Every finding on record at Hot Springs Health & Rehabilitation Center

Based on interview and record review, the facility failed to develop comprehensive care plans that included resident-specific care items and or accurate levels of care required for ADLs for 4 (#s 2, 11, 22, and 28) of 19 sampled residents. The deficient practice placed residents at risk for unmet care needs and at risk for not maintaining their highest practicable level. Findings include:During an interview on 2/9/26 at 8:08 a.m., staff member A stated the facility followed the RAI manual as the care planning policy. Staff member A stated he wasn't sure why some CAAs were not on the care plan.During an interview on 2/9/26 at 10:38 a.m., staff member A stated they are following the new objectives on cutting down on care plans. During an interview on 2/9/26 at 11:52 a.m., staff member C stated the IDT is involved in care planning, but any nurse can update a care plan as necessary. The care plans are updated as individual needs come up for the residents.During an interview on 2/9/26 at 2:26 p.m., staff member A stated he would expect to see the individual needs of a resident on the care plan and would expect it to be inclusive but condensed enough to read. During an interview on 2/9/26 at 2:52 p.m., staff member G stated when a CAA was triggered on the MDS it should be addressed in the care plan. Staff member G stated once section V of the MDS was completed, the comprehensive care plan was updated based on triggered areas. Staff member G stated she made sure the care plan had been updated for the triggered areas prior to submission of the MDS. Staff member G stated that care plans were updated by the department managers when an MDS was being completed and the need for updates were identified and reviewed by the Interdisciplinary Team as a whole. Staff member G stated weekly updates were completed during the utilization review meeting. Staff member G stated when she found changes in the sections of the MDS she updated the care plan at that time. Staff member G did not know why some of the care plans did not reflect some of the areas triggered in the MDS, but it was possible some of the ADLs got missed.a. A review of resident #2's Comprehensive MDS, with an ARD of 5/19/25 showed, resident #2 refused bathing and was dependent for oral hygiene.A review of resident #2's Quarterly MDS, with an ARD of 1/28/26 showed, resident #2 required substantial/maximal assistance with bathing and substantial/maximal assistance with oral hygiene.A review of resident #2's care plan, updated 2/8/26 showed, Needs limited to extensive assist with bathing and failed to identify the level of care needed for oral hygiene.b. A review of resident #22's Comprehensive MDS, with an ARD of 7/28/25 showed, resident #22 was dependent for bathing.A review of resident #22's Quarterly MDS, with an ARD of 1/15/26 showed, resident #22 was dependent for bathing.A review of resident #22's care plan, updated 1/27/26 showed, Bathing: Bathe/shower self Extensive assistance of one staff. [sic]c. A review of resident #28's Comprehensive MDS, with an ARD of 8/11/25 showed, resident #28 required partial/moderate assistance with tub/shower transfers and partial/moderate assistance with bathing. Resident #28 was marked on the MDS as being at risk for developing pressure ulcers/injuries. The CAA worksheet indicated this risk would be addressed in the care plan.A review of resident #28's Quarterly MDS, with an ARD of 1/28/26 showed, resident #28 required supervision or touch assistance with tub/shower transfers and partial/moderate assistance with bathing. It also showed resident #28 was at risk for developing pressure ulcers/injuries.A review of resident #28's care plan, updated 1/28/26 showed, the care plan did not contain a level of assistance for tub/shower transfers or bathing. The care plan did not identify that resident #28 was at risk for developing pressure ulcers/injuries or include interventions to prevent or relieve pressure areas.d. A review of resident #11's Comprehensive MDS, with an ARD of 1/7/26 showed, resident #11 was dependent for bathing. The MDS indicated resident #11 did not walk 10 feet. This was coded as 09. Not applicable- Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.A review of resident #11's care plan, updated 1/27/26 showed, the care plan did not contain a level of assistance for bathing and listed a non-pharmaceutical pain intervention of walking with supervision.A review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, effective 10/1/25, showed: . Chapter 4: Care Area Assessment (CAA) Process and Care Planning. the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. The CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care. The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. it is expected that nursing homes will assess resident needs, plan care and implement interventions in a timely manner.

Based on observation, interview, and record review, the facility failed to maintain a clean bathroom for the resident(s) to use for 1 (#5) of 19 sampled residents. This deficient practice caused the facility to be odorous of urine. Findings include:During an observation on 2/7/26 at 12:39 p.m., the bathroom located outside of resident #5's room had a urine odor. There was what appeared to be urine built up at the base of the toilet. When wiped with a dry white cloth, the cloth became soiled with urine. During an observation on 2/8/26 at 8:20 a.m., the bathroom near resident #5's room smelled of urine, and there was what appeared to be urine built up around the base of the toilet. There was a toilet riser over the toilet, and the lid to the toilet tank was missing. When a paper towel was used to wipe the spot of urine in front of the toilet, the paper towel became soiled with urine.During an observation on 2/8/26 at 10:27 a.m., staff member J was cleaning the bathroom next to resident #5's room. During an observation on 2/8/26 at 11:11 a.m., the bathroom next to resident #5's room still smelled of urine, and the spot that appeared to be urine was still apparent on the floor in front of the base of the toilet. The lid to the back of the toilet was now on the back of the toilet. During an interview on 2/8/26 at 12:30 p.m., staff member J stated the bathroom next to resident #5's room was cleaned daily. Staff member J stated the bathroom next to resident #5's room is not just for resident #5; it is a communal bathroom, and it gets used quite a bit. During an observation and interview on 2/9/26 at 9:01 a.m., staff member F stated the bathroom next to resident #5's room is cleaned daily and deep cleaned once a month. When staff member F observed the bathroom, she stated, That looks like urine. The urine spot in front of the toilet was still present, and when wiped with a white cloth, the cloth became soiled with urine. Staff member F stated, I will get right on it and clean that bathroom. Review of a facility email document titled 5 Step Room Cleaning with an emailed date of 2/8/26 showed: 5 Steps Room Cleaning.3. Vertical surfaces (look for spills, markings, stains. All vertical surfaces are not cleaned daily, but should be inspected and spot cleaned)4. Dry mop5. Damp mop.

