Every finding on record at Hays Nursing and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 9 residents (Residents #1, #17, #45 and #35) reviewed for ADL care. The facility failed to ensure Residents #1, #17, #45 and #35 did not have long, jagged, and dirty fingernails from 03/03/2026 to 03/05/2026. This failure could place residents at risk of skin tears, infection, and embarrassment.1. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus (a disease characterized by inability to process carbohydrates leading to poor circulation in the arms and legs when poorly controlled), anoxic brain damage (damage due to lack of oxygen to the brain), bipolar disorder (a mental health condition that causes extreme mood swings), moderate protein calorie malnutrition (insufficient protein and calories), generalized anxiety disorder, and dysphagia (trouble swallowing). Record review of Resident #1's quarterly MDS assessment, dated 12/03/2025, reflected a BIMS score of 10, which indicated a moderate cognitive impairment. She had functional limitation in her range of motion on one side of her upper extremities (shoulder, elbow, wrist, hand). It reflected she was dependent on staff for personal hygiene, which indicated the helper did all the effort and Resident #1 did not help with the effort at all. Record review of Resident #1's care plan, dated 06/27/25, reflected the following:Focus: ADL self-care performance deficit R/T impaired mobility.Goal: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene through the review date.Interventions: Personal hygiene - dependent Record review of Resident #1's nail care documentation reflected no attempt at nail care was documented in the 30-day lookback period from 02/03/2026 to 03/05/2026. Observation on 03/03/2026 at 09:25 AM revealed Resident #1 lying in bed with her hand in her lap. Her fingernails were long, jagged, and two of them had a red substance underneath. Observation on 03/05/2026 at 11:50 AM revealed Resident #1 still had long and jagged fingernails. 2. Record review of Resident #35's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia with agitation, schizoaffective disorder (coexistence of psychosis and mood disorder), major depressive disorder, anxiety disorder, and chronic pain. Record review of Resident #35's quarterly MDS assessment, dated 12/18/2025, reflected she was not able to complete a BIMS assessment for cognition, but the staff assessment for cognition indicated she had a memory problem and her cognitive skills for daily decision making were severely impaired. Resident #35 was dependent on staff for personal hygiene tasks. Record review of Resident #35's care plan, dated 01/04/2025, reflected the following: Focus: ADL self-care performance deficit R/T limited mobility, fatigue, impaired balance, confusion - unable to communicate needs dx dementia.Goals: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene through the review date.Interventions: Personal hygiene routine: dependent Record review of Resident #35's nail care documentation reflected no attempt at nail care documented in the 30-day lookback period from 02/03/2026 to 03/05/2026. Observation on 03/03/2026 at 10:12 AM revealed Resident #35 had long and jagged fingernails. When asked if she wanted her fingernails cut, she said yes but then began to speak about unrelated topics in a confused manner. Observation on 03/04/2026 at 08:03 PM revealed Resident #35 was in and out of sleep and did not respond to efforts to interview her. Her fingernails were still long and jagged. 3. Record review of Resident #45's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (area of brain death), hemiplegia and hemiparesis (paralysis on one side of the body), rheumatoid arthritis (chronic autoimmune disease that causes inflammation and damage in the joints and other body part), changes in skin texture, dementia without behavioral disturbance, lack of coordination, cognitive communication deficit (cognitive impairments, rather than language or speech problems, disrupt a person's ability to communicate effectively), delusional disorders, adjustment disorder with mixed anxiety and depressed mood (stress-related condition where a person develops significant anxiety symptoms in response to an identifiable life stressor), major depressive disorder, generalized anxiety disorder, and need for assistance with personal care. Record review of Resident #45's quarterly MDS assessment, dated 02/10/2026, reflected a BIMS score of 09, which indicated a moderate cognitive impairment. Resident #45 required partial to moderate assistance with personal hygiene. Record review of Resident #45's care plan, dated 07/05/2025, reflected the following: Focus: ADL self-care performance deficit R/T impaired mobility, hemiplegia and hemiparesis, following cerebral infarction affecting left non-dominant side, diastolic heart failure, joint disorder of the left shoulder, blindness of the left eye, rheumatoid arthritis.Goals: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene according to therapy goals throughout the review date.Interventions: Personal care: partial/moderate assist. Record review of Resident #45's nail care documentation reflected no attempt at nail care documented in the 30-day lookback period from 02/03/2026 to 03/05/2026. Observation and interview on 03/03/2026 at 09:36 AM revealed Resident #45 was seated in his wheelchair eating breakfast. His fingernails were slightly long, not jagged, but there was a brown substance underneath them and all around the nail bed. When asked if he preferred his nails to be clean, he stated his family member was a barber and came to do his nails. He looked at his fingernails and said, Yep, he always does a great job. Observation and interview on 03/05/2026 at 11:43 AM revealed Resident #45's fingernails were still dirty with the brown substance. He stated he did liked his fingernails cleaned and trimmed and said, Thank you kindly for looking at them. Please keep up with them! 4, Record review of Resident #17's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (area of brain death), hemiplegia and hemiparesis (paralysis on one side of the body), epilepsy (seizure disorder), post-traumatic stress disorder, and generalized anxiety disorder, Record review of Resident #17's quarterly MDS assessment, dated 02/09/2026, reflected she was not able to participate in a BIMS assessment for cognition, but the staff assessment for cognition indicated she had a memory problem and her cognitive skills for daily decision making were severely impaired. Resident #17 was dependent on staff for personal hygiene tasks. Record review of Resident #17's care plan, dated 07/09/2025, reflected the following: Focus: ADL self-care performance deficit R/T recent stroke and write hemiplegia. Goals: Will maintain current level of function.Interventions: Personal hygiene/oral care: dependent Record review of Resident #17's nail care documentation reflected no attempt at nail care documented in the 30-day lookback period from 02/03/2026 to 03/05/2026. Record review of the shower schedule, updated 03/05/2026, reflected Residents #17, 35, and 45's shower scheduled for the 6 AM to 2 PM shift Tuesday, Thursday, and Saturday. Record review of staffing schedules for 03/03/2026 to 03/05/2026 reflected CNAs H and I worked the 6 AM to 2 PM shift. Observation on 03/03/2026 at 09:59 AM revealed Resident #17 lying in bed watching television. She was clutching her blankets, and her fingernails were very long and jagged. She did not respond when asked if she preferred her fingernails long. During an interview on 03/03/2026 at 12:40 PM, CNA H stated the procedure for nail care was if they noticed a residents fingernails were long or dirty they were to do the nail care. He stated they did not really have anyone on their hall who refused nail care. She stated Resident #35 sometimes refused care, but they just had to try again a little later. He stated Resident #45 sometimes dug in the back side of his brief and his hands came back out dirty. He stated they had access to wooden cleaning sticks and clippers in the supply room, and they were only supposed to use each tool once. Observation on 03/05/2026 at 11:48 AM revealed Resident #17 still had long, jagged fingernails. During an interview on 03/05/2026 at 12:40 PM, CNA H stated she did nail care for residents who did not have diabetes, and the nurse or podiatrist did it for residents who did. She stated Resident #17 rarely let the staff trim her finger nails and would barely let them put on her clothes. CNA H stated she documented when Resident #17 refused. She stated she had not documented in 30 days, because she probably did not try as often as she should. CNA H stated Resident #45 did not usually refuse nail care, and she did check the nails daily, but she did not know why she did not notice his dirty nails for three days. She stated the CNAs in the hall could have made the time to provide nail care for the residents and they needed to do better. She stated they were trained to check the nails every day and provide care as needed and to notify a nurse if the nails were a problem. She stated it was her responsibility, and she could have done a better job. She stated possible negative consequences of not providing nail care were infection or digging into the skin. During an interview on 03/05/2026 at 12:55 PM, CNA I stated he was trained to provide nail care if the resident did not have diabetes. He stated Residents #35 and #45 received bed baths most of the time, and he did not know why there had been no documentation for the nail care. He stated it would be good for there to be a designated time that nail care was done for each resident and then it would not fall through the cracks. He stated Resident #45 put his hand in his brief to scratch, and he could get dirty fingernails easily. He stated Resident #45 had just received a bed bath that morning, but they had not provided nail care, and he guessed they just forgot. He stated it was important to clean Resident #45's nails when they were dirty, because he could get an infection. He stated Resident #17 would not let them do anything with her nails, but they should still be documenting refusals and telling the nurse. He stated Resident #1 liked her nails long, but she wanted them to be filed and neat and painted, if possible. During an interview on 03/05/2026 at 01:19 PM, LPN D stated if residents did not have diabetes or staff were not comfortable cutting nails, it would become her responsibility. She stated the verbal people would sometimes ask, but they tried to keep on top of the nonverbal people. LPN D stated they were trying to cut Resident #17's nails for weeks, and she has let them before but not lately. She stated it should have been reported to the ADON. She stated the first step if a resident refused was for the aides to notify the charge nurses, then the charge nurses were to document the refusal, try again, and send someone else in to try. She stated Resident #1 had diabetes, so nail care was LPN D's responsibility. She stated she had not asked Resident #1 if she wanted her fingernails cut in about two months. She stated they were supposed to document refusals so the underlying reason for refusal could be investigated. She stated leaving residents nails long, jagged, or dirty could cause infection or skin tears. During an interview on 03/05/2026 at 03:17 PM, ADON A stated her expectation was fingernails should be checked at every bath or shower to see if care was needed. If aides providing showers determined nails needed to be cleaned, they could clean them regardless, and if they determined nails needed to be trimmed, they were to always verify first if the resident was diabetic. She stated aides could still file nails for a diabetic resident. She stated if the resident refused, she expected the aide to notify the nurse so the nurse could follow up and try to convince or educate the resident. She stated if they continued to refuse, the nurse should have notified the MDS nurse so the refusal could be added to the care plan. She stated there was an expectation for the aides to document on the point of care system, and that documentation was required. She stated the point of care documentation was looked at by herself and ADON B for every single resident on shift. She stated ADON B oversaw the system for showers in the facility, but the charge nurse for each hall was the person responsible for ensuing nail care was done or at least offered. She stated infection was a possible negative impact of having long, jagged, or dirty fingernails. During an interview on 03/05/2026 at 03:31 PM, ADON B stated she did not have a report that popped up automatically for nail care. She stated the shower report did show up and she tracked it daily. She stated she was not specifically looking at nail care as a system and had been rolling it in with showers. She stated she expected the aides to be documenting refusals and the nurses to report frequent refusals to her or one of the other members of nurse management. She stated the potential negative impacts of not providing nail care was the nails could become an infection source or residents could scratch or harm themselves. During an interview on 03/05/2026 at 03:35 PM, the DON stated she generally oversaw charge nurses, but she might have needed to do a little better of a job monitoring for nail care on the halls. She stated they monitored skin issues and showers on the halls, including when residents refused, but they had not been monitoring nail care refusals as closely. She stated thepotential negative impact was residents could get infections and have skin breakdown. During an interview on 03/05/2026 at 03:51 PM, the ADM stated the nursing team was responsible for ensuring nail care was done. He stated he knew they talked about showers in general in their morning meeting, but he was not sure if nail care was a part of that. He stated he did not know the potential negative impact on residents. Record review of the facility's, undated, policy titled Nail Care reflected the following: It is the policy of this facility to promote cleanliness, safety, and neat appearance of our residents. Record review of the facility's, undated, policy titled ADL, Services reflected the following: It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADLs) will receive necessary services to maintain:-Good nutrition-Grooming-Personal hygiene-Oral hygiene

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure CK L cleaned and sanitized the kitchen countertop prior to preparing pureed food for lunch service on 03/03/2026. The facility failed to ensure CK L sanitized the food processor and spatula before and after use when preparing pureed food for lunch service on 03/03/2026. The facility failed to ensure CK L used proper hand hygiene while preparing pureed food for residents on 03/03/2026. These failures could place residents at risk for food contamination and foodborne illness.Findings include:An observation on 03/03/2026 at 9:30 a.m. revealed the kitchen counter was visibly soiled with food particles, liquid spills, and stains.During an observation on 03/03/2026 between 9:33 a.m. and 9:50 a.m., CK L was observed to clean her hands twice by dipping them into the water in the 3 sink dish area used for washing and sanitizing dishes.An observation on 03/03/2026 at 9:33 a.m. revealed CK L began the puree lunch process on the dirty kitchen counter without cleaning or sanitizing it. CK L washed the food processor equipment in the 3 sink wash, dipped the bowl and blade in the sanitization water for a few seconds, and removed them. With the equipment still wet, CK L placed the blade on the dirty counter and then placed it inside the food processor bowl for the rice puree.An observation on 03/03/2026 at 9:38 a.m. revealed CK L washed a spatula in the 3 sink wash, dipped it in the sanitization water for a few seconds, and removed it. While still wet, CK L placed the spatula on the dirty counter, then picked it up and stirred the rice puree.An observation on 03/03/2026 at 9:41 a.m. revealed CK L washed dishes with bare hands and, without washing or sanitizing her hands or putting on gloves, placed a plastic liner inside the puree rice container, touching the inside of the liner with her bare hand, and then poured the rice inside.An observation on 03/03/2026 at 9:44 a.m. revealed CK L wore gloves and washed the food processor. CK L dipped the bowl and blade in the sanitization water and immediately removed them. Without washing hands or changing gloves, CK L assembled the food processor for the beef enchiladas puree and touched the blade and inside of the bowl.An observation on 03/03/2026 at 9:50 a.m. revealed CK L completed multiple tasks-putting away food in the walk in refrigerator, removing pans from sanitized water, filling a pan with water and placing it on the stove, turning on the stove, removing another pan from the sanitize sink, and placed a plastic liner inside the pan-without washing hands or changing gloves. CK L removed one glove, placed her bare hand inside the plastic liner, and poured the beef enchiladas puree.During an interview on 03/03/2026 at 12:40 p.m., CK L stated she worked at the facility for one month and was trained in preparing puree food, hand hygiene, and sanitizing counters, equipment, and utensils. She stated she was supposed to wipe down and sanitize kitchen surfaces before and after every task. She stated she was trained to wash her hands for 30 seconds with hot water and soap at the employee hand sink and not to use the dish wash sinks for handwashing. She stated she had to wear gloves when handling food and to change gloves and wash hands when changing tasks, when visibly dirty, or when gloves were damaged. She stated dishes and equipment should sit in sanitization water for at least 60 seconds and be dried before use. She stated these procedures were important to avoid cross contamination. She stated she did not know why she did not follow procedures and being observed by a state surveyor caught her off guard. During an interview on 03/03/2026 at 12:50 p.m., the DM stated she trained staff in kitchen sanitation and hand hygiene. She stated kitchen surfaces should be cleaned and sanitized before food preparation, when dirty, about once an hour, and after every meal. She stated staff should wash hands with soap and hot water in the employee sink for 20 seconds and dry hands. She stated staff should not wash hands in dish wash sinks. She stated dishes and equipment should remain in sanitization water for one minute and a sign above the sink reflected this. She stated these procedures were important to avoid cross contamination which could make residents sick. She stated it would not meet her expectations for CK L to prepare puree on a dirty counter, wash hands in the dish wash sink, fail to wash hands or change gloves after washing dishes, remove equipment from sanitization water immediately, or place utensils on a dirty counter. She stated she would in service staff. During an interview on 03/03/2026 at 1:05 p.m., CK M stated she was trained in puree meals, hand hygiene, and kitchen sanitization. She stated it was important to clean and sanitize counters and hands between tasks to avoid making residents sick. She stated counters should be cleaned before starting a task and hands should be washed with soap and hot water in the employee sink. She stated staff should not wash hands in the dish wash area because the water was dirty. She stated equipment should be cleaned and sanitized in the sanitization sink but did not know the required time. She stated gloves must be worn while preparing food. An observation on 03/03/2026 at 1:10 p.m. revealed a Three-Compartment Sink Procedures poster above the dish wash sinks reflected, SanitizeFill sanitizer compartment with proper sanitizer solution. Completely immerse cleaned items in the sanitizer solution for at least one minute. Air DryRemove and place on clean surface to air dry. During an interview on 03/05/2026 at 9:41 a.m., the DON stated she was trained in hand hygiene but not in kitchen cleaning or sanitization. She stated the dietary manager was responsible for ensuring cooks used proper hand hygiene and sanitation practices. She stated it would not meet her expectations that CK L did not clean and sanitize the counter, food processor, or spatula, or perform hand hygiene during the puree meal. She stated kitchen staff needed training in hand hygiene, kitchen sanitization, and glove usage. The DON stated proper hand hygiene and following proper sanitization procedures in the kitchen were important to avoid cross contamination which could make residents ill. During an interview on 03/05/2026 at 10:01 a.m., the ADM stated he was trained in hand hygiene but not in kitchen sanitization or cleaning. He stated the dietary manager was responsible for training kitchen staff and ensuring they followed procedures; however, he was ultimately responsible for everything in his facility. He stated it was important to follow procedures to prevent residents from becoming sick. He stated CK L's actions during the puree meal did not meet his expectations. Record review of the facility's Infection Control Policy & Procedure, revised 05/2024, reflected, Policy:It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedure:Personal HygieneD. Adequate numbers of hand washing sinks with soap dispensers and single use towels are provided.1) Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning.after handling dirty dishes; before touching food, clean dishes and silverware.2) Hand washing procedurea. wet hand thoroughlyb. lather with soap to wrist and use frictionc. rinse, clean nailsd. lather second timee. rinse with water running from wrist downf. dry on paper towelg. turn faucet off with paper towel6. Proper Food HandlingS. All food grinders, choppers, mixes, etc. should be cleaned, sanitized, dried and reassembled after each use. 8. Dietary HousekeepingD. All work surfaces, utensils, and equipment should be cleaned and sanitized after each use. Review of the facility's undated Hand Washing Inservice Training reflected, 1. Hand WashingTHE MOST IMPORTANT personal hygiene practiceWhenvii. After handling soiled dishes or trashviii. Before food prepix. Before putting on gloves.Where and HowOnly in the hand washing sinkWarm waterUp to elbowsWash for 15 to 20 secondsDry with a paper towelUse the towel to turn off the facetGloves and sanitizer do not replace hand washing2. Glove usage a. One time use When do I have to replace or change gloves?Always change gloves if the gloves get ripped, torn, or contaminated.Before putting on new gloves and each time gloves are changed, hands should be washed thoroughly. Record review of How to Clean and Sanitize in a Three-Compartment Sink provided by the facility, dated 2019, from the National Restaurant Association Educational Foundation reflected, .Follow the 5 steps for cleaning and sanitizing in a three-compartment sink. 4. Sanitize items in the third sink. Check the time and temperature requirements for the sanitizer you are using.5. Air dry all items. Place items upside down so they will drain. Never use a towel to dry items.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 1 of 1 residents (Resident #20 and Resident #62) reviewed for infection control. 1. The facility failed to ensure medications and biologicals in the refrigerator of the facility's medication room were maintained in a clean and sanitary condition. 2. The facility failed to ensure LPN C and CNA G changed gloves and performed hand hygiene during incontinent care provided to Resident #20. 3. The facility failed to ensure MA F performed hand hygiene before and after administering medications to Resident #62These failures could place residents at risk for cross contamination and the spread of infection.1. During an observation on 03/03/2026 at 1:17 p.m. revealed the medications and biologicals storage refrigerator in the facility's medication room had a dark red substance on the bottom of the refrigerator (under the crispy drawers). The substance was about 40 cm long and 5 cm wide. There were multiple nurses who opened the refrigerator to pick up medications out of the refrigerator and the dark substance remained unnoticed. 2. Record review of Resident # 20's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (artery blockage cuts off blood flow and oxygen to the brain), hemiplegia (a severe or total paralysis of one side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body), type 2 diabetes mellitus with hyperglycemia (a chronic metabolic condition where the body cannot effectively use insulin, insulin resistance or produce enough of it, leading to elevated blood sugar levels), neuromuscular dysfunction of bladder (nerve damage from conditions like spinal cord injury, or diabetes disrupts brain-bladder communication), and retention of urine, unspecified (the inability to completely empty the bladder). Record review of Resident #20's Comprehensive MDS assessment, dated 02/17/2026, reflected a BIMS score of 13, which indicated intact cognitive response. Record review of Resident #20's, undated, care plan reflected Resident #20 had an indwelling catheter related toneurogenic bladder. Provide catheter care every shift and as needed. Perform incontinent care as needed. During an observation of Resident #20's incontinent care on 03/03/2026 at 2:10 p.m. revealed LPN C and CNA G entered Resident #20's room to provide perineal care with catheter. LPN C and CNA G took a stand on both sides of Resident #20's bed and unfastened his brief. CNA G wiped Resident 20's pubic area and penis with wipes. CNA G did not wipe the resident's scrotum area and did not wipe the indwelling catheter from the tip of the penis moving downward away from the body. CNA G picked up the bag with wipes from the middle of the bed and placed it at the resident's feet without removing her gloves and performing any hand hygiene. LPN C and CNA G placed a new brief after peri care provided, and LPN C picked up the bag with wipes at the resident's feet and placed it inside of the resident's nightstand drawer. 3. Record review of Resident # 62's, undated, face sheet reflected a [AGE] year-old-male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction (artery blockage cuts off blood flow and oxygen to the brain), hemiplegia (a severe or total paralysis of one side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body), acute and chronic respiratory failure with hypoxia (a sudden worsening of breathing with long-term lung disease), heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen) and essential hypertension (chronic high blood pressure with no single, identifiable medical cause). Record review of Resident #62's quarterly MDS assessment, dated 12/31/2025, reflected Resident #62 had a BIMS score of 09, which indicated moderate cognitive impairment.Record review of Resident #62's, undated, Care Plan reflected Resident #62 was at risk for infection. His baseline forehead temperature of 97.4F will be used as a reference point for monitoring potential signs of infection. During an observation of the medications administration on 03/04/2026 at 8:00 a.m. revealed MA F did not perform hand hygiene before she went to Resident 62's room to administer medications. MA F did not perform hand after administering medications, she left the resident's room and logged back on the facility's laptop without performing hand hygiene and started charting. During an interview on 03/05/2026 at 8:35 a.m. with LPN C, she stated she was trained in Peri care with foley catheter and infection control. She stated she should have changed her gloves and performed hand hygiene before moving the bag with wipes to the resident's drawer. LPN C stated failing to provide proper peri care and hand hygiene exposed the residents to infections and possibly to urinary tract infections. During an interview on 03/05/2026 at 10:16 a.m. with CNA G, she stated she was trained in perineal care with foley catheter and infection control. She stated hands should be washed before peri care was provided. Gloves should be on during peri care. Gloves should be removed and hands washed if gloves were visibly soiled. Gloves should be removed and hands sanitized before new briefs were placed on the resident. Gloves should be washed after residents assisted with peri care. CNA G stated gloves should be removed and hand hygiene performed before touching the bag with wipes. CNA G stated she recalled touching the bag with wipes without removing her gloves and performing hand hygiene. CNA G stated the indwelling catheter should be cleaned during peri care, but she could not recall if she did it or how it should be done properly. She stated not following perineal care and infection control procedures could cause spreading of infection and residents could get UTIs During an interview on 03/05/2026 at 10:03 a.m. with MA F stated she was trained in infection control and hand hygiene. MA F stated she sanitized her hands before putting residents' medications together and she further stated she always sanitized her hands before going to the residents' rooms and after leaving the residents' rooms. MA F stated she did not note she did not sanitize her hands before and after going to Resident #66's room. MA F stated not following the infection control procedures like washing hands or sanitizing hands could spread infection among the residents and staff and it could make them sick. During an interview on 03/05/2026 at 10:10 a.m. with ADON A, she stated she was also the infection preventionist. She stated staff had daily infection control hurdles during shifts change and any time trend of infections noted. She stated hands should be washed before peri care and after peri care and anytime during peri care when gloves got visibly soiled. Gloves must be removed and hands sanitized during peri care going from dirty to clean area. ADON A stated hands must be sanitized between residents during administration of medications. She stated the management team and herself all were responsible for monitoring hand hygiene practices. ADON A did not know what the dark red substance was found inside of the medication storage refrigerator. She stated it should not be there. It was solely for medication storage. It potentially could get on something else and cause cross contamination. During an interview on 03/05/2026 at 12:20 p.m. with the DON, she stated she was trained in infection control. She stated handwashing with soap and water was expected to be performed before starting peri care and after, also anytime the gloves became visibly soiled during peri care. She stated the indwelling catheter must be cleaned by going from the point of the insertion and downward. Not following the infection control measures potentially may cause infections and UTIs. The DON stated hands must be washed when staff arrive at the facility, any time after bathroom use, after eating food and when hands become visibly soiled. Hands must be sanitized between residents during administration of medications. She stated infection control was teamwork. The DON stated she was not aware of the presence of the dark red substance inside of the medication storage refrigerator. She stated it potentially could affect the residents' medications there. It was best practice to keep the medications' refrigerator clean. During an interview on 03/05/2026 at 4:05 p.m. with the ADMADON, he stated he had been working in the facility for over 5 years. He stated his last infection control training was probably in October of 2025 and last month was the state required infection control training. He stated the staff's infection control training was an ongoing process. The ADMADON stated he did not worry about the dark red substance inside of the medication storage refrigerator unless it had potential to come in contact with the resident's medications. Record review of the facility's, undated, Policy and Procedure titled Policy/Procedures-Nursing Clinical, Subject: Medication Access and Storage, revised on 05/2007, reflected:Medication storage areas are kept clean, well-lit and free of clutter. Record review of the facility's, undated, Policy and Procedure titled Perineal Care, revised on 10/2027, reflected:Hold catheter tubing to one side, as described above. Wipe catheter from the tip of the penis towards 3-6 inches away in circulating motions. Record review of the facility's, undated, Policy and Procedure titled Perineal Care, revised on 10/2007, reflected for all variations, complete procedures as follows:Remove dirty gloves.Wash hands/sanitize properly before touching other items in the room after peri care such as call light, telephone and others. Record review of the facility's, undated, Policy and Procedure-Nursing Clinical titled Medications Administration revised on 05/2007 reflected:Wash hands.

