4 units [DATE], CBG 158, received 2 units [DATE], CBG 237, received 4 units [DATE], CBG 195, received 2 units [DATE], CBG 158, received 2 units [DATE], CBG 173, received 2 units [DATE], CBG 208, received 4 units [DATE], CBG 232, received 4 units [DATE], CBG 224, received 4 units [DATE], CBG 166, received 2 units [DATE], CBG 183, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 282, received 6 units [DATE], CBG 290, received 6 units [DATE], CBG 198, received 2 units [DATE], CBG 190, received 2 units [DATE], CBG 200, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 159, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 208, received 4 units [DATE], CBG 153, received 2 units [DATE], CBG 215, received 2 units [DATE], CBG 241, received 4 units [DATE], CBG 180, received 2 units [DATE], CBG 151, received 2 units [DATE], CBG 167, received 2 units [DATE], CBG 285, received 6 units [DATE], no CBG recorded [DATE], CBG 201, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 175, received 2 units [DATE], CBG 157, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 171, received 2 units [DATE], CBG 170, received 2 units [DATE], CBG 184, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 214, received 4 units [DATE], CBG 155, received 2 units [DATE], CBG 188, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 177, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 175, received 2 units [DATE], CBG 150, received 2 units [DATE], CBG 187, received 2 units [DATE], CBG 205, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 227, received 2 units During interview on [DATE] at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from [DATE] through the date of survey review on [DATE] revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's order. On [DATE] at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. b) Additionally, for Resident #4, the facility failed to accurately administer multiple doses of Humalog insulin based on the sliding scale ordered by the physician s

Based on record reviews, observations and staff interviews, the facility was not managed in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings included: The survey team found quality of life and quality of care issues that impacted the residents daily life. In addition the facility staff's failure to follow policy and procedures were determined widespread. During the survey dated 9/3/13 - 9/13/13, the survey team found the facility's medication management system to be inaccurate and ineffective. The survey team found medication errors, transcription errors, the inaccurate editing of physician orders, and administration of medications that included the wrong dose and wrong directions. The facility's pharmacy services filled prescriptions with no physician orders, monthly pharmacy reviews did not include identifying inaccurate physician's orders or medication errors. The facility did not follow their policy and procedure for ordering and receiving medications. Please refer to the F281, F309, F329, F425, F428, F520.

Based on record and document review, observation, interview with staff, interview with residents and families, the facility failed to provide pharmaceutical services that ensured 1) the accuracy of insulin, 2) identify an inaccurate physician order [REDACTED].#20 and #21) in a total sample of 27 residents. Findings include: 1. For Resident #20, the facility failed to identify that the pharmacy-generated label on the vial of Levemir insulin was incorrect. The pharmacy label indicated the dose was ten times the actual dose ordered by the physician, with the potential for serious harm for the resident.. On 9/4/13 at 5:45 A.M. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 25 taken by Nurse #1 (normal range 70-120). The resident expired at the facility at 6:20 A.M. Resident #20 had [DIAGNOSES REDACTED]. The resident was receiving Levemir insulin 12 units daily every morning since 2011. Review of the telephone order sheets revealed that on 7/15/13 the physician added a new order for Levemir insulin 8 units daily at 4:30 P.M. Review of the August Medication Administration Record (MAR) revealed that this new order was handwritten on the MAR. Review of the September MAR revealed a printed entry reading Levemir 80 units daily at 4:30 P.M. Further review of the September 2013 MAR revealed that three different nursing staff had signed that they administered 80 units of Levemir at 4:30 P.M. on 9/1/13, 9/2/13 and 9/3/13. There was no documentation on the MARs or in the nurses' notes that any of the three nurses questioned the order for 80 mg of Levemir. A review of the facility's policy and procedure for medication ordering and receiving from the pharmacy indicated that medications were received on a timely basis and the facility was to maintain accurate records of medication orders and receipts. A drug reorder book would serve as the facility's permanent record of medication procurement and will be located at each wing. A review of the drug re-ordering and receiving medication orders for Unit 2 and interview with Unit Manager #2 on 9/9/13 at 9:10 A.M., the Unit Manager #2 said "we used to have a book but I haven't seen one this year." The manager then pulled some drug reorder receipts scattered all over the unit. The facility's nurse consultant went with the surveyor to Unit 2 at 9:40 A.M.and searched the unit for the drug re-order book and said, "the facility has to have one on that unit." The nurse consultant was observed to open every drawer at the nurses' station, looked on all the shelves, in between books/folders and in the cabinets of the unit and found no re-ordering drug book. The nurse consultant also found some drug re-order receipts from the pharmacy scattered all over the unit and said there was no pharmacy book. A review of the facility's policy and procedure for monthly physician orders [REDACTED]. The policy indicated that two designated licensed nurses will review the new printed monthly physician order [REDACTED]. An investigation by the Pharmacy Manager, following inquiry by the surveyor, indicated that the pharmacy did not receive the physician's telephone order slip for Levemir insulin for the 7/15/13 physician's orders [REDACTED]. In addition, the pharmacy investigation determined that the Levemir insulin was dispensed to the facility based on the hand-written entry on the August MAR and the signatures of the two nurses who indicated they had edited that MAR. During interview on 9/9/13 at 10:30 A.M., the Pharmacy Director reviewed the pharmacy's investigation completed for Resident #20. The investigation report reviewed how the resident receiving Levemir insulin received the erroneous dosage of 80 units. The Pharmacy Director said the facility received a telephone order from the resident's doctor on 7/15/13 for insulin Levemir 8 units at 4:30 P.M., for Resident #20. The Pharmacy Director said the pharmacy did not receive the telephone order in July 2013 and had no record of the 8 units of Levemir. The Pharmacy Director said the pharmacy received the August monthly edit for Resident #20 and noted the hand written entry for Levemir insulin 8 units at 4:30 P.M. The investigation report indicated the pharmacy's consulting pharmacist read the August edit record and entered in the pharmacy computer Levemir 12 units everyday and 80 units every day at 1630 (4:30 P.M.) The report indicated the pharmacist entry of 80 units was apparently due to mis-reading the "U" in units as a "O". The facility submitted a refill request using the refill sticker for the insulin and on 8/21/13 the pharmacy filled the prescription using the Levemir 12 units daily and 80 units at 1630. This was packed by a technician and verified with another pharmacist. The report had no information of how the pharmacist verified the original insulin order of 8 units of Levemir insulin and no verification of a physician's orders [REDACTED]. According to the pharmacy order sheet, which had a printed date of 8/21/13, provided by the pharmacy upon surveyor request, for Resident #20, the facility received one vial of Levemir insulin 100 units per milliliter (ml), quantity 10 (i.e. 10 ml). On 9/9/13, two vials of Levemir insulin, labeled with Resident #20's name, were brought to the surveyor, both of which were printed as filled on 8/22/13. The label on each vial had the same instructions, "Inject 12 units subcutaneously daily and inject 80 units subcutaneously at 4:30 P.M." These instructions, compared to the physician order, were incorrect for the 4:30 P.M. dose of Levemir insulin. Resident #20 should have received only 8 units of Levemir insulin as the physician had ordered. 2. For Resident #21, the facility failed to recognize a discrepancy between the physician's orders [REDACTED]. The physician ordered that the resident receive the medication once daily for seven days. The pharmacy dispensed 30 tablets with 6 available refills. The medication label did not reflect the physician order [REDACTED]. A review of the facility's policy and procedure for medication ordering and receiving from the pharmacy indicated that medications were received on a timely basis and the facility was to maintain accurate records of medication orders and receipts. A drug order book would serve as the facility's permanent record of medication procurement and will be located at each wing. A review of the drug re-ordering and receiving medication orders for Unit 2 on 9/9/13 at 9:10 A.M., the Unit Manager #2 said "we used to have a book but I haven't seen one this year." The manager then pulled some drug reorder receipts scattered all over the unit. The facility's nurse consultant went with the surveyor to Unit 2 at 9:40 A.M.and searched the unit for the drug re-order book and said, "the facility has to have one on that unit." The nurse consultant was observed to open every drawer at the nurses' station, looked on all the shelves, in between books/folders and in the cabinets of the unit and found no re-ordering drug book. The nurse consultant also found some drug re-order receipts from the pharmacy scattered all over the unit and said there was no pharmacy book. Resident #21 had lived at the facility for several months and had [DIAGNOSES REDACTED]. Review of the resident's record revealed that on 7/16/13, the physician gave an interim order for the resident to receive Flexeril, a muscle relaxant, 5 mg at bedtime for one week. Review of the Medication Administration Record (MAR) for July 2013 revealed that the order was transcribed onto the MAR incorrectly, noting that the drug was to be administered at 6:00 A.M. The nurses signed that the resident received Flexeril on 6 consecutive days at 6:00 A.M. The last nurse signature was circled, indicating that the last dose was not given, according to interview with the Director of Nursing on 9/13/13 at 11:00 A.M. The Director of Nursing provided a copy of a Medication Error Report, dated 7/23/13, which identified the error in timing of administration, i.e. that the order indicated the drug was to be given at bedtime and the order was transcribed onto the MAR to be given at 6:00 A.M. The outcome was written that no effect was noted for the resident. Measures taken to prevent recurrence were noted as education provided on 24 hour checks and telephone order transcription. Attached to the Medication Error Report was a copy of the drug blister pack sent to the facility with the Flexeril. The label on the blister pack had the resident's name and date of 7/16/13. The order printed on the label read cyclobenzaprine (generic name of Flexeril) 5 mg tablet, give 1 tablet by mouth at bedtime, and the quantity was noted as 30 tablets, with 6 refills available. The copy of the blister pack showed that 10 pills had been popped from the blister pack and 20 pills remained. Review of this copy of the blister pack revealed a discrepancy with documentation in the resident's record. The physician order [REDACTED]. The pharmacy label did not note that it was only for 7 days and 30 pills had been in the blister pack, and indicated there were were 6 refills for this prescription. During interview on 9/12/13 at 2:50 P.M., the above information was discussed with the Director of Nursing, and a request was made for more information to clarify the identified discrepancies. The Director of Nursing had no immediate explanation or clarification of the issues. On 9/13/13 at 3:50 P.M., the Director of Nursing said that the pharmacy had been called but they could not provide any clarification on the identified discrepancy or any documentation related to the drug order. The pharmacy staff had advised the Director of Nursing that they would initiate an investigation. The Director of Nursing said no documentation or evidence of the physician order [REDACTED].