Based on observation, interview, and record review, the facility failed to assess a resident for the risk of entrapment from bed rails and failed to obtain consent from the resident's POA, prior to installation of grab bars for 1 (#38) of 19 sampled residents. The deficient practice had the potential to cause an entrapment risk for the resident. Findings include:During an observation on 2/8/26 at 1:11 p.m., resident #38 was sleeping in his wheelchair, in his room, next to his bed. His bed was noted to have two bed rails/grab bars, one on each side of his bed.During an interview on 2/8/26 at 2:56 p.m., staff member A stated resident #38 should not have had bed rails, they were mounted to his bed and should not have been. Staff member A further stated that both bed rails had been removed.During an observation on 2/9/26 at 10:45 a.m., resident #38 was sitting in his wheelchair watching tv and there was a bed rail up on the room door side of the bed.During an interview on 2/9/26 at 10:51 a.m., staff member E stated he had only removed the bed rail on the window side of the bed.During an interview on 2/9/26 at 10:52 a.m., staff member C stated that both of resident #38's bed rails were removed yesterday.A review of a facility policy titled, Physical Restraints and Enablers/Devices, with a updated date of January 2025, showed: Policy Statement: It is the policy of this center that residents have the right to be free from any physical restraints imposed for purposes of discipline or staff convenience, and not required to treat the resident's medical symptoms. Restraints are only used to treat the resident's medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining the highest practicable level of physical and psychosocial well-being.DEFINITIONA physical restraint is defined as, 1 'Any manual method, physical or mechanical device, equipment or material attached or adjacent to the resident's body that meets all of the following criterion:Is attached or adjacent to the residents body;Cannot be removed easily by the resident; andRestricts the resident's freedom of movement or normal access to his/her body.' .2. If it is determined that a resident has symptom necessitating the use of a physical or a mechanical device, the Device Evaluation is completed prior to the device being initiated, annually and on change of condition, if the condition affects the use of the device. The 'EFFECT NOT THE INTENT' is evaluated to determine if the device used is a restraint or an enabler. If it is determined that restraint usage is needed, the least restrictive device is used.a. Devices may include but are not limited to the following: i. Bed rails (quarter, 1/2, 3/4 full) .5. The resident and/or resident representative is provided risks/benefits of restraint use or enabler/device use, and consent obtained prior to implementation of the device. 8. The resident is evaluated using the Device Evaluation on admission, re-admission, annually, and with significant change in condition (as the condition change applies to the use of the restraint or device), for the continued need for the device and evaluation of the effect on the resident.[sic]A request for a bed rail/grab bar consent and an assessment/evaluation for resident #38 was made on 2/8/26 at 1:23 p.m., and was not received by the end of the survey period.

Based on observation, interview, and record review, the facility failed to ensure staff followed safe food handling practices and ensure staff used proper hair and beard coverings while meals were prepared and served, which may affect any resident receiving meals or meal services from the staff or kitchen. Findings include: During an observation on 12/17/24 at 12:03 p.m., staff member N had a goatee, which was not covered with a beard net, while N was cooking at the stove. Staff member F was working in the kitchen during meal service, installing new equipment, with no hairnet and beard net. Staff member F had long hair, and a long, full beard. During an observation and interview on 12/17/24 at 12:18 p.m., staff member N was plating resident lunch trays without a beard cover in place. Staff member N said he was to be wearing a beard cover when in the kitchen. Record review of a facility policy, Personal Hygiene Standards, updated June 2021, showed: .a. Hair restraining devices (e.g. hair nets), covering all hair, are worn while on duty. Hair restraining devices are provided for vendors working in the kitchen. b. If a hat is worn, all exposed hair should be covered with a hair net. Hats must be kept clean, and designated for kitchen use only. . k. For those employees with beards, beard guards are worn . 48261

Based on interviews and record review, the facility failed to take actions aimed at performance improvement, and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained: failed to identify and develope policies and procedures that direct staff on resident care expectations. This deficient practice had the potential to affect all residents within the facility who required complete medical records for medical review, residents who fall, residents who were cared for without accurate comprehensive care plans, and staff direction for resident care. Findings include: During an interview on 12/18/24 at 8:44 a.m., staff member B said the facility did not have the requested policies and procedures to provide the surveyors. Policies and procedures requested; Advance Directives Policy, PASARR Level I and Level II Policy, Care Plan Policy, Significant Change Policy, and a Call Light Safety Policy. During an interview and record review, on 12/19/24 at 9:11 a.m., staff member B stated the facility did not have any active Performance Improvement plans (PIPs). Staff member B stated she would need to talk to staff member A, as there were no PIPs in the QAPI book. Staff member B stated the facility was aware of the missing physician history and physicals, and working on correcting the issue, but did not have a PIP in place for plan or corrections. Staff member B stated the QAPI team reviewed falls at each meeting, and did not have a PIP, related to falls, for the prevention of falls. Staff member B stated the QAPI team was aware of the inaccuracy of the comprehensive care plans, and was talking about auditing and educating nurses on resolving problems, as needed, with the care plans. Staff member B stated no PIP was completed on the care plan concerns. Staff member B stated the QAPI team was aware of the missing history and physicals completed by physicians in the residents' EHRs. Staff member B stated there was a system change for scanning, and now the scanning was backlogged. Staff member B stated the scanning process needed to be streamlined, so she was talking to IT for help. Staff member B stated there was not a PIP for the EHR inaccuracies or missing information. During an interview on 12/19/24 at 10:23 a.m., staff member A presented a PIP, which was in the book, for falls with fractures. Staff member A stated he had not had time to fill out the Fall PIP components for the first three falls with fractures, until this week. Staff member A stated he had not started another PIP for the 3 new falls with fractures that occurred this past fall, as he intended. During an interview and record review on 12/19/24 at 10:30 a.m., staff member O stated the Fall PIP was not completed and failed to identify the bigger picture (related to fall prevention), follow-up, and document the additional interventions that have been done, like the standup rounds and high-risk meetings on Fridays. Staff member O stated he did not feel the Fall PIP met the requirements for a PIP. Review of the facility PIP, (Draft) Falls with Fracture, dated 6/25/24, reflected three falls with fractures. The following information was missing or completed after the survey began: - Check-In dates: No check-in dates found - Goal Statements: To reduce falls with fractures dated 12/17/24 (after the arrival of surveyors) - Identified and Plan: Review of medications that might contribute to falls, review equipment for assistive devices, and in-service staff on fall prevention, dated 12/17/24 (after the arrival of surveyors) - Team Members: No users found - Education of Staff: No assignments found - Attachments: No attachments found Review of the facility's policy, QAPI Plan, dated October 2018, reflected: - .Performance Improvement Process: - .1. QAA Committee evaluates ongoing effectiveness of Performance Improvement Plan (PIP). - 2. QAA Committee sets timetable for follow-up review, if necessary. - 3. QAA Committee determines duration of continued monitoring for sustained improvement. - 4. QAA Committee repeats/returns to PDSA (Plan, Do, Study, ACT) if sustained improvement is not achieved .