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 of 11 residents (Residents #42, #48, #20, #66, and #8) reviewed for environment. The facility failed to ensure the privacy curtains in the rooms of Residents #42, #48, #20, #66 and #8 were clean. This failure could place residents at risk of infection and diminished quality of life.Findings include: 1. Record review of Resident #66's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease. 2. Record review of Resident #42's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression. 3. Record review of Resident #48's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (acute neurological disorder caused by vitamin B1 deficiency), adjustment disorder with anxiety (stress-related condition where a person develops significant anxiety symptoms in response to an identifiable life stressor), need for assistance with personal care, cognitive communication deficit(cognitive impairments, rather than language or speech problems, disrupt a person's ability to communicate effectively), and anxiety disorder. 4. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included lack of coordination, anxiety disorder, insomnia, need for assistance with personal care, mild vascular dementia (caused by impaired blood flow to the brain), major depressive disorder. 5. Record review of Resident #20's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acquired absence of right leg below knee (lower left leg amputation), cerebral infarction (area of brain death), hemiplegia and hemiparesis (paralysis on one side of the body), and full incontinence of feces. Observation on 03/03/2026 at 09:56 AM revealed a crusty brown stain on the privacy curtain between Residents #42 and 48's beds. Resident #42 did not respond verbally to efforts to interview her, and Resident #48 shrugged her shoulders when asked about the stain and whether it bothered her but said nothing. Observations on 03/03/2027 at 09:43 AM and 02:27 PM revealed three crusty brown stains on the privacy curtain next to Resident #20's bed. During an interview on 03/03/2026 at 03:22 PM, Resident #20 stated he noticed the stains on the curtain but he did not know what they were and did not want to know what they were. He stated he did not think he reported the dirty curtain to anyone. He stated the housekeeper came in his room every day and cleaned up, but he had not seen anyone remove and wash the privacy curtain since he had been there. He stated he would like the curtain cleaned. Observation on 03/04/2026 at 07:40 AM revealed the privacy curtain next to Resident #66's bed had several permanent stains and two crusty brown stains. She did not respond to efforts to interview her. Her roommate, Resident # 8, lay in the bed next to her. During an interview on 03/04/2026 at 07:40 AM, Resident #8 stated the housekeepers were wonderful, but she was not sure she ever saw them clean the privacy curtains, and that was disgusting. She stated there were lots of food and other types of fluids being tossed around in the room, and she dared not imagine what the crusty brown substance was on her roommate's privacy curtain. She stated it did not bother her before, because she had not seen it, but she wanted it washed now that she knew it was there and would be sure to tell the housekeeper, whose name she could not remember. During an interview on 03/04/2026 at 08:00 AM, HK N stated they checked the curtains when they cleaned the rooms, but sometimes the curtains were pushed back, and they could not see the whole thing. She stated she was trained to pull the curtain back and check it thoroughly, but she did not know why she did not notice the stains on the curtains for Residents #42, #48, #20 and #66. She stated she did not know what the substances were but there could be infection because of them. During an interview on 03/05/2026 at 02:58 PM, the MAINTD stated he was also the head of housekeeping. He stated the housekeepers were trained to check the privacy curtains and if they were soiled, stained, ripped, or torn they were told to pull the curtains and replace them. He stated there was no detailed, routine washing schedule for the privacy curtains, but they were washed as needed. He stated the room should have always been inspected when cleaned, and everything should have been clean including the curtains. He stated he was not checking privacy curtains regularly and his system to monitor compliance with cleanliness requirements was still in development, as he had only been at the facility for two months and there were many systems that needed changes. He stated the negative impact of the dirty curtains on residents was environmental. During an interview on 03/05/2026 at 03:51 PM, the ADM stated housekeeping and maintenance were responsible for ensuring privacy curtains were cleaned when they were dirty. He stated it was the MAINTD's responsibility, and he (the ADM) was not aware of the procedures in place to ensure compliance. He stated he did not monitor compliance in this area. He stated the potential negative impact to the residents was It's a dirty situation. Record review of facility's, undated, policy titled Homelike reflected the following: It is the policy of this facility to provide a home like environment, and to encourage and provide opportunities for each resident to occupy an area.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for four of twenty-five residents (Resident #4, Resident 73, Resident #83, and Resident #1) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #4's room was in a position accessible to the resident on 03/03/2026. 2. The facility failed to ensure the call light system in Resident #73's room was in a position accessible to the resident on 03/03/2026. 3. The facility failed to ensure the call light system in Resident #83's room was in a position accessible to the resident on 03/03/2026. 4. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 03/04/2026. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.1. Record review of Resident #4's admission Record, dated 03/04/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #4's Diagnosis Report, dated 03/04/2026, reflected diagnoses which included senile degeneration of brain, not elsewhere classified (condition where the brain has declined due to aging, causing problems with memory, thinking and judgement), unspecified severe protein-calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss, weakness, and poor overall health) and anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life) Record review of Resident #4's Annual MDS, dated [DATE], reflected Resident #4 had a BIMS score of 0, indicating which indicated she was severely cognitively impaired. Resident #4 was dependent on her self-care needs and mobility needs. Record review of Resident #4's, undated, Care Plan, undated and accessed on 03/04/2026, reflected Resident #4 was at risk for falls and, poor safety awareness, initiated 01/21/2025. An intervention included Be sure the call light is within reach and encourage to use it to call for assistance as needed. 2. Record review of Resident #73's admission Record, dated 03/04/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #73's Diagnosis Report, dated 03/04/2026, reflected diagnoses which included epilepsy (condition that causes a person to have repeated seizures due to abnormal electrical activity in the brain), dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life), and hypertension (high blood pressure). Record review of Resident #73's Annual MDS, dated [DATE], reflected Resident #73 had a BIMS score of 0, which indicated she was severely cognitively impaired. Resident #73 was dependent on her self-care needs and mobility needs. Record review of Resident #73's, undated, Care Plan, accessed on 03/04/2026, reflected Resident #73 was at risk for falls and, poor safety awareness, initiated 04/03/2024 and revised on 10/17/2025. An intervention included Be sure the call light is within reach and encourage to use it to call for assistance as needed. 3. Record review of Resident #83's admission Record, dated 03/04/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #83's Diagnosis Report, dated 03/04/2026, reflected diagnoses which included hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease (condition where long-term high blood pressure has damaged the heart and kidneys causing heart failure and reduced kidney function) and depression (condition that affects mood and daily functioning, resulting in sadness, low energy, and reduced interest in usual activities.) Record review of Resident #83's Annual MDS, dated [DATE], reflected Resident #83 had a BIMS score of 02, which indicated she was severely cognitively impaired. Resident #83 was dependent on her self-care needs and mobility needs. Record review of Resident #83's, undated, Care Plan accessed on 03/04/2026, reflected Resident #83 was at risk for falls and poor safety awareness initiated 08/25/2024. An intervention included Be sure the call light is within reach and encourage to use it to call for assistance as needed. 4. Record review of Resident #1's, undated, admission Record for Resident #1 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's, undated, Diagnosis Report included anoxic brain damage (damage due to lack of oxygen to the brain), bipolar disorder (a mental health condition that causes extreme mood swings), moderate protein calorie malnutrition (insufficient protein and calories), generalized anxiety disorder, and dysphagia (trouble swallowing). Record review of the Resident #1's quarterly MDS assessment, for Resident #1 dated 12/03/2025, reflected a BIMS score of 10, indicating which indicated a moderate cognitive impairment. It also reflected that she Resident #1 had functional limitation in her range of motion on one side of her upper extremities (shoulder, elbow, wrist, hand). It reflected that she was dependent on staff for transfers out of bed, indicating which indicated that the helper did all the effort and Resident #1 did not help with the effort at all. Record review of the Resident #1's care plan, for Resident #1 dated 11/5/2025, reflected the following: Focus: Resident is at risk for falls R/T cognitive deficit, impaired mobility, psychotropic medication use.Goals: Will be free of balls through the of your date.Interventions: Be sure the call is within reach and encouraged to use it to call for assistance as needed. During an observations on 03/03/2026 at 9:44 AM and 11:18 AM, Resident #4, was observed lying in her bed in the lowest position with a fall mat beside it. Her call light was observed on the floor at the foot of her bed. The resident has had a roommate who was also in bed and her call light was attached to her bed within reach. During observations on 03/03/2026 at 9:38 AM and 11:15 AM, Resident #73, was observed lying in her bed. Resident #73 call light was on the floor at the foot of her bed. During an observation on 03/03/2026 at 10:02 AM. Resident #83, was observed lying in her bed with her call light pinned to the privacy curtain located behind her head. A second observation at 11:18 AM revealed the call light was attached to her bed. It was located above her head on the right side. During an interview on 03/04/2026, at 7:50 AM, CNA J said the call light should not be on the floor at the foot of the bed. The call light should be on the bed where the resident could reach it. CNA J stated sometimes after Hospice visited the residents and completed a bed bath, they might forget to put the call light back on the residents' bed. CNA J said it was the facility's responsibility to come behind Hospice to double check that the call light was on the bed but sometimes the staff forgot. During an interview on 03/04/2026 at 8:12 AM, the DON stated her expectation was when residents were in bed, call lights should be on the bed where the resident could reach it. All staff were trained to place the call light on residents' bed, within reach. She stated all staff were in serviced on call light placement. The DON stated the call lights sometimes were not on the bed because they were not clipped. The facility was in the process of buying more clips for call lights. The DON stated her expectation was call lights were always within reach of the resident when they were in bed. During observation and interview on 03/04/2026 at 01:21 PM, someone called for help behind Resident #1's door. Upon knocking and being granted verbal permission to enter by Resident #1, she was observed sitting on her bed, with the head of the bed elevated and a lunch tray in front of her. She was holding a disposable foam cup she had punctured with her right thumbnail, causing which caused the water in the cup to spill over the front of her blanket and her lunch tray. She stated she was thirsty and wanted water. She stated she did not know where her call button was. She stated water several times with increasing emphasis. Her call button was lying on the bed above her right shoulder. She stated she did not know where her call button was. When it was pointed out to her, she tried to reach it and could not with either her left or right hand due to range of motion limitations. She stated it was usually on her chest and she could reach it. She took it in her hand and demonstrated her ability to press it. CNAs H and I entered the room within eight seconds and asked her what she needed. CNA I clipped her call button to the chest part of her gown and commented that her gown and blanket were wet. CNA H began to move her lunch tray and her wet blankets while LPN D entered the room. Resident #1 was still saying water, and LPN D left, returning a few moments later with a new disposable foam cup of water and held the straw to her mouth to allow her to drink. Resident #1 drank deeply for five full seconds and then asked for more. CNAs H and I explained they would be changing Resident #1 into dry clothing, and the state surveyor exited the room for Resident #1's privacy. During an interview on 03/05/2026 at 12:40 PM, CNA H stated Resident #1 knew how to use her call button and used it frequently but not overly often. She stated they always clipped it to the front of her gown because she could not reach very far and needed to be able to see it. She stated she did not know why the button was not clipped to her gown during the previous day's lunch meal, but it should have been clipped to her.During an interview on 03/05/2026 at 12:55 PM, CNA I stated he did not know why Resident #1's call button was up by her shoulder but that he had probably missed putting it back when he set up her lunch tray. He stated it was important to make sure the call button was in reach for her, because she could use it and get what she wanted. He stated she could not get herself up and get what she wanted on her own. He stated he was trained to ensure residents had their call buttons accessible to them.During an interview on 03/05/2026 at 01:19 PM, LPN D stated Resident #1 could not reach the call button on 03/04/2026 when she broke her foam cup and did not have a two-handled cup. LPN D stated everyone on the hall was responsible for ensuring residents could reach their call buttons. She stated a possible negative impact of not being able to reach her call button was the resident would have something bad happen and not be able to reach anyone.During an interview on 03/05/2026 at 01:35 PM with the ADM, he stated he expected all staff to place the call light on the bed where it could be reached. The ADM stated the department heads had begun a program for making rounds where they walked down the halls in the morning, but they were not doing it regularly, but he planned to re implement it.Record review of the facility's policy, Call System, Residents, dated as Updated: March 2026) Policy StatementResidents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview and record review the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals and snacks for 1 of 8 residents (Resident #1) reviewed for special eating equipment. The facility failed to ensure Resident #1 received a two-handled drinking cup on her tray as ordered by the dietitian. This failure could place residents at risk of aspiration and dehydration.Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anoxic brain damage, schizophreniform disorder (mixed psychotic and mood disorder), bipolar disorder (mood disorder), moderate protein calorie malnutrition, generalized anxiety disorder, and dysphagia (trouble swallowing). Record review of Resident #1's quarterly MDS assessment, dated 12/03/2025, reflected a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1 had weight loss of more than 5% in the previous three months or 10% in the previous six months and she was not on physician-prescribed weight loss regimen. Record review of Resident #1's care plan, dated 11/5/25, reflected the following:Focus: Resident is at risk for nutritional problem related to dysphasia as evidenced by mechanically, altered diet, missing teeth, poor vision, diabetes, morbid obesity.Goals: Will maintain adequate nutritional status as evidenced by maintaining weight with no S/SX of malnutrition through review dateInterventions: Regular diet, puree, texture, thin liquids consistency. No fried food. Adaptive equipment: scoop dish and two handled cup with meals. Provide, serve diet as ordered, monitor intake, and record each meal. Record review of a quarterly dietitian note, dated 11/16/2025, reflected the following:Diet: regular, puree, thin liquids. No fried foods, small portions with meals. Scoop dish, to handle cups. During observation and interview on 03/04/2026 at 01:21 PM, someone called for help behind Resident #1's door. Upon knocking and being granted verbal permission to enter by Resident #1, she was observed sitting on her bed, with the head of the bed elevated and lunch tray in front of her. She was holding a disposable foam cup she punctured with her right thumbnail, which caused the water in the cup to spill over the front of her blanket and her lunch tray. She stated she was thirsty and wanted water. She stated she did not know where her call button was. She then stated water several times with increasing emphasis. Her call button was lying on the bed above her right shoulder. When it was pointed out to her, she tried to reach it and could not with either her left or right hand due to range of motion limitations. She stated it was usually on her chest and she could reach it. She took it in her hand and demonstrated her ability to press it. CNA H and CNA I entered the room within eight seconds and asked her what she needed. CNA I clipped her call button to the chest part of her gown and commented that her gown and blanket were wet. CNA H began to move her lunch tray and her wet blankets while LPN D entered the room. Resident #1 was still saying water, and LPN D left, returning a few moments later with a new disposable foam cup of water and held the straw to her mouth to allow her to drink. Resident #1 drank deeply for five full seconds and then asked for more. LPN D stated Resident #1 was supposed to have a sippy cup, but the kitchen often did not send it. During an interview on 03/05/2026 at 12:40 PM, CNA H stated the sippy cup was sometimes there on Resident #1's tray and sometimes not. She stated there were times they would go ask the kitchen for one, and the kitchen would not know where one was. LPN D stated Resident #1 would nearly always put on her light and ask for help with the foam cup. She stated the only person she knew to report to was the DM. During an interview on 03/05/2026 on 12:55 PM, CNA I stated Resident #1's two-handled cup was sometimes on the tray and sometimes not. He stated the kitchen staff told them they lost the cups frequently. He stated he did not see there would be an outcome usually, because Resident #1 used her call button and they would come to help her take drinks. Observation on 03/05/2026 at 01:00 PM revealed Resident #1 in her bed with head of bed elevated and her lunch tray in her lap. Her tray had a colorful, two-handled cup on it filled with water. She stated she liked the colorful cup. During an interview on 03/05/2026 at 01:19 PM, LPN D stated Resident #1's two-handled cup was missing about 15% of the time, and they reported to the DM the cup was missing so they could reorder cups. LPN D stated they tried to go in the kitchen and look for a cup, but there was not always time for that. LPN D stated she had not been reporting to her nurse management when the two-handled cup was missing, but she had reported the incident that was witnessed by the state surveyor on 03/04/2026 at 01:21 PM to ADON A, which was why she thought the new, colorful cups had appeared. During an interview on 03/05/2026 at 01:20 PM, a dietary manager from a sister facility, SFDM stated the DM was not in the building and not available for interview, so she was covering the kitchen. She stated the facility policy was for residents to receive their adaptive dietary equipment. Resident #1 had a dietitian order for it, and she should have received it every day. She stated if the two-handled cup was not available, someone should have gone to the store to get it right away. She stated the possible negative outcome of residents not having their adaptive equipment was they might not be able to drink or eat and have a decline in nutrition or hydration. During an interview on 03/05/2026 at 03:17 PM, ADON A stated she found out about Resident #1 not having her two-handled cup yesterday (03/04/2026) after lunch and called the MAINTD, who was already out running an errand, and asked him to pick up some handled cups. She stated her expectation for that situation was they followed the dietitian order. She stated it was on the diet slip, and the kitchen staff should have been providing it. She stated the dietary staff was responsible, but then when the charge nurse checked the tray, she should also notice if it's not present. She stated the next step was to notify the kitchen, and if the equipment was not available, the DM. She stated potential negative impacts of the failure was dehydration and indignity. During an interview on 03/05/2026 at 03:35 PM, the DON stated the kitchen was responsible for ensuring Resident #1's two-handled cup was available and the charge nurse was responsible for monitoring for compliance. She stated a potential negative impact on the resident of this failure was she might not get her fluids. During an interview on 03/05/2026 at 03:51 PM, the ADM stated it was dietary's responsibility to acquire and offer the two-handled cup on Resident #1's tray, but the failure in this case was multi-level. He stated the kitchen staff, DM, CNAs, and nurses should have all worked to ensure Resident #1 was able to drink. He stated he did not know the potential negative outcome of the failure. A facility policy for specialized, adaptive dietary equipment was requested from the ADM on 03/05/2026 at 02:00 PM but not received as of exit at 04:30 PM.

Based on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 3 of 10 residents (Resident #34, Resident #40, and Resident #54) residents reviewed for resident rights. The facility failed to knock on Resident #34, Resident #40, and Resident #54's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #34 Face Sheet dated 01/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34's diagnoses insomnia (difficulty sleeping), hypertension (high blood pressure), muscle wasting, muscle weakness, history of falling, lack of coordination, unsteadiness on feet, overactive bladder, vitamin deficiency, hyperlipidemia (high cholesterol), cognitive communication deficit (problems with communication),and need for assistance with personal care. Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed that Resident #34's BIMS score was 12 indicating Resident #34 was moderately impaired. Review of Resident #40's Face Sheet dated 01/16/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #40's diagnoses included heart failure, hyperlipidemia (high cholesterol), hypertension (high blood pressure), unsteadiness on feet, muscle weakness, chronic pain, vitamin deficiency, insomnia (difficulty sleeping), edema (swelling), depression, history of falling, need for assistance with personal care, chronic kidney disease, and morbid obesity. Record review of Resident #40's Quarterly MDS dated [DATE] revealed that Resident #40's BIMS score was 15 indicating Resident #40 had intact cognitive response. Review of Resident #54's Face Sheet dated 01/16/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54's diagnoses included heart failure, adjustment disorder, depressive disorder, lack of coordination, insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), muscle wasting, unsteadiness on feet, need for assistance with personal care, and reflux. Record review of Resident #54's Quarterly MDS dated [DATE] revealed that Resident #78's BIMS score was 12 indicating Resident #54 had moderate impairment. Observation on 100 hall on 01/14/2025 at 09:30 am revealed that CNA A did not knock on Resident #54's door before entering. Observation of lunch trays being passed on 100 hall on 01/14/2025 at 12:17 pm revealed that CNA A did not knock on Resident #34's door before entering. Observation on 100 hall on 01/15/2025 at 09:04 am revealed that the BOM walked into Resident #40's room without knocking. An interview with Resident #54 on 01/14/2025 at 10:23 am revealed that staff did not always knock on the door when going into his room. He stated that the staff should knock before they entered into the room. He said he did not get upset but he did want staff to knock. An interview with Resident #34 on 01/14/2025 at 12:40 pm revealed that staff do not always knock on her door. She said that when the door was closed the staff will just walk in and she had to tell them to knock before coming in. She said that staff just walked in, and did not say anything. She said she did not appreciate them walking in and not speaking. An interview with Resident #40 on 01/15/2025 at 9:06 am revealed that staff did not knock all the time. He said that he wanted staff to knock all the time. He also said that if his door was closed or half closed, and staff do not knock that is when it bothered him because he could be changing. An interview with CNA A on 01/16/2025 at 1:26 pm revealed that she had been trained on resident rights. She stated the policy for knocking was that all staff were to knock before entering the resident's room. She said that a resident may feel like his or her privacy was being invaded or may feel as if the facility was not their home. She said nurses were responsible for monitoring to ensure staff were knocking. She said it was monitored by observations and when the facility did skill checks. She said she did not realize she did not knock because she was probably in a rush to do something. An interview with the BOM on 01/16/2025 at 3:41 am revealed that she had been trained on resident rights. She said that staff were required to knock, try to wait for a response and if no response crack the door and greet the resident. She said staff should always knock except in an emergency. She said if staff do not knock residents may feel like their privacy is invaded. She said management was responsible for monitoring to ensure staff were Knocking on the residents door. She said that management monitors by watching staff on the halls. She said she did not remember knocking on the resident's door. Record Review of Resident Rights Dignity and Respect Policy dated 03/2024 revealed the staff shall display respect for Resident's when speaking with, caring for or talking about them, as constant affirmation of their individuality and dignity as human beings. Staff members shall knock before entering the Resident's room.

Based on interviews and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were filled out completely for 2 of 9 residents (Residents #56, and 66) reviewed for pharmacy services. 1. The facility did not follow up on the pharmacy consultant's recommendations for Resident # 56 dated 10/31/2024 and 12/30/2024. 2. The facility did not follow up on the pharmacy consultant's recommendations for Resident # 66 dated 05/30/2024 and 06/26/2024. These failures could put the residents at risk for medications errors, unnecessary medications, and incorrect administration. Findings include: Record review of Resident #56's admission record dated 01/16/2024 revealed a [AGE] year-old female, admitted on [DATE], admitted with diagnoses including Parkinson's disease (progressive disease of the nervous system that affects movement), hypertension (high blood pressure), anxiety disorder (the intense, excessive and persistent worry and fear about everyday situations), atrial fibrillation (an abnormal heart rhythm), delusional disorder (a mental health disorder that causes unshakable beliefs in something that's untrue), insomnia (a sleeping disorder that makes it hard to fall asleep or stay asleep), and dementia (a progressive group of symptoms that affect memory, thinking and social abilities). Record review of Resident #56's quarterly MDS assessment, dated 12/17/2024, revealed a BIMS score of 10 which indicated mild cognitive impairment. Section N-Medications revealed Resident #56 received antipsychotic, hypnotic, antiplatelet and anticonvulsant medications. Record review of Resident #56's order summary dated 01/16/2025 revealed orders for: 1. Pimavanserin tartrate (Nuplazid) 34mg Give 1 capsule by mouth one time a day related to delusional disorders. 2. Quetiapine fumarate (Seroquel) 100mg Give 1 tablet by mouth at bedtime related to psychotic disorder with delusions. 3. Quetiapine fumarate (Seroquel) 25mg Give 1 tablet by mouth one time a day for psychosis. 4. Quetiapine fumarate (Seroquel) 25mg Give 1 tablet by mouth one time a day related to psychotic disorder with delusions. 5. Quetiapine fumarate (Seroquel) 50mg Give 1 tablet by mouth at bedtime related to psychotic disorder with delusions. 6. Zolpidem Tartrate (Ambien) 5mg Give 1 tablet by mouth at bedtime for insomnia. Record review of Resident #56's Consultant Pharmacist-Physician Communication dated 12/30/2024 revealed Federal guidelines state sedative hypnotic drugs should have an attempt at a gradual dose reduction (GDR) approximately every 6 months, when used routinely and beyond the manufacturer's recommendations for duration of use. This resident has been taking Ambien CR 6.25mg 1 PO QHS since 7/8/24 without a GDR in last 6 months. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? The box next to The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to: was marked and the form was signed off by NP on 1/14/2025 without further clarification. Record review of Resident #56's Consultant Pharmacist-Physician Communication dated 10/31/2024 revealed Patient has been taking 1. Ativan 0.5mg 1 PO Q8HR PRN anxiety since 10/24/24 2. Ativan conc 2mg/ml give 0.5mg PO Q8HR PRN since 10/24/24 PRN orders for psychotropic drugs are limited to 14 days (even in hospice patients). If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. The box next to add a longer stop date and document a reason for need to continue past 14 days. Stop date or duration:____________ Rationale:[handwritten] 6 weeks was marked and the form was signed off by NP on 11/5/2024 without further clarification. Record review of Resident #66's admission record dated 01/16/2025 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including major depressive disorder (persistent feelings of sadness and loss of interest), bipolar disorder (a mental condition that causes extreme mood swings), primary insomnia (a sleeping disorder that makes it hard to fall asleep or stay asleep), and generalized anxiety disorder (a condition that causes excessive, ongoing worry and interferes with daily life). Record review of Resident #66's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Section N-Medications revealed Resident #66 received antianxiety, antidepressant, hypnotic, anticoagulant, diuretic, opioid, and hypoglycemic medications. Record review of Resident #66's order summary dated 01/17/2025 revealed orders for 1. Buspirone Hcl (Buspar) 15mg Give 1 tablet by mouth three times a day for anxiety. 2. Divalproex sodium (Depakote) DR 250mg Give 500mg by mouth three times a day related to bipolar disorder. 3. Duloxetine Hcl (Cymbalta) DR Sprinkle 60mg Give 1 capsule by mouth one time a day for depression. 4. Zolpidem tartrate (Ambien) 5mg Give 1 tablet by mouth every 24 hours as needed for sleep related to primary insomnia. Record review of Resident #66's Consultant Pharmacist-Physician Communication dated 05/30/2024 revealed Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking Cymbalta 60 mg 1 PO daily since 11/13/23 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: The box next to Use is in accordance with relevant current standards of practice was marked and the form was signed off by NP, but no date or further clarification was noted. Record review of Resident #66's Consultant Pharmacist-Physician Communication dated 06/26/2024 revealed Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking Buspar 15 mg 1 PO TID since 7/28/23 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: The box next to Use is in accordance with relevant current standards of practice was marked, a notation of resident with increased anxiety, and the form was signed off by NP, but no date was noted. An interview on 01/16/2025 at 05:10 PM with the NP revealed she was responsible for completing the pharmacy consult recommendations. She stated the facility wanted the forms back quickly. The NP stated any residents who were prescribed medication for any psychiatric condition were referred to the psychiatric services to ensure all residents were dosed correctly. When asked about completing forms with a rationale she stated she had not filled out the rationale. She stated the rationale should have been in the notes from the psychologist. The NP stated there are no detrimental effects to taking antipsychotic and antidepressant medications long term for the residents. During an interview on 01/16/2025 at 05:58 PM with the DON, she stated she expected the providers to communicate with her about the GDR recommendations. She stated the rationale should have been documented in the psychologist notes and in the interdisciplinary meeting notes. The DON stated the providers worked together. She stated the NP was responsible for signing the pharmacy recommendations and the psychologist was responsible for documenting a rationale for the medication dosage. The DON stated the residents could become over sedated if GDR are not considered or they could be on medications that are no longer indicated. During an interview on 01/16/2025 at 06:18 PM with the ADM, he stated he expected the pharmacy consults to be completed with a rationale by the provider in a timely manner. He stated he was sure there could be a potential effect, though, he was not sure what for not completing the pharmacy GDR consultation forms.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals in accordance with currently accepted practices for 3 of 9 (hall 400 and 200 cart) medication carts and 1 of 2 medication rooms (overstock medication room) reviewed in that: The medication cart for the 400 hall and 200 halls had nine unidentified loose pills. The medication room had 39 expired Acetaminophen oral solution medications. These deficient practices could result in a drug diversion due to medications not being properly disposed of in the drug buster and secured. The findings were: Observation of medication cart for the 400-hall right side cart on 01/14/2025 at 03:38 PM revealed one round peach pill with O imprint: on one side and G on the other side, one white round pill with EPV 904 on one side and blank on the other side. One round white pill with L194 on one side and blank on the other side. LVN F was not able to identify the three loose pills. Observation of medication cart for the 400-hall left side cart on 01/14/2025 at 03:49 PM revealed one oblong purple and grey pill with Omeprazole 20mg: on one side and R644 on the other side, one peach round pill with L141 on one side and blank on the other side. One round white pill with no letters or numbers blank on both sides. One big white pill with AZ011 on one side and blank on the other side. One white oval pill with 379 imprinted on one side and 5G on the other side. LVN F was only able to identify the omeprazole pill but could not identify the other 4 pills. Observation of medication cart for the 300-hall cart on 01/14/2025 at 04:14 PM revealed one round white pill with ZD15 on one side and blank on the other side. LVN E could not identify the loose pill. Observation on 01/15/2025 at 08:23 AM revealed the facility Medication room with 39 Acetaminophen oral solution (325mg| 10.15 mL) with expiration dates of November 2024. Observation on 01/15/2025 at 08:46 AM, The Director of Nursing disposed of the expired medications in the drug buster (container used to dispose of medications) found in the medication room during the inspection. In an interview with LVN F on 01/14/2025 at 04:04 PM, she verbalized I don't know why there are loose pills if there are too many pill packets in the carts or if staff are dropping them when they are preparing them for administration. LVN F voiced that residents could not get to the loose pills in the carts. She added that if she ever would ever drop a pill, she would get another pill and go on. LVN F verbalized if staff slowed down that could prevent the loose pills issue from happening. LVN F voiced the Director of Nursing checks the carts for loose pills and expired medications weekly. She added that the individual nurse should be checking carts daily for loose pills and expired medications. If we see it, we fix it voiced LVN F. LVN F stated if she found a loose pill, she would put them in the drug buster for destruction. with LVN E on 01/14/2025 at 04:14 PM, she verbalized she noticed loose pills in the carts. LVN E voiced when she sees loose pills in the cart, she picks them up and put them in the drug buster for destruction. She verbalized that everyone is responsible for upkeeping and inspecting the carts daily. She added that the ADON goes through the carts monthly to check them too. LVN E verbalized residents cannot get the medications from the carts when asked if there could be a potential adverse effect of loose pills in the carts. In an interview with LVN G on 01/14/2025 at 04:28 PM, she verbalized all the nurses upkeep with the medication carts and inspect them regularly. LVN G verbalized she has never noticed loose pills in the bottom of the medication carts. LVN G voiced that if she would ever find a loose pill, she would dispose of it in the drug buster disposal immediately. LVN G verbalized yes, something bad can happen if there are loose pills in the bottom of the cart, because as staff member could accidentally give it to another resident. She added because you really don't know what it is. LVN G voiced staff have not been in-serviced on loose medication in carts, but they have been told verbally to put them in the drug buster destroyer if they did find any loose pills. During an interview on 01/15/2025 at 10:30 AM, LVN H voiced all the nurses should be responsible of checking carts and all staff kept up with it now. LVN H voiced she has never noticed loose pills on the bottom of the cart. If staff find loose pills, they cannot use them; they are to dispose of them in the drug buster disposal. LVN H voiced that a lot of pills that look alike could be dangerous if found at the bottom of the cart and given to a resident and staff would have to monitor for any reactions and contact the doctor if that happened. During an interview on 01/16/2025 at 11:27 AM, RN K verbalized whoever was on shift should be checking the medication carts for loose pills and checking medications for expired dates. RN K added that when she comes on a shift, she makes sure that everything is in order and when she is giving medications, she makes sure to check medication expired dates, and she is hopeful other shifts are doing that too. RN K voiced that she thinks the medications may become loose in the carts because when staff are dispensing them into a medication cup, they are probably holding the blister pack over the cup, but hovered over the medication cart while open. If staff drop pills, they probably look for them but if they cannot find the pills, they just get another one. RN K voiced there could be an adverse effect if the loose pill were ever given to another resident because they would not know what the pills are, and the resident could have an allergic reaction to the pill. RN K voiced staff have been in-serviced on loose pills and expired medications, but she could not recall when the last time was. During an interview on 01/16/2025 at 11:33 AM, LVN L voiced nurses were responsible for expired medications. She stated they are placed in the medication room in the disposal vin and the DON disposes of them with pharmacy. LVN L verbalized she has noticed loose pills in the medication carts sometimes. LVN L voiced if she found loose pills, she would put on a glove and dispose of the pills in the drug buster disposal that is located inside the medication . LVN L voiced there might be loose pills in the carts because staff are not punching it right in the cup or they pull too much over. LVN L verbalized staff should pick the pill up and dispose of it, it is contaminated. They should not give it to another resident. This could make a resident's vital signs be all over the place, have an allergic reaction and or affect their mental status. LVN L stated staff have been in-serviced on expired meds but not on loose meds and she could not recall when the in-service was held. During an interview on 01/16/2025 at 04:30 PM, the DON stated everyone is responsible for upkeeping with the medication carts. This includes inspecting for loose pills and checking expired dates on medications. DON verbalized she does spot checks monthly. DON voiced she has found loose pills in the carts while doing spot check inspections in the past, and she has put them in the destruction disposal and has informed all staff to do the same and to let her know. DON verbalized that she cannot say for sure why the pills are loose in the medication carts, but sometimes the pills packs can open if you bump them around in the carts and they can come out of the packaging. DON added the loose pills could be caused by someone being careless and popping the medications out too fast and they fall out into the carts. DON voiced the adverse effects of expired medications could be that they would not be as effective if given to a resident and it could potentially cause harm to the resident depending on what kind of medication it is. DON voiced that she has provided an in-service for staff, and she reminds staff every day during huddle to inspect carts and inspect for loose pills in the carts. During an interview on 01/16/2025 at 06:21 PM, the ADM verbalized his expectations on medication storage for staff was that staff or storing it properly. ADM voiced that staff check for expired medications regularly. ADM added that staff inspect carts for discharged residents' medications to be disposed of, loose pills, and to make sure there is nothing in there that should not be in there. Record review of the Policy/Procedure - Nursing Clinical stated: Policy: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedures: #13. Stated: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closers are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from pharmacy, if a current order exists.