Based on record review, staff interview and review of pharmacy records for the facility, the consultant pharmacist failed, during monthly review of each resident's regimen of medications, to identify and report all irregularities to the attending physician and the director of nursing, for 10 of 27 residents (#1, #2, #4, #9, #11, #12, #20, #21, #25 and #27) with identified medication errors, and 5 of these 10 residents had more than one medication error identified during survey (#2, #4, #12, #21 and #25). The facility had a pharmacy services agreement with the pharmacy that included the provision of drugs and the services of a consultant licensed pharmacist. A review of the agreement indicated the consultant pharmacist would provide a written monthly review of each resident's drug regimen. A review of the residents' medication administration records and physicians' orders indicated numerous medication errors not identified by the consultant pharmacist. Findings include: 1. For Resident #4, the consultant pharmacist failed to identify and report that staff were administering insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on 3/17/13, the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. CBG check, though it was to be used at the other three times. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer insulin at 6:30 A.M. from the time of the change in order on 3/17/13 through the date of survey review on 9/3/13, as follows: 3/25/13, CBG 276, received 6 units of insulin 3/26/13, CBG 190, received 2 units 3/27/13, CBG 160, received 2 units 4/2/13, CBG 203, received 4 units 4/4/13, CBG 158, received 2 units 4/15/13, CBG 237, received 4 units 4/16/13, CBG 195, received 2 units 5/2/13, CBG 158, received 2 units 5/6/13, CBG 173, received 2 units 5/9/13, CBG 208, received 4 units 5/12/13, CBG 232, received 4 units 5/13/13, CBG 224, received 4 units 5/15/13, CBG 166, received 2 units 5/17/13, CBG 183, received 2 units 5/17/13, CBG 166, received 2 units 5/19/13, CBG 282, received 6 units 5/20/13, CBG 290, received 6 units 5/25/13, CBG 198, received 2 units 5/26/13, CBG 190, received 2 units 5/27/13, CBG 200, received 2 units 5/29/13, CBG 164, received 2 units 5/31/13, CBG 159, received 2 units 6/1/13, CBG 219, received 4 units 6/2/13, CBG 208, received 4 units 6/3/13, CBG 153, received 2 units 6/5/13, CBG 215, received 2 units 6/6/13, CBG 241, received 4 units 6/7/13, CBG 180, received 2 units 6/9/13, CBG 151, received 2 units 6/12/13, CBG 167, received 2 units 6/13/13, CBG 285, received 6 units 6/14/13, no CBG recorded 6/15/13, CBG 201, received 4 units 6/20/13, CBG 163, received 2 units 6/26/13, CBG 175, received 2 units 7/1/13, CBG 157, received 2 units 7/2/13, CBG 219, received 4 units 7/4/13, CBG 171, received 2 units 7/16/13, CBG 170, received 2 units 7/19/13, CBG 184, received 2 units 7/21/13, CBG 160, received 2 units 7/30/13, CBG 214, received 4 units 8/4/13, CBG 155, received 2 units 8/5/13, CBG 188, received 2 units 8/8/13, CBG 164, received 2 units 8/14/13, CBG 177, received 2 units 8/15/13, CBG 166, received 2 units 8/18/13, CBG 225, received 4 units 8/21/13, CBG 175, received 2 units 8/24/13, CBG 150, received 2 units 8/25/13, CBG 187, received 2 units 8/29/13, CBG 205, received 4 units 8/30/13, CBG 163, received 2 units 8/31/13, CBG 225, received 4 units 9/1/13, CBG 227, received 2 units During interview on 9/3/13 at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from March 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On 9/3/13 at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. Additionally, for Resident #4, the consultant pharmacist failed to identify and report that staff did not accurately administer multiple doses of Humalog insulin based on the sliding scale ordered by the physician since at least January 2013. Resident #4 had a [DIAGNOSES REDACTED].M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The resident received Novolog insulin based on a sliding scale as follows: CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and call the physician Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record [REDACTED] (Prior to 3/17/13 there was an order to give at 6:30 A.M., and errors at that time are counted. After 3/17/13, any insulin given at 6:30 A.M. was not counted. ) 1/14/13, 8:00 P.M., CBG 411, given no insulin, should have received 12 units 1/16/13, 6:30 A.M., CBG 184, given no insulin, should have received 2 units 2/1/13, 11:30 A.M., CBG 272, given no insulin, should ahve received 6 units 2/1/13, 8:00 P.M., CBG 319, given no insulin, should have received 8 units 2/7/13, 8:00 P.M., CBG 315, given 6 units, should have received 8 units 2/11/13, 6:30 A.M., CBG 238, given 8 units, should have received 4 units 2/15/13, 6:30 A.M., CBG 263, no insulin documented as given, should have received 6 units 2/15/13, 4:30 P.M., CBG 373, given 8 units, should have received 10 units 2/17/13, 8:00 P.M., CBG 356, no insulin documented as given, should have received 10 units 2/21/13, 6:30 A.M., CBG 187, no insulin documented as given, should have received 2 units 2/24/13, 4:30 P.M., CBG 491, given 12 units, should have received 14 units 2/26/13, 4:30 P.M., no CBG recorded, no insulin documented as given 2/26/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/27/13, 4:30 P.M., no CBG recorded, no insulin documented as given 2/27/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/28/13, 6:30 A.M., CBG 339, given 6 units, should have received 8 units 2/28/13, 4:30 P.M., CBG 425, no insulin documented as given, should have received 12 units 2/28/13, 8:00 P.M., CBG 491, no insulin documented as given, should have received 8 units 3/3/13, 4:30 P.M., CBG 400, given 10 units, should have received 12 units 3/6/13, 8:00 P.M., CBG 349, given 10 units, should have received 8 units 3/8/13, 6:30 A.M., CBG 284, no insulin documented as given, should have received 6 units 3/14/13, 4:30 P.M., CBG 290, no documentation of insulin given, should have received 6 units 3/14/13, 8:00 P.M., CBG 320, given 10 units, should have received 8 units 3/15/13, 6:30 A.M., CBG 291, no insulin documented as given, should have received 6 units 3/15/13, 4:30 P.M., CBG 308, no insulin documented as given, should have received 8 units 3/14/13, 8:00 P.M., CBG 320, given 10 units, should have received 8 units 3/16/13, 8:00 P.M., CBG 275, given 8 units, should have received 6 units (on 3/17/13, the times of the CBG and insulin was changed by the physician to 6:30 A.M., 10:30 A.M., 2:00 P.M. and 8:00 P.M.) 3/17/13, 2:00 P.M., CBG 452, given 12 units, should have received 14 units 3/19/13, 2:00 P.M., no CBG recorded, no insulin documented as given 3/20/13, 8:00 P.M., CBG 375, no insulin documented as given, should have received 10 units 3/25/13, 10:30 A.M., CBG 251, given 4 units, should have received 6 units 3/38/13, 8:00 P.M., CBG 184, no insulin was documented as given, should have received 2 units 3/29/13, 10:30 A.M., no CBG recorded, no insulin documented as given 3/29/13, 8:00 P.M., no CBG recorded, no insulin documented as given 3/30/13, 8:00 P.M., no CBG recorded, no insulin documented as given 3/31/13, 8:00 P.M., CBG 277, no insulin was documented as given, should have received 6 units 4/2/13, 8:00 P.M., CBG 293, no insulin documented as given, should have received 6 units 4/3/13, 8:00 P.M., CBG 290, no insulin documented as given, should have received 6 units 4/8/13, 8:00 P.M., CBG 251, no insulin documented as given, should have received 6 units 4/9/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/12/13, 8:00 P.M., CBG 288, no documentation of insulin given, should have received 6 units 4/17/13, 8:00 P.M., CBG 257, no documentation of insulin given, should have received 6 units 4/18/13, 10:30 A.M., CBG 156, no insulin documented as given, should have received 2 units 4/19/13, 2:00 P.M., CBG 202, no insulin documented as given, should have received 4 units 4/20/13, 8:00 P.M., CBG 279, no insulin documented as given, should have received 6 units 4/25/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/25/13, 8:00 P.M., CBG 204, no insulin documented as given, should have received 4 units 4/28/13, 8:00 P.M., CBG 184, given 4 units insulin, should have received 2 units 4/29/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/30/13, 2:00 P.M., no CBG recorded, no insulin documented as given 5/1/13, 8:00 P.M., CBG 232, given 6 units, should have received 4 units 5/5/13, 8:00 P.M., CBG 292, given 8 units, should have received 6 units 5/13/13, 2:00 P.M., CBG 182, given no insulin, should have received 2 units 5/16/13, 8:00 P.M., CBG 230, no insulin given, should have received 4 units 5/18/13, 8:00 P.M., CBG 445, no insulin given, should have received 12 units 5/23/13, 8:00 P.M., CBG 181, no insulin given, should have received 2 units 6/3/13, 8:00 P.M., CBG 160, no insulin given, should have received 2 units 6/6/13, 10:30 A.M., CBG 262, given 4 units, should have received 6 units 6/14/13, 8:00 P.M., no CBG recorded, no insulin documented as given 6/20/13, 8:00 P.M., CBG 248, given 6 units, should have received 4 units 6/21/13, 8:00 P.M., CBG 247, given 6 units, should have received 4 units 6/22/13, 10:30 A.M., CBG 322, given 6 units, should have received 8 units 6/22/13, 2:00 P.M., CBG 301, given 6 units, should have received 8 units 6/23/13, 2:00 P.M., no CBG recorded, no insulin documented as given 6/25/13, 2:00 P.M., CBG 232, given 6 units, should have received 4 units 6/28/13, 2:00 P.M., CBG 269, given 8 units, should have received 6 units 6/30/13, 8:00 P.M., CBG 223, no insulin documented as given, should have received 4 units 7/3/13, 10:00 A.M., CBG 441, no insulin documented as given, should have received 12 units 7/4/13, 10:00 A.M., CBG 255, given 4 units, should have received 6 units 7/5/13, 2:00 P.M., CBG 250, no insulin documented as given, should have received 6 units 7/7/13, 10:00 P.M., CBG 308, no insulin documented as given, should have received 8 units 7/13/13, 2:00 P.M., no CBG recorded, no insulin documented as given 7/14/13, 2:00 P.M., no CBG recorded, no insulin documented as given 7/18/13, 8:00 P.M., CBG 362, given 8 units, should have received 10 units 7/21/13, 10:00 P.M., CBG 243, given 6 units, should have received 4 units 7/23/13, 8:00 P.M., CBG 321, given 6 units, should have received 8 units 7/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/2/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/7/13, 2:00 P.M., CBG 178, no insulin documented as given, should have received 2 units 8/8/13, 2:00 P.M., CBG 155, no insulin documented as given, should have received 2 units 8/10/13, 10:30 A.M., CBG 150, no insulin documented as given, should have received 2 units 8/14/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/15/13, 8:00 P.M., CBG 351, given 8 units, should have received 10 units 8/21/13, 8:00 P.M., CBG 386, given 8 units, should have received 10 units 8/31/13, 8:00 P.M., CBG 350, given 8 units, should have received 10 units 9/3/13, 2:00 P.M., CBG 150, no insulin was documented as given, should have received 2 units Review of the monthly drug regimen review by the consultant pharmacist from March 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 6 month period. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as outlined above. 2. a) For Resident #21, the consultant pharmacist failed to identify and report that the physician interim orders were not accurately transcribed for the time of administration of Flexeril, that staff failed to administer the drug Flexeril as ordered by the physician, that staff failed to document the reason for not administering the drug as ordered, that staff failed to recognize a discrepancy between the physician's orders [REDACTED]. Resident #21 had lived at the facility for several months and had [DIAGNOSES REDACTED]. Review of the resident's record revealed that on 7/16/13, the physician gave an interim order for the resident to receive Flexeril, a muscle relaxant, 5 mg at bedtime for one week. Review of the Medication Administration Record [REDACTED].M. The nurses signed that the resident received Flexeril on 6 consecutive days at 6:00 A.M. The last nurse signature was circled, indicating that the last dose was not given, according to interview with the Director of Nursing on 9/13/13 at 11:00 A.M. The Director of Nursing provided a copy of a Medication Error Report, dated 7/23/13, which identified the error in timing of administration, i.e. that the order indicated the drug was to be given at bedtime and the order was transcribed onto the MAR indicated [REDACTED].M. The outcome was written that no effect was noted for the resident. Measures taken to prevent recurrence were noted as education provided on 24 hour checks and telephone order transcription. Attached to the Medication Error Report was a copy of the drug blister pack sent to the facility with the Flexeril. The label on the blister pack had the resident's name and date of 7/16/13. The order printed on the label read cyclobenzaprine (generic name of Flexeril) 5 mg tablet, give 1 tablet by mouth at bedtime, and the quantity was noted as 30 tablets, with 6 refills available. The copy of the blister pack showed that 10 pills had been popped from the blister pack and 20 pills remained. Review of this copy of the blister pack revealed two discrepancies with documentation in the resident's record, as follows: a) the physician order [REDACTED]. b) the MAR indicated [REDACTED]. During interview on 9/12/13 at 2:50 P.M., the above information was discussed with the Director of Nursing, and a request was made for more information to clarify the identified discrepancies. The Director of Nursing had no immediate explanation or clarification of the issues. Review of the monthly drug regimen review by the consultant pharmacist from July 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of the issues or discrepancies related to the Flexeril dispensing by the pharmacy or administration by facility staff. On 9/13/13 at 11:00 A.M., the Director of Nursing said that no documentation by the nurse who had circled the last dose as not given had been found. The Director of Nursing said that there should have been a note by the nurse, with an explanation why it was not administered to the resident. The Director of Nursing said she thought it might have been because the nurse noticed the timing discrepancy, but had no explanation why the nurse did not then correct the error on the MAR indicated [REDACTED]. The Director of Nursing had no explanation why the pharmacy label differed significantly from the facility's physician interim order, and had no explanation why 10 pills instead of only 6 were missing from the blister pack. On 9/13/13 at 3:50 P.M., the Director of Nursing said that the pharmacy had been called but they could not provide any clarification on the two identified discrepancies or any documentation related to the drug order. The pharmacy staff had advised the Director of Nursing that they would initiate an investigation. The Director of Nursing said no documentation or evidence of the physician order [REDACTED]. The facility was advised to contact the state Drug Diversion Control unit, and the Director of Nursing agreed. b) Additionally, for Resident #21, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale ordered by the physician were not accurately administered by staff since at least January 2013. The resident had a physician order [REDACTED]. CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and call the physician The resident's record was reviewed from 1/1/13 through the date of survey review on 9/12/13 for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. Multiple errors were found in several months, as follows: 1/17/13, 8:00 P.M., CBG 338, no insulin documented as given, should have received 8 units 1/18/13, 11:30 P.M., CBG 170, no insulin documented as given, should have received 2 units 1/18/13, 8:00 P.M., CBG 325, given 10 units, should have received 8 units 1/22/13, 4:30 P.M., no CBG recorded, no insulin documented as given 1/22/13, 8:00 P.M., no CBG recorded, no insulin documented as given 1/28/13, 4:30 P.M., no CBG recorded, no insulin documented as given 1/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 1/29/13, 8:00 P.M., CBG 179, no insulin given, should have received 2 units 2/1/13, 4:30 P.M., CBG 321, no insulin documented as given, should have received 8 units 2/6/13, 8:00 P.M., CBG 193, no insulin documented as given, should have received 2 units 2/7/13, 8:00 P.M., CBG 247, given 6 units, should have received 4 units 2/8/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/10/13, 8:00 P.M., CBG 180, no insulin documented as given, should have received 2 units 2/12/13, 11:30 A.M., CBG 279, given 8 units, should have received 6 units 2/12/13, 8:00 P.M., CBG 317, given 4 units, should have received 8 units 3/2/13, 4:30 P.M., CBG 248, given 6 units, should have received 4 units 3/3/13, 4:30 P.M., CBG 248, given 6 units, should have received 4 units 3/11/13, 6:30 A.M., CBG 154, no insulin given, should have received 2 units 3/16/13, 8:00 P.M., CBG 216, no insulin documented as given, should have received 4 units 3/17/13, 4:30 P.M., CBG 205, no insulin documented as given, should have received 4 units 3/17/13, 8:00 P.M., CBG 202, no insulin documented as given, should have received 4 units 3/20/13, 6:30 A.M., CBG 175, no insulin documented as given, should have received 2 units 3/22/13, 4:30 P.M., CBG 209, no insulin documented as given, should have received 4 units 3/30/13, 6:30 A.M., CBG 160, no insulin given, should have received 2 units 3/30/13, 4:00 P.M., CBG 168, no insulin documented as given, should have received 2 units 3/31/13, 4:30 P.M., CBG 235, no insulin documented as given, should have received 4 units 3/31/13, 8:00 P.M., CBG 242, no insulin documented as given, should have received 4 units 5/19/13, 8:00 P.M., CBG 250, given 4 units, should have received 6 units 5/23/13, 11:30 A.M., no CBG recorded, no insulin documented as given 5/25/13, 8:00 P.M., CBG 250, given 4 units, should have received 6 units 5/31/13, 4:30 P.M., CBG 298, given 5 units, should have received 6 units 6/15/13, 6:30 A.M., CBG 180, no insulin given, should have received 2 units 6/16/13, 11:30 A.M., no CBG recorded, no insulin documented as given 6/18/13, 11:30 A.M., CBG 270, given 2 units, should have received 4 units 6/25/13, 4:30 P.M., no CBG recorded, no insulin documented as given 6/25/13, 8:00 P.M., no CBG recorded, no insulin documented as given 6/28/13, 8:00 P.M., CBG 176, given 4 units, should have received 2 units 6/30/13, 11:30 A.M., no CBG recorded, no insulin documented as given 7/22/13, 11:30 A.M., no CBG recorded, no insulin documented as given 7/22/13, 8:00 P.M., no CBG recorded, no insulin documented as given 7/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 7/29/13, 8:00 P.M., CBG 170, no insulin given, should have received 2 units 8/13/13, 4:30 P.M., CBG 245, given 6 units, should have received 4 units 8/14/13, 6:30 A.M., CBG 167, no insulin given, should have received 2 units 8/24/13, 4:30 P.M., CBG 202, given 2 units, should have received 4 units 8/31/13, 4:30 P.M., CBG 264, given 4 units, should have received 6 units Review of the monthly drug regimen review by the consultant pharmacist from January 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 9 month period. On 9/13/13 at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 3. For Resident #11, the consultant pharmacist failed to identify and report that staff failed to accurately administer two doses of Novolog insulin based on the sliding scale ordered by the physician from admission through the time of survey review on 9/4/13. Resident #11 was admitted to the facility for short term rehabilitation services following a hospitalization , and had [DIAGNOSES REDACTED]. Record review revealed that at the time of admission the resident was receiving scheduled insulin, Lantus 9 units at bedtime. This dose was increased to 12 units on 8/26/13. The resident also received Novolog insulin according to a sliding scale based on Capillary Blood Glucose (CBG) testing before meals and at bedtime. Review of the physician orders [REDACTED]. The physician order [REDACTED]. CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [REDACTED]. As documented on the Diabetic Monitoring Flow Sheet, on 8/30/13, the CBG result was 347 and the resident received 10 units of Novolog insulin instead of 8 units as indicated by the sliding scale. As documented on the Diabetic Monitoring Flow Sheet, on 8/31/13, the CBG result was 372 and the resident received 6 units of Novolog insulin instead of 10 units as indicated by the sliding scale. Review of the monthly drug regimen review by the consultant pharmacist for August 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report these two insulin administration errors. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as noted above. 4. For Resident #12, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale ordered by the physician were not accurately administered, from 1/1/13 through the time of survey review on 9/4/13. Resident #12 had lived at the facility for several years and had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. CBG 51-70, give 180 ml apple juice, and recheck CBG in 10 minutes, notify physician if needed CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the physician orders [REDACTED]. - Capillary Blood Glucose (CBG) four times daily (6:30 A.M., 10:00 A.M., 2:00 P.M., 8:00 P.M.), - Hold sliding scale coverage unless CBG is over 400, and - do not cover bedtime CBG Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [REDACTED] 1/2/13 - at 8:00 P.M. (the bedtime dose), the resident was given 3 units of Novolog insulin for a CBG of 267, when the physician order [REDACTED]. 1/22/13 - at 10:00 A.M., CBG of 419 and 10 units administered, which should have been 8 units according to the sliding scale 1/23/13 - at 10:00 A.M., CBG of 411 and 10 units administered, which should have been 8 units according to the sliding scale 2/13/13 - at 8:00 P.M., the resident was given 8 units of Novolog insulin for a CBG of 476, when the physician order [REDACTED]. 2/19/13 - at 8:00 P.M., the resident was given 10 units of Novolog insulin for a CBG of 510, when the physician order [REDACTED]. 3/1/13 - at 8:00 P.M., the resident was given 8 units of Novolog insulin for a CBG of 402, when the physician order [REDACTED]. 3/8/13 - at 2:00 P.M., no CBG result was recorded 3/11/13 - at 2:00 P.M., no CBG result was recorded 3/26/13 - at 8:00 P.M., no CBG result was recorded 4/8/13, 4/11/13, 4/13/13, 4/14/13, 4/15/13 - at 10:00 A.M., the resident was given Novolog insulin according to the sliding scale even though coverage should not have been given for CBG less than 400 4/11/13, 4/13/13, 4/14/13 - at 2:00 P.M., the resident was given Novolog insulin according to the sliding scale even though coverage should not have been given for CBG less than 400 4/15/13 and 4/19/13 - at 2:00 P.M., no CBG result recorded 4/20/13 - at 8:00 P.M., no CBG result recorded Record review revealed that on 4/26/13, the physician changed the CBG and sliding scale orders, with no change to the sliding scale dosing, as follows: - Check the CBG level twice daily at 11:30 A.M. and 8:00 P.M., and - Give sliding scale Novolog insulin coverage only if the CBG was over 400 Sliding scale insulin administration errors, after 4/26/13, were identified as follows: 5/4/13, 8:00 P.M., the CBG was 408 but no insulin was given 5/22/13, 8:00 P.M., the CBG was 445 but no insulin was given 6/19/13, 8:00 P.M., the CBG was 446 but no insulin was given 7/16/13, 8:00 P.M., the CBG was 421 but no insulin was given 7/20/13, 8:00 P.M., the CBG was 432 but no insulin was given 9/9/13, 8:00 P.M., the CBG was 270 and it was documented that 4 units of insulin was given Review of the monthly drug regimen review by the consultant pharmacist from January 2013 through the date of survey review on 9/4/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 9 month period. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised that there were multiple insulin errors as noted above. 5. For Resident #27, the consultant pharmacist failed to identify and report that staff failed to follow physician orders [REDACTED]. Resident #27 was a long term resident at the facility, with [DIAGNOSES REDACTED]. Record review revealed that there as of January 2013 there was an order for [REDACTED]. CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [REDACTED]. The resident should have received 2 units of Novolog insulin based on the sliding scale, but the documentation indicated that no insulin was administered. Further review revealed that on 7/26/13, the physician changed the CBG order to two times daily at 6:30 A.M. and 8:00 P.M. on Monday, Wednesday and Friday. Review of the monthly Diabetic Monitoring Flow Sheet for August 2013 revealed that the physician order [REDACTED]. Despite these notations and documentation that the CBG and insulin coverage was done as ordered, CBG testing was additionally done two times on Tuesday 8/13/13 at 8:00 P.M., on Sunday 8/18/13 at 8:00 P.M., on Tuesday 8/20/13 at 8:00 P.M., on Tuesday 8/27/13 at 8:00 P.M., on Thursday 8/29/13 at 8:00 P.M., and Saturday 8/31/13 at 8:00 P.M. On 8/31/13, the resident's CBG was noted as 159, which would indicate 2 units of insulin to be administered per the sliding scale. The nurse signed that no insulin was administered. Review of the monthly drug regimen review by the consultant pharmacist from May 2013 through the date of survey review on 9/4/13 revealed that the pharmacist did not identify or report any of these insulin administration and CBG testing errors. On 9/13/13 at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 6. For Resident #20, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale orde