Based on observation, interview, and record review, the facility failed to update and maintain current individualized care plans, to include when a change to the resident's care occurred, for activity preferences, or ensure staff were aware of how to use/find the individualized comprehensive care plans for use, for 6 (#s 1, 3, 6, 10, 20, and 22) of 19 sampled residents. Findings include: 1. During an interview on 12/17/24 at 2:56 p.m., staff member B said she had been at the facility for [AGE] years, and resident #1's behaviors and care had not changed. Staff member B said all resident care plans were accurate for the residents. Record Review of resident #1's comprehensive care plan showed an admitted [DATE]. Resident #1 had multiple diagnoses identified, including severe intellectual disabilities, bipolar disorder, conduct disorder, unspecified psychosis, unidentified mood disorder, anxiety disorder, and moderate dementia with behavioral disturbance(s). Resident #1 was care planned for behavior of hitting, kicking, scratching, and resistant to cares, with an initiation date of 7/23/2018, and a revision date of 11/14/22. The last documented intervention revision was noted on 11/14/22. Resident #1 was care planned for impaired cognitive function related to bipolar disorder, dementia, and severe intellectual disability, with an initiation date of 7/23/18, and a revision date of 8/26/19. The last documented intervention was noted on 10/2/20. During an interview on 12/18/24 at 10:38 a.m., staff member E said the resident care plans were updated quarterly. Staff member E noted not all residents had activities listed in their care plan. She was working to update all resident care plans with the resident's preferences for activities. During an interview on 12/19/24 at 8:50 a.m., staff member B said the resident care plans were so long and cumbersome, staff did not go by the care plan. The facility staff used the individualized service plan within the electronic medical record. Staff member B said the care plan would be updated by the interdisciplinary team when the resident had a fall, or it would be updated when the resident had a change. Otherwise, the resident care plan was reviewed during the quarterly review period. During an interview on 12/19/24 at 9:23 a.m., staff member M said she had recently returned to work at the facility. Staff member M said she would ask the charge nurse about resident care preferences and needs, because the care plans were not up to date. She was not familiar with the individualized service plans for each resident. 46400 2. Review of resident #22's EMR showed the resident had a diagnosis of obstructive sleep apnea. Review of resident #22's Treatment Administration Record, dated December 2024, showed morning and evening on and off instructions for EPAP 8, PS 3-15 cm H2O with heated humidity. All administrations were marked as resident refused. During an interview on 12/19/24 at 9:30 a.m., resident #22 stated his CPAP was denied by insurance, and he did not wear anything at night for his sleep apnea. During an interview on 12/19/24 at 9:35 a.m., staff member D stated #22's CPAP was denied due to noncompliance. The resident's CPAP machine had a remote monitoring device that tracked settings and usage. Review of the device data had shown the resident was not consistently wearing his CPAP, and it had therefore been declined by insurance. During an interview on 12/19/24 at 9:50 a.m., staff member K stated the facility went through a lot of channels to get the resident the EPAP since he did not like the CPAP mask. Staff member K stated she asked resident #22 every night she worked, about setting up the EPAP before bedtime, and he always refused. Review of resident #22's comprehensive care plan, with a recent revision date of 10/19/24, failed to show any procedure, resident preference, or refusal related to his sleep apnea equipment. 3. During an observation on 12/16/24 at 3:19 p.m., resident #3 had an orthopedic boot on her left foot. Resident #3 stated it was due to an old broken ankle injury. During an interview on 12/18/24 at 10:10 a.m., staff member H stated the resident wore the orthopedic boot after an old injury and was fearful to get rid of it. During an observation and interview on 12/18/24 at 1:45 p.m., staff member K removed resident #3's boot to reveal the resident's ankle and foot and examine for any skin impairment related to the boot. Staff member K stated the resident slept in the boot and only took it off for showers. Review of resident #3's comprehensive care plan, with a most recent revision date of 4/17/24, showed under the problem section, The resident has acute pain r/t left ankle fracture. The interventions failed to show the resident's use of the orthopedic boot, anxiety around removing the boot, or any concerns for skin impairment related to the resident using the boot. 48261 4. Review of resident #6's EHR Care Plan, with a revision date of 10/17/24, reflected: - [Resident #6] has two open sheared/macerated areas to left buttock secondary to decreased mobility s/p hip fracture, incontinence, rejection of repositioning at times . During an interview on 12/18/24 at 11:23 a.m., staff member K stated resident #6 did not have wounds on her buttocks or maceration during an observation that day. Staff member K stated she observed the resident's buttocks today and found no redness, wounds or maceration. Staff member K stated resident #6 did have maceration quite a while back, but nothing currently. 5. During an interview on 12/16/24 at 3:08 p.m., resident #10 was in his bed and stated he could no longer walk. During an interview on 12/17/24 at 10:13 a.m., staff member H stated resident #10 did not walk and remained in his bed. Staff member H stated resident #10 preferred to stay in his room, in bed, watching television. Review of resident #10's EHR physician history and physical, dated 11/12/24, reflected resident #10 was confined to his bed. Review of resident #10's Care Plan, with a revision date of 3/14/24, reflected: - . The resident is WEIGHT-BEARING - AMBULATION: The resident uses walker for walking. 6. During an interview on 12/17/24 at 10:13 a.m., staff member H stated resident #20 slept most of the days. Staff member H stated she slept more now than she used to, and she was often fed in bed. During an observation and interview on 12/17/24 at 11:50 a.m., staff member J was in resident #20's room feeding the resident, with the bed raised. Resident #20's eyes remained closed during the meal assistance, and staff member J stated resident #20 was, . really declining. Staff member J stated the decline started somewhere between four and six weeks ago. Staff member J stated resident #20 became weaker and started dragging her right foot. Staff member J stated she put the resident to bed because she did not want her to fall. Staff member J stated when resident #20 was walking in the merry walker (specialty walker), she would walk 10 miles a day, wandering in and out of everyone's rooms, now she just slept most of the time and was not walking anymore. During an observation on 12/17/24 at 1:19 p.m., resident #20 was lying half on her bed, with her feet and legs off the bed, and her head was lying against the wall. Staff member J assisted resident #20 back into the bed and offered to get her up. Resident #20 stated she did not want to get up. Resident #20 spoke in nonsensical mumbling that was not understandable. Staff member J checked the resident's brief, and placed a pillow under the resident's head. Resident #20 was grabbing the call light and wrapping it across her body and head. Staff member J stated resident #20 had a severe decline over the past couple of months and was sleeping most of the time and not walking the halls as she had prior. During an interview on 12/17/24 at 1:42 p.m. staff member B stated resident #20 had not used the call light in some time and should not have a call light for safety. Staff member J entered the room and stated resident #20 scares her all the time, and she even puts the pillow over her own head. The call light was removed, and thirty-minute checks were initiated. During an interview on 12/17/24 at 2:56 p.m., staff member B stated resident #20 was up walking last Friday, so she considered the current care plan plan accurate, regardless of what staff on the unit were saying. During an interview on 12/17/24 at 4:45 p.m., staff member L stated resident #20 slept most of the time. Staff member L stated resident #20 used to get up, she would wander the halls with her merry walker, but now she was very difficult to get up, and she required maximum assistance with most tasks, including getting out of bed and eating. During an observation and interview on 12/18/24 at 7:35 a.m., staff member K stated she told the CNAs to get resident #20 up this morning. Resident #20 was in the hallway sitting in her merry walker. Resident #20 did not walk or move her merry walker during the observation period. Resident #20 was repetitively mumbling unintelligible words and then fell asleep in the chair, where she remained until the CNAs took her to the dining room, and then assisted 1-1 maximum assistance, assisted her with the meal and her eating it. The CNAs then placed resident #20 back in bed. Staff member K stated the resident really had a decline with her dementia over the past few months. Resident #20 required maximum assistance to get into the bed, and to go from sitting to lying down, in the bed. Review of resident #20's Care Plan, dated 12/17/24, reflected the following: - . PERSONAL HYGIENE/ORAL CARE: [Resident #20] is able to provide her own personal hygiene with cueing. Assist of one staff at times. Revision on: 10/02/2020 - TOILET USE: [Resident #20] requires cueing by one staff for toileting. Revision on: 10/02/2020 - AMBULATION/MOBILITY: Assist: Supervision. Revision on: 02/23/2024 - BED MOBILITY: Independent. Date Initiated: 07/19/2022 - COMMUNICATION: Clear. Date Initiated: 07/19/2022 - Merry walker when up so she can ambulate AD LIB. Date Initiated: 03/13/2024. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the facility did not have a care plan policy.