50872 Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 3 of 5 (Residents #86, #87 and #13) residents reviewed for activities. This facility failed to implement an ongoing resident centered activities program for Residents #86, #87 and #13 that incorporated these residents interests, hobbies and cultural preferences. This failure could put residents at risk for a decrease quality of life. Findings included: Review of the 01/15/2025 face sheet for Resident #86 reflected an [AGE] year-old female had an original admitted [DATE] with diagnoses of Major depressive disorder, difficulty in walking, other seasonal allergic rhinitis, Acquired deformities of toes, unsteadiness of feet, unspecified abnormalities of gait and mobility, adjustment disorder with mixed anxiety and depressed mood, other insomnia not due to a substance or known physiological condition, COVID-19, Vitamin D deficiency, unspecified dementia. Review of the annual MDS for Resident #86 dated 11/19/2024 reflected a BIMS score of 13, indicating that the resident is cognitively intact. Review of the care plan for Resident #86 dated 09/24/2024 reflected the following: Resident #86 experienced altered mood related to diagnosis of depression, ineffective coping skills, dementia with evidence of tearfulness. Goal: Resident #86 will remain free of signs and symptoms of depression, anxiety or sad mood by through review date. Interventions: Assist in developing/providing with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Antidepressant medication use related to depression. Interventions: Does not enjoy usual activities. Non-pharmacological interventions: take to activities. Review of face sheet for Resident #87 reflected an [AGE] year-old-male with an original admitted [DATE] with the following diagnoses: Hemiplegia and hemiparesis following cerebral infarction (a type of stroke that occurs when brain tissue dies due to reduced blood flow) affecting right dominant side, type 2 diabetes mellitus without complications, essential primary hypertension, hyperlipidemia (a condition where there are high levels of fats in the blood), cerebral infarction, difficulty walking, insomnia, type 2 diabetes mellitus with proliferative diabetic retinopathy (a chronic eye condition that occurs when diabetes damages the blood vessels in the retina) with macular edema (a condition that occurs when fluid builds up in the macula, the central part of the retina at the back of the eye), bilateral, lack of coordination, muscle weakness, anemia, unsteadiness on feet, abnormalities of gait and mobility. Review of Resident #87's Admission MDS dated [DATE] reflected resident had a BIMS score of 15 indicating that his cognition was intact. Review of Resident #87's Comprehensive Care Plan dated 09/25/2024 reflected resident has acute/chronic pain related to history of CVA with right sided weakness. Goal: will not have an interruption in normal activities due to pain through the review date. Interventions: Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complains of pain or discomfort. Review of the face sheet dated 01/15/2025 for Resident #13 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus, irritant contact dermatitis, primary osteoarthritis, right shoulder, shortness of breath, vitamin D deficiency, Irritant contact dermatitis due friction, disruption of wound, chronic atrial fibrillation (is a condition that causes the heart's upper chambers to beat irregularly and rapidly), localized edema, morbid (severe) obesity with alveolar hypoventilation, dry eye syndrome, muscle wasting and atrophy, unsteadiness on feet, major depressive disorder, cognitive communication deficit, Vitamin B 12 deficiency anemia, hyperkalemia (a condition in which there is too much potassium in the blood), lack of coordination, chronic pain, abnormalities of gait and mobility, major depressive disorder, Vitamin D deficiency, primary insomnia, muscle weakness. Review of the MDS for Resident #13 dated 01/03/2025 reflected a BIMS score of 15 indicating cognitive intact responses. Review of the care plan for Resident #13 with date initiated of 03/06/2021 and revised on 05/19/2021 reflected the following: I am independent in my leisure I can choose activities of interest I can structure my own time. I am at risk for reduction in activity level as evidence by personal loss and health issues Pain and fatigue limits OOR activities at times. Goal. Resident will participate in activities related to interest and health status to promote a daily feeling of well-being, improved mood and enhanced dignity; resident will participate in activities of important/intellectual daily. Interventions: Allow resident to assist with decorations and crafts like cutting material out for activities for residents, encourage participation in activities of choice, offer ongoing supplies for self-initiated activities such as books, writing materials, videos, tapes, music, etc. Review of another care plan for Resident #13 was initiated on 03/06/2021 and revised on 05/19/2021 reflected the following: Resident has an alteration in psychosocial wellbeing problem and patient reporting that she has little interest/pleasure in doing things. Interventions: Encourage participation in favorite activities. Review of progress notes for Resident #13 reflected on 01/10/2025 Patient seen using patient desktop computer in the dayroom, performing therapeutic activities for this visit. Review of the January 2025 Activity Calendar for the week of 01/12/2025 - 01/18/2025 reflected the following: Sunday 01/12/2025 No time indicated Devotional and Independent Leisure all day. Monday 01/13/2025 10:00 Seated Chair Exercises 10:15 Worship Music 11:00 Teatime 7:00 Pizza Night & MNF Vikings Vs Rams Tuesday 01/14/2025 10:00 Bingo 01:00 300 Activity 02:00 Resident Council Wednesday 01/15/2025 09:30Church Singing 10:30 Rosary 1:00 300 Activity 02:00 p.m. [NAME] Music Thursday 01/16/2025 10:00 Bingo No time indicated: QAPI. 2:00 Popcorn & Movie Friday 01/17/2025 09:00 - 11:30 Walmart Outing 09:00 Volunteer Music 01:30 300 Activity 02:30 Loteria Saturday 01/18/2025 No time indicated: Leisure time. Activity Director Off Review of January Calendar 2025 revealed a note at the bottom of the page that read All activities subject to change. Resident #86 was not observed in any activities on 01/14/2025. Observation of Resident #86 on 01/16/2025 at 11:25 AM walking with physical therapy in the hallway. On 01/16/2025 at 2:47 p.m. Observation of resident #86, sitting in dining room watching a movie during activity time set up by the facility for all residents. Observation on 01/16/2025 at 2:47 p.m. revealed Resident #13, sitting in dining room watching a movie. During an interview on 01/14/2025 at 09:37 a.m., Resident #86 voiced there were no activities on Saturdays and Sundays. A resident has started to run bingo on Sunday's. Interview on 01/15/2025 at 10:13 a.m., Resident #13 verbalized there are no tables in the day room on a regular basis because they do not want anyone eating in the day room. But there are residents who like to color and need the tables. It is loud in the dining room and there are activities going on in there. Resident voiced she would like to color and watch tv in the day room with everyone voiced Resident 13. She added there is not a lot going on, on the weekends. There is not an assistant to do activities on the weekend anymore, but they are looking to hire someone. They have community groups come to visit on the weekend but that is about it. They have over the past year worked to get me out of the facility more. Due to my weight, I cannot just go anywhere because the van will not support my weight, but they have started taking me to [NAME] schnitzel down the road. Interview on 01/16/2025 at 08:35 a.m., Resident #86 answered the following: How important is it to you to have books, magazines, or newspapers to read? I used to read all the time, I loved to read, I used to read several books. I like to do scrap booking, which is one of my favorite. How important is it to you to listen to music that you like? Very much important, I am a Christian and I like to listen to Christian music. Sometimes, I like soft rock to listen to occasionally. How important is it to you to be around animals such as pets? Very important How important is it to you to keep up with the news? Sometimes I do not keep up with the news. How important is it to you to do things with groups of people? I like to be with other people. How important is it to you to do your favorite activities? I like scrapbooking and color the books and everything. I like the chicken soup book for the soul book. How important is it to you to go outside to get fresh air when the weather is good? I like to go outside. How often do you go outside? I have not been out lately because it is cold outside. How important is it to you to participate in religious services or practices? Very important. During an interview on 01/16/2025 at 08:47 a.m., Resident #87 answered the following: How important is it to you to have books, magazines, or newspapers to read? It is important but not super important but because my eyes are so great now . How important is it to you to listen to music that you like? Very important How important is it to you to be around animals such as pets? Important How important is it to you to keep up with the news? Somewhat because I used to watch it all the time, but it is all bad news. How important is it to you to do things with groups of people? Very important How important is it to you to do your favorite activities? Important How important is it to you to go outside to get fresh air when the weather is good? Important How important is it to you to participate in religious services or practices? Very important. One person comes in on Wed that speaks English; There is someone that comes in on Sundays to provide bilingual services, but they focus more on Spanish. Would prefer English too. On Monday, the activity director sings church songs for us in English. In an Interview on 01/16/2025 at 08:47 a.m., Resident #13 answered the following: How important is it to you to have books, magazines, or newspapers to read? It is very important for it to be available yes. Is it available? It is scattered but it is available. How important is it to you to listen to music that you like? Very imp to have the ability to do so, I am not a music person, but they do have musicians coming to do stuff and I have my tablet. It is availability and they do have several times a month someone comes in and they also have gospel singing on Mondays and Wednesday a gentleman comes in and every other wed a girl comes in and plays guitar for us. How important is it to you to be around animals such as pets? I would love to How important is it to you to keep up with the news? It is not that important to me. How important is it to you to do things with groups of people? Certain things I would like to do with them so, yes, it is important to me. How important is it to you to do your favorite activities? Very important How important is it to you to go outside to get fresh air when the weather is good? Very important How important is it to you to participate in religious services or practices? very important Do you feel like there is enough activities to do here? Most of the times there is but sometimes it is not happening. Interview on 01/15/2025 at 1:25 p.m. the Activities Director (AD ) verbalized when asked I noticed that your activity calendar for January indicates on Saturday and Sundays that residents have independent leisure how do you ensure that residents have things to do? Well because I do not work 7 days a week. We have groups that come out and sing and volunteers fluctuate depending on what they have going on. Managers are here on the weekends sometimes, the activities director voiced. When I am the manager on duty then I will have things planned for residents to do. Some of the things they do is bingo. AD verbalized some of the residents have taken it upon themselves to take lead on the bingo games on the weekends. AD verbalized he leaves the bingo supplies out for them to get so they can take lead on the weekends. Interview on 01/16/2025 at 04:30 p.m., the DON stated if residents do not do activities on a regular basis, it could make them feel sad and emotionally depressed. That is if they choose to but sometimes a lot of people do not like to do activities. DON stated residents who are confined to their rooms are cannot come out to the common areas for activities have been offered hallway bingo by the activities director, music and games. In an interview on 01/16/2025 at 09:40 a.m., The Activities Director (AD) verbalized that he does offer tactile activities from time to time to blind and deaf resident. The Activity Director voiced since the building remodel one of the things that the facility wants to do is set up an area where residents can access books to read. He is unsure when that will be completed. AD voiced he does have box of books for residents, but they are locked in his office during the weekends. AD voiced he is trying to get an assistant to come in to assist him when he is not available and on the weekends. Observation on 01/16/2025 at 11:22 a.m., hall 300 (memory care unit) residents were doing activities in the common area. Deck of cards , one resident was observed looking through a coloring book. A blind resident was observed with a stuffed animal on the desk sitting in front of her within reach. In an interview on 01/16/2025 at 11:47 a.m., CNA I stated when asked what kind of activities are offered to residents? Bingo, sometimes they have hospice come out to do paintings and music. They have outings to Walmart or lunch like twice a month. It is done like every 2 weeks, one Thursday or Friday they will go to Lunch and the next time they will go to Walmart. CNA, I verbalized that some residents do activities in their rooms. They do blocks like for mind control to see if they can stack them, pegs are done with therapy and some color. CNA, I voiced residents do activities every day and most of them come out of their rooms to do activities. CNA I was not sure what kind of activities are offered are provided for residents who cannot come out of their rooms. CNA, I voiced that if residents do not do activities on a regular basis that could make them feel left out and or lonely. In an observation on 01/16/2025 at 11:53 a.m., residents were in the common area in front of nurses station watching TV and talking amongst each other. In an interview on 01/16/2025 at 12:00 p.m., CNA J stated residents do activities in their rooms sometimes. CNA J voiced they watch TV, read books, residents like talking to other people. CNA J voiced residents do activities a lot of the weekends. She added some choose to come out of their rooms on the weekends and some stay in their rooms. CNA J voiced for the residents who cannot get out of their beds staff always help them. Like if they want to get out of the bed. If they do not want to, we keep them in the bed. When CNA J was asked, if they want to stay in the bed what kind of activities do they do? She voiced they watch TV play ball with each other. Mostly like watching TV. Mostly lying in bed. Most people color in their rooms. CNA J voiced I feel like I see them happy when they do activities. But mostly they like talking. Observation on 01/16/2025 at 04:11 p.m., The Activities Director (AD) was walking down the hall passing out popcorn to residents who did not attend the 2:00 p.m. movie and popcorn activity event. In an interview on 01/16/2025 at 04:12 p.m., The Activities Director (AD) verbalized if residents don't get regular activities, they could isolate mentally, physically, or both, which could lead to anxiety or depression. AD stated that the residents can have decreased overall social wellness and might be more difficult to engage in activities they like. He adds the overall quality of life would decrease for sure unless that is what they want because sometimes not participating is their desire. Sometimes they want to stay in their room and that is okay because that is what they want. AD voiced, for instance, if someone is insisting they do not want to socialize or come out of their room, they can become more depressed, and activities can provide social wellness.

Based on observations, interviews, and record review, the facility failed to provide a safe, comfortable, and homelike environment for the 1 of 8 residents (Resident #29) reviewed for a safe and comfortable environment. The facility failed to report maintenance issues to the MAIN and make repairs to a broken door in Resident #29's bathroom. This failure could have placed the resident at risk of decreased resident's satisfaction with their environment and a lack of a homelike environment. Findings included: Record review of Resident #29's admission record, dated 01/16/2025, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses including end stage renal disease (the kidneys are not filtering waste appropriately), major depressive disorder (persistent feelings of sadness and loss of interest), heart failure (the heart's inability to pump blood effectively to meet the needs of the body), monoplegia of lower limb following cerebral infarction (paralysis of one leg after having a stroke), irritable bowel syndrome with diarrhea (a syndrome that causes diarrhea, belly pain and frequent bowel movements), type 2 diabetes mellitus (the body's inability to regulate blood sugar levels), and chronic viral hepatitis C (a long lasting infection that causes inflammation of the liver). Record review of Resident #29's quarterly MDS assessment, dated 12/19/2024, revealed a BIMS score of 13 which indicated mild cognitive impairment. The resident was occasionally incontinent of bladder and continent of bowel. Record review of Resident #29's care plan revealed no care plans associated to physical environment surroundings. An observation on 01/14/2025 at 10:02 AM revealed the bathroom door for Resident #29 had more than 15 holes including one hole that was the width of half of the door and up to approximately 2 inches tall in some areas for the largest hole on the side of the door that faces the bathroom. The side of the door that faces the room had approximately 14 holes with one hole being about the side of a golf ball. No residents observed in the room. During an interview on 01/15/2025 at 1:30 PM with ADM, he revealed he had no knowledge of any holes in the bathroom door for Resident #29. During an interview and observation on 01/16/202 at 08:36 AM, Resident #29 stated the bathroom door had been like that a long time. Resident #29 stated he told someone about the holes a long time ago, before the renovation, but nothing had been done. He stated he was not sure when or who he talked to about the door. Observation of the bathroom door revealed holes remained in the door on both sides. During an interview on 01/16/2025 at 02:30 PM with HKS, she stated she was aware of the holes in Resident #29's bathroom door. She stated that she put in a work order in maintenance tracking system a long time ago although she could not recall when. She stated she was under the impression that they were going to replace all the interior doors with the recent renovation. HKS stated if something was broken or not working then her staff were supposed to report the issue to her so that she could enter it into the maintenance tracking system. She stated she did not follow up on the work order. During an interview on 01/16/2025 at 03:13 PM with the ADM, he revealed an online database that showed no work orders (opened or closed) for Resident #29's bathroom door. During an interview on 01/16/2025 at 05:22 PM with the MAIN, he revealed he checked the online maintenance database daily and hourly when in the facility. He stated he carried around a walkie talkie for issues that may arise throughout the day. He stated the staff have notified him immediately for maintenance issues related to TVs, call lights, and water, everything else was put in the maintenance online tracking system. The MAIN stated if a resident had a request, then they have told the front desk employee in the past, and she has put it in the system. He stated he conducted a walk through the facility on Friday afternoons and Monday mornings to assess for any needs. He stated there was a new system in place to contact him on the weekends for emergent needs. The MAIN stated he was unaware of any issues for Resident #29's room, and he was last in that bathroom around early November. He stated that holes in the bathroom door could affect the dignity of the resident. During an interview on 01/16/2025 at 05:58 PM, the DON stated management staff was responsible for conducting daily rounds to look for trash, dirty dishes, oxygen tubing, and any other issues. She stated the rounds should include the bathrooms, and a hole in the door should have been addressed. She stated that a hole in the bathroom door could be a potential safety issue from sharp edges or it could affect the resident's quality of life. During an interview on 01/16/2025 at 06:18 PM, the ADM stated every day the managers should be rounding on their designated rooms to check for physical environment. He stated the bathroom was not part of the sheet that they were responsible for checking off, and he should have added bathrooms to it. He stated his expectation for staff if they saw something that was broken to put a work order in the maintenance tracking system if they were able to, if not then tell someone that was able to put in a work order. The ADM stated holes in the door or wall could impact each resident differently, but for the facility to be more homelike they wanted to fix any holes in the walls or doors.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure [NAME] B were practicing proper hand hygiene while preparing foods. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Observation of [NAME] B preparing puree foods on 01/15/2025 at 11:13 am revealed that he threw trash away without washing or sanitizing his hands before going back to prepare puree food . [NAME] B also did not wash his hands after wiping down the counter. An interview with [NAME] B on 01/16/2025 at 1:01 pm revealed that he had been trained on infection control and proper hand washing. He said that the policy for hand washing was staff were to wash their hands with soap and water for 30 seconds. He said that staff were to wash their hands before performing a task and after touching food or any object. He said if staff did not practice proper hand hygiene it could put the resident at risk of getting sick. He said he was nervous and thought that was why he did not wash his hands. An interview with the DS on 01/16/2025 at 1:13 pm revealed that she had been trained on infection control and proper hand hygiene. She said that staff were supposed to wash their hands after each task. She said everyone was responsible for washing their hands when changing tasks. She said if staff did not perform proper hand hygiene it could cause the food to become contaminated and make the residents sick. She said that she thought [NAME] B was nervous. She said she was responsible for monitoring to ensure that all staff are washing their hands. She said that she monitors the hand washing by reminding the staff and observation. An interview with the ADM on 01/16/2025 at 6:24 pm revealed that he had been trained on infection control and hand hygiene. He said that all staff were to wash their hands between tasks regardless of what department they were in. He said that in the kitchen they should wash their hands before and after touching anything. He said that if staff do not perform proper hand hygiene, people could die. He also said that someone could get sick if staff were not washing their hands. He said the DS was responsible for monitoring the kitchen staff hand washing. He said that the did not know why [NAME] B did not wash his hands after touching the trash can or the rag. Record Review of Sanitation and Infection Control: Hand Hygiene Policy dated April 2023 revealed employees were to wash their hands when entering the kitchen, during food preparation, after engaging in other activities that contaminate the hands such as handling trash. Review of 2022 Food Code states: 2-301.14 States: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control. The facility failed to ensure that Resident #1 did not sleep in the bed of Resident #2 twice on 07/09/24. The facility failed to ensure that Resident #1 did not eat off Resident #3's meal tray and that Resident #3 did not eat after Resident #1. The facility failed to ensure a shared baby doll was sanitized after it had been in bed with Resident #5 and before Resident #4 came into close contact with it. These failures placed residents at risk of infectious disease. Findings included: Resident #1 Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular, dementia, need assistance with personal care, generalized anxiety disorder, cognitive communication deficit, major depressive disorder, cortical age-related cataract, adjustment disorder with mixed anxiety and depressed mood, and insomnia. Review of the quarterly MDS for Resident #1 dated 04/12/24 reflected her cognition was severely impaired, and she rarely or never made decisions. It reflected she was always incontinent of bowel and bladder. Review of the care plan for Resident #1 dated 11/19/23 reflected the following: [Resident #1] has bowel/bladder incontinence r/t impaired cognition , unaware of need. o BRIEF USE: uses disposable briefs. Change prn. o INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. The care plan did not address the re goals or interventions related to her behaviors. Review of the nursing progress notes for Resident #1 reflected the following: *03/17/24 documented by LVN B Note Text: Resident observed lying on another resident's bed, staff attempted to redirect resident, but she refused, putting herself on the floor and started crawling. Staff managed to assist resident to chair and placed resident in dining room. *06/11/24 documented by LVN C Note Text: Resident noted going into other resident's rooms and trying to get in their beds. Resident redirected and assisted back to her room and into bed several times throughout the evening. Resident #2 Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia, anxiety disorder, major depressive disorder, cognitive communication deficit, insomnia, urinary incontinence, need for assistance with personal care, overactive bladder, and unspecified mood disorder. Review of the quarterly MDS for Resident #2 dated 04/26/24 reflected her cognition was severely impaired, and she rarely or never made decisions. It reflected she was always incontinent of bowel and bladder. Review of the care plan for Resident #2 dated 05/05/23 reflected the following: Has bowel/bladder incontinence r/t Resident incont of b/b all the time and has dx urine retention/OAB. Has dementia and impaired cognition and unaware of when needs to toilet. o ACTIVITIES: notify nursing if incontinent during activities. o Adm med for OAB as ordered o BRIEF USE: uses disposable briefs. Change prn. o INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Resident #3 Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia, paranoid schizophrenia, cognitive communication deficit, generalized anxiety disorder, need for assistance with personal care, cortical age-related cataract, major depressive disorder, and vitamin deficiency. Review of the quarterly MDS for Resident #3 dated 04/14/24 reflected her cognition was severely impaired, and she rarely or never made decisions. It reflected she required setup or clean-up assistance [during eating], which meant helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Review of the care plan for Resident #3 dated 11/22/21 reflected the following: Has potential nutritional problem r/t memory problems, mental dx, intake of multiple psychotropic meds. Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. o REGULAR diet, MECHANICAL SOFT texture, THIN LIQUIDS consistency No mixed consistencies, extra gravy, no breads/dry solids. Double protein portions TID with meals. Resident #4 Review of the undated face sheet for Resident #4 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, cognitive communication deficit, and need for assistance with personal care. Review of the quarterly MDS for Resident #4 dated 04/25/24 reflected her cognition was severely impaired, and she rarely or never made decisions. Review of the care plan for Resident #4 dated 05/05/24 reflected the following: [Resident #4] is at risk for severe acute respiratory infection r/t exposure of transmissible respiratory disease (e.g. COVID, Influenza, RSV, etc.). Will be free of s/sx of infection through the review date. Observation on 07/09/24 at 01:04 PM revealed Resident #1 lying on her side asleep in Resident #2's bed with her head on the pillow and her mouth over the exposed top of the fitted sheet. The bed was made neatly, but the blankets were only pulled 3/4 up the mattress, and the sheet and pillow were exposed to Resident #1's hands, face, and hair. During an interview on 07/09/24 at 09:23 AM, the ABOM stated the person lying in Resident #2's bed was Resident #1. During an interview on 07/09/24 at 12:59 PM, the ABOM stated she noticed earlier that morning that Resident #1 had been lying in another resident's bed. The ABOM stated she thought the behavior of sleeping in other residents' beds was care planned for Resident #1. She stated the interventions staff should attempt when Resident #1 slept in another resident's bed were to redirect if the behavior affected the other resident. The ABOM stated she thought the behavior was chronic and thus not affecting other residents, so the staff should have been keeping an eye on the situation (of Resident #1 being in other residents' beds) The ABOM stated if Resident #1 went into a room of a resident on isolation precautions, they would definitely redirect her. The ABOM stated they also made sure the beds were made and cleaned after she slept in them. She stated they did not change the bed linens every time, because they did not always see her in the beds, and if she was lying on top of the blankets, there would be no transmission of any bodily fluids. The ABOM stated if Resident #1's brief leaked, they would notice, and the bed linens would be changed. The ABOM stated she had not noticed when Resident #1 got out of Resident #2's bed and had not spoken to staff about it. She stated she was sure the staff in the unit had been keeping an eye out for any problems related to Resident #1 lying in other resident beds. During an interview on 07/09/24 at 01:09 PM, LVN A stated Resident #1 got into other residents' beds frequently, and if they got her up out of one bed, she would go to another bed. She stated Resident #1 was a heavy wetter and they had to check the beds after she got out of them to see if they needed to be changed. LVN A stated Resident #1 also got dirty when she ate and could have smeared some food on the other resident's pillows. LVN A stated it was also possible for Resident #1 to be exposed to Resident #2's bodily fluids or food particles when lying in her bed. She stated they should have cleaned up the linens after Resident #1 slept in them. She stated she did not know why that was not done. She stated it was probably not realistic for them to change the linens every time. Observation on 07/09/24 at 11:46 AM revealed Resident #1 seated in a chair at a dining table in the secure unit and eating lunch. After she finished eating her dessert (diced peaches), she got up from the table and walked to Resident #3's table, picked up a spoon from Resident #3's tray, and began eating Resident #3's peaches. She took several bites before CNA B stopped her, took the spoon, and redirected Resident #1 to her own plate. The peaches remained on Resident #3's plate and Resident #3 picked up her fork and began eating them. She ate the rest of the peaches. Observation on 07/09/24 at 11:56 AM revealed CNA B asked Resident #4, who was ambulating down the hall of the secure unit toward the rooms in her wheelchair, if she wanted to hold her baby. Resident #4 stopped going down the hall and came back to the common area of the secure unit. CNA B went into the room of Resident #5 who was sleeping under the covers with a baby doll in her arms and pressed up against her face. CNA B carefully removed the doll from Resident #5's arms without waking her up and brought it to Resident #4, who took it and immediately began kissing the doll and touching its face, head, and body. MA C assisted Resident #4 with a yogurt snack, and Resident #4 kissed the doll and got yogurt on the doll's face, which MA C helped clean up with a towel. During an interview on 07/09/24 at 12:05 PM, MA C stated they only had one big baby doll, so the residents shared it. MA C stated they had two small baby dolls, but the residents placed those in drawers sometimes, so they got lost. MA C stated the residents loved holding the doll, and she and CNA B had been discussing the need for more baby dolls but had not brought it to the attention of the activity director or ADM. MA C stated they were supposed to sanitize the doll when they gave it to a different resident. She stated they had purple-topped or bleach wipes they could have used and should have sanitized between uses. During an interview on 07/09/24 at 01:40 PM, the DON stated she had seen Resident #1 lie down in other residents' beds but did not know it was a frequent behavior. The DON stated it had been a long time since she had seen it. The DON stated the behavior could cause cross-contamination and infection. She stated the doll should have been disinfected before it was given to a different residents. She stated Resident #2 should not have been allowed to eat the contaminated peaches and should have been provided with a fresh dish of peaches. The DON stated it was hard to prevent contamination in the secure unit, because all the residents wandered, but they had to try. She stated she was the infection preventionist and was responsible for ensuring infection control was effective. She stated she monitored the system for compliance by in-servicing the staff daily during their 02:00 PM stand up meeting. She stated she was not sure why the staff in the secure unit had allowed so many instances of cross contamination. The DON stated she had not specifically in-serviced about the dolls, Resident #1 lying down in people's beds, or Resident #1 trying to take food off people's trays. She stated they did a lot of general infection control training. During an interview on 07/09/24 at 02:41 PM, the ADM stated he was ultimately responsible for the facility as a whole, but the DON was more directly responsible for the infection control program. He stated he did not know if they trained specifically on those issues occurring in the secure unit. He stated they had done tons of infection control training. He stated the concepts were similar, but the specifics were different, and the sometimes figured out that staff did not know a certain situation (such as the baby doll) qualified as the multiple-use items they trained on. Review of facility policy dated 10/22 and titled reflected the following: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic, stewardship, outbreak management, prevention of infection, and employee health and safety. Goals: decrease the risk of infection to residence and personnel; recognize infection control practices while providing care; identify and correct problems related to infection control; ensure compliance with state and federal regulations related to infection control; promote individual residents' rights, and well-being while trying to prevent and control the spread of infection; and monitor personnel health and safety.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to include in Resident #1's comprehensive care plan the behaviors of sleeping in other residents' beds. This failure placed residents at risk of not having their individual care needs met. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular, dementia, need assistance with personal care, generalized anxiety disorder, cognitive communication deficit, major depressive disorder, cortical age-related cataract, adjustment disorder with mixed anxiety and depressed mood, and insomnia. Review of the quarterly MDS for Resident #1 dated 04/12/24 reflected her cognition was severely impaired, and she rarely or never made decisions. It reflected she was always incontinent of bowel and bladder. Review of the care plan for Resident #1 dated 11/19/23 reflected the care plan did not address the residents behaviors. Review of the nursing progress notes from March through June 2024 for Resident #1 reflected the following: *03/17/24 documented by LVN B Note Text: Resident observed lying on another resident's bed, staff attempted to redirect resident, but she refused, putting herself on the floor and started crawling. Staff managed to assist resident to chair and placed resident in dining room. *06/11/24 documented by LVN C Note Text: Resident noted going into other resident's rooms and trying to get in their beds. Resident redirected and assisted back to her room and into bed several times throughout the evening. Observation on 07/09/24 at 09:23 AM revealed Resident #1 asleep in Resident #2's bed in the secure unit. Observation on 07/09/24 at 01:04 PM revealed Resident #1 lying on her side asleep in Resident #2's bed with her head on the pillow and her mouth over the exposed top of the fitted sheet. During an interview on 07/09/24 at 12:59 PM, the ABOM stated she thought the behavior of sleeping in other residents' beds was care planned for Resident #1. She stated the interventions staff should attempt when Resident #1 slept in another resident's bed were to redirect if the behavior affected the other resident. During an interview on 07/09/24 at 01:40 PM, the DON stated she had seen Resident #1 lie down in other residents' beds but did not know it was a frequent behavior. The DON stated Resident #1's behavior of sleeping in other residents' beds should have been care planned. She stated the MDS nurse did most of the care planning, but this issue was probably not the MDS nurse's responsibility, because it had not been discussed with her in morning meeting or shown up as a concern. The DON stated she did not know whose responsibility it was, yet, because she still had to investigate. Review of facility policy dated 12/23 and titled Comprehensive Resident Centered Care Plan reflected the following: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 4. The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for two (Resident #1 and Resident #2) of four residents reviewed for abuse, in that: The facility failed to protect Resident #1 and Resident #2 who resided in the MCU (Memory Care Unit) from engaging in sexual activities when neither had the capacity to consent. An IJ was identified on 05/01/24. The IJ template was provided to the facility on [DATE] at 10:50 AM. While the IJ was removed on 05/02/24, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for abuse. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cognitive communication deficit, Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), and hallucinations. She resided in the memory care unit. Review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected a BIMS of 99, indicating she was unable to complete the interview. Review of Resident #1's quarterly care plan, revised 01/25/24, reflected she was at risk for impaired cognitive function/dementia or impaired thought process r/t dementia with an intervention of needing supervision/assistance with all decision making. It further reflected she was an elopement risk/wanderer r/t disoriented to place with an impaired safety awareness with an intervention of documenting wandering behavior and attempted diversional interventions . Review of Resident #1's progress note, dated 04/14/24 at 9:23 PM and documented by LVN A , reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #1] was found in bed with [Resident #2] performing fell atio (oral sex). Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #1] was sitting next to [Resident #2] fully clothed upset that we interrupted. [Resident #2] was sitting in his brief upset a well. When I spoke with [Resident #1] she kept saying it was her husband, calling him (name). It appeared consensual . Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia (a type of dementia caused by conditions that damage blood vessels and block blood flow to the brain), frontal lobe and executive function deficit following cerebral infarction, memory deficit following cerebral infarction, and other speech and language deficits following cerebral infarction. He resided on the memory care unit. Review of Resident #2's admission MDS assessment, dated 04/15/24, reflected a BIMS of 10, indicating a moderate cognitive impairment. Review of Resident #2's admission care plan, revised 04/16/24, reflected he had impaired cognitive function/dementia or impaired thought processes r/t diagnoses of vascular dementia and history of cerebral infarction (stroke) with an intervention of him requiring the secured unit. It further reflected he had some sexual inappropriateness with another resident on 04/14/24 with an intervention of being on 1:1 with staff member at all times for safety immediately. Review of Resident #2's progress note, dated 04/14/24 at 9:38 PM and documented by LVN A, reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #2] was found in bed with [Resident #1] fell atio performed to him. Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #2] was sitting next to [Resident #1] in his brief. [Resident #1] was fully clothed and upset. [Resident #2] kept saying it was consensual . During an interview on 04/16/24 at 8:42 AM, the DON stated the incident between Resident #1 and #2 was not reported to HHSC because after reviewing video footage and gathering interviews it was obvious it was consensual and they were both confused. She stated there was no harm from the incident. During an interview on 04/16/24 at 9:35 AM, the ADM stated they went back-and-forth with whether to report the incident to HHSC or not. He stated after reviewing the video footage from multiple angles of Resident #2 pushing Resident #1 down to his room, it was obvious it was consensual as she was not fighting back. He stated although they were both confused, they were upset they were interrupted and wanted to be with each other. He stated residents had the right to engage in sexual activities. During a telephone interview on 04/30/24 at 4:43 PM, Resident #1's FM A stated the incident that happened with Resident #1 and #2 was very upsetting. She stated that was not something Resident #1 would have wanted to have been doing if she was in her right mind. She stated the ADM told her it was consensual and she became tearful and stated, She was in a wheelchair, she did not wheel herself back there herself. How is that consensual? During a telephone interview on 05/01/24 at 8:53 AM, Resident #1 and #2's PPA stated both residents did not have the ability to consent and they were both in the locked dementia unit. She stated something like this happening to someone that may be able to remember could cause fear and isolation. She stated sexual assault had the most triggers for PTSD . During an interview on 05/01/24 at 10:07 AM, the ADON was asked how they assessed residents for the capacity to consent in sexual situations. She stated it depended how you looked at it. She stated some residents' cognitive function went in and out - one day you could have a conversation with them and the next day they were not able. She stated in that moment, Resident #1 wanted to be with Resident #2. She stated it depended on residents' cognitive function. She stated if one resident was able to consent and one was not and something like that happened, it could cause emotional trauma. Review of the facility's Freedom from Abuse, Neglect, and Exploitation Policy, revised 12/2023, reflected the following: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. . Sexual abuse is non-consensual sexual contact of any type with a resident. The ADM and ADON were notified on 05/01/24 at 10:50 AM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/02/24 at 12:25 PM: F600 1. The Medical Director was notified of the Immediate Jeopardy on 5/1/2024 at 11:31 am. 2. Resident #1 was assessed on 5/1/2024 by ADON with no adverse effects. Resident #2 was discharged from facility on 4/23/2024. All Full-time, Part-time, PRN and agency staff will be in-serviced prior to working the floor on how to handle residents engaging in a sexual encounters. In-service includes separating residents and informing ED or DON/ADON immediately and IDT meeting will be scheduled. New staff will also be in-serviced during the orientation process prior to resident interactions. All staff currently working the floor have already been in-serviced today 5/1/2024 by RN interim DON. 3. Staff will separate residents wanting to engage in sexual encounter until the IDT process is completed and staff have been informed of IDT decision by ED or DON and plan of care is updated. These individuals will be identified based on staff interviews and observations. 4. Facility process for residents to have sexual encounter is for staff to inform ED or DON of residents' desire based on interviews or observed behaviors. It will then be brought to the IDT (to include, but not limited to MD, ED, DON, ADON, SW) for them to make a determination of consent and need for further interventions and care plan updates, which will be done as soon as possible but up to three days. Staff made aware on case by case basis based on IDT determination. Facility will determine if needs or choices are changed as identified during quarterly care plan reviews. Staff will be made aware based on care plan. If staff encounter a situation involving residents, they will separate the residents and inform the ED or DON/ADON. 5. Train the trainer in-service was given by the Clinical Resource RN and was completed with interim DON and Executive Director on 5/1/24 related to resident's capacity to consent and the IDT process to determine consensual relationships of residents. 6. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The Surveyor monitored the POR on 05/02/24 as followed: During an interview on 05/02/24 at 12:28 PM, the ADM stated they had in-serviced almost 100% of their staff. They were doing in-person in-services as well as their computer-based trainings on Abuse and Neglect. During an interview on 05/02/24 at 12:32 PM, the ADON stated Resident #2 no longer resided at their facility. She stated in-servicing started the day prior (05/01/24) with the day shift and it was continued at 10:00 PM with the night shift. She stated all staff were being in-serviced before working their shifts. During interviews on 05/02/24 from 12:37 PM - 1:40 PM, a HSK, three CNAs, a ST, the AD, one RN, and two LVNs (from different shifts) all stated they were in-serviced before they worked their shift on abuse, neglect, and sexual relationships between residents. All gave examples of abuse such as physical, sexual, emotional, and financial and knew their ADM was the Abuse and Neglect Coordinator. All stated residents needing to have the capacity to give consent was necessary for them to have any sort of sexual relationship or it would be considered abuse. Each staff member gave an example of when they would need to separate residents and to notify their ADM/ADON immediately such as handholding, touching, or residents expressing their desire to engage in a sexual relationship. They all knew it was a resident's right to engage in sexual acts but it would be up to the leadership team to determine if they had the capacity to consent. Review of the facility's QAPI agenda, dated 05/01/24, reflected the MD, ADM, DOR, MDSC, AD, SW, NP, and ADON were in attendance. Review of the facility's in-service entitled Abuse and Neglect, dated 05/01/24 and conducted by the ADM, reflected all staff from each shift were in-serviced on their Abuse and Neglect Policy. Review of the facility's in-serviced entitled How to Handle Resident Engaging in a Sexual Encounter, dated 05/01/24 and conducted by the ADM, reflected all staff from each shift were in-serviced on the following: If residents are observed to be having a relationship, gently separate the two from touching and notify the ADON/Administrator immediately and the management team will have a process to meet and determine consent. An IJ was identified on 05/01/24. The IJ template was provided to the facility on [DATE] at 10:50 AM. While the IJ was removed on 05/02/24, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for two (Resident #1 and Resident #2) of four residents reviewed for developing and implementing abuse and neglect policies, in that: The facility failed to implement facility abuse policy when they failed to protect Resident #1 and Resident #2 who resided in the MCU (Memory Care Unit) from engaging in sexual activities when neither had the capacity to consent. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/01/24 at 10:50 AM. While the IJ was removed on 05/02/24 at 1:45 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not being protected from abuse, neglect, or exploitation. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cognitive communication deficit, Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), and hallucinations. She resided in the memory care unit. Review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected a BIMS of 99, indicating she was unable to complete the interview. Review of Resident #1's quarterly care plan, revised 01/25/24, reflected she was at risk for impaired cognitive function/dementia or impaired thought process r/t dementia with an intervention of needing supervision/assistance with all decision making. It further reflected she was an elopement risk/wanderer r/t disoriented to place with an impaired safety awareness with an intervention of documenting wandering behavior and attempted diversional interventions. Review of Resident #1's progress note, dated 04/14/24 at 9:23 PM and documented by LVN A, reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #1] was found in bed with [Resident #2] performing fell atio (oral sex). Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #1] was sitting next to [Resident #2] fully clothed upset that we interrupted. [Resident #2] was sitting in his brief upset a well. When I spoke with [Resident #1] she kept saying it was her husband, calling him (name). It appeared consensual . Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia, frontal lobe and executive function deficit following cerebral infarction , memory deficit following cerebral infarction, and other speech and language deficits following cerebral infarction. He resided on the memory care unit. Review of Resident #2's admission MDS assessment, dated 04/15/24, reflected a BIMS of 10, indicating a moderate cognitive impairment. Review of Resident #2's admission care plan, revised 04/16/24, reflected he had impaired cognitive function/dementia or impaired thought processes r/t diagnoses of vascular dementia and history of cerebral infarction with an intervention of him requiring the secured unit. It further reflected he had some sexual inappropriateness with another resident on 04/14/24 with an intervention of being on 1:1 with staff member at all times for safety immediately. Review of Resident #2's progress note, dated 04/14/24 at 9:38 PM and documented by LVN A, reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #2] was found in bed with [Resident #1] fell atio performed to him. Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #2] was sitting next to [Resident #1] in his brief. [Resident #1] was fully clothed and upset. [Resident #2] kept saying it was consensual . During an interview on 04/16/24 at 8:42 AM, the DON stated the incident between Resident #1 and #2 was not reported to HHSC because after reviewing video footage and gathering interviews it was obvious it was consensual and they were both confused. She stated there was no harm from the incident. During an interview on 04/16/24 at 9:35 AM, the ADM stated they went back-and-forth with whether to report the incident to HHSC or not. He stated after reviewing the video footage from multiple angles of Resident #2 pushing Resident #1 down to his room, it was obvious it was consensual as she was not fighting back. He stated although they were both confused, they were upset they were interrupted and wanted to be with each other. He stated residents had the right to engage in sexual activities. During a telephone interview on 05/01/24 at 8:53 AM, Resident #1 and #2's PPA stated both residents did not have the ability to consent and they were both in the locked dementia unit. She stated something like this happening to someone that may be able to remember could cause fear and isolation. She stated sexual assault had the most triggers for PTSD . During an interview on 05/01/24 at 10:07 AM, the DON was asked how they assessed residents for the capacity to consent in sexual situations. She stated it depended how you looked at it. She stated some residents' cognitive function went in and out - one day you could have a conversation with them and the next day they were not able. She stated in that moment, Resident #1 wanted to be with Resident #2. She stated it depended on residents' cognitive function. She stated if one resident was able to consent and one was not and something like that happened, it could cause emotional trauma. Review of the facility's Freedom from Abuse, Neglect, and Exploitation Policy, revised 12/2023, reflected the following: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. . Sexual abuse is non-consensual sexual contact of any type with a resident. . Reporting/Response: . 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Review of HHSC's PL 19-17, dated 07/10/19, reflected the following: An incident that does not result in serious bodily injury and involves abuse or neglect should be reported immediately, but not later than 24 hours after the incident occurs or is suspected. The ADM and ADON were notified on 05/01/24 at 10:50 AM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/02/24 at 12:25 PM: F607 1. The Medical Director was notified of the Immediate Jeopardy on 5/1/2024 at 11:31 am. 2. Resident #1 was assessed on 5/1/2024 by ADON with no adverse effects. Resident #2 was discharged from facility on 4/23/2024. All Full-time, Part-time, PRN and agency staff will be in-serviced prior to working the floor on Abuse and Neglect policy. New staff will also be in-serviced during orientation process prior to resident interactions. All Staff currently working the floor have already been in-serviced today 5/1/2024, by RN interim DON 3. Facility process for residents to have sexual encounter is for staff to inform ED or DON of residents' desire based on interviews or observed behaviors. It will then be brought to the IDT (to include, but not limited to MD, ED, DON, ADON, SW) for them to make a determination of consent and need for further interventions and care plan updates, which will be done as soon as possible but up to three days. Staff made aware as needed on a case by case basis based on IDT determination. Facility will determine if needs or choices are changed as identified during quarterly care plan reviews. Staff will be made aware based on care plan. If staff encounter a situation involving residents, they will separate the residents and inform the ED or DON/ADON immediately and IDT meeting will be scheduled. 4. Train the trainer in-service was given by the Clinical Resource RN and was completed with interim DON and Executive Director on 5/1/24 related to resident's compacity to consent and the IDT process to determine consensual relationships of residents. 5. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The Surveyor monitored the POR on 05/02/24 as followed: During an interview on 05/02/24 at 12:28 PM, the ADM stated they had in-serviced almost 100% of their staff. They were doing in-person in-services as well as their computer-based trainings on Abuse and Neglect. During an interview on 05/02/24 at 12:32 PM, the ADON stated Resident #2 no longer resided at their facility. She stated in-servicing started the day prior (05/01/24) with the day shift and it was continued at 10:00 PM with the night shift. She stated all staff were being in-serviced before working their shifts. During interviews on 05/02/24 from 12:37 PM - 1:40 PM, a HSK, three CNAs, a ST, the AD, one RN, and two LVNs (from different shifts) all stated they were in-serviced before they worked their shift on abuse, neglect, and sexual relationships between residents. All gave examples of abuse such as physical, sexual, emotional, and financial and knew their ADM was the Abuse and Neglect Coordinator. All stated residents needing to have the capacity to give consent was necessary for them to have any sort of sexual relationship or it would be considered abuse. Each staff member gave an example of when they would need to separate residents and to notify their ADM/ADON immediately such as handholding, touching, or residents expressing their desire to engage in a sexual relationship. They all knew it was a resident's right to engage in sexual acts but it would be up to the leadership team to determine if they had the capacity to consent. Review of the facility's QAPI agenda, dated 05/01/24, reflected the MD, ADM, DOR, MDSC, AD, SW, NP, and ADON were in attendance. Review of the facility's in-service entitled Abuse and Neglect, dated 05/01/24 and conducted by the ADM, reflected all staff from each shift were in-serviced on their Abuse and Neglect Policy. Review of the facility's in-serviced entitled How to Handle Resident Engaging in a Sexual Encounter, dated 05/01/24 and conducted by the ADM, reflected all staff from each shift were in-serviced on the following: If residents are observed to be having a relationship, gently separate the two from touching and notify the ADON/Administrator immediately and the management team will have a process to meet and determine consent. While the IJ was removed on 05/02/24 at 1:45 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately or no later than 24 hours for two (Resident #1 and Resident #2) of four residents reviewed for abuse and neglect, in that: The facility failed to report to the State Agency an incident where two residents (Resident #1 and #2) who were not cognitively able to give consent were found engaging in sexual activities. This failure could place residents at risk of not required incidents reported as required and timely. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cognitive communication deficit, Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), and hallucinations. She resided in the memory care unit. Review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected a BIMS of 99, indicating she was unable to complete the interview. Review of Resident #1's quarterly care plan, revised 01/25/24, reflected she was at risk for impaired cognitive function/dementia or impaired thought process r/t dementia with an intervention of needing supervision/assistance with all decision making. It further reflected she was an elopement risk/wanderer r/t disoriented to place with an impaired safety awareness with an intervention of documenting wandering behavior and attempted diversional interventions. Review of Resident #1's progress note, dated 04/14/24 at 9:23 PM and documented by LVN A, reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #1] was found in bed with [Resident #2] performing fell atio (oral sex). Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #1] was sitting next to [Resident #2] fully clothed upset that we interrupted. [Resident #2] was sitting in his brief upset a well. When I spoke with [Resident #1] she kept saying it was her husband, calling him (name). It appeared consensual . Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia, frontal lobe and executive function deficit following cerebral infarction , memory deficit following cerebral infarction, and other speech and language deficits following cerebral infarction. He resided on the memory care unit. Review of Resident #2's admission MDS assessment, dated 04/15/24, reflected a BIMS of 10, indicating a moderate cognitive impairment. Review of Resident #2's admission care plan, revised 04/16/24, reflected he had impaired cognitive function/dementia or impaired thought processes r/t diagnoses of vascular dementia and history of cerebral infarction with an intervention of him requiring the secured unit. It further reflected he had some sexual inappropriateness with another resident on 04/14/24 with an intervention of being on 1:1 with staff member at all times for safety immediately. Review of Resident #2's progress note, dated 04/14/24 at 9:38 PM and documented by LVN A, reflected the following: At (6:00 PM) [CNA B] came to report that [Resident #2] was found in bed with [Resident #1] fell atio performed to him. Per [CNA B] they stopped when they noticed him walking in. When I walked in [Resident #2] was sitting next to [Resident #1] in his brief. [Resident #1] was fully clothed and upset. [Resident #2] kept saying it was consensual . During an interview on 04/16/24 at 8:42 AM, the DON stated the incident between Resident #1 and #2 was not reported to HHSC because after reviewing video footage and gathering interviews it was obvious it was consensual and they were both confused. She stated there was no harm from the incident. During an interview on 04/16/24 at 9:35 AM, the ADM stated they went back-and-forth with whether to report the incident to HHSC or not. He stated after reviewing the video footage from multiple angles of Resident #2 pushing Resident #1 down to his room, it was obvious it was consensual as she was not fighting back. He stated although they were both confused, they were upset they were interrupted and wanted to be with each other. He stated residents had the right to engage in sexual activities. Review of the facility's Freedom from Abuse, Neglect, and Exploitation Policy, revised 12/2023, reflected the following: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. . Sexual abuse is non-consensual sexual contact of any type with a resident. . Reporting/Response: . 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Review of HHSC's PL 19-17, dated 07/10/19, reflected the following: An incident that does not result in serious bodily injury and involves abuse or neglect should be reported immediately, but not later than 24 hours after the incident occurs or is suspected.