Based on record review, staff interview and review of pharmacy records for the facility, the consultant pharmacist failed, during monthly review of each resident's regimen of medications, to identify and report all irregularities to the attending physician and the director of nursing, for 10 of 27 residents (#1, #2, #4, #9, #11, #12, #20, #21, #25 and #27) with identified medication errors, and 5 of these 10 residents had more than one medication error identified during survey (#2, #4, #12, #21 and #25). The facility had a pharmacy services agreement with the pharmacy that included the provision of drugs and the services of a consultant licensed pharmacist. A review of the agreement indicated the consultant pharmacist would provide a written monthly review of each resident's drug regimen. A review of the residents' medication administration records and physicians' orders indicated numerous medication errors not identified by the consultant pharmacist. Findings include: 1. For Resident #4, the consultant pharmacist failed to identify and report that staff were administering insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on 3/17/13, the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. CBG check, though it was to be used at the other three times. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer insulin at 6:30 A.M. from the time of the change in order on 3/17/13 through the date of survey review on 9/3/13, as follows: 3/25/13, CBG 276, received 6 units of insulin 3/26/13, CBG 190, received 2 units 3/27/13, CBG 160, received 2 units 4/2/13, CBG 203, received 4 units 4/4/13, CBG 158, received 2 units 4/15/13, CBG 237, received 4 units 4/16/13, CBG 195, received 2 units 5/2/13, CBG 158, received 2 units 5/6/13, CBG 173, received 2 units 5/9/13, CBG 208, received 4 units 5/12/13, CBG 232, received 4 units 5/13/13, CBG 224, received 4 units 5/15/13, CBG 166, received 2 units 5/17/13, CBG 183, received 2 units 5/17/13, CBG 166, received 2 units 5/19/13, CBG 282, received 6 units 5/20/13, CBG 290, received 6 units 5/25/13, CBG 198, received 2 units 5/26/13, CBG 190, received 2 units 5/27/13, CBG 200, received 2 units 5/29/13, CBG 164, received 2 units 5/31/13, CBG 159, received 2 units 6/1/13, CBG 219, received 4 units 6/2/13, CBG 208, received 4 units 6/3/13, CBG 153, received 2 units 6/5/13, CBG 215, received 2 units 6/6/13, CBG 241, received 4 units 6/7/13, CBG 180, received 2 units 6/9/13, CBG 151, received 2 units 6/12/13, CBG 167, received 2 units 6/13/13, CBG 285, received 6 units 6/14/13, no CBG recorded 6/15/13, CBG 201, received 4 units 6/20/13, CBG 163, received 2 units 6/26/13, CBG 175, received 2 units 7/1/13, CBG 157, received 2 units 7/2/13, CBG 219, received 4 units 7/4/13, CBG 171, received 2 units 7/16/13, CBG 170, received 2 units 7/19/13, CBG 184, received 2 units 7/21/13, CBG 160, received 2 units 7/30/13, CBG 214, received 4 units 8/4/13, CBG 155, received 2 units 8/5/13, CBG 188, received 2 units 8/8/13, CBG 164, received 2 units 8/14/13, CBG 177, received 2 units 8/15/13, CBG 166, received 2 units 8/18/13, CBG 225, received 4 units 8/21/13, CBG 175, received 2 units 8/24/13, CBG 150, received 2 units 8/25/13, CBG 187, received 2 units 8/29/13, CBG 205, received 4 units 8/30/13, CBG 163, received 2 units 8/31/13, CBG 225, received 4 units 9/1/13, CBG 227, received 2 units During interview on 9/3/13 at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from March 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On 9/3/13 at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. Additionally, for Resident #4, the consultant pharmacist failed to identify and report that staff did not accurately administer multiple doses of Humalog insulin based on the sliding scale ordered by the physician since at least January 2013. Resident #4 had a [DIAGNOSES REDACTED].M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The resident received Novolog insulin based on a sliding scale as follows: CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and call the physician Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] (Prior to 3/17/13 there was an order to give at 6:30 A.M., and errors at that time are counted. After 3/17/13, any insulin given at 6:30 A.M. was not counted. ) 1/14/13, 8:00 P.M., CBG 411, given no insulin, should have received 12 units 1/16/13, 6:30 A.M., CBG 184, given no insulin, should have received 2 units 2/1/13, 11:30 A.M., CBG 272, given no insulin, should ahve received 6 units 2/1/13, 8:00 P.M., CBG 319, given no insulin, should have received 8 units 2/7/13, 8:00 P.M., CBG 315, given 6 units, should have received 8 units 2/11/13, 6:30 A.M., CBG 238, given 8 units, should have received 4 units 2/15/13, 6:30 A.M., CBG 263, no insulin documented as given, should have received 6 units 2/15/13, 4:30 P.M., CBG 373, given 8 units, should have received 10 units 2/17/13, 8:00 P.M., CBG 356, no insulin documented as given, should have received 10 units 2/21/13, 6:30 A.M., CBG 187, no insulin documented as given, should have received 2 units 2/24/13, 4:30 P.M., CBG 491, given 12 units, should have received 14 units 2/26/13, 4:30 P.M., no CBG recorded, no insulin documented as given 2/26/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/27/13, 4:30 P.M., no CBG recorded, no insulin documented as given 2/27/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/28/13, 6:30 A.M., CBG 339, given 6 units, should have received 8 units 2/28/13, 4:30 P.M., CBG 425, no insulin documented as given, should have received 12 units 2/28/13, 8:00 P.M., CBG 491, no insulin documented as given, should have received 8 units 3/3/13, 4:30 P.M., CBG 400, given 10 units, should have received 12 units 3/6/13, 8:00 P.M., CBG 349, given 10 units, should have received 8 units 3/8/13, 6:30 A.M., CBG 284, no insulin documented as given, should have received 6 units 3/14/13, 4:30 P.M., CBG 290, no documentation of insulin given, should have received 6 units 3/14/13, 8:00 P.M., CBG 320, given 10 units, should have received 8 units 3/15/13, 6:30 A.M., CBG 291, no insulin documented as given, should have received 6 units 3/15/13, 4:30 P.M., CBG 308, no insulin documented as given, should have received 8 units 3/14/13, 8:00 P.M., CBG 320, given 10 units, should have received 8 units 3/16/13, 8:00 P.M., CBG 275, given 8 units, should have received 6 units (on 3/17/13, the times of the CBG and insulin was changed by the physician to 6:30 A.M., 10:30 A.M., 2:00 P.M. and 8:00 P.M.) 3/17/13, 2:00 P.M., CBG 452, given 12 units, should have received 14 units 3/19/13, 2:00 P.M., no CBG recorded, no insulin documented as given 3/20/13, 8:00 P.M., CBG 375, no insulin documented as given, should have received 10 units 3/25/13, 10:30 A.M., CBG 251, given 4 units, should have received 6 units 3/38/13, 8:00 P.M., CBG 184, no insulin was documented as given, should have received 2 units 3/29/13, 10:30 A.M., no CBG recorded, no insulin documented as given 3/29/13, 8:00 P.M., no CBG recorded, no insulin documented as given 3/30/13, 8:00 P.M., no CBG recorded, no insulin documented as given 3/31/13, 8:00 P.M., CBG 277, no insulin was documented as given, should have received 6 units 4/2/13, 8:00 P.M., CBG 293, no insulin documented as given, should have received 6 units 4/3/13, 8:00 P.M., CBG 290, no insulin documented as given, should have received 6 units 4/8/13, 8:00 P.M., CBG 251, no insulin documented as given, should have received 6 units 4/9/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/12/13, 8:00 P.M., CBG 288, no documentation of insulin given, should have received 6 units 4/17/13, 8:00 P.M., CBG 257, no documentation of insulin given, should have received 6 units 4/18/13, 10:30 A.M., CBG 156, no insulin documented as given, should have received 2 units 4/19/13, 2:00 P.M., CBG 202, no insulin documented as given, should have received 4 units 4/20/13, 8:00 P.M., CBG 279, no insulin documented as given, should have received 6 units 4/25/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/25/13, 8:00 P.M., CBG 204, no insulin documented as given, should have received 4 units 4/28/13, 8:00 P.M., CBG 184, given 4 units insulin, should have received 2 units 4/29/13, 2:00 P.M., no CBG recorded, no insulin documented as given 4/30/13, 2:00 P.M., no CBG recorded, no insulin documented as given 5/1/13, 8:00 P.M., CBG 232, given 6 units, should have received 4 units 5/5/13, 8:00 P.M., CBG 292, given 8 units, should have received 6 units 5/13/13, 2:00 P.M., CBG 182, given no insulin, should have received 2 units 5/16/13, 8:00 P.M., CBG 230, no insulin given, should have received 4 units 5/18/13, 8:00 P.M., CBG 445, no insulin given, should have received 12 units 5/23/13, 8:00 P.M., CBG 181, no insulin given, should have received 2 units 6/3/13, 8:00 P.M., CBG 160, no insulin given, should have received 2 units 6/6/13, 10:30 A.M., CBG 262, given 4 units, should have received 6 units 6/14/13, 8:00 P.M., no CBG recorded, no insulin documented as given 6/20/13, 8:00 P.M., CBG 248, given 6 units, should have received 4 units 6/21/13, 8:00 P.M., CBG 247, given 6 units, should have received 4 units 6/22/13, 10:30 A.M., CBG 322, given 6 units, should have received 8 units 6/22/13, 2:00 P.M., CBG 301, given 6 units, should have received 8 units 6/23/13, 2:00 P.M., no CBG recorded, no insulin documented as given 6/25/13, 2:00 P.M., CBG 232, given 6 units, should have received 4 units 6/28/13, 2:00 P.M., CBG 269, given 8 units, should have received 6 units 6/30/13, 8:00 P.M., CBG 223, no insulin documented as given, should have received 4 units 7/3/13, 10:00 A.M., CBG 441, no insulin documented as given, should have received 12 units 7/4/13, 10:00 A.M., CBG 255, given 4 units, should have received 6 units 7/5/13, 2:00 P.M., CBG 250, no insulin documented as given, should have received 6 units 7/7/13, 10:00 P.M., CBG 308, no insulin documented as given, should have received 8 units 7/13/13, 2:00 P.M., no CBG recorded, no insulin documented as given 7/14/13, 2:00 P.M., no CBG recorded, no insulin documented as given 7/18/13, 8:00 P.M., CBG 362, given 8 units, should have received 10 units 7/21/13, 10:00 P.M., CBG 243, given 6 units, should have received 4 units 7/23/13, 8:00 P.M., CBG 321, given 6 units, should have received 8 units 7/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/2/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/7/13, 2:00 P.M., CBG 178, no insulin documented as given, should have received 2 units 8/8/13, 2:00 P.M., CBG 155, no insulin documented as given, should have received 2 units 8/10/13, 10:30 A.M., CBG 150, no insulin documented as given, should have received 2 units 8/14/13, 8:00 P.M., no CBG recorded, no insulin documented as given 8/15/13, 8:00 P.M., CBG 351, given 8 units, should have received 10 units 8/21/13, 8:00 P.M., CBG 386, given 8 units, should have received 10 units 8/31/13, 8:00 P.M., CBG 350, given 8 units, should have received 10 units 9/3/13, 2:00 P.M., CBG 150, no insulin was documented as given, should have received 2 units Review of the monthly drug regimen review by the consultant pharmacist from March 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 6 month period. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as outlined above. 2. a) For Resident #21, the consultant pharmacist failed to identify and report that the physician interim orders were not accurately transcribed for the time of administration of Flexeril, that staff failed to administer the drug Flexeril as ordered by the physician, that staff failed to document the reason for not administering the drug as ordered, that staff failed to recognize a discrepancy between the physician's orders [REDACTED]. Resident #21 had lived at the facility for several months and had [DIAGNOSES REDACTED]. Review of the resident's record revealed that on 7/16/13, the physician gave an interim order for the resident to receive Flexeril, a muscle relaxant, 5 mg at bedtime for one week. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. The nurses signed that the resident received Flexeril on 6 consecutive days at 6:00 A.M. The last nurse signature was circled, indicating that the last dose was not given, according to interview with the Director of Nursing on 9/13/13 at 11:00 A.M. The Director of Nursing provided a copy of a Medication Error Report, dated 7/23/13, which identified the error in timing of administration, i.e. that the order indicated the drug was to be given at bedtime and the order was transcribed onto the MAR indicated [REDACTED].M. The outcome was written that no effect was noted for the resident. Measures taken to prevent recurrence were noted as education provided on 24 hour checks and telephone order transcription. Attached to the Medication Error Report was a copy of the drug blister pack sent to the facility with the Flexeril. The label on the blister pack had the resident's name and date of 7/16/13. The order printed on the label read cyclobenzaprine (generic name of Flexeril) 5 mg tablet, give 1 tablet by mouth at bedtime, and the quantity was noted as 30 tablets, with 6 refills available. The copy of the blister pack showed that 10 pills had been popped from the blister pack and 20 pills remained. Review of this copy of the blister pack revealed two discrepancies with documentation in the resident's record, as follows: a) the physician order [REDACTED]. b) the MAR indicated [REDACTED]. During interview on 9/12/13 at 2:50 P.M., the above information was discussed with the Director of Nursing, and a request was made for more information to clarify the identified discrepancies. The Director of Nursing had no immediate explanation or clarification of the issues. Review of the monthly drug regimen review by the consultant pharmacist from July 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of the issues or discrepancies related to the Flexeril dispensing by the pharmacy or administration by facility staff. On 9/13/13 at 11:00 A.M., the Director of Nursing said that no documentation by the nurse who had circled the last dose as not given had been found. The Director of Nursing said that there should have been a note by the nurse, with an explanation why it was not administered to the resident. The Director of Nursing said she thought it might have been because the nurse noticed the timing discrepancy, but had no explanation why the nurse did not then correct the error on the MAR indicated [REDACTED]. The Director of Nursing had no explanation why the pharmacy label differed significantly from the facility's physician interim order, and had no explanation why 10 pills instead of only 6 were missing from the blister pack. On 9/13/13 at 3:50 P.M., the Director of Nursing said that the pharmacy had been called but they could not provide any clarification on the two identified discrepancies or any documentation related to the drug order. The pharmacy staff had advised the Director of Nursing that they would initiate an investigation. The Director of Nursing said no documentation or evidence of the physician order [REDACTED]. The facility was advised to contact the state Drug Diversion Control unit, and the Director of Nursing agreed. b) Additionally, for Resident #21, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale ordered by the physician were not accurately administered by staff since at least January 2013. The resident had a physician order [REDACTED]. CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and call the physician The resident's record was reviewed from 1/1/13 through the date of survey review on 9/12/13 for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. Multiple errors were found in several months, as follows: 1/17/13, 8:00 P.M., CBG 338, no insulin documented as given, should have received 8 units 1/18/13, 11:30 P.M., CBG 170, no insulin documented as given, should have received 2 units 1/18/13, 8:00 P.M., CBG 325, given 10 units, should have received 8 units 1/22/13, 4:30 P.M., no CBG recorded, no insulin documented as given 1/22/13, 8:00 P.M., no CBG recorded, no insulin documented as given 1/28/13, 4:30 P.M., no CBG recorded, no insulin documented as given 1/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 1/29/13, 8:00 P.M., CBG 179, no insulin given, should have received 2 units 2/1/13, 4:30 P.M., CBG 321, no insulin documented as given, should have received 8 units 2/6/13, 8:00 P.M., CBG 193, no insulin documented as given, should have received 2 units 2/7/13, 8:00 P.M., CBG 247, given 6 units, should have received 4 units 2/8/13, 8:00 P.M., no CBG recorded, no insulin documented as given 2/10/13, 8:00 P.M., CBG 180, no insulin documented as given, should have received 2 units 2/12/13, 11:30 A.M., CBG 279, given 8 units, should have received 6 units 2/12/13, 8:00 P.M., CBG 317, given 4 units, should have received 8 units 3/2/13, 4:30 P.M., CBG 248, given 6 units, should have received 4 units 3/3/13, 4:30 P.M., CBG 248, given 6 units, should have received 4 units 3/11/13, 6:30 A.M., CBG 154, no insulin given, should have received 2 units 3/16/13, 8:00 P.M., CBG 216, no insulin documented as given, should have received 4 units 3/17/13, 4:30 P.M., CBG 205, no insulin documented as given, should have received 4 units 3/17/13, 8:00 P.M., CBG 202, no insulin documented as given, should have received 4 units 3/20/13, 6:30 A.M., CBG 175, no insulin documented as given, should have received 2 units 3/22/13, 4:30 P.M., CBG 209, no insulin documented as given, should have received 4 units 3/30/13, 6:30 A.M., CBG 160, no insulin given, should have received 2 units 3/30/13, 4:00 P.M., CBG 168, no insulin documented as given, should have received 2 units 3/31/13, 4:30 P.M., CBG 235, no insulin documented as given, should have received 4 units 3/31/13, 8:00 P.M., CBG 242, no insulin documented as given, should have received 4 units 5/19/13, 8:00 P.M., CBG 250, given 4 units, should have received 6 units 5/23/13, 11:30 A.M., no CBG recorded, no insulin documented as given 5/25/13, 8:00 P.M., CBG 250, given 4 units, should have received 6 units 5/31/13, 4:30 P.M., CBG 298, given 5 units, should have received 6 units 6/15/13, 6:30 A.M., CBG 180, no insulin given, should have received 2 units 6/16/13, 11:30 A.M., no CBG recorded, no insulin documented as given 6/18/13, 11:30 A.M., CBG 270, given 2 units, should have received 4 units 6/25/13, 4:30 P.M., no CBG recorded, no insulin documented as given 6/25/13, 8:00 P.M., no CBG recorded, no insulin documented as given 6/28/13, 8:00 P.M., CBG 176, given 4 units, should have received 2 units 6/30/13, 11:30 A.M., no CBG recorded, no insulin documented as given 7/22/13, 11:30 A.M., no CBG recorded, no insulin documented as given 7/22/13, 8:00 P.M., no CBG recorded, no insulin documented as given 7/28/13, 8:00 P.M., no CBG recorded, no insulin documented as given 7/29/13, 8:00 P.M., CBG 170, no insulin given, should have received 2 units 8/13/13, 4:30 P.M., CBG 245, given 6 units, should have received 4 units 8/14/13, 6:30 A.M., CBG 167, no insulin given, should have received 2 units 8/24/13, 4:30 P.M., CBG 202, given 2 units, should have received 4 units 8/31/13, 4:30 P.M., CBG 264, given 4 units, should have received 6 units Review of the monthly drug regimen review by the consultant pharmacist from January 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 9 month period. On 9/13/13 at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 3. For Resident #11, the consultant pharmacist failed to identify and report that staff failed to accurately administer two doses of Novolog insulin based on the sliding scale ordered by the physician from admission through the time of survey review on 9/4/13. Resident #11 was admitted to the facility for short term rehabilitation services following a hospitalization , and had [DIAGNOSES REDACTED]. Record review revealed that at the time of admission the resident was receiving scheduled insulin, Lantus 9 units at bedtime. This dose was increased to 12 units on 8/26/13. The resident also received Novolog insulin according to a sliding scale based on Capillary Blood Glucose (CBG) testing before meals and at bedtime. Review of the physician orders [REDACTED]. The physician order [REDACTED]. CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. As documented on the Diabetic Monitoring Flow Sheet, on 8/30/13, the CBG result was 347 and the resident received 10 units of Novolog insulin instead of 8 units as indicated by the sliding scale. As documented on the Diabetic Monitoring Flow Sheet, on 8/31/13, the CBG result was 372 and the resident received 6 units of Novolog insulin instead of 10 units as indicated by the sliding scale. Review of the monthly drug regimen review by the consultant pharmacist for August 2013 through the date of survey review on 9/3/13 revealed that the pharmacist did not identify or report these two insulin administration errors. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as noted above. 4. For Resident #12, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale ordered by the physician were not accurately administered, from 1/1/13 through the time of survey review on 9/4/13. Resident #12 had lived at the facility for several years and had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. CBG 51-70, give 180 ml apple juice, and recheck CBG in 10 minutes, notify physician if needed CBG 80-149, no coverage CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the physician orders [REDACTED]. - Capillary Blood Glucose (CBG) four times daily (6:30 A.M., 10:00 A.M., 2:00 P.M., 8:00 P.M.), - Hold sliding scale coverage unless CBG is over 400, and - do not cover bedtime CBG Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1/2/13 - at 8:00 P.M. (the bedtime dose), the resident was given 3 units of Novolog insulin for a CBG of 267, when the physician order [REDACTED]. 1/22/13 - at 10:00 A.M., CBG of 419 and 10 units administered, which should have been 8 units according to the sliding scale 1/23/13 - at 10:00 A.M., CBG of 411 and 10 units administered, which should have been 8 units according to the sliding scale 2/13/13 - at 8:00 P.M., the resident was given 8 units of Novolog insulin for a CBG of 476, when the physician order [REDACTED]. 2/19/13 - at 8:00 P.M., the resident was given 10 units of Novolog insulin for a CBG of 510, when the physician order [REDACTED]. 3/1/13 - at 8:00 P.M., the resident was given 8 units of Novolog insulin for a CBG of 402, when the physician order [REDACTED]. 3/8/13 - at 2:00 P.M., no CBG result was recorded 3/11/13 - at 2:00 P.M., no CBG result was recorded 3/26/13 - at 8:00 P.M., no CBG result was recorded 4/8/13, 4/11/13, 4/13/13, 4/14/13, 4/15/13 - at 10:00 A.M., the resident was given Novolog insulin according to the sliding scale even though coverage should not have been given for CBG less than 400 4/11/13, 4/13/13, 4/14/13 - at 2:00 P.M., the resident was given Novolog insulin according to the sliding scale even though coverage should not have been given for CBG less than 400 4/15/13 and 4/19/13 - at 2:00 P.M., no CBG result recorded 4/20/13 - at 8:00 P.M., no CBG result recorded Record review revealed that on 4/26/13, the physician changed the CBG and sliding scale orders, with no change to the sliding scale dosing, as follows: - Check the CBG level twice daily at 11:30 A.M. and 8:00 P.M., and - Give sliding scale Novolog insulin coverage only if the CBG was over 400 Sliding scale insulin administration errors, after 4/26/13, were identified as follows: 5/4/13, 8:00 P.M., the CBG was 408 but no insulin was given 5/22/13, 8:00 P.M., the CBG was 445 but no insulin was given 6/19/13, 8:00 P.M., the CBG was 446 but no insulin was given 7/16/13, 8:00 P.M., the CBG was 421 but no insulin was given 7/20/13, 8:00 P.M., the CBG was 432 but no insulin was given 9/9/13, 8:00 P.M., the CBG was 270 and it was documented that 4 units of insulin was given Review of the monthly drug regimen review by the consultant pharmacist from January 2013 through the date of survey review on 9/4/13 revealed that the pharmacist did not identify or report any of these insulin administration errors over the 9 month period. On 9/12/13 at 2:00 P.M., the Assistant Director of Nursing was advised that there were multiple insulin errors as noted above. 5. For Resident #27, the consultant pharmacist failed to identify and report that staff failed to follow physician orders [REDACTED]. Resident #27 was a long term resident at the facility, with [DIAGNOSES REDACTED]. Record review revealed that there as of January 2013 there was an order for [REDACTED]. CBG 150-199, 2 units CBG 200-249, 4 units CBG 250-299, 6 units CBG 300-349, 8 units CBG 350-399, 10 units CBG 400-449, 12 units CBG of 450 or greater, 14 units and notify the physician Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident should have received 2 units of Novolog insulin based on the sliding scale, but the documentation indicated that no insulin was administered. Further review revealed that on 7/26/13, the physician changed the CBG order to two times daily at 6:30 A.M. and 8:00 P.M. on Monday, Wednesday and Friday. Review of the monthly Diabetic Monitoring Flow Sheet for August 2013 revealed that the physician order [REDACTED]. Despite these notations and documentation that the CBG and insulin coverage was done as ordered, CBG testing was additionally done two times on Tuesday 8/13/13 at 8:00 P.M., on Sunday 8/18/13 at 8:00 P.M., on Tuesday 8/20/13 at 8:00 P.M., on Tuesday 8/27/13 at 8:00 P.M., on Thursday 8/29/13 at 8:00 P.M., and Saturday 8/31/13 at 8:00 P.M. On 8/31/13, the resident's CBG was noted as 159, which would indicate 2 units of insulin to be administered per the sliding scale. The nurse signed that no insulin was administered. Review of the monthly drug regimen review by the consultant pharmacist from May 2013 through the date of survey review on 9/4/13 revealed that the pharmacist did not identify or report any of these insulin administration and CBG testing errors. On 9/13/13 at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 6. For Resident #20, the consultant pharmacist failed to identify and report that multiple doses of Novolog insulin based on the sliding scale orde

Based on record reviews, observations and staff interviews, the facility was not managed in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings included: The survey team found quality of life and quality of care issues that impacted the residents daily life. In addition the facility staff's failure to follow policy and procedures were determined widespread. During the survey dated 9/3/13 - 9/13/13, the survey team found the facility's medication management system to be inaccurate and ineffective. The survey team found medication errors, transcription errors, the inaccurate editing of physician orders, and administration of medications that included the wrong dose and wrong directions. The facility's pharmacy services filled prescriptions with no physician orders, monthly pharmacy reviews did not include identifying inaccurate physician's orders or medication errors. The facility did not follow their policy and procedure for ordering and receiving medications. Please refer to the F281, F309, F329, F425, F428, F520.