Based on interview and record review, the facility governing body failed to ensure the facility implemented and operationalized policies and procedures related to Advance Directives, PASARR Screenings, Care Plans, and Accidents/Hazards. This failure increased the risk of any resident in the facility being negatively affected due to the lack policies and procedures. Surveyors identified deficient practices for resident #s (6, 20, 30, and 32.) of 19 residents sampled, and for these specific residents, the facility did not have policies or procedures for the facility or staff to utilize. Findings include: A review of the policies and procedures during the recertification survey, showed the facility failed to develop and operationalize polices for Advance Directives, PASARR Level One and Two screenings, Care planning, and Accidents and Hazards. Advance Directives: During a review of resident #30's POLST, it was found resident #30 had not dated the form, and the physician did not date the form. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the POLST forms are required to be fully completed, including dates. Staff member B stated the facility did not have an Advanced Directives policy. PASARR Screening: Review of resident #6's EHR reflected no PASARR Level I or II was completed. During an interview on 12/18/24 at 12:10 p.m., staff member B stated resident #6 did not have a PASARR Level I or II since admission to the facility. Staff member B stated she did not know why a PASARR I had not been completed, but one was being completed now. Staff member B stated the facility did not have a policy regarding PASARR Level I's or II's. Developing/Implementing Care Plans: Review of resident #32's electronic medical record showed an admitted [DATE]. Review of resident #32's care plan showed a baseline care plan was initiated on 11/12/24, with revisions made on 11/15/24. No comprehensive care plan had been developed following the resident's admission. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the facility did not have a care plan policy or a significant change policy, and the facility followed the RAI manual. Accidents and Hazards: During an observation and interview on 12/17/24 at 1:42 p.m., resident #20 continued to pull the call light cord over herself, over her chest, and then her neck. Staff member B stated the facility did not usually assess for call light safety, but would use alternate styles of call lights when residents were unable to use a standard button light. During an interview on 12/19/24 at 9:15 a.m., staff member B stated the facility did not have a policy or procedure related to call light safety.

Based on interview and record review, the facility physician failed to document resident assessments or physician visits for 4 (#s 1, 4, 6, and 20) of 19 sampled residents. This failure increased the risk of others not having the pertinent medical information available, when needed, to address resident care needs. Findings include: 1. A request was made on 12/17/24 for resident #1's current history and physical. A hospital admission physical, dated 5/5/14, was provided. No current history and physical for resident #1 was located in the resident's electronic medical record. 2. A request was made on 12/17/24 for resident #4's current history and physical, no current history and physical was located in the electronic medical record, or provided by the facility. 48261 3. Review of resident #20's EHR reflected no history and physical had been completed by the physician. Resident #20 was admitted to the facility on [DATE]. A request for the most recent history and physical completed for resident #20 was made, but nothing not provided by the facility. 4. Review of resident #6's EHR reflected no physician history and physical had been completed. Resident #6 was admitted to the facility on [DATE]. A request for the most recent history and physical completed for resident #6 was made, but nothing was provided by the facility. During an interview on 12/17/24 at 2:20 p.m., staff member B said the facility recognized physician visits were not being documented within the resident's electronic medical records. The facility was working to bring physician visit documentation up to date, and currently had about half of the resident history and physicals up to date. Staff member B said the facility did not have current history and physicals for four of those requested.

Based on interviews and record review, the facility failed to ensure advanced directives were complete for 4 (#s 1, 9, 16, and 30) of 19 sampled residents. This deficiency increased the risk of of the resident's wishes not being met or followed. Findings include: Review of resident #1's POLST, dated 7/8/21, showed a verbal consent by resident #1's guardian. No physical signature by the guardian was present on the form. During a review of resident #9's POLST, dated 4/11/17, showed the physician failed to date the document or complete the provider contact information. During a review of resident #16's POLST, dated 8/25/22, it was found the physician failed to complete the sections labeled, Printed Name of Physician, Date and Time, and Provider Phone Number. During a review of resident #30's POLST, it was found resident #30 had not dated the form, and the physician did not date the form. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the POLST forms are required to be fully completed, including dates. Staff member B stated the facility did not have an Advanced Directives policy. Review of the the Appendix PP, State Operations Manual, for LTC, showed under F578 a facility must, S483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) . (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. 45448

Based on observation and interview, the facility staff failed to remove expired medications, and allowed the expired items to remain in the same location as the unexpired medications, which increased the risk of misuse. Findings include: During an observation on 12/19/24 at 8:48 a.m., there were the following expired medications located in the facility stock medication cupboard: - Two bottles of Magnesium Chloride, expiration date of 9/2024, - Three bottles of Ferrous Gluconate, expiration date of 5/2024, - One bottle of Iron 27 mg, expiration date of 4/2024, - Three bottles of Meclizine, expiration date of 7/2024, - One bottle of COQ10, expiration date of 8/2024, and - One bottle of Senna Plus, expiration date of 9/2024. During an interview on 12/19/24 at 8:50 a.m., staff member K stated the process of checking on expiration dates and removing medication was supposed to be done by pharmacy as they maintained the medication supply.

Based on observations and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living for oral care received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, for 1 (#10) of 19 sampled residents. Findings include: During an observation and interview on 12/17/24 at 3:10 p.m., resident #10 had no dentures in his mouth and stated the dentures were still over on the sink. Resident #10 stated, No one gave them to me or put glue on them, so I haven't had them in today. During an observation and interview on 12/18/24 at 10:11 a.m., resident #10 stated, They (CNAs) haven't put them in yet, they are still on the sink, just need some glue, and (to) give them to me. During an interview on 12/18/24 at 10:20 a.m., staff member H stated the CNAs often did not put his dentures in for a few days to allow his mouth to rest, so he did not get a mouth sore. Staff member H stated the nurse made the decision on who and when residents got dentures. Staff member H stated she was not aware no one had put resident #10's dentures in. Staff member H went to put in resident #10's dentures, and returned stating resident #10 was happy, to have received his dentures and have them put in. Review of resident #10's Care Plan, with a revision date of 6/7/21, reflected: - TEETH: Full Denture: upper, no bottoms. Date Initiated: 06/08/2021 . - Provide mouth care as per ADL personal hygiene. Date Initiated: 06/11/2021 .