Based on observation, interview, and record review, the facility failed to ensure mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 1 dish room. The facility failed to ensure the kitchen dishwasher did not leak and the garbage disposal attached to the dishwasher worked. This failure placed residents at risk of food borne illness and staff at risk of slipping. Findings included: Observation on 12/13/23 at 09:21 AM revealed standing water on the floor outside dishwasher. The water was confined to the dish room and was 1/4 inch deep. DA H was working on washing dishes and cautiously maneuvering around the standing water. During an interview on 12/13/23 at 09:21 AM, DA H stated she was trying not to get her shoes wet . She stated she had gotten some rain boots when she started to work at the facility, but they had been too slippery. She stated the drain was clogged and so the water was leaking out of the bottom of the drain. She stated it had been like that since she started working which was 11/17/23. DA H stated MAINT had been back to the kitchen and looked at it, but nothing had been done yet. During an interview on 12/12/23 at 09:32 AM, the DM stated she had notified MAINT of the leaking pipe on Friday 12/01/23 and then reminded MAINT again on Friday 12/08/23 and Monday 12/11/23. The DM stated sometimes it took a long time to get a response from MAINT with issues. The DM stated the problem with the dishwasher was the attached garbage disposal did not work, and there was a backup in the pipe, so when the dishwasher was running, the base of the pipe leaked. The DM stated the water stayed in the dish room, because the floor was sloped toward a drain in the middle of the room. The DM stated they had a squeegee and staff knew to squeegee the water into the drain when it got in the way. During an interview on 12/13/23 at 01:33 PM, the DM stated the garbage disposal did not work on the sink attached to the dishwasher. She stated she had entered a work order several weeks prior, but she was not sure what date, and she had not heard back from MANT about it. She stated MAINT had been in the kitchen to look at the machine and had seen the standing water next to the dishwasher. The DM stated the upkeep and monitoring of equipment in the kitchen was the responsibility of MAINT. The DM stated a potential risk of the dishwasher leaking was that someone could slip. The DM stated they scrubbed the floor after each meal to ensure the water leaking onto the floor was cleaned up. During an interview on 12/13/23 at 02:12 PM, MAINT stated he had worked at the facility for four years. The MAINT stated Friday afternoon 12/08/23 the DM contacted him and told him they had been doing dishes and noticed water was leaking heavily from the dishwasher. MAINT stated kitchen staff were able to squeegee the water, so it never reached the dining room or clean side of the kitchen. MAINT stated he had a plumber coming the next day, on 12/14/23. MAINT stated they called the plumber on Friday afternoon 12/08/23. MAINT stated the garbage disposal had not been fixed, because it needed to be replaced. He stated his procedure was that a maintenance request was closed when it either got fixed or became a project. He stated the garbage disposal had become a project. MAINT stated there had not been any incidents because of the dishwasher leak. MAINT stated a potential impact of the dishwasher malfunction was sanitation in the kitchen could have been compromised. During an interview on 12/14/23 at 03:01 PM, the ADM stated he monitored that equipment was in safe operating condition by relying on the department heads for the equipment. The ADM stated he did not wash dishes, so he did not know much about the dishwasher, and there were lots of problems he never found out about. The ADM stated he was not familiar with the actual problem, so he could not remark on the possible impact, but he thought standing water could grow bacteria and be a sanitation issue. He stated the facility had no specific policy for safe operating equipment.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment for 3 of 4 halls (halls 100, 200, and 300) and 1 of 2 common areas (central great room) reviewed for environment. The facility failed to ensure that halls 100, 200, 300 (secure unit), and the common great room did not have a pervasive foul urine odor. This failure placed residents at risk of diminished quality of life. Findings included: Observation on 12/12/23 at 09:59 AM in the 300 hall secure unit revealed a faint foul urine odor in the entrance area and dining room of the unit. The smell was stronger further down the hall. Observation on 12/12/23 at 10:00 AM revealed a foul smell was present in the 200 hall with no immediately apparent cause. Observation on 12/12/23 at 11:57 AM revealed the foul urine odor was still present just outside the doors to the secure unit and immediately upon entrance into the unit. The hallway of the secure unit also had a strong foul smell. Observation on 12/12/23 at 01:30 PM revealed the foul smell of urine was still present in the 200 hall. Observation on 12/12/23 at 02:40 PM revealed the foul urine odor was still present in the secure unit. During an interview on 12/12/23 at 03:50 PM, the ADM stated the facility policy on safe, clean, comfortable, and homelike environment was included in the overall facility policy titled Resident Rights. Review of the policy reflected no mention of the physical environment. During a confidential interview with 13 anonymous residents, every resident agreed they had noticed the foul urine odor in the building being very strong. Several residents stated they believed the smell was coming from the facility carpet. Several of the residents stated the bad odor smelled like urine and they had gotten used to it, but they still greatly disliked it. Observation on 12/13/23 at 08:18 AM revealed a foul urine odor in the 100 hall. During interviews on 12/13/23 between 09:54 AM and 03:32 PM, the RPs of four residents stated they had noticed the foul urine odor in the facility and more particularly in the secure unit. One of the RPs stated she had noticed the odor in other areas of the facility. Observations on 12/13/23 at 10:56 AM and 02:07 PM revealed the secure unit still had the foul urine odor, somewhat faint in the common area and stronger down the hallway. No resident in the unit was observably the source of the odor. Observations on 12/14/23 from 09:50 AM to 12:15 PM revealed a strong odor of air freshener, but the unpleasant odor was still detectable underneath it. During an interview on 12/13/23 at 20:39 PM CNA E stated she had noticed the odor in the secure unit, and she believed it was the carpet. CNA E stated the residents with dementia and Alzheimer's disease sometimes urinated in places that were not the toilet, and while the staff came back and cleaned up, they could not get it entirely clean. CNA E stated she had not heard the residents complain about the smell, but they all had dementia and were not able to speak about their feelings very easily. CNA E stated the management staff had recently done a much better job at trying to get rid of the smell. CNA E stated she thought they started trying to fix the problem a few months ago and had been using a carpet cleaner almost every day and putting in air fresheners. During an interview on 12/14/23 at 08:42 AM CNA D stated the foul urine odor on the secure unit used to be very noticeable when they walked in but recently, she had noticed it had lessened compared to what it was during the summer. CNA D stated they had been more on top of getting residents changed as soon as they smelled anything funky. She stated they had also been keeping the linen cart away in the restroom, so the odor did not linger. CNA D stated the carpets would be removed from the building because they were old carpets and there had been toileting accidents on them. CNA D stated housekeeping had brought the carpet cleaner back to the unit every other day. CNA D stated Resident #80 had commented that it smelled bad in the unit, but no other resident had complained about it. CNA D stated she did not think the other residents noticed the odor, but she would not want to live in it and did not think it was the best situation for them. CNA D stated there were a lot of heavy wetters in the secure unit, and it was difficult to catch them before they got urine on the carpet. During an interview on 12/14/23 at 09:19 AM, CNA F stated she had worked in the secure unit for three years. She stated they had been trying to catch ithe source of the odor more and changing residents more frequently, but she felt the urine had sunk into eh carpet and could not be removed. She stated it was known that there was a urine odor in the secure unit. CNA F stated she did not think the smell bothered them except for Resident #80. During an interview on 12/14/23 at 09:45 AM, the AD stated he was immune to any odor in the facility, so it took a significant smell to hit his nose. The AD stated it was well known in the building that the carpet in the facility, especially the secure unit, had a bad odor. The AD stated he thought the smell was due to some residents having urinary accidents. He stated he had not heard any residents complain about the smell. During an interview on 12/14/23 at 02:13 PM, the DON stated she had noticed the urine odor in the facility on and off. The DON stated she had noticed it more specifically and prevalently in the secure unit. She stated the potential impact of unpleasant odors in the facility was a negative emotional impact on the residents. During an interview on 12/14/23 at 03:01 PM, the ADM stated he was aware of odors in the secure unit, and he thought it was urine. He stated he thought it was because people were urinating on the floor multiple times, they had carpeted floors, and all the urine could not be removed. He stated the sent the carpet cleaner into the unit, but there were limitations on what the carpet cleaner could do. The ADM stated the whole facility was being renovated, and the floors would be replaced, but he did not know how long that would take. He stated he had been told the entire project would take six months. The ADM stated the renovation was happening with certainty, and they had already chosen all the flooring, fixtures, and paint. He stated the painting would be first, and the floors after that. The ADM stated he had somewhat of a say in the order in which the work was done but not a complete say. He stated the lobby in the front of the building was being done first, because the contracted vendors had been testing paint samples in that area, and the lobby did not require anyone to move out of the area. The ADM stated he felt the urine odor had less of an effect on the residents than it did the staff, and unfortunately the residents had probably become used to it and no longer noticed it. He stated it was not pleasant for the residents and might have an impact, but he did not know what the impact would be.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for 1 of 4 halls (300 hall/secure unit) and 1 of 8 residents (Resident #66) reviewed for accident hazards. The facility failed to ensure that all electrical outlets in the secure unit were fully covered with socket plates and live parts of the outlet inaccessible to residents in the unit with dementia and wandering behaviors. This failure placed residents at risk of electric shock. Findings included: Review of the undated face sheet for Resident #66 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, Parkinson's disease, insomnia, anxiety disorder, cognitive communication deficit (communication problems caused by cognitive impairment), age-related cataract, and Alzheimer's disease. Review of the admission MDS assessment for Resident #66 dated 10/04/23 reflected a BIMS score of 01, indicating severe cognitive impairment. Review of the section titled Behaviors reflected behavior of wandering occurred 1 to 3 days. Review of the care plan for Resident #66 dated 10/02/23 reflected the following: Elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wanders aimlessly. Safety will be maintained through the review date. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Document wandering behavior and attempted diversional interventions. Monitor for fatigue and weight loss. Observation on 12/13/23 at 02:48 PM revealed a plastic mounting recess on the wall of the common area in the secure unit. The recess contained a metal electrical box with two outlets and two thick cables: one blue and the other black. Two thin metal mounting plates were attached to the front of the recess, and the open space between them was three inches wide, allowing room for an adult human hand to get through. Observation on 12/13/23 at 02:50 PM revealed Resident #66 was walking around and attempting to manipulate various fixtures in the common area of the secure unit such as doorknobs and hinges. During an interview on 12/13/23 at 02:55 PM, LVN B stated she had not noticed the exposed electrical outlet on the wall in the secure unit dining area. She stated Resident #66 was constantly fiddling with things around the secure unit, mostly trying to get out. LVN B stated they had just replaced a socket plate on an electrical outlet behind the nurse's station that Resident #66 had torn off. During an interview on 12/13/23 at 03:12 PM, MAINT stated he was not aware of the electrical socket being exposed in the mounting recess in the secure unit. When he observed the outlet, he stated the outlet had power running to it currently and thus did pose a risk of electrical shock to anyone who reached in to touch it. He stated the situation was not safe, and he would rectify it immediately. Observation on 12/13/23 at 03:40 PM revealed a socket plate had been installed over the electrical outlet cover and a plastic sheet placed over the opening to the mounting recess. During an interview on 12/14/23 at 02:13 PM, the DON stated she had been told about the exposed outlet in the mounting recess, and it was her understanding that MAINT had covered it up. The DON stated she went into the secure unit every day but had not noticed it. The DON stated a potential impact of the exposed socket was residents could put their hands in there. During an interview on 12/14/23 at 03:01 PM, the ADM stated they monitored for accident hazards in the secure unit by doing walkthroughs, but they obviously had not done a good job of monitoring if there was an exposed electrical outlet right there in the unit. The ADM stated the managers did rounding, and they had an electronic maintenance request system for people to enter work requests. The ADMstated he could not personally see everything that went on, but someone should have seen that exposed socket during rounds. The ADM stated a potential negative impact of the exposed socket was residents could be electrocuted. Review of facility policy dated 05/07 and titled Accident Intervention reflected the following: It is the policy of this facility that the resident environment remains as free of accident hazards as possible and then each resident receives adequate supervision and assistance devices to prevent accidents. Purpose: the purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: identify hazards and risks; evaluate and analyze hazards and risks; implement interventions to reduce hazards and risks; and monitor for effectiveness and modify approaches as indicated.

Based on observation, interview and record review the facility failed to provide pharmaceutical services that included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 6 of 10 residents (Resident # 1, #2, #6, #7, #10 and # 12) reviewed for diabetic services. A. The facility had no physician order(s) and no written protocol for parameters of blood glucose levels when they administered glucose gel from the emergency kit and held Resident # 2's routine insulin on multiple occasions from 11/25/2012 through 12/11/2012 when Resident # 2 showed clinical signs and symptoms of [DIAGNOSES REDACTED] including confusion, seeing stars, weakness and a feeling of anxiety evidenced by trembling hands. This deficient practice resulted in an Immediate Jeopardy (IJ) on 12/11/2012. While the IJ was removed on 12/13/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. B. Residents # 1, #6, #7, #10 and #12 had [DIAGNOSES REDACTED]. There were no physician ordered parameters to ensure notification to the physician if the resident's glucose level was too low or too high so that adjustments in treatment could be made if necessary. These deficient practices had the potential to result in delay of physician intervention, medical treatment, coma, and permanent neurological damage, up to and including death and could place 42 residents at risk who were identified as having diabetes. Findings Include: A. Review of Resident #2 ' s Face Sheet reflected that Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 12/10/12 at 10:56 AM Resident #2 stated that she was not feeling well today. She stated that she had a low blood sugar level of 50. She said that she had gotten some juice but that the Medication Aide (MA) did not come back to check on her and that she was worried about her sugar level. Resident #2 stated that she had been having episodes of seeing stars and the light occasionally got dim. She stated that she had been a diabetic for [AGE] years and she could tell when her sugar levels were getting low. She stated that she gets weak and "can barely get myself together to call for help sometimes." Resident #2 stated that she does not have snacks in her room and she really needs those so that she can bring up her sugar because "it could get serious." Observation on 12/10//2012 at 10:58 AM, with Licensed Vocational Nurse Z, revealed Resident # 2 showed signs of anxiety and confusion. Resident # 2 had delayed thought pattern and delayed speech. Resident # 2's hands were trembling and she was unable to button her shirt. Resident # 2 asked LVN Z to button the last two buttons on her shirt. Review of Resident # 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated the resident is cognitively intact. Review of the University of Maryland ' s Medical Center website reflected the following information regarding [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (low blood sugar) is a condition in which there is an abnormally low level of glucose (sugar) in your blood. But factors such as disease or a poor diet can disrupt the mechanisms that regulate your sugar levels. Too much glucose results in hyperglycemia, one of the major symptoms of diabetes. However, [DIAGNOSES REDACTED] is most common among people with diabetes, as too much insulin can cause blood sugar levels to fall (an insulin reaction). Left untreated, [DIAGNOSES REDACTED] can cause permanent neurological damage and death. Signs and Symptoms: headache, excessive sweating, blurred vision, dizziness, trembling, lack of coordination, depression, anxiety, mental confusion, irritability, heart palpitations, slurred speech, seizures, fatigue, and coma. Source: http://www.umm.edu/altmed/articles/[DIAGNOSES REDACTED]- 0.htm#ixzz2GwEPKTfh Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected a short term goal as "Resident will exhibit no signs of hypo or hyperglycemia through the next review date x 90 days. Approaches listed are: accu-checks per physician's orders - morning and evening, observe for signs and symptoms of hyper and [DIAGNOSES REDACTED] administer insulin/physician's orders & observe for S.E. urticarial, pruritic swelling, warmth at injection site. Further review of Resident #2 ' s current Care Plan dated 8/24/12 and updated on 10/09/12 reflected the following progress notes: 09/11/12 has had mult. low levels and glucose gel and food given to bring up. 10/09/12 on 10/03/12 HS (evening) dose of Novolog 70/30 insulin, multiple episodes still of low blood sugar and intramuscular glucagon (an injectable medication used to raise blood sugar) or glucose gel being administered as needed. 11/29/12 nursing continue to perform accu-checks as needed and administer insulin as ordered, acute complications. Review of Resident #2 ' s Consolidated Physician ' s Orders dated December 2012 reflected the following orders: Novolog Mix 70/30 inject 18 units subcutaneously every morning; start date 09/24/12 Novolog Mix 70/30 inject 20 units subcutaneously at bedtime; start date 10/03/12 **Insulin orders** Accu-checks as needed for signs / symptoms of hyper / [DIAGNOSES REDACTED] Hand written on these orders: "accu-checks AC (morning) and HS (evening)" There were no parameters for holding insulin or notifying the physician when indicated on these orders and there was no sliding scale to administer insulin if the blood sugar was elevated. In an interview on 12/11/12 at 7:24 PM the Director of Nurses (DON) stated that the facility had no standing orders. He stated that this included no standing parameters for blood sugar levels or insulin administration. Review of Resident #2 ' s diet card that accompanied her lunch meal on 12/11/12 reflected a regular texture diet with low concentrated sweets, no sweet protein or veg. Likes: wheat bread, Dislikes: glazed meat or sweet vegetables. Observation on 12/11/12 at 12:20 PM revealed Resident #2 in bed with her lunch tray on her bedside table. The tray included vanilla ice cream, sliced turkey with cranberry glaze, yams, broccoli, a slice of white bread, a bowl of canned fruit cocktail in syrup, a glass of apple juice, and a glass of tea. In an interview on 12/11/12 at 6:30 PM the Dietician stated that the facility had been liberalizing the low concentrated sweets diet plan but she did not believe that the meal Resident #2 on 12/11/12 for lunch met the requirements for low concentrated sweets. In an interview on 12/11/12 at 12:20 PM Resident #2 stated that she had eaten the ice cream that was on her tray. Resident #2 stated that she had talked to the dietary manager several times and she had updated her preferences with him however "they don't pay attention to that card they just throw stuff on there and expect you to eat it." Resident #2 patted her stomach which was making very loud gurgling sounds and stated that she has a "touchy stomach" and sometimes she can't keep food down and coughs it up along with phlegm at times. Resident #2 stated that she "prayed for better food." She stated that sometimes she will eat the things on her tray "that are not really good for diabetics." Resident #2 took the cup of cocktail fruit and placed it on her bedside table. She patted the top of the cup and stated "this might just save my life later." Resident # 2 stated she saved the cup of cocktail fruit because she knows it has sugar in it and when she feels her blood sugar is dropping she can eat it to bring the level back up. Review of Medline Plus, a service of the U.S. National Library of Medicine National Institutes of Health reflected: a fasting blood glucose test level between 70 and100 milligrams per deciliter (mg/dL) is considered normal. A random blood glucose test, normal results depend on when you last ate. Most of the time, blood glucose levels will be below 125 mg/dL. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Review of Resident #2 ' s Diabetic Flow Record dated December 2012 reflected that Resident #2 had low blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 12/01/12 7:00 AM BS 62 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 12/02/12 7:00 AM BS 52 Routine dose of insulin was held, orange juice was administered. No documented evidence the physician was notified. 12/03/12 7:00 AM BS 80 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 7:00 AM BS 58 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 11:30 PM BS 92, Pudding and graham crackers were administered. 12/06/12 1:00 AM BS 34 Peanut butter and jelly was administered, refused glucose gel. No documented evidence the physician was notified. 12/06/12 1:20 AM BS 60 Coca-Cola per patient request. No documented evidence the physician was notified. 12/07/12 11:30 AM BS 41 Snack and lunch were administered. No documented evidence the physician was notified. 12/07/12 7:00 AM BS 95 Routine dose of insulin was held. No documented evidence the physician was notified. 12/08/12 7:00 AM BS 76 Routine dose of insulin was held. No documented evidence the physician was notified. 12/09/12 7:00 AM BS 85 Routine dose of insulin was held. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 53 Snack and juice were administered. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 54 Snack, juice, and lunch were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Diabetic Flow Record dated 11/25/12 to 11/30/12 reflected that Resident #2 had low or high blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 11/25/12 7:00 AM BS 38 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 11/25/12 4:30 PM BS 364. No documented evidence the physician was notified. 11/26/12 11:00 AM BS 54 Orange juice and a snack were administered. No documented evidence the physician was notified. 11/27/12 7:00 AM BS 52 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/28/12 7:00 AM BS 60 Routine dose of insulin was held and a snack was administered. No documented evidence the physician was notified. 11/28/12 4:30 PM BS 326. No documented evidence the physician was notified. 11/29/12 7:00 AM BS 44 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. 11/30/12 4:25 AM BS 52 Patient requested yogurt and applesauce. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Nurses Notes dated 11/25/12 to 12/09/12 reflected no documentation of any notification to the physician for any episode of hyper or [DIAGNOSES REDACTED]. Note dated 11/30/12 reflected that Resident #2's blood sugar level was 37 and she was administered glucose gel however there was no documentation of any follow up with the physician. No other note during this time period reflected the blood sugar level, interventions used, condition of the resident during episodes of hyper or [DIAGNOSES REDACTED], justification for holding insulin with normal blood sugar levels, or any notification to the physician. Review of Resident #2's clinical record reflected a copy of a fax dated Saturday, 12/08/12 that was addressed to a physician who was not Resident #2's attending physician stating, "please review pt's accu check logs. Runs low in AM. Do you want to DC PM 70/30 insulin?" No reply to this fax was found or noted in the chart and there was no follow-up to this fax to ensure the physician received the information. There was no record of an amended fax to the correct physician. Review of the facility Resident Weight Change Report dated 12/12/2012 reflected Resident # 2 lost weight as follows: August, 2012 - 141 pounds (lbs) September, 2012 - 141 lbs October, 2012 - 144 lbs November, 2012 - 138 lbs December, 2012 - 124 lbs In an interview on 12/11/12 at 5:39 PM the Medical Director (MD A), who was also Resident #2 ' s attending Physician, stated that he was not notified that Resident #2 was losing weight and reported seeing stars and sometimes felt confused and disoriented. He stated that this is a possible outcome of her hypoglycemic episodes. He stated that Resident #2 was not on a planned weight loss program and the weight loss might actually be making her diabetes better, causing her blood sugar to be lower than what it had been treated for [REDACTED]. MD A stated this certainly could be part of the reason her blood sugar was low and "I ' ll look into the low blood sugars and do something about that. Intermittent hypoglycemic blood sugars indicate that the current treatment should be reviewed and possibly changed." MD A stated that, if he had known of Resident # 2's condition, he would have recommended that the resident's insulin be held for a blood sugar under 80. He stated that he expected nurses to administer glucose gel for blood sugar levels under 60 or if a resident is unable to consume oral carbohydrates. MD A stated that he then expected nurses to notify him if a resident ' s blood sugar level was below 50 or they were unable to administer oral carbohydrates. MD A stated that he had not been notified that resident #2 ' s blood sugar levels were below during the month of December nor late November. In an interview on 12/11/12 at 3:36 PM the Contracted Registered Pharmacist (PharmD) stated that he considers blood sugar readings from 60-130 within normal limits. He would expect that nurses would notify the physician if a resident's blood sugar reading was below 50. The PharmD stated that he would expect a nurse to recheck a blood sugar level 10-15 minutes after administering juice or a snack in an effort to raise a low blood sugar level. He stated that he would expect the nurse to first use juice and/or a snack to raise a conscious resident ' s blood sugar level then glucose gel and finally injectable glucagon. He stated that he would expect a nurse to have a physician's order and notification of the physician if they opened the emergency medication kit. In an interview on 12/11/12 at 3:50 PM the Corporate Nurse C stated that the facility did not have a policy or standard protocol on blood sugar monitoring, however, they did use Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills to use as procedure. Review of a Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills, provided by the facility as their procedures for blood glucose monitoring, reflected: Understanding blood chemistry tests: Evaluate client ' s test results and compare with normal values. Standard Values of Chem 7: Glucose (fasting) 65 to 110 mg/dL. Evaluate client results that follow above or below the critical lab values limit ... Follow appropriate nursing action as determined by facility policy and procedure. Principles of measuring blood glucose: Appropriate nursing actions need to be taken whenever client results exceed critical lab values. Documentation for blood specimens: date and time of blood withdraw, any unusual conditions in either the client or specimen, results of blood glucose reading, insulin administered type amount location of injection, notification of physician of critical lab values orders or interventions. In interviews conducted on 12/11/2012 between 5:25 PM and 5:32 PM, Licensed Vocational Nurses (LVN) E, F and G all stated they knew of no facility protocol regarding blood sugar checks, interventions and notification to the physician. Review of the Facility Policy Notification Requirements dated 01/01/07 reflected the following: Policy: It is the policy of this facility to notify the resident, his or her attending physician, and representative of changes in the resident ' s condition. Procedure: 1. The facility should notify the resident ' s attending physician and representative when: b. There is significant change in the resident ' s physical, mental, or psychosocial status. c. There is a need to alter the resident ' s treatment significantly. On 12/11/2012 at 7:10 PM the Vice President of Operations, Director of Clinical Services, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. (The Administrator was on vacation, out of the country) On 12/12/2012 at 6:00 PM, the Vice President of Operations provided the surveyor with a written plan of removal, which was accepted and reflected the following: What is the Jeopardy: In recognition of the concerns addressed in the Immediate Jeopardy Notification issued to the facility on [DATE], the Immediate Jeopardy was caused by a failure to notify physician of a residents symptoms of [DIAGNOSES REDACTED], failure to obtain physician orders to hold insulin, failure to have parameters for physician notification for one resident, and failure to notify physician for order for administration of IM Glucagon for one resident. Residents Impacted by the Jeopardy The resident identified as being impacted by the Immediate Jeopardy was Resident # 2. What staff were involved in the Jeopardy: Staff involved in the Immediate Jeopardy situation include Licensed Nurses. The following actions have been taken to remove jeopardy for our resident. For Residents Identified: Resident # 2 physician was notified by unit manager with orders received for blood sugar level parameters as follows: Accu-check less than 60 or greater than 250 call MD. May hold insulin if less than 60 and call MD. Readily available snacks have been placed in the resident ' s room with an update to the care plan. Unit Managers will monitor that Resident # 2 has snacks readily available at bedside daily. MD will visit resident on 12/12/12. If Resident # 2 exhibits signs or symptoms of [DIAGNOSES REDACTED], the nurse will perform blood sugar check, if less than 60 will hold the insulin per MD order, give juice followed by insulin sustaining protein such as milk or snack, repeat Accu-check and notify MD. Interventions: In-servicing on Notification Requirement Policy and Diabetic Monitoring training resource was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. Currently 68^% of the licensed staff has been educated at this time. On 12/12/2012 the records of the residents who have been identified as diabetics were reviewed by DON and Unit Managers to verify their interventions, including the need for blood sugar level parameters for notification to physician and orders for parameters to hold insulin,. Residents reviewed have had clarification from physicians for these types of orders. Training Re-education through in servicing of licensed staff regarding Notification Requirement Policy and Diabetic Monitoring was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. The Director of Nursing has a facility employee list and is checking to verify that employees are coming on duty have been trained or will be trained before providing direct care. In his absence the shift supervisor will verify that all oncoming staff have been trained. Monitoring: The Director of Nurses is responsible to verify that training/education of Notification Requirement Policy and Diabetic Monitoring has been initiat4ed, and staff demonstrate understanding of their responsibility. Director of Nurses, Staff Development Coordinator and/or Unit Managers will monitor compliance of physician notification and diabetic monitoring through review of 24 hour report, telephone orders and diabetic flow sheet daily Monday through Friday the first 30 days. Notification made to Medical Director of Immediate Jeopardy assigned. Emergency Quality Assurance and Assessment Meeting conducted with action plan developed. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Resident # 2's Care Plan was updated on 12/11/2012 as follows: Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected an update on 12/11/12 to have snacks available at bedside and further updated on 12/12/12 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. Review of the physician orders reflected a current telephone order dated 12/12/2012 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. The physician order also reflected an adjustment/reduction in insulin as: Novolog 20 Units in the morning and Novolog 16 Units in the evening. Observation made on 12/12/2012 at 6:30 PM revealed Resident # 2 was smiling and was able to answer questions quickly without delay in her thought process. Resident # 2's hands were not trembling. In an interview on 12/12/2012 at 6:33 PM Resident # 2 stated she had prayed for some help. Resident # 2 stated she felt so much better and the facility had begun to care for her in a manner she had not been cared for in the past. Resident # 2 stated her nausea had begun to subside and she felt she could eat in the dining room again and got great comfort in knowing she had snacks in her room to eat if she felt signs and symptoms of low blood sugar. Record review of the in-service sign-in sheets reflected approximately 70% of facility staff had been in-serviced. Interviews with staff on 12/13/2012 between 3:00 PM and 4:00 PM revealed the in-service regarding diabetic monitoring, notification to the physician and following physician orders had been provided to the staff on duty. The facility provided a list of residents identified as having Diabetes and physician orders, care plans and interventions had been put into place for those residents. While the IJ was removed on 12/13/12 at 6:30 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. B. Review of Resident #1's face sheet reflected the Resident was [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident to have a [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan conducted on 12/10/2012 dated 11/16/2012 reflected the Resident had a [DIAGNOSES REDACTED]. Approaches included to perform accuchecks as ordered and monitor for signs and symptoms of hypo/hyperglycemia. Review of Resident # 1's physician orders for December, 2012, reflected an order for [REDACTED]. There were no parameters to ensure the resident's blood glucose was monitored and reported to the physician if too high or low. Review of Resident # 1's record of accuchecks for October, November, and December of 2012 reflected blood glucose level was within normal range. Review of the physician telephone orders for Resident # 1, after the facility had been made aware of the deficient practice with blood glucose levels and the absence of parameters to notify a physician, reflected an order dated 12/11/2012 to "Accucheck lower than 70 call MD and higher than 300 call MD". C. Review of Resident # 6's Face Sheet reflected a [AGE] year old male who entered the facility on 01/22/2010 with [DIAGNOSES REDACTED]. Review conducted on 12/10/2012 of Resident # 6's Quarterly MDS assessment dated [DATE] reflected the Resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 6 scored 15 out of a possible 15 on the BIMS scale and indicated the resident was cognitively intact. Review of Resident # 6's Comprehensive Care Plan conducted on 12/10/2012 dated 03/05/2012 reflected the Resident had a [DIAGNOSES REDACTED]. Approaches included to perform accuchecks as ordered and monitor for acute signs and symptoms of hypo/hyperglycemia and report if noted. Review of Resident # 6's physician orders for December, 2012, reflected an order for [REDACTED]. There were no parameters to ensure the resident's blood glucose was monitored and reported to the physician if too high or low. Review of Resident # 6's record of accuchecks for October, November and December of 2012 reflected had been checked twice daily for those months. During the period from October 1, 2012 through December 10, 2012 Resident # 6's blood glucose level had been checked twice daily. Resident # 6's blood glucose level ranged from a low of 68 to a high of 232 between October 1, 2012 through December 10, 2012. The physician had not been notified. Review of the physician telephone orders for Resident # 6, after the facility had been made aware of the deficient practice with blood glucose levels and the absence of parameters to notify a physician, reflected an order dated 12/11/2012 to "Accucheck lower than 70 call MD and higher than 200 call MD". D. Review of Resident # 7's Face Sheet reflected an [AGE] year old female who entered the facility on 07/11/2011 with [DIAGNOSES REDACTED]. Review of Resident # 7's Annual MDS assessment dated [DATE] reflected the Resident scored 02 out of 15 on the BIMS assessment and indicated the resident was severely cognitively impaired. The assessment reflected a [DIAGNOSES REDACTED]. Review of Resident # 7's Comprehensive Care Plan dated 10/05/2012 reflected the Resident had a [DIAGNOSES REDACTED]. Approaches included accuchecks per physician order and observe for signs and symptoms of hyper and/or [DIAGNOSES REDACTED]. Review of Resident # 7's recapitulated orders dated December, 2012, reflected an order to complete accu-checks every day. There were no parameters for the accu-checks as to when to contact the physician. Review of Resident # 7's record of accuchecks for October, November and December of 2012 reflected had been checked once daily for those months. Resident # 7's blood glucose level ranged from a low of 85 to a high of 150 between October 1, 2012 through December 10, 2012. Review of the physician telephone orders for Resident # 7, after the facility had been made aware of the deficient practice with blood glucose levels and the absence of parameters to notify a physician, reflected an order dated 12/11/2012 to "Accucheck lower than 70 call MD and higher than 200 call MD". E. Review of Resident # 10's Face Sheet reflected an [AGE] year old female who entered the facility on 07/09/2012 with [DIAGNOSES REDACTED]. Review conducted on 12/10/2012 of Resident # 10's Quarterly MDS assessment dated [DATE] reflected the Resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 10 scored 02 out of a possible 15 on the BIMS scale and indicated the resident was severely cognitively impaired. Review of Resident # 10's Comprehensive Care Plan conducted on 12/10/2012 dated 07/12/2012 reflected the resident had a [DIAGNOSES REDACTED]. Approaches included to perform accuchecks as ordered, monitor for acute signs and symptoms of hypo and/or hyperglycemia and administer insulin per MD orders and observe for any urticaria, pruritic swelling, redness, and warmth at injection site. Review of Resident # 10's physician orders for December, 2012 reflected an order for [REDACTED]. The order for sliding scale insulin had been discontinued on 10/09/2012. There were no parameters to ensure the resident's blood glucose was monitored and reported to the physician if too high or low. Review of Resident # 10's record of accuchecks for October, November and December of 2012 reflected had been checked daily as ordered for those months. During the period from October 1, 2012 through December 10, 2012 Resident # 10's blood glucose level ranged from a low of 95 to a high of 252 between October 1, 2012 through December 10, 2012. The physician had not been notified. Review of the physician telephone orders for Resident # 10, after the facility had been made aware of the deficient practice with blood glucose levels and the absence of parameters to notify a physician, reflected an order dated 12/11/2012 to "Call MD if blood sugar is less than 70 or higher than 200." F. Review of Resident #12's Face Sheet reflected a [AGE] year old male who entered the facility on 07/17/2012 with [DIAGNOSES REDACTED]. Resident #12 listed as Clinical Decision Maker for self. Review conducted on 12/11/2012 of Resident #12's Significant Change MDS assessment dated [DATE] reflected the Resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident #12 scored 14 out of possible 15 on the BIMS scale and indicated the Resident was cognitively sound. Review of Resident #12's physician orders for December 2012 reflected an order for [REDACTED].=1 unit, 200-249=2 units, 250-299=3 units, 300-349=4 units, 350-399=5 units, greater than 399=6 units and call MD. " There was no order for accu-check reading 70 and below or to call the MD. After the facility had been made aware of the deficient practice with blood glucose levels and the absence of parameters to notify a physician, revi

Based on observation, interview, and record review the facility failed to adequately monitor the insulin drug regimen and notify the physician regarding the presence of adverse consequences for 1 of 10 resident's (Resident #2) to ensure the resident was free from unnecessary drugs. Resident #2 was on an insulin drug regimen when she lost weight and developed clinical signs and symptoms of [DIAGNOSES REDACTED] that included confusion, seeing stars, weakness and a feeling of anxiety evidenced by trembling hands. No notification was made to Resident # 2's physician which prevented the resident's drug review and potential reduction. This deficient practice resulted in an Immediate Jeopardy (IJ) on 12/11/2012. While the IJ was removed on 12/13/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice had the potential to result in delay of drug reduction and causing Resident # 2 to experience hypoglycemic conditions and could place 41 additional residents at risk for delay of physician intervention, medication review, coma, and permanent neurological damage, up to and including death who were identified as having diabetes Findings include: Review of Resident #2 ' s Face Sheet reflected that Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 12/10/12 at 10:56 AM Resident #2 stated that she was not feeling well today. She stated that she had a low blood sugar level of 50. She said that she had gotten some juice but that the Medication Aide (MA) did not come back to check on her and that she was worried about her sugar level. Resident #2 stated that she had been having episodes of seeing stars and the light occasionally got dim. She stated that she had been a diabetic for [AGE] years and she could tell when her sugar levels were getting low. She stated that she gets weak and "can barely get myself together to call for help sometimes." Resident #2 stated that she does not have snacks in her room and she really needs those so that she can bring up her sugar because "it could get serious." Observation on 12/10//2012 at 10:58 AM, with Licensed Vocational Nurse Z, revealed Resident # 2 showed signs of anxiety and confusion. Resident # 2 had delayed thought pattern and delayed speech. Resident # 2's hands were trembling and she was unable to button her shirt. Resident # 2 asked LVN Z to button the last two buttons on her shirt. Review of Resident # 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated the resident is cognitively intact. Review of the University of Maryland ' s Medical Center website reflected the following information regarding [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (low blood sugar) is a condition in which there is an abnormally low level of glucose (sugar) in your blood. But factors such as disease or a poor diet can disrupt the mechanisms that regulate your sugar levels. Too much glucose results in [MEDICAL CONDITION], one of the major symptoms of diabetes. However, [DIAGNOSES REDACTED] is most common among people with diabetes, as too much insulin can cause blood sugar levels to fall (an insulin reaction). Left untreated, [DIAGNOSES REDACTED] can cause permanent neurological damage and death. Signs and Symptoms: headache, excessive sweating, blurred vision, dizziness, trembling, lack of coordination, depression, anxiety, mental confusion, irritability, heart palpitations, slurred speech, [MEDICAL CONDITION], fatigue, and coma. Source: http://www.umm.edu/altmed/articles/[DIAGNOSES REDACTED]- 0.htm#ixzz2GwEPKTfh Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected a short term goal as "Resident will exhibit no signs of hypo or [MEDICAL CONDITION] through the next review date x 90 days. Approaches listed are: accu-checks per physician's orders - morning and evening, observe for signs and symptoms of hyper and [DIAGNOSES REDACTED] administer insulin/physician's orders & observe for S.E. urticarial, pruritic swelling, warmth at injection site. Further review of Resident #2 ' s current Care Plan dated 8/24/12 and updated on 10/09/12 reflected the following progress notes: 09/11/12 has had mult. low levels and glucose gel and food given to bring up. 10/09/12 on 10/03/12 HS (evening) dose of [MEDICATION NAME] 70/30 insulin, multiple episodes still of low blood sugar and intramuscular [MEDICATION NAME] (an injectable medication used to raise blood sugar) or glucose gel being administered as needed. 11/29/12 nursing continue to perform accu-checks as needed and administer insulin as ordered, acute complications. Review of Resident #2 ' s Consolidated Physician ' s Orders dated December 2012 reflected the following orders: [MEDICATION NAME] Mix 70/30 inject 18 units subcutaneously every morning; start date 09/24/12 [MEDICATION NAME] Mix 70/30 inject 20 units subcutaneously at bedtime; start date 10/03/12 **Insulin orders** Accu-checks as needed for signs / symptoms of hyper / [DIAGNOSES REDACTED] Hand written on these orders: "accu-checks AC (morning) and HS (evening)" There were no parameters for holding insulin or notifying the physician when indicated on these orders and there was no sliding scale to administer insulin if the blood sugar was elevated. In an interview on 12/11/12 at 7:24 PM the Director of Nurses (DON) stated that the facility had no standing orders. He stated that this included no standing parameters for blood sugar levels or insulin administration. Review of Resident #2 ' s diet card that accompanied her lunch meal on 12/11/12 reflected a regular texture diet with low concentrated sweets, no sweet protein or veg. Likes: wheat bread, Dislikes: glazed meat or sweet vegetables. Observation on 12/11/12 at 12:20 PM revealed Resident #2 in bed with her lunch tray on her bedside table. The tray included vanilla ice cream, sliced turkey with cranberry glaze, yams, broccoli, a slice of white bread, a bowl of canned fruit cocktail in syrup, a glass of apple juice, and a glass of tea. In an interview on 12/11/12 at 6:30 PM the Dietician stated that the facility had been liberalizing the low concentrated sweets diet plan but she did not believe that the meal Resident #2 on 12/11/12 for lunch met the requirements for low concentrated sweets. In an interview on 12/11/12 at 12:20 PM Resident #2 stated that she had eaten the ice cream that was on her tray. Resident #2 stated that she had talked to the dietary manager several times and she had updated her preferences with him however "they don't pay attention to that card they just throw stuff on there and expect you to eat it." Resident #2 patted her stomach which was making very loud gurgling sounds and stated that she has a "touchy stomach" and sometimes she can't keep food down and coughs it up along with phlegm at times. Resident #2 stated that she "prayed for better food." She stated that sometimes she will eat the things on her tray "that are not really good for diabetics." Resident #2 took the cup of cocktail fruit and placed it on her bedside table. She patted the top of the cup and stated "this might just save my life later." Resident # 2 stated she saved the cup of cocktail fruit because she knows it has sugar in it and when she feels her blood sugar is dropping she can eat it to bring the level back up. Review of Medline Plus, a service of the U.S. National Library of Medicine National Institutes of Health reflected: a fasting blood glucose test level between 70 and100 milligrams per deciliter (mg/dL) is considered normal. A random blood glucose test, normal results depend on when you last ate. Most of the time, blood glucose levels will be below 125 mg/dL. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Review of Resident #2 ' s Diabetic Flow Record dated December 2012 reflected that Resident #2 had low blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 12/01/12 7:00 AM BS 62 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 12/02/12 7:00 AM BS 52 Routine dose of insulin was held, orange juice was administered. No documented evidence the physician was notified. 12/03/12 7:00 AM BS 80 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 7:00 AM BS 58 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 11:30 PM BS 92, Pudding and graham crackers were administered. 12/06/12 1:00 AM BS 34 Peanut butter and jelly was administered, refused glucose gel. No documented evidence the physician was notified. 12/06/12 1:20 AM BS 60 Coca-Cola per patient request. No documented evidence the physician was notified. 12/07/12 11:30 AM BS 41 Snack and lunch were administered. No documented evidence the physician was notified. 12/07/12 7:00 AM BS 95 Routine dose of insulin was held. No documented evidence the physician was notified. 12/08/12 7:00 AM BS 76 Routine dose of insulin was held. No documented evidence the physician was notified. 12/09/12 7:00 AM BS 85 Routine dose of insulin was held. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 53 Snack and juice were administered. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 54 Snack, juice, and lunch were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Diabetic Flow Record dated 11/25/12 to 11/30/12 reflected that Resident #2 had low or high blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 11/25/12 7:00 AM BS 38 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 11/25/12 4:30 PM BS 364. No documented evidence the physician was notified. 11/26/12 11:00 AM BS 54 Orange juice and a snack were administered. No documented evidence the physician was notified. 11/27/12 7:00 AM BS 52 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/28/12 7:00 AM BS 60 Routine dose of insulin was held and a snack was administered. No documented evidence the physician was notified. 11/28/12 4:30 PM BS 326. No documented evidence the physician was notified. 11/29/12 7:00 AM BS 44 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. 11/30/12 4:25 AM BS 52 Patient requested yogurt and applesauce. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Nurses Notes dated 11/25/12 to 12/09/12 reflected no documentation of any notification to the physician for any episode of hyper or [DIAGNOSES REDACTED]. Note dated 11/30/12 reflected that Resident #2's blood sugar level was 37 and she was administered glucose gel however there was no documentation of any follow up with the physician. No other note during this time period reflected the blood sugar level, interventions used, condition of the resident during episodes of hyper or [DIAGNOSES REDACTED], justification for holding insulin with normal blood sugar levels, or any notification to the physician. Review of Resident #2's clinical record reflected a copy of a fax dated Saturday, 12/08/12 that was addressed to a physician who was not Resident #2's attending physician stating, "please review pt's accu check logs. Runs low in AM. Do you want to DC PM 70/30 insulin?" No reply to this fax was found or noted in the chart and there was no follow-up to this fax to ensure the physician received the information. There was no record of an amended fax to the correct physician. Review of the facility Resident Weight Change Report dated 12/12/2012 reflected Resident # 2 lost weight as follows: August, 2012 - 141 pounds (lbs) September, 2012 - 141 lbs October, 2012 - 144 lbs November, 2012 - 138 lbs December, 2012 - 124 lbs In an interview on 12/11/12 at 5:39 PM the Medical Director (MD A), who was also Resident #2 ' s attending Physician, stated that he was not notified that Resident #2 was losing weight and reported seeing stars and sometimes felt confused and disoriented. He stated that this is a possible outcome of her hypoglycemic episodes. He stated that Resident #2 was not on a planned weight loss program and the weight loss might actually be making her diabetes better, causing her blood sugar to be lower than what it had been treated for [REDACTED]. MD A stated this certainly could be part of the reason her blood sugar was low and "I ' ll look into the low blood sugars and do something about that. Intermittent hypoglycemic blood sugars indicate that the current treatment should be reviewed and possibly changed." MD A stated that, if he had known of Resident # 2's condition, he would have recommended that the resident's insulin be held for a blood sugar under 80. He stated that he expected nurses to administer glucose gel for blood sugar levels under 60 or if a resident is unable to consume oral carbohydrates. MD A stated that he then expected nurses to notify him if a resident ' s blood sugar level was below 50 or they were unable to administer oral carbohydrates. MD A stated that he had not been notified that resident #2 ' s blood sugar levels were below during the month of December nor late November. In an interview on 12/11/12 at 3:36 PM the Contracted Registered Pharmacist (PharmD) stated that he considers blood sugar readings from 60-130 within normal limits. He would expect that nurses would notify the physician if a resident's blood sugar reading was below 50. The PharmD stated that he would expect a nurse to recheck a blood sugar level 10-15 minutes after administering juice or a snack in an effort to raise a low blood sugar level. He stated that he would expect the nurse to first use juice and/or a snack to raise a conscious resident ' s blood sugar level then glucose gel and finally injectable [MEDICATION NAME]. He stated that he would expect a nurse to have a physician's order and notification of the physician if they opened the emergency medication kit. In an interview on 12/11/12 at 3:50 PM the Corporate Nurse C stated that the facility did not have a policy or standard protocol on blood sugar monitoring, however, they did use Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills to use as procedure. Review of a Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills, provided by the facility as their procedures for blood glucose monitoring, reflected: Understanding blood chemistry tests: Evaluate client ' s test results and compare with normal values. Standard Values of Chem 7: Glucose (fasting) 65 to 110 mg/dL. Evaluate client results that follow above or below the critical lab values limit ... Follow appropriate nursing action as determined by facility policy and procedure. Principles of measuring blood glucose: Appropriate nursing actions need to be taken whenever client results exceed critical lab values. Documentation for blood specimens: date and time of blood withdraw, any unusual conditions in either the client or specimen, results of blood glucose reading, insulin administered type amount location of injection, notification of physician of critical lab values orders or interventions. In interviews conducted on 12/11/2012 between 5:25 PM and 5:32 PM, Licensed Vocational Nurses (LVN) E, F and G all stated they knew of no facility protocol regarding blood sugar checks, interventions and notification to the physician. Review of the Facility Policy Notification Requirements dated 01/01/07 reflected the following: Policy: It is the policy of this facility to notify the resident, his or her attending physician, and representative of changes in the resident ' s condition. Procedure: 1. The facility should notify the resident ' s attending physician and representative when: b. There is significant change in the resident ' s physical, mental, or psychosocial status. c. There is a need to alter the resident ' s treatment significantly. On 12/11/2012 at 7:10 PM the Vice President of Operations, Director of Clinical Services, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. (The Administrator was on vacation, out of the country) On 12/12/2012 at 6:00 PM, the Vice President of Operations provided the surveyor with a written plan of removal, which was accepted and reflected the following: What is the Jeopardy: In recognition of the concerns addressed in the Immediate Jeopardy Notification issued to the facility on [DATE], the Immediate Jeopardy was caused by a failure to notify physician of a residents symptoms of [DIAGNOSES REDACTED], failure to obtain physician orders to hold insulin, failure to have parameters for physician notification for one resident, and failure to notify physician for order for administration of IM [MEDICATION NAME] for one resident. Residents Impacted by the Jeopardy The resident identified as being impacted by the Immediate Jeopardy was Resident # 2. What staff were involved in the Jeopardy: Staff involved in the Immediate Jeopardy situation include Licensed Nurses. The following actions have been taken to remove jeopardy for our resident. For Residents Identified: Resident # 2 physician was notified by unit manager with orders received for blood sugar level parameters as follows: Accu-check less than 60 or greater than 250 call MD. May hold insulin if less than 60 and call MD. Readily available snacks have been placed in the resident ' s room with an update to the care plan. Unit Managers will monitor that Resident # 2 has snacks readily available at bedside daily. MD will visit resident on 12/12/12. If Resident # 2 exhibits signs or symptoms of [DIAGNOSES REDACTED], the nurse will perform blood sugar check, if less than 60 will hold the insulin per MD order, give juice followed by insulin sustaining protein such as milk or snack, repeat Accu-check and notify MD. Interventions: In-servicing on Notification Requirement Policy and Diabetic Monitoring training resource was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. Currently 68^% of the licensed staff has been educated at this time. On 12/12/2012 the records of the residents who have been identified as diabetics were reviewed by DON and Unit Managers to verify their interventions, including the need for blood sugar level parameters for notification to physician and orders for parameters to hold insulin,. Residents reviewed have had clarification from physicians for these types of orders. Training Re-education through in servicing of licensed staff regarding Notification Requirement Policy and Diabetic Monitoring was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. The Director of Nursing has a facility employee list and is checking to verify that employees are coming on duty have been trained or will be trained before providing direct care. In his absence the shift supervisor will verify that all oncoming staff have been trained. Monitoring: The Director of Nurses is responsible to verify that training/education of Notification Requirement Policy and Diabetic Monitoring has been initiat4ed, and staff demonstrate understanding of their responsibility. Director of Nurses, Staff Development Coordinator and/or Unit Managers will monitor compliance of physician notification and diabetic monitoring through review of 24 hour report, telephone orders and diabetic flow sheet daily Monday through Friday the first 30 days. Notification made to Medical Director of Immediate Jeopardy assigned. Emergency Quality Assurance and Assessment Meeting conducted with action plan developed. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Resident # 2's Care Plan was updated on 12/11/2012 as follows: Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected an update on 12/11/12 to have snacks available at bedside and further updated on 12/12/12 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. Review of the physician orders reflected a current telephone order dated 12/12/2012 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. The physician order also reflected an adjustment/reduction in insulin as: [MEDICATION NAME] 20 Units in the morning and [MEDICATION NAME] 16 Units in the evening. Observation made on 12/12/2012 at 6:30 PM revealed Resident # 2 was smiling and was able to answer questions quickly without delay in her thought process. Resident # 2's hands were not trembling. In an interview on 12/12/2012 at 6:33 PM Resident # 2 stated she had prayed for some help. Resident # 2 stated she felt so much better and the facility had begun to care for her in a manner she had not been cared for in the past. Resident # 2 stated her nausea had begun to subside and she felt she could eat in the dining room again and got great comfort in knowing she had snacks in her room to eat if she felt signs and symptoms of low blood sugar. Record review of the in-service sign-in sheets reflected approximately 70% of facility staff had been in-serviced. Interviews with staff on 12/13/2012 between 3:00 PM and 4:00 PM revealed the in-service regarding diabetic monitoring, notification to the physician and following physician orders had been provided to the staff on duty. The facility provided a list of residents identified as having Diabetes and physician orders, care plans and interventions had been put into place for those residents. While the IJ was removed on 12/13/12 at 6:30 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. The facility provided a list of 42 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for 1 of 10 resident's (Resident #2) when they failed to adequately monitor the insulin drug regimen and notify the physician regarding the presence of adverse consequences. Resident #2 was on an insulin drug regimen when she developed clinical signs and symptoms of [DIAGNOSES REDACTED] that included confusion, seeing stars, weakness and a feeling of anxiety evidenced by trembling hands. No notification was made to Resident # 2's physician which prevented the resident's drug review and potential reduction. This deficient practice resulted in an Immediate Jeopardy (IJ) on 12/11/2012. While the IJ was removed on 12/13/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice had the potential to result in hypoglycemic reactions including disorientation, confusion, weakness, anxiety, coma and death in 42 residents identified as Diabetic residents who required accu-checks. Findings include: Review of Resident #2 ' s Face Sheet reflected that Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 12/10/12 at 10:56 AM Resident #2 stated that she was not feeling well today. She stated that she had a low blood sugar level of 50. She said that she had gotten some juice but that the Medication Aide (MA) did not come back to check on her and that she was worried about her sugar level. Resident #2 stated that she had been having episodes of seeing stars and the light occasionally got dim. She stated that she had been a diabetic for [AGE] years and she could tell when her sugar levels were getting low. She stated that she gets weak and "can barely get myself together to call for help sometimes." Resident #2 stated that she does not have snacks in her room and she really needs those so that she can bring up her sugar because "it could get serious." Observation on 12/10//2012 at 10:58 AM, with Licensed Vocational Nurse Z, revealed Resident # 2 showed signs of anxiety and confusion. Resident # 2 had delayed thought pattern and delayed speech. Resident # 2's hands were trembling and she was unable to button her shirt. Resident # 2 asked LVN Z to button the last two buttons on her shirt. Review of Resident # 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated the resident is cognitively intact. Review of the University of Maryland ' s Medical Center website reflected the following information regarding [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (low blood sugar) is a condition in which there is an abnormally low level of glucose (sugar) in your blood. But factors such as disease or a poor diet can disrupt the mechanisms that regulate your sugar levels. Too much glucose results in [MEDICAL CONDITION], one of the major symptoms of diabetes. However, [DIAGNOSES REDACTED] is most common among people with diabetes, as too much insulin can cause blood sugar levels to fall (an insulin reaction). Left untreated, [DIAGNOSES REDACTED] can cause permanent neurological damage and death. Signs and Symptoms: headache, excessive sweating, blurred vision, dizziness, trembling, lack of coordination, depression, anxiety, mental confusion, irritability, heart palpitations, slurred speech, [MEDICAL CONDITION], fatigue, and coma. Source: http://www.umm.edu/altmed/articles/[DIAGNOSES REDACTED]- 0.htm#ixzz2GwEPKTfh Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected a short term goal as "Resident will exhibit no signs of hypo or [MEDICAL CONDITION] through the next review date x 90 days. Approaches listed are: accu-checks per physician's orders - morning and evening, observe for signs and symptoms of hyper and [DIAGNOSES REDACTED] administer insulin/physician's orders & observe for S.E. urticarial, pruritic swelling, warmth at injection site. Further review of Resident #2 ' s current Care Plan dated 8/24/12 and updated on 10/09/12 reflected the following progress notes: 09/11/12 has had mult. low levels and glucose gel and food given to bring up. 10/09/12 on 10/03/12 HS (evening) dose of [MEDICATION NAME] 70/30 insulin, multiple episodes still of low blood sugar and intramuscular [MEDICATION NAME] (an injectable medication used to raise blood sugar) or glucose gel being administered as needed. 11/29/12 nursing continue to perform accu-checks as needed and administer insulin as ordered, acute complications. Review of Resident #2 ' s Consolidated Physician ' s Orders dated December 2012 reflected the following orders: [MEDICATION NAME] Mix 70/30 inject 18 units subcutaneously every morning; start date 09/24/12 [MEDICATION NAME] Mix 70/30 inject 20 units subcutaneously at bedtime; start date 10/03/12 **Insulin orders** Accu-checks as needed for signs / symptoms of hyper / [DIAGNOSES REDACTED] Hand written on these orders: "accu-checks AC (morning) and HS (evening)" There were no parameters for holding insulin or notifying the physician when indicated on these orders and there was no sliding scale to administer insulin if the blood sugar was elevated. In an interview on 12/11/12 at 7:24 PM the Director of Nurses (DON) stated that the facility had no standing orders. He stated that this included no standing parameters for blood sugar levels or insulin administration. Review of Resident #2 ' s diet card that accompanied her lunch meal on 12/11/12 reflected a regular texture diet with low concentrated sweets, no sweet protein or veg. Likes: wheat bread, Dislikes: glazed meat or sweet vegetables. Observation on 12/11/12 at 12:20 PM revealed Resident #2 in bed with her lunch tray on her bedside table. The tray included vanilla ice cream, sliced turkey with cranberry glaze, yams, broccoli, a slice of white bread, a bowl of canned fruit cocktail in syrup, a glass of apple juice, and a glass of tea. In an interview on 12/11/12 at 6:30 PM the Dietician stated that the facility had been liberalizing the low concentrated sweets diet plan but she did not believe that the meal Resident #2 on 12/11/12 for lunch met the requirements for low concentrated sweets. In an interview on 12/11/12 at 12:20 PM Resident #2 stated that she had eaten the ice cream that was on her tray. Resident #2 stated that she had talked to the dietary manager several times and she had updated her preferences with him however "they don't pay attention to that card they just throw stuff on there and expect you to eat it." Resident #2 patted her stomach which was making very loud gurgling sounds and stated that she has a "touchy stomach" and sometimes she can't keep food down and coughs it up along with phlegm at times. Resident #2 stated that she "prayed for better food." She stated that sometimes she will eat the things on her tray "that are not really good for diabetics." Resident #2 took the cup of cocktail fruit and placed it on her bedside table. She patted the top of the cup and stated "this might just save my life later." Resident # 2 stated she saved the cup of cocktail fruit because she knows it has sugar in it and when she feels her blood sugar is dropping she can eat it to bring the level back up. Review of Medline Plus, a service of the U.S. National Library of Medicine National Institutes of Health reflected: a fasting blood glucose test level between 70 and100 milligrams per deciliter (mg/dL) is considered normal. A random blood glucose test, normal results depend on when you last ate. Most of the time, blood glucose levels will be below 125 mg/dL. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Review of Resident #2 ' s Diabetic Flow Record dated December 2012 reflected that Resident #2 had low blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 12/01/12 7:00 AM BS 62 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 12/02/12 7:00 AM BS 52 Routine dose of insulin was held, orange juice was administered. No documented evidence the physician was notified. 12/03/12 7:00 AM BS 80 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 7:00 AM BS 58 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 11:30 PM BS 92, Pudding and graham crackers were administered. 