Based on record review, resident interview, staff interview and observation, the facility failed to ensure that residents were not exposed to risk of serious harm from medication errors, for 8 residents (#2, #4, #11, #12, #20, #21, #25 and #27) in a total sample of 27 residents. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 26 (normal range ,[DATE]) and the resident expired at the facility. Findings include: 1. a) For Resident #20, the facility failed to ensure the medication ordered by the physician was documented correctly on the medication administration record (MAR) and administered as ordered. Staff failed to recognize and clarify the medication administration record for three days and documented that the wrong dose of medication was administered. The resident, who showed significant changes in condition, was not provided timely clinical interventions following the administration of the incorrect dose of medication. The resident died the next morning. Resident #20's medical record was reviewed by the surveyor on [DATE] at 1:45 P.M. and initial review indicated a potential medication error. Documentation on the [DATE] MAR indicated that 80 units (10 times the original ordered amount) of [MEDICATION NAME]had been administered on [DATE], [DATE] and [DATE] at 4:30 P.M. The medical record indicated on [DATE], the physician had ordered [MEDICATION NAME]8 units daily at 4:30 P.M. (not 80 units). The July and [DATE] MARs indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M.. During an interview on [DATE] at 1:50 P.M., Unit Manager #2 said the resident had died on [DATE]. The Manager said he/she and the physician were surprised when informed of the resident's death. He/she said the resident had been at his/her baseline the day before and his/her death was not anticipated or expected. On [DATE] at 2:50 P.M., a subsequent interview was conducted with the Director of Nurses and Unit Manager #2. Prior to discussion the medical record indicated the resident had been administered a 10 times higher dose of [MEDICATION NAME]then ordered. The Unit Manager #2 said that the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) had told him/her that he/she had gone into the resident's room to obtain the morning blood sugar and got a blood sugar of 25. The manager said the nurse administered the [MEDICATION NAME] (anti-hypoglycemic) and oxygen, but that the resident died and he/she made the RN Nurse Pronouncement. Upon further inquiry with the Director of Nurses and Unit Manager #2, the dose of the [MEDICATION NAME]was discussed. Both agreed that the [DATE] MAR and physician order [REDACTED].M. The MAR indicated that three different nurses signed the MAR that the resident was administered 80 units of [MEDICATION NAME] insulin. The Director of Nurses said he/she would look into the incident and provide an investigation why the 8 units was incorrectly printed on both the MAR and the orders as 80 units. On [DATE] at 3:30 P.M., Nurse #1 was interviewed and said he/she had worked from 3:00 P.M. to 7:00 A.M. on [DATE]-[DATE]. Nurse #1 said he/she worked as many doubles as he/she could, but mainly worked the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said he/she knew the resident but usually worked on another unit. Nurse #1 said he/she had been told the resident had not eaten much of his/her lunch or dinner on [DATE] and had told the certified nursing assistants (CNA) to make sure the resident was given a snack. The nurse said he/she was not sure if the resident received a snack. Nurse #1 said he/she had administered the 4:30 P.M. dose of [MEDICATION NAME]on [DATE], but had not administered 80 units. Nurse #1 said he/she wrote 8 units on his/her work sheet and had later signed the MAR that read 80 units. Nurse #1 said he/she noticed the MAR indicated that 80 units of [MEDICATION NAME]was to be administered on [DATE] at 4:30 P.M., but did not clarify or attempt to correct the order. Nurse #1 said he/she thought a staff had told him/her the resident was tired or something that night, but could not clearly remember. The nurse said the information did not indicate a change to him/her because the resident had been showing a decline over the past few months. Nurse #1 said he/she was unclear when he/she had administered the resident's medications, but thinks the last time he was in the resident's room during the 3:00 P.M. to 11:00 P.M. shift on [DATE] was when he administered the roommates medication at around 8:00 P.M. Nurse #1 said the next time he/she saw the resident was on [DATE] at 5:45 A.M. to obtain the morning blood sugar. The nurse said when he/she entered the room the resident was "mouth breathing ... he/she looked like a fish out of water." The nurse took the resident's blood sugar which was 25, then took a second blood sugar which was 46. The nurse said he/she left the resident to get [MEDICATION NAME] (antihypoglycemic agent), an oxygen tank, a rebreather mask and to check the resident's advance directive status. The nurse said when he/she returned to the resident's room the resident continue to breath like a fish out of water and his/her nail beds were blue. Nurse #1 then demonstrated how the resident was breathing to the surveyors. The nurse said he/she administered the [MEDICATION NAME] and rechecked the blood sugar. Nurse #1 said the resident's code status was DNR (do not resuscitate) and do not transfer. Nurse #1 said the resident died and added that he/she asked the CNA how the resident had been the hour prior to his/her obtaining the blood sugar. The nurse said the CNA #3 had told him/her the resident was full of "piss and vinegar," i.e. feisty. During interview on [DATE] at 3:50 P.M. with Nurse #2, the nurse said he/she had signed the MAR on [DATE] indicating the resident was given 80 units of [MEDICATION NAME]at 4:30 P.M. Nurse #2 said he/she knew the amount was wrong and had gone back and looked at the [DATE] MAR before administering the insulin. The nurse said he/she gave the resident 8 units of Levimer insulin. The nurse said the facility had a lot of transcription errors and that was why he/she had checked the previous MAR. Nurse #2 said he/she did not check the physician orders [REDACTED]. Record review, on [DATE] indicated Resident #20 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Assessment ((MDS) dated [DATE], indicated the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and dependent on staff for all his/her activities of daily living. The record indicated the resident was being treated for [REDACTED]. Review of the MAR for [DATE] indicated the resident was given scheduled insulin of [MEDICATION NAME] and [MEDICATION NAME] sliding scale insulin. The physician's orders [REDACTED].M. and [MEDICATION NAME] 80 units at 4:30 P.M., and [MEDICATION NAME](short acting insulin) based on blood sugars obtained at 6:30 A.M. and 4:30 P.M.. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Review of the nurses' notes indicated from [DATE] through [DATE] (7:00 A.M.- 3:00 P.M.), the resident continued on an antibiotic for a urinary tract infection and had no complaints. A subsequent nurses' note dated [DATE] indicated the resident was sleepy at times and had a good appetite at lunch and dinner. On [DATE], Nurse #1 documented at 10:00 P.M., the resident had no complaints, required assistance with care by two staff and that his/her cardiac, respiratory status was without signs and symptoms of acute distress and that he/she was sleeping most of the shift. The note did not include any vital signs. On [DATE], Nurse #1 documented that he/she went into the resident's room at 5:45 A.M. to obtain a blood sugar. The nurse documented a blood sugar of 25. The nurse indicated he/she administered [MEDICATION NAME], as per house protocol, and rechecked the resident's blood sugar. The note indicated the second blood sugar was 46. The nurse increased the resident's oxygen to 15 liters and added a rebreathing mask for comfort. The note indicated the resident was gasping for air and the nail beds were blue, the nurse rechecked the resident's blood sugar and obtained a result of 96. The nurse then indicated the resident had no pulse, breath sounds and did not respond to stimuli. The note indicated the nurse had checked the resident's advance directives and determined the resident was a do not resuscitate and a do not transfer. The record indicated a physician order [REDACTED].M. on [DATE]. On [DATE] at 10:30 A.M., the Director of Nurses said the facility had completed an investigation and obtained staff statements. Review of the investigation and staff statements indicated on [DATE] from 3:30 P.M. to 10:00 P.M., CNA #1 identified and reported a change in the resident's condition to Nurse #1 twice. CNA #1's witness statement and who was also interviewed on the phone by the surveyor on [DATE] at 11:30 A.M., said he/she was assigned to Resident #20 on [DATE] and had been a CNA for 5 years. The CNA said when he/she changed the resident at 3:30 P.M. he/she noticed the resident was not him/herself. CNA #1 said it wasn't until he/she returned to the resident's room at 7:30 P.M. that she observed a significant change. The CNA said the resident was "very pale and was out of it ... and about to die." CNA #1 said the resident looked like another resident who had died . The CNA said after he/she provided care he/she told Nurse #1 to go look at Resident #20. CNA #1 said he/she did not know if Nurse #1 went to see the resident. At 10:00 P.M., CNA #1 said he/she went into the resident's room to provide care. CNA #1 said the resident was "very, very unresponsive." The CNA said he/she went and got another CNA (CNA #2) to look at the resident. The CNA said that CNA #2 was more experienced and that he/she had asked if he/she had notified the nurse. The CNA said he/she told CNA #2 that Nurse #1 had been notified at 7:30 P.M. CNA #1 said that he/she went and told Nurse #1 at 10:00 P.M. that he/she "really, really needed to check the resident ... because the resident was very, very unresponsive and would not open his/her eyes." CNA #1 said he/she found out later that the resident had passed away. Upon further inquiry by the surveyor, CNA #1 said that although he/she had not fed the resident, he/she had been told that the resident had not eaten dinner and had not eaten much of his/her lunch. According to CNA #2's witness statement it indicated that he/she had worked on [DATE] (3:00 P.M. to 11:00 P.M.). The CNA stated he/she assisted the resident at 4:00 P.M. and noted the resident was not his/her usual self. CNA #2 indicated he/she thought the resident was sleepy. At 10:00 P.M., CNA #1 asked CNA #2 for assistance and noted they had difficulty rolling the resident over, the resident was very quiet and was having difficulty breathing. CNA #2 told CNA #1 to tell the nurse and subsequently observed CNA #1 informing Nurse #1. According to CNA #3's witness statement it indicated he/she first saw the resident on [DATE] at 2:00 A.M. CNA #3 indicated the resident was sleepy, hard to wake up and had opened his/her eyes and then went back to sleep. At 5:00 A.M., CNA #3 indicated that there was something wrong with the resident and at this time reported the change to Nurse #1. CNA #3 said Nurse #1 said the resident had a urinary track infection. CNA #3 indicates that Nurse #1 had gone to see the resident and later informed him/her that the Resident's BS was low and nail beds were purple. According to the facility investigation and witness statements, it was determined that there was a medication error in the editing process for the resident's record. As a result the September MAR indicated an order for [REDACTED].M. The facility investigation indicated that three nurses signed the September MAR indicating that the resident was administered 80 units of [MEDICATION NAME], however the three nurses stated they had not administered 80 units and knew the order was for 8 units. The facility investigation indicated that through interviews with three CNAs (#1, #2, and #3) that Nurse #1 had been informed at 7:30 P.M., 10:00 P.M. and 5:00 A.M. that there was a significant change in the resident's condition. The investigation indicated that Nurse #1 was asked about the CNAs' concerns, and Nurse #1 said he/she did not recall receiving any reports from staff regarding a change in condition. Nurse #1 said he/she found the resident having difficulty breathing when he/she went in to do the morning blood sugar at 5:45 A.M., which was 45 minutes after the 5:00 A.M. report by the CNA of a change in condition. During interview on [DATE] at 10:15 A.M., Resident #20's primary physician stated he/she saw the resident on [DATE] in the morning and that he/she looked perfectly fine. The physician said he/she had not been notified of any change in the resident's condition until he/she was notified of the resident's death. The physician said he/she was surprised the resident had died and attributed the cause to a [MEDICAL CONDITION] infarct ([MEDICAL CONDITION]). The physician said he/she was notified of the medication transcription error on [DATE] and is now unsure of the cause of death. The physician reviewed the resident's condition and regular medications with the surveyor and said that the cause of death would most likely remain unknown. The physician said he had not completed the discharge summary, but had signed the death certificate prior to his knowledge of the medication error. During interview on [DATE] at 2:45 P.M., Resident #4 (roommate of Resident #20) said he/she missed his/her roommate. Resident #4 said he/she heard Nurse #1 trying to wake Resident #20 up but could not. Resident #4 said he/she did not know what happened but that the roommate was gone. The resident said it happened in the middle of the night, but could not remember what time. Resident #20's ordered medication was not documented correctly on the MAR, and three nurses signed that the incorrect dose was administered for three days. Nursing staff took no action to correct the error to prevent future medication errors. According to the facility's investigation, three CNAs reported the resident showed a significant change in his/her medical condition, without documented nursing interventions. b) Further review of Resident #20's record indicated the nursing staff failed to administer accurate doses of [MEDICATION NAME]based on the sliding scale ordered by the physician since at least [DATE]. The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Multiple errors were found in several months, as follows: [DATE], 4:30 P.M., CBG 207, given 2 units of insulin, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 213, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 215, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 213, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 157, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 265, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 342, given 10 units, sliding scale order was for 8 units [DATE], 6:30 A.M., CBG 189, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 232, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 251, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 246, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG not documented, no insulin given [DATE], 4:30 P.M., CBG 247, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 310, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 249, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 226, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 220, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 300, given 6 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 260, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 258, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 219, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 258, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 327, given 4 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 332, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 341, given no insulin, sliding scale order was for 8 units [DATE], 6:30 A.M., CBG 250, given 4 units, sliding scale order was for 6 units [DATE], 4:30 A.M., CBG 309, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 278, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 285, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 270, given 8 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 286, given 8 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 178, given 4 units, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 251, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 335, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 278, given no insulin, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 267, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 261, given no insulin, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 156, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 303, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 245, given 6 units, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG no obtained, no insulin given [DATE], 6:30 A.M., CBG 260, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 260, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 295, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 281, given 4 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 156, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 155, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 261, insulin coverage not legible, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 179, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 171, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 254, given 2 units, sliding scale order was for 6 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 2. For Resident #2, the facility failed to follow the physician orders [REDACTED]. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. Record review revealed that there was an order for [REDACTED]. According to physician orders [REDACTED]. CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG is ,[DATE], give 180 ml apple juice, recheck blood sugar in 10 min and notify the physician if needed. Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, multiple errors were found. [DATE], 6:30 A.M., CBG 201, given no insulin, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 266, given 6 units, sliding scale indicated should receive 6 units [DATE], 8:00 P.M., CBG 202, given 2 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 210, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 208, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 223, given 6 units, sliding scale indicated should receive 4 units [DATE], 6:30 A.M., CBG 159, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 184, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 160, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 151, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:00 A.M., CBG 156, given no insulin, sliding scale indicated should receive 2 units On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 3. For Resident #25, the nursing staff failed to administer two medications within the ordered physician parameters. Resident #25 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the monthly medication orders indicated that the physician ordered [MEDICATION NAME] HCL (anti-hypertensive medication) 50 milligrams three times per day and hold if the systolic blood pressure (SBP) is less than 130. Review of the monthly medication administration records (MAR) and nurses' notes indicated the following errors for the administration of the antihypertensive medication [MEDICATION NAME] HCL, which had parameters to hold if the systolic blood pressure was less than 130. [DATE], 8:00 P.M., Blood Pressure (BP) recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 A.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 A.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet and MAR revealed these errors. 4. a) For Resident #4, the facility failed to ensure that staff did not administer insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on [DATE], the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. There was no evidence that the physician was contacted to clarify the timing of the CBG and the sliding scale. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer sliding scale insulin, contrary to the physician's orders [REDACTED]. from the time of the change in order on [DATE] through the date of survey review on [DATE], as follows: [DATE], CBG 276, received 6 units of insulin [DATE], CBG 190, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 203, received 4 units [DATE], CBG 158, received 2 units [DATE], CBG 237, received 4 units [DATE], CBG 195, received 2 units [DATE], CBG 158, received 2 units [DATE], CBG 173, received 2 units [DATE], CBG 208, received 4 units [DATE], CBG 232, received 4 units [DATE], CBG 224, received 4 units [DATE], CBG 166, received 2 units [DATE], CBG 183, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 282, received 6 units [DATE], CBG 290, received 6 units [DATE], CBG 198, received 2 units [DATE], CBG 190, received 2 units [DATE], CBG 200, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 159, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 208, received 4 units [DATE], CBG 153, received 2 units [DATE], CBG 215, received 2 units [DATE], CBG 241, received 4 units [DATE], CBG 180, received 2 units [DATE], CBG 151, received 2 units [DATE], CBG 167, received 2 units [DATE], CBG 285, received 6 units [DATE], no CBG recorded [DATE], CBG 201, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 175, received 2 units [DATE], CBG 157, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 171, received 2 units [DATE], CBG 170, received 2 units [DATE], CBG 184, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 214, received 4 units [DATE], CBG 155, received 2 units [DATE], CBG 188, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 177, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 175, received 2 units [DATE], CBG 150, received 2 units [DATE], CBG 187, received 2 units [DATE], CBG 205, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 227, received 2 units During interview on [DATE] at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from [DATE] through the date of survey review on [DATE] revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On [DATE] at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. b) Additionally, for Resident #4, the facility failed to accurately administer multiple doses of Humalog insulin based on the sliding scale ordered by the physician since at least [DATE]. Resident #4 had a [DIAGNOSES REDACTED]. Review of the clinical record revealed the facility scheduled the CBGs at 6:30 A.M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The resident received [MEDICATION NAME]based on a sliding scale as follows: CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, showed multiple medication errors, including dose administration, for the time period from [DATE] through the time of survey review on [DATE], as follows: (Prior to [DATE] there was an order to give at 6:30 A.M., and errors at that time are counted. After [DATE], any insulin given at 6:30 A.M. was not counted. ) [DATE], 8:00 P.M., CBG 411, given no insulin, should have received 12 units [DATE], 6:30 A.M., CBG 184, given no insulin, should have received 2 units [DATE], 11:30 A.M., CBG 272, given no insulin, should have received 6 units [DATE], 8:00 P.M., CBG 319, given no insulin, should have received 8 units [DATE], 8:00 P.M., CBG 315, given 6 units, should have received 8 units [DATE], 6:30 A.M., CBG 238, given 8 units, should have received 4 units [DATE], 6:30 A.M., CBG 263, no insulin documented as given, should have received 6 units [DATE], 4:30 P.M., CBG 373, given 8 units, should have received 10 units [DATE], 8:00 P.M., CBG 356, no insulin documented as given, should have received 10 units [DATE], 6:30 A.M., CBG 187, no insulin documented as given, should have received 2 units [DATE], 4:30 P.M., CBG 491, given 12 units, should have received 14 units [DATE], 4:30 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given ,[DATE]

Based on record review, resident/family interviews and staff interviews, the facility failed to report and thoroughly investigate an allegation of an injury received during care for 1 sampled resident (#14) and failed to investigate family complaints of neglect for 1 sampled resident (#25). The facility did not follow their policy and procedure for reporting and investigating accidents and incidents. The total sample was 27 residents. Findings include: A review of the facility's Resident Abuse, Prevention, Investigation and Reporting policy for accidents and incidents indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises must be investigated and reported to the Administrator. 1. For Resident #14, the facility failed to thoroughly investigate the resident's complaint of injury when transferred with the mechanical lift. The resident reported an injury (hematoma) to two staff persons. The resident was later hospitalized and required surgery for [REDACTED]. Resident #14 was admitted with multiple [DIAGNOSES REDACTED]. The initial hospital history and physical dated 5/23/13, indicated the resident had an increase in [MEDICAL CONDITION] of the lower extremities. A review of the initial Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had no memory or recall issues, did have some trouble sleeping and had no behaviors. The assessment indicated the resident was totally dependent on staff for transfers and nonambulatory. The medical record indicated the resident had another hospitalization [DATE] - 8/6/13 and a review of the hospital consultation report indicated the resident was brought to the hospital for pain, swelling and [DIAGNOSES REDACTED] (redness) in the right leg. The report documented the resident two weeks prior to this admission said he/she was being lifted with a Hoyer (mechanical) lift and his/her leg got in the wrong spot. The report indicated in the emergency room the resident was found to have a large hematoma of the right lower leg that was felt to be infected. The report indicated an incision and drainage was performed and 200 ml (milliliters) of infected hematoma was evacuated. During interview and record review on 9/5/13 at 11:30 A.M., the Director of Nurses said he/she was not aware of the resident having any injury with the mechanical lift and no staff had reported anything to him/her or the Administrator. The Director said she would look into it. During interview on 9/6/13 at 8:20 A.M., the resident said when "transferred with the Hoyer (mechanical) lift I felt the strap on the back of my leg and felt a pop." The resident said this developed into a large area from the varicose vein. The resident said his/her primary care physician saw the area and sent him/her to the hospital. The resident said "the wound was drained of 200 ml. of fluid." The resident was asked if he/she had reported the injury with the mechanical lift to staff at the facility and the resident replied he/she informed the staff. After the facility investigated the resident's allegation, the Director of Nurses on 9/6/13 at 11:50 A.M., said he/she could not identify exactly what happened with the transfers of the resident and the injury but said two staff were aware of the resident's complaint after returning from the hospital. The Director of Nurses said from the investigation two staff, the bookkeeper and Social Worker #1, were aware on 8/12/13 of the resident's complaint and had not initiated and informed the Director of Nurses of the residents complaint. There was no incident report and no investigation completed when the staff were informed by the resident. A review of the written statements from the bookkeeper, dated 9/6/13, indicated the resident was informed about financial matters. The resident told the bookkeeper that he/she shouldn't have to pay anything because he/she was dropped here from the Hoyer. Review of the Social Worker #1 written statement dated 9/6/13 said the he/she was approached by the business office and relayed the story of the resident not paying because he/she was injured here and transferred to the hospital. The Social Worker interviewed the resident who stated the same information of an injury at the facility and hospitalization . The resident informed the facility's staff of an allegation of being injured while transferred at the facility and the two staff persons did not report the resident's allegations to the facility's management team and no report or investigation was done. 2. For Resident #25, the facility failed to report and thoroughly investigate the family's complaint of neglect. The resident's family had reported multiple incidents of poor staff response and resident care. The family reported staff bullied and intimidated the resident and that their reports were ignored. The family reported that the resident was fearful of using his/her call light and would therefore attempt to care for self. The family reported the resident's response to treatment left him/her at risk for injury. Resident #25 had been admitted in October 2012 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS dated [DATE], indicated the resident understood and could make self understood and had some cognitive long and short term memory impairment. The MDS indicated the resident was continent of both bladder and bowel function and required extensive assistance from staff for activities of daily living, including transfers and ambulation. On 9/9/13 at 1:00 P.M., Resident #25's family approached the surveyors and asked to be interviewed. The family reported that one of the two family members was the activated primary health care agent. They said that they had multiple complaints and had multiple meetings with the facility to discuss and resolve their issues. The family said that there has been no resolution to any of the problems identified and that the facility was neglectful. The family said that the resident was fearful and was at risk of injury because he/she did not want to get the staff mad when he/she needed help. The family said they had spoken to the nursing staff, Social Worker, Physician, Administrator, Director of Nurses and ombudsman advocate. The family said the resident was alert and oriented and the primary language was not English. The resident had resided on the current unit since June 2013 and since the transfer there had been multiple problems with care and poor communication, by the facility, with the family, who are available, as multiple family members visit daily throughout the day. The family said the following incidents and complaints had been reported to the facility staff. - The family reported the resident was an insulin dependent diabetic and on multiple occasions the resident had not received the correct meal. The meals included high sugar foods and snacks. The family reported that on multiple occasions these incidents had caused a spike in the resident's blood sugar. The family reported they had involved the ombudsman and still had no resolution and the problem continued. - The family reported that the staff's response to the call light was poor. The resident would put on his/her call bell, but would wait too long and have a bladder or bowel accident. The family said that when staff answered the call light, they had observed certified nursing (CNA) staff bullying and embarrassing the resident. On one occasion, the resident was in bed and exposed. The resident put on the call bell and, when the CNA entered the room, he/she said in a berating tone "you need to go to the bathroom again." The family explained that the resident was on high doses of diuretics and frequently needed to void. - The family said about a week earlier on a Saturday, the family observed the resident in a chair with his/her breakfast. The resident's nightgown was saturated and smelled of urine, the bed was urine soaked, and the commode had feces and urine in it. The commode was placed next to the resident who was eating his/her breakfast. The family reported the incident and asked the nurse to assess the situation. The family said the nurse agreed the situation was unacceptable and would look into it. The family said that there had been no communication by the facility to them about this incident. - Other issues included laboratory tests that had been ordered but not done, staff taking pictures of the resident's leg on a cell phone without permission and sending them to a covering physician, poor infection control practices between the resident and roommate, and lack of communication of resident care and status changes with the health care proxy. The family said that the resident was so afraid that staff would be mean to him/her if she put her call bell on that the resident would attempt to care for self and had several falls. The family said the resident was reprimanded when he/she had fallen. Review of the nurses' notes indicated on 7/15/13, the CNA reported the resident accused the staff of lying because they had not toileted him/her. The nurse indicated the staff reported they had provided a bedpan and her toileted him/her frequently. On 7/26/13, the nurse documented the family met with the physician and the resident's frequency to void at night was discussed. The facility explained to the family it was because the resident was on multiple diuretics. On 7/28/13 and 7/29/13 (the 11:00 P.M. to 7:00 A.M. shift), the nurses documented the resident yelled at staff that they had not answered the call light, had shut off the call light and not helped her go the bathroom. The nurses indicated the resident was toileted multiple times. On 8/1/13, the nurse documented the resident tore off a brief, threw it on the floor and urinated in the bed. The staff encouraged the resident to use call bell. On 8/24/13, the nurse documented the family complained about the commode and was referred to the social worker. Review of Social Worker #2's progress notes indicated that on 8/8/13, the family reported concerns that the resident's increased frequency to urinate was not being addressed. The facility plan was to put a commode next to the resident's bed. On 8/24/13, Social Worker #2 indicated that she received an additional complaint about the commode from the family. Issues included use, infection control and protocols between both residents in the room. Social Worker #2 indicated he/she referred the issues to the Director of Nurses. There was no subsequent note that followed. After reviewing the medical record and reviewing the facility's grievance log, obtained for review on 9/12/13 at 4:00 P.M., there was evidence that the facility had met with the family and that some of the issues had been discussed. However, the grievance log failed to identify any family complaints or grievances as outlined by the family. During interview on 9/13/13 at 7:30 A.M., Unit Manager #2 said he/she, the physician and Social Worker #2 had met and talked with the resident and family on several occasions and that currently there were no issues that he/she was unaware of. The Assistant Director of Nurses was interviewed on 9/13/13 at 7:45 A.M. and said he/she had a good relationship with the family. He/she said he/she had just recently sat with them at an activity and had a wonderful conversation. Social Worker #2 was interviewed on 9/13/13 at 9:10 A.M. and said there were no issues. The surveyor inquired about the family's complaint to him/her that the staff had bullied and reprimanded the resident when he/she requested to be toileted too often, and that the resident was afraid. The surveyor stated that the family had said that the Social Worker would complete an investigation. Social Worker #2 had no response to the inquiry. On 9/13/13 at 11:00 A.M., the Ombudsman called the surveyor and said that he/she had been involved with the family's complaints to the facility and confirmed that the facility was aware of the complaints. A subsequent meeting with Social Worker #2, Director of Nurses, Unit Manager #2 and Assistant Director of Nurses on 9/13/13 at approximately 1:00 P.M., confirmed that the facility had not fully investigated the family's multiple complaints of poor care that was identified by the family as neglect