Based on observations and interviews, the facility failed to ensure a resident's environment was addressed for safety related to hazards, and the resident had dementia, and misused the call light/cord, and a staff member reported a concern related to the resident's use of a pillow, for 1 (#20) of 19 sampled residents. Findings include: During an observation on 12/17/24 at 1:19 p.m., resident #20 was lying half on the bed, and her feet and legs were off the bed, and her head was lying against the wall. Staff member J assisted resident #20 back into the bed and offered to get the resident up, but she didn't want up. Resident #20 was mumbling, but her words were not clear and comprehensable. Resident #20 was grabbing the call light and wrapping it across her body and her head. Staff member J stated resident #20 had a severe decline over the past couple of months, and the resident was sleeping most of the time, not walking the halls as she had prior. Resident #20 continued to grab the call light cord, mumbling loudly. During an observation and interview on 12/17/24 at 1:27 p.m., resident #20 was in her room, in bed, with the lights off. Resident #20 was still grabbing the call light cord on the wall. Staff member J entered the room, pulled resident #20's pants up, and covered resident #20 with a blanket while resident #20 continued to grab and pull on the call light cord. Staff member J stated, I just don't know what to do with her anymore. Resident #20 continued to gesture or make circles with the cord. She was facing the wall, and continuing to mumble unintelligible words. Staff member J left the room, and went on break, out the back door. During an observation and interview on 12/17/24 at 1:42 p.m., resident #20 continued to pull the call light cord over herself, over her chest, and then her neck. The surveyor immediately notified staff member B, who then entered and observed the behavior. Staff member B removed the call light for safety, and staff member B stated the facility would be implementing thirty-minute checks for the resident, in place of the call light. Staff member B stated resident #20 had not used the call light in some time, and the resident should not have one. Staff member B stated the facility did not usually assess for call light safety, but would use alternate styles of call lights when residents were unable to use a standard button light. Staff member J entered the room and stated, Resident #20 scares me all the time, she even puts the pillow over her head. During an interview on 12/19/24 at 9:15 a.m., staff member B stated the facility did not have a policy or procedure related to call light safety.

Based on interviews and record review, the facility failed to complete a PASARR level I or II for 1 (#6) of 19 sampled residents. Findings include: Review of resident #6's EHR reflected no PASARR Level I or II was completed. During an interview on 12/18/24 at 12:10 p.m., staff member B stated resident #6 did not have a PASARR Level I or II since admission to the facility. Staff member B stated she did not know why a PASARR I had not been completed, but one was being completed now. Staff member B stated the facility did not have a policy regarding PASARR Level I's or II's. During an interview on 12/18/24 at 3:23 p.m., NF1 stated when a resident transferred from one nursing facility to another, the new facility should complete their own PASARR Level I, no later than the day of admission, to determine if they are able to provide the resident the services needed.

Based on interview and record review, the facility failed to implement a comprehensive, resident centered care plan, which identified the resident's physical and psychological needs and wishes, for 1 (#32) of 19 sampled residents. Findings include: During an interview on 12/18/24 at 8:44 a.m., staff member B stated the facility did not have a care plan policy or a significant change policy, and the facility followed the RAI manual. Review of resident #32's electronic medical record showed an admitted [DATE]. Review of resident #32's care plan showed a baseline care plan was initiated on 11/12/24, with revisions made on 11/15/24. No comprehensive care plan had been developed following the resident's admission.

Based on interview and record review, facility staff failed to ensure a resident's medical condition remained confidential for 1 (#1) of 5 sampled residents. Findings include: During an interview on 3/25/24 at 2:53 p.m., NF1 (not employed by the facility) stated she had seen resident #1's right foot on or about 3/6/24, the day after the resident fell and noticed it was swollen. NF1 alerted a staff member. NF1 stated I have broken my foot before, and I told the staff member (about resident #1) I'll bet it's broke. During an interview on 3/25/24 at 3:14 p.m., NF1 stated an x-ray was done on resident #1, and the next time she came to the facility [Staff member C] told her that there was a fracture to resident #1's foot. During an interview on 3/25/24 at 10:51 a.m., staff member C stated she was informed during shift report resident #1 had a fracture to her foot and she might have told NF1 resident #1 had a fracture. During an interview on 3/26/24 at 11:45 a.m., NF2 stated I don't want [NF1] told things about [Resident #1's] conditions. During an interview on 3/26/24 at 12:27 p.m., staff member D stated if a resident had a non facility caregiver coming in to see a resident, she would absolutely inform the caregiver if the resident's foot was broken, to protect my patients. During an interview on 3/26/24 at 12:36 p.m., staff member B stated NF1 had worked at the facility in the past and staff would probably be comfortable telling her resident #1's foot was broken. During an interview on 3/26/24 at 12:38 p.m., staff member A stated facility staff are not supposed to tell a resident's visitor the resident's medical condition without assuring the person is allowed to know. A review of a facility document, titled, Notice of Privacy Practices, updated August 2014, showed: . We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your protected health information, and to notify affected individuals following a breach of unsecured protected health information .

Based on interview and record review, the facility failed to provide scheduled medication, as ordered by the physician, to 1 (#26) of 15 sampled residents. This deficient practice resulted in undue physical symptoms for the resident. Findings include: During an interview on 12/4/23 at 1:18 p.m., resident #26 stated, They (the facility) ran out of my nausea medication on Sunday, and I didn't get any until Friday. I went through such withdrawals; I was so sick and all they said was it was on order day after day. I had hot and cold sweats, puked for days and that's not right. Review of resident #26's medication administration record showed Promethazine HCl Tablet 25 MG was not given on 11/27/23 through 12/1/23 for the following times: -11/27/23 9:00 a.m.: OO=On Order from Pharmacy -11/27/23 8:00 p.m.: OO=On Order from Pharmacy -11/28/23 9:00 a.m.: OO=On Order from Pharmacy -11/29/23 9:00 a.m.: OO=On Order from Pharmacy -11/30/23 9:00 a.m.: OO=On Order from Pharmacy -12/1/23 9:00 a.m.: OO=On Order from Pharmacy During an interview on 12/6/23 at 8:34 a.m., staff member B stated if medication ran out, the nurse should have called the pharmacy and obtained the medication from the Cubex, if possible. If the medication was not in the Cubex the nurse would have needed to get the medication satellited from the local pharmacy. The nurse should have notified the physician and checked to see if the medication could be changed to an alternate medication. Staff member B stated, I didn't hear [resident #26] was out of the Promethazine until it had already arrived. During an interview on 12/6/23 at 9:00 a.m., staff member B stated there was no notification to the physician for the Promethazine outage. In addition, staff member B stated the Promethazine was not in the Cubex. When asked about the medication administration record showing the medication was given in the evenings on 11/28/23 through 11/30/23, staff member B stated the medication was on order so she would suspect those entries were in error.