12/06/12 1:00 AM BS 34 Peanut butter and jelly was administered, refused glucose gel. No documented evidence the physician was notified. 12/06/12 1:20 AM BS 60 Coca-Cola per patient request. No documented evidence the physician was notified. 12/07/12 11:30 AM BS 41 Snack and lunch were administered. No documented evidence the physician was notified. 12/07/12 7:00 AM BS 95 Routine dose of insulin was held. No documented evidence the physician was notified. 12/08/12 7:00 AM BS 76 Routine dose of insulin was held. No documented evidence the physician was notified. 12/09/12 7:00 AM BS 85 Routine dose of insulin was held. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 53 Snack and juice were administered. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 54 Snack, juice, and lunch were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Diabetic Flow Record dated 11/25/12 to 11/30/12 reflected that Resident #2 had low or high blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 11/25/12 7:00 AM BS 38 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 11/25/12 4:30 PM BS 364. No documented evidence the physician was notified. 11/26/12 11:00 AM BS 54 Orange juice and a snack were administered. No documented evidence the physician was notified. 11/27/12 7:00 AM BS 52 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/28/12 7:00 AM BS 60 Routine dose of insulin was held and a snack was administered. No documented evidence the physician was notified. 11/28/12 4:30 PM BS 326. No documented evidence the physician was notified. 11/29/12 7:00 AM BS 44 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. 11/30/12 4:25 AM BS 52 Patient requested yogurt and applesauce. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Nurses Notes dated 11/25/12 to 12/09/12 reflected no documentation of any notification to the physician for any episode of hyper or [DIAGNOSES REDACTED]. Note dated 11/30/12 reflected that Resident #2's blood sugar level was 37 and she was administered glucose gel however there was no documentation of any follow up with the physician. No other note during this time period reflected the blood sugar level, interventions used, condition of the resident during episodes of hyper or [DIAGNOSES REDACTED], justification for holding insulin with normal blood sugar levels, or any notification to the physician. Review of Resident #2's clinical record reflected a copy of a fax dated Saturday, 12/08/12 that was addressed to a physician who was not Resident #2's attending physician stating, "please review pt's accu check logs. Runs low in AM. Do you want to DC PM 70/30 insulin?" No reply to this fax was found or noted in the chart and there was no follow-up to this fax to ensure the physician received the information. There was no record of an amended fax to the correct physician. Review of the facility Resident Weight Change Report dated 12/12/2012 reflected Resident # 2 lost weight as follows: August, 2012 - 141 pounds (lbs) September, 2012 - 141 lbs October, 2012 - 144 lbs November, 2012 - 138 lbs December, 2012 - 124 lbs In an interview on 12/11/12 at 5:39 PM the Medical Director (MD A), who was also Resident #2 ' s attending Physician, stated that he was not notified that Resident #2 was losing weight and reported seeing stars and sometimes felt confused and disoriented. He stated that this is a possible outcome of her hypoglycemic episodes. He stated that Resident #2 was not on a planned weight loss program and the weight loss might actually be making her diabetes better, causing her blood sugar to be lower than what it had been treated for [REDACTED]. MD A stated this certainly could be part of the reason her blood sugar was low and "I ' ll look into the low blood sugars and do something about that. Intermittent hypoglycemic blood sugars indicate that the current treatment should be reviewed and possibly changed." MD A stated that, if he had known of Resident # 2's condition, he would have recommended that the resident's insulin be held for a blood sugar under 80. He stated that he expected nurses to administer glucose gel for blood sugar levels under 60 or if a resident is unable to consume oral carbohydrates. MD A stated that he then expected nurses to notify him if a resident ' s blood sugar level was below 50 or they were unable to administer oral carbohydrates. MD A stated that he had not been notified that resident #2 ' s blood sugar levels were below during the month of December nor late November. In an interview on 12/11/12 at 3:36 PM the Contracted Registered Pharmacist (PharmD) stated that he considers blood sugar readings from 60-130 within normal limits. He would expect that nurses would notify the physician if a resident's blood sugar reading was below 50. The PharmD stated that he would expect a nurse to recheck a blood sugar level 10-15 minutes after administering juice or a snack in an effort to raise a low blood sugar level. He stated that he would expect the nurse to first use juice and/or a snack to raise a conscious resident ' s blood sugar level then glucose gel and finally injectable [MEDICATION NAME]. He stated that he would expect a nurse to have a physician's order and notification of the physician if they opened the emergency medication kit. In an interview on 12/11/12 at 3:50 PM the Corporate Nurse C stated that the facility did not have a policy or standard protocol on blood sugar monitoring, however, they did use Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills to use as procedure. Review of a Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills, provided by the facility as their procedures for blood glucose monitoring, reflected: Understanding blood chemistry tests: Evaluate client ' s test results and compare with normal values. Standard Values of Chem 7: Glucose (fasting) 65 to 110 mg/dL. Evaluate client results that follow above or below the critical lab values limit ... Follow appropriate nursing action as determined by facility policy and procedure. Principles of measuring blood glucose: Appropriate nursing actions need to be taken whenever client results exceed critical lab values. Documentation for blood specimens: date and time of blood withdraw, any unusual conditions in either the client or specimen, results of blood glucose reading, insulin administered type amount location of injection, notification of physician of critical lab values orders or interventions. In interviews conducted on 12/11/2012 between 5:25 PM and 5:32 PM, Licensed Vocational Nurses (LVN) E, F and G all stated they knew of no facility protocol regarding blood sugar checks, interventions and notification to the physician. Review of the Facility Policy Notification Requirements dated 01/01/07 reflected the following: Policy: It is the policy of this facility to notify the resident, his or her attending physician, and representative of changes in the resident ' s condition. Procedure: 1. The facility should notify the resident ' s attending physician and representative when: b. There is significant change in the resident ' s physical, mental, or psychosocial status. c. There is a need to alter the resident ' s treatment significantly. In an interview on 12/13/2012 at 5:30 PM the DON stated he did not feel the instance with Resident # 2 was "willful" neglect. Review of the facility Alleged Abuse/Potential Neglect/Exploitation/Investigation Policy dated 1/2007 reflected" The policy defined Neglect as: A failure or omission on the part of a care giver to provide the care, supervision and services necessary to maintain the physical and mental health of the disabled adult or elderly person, including, but not limited to providing food, clothing, medicine, shelter, supervision and medical services that a prudent person would consider essential for the wellbeing of the disabled adult or elderly person. ........Neglect can be either repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Policy: It is the policy of this facility to provide an environment that promotes dignity and respect for residents and one that prohibits abuse and/or neglect. Procedure: 1. The facility leadership will consistently strive to foster an environment which establishes the facility's values and commitment to prevention of abuse and/or neglect. 3. Facility systems are utilized to facilitate identification of abuse, neglect or exploitation. On 12/11/2012 at 7:10 PM the Vice President of Operations, Director of Clinical Services, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. (The Administrator was on vacation, out of the country) On 12/12/2012 at 6:00 PM, the Vice President of Operations provided the surveyor with a written plan of removal, which was accepted and reflected the following: What is the Jeopardy: In recognition of the concerns addressed in the Immediate Jeopardy Notification issued to the facility on [DATE], the Immediate Jeopardy was caused by a failure to notify physician of a residents symptoms of [DIAGNOSES REDACTED], failure to obtain physician orders to hold insulin, failure to have parameters for physician notification for one resident, and failure to notify physician for order for administration of IM [MEDICATION NAME] for one resident. Residents Impacted by the Jeopardy The resident identified as being impacted by the Immediate Jeopardy was Resident # 2. What staff were involved in the Jeopardy: Staff involved in the Immediate Jeopardy situation include Licensed Nurses. The following actions have been taken to remove jeopardy for our resident. For Residents Identified: Resident # 2 physician was notified by unit manager with orders received for blood sugar level parameters as follows: Accu-check less than 60 or greater than 250 call MD. May hold insulin if less than 60 and call MD. Readily available snacks have been placed in the resident ' s room with an update to the care plan. Unit Managers will monitor that Resident # 2 has snacks readily available at bedside daily. MD will visit resident on 12/12/12. If Resident # 2 exhibits signs or symptoms of [DIAGNOSES REDACTED], the nurse will perform blood sugar check, if less than 60 will hold the insulin per MD order, give juice followed by insulin sustaining protein such as milk or snack, repeat Accu-check and notify MD. Interventions: In-servicing on Notification Requirement Policy and Diabetic Monitoring training resource was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. Currently 68^% of the licensed staff has been educated at this time. On 12/12/2012 the records of the residents who have been identified as diabetics were reviewed by DON and Unit Managers to verify their interventions, including the need for blood sugar level parameters for notification to physician and orders for parameters to hold insulin,. Residents reviewed have had clarification from physicians for these types of orders. Training Re-education through in servicing of licensed staff regarding Notification Requirement Policy and Diabetic Monitoring was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. The Director of Nursing has a facility employee list and is checking to verify that employees are coming on duty have been trained or will be trained before providing direct care. In his absence the shift supervisor will verify that all oncoming staff have been trained. Monitoring: The Director of Nurses is responsible to verify that training/education of Notification Requirement Policy and Diabetic Monitoring has been initiat4ed, and staff demonstrate understanding of their responsibility. Director of Nurses, Staff Development Coordinator and/or Unit Managers will monitor compliance of physician notification and diabetic monitoring through review of 24 hour report, telephone orders and diabetic flow sheet daily Monday through Friday the first 30 days. Notification made to Medical Director of Immediate Jeopardy assigned. Emergency Quality Assurance and Assessment Meeting conducted with action plan developed. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Resident # 2's Care Plan was updated on 12/11/2012 as follows: Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected an update on 12/11/12 to have snacks available at bedside and further updated on 12/12/12 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. Review of the physician orders reflected a current telephone order dated 12/12/2012 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. The physician order also reflected an adjustment/reduction in insulin as: [MEDICATION NAME] 20 Units in the morning and [MEDICATION NAME] 16 Units in the evening. Observation made on 12/12/2012 at 6:30 PM revealed Resident # 2 was smiling and was able to answer questions quickly without delay in her thought process. Resident # 2's hands were not trembling. In an interview on 12/12/2012 at 6:33 PM Resident # 2 stated she had prayed for some help. Resident # 2 stated she felt so much better and the facility had begun to care for her in a manner she had not been cared for in the past. Resident # 2 stated her nausea had begun to subside and she felt she could eat in the dining room again and got great comfort in knowing she had snacks in her room to eat if she felt signs and symptoms of low blood sugar. Record review of the in-service sign-in sheets reflected approximately 70% of facility staff had been in-serviced. Interviews with staff on 12/13/2012 between 3:00 PM and 4:00 PM revealed the in-service regarding diabetic monitoring, notification to the physician and following physician orders had been provided to the staff on duty. The facility provided a list of residents identified as having Diabetes and physician orders, care plans and interventions had been put into place for those residents. While the IJ was removed on 12/13/12 at 6:30 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. The facility provided a list of 42 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 10 resident's (Resident #2) when they failed to adequately monitor the insulin drug regimen and notify the physician regarding the presence of adverse consequences. Resident #2 was on an insulin drug regimen when she developed clinical signs and symptoms of [DIAGNOSES REDACTED] that included confusion, seeing stars, weakness and a feeling of anxiety evidenced by trembling hands. No notification was made to Resident # 2's physician which prevented the resident's drug review and potential reduction. This deficient practice resulted in an Immediate Jeopardy (IJ) on 12/11/2012. While the IJ was removed on 12/13/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice had the potential to result in hypoglycemic reactions including disorientation, confusion, weakness, anxiety, coma and death in 42 residents identified as Diabetic residents who required accu-checks. Findings include: Review of Resident #2 ' s Face Sheet reflected that Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 12/10/12 at 10:56 AM Resident #2 stated that she was not feeling well today. She stated that she had a low blood sugar level of 50. She said that she had gotten some juice but that the Medication Aide (MA) did not come back to check on her and that she was worried about her sugar level. Resident #2 stated that she had been having episodes of seeing stars and the light occasionally got dim. She stated that she had been a diabetic for [AGE] years and she could tell when her sugar levels were getting low. She stated that she gets weak and "can barely get myself together to call for help sometimes." Resident #2 stated that she does not have snacks in her room and she really needs those so that she can bring up her sugar because "it could get serious." Observation on 12/10//2012 at 10:58 AM, with Licensed Vocational Nurse Z, revealed Resident # 2 showed signs of anxiety and confusion. Resident # 2 had delayed thought pattern and delayed speech. Resident # 2's hands were trembling and she was unable to button her shirt. Resident # 2 asked LVN Z to button the last two buttons on her shirt. Review of Resident # 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated the resident is cognitively intact. Review of the University of Maryland ' s Medical Center website reflected the following information regarding [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (low blood sugar) is a condition in which there is an abnormally low level of glucose (sugar) in your blood. But factors such as disease or a poor diet can disrupt the mechanisms that regulate your sugar levels. Too much glucose results in [MEDICAL CONDITION], one of the major symptoms of diabetes. However, [DIAGNOSES REDACTED] is most common among people with diabetes, as too much insulin can cause blood sugar levels to fall (an insulin reaction). Left untreated, [DIAGNOSES REDACTED] can cause permanent neurological damage and death. Signs and Symptoms: headache, excessive sweating, blurred vision, dizziness, trembling, lack of coordination, depression, anxiety, mental confusion, irritability, heart palpitations, slurred speech, [MEDICAL CONDITION], fatigue, and coma. Source: http://www.umm.edu/altmed/articles/[DIAGNOSES REDACTED]- 0.htm#ixzz2GwEPKTfh Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected a short term goal as "Resident will exhibit no signs of hypo or [MEDICAL CONDITION] through the next review date x 90 days. Approaches listed are: accu-checks per physician's orders - morning and evening, observe for signs and symptoms of hyper and [DIAGNOSES REDACTED] administer insulin/physician's orders & observe for S.E. urticarial, pruritic swelling, warmth at injection site. Further review of Resident #2 ' s current Care Plan dated 8/24/12 and updated on 10/09/12 reflected the following progress notes: 09/11/12 has had mult. low levels and glucose gel and food given to bring up. 10/09/12 on 10/03/12 HS (evening) dose of [MEDICATION NAME] 70/30 insulin, multiple episodes still of low blood sugar and intramuscular [MEDICATION NAME] (an injectable medication used to raise blood sugar) or glucose gel being administered as needed. 11/29/12 nursing continue to perform accu-checks as needed and administer insulin as ordered, acute complications. Review of Resident #2 ' s Consolidated Physician ' s Orders dated December 2012 reflected the following orders: [MEDICATION NAME] Mix 70/30 inject 18 units subcutaneously every morning; start date 09/24/12 [MEDICATION NAME] Mix 70/30 inject 20 units subcutaneously at bedtime; start date 10/03/12 **Insulin orders** Accu-checks as needed for signs / symptoms of hyper / [DIAGNOSES REDACTED] Hand written on these orders: "accu-checks AC (morning) and HS (evening)" There were no parameters for holding insulin or notifying the physician when indicated on these orders and there was no sliding scale to administer insulin if the blood sugar was elevated. In an interview on 12/11/12 at 7:24 PM the Director of Nurses (DON) stated that the facility had no standing orders. He stated that this included no standing parameters for blood sugar levels or insulin administration. Review of Resident #2 ' s diet card that accompanied her lunch meal on 12/11/12 reflected a regular texture diet with low concentrated sweets, no sweet protein or veg. Likes: wheat bread, Dislikes: glazed meat or sweet vegetables. Observation on 12/11/12 at 12:20 PM revealed Resident #2 in bed with her lunch tray on her bedside table. The tray included vanilla ice cream, sliced turkey with cranberry glaze, yams, broccoli, a slice of white bread, a bowl of canned fruit cocktail in syrup, a glass of apple juice, and a glass of tea. In an interview on 12/11/12 at 6:30 PM the Dietician stated that the facility had been liberalizing the low concentrated sweets diet plan but she did not believe that the meal Resident #2 on 12/11/12 for lunch met the requirements for low concentrated sweets. In an interview on 12/11/12 at 12:20 PM Resident #2 stated that she had eaten the ice cream that was on her tray. Resident #2 stated that she had talked to the dietary manager several times and she had updated her preferences with him however "they don't pay attention to that card they just throw stuff on there and expect you to eat it." Resident #2 patted her stomach which was making very loud gurgling sounds and stated that she has a "touchy stomach" and sometimes she can't keep food down and coughs it up along with phlegm at times. Resident #2 stated that she "prayed for better food." She stated that sometimes she will eat the things on her tray "that are not really good for diabetics." Resident #2 took the cup of cocktail fruit and placed it on her bedside table. She patted the top of the cup and stated "this might just save my life later." Resident # 2 stated she saved the cup of cocktail fruit because she knows it has sugar in it and when she feels her blood sugar is dropping she can eat it to bring the level back up. Review of Medline Plus, a service of the U.S. National Library of Medicine National Institutes of Health reflected: a fasting blood glucose test level between 70 and100 milligrams per deciliter (mg/dL) is considered normal. A random blood glucose test, normal results depend on when you last ate. Most of the time, blood glucose levels will be below 125 mg/dL. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Review of Resident #2 ' s Diabetic Flow Record dated December 2012 reflected that Resident #2 had low blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 12/01/12 7:00 AM BS 62 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 12/02/12 7:00 AM BS 52 Routine dose of insulin was held, orange juice was administered. No documented evidence the physician was notified. 12/03/12 7:00 AM BS 80 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 7:00 AM BS 58 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 11:30 PM BS 92, Pudding and graham crackers were administered. 12/06/12 1:00 AM BS 34 Peanut butter and jelly was administered, refused glucose gel. No documented evidence the physician was notified. 12/06/12 1:20 AM BS 60 Coca-Cola per patient request. No documented evidence the physician was notified. 12/07/12 11:30 AM BS 41 Snack and lunch were administered. No documented evidence the physician was notified. 12/07/12 7:00 AM BS 95 Routine dose of insulin was held. No documented evidence the physician was notified. 12/08/12 7:00 AM BS 76 Routine dose of insulin was held. No documented evidence the physician was notified. 12/09/12 7:00 AM BS 85 Routine dose of insulin was held. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 53 Snack and juice were administered. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 54 Snack, juice, and lunch were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Diabetic Flow Record dated 11/25/12 to 11/30/12 reflected that Resident #2 had low or high blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 11/25/12 7:00 AM BS 38 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 11/25/12 4:30 PM BS 364. No documented evidence the physician was notified. 11/26/12 11:00 AM BS 54 Orange juice and a snack were administered. No documented evidence the physician was notified. 11/27/12 7:00 AM BS 52 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/28/12 7:00 AM BS 60 Routine dose of insulin was held and a snack was administered. No documented evidence the physician was notified. 11/28/12 4:30 PM BS 326. No documented evidence the physician was notified. 11/29/12 7:00 AM BS 44 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. 11/30/12 4:25 AM BS 52 Patient requested yogurt and applesauce. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Nurses Notes dated 11/25/12 to 12/09/12 reflected no documentation of any notification to the physician for any episode of hyper or [DIAGNOSES REDACTED]. Note dated 11/30/12 reflected that Resident #2's blood sugar level was 37 and she was administered glucose gel however there was no documentation of any follow up with the physician. No other note during this time period reflected the blood sugar level, interventions used, condition of the resident during episodes of hyper or [DIAGNOSES REDACTED], justification for holding insulin with normal blood sugar levels, or any notification to the physician. Review of Resident #2's clinical record reflected a copy of a fax dated Saturday, 12/08/12 that was addressed to a physician who was not Resident #2's attending physician stating, "please review pt's accu check logs. Runs low in AM. Do you want to DC PM 70/30 insulin?" No reply to this fax was found or noted in the chart and there was no follow-up to this fax to ensure the physician received the information. There was no record of an amended fax to the correct physician. Review of the facility Resident Weight Change Report dated 12/12/2012 reflected Resident # 2 lost weight as follows: August, 2012 - 141 pounds (lbs) September, 2012 - 141 lbs October, 2012 - 144 lbs November, 2012 - 138 lbs December, 2012 - 124 lbs In an interview on 12/11/12 at 5:39 PM the Medical Director (MD A), who was also Resident #2 ' s attending Physician, stated that he was not notified that Resident #2 was losing weight and reported seeing stars and sometimes felt confused and disoriented. He stated that this is a possible outcome of her hypoglycemic episodes. He stated that Resident #2 was not on a planned weight loss program and the weight loss might actually be making her diabetes better, causing her blood sugar to be lower than what it had been treated for [REDACTED]. MD A stated this certainly could be part of the reason her blood sugar was low and "I ' ll look into the low blood sugars and do something about that. Intermittent hypoglycemic blood sugars indicate that the current treatment should be reviewed and possibly changed." MD A stated that, if he had known of Resident # 2's condition, he would have recommended that the resident's insulin be held for a blood sugar under 80. He stated that he expected nurses to administer glucose gel for blood sugar levels under 60 or if a resident is unable to consume oral carbohydrates. MD A stated that he then expected nurses to notify him if a resident ' s blood sugar level was below 50 or they were unable to administer oral carbohydrates. MD A stated that he had not been notified that resident #2 ' s blood sugar levels were below during the month of December nor late November. In an interview on 12/11/12 at 3:36 PM the Contracted Registered Pharmacist (PharmD) stated that he considers blood sugar readings from 60-130 within normal limits. He would expect that nurses would notify the physician if a resident's blood sugar reading was below 50. The PharmD stated that he would expect a nurse to recheck a blood sugar level 10-15 minutes after administering juice or a snack in an effort to raise a low blood sugar level. He stated that he would expect the nurse to first use juice and/or a snack to raise a conscious resident ' s blood sugar level then glucose gel and finally injectable [MEDICATION NAME]. He stated that he would expect a nurse to have a physician's order and notification of the physician if they opened the emergency medication kit. In an interview on 12/11/12 at 3:50 PM the Corporate Nurse C stated that the facility did not have a policy or standard protocol on blood sugar monitoring, however, they did use Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills to use as procedure. Review of a Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills, provided by the facility as their procedures for blood glucose monitoring, reflected: Understanding blood chemistry tests: Evaluate client ' s test results and compare with normal values. Standard Values of Chem 7: Glucose (fasting) 65 to 110 mg/dL. Evaluate client results that follow above or below the critical lab values limit ... Follow appropriate nursing action as determined by facility policy and procedure. Principles of measuring blood glucose: Appropriate nursing actions need to be taken whenever client results exceed critical lab values. Documentation for blood specimens: date and time of blood withdraw, any unusual conditions in either the client or specimen, results of blood glucose reading, insulin administered type amount location of injection, notification of physician of critical lab values orders or interventions. In interviews conducted on 12/11/2012 between 5:25 PM and 5:32 PM, Licensed Vocational Nurses (LVN) E, F and G all stated they knew of no facility protocol regarding blood sugar checks, interventions and notification to the physician. Review of the Facility Policy Notification Requirements dated 01/01/07 reflected the following: Policy: It is the policy of this facility to notify the resident, his or her attending physician, and representative of changes in the resident ' s condition. Procedure: 1. The facility should notify the resident ' s attending physician and representative when: b. There is significant change in the resident ' s physical, mental, or psychosocial status. c. There is a need to alter the resident ' s treatment significantly. In an interview on 12/13/2012 at 5:30 PM the DON stated he did not feel the instance with Resident # 2 was "willful" neglect. Review of the facility Alleged Abuse/Potential Neglect/Exploitation/Investigation Policy dated 1/2007 reflected" The policy defined Neglect as: A failure or omission on the part of a care giver to provide the care, supervision and services necessary to maintain the physical and mental health of the disabled adult or elderly person, including, but not limited to providing food, clothing, medicine, shelter, supervision and medical services that a prudent person would consider essential for the wellbeing of the disabled adult or elderly person. ........Neglect can be either repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. Policy: It is the policy of this facility to provide an environment that promotes dignity and respect for residents and one that prohibits abuse and/or neglect. Procedure: 1. The facility leadership will consistently strive to foster an environment which establishes the facility's values and commitment to prevention of abuse and/or neglect. 3. Facility systems are utilized to facilitate identification of abuse, neglect or exploitation. On 12/11/2012 at 7:10 PM the Vice President of Operations, Director of Clinical Services, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. (The Administrator was on vacation, out of the country) On 12/12/2012 at 6:00 PM, the Vice President of Operations provided the surveyor with a written plan of removal, which was accepted and reflected the following: What is the Jeopardy: In recognition of the concerns addressed in the Immediate Jeopardy Notification issued to the facility on [DATE], the Immediate Jeopardy was caused by a failure to notify physician of a residents symptoms of [DIAGNOSES REDACTED], failure to obtain physician orders to hold insulin, failure to have parameters for physician notification for one resident, and failure to notify physician for order for administration of IM [MEDICATION NAME] for one resident. Residents Impacted by the Jeopardy The resident identified as being impacted by the Immediate Jeopardy was Resident # 2. What staff were involved in the Jeopardy: Staff involved in the Immediate Jeopardy situation include Licensed Nurses. The following actions have been taken to remove jeopardy for our resident. For Residents Identified: Resident # 2 physician was notified by unit manager with orders received for blood sugar level parameters as follows: Accu-check less than 60 or greater than 250 call MD. May hold insulin if less than 60 and call MD. Readily available snacks have been placed in the resident ' s room with an update to the care plan. Unit Managers will monitor that Resident # 2 has snacks readily available at bedside daily. MD will visit resident on 12/12/12. If Resident # 2 exhibits signs or symptoms of [DIAGNOSES REDACTED], the nurse will perform blood sugar check, if less than 60 will hold the insulin per MD order, give juice followed by insulin sustaining protein such as milk or snack, repeat Accu-check and notify MD. Interventions: In-servicing on Notification Requirement Policy and Diabetic Monitoring training resource was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. Currently 68^% of the licensed staff has been educated at this time. On 12/12/2012 the records of the residents who have been identified as diabetics were reviewed by DON and Unit Managers to verify their interventions, including the need for blood sugar level parameters for notification to physician and orders for parameters to hold insulin,. Residents reviewed have had clarification from physicians for these types of orders. Training Re-education through in servicing of licensed staff regarding Notification Requirement Policy and Diabetic Monitoring was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. The Director of Nursing has a facility employee list and is checking to verify that employees are coming on duty have been trained or will be trained before providing direct care. In his absence the shift supervisor will verify that all oncoming staff have been trained. Monitoring: The Director of Nurses is responsible to verify that training/education of Notification Requirement Policy and Diabetic Monitoring has been initiat4ed, and staff demonstrate understanding of their responsibility. Director of Nurses, Staff Development Coordinator and/or Unit Managers will monitor compliance of physician notification and diabetic monitoring through review of 24 hour report, telephone orders and diabetic flow sheet daily Monday through Friday the first 30 days. Notification made to Medical Director of Immediate Jeopardy assigned. Emergency Quality Assurance and Assessment Meeting conducted with action plan developed. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Resident # 2's Care Plan was updated on 12/11/2012 as follows: Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected an update on 12/11/12 to have snacks available at bedside and further updated on 12/12/12 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. Review of the physician orders reflected a current telephone order dated 12/12/2012 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. The physician order also reflected an adjustment/reduction in insulin as: [MEDICATION NAME] 20 Units in the morning and [MEDICATION NAME] 16 Units in the evening. Observation made on 12/12/2012 at 6:30 PM revealed Resident # 2 was smiling and was able to answer questions quickly without delay in her thought process. Resident # 2's hands were not trembling. In an interview on 12/12/2012 at 6:33 PM Resident # 2 stated she had prayed for some help. Resident # 2 stated she felt so much better and the facility had begun to care for her in a manner she had not been cared for in the past. Resident # 2 stated her nausea had begun to subside and she felt she could eat in the dining room again and got great comfort in knowing she had snacks in her room to eat if she felt signs and symptoms of low blood sugar. Record review of the in-service sign-in sheets reflected approximately 70% of facility staff had been in-serviced. Interviews with staff on 12/13/2012 between 3:00 PM and 4:00 PM revealed the in-service regarding diabetic monitoring, notification to the physician and following physician orders had been provided to the staff on duty. The facility provided a list of residents identified as having Diabetes and physician orders, care plans and interventions had been put into place for those residents. While the IJ was removed on 12/13/12 at 6:30 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. The facility provided a list of 42 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to consult and immediately notify the physician for 1 of 10 residents (Resident #2), reviewed for diabetes, when Resident #2 developed clinical signs and symptoms of [DIAGNOSES REDACTED] that required nursing interventions. The facility had no physician order(s) and no written protocol for parameters of blood glucose levels when they administered glucose gel from the emergency kit and held Resident # 2's routine insulin on multiple occasions from 11/25/2012 through 12/11/2012. The physician was not notified when Resident # 2 showed signs and symptoms of [DIAGNOSES REDACTED] including confusion, seeing stars, weakness and a feeling of anxiety evidenced by trembling hands. This deficient practice resulted in an Immediate Jeopardy (IJ) on 12/11/2012. While the IJ was removed on 12/13/2012, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice had the potential to result in delay of physician intervention, medical treatment, coma, and permanent neurological damage, up to and including death and could place 41 additional residents at risk who were identified as having diabetes. Findings include: Review of Resident #2 ' s Face Sheet reflected that Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 12/10/12 at 10:56 AM Resident #2 stated that she was not feeling well today. She stated that she had a low blood sugar level of 50. She said that she had gotten some juice but that the Medication Aide (MA) did not come back to check on her and that she was worried about her sugar level. Resident #2 stated that she had been having episodes of seeing stars and the light occasionally got dim. She stated that she had been a diabetic for [AGE] years and she could tell when her sugar levels were getting low. She stated that she gets weak and "can barely get myself together to call for help sometimes." Resident #2 stated that she does not have snacks in her room and she really needs those so that she can bring up her sugar because "it could get serious." Observation on 12/10//2012 at 10:58 AM, with Licensed Vocational Nurse Z, revealed Resident # 2 showed signs of anxiety and confusion. Resident # 2 had delayed thought pattern and delayed speech. Resident # 2's hands were trembling and she was unable to button her shirt. Resident # 2 asked LVN Z to button the last two buttons on her shirt. Review of Resident # 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident had a [DIAGNOSES REDACTED]. The assessment reflected Resident # 2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) and indicated the resident is cognitively intact. Review of the University of Maryland ' s Medical Center website reflected the following information regarding [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (low blood sugar) is a condition in which there is an abnormally low level of glucose (sugar) in your blood. But factors such as disease or a poor diet can disrupt the mechanisms that regulate your sugar levels. Too much glucose results in [MEDICAL CONDITION], one of the major symptoms of diabetes. However, [DIAGNOSES REDACTED] is most common among people with diabetes, as too much insulin can cause blood sugar levels to fall (an insulin reaction). Left untreated, [DIAGNOSES REDACTED] can cause permanent neurological damage and death. Signs and Symptoms: headache, excessive sweating, blurred vision, dizziness, trembling, lack of coordination, depression, anxiety, mental confusion, irritability, heart palpitations, slurred speech, [MEDICAL CONDITION], fatigue, and coma. Source: http://www.umm.edu/altmed/articles/[DIAGNOSES REDACTED]- 0.htm#ixzz2GwEPKTfh Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected a short term goal as "Resident will exhibit no signs of hypo or [MEDICAL CONDITION] through the next review date x 90 days. Approaches listed are: accu-checks per physician's orders - morning and evening, observe for signs and symptoms of hyper and [DIAGNOSES REDACTED] administer insulin/physician's orders & observe for S.E. urticarial, pruritic swelling, warmth at injection site. Further review of Resident #2 ' s current Care Plan dated 8/24/12 and updated on 10/09/12 reflected the following progress notes: 09/11/12 has had mult. low levels and glucose gel and food given to bring up. 10/09/12 on 10/03/12 HS (evening) dose of [MEDICATION NAME] 70/30 insulin, multiple episodes still of low blood sugar and intramuscular [MEDICATION NAME] (an injectable medication used to raise blood sugar) or glucose gel being administered as needed. 11/29/12 nursing continue to perform accu-checks as needed and administer insulin as ordered, acute complications. Review of Resident #2 ' s Consolidated Physician ' s Orders dated December 2012 reflected the following orders: [MEDICATION NAME] Mix 70/30 inject 18 units subcutaneously every morning; start date 09/24/12 [MEDICATION NAME] Mix 70/30 inject 20 units subcutaneously at bedtime; start date 10/03/12 **Insulin orders** Accu-checks as needed for signs / symptoms of hyper / [DIAGNOSES REDACTED] Hand written on these orders: "accu-checks AC (morning) and HS (evening)" There were no parameters for holding insulin or notifying the physician when indicated on these orders and there was no sliding scale to administer insulin if the blood sugar was elevated. In an interview on 12/11/12 at 7:24 PM the Director of Nurses (DON) stated that the facility had no standing orders. He stated that this included no standing parameters for blood sugar levels or insulin administration. Review of Resident #2 ' s diet card that accompanied her lunch meal on 12/11/12 reflected a regular texture diet with low concentrated sweets, no sweet protein or veg. Likes: wheat bread, Dislikes: glazed meat or sweet vegetables. Observation on 12/11/12 at 12:20 PM revealed Resident #2 in bed with her lunch tray on her bedside table. The tray included vanilla ice cream, sliced turkey with cranberry glaze, yams, broccoli, a slice of white bread, a bowl of canned fruit cocktail in syrup, a glass of apple juice, and a glass of tea. In an interview on 12/11/12 at 6:30 PM the Dietician stated that the facility had been liberalizing the low concentrated sweets diet plan but she did not believe that the meal Resident #2 on 12/11/12 for lunch met the requirements for low concentrated sweets. In an interview on 12/11/12 at 12:20 PM Resident #2 stated that she had eaten the ice cream that was on her tray. Resident #2 stated that she had talked to the dietary manager several times and she had updated her preferences with him however "they don't pay attention to that card they just throw stuff on there and expect you to eat it." Resident #2 patted her stomach which was making very loud gurgling sounds and stated that she has a "touchy stomach" and sometimes she can't keep food down and coughs it up along with phlegm at times. Resident #2 stated that she "prayed for better food." She stated that sometimes she will eat the things on her tray "that are not really good for diabetics." Resident #2 took the cup of cocktail fruit and placed it on her bedside table. She patted the top of the cup and stated "this might just save my life later." Resident # 2 stated she saved the cup of cocktail fruit because she knows it has sugar in it and when she feels her blood sugar is dropping she can eat it to bring the level back up. Review of Medline Plus, a service of the U.S. National Library of Medicine National Institutes of Health reflected: a fasting blood glucose test level between 70 and100 milligrams per deciliter (mg/dL) is considered normal. A random blood glucose test, normal results depend on when you last ate. Most of the time, blood glucose levels will be below 125 mg/dL. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm Review of Resident #2 ' s Diabetic Flow Record dated December 2012 reflected that Resident #2 had low blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 12/01/12 7:00 AM BS 62 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 12/02/12 7:00 AM BS 52 Routine dose of insulin was held, orange juice was administered. No documented evidence the physician was notified. 12/03/12 7:00 AM BS 80 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 7:00 AM BS 58 Routine dose of insulin was held. No documented evidence the physician was notified. 12/05/12 11:30 PM BS 92, Pudding and graham crackers were administered. 12/06/12 1:00 AM BS 34 Peanut butter and jelly was administered, refused glucose gel. No documented evidence the physician was notified. 12/06/12 1:20 AM BS 60 Coca-Cola per patient request. No documented evidence the physician was notified. 12/07/12 11:30 AM BS 41 Snack and lunch were administered. No documented evidence the physician was notified. 12/07/12 7:00 AM BS 95 Routine dose of insulin was held. No documented evidence the physician was notified. 12/08/12 7:00 AM BS 76 Routine dose of insulin was held. No documented evidence the physician was notified. 12/09/12 7:00 AM BS 85 Routine dose of insulin was held. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 53 Snack and juice were administered. No documented evidence the physician was notified. 12/11/12 10:00 AM BS 54 Snack, juice, and lunch were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Diabetic Flow Record dated 11/25/12 to 11/30/12 reflected that Resident #2 had low or high blood sugars (BS), insulin was held, or a nursing intervention was implemented on the following dates: 11/25/12 7:00 AM BS 38 Routine dose of insulin was held, orange juice and a snack were administered. No documented evidence the physician was notified. 11/25/12 4:30 PM BS 364. No documented evidence the physician was notified. 11/26/12 11:00 AM BS 54 Orange juice and a snack were administered. No documented evidence the physician was notified. 11/27/12 7:00 AM BS 52 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/28/12 7:00 AM BS 60 Routine dose of insulin was held and a snack was administered. No documented evidence the physician was notified. 11/28/12 4:30 PM BS 326. No documented evidence the physician was notified. 11/29/12 7:00 AM BS 44 Routine dose of insulin was held and orange juice was administered. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. 11/30/12 4:25 AM BS 52 Patient requested yogurt and applesauce. No documented evidence the physician was notified. 11/30/12 4:00 AM BS 37 Glucose gel and two glasses of orange juice were administered. No documented evidence the physician was notified. Review of Resident #2 ' s Nurses Notes dated 11/25/12 to 12/09/12 reflected no documentation of any notification to the physician for any episode of hyper or [DIAGNOSES REDACTED]. Note dated 11/30/12 reflected that Resident #2's blood sugar level was 37 and she was administered glucose gel however there was no documentation of any follow up with the physician. No other note during this time period reflected the blood sugar level, interventions used, condition of the resident during episodes of hyper or [DIAGNOSES REDACTED], justification for holding insulin with normal blood sugar levels, or any notification to the physician. Review of Resident #2's clinical record reflected a copy of a fax dated Saturday, 12/08/12 that was addressed to a physician who was not Resident #2's attending physician stating, "please review pt's accu check logs. Runs low in AM. Do you want to DC PM 70/30 insulin?" No reply to this fax was found or noted in the chart and there was no follow-up to this fax to ensure the physician received the information. There was no record of an amended fax to the correct physician. Review of the facility Resident Weight Change Report dated 12/12/2012 reflected Resident # 2 lost weight as follows: August, 2012 - 141 pounds (lbs) September, 2012 - 141 lbs October, 2012 - 144 lbs November, 2012 - 138 lbs December, 2012 - 124 lbs In an interview on 12/11/12 at 5:39 PM the Medical Director (MD A), who was also Resident #2 ' s attending Physician, stated that he was not notified that Resident #2 was losing weight and reported seeing stars and sometimes felt confused and disoriented. He stated that this is a possible outcome of her hypoglycemic episodes. He stated that Resident #2 was not on a planned weight loss program and the weight loss might actually be making her diabetes better, causing her blood sugar to be lower than what it had been treated for [REDACTED]. MD A stated this certainly could be part of the reason her blood sugar was low and "I ' ll look into the low blood sugars and do something about that. Intermittent hypoglycemic blood sugars indicate that the current treatment should be reviewed and possibly changed." MD A stated that, if he had known of Resident # 2's condition, he would have recommended that the resident's insulin be held for a blood sugar under 80. He stated that he expected nurses to administer glucose gel for blood sugar levels under 60 or if a resident is unable to consume oral carbohydrates. MD A stated that he then expected nurses to notify him if a resident ' s blood sugar level was below 50 or they were unable to administer oral carbohydrates. MD A stated that he had not been notified that resident #2 ' s blood sugar levels were below during the month of December nor late November. In an interview on 12/11/12 at 3:36 PM the Contracted Registered Pharmacist (PharmD) stated that he considers blood sugar readings from 60-130 within normal limits. He would expect that nurses would notify the physician if a resident's blood sugar reading was below 50. The PharmD stated that he would expect a nurse to recheck a blood sugar level 10-15 minutes after administering juice or a snack in an effort to raise a low blood sugar level. He stated that he would expect the nurse to first use juice and/or a snack to raise a conscious resident ' s blood sugar level then glucose gel and finally injectable [MEDICATION NAME]. He stated that he would expect a nurse to have a physician's order and notification of the physician if they opened the emergency medication kit. In an interview on 12/11/12 at 3:50 PM the Corporate Nurse C stated that the facility did not have a policy or standard protocol on blood sugar monitoring, however, they did use Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills to use as procedure. Review of a Clinical Nursing Skills Manual, Seventh Edition, Basic to Advanced Skills, provided by the facility as their procedures for blood glucose monitoring, reflected: Understanding blood chemistry tests: Evaluate client ' s test results and compare with normal values. Standard Values of Chem 7: Glucose (fasting) 65 to 110 mg/dL. Evaluate client results that follow above or below the critical lab values limit ... Follow appropriate nursing action as determined by facility policy and procedure. Principles of measuring blood glucose: Appropriate nursing actions need to be taken whenever client results exceed critical lab values. Documentation for blood specimens: date and time of blood withdraw, any unusual conditions in either the client or specimen, results of blood glucose reading, insulin administered type amount location of injection, notification of physician of critical lab values orders or interventions. In interviews conducted on 12/11/2012 between 5:25 PM and 5:32 PM, Licensed Vocational Nurses (LVN) E, F and G all stated they knew of no facility protocol regarding blood sugar checks, interventions and notification to the physician. Review of the Facility Policy Notification Requirements dated 01/01/07 reflected the following: Policy: It is the policy of this facility to notify the resident, his or her attending physician, and representative of changes in the resident ' s condition. Procedure: 1. The facility should notify the resident ' s attending physician and representative when: b. There is significant change in the resident ' s physical, mental, or psychosocial status. c. There is a need to alter the resident ' s treatment significantly. On 12/11/2012 at 7:10 PM the Vice President of Operations, Director of Clinical Services, Regional Nurse Consultant and Director of Nurses were informed that an IJ and SQC existed. (The Administrator was on vacation, out of the country) On 12/12/2012 at 6:00 PM, the Vice President of Operations provided the surveyor with a written plan of removal, which was accepted and reflected the following: What is the Jeopardy: In recognition of the concerns addressed in the Immediate Jeopardy Notification issued to the facility on [DATE], the Immediate Jeopardy was caused by a failure to notify physician of a residents symptoms of [DIAGNOSES REDACTED], failure to obtain physician orders to hold insulin, failure to have parameters for physician notification for one resident, and failure to notify physician for order for administration of IM [MEDICATION NAME] for one resident. Residents Impacted by the Jeopardy The resident identified as being impacted by the Immediate Jeopardy was Resident # 2. What staff were involved in the Jeopardy: Staff involved in the Immediate Jeopardy situation include Licensed Nurses. The following actions have been taken to remove jeopardy for our resident. For Residents Identified: Resident # 2 physician was notified by unit manager with orders received for blood sugar level parameters as follows: Accu-check less than 60 or greater than 250 call MD. May hold insulin if less than 60 and call MD. Readily available snacks have been placed in the resident ' s room with an update to the care plan. Unit Managers will monitor that Resident # 2 has snacks readily available at bedside daily. MD will visit resident on 12/12/12. If Resident # 2 exhibits signs or symptoms of [DIAGNOSES REDACTED], the nurse will perform blood sugar check, if less than 60 will hold the insulin per MD order, give juice followed by insulin sustaining protein such as milk or snack, repeat Accu-check and notify MD. Interventions: In-servicing on Notification Requirement Policy and Diabetic Monitoring training resource was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. Currently 68^% of the licensed staff has been educated at this time. On 12/12/2012 the records of the residents who have been identified as diabetics were reviewed by DON and Unit Managers to verify their interventions, including the need for blood sugar level parameters for notification to physician and orders for parameters to hold insulin,. Residents reviewed have had clarification from physicians for these types of orders. Training Re-education through in servicing of licensed staff regarding Notification Requirement Policy and Diabetic Monitoring was initiated on 12/11/2012 with staff present and has been provided to oncoming staff on or before their next shift worked. The training was provided by the Director of Nursing, Staff Development Coordinator, Unit Managers and Shift Supervisor. The Director of Nursing has a facility employee list and is checking to verify that employees are coming on duty have been trained or will be trained before providing direct care. In his absence the shift supervisor will verify that all oncoming staff have been trained. Monitoring: The Director of Nurses is responsible to verify that training/education of Notification Requirement Policy and Diabetic Monitoring has been initiat4ed, and staff demonstrate understanding of their responsibility. Director of Nurses, Staff Development Coordinator and/or Unit Managers will monitor compliance of physician notification and diabetic monitoring through review of 24 hour report, telephone orders and diabetic flow sheet daily Monday through Friday the first 30 days. Notification made to Medical Director of Immediate Jeopardy assigned. Emergency Quality Assurance and Assessment Meeting conducted with action plan developed. The survey team confirmed the facility had begun to carry out the Plan of Removal as follows: Resident # 2's Care Plan was updated on 12/11/2012 as follows: Review of the current Care Plan dated 8/24/12 and updated on 10/09/12 reflected Resident #2 has Diabetes and is at risk for further complications. The plan of care reflected an update on 12/11/12 to have snacks available at bedside and further updated on 12/12/12 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. Review of the physician orders reflected a current telephone order dated 12/12/2012 to call physician if accu-check is less than 60 or greater than 250, may hold insulin if accu-check is less than 60. The physician order also reflected an adjustment/reduction in insulin as: [MEDICATION NAME] 20 Units in the morning and [MEDICATION NAME] 16 Units in the evening. Observation made on 12/12/2012 at 6:30 PM revealed Resident # 2 was smiling and was able to answer questions quickly without delay in her thought process. Resident # 2's hands were not trembling. In an interview on 12/12/2012 at 6:33 PM Resident # 2 stated she had prayed for some help. Resident # 2 stated she felt so much better and the facility had begun to care for her in a manner she had not been cared for in the past. Resident # 2 stated her nausea had begun to subside and she felt she could eat in the dining room again and got great comfort in knowing she had snacks in her room to eat if she felt signs and symptoms of low blood sugar. Record review of the in-service sign-in sheets reflected approximately 70% of facility staff had been in-serviced. Interviews with staff on 12/13/2012 between 3:00 PM and 4:00 PM revealed the in-service regarding diabetic monitoring, notification to the physician and following physician orders had been provided to the staff on duty. The facility provided a list of residents identified as having Diabetes and physician orders, care plans and interventions had been put into place for those residents. While the IJ was removed on 12/13/12 at 6:30 PM, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. The facility provided a list of 42 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to provide services in accordance with each resident's written plan of care by failing to not implement new physician's orders [REDACTED]. Resident #1 was being treated for [REDACTED]. On 11/28/12 Resident #1 received new physician orders [REDACTED]. The new order was not implemented by the facility until surveyor intervention on 12/12/12. During this two week period of time the pressure ulcer increased in size and developed a tunnel into an area of previously healthy tissue. This deficient practice could place 6 residents who receive pressure ulcer treatment at risk for deterioration of pressure ulcers causing pain, infection and decline in physical and psychosocial well-being. Findings include: Review of Resident #1's Face Sheet reflected the Resident was a [AGE] year old female, admitted to the facility on [DATE]. Review of a list of Resident's Active diagnosis, dated 11/19/12, included of Senile Dementia, Traumatic Fracture (FX) Lower Leg, and Osteo[DIAGNOSES REDACTED], [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Neuralgia, [MEDICAL CONDITIONS], Left AKA, and Diabetes Type ll. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected a Stage IV pressure ulcer measuring 2.2cm in length, 2.0 cm wide, and 0.2 cm deep with granulation tissue present on the wound bed. The MDS reflected the Resident had clear speech, was understood by others, and understands verbal content. The MDS reflected the Resident to be always incontinent of bowel and bladder. Review of Resident #1's Care Plan (CP) dated 11/26/12 reflected the Resident had a Stage IV pressure area to the sacrum with TX to be performed as ordered by wound clinic physician. The CP reflected that Resident was to be assisted with repositioning in bed and wheelchair as outlined per physical therapy (PT) on 08/24/12. Review of Resident #1's undated Therapy Communication to Nursing for Positioning form instructs staff to position the Resident with a foam wedge, or two pillows, under patient's back, place a pillow between thighs making sure both hips are bent, the pillow is high enough to support her neck, and to place one pillow at chest to support arms. Review of Resident #1's November and December, 2012, monthly consolidated physician's orders [REDACTED]. "right foot with prevalon boot while in bed and wheelchair at all times." Observation on 12/10/12 at 3:10 PM revealed Resident #1 in bed, positioned slightly to the left side with a foam wedge partially supporting her back but not her neck. Resident's knees were bent and no pillow was between her thighs and no pillow at chest to support arms. In an interview on 12/10/12 at 6:10 PM resident did not respond to surveyor's greeting or attempts to engage in conversation. Resident would not look toward surveyor. In an interview on 12/11/12 at 10:55 AM, LVN H stated that Resident #1 should be positioned in bed to offload the sacrum and that a pillow should fully support back and neck with another pillow placed between the thighs. LVN did state that if resident was positioned as described by surveyor in the observation on 12/10/12 at 6:10 PM she was positioned incorrectly. Review of Resident #1's wound care physician's orders [REDACTED]." Review of Resident #1's Nurse's Notes dated 11/28/12 reflected that the Resident was taken to an appointment at the wound clinic on this date, and that no changes were noted by the nurse with follow up visit scheduled for 12/28/12 at 2:30 PM. Observation on 12/11/12 at 10:30 AM of LVN H performing wound care treatment to Resident #1's sacral pressure ulcer revealed LVN H to cleanse the area with soap and water and pack the pressure ulcer with Boric Acid soaked gauze, then an abdominal pad was applied and covered with tape. This treatment did not reflect treatment consistent with Resident #1's most current Wound Care physician's orders [REDACTED]. In an interview on 12/11/12 at 10:55 AM, LVN H stated that Resident #1's wound "had tunneled some in the last few days". LVN H stated that the Resident goes to the wound care doctor "weekly or bi-weekly." LVN H stated she does not "measure wounds. I just do the wound treatments on my assigned residents; another nurse does the weekly skin assessments." LVN H stated that the Resident's pressure area to the sacrum had only gotten worse" in the last few days", and that she had not reported it to the Wound Nurse. Review of the Admission/Weekly Wound Analysis reports reflected that on both 11/23/12 and 11/30/12 Resident #1's sacral pressure ulcer measured 2.1 cm in length, 2 cm wide, and 0.8 cm in depth and reflected there was no change in the treatment orders received. The weekly wound analysis report dated 12/7/12 reflected that the sacral pressure ulcer measured 2.1 cm in length, 2 cm wide, and 1.4 cm deep. Observation on 12/12/12 at 1:55 PM of LVN J's assessment of Resident #1's Sacral Pressure Ulcer revealed measurements of pressure ulcer to be 2.4 centimeters (cm) in length, 2.2 cm wide, 1.0 cm deep with tunneling of 2.0 cm at the11:00 o'clock position on pressure ulcer. Observation on 12/12/12 at 2:00 PM of LVN H's wound care treatment to Resident #1's sacral pressure ulcer revealed the LVN cleansed pressure area with soap and water and packed the pressure ulcer with boric acid soaked gauze, then an abdominal pad was applied and covered with tape to secure. This treatment did not reflect treatment consistent with Resident #1's most current Wound Care physician's orders [REDACTED]. In an interview on 12/12/12 at 3:10 PM LVN J stated that "LVN H did report the change" in the Resident's pressure ulcer condition on 12/11/12, and stated "I was busy and I should have measured the Resident's wound and called the doctor yesterday and did not." LVN J stated that LVN H had "called the physician and left a message for him yesterday, and I left one this morning and I will call again." In an interview on 12/12/12 at 3:25 PM the Director of Nursing (DON) stated it was his expectation that "LVN's should report any changes found in a resident's condition to the charge nurse", and charge nurse should assess resident's condition. The DON stated, "If a resident has any skin issues, the charge nurse should notify the wound nurse and physician. As far as the treatment orders not being changed when we received them, it was just a mistake, an error. The bus driver hands them to the nurse and it got missed." In an interview on 12/13/2012 at 1:10 PM with Resident #1's wound Doctor, he stated that he was not aware that the facility did not carry out his order written on 11/28/2012 to begin the new treatment. The Doctor stated, "They (the facility) did not tell me they did not change the order." The doctor stated the wound was "clean and granular and boric acid is an acidic debrider that loosens necrotic (dead) tissue. When the wound was clean and granular, the treatment was changed to a less corrosive agent. I ordered [MEDICATION NAME]." Review of the facility's Pressure Ulcer/Wound Care Clinical practice guidelines dated 7/26/12 reflected, "if the weekly wound analysis shows decline, consult the physician for possible need of treatment modification." The facility provided CMS Form 672 that reflected 6 residents currently with pressure ulcers.

Based on observation, interview and record review the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, and prevent new pressure ulcer development for 1 of 5 residents (Resident #1) reviewed for pressure ulcers. Resident #1 was being treated for [REDACTED]. This pressure area deteriorated in condition. On 11/28/12 Resident #1 received new physician orders [REDACTED]. During this two week period of time the pressure ulcer increased in size and developed a tunnel into an area of previously healthy tissue. This deficient practice affected 1 resident with pressure ulcers whose pressure ulcer worsened by increasing in size and characteristics. This deficient practice could affect 5 additional residents with pressure ulcers who may fail to receive the necessary treatment and services to promote healing resulting in a decline in the condition of their pressure ulcers. Findings include: Review of Resident #1's Face Sheet reflected the Resident was a [AGE] year old female, admitted to the facility on [DATE]. Review of a list of Resident's Active diagnosis, dated 11/19/12, included of Senile Dementia, Traumatic Fracture (FX) Lower Leg, and Osteo[DIAGNOSES REDACTED], [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Neuralgia, [MEDICAL CONDITIONS], Left AKA, and Diabetes Type ll. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected a Stage IV pressure ulcer measuring 2.2cm in length, 2.0 cm wide, and 0.2 cm deep with granulation tissue present on the wound bed. The MDS reflected the Resident had clear speech, was understood by others, and understands verbal content. The MDS reflected the Resident to be always incontinent of bowel and bladder. Review of Resident #1's Care Plan (CP) dated 11/26/12 reflected the Resident had a Stage IV pressure area to the sacrum with TX to be performed as ordered by wound clinic physician. The CP reflected that Resident was to be assisted with repositioning in bed and wheelchair as outlined per physical therapy (PT) on 08/24/12. Review of Resident #1's undated Therapy Communication to Nursing for Positioning form instructs staff to position the Resident with a foam wedge, or two pillows, under patient's back, place a pillow between thighs making sure both hips are bent, the pillow is high enough to support her neck, and to place one pillow at chest to support arms. Review of Resident #1's November and December, 2012, monthly consolidated physician's orders [REDACTED]. "right foot with prevalon boot while in bed and wheelchair at all times." Observation on 12/10/12 at 3:10 PM revealed Resident #1 in bed, positioned slightly to the left side with a foam wedge partially supporting her back but not her neck. Resident's knees were bent and no pillow was between her thighs and no pillow at chest to support arms. In an interview on 12/10/12 at 6:10 PM resident did not respond to surveyor's greeting or attempts to engage in conversation. Resident would not look toward surveyor. In an interview on 12/11/12 at 10:55 AM, LVN H stated that Resident #1 should be positioned in bed to offload the sacrum and that a pillow should fully support back and neck with another pillow placed between the thighs. LVN did state that if resident was positioned as described by surveyor in the observation on 12/10/12 at 6:10 PM she was positioned incorrectly. Review of Resident #1's wound care physician's orders [REDACTED]." Review of Resident #1's Nurse's Notes dated 11/28/12 reflected that the Resident was taken to an appointment at the wound clinic on this date, and that no changes were noted by the nurse with follow up visit scheduled for 12/28/12 at 2:30 PM. Observation on 12/11/12 at 10:30 AM of LVN H performing wound care treatment to Resident #1's sacral pressure ulcer revealed LVN H to cleanse the area with soap and water and pack the pressure ulcer with Boric Acid soaked gauze, then an abdominal pad was applied and covered with tape. This treatment did not reflect treatment consistent with Resident #1's most current Wound Care physician's orders [REDACTED]. In an interview on 12/11/12 at 10:55 AM, LVN H stated that Resident #1's wound "had tunneled some in the last few days". LVN H stated that the Resident goes to the wound care doctor "weekly or bi-weekly." LVN H stated she does not "measure wounds. I just do the wound treatments on my assigned residents; another nurse does the weekly skin assessments." LVN H stated that the Resident's pressure area to the sacrum had only gotten worse" in the last few days", and that she had not reported it to the Wound Nurse. Review of the Admission/Weekly Wound Analysis reports reflected that on both 11/23/12 and 11/30/12 Resident #1's sacral pressure ulcer measured 2.1 cm in length, 2 cm wide, and 0.8 cm in depth and reflected there was no change in the treatment orders received. The weekly wound analysis report dated 12/7/12 reflected that the sacral pressure ulcer measured 2.1 cm in length, 2 cm wide, and 1.4 cm deep. Observation on 12/12/12 at 1:55 PM of LVN J's assessment of Resident #1's Sacral Pressure Ulcer revealed measurements of pressure ulcer to be 2.4 centimeters (cm) in length, 2.2 cm wide, 1.0 cm deep with tunneling of 2.0 cm at the11:00 o'clock position on pressure ulcer. Observation on 12/12/12 at 2:00 PM of LVN H's wound care treatment to Resident #1's sacral pressure ulcer revealed the LVN cleansed pressure area with soap and water and packed the pressure ulcer with boric acid soaked gauze, then an abdominal pad was applied and covered with tape to secure. This treatment did not reflect treatment consistent with Resident #1's most current Wound Care physician's orders [REDACTED]. In an interview on 12/12/12 at 3:10 PM LVN J stated that "LVN H did report the change" in the Resident's pressure ulcer condition on 12/11/12, and stated "I was busy and I should have measured the Resident's wound and called the doctor yesterday and did not." LVN J stated that LVN H had "called the physician and left a message for him yesterday, and I left one this morning and I will call again." In an interview on 12/12/12 at 3:25 PM the Director of Nursing (DON) stated it was his expectation that "LVN's should report any changes found in a resident's condition to the charge nurse", and charge nurse should assess resident's condition. The DON stated, "If a resident has any skin issues, the charge nurse should notify the wound nurse and physician. As far as the treatment orders not being changed when we received them, it was just a mistake, an error. The bus driver hands them to the nurse and it got missed." In an interview on 12/13/2012 at 1:10 PM with Resident #1's wound Doctor, he stated that he was not aware that the facility did not carry out his order written on 11/28/2012 to begin the new treatment. The Doctor stated, "They (the facility) did not tell me they did not change the order." The doctor stated the wound was "clean and granular and boric acid is an acidic debrider that loosens necrotic (dead) tissue. When the wound was clean and granular, the treatment was changed to a less corrosive agent. I ordered [MEDICATION NAME]." Review of the facility's Pressure Ulcer/Wound Care Clinical practice guidelines dated 7/26/12 reflected, "if the weekly wound analysis shows decline, consult the physician for possible need of treatment modification." The facility provided CMS Form 672 that reflected 6 residents currently with pressure ulcers.