Based on record review, resident interview, staff interview and observation, the facility failed to ensure that residents were not exposed to risk of serious harm from medication errors, for 8 residents (#2, #4, #11, #12, #20, #21, #25 and #27) in a total sample of 27 residents. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 26 (normal range ,[DATE]) and the resident expired at the facility. Findings include: 1. a) For Resident #20, the facility failed to ensure the medication ordered by the physician was documented correctly on the medication administration record (MAR) and administered as ordered. Staff failed to recognize and clarify the medication administration record for three days and documented that the wrong dose of medication was administered. The resident, who showed significant changes in condition, was not provided timely clinical interventions following the administration of the incorrect dose of medication. The resident died the next morning. Resident #20's medical record was reviewed by the surveyor on [DATE] at 1:45 P.M. and initial review indicated a potential medication error. Documentation on the [DATE] MAR indicated that 80 units (10 times the original ordered amount) of [MEDICATION NAME]had been administered on [DATE], [DATE] and [DATE] at 4:30 P.M. The medical record indicated on [DATE], the physician had ordered [MEDICATION NAME]8 units daily at 4:30 P.M. (not 80 units). The July and [DATE] MARs indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M.. During an interview on [DATE] at 1:50 P.M., Unit Manager #2 said the resident had died on [DATE]. The Manager said he/she and the physician were surprised when informed of the resident's death. He/she said the resident had been at his/her baseline the day before and his/her death was not anticipated or expected. On [DATE] at 2:50 P.M., a subsequent interview was conducted with the Director of Nurses and Unit Manager #2. Prior to discussion the medical record indicated the resident had been administered a 10 times higher dose of [MEDICATION NAME]then ordered. The Unit Manager #2 said that the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) had told him/her that he/she had gone into the resident's room to obtain the morning blood sugar and got a blood sugar of 25. The manager said the nurse administered the [MEDICATION NAME] (anti-hypoglycemic) and oxygen, but that the resident died and he/she made the RN Nurse Pronouncement. Upon further inquiry with the Director of Nurses and Unit Manager #2, the dose of the [MEDICATION NAME]was discussed. Both agreed that the [DATE] MAR and physician order [REDACTED].M. The MAR indicated that three different nurses signed the MAR that the resident was administered 80 units of [MEDICATION NAME] insulin. The Director of Nurses said he/she would look into the incident and provide an investigation why the 8 units was incorrectly printed on both the MAR and the orders as 80 units. On [DATE] at 3:30 P.M., Nurse #1 was interviewed and said he/she had worked from 3:00 P.M. to 7:00 A.M. on [DATE]-[DATE]. Nurse #1 said he/she worked as many doubles as he/she could, but mainly worked the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said he/she knew the resident but usually worked on another unit. Nurse #1 said he/she had been told the resident had not eaten much of his/her lunch or dinner on [DATE] and had told the certified nursing assistants (CNA) to make sure the resident was given a snack. The nurse said he/she was not sure if the resident received a snack. Nurse #1 said he/she had administered the 4:30 P.M. dose of [MEDICATION NAME]on [DATE], but had not administered 80 units. Nurse #1 said he/she wrote 8 units on his/her work sheet and had later signed the MAR that read 80 units. Nurse #1 said he/she noticed the MAR indicated that 80 units of [MEDICATION NAME]was to be administered on [DATE] at 4:30 P.M., but did not clarify or attempt to correct the order. Nurse #1 said he/she thought a staff had told him/her the resident was tired or something that night, but could not clearly remember. The nurse said the information did not indicate a change to him/her because the resident had been showing a decline over the past few months. Nurse #1 said he/she was unclear when he/she had administered the resident's medications, but thinks the last time he was in the resident's room during the 3:00 P.M. to 11:00 P.M. shift on [DATE] was when he administered the roommates medication at around 8:00 P.M. Nurse #1 said the next time he/she saw the resident was on [DATE] at 5:45 A.M. to obtain the morning blood sugar. The nurse said when he/she entered the room the resident was "mouth breathing ... he/she looked like a fish out of water." The nurse took the resident's blood sugar which was 25, then took a second blood sugar which was 46. The nurse said he/she left the resident to get [MEDICATION NAME] (antihypoglycemic agent), an oxygen tank, a rebreather mask and to check the resident's advance directive status. The nurse said when he/she returned to the resident's room the resident continue to breath like a fish out of water and his/her nail beds were blue. Nurse #1 then demonstrated how the resident was breathing to the surveyors. The nurse said he/she administered the [MEDICATION NAME] and rechecked the blood sugar. Nurse #1 said the resident's code status was DNR (do not resuscitate) and do not transfer. Nurse #1 said the resident died and added that he/she asked the CNA how the resident had been the hour prior to his/her obtaining the blood sugar. The nurse said the CNA #3 had told him/her the resident was full of "piss and vinegar," i.e. feisty. During interview on [DATE] at 3:50 P.M. with Nurse #2, the nurse said he/she had signed the MAR on [DATE] indicating the resident was given 80 units of [MEDICATION NAME]at 4:30 P.M. Nurse #2 said he/she knew the amount was wrong and had gone back and looked at the [DATE] MAR before administering the insulin. The nurse said he/she gave the resident 8 units of Levimer insulin. The nurse said the facility had a lot of transcription errors and that was why he/she had checked the previous MAR. Nurse #2 said he/she did not check the physician orders [REDACTED]. Record review, on [DATE] indicated Resident #20 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Assessment ((MDS) dated [DATE], indicated the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and dependent on staff for all his/her activities of daily living. The record indicated the resident was being treated for [REDACTED]. Review of the MAR for [DATE] indicated the resident was given scheduled insulin of [MEDICATION NAME] and [MEDICATION NAME] sliding scale insulin. The physician's orders [REDACTED].M. and [MEDICATION NAME] 80 units at 4:30 P.M., and [MEDICATION NAME](short acting insulin) based on blood sugars obtained at 6:30 A.M. and 4:30 P.M.. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Review of the nurses' notes indicated from [DATE] through [DATE] (7:00 A.M.- 3:00 P.M.), the resident continued on an antibiotic for a urinary tract infection and had no complaints. A subsequent nurses' note dated [DATE] indicated the resident was sleepy at times and had a good appetite at lunch and dinner. On [DATE], Nurse #1 documented at 10:00 P.M., the resident had no complaints, required assistance with care by two staff and that his/her cardiac, respiratory status was without signs and symptoms of acute distress and that he/she was sleeping most of the shift. The note did not include any vital signs. On [DATE], Nurse #1 documented that he/she went into the resident's room at 5:45 A.M. to obtain a blood sugar. The nurse documented a blood sugar of 25. The nurse indicated he/she administered [MEDICATION NAME], as per house protocol, and rechecked the resident's blood sugar. The note indicated the second blood sugar was 46. The nurse increased the resident's oxygen to 15 liters and added a rebreathing mask for comfort. The note indicated the resident was gasping for air and the nail beds were blue, the nurse rechecked the resident's blood sugar and obtained a result of 96. The nurse then indicated the resident had no pulse, breath sounds and did not respond to stimuli. The note indicated the nurse had checked the resident's advance directives and determined the resident was a do not resuscitate and a do not transfer. The record indicated a physician order [REDACTED].M. on [DATE]. On [DATE] at 10:30 A.M., the Director of Nurses said the facility had completed an investigation and obtained staff statements. Review of the investigation and staff statements indicated on [DATE] from 3:30 P.M. to 10:00 P.M., CNA #1 identified and reported a change in the resident's condition to Nurse #1 twice. CNA #1's witness statement and who was also interviewed on the phone by the surveyor on [DATE] at 11:30 A.M., said he/she was assigned to Resident #20 on [DATE] and had been a CNA for 5 years. The CNA said when he/she changed the resident at 3:30 P.M. he/she noticed the resident was not him/herself. CNA #1 said it wasn't until he/she returned to the resident's room at 7:30 P.M. that she observed a significant change. The CNA said the resident was "very pale and was out of it ... and about to die." CNA #1 said the resident looked like another resident who had died . The CNA said after he/she provided care he/she told Nurse #1 to go look at Resident #20. CNA #1 said he/she did not know if Nurse #1 went to see the resident. At 10:00 P.M., CNA #1 said he/she went into the resident's room to provide care. CNA #1 said the resident was "very, very unresponsive." The CNA said he/she went and got another CNA (CNA #2) to look at the resident. The CNA said that CNA #2 was more experienced and that he/she had asked if he/she had notified the nurse. The CNA said he/she told CNA #2 that Nurse #1 had been notified at 7:30 P.M. CNA #1 said that he/she went and told Nurse #1 at 10:00 P.M. that he/she "really, really needed to check the resident ... because the resident was very, very unresponsive and would not open his/her eyes." CNA #1 said he/she found out later that the resident had passed away. Upon further inquiry by the surveyor, CNA #1 said that although he/she had not fed the resident, he/she had been told that the resident had not eaten dinner and had not eaten much of his/her lunch. According to CNA #2's witness statement it indicated that he/she had worked on [DATE] (3:00 P.M. to 11:00 P.M.). The CNA stated he/she assisted the resident at 4:00 P.M. and noted the resident was not his/her usual self. CNA #2 indicated he/she thought the resident was sleepy. At 10:00 P.M., CNA #1 asked CNA #2 for assistance and noted they had difficulty rolling the resident over, the resident was very quiet and was having difficulty breathing. CNA #2 told CNA #1 to tell the nurse and subsequently observed CNA #1 informing Nurse #1. According to CNA #3's witness statement it indicated he/she first saw the resident on [DATE] at 2:00 A.M. CNA #3 indicated the resident was sleepy, hard to wake up and had opened his/her eyes and then went back to sleep. At 5:00 A.M., CNA #3 indicated that there was something wrong with the resident and at this time reported the change to Nurse #1. CNA #3 said Nurse #1 said the resident had a urinary track infection. CNA #3 indicates that Nurse #1 had gone to see the resident and later informed him/her that the Resident's BS was low and nail beds were purple. According to the facility investigation and witness statements, it was determined that there was a medication error in the editing process for the resident's record. As a result the September MAR indicated an order for [REDACTED].M. The facility investigation indicated that three nurses signed the September MAR indicating that the resident was administered 80 units of [MEDICATION NAME], however the three nurses stated they had not administered 80 units and knew the order was for 8 units. The facility investigation indicated that through interviews with three CNAs (#1, #2, and #3) that Nurse #1 had been informed at 7:30 P.M., 10:00 P.M. and 5:00 A.M. that there was a significant change in the resident's condition. The investigation indicated that Nurse #1 was asked about the CNAs' concerns, and Nurse #1 said he/she did not recall receiving any reports from staff regarding a change in condition. Nurse #1 said he/she found the resident having difficulty breathing when he/she went in to do the morning blood sugar at 5:45 A.M., which was 45 minutes after the 5:00 A.M. report by the CNA of a change in condition. During interview on [DATE] at 10:15 A.M., Resident #20's primary physician stated he/she saw the resident on [DATE] in the morning and that he/she looked perfectly fine. The physician said he/she had not been notified of any change in the resident's condition until he/she was notified of the resident's death. The physician said he/she was surprised the resident had died and attributed the cause to a [MEDICAL CONDITION] infarct ([MEDICAL CONDITION]). The physician said he/she was notified of the medication transcription error on [DATE] and is now unsure of the cause of death. The physician reviewed the resident's condition and regular medications with the surveyor and said that the cause of death would most likely remain unknown. The physician said he had not completed the discharge summary, but had signed the death certificate prior to his knowledge of the medication error. During interview on [DATE] at 2:45 P.M., Resident #4 (roommate of Resident #20) said he/she missed his/her roommate. Resident #4 said he/she heard Nurse #1 trying to wake Resident #20 up but could not. Resident #4 said he/she did not know what happened but that the roommate was gone. The resident said it happened in the middle of the night, but could not remember what time. Resident #20's ordered medication was not documented correctly on the MAR, and three nurses signed that the incorrect dose was administered for three days. Nursing staff took no action to correct the error to prevent future medication errors. According to the facility's investigation, three CNAs reported the resident showed a significant change in his/her medical condition, without documented nursing interventions. b) Further review of Resident #20's record indicated the nursing staff failed to administer accurate doses of [MEDICATION NAME]based on the sliding scale ordered by the physician since at least [DATE]. The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Multiple errors were found in several months, as follows: [DATE], 4:30 P.M., CBG 207, given 2 units of insulin, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 213, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 215, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 213, given 2 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 157, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 265, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 342, given 10 units, sliding scale order was for 8 units [DATE], 6:30 A.M., CBG 189, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 232, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 251, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 246, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG not documented, no insulin given [DATE], 4:30 P.M., CBG 247, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 310, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 249, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 226, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 220, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 300, given 6 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 260, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 258, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 219, given no insulin, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG 258, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 327, given 4 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 332, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 341, given no insulin, sliding scale order was for 8 units [DATE], 6:30 A.M., CBG 250, given 4 units, sliding scale order was for 6 units [DATE], 4:30 A.M., CBG 309, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 278, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 285, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 270, given 8 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 286, given 8 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 178, given 4 units, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 251, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 335, given no insulin, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 278, given no insulin, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 267, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 261, given no insulin, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 156, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 303, given no insulin, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 245, given 6 units, sliding scale order was for 4 units [DATE], 6:30 A.M., CBG no obtained, no insulin given [DATE], 6:30 A.M., CBG 260, given 4 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 260, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 295, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 281, given 4 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 156, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 155, given no insulin, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 261, insulin coverage not legible, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 179, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 171, given no insulin, sliding scale order was for 2 units [DATE], 6:30 A.M., CBG 254, given 2 units, sliding scale order was for 6 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 2. For Resident #2, the facility failed to follow the physician orders [REDACTED]. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. Record review revealed that there was an order for [REDACTED]. According to physician orders [REDACTED]. CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG is ,[DATE], give 180 ml apple juice, recheck blood sugar in 10 min and notify the physician if needed. Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, multiple errors were found. [DATE], 6:30 A.M., CBG 201, given no insulin, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 266, given 6 units, sliding scale indicated should receive 6 units [DATE], 8:00 P.M., CBG 202, given 2 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 210, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 208, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 223, given 6 units, sliding scale indicated should receive 4 units [DATE], 6:30 A.M., CBG 159, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 184, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 160, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:30 A.M., CBG 151, given no insulin, sliding scale indicated should receive 2 units [DATE], 6:00 A.M., CBG 156, given no insulin, sliding scale indicated should receive 2 units On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 3. For Resident #25, the nursing staff failed to administer two medications within the ordered physician parameters. Resident #25 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the monthly medication orders indicated that the physician ordered [MEDICATION NAME] HCL (anti-hypertensive medication) 50 milligrams three times per day and hold if the systolic blood pressure (SBP) is less than 130. Review of the monthly medication administration records (MAR) and nurses' notes indicated the following errors for the administration of the antihypertensive medication [MEDICATION NAME] HCL, which had parameters to hold if the systolic blood pressure was less than 130. [DATE], 8:00 P.M., Blood Pressure (BP) recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 A.M., BP recorded as ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 A.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., no BP recorded, not signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 8:00 P.M., BP recorded ,[DATE], nurse signed that drug was given [DATE], 2:00 P.M., no BP recorded, not signed that drug was given On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet and MAR revealed these errors. 4. a) For Resident #4, the facility failed to ensure that staff did not administer insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on [DATE], the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. There was no evidence that the physician was contacted to clarify the timing of the CBG and the sliding scale. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer sliding scale insulin, contrary to the physician's orders [REDACTED]. from the time of the change in order on [DATE] through the date of survey review on [DATE], as follows: [DATE], CBG 276, received 6 units of insulin [DATE], CBG 190, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 203, received 4 units [DATE], CBG 158, received 2 units [DATE], CBG 237, received 4 units [DATE], CBG 195, received 2 units [DATE], CBG 158, received 2 units [DATE], CBG 173, received 2 units [DATE], CBG 208, received 4 units [DATE], CBG 232, received 4 units [DATE], CBG 224, received 4 units [DATE], CBG 166, received 2 units [DATE], CBG 183, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 282, received 6 units [DATE], CBG 290, received 6 units [DATE], CBG 198, received 2 units [DATE], CBG 190, received 2 units [DATE], CBG 200, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 159, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 208, received 4 units [DATE], CBG 153, received 2 units [DATE], CBG 215, received 2 units [DATE], CBG 241, received 4 units [DATE], CBG 180, received 2 units [DATE], CBG 151, received 2 units [DATE], CBG 167, received 2 units [DATE], CBG 285, received 6 units [DATE], no CBG recorded [DATE], CBG 201, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 175, received 2 units [DATE], CBG 157, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 171, received 2 units [DATE], CBG 170, received 2 units [DATE], CBG 184, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 214, received 4 units [DATE], CBG 155, received 2 units [DATE], CBG 188, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 177, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 175, received 2 units [DATE], CBG 150, received 2 units [DATE], CBG 187, received 2 units [DATE], CBG 205, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 227, received 2 units During interview on [DATE] at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from [DATE] through the date of survey review on [DATE] revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On [DATE] at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. b) Additionally, for Resident #4, the facility failed to accurately administer multiple doses of Humalog insulin based on the sliding scale ordered by the physician since at least [DATE]. Resident #4 had a [DIAGNOSES REDACTED]. Review of the clinical record revealed the facility scheduled the CBGs at 6:30 A.M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The resident received [MEDICATION NAME]based on a sliding scale as follows: CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, showed multiple medication errors, including dose administration, for the time period from [DATE] through the time of survey review on [DATE], as follows: (Prior to [DATE] there was an order to give at 6:30 A.M., and errors at that time are counted. After [DATE], any insulin given at 6:30 A.M. was not counted. ) [DATE], 8:00 P.M., CBG 411, given no insulin, should have received 12 units [DATE], 6:30 A.M., CBG 184, given no insulin, should have received 2 units [DATE], 11:30 A.M., CBG 272, given no insulin, should have received 6 units [DATE], 8:00 P.M., CBG 319, given no insulin, should have received 8 units [DATE], 8:00 P.M., CBG 315, given 6 units, should have received 8 units [DATE], 6:30 A.M., CBG 238, given 8 units, should have received 4 units [DATE], 6:30 A.M., CBG 263, no insulin documented as given, should have received 6 units [DATE], 4:30 P.M., CBG 373, given 8 units, should have received 10 units [DATE], 8:00 P.M., CBG 356, no insulin documented as given, should have received 10 units [DATE], 6:30 A.M., CBG 187, no insulin documented as given, should have received 2 units [DATE], 4:30 P.M., CBG 491, given 12 units, should have received 14 units [DATE], 4:30 P.M., no CBG recorded, no insulin documented as given [DATE], 8:00 P.M., no CBG recorded, no insulin documented as given [DATE], 4:30 P.M., n