Based on interview and record review, the facility failed to properly identify, document, and implement physicians' orders and appropriate interventions to treat the resident's conditions in a timely manner. This included a skin condition on the entire buttocks of a resident, which was found to be related to sepsis and UTI due to incontinence, and required IV antibiotics and catheter placement during hospitalization for 1 (#32) of 15 sampled residents. Findings include: During an interview on 12/5/23 at 8:12 a.m., NF1 stated they had concerns for resident #32 from a hospital stay with high blood sugar and burns on her buttocks from sitting in soiled briefs and then discharged AMA to another facility and passed away. During an interview on 12/6/23 at 11:09 a.m., staff member B stated resident #32 had a long history of behaviors, including during blood sugar checks. The blood sugar checks were discontinued because of the behaviors, and resident #32 was no longer taking insulin. Staff member B stated resident #32's son discharged her after a hospital stay to move her to a different facility closer to the hospital. The discharge was AMA because he did not give the facility enough notice, and they had no physicians' orders. A phone interview was attempted on 12/6/23 at 2:00 p.m. and 3:46 p.m. to resident #32's provider NF3. During an interview on 12/6/23 at 2:17 p.m., NF2 stated resident #32 was not being changed enough for her incontinence. NF2 had asked the facility to change her more frequently because she was getting frequent infections and had developed a sore on her bottom. He thought they did not take care of her because of her behaviors and he observed the staff sitting at the nurses station on their phones instead of assisting residents. NF2 stated he took resident #32 to the hospital because she had been declining for a few weeks, and the facility stated it could be another week before the doctor would be visiting. He was told by the hospital doctor and nurses in the emergency room the sore on her bottom looked like a burn from sitting in soaked briefs, and the area covered her entire bottom. NF2 stated the bottom sore was downplayed by the facility as a small healing rash. NF2 stated the hospital also found resident #32's blood sugar was really high, she had sepsis, and her urine was like pus. NF2 stated he moved resident #32 to a different facility to be closer to the hospital and get the care she needed. During an interview on 12/6/23 at 4:19 p.m., staff member B stated resident #32 had barrier cream and an air mattress as interventions for the wound on her buttocks. Staff member B stated the wound would show improvement without being measured because it was the same nurse who would do the wound care each time. Staff member B stated orders would be in the orders section of PCC and on the TAR. Review of resident #32's September 2023 TAR showed an order for weekly skin audits on Fridays 9/1/23, 9/8/23, 9/15/23, 9/22/23, and 9/29/23. All were marked with no new skin impairments for the month. Review of resident #32's Weekly Skin observation tool showed: -one was started on 9/19/23 and locked on 9/21/23. The assessment noted a new redness to the entire buttocks due to, incontinence dermatitis . with excoriation . notified the RD [sic] on 9/22/23, and the wound looked Pink/Beefy Red. The additional comments noted, Resident has been refusing cares and rarely allows staff to assist with peri care. Resident has been given an alternating air flow mattress, commode at bedside, barrier cream, increased rounding. -another was started on 9/26/23 and completed on 9/27/23 noting resident #32's buttocks were improving, round rash on the left cheek and also covering the entire buttocks. Resident #32 was not at the facility on 9/26/23 and readmitted to the facility on [DATE]. -Neither skin assessment was completed on days ordered on the MAR/TAR. Review of a written physician fax order on 9/22/23 for resident #32 showed the facility requested an order for a new mattress due to incontinence dermatitis to her buttocks, and the physician also ordered to apply barrier cream when providing cares. The orders had not been entered into the EHR to administer in September 2023 or October 2023. Review of resident #32's September and October 2023 MAR/TAR showed no orders for barrier cream, alternating air flow mattress, commode at bedside, the new catheter placed at the hospital, or any other interventions for the sore on her buttocks. Review of resident #32's Care Plan, closed date of 10/10/23, showed none of the noted interventions of a commode at bedside, alternating air flow mattress, or barrier cream for the sore on her buttocks. Review of resident #32's progress notes showed: -No progress notes from 9/16/23 through 9/22/23. -9/23/23, Resident transported per son to [local hospital] for evaluation. Residents mentation/behavior altered and son felt she needed to be seen. Son preferred transporting resident rather than facility or ambulance. DON, MD notified. [local hospital] ER charge nurse notified. -9/27/23, Resident readmitted to facility from [local hospital] at 1225 PM (12:25 p.m.) Transported by facility staff/van. Resident has a Foley catheter that is patent and draining to gravity. Urine is clear with a reddish tinge. Catheter changed at [local hospital] today prior to discharge. Per report last BM was on 9/26/23. [sic] -9/29/23, Daily Skilled Evaluation for Behavior/Dementia/Depression: Resident history of dementia and confusion especially late in day as evening starts. History of recent UTI and elevated blood sugar levels. Was hospitalized for this and completed a course of antibiotics for UTI. Less confusion noted during daytime hours but remains same as day progresses and night falls her cognitive ability is impaired and has poor judgement. No complaints of pain or discomfort. Taking her meds well. Educated on fall safety and resident verbalized some understanding to instructions given Daily Skilled Evaluation for Diabetes: Continues to eat poorly during daytime and does have a small snack at bedtime Continues with rash and redness to entire buttock region and A&D oint and calzime oint applied topically to buttock region at each diaper change alternating ointments. some improvement noted to skin [sic] -10/6/23, At approximately [11:00 a.m.,] residents son called the facility to tell staff he was on his way over to discharge his mother from the facility. Son notified that was not enough notice to prepare a discharge and that she would be considered leaving AMA . -10/6/23 at 1:45 p.m., .POA signed AMA paperwork and packed many of the residents belongings . ED, and PCP notified of resident's discharge. Review of resident #32's hospital records for her 9/23/23-9/27/23 stay showed: -Current assessment and plan: Complicated UTI .tachycardic . Marked hyperglycemia on arrival (1201) [extremely high blood sugar level] . A1C over 15 [extremely high] . Lactic acidosis and dehydration suspect related to hyperglycemia/sepsis . -Significant beefy redness to the vaginal area, groin skin folds, and buttock area. There are a few satellite lesions. On arrival she presented with some white matter (possibly ointment as well as fecal matter in the groin area. -[Resident #32] is incontinent of urine and stool. Buttocks and peri area is extremely red and tender to the touch. Area is gently cleansed with warm barrier wipes explaining care along the way. Calazime cream applied to reddened areas. Padding placed between creases. Pt is able to help with changes by making a bridge. -Foley Catheter management per nursing protocol-indication: significant skin issues related to urinary incontinence. Foley changed 9/27/23. Temporary foley placement. Also noted to keep skin in perineal area dry, change frequently, and apply barrier cream several times per day.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene during medication administration for 4 (#s 9, 26, 29, and 31) of 15 sampled residents; and failed to dispose of a moldy, rotten pumpkin, resulting in foul odor and a dusty fly covered fly tape trap in the common area. Findings include: 1. During an observation on 12/4/23 at 2:16 p.m., staff member I administered medications to resident #26. Staff member I did not use hand hygiene before or after administering the medications. During an observation on 12/4/23 at 3:26 p.m., staff member I administered medications to resident #29. Staff member I did not use hand hygiene before or after administering the medications. During an observation on 12/4/23 at 3:33 p.m., staff member I administered a medication to resident #31. Staff member I did not use hand hygiene before administering the medication. During an interview on 12/4/23 at 3:45 p.m., staff member I stated staff were to wash their hands if they were soiled, otherwise they can use antibacterial gel. Staff member I stated she did not know if she was supposed to use hand hygiene before entering a room to administer medications to residents, and would have to get back to the surveyor with an answer. Staff member I stated staff did use hand hygiene after administering medications. During an interview on 12/5/23 at 10:58 a.m., staff member I stated she knew she was not doing the right hand hygiene the day prior, and would probably mess up that day as well. During an observation on 12/5/23 at 11:26 a.m., staff member I administered medications to resident #9. Staff member I did not use hand hygiene before administering medications to the resident. During an interview on 12/6/23 at 10:12 a.m., staff member B stated she did not include medication administration hand hygiene audits on the facility hand hygiene audits quarterly. Review of the facility's policy, Medication Administration, updated 6/2017, showed, .12. The nurse washes his/her hands between residents or uses approved hand-sanitizer between residents. 41952 2. During an observation on 12/4/23 at 3:31 p.m., in the common room, a dusty fly covered fly tape trap was dangling from the ceiling above the doors to the courtyard. A pungent odor filled the room and was noted to be coming from a basketball sized rotten pumpkin sitting on a table next to resident drink cups. The pumpkin top was caving in and covered in thick, fuzzy, green, grey, and white mold. During an observation on 12/5/23 at 8:32 a.m., the rotten moldy pumpkin was still on the table next to resident's dirty breakfast trays in the common room with the strong odor present. During an observation and interview, on 12/5/23 at 12:31 p.m., the surveyor informed staff member Q of the rotten moldy pumpkin from the table in the common room, for removal. Staff member A stated she was not aware there were still pumpkins in the building and would remove them herself. Staff member Q walked to the common room to remove all of the pumpkins.