Based on record review and staff interview, the facility failed for 3 residents (#2, #4 and #20) of 27 sampled residents to provide timely notification to the physician when there was a change in condition. Findings include: 1. For Resident #20, the facility failed to provide timely notification to the physician when there was a change in condition. The resident died on [DATE] at 7:00 A.M. Resident #20, a long term care resident, who had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Assessment ((MDS) dated [DATE], the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and that he/she was dependent on staff for all his/her activities of daily living. During record review on [DATE], the record indicated the resident was currently being treated for [REDACTED]. Review of the [DATE] MAR indicated that 80 units of [MEDICATION NAME]had been documented as administered on [DATE], [DATE] and [DATE] at 4:30 P.M. The monthly physician order [REDACTED]. Further review indicated the physician had not changed the [MEDICATION NAME]order since 8 units was ordered on [DATE]. Review of the current signed physician orders, dated [DATE], indicated the [MEDICATION NAME]sliding scale was as follows: Capillary Blood Glucose (CBG) of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units a CBG greater than 450 notify the physician or if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Record review indicated on [DATE], the physician had ordered [MEDICATION NAME]8 units daily at 4:30 P.M. Review of the July and [DATE] MARs (medication administration records) indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M. During interview on [DATE] at 2:50 P.M., the surveyor brought to the attention of the Director of Nurses and Unit Manager #2, that the medical record had indicated the resident had been administered a 10 times higher dose of [MEDICATION NAME]than originally ordered on three consecutive days. Unit Manager #2 had no response to the medication issue, but said that the resident had been stable and his/her death had not been anticipated or expected. The Unit Manager #2 said the physician had seen the resident the day before ([DATE]) and noted the resident was at baseline. Unit Manager #2 said that the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) had said he/she found the resident with a low blood sugar of 25 when he/she had gone into the resident's room to obtain the morning blood sugar. Unit Manager #2 said Nurse #1 had given medication to elevate the resident's blood sugar, but attempts to alter the resident's condition failed. Unit Manager #2 said the physician was notified of the resident's death. The Director of Nurses said he/she would look into the incident and provide an investigation. On [DATE] at 3:30 P.M., Nurse #1 was interviewed and said he/she had worked from 3:00 P.M. to 7:00 A.M. on [DATE]-[DATE]. Nurse #1 said he/she had signed the MAR and administered the 4:30 P.M. dose of [MEDICATION NAME]on [DATE], but said he/she had not administered 80 units. Nurse #1 said he/she thought a staff had told him/her the resident was tired that night, but could not clearly remember. The nurse said the information did not indicate a change to him/her because the resident had been showing a decline over the past few months. Nurse #1 said he/she was unclear when he/she had seen the resident during his/her two shifts ([DATE] - [DATE] from 3:00 P.M. - 7:00 A.M.). Nurse #1 indicated he/she may have been in the room giving the roommate medications at 8:00 P.M. and his/her subsequent observation was at 5:45 A.M. to obtain the morning blood sugar. The nurse said the resident was breathing like a "fish out of water" and demonstrated his/her observation. He/she said [MEDICATION NAME] (anti-hypoglycemic) was administered and the blood sugar was rechecked. Nurse #1 said he/she checked the the resident's code status and it was a DNR (do not resuscitate) and do not transfer. Nurse #1 said the resident died and then called the physician. The nurse said he/she asked Certified Nurse Aide (CNA) #3 how the resident had been during the 5:00 A.M. rounds and the CNA said the resident was full of "piss and vinegar, " i.e. feisty. On [DATE], Nurse #1 documented at 10:00 P.M., the resident had no complaints, required assistance with care by two staff and that his/her cardiac, respiratory status was without signs and symptoms of acute distress and that he/she was sleeping most of the shift. The note did not include any vital signs. On [DATE], Nurse #1 documented in a nurse's note that he/she went into the resident's room at 5:45 A.M. to obtained a blood sugar. The nurse documented a blood sugar of 25. The nurse indicated he/she administered [MEDICATION NAME], as per house protocol, and rechecked the resident's blood sugar. The note indicated the second blood sugar was 46, but did not indicate that the physician was notified as specified by the physician order [REDACTED]. The nurse increased the resident's oxygen to 15 liters and added a rebreathing mask for comfort. The note indicated the resident was gasping for air and the nail beds were blue, the nurse rechecked the resident's blood sugar and obtained a result of 96. The nurse then indicated the resident had no pulse, breath sounds and did not respond to stimuli. The note indicated the nurse had checked the resident's advance directives and determined the resident was a do not resuscitate and a do not transfer. Nurse #1 indicated he/she called the physician and obtained an order for [REDACTED]. There was no documentation that the physician was notified when the nurse first observed the resident's change in condition at 5:45 A.M. During interview on [DATE] at 10:15 A.M., Resident #20's primary physician said he/she saw the resident on [DATE] and the resident was fine. The physician said he/she had not been notified of any change in the resident's condition until he/she was notified of the resident's death. 2. For Resident #4, the facility failed to notify the physician of a significant change in the resident's diabetic condition and failed to follow the parameter for physician notification identified in the sliding scale insulin orders. The sliding scale insulin order indicated that the physician was to be notified if the resident's Capillary Blood Glucose (CBG) level was 450 or greater. The facility failed to notify the physician on 9 of 16 occasions when the CBG level exceeded the parameter. Resident #4 had a [DIAGNOSES REDACTED]. Review of the clinical record indicated the facility scheduled the CBG's at 6:30 A.M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The physician's orders [REDACTED]. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their Medication Administration Record (MAR) for insulin administered according to the sliding scale, from [DATE] through the date of survey review on [DATE] indicated the resident had 16 occurrences when the CBG result was 450 or greater. Based on review of the nurses' notes and documentation on the MAR, for 9 of the 16 occurrences there was no evidence that the physician was notified of the high CBG result. Findings are as follows: [DATE] - on [DATE] the CBG was 454, no evidence of notification February 2013 - no evidence of notification on [DATE] for CBG of 483, and [DATE] for CBG of 491 [DATE] - no evidence of notification on [DATE] for CBG of 519, [DATE] for CBG of 500, [DATE] for CBG of 459, and [DATE] for CBG of 452 [DATE] - no evidence of notification on [DATE] for CBG of 458 [DATE] - no evidence of notification on [DATE] for CBG of 490 During interview on [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the lack of evidence of notification as outlined above. This was discussed with the Director of Nursing and Administrator on [DATE] at 3:15 P.M. No additional documentation or information was provided during the survey. 3. For Resident #2, the facility failed to notify the physician of the resident's significant weight loss. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was independent with set up for eating. The MDS assessment also indicated the resident had significant change in status for ability to make needs known and required extensive assistance from staff for activities of daily living. Review of the facility weight records revealed the resident's weight status was monitored weekly and had been stable at around 202 pounds from [DATE] through [DATE], at which time the resident's weight was 199.8 pounds. During the month of July, the resident's weight fluctuated. On [DATE], the resident weight was 184 pounds (a 15.8 pound weight loss) and on [DATE] was 181.1 pounds (an additional 3 pound weight loss). On [DATE], the dietician's progress note indicated that he/she was notified by the nursing staff of an unplanned change in weight of 10.4 % or 19.1 pounds in less than 10 days. On [DATE], a nutritional assessment was completed. The dietician indicated the assessment was completed due to weight loss, a decline in ambulation and cognitive changes. The dietician noted that the resident had a 10% weight loss (19.1 pounds in one month). The dietician indicated the resident had no difficulty eating and had no other recommendations or plan as is "await MD's decision." However, there is no evidence the physician was notified of the significant weight loss. On [DATE], the resident was hospitalized for [REDACTED]. The resident was readmitted on [DATE] with a readmission weight of 203.4 pounds. The [DATE] admission assessment indicated the resident was alert, without respiratory distress and had 2 plus [MEDICAL CONDITION] to both feet. Review of the re-admission physician orders [REDACTED]. Review of the [DATE] weight record indicated that on [DATE] the resident's weight was 202.8 pounds, a 0.6 pound weight loss since the day before. On [DATE], the resident's weight was 195.4 pounds (an 8 pound weight loss in 5 days). According to review of the medical record, staff did not identify or assess this weight loss. There was no evidence that staff notified the physician of weight loss, Subsequent weekly weights were as follows: [DATE] - 185.8 pounds (9.6 weight loss in 7 days), [DATE] - 185.2 pounds, [DATE] - 183.8 pounds From the resident's re-admission weight of 203.4 pounds on [DATE], the resident lost 18.4 pounds in less than one month. During interview on [DATE] at 7:35 A.M. with Unit Manager #2 and the Charge Nurse, the Charge Nurse said the resident had [MEDICAL CONDITION] and was on fluid pills. The Charge Nurse said when the resident was readmitted on [DATE], his/her face was "full and round" and now it was "thin." The Charge Nurse and Unit Manager #2 reviewed the medical record and both said they agreed there was no evidence the resident's weight loss was reported to the physician. A review of the physician progress notes [REDACTED]. During interview on [DATE] at 12:00 P.M., the resident's primary care physician reviewed the weight records from [DATE] through [DATE] and said that he/she was not aware of weight loss.

Based on record review, resident observations, resident interviews and interviews with staff, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, particularly by providing adequate interventions and evaluating their effectiveness to maintain body weight and prevent significant weight loss, for 1 resident (#2) who had unplanned significant weight loss in a total sample of 27 residents. Findings include: The requirements for completing the standardized Resident Assessment Instrument (RAI) define significant weight change as any loss or gain of 5% or more in the past 30 days or 10% or more in the last 180 days. The RAI guidelines specify that "Weight loss should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS (Minimum Data Set) assessment." The facility failed to provide adequate interventions and services to attempt to maintain body weight and prevent additional unplanned significant weight loss for Resident #2. In 30 days the resident lost 21 pounds, or 10.3% of the resident's body weight. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 8/15/13, indicated the resident was independent with set up for eating. The MDS assessment also indicated the resident had significant change in status for ability to make needs known and required extensive assistance from staff for activities of daily living. Review of the facility weight records revealed the resident's weight status was monitored weekly and had been stable at around 202 pounds from January 3, 2013 through July 10, 2013, at which time the resident's weight was 199.8 pounds. During the month of July, the resident's weight fluctuated. On 7/17/13, the resident weight was 184 pounds (a 15.8 pound weight loss) and on 7/18/13 was 181.1 pounds (an additional 3 pound weight loss). On 7/18/13, the dietician's progress note indicated that he/she was notified by the nursing staff of an unplanned change in weight of 10.4 % or 19.1 pounds in less than 10 days. The dietician questions if the weight loss is due to a decline in cognition and the resident's inability to to recognize the need to eat. The dietician indicated that the staff state that resident eats well when alert. The dietician recommends a sugar free mighty shake twice a day. On 7/23/13, a significant change clinical dehydration assessment was completed. The assessment indicated that the resident was noted to have a recent weight loss. The assessment indicated the resident's baseline weight was 207 pounds and his/her current weight was 185 pounds. The nurse documented that the resident ate 75 to 100% of meals and had no symptoms of dehydration. On 7/25/13, a nutritional assessment was completed. The dietician indicated the assessment was completed due to weight loss, a decline in ambulation and cognitive changes. The dietician noted that the resident had a 10% weight loss (19.1 pounds in one month). The dietitian recommended large portions and to continue the sugar free mighty shakes two times per day. The dietician indicated the resident had no difficulty eating and had no other recommendations or plan as is "await MD's decision." However, there is no evidence the physician was notified of the significant weight loss. On 7/26/13, the resident was hospitalized for [REDACTED]. The resident was readmitted on [DATE] with a readmission weight of 203.4 pounds. The 8/8/13 admission assessment indicated the resident was alert, without respiratory distress and had 2 plus [MEDICAL CONDITION] to both feet. The resident was identified as having swallowing difficulties and his/her diet was changed from regular texture to ground with honey thick liquids. The large portions and mighty shakes, that were previously recommended by the dietitian, were not included in the re-admission diet plan. Review of the re-admission physician orders [REDACTED]. Review of the August 2013 weight record indicated that on 8/9/13 the resident's weight was 202.8 pounds, a 0.6 pound weight loss since the day before. The 8/9/13 weight included the word "[MEDICAL CONDITION]" written next to the weight, with no other explanation. There was no other documentation or evidence in the record that the [MEDICAL CONDITION] was being monitored since re-admission. On 8/14/13, the resident's weight was 195.4 pounds (an 8 pound weight loss in 5 days). According to review of the medical record, staff did not identify or assess this weight loss. There was no evidence that staff were monitoring for [MEDICAL CONDITION]. On 8/20/13, the dietician's progress note identified the resident's previous week's weight of 195.4 pounds, but did not note this was a weight loss. The dietitian wrote that the resident's intake was good at 75 to 100% of meal intake. The dietician wrote that the resident was overweight and he/she made no changes to the plan of care. Subsequent weekly weights were as follows: 8/21/13 - 185.8 pounds (9.6 weight loss in 7 days), 8/28/13 - 185.2 pounds, 9/3/13 - 183.8 pounds From the resident's re-admission weight of 203.4 pounds on 8/8/13, the resident lost 18.4 pounds in less than one month. On 9/5/13, the dietician's progress note incorrectly indicated that the resident was receiving large portions for all three meals. The dietician indicated that the resident was "basically stable during past 30 days and (weight) may vary secondary to fluid status." During observations of the resident on 9/5/13 at 11:40 A.M., 9/6/13 at 8:05 A.M. and 11:45 A.M., the meal slip did not indicate the portion size was large or regular and the resident received no supervision to ensure appropriate nutritional intake. During interview on 9/6/13 at 7:35 A.M. with Unit Manager #2 and the Charge Nurse, the Charge Nurse said the resident had [MEDICAL CONDITION] and was on fluid pills. The Charge Nurse said when the resident was readmitted on [DATE], his/her face was "full and round" and now it was "thin." The surveyor inquired if the resident had [MEDICAL CONDITION], as the only mention of [MEDICAL CONDITION] was on the initial admission assessment dated [DATE] and on the weight record. The Charge Nurse and Unit Manager #2 reviewed the medical record and both said they agreed there was no evidence the resident's weight loss was due to [MEDICAL CONDITION] and/or fluid loss. The Charge Nurse said that the only documentation about the resident's leg [MEDICAL CONDITION] had been on the resident's readmission on 8/8/13. Review of the record indicated that the physician ordered a low dose of [MEDICATION NAME] (diuretic) 20 mg every other day. A review of the physician progress notes [REDACTED]. Later in the late morning on 9/6/13 at approximately 12:00 P.M., the resident's primary care physician was interviewed. The physician reviewed the weights from 8/9/13 through 9/4/13 and said that he was not aware of weight loss. Based on review of the nurses' notes and treatment records for August 2013 and September 2013, there was no evidence or documentation that the nursing staff identified the fluid status/[MEDICAL CONDITION] as related to the resident's weight loss. During interview on 9/12/13 at 12:15 P.M., the dietician said he/she reviewed the record and that the resident did have significant weight loss.

Based on record review, resident observations, resident interviews and interviews with staff, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, particularly by providing adequate interventions and evaluating their effectiveness to maintain body weight and prevent significant weight loss, for 1 resident (#2) who had unplanned significant weight loss in a total sample of 27 residents. Findings include: The requirements for completing the standardized Resident Assessment Instrument (RAI) define significant weight change as any loss or gain of 5% or more in the past 30 days or 10% or more in the last 180 days. The RAI guidelines specify that "Weight loss should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS (Minimum Data Set) assessment." The facility failed to provide adequate interventions and services to attempt to maintain body weight and prevent additional unplanned significant weight loss for Resident #2. In 30 days the resident lost 21 pounds, or 10.3% of the resident's body weight. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 8/15/13, indicated the resident was independent with set up for eating. The MDS assessment also indicated the resident had significant change in status for ability to make needs known and required extensive assistance from staff for activities of daily living. Review of the facility weight records revealed the resident's weight status was monitored weekly and had been stable at around 202 pounds from January 3, 2013 through July 10, 2013, at which time the resident's weight was 199.8 pounds. During the month of July, the resident's weight fluctuated. On 7/17/13, the resident weight was 184 pounds (a 15.8 pound weight loss) and on 7/18/13 was 181.1 pounds (an additional 3 pound weight loss). On 7/18/13, the dietician's progress note indicated that he/she was notified by the nursing staff of an unplanned change in weight of 10.4 % or 19.1 pounds in less than 10 days. The dietician questions if the weight loss is due to a decline in cognition and the resident's inability to to recognize the need to eat. The dietician indicated that the staff state that resident eats well when alert. The dietician recommends a sugar free mighty shake twice a day. On 7/23/13, a significant change clinical dehydration assessment was completed. The assessment indicated that the resident was noted to have a recent weight loss. The assessment indicated the resident's baseline weight was 207 pounds and his/her current weight was 185 pounds. The nurse documented that the resident ate 75 to 100% of meals and had no symptoms of dehydration. On 7/25/13, a nutritional assessment was completed. The dietician indicated the assessment was completed due to weight loss, a decline in ambulation and cognitive changes. The dietician noted that the resident had a 10% weight loss (19.1 pounds in one month). The dietitian recommended large portions and to continue the sugar free mighty shakes two times per day. The dietician indicated the resident had no difficulty eating and had no other recommendations or plan as is "await MD's decision." However, there is no evidence the physician was notified of the significant weight loss. On 7/26/13, the resident was hospitalized for [REDACTED]. The resident was readmitted on [DATE] with a readmission weight of 203.4 pounds. The 8/8/13 admission assessment indicated the resident was alert, without respiratory distress and had 2 plus [MEDICAL CONDITION] to both feet. The resident was identified as having swallowing difficulties and his/her diet was changed from regular texture to ground with honey thick liquids. The large portions and mighty shakes, that were previously recommended by the dietitian, were not included in the re-admission diet plan. Review of the re-admission physician orders [REDACTED]. Review of the August 2013 weight record indicated that on 8/9/13 the resident's weight was 202.8 pounds, a 0.6 pound weight loss since the day before. The 8/9/13 weight included the word "[MEDICAL CONDITION]" written next to the weight, with no other explanation. There was no other documentation or evidence in the record that the [MEDICAL CONDITION] was being monitored since re-admission. On 8/14/13, the resident's weight was 195.4 pounds (an 8 pound weight loss in 5 days). According to review of the medical record, staff did not identify or assess this weight loss. There was no evidence that staff were monitoring for [MEDICAL CONDITION]. On 8/20/13, the dietician's progress note identified the resident's previous week's weight of 195.4 pounds, but did not note this was a weight loss. The dietitian wrote that the resident's intake was good at 75 to 100% of meal intake. The dietician wrote that the resident was overweight and he/she made no changes to the plan of care. Subsequent weekly weights were as follows: 8/21/13 - 185.8 pounds (9.6 weight loss in 7 days), 8/28/13 - 185.2 pounds, 9/3/13 - 183.8 pounds From the resident's re-admission weight of 203.4 pounds on 8/8/13, the resident lost 18.4 pounds in less than one month. On 9/5/13, the dietician's progress note incorrectly indicated that the resident was receiving large portions for all three meals. The dietician indicated that the resident was "basically stable during past 30 days and (weight) may vary secondary to fluid status." During observations of the resident on 9/5/13 at 11:40 A.M., 9/6/13 at 8:05 A.M. and 11:45 A.M., the meal slip did not indicate the portion size was large or regular and the resident received no supervision to ensure appropriate nutritional intake. During interview on 9/6/13 at 7:35 A.M. with Unit Manager #2 and the Charge Nurse, the Charge Nurse said the resident had [MEDICAL CONDITION] and was on fluid pills. The Charge Nurse said when the resident was readmitted on [DATE], his/her face was "full and round" and now it was "thin." The surveyor inquired if the resident had [MEDICAL CONDITION], as the only mention of [MEDICAL CONDITION] was on the initial admission assessment dated [DATE] and on the weight record. The Charge Nurse and Unit Manager #2 reviewed the medical record and both said they agreed there was no evidence the resident's weight loss was due to [MEDICAL CONDITION] and/or fluid loss. The Charge Nurse said that the only documentation about the resident's leg [MEDICAL CONDITION] had been on the resident's readmission on 8/8/13. Review of the record indicated that the physician ordered a low dose of [MEDICATION NAME] (diuretic) 20 mg every other day. A review of the physician progress notes [REDACTED]. Later in the late morning on 9/6/13 at approximately 12:00 P.M., the resident's primary care physician was interviewed. The physician reviewed the weights from 8/9/13 through 9/4/13 and said that he was not aware of weight loss. Based on review of the nurses' notes and treatment records for August 2013 and September 2013, there was no evidence or documentation that the nursing staff identified the fluid status/[MEDICAL CONDITION] as related to the resident's weight loss. During interview on 9/12/13 at 12:15 P.M., the dietician said he/she reviewed the record and that the resident did have significant weight loss.

Based on record review and interview, the facility administered an excessive doses of insulin, higher than the original dose ordered by the physician, for 6 residents (#2, #4, #11, #12, #20 and #21) of a total of 27 sampled residents. Findings include: 1. a) Resident #20 had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Assessment ((MDS) dated [DATE], indicated the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and dependent on staff for all his/her activities of daily living. Record review indicated the resident was receiving [MEDICATION NAME]12 units daily since 2011. Review of the telephone order sheets revealed that on [DATE] the physician had increased the [MEDICATION NAME]due to elevated CBG (capillary blood glucose) results. The physician ordered an additional 8 units daily at 4:30 P.M. Review of the July and August Medication Administration Record (MAR) indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M. Review of the September MAR revealed an entry reading [MEDICATION NAME] 80 units daily at 4:30 P.M. According to the [DATE] MAR, three different nurses signed that they had administered 80 units (not 8 units as ordered) of [MEDICATION NAME]on [DATE], [DATE] and [DATE] at 4:30 P.M. There was no documentation on the MARs or in the nurses' notes that any of the three nurses questioned the order for 80 mg of [MEDICATION NAME]. On [DATE] at 5:45 A.M. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 26 (normal range ,[DATE]) taken by the nurse. The resident expired at the facility at 6:20 A.M. On [DATE] at 2:50 P.M., the surveyor met with the Director of Nurses and Unit Manager #2 to discuss that the medical record indicated the resident had been incorrectly administered a 10 times higher dose of [MEDICATION NAME]than ordered. Both staff agreed that the [DATE] MAR and the signed physician orders [REDACTED].M. The MAR indicated that three different nurses had signed that the resident was incorrectly given the 80 units of [MEDICATION NAME] insulin. The Director of Nurses said he/she would look into the incident and provide an investigation. On [DATE] at 10:30 A.M., the Director of Nurses said the facility had completed an investigation and provided two vials of [MEDICATION NAME] insulin. Review of the insulin vials indicated that one was opened and the other unopened. The prescription was labeled with the resident's name and dated [DATE]. The contents of the vials when full held 10 milliliters of insulin. The prescription indicated to "Inject 12 units subcutaneously daily and inject 80 units subcutaneously at 4:30 P.M." According to the facility's investigation, the medication administration record for [DATE], the nurse's note dated [DATE] and staff interviews completed for the facility investigation dated [DATE], indicated that on [DATE], [DATE], and [DATE] at 4:30 P.M., three nurses signed as administering the 80 units of [MEDICATION NAME], three certified nursing assistants stated that the resident had shown a change in condition on [DATE] at 7:30 P.M. and 10:00 P.M., and on [DATE] at 5:00 A.M. The nurses' note dated [DATE], indicated the resident's blood sugar was 25. The note indicated that even with interventions the resident condition remained critical and was pronounced dead at 7:00 A.M. b) Further review of Resident #20's record indicated the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician since at least [DATE], and the resident received insulin in excess of the ordered doses. The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. The resident received excess doses of insulin at the following times: [DATE], 4:30 P.M., CBG 248, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 342, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 247, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 310, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 249, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 226, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 220, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 270, given 8 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 286, given 8 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 178, given 4 units, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 245, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 260, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 295, given 10 units, sliding scale order was for 6 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 2. For Resident #2, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on three occasions. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. Record review revealed that there was an order for [REDACTED]. According to physician orders [REDACTED]. CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG is ,[DATE], give 180 ml apple juice, recheck blood sugar in 10 min and notify the physician if needed. According to review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: [DATE], 8:00 P.M., CBG 210, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 208, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 223, given 6 units, sliding scale indicated should receive 4 units On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 3. a) For Resident #4, the facility failed to ensure that staff did not administer insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered excessive doses of insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on [DATE], the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. There was no evidence that the physician was contacted to clarify the timing of the CBG and the sliding scale. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer sliding scale insulin, contrary to the physician's orders [REDACTED]. from the time of the change in order on [DATE] through the date of survey review on [DATE], as follows: [DATE], CBG 276, received 6 units of insulin [DATE], CBG 190, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 203, received 4 units [DATE], CBG 158, received 2 units [DATE], CBG 237, received 4 units [DATE], CBG 195, received 2 units [DATE], CBG 158, received 2 units [DATE], CBG 173, received 2 units [DATE], CBG 208, received 4 units [DATE], CBG 232, received 4 units [DATE], CBG 224, received 4 units [DATE], CBG 166, received 2 units [DATE], CBG 183, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 282, received 6 units [DATE], CBG 290, received 6 units [DATE], CBG 198, received 2 units [DATE], CBG 190, received 2 units [DATE], CBG 200, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 159, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 208, received 4 units [DATE], CBG 153, received 2 units [DATE], CBG 215, received 2 units [DATE], CBG 241, received 4 units [DATE], CBG 180, received 2 units [DATE], CBG 151, received 2 units [DATE], CBG 167, received 2 units [DATE], CBG 285, received 6 units [DATE], no CBG recorded [DATE], CBG 201, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 175, received 2 units [DATE], CBG 157, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 171, received 2 units [DATE], CBG 170, received 2 units [DATE], CBG 184, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 214, received 4 units [DATE], CBG 155, received 2 units [DATE], CBG 188, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 177, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 175, received 2 units [DATE], CBG 150, received 2 units [DATE], CBG 187, received 2 units [DATE], CBG 205, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 227, received 2 units During interview on [DATE] at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from [DATE] through the date of survey review on [DATE] revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On [DATE] at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. b) Additionally, for Resident #4, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. The resident received [MEDICATION NAME]based on a sliding scale as follows: CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician According to review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: Prior to [DATE] there was an order to give at 6:30 A.M., and errors at that time are counted. After [DATE], any insulin given at 6:30 A.M. was not counted. [DATE], 6:30 A.M., CBG 238, given 8 units, should have received 4 units [DATE], 8:00 P.M., CBG 349, given 10 units, should have received 8 units [DATE], 4:30 P.M., CBG 290, no documentation of insulin given, should have received 6 units [DATE], 8:00 P.M., CBG 320, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 275, given 8 units, should have received 6 units (on [DATE], the times of the CBG and insulin was changed by the physician to 6:30 A.M., 10:30 A.M., 2:00 P.M. and 8:00 P.M.) [DATE], 8:00 P.M., CBG 184, given 4 units insulin, should have received 2 units [DATE], 8:00 P.M., CBG 232, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 292, given 8 units, should have received 6 units [DATE], 8:00 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 247, given 6 units, should have received 4 units [DATE], 2:00 P.M., CBG 232, given 6 units, should have received 4 units [DATE], 2:00 P.M., CBG 269, given 8 units, should have received 6 units [DATE], 10:00 P.M., CBG 243, given 6 units, should have received 4 units On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as outlined above. 4. For Resident #21, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. Resident #21 had [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. CBG ,[DATE], no coverage CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. According to review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: [DATE], 8:00 P.M., CBG 325, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 247, given 6 units, should have received 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 176, given 4 units, should have received 2 units [DATE], 4:30 P.M., CBG 245, given 6 units, should have received 4 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 5. For Resident #11, the nursing staff administered one incorrect dose of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on [DATE]. Resident #11 was admitted to the facility for short term rehabilitation services following a hospitalization , and had [DIAGNOSES REDACTED]. Record review revealed that at the time of admission the resident was receiving scheduled [MEDICATION NAME] 9 units at bedtime. This dose was increased to 12 units on [DATE]. The resident also received [MEDICATION NAME]according to a sliding scale based on Capillary Blood Glucose (CBG) testing before meals and at bedtime. Review of the physician orders [REDACTED]. The physician order [REDACTED]. CBG ,[DATE], no coverage CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and notify the physician Review of the Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, revealed one error for an excess dose of [MEDICATION NAME]administered by the sliding scale. As documented on the Diabetic Monitoring Flow Sheet, on [DATE], the CBG result was 347 and the resident received 10 units of [MEDICATION NAME]instead of 8 units as indicated by the sliding scale. On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin error as noted above. 6. For Resident #12, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. Resident #12 had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. - Capillary Blood Glucose (CBG) four times daily (6:30 A.M., 10:00 A.M., 2:00 P.M., 8:00 P.M.), - Hold sliding scale [MEDICATION NAME]unless CBG is over 400 - do not give insulin at bedtime Review of the physician orders [REDACTED]. CBG ,[DATE], 8 units CBG of 450 or greater, 10 units and notify the physician Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, revealed the following errors: [DATE], 8:00 P.M. (the bedtime dose), CBG 267, given 3 units, should have received no insulin coverage [DATE], 10:00 A.M., CBG 419, given 10 units, should have received 8 units [DATE], 10:00 A.M., CBG 411, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 476, given 8 units, should have received no insulin coverage [DATE], 8:00 P.M., CBG 510, given 10 units, should have received no insulin coverage [DATE], 8:00 P.M., CBG 402, given 8 units, should have received no insulin coverage [DATE], 10:00 A.M., CBG 164, given 1 unit, should have received no insulin coverage [DATE], 10:00 A.M., CBG 283, given 3 units, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 353, given 6 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 259, given 3 units, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 312, given 4 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 163, given 1 unit, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 271, given 3 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 158, given 1 unit, should have received no insulin coverage Record review revealed that on [DATE], the physician changed the CBG and sliding scale orders, with no change to the sliding scale dosing, as follows: - Check the CBG level twice daily at 11:30 A.M. and 8:00 P.M., and - Give sliding scale [MEDICATION NAME]coverage only if the CBG was over 400 Sliding scale insulin administration errors, after [DATE], were identified as follows: [DATE], 8:00 P.M., CBG 270, given 4 units, should have received no insulin coverage On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised that there were multiple insulin errors as noted above.

Based on record review and interview, the facility administered an excessive doses of insulin, higher than the original dose ordered by the physician, for 6 residents (#2, #4, #11, #12, #20 and #21) of a total of 27 sampled residents. Findings include: 1. a) Resident #20 had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Assessment ((MDS) dated [DATE], indicated the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and dependent on staff for all his/her activities of daily living. Record review indicated the resident was receiving [MEDICATION NAME]12 units daily since 2011. Review of the telephone order sheets revealed that on [DATE] the physician had increased the [MEDICATION NAME]due to elevated CBG (capillary blood glucose) results. The physician ordered an additional 8 units daily at 4:30 P.M. Review of the July and August Medication Administration Record (MAR) indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M. Review of the September MAR revealed an entry reading [MEDICATION NAME] 80 units daily at 4:30 P.M. According to the [DATE] MAR, three different nurses signed that they had administered 80 units (not 8 units as ordered) of [MEDICATION NAME]on [DATE], [DATE] and [DATE] at 4:30 P.M. There was no documentation on the MARs or in the nurses' notes that any of the three nurses questioned the order for 80 mg of [MEDICATION NAME]. On [DATE] at 5:45 A.M. Resident #20 was found unresponsive with a capillary blood glucose (CBG) level of 26 (normal range ,[DATE]) taken by the nurse. The resident expired at the facility at 6:20 A.M. On [DATE] at 2:50 P.M., the surveyor met with the Director of Nurses and Unit Manager #2 to discuss that the medical record indicated the resident had been incorrectly administered a 10 times higher dose of [MEDICATION NAME]than ordered. Both staff agreed that the [DATE] MAR and the signed physician orders [REDACTED].M. The MAR indicated that three different nurses had signed that the resident was incorrectly given the 80 units of [MEDICATION NAME] insulin. The Director of Nurses said he/she would look into the incident and provide an investigation. On [DATE] at 10:30 A.M., the Director of Nurses said the facility had completed an investigation and provided two vials of [MEDICATION NAME] insulin. Review of the insulin vials indicated that one was opened and the other unopened. The prescription was labeled with the resident's name and dated [DATE]. The contents of the vials when full held 10 milliliters of insulin. The prescription indicated to "Inject 12 units subcutaneously daily and inject 80 units subcutaneously at 4:30 P.M." According to the facility's investigation, the medication administration record for [DATE], the nurse's note dated [DATE] and staff interviews completed for the facility investigation dated [DATE], indicated that on [DATE], [DATE], and [DATE] at 4:30 P.M., three nurses signed as administering the 80 units of [MEDICATION NAME], three certified nursing assistants stated that the resident had shown a change in condition on [DATE] at 7:30 P.M. and 10:00 P.M., and on [DATE] at 5:00 A.M. The nurses' note dated [DATE], indicated the resident's blood sugar was 25. The note indicated that even with interventions the resident condition remained critical and was pronounced dead at 7:00 A.M. b) Further review of Resident #20's record indicated the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician since at least [DATE], and the resident received insulin in excess of the ordered doses. The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. The facility used a Diabetic Monitoring Flow Sheet to record CBG results and the dose of insulin administered according to the physician ordered sliding scale. The [MEDICATION NAME]sliding scale was as follows: CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. The resident received excess doses of insulin at the following times: [DATE], 4:30 P.M., CBG 248, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 342, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 247, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 310, given 10 units, sliding scale order was for 8 units [DATE], 4:30 P.M., CBG 249, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 226, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 220, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 270, given 8 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 286, given 8 units, sliding scale order was for 6 units [DATE], 6:30 A.M., CBG 178, given 4 units, sliding scale order was for 2 units [DATE], 4:30 P.M., CBG 245, given 6 units, sliding scale order was for 4 units [DATE], 4:30 P.M., CBG 260, given 10 units, sliding scale order was for 6 units [DATE], 4:30 P.M., CBG 295, given 10 units, sliding scale order was for 6 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 2. For Resident #2, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on three occasions. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. Record review revealed that there was an order for [REDACTED]. According to physician orders [REDACTED]. CBG of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units CBG greater than 450 notify the physician if CBG is ,[DATE], give 180 ml apple juice, recheck blood sugar in 10 min and notify the physician if needed. According to review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: [DATE], 8:00 P.M., CBG 210, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 208, given 6 units, sliding scale indicated should receive 4 units [DATE], 8:00 P.M., CBG 223, given 6 units, sliding scale indicated should receive 4 units On [DATE] at 3:30 P.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed these errors. 3. a) For Resident #4, the facility failed to ensure that staff did not administer insulin on a sliding scale basis at a time that was not part of the diabetic management plan. The facility administered excessive doses of insulin based on a sliding scale at 6:30 A.M. despite the physician's specific order not to do so, for almost 6 months until identified during survey record review. Resident #4 had a [DIAGNOSES REDACTED]. Record review revealed that on [DATE], the physician made a number of changes to the resident's diabetic regimen. The physician wrote an interim order for CBG testing to be done at 6:30 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M. The insulin sliding scale did not change but the physician ordered not to use the sliding scale at the 6:30 A.M. There was no evidence that the physician was contacted to clarify the timing of the CBG and the sliding scale. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their MAR for insulin administered according to the sliding scale, revealed that nursing staff consistently continued to administer sliding scale insulin, contrary to the physician's orders [REDACTED]. from the time of the change in order on [DATE] through the date of survey review on [DATE], as follows: [DATE], CBG 276, received 6 units of insulin [DATE], CBG 190, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 203, received 4 units [DATE], CBG 158, received 2 units [DATE], CBG 237, received 4 units [DATE], CBG 195, received 2 units [DATE], CBG 158, received 2 units [DATE], CBG 173, received 2 units [DATE], CBG 208, received 4 units [DATE], CBG 232, received 4 units [DATE], CBG 224, received 4 units [DATE], CBG 166, received 2 units [DATE], CBG 183, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 282, received 6 units [DATE], CBG 290, received 6 units [DATE], CBG 198, received 2 units [DATE], CBG 190, received 2 units [DATE], CBG 200, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 159, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 208, received 4 units [DATE], CBG 153, received 2 units [DATE], CBG 215, received 2 units [DATE], CBG 241, received 4 units [DATE], CBG 180, received 2 units [DATE], CBG 151, received 2 units [DATE], CBG 167, received 2 units [DATE], CBG 285, received 6 units [DATE], no CBG recorded [DATE], CBG 201, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 175, received 2 units [DATE], CBG 157, received 2 units [DATE], CBG 219, received 4 units [DATE], CBG 171, received 2 units [DATE], CBG 170, received 2 units [DATE], CBG 184, received 2 units [DATE], CBG 160, received 2 units [DATE], CBG 214, received 4 units [DATE], CBG 155, received 2 units [DATE], CBG 188, received 2 units [DATE], CBG 164, received 2 units [DATE], CBG 177, received 2 units [DATE], CBG 166, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 175, received 2 units [DATE], CBG 150, received 2 units [DATE], CBG 187, received 2 units [DATE], CBG 205, received 4 units [DATE], CBG 163, received 2 units [DATE], CBG 225, received 4 units [DATE], CBG 227, received 2 units During interview on [DATE] at 3:30 P.M., Unit Manager #2 said he/she was not aware that the resident was receiving insulin at 6:30 A.M. in conflict with the physician order. Review of the monthly drug regimen review by the consultant pharmacist from [DATE] through the date of survey review on [DATE] revealed that the pharmacist did not identify or report that the resident was receiving insulin at 6:30 A.M. in conflict with the physician's orders [REDACTED]. On [DATE] at 4:10 P.M., the surveyor spoke briefly with the Director of Nursing to advise of the identified error with insulin administration. The Director of Nursing said he/she had already been told by Unit Manager #2. b) Additionally, for Resident #4, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. The resident received [MEDICATION NAME]based on a sliding scale as follows: CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician According to review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: Prior to [DATE] there was an order to give at 6:30 A.M., and errors at that time are counted. After [DATE], any insulin given at 6:30 A.M. was not counted. [DATE], 6:30 A.M., CBG 238, given 8 units, should have received 4 units [DATE], 8:00 P.M., CBG 349, given 10 units, should have received 8 units [DATE], 4:30 P.M., CBG 290, no documentation of insulin given, should have received 6 units [DATE], 8:00 P.M., CBG 320, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 275, given 8 units, should have received 6 units (on [DATE], the times of the CBG and insulin was changed by the physician to 6:30 A.M., 10:30 A.M., 2:00 P.M. and 8:00 P.M.) [DATE], 8:00 P.M., CBG 184, given 4 units insulin, should have received 2 units [DATE], 8:00 P.M., CBG 232, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 292, given 8 units, should have received 6 units [DATE], 8:00 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 247, given 6 units, should have received 4 units [DATE], 2:00 P.M., CBG 232, given 6 units, should have received 4 units [DATE], 2:00 P.M., CBG 269, given 8 units, should have received 6 units [DATE], 10:00 P.M., CBG 243, given 6 units, should have received 4 units On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin errors as outlined above. 4. For Resident #21, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. Resident #21 had [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. CBG ,[DATE], no coverage CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and call the physician The resident's record was reviewed from [DATE] through the date of survey review on [DATE] for accuracy of sliding scale insulin dose administration, based on Capillary Blood Glucose (CBG) testing. According to review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, the resident received excess doses of insulin at the following times: [DATE], 8:00 P.M., CBG 325, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 247, given 6 units, should have received 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 4:30 P.M., CBG 248, given 6 units, should have received 4 units [DATE], 8:00 P.M., CBG 176, given 4 units, should have received 2 units [DATE], 4:30 P.M., CBG 245, given 6 units, should have received 4 units On [DATE] at 11:00 A.M., the Director of Nursing was advised that the documentation on the Diabetic Monitoring Flow Sheet revealed multiple errors. 5. For Resident #11, the nursing staff administered one incorrect dose of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on [DATE]. Resident #11 was admitted to the facility for short term rehabilitation services following a hospitalization , and had [DIAGNOSES REDACTED]. Record review revealed that at the time of admission the resident was receiving scheduled [MEDICATION NAME] 9 units at bedtime. This dose was increased to 12 units on [DATE]. The resident also received [MEDICATION NAME]according to a sliding scale based on Capillary Blood Glucose (CBG) testing before meals and at bedtime. Review of the physician orders [REDACTED]. The physician order [REDACTED]. CBG ,[DATE], no coverage CBG ,[DATE], 2 units CBG ,[DATE], 4 units CBG ,[DATE], 6 units CBG ,[DATE], 8 units CBG ,[DATE], 10 units CBG ,[DATE], 12 units CBG of 450 or greater, 14 units and notify the physician Review of the Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, revealed one error for an excess dose of [MEDICATION NAME]administered by the sliding scale. As documented on the Diabetic Monitoring Flow Sheet, on [DATE], the CBG result was 347 and the resident received 10 units of [MEDICATION NAME]instead of 8 units as indicated by the sliding scale. On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the insulin error as noted above. 6. For Resident #12, the nursing staff administered incorrect doses of [MEDICATION NAME]based on the sliding scale ordered by the physician and the resident received insulin in excess of the ordered dose on multiple occasions. Resident #12 had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. - Capillary Blood Glucose (CBG) four times daily (6:30 A.M., 10:00 A.M., 2:00 P.M., 8:00 P.M.), - Hold sliding scale [MEDICATION NAME]unless CBG is over 400 - do not give insulin at bedtime Review of the physician orders [REDACTED]. CBG ,[DATE], 8 units CBG of 450 or greater, 10 units and notify the physician Review of the monthly Diabetic Monitoring Flow Sheet, which the facility used as the Medication Administration Record (MAR) for insulin administered according to the sliding scale, revealed the following errors: [DATE], 8:00 P.M. (the bedtime dose), CBG 267, given 3 units, should have received no insulin coverage [DATE], 10:00 A.M., CBG 419, given 10 units, should have received 8 units [DATE], 10:00 A.M., CBG 411, given 10 units, should have received 8 units [DATE], 8:00 P.M., CBG 476, given 8 units, should have received no insulin coverage [DATE], 8:00 P.M., CBG 510, given 10 units, should have received no insulin coverage [DATE], 8:00 P.M., CBG 402, given 8 units, should have received no insulin coverage [DATE], 10:00 A.M., CBG 164, given 1 unit, should have received no insulin coverage [DATE], 10:00 A.M., CBG 283, given 3 units, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 353, given 6 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 259, given 3 units, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 312, given 4 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 163, given 1 unit, should have received no insulin coverage [DATE] - at 2:00 P.M., CBG 271, given 3 units, should have received no insulin coverage [DATE] - at 10:00 A.M., CBG 158, given 1 unit, should have received no insulin coverage Record review revealed that on [DATE], the physician changed the CBG and sliding scale orders, with no change to the sliding scale dosing, as follows: - Check the CBG level twice daily at 11:30 A.M. and 8:00 P.M., and - Give sliding scale [MEDICATION NAME]coverage only if the CBG was over 400 Sliding scale insulin administration errors, after [DATE], were identified as follows: [DATE], 8:00 P.M., CBG 270, given 4 units, should have received no insulin coverage On [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised that there were multiple insulin errors as noted above.