Based on interview and record review, the facility failed to notify the physician of medication errors for 1 (#26) of 15 sampled residents. Findings include: During an interview on 12/4/23 at 1:18 p.m., resident #26 stated, They (the facility) ran out of my nausea medication on Sunday, and I didn't get any until Friday. I went through such withdrawals, I was so sick and all they said was it was on order day after day. I had hot and cold sweats, puked for days and that's not right. Review of resident #26's medication administration record showed Promethazine HCl Tablet 25 MG was not given on 11/27/23 through 12/1/23 for the followiong times: 11/27/23 9 a.m.: OO=On Order from Pharmacy 11/27/23 8 p.m.: OO=On Order from Pharmacy 11/28/23 9 a.m.: OO=On Order from Pharmacy 11/29/23 9 a.m.: OO=On Order from Pharmacy 11/30/23 9 a.m.: OO=On Order from Pharmacy 12/1/23 9 a.m.: OO=On Order from Pharmacy During an interview on 12/6/23 at 8:34 a.m., staff member B stated if medication ran out, the nurse should have called the pharmacy and obtained the medication from the Cubex, if possible. If the medication was not in the Cubex the nurse would need to get the medication satellited from [city] pharmacy. The nurse should have notified the physician and check to see if the medication could be changed to an alternate medication. Staff member B stated,I didnt hear [resident #26] was out of the Promethazine until it had already arrived. Review of resident #26's EMR showed no documentation of physician notification in the progress notes and no new orders for an alternate medication to address resident #26's nausea, vomiting and hot/cold sweats. During an interview on 12/6/23 at 9:00 a.m., staff member B stated there was no notification to the physician for the Promethazine outage and the Promethazine was not in the Cubex.

Based on interview and record review, facility staff failed to respect the dignity of residents when they were talking about them at the nursing station, and a resident overheard them and filed a grievance, for 1 (#24) if 15 sampled residents, and this had the potential to affect others. Findings include: Review of the grievance by resident #24 showed the grievance was received on 9/25/23 at 6:45 a.m., and: - the grievance reported was, 9/22 or 9/23 around 0200 (2:00 a.m.) I heard [staff members P and O] talking from the nurses' desk, negatively about other staff and residents. I am mad . - the grievance investigation showed, .upon returning to his room [resident #24] was able to hear the staff's conversation. Interviewed other residents and all denied staff talking too loudly at night. - action taken as, Spoke with [staff members P and O] reminded them to make sure conversations at the nurses' station are appropriate and to maintain a quiet environment during noc shift . Signed and dated on 9/27/23 by staff member B. - findings were confirmed as, Staff were talking too loudly during NOC shift upsetting a resident with their volume and topic of conversation. -The grievance was signed by staff member A on 9/29/23. During an interview on 12/5/23 at 2:57 p.m., staff member G stated she moved to the social services department in the last few months and had just started handling the grievance process. Staff member G stated she attempted to have the grievance resolved within 48 hours, if possible. Staff member G stated if the grievance was a specific department, it would be handled by the department. They would know it was for the department because the management team reviewed them in the morning meetings. Staff member G stated if she felt a grievance was really an abuse allegation, she would report it to staff members A and B right away. During an interview on 12/6/23 at 10:53 a.m., staff member B stated she came to the night shift the day after the grievance was made and, Reiterated low volume appropriate topics, and being mindful of who can hear them talking, to staff members P and O mentioned in the grievance. Staff member B stated resident #24 was upset by how the staff were talking to another resident while putting him to bed. The other resident had no concerns and resident #24 did not say the staff were abusive or neglectful. There was no other documentation other than the grievance form. Staff member B stated only staff member A had access to enter reportable incidents but did not feel the need to get involved in this matter. During an interview on 12/6/23 at 11:37 a.m., staff member A stated if something was a grievance it was not required to be reported to the State Survey Agency. When a complaint was made, you would have to determine if it could be abuse or not, otherwise continue as a grievance if it does not rise to the level of abuse reporting. Staff member A stated he was not involved in the complaint made by resident #24 regarding staff members P and O because it was regarding nursing staff. Staff member B handled it and did not think it was abuse so it was handled as a grievance. During an interview on 12/6/23 at 3:12 p.m. resident #24 stated he reported the complaint regarding the night shift staff members P and O because he felt what he could hear them saying from the nurses station was inappropriate to be talked about openly and too loud. Resident #24 stated he knew the staff and residents they were talking about and the problems they were mentioning. Resident #24 even heard his own name mentioned. Review of the Grievance Procedure policy, last updated November 2016, showed, If the grievance involves abuse, neglect, exploitation, or misappropriation of resident property, the ED is notified immediately and an investigation begins. (See Abuse Prohibition Manual, and notify state agencies where applicable.)