Based on record review, resident/family interviews and staff interviews, the facility failed to report and thoroughly investigate an allegation of an injury received during care for 1 sampled resident (#14) and failed to investigate family complaints of neglect for 1 sampled resident (#25). The facility did not follow their policy and procedure for reporting and investigating accidents and incidents. The total sample was 27 residents. Findings include: A review of the facility's Resident Abuse, Prevention, Investigation and Reporting policy for accidents and incidents indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises must be investigated and reported to the Administrator. 1. For Resident #14, the facility failed to thoroughly investigate the resident's complaint of injury when transferred with the mechanical lift. The resident reported an injury (hematoma) to two staff persons. The resident was later hospitalized and required surgery for [REDACTED]. Resident #14 was admitted with multiple [DIAGNOSES REDACTED]. The initial hospital history and physical dated 5/23/13, indicated the resident had an increase in [MEDICAL CONDITION] of the lower extremities. A review of the initial Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had no memory or recall issues, did have some trouble sleeping and had no behaviors. The assessment indicated the resident was totally dependent on staff for transfers and nonambulatory. The medical record indicated the resident had another hospitalization [DATE] - 8/6/13 and a review of the hospital consultation report indicated the resident was brought to the hospital for pain, swelling and [DIAGNOSES REDACTED] (redness) in the right leg. The report documented the resident two weeks prior to this admission said he/she was being lifted with a Hoyer (mechanical) lift and his/her leg got in the wrong spot. The report indicated in the emergency room the resident was found to have a large hematoma of the right lower leg that was felt to be infected. The report indicated an incision and drainage was performed and 200 ml (milliliters) of infected hematoma was evacuated. During interview and record review on 9/5/13 at 11:30 A.M., the Director of Nurses said he/she was not aware of the resident having any injury with the mechanical lift and no staff had reported anything to him/her or the Administrator. The Director said she would look into it. During interview on 9/6/13 at 8:20 A.M., the resident said when "transferred with the Hoyer (mechanical) lift I felt the strap on the back of my leg and felt a pop." The resident said this developed into a large area from the varicose vein. The resident said his/her primary care physician saw the area and sent him/her to the hospital. The resident said "the wound was drained of 200 ml. of fluid." The resident was asked if he/she had reported the injury with the mechanical lift to staff at the facility and the resident replied he/she informed the staff. After the facility investigated the resident's allegation, the Director of Nurses on 9/6/13 at 11:50 A.M., said he/she could not identify exactly what happened with the transfers of the resident and the injury but said two staff were aware of the resident's complaint after returning from the hospital. The Director of Nurses said from the investigation two staff, the bookkeeper and Social Worker #1, were aware on 8/12/13 of the resident's complaint and had not initiated and informed the Director of Nurses of the residents complaint. There was no incident report and no investigation completed when the staff were informed by the resident. A review of the written statements from the bookkeeper, dated 9/6/13, indicated the resident was informed about financial matters. The resident told the bookkeeper that he/she shouldn't have to pay anything because he/she was dropped here from the Hoyer. Review of the Social Worker #1 written statement dated 9/6/13 said the he/she was approached by the business office and relayed the story of the resident not paying because he/she was injured here and transferred to the hospital. The Social Worker interviewed the resident who stated the same information of an injury at the facility and hospitalization . The resident informed the facility's staff of an allegation of being injured while transferred at the facility and the two staff persons did not report the resident's allegations to the facility's management team and no report or investigation was done. 2. For Resident #25, the facility failed to report and thoroughly investigate the family's complaint of neglect. The resident's family had reported multiple incidents of poor staff response and resident care. The family reported staff bullied and intimidated the resident and that their reports were ignored. The family reported that the resident was fearful of using his/her call light and would therefore attempt to care for self. The family reported the resident's response to treatment left him/her at risk for injury. Resident #25 had been admitted in October 2012 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS dated [DATE], indicated the resident understood and could make self understood and had some cognitive long and short term memory impairment. The MDS indicated the resident was continent of both bladder and bowel function and required extensive assistance from staff for activities of daily living, including transfers and ambulation. On 9/9/13 at 1:00 P.M., Resident #25's family approached the surveyors and asked to be interviewed. The family reported that one of the two family members was the activated primary health care agent. They said that they had multiple complaints and had multiple meetings with the facility to discuss and resolve their issues. The family said that there has been no resolution to any of the problems identified and that the facility was neglectful. The family said that the resident was fearful and was at risk of injury because he/she did not want to get the staff mad when he/she needed help. The family said they had spoken to the nursing staff, Social Worker, Physician, Administrator, Director of Nurses and ombudsman advocate. The family said the resident was alert and oriented and the primary language was not English. The resident had resided on the current unit since June 2013 and since the transfer there had been multiple problems with care and poor communication, by the facility, with the family, who are available, as multiple family members visit daily throughout the day. The family said the following incidents and complaints had been reported to the facility staff. - The family reported the resident was an insulin dependent diabetic and on multiple occasions the resident had not received the correct meal. The meals included high sugar foods and snacks. The family reported that on multiple occasions these incidents had caused a spike in the resident's blood sugar. The family reported they had involved the ombudsman and still had no resolution and the problem continued. - The family reported that the staff's response to the call light was poor. The resident would put on his/her call bell, but would wait too long and have a bladder or bowel accident. The family said that when staff answered the call light, they had observed certified nursing (CNA) staff bullying and embarrassing the resident. On one occasion, the resident was in bed and exposed. The resident put on the call bell and, when the CNA entered the room, he/she said in a berating tone "you need to go to the bathroom again." The family explained that the resident was on high doses of diuretics and frequently needed to void. - The family said about a week earlier on a Saturday, the family observed the resident in a chair with his/her breakfast. The resident's nightgown was saturated and smelled of urine, the bed was urine soaked, and the commode had feces and urine in it. The commode was placed next to the resident who was eating his/her breakfast. The family reported the incident and asked the nurse to assess the situation. The family said the nurse agreed the situation was unacceptable and would look into it. The family said that there had been no communication by the facility to them about this incident. - Other issues included laboratory tests that had been ordered but not done, staff taking pictures of the resident's leg on a cell phone without permission and sending them to a covering physician, poor infection control practices between the resident and roommate, and lack of communication of resident care and status changes with the health care proxy. The family said that the resident was so afraid that staff would be mean to him/her if she put her call bell on that the resident would attempt to care for self and had several falls. The family said the resident was reprimanded when he/she had fallen. Review of the nurses' notes indicated on 7/15/13, the CNA reported the resident accused the staff of lying because they had not toileted him/her. The nurse indicated the staff reported they had provided a bedpan and her toileted him/her frequently. On 7/26/13, the nurse documented the family met with the physician and the resident's frequency to void at night was discussed. The facility explained to the family it was because the resident was on multiple diuretics. On 7/28/13 and 7/29/13 (the 11:00 P.M. to 7:00 A.M. shift), the nurses documented the resident yelled at staff that they had not answered the call light, had shut off the call light and not helped her go the bathroom. The nurses indicated the resident was toileted multiple times. On 8/1/13, the nurse documented the resident tore off a brief, threw it on the floor and urinated in the bed. The staff encouraged the resident to use call bell. On 8/24/13, the nurse documented the family complained about the commode and was referred to the social worker. Review of Social Worker #2's progress notes indicated that on 8/8/13, the family reported concerns that the resident's increased frequency to urinate was not being addressed. The facility plan was to put a commode next to the resident's bed. On 8/24/13, Social Worker #2 indicated that she received an additional complaint about the commode from the family. Issues included use, infection control and protocols between both residents in the room. Social Worker #2 indicated he/she referred the issues to the Director of Nurses. There was no subsequent note that followed. After reviewing the medical record and reviewing the facility's grievance log, obtained for review on 9/12/13 at 4:00 P.M., there was evidence that the facility had met with the family and that some of the issues had been discussed. However, the grievance log failed to identify any family complaints or grievances as outlined by the family. During interview on 9/13/13 at 7:30 A.M., Unit Manager #2 said he/she, the physician and Social Worker #2 had met and talked with the resident and family on several occasions and that currently there were no issues that he/she was unaware of. The Assistant Director of Nurses was interviewed on 9/13/13 at 7:45 A.M. and said he/she had a good relationship with the family. He/she said he/she had just recently sat with them at an activity and had a wonderful conversation. Social Worker #2 was interviewed on 9/13/13 at 9:10 A.M. and said there were no issues. The surveyor inquired about the family's complaint to him/her that the staff had bullied and reprimanded the resident when he/she requested to be toileted too often, and that the resident was afraid. The surveyor stated that the family had said that the Social Worker would complete an investigation. Social Worker #2 had no response to the inquiry. On 9/13/13 at 11:00 A.M., the Ombudsman called the surveyor and said that he/she had been involved with the family's complaints to the facility and confirmed that the facility was aware of the complaints. A subsequent meeting with Social Worker #2, Director of Nurses, Unit Manager #2 and Assistant Director of Nurses on 9/13/13 at approximately 1:00 P.M., confirmed that the facility had not fully investigated the family's multiple complaints of poor care that was identified by the family as neglect

Based on record review and staff interview, the facility failed for 3 residents (#2, #4 and #20) of 27 sampled residents to provide timely notification to the physician when there was a change in condition. Findings include: 1. For Resident #20, the facility failed to provide timely notification to the physician when there was a change in condition. The resident died on [DATE] at 7:00 A.M. Resident #20, a long term care resident, who had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Assessment ((MDS) dated [DATE], the resident was cognitively intact and scored a 13 out 15 on his/her mini mental status. The MDS indicated no behaviors or exhibited altered mood and that he/she was dependent on staff for all his/her activities of daily living. During record review on [DATE], the record indicated the resident was currently being treated for [REDACTED]. Review of the [DATE] MAR indicated that 80 units of [MEDICATION NAME]had been documented as administered on [DATE], [DATE] and [DATE] at 4:30 P.M. The monthly physician order [REDACTED]. Further review indicated the physician had not changed the [MEDICATION NAME]order since 8 units was ordered on [DATE]. Review of the current signed physician orders, dated [DATE], indicated the [MEDICATION NAME]sliding scale was as follows: Capillary Blood Glucose (CBG) of ,[DATE], no coverage, CBG ,[DATE], 2 units, CBG ,[DATE], 4 units, CBG ,[DATE], 6 units, CBG ,[DATE], 8 units, CBG ,[DATE], 10 units, CBG ,[DATE], 12 units a CBG greater than 450 notify the physician or if CBG less than 60, provide juice or snack if responsive, recheck blood sugar in 15 min or administer an intramuscular medication called [MEDICATION NAME] 1 milligram and call the physician. Record review indicated on [DATE], the physician had ordered [MEDICATION NAME]8 units daily at 4:30 P.M. Review of the July and [DATE] MARs (medication administration records) indicated that 8 units of [MEDICATION NAME]was administered consistently at 4:30 P.M. During interview on [DATE] at 2:50 P.M., the surveyor brought to the attention of the Director of Nurses and Unit Manager #2, that the medical record had indicated the resident had been administered a 10 times higher dose of [MEDICATION NAME]than originally ordered on three consecutive days. Unit Manager #2 had no response to the medication issue, but said that the resident had been stable and his/her death had not been anticipated or expected. The Unit Manager #2 said the physician had seen the resident the day before ([DATE]) and noted the resident was at baseline. Unit Manager #2 said that the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) had said he/she found the resident with a low blood sugar of 25 when he/she had gone into the resident's room to obtain the morning blood sugar. Unit Manager #2 said Nurse #1 had given medication to elevate the resident's blood sugar, but attempts to alter the resident's condition failed. Unit Manager #2 said the physician was notified of the resident's death. The Director of Nurses said he/she would look into the incident and provide an investigation. On [DATE] at 3:30 P.M., Nurse #1 was interviewed and said he/she had worked from 3:00 P.M. to 7:00 A.M. on [DATE]-[DATE]. Nurse #1 said he/she had signed the MAR and administered the 4:30 P.M. dose of [MEDICATION NAME]on [DATE], but said he/she had not administered 80 units. Nurse #1 said he/she thought a staff had told him/her the resident was tired that night, but could not clearly remember. The nurse said the information did not indicate a change to him/her because the resident had been showing a decline over the past few months. Nurse #1 said he/she was unclear when he/she had seen the resident during his/her two shifts ([DATE] - [DATE] from 3:00 P.M. - 7:00 A.M.). Nurse #1 indicated he/she may have been in the room giving the roommate medications at 8:00 P.M. and his/her subsequent observation was at 5:45 A.M. to obtain the morning blood sugar. The nurse said the resident was breathing like a "fish out of water" and demonstrated his/her observation. He/she said [MEDICATION NAME] (anti-hypoglycemic) was administered and the blood sugar was rechecked. Nurse #1 said he/she checked the the resident's code status and it was a DNR (do not resuscitate) and do not transfer. Nurse #1 said the resident died and then called the physician. The nurse said he/she asked Certified Nurse Aide (CNA) #3 how the resident had been during the 5:00 A.M. rounds and the CNA said the resident was full of "piss and vinegar, " i.e. feisty. On [DATE], Nurse #1 documented at 10:00 P.M., the resident had no complaints, required assistance with care by two staff and that his/her cardiac, respiratory status was without signs and symptoms of acute distress and that he/she was sleeping most of the shift. The note did not include any vital signs. On [DATE], Nurse #1 documented in a nurse's note that he/she went into the resident's room at 5:45 A.M. to obtained a blood sugar. The nurse documented a blood sugar of 25. The nurse indicated he/she administered [MEDICATION NAME], as per house protocol, and rechecked the resident's blood sugar. The note indicated the second blood sugar was 46, but did not indicate that the physician was notified as specified by the physician order [REDACTED]. The nurse increased the resident's oxygen to 15 liters and added a rebreathing mask for comfort. The note indicated the resident was gasping for air and the nail beds were blue, the nurse rechecked the resident's blood sugar and obtained a result of 96. The nurse then indicated the resident had no pulse, breath sounds and did not respond to stimuli. The note indicated the nurse had checked the resident's advance directives and determined the resident was a do not resuscitate and a do not transfer. Nurse #1 indicated he/she called the physician and obtained an order for [REDACTED]. There was no documentation that the physician was notified when the nurse first observed the resident's change in condition at 5:45 A.M. During interview on [DATE] at 10:15 A.M., Resident #20's primary physician said he/she saw the resident on [DATE] and the resident was fine. The physician said he/she had not been notified of any change in the resident's condition until he/she was notified of the resident's death. 2. For Resident #4, the facility failed to notify the physician of a significant change in the resident's diabetic condition and failed to follow the parameter for physician notification identified in the sliding scale insulin orders. The sliding scale insulin order indicated that the physician was to be notified if the resident's Capillary Blood Glucose (CBG) level was 450 or greater. The facility failed to notify the physician on 9 of 16 occasions when the CBG level exceeded the parameter. Resident #4 had a [DIAGNOSES REDACTED]. Review of the clinical record indicated the facility scheduled the CBG's at 6:30 A.M., 10: 30 A.M., 2:00 P.M. and 8:00 P.M. The physician's orders [REDACTED]. Review of the monthly Diabetic Monitoring Flow Sheets, which the facility used as their Medication Administration Record (MAR) for insulin administered according to the sliding scale, from [DATE] through the date of survey review on [DATE] indicated the resident had 16 occurrences when the CBG result was 450 or greater. Based on review of the nurses' notes and documentation on the MAR, for 9 of the 16 occurrences there was no evidence that the physician was notified of the high CBG result. Findings are as follows: [DATE] - on [DATE] the CBG was 454, no evidence of notification February 2013 - no evidence of notification on [DATE] for CBG of 483, and [DATE] for CBG of 491 [DATE] - no evidence of notification on [DATE] for CBG of 519, [DATE] for CBG of 500, [DATE] for CBG of 459, and [DATE] for CBG of 452 [DATE] - no evidence of notification on [DATE] for CBG of 458 [DATE] - no evidence of notification on [DATE] for CBG of 490 During interview on [DATE] at 2:00 P.M., the Assistant Director of Nursing was advised of the lack of evidence of notification as outlined above. This was discussed with the Director of Nursing and Administrator on [DATE] at 3:15 P.M. No additional documentation or information was provided during the survey. 3. For Resident #2, the facility failed to notify the physician of the resident's significant weight loss. Resident #2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was independent with set up for eating. The MDS assessment also indicated the resident had significant change in status for ability to make needs known and required extensive assistance from staff for activities of daily living. Review of the facility weight records revealed the resident's weight status was monitored weekly and had been stable at around 202 pounds from [DATE] through [DATE], at which time the resident's weight was 199.8 pounds. During the month of July, the resident's weight fluctuated. On [DATE], the resident weight was 184 pounds (a 15.8 pound weight loss) and on [DATE] was 181.1 pounds (an additional 3 pound weight loss). On [DATE], the dietician's progress note indicated that he/she was notified by the nursing staff of an unplanned change in weight of 10.4 % or 19.1 pounds in less than 10 days. On [DATE], a nutritional assessment was completed. The dietician indicated the assessment was completed due to weight loss, a decline in ambulation and cognitive changes. The dietician noted that the resident had a 10% weight loss (19.1 pounds in one month). The dietician indicated the resident had no difficulty eating and had no other recommendations or plan as is "await MD's decision." However, there is no evidence the physician was notified of the significant weight loss. On [DATE], the resident was hospitalized for [REDACTED]. The resident was readmitted on [DATE] with a readmission weight of 203.4 pounds. The [DATE] admission assessment indicated the resident was alert, without respiratory distress and had 2 plus [MEDICAL CONDITION] to both feet. Review of the re-admission physician orders [REDACTED]. Review of the [DATE] weight record indicated that on [DATE] the resident's weight was 202.8 pounds, a 0.6 pound weight loss since the day before. On [DATE], the resident's weight was 195.4 pounds (an 8 pound weight loss in 5 days). According to review of the medical record, staff did not identify or assess this weight loss. There was no evidence that staff notified the physician of weight loss, Subsequent weekly weights were as follows: [DATE] - 185.8 pounds (9.6 weight loss in 7 days), [DATE] - 185.2 pounds, [DATE] - 183.8 pounds From the resident's re-admission weight of 203.4 pounds on [DATE], the resident lost 18.4 pounds in less than one month. During interview on [DATE] at 7:35 A.M. with Unit Manager #2 and the Charge Nurse, the Charge Nurse said the resident had [MEDICAL CONDITION] and was on fluid pills. The Charge Nurse said when the resident was readmitted on [DATE], his/her face was "full and round" and now it was "thin." The Charge Nurse and Unit Manager #2 reviewed the medical record and both said they agreed there was no evidence the resident's weight loss was reported to the physician. A review of the physician progress notes [REDACTED]. During interview on [DATE] at 12:00 P.M., the resident's primary care physician reviewed the weight records from [DATE] through [DATE] and said that he/she was not aware of weight loss.