Based on record review, protocol review, and staff interview, the facility failed to ensure 2 (#s 1 and 2) of 8 diabetic residents were monitored for hypoglycemic reactions and failed to follow facility policy and procedure to provide necessary care to obtain the highest practical well being. Findings include: 1. Review of records dated [DATE], for residents #1 and #2, the same physician order [REDACTED]. Hold insulin until order obtained from physician. 1) Give [MEDICATION NAME] 1.0 mg IM. Recheck blood glucose in 10 - 15 minutes. If resident able to swallow and BS remains below 70 mg/dl (deciliter) go to section A and follow. 2) Repeat [MEDICATION NAME] 1.0 mg IM if resident still unable to swallow and notify physician immediately of measures taken/resident status." 2. The facility's 2004 Blood Glucose Monitoring protocol was the same as the physician's orders [REDACTED]. The care plans for residents #1 and #2 were the same. Both care plans identified the problem of insulin dependent diabetes which included the policy/standard of practice parameters to treat/report: Below 70. The interventions included: -Treat [DIAGNOSES REDACTED] that is unresponsive to treatment as a life threatening medical emergency. -Report signs and symptoms of [DIAGNOSES REDACTED] to nurse immediately: shaky, nervous, cold, clammy skin, pale, hunger, nausea, vomiting, confusion, lethargy, thirst, unresponsiveness. -Report signs and symptoms of [MEDICAL CONDITION] to nurse immediately: decreased appetite, nausea, vomiting, fruity odor to breath, confusion, increased urine output, hot, dry skin, flushed, vision problems. -Notify MD if blood glucose levels fluctuate markedly or are consistently out of range or require consistent sliding scale coverage. -Orange juice or milk for BS below 60. 3. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. During review of the MAR, the surveyor noted the following blood sugar information: - On [DATE] at 6:00 a.m., 62. - On [DATE] at 3:30 p.m.,34. - On [DATE] at 7:00 a.m., 54. - On [DATE] at 6:00 a.m., 50. - On [DATE] at 6:00 a.m., 43. - On [DATE] at 6:00 a.m., 47. - On [DATE] at 6:00 a.m., 65. Upon medical record review of resident A, the surveyor noted the following information in the Nurses' Notes: On [DATE] 6:00 a.m., the blood sugar was 27. The resident expires. According to the nurses' notes, at 6:20 a.m. "0530 (5:30 a.m.) resident unresponsive fbs (fasting blood sugar) 27. Glucose tubes X 3 given-still unresponsive-911 called about 0600 (6:00 a.m.). Same time resident expired. NOK (next of kin) notified." On [DATE] at 6:20 a.m., according to the nurses' notes, "Resident supine in bed, at 0620 (6:20 a.m.), blood sugars dropped below 30. Along with blood pressure and pulse. 02 (oxygen) at 2 LPM (liters per minute). Resident passed away at 0620. Family contacted and funeral home notified." The facility failed to do the 15 minute rechecks for 4 of 8 low blood sugar readings. The facility failed to initiate treatment as ordered for the blood sugars below 70. The facility failed to notify the physician for 2 of 8 low blood sugar events. The facility failed to have [MEDICATION NAME] available in the building. The surveyor noted an order for [REDACTED]. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the MARs the surveyor noted the following blood sugar information: - On [DATE] at 8:00 a.m., 49. - On [DATE] at 8:00 a.m., 47. - On [DATE] at 8:00 a.m., 54. - On [DATE] at 8:00 a.m., 36. - On [DATE] at 8:00 a.m., 52. - On [DATE] at 8:00 a.m., 41. For the six events of low blood sugars, there was no documentation that the physician was contacted. Five of the six events lacked documentation for rechecks of blood sugars and the MARs indicated the insulin was administered. INTERVIEWS: 1. On [DATE] at 6:30 p.m., the surveyor interviewed staff members B and D regarding E kit [MEDICATION NAME]. Staff members B, the DON, and D, a RN, stated [MEDICATION NAME] was not available in the facility. 2. On [DATE] at 9:25 a.m. the surveyor interviewed the medical director. The medical director stated " I was unaware the facility did not have [MEDICATION NAME] for emergencies...sometimes the pharmacy does not send all of the meds that are ordered." 3. On [DATE] at 10:15 a.m., the surveyor interviewed staff member A, a LPN. Staff member A stated "recheck of blood sugars are supposed to be documented on the MARs. 4. On [DATE] at 10:20 a.m., the surveyor interviewed staff member B. Staff member B stated "my guess is the nurses gave the rechecks in report." At approximately 12:35 p.m. on [DATE], the facility administrator was given verbal notice via telephone that an immediate jeopardy (IJ) was present as a result of nursing staff not following physician orders [REDACTED]. The facility failed to follow physician orders [REDACTED]. On [DATE] at 11:16 a.m., the administrator submitted an acceptable allegation to lift the IJ which included the following: 1. Resident #1 does not reside in the facility. Resident #2's diabetic status was reviewed with physician on [DATE] and new orders for insulin have been received. The nurse consultant (NC) and Director of Nursing (DNS) reviewed resident #2's care plan and made revisions as appropriate on [DATE]. [MEDICATION NAME] was received from the pharmacy [DATE]. The pharmacy has built new e (emergency)-kits with [MEDICATION NAME] and the facility will receive the new e-kit in addition to the [MEDICATION NAME] satellited from the back up pharmacy. During a surveyor's Interview with floor nurse on [DATE] at 10:05 a.m., the floor nurse stated [MEDICATION NAME] IM is in the med carts. 2. The NC and DNS reviewed the clinical records of all residents with [DIAGNOSES REDACTED]. Upon review of the medical records by the surveyor, the records for 8 diabetic residents provided documentation of physician orders [REDACTED]. 3. All licensed nurses were inserviced by [DATE] regarding facility policy and procedure for "Blood Glucose Monitoring", including symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] and reporting and documentation practices. The NC, DNS or designee will provide monthly in-service on aspects of diabetes for the next 3 months. Documentation of nurses attending inservice for "Blood Glucose Monitoring" was received on [DATE]. PRN nurses will receive this inservice prior to their next shift at the facility. 4. The DNS or designee with complete daily audits 5 times a week for the next 30 days, then random audits weekly thereafter for each diabetic resident to validate that facility policy and procedures and physician orders [REDACTED]. The NC will perform random audits to validate that the Plan of Correction is being sustained. 5. Alleged compliance date: [DATE]/2011. On [DATE], the surveyors received an Audit tool and a written statement by the NC for daily audits of each diabetic resident using the requirements of the facility policy and procedure. The Audit tool and written statement included that physician orders [REDACTED]. On [DATE] at 1:40 p.m., based on the accepted allegation, the IJ was lifted.